Rates of paclitaxel hypersensitivity reactions using a modified Markman's infusion protocol as primary prophylaxis

PURPOSE

Markman's desensitisation protocol allows successful retreatment of patients who have had significant paclitaxel hypersensitivity reactions. We aimed to reduce the risk and severity of paclitaxel hypersensitivity reactions by introducing this protocol as primary prophylaxis.

METHODS

We evaluated all patients with a gynaecological malignancy receiving paclitaxel before (December 2018 to September 2019) and after (October 2019 to July 2020) the implementation of a modified Markman's desensitisation protocol. The pre-implementation group received paclitaxel over a gradually up-titrated rate from 60 to 180 ml/h. The post-implementation group received paclitaxel via 3 fixed-dose infusion bags in the first 2 cycles. Rates and severity of paclitaxel hypersensitivity reactions were compared.

RESULTS

A total of 426 paclitaxel infusions were administered to 78 patients. The median age was 64 years (range 34-81), and the most common diagnosis was ovarian, fallopian tube and primary peritoneal cancer (67%, n = 52/78). Paclitaxel hypersensitivity reaction rates were similar in the pre-implementation (8%, n = 16/195) and post-implementation groups (9%, n = 20/231; p = 0.87). Most paclitaxel hypersensitivity reactions occurred within 30 min (pre- vs. post-implementation, 88% [n = 14/16] vs. 75% [n = 15/20]; p = 0.45) and were grade 2 in severity (pre- vs. post-implementation, 81% [n = 13/16] vs. 75% [n = 15/20]; p = 0.37). There was one grade 3 paclitaxel hypersensitivity reaction in the pre-implementation group. All patients were successfully rechallenged in the post-implementation group compared to 81% (n = 13/16) in the pre-implementation group (p = 0.43).

CONCLUSION

The modified Markman's desensitisation protocol as primary prophylaxis did not reduce the rate or severity of paclitaxel hypersensitivity reactions, although all patients could be successfully rechallenged.

Considerations for Research Funders and Managers to Facilitate the Translation of Scientific Knowledge into Practice

Research funders and managers can play a critical role in supporting the translation of knowledge into action by facilitating the brokering of knowledge and partnerships. We use semi-structured interviews with a research funding agency, the Australian Centre for International Agricultural Research (ACIAR), to explore (i) ways that funders can facilitate knowledge brokering, the (ii) barriers to, and (iii) enablers for, facilitating knowledge brokering, and (iv) the individual skills and attributes for research program funders and managers to be effective brokers. Based on these findings, we generate three considerations for research funders elsewhere, in particular R4D funders, seeking to build capacity for knowledge brokering: (i) formalise the process and practice, (ii) develop shared language and understanding, and (iii) build individual competencies and capabilities. Our findings complement the existing literature with a context specific analysis of how research funders can facilitate knowledge brokering, and by identifying the barriers and enablers in doing so.

"Worlds. . .[of] Contingent Possibilities": Genderqueer and Trans Adolescents Reading Fan Fiction

Cultural studies scholars have long been interested in the nexus between people's online activities and their identities. One activity that has drawn attention is reading/writing fan fiction (fictions written by and for fans that build upon the characters and worlds depicted in commercial texts). While fan fiction and its surrounding communities have long been understood as resistant to heteronormativity, previous work exploring the fans who produce and consume fan fiction has largely insisted that most of these fans are adult ciswomen. Little has been written about the experiences of trans and genderqueer fans. To remedy this elision, this article explores two trans and genderqueer individuals' experiences with fan fiction. It closely examines the roles reading, and especially reading fan fiction, has or has not played in their understandings of themselves, their identities, and their places in the world.

85 QUALITY IMPROVEMENT INITIATIVE TO ASSESS FRAILTY AWARENESS AND USE CLINICAL FRAILTY SCALE AMONGST STAFF IN ACUTE AND PRIMARY CARE SITES

Background

Frailty describes a condition characterized by decreased physiological reserve and a decreased resistance to stressors, leading to an increased vulnerability to adverse outcomes. Identification of frailty can generate greater complexity in treatment choices, care planning, and costs of care.

Methods

30 inpatient, Emergency Department and Ambulatory Hub charts were audited to assess the presence of the word Frailty. The use of the Clinical Frailty Scale or alternative frailty scale was also audited. A staff survey was completed across four sites, a total of 115 staff were surveyed.

Results

Awareness of frailty across all services is very good ranging from 92% to 100%. The use and awareness of the Clinical Frailty Scale varied with 41% Emergency department and 12% of acute staff respectively but only 25% Emergency Department and 12% of acute staff feeling competent to complete the scale. Conversely, there was a 73% awareness of the Clinical Frailty Scale amongst primary care staff, 33% feeling competent in it's use. The Ambulatory Hub had 100% awareness of the scale with 54% of staff feeling competent.

The chart audit showed that 20% of charts in the Emergency Department identified frailty, all by the Frailty Intervention Team. 26% of the inpatient charts identified Frailty by the Frailty Intervention Team's notes and from one visiting consultant. Frailty was identified and measured using the Clinical Frailty Scale in all cases of the Ambulatory Hub notes.

Conclusion

By identifying frailty at the first point of contact, targeted specialist interventions and services can be planned for the service user. Frailty identification on the acute site was mainly linked to the Frailty Intervention Team with the Ambulatory Hub leading out on frailty identification and measurement in the community. Future initiatives aim to increase frailty identification and awareness in acute and primary care sites.

61 AUDIT: MEDICATION REVIEW POST INPATIENT FALLS

Background

Falls are the most commonly reported incident in the Health Service Executive (HSE). Inappropriate medications and polypharmacy in the elderly can contribute to increased falls risk.

Our aim was to assess whether a medication review was being completed at the time of the post-fall clinician review.

Methods

We completed a retrospective chart review using an audit tool of consecutive inpatient falls, resulting in serious injury, from March–December 2019.

Standards measured against were: HSE Guideline—Service User Falls: A Practical Guide for Review, Medicines and Falls in Hospital: British Society Guidelines, STOPP & START criteria and NICE Guidelines: Falls in Older People 2013.

Results

We identified 33 charts for review (n = 33)—54.55% (18) female and 45.45% (15) male. Average age was 81 ± 11.2 years. The immediate post-fall review was mainly completed by interns (48.49% (16)) and SHO’s (39.39% (13)). A medication review was carried out 9.09% (3) of the time.

A total of n = 28 (84.85%) had poly pharmacy. When analysed for medications known to increase risk of falling, 51.52% (n = 17) were on anti-hypertensives, 45.45% (n = 15) on laxatives, 24.24% (n = 8) on sedative medications, 18.18% (n = 6) on hypnotics/anxiolytics, 15.15% (n = 5) on opioids and 15.15% (n = 5) on diuretics at the time of fall. The majority of these medications (77.42% (n = 24)) were commenced prior to admission. None of these medications were discontinued or the dose changed on review post fall.

Conclusion

Our audit demonstrates that in a cohort of patients who had an inpatient fall medication discontinuation and dose reductions were not performed. Yet, a high burden of polypharmacy and high-risk falls medication were found. This may result in missing a pertinent opportunity to prevent future falls. We advise a structured medication review is carried out for each patient who suffers an in-patient fall to efficiently modify such an easily identifiable risk factor.

57 POTENTIALLY INAPPROPRIATE MEDICATION USE AND MORTALITY IN PATIENTS WITH COGNITIVE IMPAIRMENT

Background

Potentially inappropriate medications (PIMs are associated with falls, hospitalisation, and cognitive decline. Few studies have investigated the association between PIMs related to cognitive impairment (PIMCog) and mortality in dementia or mild cognitive impairment (MCI).

Methods

This was a retrospective observational study. Patients diagnosed with MCI or dementia (DSM-IV criteria) presenting to a tertiary-referral memory clinic from 2013–2019 were eligible. The primary outcome was all-cause death. Secondary outcomes were vascular death and non-vascular death defined according to formal certification. The primary exposure variable of interest was PIMCog, defined as any medication in the Beers 2015 or STOPP criteria, classified as potentially inappropriate for patients with cognitive impairment. Anticholinergic burden was measured using the anticholinergic cognitive burden (ACB) scale. Polypharmacy was defined as ≥5 medications. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs).

Results

There were 418 patients included (n = 261 dementia, n = 157 MCI). The median age was 79 (interquartile range {IQR} 74–82) and median follow-up was 809 days (IQR 552–1,571). One or more PIMCog was prescribed in 141 patients (33.4%). PIMCog use was associated with all-cause mortality after adjustment for age, sex, dementia severity, Charlson Co-morbidity Index, chronic obstructive pulmonary disease, congestive cardiac failure, and peripheral vascular disease (HR 1.96, 95% CI 1.24–3.09). PIMCog use was associated with vascular death (HR 3.28, 95% CI 1.51–7.11) but not with non-vascular death (HR 1.40 95% CI: 0.78–2.52). Neither an ACB ≥3 (HR 0.87, 95% CI: 0.46–1.64) or polypharmacy (HR 1.87, 95% CI: 0.67–5.24) were associated with death.

Conclusion

The burden of PIMCog use in patients with cognitive impairment is high. PIMCog use is independently associated with all-cause mortality and vascular death. This is a potential modifiable risk factor for death in patients with neurocognitive disorders. Further research is required to independently validate this finding.

Cell-free DNA is abundant in ascites and represents a liquid biopsy of ovarian cancer

OBJECTIVE

Malignant ascites is a common clinical feature of ovarian cancer and represents a readily accessible sample of tumour cells and tumour DNA. This study aimed to characterise the cell-free DNA (cfDNA) in ascites in terms of its size profile, stability and cell-free tumour DNA (cftDNA) content.

METHODS

Cell spheroids, loose cells and cell-free fluid was collected from ascites from 18 patients with ovarian cancer. cfDNA was isolated and assessed for size by electrophoresis, concentration by fluorometry,cftDNA content by methylation specific qPCR of HOXA9 and IFFO1 promoter regions and by targeted sequencing. Stability was assessed after ascites fluid was stored at 4 °C for 24 and 72 h before fractionating.

RESULTS

The concentration of cfDNA in ascites ranged from 6.6 to 300 ng/mL. cfDNA size distribution resembled blood plasma-derived cfDNA, with major peaks corresponding to mono- and di-nucleosome DNA fragments. High molecular weight cfDNA was observed in 7 of 18 patients and appeared to be associated with extracellular vesicles. IFFO1 and HOXA9 methylation was proportionately higher in cfDNA than spheroid- and loose-cell fractions and was not observed in healthy primary cells. Variant allele frequency was highest in cfDNA compared to single cells and spheroids from ascites. Though cancer cell numbers in ascites declined to near zero in recurrent ascites from one patient undertaking chemotherapy, cftDNA could still be sampled. cfDNA size, concentration and tumour content was stable over 72 h.

CONCLUSION

cfDNA in ovarian cancer ascites demonstrates inter-patient variability, yet is consistently a rich source of cftDNA, which is a stable substrate. This supports the wider clinical use of ascites in the molecular analysis of ovarian cancer.

509 POTENTIALLY INAPPROPRIATE MEDICATION USE AND MORTALITY IN PATIENTS WITH COGNITIVE IMPAIRMENT

Introduction

Potentially inappropriate medications (PIMsare associated with falls, hospitalisation, and cognitive decline. Few studies have investigated the association between PIMsrelated to cognitive impairment (PIMCog) and mortality in dementia or mild cognitive impairment (MCI).

Methods

This was a retrospective observational study. Patients diagnosed with MCI or dementia (DSM-IV criteria) presenting to a tertiary-referral memory clinic from 2013–2019 were eligible. The primary outcome was all-cause death. Secondary outcomes were vascular death and non-vascular death defined according to formal certification. The primary exposure variable of interest was PIMCog, defined as any medication in the Beers 2015 or STOPP criteria, classified as potentially inappropriate for patients with cognitive impairment. Anticholinergic burden was measured using the anticholinergic cognitive burden (ACB) scale. Polypharmacy was defined as ≥5 medications. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs).

Results

There were 418 patients included (n = 261 dementia, n = 157 MCI). The median age was 79 (interquartile range {IQR} 74–82) and median follow-up was 809 days (IQR 552–1,571). One or more PIMCog was prescribed in 141 patients (33.4%). PIMCog use was associated with all-cause mortality after adjustment for age, sex, dementia severity, Charlson Co-morbidity Index, chronic obstructive pulmonary disease, congestive cardiac failure, and peripheral vascular disease. (HR 1.96, 95% CI 1.24–3.09). PIMCog use was associated with vascular death (HR 3.28, 95% CI 1.51–7.11) but not with non-vascular death (HR 1.40 95% CI: 0.78–2.52). Neither an ACB ≥3 (HR 0.87, 95% CI: 0.46–1.64) or polypharmacy (HR 1.87, 95% CI: 0.67–5.24) were associated with death.

Conclusion

The burden of PIMCog use in patients with cognitive impairment is high. PIMCog use is independently associated with all-cause mortality and vascular death. This is a potential modifiable risk factor for death in patients with neurocognitive disorders. Further research is required to independently validate this finding.

Transformative Readings: Harry Potter Fan Fiction, Trans/Queer Reader Response, and J. K. Rowling

The politics of children's literature and the actors surrounding it have never been more visible than they are now, in the digital age. As one of the first children's series to gain widespread popularity concurrently with the spread of the internet, the Harry Potter septet arrived on the global stage at the perfect moment to develop an avid, connected fandom. But the fandom has laid bare the many conflicting ideologies of the fans themselves and of the actors surrounding the texts. This article examines the contentious issue of gender nonnormativity and its relation to the Harry Potter texts, the queer/trans reading practices and political resistance common to the fandom, and the ongoing disagreements over gender, made visible on social media, between Rowling and the fans of her series. The article discusses the Harry Potter novels' varied and conflicting ideologies; queer/trans readings of the Potter septet, including both invitations and resistances to queer/trans reading by Rowling herself; how gender is queered and queried in and through fan fiction; and finally, the recent hostilities between Rowling and her fans. It concludes by discussing the worsening relationship between Rowling and her fans and highlighting how fans are using their collective power to undermine Rowling's gender politics through fan fiction. By doing so, the article traces the complex politics of the reception of books for young people in the digital age, demonstrating that authors' powerful voices continue to shape readers' responses to texts long after their publication but showing, too, that readers often resist authors' attempts to influence not only their textual interpretations but their politics.

Estimating bias in derived body mass index in the Maternity Experiences Survey

INTRODUCTION

The objective of this study was to assess bias in the body mass index (BMI) measure in the Canadian Maternity Experiences Survey (MES) and possible implications of bias on the relationship between BMI and selected pregnancy outcomes.

METHODS

We assessed BMI classification based on self-reported versus measured values. We used a random sample of 6175 women from the MES, which derived BMI from self-reported height and weight, and a random sample of 259 women who had previously given birth from the Canadian Health Measures Survey (CHMS), which derived BMI from self-reported and measured height and weight. Two correction equations were applied to self-reported based BMI, and the impact of these corrections on associations between BMI and caesarean section, small-for-gestational age (SGA) and large-for-gestational age (LGA) births was studied.

RESULTS

Overall, 86.9% of the CHMS subsample was classified into the same BMI category based on self-reported versus measured data. However, misclassification had a substantial effect on the proportion of women in underweight and obese BMI categories. For example, 14.5% versus 20.8% of women were classified as obese based on self-reported data versus measured data. Corrections improved estimates of obesity prevalence, but over- and underestimated other BMI categories. Corrections had nonsignificant effects on the associations between BMI and SGA, LGA, and caesarean section.

CONCLUSION

While there was high concordance in BMI classification based on selfreported versus measured height and weight, bias in self-reported based measures may slightly over- or underestimate the risks associated with a particular BMI class. However, the general trend in associations is unaffected.

Falls and fractures 2 years after acute stroke: the North Dublin Population Stroke Study

BACKGROUND

Stroke patients are at increased risk of falls and fractures. The aim of this study was to determine the rate, predictors and consequences of falls within 2 years after stroke in a prospective population-based study in North Dublin, Ireland.

DESIGN

Prospective population-based cohort study.

SUBJECTS

567 adults aged >18 years from the North Dublin Population Stroke Study.

METHODS

Participants were enrolled from an Irish urban population of 294,592 individuals, according to recommended criteria. Patients were followed for 2 years. Outcome measures included death, modified Rankin Scale (mRS), fall and fracture rate.

RESULTS

At 2 years, 23.5% (124/522) had fallen at least once since their stroke, 14.2% (74/522) had 2 or more falls and 5.4% (28/522) had a fracture. Of 332 survivors at 2 years, 107 (32.2%) had fallen, of whom 60.7% (65/107) had 2 or more falls and 23.4% (25/107) had fractured. In a multivariable model controlling for age and gender, independent risk factors for falling within the first 2 years of stroke included use of alpha-blocker medications for treatment of hypertension (P = 0.02). When mobility measured at Day 90 was included in the model, patients who were mobility impaired (mRS 2-3) were at the highest risk of falling within 2 years of stroke [odds ratio (OR) 2.30, P = 0.003] and those functionally dependent (mRS 4-5) displayed intermediate risk (OR 2.02, P = 0.03) when compared with independently mobile patients.

CONCLUSION

Greater attention to falls risk, fall prevention strategies and bone health in the stroke population are required.

Patient transfer forms enhance key information between nursing homes and emergency department

The purpose of this study was to determine whether the use of a transfer form increases the availability of essential information needed for patient care and to examine its effect on case resolution time and disposition status. A retrospective review was performed that included patients 65 years old or greater arriving from nursing homes to an academic Emergency Department from January to June 2009. Eighty randomly selected charts were reviewed. Sixteen items were deemed essential based on an expert-based rubric published in 2006. Each case was scored accordingly. Results indicate that the transfer form group had available, on average, 71% of the essential items as compared to 28% for cases without a transfer form (p < 0.001). There was no difference in the case resolution time (p = 0.94) or in disposition status (p = 0.12). In conclusion, essential information for providing emergency department patient care was significantly increased with the use of a transfer form.

Stroke recurrence within the time window recommended for carotid endarterectomy

OBJECTIVE

In the North Dublin Population Stroke Study, we investigated the risk of recurrent stroke within the 14-day time window recommended for endarterectomy.

METHODS

In a population-based prospective cohort study, all ischemic stroke patients were identified over 1 year and categorized into those with (CS-positive) and without (CS-negative) ipsilateral carotid stenosis (CS) (≥50% lumen narrowing). Nonprocedural stroke recurrence was determined at 72 hours and 7 and 14 days.

RESULTS

Of 365 ischemic stroke patients with carotid imaging, 51 were excluded due to posterior circulation or nonlateralizing stroke, ipsilateral carotid occlusion, or intracranial stenosis, leaving 314 included for analysis (36 CS-positive and 278 CS-negative). Recurrent stroke occurred in 5.6% (2/36) CS-positive and 0.4% (1/278) CS-negative patients by 72 hours of symptom onset (p =0.003), 5.6% (2/36) CS-positive and 0.7% (2/278) CS-negative patients (p =0.01) by 7 days, and in 8.3% (3/36) CS-positive and 1.8% (5/278) CS-negative patients by 14 days (p =0.02). On multivariable Cox regression analysis, CS was the only independent predictor of recurrence at 72 hours (adjusted hazard ratio [HR] 36.1, 95% confidence interval [CI] 1.6-837.5, p =0.03), and 7 days (HR 9.1, 1.1-79.2, p =0.05), with a trend at 14 days (HR 4.6, 0.9-22.8, p =0.06).

CONCLUSIONS

Although only a minority of patients with symptomatic CS had a recurrent stroke within 14 days, early recurrent stroke risk was high, particularly within the first 72 hours. Earlier carotid revascularization or improved acute medical treatment may reduce recurrence in this high-risk group.

Imaging multiple phases of neurodegeneration: a novel approach to assessing cell death in vivo

Nerve cell death is the key event in all neurodegenerative disorders, with apoptosis and necrosis being central to both acute and chronic degenerative processes. However, until now, it has not been possible to study these dynamically and in real time. In this study, we use spectrally distinct, well-recognised fluorescent cell death markers to enable the temporal resolution and quantification of the early and late phases of apoptosis and necrosis of single nerve cells in different disease models. The tracking of single-cell death profiles in the same living eye over hours, days, weeks and months is a significant advancement on currently available techniques. We identified a numerical preponderance of late-phase versus early-phase apoptotic cells in chronic models, reinforcing the commonalities between cellular mechanisms in different disease models. We showed that MK801 effectively inhibited both apoptosis and necrosis, but our findings support the use of our technique to investigate more specific anti-apoptotic and anti-necrotic strategies with well-defined targets, with potentially greater clinical application. The optical properties of the eye provide compelling opportunities for the quantitative monitoring of disease mechanisms and dynamics in experimental neurodegeneration. Our findings also help to directly observe retinal nerve cell death in patients as an adjunct to refining diagnosis, tracking disease status and assessing therapeutic intervention.

Antiretroviral therapy in the lives of women of colour with HIV

Non-adherence to antiretroviral medication is associated with adverse patient outcomes. Considerable research and clinical work has focused on issues surrounding patient compliance to prescribed regimens. Few studies have explored the essence of antiretroviral medications in the lives of women of colour with HIV. A qualitative study of HIV-infected women of colour was undertaken in response to the question: What is the role of antiretroviral medication in your life? Taped interviews were conducted with graduate psychology students and commercially transcribed. Transcriptions were analyzed by Spiegelberg's category-cluster-theme process by four different reviewers. Three themes were distilled: trust/mistrust, approach/avoidance motivation and 'constantly tethered'. Strategies designed to increase medication adherence may need to consider these basic themes in order to be successful.

The effect of cricoid pressure on intubation facilitated by the gum elastic bougie

Tracheal tube impingement is common during gum elastic bougie facilitated intubation and a 90 degrees anti-clockwise rotation of the tube usually relieves it. We detail a case where this manoeuvre failed in the presence of cricoid pressure. We investigated the effect of cricoid pressure on gum elastic bougie facilitated intubation in 120 patients randomly allocated to receive sham cricoid pressure (n = 60) or 30 N cricoid pressure (n = 60). Impingement occurred in 23/60 (38%) with sham cricoid pressure and 36/60 (60%) with 30 N cricoid pressure (p < 0.025). Only females showed an increase in impingement with cricoid pressure: 29% sham cricoid pressure vs 63% 30 N cricoid pressure, p < 0.01, whereas the impingement in males was approximately 60% in both groups. Ninety degree anti-clockwise rotation of the tube was successful in all 23 patients (100%) with sham cricoid pressure and in 32/36 patients (89%) with 30 N cricoid pressure. Releasing cricoid pressure relieved the obstruction in the four cases where 90 degrees anti-clockwise rotation of the tube failed. Impingement is common and 90 degrees anti-clockwise rotation is highly effective in both the presence and absence of cricoid pressure. In a small number of cases, cricoid pressure may cause the manoeuvre to fail.

Anticonvulsant use in elderly patients in long-term care units

BACKGROUND

Elderly patients in long-term care units are frailer than their community-dwelling peers and may be more at risk from toxic side-effects of anticonvulsant medication at standard doses.

AIM

To examine the prescribing of anticonvulsants to patients in elderly care units.

METHODS

Drug prescription sheets and case notes were reviewed. Serum anticonvulsant concentration, renal and liver profiles and albumin level were measured.

RESULTS

Anticonvulsants were prescribed to twice as many male as female patients (32 vs 14%; p<0.03) and to 33% of those younger than 80 years of age versus 10% of those aged 80 years or older (p<0.0002). No patient had significant hypoalbuminaemia and routine measurement of serum anticonvulsant concentration did not indicate an alteration of dosage.

CONCLUSIONS

Anticonvulsants appear to be well tolerated in these patients. The younger age of those receiving anticonvulsants is inadequately explained by the characteristics of the patient cohort and may reflect a shift towards a younger age in patients requiring anticonvulsants due to increased mortality in this group.

Benefits of treating hypertension in the elderly: should age affect treatment decisions?

Do the benefits of treating hypertension extend equally to all age groups, particularly the very elderly? Several large controlled trials have been published in recent years that confirm the benefits of the treatment of hypertension in terms of morbidity and mortality. However, these trials included only relatively small numbers of patients aged > or = 80 years. Data regarding such patients have been extracted and subjected to meta-analysis, but with inconclusive results. Further difficulties arise as a result of the range of therapeutic agents employed. Therefore, uncertainty still surrounds the value of treating very elderly patients with hypertension. The J-curve hypothesis, i.e. that a blood pressure threshold exists below which there is an increase in the rate of cardiac events, has been a concern in treating elderly patients. Upon close examination, this appears to be spurious. The Hypertension in the Very Elderly Trial study sets out to provide conclusive evidence for the benefits or otherwise of treating hypertension in the very elderly and has just commenced. The results of this trial will not be available for some time. In the meantime, should physicians initiate or continue treatment for very elderly individuals with hypertension? If so, what regimens should be employed and should target blood pressure levels be set? At the present time, it would appear sensible to provide treatment for very elderly patients with hypertension, particularly those with evidence of complications or target organ damage. In relatively healthy individuals with mild-to-moderate hypertension, the guiding principle should be 'the lower the blood pressure the better'. Regarding the choice of therapeutic agent, a low-dose diuretic remains the first choice therapy.

Motor block in regional anaesthesia. Quantification by muscle strength at the ankle joint

A device based on a load cell was constructed to measure the strength of foot dorsiflexion and plantarflexion. Performance of the device was evaluated for both movements. The influence of foot position within the device, its use over a 30-min period at 30-s intervals and the effect of the removal and reapplication of the device on measured force of dorsiflexion and plantarflexion was studied in six volunteers. Both dorsiflexion and plantarflexion are suitable movements on which to base a device to quantify the density of motor block during the onset and offset of neuraxial block. Dorsiflexion has a number of advantages: muscle strength is independent of knee position, and therefore a below-knee device can be constructed; strength of dorsiflexion is less affected by the foot position; we found the device easier to apply using dorsiflexion as the heel tended to self-locate; innervation of the muscles responsible for dorsiflexion involves fewer spinal segments.

Tsl and LP-BM5: a comparison of two murine retrovirus models for HIV

The ts1 murine leukemia virus produces an immunodeficiency state in mice that parallels human immunodeficiency virus (HIV) infection in humans. Other murine leukemia viruses, such as LP-BM5 used in the murine acquired immune deficiency virus (MAIDS) model, have been studied extensively as a small animal model for HIV research, but lack many key similarities to HIV. Mice infected with ts1, however, utilize CD4 target cells for infection, undergo neuronal loss and demyelination, and develop clinical immunodeficiency. These features make this retrovirus in many ways an ideal candidate for a small animal model for HIV research. In this review article, the early development, the molecular and clinical pathogenesis of both the ts1 mutant of the Moloney murine leukemia virus and LP-BM5 are examined. Based on an extensive evaluation of the literature on LP-BM5 and ts1, it is concluded that the ts1 virus may serve as a better animal model to human retrovirus infection.

The efficacy of subsurface flow reed bed treatment in the removal of Campylobacter spp., faecal coliforms and Escherichia coli from poultry litter

The use of poultry waste as a fertiliser on arable land is an accepted method of waste treatment. However, run-off from such practices may result in contamination of the watercourse by human pathogens. In this study the effectiveness of using constructed wetlands as an alternative treatment for poultry manure waste was evaluated. Enumeration of Campylobacter spp., Escherichia coli, total coliforms and total aerobes were carried out on influent and effluent samples from reed beds loaded with poultry waste. For both sequential loading and continuous loading there was a statistically significant mean log reduction of 3.56 and 4.25 for E. coli, 3.2 and 3.88 for coliforms, 3.85 and 4.2 for total aerobic counts and 3.13 and 2.96 for Campylobacter spp., respectively. This method, which has been previously recognised as cost-effective and environmentally acceptable, provides an efficient method for reducing numbers of these bacteria in poultry waste and therefore an effective alternative treatment for such waste or waters containing run off from land previously spread with poultry manure.

Use of complementary and alternative therapies in HIV-infected patients

The use of complementary and alternative medicine (CAM) therapies is widespread in many chronic illnesses, including human immunodeficiency virus (HIV) infection. The objective of this study was to determine the impact of increasingly effective antiretroviral therapy on the use of CAM in an HIV-positive patient population. A written survey was given to 191 HIV-positive outpatients. Participation was voluntary and anonymous. One hundred twenty-eight patients (67%) used CAM at some time to control HIV and 76 (40%) of the patients were currently using CAM. The major forms of CAM used were exercise (43%), lifestyle changes (38%), dietary supplements (37%), counseling (27%), herbal medications (26%), megavitamins (24%), and prayer therapy (24%). One hundred forty-one patients (74%) used a protease inhibitor medication, 28 (15%) used a protease inhibitor sparing regime, and 22 (11%) had no current or prior antiretroviral use. Eighty-two (43%) patients indicated that their doctor knew they used CAM and 56 patients (29%) received their information about CAM from a doctor or other health care professional. Of 128 patients who used CAM, 90 (70%) felt CAM improved their quality of life. Income of $15,000 or more per year and discontinuation of medications by patients for any reason in the past were the best predicators of CAM use for patients in general and also those on protease inhibitor therapy. CD(4) count, educational status, year of HIV diagnosis, and martial status were not effective predictors of CAM use. Use of CAM remains widespread among patients with HIV infection even with the availability of effective, yet noncurative antiretroviral therapy and does not correlate with type of antiretroviral therapy used or clinical status.

Colorectal cancer screening:potential pitfalls

The National Health and Medical Research Council has recently issued guidelines on colo-rectal cancer, and givensignificant support to Colorectal Cancer Screening. However, the evidence of cost-effectiveness is inconclusiveaccording to the Cochrane Centre.I argue that it would be wise to undertake trials that are appropriately funded. Otherwise, there is a risk that muchmoney will be spent that cannot subsequently be justified.

Vaccine era measles in an adult

Measles should be included in the differential diagnosis of patients with fever and the characteristic viral exanthem, even if a history of adequate immunization is obtained. We present the case of a 23-year-old white female who developed high fever (103 degrees F), brightly erythematous eruptions on the face, sore throat, dry cough, and myalgia 5 days after her return to the United States following a trip to Calcutta, India. The patient had extensive facial erythema from the hairline to the neck, but some areas beneath the chin were spared. Fine erythematous papules extended down the anterior neck, and white papules were seen on the buccal mucosa. The erythematous macules spread to the trunk and extremities, eventually becoming confluent and desquamating over a period of 1 week. Defervescence occurred with desquamation. Measles serology revealed the IgM antibody as positive and the IgG antibody as negative despite 2 measles, mumps, and rubella (MMR) vaccinations at ages 15 months and 7 years. Skin biopsy was consistent with viral infection.

Connective tissue growth factor: potential role in glomerulosclerosis and tubulointerstitial fibrosis

Transforming growth factor beta (TGF-beta) is a pivotal driver of glomerulosclerosis and tubulointerstitial fibrosis in renal diseases. Because TGF-beta also plays important anti-inflammatory and antiproliferative roles in mammalian systems, there has been a recent drive to elucidate downstream mediators of TGF-beta's pro-fibrotic effects with the ultimate goal of developing new anti-fibrotic strategies for treatment of chronic diseases. Connective tissue growth factor (CTGF) belongs to the CCN family of immediate early response genes. Several lines of evidence suggest that CTGF is an important pro-fibrotic molecule in renal disease and that CTGF contributes to TGF-beta bioactivity in this setting. CTGF expression is increased in the glomeruli and tubulointerstium in a variety of renal disease in association with scarring and sclerosis of renal parenchyma. In model systems in vitro, mesangial cell CTGF expression is induced by high extracellular glucose, cyclic mechanical strain and TGF-beta. Recombinant human CTGF augments the production of fibronectin and type IV collagen by mesangial cells and the effects of high glucose on mesangial cell CTGF expression and matrix production are attenuated, in part, by anti-TGF-beta antibody. In aggregate, these observations identify CTGF as an attractive therapeutic target in fibrotic renal diseases.

Reproductive issues in HIV-seropositive women: a survey regarding counseling, contraception, safer sex, and pregnancy choices

Sixty-nine HIV-seropositive women were surveyed with regard to the reproductive counseling they had received, contraception, safer sex practices, pregnancy histories, and pregnancy plans. Of the women surveyed, 84% and 90%, respectively, felt that they had access to the birth control and safer sex methods of their choice. Less than half felt that their physician had adequately counseled them about birth control. Women primarily cited social workers (46.4%) or nurses (34.8%) as the counseling source for birth control and safer sex. When informed about the reduced risk of vertical transmission with zidovudine (AZT), 33 women indicated that information regarding AZT would affect their future pregnancy decisions. Health care professionals need to be aware of this and counsel patients accordingly.

Renal-dose (low-dose) dopamine for the treatment of sepsis-related and other forms of acute renal failure: ineffective and probably dangerous

1. Low-dose ('renal-dose') dopamine (i.e. 1-3 micrograms/kg per min) is used widely for the treatment of acute renal failure induced by ischaemia, toxins and/or sepsis. Here we review the scientific rationale, experimental studies and clinical trials evaluating its use in these settings. 2. Renal-dose dopamine augments renal blood flow, sodium excretion and probably glomerular filtration rate in healthy humans and experimental animals and limits ATP utilization and oxygen requirements in nephron segments at risk of ischaemic injury. Renal-dose dopamine is renoprotective in several ischaemic and nephrotoxic models of acute renal failure. 3. However, most studies in humans have not demonstrated prevention of acute renal failure in high-risk patients or improved outcome in those with established acute renal failure. While the safety profile of dopamine in these settings has not been extensively defined, it is known the drug may precipitate serious cardiovascular and metabolic complications in the critically ill. Therefore, we suggest that renal-dose dopamine should not be used for selective renal vasodilatory and natriuretic actions in those patients with acute renal failure until its efficacy is established in randomized control trials. 4. Renal-dose dopamine may be most valuable when combined with agents targeting other events in acute renal failure, such as cast formation, epithelial cell injury and tubule regeneration. These recommendations should not preclude the use of dopamine for its systemic effects in heart failure and septic shock.