A cool modality to restore sinus rhythm

Background

Slowing electrical conduction by cooling the myocardium can be used for defibrillation. We previously demonstrated the efficacy of a small cold device placed in oblique sinus (OS) in terminating atrial fibrillation (AF). However, the parameters needed to achieve effective atrial defibrillation are unknown.

Purpose

Assess effect of the size of cooled myocardium on frequency of AF termination in acute canine animal models.

Methods

Sternotomy was performed under general anesthesia in 10 acute canine experiments. AF was induced using rapid atrial pacing and intra-myocardial epinephrine and acetylcholine injections. Once AF sustained for at least 30s, either a cool (7–9°C) or placebo (body temperature) device was placed in the OS. Four device sizes were tested; ½X½, ¾X¾, and 1X1 inch devices and two ¾X¾ inch devices placed side by side simultaneously. Time to AF termination was recorded. Chi-squared or Fisher's exact test were used to compare the frequency of arrhythmia termination with cooling versus placebo.

Results

A total of 166 applications were performed (89 cool vs 77 placebo) in 10 animal experiments. Overall, AF terminated in 82% of the cooling applications vs. 67.5% of placebo (P=0.03, Figure 1). For the ½X½ inch device 88% of cold applications restored sinus rhythm vs. 63.6% for placebo (P=0.05). The frequency of sinus restoration for cold ¾X¾, 1X1 and two ¾X¾ side by side devices was 86.7%, 83.3% and 70% respectively. Time to sinus restoration when achieved was within three minutes was also not significantly changed.

Conclusion

Placing a cool device in the oblique sinus can terminate AF and efficacy is not affected by the size of device.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): MediCool Technologies

Training Community Health Ambassadors to Administer SOPARC

Preparing lay Community Health Ambassadors (CHA) to assess, document and monitor physical activity using standardized instruments can be daunting. Administering some instruments needs specialized training. System for Observing Play and Recreation in Communities (SOPARC) is a standardized instrument requiring extensive training. The question guiding this project was: Can lay Community Health Ambassadors (CHA) be trained to administer SOPARC at Racial and Ethnic Approaches to Community Health (REACH) physical activity fitness sites? This manuscript presents the process undertaken to train Community Health Ambassadors (CHAs) and some preliminary results. Preliminary results are that fifty-six (56) Community Health Ambassadors (CHAs) representing four (4) community partner groups were certified in the SOPARC training. These CHAs successfully documented pre/post data for 20 different physical activity sites. Additionally, the results support the premise that Community Health Ambassadors are a viable liaison in community health delivery.

Survival from Septic Shock Secondary to Disseminated Group A Streptococcal Infection after Central Extracorporeal Membrane Oxygenation

Objective The objective of this study was to describe a case of severe life-threatening acute respiratory distress syndrome (ARDS) and septic shock in a child who responded to a prolonged extracorporeal membrane oxygenation (ECMO) support course utilizing different cannulation techniques depending on the physiological derangement until he recovered.

Design This is a case report.

Setting This study was done at the medical–surgical pediatric intensive care unit in an academic freestanding children's hospital.

Patient A previously healthy 4-year-old boy was presented with respiratory distress and fever. He was diagnosed with respiratory syncytial viral upper respiratory tract infection and group A β-hemolytic Streptococcus septic shock.

Interventions The patient was referred to peripheral ECMO for hemodynamic, ventilatory, and oxygenation support; conversion to central ECMO to augment blood flow; and transition to extracorporeal carbon dioxide removal before successful wean off extracorporeal support.

Measurements and Main Results Patient experienced severe pediatric ARDS and septic shock that were refractory to maximal medical therapy. Patient was able to be decannulated after 75 days of extracorporeal support. He was weaned completely off of mechanical ventilation and oxygen after 6 months. The only neurological deficit he exhibited was poor fine motor skills of his hands for which he continued to receive physical therapy.

Conclusion Central ECMO may benefit children with pediatric ARDS and septic shock who require higher flows than what can be provided from peripheral ECMO. Extracorporeal membrane carbon dioxide removal may be an effective option in children who do not respond to mechanical ventilation alone.

Echocardiographic imaging options in ovine research subjects

OBJECTIVES

To determine the feasibility of acquiring quality transesophageal (TEE), epicardial (EE), and intracardiac (ICE) echocardiographic images in ovine subjects and to discuss the merits of each technique with a focus on ICE image acquisition.

ANIMALS

Eleven male castrated Dorset adult sheep.

METHODS

Transesophageal echocardiography was performed under general anesthesia. Epicardial echocardiography was performed as part of an open chest (thoracotomy or sternotomy) experiment. Subjects were recovered with permanent jugular vein indwelling catheter and ICE from this approach was described. Feasibility of each technique was qualitatively assessed based on subjective image quality from three images for each image plane in each sheep.

RESULTS

Transesophageal echocardiography was technically challenging and did not provide adequate image quality for consistent interpretation. Epicardial echocardiography and ICE had more favorable results with ICE demonstrating unique benefits for post-operative serial monitoring.

CONCLUSIONS

Epicardial echocardiography and ICE were effective imaging techniques. Epicardial echocardiography required the least specialized training but was considered to have limited feasibility due to its requirement for an open chest procedure. Even with the necessity for permanent indwelling jugular cannulation, ICE was the least invasive of the three imaging techniques and potentially the most practical approach for chronic studies by minimizing post-operative stress. Transesophageal echocardiography was not a feasible technique in this study.

Successful pharmacotherapy for the treatment of severe feeding aversion with mechanistic insights from cross-species neuronal remodeling

Pediatric feeding disorders affect up to 5% of children, causing severe food intake problems that can result in serious medical and developmental outcomes. Behavioral intervention (BI) is effective in extinguishing feeding aversions, and also expert-dependent, time/labor-intensive and not well understood at a neurobiological level. Here we first conducted a double-blind, placebo-controlled trial comparing BI with BI plus d-cycloserine (DCS). DCS is a partial N-methyl-d-aspartate (NMDA) receptor agonist shown to augment extinction therapies in multiple anxiety disorders. We examined whether DCS enhanced extinction of feeding aversion in 15 children with avoidant/restrictive food intake disorder (ages 20-58 months). After five treatment days, BI improved feeding by 37%. By contrast, BI+DCS improved feeding by 76%. To gain insight into possible mechanisms of successful intervention, we next tested the neurobiological consequences of DCS in a murine model of feeding aversion and avoidance. In mice with conditioned food aversion, DCS enhanced avoidance extinction across a broad dose range. Confocal fluorescence microscopy and three-dimensional neuronal reconstruction indicated that DCS enlarged dendritic spine heads-the primary sites of excitatory plasticity in the brain-within the orbitofrontal prefrontal cortex, a sensory-cognition integration hub. DCS also increased phosphorylation of the plasticity-associated extracellular signal-regulated kinase 1/2. In summary, DCS successfully augments the extinction of food aversion in children and mice, an effect that may involve plasticity in the orbitofrontal cortex. These results warrant a larger-scale efficacy study of DCS for the treatment of pediatric feeding disorders and further investigations of neural mechanisms.

Remineralization of particulate organic carbon in an ocean oxygen minimum zone

Biological oceanic processes, principally the surface production, sinking and interior remineralization of organic particles, keep atmospheric CO₂ lower than if the ocean was abiotic. The remineralization length scale (RLS, the vertical distance over which organic particle flux declines by 63%, affected by particle respiration, fragmentation and sinking rates) controls the size of this effect and is anomalously high in oxygen minimum zones (OMZ). Here we show in the Eastern Tropical North Pacific OMZ 70% of POC remineralization is due to microbial respiration, indicating that the high RLS is the result of lower particle fragmentation by zooplankton, likely due to the almost complete absence of zooplankton particle interactions in OMZ waters. Hence, the sensitivity of zooplankton to ocean oxygen concentrations can have direct implications for atmospheric carbon sequestration. Future expansion of OMZs is likely to increase biological ocean carbon storage and act as a negative feedback on climate change.

The downward transfer of organic carbon from the surface to the deep ocean is increased in oxygen minimum zones relative to oxic waters. Here, the authors show reduced interactions of zooplankton with sinking particles owing to low oxygen are likely the primary reason for the observed high transfer of carbon.

The Value of Skull Radiography in Ophthalmology

Skull radiographs and special views are still requested in ophthalmology despite the increasing availability of other radiological investigations such as CT, MR imaging and ultrasound. In order to assess the value of skull radiography in ophthalmology we retrospectively studied the use of skull radiographs and CT images in our department. In only one instance was patient management based purely on skull radiograph findings. Over 50% of CT examinations had been preceded by skull films which made no contribution towards management. In some cases the skull films had been misleading by not showing significant pathology and had consequently created considerable delay before diagnosis was reached. It is therefore unjustifiable to use skull films as a method of screening for orbital or intracranial disease and there is little indication for skull radiography in ophthalmology, except in detection of intraocular foreign bodies, facial and orbital fractures and simple sinusitis.

Metastatic Carcinoma Presenting as Cranial Nerve Palsy

Adult onset, multiple oculo-motor nerve palsies are usually due to neoplasia and trauma. We report two cases whose initial presenting sign was oculo-motor cranial nerve palsy and were later found to have metastatic carcinoma.

Improving patient access to prevent sight loss: ophthalmic electronic referrals and communication (Scotland)

INTRODUCTION

With the number of people with sight loss predicted to double to four million people in the UK by the year 2050, preventable visual loss is a significant public health issue. Sight loss is associated with an increased risk of falls, accidents and depression and evidence suggests that 50% of sight loss can be avoided. Timely diagnosis is central to the prevention of sight loss. Access to care can be a limiting factor in preventable cases. By improving referrals and access to hospital eye services it is possible to treat and minimise the number of patients with preventable sight loss and the impact this has on wider society.

CLINICAL PILOT STUDY

In 2005, NHS Fife took part in a flagship pilot funded by the Scottish government e-health department to evaluate the feasibility, safety, clinical effectiveness, and cost of electronic referral with images of patients directly from community optometrists to Hospital Eye Service (HES). The pilot study showed that electronic referral was feasible, fast, safe, and obviated the need for outpatient appointments in 128 (37%) patients with a high patient satisfaction.

CENTRALISED OPHTHALMIC ELECTRONIC REFERRAL UNIT

The results of the pilot study were presented and in May 2007, the electronic referral system was rolled out regionally in southeast Scotland. Referrals were accepted at a single site with vetting by a trained team and appointments were allocated within 48 hours. Following the implementation of electronic referral, waiting times were reduced from a median of 14 to 4 weeks. Significantly fewer new patients were seen (7462 vs 8714 [p < 0.001]). There were also fewer casualties (1984 vs 2671 [p < 0.001]) and 'did not arrive' (DNA) new patients (503 vs 635 [p < 0.001]).

EYE CARE INTEGRATION PROJECT (SCOTLAND)

In 2010 the Scottish Government Health Department committed £ 6.6 million to community and hospital ophthalmic services forming the Eyecare Integration Project in 2011. The main aim of this project was to create electronic communication between community optometry practices and hospital eye departments. Five electronic forms were specifically designed for cataract, glaucoma, macula, paediatric and general ophthalmic disease. A Virtual Private Network was created which enabled optometrists to connect to the Scottish clinical information gateway system and send referrals to hospital and receive referral status feedback. Numerous hurdles have been encountered and overcome in order to deliver this project.

DISCUSSION

An efficient unique system has been described within the NHS whereby the provision of eye care has been modernised by creating a user-friendly electronic interface between the community and HES. This system ensures patients are vetted into the correct specialist clinic and thus will be less likely to go blind from treatable conditions. Urgent conditions will continue to be prioritised and savings made with efficiencies gained can be re-invested towards better overall patient care.

Using electronic referral with digital imaging between primary and secondary ophthalmic services: a long term prospective analysis of regional service redesign

PURPOSE

Demands on publicly funded ophthalmic services worldwide continue to increase with new treatments, waiting time targets, working time limits, and restricted budgets. These highlight the necessity to develop innovative ways of utilising existing capacity more effectively.

METHOD

A new regional, fully electronic ophthalmic-referral service with digital imaging was trialled using existing information-technology (IT) infrastructure. Following successful pilot study, the service was rolled out regionally. Service delivery data was prospectively collated for all the attendances in the year prior to (2006) and the year following (2008) introduction.

RESULTS

Comparing 2006 against 2008, median waiting times reduced (14 vs 4 weeks), and fewer new patients were observed (8714 vs 7462 P<0.0001), with 1359 referrals receiving electronic diagnosis (e-diagnosis). New patient did not arrive (635 vs 503 P<0.0001) and emergencies also reduced (2671 v 1984 P<0.0001).

DISCUSSION

Novel use of existing IT infrastructure improves communication between primary and secondary care. This promotes more effective use of limited outpatient capacity by retaining patients with non-progressive, asymptomatic pathology in the community, whilst fast-tracking patients with sight-threatening disease. Resultant significant, sustained improvements in regional service delivery point to a simple model that could easily be adopted by other providers of universal healthcare globally.

Surveillance for ocular hypertension: an evidence synthesis and economic evaluation

OBJECTIVES

To determine effective and efficient monitoring criteria for ocular hypertension [raised intraocular pressure (IOP)] through (i) identification and validation of glaucoma risk prediction models; and (ii) development of models to determine optimal surveillance pathways.

DESIGN

A discrete event simulation economic modelling evaluation. Data from systematic reviews of risk prediction models and agreement between tonometers, secondary analyses of existing datasets (to validate identified risk models and determine optimal monitoring criteria) and public preferences were used to structure and populate the economic model.

SETTING

Primary and secondary care.

PARTICIPANTS

Adults with ocular hypertension (IOP > 21 mmHg) and the public (surveillance preferences).

INTERVENTIONS

We compared five pathways: two based on National Institute for Health and Clinical Excellence (NICE) guidelines with monitoring interval and treatment depending on initial risk stratification, 'NICE intensive' (4-monthly to annual monitoring) and 'NICE conservative' (6-monthly to biennial monitoring); two pathways, differing in location (hospital and community), with monitoring biennially and treatment initiated for a ≥ 6% 5-year glaucoma risk; and a 'treat all' pathway involving treatment with a prostaglandin analogue if IOP > 21 mmHg and IOP measured annually in the community.

MAIN OUTCOME MEASURES

Glaucoma cases detected; tonometer agreement; public preferences; costs; willingness to pay and quality-adjusted life-years (QALYs).

RESULTS

The best available glaucoma risk prediction model estimated the 5-year risk based on age and ocular predictors (IOP, central corneal thickness, optic nerve damage and index of visual field status). Taking the average of two IOP readings, by tonometry, true change was detected at two years. Sizeable measurement variability was noted between tonometers. There was a general public preference for monitoring; good communication and understanding of the process predicted service value. 'Treat all' was the least costly and 'NICE intensive' the most costly pathway. Biennial monitoring reduced the number of cases of glaucoma conversion compared with a 'treat all' pathway and provided more QALYs, but the incremental cost-effectiveness ratio (ICER) was considerably more than £30,000. The 'NICE intensive' pathway also avoided glaucoma conversion, but NICE-based pathways were either dominated (more costly and less effective) by biennial hospital monitoring or had a ICERs > £30,000. Results were not sensitive to the risk threshold for initiating surveillance but were sensitive to the risk threshold for initiating treatment, NHS costs and treatment adherence.

LIMITATIONS

Optimal monitoring intervals were based on IOP data. There were insufficient data to determine the optimal frequency of measurement of the visual field or optic nerve head for identification of glaucoma. The economic modelling took a 20-year time horizon which may be insufficient to capture long-term benefits. Sensitivity analyses may not fully capture the uncertainty surrounding parameter estimates.

CONCLUSIONS

For confirmed ocular hypertension, findings suggest that there is no clear benefit from intensive monitoring. Consideration of the patient experience is important. A cohort study is recommended to provide data to refine the glaucoma risk prediction model, determine the optimum type and frequency of serial glaucoma tests and estimate costs and patient preferences for monitoring and treatment.

FUNDING

The National Institute for Health Research Health Technology Assessment Programme.

Kinematic and electromyographic changes during 200 m front crawl at race pace

The purpose of this study was to analyse eventual kinematic and electromyographic changes during a maximal 200 m front crawl at race pace. 10 male international level swimmers performed a 200 m maximal front crawl test. Images were recorded by 2 above and 4 under water cameras, and electromyographic signals (EMG) of 7 upper and lower limbs muscles were analysed for 1 stroke cycle in each 50 m lap. Capillary blood lactate concentrations were collected before and after the test. The variables of interest were: swimming speed, stroke length, stroke and kick frequency, hand angular velocity, upper limb and foot displacement, elbow angle, shoulder and roll angle, duration of stroke phases, and EMG for each muscle in each stroke phase. Generally, the kinematic parameters decreased, and a relative duration increased for the entry and pull phases and decreased for the recovery phase. Muscle activation of flexor carpi radialis, biceps brachii, triceps brachii, peitoral major and upper trapezius increased during specific stroke phases over the test. Blood lactate concentration increased significantly after the test. These findings suggest the occurrence of fatigue, characterised by changes in kinematic parameters and selective changes in upper limbs muscle activation according to muscle action.

Clinical potential of DAS181 for treatment of parainfluenza-3 infections in transplant recipients

Parainfluenza virus (PIV) infections can cause serious respiratory infections and death in immunocompromised patients. No antiviral agents have proven efficacy against PIV, and therapy generally consists of supportive care. DAS181, a novel sialidase fusion protein that temporarily disables airway epithelial PIV receptors by enzymatic removal of sialic acid moieties, has been shown to inhibit infection with PIV strains in vitro and in an animal model. We describe here the clinical course of 2 immunocompromised patients with PIV-3 infection, one with a history of lung transplantation and the other neutropenic after autologous hematopoietic stem cell transplantation for multiple myeloma. Both patients had substantial clinical improvement in respiratory and systemic symptoms after a 5-day DAS181 treatment course, although the clinical improvement in the autologous stem cell transplantation patient also paralleled neutrophil engraftment.

A rare case of zolendronate infusion complication leading to glaucoma filtration surgery

Zolendronic acid is a nitrogenous biphosphonate commonly used as an intravenous infusion for the management of Paget's disease, osteoporosis, and hypercalcemia of malignancy. We report a rare and challenging complication of zolendronate infusion: unilateral acute anterior uveitis followed by persistently raised intraocular pressure despite being on four different classes of antiglaucoma medication. The challenge was that the patient required topical steroid to treat her uveitis in the background of known glaucoma with corresponding steroid response. She eventually underwent a left phacotrabeculectomy augmented with 5-fluorouracil. Four weeks postoperatively she developed an encapsulated bleb and underwent needling with 5-fluorouracil. This case highlights the importance of having a high index of suspicion for anterior uveitis in patients with a red and painful eye after initiating biphosphonate therapy. Caution should also be exercised when prescribing biphosponates to glaucoma patients.

Revalidation and electronic cataract surgery audit: a Scottish survey on current practice and opinion

PURPOSE

To determine current knowledge and opinion on revalidation, and methods of cataract surgery audit in Scotland and to outline the current and future possibilities for electronic cataract surgery audit.

METHODS

In 2010 we conducted a prospective, cross-sectional, Scottish-wide survey on revalidation knowledge and opinion, and cataract audit practice among all senior NHS ophthalmologists. Results were anonymised and recorded manually for analysis.

RESULTS

In all, 61% of the ophthalmologists surveyed took part. Only 33% felt ready to take part in revalidation, whereas 76% felt they did not have adequate information about the process. Also, 71% did not feel revalidation would improve patient care, but 85% agreed that cataract surgery audit is essential for ophthalmic practice. In addition, 91% audit their cataract outcomes; 52% do so continuously. Further, 63% audit their subspecialist surgical results. Only 25% audit their cataract surgery practice electronically, and only 12% collect clinical data using a hospital PAS system. Funding and system incompatibility were the main reasons cited for the lack of electronic audit setup. Currently, eight separate hospital IT patient administration systems are used across 14 health boards in Scotland.

CONCLUSION

Revalidation is set to commence in 2012. The Royal College of Ophthalmologists will use cataract outcome audit as a tool to ensure surgical competency for the process. Retrospective manual auditing of cataract outcome is time consuming, and can be avoided with an electronic system. Scottish ophthalmologists view revalidation with scepticism and appear to have inadequate knowledge of the process. However, they strongly agree with the concept of cataract surgery audit. The existing and future electronic applications that may support surgical audit are commercial electronic records, web-based applications, centrally funded software applications, and robust NHS connections between community and hospital.

IDEA (Intellectual Disability Exploring Answers): A population-based database for intellectual disability in Western Australia

Despite the demands it places on individuals, families and the community, intellectual disability (ID) is a neglected area of public health. Accurate estimates of prevalence are sparse and range from 0.5 to 3.0%. The cause of the condition is unknown in at least 50% of cases. This paper describes the Intellectual Disability Exploring Answers (IDEA) database set up in Western Australia to provide an infrastructure for research and to facilitate the planning of service provision for people with ID. Since 1953 a database for ID has been maintained in Western Australia, a state with a population of 1.95 million in an area of 2.52 million km2. The current IDEA database aims to obtain ongoing population-based ascertainment of ID from providers of clinical and educational services, with the potential for linkage to a network of other state databases. The average prevalence of ID for children born in Western Australia over the years 1983-1996 was 15.2 per 1000 live births, with 50% ascertained only through the education system. During this time period 60% of cases were male. Of children with an ID born in Western Australia in 1980-1999 and surviving to 1 year, 30.1% had a birth defect, and the prevalence ratio of birth defects in this group compared to the population with no birth defects was 6.5 (CI 6.3-6.8).

Ocean fertilization: a potential means of geoengineering?

The oceans sequester carbon from the atmosphere partly as a result of biological productivity. Over much of the ocean surface, this productivity is limited by essential nutrients and we discuss whether it is likely that sequestration can be enhanced by supplying limiting nutrients. Various methods of supply have been suggested and we discuss the efficacy of each and the potential side effects that may develop as a result. Our conclusion is that these methods have the potential to enhance sequestration but that the current level of knowledge from the observations and modelling carried out to date does not provide a sound foundation on which to make clear predictions or recommendations. For ocean fertilization to become a viable option to sequester CO2, we need more extensive and targeted fieldwork and better mathematical models of ocean biogeochemical processes. Models are needed both to interpret field observations and to make reliable predictions about the side effects of large-scale fertilization. They would also be an essential tool with which to verify that sequestration has effectively taken place. There is considerable urgency to address climate change mitigation and this demands that new fieldwork plans are developed rapidly. In contrast to previous experiments, these must focus on the specific objective which is to assess the possibilities of CO2 sequestration through fertilization.

The implementation of Restoring Health – a chronic disease model of care to decrease acute health care utilization

The Restoring Health Program, a multi-disciplinary model of care for patients with chronic lung diseases, heart failure, and diabetes, was established to improve the quality of life and function for patients with these target chronic diseases, while reducing their disproportionately high demand on acute health care services. Acute health care utilization at St Vincent’s Hospital Melbourne for all patients recruited between February 2003 and June 2005 ( n = 351) was analyzed using within-subjects paired sample t-tests to compare the 6 months of pre-recruitment with 6 months of post-recruitment. Analysis showed statistically significant decreases in emergency department presentations ( P < 0.001), hospital admissions ( P < 0.001), and length of stay ( P < 0.001). This article describes the current model of care, the program’s enablers, and its impact on health service demand after the first 4 years of implementation.

Evaluation of Permacol as a cultured skin equivalent

Skin loss following severe burn requires prompt wound closure to avoid such complications as fluid and electrolyte imbalance, infection, immune suppression, and pain. In clinical situations in which insufficient donor skin is available, the development of cultured skin equivalents (dermal matrices seeded with keratinocytes and fibroblasts) may provide a useful alternative. The aim of this study was to assess the suitability of a porcine-derived dermal collagen matrix (Permacol) to function as a cultured skin equivalent in supporting the growth of keratinocytes in vitro and providing cover to full thickness wounds in the BALB C/nude mouse model. A histological comparison was against Glycerol treated-Ethylene Oxide Sterilised Porcine Dermis (Gly-EO Dermis) which has successfully been used as a cultured skin equivalent in previous studies. Both Gly-EO Dermis and to a lesser extent Permacol were able to support the growth of cultured keratinocytes following a 16-day period of cell culture, however, this study was only able to demonstrate the presence of an epidermal layer on Gly-EO dermis 2 weeks after grafting onto full-thickness wounds in the BALB C/nude mouse model.

Automated home-based symptom monitoring coupled with centralized telecare management in a statewide trial involving rural and urban community-based oncology practices

9089

Background: Pain and depression are two of the most prevalent and treatable cancer-related symptoms, each present in at least 20–30% of oncology patients. Therefore, we are conducting the NCI-funded Indiana Cancer Pain and Depression (INCPAD) study, a randomized clinical trial conducted in a statewide network of 13 community-based cancer clinics located in both rural and urban oncology practices. Methods: Patients are screened at the local clinics followed by telephone-based enrollment and informed consent, depression and pain care management, and serial research outcome assessments over a 12-month period. Patients randomized to the intervention complete automated home-based symptom monitoring by interactive voice-recorded phone calls or by internet on a tapering schedule (twice a week tapering to monthly), allowing a single nurse care manager to centrally monitor treatment of patients asynchronously and efficiently. Results: Of the first 1,612 patients screened for the trial, 820 (51%) screened positive for depression and/or pain. Of these screen-positive patients, 760 (93%) were successfully contacted by telephone, of whom 203 were ineligible (most often because of symptoms that did not reach severity thresholds), 299 refused, and 163 were enrolled. Reasons that patients refused included lack of interest in trial participation (n=176), the belief their symptoms were not cancer-related (n=35), too sick (n = 30), too busy (n = 21), or other reasons (n = 36). Conclusions: INCPAD demonstrates the feasibility of enrolling cancer patients from multiple geographically-dispersed practices and providing centralized symptom care management. The fact that two-thirds of eligible patients still refuse to participate in a relatively “low burden” trial focused on alleviating bothersome symptoms and conducted almost exclusively by telephone highlights the need for additional strategies to facilitate enrollment in cancer trials. In particular, specific approaches to overcome low enthusiasm for trial participation need to be developed.

No significant financial relationships to disclose.

A prospective analysis of c-myc oncoprotein levels as a prognostic marker in malignant melanoma

BACKGROUND

Previous studies from our group had identified c-myc oncoprotein expression as an important prognostic parameter in a series of retrospective studies of primary and metastatic melanoma and other variants of this disease. This study set out to prospectively evaluate the prognostic significance of c-myc positivity in a consecutive series of primary melanomas presenting at Mount Vernon Hospital Regional Plastic Surgery and Burns Centre.

METHODS

A consecutive series of 117 primary melanomas underwent flow cytometric analysis for c-myc expression at diagnosis. Routine clinical and histological parameters were collected from each patient's clinical records and survival assessed. The mean follow up was 45 months.

RESULTS

Kaplan-Meier survival analysis demonstrated that Breslow depth, histogenic subtype, ulceration, age and sex had prognostic significance. Survival analysis revealed high c-myc positivity to be significantly associated with poorer outcome (P<0.043). Each of the main prognostic parameters were assessed for their independent significance using Cox Proportional Hazards; only c-myc retained independent significance (P<0.039).

CONCLUSIONS

The strength of this study is that it was performed in a consecutive series of patients followed up in a longitudinal prospective study. c-myc was not the strongest predictor of survival in univariate analysis, but was the only parameter that retained significance in multivariate analysis.

The effect of aspirin and warfarin therapy in trabeculectomy

AIM

The management of patients on antiplatelet and anticoagulation therapy (APACT) in glaucoma surgery currently has no specific recommendations. We aimed to establish the risk of haemorrhagic complications and surgical outcome in patients on APACT in glaucoma surgery.

METHODS

We retrospectively examined 367 consecutive trabeculectomies performed between 1994 and 1998. Preoperatively 60 (16.4%) patients were on APACT (55 on aspirin and five on warfarin). The incidence of hyphaema and haemorrhagic complications between patients with and without APACT was documented. Surgical success was defined in two categories as an intraocular pressure (IOP) <21 mmHg and an IOP <16 mmHg 2 years following trabeculectomy with and without antiglaucoma medication.

RESULTS

None of the patients on aspirin suffered significant intra or postoperative haemorrhage. Aspirin was associated with a significantly higher risk of hyphaema (P=0.0015) but this was not found to significantly affect IOP control at 2 years. Patients on warfarin suffered haemorrhagic complications and trabeculectomy failure.

CONCLUSIONS

Aspirin appears to be safe to continue with during trabeculectomy. Patients on aspirin have an increased risk of hyphaema following trabeculectomy. This however does not appear to affect surgical outcome. Warfarinised patients are at risk of serious bleeding complications. They require careful monitoring pre- and postoperatively and are at risk of trabeculectomy failure.

Psychological and social factors in reconstructive surgery for hemi-facial palsy

This paper examines the psychological and social impact of reconstructive surgery for hemi-facial palsy and considers psychosocial factors which may be associated with patient satisfaction. It reports a retrospective study in which 106 adults were assessed using primarily qualitative methods. All participants had undergone two-stage reconstruction using vascularised free muscle grafts, with all procedures having been carried out by the same surgeon. The participants were all at least 12 months post-surgery. They were assessed using demographic questionnaires, the hospital anxiety and depression scale (HADS) and the facial paralysis evaluation measure (FPEM). In addition, all participants were interviewed using a semi-structured format, the interviews were recorded verbatim and the transcripts were analysed using thematic analysis. Of the total study group, 67% had acquired facial palsy. The mean age of the total group was 44.7 years and 67.9% were female. As a group they were rather less depressed than the normal population with similar levels of anxiety to population norms. The primary motivation for surgery was appearance rather than function. Using interview data in addition to the FPEM, satisfaction with the process and outcome of surgery was assessed. Thirty five percent were very satisfied with both process and outcome, 34% were satisfied with the outcome but found the treatment process stressful, 15.1% were not entirely satisfied with process or outcome but felt surgery had been worthwhile as there had been some improvement. The remainder were very dissatisfied with both process and outcome and regretted having undergone surgery. There was no significant association between dissatisfaction and anxiety, the cause of the acquired palsy, longevity prior to surgery, gender nor whether the condition was acquired or congenital. There was a significant relationship with depression, in that those who were suffering from depression were more likely to be dissatisfied with surgery. Participants were asked in interview about social pressures and comments or remarks made by others about their condition. The majority (89.6%) of the total study group reported intrusive questions by acquaintances and strangers, with more than half of these being distressed by such questions. Following surgery, there was a significant reduction in the incidence of these questions. There was no relationship between distress in response to these questions prior to surgery and dissatisfaction with surgery. However, 27.4% also reported aggressive hurtful comments before surgery with a minimal improvement in incidence following surgery. These participants also reported consistent patterns of social avoidance and social isolation before and after surgery, and were more likely to be depressed than the rest of the study group. They were significantly more likely to be dissatisfied with surgery (p=.016). It is recommended that patients are screened and counseled prior to surgery to identify such problems and referred for psychological treatment in order to ensure they gain maximum benefit from reconstructive surgery.

Glaucoma electronic patient record--design, experience and study of high-risk patients

AIM

To set-up a glaucoma electronic patient record (GEPR) and study referral details to a new glaucoma service, concentrating on high-risk patients.

METHOD

A GEPR was designed using the pre-existing hospital information technology (IT) infrastructure. Referral details of all new patients to the glaucoma service were completely electronically entered and analysed.

RESULTS

A GEPR was successfully established. A total of 402 referrals were studied. In all, 43% (40) of high-risk clinic patients (IOP>29 mmHg, or C/D ratio >0.8 or moderate to advanced visual field defects) had to wait longer than 8 weeks from GP referral to be seen at the glaucoma service. Of these, nine patients lost more than one line of Snellen's visual acuity attributable to glaucoma. The optometrist failed to document IOP in 17%, fundoscopy in 30%, and visual fields in 45% of all referrals.

CONCLUSIONS

A GEPR can be introduced in an NHS setting without disruption of clinical care and ophthalmic training, and facilitates detailed, accurate and rapid audit. Study of high-risk glaucoma referrals showed inadequate optometric referral details and poor prioritisation of urgent cases. This information is being utilised with the cooperation of local optometrists to refine the pattern of glaucoma referrals.

Long term follow-up of c-myc, p53 and proliferation measurements in malignant melanoma

AIMS

We report a prospective study examining the prognostic significance of the c-myc oncoprotein, p53 tumour suppressor gene and proliferation rate measurements in malignant melanoma.

METHODS

Flow cytometry (FCM) was used to measure the expression of c-myc, p53 and proliferation parameters in patients who had received an injection of the thymidine analogue bromodeoxyuridine prior to surgery.

RESULTS

Sixty-seven patients had successful FCM measurements of the three parameters. c-myc was detected in 97% of patients with a median cell positivity of 62%. The median p53 positivity was 13%. The median potential doubling time (T(pot)) of the tumours wasf 9.4 days. In univariate analysis, each of the parameters showed an association with survival in metatstatic disease with rapid proliferation (p=0.006) or overexpression of c-myc (p=0.038) related to poor survival whereas increased positivity for p53 predicted better survival (p=0.013).

CONCLUSIONS

These data indicate that laser cytometric technology can be used to obtain quantitative data on oncoproteins expression and cell proliferation rates in clinical samples of malignant melanoma.

Visual impairment in elderly patients with hip fracture: causes and associations

AIMS

To evaluate the current visual status and ophthalmic history of a sample of elderly patients with fractured neck of femur and to study the relationship between visual status and demographic factors.

METHODS

A four-centre study of all patients admitted to hospital with fractured neck of femur. The setting was two district (Ayr, Dunfermline) and two teaching (Glasgow, Dundee) hospitals in Scotland. The study examined 537 patients aged 65 years and over admitted with acute fractured neck of femur to hospital.

RESULTS

Bilateral visual impairment (binocular visual acuity worse than 6/12) was found in 239 of 518 patients (46%). Of this group, the principal causes for visual deficit were untreated cataract (49%), macular degeneration (21%), uncorrected refractive error (17%), and glaucoma (3%). The visually impaired group were more likely to have symptomatic visual complaints (58 vs 26%), however, were less likely to be under optometric care (71 vs 85%). A higher proportion of the group with visual impairment lived in areas of social deprivation (40 vs 26%).

CONCLUSIONS

Patients with fractured neck of femur represent a frail elderly group that have poorer vision than that documented in any other elderly population. The visual defect was potentially remediable in the majority of cases but this group of individuals are not generally in touch with the ophthalmic services. Social deprivation appears to be associated with this groups' inability to access ophthalmic care.

South-East Scotland trabeculectomy survey

AIM

Assessment of trabeculectomy in South-East Scotland (SESTS) with comparison to National Survey of Trabeculectomy (NST) and outcomes of consultant and trainee surgery.

METHOD

A retrospective study of 304 consecutive, primary trabeculectomies, in two Scottish centres (Edinburgh and Dunfermline) with two glaucoma specialists and higher surgical trainees, was performed. The study group had primary open angle glaucoma (65.5%), pseudoexfoliation (6.9%), normal tension glaucoma (7.6%), pigment dispersion syndrome (1.6%), and other complicated glaucoma (18.4%). All patients underwent trabeculectomy by the glaucoma specialist (57.6%) and higher surgical trainee (42.4%) with close scrubbed supervision.

RESULTS

Compared to the NST, the waiting time for surgery (<3 months) was significantly less in the SESTS (P<0.001). There was also significantly more use of intraoperative antimetabolites (P<0.01), bleb intervention (P<0.001), and a higher rate of early complications (P<0.025). There was no significant difference in outcome at intraocular pressure (IOP)<2/3 listing IOP (qualified and unqualified) between the SESTS and the NST. Significantly, more patients achieved an unqualified success of IOP<21 mmHg (P<0.01) and an unqualified success of IOP<16 mmHg in the SESTS than the NST (P<0.05). At 1 year post surgery, visual loss of greater than one Snellen line was more common in the NST (P<0.01) as was the use of anti-glaucoma medication (P<0.001). Trainee cases returned to theatre more frequently (P<0.025) and merited more bleb intervention (P<0.01) than consultant cases, but the long-term outcome was similar.

CONCLUSION

Our study highlights significant changes in the practice and outcome of trabeculectomy compared to the national survey conducted a decade ago.

Histological evaluation of Permacol as a subcutaneous implant over a 20-week period in the rat model

This study assessed the suitability of Permacol (a porcine derived, isocyanate cross linked collagen based biomaterial) as an alternative to autologous tissue in soft tissue reconstruction. The Sprague-Dawley rat was used as a model for subcutaneous implantation over a 20 week period and comparison made with two other porcine biomaterials (small intestinal submucosa and glycerol treated-ethylene oxide sterilised porcine dermis). Implants were scored histometrically on the degree of acute inflammation, chronic inflammation, fibrosis and stromal response. The vascularity and percentage composition of collagen within Permacol were assessed by stereology and seescan image analysis, respectively. In general terms, Permacol was well tolerated as a subcutaneous implant, with only a minor chronic inflammatory response remaining after a 20 week period of implantation. There was evidence of collagen degradation during this period and vascular ingrowth into Permacol was limited. Permacol has the potential for a broad range of applications in plastic surgery, but may benefit from modification to promote a more rapid degree of vascularisation.

Optometric and ophthalmic contact in elderly hip fracture patients with visual impairment*

AIM

To describe previous contact with optometry and ophthalmic services in a group of elderly patients with and without visual impairment (VI) who had fallen and sustained a fractured neck of femur.

METHOD

A cross sectional study of 537 patients aged 65 and over who had undergone hip fracture surgery in four Scottish centres (Glasgow, Ayr, Dundee and Fife). All patients had an in-depth optometric history, ophthalmic history and examination.

RESULTS

Three hundred and ninety-three (79%) patients reported optometric contact in the 3 years preceding surgery and 107 (21%) patients had not seen an optometrist for more than 3 years. In the latter group, 64 had VI, which was due to uncorrected refractive error in 17 (27%) and untreated cataract in 20 (31%). VI (best binocular visual acuity of 6/18 or less) was found in 239 (46%) patients. A past ophthalmic history was present in 257 (50%) patients. Only 39 (16%) patients with VI were under ophthalmic care at the time of the study.

CONCLUSIONS

There was significantly poor optometric and ophthalmic contact in patients who had VI and had fallen and sustained hip fracture. A proportion of the VI (66%) was due to uncorrected refractive error and untreated cataract. Public health providers should be made aware of the fact that current optometric and ophthalmic care pathways are not accessed by this group of elderly patients with VI and at risk of falling.

Evaluation of a porcine origin acellular dermal matrix and small intestinal submucosa as dermal replacements in preventing secondary skin graft contraction

The degree to which a split thickness skin graft (STSG) contracts after application to its recipient bed is related in part to the proportion of the dermis harvested from the donor site. Harvesting thicker skin grafts may produce better cosmetic results in the recipient bed but result in increased donor site morbidity. The combination of an autologous ultra thin split thickness graft with an underlying non-autologous dermal component may reduce secondary skin graft contraction without further increasing donor site morbidity. This study was aimed at assessing the suitability of two porcine derived biomaterials (Permacol and small intestinal submucosa, SIS) for use in combination with skin grafts in a Sprague-Dawley rat model. Full thickness wounds (1 cm(2)) were created in Sprague-Dawley rats and grafted with skin in combination with Permacol or SIS either as a one-stage operation or following a 2-week-period of vascularisation of these dermal matrices before a second stage operation to cover with skin. Skin graft viability and wound area were assessed at weekly intervals until 4 weeks after graft application. Both Permacol and SIS were able to support an overlying skin graft but had no beneficial effect on skin graft contraction in this model compared to skin grafts alone.

The diamond CO2 laser as a method of improving the vascularisation of a permanent collagen implant

For a biomaterial to be considered as anything other than a simple filler material it must allow a certain degree of ingrowth from the surrounding host tissues. Permacol is a novel porcine derived biomaterial that is isocynate crosslinked to prevent its degradation in vivo, but while it appears to be biocompatible in terms of its histological tissue response, our early studies demonstrate only a limited degree of fibrovascular ingrowth. The aim of this study was to assess the effectiveness of both laser perforations and topically applied VEGF as methods of encouraging fibrovascular ingrowth. Treatment of Permacol with the diamond CO(2) laser significantly increased the porosity of the material as assessed by seescan image analysis. Fibrovascular ingrowth as assessed in the Sprague-dawley rat model was found to be limited to the pores themselves and not the surrounding native matrix. Pre-soaking of laser treated Permacol in vascular endothelial growth factor (VEGF) did not further increase fibrovascular ingrowth. Increasing the porosity of Permacol may allow its use as a dermal replacement in the support of an overlying skin graft or keratinocyte sheet; however using the laser may not be the optimal method of achieving this aim.

Blindness From Acute Angle-Closure Glaucoma After Blepharoplasty

An elderly man had acute angle-closure glaucoma soon after undergoing bilateral lower eyelid blepharoplasty that resulted in complete loss of vision in one eye. Glaucoma is a rare complication of blepharoplasty surgery; only two previous cases have been reported to our knowledge. Risk factors for the development of glaucoma in the setting of blepharoplasty are discussed.

Ten years of glaucoma blindness in Fife 1990-99 and the implications for ophthalmology, optometry and rehabilitation services*

The aim of this study was to determine the characteristics of the patients in Fife who were registered as blind with a main diagnosis of glaucoma between 1990 and 1999. The case notes of 87 people were studied. The average age at registration was 78 years (S.D. = 14). By the time of first referral to hospital, more than half were already aware of visual loss. Forty-five per cent of referrals had no optometry input. Compliance with treatment was poor in at least 26% of patients. Only 44% had glaucoma surgery. There were significant findings with regard to mental health, particularly dementia, which was eventually present in 24%. At least one-third of patients had a hearing impairment. One-third of those registered as blind could have been registered earlier. However, staff from the local provider of rehabilitation and social work services for the blind were shown to have provided prompt and helpful support to 95% of those registered. Consideration should be given to the way in which elderly patients with advanced glaucoma are managed, with awareness of mental health and hearing problems and emphasis on early referral to rehabilitation services.

Use of an early-detection strategy to improve disease control in melanoma patients

In order to assess whether early detection might lead to improvement in disease control for patients with melanoma, a rapid access pigmented lesion clinic (PLC) was set up at Mount Vernon Hospital, UK in 1993. Previously we have shown that thinner melanomas were detected via the PLC compared with those presenting prior to its establishment and with those referred via existing routes of referral. The aim of this study was to investigate whether both rates of disease recurrence and disease-free interval were improved via a rapid access PLC. A retrospective case notes audit was performed on three patient groups: those diagnosed with melanoma 1991-1992, those diagnosed via the PLC (1993-1996) and those diagnosed with melanoma through existing routes of referral after establishment of the PLC (1993-1996). There was a significantly improved disease-free interval for patients with regional recurrences diagnosed via the pigmented lesion clinic (PLC) when compared with pre-PLC, non-PLC groups (chi2=13.8487, p=0.0002; chi2=17.0164, p<0.0001, respectively), and when compared with all melanoma patients diagnosed after the establishment of the PLC, irrespective of route of referral (chi2=5.2773, p=0.0216). Local recurrences developed later in patients in the PLC group compared with the pre-PLC group (chi2=6.4883, p=0.0109), and the non-PLC group (chi2=18.49, p<0.0001). In addition there was a reduction in the proportion of regional and local recurrences in the PLC group when compared with the pre-PLC group (chi2=13.92, P<0.001; chi2=2.85, P=0.09 respectively) and non-PLC group (chi2=17.15, P<0.001; chi2=7.73, P=0.005, respectively). These results support the use of rapid access PLCs as a means of improving disease control for melanoma patients.