Economic evaluation of the Very Early Rehabilitation in SpEech (VERSE) intervention

INTRODUCTION

There is limited evidence on the costs and outcomes of patients with aphasia after stroke. The aim of this study was to estimate costs in patients with aphasia after stroke according to the aphasia therapies provided.

METHODS

A three-arm, prospective, randomized, parallel group, open-label, blinded endpoint assessment trial conducted in Australia and New Zealand. Usual ward-based care (Usual Care) was compared to additional usual ward-based therapy (Usual Care Plus) and a prescribed and structured aphasia therapy program in addition to Usual Care (the VERSE intervention). Information about healthcare utilization and productivity were collected to estimate costs in Australian dollars for 2017-18. Multivariable regression models with bootstrapping were used to estimate differences in costs and outcomes (clinically meaningful change in aphasia severity measured by the WAB-R-AQ).

RESULTS

Overall, 202/246 (82%) participants completed follow-up at 26 weeks. Median costs per person were $23,322 (Q1 5,367, Q3 52,669, n = 63) for Usual Care, $26,923 (Q1 7,303, Q3 76,174, n = 70) for Usual Care Plus and $31,143 (Q1 7,001. Q3 62,390, n = 69) for VERSE. No differences in costs and outcomes were detected between groups. Usual Care Plus was inferior (i.e. more costly and less effective) in 64% of iterations, and in 18% was less costly and less effective compared to Usual Care. VERSE was inferior in 65% of samples and less costly and less effective in 12% compared to Usual Care.

CONCLUSION

There was limited evidence that additional intensively delivered aphasia therapy within the context of usual acute care provided was worthwhile in terms of costs for the outcomes gained.

Search for Evidence of Baryogenesis and Dark Matter in B^{+}→ψ_{D}+p Decays at BABAR

A new dark sector antibaryon, denoted ψ_{D}, could be produced in decays of B mesons. This Letter presents a search for B^{+}→ψ_{D}+p (and the charge conjugate) decays in e^{+}e^{-} annihilations at 10.58 GeV, using data collected in the BABAR experiment. Data corresponding to an integrated luminosity of 398  fb^{-1} are analyzed. No evidence for a signal is observed. Branching fraction upper limits in the range from 10^{-7}-10^{-5} are obtained at 90% confidence level for masses of 1.0 Collapse

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Evaluation of Antibody Tests for Mycobacterium bovis Infection in Pigs and Deer

This study addressed the need in Great Britain for supplementary blood tests for deer and pig herds under movement restrictions due to confirmed Mycobacterium bovis infection-to enhance the overall sensitivity and reliability of tuberculosis (TB) testing and contribute to an exit strategy for these herds. We evaluated four antibody tests (lateral flow DPP VetTB Assay for Cervids, M. bovis IDEXX ELISA, Enferplex Cervid and Porcine antibody tests and an in-house comparative PPD ELISA) using serum samples from defined cohorts of TB-infected and TB-free deer and pigs. TB-infected deer included two separate cohorts; farmed deer that had received a tuberculin skin test less than 30 days prior, and park deer that had received no prior skin test. In this way, we were able to assess the effect of the skin test anamnestic boost upon antibody test sensitivity. We tested a total of 402 TB-free pigs and 416 TB-free deer, 77 infected farmed deer and 105 infected park deer, and 29 infected pigs (including 2 wild boar). For deer, we found an equivalent high performance of all four tests: specificity range 98.8-99.5% and sensitivity range 76.6-85.7% for skin test-boosted infected deer, and 51.4-58.1% for non-boosted infected deer. These data suggest an overall approximate 25% increase in test sensitivity for infected deer following a skin test boost. For pigs, the tests again had equivalent high specificity of 99-99.5% and a sensitivity range of 62.1-86.2%, with substantial agreement for three of the four tests. Retrospective application of the ELISA tests to individual culled park deer and wild boar that showed no obvious evidence of TB at larder inspection identified a significant seropositivity within wild boar suggestive of low-level M. bovis infection that would otherwise not have been detected. Overall this investigation provided a robust evaluation of four antibody tests, which is essential to generate confidence in test performance before a wider deployment within TB control measures can be considered.

Evaluating remote facilitation intensity for multi-national translation of nurse-initiated stroke protocols (QASC Australasia): a protocol for a cluster randomised controlled trial

BACKGROUND

Facilitated implementation of nurse-initiated protocols to manage fever, hyperglycaemia (sugar) and swallowing difficulties (FeSS Protocols) in 19 Australian stroke units resulted in reduced death and dependency for stroke patients. However, a significant gap remains in translating this evidence-based care bundle protocol into standard practice in Australia and New Zealand. Facilitation is a key component for increasing implementation. However, its contribution to evidence translation initiatives requires further investigation. We aim to evaluate two levels of intensity of external remote facilitation as part of a multifaceted intervention to improve FeSS Protocol uptake and quality of care for patients with stroke in Australian and New Zealand acute care hospitals.

METHODS

A three-arm cluster randomised controlled trial with a process evaluation and economic evaluation. Australian and New Zealand hospitals with a stroke unit or service will be recruited and randomised in blocks of five to one of the three study arms-high- or low-intensity external remote facilitation or a no facilitation control group-in a 2:2:1 ratio. The multicomponent implementation strategy will incorporate implementation science frameworks (Theoretical Domains Framework, Capability, Opportunity, Motivation - Behaviour Model and the Consolidated Framework for Implementation Research) and include an online education package, audit and feedback reports, local clinical champions, barrier and enabler assessments, action plans, reminders and external remote facilitation. The primary outcome is implementation effectiveness using a composite measure comprising six monitoring and treatment elements of the FeSS Protocols. Secondary outcome measures are as follows: composite outcome of adherence to each of the combined monitoring and treatment elements for (i) fever (n=5); (ii) hyperglycaemia (n=6); and (iii) swallowing protocols (n=7); adherence to the individual elements that make up each of these protocols; comparison for composite outcomes between (i) metropolitan and rural/remote hospitals; and (ii) stroke units and stroke services. A process evaluation will examine contextual factors influencing intervention uptake. An economic evaluation will describe cost differences relative to each intervention and study outcomes.

DISCUSSION

We will generate new evidence on the most effective facilitation intensity to support implementation of nurse-initiated stroke protocols nationwide, reducing geographical barriers for those in rural and remote areas.

TRIAL REGISTRATION

ACTRN12622000028707. Registered 14 January, 2022.

Delivery outcomes as a result of snoring as determined by standard sleep surveys

Background

Sleep-disordered breathing (SDB), is an umbrella term that encompasses obstructive sleep apnea (OSA), central sleep apnea (CSA) and hypoventilation. is common but studies in the pregnant population are limited. Data suggests relationships between OSA and preeclampsia, but the relationship between snoring and pregnancy outcomes is unknown.

Methods

A prospective study of 2224 singleton pregnancies was undertaken. Women were questioned using the Berlin Questionnaire (BQ- 2 or more categories where the score is positive.) and the Epworth Sleepiness Scale (ESS >10/24), the results compared with pregnancy outcomes with regard to hypertension in pregnancy.

Results

Women having symptoms raising the possibility of OSA defined by the BQ with a score >7 was 45.5%, and using ESS with a score >10, was 36%. The birth and neonatal outcomes for self-reported snoring and increased daytime sleepiness showed increased adverse outcomes notably increased caesarean section rates and low APGAR scores but not birth before 37 weeks of gestation.

Conclusion

Using questionnaires designed for the general population, the prevalence of possible undiagnosed OSA is high in the pregnant population. The increased adverse delivery and neonatal outcomes for self-reported snoring and increased daytime sleepiness with these tools indicated the need for further investigation of the links between snoring SDB and pregnancy outcomes.

543 Bouveret Syndrome: A Rare Presentation of Gastric Outlet Obstruction

A 76-year-old lady presented with a 5-day history of lower abdominal pain and vomiting. She had not opened her bowels for 3 days and 24 hours prior to admission had coffee ground vomitus. A CT abdomen and pelvis showed gastric outflow obstruction secondary to a large 3.5cm gallstone within the pylorus (Bouveret syndrome).

She was initially treated conservatively for bowel obstruction and underwent an OGD where attempts to retrieve the stone were unsuccessful. A subsequent laparoscopic gastrotomy revealed a large stone in the duodenum and was successfully removed.

This case highlights how this rare syndrome can present with non-specific symptoms, diagnosis can be challenging and relies on imaging, therefore patients should be worked up thoroughly to ensure a correct diagnosis. There are currently no standardised management guidelines for Bouveret syndrome, mainly due to its rare prevalence and this case demonstrates a variety of management options.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Search for an Axionlike Particle in B Meson Decays

Axionlike particles (ALPs) are predicted in many extensions of the standard model, and their masses can naturally be well below the electroweak scale. In the presence of couplings to electroweak bosons, these particles could be emitted in flavor-changing B meson decays. We report herein a search for an ALP, a, in the reaction B^{±}→K^{±}a, a→γγ using data collected by the BABAR experiment at SLAC. No significant signal is observed, and 90% confidence level upper limits on the ALP coupling to electroweak bosons are derived as a function of ALP mass, improving current constraints by several orders of magnitude in the range 0.175  GeV<m_{a}<4.78  GeV.

Estimation of Bait Uptake by Badgers, Using Non-invasive Methods, in the Perspective of Oral Vaccination Against Bovine Tuberculosis in a French Infected Area

Although France is officially declared free of bovine tuberculosis (TB), Mycobacterium bovis infection is still observed in several regions in cattle and wildlife, including badgers (Meles meles). In this context, vaccinating badgers should be considered as a promising strategy for the reduction in M. bovis transmission between badgers and other species, and cattle in particular. An oral vaccine consisting of live Bacille Calmette–Guérin (BCG) contained in bait is currently under assessment for badgers, for which testing bait deployment in the field and assessing bait uptake by badgers are required. This study aimed to evaluate the bait uptake by badgers and determine the main factors influencing uptake in a TB-infected area in Burgundy, north-eastern France. The baits were delivered at 15 different setts located in the vicinity of 13 pastures within a TB-infected area, which has been subject to intense badger culling over the last decade. Pre-baits followed by baits containing a biomarker (Rhodamine B; no BCG vaccine) were delivered down sett entrances in the spring (8 days of pre-baiting and 4 days of baiting) and summer (2 days of pre-baiting and 2 days of baiting) of 2018. The consumption of the marked baits was assessed by detecting fluorescence, produced by Rhodamine B, in hair collected in hair traps positioned at the setts and on the margins of the targeted pastures. Collected hairs were also genotyped to differentiate individuals using 24 microsatellites markers and one sex marker. Bait uptake was estimated as the proportion of badgers consuming baits marked by the biomarker over all the sampled animals (individual level), per badger social group, and per targeted pasture. We found a bait uptake of 52.4% (43 marked individuals of 82 genetically identified) at the individual level and a mean of 48.9 and 50.6% at the social group and pasture levels, respectively. The bait uptake was positively associated with the presence of cubs (social group level) and negatively influenced by the intensity of previous trapping (social group and pasture levels). This study is the first conducted in France on bait deployment in a badger population of intermediate density after several years of intensive culling. The results are expected to provide valuable information toward a realistic deployment of oral vaccine baits to control TB in badger populations.

Search for Lepton Flavor Violation in ϒ(3S)→e^{±}μ^{∓}

We report on the first search for electron-muon lepton flavor violation (LFV) in the decay of a b quark and b antiquark bound state. We look for the LFV decay ϒ(3S)→e^{±}μ^{∓} in a sample of 118 million ϒ(3S) mesons from 27  fb^{-1} of data collected with the BABAR detector at the SLAC PEP-II e^{+}e^{-} collider operating with a 10.36 GeV center-of-mass energy. No evidence for a signal is found, and we set a limit on the branching fraction B[ϒ(3S)→e^{±}μ^{∓}]<3.6×10^{-7} at 90% C. L. This result can be interpreted as a limit Λ_{NP}/g_{NP}^{2}>80  TeV on the energy scale Λ_{NP} divided by the coupling-squared g_{NP}^{2} of relevant new physics (NP).

Barriers and enablers to implementinghospital-acquired urinary tract infection prevention strategies: a qualitative study using the Theoretical Domains Framework

BACKGROUND

Consistent implementation of evidence-based hospital-acquired urinary tract infection (UTI) prevention strategies remains a challenge in acute and subacute care settings. Addressing the evidence-practice gap requires an understanding of factors affecting implementation of hospital-acquired UTI prevention strategies in this high-risk setting.

AIM

To identify the perceived barriers and enablers of clinicians to implementing hospital-acquired UTI prevention strategies in an Australian subacute hospital.

METHODS

Qualitative semi-structured virtual interviews, underpinned by the Theoretical Domains Framework (TDF), were conducted with purposively selected nurses (N = 8) and doctors (N = 2) at one subacute metropolitan hospital. Interview data were content-analysed using the TDF as the coding framework.

FINDINGS

Eight TDF domains were identified as important in understanding barriers and enablers to implementing hospital-acquired UTI prevention strategies: Knowledge, Skills, Beliefs about capabilities, Emotion, Professional role and identity, Environmental context and resources, Goals, and Behavioural regulation. Barriers were poor awareness of clinical practice guidelines for hospital-acquired UTI prevention; lack of training; staff shortages; competing workloads; lack of procedural equipment for urinary catheterization; difficulty with implementing prevention strategies in cognitively impaired patients; language barriers; and lack of feedback and use of incident reporting data to influence clinical practice. Presence of a proactive staff culture and positive team approach to work emerged as enablers. Audit and feedback, clinical champions, education, and patient information resources in languages other than English were identified as potential enablers.

CONCLUSION

The findings will inform development of theoretically informed behaviour change interventions to promote successful implementation of hospital-acquired UTI prevention strategies in the subacute setting.

Self-care research: How to grow the evidence base? (reprint)

BACKGROUND AND OBJECTIVE

The number of studies in the area of self-care is growing and international researchers are increasingly developing self-care interventions to improve outcomes of individual patients and communities. However, growth of the evidence is still slow due to challenges with designing and testing self-care interventions. In this article we address major methodological challenges with regard to the definition of self-care, use of theory, and research design, intended to provide guidance to researchers in this field.

METHOD

During the inaugural conference of the International Center for Self-Care Research held in Rome, Italy in June 2019 we identified important issues in existing self-care research. Discussion and literature review lead to eight recommendation for future self-care research.

RESULTS

In preparation, begin with a theoretically sound definition of self-care. In planning the intervention, build on and extend previous studies. Use theory to develop self-care interventions and consider translational models to guide development, evaluation and implementation of complex self-care interventions. Employ a study design that fits the current phase and objectives of the research and measure self-care and related factors carefully. In reporting, describe the sample and setting sufficiently so that others can draw conclusions about generalizability and applicability to their practice and patient population. In interpretation, describe how the intervention is assumed to work (causal assumptions) and its key components.

CONCLUSION

Our review of existing self-care research clearly illustrates that the recommendations we provide are needed if we are to substantially grow the evidence base supporting self-care. Embracing a core set of principles will allow us to build on each other's work. Tweetable abstract: A core set of methodological principles is needed to substantially grow the evidence base supporting self-care.

A molecularly defined skin test reagent for the diagnosis of bovine tuberculosis compatible with vaccination against Johne's Disease

Tuberculin Purified Protein Derivatives (PPDs) exhibit multiple limitations: they are crude extracts from mycobacterial cultures with largely unknown active components; their production depends on culture of mycobacteria requiring expensive BCL3 production facilities; and their potency depends on the technically demanding guinea pig assay. To overcome these limitations, we developed a molecularly defined tuberculin (MDT) by adding further antigens to our prototype reagent composed of ESAT-6, CFP-10 and Rv3615c (DIVA skin test, DST). In vitro screening using PBMC from infected and uninfected cattle shortlisted four antigens from a literature-based list of 18 to formulate the MDT. These four antigens plus the previously identified Rv3020c protein, produced as recombinant proteins or overlapping synthetic peptides, were formulated together with the three DST antigens into the MDT to test cattle experimentally and naturally infected with M. bovis, uninfected cattle and MAP vaccinated calves. We demonstrated significant increases in MDT-induced skin responses compared to DST in infected animals, whilst maintaining high specificity in unvaccinated or MAP vaccinated calves. Further, MDT can also be applied in in vitro blood-based interferon-gamma release assays. Thus, MDT promises to be a robust diagnostic skin and blood test reagent overcoming some of the limitations of PPDs and warrants full validation.

International translation of Fever, Sugar, Swallow Protocols: The Quality in Acute Stroke Care Europe Project

The Quality in Acute Stroke (QASC) trial demonstrated a significant reduction in death and disability when clinicians were assisted to introduce protocols to manage fever, hyperglycaemia (sugar) and swallowing (FeSS) following stroke. We describe a unique international collaboration between the Nursing Research Institute at Australian Catholic University; the European Stroke Organisation; and the Angels Initiative, working collaboratively to support implementation of the nurse-led FeSS Protocols in 20 European countries. We currently have 71 hospitals from 16 countries participating (hospitals from four countries are in the preparation phase) with 49 hospitals currently entering data (n=2819 patients to-date). Baseline data have been received from 39 hospitals, with FeSS Protocol implementation commenced at 16 hospitals. Five hospitals have completed the Project. 'Upscale and spread' of these evidence-based, nursing protocols into countries with vastly different healthcare systems, many of whom also have no access to the latest stroke therapies, is likely to make a significant impact in reducing death and disability after stroke.

Increased fluid intake for the prevention of urinary tract infection in adults and children in all settings: a systematic review

BACKGROUND

Non-antibiotic interventions for urinary tract infection (UTI) prevention have been investigated as a strategy to reduce antibiotic prescribing for UTI and subsequent antibiotic resistance. Increased hydration is widely advocated for preventing UTI; however, evidence for its effectiveness is unknown.

AIM

To systematically review the published literature on the effectiveness of increased fluid intake as a preventive intervention for UTI in adults and children in any setting.

METHODS

Five electronic databases were searched from inception to February 2019 to identify published randomized controlled trials (RCTs) and quasi-experimental studies evaluating the effectiveness of high (≥1.5 L/24 h) versus normal/low (<1.5 L/24 h) fluid intake for UTI prevention. The outcome was UTI incidence. Risk of bias was assessed using the Cochrane Collaboration's tool. Due to the small number of studies identified, meta-analysis was not possible. Hence a narrative synthesis was undertaken.

FINDINGS

Of the 2822 potentially relevant papers, two were eligible for inclusion: an RCT (individual randomization) and a cluster-RCT. Both studies differed regarding participants, setting, sample size, UTI definition, and intervention. The RCT was assessed as having a low risk of bias whereas the cluster-RCT had a high risk of bias. Only the RCT, which included healthy premenopausal women visiting primary care clinics, demonstrated statistical significance for the effect of high fluid intake for UTI prevention.

CONCLUSION

The lack of enough adequately powered and robust RCTs highlights the need for further research on the effectiveness of this intervention for UTI prevention.

Discharge on the day of surgery following unicompartmental knee arthroplasty within the United Kingdom NHS

AIMS

Unicompartmental knee arthroplasty (UKA) has been successfully performed in the United States healthcare system on outpatients. Despite differences in healthcare structure and financial environment, we hypothesised that it would be feasible to replicate this success and perform UKA with safe day of surgery discharge within the NHS, in the United Kingdom. This has not been reported in any other United Kingdom centres.

PATIENTS AND METHODS

We report our experience of implementing a pathway to allow safe day of surgery discharge following UKA. Data were prospectively collected on 72 patients who underwent UKA as a day case between December 2011 and September 2015.

RESULTS

A total of 61 patients (85%) were discharged on the same day. The most common reason for failure was logistical; five patients had their operation too late in the day. Three patients failed to mobilise safely, two had inadequate control of pain and one had a leaking wound. The mean length of stay for those who were not discharged on the same day was 1.2 nights (1 to 3). During the same time, 58 patients underwent planned inpatient UKA, as they were deemed inappropriate for discharge on the day of surgery. However, three of these were safely discharged on the same day. Follow-up data, 24 hours post-operatively, were available for 70 patients; 51 (73%) reported no or mild pain, 14 (20%) had moderate pain and five (7%) had severe pain. There were no re-admissions. All patients had a high level of satisfaction.

CONCLUSION

We found that patients can be safely and effectively discharged on the day of surgery after UKA, with high levels of satisfaction. This clearly offers improved management of resources and financial savings to healthcare trusts. Cite this article: Bone Joint J 2017;99-B:788-92.

Decortication and osteotomy for the correction of multiplanar deformity in the treatment of malunion in adult diaphyseal femoral deformity: a case series and technique description

AIM

To review patients that have undergone correction of a symptomatic femoral malunion using osteotomy combined with decortication.

METHODS

A retrospective review of all patients who have undergone decortication and multiplanar osteotomy, looking at the pre-operative deformity, correction achieved, time to union and complications.

RESULTS

Seven patients underwent correction under the senior author from 2003 to 2012. Average age was 46 years (range 32-60 years). All had femoral shortening deformity (average 2.7 cm, range 2-4 cm). Each also had at least one other plane of deformity with rotation being the next most commonly encountered in 5 out of the 7 (average 33°, range 0°-45°). Two had tri-planar deformity with the five having bi-planar deformity. Average time to union was 16.3 months (range 7-39 months) with an average of 1.5 operations (range 1-3 operations) to union. One patient has a non-union after five corrective operations.

CONCLUSION

Correction of multiplanar deformity of the femur is challenging. Osteotomy with decortication provides a technique to achieve significant femoral multiplanar deformity correction in a single operation. This publication provides technical description of the operative technique, guidance and results.

Cytomegalovirus Infection and Rates of Antiviral Resistance Following Intestinal and Multivisceral Transplantation

BACKGROUND

Cytomegalovirus (CMV) disease is a common and clinically significant complication following intestinal or multivisceral transplantation. CMV disease is more common in cases of serologic mismatch between donor and recipient. Though in some cases it may be asymptomatic, in the immunosuppressed population it often manifests with evidence of systemic infection or end-organ disease.

METHODS

We conducted a retrospective review of all patients undergoing intestinal or multivisceral transplantation over 8 years at our institution.

RESULTS

Forty-eight transplantations were performed, with 40% of the patients (19/48) having ≥1 episode of CMV viremia, which rose to 90% in the "donor-positive, recipient-negative" (DPRN) serologic mismatch group. The median time to 1st episode following transplantation was 22.3 weeks (range, 1-78) and median duration of each episode was 4.9 weeks (range, 1.6-37.4). Six of the 19 viremic patients (31.6%) developed virologic resistance with 4 of these occurring in the DPRN group. Four of the 6 patients with drug-resistant CMV died with CMV viremia. All patients with drug resistance acquired ganciclovir resistance; these patients were more challenging to manage with second-line toxicity-limited treatments, including foscarnet, cidofovir, and leflunomide. CMV immunoglobulin has been used and we briefly discuss the use of CMV-specific adoptive T-lymphocyte transfer in the management of 1 case.

CONCLUSIONS

Post-transplantation CMV disease continues to be challenging to manage, and there is little consensus on optimal management strategies in this patient group, with a significant requirement for novel therapies; these may be pharmacologic or cell based. Extensive multidisciplinary discussion is important for most cases, but particularly for those patients who acquire virologic resistance.

Allergy in total knee arthroplasty: a review of the facts

We explored the literature surrounding whether allergy and hypersensitivity has a clinical basis for implant selection in total knee arthroplasty (TKA). In error, the terms hypersensitivity and allergy are often used synonymously. Although a relationship is present, we could not find any evidence of implant failure due to allergy. There is however increasing basic science that suggests a link between loosening and metal ion production. This is not an allergic response but is a potential problem. With a lack of evidence logically there can be no justification to use 'hypoallergenic' implants in patients who have pre-existing skin sensitivity to the metals used in TKA.

Reconciliation of international administrative coding systems for comparison of colorectal surgery outcome

AIM

Significant variation in colorectal surgery outcomes exists between different countries. Better understanding of the sources of variable outcomes using administrative data requires alignment of differing clinical coding systems. We aimed to map similar diagnoses and procedures across administrative coding systems used in different countries.

METHOD

Administrative data were collected in a central database as part of the Global Comparators (GC) Project. In order to unify these data, a systematic translation of diagnostic and procedural codes was undertaken. Codes for colorectal diagnoses, resections, operative complications and reoperative interventions were mapped across the respective national healthcare administrative coding systems. Discharge data from January 2006 to June 2011 for patients who had undergone colorectal surgical resections were analysed to generate risk-adjusted models for mortality, length of stay, readmissions and reoperations.

RESULTS

In all, 52 544 case records were collated from 31 institutions in five countries. Mapping of all the coding systems was achieved so that diagnosis and procedures from the participant countries could be compared. Using the aligned coding systems to develop risk-adjusted models, the 30-day mortality rate for colorectal surgery was 3.95% (95% CI 0.86-7.54), the 30-day readmission rate was 11.05% (5.67-17.61), the 28-day reoperation rate was 6.13% (3.68-9.66) and the mean length of stay was 14 (7.65-46.76) days.

CONCLUSION

The linkage of international hospital administrative data that we developed enabled comparison of documented surgical outcomes between countries. This methodology may facilitate international benchmarking.

The principles of managing open fractures

Any fracture of a bone which communicates with the outside environment via a wound in the skin is classified as an open fracture. This may be from penetration by sharp objects from the exterior, laceration caused by the fracture fragments, or shearing forces that tear or de-glove soft tissue from a limb. These injuries vary in mechanism and severity, ranging from a broken finger caught in a bulkhead door to a catastrophic lower limb fracture suffered from an improvised explosive device (IED). We address the management principles that can be applied to all open fractures regardless of cause.

Total mesorectal excision for cancer following ventral mesh rectopexy

Since the introduction of ventral mesh rectopexy for rectal prolapse, concern exists as to how this may interfere with subsequent rectal cancer surgery. To our knowledge, this is the first report of total mesorectal excision for cancer after such a rectopexy. We discuss surgical technique, pitfalls encountered and oncological outcome.

PP162. sFlt-1 controlled by CPAP in a pregnant patient with chronic hypertension

INTRODUCTION

Preeclampsia is recognised as the leading cause of perinatal mortality and morbidity worldwide. Interest has been increasing recently as to the possible impact of sleep disordered breathing (SDB) on the mechanisms of preeclampsia, possibly by augmenting placental hypoxia during sleep. A biomarker of preeclampsia, sFlt-1, has also come to prominence in recent years and is postulated to be a good predictor of preeclampsia as well as a strong indicator of the severity of the disease.

OBJECTIVES

The aim of this study was to investigate the effect of CPAP treatment for SDB on sFlt-1 concentrations during pregnancy.

METHODS

Patients were recruited from the outpatients' clinic in Campbelltown Hospital, Campbelltown, NSW in the first half of 2011. The levels of sFlt-1 in four pregnant women, with or without hypertensive disorders of pregnancy, and with or without SDB were measured using ELISA.

RESULTS

Women with SDB and chronic hypertension or preeclampsia had higher levels of sFlt-1 and a greater percentage increase of this marker, and CPAP treatment appeared to attenuate the rise of sFlt-1 as shown in the table below.

CONCLUSION

Elevated sFlt-1 was associated with untreated SDB in those with chronic hypertension. This study provides feasibility for a larger scale study to occur, to further examine the validity of the hypothesis that CPAP treatment has a beneficial effect on sFLt-1 levels and therefore, may lower the risk and severity of preeclampsia.

PP154. Relationship between recorded and reported snoring during pregnancy: Objective measurement versus questionnaire responses

INTRODUCTION

Snoring is a common symptom of sleep disordered breathing (SDB), a condition that is present in 4% of the general population. SDB is identified by snoring and repetitive cessation of breathing during sleep accompanied by repetitive hypoxia and has been found to be associated with hypertension, stroke and heart attack. There is not depth of knowledge examining the association between SDB and pregnancy outcomes.

OBJECTIVES

To examine the prevalence of self reported snoring in pregnancy and the potential association between self reported snoring and the development of Hypertensive Disorders of Pregnancy (HDP) within a larger cohort from a prevalence of SDB in pregnancy study.

METHODS

Questionnaires were administered to pregnant women attending an outpatient's antenatal clinic. The self reported snoring is a component of the Epworth scale. Pregnancy progression and outcome data were collected on all participants and analyse by IBM SPSS v.20™ utilising Chi-square analysis, Student T test and logistic regression analysis. HDP diagnoses were in alignment with the SOMANZ (2009) diagnostic criteria.

RESULTS

Questionnaires were administered and outcomes collected on 2023 pregnancies. Snoring was reported by 49.2% of women. HDP affected 10.1% of the cohort, 3.3% of whom were preeclamptic. Of the pregnancies affected by HDP self reported snoring occurred in 57.7% in comparison to 43.3% who do not report snoring (p<0.001).

CONCLUSION

This would indicate that there is an association between self reported snoring and the development of HDP. Further analysis will be undertaken to model the effect of other potential risk factors such as maternal age, parity, pre-pregnancy BMI and other co morbidities.

Influence of signalment on developing cranial cruciate rupture in dogs in the UK

OBJECTIVES

To investigate risk factors associated with cranial cruciate ligament rupture in dogs.

METHODS

Retrospective case-control study: medical records of a first-opinion veterinary practice were searched for dogs diagnosed with cranial cruciate ligament rupture (1995 to 2007). For each case, six unaffected dogs were randomly selected from all dogs presenting that day for comparison. Multi-variable binary logistic regression was performed to assess the association of variables on likelihood of cruciate rupture.

RESULTS

Frequency of cranial cruciate ligament rupture was 1·19% [95% confidence interval (CI) 1·02 to 1.36%]. West Highland white terriers (n=17), Yorkshire terriers (n=14) and Rottweilers (n=11) were at significantly increased risk of cranial cruciate ligament rupture (P≤0·002). Rottweilers were at five times greater risk compared with other pure breeds (OR 5·12, 95% CI 2·281 to 11·494, P<0·001), obesity quadrupled the risk of cranial cruciate ligament rupture (OR 3·756, 95% CI 1·659 to 8·502, P=0·001) and females were twice as likely to suffer cranial cruciate ligament failure compared to males (OR 2·054, 95% CI 1·467 to 2·877, P<0·001). Dogs less than two years old were statistically less likely to sustain cranial cruciate ligament rupture than dogs older than eight years (OR 0·246, 95% CI 0·127 to 0·477, P<0·001). There was no significant difference in median weights (in kilograms) of neutered dogs, compared to their entire counterparts in either the case group (P=0·994) or in the control group (P=0·630). There was also no significant difference in body condition (-underweight/normal weight/overweight/obese) of neutered versus entire dogs among the cases (P=0·243), or the controls (P=0·211).

CLINICAL SIGNIFICANCE

Cranial cruciate ligament rupture is more likely in Rottweilers and in female dogs, older dogs and obese dogs. Following multi-variable analysis, it was established that neutering was not associated with increased risk of cranial cruciate ligament rupture.

A software module for the adaptive estimation of steady state auditory evoked potentials

A graphical user interface (GUI) implementing a novel technique of fast estimation of steady state auditory evoked potentials (SSAEPs) for rapid assessment of the functionality of the human auditory nervous system is presented. The proposed signal estimator has shown great promise in the fast extraction of weak signals buried under large amounts of noise such as the case with SSAEP signals. Currently, the main technical impediment in the widespread clinical use of the SSAEP testing for hearing assessment is the excessively long measurement time needed for the estimation process due to the presence of large amounts of background noise. The presented software module that is publicly disseminated through the Internet is meant to facilitate the use of an efficient signal processing technique by the hearing researchers. The software environment allows for loading previously recorded SSAEP signals into the workspace for analysis. Moreover, it enables the user to add simulated SSAEP signals to the background EEG for the purpose of testing the capability of the underlying signal processing algorithm.

Massive scrotal haematoma: a complication of percutaneous transluminal angioplasty

Scrotal haematoma is an unusual complication following percutaneous transluminal angioplasty. It carries significant morbidity and causes extreme discomfort to the patient. We describe the case of a 75-year-old diabetic man who developed this complication. Recommendations are made for investigation and management of this problem, which is so infrequently encountered in clinical practice.

Development and validation of a self-report symptom inventory to assess the severity of oral-pharyngeal dysphagia

BACKGROUND & AIMS

The aim of this study was to develop and evaluate the validity and reliability of a self-report inventory to measure symptomatic severity of oral-pharyngeal dysphagia.

METHODS

Test-retest reliability and face, content, and construct validity of a prototype visual analogue scale inventory were assessed in 45 patients who had stable, neuromyogenic dysphagia.

RESULTS

Normalized scores varied over time by -0.5% +/- 17.6% (95% confidence interval, -9.2% to 8.2%). Factor analysis identified a single factor (dysphagia), to which 18 of 19 questions contributed significantly, that accounted for 56% of total variance (P < 0.0001). After deletion of 2 questions with poor face validity and patient compliance, this proportion increased to 59%; mean test-retest change was -2% (95% confidence interval, -11% to 7%); and total score correlated highly with an independent global assessment severity score (r = 0.7; P < 0.0001). A mean 70% reduction in score (P < 0.0001) was observed after surgery in patients with Zenker's diverticulum (discriminant validity).

CONCLUSIONS

Applied to patients with neuromyogenic dysphagia, the 17-question inventory shows strong test-retest reliability over 2 weeks as well as face, content, and construct validity. Discriminant validity (responsiveness) has been demonstrated in a population with a correctable, structural cricopharyngeal disorder. Responsiveness of the instrument to treatment in neuromyogenic dysphagia remains to be quantified.

Outcome evaluation in nursing in Australia, 1960-1980

While empirical evaluation of the outcome of patient care has come to the fore in recent years due to political initiatives, there has always been a professional interest by nurses in the end result of their care. A review of the literature shows that outcome evaluation was advocated for nursing as early as the 1860s by Florence Nightingale. This article explores the evolvement of outcome evaluation within nursing in Australia, discussing its origins during the 1960s and 1970s. The measurement of patient outcomes is more relevant than ever before, with the recent drive for an evidence-based approach to nursing care.

Measuring outcomes from the patients' perspective

This descriptive study examines the outcomes of care from the perspective of patients following a recent orthopaedic admission at a teaching hospital in Sydney. Results were extracted and analysed from transcripts of audio-taped focus groups. Participants identified five nursing activities that made a positive difference to patient outcomes. These activities were: (i) patient-controlled analgesia; (ii) water-filled gloves placed under patients' heels; (iii) cream rubbed into patients' heels; (iv) an explanation, at pre-admission clinic, of the impending operation; and (v) being informed about the details of their treatment while in hospital. Three activities that participants felt made a negative difference to their outcome were also identified, as were seven activities not performed by nursing staff that participants felt would have made a positive difference to their outcome. The results from this study reinforce the importance of basic nursing care, and the value of measuring outcomes, not only from the professional perspective, but also from the patients' viewpoint.

Comparing professional and patient outcomes for the same episode of care

Following an acute hospital admission, patients' perceptions of the acceptability of their own outcomes were compared with professionally derived outcomes of care developed for the same patients by nurses. Professional opinion was obtained from the Nursing Practice--Casemix and Outcomes Project undertaken by the Sydney Metropolitan Teaching Hospitals Nursing Consortium, where patient outcomes were classified by nurses into three groups: Outcomes Acceptable; Outcomes Not Acceptable but Justified and Outcomes Not Acceptable and Not Justified. Fifteen male patients in the present study discussed their outcomes following recent orthopaedic surgery at a series of focus groups organised according to the three outcome categories. Findings from the study showed the majority of patients were satisfied with their outcomes. Patient agreement with nurses regarding the acceptability of outcomes was highest for patients from the Outcomes Acceptable group and lowest for those from the Outcomes Not Acceptable and Not Justified group. This work is significant in that it is one of the first nursing studies to compare outcomes developed by practitioners for a particular group of patients with actual outcomes experienced by the same group of patients.

Glutamine oxidation and utilization by rat and human oesophagus and duodenum

The rates of utilization and oxidation of glutamine and glucose by oesophageal and duodenal tissues have been investigated in both rats and human subjects. In the rat, glutamine utilization by oesophageal tissue was 2-3-fold lower than that in the duodenum, and this substrate contributed less than 10% to the total oxidative metabolism of the tissue, even when glutamine was the only substrate provided. In contrast, rat duodenal tissue derived about 34% of the total CO2 production from glutamine-C, and this contribution was not suppressed by the addition of either glucose or a mixture of the other substrates. Rates of glucose utilization and oxidation by the duodenum were lower than those for glutamine, and were significantly (P < 0.001) suppressed by addition of glutamine. In both oesophageal and duodenal tissues, less than 10% of the glutamine-C utilized was fully oxidized, approximately 60-70% was converted to glutamate, and 30-40% to alanine. Results obtained using human biopsy tissue samples were similar to those observed in the rat. Glutamine oxidation contributed 34 (SD 4)% of the total CO2 production by the duodenal tissue, but only 8 (SD 4)% to oesophageal tissue oxidation. The findings suggest that glutamine is not an important or preferred fuel for oesophageal tissue, whereas it is for duodenal tissue. Thus, these tissues can be expected to respond differently to glutamine administration.

[Value of human colonic cancer models by surgical cecal implantation in nude mice]

A better understanding of the nature and treatment of colon cancer, and of by metastatic dissemination should be achieved by the use and study of appropriate animal models. Such models can be created by grafting human cancer cells or tumour fragments orthotopically into the colon or caecum of nude mice. This review examines the rationale behind these models and the principal results of orthotopic transplantation. Despite the fact that they require surgical expertise and are time-consuming, they provide valuable information on the mechanism of metastasis and the efficacy of novel treatments.

Fibrinogen-coated albumin microcapsules reduce bleeding in severely thrombocytopenic rabbits

Severe thrombocytopenia frequently occurs in patients receiving chemotherapy and in patients with autoimmune disorders. Thrombocytopenia is associated with bleeding, which may be serious and life threatening. Current treatment strategies for thrombocytopenia may require transfusion of allogeneic platelets, which is associated with serious drawbacks. These include the occurrence of anti-platelet antibodies, which may result in refractoriness to further platelet transfusions, and the potential risk of transfer of blood-borne diseases. Therefore, we have recently developed a platelet substitute product (Synthocytes), which is composed of human albumin microcapsules with fibrinogen immobilized on their surface. Here we show that the intravenous administration of these microcapsules not only corrects the prolonged bleeding time in rabbits rendered thrombocytopenic either by anti-platelet antibodies or by chemotherapy, but also reduces bleeding from surgical wounds inflicted in the abdominal skin and musculature. No potential systemic prothrombotic effect of the microcapsules was observed in a model of rabbit venous thrombosis. As for the mechanism of action, experiments with normal and thrombocytopenic human blood in an endothelial cell matrix-coated perfusion chamber demonstrated an interaction between the fibrinogen-coated albumin microcapsules and native platelets. It was shown that the fibrinogen-coated albumin microcapsules could facilitate platelet adhesion to endothelial cell matrix and correct the impaired formation of platelet aggregates in relatively platelet-poor blood. This study indicates that fibrinogen-coated albumin microcapsules can act to improve primary hemostasis under thrombocytopenic conditions and may eventually be a promising agent for prophylaxis and treatment of bleeding in patients with severe thrombocytopenia.