Blood Pressure Measurements Obtained by Community-Dwelling Adults Are Similar to Nurse-Obtained Measurements: The SMART-BP Validate Study

BACKGROUND

Self-measured blood pressure (SMBP) is an effective strategy for managing and controlling hypertension. However, uncertainty regarding patients' ability to accurately measure their blood pressure (BP) contributes to treatment inertia. Therefore, we compared BP measurements with the Omron HEM-9210T device obtained by nurses and community-dwelling adults after training.

METHODS

This cross-sectional study was conducted in a simulated home environment at an academic institution. After a 5-min rest, a trained nurse measured a participant's BP twice at a 1-min interval. The participants then ambulated at their usual pace for 2 min. Next, they were asked to rest for 5 min, during which each individual watched a 3-min video on SMBP. Following the rest, the participants obtained two readings at a 1-min interval.

RESULTS

We recruited 102 community-dwelling adults with a mean age of 54 (±14) years; 59% female, 88% Black race, and 63% with a hypertension diagnosis. Half (n = 51) had a home BP monitor. Overall, there were no significant differences between nurse- and participant-obtained systolic BP (mean difference [MD]: -1.1; standard deviation [SD]: 8.0; P = 0.178) or diastolic BP (MD: -0.9; SD: 5.5; P = 0.111). Participants who used an extra-large cuff had higher self-measured diastolic BP (MD: -2.9; SD: 4.5; P = 0.010). All participants demonstrated satisfactory SMBP skills after the training.

CONCLUSIONS

Community-dwelling adults can accurately measure BP after a 3-min video training. Integrating SMBP training into patient encounters may result in reliable home BP measurements, improving hypertension management and clinical decision making.

Abstract P016: Blood Pressure Measurements Obtained By Community-dwelling Adults Are Similar To Clinician-obtained Measurements: The SMART-BP Validate Study

Background: Home blood pressure (BP) monitoring is an effective strategy to diagnose and manage BP. However, uncertainty regarding patients’ ability to accurately measure their BP contributes to treatment inertia. Thus, we compared BP measurements with the Omron 9210T device obtained by clinicians and community-dwelling adults, after training.

Methods: This cross-sectional study was conducted in a simulated home environment at an academic center in Maryland. After a 5-minute rest period, a trained clinician measured participants’ BP, twice at a 1-minute interval. Participants then ambulated at their usual pace for two minutes followed by a 5-minute rest. During the second rest period, the participant viewed a 3-minute video on how to measure their BP. They obtained two measurements at a 1-minute interval.

Results: We included 90 adults with a mean age of 55 (±13.9) years, 58% were female, 88% were Black, 39% had annual income <$25,000, 64% had diagnosed hypertension, and 53% had BMI > 30 kg/m 2 . About half (52%) had a home BP monitor. There were no significant differences between clinician- and participant-obtained systolic BP (mean difference [MD]: -1.22, 95% confidence interval [CI]: -2.98-0.54, p = 0.173) or diastolic BP (MD: -0.62, 95% CI: -1.35-0.12, p = 0.094). There was no difference in between the large or extra-large cuff sizes. All participants demonstrated satisfactory self-measured BP skills after the training.

Conclusions: Community-dwelling adults can accurately measure BP after a brief training. Integration of BP training into patient encounters may result in reliable home BP measurements, and use of home BP measures may potentially reduce clinical inertia.

Lower extremity arterial interventions in England

INTRODUCTION

The increasing prevalence of diabetes mellitus and advances in endovascular therapies continue to have an impact on the epidemiology and management of lower extremity arterial disease. This study describes trends in lower extremity revascularisation and major lower limb amputation in NHS England over the past two decades (2000-2019).

METHODS

Numbers of lower extremity endovascular interventions, open surgical procedures and major lower limb amputations performed in NHS England between 2000 and 2019 were extracted from publicly available hospital admitted patient care activity reports. Trends in intervention were assessed with linear regression models and chi-square tests for trend.

RESULTS

Over this period, 527,131 revascularisations and 92,053 amputations were performed. The mean age of patients was 67.5 years (standard deviation 1.6 years) and 65.3% were male. The number of lower limb revascularisation procedures increased by 402.4 units/year (95% confidence interval, CI, 290.1-514.6, p < 0.001). The number of endovascular interventions rose by 43.5% (10,912 in 2000 vs 15,657 in 2019; β = 359.5.0, 95% CI 279.3-439.8, p < 0.001) compared with no significant increase in the number of open surgical procedures (8,483 in 2000 vs 7,872 in 2019; β = 42.8, 95% CI -8.3 to 94.0, p = 0.095). The number of major lower limb amputations has decreased by 9.4% (5,418 in 2000 vs 4,907 in 2019; β = -31.0; 95% CI -49.6 to -12.5, R² = 0.42, p = 0.003).

CONCLUSIONS

There has been a significant increase in the rate of lower limb revascularisation procedures associated with decreased numbers of major lower limb amputations over the past two decades. These changes in overall trends may affect both service provision and vascular surgery training planning.

Regression of cardiac amyloid deposits with novel therapeutics: reaching new frontiers in cardiac ATTR amyloidosis

Background

Cardiac involvement is the main driver of outcome in ATTR amyloidosis. Advances in therapeutics hold potential in transforming the course of the disease but the impact on cardiac amyloid load is unknown. The aim of this study was to evaluate the impact of patisiran, a new double stranded RNA based gene silencing therapy and a stabilizer, diflunisal, on cardiac amyloid load as measured by CMR and T1 mapping, in patients with ATTR amyloidosis.

Methods and results

Thirty-two patients with hereditary cardiac amyloidosis were studied. Sixteen patients received treatment with patisiran, and sixteen control subjects did not receive any disease modifying treatment. Patients were assessed with echocardiogram, CMR, NT-proBNP and six-minute walk time measurements at baseline and at 1 year (Mean interval 11.45±3.08 months in treatment group, mean interval 12.82±5.06 months in the control group). CMR analysis comprised LV volumes, T1 mapping to measure the extracellular volume (ECV) occupied by amyloid, T2 mapping and late gadolinium enhancement imaging. At 1-year follow-up, there was a substantial reduction in cardiac amyloid burden, in keeping with cardiac amyloid regression in 45% of patients on treatment. Overall the treatment group showed a reduction in ECV at 1 year follow up compared to an increase in ECV at 1 year in the control group (−1.37%, 95% CI: −3.43 to 0.68% versus 5.02%, 95% CI: 2.86% to 7.18% respectively, p&lt;0.001). The treatment group also showed an improvement in change in 6MWT at 1 year follow up compared to 6MWT at 1 year in the control group (−8.12 meters, 95% CI: −50.8 to 34.6 meters in the treatment group versus −132.27 meters, 95% CI: −216 to −48.6 meters in the control group, p=0.002). The treatment group showed a reduction in BNP at 1 year follow up compared to an increase in the control group (−567.87, 95% CI: −1288.90 to 153.15 in the treatment group versus 2004, 95% CI: 12.82 to 3995.45 in the control group, p&lt;0.001). There was no significant difference from baseline and 1-year data between the control and treatment groups for the difference in echocardiographic parameters, native T1, T2. There was a significant reduction in the percentage of injected dose by 99Tc-DPD scintigraphy in treated patients at 1 year compared to baseline.

Conclusions

These findings provide the first compelling evidence of substantial cardiac amyloid regression in ATTR amyloidosis, as well as the potential for CMR to be used to track response in treated patients with ATTR cardiac amyloidosis. Combination therapy with transthyretin knock down and stabilizing agents may well be synergistic given enhanced stoichiometry of stabilizers in the face of much reduced plasma transthyretin concentration.

Funding Acknowledgement

Type of funding source: None

Atrial strain in cardiacATTR amyloidosis from pathophysiology to prognosis: is it time to rethink our approach to disease?

Background

Left atrial (LA) involvement in cardiac ATTR amyloidosis (ATTR-CM) has never being explored. The aim of the study is to characterize the spectrum of changes in LA structure in ATTR-CM, the functional consequences on LA mechanics and the association with mortality.

Methods

We studied 936 patients with ATTR-CM who underwent prospective protocolized evaluations comprising ECG, full echocardiographic assessment, 6MWT, blood biomarkers sampling and survival assessment between 2000 and 2019. Reservoir (LAr), conduit (LAcd) and booster (LAcont) function were assessed according to current guidelines. LA stiffness (LAstiff) was estimated as the ratio between E/e' and LAr. The presence and extent of amyloid infiltration was assessed in two autopsied hearts from patients ATTR-CM with congo red staining and TTR antibodies.

Results

936 patients with ATTR-CM were included, 567 with wtATTR-CM and 346 with hATTR-CM, of whom 246 had the V122I variant and 100 the T60A variant. LA indexed area was similar across the 3 genotypes, whilst LAr, LAcd and LAcont were significantly reduced in V122I patients compared to Wt and T60A patients (LAr: 10.4±6.4 vs 12.8±8.5 vs 8.59±5.7%, p&lt;0.0001; LAcd: 5.6±5.0 vs 6.9±5.7 vs 4.0±3.6%, p&lt;0.0001; LAcont 7.5±4.1 vs 8.2±4.9 vs 6.7±4.2%, p=0.023; in Wt, T60 and V122I respectively). Similarly, LAstiff was significantly worse in V122I compared to Wt and T60A (LAstiff: 2.39±2.62 vs 2.59±4.83 vs 2.96±2.88, p&lt;0.0001, in Wt, T60 and V122I respectively). In the overall population, LAstiff remained independently associated with mortality, after adjusting for rhythm, systolic and diastolic functional parameters, ventricular longitudinal strain, genotypes, clinical variables and NAC staging system (lnLA stiff: HR=1.26, CI: 1.07–1.57; p=0.009). In the overall population, 584 patients were in sinus rhythm and 344 in atrial fibrillation, atrial flutter or atrial tachycardia (non-sinus rhythm group – NSR). Among patients in SR, 21.6% did not show a measurable LA mechanical contraction on strain analysis (LAcont). Patients in SR without LAcont on strain analysis showed similar structural and functional LA changes, NTproBNP, NYHA class, and 6MWT to NSR patients. Mortality of patients in SR with no LAcont was significantly reduced compared to patients in SR with LAcont and similar to patients in AF (Figure 1). On the two autopsies hearts there was extensive amyloid infiltration of TTR type in the atrial wall as confirmed with CR and TTR antibodies (Figure 1).

Conclusions

ATTR-CM is characterized by primary infiltration of the atrial walls with progressive loss of atrial function and increased stiffness. LA stiffness is a strong independent predictor of mortality after adjusting for known predictors. Atrial electro-mechanical dissociation emerged as a distinctive functional phenotype identifying patients in SR with worse prognosis.

Figure 1

Funding Acknowledgement

Type of funding source: None

Real-time assessment of learning curve for robot-assisted laparoscopic prostatectomy

INTRODUCTION

The learning curves analysed to date for robot-assisted laparoscopic prostatectomy are based on arbitrary cut-offs of the total cases.

METHODS

We analysed a large dataset of robot-assisted laparoscopic prostatectomies from a single centre between 2008 and 2019 for assessment of the learning curve for perioperative outcomes with respect to time and individual cases.

RESULTS

A total of 1,406 patients were evaluated, with mean operative time 198.08 minutes and mean console time 161.05 minutes. A plot of operative time and console time showed an initial decline followed by a near-constant phase. The inflection points were detected at 1,398 days (308th case) for operative time and 1,470 days (324th case) for console time, with a declining trend of 8.83 minutes and 7.07 minutes, respectively, per quarter-year (p<0.001). Mean estimated blood loss showed a 70.04% reduction between the start (214.76ml) and end (64.35ml) (p<0.001). The complication rate did not vary with respect to time (p=0.188) or the number of procedures (p=0.354). There was insufficient evidence to claim that the number of operations (p=0.326), D'Amico classification (p=0.114 for intermediate versus low; p=0.158 for high versus low) or time (p=0.114) was associated with the odds of positive surgical margins.

CONCLUSIONS

It takes about 300 cases and nearly 4 years to standardise operative and console times, with a requirement of around 80 cases per annum for a single surgical team in the initial years to optimise the outcomes of robot-assisted laparoscopic prostatectomy.

FRI0457 LONG-TERM OUTCOMES AND TREATMENT EFFICACY IN PATIENTS WITH TNF RECEPTOR-ASSOCIATED AUTOINFLAMMATORY SYNDROME (TRAPS) FROM THE EUROFEVER INTERNATIONAL REGISTRY

Background:

Tumour necrosis factor (TNF) receptor-associated periodic syndrome (TRAPS) is one of the best-known monogenic auto-inflammatory disorders resulting from an autosomal dominant variation in the TNF super family receptor 1A (TNFRSF1A) gene (1).

Objectives:

To define best treatment approach in patients with TRAPS and effect on long-term outcomes.

Methods:

We reviewed all data on patients with TRAPS enrolled in the Eurofever international registry according the INSAID gene variant classification and the new Eurofever/PRINTO classification criteria (EPCC).

Results:

Data on 226 patients were available. Patients not fulfilling the EPCC carrying likely benign/benign variants (21 patients, 9%) or VOUS/not classified variants (40 patients, 18%) displayed a milder disease than the patients fulfilling the EPCC with VOUS/not classified variants (38 patients, 17%) or pathogenic/likely pathogenic variants (127 patients, 56%). In particular, in patients not fulfilling the EPCC, less frequent abdominal pain and skin rashes, higher efficacy rate of colchicine and no development of AA amyloidosis have been reported. Almost 90% of patients fulfilling the EPCC required maintenance therapy and anti-interleukin (IL)-1 drugs were the most frequently used, with the highest efficacy rate (>85% complete response), while Etanercept was less effectively used and discontinued in 65% of patients.

Conclusion:

Anti-IL-1 drugs are the best maintenance treatment in TRAPS with potential to reverse the most serious disease complications of AA amyloidosis and infertility. The diagnosis of TRAPS should be considered very carefully in patients carrying VOUS/not classified variants not fulfilling the EPCC.

References:

[1]Lachmann HJ, Papa R, Gerhold K, Obici L, Touitou I, Cantarini L, et al. The phenotype of TNF receptor-associated autoinflammatory syndrome (TRAPS) at presentation: a series of 158 cases from the Eurofever/EUROTRAPS international registry. Annals of the rheumatic diseases 2014;73:2160-7.

Acknowledgments:

RP would like to thank the European Federation of Immunology (EFIS) for the short-term bursary and HL for her continuous support and guidance during the fellowship at the National Amyloidosis Centre in London.

Disclosure of Interests:

Riccardo Papa: None declared, Thirusha Lane: None declared, Francesca Bovis: None declared, Kirsten Minden Consultant of: GlaxoSmithKline, Sanofi, Speakers bureau: Roche, Isabelle Touitou: None declared, Luca Cantarini: None declared, Marco Cattalini: None declared, Laura Obici: None declared, Annette Jansson: None declared, Alexander Belot: None declared, Beata Woska-Kuśnierz: None declared, Rainer Berendes: None declared, Agustin Remesal: None declared, Marija Jelusic: None declared, Graciela Espada: None declared, Irina Nikishina: None declared, Esther Hoppenreijs: None declared, Maria Cristina Maggio: None declared, Taryn Youngstein: None declared, Tamer Rezk: None declared, Charalampia Papadopoulou: None declared, Paul Brogan Grant/research support from: Roche, Novartis, SOBI, Chemocentryx, Novimmune, Consultant of: Roche, SOBI, UCB, Novartis, Speakers bureau: Roche, SOBI, UCB, Novartis, Philip N Hawkins: None declared, Patricia Woo: None declared, Nicolino Ruperto Grant/research support from: Bristol-Myers Squibb, Eli Lily, F Hoffmann-La Roche, GlaxoSmithKline, Janssen, Novartis, Pfizer, Sobi (paid to institution), Consultant of: Ablynx, AbbVie, AstraZeneca-Medimmune, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lily, EMD Serono, GlaxoSmithKline, Hoffmann-La Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, Sanofi, Servier, Sinergie, Sobi, Takeda, Speakers bureau: Ablynx, AbbVie, AstraZeneca-Medimmune, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lily, EMD Serono, GlaxoSmithKline, Hoffmann-La Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, Sanofi, Servier, Sinergie, Sobi, Takeda, Marco Gattorno Consultant of: Sobi, Novartis, Speakers bureau: Sobi, Novartis, Helen J. Lachmann: None declared

The Lister AirSeal® port closure technique - Initial patient outcomes

INTRODUCTION

The 12-mm AirSeal® port is widely used in robotically assisted laparoscopic prostatectomy due to its ability to maintain stable pneumoperitoneal pressures and smoke evacuation. However, it creates a potential risk of port site hernia. We have traditionally used EndoClose™ to perform full thickness closure of this port, but noted that patients experienced increased pain related to this procedure, which sometimes persisted for several months. Using the Da Vinci Si we performed peritoneal closure with 2-0 vicryl by switching the fourth arm to the right master controller. The external oblique sheath was closed outside with 1 Ethibond.

MATERIALS AND METHODS

We performed this closure in 20 consecutive patients (group 1). Postoperative day 1, 2 and post-discharge telephone consultation pain scores (1-10) were recorded and compared with the previous 20 consecutive patients who had the EndoClose closure (group 2).

RESULTS

We recorded an instructional video to enable reproduction of the new technique. The mean length of stay was 1.5 days for patients in group 1 and 1.9 days for those in group 2 (P = 0.04). There was no difference in operating time or average day 1 pain scores. Post-discharge follow-up call revealed 1 of 20 patients who had AirSeal port site pain in group 1 and 5 of 17 in group 2 (P = 0.04). Pain scores also tended to be higher for group 2.

CONCLUSIONS

Our preliminary analysis of this novel technique to close the AirSeal port in two separate layers improves postoperative pain related to this port site.

Observational study of the medical management of patients with peripheral artery disease

BACKGROUND

Previous research has suggested that patients with peripheral artery disease (PAD) are not offered adequate risk factor modification, despite their high cardiovascular risk. The aim of this study was to assess the cardiovascular profiles of patients with PAD and quantify the survival benefits of target-based risk factor modification.

METHODS

The Vascular and Endovascular Research Network (VERN) prospectively collected cardiovascular profiles of patients with PAD from ten UK vascular centres (April to June 2018) to assess practice against UK and European goal-directed best medical therapy guidelines. Risk and benefits of risk factor control were estimated using the SMART-REACH model, a validated cardiovascular prediction tool for patients with PAD.

RESULTS

Some 440 patients (mean(s.d.) age 70(11) years, 24·8 per cent women) were included in the study. Mean(s.d.) cholesterol (4·3(1·2) mmol/l) and LDL-cholesterol (2·7(1·1) mmol/l) levels were above recommended targets; 319 patients (72·5 per cent) were hypertensive and 343 (78·0 per cent) were active smokers. Only 11·1 per cent of patients were prescribed high-dose statin therapy and 39·1 per cent an antithrombotic agent. The median calculated risk of a major cardiovascular event over 10 years was 53 (i.q.r. 44-62) per cent. Controlling all modifiable cardiovascular risk factors based on UK and European guidance targets (LDL-cholesterol less than 2 mmol/l, systolic BP under 140 mmHg, smoking cessation, antiplatelet therapy) would lead to an absolute risk reduction of the median 10-year cardiovascular risk by 29 (20-38) per cent with 6·3 (4·0-9·3) cardiovascular disease-free years gained.

CONCLUSION

The medical management of patients with PAD in this secondary care cohort was suboptimal. Controlling modifiable risk factors to guideline-based targets would confer significant patient benefit.

HIV self-screening distribution preferences and experiences among men who have sex with men in Mpumalanga Province: Informing policy for South Africa

Current research suggests that HIV self-screening (HIVSS) is a feasible and acceptable approach to increase HIV testing among men who have sex with men (MSM). However, few data are available to shape policy around dissemination and implementation. Gaps in knowledge include preferences for distribution of HIVSS kits, potential social harms and benefits of their use, and how much test users would be willing to pay for the kits. The aim was to inform policy recommendations to optimise distribution of HIVSS kits to MSM in South Africa (SA), where there is a high HIV incidence and unmet testing needs. MSM in the high-HIV-prevalence Gert Sibande and Ehlanzeni districts of Mpumalanga Province, SA, were enrolled between October 2015 and May 2017. Participants were provided with their choice of blood or oral fluid HIVSS test kits, receiving 5 kits at enrolment and 4 additional kits at the 3-month follow-up visit. Questionnaires were administered at enrolment, 3 months and 6 months. We analysed participants' reported social benefits and harms, and their preferences for kit distribution and pricing. Among 127 MSM screened and enrolled, 114 responded to follow-up questionnaires regarding distribution preferences, 49.3% preferred to acquire HIVSS kits at a community-based organisation (CBO) and 42.7% at a clinic, with 8% preferring a pharmacy. Participants with higher education preferred CBO sites for distribution; in other respects preferences were similar by demographic characteristics. Reported social benefits were common, including knowing one's status, prevention knowledge gained and improved communication with partners. Despite ubiquitous interest in using the kits, the majority of MSM could not afford to purchase test kits. SA guidelines have integrated HIVSS into HIV and testing policy, but little has been published regarding distribution channels of the kits for MSM and other key populations. There is a partnership between the National Department of Health and CBOs that specialise in key population programming to ensure MSM and other populations with unmet testing needs can access affordable test kits. We observed no social harms, and there were multiple social benefits. Consequently, we recommend immediate free or low-cost distribution of HIVSS kits to MSM through community-based initiatives. Future research should continue to assess optimised linkage to care.

Comparison of Free Light Chain Assays: Freelite and N Latex in Diagnosis, Monitoring, and Predicting Survival in Light Chain Amyloidosis

OBJECTIVES

Measurement of serum free light chains (FLCs) is critical in diagnosis, prognosis, and monitoring treatment responses in light chain (AL) amyloidosis. We compare the Freelite assay (polyclonal antibodies to hidden light chain epitopes), which is the current gold standard, with a new assay: a mixture of monoclonal antibodies to light chain epitopes (N Latex).

METHODS

We collected 240 serum samples from 94 consecutive patients with newly diagnosed AL amyloidosis (at least three serial serum samples during the first 6 months) analyzed at the National Amyloidosis Centre, London, from January 2011 to April 2012. Concordance in detecting abnormal light chain components and hematologic response was assessed at 2, 4, and 6 months.

RESULTS

The κ and λ clonal light chain involvement was 21% and 79%, respectively, with an abnormal κ/λ ratio or detectable protein in 78.7%. Median κ, λ, and difference in involved and uninvolved FLCs by Freelite and N Latex assays were 17.3 vs 16 mg/L (R(2 ) = 0.91), 48.8 vs 52.6 mg/L (R(2) = 0.52), and 43.2 vs 39.1 mg/L, respectively. Discordant κ/λ ratios at presentation were as follows: 10 of 90 abnormal by Freelite/normal by N Latex and 11 of 90 abnormal by N Latex/normal by Freelite.

CONCLUSIONS

Both FLC assays show good correlation in detecting the abnormal light chain subtype with discordance in absolute values and thus are not interchangeable.

Neurology of the cryopyrin-associated periodic fever syndrome

BACKGROUND AND PURPOSE

The cryopyrin-associated periodic fever syndrome (CAPS) is an autosomal dominant autoinflammatory disorder caused by mutations in the NLRP3 gene and is typified by recurrent episodes of systemic inflammation resulting in fever, urticarial rash and arthralgia. In addition to these systemic aspects, CAPS has multiple neurological manifestations. The largest case series to date is presented focusing on the neurological features of this disorder.

METHODS

The case histories of a cohort of 38 UK patients with genetically proven CAPS who were treated with interleukin 1β (IL-1β) inhibition as part of a national treatment programme and underwent detailed neurological assessment were reviewed.

RESULTS

Across the entire disease course neurological manifestations were present in 95% of patients; 84% had some form of headache; 66% sensorineural hearing loss; 60% myalgia; 34% papilloedema and 26% optic atrophy. Patients with the T348M mutation tended to have a more severe neurological phenotype with an earlier age of onset. Four patients had cerebrospinal fluid examination, three of whom had evidence of aseptic meningitis. There was a marked response to IL-1β inhibition, which has revolutionized management of these patients (29/32 patients with headache responding).

CONCLUSION

Neurological symptoms are extremely common in CAPS and these results highlight the importance of increasing awareness amongst neurologists, particularly as highly effective therapies are available.

Systematic review of sonographic chronic cerebrospinal venous insufficiency findings in multiple sclerosis

OBJECTIVE

The sonographic findings of chronic cerebrospinal venous insufficiency (CCSVI) are used by some as selection criteria for venography. We performed a systematic review to establish the prevalence and strength of association between sonographic CCSVI and multiple sclerosis (MS).

METHOD

Two reviewers searched PubMed and EMBASE from 1948 to date using the keywords 'chronic cerebrospinal venous insufficiency' according to PRISMA guidelines.

RESULTS

Four cross-sectional studies met the criteria for inclusion. The prevalence of CCSVI ranged from 7% to 100% in MS patients and from 2% to 36% in healthy controls. Diagnostic odds ratios for MS varied between 2 and 26, 499 (I(2) = 94%). Sensitivities of CCSVI for MS varied between 7% and 100% (I(2) = 98%). Specificities varied between 64% and 100% (I(2) = 95%).

CONCLUSION

There is substantial variation in the strength of association between CCSVI and MS beyond that explained by demographic differences or sonographer training. Reliable evidence on which to base decisions requires sonographic consensus and assessment of the reproducibility of individual criteria between trained sonographers.

“I Can’t Go to School and Leave Her in So Much Pain”

“I go to the hospital with my mother when she is sick. I can’t go to school and leave her in so much pain. I won’t concentrate.” Millions of adolescents live with AIDS-affected parents or primary caregivers. Little is known about educational impacts of living in an AIDS-affected home, or of acting as a “young carer” in the context of AIDS. This study combined qualitative and quantitative methods to determine educational impacts of household AIDS-sickness and other-sickness. Six hundred and fifty-nine adolescents (aged 10-20) were interviewed in high-poverty areas of urban and rural South Africa. Qualitative findings identified three major themes of missing school, being hungry at school, and concentration problems due to worry about the sick person. In quantitative analyses, living in an AIDS-affected home predicted all these three outcomes ( p < .001) compared to homes affected by other sickness and to healthy homes, and independent of sociodemographic cofactors. This study demonstrates that familial AIDS-sickness is associated with negative educational impacts for adolescents. It is important that policies are developed to support young people in these circumstances to continue with their education.

Scalable learning of large networks

Cellular networks inferred from condition-specific microarray data can capture the functional rewiring of cells in response to different environmental conditions. Unfortunately, many algorithms for inferring cellular networks do not scale to whole-genome data with thousands of variables. We propose a novel approach for scalable learning of large networks: cluster and infer networks (CIN). CIN learns network structures in two steps: (a) partition variables into smaller clusters, and (b) learn networks per cluster. We optionally revisit the cluster assignment of variables with poor neighbourhoods. Results on networks with known topologies suggest that CIN has substantial speed benefits, without substantial performance loss. We applied our approach to microarray compendia of glucose-starved yeast cells. The inferred networks had significantly higher number of subgraphs representing meaningful biological dependencies than random graphs. Analysis of subgraphs identified biological processes that agreed well with existing information about yeast populations under glucose starvation, and also implicated novel pathways that were previously not known to be associated with these populations. [Includes supplementary material].

"They see you as a different thing": the experiences of men who have sex with men with healthcare workers in South African township communities

OBJECTIVES

To describe interactions between men who have sex with men (MSM) and healthcare workers (HCW) in peri-urban township communities in South Africa.

METHOD

Qualitative study using semistructured in-depth interviews and focus group discussions in the Gauteng province townships of Soweto and Mamelodi. 32 MSM were purposively sampled for in-depth interviews and 15 for focus group discussions. Topics explored included identity, sexuality, community life, use of health services and experiences of stigma and discrimination.

RESULTS

MSM felt their options for non-stigmatising sexual healthcare services were limited by homophobic verbal harassment by HCW. Gay-identified men sought out clinics with reputations for employing HCW who respected their privacy and their sexuality and challenged those HCW who mistreated them. Non-gay-identified MSM presented masculine, heterosexual identities when presenting for sexual health problems and avoided discussing their sexuality with HCW.

CONCLUSIONS

The strategies MSM employ to confront or avoid homophobia from HCW may not be conducive to sexual health promotion in this population. Interventions that increase the capacity of public sector HCW to provide appropriate sexual health services to MSM are urgently needed.

Hybrid ICA-Bayesian network approach reveals distinct effective connectivity differences in schizophrenia

We utilized a discrete dynamic Bayesian network (dDBN) approach (Burge, J., Lane, T., Link, H., Qiu, S., Clark, V.P., 2007. Discrete dynamic Bayesian network analysis of fMRI data. Hum Brain Mapp.) to determine differences in brain regions between patients with schizophrenia and healthy controls on a measure of effective connectivity, termed the approximate conditional likelihood score (ACL) (Burge, J., Lane, T., 2005. Learning Class-Discriminative Dynamic Bayesian Networks. Proceedings of the International Conference on Machine Learning, Bonn, Germany, pp. 97-104.). The ACL score represents a class-discriminative measure of effective connectivity by measuring the relative likelihood of the correlation between brain regions in one group versus another. The algorithm is capable of finding non-linear relationships between brain regions because it uses discrete rather than continuous values and attempts to model temporal relationships with a first-order Markov and stationary assumption constraint (Papoulis, A., 1991. Probability, random variables, and stochastic processes. McGraw-Hill, New York.). Since Bayesian networks are overly sensitive to noisy data, we introduced an independent component analysis (ICA) filtering approach that attempted to reduce the noise found in fMRI data by unmixing the raw datasets into a set of independent spatial component maps. Components that represented noise were removed and the remaining components reconstructed into the dimensions of the original fMRI datasets. We applied the dDBN algorithm to a group of 35 patients with schizophrenia and 35 matched healthy controls using an ICA filtered and unfiltered approach. We determined that filtering the data significantly improved the magnitude of the ACL score. Patients showed the greatest ACL scores in several regions, most markedly the cerebellar vermis and hemispheres. Our findings suggest that schizophrenia patients exhibit weaker connectivity than healthy controls in multiple regions, including bilateral temporal, frontal, and cerebellar regions during an auditory paradigm.

Effect of airway clearance techniques on the efficacy of the sputum induction procedure

Sputum induction is used in the early identification of tuberculosis (TB) and pneumocystis infections of the lung. Although manual physiotherapy techniques to clear the airways are often incorporated in the sputum induction procedure, their efficacy in this setting is unknown. This randomised, crossover trial enrolled adults referred for sputum induction for suspected TB and pneumocystis infections of the lung. All participants underwent two sputum induction procedures, inhaling 3% saline via ultrasonic nebuliser. During one randomly allocated procedure, airway clearance techniques (chest wall percussion, vibration, huffing) were incorporated. In total, 59 participants completed the trial. The airway clearance techniques had no significant effect on how the test was tolerated, the volume expectorated or the quality of the sample obtained (assessed by the presence of alveolar macrophages). The techniques did not significantly affect how often the test identified a suspected organism, nor the sensitivity or specificity of sputum induction. In conclusion, the study was unable to demonstrate any effect of airway clearance techniques on the sputum induction procedure. The results provide some justification for not including airway clearance techniques as part of the sputum induction procedure.

FLAG chemotherapy followed by allogeneic stem cell transplant using nonmyeloablative conditioning induces regression of myelofibrosis with myeloid metaplasia

A 38-year-old woman with agnogenic myeloid metaplasia complicated by the poor prognostic factors of severe osteosclerosis, prominent hepatosplenomegaly, and profound anemia was treated with FLAG chemotherapy to decrease her organomegaly before undergoing a nonmyeloablative allogeneic stem cell transplant from a matched-sibling donor. The patient's pre- and post transplant course were complicated by an autoimmune disorder and her post transplant course was complicated by severe hepatic and gastrointestinal GVHD. A technetium-99m sulfur colloid scan 4 months post transplant and bone marrow studies 8 months post transplant demonstrated intramedullary hematopoiesis, complete resolution of marrow fibrosis, and partial resolution of osteosclerosis.

Urethral catheter: a pain in the neck!

Long-term urinary catheterization is well recognized in the literature as being associated with significant morbidity and mortality. We present a rare and previously unreported complication of a cervical spine abscess resulting from methicillin-resistant Staphylococcus aureus septicaemia originating from the urinary tract in a patient with a urinary catheter.