The SelfSTarT intervention for low back pain patients presenting to first contact physiotherapists: A mixed methods service evaluation

INTRODUCTION

Globally, back pain is the leading cause of years of disability. In the United Kingdom, over 20 million people live with musculoskeletal (MSK) pain, with low back pain being one of the most common causes. National strategies promote self-management and the use of digital technologies to empower populations.

AIMS

To evaluate the uptake and impact of providing the SelfSTart approach (STarT Back and SelfBACK App) when delivered by a First Contact Physiotherapist (FCP) to people presenting with low back pain in primary care.

METHODS

Patients presenting with a new episode of low back pain underwent routine assessment and completion of a STarT Back questionnaire. Patients with low/medium scores were offered the SelfBACK App. A control population was provided by the MIDAS-GP study. Patient Experience, outcome measures, healthcare utilisation and retention were captured through the app and clinical systems (EMIS). Interviews with five FCPs explored the experiences of using the SelfSTart approach.

RESULTS

SelfSTarT was taken up by almost half (48%) of those to whom it was offered. Compared to MIDAS-GP, users were more likely to be younger, male, in work, and with higher health literacy. SelfSTarT users reported significant improved experiences relating to receiving an agreed care plan and receiving sufficient information. There were no significant differences in treatments offered. FCPs were positive about the app and felt it had value but wanted feedback on patient progress. They recognised that a digital solution would not be suitable for all.

CONCLUSION

This approach offers an opportunity to empower and support self-management, using robustly evaluated digital technology.

522 Early Follow-Up Quality of Life and Mental Health of Patients with Congenital Vascular Malformations Cared for in a Multi-Disciplinary Specialist Center

Aim

To evaluate the early follow-up quality of life (QoL), pain and mental health of patients with congenital vascular malformation (CVM) receiving care by a single multi-disciplinary specialist center

Method

This was a prospective observational study. All patients with CVM who received care (supportive treatment only, open surgery, targeted pharmacological therapy, embolosclerotherapy), and had follow-up, between February 1st 2018 and January 31st 2020 were included. The health-related QoL, pain, and mental health were assessed with validated questionnaires: SF-36, VAS-P and HADS. The CVM were categorized into types – low-flow (LFVM) and high-flow (HFVM), and anatomical locations. Paired t-test was used for all analyses. P<0.05 were considered significant.

Results

110 patients (85 LFVM and 25 HFVM) with a mean age of 36.9 years were included. Significant improvement was found in the bodily pain domain of SF-36 and VAS-P (both P = 0.01) in all patients. However, only patients with HFVM reported significant improvement in the bodily pain domain of SF-36 (P=0.002) and VAS-P (P = 0.02). Patients who received supportive treatment only reported significant improvement in mental health (P=0.004) and social functioning (P=0.03) domains of SF-36. Meanwhile, patients treated with embolo-sclerotherapy reported significant improvement only in VAS-P (P=0.02). Patients who received targeted pharmacological therapy reported no significant early changes.

Conclusions

The effects of care on early follow-up QoL, pain and mental health of patients with CVM were heterogenous. Future research is required to understand the various factors that affect the QoL and mental health of these patients, as well as the holistic approaches to manage them.

518 Efficacy and Safety of Embolo-Sclerotherapy of Low-Flow Vascular Malformations Based on the Experience from a Single Specialist Centre

Aim

To evaluate the efficacy and safety of embolo-sclerotherapy (EST) of low-flow vascular malformations (LFVM) in a specialist vascular anomalies centre.

Method

All patients with LFVM who underwent EST from 01 January 2015–31 December 2019 were retrospectively reviewed. All ESTs were performed with foam STS 3%, ethanol, coils and/or other substances e.g., triamcinolone. LFVMs were grouped according to Puig's classification. The outcome measures were treatment effects and complications. Continuous variables were compared using analysis of variance (ANOVA) F test. Other discrete variables were compared using Chi-squared tests. P<0.05 were considered significant.

Results

A total of 207 patients, with a mean age of 32 years (range 1–71 years) were included. The use of EST with foam STS was significantly lower for type I LFVM (61.8%) compared to others (p<0.001). However, significantly higher type I LFVM (26.5%) were treated with surgery than EST (p<0.001). Overall, outcome categories were significantly different across all types of LFVM (p<0.001), with more discharges for Type I (52.9%) LFVMs but more failure to follow-up in patients with Type II (24.5%) LFVM. EST complications was significantly higher with type I (14.7%) LFVMs (p=0.030). The doses of STS in the first procedure were significantly different across all types of LFVM (p<0.001) with most type I LFVM patients receiving ≤2ml.

Conclusions

EST particularly with foam sclerotherapy is clinically effective and safe for patients with LFVM especially in those with Puig's type I and II lesions. This classification may provide an important guide to volume of sclerosant required and the potential success rate.

O064 Early follow-up quality of life and mental health of patients with congenital vascular malformations cared for in a multi-disciplinary specialist center

Introduction

To evaluate the early follow-up quality of life (QoL), pain and mental health of patients with congenital vascular malformation (CVM) receiving care by a single multi-disciplinary specialist centre

Methods

All patients with CVM who received care (supportive treatment only, open surgery, targeted pharmacological therapy, embolosclerotherapy), and had follow-up, between 1 February 2018 and 31 January 2020 were included. The health-related QoL, pain, and mental health were assessed with validated questionnaires: SF-36, VAS-P and HADS. The CVM were categorized into types – low-flow (LFVM) and high-flow (HFVM), and anatomical locations. Paired t-test was used for all analyses. Differences were considered significant at P<0.05.

Results

110 patients (85 LFVM and 25 HFVM) with a mean age of 36.9 years were included. Significant improvement was found in the bodily pain domain of SF-36 and VAS-P (both P = 0.01) in all patients. However, only patients with HFVM reported significant improvement in the bodily pain domain of SF-36 (P=0.002) and VAS-P (P = 0.02). Patients who received supportive treatment only reported significant improvement in mental health (P=0.004) and social functioning (P=0.03) domains of SF-36. Meanwhile, patients treated with embolosclerotherapy reported significant improvement only in VAS-P (P=0.02). Patients who received targeted pharmacological therapy reported no significant early changes.

Conclusion

The effects of care on early follow-up QoL, pain and mental health of patients with CVM were heterogenous. Future research is required to understand the various factors that affect the QoL and mental health of these patients, as well as the holistic approaches to manage them.

Take-home message

The effects of care on early follow-up QoL, pain and mental health of patients with CVM were heterogenous. Future research is required to understand the various factors that affect the QoL and mental health of these patients, as well as the holistic approaches to manage them.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

A reassessment of TBT action levels for determining the fate of dredged sediments in the United Kingdom

As part of reviewing the United Kingdom (UK) action levels (ALs) of contaminants for managing the disposal of dredged marine sediment material, tributyl tin (TBT) has been reassessed. TBT is a banned biocide capable of causing severe harm to the marine environment. Its presence is routinely screened for prior to marine disposal of dredged sediment material. Dredged sediment TBT concentrations have been studied using UK monitoring data obtained between 2000 and 2018. The changes in these TBT concentrations have guided the reassessment of ALs. Recent toxicity studies have also guided the reassessment of TBT ALs. This study, which itself forms part of a larger review by the Department for Environment, Food and Rural Affairs, has concluded that current UK TBT ALs may no longer be fit for purpose. A more environmentally protective approach for controlling release of TBT into the marine environment is recommended.

Physician Assisted Death for Psychiatric Suffering: Experiences in the Netherlands

Physician assisted death (PAD) for patients with a psychiatric disorder is a controversial topic of increasing relevance, since a growing number of countries are allowing it. General requirements for PAD include that patients possess decision-making capacity to decide on PAD and that their suffering is unbearable and irremediable. In the Netherlands PAD has been eligible for patients with psychiatric disorders since the 1990s, making it one of the few countries that can offer insights on the practice from real life experience. Much of the literature describing these experiences is only available in Dutch. This article aims to make this knowledge more widely available and provide a comprehensive overview of the experience with PAD for psychiatric suffering in the Netherlands. First, the history of PAD for patients suffering from a psychiatric disorder is described. Second, an overview of relevant rules and regulations governing the practice is given. Third, an overview is provided of the scarce epidemiological data. Finally, we will discuss two major clinical challenges; establishing irremediability and decision-making capacity.

875 Using Stress Testing to Identify Vulnerabilities in Artificial Intelligence Models for the Identification of Culprit Carotid Lesions in Cerebrovascular Events

Introduction

Carotid atherosclerosis is a major risk factor for ischaemic stroke, a leading cause of death. Carotid CT angiography (CTA) is commonly performed following a stroke or transient ischaemic attack (TIA) to help guide patient management in secondary prevention of stroke. Deep learning algorithms can help extract greater information from scans.

Method

The dataset comprised CTA scans from 40 culprit and 40 non-culprit carotid arteries of patients with recent stroke/TIA, and 40 carotid arteries of asymptomatic patients without previous stroke/TIA. A 3D convolutional neural network was trained to classify carotid artery type. Each input comprised 14 axial CTA carotid patches (centred around the carotid artery) concatenated together to form a 3D volume (capturing ∼3cm of artery). 75% of the dataset was used for training and 25% for internal validation. Following training, computer vision operations were applied to input images to assess their impact on the model’s classification decisions.

Results

The model achieved 100% accuracy on the training set and 67% on the internal validation set. However, after subjecting input images to image operations, vulnerabilities in the deep learning model were revealed, even when using input images from the training set. For example, using a Gaussian blur filter with sigma 1.0 was sufficient to change classification decisions, as was horizontally flipping the image.

Conclusions

Deep learning has exceptional capabilities for learning, however the risk with such high-capacity models is failure to learn relevant features from the data. Stress testing provides a viable method to further evaluate deep learning models before clinical deployment.

The experience of using prompting technology from the perspective of people with Dementia and their primary carers

OBJECTIVES

People who are living with dementia typically experience difficulties in completing multi-step, everyday tasks. However, digital technology such as touchscreen tablets provide a means of delivering concise personalised prompts that combine audio, text and pictures. This study was one component of a broader, mixed methods study that tested how an application (app) -based prompter running on a touchscreen tablet computer could support everyday activities in individuals with mild to moderate dementia. In this study we set out to understand the experiences of people living with dementia and their primary carer in using the prompter over a four-week period.

METHOD

We collected qualitative data using semi-structured interviews from 26 dyads, composed of a person living with dementia and their carer. Dyads were interviewed at the start and end of this period. Transcripts were then analysed using thematic analysis.

RESULTS

The study identified three overarching themes related to: participants' attitudes towards the technology; their judgements about how useful the prompter would be; and the emotional impact of using it.

CONCLUSION

Consistent with the Technology Acceptance Model, carers and participants were influenced by their approaches to technology and determined the usefulness of the prompter according to whether it worked for them and fitted into their routines. In addition, participants' decisions about using the prompter were also determined by the extent to which doing so would impact on their self-identity.

O75: SINGLE CENTRE EXPERIENCE OF SIROLIMUS THERAPY IN HEAD AND NECK VASCULAR MALFORMATIONS

Introduction

To assess the efficacy and safety of Sirolimus in the treatment of low-flow head and neck (H&N) vascular malformations

Method

Patients who presented to our tertiary referral clinic were assessed for eligibility. Suitable patients were commenced on Sirolimus at 0.8 mg/m2, administered orally twice daily, which was approved by our trust Drug and Therapeutic Committee. Patients were reviewed on a monthly basis for a total of six months with an additional one-month review to check for effects upon ceasing treatment. Efficacy and safety were measured through functional and radiological response, laboratory investigations and quality of life questionnaire (36-Item Short Form Health Survey (SF-36), Hospital Anxiety and Depression Scale (HADS) and Visual Analogue Score for Pain (VAS-P)).

Result

Seven patients (mean age 39 years, range 23-65 years) were recruited. One patient did not complete treatment due to intolerable side effects. All patients had a partial response with no patients showing disease progression or complete response. All post-treatment MRI scans showed stable disease with five patients demonstrating a decrease in lesion volume. Five patients reported return of symptoms at one-month post review upon discontinuation of treatment. No statistical significance (P>0.05) in all eight domains of SF-36, HADS, VAS-P and radiological vascular lesion volume between pre- and post-treatment. Most common reported side effects were mouth ulcers (n=2) and metabolic/laboratory abnormality (n=2)

Conclusion

Sirolimus is an effective and safe treatment for patients with complicated low-flow H&N vascular malformations. This provides an alternative treatment where interventional therapy is considered to be limited or challenging.

Take-home message

Sirolimus is an effective and safe treatment option for patients with complicated low-flow head and neck vascular malformations where interventional therapy is limited or challenging.

The transcription factor scleraxis differentially regulates gene expression in tenocytes isolated at different developmental stages

The transcription factor scleraxis (SCX) is expressed throughout tendon development and plays a key role in directing tendon wound healing. However, little is known regarding its role in fetal or young postnatal tendons, stages in development that are known for their enhanced regenerative capabilities. Here we used RNA-sequencing to compare the transcriptome of adult and fetal tenocytes following SCX knockdown. SCX knockdown had a larger effect on gene expression in fetal tenocytes, affecting 477 genes in comparison to the 183 genes affected in adult tenocytes, indicating that scleraxis-dependent processes may differ in these two developmental stages. Gene ontology, network and pathway analysis revealed an overrepresentation of extracellular matrix (ECM) remodelling processes within both comparisons. These included several matrix metalloproteinases, proteoglycans and collagens, some of which were also investigated in SCX knockdown tenocytes from young postnatal foals. Using chromatin immunoprecipitation, we also identified novel genes that SCX differentially interacts with in adult and fetal tenocytes. These results indicate a role for SCX in modulating ECM synthesis and breakdown and provide a useful dataset for further study into SCX gene regulation.

PARE0018 WEBSITE FOR PARENTS OF CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS REDUCES PARENTING STRESS

Background:

Having a child with JIA presents many challenges. Many parents experience considerable stress. Parental distress and functioning have been found to be related to child outcomes (Cousino, 2013), therefore interventions that help parents to manage their child’s illness are important for both parents and child. We developed a website for parents of children with newly diagnosed JIA to help increase parental confidence in managing their child’s arthritis and reduce parenting stress.

Objectives:

To evaluate the efficacy of a web-based tool ‘WebParC’ for parents of children with JIA.

Methods:

Design:Multi-centre randomised controlled trial conducted in 16 tertiary paediatric rheumatology centres in England.

Participants:Parent(s) of children aged ≤12 years, diagnosed with JIA within the previous six months.

Procedures:Parents were enrolled when they attended the rheumatology service and were randomised by household to either the intervention arm (I) who were given access to the website in addition to their child’s standard care or the control arm (C) who received standard care alone.

The primary outcome was parenting stress, measured with the Pediatric Inventory for Parents (PIP) (Streisand, 2001), which parents completed prior to randomisation and at 4-months and 12-months post randomisation.

Website content was developed by a multidisciplinary team including rheumatology, physiotherapy, ophthalmology, social work, podiatry, occupational therapy, clinical and health psychology along with parents of children with JIA. It includes information about JIA and its treatment plus a ‘toolkit’ for parents. The toolkit is based on cognitive-behavioural principles to develop skills for managing JIA-related issues.

Analysis:We conducted linear mixed models to examine the main effect of trial arm (I vs C), main effect of time (between 4M and 12M scores), and interaction between trial arm and time on PIP scores, after controlling for baseline scores.

Results:

A total of 220 parents (183 mothers, 37 fathers) of 203 children were randomised, 106 intervention and 114 controls. Parents mean (SD) age was 36.5 (6.5). Their children with JIA were mostly female (137/203, 67.5%), mean (SD) age of 6.1 (3.4) years. There were 107 (52.7%) with oligoarthritis, 65 (32%) polyarthritis, 8 (3.9%) systemic and 23 (11.3%) other JIA subtypes. Seventy (34.5%) were prescribed methotrexate.

Trial arms did not differ significantly at baseline except for parent education, which was higher in the intervention group and was controlled for in the analysis.

Follow-up assessments were completed by 133 (I60, C73) at 4M and 124 (I58, C66) at 12M.

We found significant main effects of trial arm on PIP Difficulty (p=0.022, Control (Mean=93.62, SE=2.717) > Intervention (Mean=84.23, SE=3.025)) and PIP Frequency (p= 0.008, Control (Mean=95.78, SE=2.400) > Intervention (Mean=86.23, SE=2.622), with Controls reporting significantly greater frequency and difficulty of stressful events than the Intervention group (Fig 1).

Conclusion:

This trial found that a website for parents of children with JIA can help to reduce parenting stress.

References:

[1]Cousino MK, Hazen RA. J Pediatr Psychol 2013; 38(8):809-28

[2]Streisand R, Braniecki S, Tercyak KP, Kazak AE. J Pediatr Psychol 2001; 26(3):155-62.

Acknowledgments:

We thank all parent participants, the health professionals and parents who developed website content and the clinical teams who supported recruitment.

Funded by NIHR RfPB.

Disclosure of Interests:

Kathleen Mulligan: None declared, Shashivadan Hirani: None declared, Sally Clarke: None declared, Neil Evans: None declared, Chris Flood: None declared, Jo Taylor: None declared, Lucy Wedderburn Speakers bureau: Pfizer, Stanton Newman Grant/research support from: Yes Baxter Healthcare Educational Grants not in relation to rheumatology, Speakers bureau: Yes Baxter Healthcare and Merke Sharp and Dome

Disrupted seasonal biology impacts health, food security and ecosystems

The rhythm of life on earth is shaped by seasonal changes in the environment. Plants and animals show profound annual cycles in physiology, health, morphology, behaviour and demography in response to environmental cues. Seasonal biology impacts ecosystems and agriculture, with consequences for humans and biodiversity. Human populations show robust annual rhythms in health and well-being, and the birth month can have lasting effects that persist throughout life. This review emphasizes the need for a better understanding of seasonal biology against the backdrop of its rapidly progressing disruption through climate change, human lifestyles and other anthropogenic impact. Climate change is modifying annual rhythms to which numerous organisms have adapted, with potential consequences for industries relating to health, ecosystems and food security. Disconcertingly, human lifestyles under artificial conditions of eternal summer provide the most extreme example for disconnect from natural seasons, making humans vulnerable to increased morbidity and mortality. In this review, we introduce scenarios of seasonal disruption, highlight key aspects of seasonal biology and summarize from biomedical, anthropological, veterinary, agricultural and environmental perspectives the recent evidence for seasonal desynchronization between environmental factors and internal rhythms. Because annual rhythms are pervasive across biological systems, they provide a common framework for trans-disciplinary research.

Systems Pharmacology Approach for Prediction of Pulmonary and Systemic Pharmacokinetics and Receptor Occupancy of Inhaled Drugs

Pulmonary drug disposition after inhalation is complex involving mechanisms, such as regional drug deposition, dissolution, and mucociliary clearance. This study aimed to develop a systems pharmacology approach to mechanistically describe lung disposition in rats and thereby provide an integrated understanding of the system. When drug‐ and formulation‐specific properties for the poorly soluble drug fluticasone propionate were fed into the model, it proved predictive of the pharmacokinetics and receptor occupancy after intravenous administration and nose‐only inhalation. As the model clearly distinguishes among drug‐specific, formulation‐specific, and system‐specific properties, it was possible to identify key determinants of pulmonary selectivity of receptor occupancy of inhaled drugs: slow particle dissolution and slow drug‐receptor dissociation. Hence, it enables assessment of factors for lung targeting, including molecular properties, formulation, as well as the physiology of the animal species, thereby providing a general framework for rational drug design and facilitated translation of lung targeting from animal to man.

Admission blood glucose helps predict 1 year, but not 2 years, mortality in an unselected cohort of acute general medical admissions

AIM

We previously showed that hyperglycaemia in newly hospitalised medical inpatients is associated with longer length of hospital stay, higher 28-day readmission rates and increased 28-day mortality. We aimed to assess whether a single blood glucose measurement taken at the time of admission could help to predict 1 and 2 years mortality.

METHODS

We retrospectively reviewed data from all 1502 patients admitted to our Acute Medical Unit during February 2010.

RESULTS

By using a blood glucose range of 6.5-7.0 mmol/l as the comparator, an admission blood glucose between 9.1 and 20 mmol/l was associated with an increased risk of death at 1 year (p < 0.05). In addition, those people with admission glucose readings of < 6.5 mmol/l showed a strong trend towards a higher mortality (p = 0.053) at 1 year.

CONCLUSION

Thus admission blood glucose can be used to help predict the risk of 1 year mortality in an unselected cohort of general medical admissions.

Tumours and tumour mimics in the olecranon

Lesions in the olecranon are rare and may be identified during the investigation of a clinically suspected abnormality or as an incidental finding. This review describes the spectrum of tumours and tumour-like lesions that can involve the olecranon and illustrates the radiographic, CT, and MRI appearances that may facilitate diagnosis. A variety of pathological processes affecting the olecranon are presented and discussed including the epidemiology and imaging features.

Modeling and Simulation Approaches for Cardiovascular Function and Their Role in Safety Assessment

Systems pharmacology modeling and pharmacokinetic-pharmacodynamic (PK/PD) analysis of drug-induced effects on cardiovascular (CV) function plays a crucial role in understanding the safety risk of new drugs. The aim of this review is to outline the current modeling and simulation (M&S) approaches to describe and translate drug-induced CV effects, with an emphasis on how this impacts drug safety assessment. Current limitations are highlighted and recommendations are made for future effort in this vital area of drug research.

Bioassay of estrogenicity and chemical analyses of estrogens in streams across the United States associated with livestock operations

Animal manures, used as a nitrogen source for crop production, are often associated with negative impacts on nutrient levels in surface water. The concentrations of estrogens in streams from these manures also are of concern due to potential endocrine disruption in aquatic species. Streams associated with livestock operations were sampled by discrete samples (n = 38) or by time-integrated polar organic chemical integrative samplers (POCIS, n = 19). Samples were analyzed for estrogens by gas chromatography-tandem mass spectrometry (GC-MS(2)) and estrogenic activity was assessed by three bioassays: Yeast Estrogen Screen (YES), T47D-KBluc Assay, MCF-7 Estrogenicity Screen (E-Screen). Samples were collected from 19 streams within small (≈ 1-30 km(2)) watersheds in 12 U.S. states representing a range of hydrogeologic conditions, dominated by: dairy (3), grazing beef (3), feedlot cattle (1); swine (5); poultry (3); and 4 areas where no livestock were raised or manure was applied. Water samples were consistently below the United Kingdom proposed Lowest Observable Effect Concentration for 17β-estradiol in fish (10 ng/L) in all watersheds, regardless of land use. Estrogenic activity was often higher in samples during runoff conditions following a period of manure application. Estrone was the most commonly detected estrogen (13 of 38 water samples, mean 1.9, maximum 8.3 ng/L). Because of the T47D-KBluc assay's sensitivity towards estrone (1.4 times 17β-estradiol) it was the most sensitive method for detecting estrogens, followed by the E-Screen, GC-MS(2), and YES. POCIS resulted in more frequent detections of estrogens than discrete water samples across all sites, even when applying the less-sensitive YES bioassay to the POCIS extracts.

Successful management of bleeding complications in patients supported with extracorporeal membrane oxygenation with primary respiratory failure

Background:

Extracorporeal membrane oxygenation (ECMO) is a lifesaving procedure in patients with severe respiratory insufficiency failing conventional support. Bleeding complications are common due to the necessity for anticoagulation and circuit-related factors.

Methods:

A retrospective review was conducted in patients requiring ECMO for respiratory failure from 7/2010 to 6/2011 to identify episodes of major bleeding, bleeding management and outcomes.

Results:

Twenty-one patients were supported with ECMO during the study although five experienced massive bleeding related to chest tube insertion, jejunal arterio-venous malformations, distal perfusion cannula dislodgement and ventricular rupture. Patients required aggressive resuscitation or endoscopic or operative intervention, totaling 28 procedures. There were no instances of dehiscence, infection or sepsis related to interventions. Anticoagulation was stopped six hours before and restarted 24 hours after major interventions, with no thrombotic or neurologic complications. All patients weaned off ECMO were discharged.

Conclusions:

ECMO bleeding complications can be managed successfully via surgical and endoscopic approaches in this high-risk population.

Randomized controlled trial of magnesium sulfate in women at risk of preterm delivery-neonatal cardiovascular effects

OBJECTIVE

Use of antenatal magnesium sulfate (MgSO(4)) may reduce cerebral palsy in infants born very preterm. Low systemic blood flow in the first day in very preterm infants has been associated with cerebral injury and adverse motor outcome. The aim was to determine the effect of MgSO(4) on systemic blood flow in preterm infants.

STUDY DESIGN

Randomized trial of MgSO(4) versus saline placebo given to mothers at risk of delivery before 30 weeks gestation. Echocardiographic monitoring performed at 3 to 5, 10 to 12 and 24 h.

RESULT

A total of 48 infants were exposed to MgSO(4) and 39 to placebo. Infants exposed to MgSO(4) were significantly more likely to receive volume expansion (42% versus 21%). Inotrope use did not differ significantly (40% versus 26%). There was no significant difference in mean lowest superior vena cava (SVC) flow or right ventricular output (RVO), or incidence of low SVC flow or RVO in the first 24 h. Infants exposed to MgSO(4) had a significantly higher heart rate and were more likely to have low SVC flow at 10 to 12 h but not other times.

CONCLUSION

Antenatal MgSO(4) produced no consistent cardiovascular effects in the infant in the first 24 h. There is no evidence from this study to suggest the mechanism by which antenatal MgSO(4) prevents cerebral palsy is through a cardiovascular effect in the newborn.

Patient reported evaluation of functional symptoms (PREFS): a simple method of ascertaining patient satisfaction post cataract surgery

No abstract available.DOI: http://dx.doi.org/10.3126/nepjoph.v4i2.6562 Nepal J Ophthalmol 2012; 4 (2): 346-347  

Can cloud computing bridge the digital divide in South African secondary education?

Cloud computing is a relatively new concept that holds significant promises for the future development and delivery of computer resources to secondary or basic education in South Africa, especially in schools most affected by the digital divide. The aim of this paper is to briefly review the extent to which cloud computing applications and services currently used by secondary education systems in developed countries around the world can be used to help breach the digital divide that currently exists in the secondary (basic) education sector in South Africa. The authors believe that South Africa has the required technology and skills to bridge the digital divide in secondary education and by doing so set the pace for the rest of the African continent. All it lacks is the political will and determination to do so.

Echocardiography and the neonatologist

Pediatric echocardiography as performed and interpreted by pediatric cardiologists provides details of cardiac structure and function as well as hemodynamic data. Functional echocardiography, in contrast to echocardiography as performed by the cardiologist, is the bedside use of cardiac ultrasound to follow functional and hemodynamic changes longitudinally. Data reflecting cardiac function and systemic and pulmonary blood flow in critically ill preterm and term neonates can be monitored using this method. Functional echocardiography is being developed and driven by neonatologists as an extension of their clinical skills. A wealth of hemodynamic information can be derived from functional echocardiography used for the sick neonate, which provides clinical information different from the assumed underlying physiology. Lack of access to appropriate training programs and interdisciplinary politics is limiting the use of this potentially valuable clinical information. Without the use of functional echocardiography, clinicians are left to speculate as to the underlying pathophysiology of circulatory compromise, and the assumptions they make often are incorrect. For functional echocardiography to fulfill its clinical potential, it needs to be available at any time and at short notice in the neonatal intensive care unit (NICU). Because most NICUs do not have external diagnostic services to provide longitudinal hemodynamic follow-up assessment at the bedside, neonatologists should be able to develop appropriate echocardiographic skills in close collaboration with their cardiologist colleagues.