Impact of different hand-drying methods on surrounding environment: aerosolization of virus and bacteria, and transfer to surfaces

BACKGROUND

In recent years, hand drying has been highlighted as a key step in appropriate hand hygiene, as moisture on hands can increase the transfer of micro-organisms from hands to surfaces and vice versa.

AIM

To understand bacterial and viral aerosolization following hand drying, and study the transfer of micro-organisms from hands to surfaces after drying using different methods.

METHODS

Groups of five volunteers had their hands pre-washed with soap, rinsed and dried, then inoculated with a concentrated mixture of Pseudomonas fluorescens and MS2 bacteriophage. Volunteers entered an empty washroom, one at a time, and rinsed their hands with water or washed their hands with soap prior to drying with a jet dryer or paper towels. Each volunteer applied one hand successively to various surfaces, while their other hand was sampled using the glove juice method. Both residual bacteria and viruses were quantified from the washroom air, surface swabs and hand samples.

FINDINGS

P. fluorescens and MS2 bacteriophages were rarely aerosolized while drying hands for any of the drying methods studied. Results also showed limited, and similar, transfer of both micro-organisms studied on to surfaces for all drying methods.

CONCLUSION

The use of jet dryers or paper towels produces low levels of aerosolization when drying hands in a washroom. Similarly, all drying methods result in low transfer to surfaces. While the coronavirus disease 2019 pandemic raised concerns regarding public washrooms, this study shows that all methods tested are hygienic solutions for dry washed hands.

Longitudinal relationships between self-compassion and depressive symptoms in midlife women

OBJECTIVE

Women in midlife face a range of biopsychosocial stressors that increase the risk of depression, with potential negative consequences in older adulthood. Lower self-compassion is known to predict subsequent depressive symptoms, but little is known about whether depressive symptoms predict subsequent levels of self-compassion. This study examined the longitudinal and reciprocal relationships between self-compassion and depressive symptoms over a 5-year period in midlife.

METHOD

This longitudinal study used data from 272 women aged 40-60 years at baseline. Cross-lagged panel analysis was used to investigate reciprocal relationships between depressive symptoms and self-compassion at baseline and 5-year follow-up.

RESULTS

After controlling for autoregressive effects, self-compassion at baseline explained 4% of unique variance in depressive symptoms 5 years later. Baseline depressive symptoms also predicted subsequent levels of self-compassion, with 2% of unique variance explained.

CONCLUSION

This is the first study to report a bidirectional longitudinal relationship between self-compassion and depressive symptoms. Midlife women may experience a negative cycle whereby low self-compassion and depressive symptoms reinforce each other through midlife and into older adulthood. Clinical trials examining self-compassion interventions in midlife are indicated.

Integrating dairy manure for enhanced resource recovery at a WRRF: Environmental life cycle and pilot-scale analyses

The Twin Falls, Idaho wastewater treatment plant (WWTP), currently operates solely to achieve regulatory permit compliance. Research was conducted to evaluate conversion of the WWTP to a water resource recovery facility (WRRF) and to assess the WRRF environmental sustainability; process configurations were evaluated to produce five resources-reclaimed water, biosolids, struvite, biogas, and bioplastics (polyhydroxyalkanoates, PHA). PHA production occurred using fermented dairy manure. State-of-the-art biokinetic modeling, performed using Dynamita's SUMO process model, was coupled with environmental life cycle assessment to quantify environmental sustainability. Results indicate that electricity production via combined heat and power (CHP) was most important in achieving environmental sustainability; energy offset ranged from 43% to 60%, thereby reducing demand for external fossil fuel-based energy. While struvite production helps maintain a resilient enhanced biological phosphorus removal (EBPR) process, MgO₂ production exhibits negative environmental impacts; integration with CHP negates the adverse consequences. Integrating dairy manure to produce bioplastics diversifies the resource recovery portfolio while maintaining WRRF environmental sustainability; pilot-scale evaluations demonstrated that WRRF effluent quality was not affected by the addition of effluent from PHA production. Collectively, results show that a WRRF integrating dairy manure can yield a diverse portfolio of products while operating in an environmentally sustainable manner. PRACTITIONER POINTS: Wastewater carbon recovery via anaerobic digestion with combined heat/power production significantly reduces water resource recovery facility (WRRF) environmental emissions. Wastewater phosphorus recovery is of value; however, struvite production exhibits negative environmental impacts due to MgO₂ production emissions. Bioplastics production on imported organic-rich agri-food waste can diversify the WRRF portfolio. Dairy manure can be successfully integrated into a WRRF for bioplastics production without compromising WRRF performance. Diversifying the WRRF products portfolio is a strategy to maximize resource recovery from wastewater while concurrently achieving environmental sustainability.

Virtual multispecialty point-of-care ultrasound rotation for fourth-year medical students during COVID-19: Innovative teaching techniques improve ultrasound knowledge and image interpretation

OBJECTIVES

Point-of-care ultrasound (PoCUS) has been integrated into undergraduate medical education. The COVID-19 pandemic forced medical schools to evolve clinical rotations to minimize interruption through implementation of novel remote learning courses. To address the students' need for remote clinical education, we created a virtual PoCUS course for our fourth-year class. We present details of the course's development, implementation, quality improvement processes, achievements, and limitations.

METHODS

A virtual PoCUS course was created for 141 fourth-year medical students. The learning objectives included ultrasound physics, performing and interpreting ultrasound applications, and incorporating PoCUS into clinical decisions and procedural guidance. Students completed a 30-question pre- and posttest focused on ultrasound and knowledge of clinical concepts. PoCUS educators from 10 different specialties delivered the course over 10 days using video-conferencing software. Students watched live scanning demonstrations and practiced ultrasound probe maneuvers using a cellular telephone to simulate ultrasound probe. Students completed daily course evaluations that were used as a continuous needs assessment to make improvements.

RESULTS

A total of 141 students participated in the course; all received a passing grade. The mean pre- and posttest scores improved from 58% to 88% (p < 0.001) through the course duration. Daily evaluations revealed the percentage of students who rated the course's live scanning sessions and didactic components as "very well" increased from 32.7% on day 1 to 69.7% on day 10. The end-of-course evaluation revealed that 91% of students agreed they received effective teaching.

CONCLUSIONS

In response to the COVID-19 pandemic, our multispecialty faculty expeditiously developed a virtual PoCUS curriculum for the entire fourth-year class. This innovative course improved students' ultrasound knowledge, image interpretation, and clinical application while utilizing novel techniques to teach a hands-on skill virtually. As the demand for PoCUS instruction continues to increase, the accessibility of virtual training and blended learning will be beneficial.

Simulation training for clinicians returning to practice

Many doctors take time out of clinical practice, and then have decreased confidence and poor performance ratings on their return. Simulation training provides a safe and effective learning platform for healthcare professionals to become immersed in realistic scenarios that provide an opportunity to develop technical and non-technical skills. A standardised, 1-day, multi-fidelity, interprofessional, simulation training course was developed and delivered at four sites, focusing on human factors, patient safety and acute clinical scenarios relevant for clinicians returning to practice in internal medicine. A total of 56 participants, with a median time out of training of 3.6 years, attended seven courses. Quantitative and qualitative analysis showed a significant pre/post-course increase in candidates' self-reported confidence in returning to practice along with learning in non-technical skills. The carefully designed standardised format may facilitate wider expansion of such training.

An Incidental Finding of Coronary-cameral Fistulas in a Critically Ill Patient with a Metastatic Cardiac Tumor

It is extremely rare for a cardiac tumor to present with coronary-cameral fistulas. A 66-year-old Caucasian male presented with worsening dyspnea and subsequently had a cardiac catheterization for an ST-elevation myocardial infarction, revealing no evidence of coronary artery disease but multiple coronary-cameral fistulas. Venoarterial (VA) extracorporeal membrane oxygenation was initiated for a severe cardiogenic shock. Workups including a transesophageal echocardiography and a right heart catheterization led to a diagnosis of metastatic melanoma involving both ventricles of his heart. Angiogenesis is well described in melanomas and our novel case reports the extremely rare association of coronary-cameral fistulas with a metastatic cardiac melanoma. How to cite this article: Thyagarajan B, Bryant C, Khanna AK. An Incidental Finding of Coronary-cameral Fistulas in a Critically Ill Patient with a Metastatic Cardiac Tumor. Indian J Crit Care Med 2021;25(3):340-342.

A systematic review of the literature assessing the outcomes of stapled haemorrhoidopexy versus open haemorrhoidectomy

Background

Symptomatic haemorrhoids affect a large number of patients throughout the world. The aim of this systematic review was to compare the surgical outcomes of stapled haemorrhoidopexy (SH) versus open haemorrhoidectomy (OH) over a 20-year period.

Methods

Randomized controlled trials published between January 1998 and January 2019 were extracted from Pubmed using defined search criteria. Study characteristics and outcomes in the form of short-term and long-term complications of the two techniques were analyzed. Any changes in trend of outcomes over time were assessed by comparing article groups 1998–2008 and 2009–2019.

Results

Twenty-nine and 9 relevant articles were extracted for the 1998–2008 (period 1) and 2009–2019 (period 2) cohorts, respectively. Over the two time periods, SH was found to be a safe procedure, associated with statistically reduced operative time (in 13/21 studies during period 1 and in 3/8 studies during period 2), statistically less intraoperative bleeding (3/7 studies in period 1 and 1/1 study in period 2) and consistently less early postoperative pain on the visual analogue scale (12/15 studies in period 1 and 4/5 studies in period 2) resulting in shorter hospital stay (12/20 studies in period 1 and 2/2 studies in period 2) at the expense of a higher cost. In the longer term, although chronic pain in SH and OH patents is comparable, patient satisfaction with SH may decline with time and at 2-year follow-up OH appeared to be associated with greater patient satisfaction.

Conclusions

SH appears to be safe with potential advantages, at least in the short term, but the evidence is lacking at the moment to suggest its routine use in clinical practice.

Assessing the Effects of RAS Fermentation on EBPR Performance and Associated Microbial Ecology

  Enhanced biological phosphorus removal (EBPR) is an engineered water resource recovery facility (WRRF) process configuration that can produce effluent P < 0.5 mg/L. To consistently achieve low effluent P concentrations, EBPR requires volatile fatty acids (VFAs) to induce requisite biochemical reactions. Moreover, returned activated sludge (RAS) nitrate concentrations must be minimized. Returned activated sludge fermentation can potentially address process needs. However, research detailed herein highlights concerns with RAS fermentation integrated with EBPR. Under 2 and 4 hours of RAS fermentation periods, no consequential VFA production was observed; similar results were observed in batch tests with RAS from a full-scale EBPR WRRF. More critically, EBPR performance was poor, with average effluent concentrations of 1.0 to 2.4 mg/L. Furthermore, the glycogen accumulating organism (GAO) fraction under RAS fermentation was 4.3 to 8.7 times higher than in a conventional EBPR mixed microbial consortium (MMC). Integrated RAS fermentation-EBPR only performed well under "high" RAS nitrate; thus, should RAS fermentation be implemented, careful control to prevent anaerobic conditions in the fermentation zone is required.

The Mental Capacity Act 2005: Considerations for obtaining consent for dental treatment

The Mental Capacity Act 2005 provides a legal framework within which specific decisions must be made when an individual lacks the mental capacity to make such decisions for themselves. With an increasingly aged, medically complex and in some cases socially isolated population presenting for dental care, dentists need to have a sound understanding of the appropriate management of patients who lack capacity to consent to treatment when they present in the dental setting. Patients with acute symptoms requiring urgent care and un-befriended patients present additional complexities. In these situations a lack of familiarity with how best to proceed and confusion in the interpretation of relevant guidance, combined with the working time pressures experienced in dental practice may further delay the timely dental management of vulnerable patients. We will present and discuss the treatment of three patients who were found to lack the mental capacity necessary to make decisions about their dental care and illustrate how their differing situations determined the appropriate management for each.

Mitogen-activated protein kinases (MAPKs) are modulated during Francisella tularensis infection, but inhibition of extracellular-signal-regulated kinases (ERKs) is of limited therapeutic benefit

Francisella tularensis is a Gram-negative intracellular bacterium that causes the disease tularemia. The disease can be fatal if left untreated and there is currently no licenced vaccine available; the identification of new therapeutic targets is therefore required. Toll-like receptors represent an interesting target for therapeutic modulation due to their essential role in generating immune responses. In this study, we analysed the in vitro expression of the key mitogen-activated protein kinases (MAPKs) p38, JNK and ERK in murine alveolar macrophages during infection with F. tularensis. The phosphorylation profile of ERK highlighted its potential as a target for therapeutic modulation and subsequently the effect of ERK manipulation was measured in a lethal intranasal F. tularensis in vivo model of infection. The selective ERK1/2 inhibitor PD0325901 was administered orally to mice either pre- or post-challenge with F. tularensis strain LVS. Both treatment regimens selectively reduced ERK expression, but only the pre-exposure treatment produced decreased bacterial burden in the spleen and liver, which correlated with a significant reduction in the pro-inflammatory cytokines IFN-γ, MCP-1, IL-6, and TNF-α. However, no overall improvements in survival were observed for treated animals in this study. ERK may represent a useful therapeutic target where selective dampening of the immune response (to control the damaging pathology seen during infection) is combined with antibiotic treatment required to eradicate bacterial infection. This combination treatment strategy has been shown to be effective in other models of tularemia.

Multiple myeloma causes clonal T-cell immunosenescence: identification of potential novel targets for promoting tumour immunity and implications for checkpoint blockade

Tumour-induced dysfunction of cytotoxic T cells in patients with multiple myeloma (MM) may contribute to immune escape and be responsible for the lack of therapeutic efficacy of immune checkpoint blockade. We therefore investigated dysfunctional clonal T cells in MM and demonstrated immunosenescence but not exhaustion as a predominant feature. T-cell clones were detected in 75% of MM patients and their prognostic significance was revalidated in a new post-immunomodulatory drug cohort. The cells exhibited a senescent secretory effector phenotype: KLRG-1+/CD57+/CD160+/CD28-. Normal-for-age telomere lengths indicate that senescence is telomere independent and potentially reversible. p38-mitogen-activated protein kinase, p16 and p21 signalling pathways known to induce senescence were not elevated. Telomerase activity was found to be elevated and this may explain how normal telomere lengths are maintained in senescent cells. T-cell receptor signalling checkpoints were normal but elevated SMAD levels associated with T-cell inactivation were detected and may provide a potential target for the reversal of clonal T-cell dysfunction in MM. Low programmed death 1 and cytotoxic T-lymphocyte-associated antigen 4 expression detected on T-cell clones infers that these cells are not exhausted but suggests that there would be a suboptimal response to immune checkpoint blockade in MM. Our data suggest that other immunostimulatory strategies are required in MM.

Profound parental bias associated with chromosome 14 acquired uniparental disomy indicates targeting of an imprinted locus

Acquired uniparental disomy (aUPD) is a common finding in myeloid malignancies and typically acts to convert a somatically acquired heterozygous mutation to homozygosity. We sought to identify the target of chromosome 14 aUPD (aUPD14), a recurrent abnormality in myeloid neoplasms and population cohorts of elderly individuals. We identified 29 cases with aUPD14q that defined a minimal affected region (MAR) of 11.2 Mb running from 14q32.12 to the telomere. Exome sequencing (n=7) did not identify recurrently mutated genes, but methylation-specific PCR at the imprinted MEG3-DLK1 locus located within the MAR demonstrated loss of maternal chromosome 14 and gain of paternal chromosome 14 (P<0.0001), with the degree of methylation imbalance correlating with the level of aUPD (r=0.76; P=0.0001). The absence of driver gene mutations in the exomes of three individuals with aUPD14q but no known haematological disorder suggests that aUPD14q may be sufficient to drive clonal haemopoiesis. Analysis of cases with both aUPD14q and JAK2 V617F (n=11) indicated that aUPD14q may be an early event in some cases but a late event in others. We conclude that aUPD14q is a recurrent abnormality that targets an imprinted locus and may promote clonal haemopoiesis either as an initiating event or as a secondary change.

Long-term survival in multiple myeloma is associated with a distinct immunological profile, which includes proliferative cytotoxic T-cell clones and a favourable Treg/Th17 balance

Despite improved outcomes in multiple myeloma (MM), a cure remains elusive. However, even before the current therapeutic era, 5% of patients survived >10 years and we propose that immune factors contribute to this longer survival. We identified patients attending our clinic, who had survived >10 years (n=20) and analysed their blood for the presence of T-cell clones, T-regulatory cells (Tregs) and T helper 17 (Th17) cells. These results were compared with MM patients with shorter follow-up and age-matched healthy control donors. The frequency of cytotoxic T-cell clonal expansions in patients with <10 years follow-up (MM patients) was 54% (n=144), whereas it was 100% (n=19/19) in the long-survivors (LTS-MM). T-cell clones from MM patients proliferated poorly in vitro, whereas those from LTS-MM patients proliferated readily (median proliferations 6.1% and 61.5%, respectively (P<0.0001)). In addition, we found significantly higher Th17 cells and lower Tregs in the LTS-MM group when compared with the MM group. These results indicate that long-term survival in MM is associated with a distinct immunological profile, which is consistent with decreased immune suppression.

The relationship between obesity and hypoferraemia in adults: a systematic review

A growing number of studies suggest a potential link between obesity and altered iron metabolism. The purpose of this systematic review was to examine existing literature on iron status in obese populations. A comprehensive literature search was conducted. Included studies recruited participants ≥ 18 years with a body mass index ≥ 30 kg m(-2) and provided descriptive statistics for haemoglobin or ferritin at a minimum. There were 25 studies meeting all eligibility criteria, of these 10 examined iron status in free-living obese individuals and 15 reported baseline iron biomarkers from bariatric surgery candidates. Non-obese comparison groups were used by 10 (40%) articles. In these, seven obese groups reported higher mean haemoglobin concentration; six reported significantly higher ferritin concentration; and four significantly lower transferrin saturation. Due to insufficient data, it was not possible to make conclusions regarding mean differences for soluble transferrin receptor (sTfR), hepcidin or C-reactive protein. Existing evidence suggests a tendency for higher haemoglobin and ferritin concentration and lower transferrin saturation in obesity. Alternation of iron biomarkers in obese populations may be a result of obesity-related inflammation and/or related comorbidities. Further research incorporating measurement of inflammatory cytokines, sTfR and hepcidin is required to confirm the impact of obesity on iron status.

Evaluation and management of depressive and anxiety symptoms in midlife

OBJECTIVES

Evaluation and management of anxiety and depression during the menopausal transition are complicated by the overlap between some symptoms of affective disorder with those of menopausal symptoms, and also by inconsistencies in the literature regarding the relationship between the menopausal transition and affective disorders.

METHODS

We have reviewed key studies over the past three decades addressing depression and anxiety during the menopause transition, in order to present a practical, clinical approach to the evaluation and management of anxiety and depressive symptoms at midlife.

RESULTS

Symptoms of anxiety and depression are common at midlife and may coincide with menopausal symptoms. Some menopausal symptoms are also symptoms of anxiety and/or depression. Management should include treatment of troublesome menopausal symptoms, providing strategies to deal with psychosocial stressors, and exclusion of clinically significant anxiety and depressive disorders. Interventions such as exercise and cognitive behavior therapy may improve mood and general health at menopause, and a multifocal approach is recommended. Depression of greater than moderate severity requires treatment with an antidepressant. Some selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors may also improve vasomotor symptoms and these should be considered in women with both affective disorder and vasomotor symptoms.

CONCLUSIONS

There is no clear evidence that the menopause transition alone increases the risk of clinically significant affective disorders, except in women with risk factors such as psychosocial stressors, severe and prolonged vasomotor symptoms and a previous history of affective disorders. Nevertheless, anxiety and depression are common in women and clinicians should be alert to the symptoms of these conditions at all encounters.

The Inhibition of Malic Dehydrogenase by Salicylate and Related Compounds

Salicylate and γ-resorcylate affected the distribution of radioactivity incorporated from labelled succinate into the soluble intermediates of rat liver mitochondria in a manner consistent with an inhibitory action of the drugs on malic dehydrogenase. The addition of nicotinamide adenosine dinucleotide to the mitochondrial preparations reversed the effects of salicylate and γ-resorcylate. A general structural requirement for inhibitory activity against malic dehydrogenase in vitro in salicylate congeners appears to be a phenolic hydroxyl group in the ortho position to a carboxyl group except that 2-hydroxyphenylacetate also inhibited the enzyme.

Abstract PD08-10: Breast Cancer Survivors Healthy Lifestyle Study: A Randomised Controlled Pilot To Test the Effects of a Behavioural Intervention (Information and Advice) on Uptake of Physical Activity in Breast Cancer Survivors

Background: Physical activity (PA) is a potentially modifiable behavioural risk factor for breast cancer recurrence. It declines during treatment, and most breast cancer survivors do not engage in PA at recommended levels. Effective interventions to increase PA after primary treatment for early stage breast cancer are needed.

Materials and Methods: Between November 2008 and January 2010, women who had completed primary treatment for early stage breast cancer, and not currently meeting PA guidelines, were randomly assigned to one of three conditions; 1) control group (UC) received a self-care fact sheet, or an intervention group 2) which received a theory based information booklet, diary and pedometer (INFO), or an alternate intervention group 3) which also received theory based information, diary and pedometer combined with a behavioural planning intervention (INFO+BPI). Measures (self reported PA, six minute walk test, mood, and quality of life) were collected at baseline (T1) and at 12 weeks (T2). The primary endpoint was self reported minutes of moderate to strenuous PA per week, secondary endpoints included mood and quality of life. A linear mixed models analysis approach was used to analyse data.

Results: 118 women were randomized and 107 completed T2 measures. The average age of participants was 54.6 years (Range 32-74), 31.8% had stage I disease, 38.3% had stage II disease, 15% had stage IIIa disease and 15% had DCIS, 58% had received adjuvant chemotherapy. Motivation (intention) to increase PA did not differ between groups at T1. There were no differences between groups in PA at T1. PA levels increased in all groups between T1 and T2 (P&lt;0.0001), but PA in the two intervention groups increased significantly more than in controls (+113.9 and +139.9 min per week increase in INFO and INFO + BPI respectively compared to +61.3 min per week in UC), such that at T2, there was a statistically significant difference between the intervention groups versus controls with +65 min per week increase on average (95% CI 25.3 to 104.8, p=0.02). There was no significant difference between the two intervention groups, with +25.9 min difference on average (95% CI -73.4 to 21.6, p=0.25). There were no significant differences in quality of life, anxiety or depression between groups at T1. No adverse events were reported.

Discussion: Minimally intensive, theory-based interventions increased PA participation over a 12 week period in this single centre study. The addition of a behavioural planning intervention to the INFO intervention did not significantly improve PA participation. Results of a T3, 12 month, follow up will be important in determining sustainability of the behaviour change following these interventions. A larger multicentre study is warranted to confirm the efficacy of the intervention.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD08-10.

Endometrial carcinoma (EC) in women 35 years of age or younger

16000

Background: Although the majority of women with EC are postmenopausal, 25% are under the age of 50 years at the time of diagnosis. The aim of this study is to describe the demographic and survival data for women presenting with EC at age 35 years or younger (YOY). Design: Patients with a diagnosis of EC were identified from the Surveillance, Epidemiology, and End Results (SEER) cancer database from 1988 to 2003. Demographic and pathologic data were collected. Chi-square and t-tests were used to examine differences between the younger and older women, and survival analyses were performed using Kaplan Meier and Cox regression models. Results: Of the 61,364 women diagnosed with EC in the study period, 931 patients 1.5% were 35 YOY. Compared to women 36 years of age or older at diagnosis, the young-onset women were more diverse in terms of race/ethnicity (p<0.0001), with white women comprising 48% of the younger population, and 80.4% of the older population. Hispanic 23.7%, black 8.3%, and other race/ethnicities 18.4% were more common in the younger age group. The mean age in the young population was 31.5 years. Mean age at diagnosis was greater for the young whites compared to the other racial groups combined (32.0 years vs. 31.0 years, p<<zemphx>0.0001). Younger women were more likely to be diagnosed in earlier stages and grades compared to their older counterparts (both p<0.0001). The overall stage by AJCC in younger women was 75.4%, 6.6%, 4.1% and 5.2% (stages I-IV, respectively), with 8.7% unstaged. In the younger women, 54.6%, 26.3%, and 9.5% of grade 1, 2, and 3 tumors were reported, respectively. Type II tumors comprised 4% (N=36) of the study population. The overall mean survival was significantly better for younger (75.4 months, 95% CI 71.8–79.0) compared to older women (66.6 months, 95% CI 66.2–67.0). The survival difference was seen for every AJCC stage of disease. Conclusions: The changing race and ethnicity demographics in the US, coupled with the increase in obesity, suggest that EC incidence may be on the rise in younger women. Early stage, well-differentiated EC represents the most common type of EC in the younger patients. As treatment standards differ for younger women who hope to preserve their fertility, it is important to follow the long-term outcomes in this group.

No significant financial relationships to disclose.

Power Doppler 'blanching' after the application of transducer pressure

The aim of this study was to determine if transducer pressure modifies power Doppler assessments of rheumatoid arthritis synovium at the metacarpophalangeal joints and metatarsophalangeal joints. Five rheumatoid arthritis patients of varying degrees of 'disease activity' and damage were assessed with power Doppler ultrasound scanning of the dominant hand second to fifth metacarpophalangeal joints. Two rheumatoid arthritis patients had their dominant foot first to fifth metatarsophalangeal joints assessed with power Doppler ultrasound. Ultrasonography was performed with a high frequency transducer (14 MHz) with a colour mode frequency of 10 Mhz, and a standard colour box and gain. In the joint that showed the highest power Doppler signal, an image was made. A further image was taken after transducer pressure was applied. In all patients, there was increased flow to at least one joint. After pressure was applied, power Doppler signal intensity markedly reduced in all images and in some there was no recordable power Doppler signal. Increased transducer pressure can result in a marked reduction or obliteration in power Doppler signal. This power Doppler 'blanching' shows the need for further studies to evaluate sources of error and standardization before power Doppler ultrasound becomes a routine measure of 'disease activity' in rheumatoid arthritis.

Footstrike is the major cause of hemolysis during running

There is a wide body of literature reporting red cell hemolysis as occurring after various forms of exercise. Whereas the trauma associated with footstrike is thought to be the major cause of hemolysis after running, its significance compared with hemolysis that results from other circulatory stresses on the red blood cell has not been thoroughly addressed. To investigate the significance of footstrike, we measured the degree of hemolysis after 1 h of running. To control for the potential effects of oxidative and circulatory stresses on the red blood cell, the same subjects cycled for 1 h at equivalent oxygen uptake. Our subjects were 10 male triathletes, who each completed two separate 1-h sessions of running and cycling at 75% peak oxygen uptake, which were performed in random order 1 wk apart. Plasma free hemoglobin and serum haptoglobin concentrations were measured as indicators of hemolysis. We also measured methemoglobin as a percentage of total hemoglobin immediately postexercise as an indicator of red cell oxidative stress. Plasma free hemoglobin increased after both running (P < 0.01) and cycling (P < 0.01), but the increase was fourfold greater after running (P < 0.01). This was reflected by a significant fall in haptoglobin 1 h after the running trials, whereas no significant changes occurred after cycling at any sample point. Methemoglobin increased twofold after both running and cycling (P < 0.01), with no significant differences between modes of exercise. The present data indicate that, whereas general circulatory trauma to the red blood cells associated with 1 h of exercise at 75% maximal oxygen uptake may result in some exercise-induced hemolysis, footstrike is the major contributor to hemolysis during running.