An Overview of Rhinoplasty Practices: European Academy of Facial Plastic Surgery, Collaborative Cross-Sectional Study

This collaborative European Academy of Plastic Surgery (EAFPS) study aimed to provide an overview of rhinoplasty practices, informing clinician and patient decision making. It is a multicenter cross-sectional study, reported as per Strengthening the Reporting of Observational Studies in Epidemiology guidelines. All EAFPS members were contacted via email, inviting them to participate. Members expressing an interest to participate were asked to anonymously complete a questionnaire, related to rhinoplasties that they performed as first/supervising surgeon over a period from January 1, 2019 to January 1, 2022. A descriptive analysis was performed. One hundred and fifteen surgeons submitted data on 41,259 rhinoplasties from 33 countries. Eighty percent of rhinoplasties were primary, and 20% were secondary. Thirty five percent of primary rhinoplasties were closed and 65% were open. Thirty one percent of primary rhinoplasties were for cosmetic indications, 11% functional and 58% were for both. Of the 8147 secondary rhinoplasties, 44% were closed and 56% were open. Thirty percent were for cosmetic indications, 11% functional, and 59% for both cosmetic and functional. Ninety-one percent of rhinoplasties were performed by ENT surgeons, 3% by plastic surgeons, 5% by maxillofacial surgeons, and 1% were dual (maxillofacial and ENT) trained. One-thousand seven-hundred thirty primary rhinoplasties underwent revision surgery (5%) and 102 secondary rhinoplasties underwent revision surgery (1%). The most commonly reported indications for revision surgery were dorsal asymmetry, nasal blockage, and dissatisfaction with nasal tip. Three percent of rhinoplasties underwent preoperative psychological assessment. To the authors knowledge, this is the largest published rhinoplasty dataset. This study provides an overview of rhinoplasty practices that can be used for benchmarking and to guide clinician and patient decision making. Psychological assessment of prerhinoplasty appears insufficient with higher levels recommended to minimize unsuccessful outcomes. This study showcases the power of collaborative research and may serve as a catalyst for future collaborative facial plastic surgery research.

The genesis of the PM-JAY health insurance scheme in India: technical and political elements influencing a national reform towards universal health coverage

Many countries are using health insurance to advance progress towards universal health coverage (UHC). India launched the Pradhan Mantri Jan Arogya Yojana (PM-JAY) health insurance scheme in 2018. We examine the political economy context around PM-JAY policy formulation, by examining the perspectives of policy stakeholders shaping decisions around the reform. More specifically, we focus on early policy design at the central (national) level. We use a framework on the politics of UHC reform proposed by Fox and Reich (The politics of universal health coverage in low- and middle-income countries: A framework for evaluation and action. J. Health Polit. Policy Law 2015;40:1023-1060), to categorize the reform into phases and examine the interactions between actors, institutions, interests, ideas and ideology which shaped reform decisions. We interviewed 15 respondents in Delhi between February and April 2019, who were either closely associated with the reform process or subject experts. The ruling centre-right government introduced PM-JAY shortly before national elections, drawing upon policy legacies from prior and state insurance schemes. Empowered policy entrepreneurs within the government focused discourse around ideas of UHC and strategic purchasing, and engaged in institution building leading to the creation of the National Health Authority and State Health Agencies through policy directives, thereby expanding state infrastructural and institutional power for insurance implementation. Indian state inputs were incorporated in scheme design features like mode of implementation, benefit package and provider network, while features like the coverage amount, portability of benefits and branding strategy were more centrally driven. These balanced negotiations opened up political space for a cohesive, central narrative of the reform and facilitated adoption. Our analysis shows that the PM-JAY reform focused on bureaucratic rather than ideological elements and that technical compromises and adjustments accommodating the interests of states enabled the political success of policy formulation. Appreciating these politics, power and structural issues shaping PM-JAY institutional design will be important to understand how PM-JAY is implemented and how it advances UHC in India.

Labeling in a Latinx Community: Public Health Implications for Youth and Role in Community Narratives

Background

Youth of color are disproportionately subjected to negative formal and informal labels by parents, peers, and teachers. This study examined the consequences of such labels on health-protective behaviors, wellbeing, peer networks and school engagement.

Methods

In-depth interviews were conducted with 39 adolescents and 20 mothers from a predominantly Latinx and immigrant agricultural community in California. Teams of coders completed iterative rounds of thematic coding to identify and refine key themes.

Results

Dichotomous labeling of "good" and "bad" was pervasive. Youth labeled as "bad" experienced limited educational opportunities, exclusion from peers, and community disengagement. Additionally, preservation of "good kid" labels compromised health protective-behaviors including foregoing contraception. Participants pushed back on negative labeling when it was applied to close family or community acquaintances.

Discussion

Targeted interventions that foster social belonging and connection rather than exclusion may facilitate health protective behaviors and have positive implications for future trajectories among youth.

Investigating Asian American Adolescents' Resiliency Factors and Young Adult Mental Health Outcomes at 14-year Follow-up: A Nationally Representative Prospective Cohort Study

There is scant research on how Asian American adolescents' resiliency relates to mental well-being in adulthood. The objective of this study was to determine the prospective associations between resiliency factors (individual, family, and school community) in adolescence and mental health outcomes in adulthood, among a national sample of Asian Americans. We analyzed data from 1020 Asian American adolescents who were followed for 14 years in the National Longitudinal Study of Adolescent to Adult Health. Of the resiliency factors, individual self-esteem (Adjusted Odds Ratio [AOR] 0.54, 95% Confidence Interval [CI] 0.37-0.79) and family connectedness (AOR 0.78, 95% CI 0.65-0.93) in adolescence were found to be protective against adult mental health outcomes in logistic regression models adjusting for sociodemographic factors and baseline mental health. Our study identified individual and family resiliency factors which can be leveraged to help Asian American adolescents and families in cultivating better mental health.

Management and Outcomes in Children with Third-Generation Cephalosporin-Resistant Urinary Tract Infections

BACKGROUND

Third-generation cephalosporin-resistant urinary tract infections (UTIs) often have limited oral antibiotic options with some children receiving prolonged parenteral courses. Our objectives were to determine predictors of long parenteral therapy and the association between parenteral therapy duration and UTI relapse in children with third-generation cephalosporin-resistant UTIs.

METHODS

We conducted a multisite retrospective cohort study of children <18 years presenting to acute care at 5 children's hospitals and a large managed care organization from 2012 to 2017 with a third-generation cephalosporin-resistant UTI from Escherichia coli or Klebsiella spp. Long parenteral therapy was ≥3 days and short/no parenteral therapy was 0-2 days of concordant parenteral antibiotics. Discordant therapy was antibiotics to which the pathogen was non-susceptible. Relapse was a UTI from the same organism within 30 days.

RESULTS

Of the 482 children included, 81% were female and the median age was 3.3 years (interquartile range: 0.8-8). Fifty-four children (11.2%) received long parenteral therapy (median duration: 7 days). Predictors of long parenteral therapy included age <2 months (adjusted odds ratio [aOR] 67.3; 95% confidence interval [CI]: 16.4-275.7), limited oral antibiotic options (aOR 5.9; 95% CI: 2.8-12.3), and genitourinary abnormalities (aOR 5.4; 95% CI: 1.8-15.9). UTI relapse occurred in 1 of the 54 (1.9%) children treated with long parenteral therapy and in 6 of the 428 (1.5%) children treated with short/no parenteral therapy (P = .57). Of the 105 children treated exclusively with discordant antibiotics, 3 (2.9%, 95% CI: 0.6%-8.1%) experienced UTI relapse.

CONCLUSIONS

Long parenteral therapy was associated with age <2 months, limited oral antibiotic options, and genitourinary abnormalities. UTI relapse was rare and not associated with duration of parenteral therapy. For UTIs with limited oral options, further research is needed on the effectiveness of continued discordant therapy.

Epidemiology and Risk Factors for Community Associated Clostridioides difficile in Children

OBJECTIVE

To assess which risk factors are associated with community-associated Clostridioides difficile infection (CDI) in children.

STUDY DESIGN

This case control study was a retrospective review of all children 1-17 years of age with stool specimens sent for C difficile testing from January 1, 2012, to December 31, 2016. Cases and controls were children who had C difficile testing performed in the community or first 48 hours of hospital admission and >12 weeks after hospital discharge, with no prior positive C difficile testing in last 8 weeks, without other identified causes of diarrhea, and with clinical symptoms. Cases had positive confirmatory testing for C difficile. Controls had negative testing for C difficile and were matched to cases 1:1 by age and year of specimen collection.

RESULTS

The overall incidence rate of community-acquired CDI in this cohort was 13.7 per 100 000 children per year. There was a substantial increase in community-acquired CDI from 9.6 per 100 000 children per year in 2012 to a peak of 16.9 per 100 000 children per year in 2015 (Cochran-Armitage test for trend P = .002). The risk factors for community-acquired CDI included non-Hispanic ethnicity; amoxicillin-clavulanate, cephalosporin, and clindamycin use within the previous 12 weeks; a previous positive C difficile test within 6 months; and increased health care visits in the last year.

CONCLUSIONS

As rates of community-acquired CDI are increasing, enhanced antibiotic stewardship and recognition of health care disparities may ease the burden of community-acquired CDI.

Clinical Response to Discordant Therapy in Third-Generation Cephalosporin-Resistant UTIs

OBJECTIVES

To describe the initial clinical response and care escalation needs for children with urinary tract infections (UTIs) resistant to third-generation cephalosporins while on discordant antibiotics.

METHODS

We performed a retrospective study of children <18 years old presenting to an acute care setting of 5 children's hospitals and a large managed care organization from 2012 to 2017 with third-generation cephalosporin-resistant UTIs (defined as the growth of ≥50 000 colony-forming units per mL of Escherichia coli or Klebsiella spp. nonsusceptible to ceftriaxone with a positive urinalysis). We included children started on discordant antibiotics who had follow-up when culture susceptibilities resulted. Outcomes were escalation of care (emergency department visit, hospital admission, or ICU transfer while on discordant therapy) and clinical response at follow-up (classified as improved or not improved).

RESULTS

Of the 316 children included, 78% were girls and the median age was 2.4 years (interquartile range 0.6-6.5). Children were evaluated in the emergency department (56%) or clinic (43%), and 90% were started on a cephalosporin. A total of 7 of 316 children (2.2%; 95% confidence interval 0.8%-4.5%) experienced escalation of care. For the 230 children (73%) with clinical response recorded, 192 of 230 (83.5%; 95% confidence interval 78.0%-88.0%) experienced clinical improvement. In children with repeat urine testing while on discordant therapy, pyuria improved or resolved in 16 of 19 (84%) and urine cultures sterilized in 11 of 17 (65%).

CONCLUSIONS

Most children with third-generation cephalosporin-resistant UTIs started on discordant antibiotics experienced initial clinical improvement, and few required escalation of care. Our findings suggest that narrow-spectrum empiric therapy is appropriate while awaiting final urine culture results.

Evaluation of the association between a single-nucleotide polymorphism of bone morphogenetic proteins 5 gene and risk of knee osteoarthritis

Background:

Osteoarthritis (OA) is a chronic degenerative disorder probably affected by both genetic and environmental causes. Bone morphogenetic proteins (BMPs) are bone-derived factors that can induce new bone formation. Single-nucleotide polymorphisms (SNPs) of BMP5 gene alters the transcriptional activity of the BMP5 promoter that has been involved in OA susceptibility. This case–control study investigated the association of rs1470527 and rs9382564 SNP of BMP5 gene with susceptibility to knee OA (KOA).

Materials and Methods:

A total of 499 cases with radiographic KOA and 458 age- and sex-matched healthy controls were enrolled. Venous blood samples were obtained from all the cases as well as controls for polymerase chain reaction-restriction fragment length polymorphism.

Results:

The genotype distribution for rs1470527 and rs9382564 SNP was significantly different in cases and controls (P < 0.0001). Within both the SNPs of BMP5 gene, genotype CT and TT were significantly (P < 0.0001) associated with KOA as compared to the CC genotype. T allele of both the studied SNP was significantly associated with KOA (P < 0.0001). The allele frequencies of rs1470527 were 0.56(T) and 0.44(C) in cases and 0.33(T) and 0.67(C) in controls and in rs9382564 were 0.57(C) and 0.43(T) in cases and 0.71(C) and 0.29(T) in controls. Further in relation with clinical severity of OA, we observed signification association of TT genotype with both visual analog scale (P < 0.0001) and Western Ontario and McMaster Universities score (P < 0.05).

Conclusion:

Our results indicate significant association of rs1470527 and rs9382564 polymorphism of BMP5 gene with KOA.

Outcomes of repeat two-stage exchange hip arthroplasty for prosthetic joint infection

Aims

The increasing infection burden after total hip arthroplasty (THA) has seen a rise in the use of two-stage exchange arthroplasty and the use of increasingly powerful antibiotics at the time of this procedure. As a result, there has been an increase in the number of failed two-stage revisions during the past decade. The aim of this study was to clarify the outcome of repeat two-stage revision THA following a failed two-stage exchange due to recurrent prosthetic joint infection (PJI).

Patients and Methods

We identified 42 patients who underwent a two-stage revision THA having already undergone at least one previous two stage procedure for infection, between 2000 and 2015. There were 23 women and 19 men. Their mean age was 69.3 years (48 to 81). The outcome was analyzed at a minimum follow-up of two years.

Results

A satisfactory control of infection and successful outcome was seen in 26 patients (57%). There therefore remained persistent symptoms that either required further surgery or chronic antibiotic suppression in 16 patients (38%). One-third of patients had died by the time of two years’ follow-up.

Conclusion

The rate of failure and complication rate of repeat two-stage exchange THA for PJI is high and new methods of treatment including host optimization, immunomodulation, longer periods between stages, and new and more powerful forms of antimicrobial treatment should be investigated. Cite this article: Bone Joint J 2019;101-B(6 Supple B):110–115.

1522. Initial Clinical Response of Children with Extended-Spectrum Cephalosporin-Resistant Urinary Tract Infections (ESC-R UTI’s) Started on Discordant Antibiotics

Background

ESC-R UTI’s in children are often resistant to common empiric regimens. Our objective was to describe the initial clinical response of children with ESC-R UTI’s while on discordant antibiotics.

Methods

We conducted a multicenter retrospective chart review of children <18 years with ESC-R UTI’s presenting to an acute care setting of 5 children’s hospitals and a large managed care organization from 2012 to 2017. ESC-R UTI was defined as having a urinalysis with positive leukocyte esterase or >5 white cells per high-power field and urine culture with ≥50,000 colony-forming units per milliliter of E. coli or Klebsiella spp. nonsusceptible to ceftriaxone. Children were included if they received initial discordant antibiotics (an agent to which their isolate was nonsusceptible) and had phone or in-person follow-up when urine culture susceptibilities resulted. Children with urologic surgery, immunosuppression and nonrenal chronic conditions were excluded. Outcomes were: (1) Escalation of care, defined as an emergency room visit, hospital admission or intensive care unit (ICU) transfer while on discordant therapy and (2) clinical response at the time of follow-up, classified as improved (complete or partial resolution of presenting symptoms) or not improved (persistence of symptoms) and assessed by a second reviewer in 20% of charts to determine inter-rater reliability.

Results

Of 253 children with ESC-R UTI’s, 76% were female, median age was 2 years (interquartile range [IQR] 0.5–6.5) and 88% were started on cephalosporins. Median time to follow-up was 3 days (IQR 2–3). Nine children (4%) had escalation of care without ICU transfer. Follow-up records with clinical response information were available for 187 children (74%); 154 (83%) were improved and 33 (17%) were not improved (κ = 0.80). Figure 1 shows improvement by symptom. In children with repeat urine testing while on discordant therapy, pyuria improved in 12/15 and urine cultures sterilized in 10/13.

Conclusion

Most children with ESC-R UTI’s experienced initial clinical improvement while on discordant antibiotics. Future studies should prospectively evaluate the in vitro and clinical effect of discordant therapy in children to assess the need for modified urine-specific breakpoints.

Disclosures

All authors: No reported disclosures.

1519. Management and Outcomes of Children with Extended-Spectrum Cephalosporin-Resistant Urinary Tract Infections (ESC-R UTIs)

Background

ESC-R UTIs often have limited oral antibiotic options with some children receiving a course of intravenous (IV) antibiotics. Our objectives were to determine predictors of long course IV therapy and the association between short-course therapy and UTI relapse.

Methods

We conducted a multicenter retrospective cohort study of children <18 years with ESC-R UTIs presenting to an acute care setting of 5 children’s hospitals and a large managed care organization from 2012 to 2017. ESC-R UTI was defined as having a urinalysis with positive leukocyte esterase or >5 white cells per high power field and urine culture with ≥50,000 colony-forming units per milliliter of E. coli or Klebsiella spp. nonsusceptible to ceftriaxone. Children with urologic surgery, immunosuppression and nonrenal chronic conditions were excluded. Long course therapy was defined as ≥5 days and short course as 0–4 days of a concordant IV antibiotic (an agent to which the isolate was susceptible). Relapse was defined as UTI with the same organism within 30 days. Limited oral antibiotic options were defined as nonsusceptibility to amoxicillin–clavulanate, ciprofloxacin, and trimethoprim–sulfamethoxazole. Predictors of long course therapy were determined using mixed effects logistic regression with hospital site as a random effect. Since UTI relapse was a rare outcome, we evaluated the association between short-course therapy and UTI relapse using Fisher’s exact test.

Results

Of 383 children with ESC-R UTIs, 80% were female, median age was 3 years (interquartile range 0.7–7.8), and 24% had a prior UTI. Forty-five children (12%) received long course therapy and 338 (87%) received short-course therapy. Predictors of long course therapy included age <2 months (adjusted odds ratio [AOR] 61.4, 95% confidence interval [CI] 12.5–302), male sex (AOR 3.0, 95% CI 1.2–7.8), and limited oral antibiotic options (AOR 5.3, 95% CI 2.2–12.6). UTI relapse occurred in 1/45 (2%) children treated with long course therapy and in 3/335 (0.9%) treated with short-course therapy (P = 0.40).

Conclusion

Long course IV therapy in children with ESC-R UTIs was more likely in infants <2 months, males and those with limited oral antibiotic options. UTI relapse was rare and not associated with short course/no IV therapy.

Disclosures

All authors: No reported disclosures.

Incidence of Pediatric Community Associated Clostridium Difficile Infection Following Common Antibotics

Background

As rates of pediatric community-associated (CA) Clostridium difficile infection (CDI) increase, additional research is needed to address rates of infection following common antibiotics.

Methods

This study was a retrospective review of the electronic health records of all children with stool specimens sent for C difficile from January first 2012 – December 31^st2016 at Kaiser Permanente Northern California. Children with clinical symptoms consistent with CDI, confirmatory laboratory testing, no other identified causes of diarrhea, and community associated disease were defined as cases. Using outpatient and ED antibiotic prescription records for children, incidence rates were calculated for subsequent CA CDI for the most commonly prescribed antibiotics.

Results

Of 507 primary CDI cases in our cohort, 327 had any antibiotic use 2012–2015. There were 205 primary CDI cases that were preceded by an antibiotic in the previous 1–365 days. Many of these patients had more than 1 antibiotic in the preceding year.

Of those, rates of CA CDI were uncommon following common antibiotics. (Table) The highest rate of CA CDI followed ceftriaxone, cefdinir, ciprofloxacin and augmentin. The lowest rates were seen following penicillin, doxycycline and azithromycin. Ninety-three percent of the antibiotic prescriptions were in outpatients, 7% in inpatients.

Conclusion

As rates of CA CDI increase, clinicians should be aware of rates of infection following administration of common antibiotics. The most common antibiotics to cause CA CDI were third-generation cephalosporins (ceftriaxone and cefdinir) and ciprofloxacin.

Disclosures

All authors: No reported disclosures.

Evaluation of a service intervention to improve awareness and uptake of bowel cancer screening in ethnically-diverse areas

BACKGROUND

Uptake of bowel cancer screening is lowest in London, in populations of lower socio-economic status, and in particular ethnic or religious groups.

METHODS

We report on the evaluation of two interventions to improve uptake in an area including populations of low socio-economic status and considerable ethnic diversity. The interventions were face-to-face health promotion on bowel cancer screening at invitees' general practice and health promotion delivered by telephone only. Nine large general practices in East London were chosen at random to offer face-to-face health promotion, and nine other large practices to offer telephone health promotion, with 24 practices of similar size as comparators. Data at practice level were analysed by Mann-Whitney-Wilcoxon tests and grouped-logistic regression.

RESULTS

There were 2034 invitees in the telephone intervention practices, 1852 in the face-to-face intervention practices and 5227 in the comparison practices. Median gFOBt kit uptake in the target population (aged 59-70) was 46.7% in the telephone practices, 43.8% in the face-to-face practices and 39.1% in the comparison practices. Significant improvements in the odds of uptake were observed following telephone intervention in both males (OR=1.39, 95% CI=1.20-1.61, P<0.001) and females (OR=1.49, 95% CI=1.29-1.73, P<0.001), while the face-to-face intervention mainly impacted uptake in males (OR=1.23, 95% CI=1.10-1.36), P<0.001) but did not lead to a significant increase in females (OR=1.12, 95% CI=0.96-1.29, P=0.2).

CONCLUSIONS

Personally delivered health promotion improved uptake of bowel cancer screening in areas of low socio-economic status and high ethnic diversity. The intervention by telephone appears to be the most effective method.

Association of cytochrome P450 2C9 polymorphism with locally advanced head and neck squamous cell carcinoma and response to concurrent cisplatin-based radical chemoradiation

Aims:

The aim of the present study is to investigate the association between polymorphism of cytochrome P450 2C9 (CYP2C9) enzyme with head and neck squamous cell carcinoma (HNSCC) and response in patients receiving cisplatin-based radical chemoradiation (CT-RT).

Materials and Methods:

Four hundred and sixty patients suffering from locally advanced HNSCC and an equal number of healthy controls were genotyped for CYP2C9*2 and CYP2C9*013, leading to poor metabolizers (PMs) by polymerase chain reaction (PCR)-based restriction fragment length polymorphism (RFLP). Each case was assessed thoroughly for treatment response as per the World Health Organization (WHO) criteria.

Results and Analysis:

The frequency of heterozygous genotypes of both CYP2C9*2 (27.8%) and CYP2C9*3 (25%) were found to be significantly higher in the HNSCC cases as compared to the healthy controls. Tobacco intake in the form of chewing or smoking and alcohol intake resulted in several folds increase in the risk to HNSCC in the cases carrying variant genotypes of CYP2C9*2 or CYP2C9*013. Further, majority of the cases assessed for response (n = 436) carrying variant alleles of CYP2C9*2 (69.6%) or CYP2C9*3 (65.2%) were found to respond poorly to cisplatin-based radical CT-RT.

Conclusion:

The data suggests a significant association of the CYP2C9 polymorphism with HNSCC and treatment outcome underlining the importance of pretherapeutic genotyping in determining the treatment protocol.

Neuroprotective potentials of neurotrophin rich olfactory ensheathing cell's conditioned media against 6OHDA-induced oxidative damage

On the basis of recent reports, we propose that impaired neurotrophin signaling (PI3k/Akt), low antioxidant levels, and generation of reactive oxygen species (ROS) conjointly participate in the progressive events responsible for the dopaminergic cell loss in Parkinson's disease (PD). In the present study we tried to target these deficits collectively through multiple neurotrophic factors (NTFs) support in the form of Olfactory Ensheathing Cell's Conditioned Media (OEC CM) using human SH-SY5Y neuroblastoma cell line exposed to 6 hydroxydopamine (6OHDA). 6OHDA exposure induced, oxidative stress-mediated apoptotic cell death viz. enhanced ROS generation, diffused cytosolic cytochrome c (cyt c), impaired Bcl-2: Bax levels along with decrease in GSH content. These changes were accompanied by loss in Akt phosphorylation and TH levels in SH-SY5Y cells. OEC CM significantly checked apoptotic cell death by preserving pAkt levels which coincided with enhanced GSH and suppressed oxidative injury. Functional integrity of OEC CM supported cells was evident by maintained tyrosine hydroxylase (TH) expression. Intercepting Akt signaling by specific inhibitor LY294002 blocked the protective effect. Taken together our findings provide important evidence that the key to protective effect of multiple NTF support via OEC CM is enhanced Akt survival signaling which promotes antioxidant defense leading to suppression of oxidative damage.

Reduction in interval cancer rates following the introduction of two-view mammography in the UK breast screening programme

BACKGROUND

The introduction of two-view mammography at incident (subsequent) screens in the National Health Service Breast Screening Programme (NHSBSP) has led to an increased number of cancers detected at screen. However, the effect of two-view mammography on interval cancer rates has yet to be assessed.

METHODS

Routine screening and interval cancer data were collated from all screening programmes in the United Kingdom for women aged 50-64, screened between 1 April 2003 and 31 March 2005. Interval cancer rates were compared based on whether two-view mammography was in use at the last routine screen.

RESULTS

The reduction in interval cancers following screening using two-view mammography compared with one view was 0.68 per 1,000 women screened. Overall, this suggests the introduction of two-view mammography at incident screen was accompanied by a 15-20% reduction in interval cancer rates in the NHSBSP.

CONCLUSION

The introduction of two-view mammography at incident screens is associated with a reduction in incidence of interval cancers. This is consistent with previous publications on a contemporaneous increase in screen-detected cancers. The results provide further evidence of the benefit of the use of two-view mammography at incident screens.

A preliminary evaluation of plasma b-type natriuretic peptide as a screening test for left ventricular diastolic dysfunction in non-cardiac intensive care

Left ventricular filling and thus diastolic function are frequently monitored and managed in critical care. However, scant data exist regarding possible screening tests for diastolic dysfunction in the intensive care unit (ICU). The present study aimed to evaluate plasma b-type natriuretic peptide (BNP) as a marker of diastolic dysfunction in a single-centre cohort of 'non-cardiac' ICU patients. The ICU is non-cardiac in that it provides mixed medical/surgical services with the exception of cardiology, cardiac surgery and solid organ transplantation. Clinical data were recorded over the first 24 hours of ICU stay for 32 consecutive patients. Transthoracic echocardiogram and blood collection for BNP assay were then performed. Diastolic dysfunction was demonstrated in 34% (n=11). Mean ± standard deviation BNP values were higher with diastolic dysfunction (238 ± 195 vs 72 ± 78 pg/ml; P=0.003). A BNP threshold of >43 pg/ml yielded a sensitivity of 80% and a specificity of 59%; area under the receiver operating characteristic curve was 0.82. BNP correlated independently with E/e' (R=0.425; P=0.015) (E/e': peak early transmitral velocity [E]/early diastolic mitral annular velocity [e']) but not left ventricular ejection fraction (P=0.8), illness severity (Acute Physiological and Chronic Health Evaluation II; P=0.3) or fluid balance (P=0.4). Diastolic dysfunction was common in this cohort of non-cardiac ICU patients and was independently associated with a significantly higher BNP. The potential application as a screening test for diastolic dysfunction is likely to require a threshold lower than previously proposed for heart failure.

A randomised trial of weekend and evening breast screening appointments

Background:

There is a need to research interventions that improve access to and convenience of breast cancer screening services.

Methods:

We conducted a randomised trial comparing invitations to out-of-hours appointments with standard office hour appointments. Women who were to be invited for routine breast screening were randomised (3 : 1 : 1 : 1) to one of these screening invitations: standard office hour appointment, office hour appointment with the option to change to an out-of-hours appointment, weekday evening appointment, or weekend appointment.

Results:

A total of 9410 women were invited to an office hour, 3519 to an office hour with the option to change, 3271 to a weekday evening, and 3162 to a weekend appointment. The offer of an initial out-of-hours appointment was associated with a non-significant decrease in attendance rates (73.7% vs 74.1%). The highest attendance was observed in the group offered an initial office hour appointment with the option to change to out-of-hours (76.1% vs 73.3% for standard office hour, P=0.001), with 7% of invitees exercising the option to change.

Conclusion:

The optimum strategy for improving attendance at breast screening is to offer a traditional office hour appointment and including in the letter of invitation an option to change to an evening or weekend appointment if wished.

Salsolinol induced apoptotic changes in neural stem cells: amelioration by neurotrophin support

Salsolinol (SAL), a catechol isoquinoline has invited considerable attention due to its structural similarity with dopaminergic neurotoxin 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP). Its high endogenous presence in Parkinsonian brain implicated its possible association with the disease process. SAL is also present in alcohol beverages and certain food materials and can get access to brain especially in conditions of immature or impaired BBB. Besides this, the effect of SAL on neural stem cells (NSCs) which are potential candidates for adult neurogenesis and transplantation mediated rejuvenating attempts for Parkinson's disease (PD) brain has not been known so far. NSCs in both the cases have to overcome suppressive cues of diseased brain for their survival and function. In this study we explored the toxicity of SAL toward NSCs focusing on apoptosis and status of PI3K survival signaling. NSCs cultured from embryonic day 11 rat fetal brain including those differentiated to TH(+ve) colonies, when challenged with SAL (1-100μM), elicited a concentration and time dependent cell death/loss of mitochondrial viability. 10μM SAL on which significant mitochondrial impairment initiated was further used to study mechanism of toxicity. Morphological impairment, enhanced TUNEL positivity, cleaved caspase-3 and decreased Bcl-2:Bax suggested apoptosis. Sal toxicity coincided with reduced pAkt level and its downstream effectors: pCREB, pGSK-3β, Bcl-2 and neurotrophins GDNF, BDNF suggesting repressed PI3K/Akt signaling. Multiple neurotrophic factor support in the form of Olfactory Ensheathing Cell's Conditioned Media (OEC CM) potentially protected NSCs against SAL through activating PI3K/Akt pathway. This was confirmed on adding LY294002 the PI3K inhibitor which abolished the protection. We inferred that SAL exerts substantial toxicity toward NSCs. These findings will lead to better understanding of endogenous threats that might affect the fate of transplanted NSCs and their probable antidotes.

Bacterial localization and viability assessment in human ex vivo dentinal tubules by fluorescence confocal laser scanning microscopy

AIM

To develop a convenient method for the localization and quantification of live and dead bacteria in human ex vivo mineralized dentinal tubules.

METHODOLOGY

The roots from human single-rooted teeth (n = 12) were infected with Enterococcus faecalis V583 and either treated with calcium hydroxide paste or left untreated; six control roots were uninoculated and untreated. Following further incubation, roots were stained with fluorescent DNA-binding reagents, washed thoroughly, sectioned and examined by confocal laser scanning microscopy. Computer-assisted determinations of fluorescence (bacterial viability) were compared statistically.

RESULTS

Bacteria were distributed in the tubules throughout the length of the roots but tubule penetration distance was slightly reduced in the apical sections. There was no significant difference in bacterial tubule penetration between roots from different teeth and small standard deviations indicated reproducibility appropriate for experimental application. Following treatment with calcium hydroxide paste, live and dead bacteria were readily distinguishable by contrasting green and red fluorescence. Bacterial viability determinations amongst roots treated in the same way were not significantly different, and the small standard deviation is commensurate with experimental application.

CONCLUSIONS

Fluorescent viability staining is a convenient, accurate and reproducible method for localizing and quantifying live and dead bacteria in human ex vivo mineralized dentinal tubules.

Using community wealth ranking to identify the poor for subsidies: a case study of community-based health insurance in Nouna, Burkina Faso

Access to health-care is low in developing countries. Poor people are less likely to seek care than those who are better off. Community-based health insurance (CBI) aims to improve healthcare utilisation by removing financial barriers, unfortunately CBI has been less effective in securing equity than expected. Poor people, who probably require greater protection from catastrophic health expenses, are less likely to enrol in such schemes. Therefore, it is important to implement targeted interventions so that the most in need are not left out. CBI has been offered to a district in Burkina Faso, comprising 7762 households in 41 villages and the district capital of Nouna since 2004. Community wealth ranking (CWR) was used in 2007 to identify the poorest quintile of households who were subsequently offered insurance at half the usual premium rate. The CWR is easy to implement and requires minimal resources such as interviews with local informants. As used in this study, the agreement between the key informants was more (37.5%) in the villages than in Nouna town (27.3%). CBI management unit only received nine complaints from villagers who considered that some households had been wrongly identified. Among the poorest, the annual enrolment increased from 18 households (1.1%) in 2006 to 186 (11.1%) in 2007 after subsidies. CWR is an alternative methodology to identify poor households and was found to be more cost and time efficient compared to other methods. It could be successfully replicated in low-income countries with similar contexts. Moreover, targeted subsidies had a positive impact on enrolment.

Effect of lindane on hepatic and brain cytochrome P450s and influence of P450 modulation in lindane induced neurotoxicity

Oral administration of lindane (2.5, 5, 10 and 15 mg/kg, body weight) for 5 days was found to produce a dose-dependent increase in the activity of P450 dependent 7-ethoxyresorufin-O-deethylase (EROD), 7-pentoxyresorufin-O-dealkylase (PROD) and N-nitrosodimethylamine demethylase (NDMA-d) in rat brain and liver. A significant increase in the hepatic and brain P450 monooxygenases was also observed when the duration of exposure of low dose (2.5 mg/kg) of lindane was increased from 5 days to 15 or 21 days. As observed with different doses, the magnitude of induction in the activity of P450 monooxygenases was several fold higher in liver microsomes when compared with the brain. Western blotting studies have indicated that the increase in the P450 enzymes could be due to the increase in the expression of P450 1A1/1A2, 2B1/2B2 and 2E1 isoenzymes. In vitro studies using organic inhibitors specific for individual P450 isoenzymes and antibody inhibition experiments have further demonstrated that the increase in the activity of PROD, EROD and NDMA-d are due to the increase in the levels of P450 2B1/2B2, 1A1/1A2 and 2E1 isoenzymes, respectively. Induction studies have further shown that while pretreatment of 3-methylcholanthrene (MC), an inducer of P4501A1/1A2, did not produce any significant effect in the incidence of lindane induced convulsions, pretreatment with phenobarbital (PB), an inducer of P450 2B1/2B2 or ethanol, an inducer of P450 2E1 catalysed reactions, significantly increased the incidence of lindane induced convulsions. Similarly, when the P450-mediated metabolism of lindane was blocked by cobalt chloride incidence of convulsions was increased in animals treated with lindane indicating that lindane per se or its metabolites formed by PB or ethanol inducible P450 isoenzymes are involved in its neurobehavioral toxicity.

Effect of pretreatment of cytochrome P450 (P450) modifiers on neurobehavioral toxicity induced by deltamethrin

To investigate the involvement of cytochrome P450 (P450) enzyme induction and the effect of different P450 modifiers in the neurobehavioral toxicity of deltamethrin, deltamethrin (10 mg/kg; orally for 1 day) was administered to young male albino Wistar rats, or in rats pretreated with phenobarbital (PB; 80 mg/kg, ip for 5 days), an inducer of P450 2B1/2B2 or 3-methylcholanthrene (MC; 30 mg/kg, ip for 5 days), an inducer of P450 1A1/1A2 or cobalt chloride (CoCl(2); sc for 2 days), a depletor of P450s. The administration of PB or MC or CoCl(2) alone did not produced any symptoms of neurobehavioral toxicity. While a single oral administration of deltamethrin produced tremors in two out of 10 rats and decreased the spontaneous locomotor activity, pretreatment with MC or PB potentiated the deltamethrin induced neurobehavioral toxicity with 50% of the treated rats exhibiting tremors. Half of the animals pretreated with MC prior to exposure to deltamethrin also exhibited choreoathetosis. The decrease in the spontaneous locomotor activity was found to be much more significant in PB- or MC-pretreated animals exposed to deltamethrin. In contrast to the pretreatment with inducers, rats pretreated with CoCl(2) exhibited no symptoms of tremors or choreoathetosis, indicating that a reactive metabolite of deltamethrin is formed by P450 catalysed reactions which is involved in the neurobehavioral toxicity of deltamethrin.

Cytochrome P450 2E1 dependent catalytic activity and lipid peroxidation in rat blood lymphocytes

To investigate the similarities in the catalytic activity of blood lymphocyte P450 2E1 in blood lymphocyte with the liver isoenzyme, NADPH dependent lipid peroxidation and activity of N-nitrosodimethyamine demethylase (NDMA-d) was studied in rat blood lymphocytes. Blood lymphocytes were found to catalyse NADPH dependent (basal) lipid peroxidation and demethylation of N-nitrosodimethylamine (NDMA). Pretreatment with ethanol or pyrazole or acetone resulted in significant increase in the NADPH dependent lipid peroxidation and the activity of NDMA-d in blood lymphocytes and liver microsomes. In vitro addition of CCl(4) to the blood lymphocytes isolated from control or ethanol pretreated rats resulted in an increase in the NADPH dependent lipid peroxidation. Significant inhibition of the basal and CCl(4) supported NADPH dependent lipid peroxidation and NDMA-d activity in blood lymphocytes isolated from control or ethanol pretreated rats by dimethyl formamide or dimethyl sulfoxide or hexane, solvents known to inhibit P450 2E1 catalysed reactions in liver and anti- P450 2E1, have indicated the role of P450 2E1 in the NADPH dependent lipid peroxidation in rat blood lymphocytes. The data indicating similarities in the NADPH dependent lipid peroxidation and NDMA-d activity in blood lymphocyte with the liver microsome have provided evidence that blood lymphocyte P450 2E1 could be used as a surrogate to monitor and predict hepatic levels of the enzyme.

Antistress effects of bacosides of Bacopa monnieri: modulation of Hsp70 expression, superoxide dismutase and cytochrome P450 activity in rat brain

The antistress effect of bacosides of Brahmi (Bacopa monnieri, BBM), dissolved in distilled water, was -studied in adult male Sprague Dawley rats by administering oral doses of 20 and 40 mg/kg for 7 consecutive days. In half of the animals treated with 20 or 40 mg/kg of BBM, stress was given 2 h after the last dose. Stress was also administered to the animals treated with distilled water alone. BBM, at both doses, did not induce a significant change in the expression of Hsp70 in any brain region studied while stress alone produced a significant increase in the Hsp70 expression in all the brain regions. A significant decrease in the activity of superoxide dismutase (SOD) was evident in the hippocampus with the lower dose of BBM and in animals given stress alone, while an increase in the activity of SOD was observed in the brain regions with the higher dose of BBM. An increase in the activity of cytochrome P450 (P450) dependent 7-pentoxyresorufin-o-dealkylase (PROD) and 7-ethoxyresorufin-o-deethylase (EROD) was observed in all the brain regions after exposure to stress alone and with both doses of BBM although the magnitude of induction of P450 expression was less with a higher dose of BBM. Interestingly, stress when given to the animals pretreated with BBM for 7 days resulted in a decrease in Hsp70 expression in all the brain regions with a significant decrease occurring only in the hippocampus. Likewise the activity of SOD was found to be further reduced in all the brain regions in the animals treated with the lower dose of BBM followed by stress. However, when stress was given to the animals pretreated with the higher dose of BBM, a significant increase in the enzyme activity was observed in the cerebral cortex and in the rest of the brain while the activity of SOD was reduced to a much greater extent in the cerebellum and in the hippocampus. Likewise, the activity of P450 enzymes was found to be restored to almost control levels in the animals given stress and pretreated with the higher dose of BBM, while a lesser degree of induction, compared with animals treated with BBM or stress alone, was observed in the animals pretreated with the lower dose of BBM and given stress. The data indicate that BBM has potential to modulate the activities of Hsp70, P450 and SOD thereby possibly allowing the brain to be prepared to act under adverse conditions such as stress.