Utility of Extended High-Frequency Audiograms in Clinical Practice

OBJECTIVES

Extended high-frequency (EHF) audiometry elicits pure-tone thresholds at frequencies above 8 kHz, which are not included in routine clinical testing. This study explores the utility of EHF audiometry in patients with various audiologic symptoms despite normal-hearing thresholds at ≤8 kHz.

METHODS

A retrospective review was performed of all patients receiving conventional (250-8 kHz) and EHF (9-20 kHz) audiometry at a tertiary otological referral center between April 2021 and August 2022. Only patients with audiologic symptoms and pure-tone thresholds ≤25 dB HL at ≤8 kHz bilaterally on routine testing were included in subsequent analysis. EHF-PTA was defined for each ear as an average of the air conduction thresholds at 9.0, 10.0, 11.2, 12.5, 14.0, 16.0, 18.0, and 20.0 kHz.

RESULTS

Of the 50 patients who received EHF testing, 40 had audiologic symptoms and normal conventional audiograms at ≤8 kHz. Twenty-five of the 40 (62.5%) were found to have hearing loss in the highest frequencies. Patients with EHF hearing loss (EHF-HL) were more likely to report subjective hearing loss. Age was significantly greater in those with EHF-HL compared with those without EHF-HL, and age was positively correlated with the degree of EHF-HL.

CONCLUSION

EHF testing correlates with audiologic symptoms in patients with normal testing at ≤8 kHz and may be considered when standard audiometry is normal. Additional data are warranted to create an evidenced-based, clinical algorithm for EHF audiometry that can guide treatment, direct mitigation strategies, and potentially identify those at higher risk of hearing loss over time.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:907-910, 2024.

Trade-offs in nutrient and sediment losses in tile drainage from no-till versus conventional conservation-till cropping systems

Nutrient and soil loss from agricultural areas impairs surface water quality globally. In the Great Lakes region, increases in the frequency and magnitude of harmful and nuisance algal blooms in freshwater lakes have been linked to elevated phosphorus (P) losses from agricultural fields, some of which are transported via tile drainage. This study examined whether concentrations and loads of P fractions, total suspended sediments (TSS), nitrate (NO3 - ), and ammonium (NH4 + ) in tile drainage in a clay soil differed between a continuous no-till system combining cover crops and surface broadcast fertilizer (no-till cover crop [NTCC]), and a more conventional tillage system with shallow tillage, fertilizer incorporation and limited use of cover crops (conventional conservation-till, CT). Both sites had modest soil fertility levels. Year-round, high-frequency observations of tile drainage flow and chemistry are described over 4 full water years and related to management practices on the associated fields. There were similar water yields in tile drainage between the two systems; however, losses of TSS, particulate P (PP), and NO3 - were consistently greater from the CT site, which received larger quantities of fertilizer. In contrast, dissolved reactive P (DRP) losses were considerably greater from the NTCC site, offsetting the lower PP losses, such that there was little difference in TP losses between sites. Approximately 60% of the DRP losses from the NTCC site over the 4 years were associated with incidental losses following surface application of fertilizer in fall. This study provides insight into trade-offs in controlling losses of different nutrient fractions using different management systems.

POS1118 METFORMIN AS A POTENTIAL DISEASE-MODIFYING DRUG IN OSTEOARTHRITIS: A SYSTEMATIC REVIEW OF PRE-CLINICAL AND HUMAN STUDIES

Background

Osteoarthritis causes significant pain and disability with no approved disease-modifying drugs. There is evidence emerging from pre-clinical and human studies suggesting metformin may have disease-modifying properties in osteoarthritis1-5. Given its pleiotropic effects and safety profile, metformin has the potential to be a novel therapy for osteoarthritis.

Objectives

We systematically reviewed the evidence from both pre-clinical and human studies for the potential disease-modifying effect of metformin in osteoarthritis.

Methods

Ovid Medline, Embase and CINAHL were searched between inception and June 2021 using MeSH terms and key words to identify studies examining the association between metformin use and outcome measures related to osteoarthritis. Two reviewers performed the risk of bias assessment and 3 reviewers extracted data independently. Qualitative evidence synthesis was performed. This systematic review is registered on PROSPERO (CRD42021261052 and CRD42021261060).

Results

Fifteen (10 pre-clinical and 5 human) studies were included. Most studies (10 pre-clinical and 3 human) assessed the effect of metformin using knee osteoarthritis models. In pre-clinical studies, metformin was assessed for the effect on structural outcomes (n=10); immunomodulation (n=5); pain (n=4); and molecular pathways of its effect in osteoarthritis (n=7). For human studies, metformin was evaluated for the effect on structural progression (n=3); pain (n=1); and immunomodulation (n=1). Overall, pre-clinical studies consistently showed metformin having a chondroprotective, immunomodulatory and analgesic effect in osteoarthritis, predominantly mediated by adenosine monophosphate-activated protein kinase activation. Evidence from human studies, although limited, was consistent with findings in pre-clinical studies.

Conclusion

We found consistent evidence across pre-clinical and human studies to support a favourable effect of metformin on chondroprotection, immunomodulation and pain reduction in knee osteoarthritis. Further high-quality clinical trials are needed to confirm these findings as metformin could be a novel therapeutic drug for the treatment of osteoarthritis.

References

[1]Li H, Ding X, Terkeltaub R, Lin H, Zhang Y, Zhou B, et al. Exploration of metformin as novel therapy for osteoarthritis: preventing cartilage degeneration and reducing pain behavior. Arthritis Res Ther. 2020;22(1):34.

[2]Li J, Zhang B, Liu WX, Lu K, Pan H, Wang T, et al. Metformin limits osteoarthritis development and progression through activation of AMPK signalling. Ann Rheum Dis. 2020;79(5):635-645.

[3]Na HS, Kwon JY, Lee SY, Lee SH, Lee AR, Woo JS, et al. Metformin Attenuates Monosodium-Iodoacetate-Induced Osteoarthritis via Regulation of Pain Mediators and the Autophagy-Lysosomal Pathway. Cells. 2021;10(3).

[4]Lu CH, Chung CH, Lee CH, Hsieh CH, Hung YJ, Lin FH, et al. Combination COX-2 inhibitor and metformin attenuate rate of joint replacement in osteoarthritis with diabetes: A nationwide, retrospective, matched-cohort study in Taiwan. PLoS ONE [Electronic Resource]. 2018;13(1):e0191242.

[5]Wang Y, Hussain SM, Wluka AE, Lim YZ, Abram F, Pelletier JP, et al. Association between metformin use and disease progression in obese people with knee osteoarthritis: data from the Osteoarthritis Initiative-a prospective cohort study. Arthritis research & therapy. 2019;21(1):127.

Disclosure of Interests

Yuan Lim: None declared, Yuanyuan Wang: None declared, Mahnuma Estee: None declared, Jawad Abidi: None declared, Maushmi Udaya Kumar: None declared, Sultana Monira Hussain: None declared, Anita Wluka: None declared, Christopher Little Grant/research support from: CBL receives research funding from pharmaceutical companies (Fidia Farmaceutici, Cynata Therapeutics, Ceva Animal Health Pty Ltd and Regeneus Pty Ltd) to investigate efficacy of novel osteoarthritis therapeutics in pre-clinical models, through specific services/testing-contract research agreements between and managed by The University of Sydney or the Northern Sydney Local Health District, Flavia Cicuttini: None declared

The role of heavy metals in thyroid cancer: A meta-analysis

INTRODUCTION

Metal ions are known to accumulate in the thyroid and some play an important role in the function and homeostatic mechanisms of the thyroid gland. Certain metal ions are known endocrine disruptors while others are classified to be carcinogenic. Although higher thyroid cancer incidence rates have been reported in regions with high metal levels in soil and drinking water, including volcanic regions, the effect of heavy metals on the thyroid is still poorly understood. To investigate the association between heavy metals and thyroid cancer, a comprehensive meta-analysis was performed to draw a more evidence-based conclusion for individual metal ions.

MATERIAL AND METHODS

Nineteen studies were included in this meta-analysis, of which 9 studies reported blood metal ion levels, 8 studies reported tissue metal ion levels and 2 studies reported blood and tissue metal ion levels. The standardized mean difference (SMD) was calculated between thyroid cancer patients group and a control group (benign thyroid patients group or healthy controls group) per study.

RESULTS

A significant positive SMD in manganese tissue levels between thyroid cancer patients and benign thyroid patients (SMD: 0.56 (95 % CI: 0.16, 0.95)) and a significant negative SMD in cobalt blood levels between thyroid cancer patients and healthy controls (SMD: -2.03 (95 % CI: -3.95, -0.10)) was found. No difference in levels of other metals in blood or thyroid tissue between thyroid cancer patients and non-thyroid cancer patients was noted.

DISCUSSION AND CONCLUSION

The present meta-analysis therefore demonstrates the urgent need for future studies, especially given the increasing exposure of the general population to various environmental pollutants, including metal ions, and the thyroid cancer burden worldwide.

398 Theatre Waste Management and the Impact of COVID-19

Introduction

Audit of waste management in an elective orthopaedic complex was interrupted due Covid-19 pandemic. We investigated the impact of the enforced changes on theatre waste due to Covid-19.

Method

Over a 1week period data on waste bag availability and number of bags of each category of waste per surgical case in an elective theatre complex was collated; this was compared to waste generated during Covid-19 pandemic.

Results

Prior to Covid-19 only clinical waste bins were available in many non-dominant clinical areas providing evidence of inappropriate routine disposal of domestic/recyclable waste. Pre-Covid-19 a mean of 6waste bags were used per surgical case (3.7yellow clinical bags, 1.3black domestic bags, 0.4clear recycling bags), with Covid-19 changes to waste management practice the mean number of waste bags used per case increased to 11 (9 orange contaminated bags, 0.5black, 0.3clear bags).

Conclusions

Clinical waste management has a significant economic and environmental impact. Covid-19 has led to nearly all waste being deemed to be contaminated and so requiring incineration, with increased volumes of waste generated per case through widespread adoption of PPE. This has increased cost and reduced the ability to recycle non-contaminated waste.

397 Impact of COVID-19 on Theatre Utility

Introduction

Covid-19 has significantly impacted the environment in which surgeons operate. Level-2 PPE is worn in our orthopaedic theatres, with increased time taken for simple tasks due to claustrophobia, excessive heat, and difficulties in communication due to masks, including donning and doffing. We sought to determine the impact of Covid-19 on theatre utility.

Method

8week period during Covid-19 was reviewed for semi-elective orthopaedic surgery. Pre-Covid-19 case controls for age, procedure and ASA were identified. Electronic database was used to determine total time in theatre complex, time taken for anaesthesia, total procedure time, and time taken for patient to leave the theatre.

Results

27patients undergoing semi-elective surgery during Covid-19 pandemic and 27-matched controls from before pandemic were identified. No statistically significant difference in procedural or anaesthetic time. Significant difference in time interval between cases (14minutes pre-Covid-19 v 58minutes during Covid-19; p < 0.05). Mean theatre start times are 51minutes later during Covid-19.

Conclusions

Procedural times of surgery have not significantly increased, however the time between cases has increased; resulting in a decrease in overall theatre complex utility and direct impact on future costing.

A Narrative Review of Pharmacologic Treatments for COVID-19: Safety Considerations and Ototoxicity

OBJECTIVE/HYPOTHESIS

The purpose of this review is to summarize evidence-based data regarding the ototoxic effects of potential COVID-19 therapeutics to treat patients suffering from SARS-CoV-2.

METHODS

Medications under investigation as novel therapeutics to treat COVID-19 were identified using the search term coronavirus therapeutics, COVID therapeutics, and SARS-CoV-2 therapeutics on ClinicalTrials.gov and the PubMed Database. A literature review was performed using the PubMed Database for each proposed COVID-19 therapeutic to identify relevant articles. Search criteria included Medical Subject Headings (MeSH) and key word search terms for ototoxicity, vestibulotoxicity, hearing disorders, and vertigo.

RESULTS

Six proposed COVID-19 therapeutics were identified as possessing ototoxic side effects including chloroquine and hydroxychloroquine, azithromycin, lopinavir-ritonavir, interferon, ribavirin, and ivermectin.

CONCLUSIONS

Available evidence suggests that ototoxic effects may be improved or mitigated by stopping the offending agent. Recognition of hearing loss, tinnitus, or imbalance/vertigo is therefore crucial to facilitate early intervention and prevent long-term damage. Hospitals should consider the inclusion of audiologic monitoring protocols for patients receiving COVID-19 therapeutics with known ototoxicity, especially in high-risk patient groups such as the elderly and hearing impaired. Laryngoscope, 131:1626-1632, 2021.

The Impact of Socioeconomic Status on the Clinical Outcomes of COVID-19; a Retrospective Cohort Study

There have been limited data assessing the influence of disadvantaged socioeconomic status (SES) on the incidence and clinical outcomes of COVID-19 patients within the diverse communities of the United States. Here, we aim to investigate the association between poverty level, as an indicator of SES, and COVID-19 related clinical outcomes including hospitalization and all-cause mortality. This retrospective cohort study included 3528 patients with laboratory confirmed COVID-19 seen at a large New York City health system between March 1, 2020 and April 1, 2020. Data for neighborhood level poverty was acquired from the American Community Survey 2014–2018 and defined as the percent of residents in each ZIP code whose household income was below the federal poverty threshold (FPT): 0% to < 20% below FPT (low poverty) and > 20% below FPT (high poverty). COVID-19 positive patients who resided in high poverty areas were significantly younger, had a higher prevalence of comorbidities and were more likely to be of female gender or a racial minority when compared to individuals living in low poverty areas. Residence in a high poverty area was not associated with an increased risk of COVID-19 related hospitalization and was found to be associated with a decreased risk of in-hospital mortality. This study suggests the existence of an unequal socioeconomic gradient in the demographic and clinical presentation of COVID-19 patients including differences in age, gender and race between poverty groups. Further studies are needed to fully assess the intersectionality of SES with the COVID-19 pandemic.

Optical ultrasound (OpUS): a novel concept for intravascular imaging

Aims

To evaluate whether Optical Ultrasound (OpUS), a novel method for performing ultrasound imaging, could provide compelling, real-time visualizations of coronary vasculature.

Methods and results

With current commercial intravascular ultrasound (IVUS) devices, piezoelectric transducers are used to electrically generate and receive Ultrasound (US). With this paradigm, there are several challenges that limit further improvement in image resolution. Firstly, with increasing miniaturization of these piezoelectric transducers it can be difficult to achieve adequate sensitivity and bandwidth for high resolution imaging. Secondly, the complexities associated with fabricating and electrically connectorising broadband piezocomposite transducers can result in high manufacturing costs. Lastly, with increasing interest in identifying the molecular composition of atherosclerotic plaque, it has been challenging to achieve high resolution and high imaging depths, whilst also allowing for hybrid imaging with photoacoustics (PA) or near-infrared spectroscopy (NIRS).

With OpUS, US is generated at the surface of a fibre optic transducer via the photoacoustic effect. Here, pulsed or modulated light from a laser source is transmitted along the fibre, absorbed in a coating on the fibre surface and converted to thermal energy. The subsequent heat rise leads to a corresponding pressure rise within the coating which propagates as ultrasound. This process is facilitated through the use of custom, engineered nanocomposite materials comprising an optical absorber with an elastomeric host. US reflections from tissue are received with optical interferometry in a method similar to optical coherence tomography (OCT) signal interrogation. For this study we included these elements into a probe and imaged ex-vivo coronary artery tissue. A novel, optically-selective nanocomposite coating enabled concurrent OpUS and PA imaging for molecular contrast using the same imaging probe.

Using OpUS we demonstrated high resolution imaging (&lt;40 microns axial), large imaging depths (&gt;2 cm) of coronary tissue and performed a comparison with histology. Numerous features of atherosclerotic plaque were identifiable, including a lipid pool, a calcified nodule, and the different layers comprising the vessel wall. The fiber-optic transducer generated ultra-high pressures and bandwidths: 21.5 MPa and 39.8 MHz respectively. Hybrid imaging using OpUS and PA was also demonstrated, highlighting regions with high lipid content.

Conclusion

This new platform for intravascular imaging offers high resolution equivalent to 60 Mhz high-definition IVUS whilst maintaining deep tissue penetration. Hybrid imaging with PA can be used for directly visualizing lipid plaque. OpUS transducers are highly flexible, with small diameters (&lt;400 microns) and have low fabrication costs, making them well suited for incorporation into interventional devices.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Wellcome Trust/EPSRC, National Institute for Health Research Biomedical Research Centre - University College London

Risk factors and outcomes of COVID-19 in New York City; a retrospective cohort study

Coronavirus disease 2019 (COVID-19) is a global pandemic and information on risk factors for worse prognosis is needed to accurately identify patients at risk and potentially provide insight into therapeutic options. In this retrospective cohort study, including 3703 patients with laboratory confirmed COVID-19, we identified risk factors associated with all-cause mortality, need for hospitalization and mechanical ventilation. Male gender was independently associated with increased risk of hospitalization (adjusted odds ratio [OR_adj ]: 1.62; 95% confidence interval [95% CI]: 1.38-1.91)), mechanical ventilation (OR_adj : 1.35; 95% CI: 1.08-1.69) and death (OR_adj : 1.46; 95% CI: 1.17-1.82). Patients > 60 years had higher risk of hospitalization (OR_adj : 5.47; 95% CI: 4.29-6.96), mechanical ventilation (OR_adj : 3.26; 95% CI: 2.08-5.11) and death (OR_adj : 13.04; 95% CI: 6.25-27.24). Congestive heart failure (ORadj: 1.47; 95% CI: 1.06-2.02) and dementia (OR_adj : 2.03; 95% CI: 1.46-2.83) were associated with increased odds of death, as well as the presence of more than two comorbidities (OR_adj : 1.90; 95% CI: 1.35-2.68). Patients with COVID-19 of older age, male gender, or having more than two comorbidities are at higher risk of hospitalization, mechanical ventilation and death, and should therefore be closely monitored.

Outcomes of Patients With Hypothyroidism and COVID-19: A Retrospective Cohort Study

Coronavirus diseases (COVID-19) is associated with high rates of morbidity and mortality and worse outcomes have been reported for various morbidities. The impact of pre-existing hypothyroidism on COVID-19 outcomes remains unknown. The aim of the present study was to identify a possible association between hypothyroidism and outcomes related to COVID-19 including hospitalization, need for mechanical ventilation, and all-cause mortality. All patients with a laboratory confirmed COVID-19 diagnosis in March 2020 in a large New York City health system were reviewed. Of the 3703 COVID-19 positive patients included in present study, 251 patients (6.8%) had pre-existing hypothyroidism and received thyroid hormone therapy. Hypothyroidism was not associated with increased risk of hospitalization [Adjusted Odds Ratio (OR_adj): 1.23 (95% Confidence Interval (CI): 0.88- 1.70)], mechanical ventilation [OR_adj: 1.17 (95% CI: 0.81-1.69)] nor death [OR_adj: 1.07 (95% CI: 0.75-1.54)]. This study provides insight into the role of hypothyroidism on the outcomes of COVID-19 positive patients, indicating that no additional precautions or consultations are needed. However, future research into the potential complications of COVID-19 on the thyroid gland and function is warranted.

P5336Waist:Hip ratio (WHR): a better predictor of cardiovascular risk (CVR) than BMI in people living with HIV

Introduction

Antiretroviral therapy (ART) has dramatically reduced morbidity and mortality among people living with HIV (PLWH), including wasting syndrome. Metabolic and cardiovascular diseases are leading causes of death for PLWH in high-income countries.

Obesity is increasing in the HIV population but a lack of data exists in PLWH, and the association with cardiovascular risk. The aim to determine if central obesity (measured using waist to hip ratio) is a better predictor of CV risk than Body Mass Index (BMI) which is the current standard to define obesity in PLWH.

Methods

Single centre, prospective study performed in a large metropolitan HIV unit. 129 PLWH had weight, height, waist and hip circumference, and blood pressure (BP) recorded. Data on sex, age, ethnicity, past medical history including CV risk factors and kidney disease, smoking status and postcode was used to calculate waist to hip ratio (W/H), BMI and Q-Risk2.

Results

The study population included 30 (23%) women and 98 (77%) men; 76 (59%) Caucasian, 38 (30%) black African/Caribbean and 14 (11%) were other ethnicity. In total, 43 (34%) were overweight and 31 (24%) obese using BMI measurement, this changed to 25 (20%) and 39 (30%) when using WHR.

Q-Risk2 demonstrated that 82 PLWH (64%) had mild risk, 25 (20%) moderate, and 21 (16%) were high cardiovascular risk (excluding HIV as a risk factor).

There was significant correlation between WHR and Q-Risk2 (r=0.44, p<0.01,graph A) but not between BMI and Q-Risk2 (r=0.13, p=0.15, graph B). ROC analysis demonstrates that WHR is able to predict Q-Risk2 (AUC 0.74, 95% CI 0.66–0.82, p<0.01) with a cut-off of 0.98 having 67% sensitivity and 81% for predicting Q-Risk2 >20 (high risk). WHR performed significantly better than BMI (AUC 0.58, 95% CI 0.49–0.67, p=0.24) at predicting Q-Risk2 (p=0.02 for difference, graph C).

W/H ratio and BMI against Q-Risk 2

Conclusion

Temporal change in waist circumference can indicate change in abdominal fat, with increased abdominal fat being associated with increased CV risk. WHR is superior to BMI at predicting high risk (Q-Risk >20%). It should be included as part of routine clinical assessment and lifestyle intervention implemented to reduce CV risk in PLWH.

1171Myocardial perfusion mapping in cardiac amyloidosis - exploring the spectrum from infiltration to ischaemia

Background

Cardiac involvement is the main driver of outcome in systemic amyloidosis, but the relationship between amyloid deposits and outcomes is not well understood. The simple explanation of physical, mechanical replacement of the interstitium by amyloid seems insufficient. Preliminary studies support the hypothesis that myocardial ischaemia could contribute to cell damage.

Purpose

(1) To assess myocardial ischaemia in cardiac amyloidosis. (2) To compare patients with cardiac amyloidosis to patients assessed on invasive coronary angiography (ICA) to have normal coronary physiology (NCP), microvascular dysfunction (MVD) and triple vessel coronary disease (3VD). (3) To assess correlation of perfusion mapping to markers of disease severity and prognosis.

Methods

86 patients and 20 healthy volunteers (HV) underwent CMR at 1.5T (Siemens) with standard cine, PSIR-LGE, T1, T2, Extracellular Volume (ECV) mapping and adenosine stress with myocardial blood flow (MBF) mapping. Thirty-eight patients also underwent ICA with 3 vessel assessment of Index of Microcirculatory Resistance and Fractional Flow Reserve: 7 had cardiac amyloidosis, 8 had NCP, 15 had MVD and 8 had 3VD.

Results

Cardiac amyloidosis patients had severe reduction in stress MBF and myocardial perfusion reserve (MPR) (1.22ml/g/min±0.70 and 1.62±0.63) compared to HV (3.21ml/g/min±0.64, p<0.001 and 4.17±0.78, p<0.001), NCP (2.66±0.56, p<0.001 and 2.51±0.43, p=0.036) and MVD (2.10±0.31, p<0.001 and 2.29±0.87, p=0.014) with the degree of reduction being similar only to patients with 3VD (1.44±0.54, p=1.000 and 1.64±0.68, p=1.000) (Figure 1). Rest MBF was also lower in amyloidosis than HV. Cardiac amyloidosis stress MBF and MPR inversely correlated with amyloid burden (ECV, r=−0.715, p<0.001, transmurality of LGE, p<0.01), systolic dysfunction (EF, r=0.405, p<0.01), and blood biomarkers (NT-proBNP (r=−0.678, p<0.001) and Troponin T (r=−0.628, p<0.001)). There was a correlation between stress MBF and native T1 (r=−0.588, p<0.001) but not T2 (p=0.591). Stress MBF and MPR were early disease markers, being elevated in patients with early cardiac amyloid infiltration (raised ECV, no LGE, P<0.01 vs HV).

Conclusion

Myocardial ischaemia is common in cardiac amyloidosis – with stress MBF and MPR similar to that of patients with 3VD. The reduction correlates with the degree of amyloid infiltration and markers of adverse prognosis, highlighting the potential role of myocardial ischaemia as a key mechanism in the pathophysiology of cardiac amyloidosis.

Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial

BACKGROUND

Results of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects.

METHODS

FOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible if they were aged 18 years or older, had a clinical stroke diagnosis, were enrolled and randomly assigned between 2 days and 15 days after onset, and had focal neurological deficits. Patients were randomly allocated fluoxetine 20 mg or matching placebo orally once daily for 6 months via a web-based system by use of a minimisation algorithm. The primary outcome was functional status, measured with the modified Rankin Scale (mRS), at 6 months. Patients, carers, health-care staff, and the trial team were masked to treatment allocation. Functional status was assessed at 6 months and 12 months after randomisation. Patients were analysed according to their treatment allocation. This trial is registered with the ISRCTN registry, number ISRCTN83290762.

FINDINGS

Between Sept 10, 2012, and March 31, 2017, 3127 patients were recruited. 1564 patients were allocated fluoxetine and 1563 allocated placebo. mRS data at 6 months were available for 1553 (99·3%) patients in each treatment group. The distribution across mRS categories at 6 months was similar in the fluoxetine and placebo groups (common odds ratio adjusted for minimisation variables 0·951 [95% CI 0·839-1·079]; p=0·439). Patients allocated fluoxetine were less likely than those allocated placebo to develop new depression by 6 months (210 [13·43%] patients vs 269 [17·21%]; difference 3·78% [95% CI 1·26-6·30]; p=0·0033), but they had more bone fractures (45 [2·88%] vs 23 [1·47%]; difference 1·41% [95% CI 0·38-2·43]; p=0·0070). There were no significant differences in any other event at 6 or 12 months.

INTERPRETATION

Fluoxetine 20 mg given daily for 6 months after acute stroke does not seem to improve functional outcomes. Although the treatment reduced the occurrence of depression, it increased the frequency of bone fractures. These results do not support the routine use of fluoxetine either for the prevention of post-stroke depression or to promote recovery of function.

FUNDING

UK Stroke Association and NIHR Health Technology Assessment Programme.

The Effect of Total Meniscectomy versus Caudal Pole Hemimeniscectomy on the Stifle Joint of the Sheep

Total medial meniscectomy and caudal pole hemimeniscectomy were performed on the stifle joints of twelve sheep. The two forms of meniscectomy produced a comparable degree of postoperative lameness that resolved within two weeks of the operations. After six months the sheep were euthanatised and the stifle joints examined. Fibrous tissue that replaced the excised meniscus in the total meniscectomy group did not cover as much of the medial tibial condyle as the residual cranial pole and caudal fibrous tissue observed following hemimeniscectomy. The articular cartilage from different regions within the joints was examined for gross and histological evidence of degeneration. Analyses of the articular cartilage for water content, glycosaminoglycan composition and DNA content were performed. The proteoglycan synthesis and release from explanted articular cartilage samples in tissue culture were also measured. There were significant pathological changes in the medial compartment of all meniscectomised joints. The degree of articular cartilage degeneration that was observed following total meniscectomy and caudal pole meniscectomy was similar. Caudal pole hemimeniscectomy, involving transection of the meniscus, causes the same degree of degeneration of the stifle joint that occurs following total meniscectomy.

The effect of total medial meniscectomy versus caudal pole hemimeniscectomy on the stifle joint of sheep was studied experimentally. Six months after the operations gross pathology, histopathology, cartilage biochemical analysis and the rate of proteoglycan synthesis in tissue culture were used to compare the articular cartilage harvested from the meniscectomised joints. Degeneration of the articular cartilage from the medial compartment of the joints was present in both of the groups. Caudal pole hemimeniscectomy induces a comparable degree of articular cartilage degeneration to total medial meniscectomy in the sheep stifle joint.

Interprofessional learning in primary care: an exploration of the service user experience leads to a new model for co-learning

BACKGROUND

Research about service user involvement in research and education focuses on the purpose, the methods, the barriers and the impact of their involvement. Few studies report on the experience of the service users who get involved. This paper reports an exploration of the experience of service users who participated in an interprofessional educational initiative in primary care - the Learning to Improve the Management of Back Pain in the Community (LIMBIC) project. Service users attended workshops with practice teams and assisted them in developing small scale quality improvement projects to improve their provision of care for people with back pain.

OBJECTIVES

To explore the experience of service users involved in the LIMBIC project.

DESIGN

Using the philosophical and methodological approaches of pragmatism this study analysed data from the wider LIMBIC project and collected primary data through semi structured interviews with service users. Secondary data were reanalysed and integrated with primary data to address the research question.

SETTING

The study was undertaken in the primary health care setting.

PARTICIPANTS

Patients participated as service users in workshops and quality improvement projects with members from their practice teams.

METHODS

Interviews with service users were transcribed and analysed thematically. Document and thematic analyses of secondary data from the LIMBIC project included focus group transcripts, patient stories, film, emails, meeting notes, a wiki and educational material such as presentations.

RESULTS

Themes identified through the analyses illustrated the importance, to the service users, of the sense of community, of clear communication, and of influencing change through involvement. A model for co-learning with service users resulted from the analyses.

CONCLUSIONS

The experience of service users can be optimised by planning, preparation and support so that their wealth of expertise can be recognised and utilised. A model for co-learning was developed and is presented in this paper.

Successful isolated intestinal transplantation in sensitized recipients with the use of virtual crossmatching

We evaluated virtual crossmatching (VXM) for organ allocation and immunologic risk reduction in sensitized isolated intestinal transplantation recipients. All isolated intestine transplants performed at our institution from 2008 to 2011 were included in this study. Allograft allocation in sensitized recipients was based on the results of a VXM, in which the donor-specific antibody (DSA) was prospectively evaluated with the use of single-antigen assays. A total of 42 isolated intestine transplants (13 pediatric and 29 adult) were performed during this time period, with a median follow-up of 20 months (6-40 months). A sensitized (PRA ≥ 20%) group (n = 15) was compared to a control (PRA < 20%) group (n = 27) to evaluate the efficacy of VXM. With the use of VXM, 80% (12/15) of the sensitized patients were transplanted with a negative or weakly positive flow-cytometry crossmatch and 86.7% (13/15) with zero or only low-titer (≤ 1:16) DSA. Outcomes were comparable between sensitized and control recipients, including 1-year freedom from rejection (53.3% and 66.7% respectively, p = 0.367), 1-year patient survival (73.3% and 88.9% respectively, p = 0.197) and 1-year graft survival (66.7% and 85.2% respectively, p = 0.167). In conclusion, a VXM strategy to optimize organ allocation enables sensitized patients to successfully undergo isolated intestinal transplantation with acceptable short-term outcomes.

Specificity and responsiveness of patient-reported and clinician-rated outcome measures in the context of elbow surgery, comparing patients with and without rheumatoid arthritis

OBJECTIVES

To examine and contrast the ability of patient-reported and clinician-rated measures, reflecting different levels of specificity, to detect differences in outcomes between patients with and without rheumatoid arthritis (RA), at 6 months following elbow surgery.

METHODS

One hundred and four consecutive patients/elbows self-completed the Oxford Elbow Score (OES), Disabilities of the Arm, Shoulder and Hand (DASH) and SF-36 general health questionnaires prior to elbow surgery. A surgeon assessed the standard Mayo Elbow Performance Score (MEPS) and recorded patients' diagnoses. Assessments were repeated 6 months following surgery in an outpatient clinic. Patients also completed pain "transition" and global satisfaction items. Patients who did not attend completed their assessment by post.

RESULTS

Twenty-three (22%) patients had RA. These patients were more likely than other patients to have bilateral elbow problems and to have total elbow replacement (85.7% versus 10.5% P<0.001). Patients with RA had more severe preoperative elbow-specific scores, and experienced a large and significantly greater amount of change in elbow function, as measured by the OES function (P=0.002) and pain scales (P=0.013). The surgeon-assessed elbow-specific MEPS score also detected a large and significant difference between the two groups (P<0.001). However, these differences were not detected by the upper limb specific DASH, by any SF-36 general health dimensions, or by transition or satisfaction items.

CONCLUSIONS

The OES performed well in assessing surgical outcomes in patients with RA. Neither the upper limb specific DASH nor the SF-36 is specific or responsive enough to warrant its exclusive use as an outcome measure for elbow surgery.

LEVEL OF EVIDENCE

Level II (prospective non-randomised study).

An outbreak of food-borne botulism in Scotland, United Kingdom, November 2011

An investigation is currently underway to explain an outbreak of food-borne botulism in Scotland. Three children in the same family were confirmed as having botulism following consumption of a meal made with a jar of korma sauce. Residual sauce from the jar, the jar lid and a remnant of the meal, all tested positive for Clostridium botulinum type A toxin. The children are recovering, although two remain ventilated and in intensive care unit.

National outbreak of Salmonella Enteritidis phage type 14b in England, September to December 2009: case-control study

We conducted an unmatched retrospective case–control study to investigate an upsurge of non-travel-related sporadic cases of infection with Salmonella enterica subsp. enterica serotype Enteritidis phage type 14b with antimicrobial resistance to nalidixic acid and partial resistance to ciprofloxacin (S. Enteritidis PT 14b NxCp(L)) that was reported in England from 1 September to 31 December 2009. We analysed data from 63 cases and 108 controls to determine whether cases had the same sources of infection as those found through investigation of 16 concurrent local foodborne outbreaks in England and Wales. Multivariable logistic regression analysis adjusting for age and sex identified food consumption at restaurants serving Chinese or Thai cuisine (odds ratio (OR): 4.4; 95% CI: 1.3–14.8; p=0.02), egg consumed away from home (OR: 5.1; 95% CI: 1.3–21.2; p=0.02) and eating vegetarian foods away from home (OR: 14.6; 95% CI: 2.1–99; p=0.006) as significant risk factors for infection with S. Enteritidis PT 14b NxCp(L). These findings concurred with those from the investigation of the16 outbreaks, which identified the same Salmonella strain in eggs from a specified source outside the United Kingdom. The findings led to a prohibition of imports from this source, in order to control the outbreak.

National outbreak of Salmonella Enteritidis phage type 14b in England, September to December 2009: case–control study

Binary file ES_Abstracts_Final_ECDC.txt matches

A double-blind randomized vehicle-controlled clinical trial investigating the effect of ZnPTO dose on the scalp vs. antidandruff efficacy and antimycotic activity

Dandruff is a common problem in approximately 30% of the world's population. Reports in the literature regarding treatment of this condition with various antidandruff shampoos usually report the level of active ingredient within the formulation. However, we propose that a more important parameter relating to antidandruff efficacy is the amount of active ingredient delivered to the scalp from the shampoo. This report describes the results from two studies designed to investigate the relationship between the level of zinc pyrithione (ZnPTO) deposited onto the scalp and the resultant scalp condition. A double-blind randomized vehicle-controlled clinical study comparing three shampoos - a vehicle, a low-depositing ZnPTO shampoo and a high-depositing ZnPTO shampoo - was carried out in the U.K. with 53 panelists with dandruff or mild-to-moderate seborrheic dermatitis of the scalp. Both shampoos containing ZnPTO were significantly superior in antidandruff efficacy to the vehicle. Furthermore, the high-depositing ZnPTO shampoo was significantly superior compared with the low-depositing ZnPTO shampoo in terms of both antidandruff efficacy and antimycotic activity. Antidandruff performance and antimycotic activity of ZnPTO-containing shampoos is highly dependent on the amount of active ingredient delivered to the scalp. Furthermore, careful manipulation of the formulation parameters of an antidandruff shampoo can result in enhanced levels of delivery of the active ingredient without having to increase the level of active ingredient within the formulation.

Evaluation of the hygiene of ready-to-eat food preparation areas and practices in mobile food vendors in the UK

This study was undertaken to assess the cleanliness of food preparation areas, cleaning methods used, and the microbiological quality of water used by 1258 mobile food vendors in the UK. Samples collected included potable water (1102), cleaning cloths (801) and environmental swabs from food preparation surfaces (2704). Cleaning cloths were more heavily contaminated with Aerobic Colony Counts, Enterobacteriaceae, Escherichia coli, and Staphylococcus aureus compared to surfaces sampled. Surfaces that were visually dirty, wet, and chopping boards that were plastic or damaged also had high levels of these bacteria. Fifty-four percent of potable water samples were of poor microbiological quality; i.e. contained coliforms, E. coli and/or enterococci. A documented food safety management system was only evident in 40.1% of vendors and cleaning schedules were only used by 43.6%. Deficiencies in the correct use of cleaning materials, such as dilution factors and the minimum contact time for disinfectants, were identified.

An overview of techniques used to measure wound area and volume

If wound area is to be used as an indicator of healing, then it is vital that all measurements are accurate and consistent. This depends largely on the measurement tool used. This paper offers an insight into the available evidence.