The prevalence of anxiety disorders in dermatology outpatients: a systematic review and meta-analysis

Anxiety is common in those with medical conditions and has significant impacts on mental well-being as well as physical health outcomes. While several systematic reviews have examined the prevalence of anxiety in specific dermatological conditions, no reviews have examined the prevalence across the entire dermatology outpatient setting. This systematic review aims to provide an overview to dermatologists of the prevalence of, and trends in, anxiety in their outpatient clinics. As such, prevalence of anxiety in dermatology outpatient clinics was examined, and variations across type of anxiety and dermatological conditions were assessed. A search of PubMed, Embase, Cochrane and PsycINFO was conducted for studies that assessed anxiety prevalence in dermatology outpatients, with the last search conducted on 7 September 2022. Results underwent title/abstract and full-text screening, followed by data extraction. Studies of patients 16 years and older and representative of dermatology clinics were included. Risk of bias was assessed using Joanna Briggs Institute Critical Appraisal Checklist. Meta-analysis was conducted using CMA software, and subgroup analysis was conducted on relevant variables. 5423 studies were identified, and 32 included, with a total n = 12,812 participants. Under the random effects model, prevalence was estimated at 26.7% (95%CI 22.4 to 31.4; 95%PI 9.7 to 55.4). Subgroup analysis revealed a higher prevalence amongst studies of psoriasis patients than general dermatology studies. Estimates of prevalence were higher when assessed via self-report screening than diagnostic interview. Anxiety occurred frequently amongst dermatology outpatients, especially psoriasis outpatients, at a higher rate than common estimates of prevalence in the general population. Given the effect of anxiety on patient outcomes and well-being, dermatologists are encouraged to consider how anxiety may impact patients in their clinic, and how they can best identify patients with anxiety and subsequently support them.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

The effect of mental fatigue on the performance of Australian football specific skills amongst amateur athletes

OBJECTIVES

This study investigated the effects of induced mental fatigue on the performance of Australian football (AF) specific skills amongst amateur AF players.

DESIGN

Randomised cross over trial.

METHODS

Twenty-five amateur AF players performed a series of standardised tests from the Australian Football League (AFL) Draft Combine after completing a 30-min Stroop test (mental fatigue condition) or 30-min control condition. The AFL Draft Combine tests included the standing vertical jump test, running vertical jump test, agility test, 20m sprint, Matthew Lloyd clean hands test, Brad Johnson goal kicking test and a Yo-Yo Intermittent Recovery Level 1 (Yo-Yo IR1) test.

RESULTS

The Stroop test score decreased during the Stroop test (first five trials: mean=84.7, SD=3.5; last five trials: mean=82.2, SD=5.0, p=0.03). The Yo-Yo IR1 test (mental fatigue: median=920m, IQR=400; control: median=1040m, IQR=760; p=0.03) and Brad Johnson goalkicking test (mental fatigue: median=19.0, IQR=5.0; control: median=25.0, IQR=10.0, p=0.048) were negatively affected by mental fatigue. No other Draft Combine tests demonstrated a negative affect from mental fatigue.

CONCLUSIONS

Mental fatigue had a detrimental influence on the performance of AF specific skills. The findings may have implications for AF players who are required to sustain attention and concentration for prolonged periods before and during matches.

Dense bone islands in pediatric patients: a case series study

Background

Dense Bone Islands (DBIs) are anatomic variants defined as radiopaque lesions consisting of hamartomatous cortical bone, often presenting as incidental radiographic findings. DBIs can also be known as idiopathic osteosclerosis, bone whorl, focal periapical osteopetrosis, bone scar and enostosis. We found a paucity of literature for management and reporting of this condition in children. For this reason, the authors describe sixteen cases of children and adolescents with dense bony islands and suggest a pathway for management.

Case series

Cases presented to the RNENT and Eastman Dental Hospital or private practice, either as chance findings or for diagnosis and treatment planning of undiagnosed radiopaque areas. The individuals were aged between 10 and 17 years; 6 boys and 10 girls. All radiographic reports described DBIs. Diagnoses were confirmed by a Dental and Maxillofacial Radiology Consultant and advised no intervention. In some cases, monitoring was advised. Caution in orthodontic tooth movement was advised for five patients.

Conclusion

DBIs are common findings that seldom require treatment; however, caution should be exercised when undertaking orthodontic movement in the area of a DBI due to a potential risk of root resorption. Accurate identification and multidisciplinary management are of utmost importance.

Guidelines for reporting on CBCT scans

The aim of a radiographic report is to provide an accurate interpretation of images to facilitate the diagnostic process, and when indicated prompt the appropriate management for the patient. It is part of the patient's clinical records. This paper describes the imaging chain involved in the cone beam computed tomography (CBCT) workflow from referring to reporting on a CBCT scan. It provides guidelines on the essential information required before and immediately after a CBCT scan is taken, and optimizing the viewing conditions. Finally, it describes a framework for a systematic, comprehensive and tailored CBCT radiographic report. It is aimed at endodontists, clinicians and radiologists reporting on CBCT scans of the dentoalveolar region.

Basal ganglia echogenicity in preterm infants: A case series

BACKGROUND

Damage to the basal ganglia and thalamus (BGT) can be caused by multiple perinatal factors and may be associated with movement disorders, cognitive delay and visual difficulties. Changes in BGT structure, seen as echogenicity on ultrasound, are difficult to objectively quantify. The aetiology, clinical relevance and developmental outcomes of BGT echogenicity are poorly understood. We aimed to gain a better understanding of the natural history of BGT echogenicity in a preterm population.

METHODS

Retrospective review of clinical course, neuroimaging and development in infants born <32weeks gestation over 5 years with evidence of BGT echogenicity.

RESULTS

BGT echogenicity was reported in 18/650 infants (2.7%). Echogenicity appeared at a median of 8 days (2-45 days) and resolved on pre-discharge ultrasound in 50%. Thirteen infants had a term corrected MRI brain with abnormal BGT signal seen in 3 infants (23%). All 3 infants had persisting echogenicity on discharge ultrasound. No infant with echogenicity resolution on ultrasound had changes on term MRI. 14 infants had developmental progress available at 1 year corrected. Abnormal development was reported in four children of whom one had BGT changes on term MRI. Two children with persistent BGT changes but an otherwise normal MRI had reported normal neurodevelopment.

CONCLUSION

BGT echogenicity is relatively common on routine ultrasound and resolves in the majority of infants by term corrected. This review suggests that at term corrected, normal cranial ultrasound may obviate the need for MRI where no other concerns exist. BGT echogenicity did not appear to independently influence neurodevelopment.

Leukocyte Adhesion Deficiency Type 1 Due to Novel ITGB2 Mutation

Aim Marked neutrophilia and omphalitis in an infant resulted in the diagnosis of the first case of leukocyte adhesion deficiency type 1 (LAD1) in Ireland. Diagnosis LAD1 requires specific molecular diagnostics for its correct identification. Results Early identification of this disorder allowed for rapid referral for haemotopoeitic stem cell transplant which has resulted in an excellent outcome for this patient. Conclusion The identification of a previously unknown ITGB2 mutation resulting in LAD1 in Ireland should alert physicians to the diagnostic possibility of this extremely rare disorder.

'Non-standard' panoramic programmes and the unusual artefacts they produce

Dental panoramic radiographs (DPTs) are commonly taken in dental practice in the UK with the number estimated to be 2.7 million per annum. They are used to diagnose caries, periodontal disease, trauma, pathology in the jaws, supernumerary teeth and for orthodontic assessment. Panoramic radiographs are not simple projections but involve a moving X-ray source and detector plate. Ideally only the objects in the focal trough are displayed. This is achieved with a tomographic movement and one or more centre(s) of rotation. One advantage of digital radiography is hardware and software changes to optimise the image. This has led to increasingly complex manufacturer specific digital panoramic programmes. Panoramic radiographs suffer from ghost artefacts which can limit the effectiveness and make interpretation difficult. Conversely 'conventional dental imaging' such as intraoral bitewings do not suffer the same problems. There are also now several 'non-standard' panoramic programmes which aim to optimise the image for different clinical scenarios. These include 'improved interproximality', 'improved orthogonality' and 'panoramic bitewing mode'.This technical report shows that these 'non-standard' panoramic programmes can produce potentially confusing ghost artefacts, of which the practitioner may not be aware.

Abstract P6-03-07: An automated DNA methylation assay (QM-MSP) for rapid breast cancer diagnosis in underdeveloped countries

BACKGROUND: Underdeveloped countries reported 882,900 new cases of breast cancer and 324,000 deaths in 2012, likely to be a gross underestimation according to recent reports. Often, mammography screening is not available, primary care services are limited, and pathology and treatment services are available only in the regional hospitals. Because of the lack of access to diagnostic and treatment services, it is estimated that more than 90% of patients with breast cancer never present for medical treatment. To address this situation, an accurate, easy-to-perform diagnostic test appropriate for use in remote clinics is desperately needed. Johns Hopkins (JH) and Cepheid partnered to translate a robust Quantitative Multiplex Methylation-Specific PCR (QM-MSP) assay to an automated, cartridge-based system that provides quantitative measures of DNA methylation within hours of fine needle aspiration or core biopsy of image-detected suspicious lesions.

METHODS: With a goal of discriminating malignant from benign breast disease with high sensitivity and specificity, we evaluated 24 breast cancer-specific DNA methylation markers (selected through comprehensive methylome analysis) in 119 invasive ductal carcinomas and 186 benign breast tissues. QM-MSP was performed on sections of formalin-fixed paraffin-embedded (FFPE) tissues to quantify DNA methylation. The dynamic range and performance of quantitative methylation detection was tested using a subset of 9 genes in the cartridge-based system.

RESULTS: QM-MSP was performed in a Training set consisting of 93 tissues [n=43 IDC, n=50 benign lesions (25 usual ductal hyperplasia, UDH, and 25 papilloma)] from the US. We selected 9 DNA markers significantly (p&lt;0.05) more methylated in malignant compared to benign lesions, which had low or no methylation. An independent Test set consisted of benign (n=26) and malignant (n=10) tissues (mostly Caucasian; JH Test Set). As a panel, the 9 markers were significantly more methylated in malignant than benign tissue (p&lt;0.001), revealing a sensitivity of 90% and specificity of 92%, using a laboratory cutoff of 9.5 CMI units (900 unit scale) based on receiver operator characteristic statistics (ROC; p&lt;0.0001, AUC=0.977). To determine if the markers characterized in the JH Test Set could perform as well in samples from a different geography, the panel was tested on 176 tissues from Wuhan, China (China Test Set). In this cohort (66 IDC and 110 benign tissues - 49 fibroadenoma, 19 benign cyst, 12 UDH, 30 papilloma), sensitivity was 89% and specificity was 89% for detection of breast cancer with ROC AUC=0.945. An advanced version of the cartridge with up to 12 methylated DNA markers is under development, thus far showing robust signals in cancer and low background in benign tissues. Current work at JH is focused on optimizing the technical performance of the cartridge.

CONCLUSIONS: We identified a panel of methylated DNA markers that discriminate malignant from benign breast lesions and built a prototype automated cartridge-based assay with promising sensitivity and specificity for breast cancer. Such an assay has the potential to aid in specimen triage in the pathology lab and provide fast, low cost and accurate diagnosis of breast cancer in LMIC settings.

Citation Format: Fackler MJ, Downs BM, Mercado-Rodriguez C, Cimino-Mathews A, Chen C, Yuan J, Cope LM, Kohlway A, Kocmond K, Lai E, Weidler J, Visvanathan K, Umbricht CB, Harvey S, Wolff AC, Bates M, Sukumar S. An automated DNA methylation assay (QM-MSP) for rapid breast cancer diagnosis in underdeveloped countries [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-03-07.

Growth hormone protects against kainate excitotoxicity and induces BDNF and NT3 expression in chicken neuroretinal cells

There is increasing evidence to suggest a beneficial neuroprotective effect of growth hormone (GH) in the nervous system. While our previous studies have largely focused on retinal ganglion cells (RGCs), we have also found conclusive evidence of a pro-survival effect of GH in cells of the inner nuclear layer (INL) as well as a protective effect on the dendritic trees of the inner plexiform layer (IPL) in the retina. The administration of GH in primary neuroretinal cell cultures protected and induced neural outgrowths. Our results, both in vitro (embryo) and in vivo (postnatal), showed neuroprotective actions of GH against kainic acid (KA)-induced excitotoxicity in the chicken neuroretina. Intravitreal injections of GH restored brain derived neurotrophic factor (BDNF) expression in retinas treated with KA. In addition, we demonstrated that GH over-expression and exogenous administration increased BDNF and neurotrophin-3 (NT3) gene expression in embryonic neuroretinal cells. Thus, GH neuroprotective actions in neural tissues may be mediated by a complex cascade of neurotrophins and growth factors which have been classically related to damage prevention and neuroretinal tissue repair.

Predictors of developmental surveillance completion at six months of age in south western Sydney

BACKGROUND

While developmental surveillance programs promote early identification of child developmental problems, evidence has indicated suboptimal uptake. This study aimed to identify predictors of developmental surveillance completion at 6 months postpartum.

METHODS

Questionnaires were administered to the parents of 510 infants who were born in south western Sydney, Australia over a 22-month period. Attendance for developmental screening and completion of the Parents' Evaluation of Developmental Status (PEDS) at 6 months postpartum were modelled separately using multivariable logistic regression.

RESULTS

Developmental surveillance attendance was predicted by higher levels of maternal education, annual income and being informed about checks. PEDS completion at 6 months of age was predicted by higher income and being informed, as well as being married, employed, speaking English at home, full-term birth and the professional status of the practitioner completing the check.

CONCLUSIONS

Barriers to developmental surveillance included low socioeconomic status, linguistic diversity and possible gaps in parental knowledge and professional education. Developmental surveillance rates may be increased by the addition of targeted parental and professional support within current universal frameworks.

Parent's use of the Internet in the search for healthcare information and subsequent impact on the doctor-patient relationship

BACKGROUND

The Internet is an unavoidable source of healthcare information. This information, both reliable and unreliable, has previously been shown to influence carer's decisions.

AIMS

Our aim was to evaluate this information seeking behavior among parents and its subsequent potential impact on the doctor-patient relationship.

METHOD

We undertook a cross-sectional questionnaire-based survey of paediatric outpatients. Enrollment took place over 4 weeks in March 2015. There were no inclusion or exclusion criteria and enrollment was voluntary. In total 100 questionnaires were completed.

RESULTS

General Practitioners were the most common source of healthcare information. The Internet ranked third as a reliable source of healthcare information. The Internet was commonly used as an educational resource to learn about causes, treatment, and medications. A significant percentage of our population expressed concern regarding Internet information reliability. A small percentage of parents were concerned that disclosing Internet usage may worsen the relationship with their doctor.

CONCLUSIONS

Parents showed a willingness to learn about diseases and treatments, and felt that the Internet was a good resource to do so. This study shows that open discussion about Internet usage between parents and doctors is not common and carers feel at risk of judgment should they admit to Internet usage. The Internet should be seen as a positive adjunct to patient education which can improve understanding, thus strengthening the doctor-patient relationship. The Internet will never replace the role of healthcare professionals but must be seen as an integral part of a multi-disciplinary approach.

Dose- and time-dependent changes in tissue levels of tetrabromobisphenol A (TBBPA) and its sulfate and glucuronide conjugates following repeated administration to female Wistar Han Rats

Tetrabromobisphenol A (TBBPA), a nongenotoxic flame retardant, causes uterine tumors in female rats. A proposed mode of action (MoA) for these tumors involves an increase in the bioavailability of estradiol as a result of TBBPA inhibiting estrogen sulfotransferases (ES), the enzymes responsible for inactivating and enhancing the elimination of estradiol. The objective of this study was to evaluate the effect of dose and repeated administration of TBBPA on the level of TBBPA, TBBPA-glucuronide (GA) and TBBPA-sulfate (S) conjugates in plasma, liver and uterus of female Wistar Han rats administered TBBPA (50, 100, 250, 500 or 1000 mg/kg) for 28 consecutive days. In accordance with this objective, TBBPA sulfation was used as a surrogate for evaluating the potential for estradiol sulfation to be limited at high dose levels of TBBPA. Blood samples were collected at 4 and 8 h post-dosing on study day 7, 14, and 28, while liver and uterus were collected at the same time points following 28 days of dosing. Tissue samples were analyzed for TBBPA, TBBPA-GA and TBBPA-S by LC–MS/MS. A dose-related increase in the concentration of all three analytes occurred in plasma (day 7, 14, and 28) as well as liver and uterus tissue (day 28) at both 4 and 8 h post dose. The plasma concentration of TBBPA-GA and TBBPA-S was higher in animals dosed for 28 days compared to those dosed for 7 or 14 days showing an increase in systemic circulation of these conjugates with repeated administration. The balance of these conjugates was also different in tissues with TBBPA-S > TBBPA-GA at high doses in the liver and TBBPA-GA > TBBPA-S in both plasma and uterus. In all three tissues the ratio of TBBPA-S/TBBPA-GA showed a decreasing trend with dose, suggesting that at high TBBPA dose levels sulfation of TBBPA becomes limited. This effect was most apparent in the liver and plasma at 28 days of administration. Together these data show that administration of high doses of TBBPA associated with the induction of uterine tumors, results in a disruption in the balance of conjugates reflected by a decrease in the TBBPA-S/TBBPA-GA ratio. A limitation in the sulfation of TBBPA in vivo supports in vitro data defining TBBPA as an inhibitor of ES activity, thus providing further support that the proposed MoA occurs under conditions of high dose, chronic TBBPA administration to Wistar Han rats. Given that the uterine tumors observed in rats (250–1000 mg/kg-day) only occur at very high doses that perturb homeostatic control, it is unlikely such effects would occur in humans given that current TBBPA exposure levels are approximately eight orders of magnitude lower than these doses that are associated with exceeding the capacity of conjugation pathways in animal studies.

Growth hormone (GH)-releasing activity of chicken GH-releasing hormone (GHRH) in chickens

Two peptides with sequence similarities to growth hormone releasing hormone (GHRH) have been identified by analysis of the chicken genome. One of these peptides, chicken (c) GHRH-LP (like peptide) was previously found to poorly bind to chicken pituitary membranes or to cloned and expressed chicken GHRH receptors and had little, if any, growth hormone (GH)-releasing activity in vivo or in vitro. In contrast, a second more recently discovered peptide, cGHRH, does bind to cloned and expressed cGHRH receptors and increases cAMP activity in transfected cells. The possibility that this peptide may have in vivo GH-releasing activity was therefore assessed. The intravenous (i.v.) administration of cGHRH to immature chickens, at doses of 3-100 μg/kg, significantly increased circulating GH concentrations within 10 min of injection and the plasma GH levels remained elevated for at least 30 min after the injection of maximally effective doses. The plasma GH responses to cGHRH were comparable with those induced by human (h) or porcine (p) GHRH preparations and to that induced by thyrotropin releasing hormone (TRH). In marked contrast, the i.v. injection of cGHRH-LP had no significant effect on circulating GH concentrations in immature chicks. GH release was also increased from slaughterhouse chicken pituitary glands perifused for 5 min with cGHRH at doses of 0.1 μg/ml or 1.0 μg/ml, comparable with GH responses to hGHRH1-44. In contrast, the perifusion of chicken pituitary glands with cGHRH-LP had no significant effect on GH release. In summary, these results demonstrate that cGHRH has GH-releasing activity in chickens and support the possibility that it is the endogenous ligand of the cGHRH receptor.

Secretagogue induction of GH release in QNR/D cells: prevention of cell death

Retinal ganglion cells (RGCs) in the chick embryonic neural retina are extrapituitary sites of growth hormone (GH) synthesis and release. The regulation of GH secretion by these cells is largely unknown, although we recently discovered several of the hypothalamic releasing factors involved in pituitary GH regulation (including GH-releasing hormone (GHRH) and thyrotropin releasing hormone, TRH) to be present in the cytoplasm of immortalized quail RGCs (QNR/D cells). QNR/D cells may therefore provide an experimental model for studies on GH regulation in the chick neural retina. The possibility that GHRH and TRH might stimulate GH secretion in QNR/D cells was therefore investigated. Both peptides acutely depleted the GH content of the QNR/D cells, as demonstrated by immunocytochemistry and ELISA, whilst increasing the GH content in incubation media. Both peptides also increased the immunochemical and ELISA content of the QNR/D cells and the content of GH in the incubation media after long-term incubation. Cell survival, determined by metabolic activity of the QNR/D cells and by TUNEL-labeling, was reduced when the endogenous GH content was reduced by GH immunoneutralization, even in the presence of exogenous GHRH or TRH. Cell survival was also reduced when endogenous GHRH was blocked by GHRH immunoneutralization, although the immunoneutralization of endogenous TRH did not affect QNR/D cell survival. In summary, these results demonstrate secretagogue actions of exogenous GHRH and TRH on the secretion of GH from QNR/D cells. They also suggest that endogenous GHRH, but not endogenous TRH, prevents cell death by increasing endogenous GH secretion in QNR/D cells.

Development and validation of a risk model for identification of non-neutropenic, critically ill adult patients at high risk of invasive Candida infection: the Fungal Infection Risk Evaluation (FIRE) Study

BACKGROUND

There is increasing evidence that invasive fungal disease (IFD) is more likely to occur in non-neutropenic patients in critical care units. A number of randomised controlled trials (RCTs) have evaluated antifungal prophylaxis in non-neutropenic, critically ill patients, demonstrating a reduction in the risk of proven IFD and suggesting a reduction in mortality. It is necessary to establish a method to identify and target antifungal prophylaxis at those patients at highest risk of IFD, who stand to benefit most from any antifungal prophylaxis strategy.

OBJECTIVES

To develop and validate risk models to identify non-neutropenic, critically ill adult patients at high risk of invasive Candida infection, who would benefit from antifungal prophylaxis, and to assess the cost-effectiveness of targeting antifungal prophylaxis to high-risk patients based on these models.

DESIGN

Systematic review, prospective data collection, statistical modelling, economic decision modelling and value of information analysis.

SETTING

Ninety-six UK adult general critical care units.

PARTICIPANTS

Consecutive admissions to participating critical care units.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Invasive fungal disease, defined as a blood culture or sample from a normally sterile site showing yeast/mould cells in a microbiological or histopathological report. For statistical and economic modelling, the primary outcome was invasive Candida infection, defined as IFD-positive for Candida species.

RESULTS

Systematic review: Thirteen articles exploring risk factors, risk models or clinical decision rules for IFD in critically ill adult patients were identified. Risk factors reported to be significantly associated with IFD were included in the final data set for the prospective data collection.

DATA COLLECTION

Data were collected on 60,778 admissions between July 2009 and March 2011. Overall, 383 patients (0.6%) were admitted with or developed IFD. The majority of IFD patients (94%) were positive for Candida species. The most common site of infection was blood (55%). The incidence of IFD identified in unit was 4.7 cases per 1000 admissions, and for unit-acquired IFD was 3.2 cases per 1000 admissions. Statistical modelling: Risk models were developed at admission to the critical care unit, 24 hours and the end of calendar day 3. The risk model at admission had fair discrimination (c-index 0.705). Discrimination improved at 24 hours (c-index 0.823) and this was maintained at the end of calendar day 3 (c-index 0.835). There was a drop in model performance in the validation sample. Economic decision model: Irrespective of risk threshold, incremental quality-adjusted life-years of prophylaxis strategies compared with current practice were positive but small compared with the incremental costs. Incremental net benefits of each prophylaxis strategy compared with current practice were all negative. Cost-effectiveness acceptability curves showed that current practice was the strategy most likely to be cost-effective. Across all parameters in the decision model, results indicated that the value of further research for the whole population of interest might be high relative to the research costs.

CONCLUSIONS

The results of the Fungal Infection Risk Evaluation (FIRE) Study, derived from a highly representative sample of adult general critical care units across the UK, indicated a low incidence of IFD among non-neutropenic, critically ill adult patients. IFD was associated with substantially higher mortality, more intensive organ support and longer length of stay. Risk modelling produced simple risk models that provided acceptable discrimination for identifying patients at 'high risk' of invasive Candida infection. Results of the economic model suggested that the current most cost-effective treatment strategy for prophylactic use of systemic antifungal agents among non-neutropenic, critically ill adult patients admitted to NHS adult general critical care units is a strategy of no risk assessment and no antifungal prophylaxis.

FUNDING

Funding for this study was provided by the Health Technology Assessment programme of the National Institute for Health Research.

Extrapituitary production of anterior pituitary hormones: an overview

Protein hormones from the anterior pituitary gland have well-established endocrine roles in their peripheral target glands. It is, however, now known that these proteins are also produced within many of their target tissues, in which they act as local autocrine or paracrine factors, with physiological and/or pathophysiological significance. This emerging concept is the focus of this brief review.

Cellular and intracellular distribution of growth hormone in the adult chicken testis

Endocrine actions of growth hormone (GH) have been implicated during the development of adult testicular function in several mammalian species, and recently intracrine, autocrine, and paracrine effects have been proposed for locally expressed GH. Previous reports have shown the distribution of GH mRNA and the molecular heterogeneity of GH protein in both adult chicken testes and vas deferens. This study provides evidence of the presence and distribution of GH and its receptor (GHR) during all stages of spermatogenesis in adult chicken testes. This hormone and its receptor are not restricted to the cytoplasm; they are also found in the nuclei of spermatogonia, spermatocytes, and spermatids. The pattern of GH isoforms was characterized in the different, isolated germ cell subpopulations, and the major molecular variant in all subpopulations was 17 kDa GH, as reported in other chicken extra-pituitary tissues. Another molecular variant, the 29 kDa moiety, was found mainly in the enriched spermatocyte population, suggesting that it acts at specific developmental stages. The co-localization of GH with the proliferative cell nuclear antigen PCNA (a DNA replication marker present in spermatogonial cells) was demonstrated by immunohistochemistry. These results show for the first time that GH and GHR are present in the nuclei of adult chicken germinal cells, and suggest that GH could participate in proliferation and differentiation during the complex process of spermatogenesis.

A cluster of Listeria monocytogenes infections in hospitalised adults, Midlands, England, February 2011

Hospital-acquired listeriosis cases are not commonly reported but remain a significant public health problem. We report on three cases in patients with underlying conditions occurring during one week in February 2011. The cases had common exposure to pre-packed sandwiches and salads manufactured in compliance with regulations. Breaches in cold chain and shelf life controls at hospital level were identified as key contributing factors. Rigorous hospital food management systems remain important for patient safety.

A cluster of Listeria monocytogenes infections in hospitalised adults, Midlands, England, February 2011

Hospital-acquired listeriosis cases are not commonly reported but remain a significant public health problem. We report on three cases in patients with underlying conditions occurring during one week in February 2011. The cases had common exposure to pre-packed sandwiches and salads manufactured in compliance with regulations. Breaches in cold chain and shelf life controls at hospital level were identified as key contributing factors. Rigorous hospital food management systems remain important for patient safety.

Expression, cellular distribution, and heterogeneity of growth hormone in the chicken cerebellum during development

Although growth hormone (GH) is mainly synthesized and secreted by pituitary somatotrophs, it is now well established that the GH gene can be expressed in many extrapituitary tissues, including the central nervous system (CNS). Here we studied the expression of GH in the chicken cerebellum. Cerebellar GH expression was analyzed by in situ hybridization and cDNA sequencing, as well as by immunohistochemistry and confocal microscopy. GH heterogeneity was studied by Western blotting. We demonstrated that the GH gene was expressed in the chicken cerebellum and that its nucleotide sequence is closely homologous to pituitary GH cDNA. Within the cerebellum, GH mRNA is mainly expressed in Purkinje cells and in cells of the granular layer. GH-immunoreactivity (IR) is also widespread in the cerebellum and is similarly most abundant in the Purkinje and granular cells as identified by specific neuronal markers and histochemical techniques. The GH concentration in the cerebellum is age-related and higher in adult birds than in embryos and juveniles. Cerebellar GH-IR, as determined by Western blot under reducing conditions, is associated with several size variants (of 15, 23, 26, 29, 35, 45, 50, 55, 80 kDa), of which the 15 kDa isoform predominates (>30% among all developmental stages). GH receptor (GHR) mRNA and protein are also present in the cerebellum and are similarly mainly present in Purkinje and granular cells. Together, these data suggest that GH and GHR are locally expressed within the cerebellum and that this hormone may act as a local autocrine/paracrine factor during development of this neural tissue.

Extrapituitary growth hormone

Pituitary somatotrophs secrete growth hormone (GH) into the bloodstream, to act as a hormone at receptor sites in most, if not all, tissues. These endocrine actions of circulating GH are abolished after pituitary ablation or hypophysectomy, indicating its pituitary source. GH gene expression is, however, not confined to the pituitary gland, as it occurs in neural, immune, reproductive, alimentary, and respiratory tissues and in the integumentary, muscular, skeletal, and cardiovascular systems, in which GH may act locally rather than as an endocrine. These actions are likely to be involved in the proliferation and differentiation of cells and tissues prior to the ontogeny of the pituitary gland. They are also likely to complement the endocrine actions of GH and are likely to maintain them after pituitary senescence and the somatopause. Autocrine or paracrine actions of GH are, however, sometimes mediated through different signaling mechanisms to those mediating its endocrine actions and these may promote oncogenesis. Extrapituitary GH may thus be of physiological and pathophysiological significance.

Growth hormone expression in stromal and non-stromal cells in the bursa of Fabricius during bursal development and involution: Causal relationships?

Growth hormone (GH) is expressed in the chicken bursa of Fabricius (BF), an organ that undergoes three distinct developmental stages: rapid growth (late embryogenesis until 6-8 weeks of age [w]), plateaued growth (between 10 and 15w), and involution (after 18-20w). The distribution and abundance of GH-immunoreactivity (GH-IR) and GH mRNA expression in stromal and non-stromal bursal cells during development, as well as the potential anti-apoptotic effect of GH in bursal cell survival were the focus of this study. GH mRNA expression was mainly in the epithelial layer and in epithelial buds at embryonic day (ED) 15; at 2w it was widely distributed within the follicle and in the interfollicular epithelium (IFE); at 10w it clearly diminished in the epithelium; whereas at 20w it occurred in only a few cortical cells and in the connective tissue. Parallel changes in the relative proportion of GH mRNA expression (12, 21, 13, 1%) and GH-IR (19, 18, 11, <3%) were observed at ED 15, 2w, 10w, and 20w, respectively. During embryogenesis, GH-IR co-localized considerably with IgM-IR, but scarcely with IgG-IR, whereas the opposite was observed after hatching. Significant differences in bursal cell death occurred during development, with 9.3% of cells being apoptotic at ED 15, 0.4% at 2w, 0.23% at 10w, and 21.1% at 20w. Addition of GH increased cultured cell survival by a mechanism that involved suppression (up to 41%) of caspase-3 activity. Results suggest that autocrine/paracrine actions of bursal GH are involved in the differentiation and proliferation of B lymphocytes and in BF growth and cell survival in embryonic and neonatal chicks, whereas diminished GH expression in adults may result in bursal involution.

Growth hormone-dependent changes in the rat lung proteome during alveorization

Growth hormone (GH) mRNA and protein have recently been demonstrated in the rat lung throughout the period of alveolarization (day 4-14 postnatally). The functional significance of this finding was therefore assessed, by determining the effects of GH mRNA knockout using aerosolized antisense oligodeoxynucleotides (ODN) directed against the GH gene. In a preliminary experiment, the effectiveness of the antisense GH ODN was demonstrated in a lung Type II epithelial cell line (L2 cells), in which constitutive GH mRNA expression was completely abolished by GH ODN transfection. Administration of the aerosolized GH ODN to 4-day-old rats for 10 days was accompanied by a widespread presence of its delivery liposomes within lung cells. Aerosolized GH ODN treatment decreased lung concentrations of IGF (insulin-like growth factor)-1 and increased concentrations of albumin, calcyclin binding protein, superoxide dismutase, RNA binding protein motif 3, and the alpha- and beta-subunits of ATP synthase and electron transfer flavoprotein. At least 32 other proteins (identified by 2D gel electrophoresis) were also significantly affected by the antisense GH ODN treatment. By changing the lung proteome, these results indicate hitherto unsuspected autocrine/paracrine actions of GH in developmental lung function.

Immune growth hormone (GH): localization of GH and GH mRNA in the bursa of Fabricius

Expression of growth hormone (GH) and GH receptor (GHR) genes in the bursa of Fabricius of chickens suggests that it is an autocrine/paracrine site of GH production and action. The cellular localization of GH and GH mRNA within the bursa was the focus of this study. GH mRNA was expressed mainly in the cortex, comprised of lymphocyte progenitor cells, but was lacking in the medulla where lymphocytes mature. In contrast, more GH immunoreactivity (GH-IR) was present in the medulla than in the cortex. In non-stromal tissues, GH-IR and GH mRNA were primarily in lymphocytes, and also in macrophage-like cells and secretory dendritic cells. In stromal tissues, GH mRNA, GH and GHR were expressed in cells near the connective tissue (CT) between follicles and below the outer serosa. In contrast, GH (but not GH mRNA or GHR), was present in cells of the interfollicular epithelium (IFE), the follicle-associated epithelium (FAE) and the interstitial corticoepithelium. This mismatch may reflect dynamic temporal changes in GH translation. Co-expression of GHR-IR, GH-IR, GH mRNA and IgG was found in immature lymphoid cells near the cortex and in IgG-IR CT cells, suggesting an autocrine/paracrine role for bursal GH in B-cell differentiation.

Growth hormone and its receptor in projection neurons of the chick visual system: retinofugal and tectobulbar tracts

Recent studies have shown the presence of growth hormone (GH) in the retinal ganglion cells (RGCs) of the neural retina in chick embryos at the end of the first trimester [embryonic day (E) 7] of the 21 day incubation period. In this study the presence of GH in fascicles of the optic fiber layer (OFL), formed by axons derived from the underlying RGCs, is shown. Immunoreactivity for GH is also traced through the optic nerve head, at the back of the eye, into the optic nerve, through the optic chiasm, into the optic tract and into the stratum opticum and the retinorecipient layer of the optic tectum, where the RGC axons synapse. The presence of GH immunoreactivity in the tectum occurs prior to synaptogenesis with RGC axons and thus reflects the local expression of the GH gene, especially as GH mRNA is also distributed within this tissue. The distribution of GH-immunoreactivity in the visual system of the E7 embryo is consistent with the distribution of the GH receptor (GHR), which is also expressed in the neural retina and tectum. The presence of a GH-responsive gene (GHRG-1) in these tissues also suggests that the visual system is not just a site of GH production but a site of GH action. These results support the possibility that GH acts as a local growth factor during early embryonic development of the visual system.

Expression, translation, and localization of a novel, small growth hormone variant

A novel transcript of the GH gene has been identified in ocular tissues of chick embryos. It is, however, unknown whether this transcript (small chicken GH, scGH) is translated. This possibility was therefore assessed. The expression of scGH mRNA was confirmed by RT-PCR, using primers that amplified a 426-bp cDNA of its coding sequence. This cDNA was inserted into an expression plasmid to transfect HEK 293 cells, and its translation was shown by specific scGH immunoreactivity in extracts of these cells. This immunoreactivity was directed against the unique N terminus of scGH and was associated with a protein of 16 kDa, comparable with its predicted size. Most of the immunoreactivity detected was, however, associated with a 31-kDa moiety, suggesting scGH is normally dimerized. Neither protein was, however, present in media of the transfected HEK cells, consistent with scGH's lack of a signal sequence. Similar moieties of 16 and 31 kDa were also found in proteins extracted from ocular tissues (neural retina, pigmented epithelium, lens, cornea, choroid) of embryos, although they were not consistently present in vitreous humor. Specific scGH immunoreactivity was also detected in these tissues by immunocytochemistry but not in axons in the optic fiber layer or the optic nerve head, which were immunoreactive for full-length GH. In summary, we have established that scGH expression and translation occurs in ocular tissues of chick embryos, in which its localization in the neural retina and the optic nerve head is distinct from that of the full-length protein.

Thiamine is synthesized by a salvage pathway in Rhizobium leguminosarum bv. viciae strain 3841

In the absence of added thiamine, Rhizobium leguminosarum bv. viciae strain 3841 does not grow in liquid medium and forms only "pin" colonies on agar plates, which contrasts with the good growth of Sinorhizobium meliloti 1021, Mesorhizobium loti 303099, and Rhizobium etli CFN42. These last three organisms have thiCOGE genes, which are essential for de novo thiamine synthesis. While R. leguminosarum bv. viciae 3841 lacks thiCOGE, it does have thiMED. Mutation of thiM prevented formation of pin colonies on agar plates lacking added thiamine, suggesting thiamine intermediates are normally present. The putative functions of ThiM, ThiE, and ThiD are 4-methyl-5-(beta-hydroxyethyl) thiazole (THZ) kinase, thiamine phosphate pyrophosphorylase, and 4-amino-5-hydroxymethyl-2-methyl pyrimidine (HMP) kinase, respectively. This suggests that a salvage pathway operates in R. leguminosarum, and addition of HMP and THZ enabled growth at the same rate as that enabled by thiamine in strain 3841 but elicited no growth in the thiM mutant (RU2459). There is a putative thi box sequence immediately upstream of the thiM, and a gfp-mut3.1 fusion to it revealed the presence of a promoter that is strongly repressed by thiamine. Using fluorescent microscopy and quantitative reverse transcription-PCR, it was shown that thiM is expressed in the rhizosphere of vetch and pea plants, indicating limitation for thiamine. Pea plants infected by RU2459 were not impaired in nodulation or nitrogen fixation. However, colonization of the pea rhizosphere by the thiM mutant was impaired relative to that of the wild type. Overall, the results show that a thiamine salvage pathway operates to enable growth of Rhizobium leguminosarum in the rhizosphere, allowing its survival when thiamine is limiting.

An evaluation of the clinical and cost-effectiveness of pulmonary artery catheters in patient management in intensive care: a systematic review and a randomised controlled trial

OBJECTIVES

To evaluate the clinical and cost-effectiveness of managing critically ill patients in adult, general intensive care with or without pulmonary artery catheters (PACs).

DESIGN

An open, multi-centre, randomised controlled trial with economic evaluation (cost-utility and cost-effectiveness analysis).

SETTING

The setting was general (mixed medical/surgical) intensive care units (ICUs) in the UK admitting adults.

PARTICIPANTS

Adult patients in participating ICUs deemed by the responsible treating clinician to require management with a PAC.

INTERVENTIONS

These were insertion of a PAC and subsequent clinical management, at the discretion of the responsible treating clinicians, using data derived from the PAC. The control group were managed without a PAC but with the option of using alternative cardiac output monitoring devices.

MAIN OUTCOME MEASURES

The main outcome measure was hospital mortality. Secondary outcome measures were length of stay in the ICU, length of stay in an acute hospital and organ-days of support in the ICU. For the economic evaluation, the main outcome measure was quality-adjusted life-years (QALYs) and the secondary outcome measure was hospital mortality.

RESULTS

Sixty-five ICUs in the UK participated. Of these, 43 (66%) used alternative cardiac output monitoring devices in control group patients. A total of 1263 patients were identified as being eligible for the trial. Of these, 1041 (82.4%) were randomised and allocated to management with (n = 519) or without (n = 522) a PAC. There were no losses to follow-up. However, 27 patients (13 in the PAC group and 14 in the control group) were withdrawn from the trial because either the patient withdrew consent on recovering mental competency or the relatives withdrew agreement following randomisation. Data on 1014 patients were included in the analysis. Participants in the two groups had similar baseline characteristics. There was no difference in hospital mortality for patients managed with (68.4%) or without (65.7%) a PAC. The adjusted hazard ratio (PAC versus no PAC) was 1.09 [95% confidence interval (CI) 0.94 to 1.27]. There was no difference in the median length of stay in ICU, the median length of stay in an acute hospital or mean organ-days of support in ICU between the two groups. The economic evaluation found that the expected cost per QALY gained from the withdrawal of PAC was 2985 pounds. The expected cost per life gained from the withdrawal of PAC was 22,038 pounds.

CONCLUSIONS

Clinical management of critically ill patients with a PAC, as currently practised in the UK, neither improves hospital survival for adult, general intensive care patients nor reduces length of stay in hospital. The lack of demonstrable benefit from a device previously believed to be beneficial could be explained by statistical chance, by misinterpretation of PAC-derived data, by ineffective treatment strategies based on data correctly interpreted using the current paradigm or by subsequent inaction following insertion of the device. It is also possible that detailed data on haemodynamics, however used, cannot modify the disease process sufficiently to influence disease outcome. The economic evaluation, using decision analysis techniques rather than conventional hypothesis testing, suggests that the withdrawal of the PAC from routine clinical practice in the NHS would be considered cost-effective in the current decision-making climate, and might result in lives or life-years being saved at modest cost. With the declining use of PACs in the UK and the findings of this report indicating no overall benefit from management with a PAC, it should now be possible to examine protocolised management with a PAC in selected groups of critically ill patients against appropriate controls, something that was difficult while PACs were the considered standard of care.

Pulmonary artery catheters for adult patients in intensive care

BACKGROUND

Pulmonary artery catheterization was adopted about 30 years ago and widely disseminated without rigorous evaluation as to whether it benefited critically ill patients. The technique is used to measure cardiac output and pressures in the pulmonary circulation to guide diagnosis and treatment. Clinicians believe these data can improve patients' outcomes, even in the absence of consensus about the specific interpretation of the data.

OBJECTIVES

To assess the effect of pulmonary artery catheterization on mortality and cost of care in adult intensive care patients.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2006); MEDLINE (all records to April 2006); EMBASE (all records to April 2006); CINAHL (all records to April 2006) and reference lists of articles. We contacted manufacturers and researchers in the field.

SELECTION CRITERIA

We included all randomized controlled trials in adults, comparing management with and without a pulmonary artery catheter (PAC).

DATA COLLECTION AND ANALYSIS

We screened the titles and abstracts of the electronic search results and obtained the full text of studies of possible relevance for independent review. We determined the final results of the literature search by consensus between the authors. We did not contact study authors for additional information.

MAIN RESULTS

We identified 12 studies. Mortality was reported as hospital, 28-day, 30-day, or intensive care unit. We considered studies of high-risk surgery patients (eight studies) and general intensive care patients (four studies) separately for the meta-analysis. The pooled odds ratio for the studies of general intensive care patients was 1.05 (95% confidence interval (CI) 0.87 to 1.26) and for the studies of high-risk surgery patients 0.99 (95% CI 0.73 to 1.24). Of the eight studies of high-risk surgery patients, five evaluated the effectiveness of pre-operative optimization but there was no difference in mortality when these studies were examined separately. Pulmonary artery catheterization did not affect intensive care unit (reported by 10 studies) or hospital (reported by nine studies) length of stay. Four studies, conducted in the United States, measured costs based on hospital charges billed to patients, which on average were higher in the PAC groups.

AUTHORS' CONCLUSIONS

To date, there have been two multi-centre trials of the effectiveness of PACs for managing critically ill patients admitted to intensive care, although only one was adequately powered. Efficacy studies are needed to determine optimal management protocols and patient groups who could benefit from management with a PAC.