The impact of offering multiple cervical screening options to women whose screening was overdue in Dumfries and Galloway, Scotland

Most women who develop cancer have not been screened regularly. One in four women in Scotland, is overdue for cervical screening. Aim was to assess the impact of offering multiple cervical screening options to women whose screening is overdue. A prospective cohort study including all women whose screening was overdue, aged 30-60 years in Dumfries and Galloway in 2012. Potentially eligible women (n = 4146) were identified split into six groups. Women aged 30-55 years were allocated to three different groups. Group 1 (letter, n = 1246), Group 2 (letter and kit, n = 221), Group 3 (letter, n = 2031). Women aged 56-60 years were allocated to: Group 4 (letter, n = 292), Group 5 (letter and kit, n = 292) and Group 6 (control, n = 64). Women who self-collected a vaginal sample were requested to complete a questionnaire. The percentages of women responding were 24 % (21-26), 32 % (25-38), 16 % (14-18), 15 % (11-20) and 12 % (9-17) in groups 1 to 5 respectively, compared with 3 % (0-11) among controls. A significantly higher number of women (n = 383, 10 % of 3815) opted for self-sampling in comparison with undergoing a cervical screening test (CST) at the GP practice (n = 197, 5 %, x2 = 59.0, p < 0.0001). The Evalyn® Brush was well accepted (218/313 = 70 %) by those who requested self-sampling. Almost all (265/272 = 97 %) women who self-collected a vaginal sample said that if they had the option of self-sampling, they would regularly participate in future cervical screening. Offering more flexible screening options, self-sampling in particular, appears to increase cervical screening participation.

Practical learning through radiation physics problem solving

INTRODUCTION

The identification of unknown radionuclides is an authentic practical activity for students that provides the foundations for clinical problem solving, especially in the storage and management of radioactive waste. As different radionuclides have different half-lives, some of which are quite long, the storage of waste material has to accommodate the longest of these. Cross contamination requires a method of identifying the radionuclide samples in a mixed sample to safely and appropriately manage disposal. Similarly, identifying a single unknown sample of a radionuclide allows correct handling and disposal.

METHODS

Performing a systematic investigation of the physical properties of unknown radioactive samples is a rich learning opportunity to instil understanding of important physics principles among students in nuclear medicine.

RESULTS

This manuscript outlines an investigation developed that would allow students to identify single unknown radionuclides based on physical properties and identify the constituent radionuclides of a mixed sample using some additional mathematical curve stripping.

CONCLUSION

The processes and solutions are provided with real data and this practical activity can be replicated by students generating their own data.

IMPLICATIONS FOR PRACTICE

This paper provides a template and analysis/interpretation guideline for educators and clinicians to deepen understanding of foundation physics. Enhanced and deeper understanding are a vehicle for improved problem solving in clinical and research practice.

748 HEARING AIDS AND GLASSES: BEDSIDE SIGNS PROMPT ASSESSMENT OF SENSORY NEEDS, AN AUDIT

Introduction

It is widely acknowledged that older adults with hearing or visual impairment are at higher risk of developing delirium. The National Institute for Clinical Excellence (NICE) guideline for delirium prevention in the hospital setting emphasises the importance of considering sensory impairment in the clinical assessment of patients at risk of delirium, yet it is often overlooked. This audit aimed to determine doctors’ documentation of sensory needs in a geriatrics department and the effect of bedside signs on this documentation.

Method

This study analysed documentation for all patients on three elderly care wards. Pre-defined search terms relating to hearing, visual and cognitive impairment were used to analyse whether sensory needs were mentioned during the patients’ hospital stay to study date. After the first round of data collection, bedside signs to indicate whether patients have hearing aids or glasses were installed, complemented by ward teaching on sensory impairment and delirium. Documentation was re-audited using the same pre-defined search terms as in the first round.

Results

The first round of data collection included 71 patients with an average age of 79 years. Only 30% of patients had documentation regarding sensory needs (hearing and/or vision) and 49% were documented as having delirium and/or dementia. The second round of data collection was completed one month after intervention and included 71 patients with an average age of 82 years. After intervention of bedside signs and ward teaching, doctors’ documentation of sensory impairment increased by 81%.

Conclusion

Installing bedside signs to indicate whether patients have hearing aids or glasses has improved documentation of sensory impairment, in turn prompting its consideration in assessment and care of patients at risk of delirium.

Dexamethasone-related adrenal insufficiency in patients with brain and skull base tumours

PURPOSE

This study aimed to evaluate the prevalence of glucocorticoid-induced adrenal insufficiency in a cohort of patients with brain and skull base tumours and to identify factors which may predict its occurrence.

METHODS

Patients with brain or skull base tumours attending for a short synacthen test (SST) (adrenocorticotropin hormone (ACTH) stimulation test) at a single institution over a 3-year period were retrospectively identified. Baseline demographics and dexamethasone exposure were examined. Only patients with dexamethasone exposure were included in the final analysis looking at the primary end point of SST failure. Fisher's exact test, Student's t test, Mann-Whitney test and the Kendall's tau-b test were used to evaluate the influence of age, gender, diagnosis and mean pituitary radiation dose on the primary endpoint. Receiver operating characteristic (ROC) curves were generated to explore the impact of duration and total exposure to dexamethasone on likelihood of SST failure.

RESULTS

Thirty-one of 51 patients with previous dexamethasone exposure failed their first SST (61%). No significant relationship was demonstrated between age, gender, diagnosis or mean pituitary radiation dose and SST failure. Duration of and total exposure to dexamethasone were significantly associated with SST failure (p = 0.001 and p = 0.007, respectively). ROC curves generated values of 78 days and 171 mg days to give a sensitivity of 94 and 97%, respectively, to detect SST failure.

CONCLUSIONS

Duration of dexamethasone use and total exposure predict for adrenal insufficiency in patients with brain and skull base tumours. Values derived from this study may be useful to identify patients at higher risk of adrenal suppression who require empirical hydrocortisone pending formal testing of the hypothalamic-pituitary-adrenal axis.

Early markers of allergic disease in a primary prevention study using probiotics: 2.5-year follow-up phase

BACKGROUND

We previously reported that a Lactobacillus acidophilus probiotic strain (LAFTI) L10/LAVRI-A1) given for the first 6 months of life increased the risk of allergen sensitization at 1 year of age.

METHODS

To assess the effects on subsequent allergic outcomes, 153 children from the initial prevention cohort (n = 178) were reviewed at 2.5 years of age. Clinical outcomes were assessed in relation to (i) probiotic supplementation; and (ii) immune function previously assessed at 6 months of age.

RESULTS

Supplementation with this probiotic did not reduce the risk of dermatitis at 2.5 years (31/74, 42%) compared with that in placebo group (25/76, 34%). There was no significant reduction in any other allergic disease or allergen sensitization. Inhalant sensitization at 2.5 years (n = 29) was associated with higher proportions of circulating CD4+ CD25+ regulatory T-cell populations (P = 0.005) and higher allergen-induced FOXP3 levels (P = 0.003) at 6 months. This was also seen in children with dermatitis. Children with dermatitis at 2.5 years also had significantly lower toll-like receptor 4 lipopolysaccharide responses at 6 months of age (IL-12 P = 0.04, IL-6 P = 0.039) and lower polyclonal (PHA) responses (IFN-gamma P = 0.005, IL-10 P = 0.001, and IL-6 P = 0.001). Children who had previously received the probiotic had fewer gastrointestinal infections in the preceding 18 months (P = 0.023).

CONCLUSION

The LAFTI L10 probiotic strain did not have any significant effect on allergy outcomes. Allergic children showed a number of early differences in immune function including altered regulatory T-cell markers and innate immune function.

Supplementation with Lactobacillus rhamnosus or Bifidobacterium lactis probiotics in pregnancy increases cord blood interferon-gamma and breast milk transforming growth factor-beta and immunoglobin A detection

BACKGROUND

This study explored the effects of maternal probiotic supplementation on immune markers in cord blood (CB) and breast milk.

METHODS

CB plasma and breast milk samples were collected from a cohort of women who had received daily supplements of either 6 x 10(9) CFU/day Lactobacillus rhamnosus HN001 (n=34), 9 x 10(9) CFU/day Bifidobacterium lactis HN019 (n=35) or a placebo (n=36) beginning 2-5 weeks before delivery and continuing for 6 months in lactating women. CB plasma and breast milk (collected at 3-7 days, 3 months and 6 months postpartum) were assayed for cytokines (IL-13, IFN-gamma, IL-6, TNF-alpha, IL-10, TGF-beta1) and sCD14. Breast milk samples were also assayed for total IgA.

RESULTS

Neonates of mothers who received a probiotic had higher CB IFN-gamma levels (P=0.026), and a higher proportion had detectable blood IFN-gamma levels, compared with the placebo group (P=0.034), although levels were undetectable in many infants. While this pattern was evident for both probiotics, when examined separately only the L. rhamnosus HN001 group showed statistically significant higher IFN-gamma levels (P=0.030) compared with the placebo group. TGF-beta1 levels were higher in early breast milk (week 1) from the probiotic groups (P=0.028). This was evident for the B. lactis HN019 group (P=0.041) with a parallel trend in the L. rhamnosus HN001 group (P=0.075). Similar patterns were seen for breast milk IgA, which was more readily detected in breast milk from both the B. lactis HN019 (P=0.008) and the L. rhamnosus HN001 group (P=0.011). Neonatal plasma sCD14 levels were lower in the B. lactis HN019 group compared with the placebo group (P=0.041).

CONCLUSION

The findings suggest that supplementation with probiotics in pregnancy has the potential to influence fetal immune parameters as well as immunomodulatory factors in breast milk.

Relationship between early intestinal colonization, mucosal immunoglobulin A production and systemic immune development

BACKGROUND

Variations in early intestinal colonization patterns have been implicated in the predispostion to allergic disease through effects on mucosal and systemic immune function.

METHODS

Colonization patterns and mucosal IgA production at 6 months of age were examined in relation to early exposures, systemic immune development and early allergic outcomes. This was performed in a cohort (n=189) who had received either Lactobacillus acidophilus or a placebo since birth.

RESULTS

Children who developed sensitization to one or more allergens by 12 months of age had significantly higher total (but not secretory) IgA levels at 6 months (P=0.024), but this was independent of probiotic treatment. There were no relationships between colonization patterns and IgA (total or secretory IgA) levels or allergic outcomes (sensitization, atopic dermatitis or food allergies). Breastfeeding, and the use of yoghurt or probiotic supplements were independently associated with significantly higher proportions of 'favourable' lactobacilli and bifidobacteria species. Caesarean delivery and the use of antibiotics during the first 6 months were not associated with significant variations in colonization. Higher proportions of 'favourable' bacteria (notably bifidobacteria) were associated with reduced production of most cytokine response to allergens, but increased expression of regulatory cell markers (P=0.009) and transforming growth factor-beta (P=0.016).

CONCLUSION

'Favourable' colonization, particularly with bifidobacteria, was associated with effects on cellular immune function, but this was not associated with mucosal immunity (secretory IgA) or reduced risk of allergic disease.

Inter-observer variability in the assessment of nerve function in leprosy patients in Ethiopia

One of the major problems in leprosy is to detect any change in nerve function early enough so as to increase the chances of recovery and prevent disability. Several tests have been developed to assess nerve function and are used in leprosy control programs worldwide, but they are frequently performed by different workers on different occasions and under variable conditions. In this study we investigated the variability between different groups of observers in the assessment of nerve function in leprosy patients in Ethiopia. Sensory function was assessed by using a set of nylon monofilaments (NF) and a ball-point pen (BP), and motor function was assessed by using voluntary motor testing (VMT). We also studied the variability between observers in the assessment of the clinical signs of neuritis. Duplicate measurements were performed in random order on 50 leprosy patients by two physio-technicians and on 50 other patients by two health assistants. The percent agreement between observers was calculated for each single nerve, and weighted kappa statistics were used to assess whether agreement was better than expected due to chance alone. Systematic differences between observers were evaluated using the Wilcoxon signed rank test. On sensory testing, inter-observer variability was found to be related to the training and experience of the observer, to the nerve tested, and to the neurological status of the patient. When tests were performed by physio-technicians, we observed 32% to 58% agreement with the NF test and 71% to 84% agreement with the BP test, measured on different scales. After weighting for the scale difference, the agreement seemed comparable with these methods but the differences in measurements with the BP test were found to be dependent upon the neurological status of the patient. The variability between observers differed according to the nerve tested, and there was some evidence of systematic differences between observers with both methods. When performed by the health assistants, agreement was between 34% and 46% with the NF and between 66% and 82% with the BP tests. After weighting for the scale difference, the agreement seemed comparable but the BP was not liable to the systematic differences seen in the NF results. These differences could be attributed to the differences in the experience of the workers with these tests. With the VMT, small variability between observers was found for all nerves tested, except the facial nerve, when performed by both the physio-technicians and by the health assistants (72% to 98% agreement).(ABSTRACT TRUNCATED AT 400 WORDS)