Healthcare Workers Beliefs about COVID-19; a Longitudinal, Mixed Methods Analysis

The psychological impact of COVID-19 on Health Care Workers (HCWs) has been widely reported. Few studies have sought to examine HCWs personal models of COVID-19 utilising an established theoretical framework. We undertook a mixed methods study of beliefs about COVID-19 held by HCWs in the Mid-West and South of Ireland during the first and third waves of COVID-19. Template analysis was undertaken on the free text responses of 408 HCWs about their perceptions of the Cause of COVID-19 as assessed by the Brief Illness Perception Questionnaire (B-IPQ). Responses were re-examined in the same cohort for stability at 3 months follow-up (n = 100). This analytic template was subsequently examined in a new cohort (n = 253) of HCWs in the third wave. Female HCWs perceived greater emotional impact of COVID-19 than men (t = -4.31, df405, p < 0.01). Differences between occupational groups were evident in relation to Timeline (F4,401 = 3.47, p < 0.01), Treatment Control (F4,401 = 5.64, p < 0.001) and Concerns about COVID-19 (F4,401 = 3.68, p < 0.01). Administration staff believed that treatment would be significantly more helpful and that COVID-19 would last a shorter amount of time than medical/nursing staff and HSCP. However, administration staff were significantly more concerned than HSCP about COVID-19. Template analysis on 1059 responses to the Cause items of the B-IPQ identified ten higher order categories of perceived Cause of COVID-19. The top two Causes identified at both Waves were 'individual behavioural factors' and 'overseas travel'. This study has progressed our understanding of the models HCWs hold about COVID-19 over time, and has highlighted the utility of the template analysis approach in analysing free-text questionnaire data. We suggest that group and individual occupational identities of HCWs may be of importance in shaping HCWs responses to working through COVID-19.

131 A REVIEW OF FRAILTY AND PATIENT DISCHARGE OUTCOMES IN A NEWLY FORMED PHYSIOTHERAPY TEAM IN A LEVEL 4 TEACHING HOSPITAL

Background

Methods

Results

Conclusion

Emotional outcomes in clinically isolated syndrome and early phase multiple sclerosis: a systematic review and meta-analysis

OBJECTIVE

To study depression, anxiety, suicide risk, and emotional health-related quality of life (HRQoL) in people with clinically isolated syndrome (CIS) and in early phase multiple sclerosis (MS).

METHODS

A systematic literature review was conducted with inclusion criteria of observational studies on outcomes of depression, anxiety, suicide risk, and emotional HRQoL in CIS and within five years since diagnosis of MS. Studies were screened using the Preferred Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, and study quality was determined for included studies. Meta-analysis and meta-regression were performed if applicable.

RESULTS

Fifty-one studies were included in the systematic review. In early phase MS, meta-analyses of the Hospital Anxiety Depression Scale (HADS) indicated prevalence levels of 17% (95% confidence interval (CI): 9 to 25%; p < .001) for depressive and 35% (95% CI: 28 to 41%; p < .001) for anxiety symptoms. Meta-regression analyses revealed an increase in mean HADS-D and HADS-A associated with larger sample size, and higher HADS-D mean with increased study quality. Similar depressive and anxiety symptoms were observed in CIS, and increased suicide risk and low emotional HRQoL was associated with depressive symptoms in early phase MS. The methodological quality of the studies was considered fair.

CONCLUSIONS

Findings suggest that mild-to-moderate symptoms of depression and anxiety might be prevalent in CIS and in early phase MS. Future research on both clinical populations are needed, especially longitudinal monitoring of emotional outcomes.

Inter-Observer Variability in the Interpretation of Mammograms

Inter-observer agreement was tested in the interpretation by 8 radiologists of mammograms from 45 women (for a total of 180 films per radiologist). The radiologists were representative of the whole range of those involved in mammography in the town of Torino, with a number of films read per year ranging from 100 to 4000. Out of the 45, 9 women were affected by breast cancer (histologically proved), 25 had benign disease (diagnosed with fine-needle aspiration) and 11 had normal breasts. Weighted kappa values were in the range 0.27–0.82 (median 0.60) for parenchymal patterns; 0.33–0.67 (0.48) for diagnosis in five categories; and 0.22–0.57 (0.38) for indications for further diagnostic tests. These values are comparable with those reported from other investigations.

Breast Cancer Diagnosis under the Age of Forty Years

The authors report on a multicentric consecutive series of 382 cases of primary breast cancer detected before the age of 40 years. Physical examination (PE) was always performed, whereas other diagnostic tests were performed in selected cases, namely mammography (M) in 334, fine needle aspiration cytology (CYT) in 188 and thermography (TH) in 123 cases. Single tests showed a high rate of false-negative/benign cases (PE, 0.23; M, 0.26; CYT, 0.37 and TH, 0.50), especially when the T1 subgroup was considered (PE, 0.34; M, 0.38; CYT, 0.42 and TH, 0.78). The poor results recorded for TH make its current diagnostic use highly questionable. The policy of extensive biopsy of all « dubious » benign lesions on PE allowed for the detection of 41 of 382 cancers and reduced the PE false-negative/benign rate to 0.12 for the total or 0.15 for T1 cancers, although about 80 unnecessary biopsies for each cancer detected were performed in this way. The association of PE to one or more tests resulted in even lower false-negative rates (0.06 for the total, 0.10 for T1 cancers). The authors criticize the aggressive policy of extensive biopsy recommendation based only on a dubious report on PE alone and stress the opportunity of the routine association of M and CYT to PE, since this combination seems to achieve a higher breast cancer detection rate even in this age group.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

A MultiCenter Pilot Randomized Controlled Trial of Remote Ischemic Preconditioning in Major Vascular Surgery

A pilot randomized controlled trial that evaluated the effect of remote ischemic preconditioning (RIPC) on clinical outcomes following major vascular surgery was performed. Eligible patients were those scheduled to undergo open abdominal aortic aneurysm repair, endovascular aortic aneurysm repair, carotid endarterectomy, and lower limb revascularization procedures. Patients were randomized to RIPC or to control groups. The primary outcome was a composite clinical end point comprising any of cardiovascular death, myocardial infarction, new-onset arrhythmia, cardiac arrest, congestive cardiac failure, cerebrovascular accident, renal failure requiring renal replacement therapy, mesenteric ischemia, and urgent cardiac revascularization. Secondary outcomes were components of the primary outcome and myocardial injury as assessed by serum troponin values. The primary outcome occurred in 19 (19.2%) of 99 controls and 14 (14.1%) of 99 RIPC group patients ( P = .446). There were no significant differences in secondary outcomes. Our trial generated data that will guide future trials. Further trials are urgently needed.

Diagnostic accuracy of non-radiologist performed ultrasound for abdominal aortic aneurysm: systematic review and meta-analysis

BACKGROUND

Ultrasonography is increasingly used by clinicians to identify abdominal aortic aneurysms (AAA). We performed a systematic review and meta-analysis comparing the accuracy of non-radiologist performed ultrasound (NRPUS) for AAA disease to the 'gold standard' of radiologist performed aortic imaging (RPI), intra-operative findings or postmortem findings.

METHODS

Cochrane Library, MEDLINE, EMBASE, SCOPUS-V.4, trial registries, conference proceedings, and article reference lists were searched to identify studies comparing NRPUS with RPI as the reference standard. Data abstracted from eligible studies was used to generate 2 × 2 contingency tables allowing calculation of pooled sensitivity and specificity values.

RESULTS

11 studies (944 patients) evaluated NRPUS for AAA detection. NRPUS had a pooled sensitivity of 0.975 [95% confidence interval (CI), 0.942-0.992] for AAA detection and a pooled specificity of 0.989 (95% CI, 0.979-0.995).

CONCLUSIONS

Non-radiologist performed ultrasound achieves acceptable sensitivity and specificity for both detection and measurement of AAA. There was no evidence of significant heterogeneity with respect to pooled sensitivity or specificity.

Paget-Schrotter syndrome and complications of management

An 18-year-old man presented to the emergency department with an acutely swollen right upper limb having spent the previous day canoeing. Venography confirmed right subclavian venous thrombosis at middle one-third of right clavicle with no evidence of cervical rib or other structural abnormalities. Following heparinisation, catheter directed thrombolysis was performed which restored luminal flow. Postprocedure the patient developed spontaneous small-volume haemoperitoneum and acute renal failure. The patient was admitted to the intensive care unit for haemodialysis and supportive management. The patients' renal function improved and he was discharged well following his 28th day of admission. Paget-Schroetter syndrome or effort thrombosis involves subclavian venous thrombosis associated with strenuous activity of upper extremities. In these cases, catheter directed thrombolysis with first rib resection provides greater patency rate than anticoagulation therapy alone. Acute kidney injury following mechanical thrombolysis is rarely reported in the literature.

Four BSE cases with an L-BSE molecular profile in cattle from Great Britain

Bovine spongiform encephalopathy (BSE) is a prion disease of cattle which was first observed in Great Britain (GB) in 1986. Throughout the subsequent BSE epidemic, cases identified by passive surveillance have shown consistent histopathological, immunohistochemical, biochemical and biological properties. However, since the start of active surveillance in 2001, across Europe and elsewhere, approximately 67 cases with different biochemical characteristics have been identified by Western blotting (WB). These cases fall into two categories; 'H-type' (H-BSE) or 'L-type' (L-BSE), based on the relatively heavy (H-BSE) or light (L-BSE) mass of the unglycosylated band of the prion protein, as compared with WB against that obtained from classical BSE (C-BSE) cases. Here we report the detection and confirmation of the first four L-BSE cases by active surveillance in GB, two of which were born after the reinforced feed ban of 1996 (BARB cases). These four L-BSE cases were found in relatively old cattle (age range; 11-21 years old) and the carcases did not enter the human food chain or animal feed chains.

Improving patient care--the first year in a dedicated surgical assessment unit

A surgical assessment unit (SAU) was established in October 2009 at the Mid-Western Regional Hospital. We assessed this servic in its initial year and compared it to Emergency Department (ED) services. We audited SAU and ED databases and theatre logbooks from November 2009 to October 2010. 1949 patients were referred to the SAU and 857 patients were admitted (44%). Only 44 SAU patients (6%) waited more than 6 hours for a bed compared to 828 patients (68%) admitted through the ED. SAU patients who required emergency surgery had a shorter waiting time before theatre (37 (18.6%) vs 9(6%) waited less than 6 hours, p < 0.05). To summarise, we found that almost 2,000 patients who would otherwise have presented to the ED were referred to the SAU. Waiting times for admission and theatre were significantly shorter. Further resource allocation could expand the service and improve it further, by diverting more patients from the ED.

Effects of intensive insulin therapy alone and in combination with pioglitazone on body weight, composition, distribution and liver fat content in patients with type 2 diabetes

AIM

To evaluate the effects of intensive insulin therapy alone and with added pioglitazone on body weight, fat distribution, lean body mass (LBM) and liver fat in type 2 diabetic patients.

METHODS

Twenty-five insulin-treated, obese patients with type 2 diabetes were randomized to addition of pioglitazone 45 mg (n = 12) or placebo (n = 13) and treated intensively for 12-16 weeks. Dual-energy X-ray absorptiometry/abdominal computed tomography scans were performed before/after treatment. LBM, visceral/subcutaneous adipose tissue (VAT/SAT) and liver/spleen (L/S) attenuation ratios were measured pre-/posttreatment (a ratio <1 represents fatty liver).

RESULTS

Intensive insulin alone and insulin + pioglitazone significantly improved glycaemic control (7.8 ± 0.3 to 7.2 ± 0.3% and 7.6 ± 0.3 to 7.1 ± 0.4%, respectively). Body weight gain was greater with insulin + pioglitazone (4.9 ± 4.5 kg) versus insulin therapy alone (1.7 ± 0.7 kg). SAT increased significantly with pioglitazone + insulin therapy (393.9 ± 48.5 to 443.2 ± 56.7 cm(2) , p < 0.01) compared to a non-significant increase with insulin therapy alone (412.9 ± 42.5 to 420.8 ± 43.8 cm(2) ). VAT decreased non-significantly in both groups (240.3 ± 41.7 to 223.8 ± 38.1 cm(2) with insulin + pioglitazone and 266.6 ± 27.4 to 250.5 ± 22.2 cm(2) with insulin therapy). LBM increased significantly by 1.92 ± 0.74 kg with insulin + pioglitazone treatment. The L/S attenuation ratio in the placebo + insulin group decreased from 1.08 ± 0.1 to 1.04 ± 0.1 (p = ns) and increased from 1.00 ± 0.1 to 1.08 ± 0.05 (p = 0.06) in the pioglitazone + insulin group.

CONCLUSIONS

Intensification of insulin therapy in type 2 diabetic patients causes modest weight gain and no change in body fat distribution, LBM or liver fat. In contrast, the addition of pioglitazone, at equivalent glycaemia, increases weight gain, fat mass and SAT; increases LBM and tends to decrease liver fat. These changes in fat distribution may contribute to the beneficial effects of pioglitazone, despite greater weight gain.

The use of laboratory sand, soil and crushed-glass filter columns for polishing domestic-strength synthetic wastewater that has undergone secondary treatment

The aim of this study was to examine the performance of intermittently loaded, 150 mm-diameter stratified filter columns of 2 depths (0.65 and 0.375 m) comprising different media--sand, crushed glass and soil--in polishing the effluent from a laboratory horizontal flow biofilm reactor (HFBR) treating synthetic domestic-strength wastewater. The HFBR has been successfully used to remove organic carbon and ammonium-nitrogen (NH4-N) from domestic wastewater. In this treatment method, wastewater is allowed to flow over and back along a stack of polyvinyl chloride (PVC) sheets. Biofilms on the sheets reduce organic carbon, suspended matter, and nutrients in the wastewater, but to achieve the quality of a septic tank system, additional treatment is required. In all filters, at a hydraulic loading rate of 100 L m(-2) d(-1), 40-65% of chemical oxygen demand (COD) and practically 100% of total suspended solids (TSS) were removed, nitrification was complete, and bacterial numbers were reduced by over 80%, with best removals achieved in the soil filters (93%). Soil polishing filters with the depth of 0.65 m performed best in terms of organic carbon, total nitrogen (Tot-N) and bacterial removal. Data from this preliminary study are useful in the design of treatment systems to polish secondary wastewaters with similar water quality characteristics.

Effects of intensive insulin therapy alone and with added pioglitazone on renal salt/water balance and fluid compartment shifts in type 2 diabetes

OBJECTIVE

To evaluate the effects of intensive insulin therapy alone or with added pioglitazone on renal salt/water balance and body fluid compartment shifts in type 2 diabetes.

METHODS

A total of 25 insulin-treated, obese patients with type 2 diabetes were randomized to pioglitazone 45 mg (n = 12) or placebo (n = 13) and treated intensively for 12-16 weeks to achieve equivalent glycaemic control. We measured total body water (TBW) and extracellular/intracellular fluid by bioimpedance analysis; plasma/RBC volume with I(131)albumin; sodium handling by fractional excretion of sodium/lithium (FeNa/FeLi) and other renal/hormonal parameters.

RESULTS

Intensification of insulin therapy and the addition of pioglitazone significantly improved glycaemia (HbA1C 7.8-7.2% and 7.6-7.1%) and increased body weight (1.7 and 4.9 kg) respectively. TBW increased 1.7 l with insulin alone (65% intracellular) and 1.6 l with added pioglitazone (75% extracellular) (p = 0.06 and 0.09 respectively). Plasma volume increased 0.2 +/- 0.1 l with insulin alone (p = 0.05) and 0.4 +/- 0.1 l with added pioglitazone (p < 0.05). Extravascular, extracellular (interstitial) fluid increased significantly and more with added pioglitazone (0.8 +/- 0.2 l, p < 0.01) than with insulin alone (0.4 +/- 0.2 l, p = ns). At steady-state, FeLi (marker of proximal-tubular sodium delivery to the distal nephron) increased significantly with added pioglitazone (12.4 +/- 1.3 to 18.0 +/- 3.2%) vs. no significant change with insulin alone (15.4 +/- 1.2 to 14.5 +/- 2.3%). There were no significant changes in the other parameters.

CONCLUSION

In intensively insulin-treated obese type 2 diabetic patients, at equivalent glycaemic control, the addition of pioglitazone causes greater weight gain, but a similar increase in body water that is mainly extracellular and interstitial compared with intracellular increase with insulin therapy alone. Pioglitazone also increases the filtered load of sodium reabsorbed at the distal nephron with no net change in FeNa.

The effects of paclitaxel (PTX) and 2-methoxyestradiol (2-ME2) on tumor oxygenation and HIF-1α in breast cancer

3517

Background: Radiation activates HIF-1a via a free radical mediated mechanism associated with reoxygenation. This response could be inhibited, resulting in reduced tumor vascularity and proliferation. Preclinical breast cancer models and a Phase Ib clinical trial (CT) were employed to look at the effects of chemo with or without an oral HIF-1a inhibitor, 2-ME2 (EntreMed) on tumor oxygenation and HIF-1a. Methods: Preclinical models of chemo effects on HIF-1a/oxygenation used 4T1 tumors and either doxorubicin (DOX) or cyclophosphamide (CTX). In addition, MDA-MB-231 tumors were treated with 2-ME2 (5days), and HIF-1a/MVD was assessed. In the CT, up to 15 pts with metastatic breast cancer, and biopsiable (>2 cm) non-bone sites were eligible. Tx was: D 1: PTX, 90 mg/m2; D 8: PTX, 90 mg/m2 with 2-ME2 (cohorts of 1,000/1,250/1,500 mg, qid). PTX was given 3 out of 4 wks. Bxs were done at enrollment, D8 (post-PTX), and D22 (post-PTX/2-ME2). Tumors were examined for changes in HIF-1a and CA9 levels, MVD, and genomic signatures of hypoxia. Plasma was obtained for osteoponin, PAI-1, and VEGF. Results: DOX and CTX both led to increases in HIF-1a, oxygenation, vascularity, and proliferation 4–10 days post treatment in the 4T1 model, while 2-ME2 reduced HIF-1a and MVD post treatment (5 d) in the MDA-MB-231 model. The CT opened in 6–2006, 9 pts have consented and 8 pts have undergone sequential biopsies and accrual continues. No DLT have been seen. Biopsy sites include chest wall, liver, and LN. Sufficient tissue/RNA/plasma has been obtained and the planned analyses will be presented. Conclusions: HIF-1a and tumor oxygenation appear to be modulated as a response to chemotherapy. The combination of PTX and 2-ME2 is clinically active, well-tolerated, and could serve as one of the first approaches to target HIF-1a in order to optimize therapy. Supported by Komen Grant BCTR0504044.

[Table: see text]

Demands for vascular access in a renal dialysis unit: Implications for a regional vascular unit

BACKGROUND

The development of regional dialysis units and the expanding indications for dialysis has led to increased demand for vascular access surgery. Consequently, the provision and maintenance of access, and the management of related complications has created a considerable burden on vascular surgical units in hospitals providing renal replacement therapy (RRT).

AIMS

The objectives of our study were to review our experience with a variety of vascular access modalities for haemodialysis and to quantify the associated surgical workload.

METHODS

We reviewed our experience in a consecutive group of dialysis patients who had access surgery for RRT in a regional hospital setting.

RESULTS

Between January 1995 and January 2000, 69 patients entered the long-term dialysis programme in the Mid-Western region (population = 320,000). Of the 158 procedures performed, 138 (87%) were for access creation, and 20 (13%) related to access revision procedures. Twenty patients (29%) developed a total of 30 access related complications. Vascular access procedures accounted for 10% of the vascular surgical workload (1598 procedures) in the five-year period.

CONCLUSION

Vascular access is an important part of the haemodialysis services and surgical expertise should be available at local level to cope with likely demand.

Comparison of standard and double reading and computer-aided detection (CAD) of interval cancers at prior negative screening mammograms: blind review

The study evaluates the role of computer-aided detection (CAD) in improving the detection of interval cancers as compared to conventional single (CONV) or double reading (DOUBLE). With this purpose, a set of 89 negative cases was seeded with 31 mammograms reported as negative and developing interval cancer in the following 2-year interval (false negative (FN)=11, minimal signs (MS)=20). A total of radiologists read the set with CONV and then with CAD. Overall, there were 589 cancer and 1691 noncancer readings with both CONV and CAD. Double reading was simulated by combining conventional readings in all 171 possible combinations of 19 radiologists, resulting in a total of 5301 cancer and 15 219 noncancer readings. Conventional single, DOUBLE and CAD readings were compared in terms of sensitivity and recall rate. Considering all 19 readings, cancer was identified in 190 or 248 of 589 readings (32.2 vs 42.1%, χ²=11.80, df=1, P<0.01) and recalls were 287 or 405 of 1691 readings (16.9 vs 23.9%, χ²=24.87, df=1, P<0.01) at CONV or CAD, respectively. When considering FN and MS cases separately, sensitivity at CONV or CAD was 50.2 or 62.6% (χ²=6.98, df=1, P=0.01) for FN and 22.3 or 30.7% (χ²=6.47, df=1, P=0.01) for MS cases, respectively. Computer-aided detection (average of 19 readings) was slightly and not significantly less sensitive (sensitivity: 42.1 vs 46.1%, χ²=3.24, df=1, P=0.07) but more specific (recall rate 23.9 vs 26.1%, χ²=3.8, df=1, P=0.04) as compared to DOUBLE (average of 171 readings). Average sensitivity for FN cases only was 62.6% for CAD and 64.8% for DOUBLE (χ²=0.32, df=1, P=0.58). Corresponding values for MS cases were 30.7% for CAD and 35.7% for DOUBLE (χ²=3.53, df=1, P=0.06). Compared to CONV, CAD allowed for improved sensitivity, though with reduced specificity, both effects being statistically significant. Computer-aided detection was almost as sensitive as DOUBLE but significantly more specific. Computer-aided detection might be used in the current practice to improve sensitivity of conventional single reading. Based on estimates of screening sensitivity and FN/MS interval cancer expected frequency, the absolute increase of screening sensitivity expected by introducing CAD-assisted reading may be estimated around 0.9%. The use of CAD as a possible surrogate to conventional DOUBLE needs to be confirmed by further studies, which should include a cost-effective analysis.

Quantitative analysis of angiogenesis using confocal laser scanning microscopy

Angiogenesis is essential for tumor growth and metastasis. Angiogenesis is commonly quantified by measuring microvessel density (MVD) within tumors. In this report, we compared light microscopy with confocal laser scanning microscopy (CLSM) in the qualitative and quantitative analysis of angiogenesis. MVDs were determined manually in a lung tumor xenograft and a normal skeletal muscle using CD31 immunohistochemical staining and light microscopy. Area of three-dimensional representation of microvessels, detected as CD31 immunofluorescence, was measured automatically using computer-assisted CLSM. By manual counting under light microscopy, the relative level of MVD of the lung tumor vs. skeletal muscle was 0.8. However, the corresponding relative level of microvessels was 3.4 as determined by computer-assisted CLSM. Furthermore, the architecture of microvessels was better delineated with CLSM than with light microscopy. We have applied this CLSM method for analyzing the antiangiogenic effect of an anticancer drug, paclitaxel, in the lung tumor xenograft model. We conclude that CLSM is an appropriate method for quantitative and qualitative analysis of microvasculature in normal and tumor tissues.

Day Case Varicose Vein Surgery: Patient Health Outcome

Background:

The success of day case varicose vein surgery (DCWS) is traditionally denned clinically. However, the patient's perception of his or her own health prior to and following DCWS has not been established. This study prospectively measured the health status of patients with varicose veins, compared this with established population norms and assessed the impact of DCWS on both general health perception and varicose vein symptoms.

Method:

Fifty-three consecutive patients undergoing DCWS over a 9 month period were enrolled in this study. The SF-36 health assessment questionnaire and a vein-symptom-specific questionnaire were administered on the morning of surgery, 7 weeks postoperatively and 1 year following surgery. All patients in this study underwent a standard varicose vein operation and followed a standard protocol of postoperative management.

Results:

DCWS population health scores were lower than general population norms preoperatively. There was a significant improvement in the 7 week postoperative group in physical function and health perception (p<0.05). One year after surgery physical function, health perception, mental health and physical role were significantly improved from preoperative scores (p<0.05). Symptom-specific scores demonstrated a sustained trend towards improvement over the postoperative year.

Conclusion:

Varicose veins are associated with diminished well-being. Day case varicose vein surgery improves patient health perception and symptoms and is the treatment of choice for suitable patients with varicose veins.

Regulation of epidermal growth factor receptor signaling by endocytosis and intracellular trafficking

Ligand activation of the epidermal growth factor receptor (EGFR) leads to its rapid internalization and eventual delivery to lysosomes. This process is thought to be a mechanism to attenuate signaling, but signals could potentially be generated after endocytosis. To directly evaluate EGFR signaling during receptor trafficking, we developed a technique to rapidly and selectively isolate internalized EGFR and associated molecules with the use of reversibly biotinylated anti-EGFR antibodies. In addition, we developed antibodies specific to tyrosine-phosphorylated EGFR. With the use of a combination of fluorescence imaging and affinity precipitation approaches, we evaluated the state of EGFR activation and substrate association during trafficking in epithelial cells. We found that after internalization, EGFR remained active in the early endosomes. However, receptors were inactivated before degradation, apparently due to ligand removal from endosomes. Adapter molecules, such as Shc, were associated with EGFR both at the cell surface and within endosomes. Some molecules, such as Grb2, were primarily found associated with surface EGFR, whereas others, such as Eps8, were found only with intracellular receptors. During the inactivation phase, c-Cbl became EGFR associated, consistent with its postulated role in receptor attenuation. We conclude that the association of the EGFR with different proteins is compartment specific. In addition, ligand loss is the proximal cause of EGFR inactivation. Thus, regulated trafficking could potentially influence the pattern as well as the duration of signal transduction.

Cholecystokinin (CCK) secretion in patients with severe short bowel syndrome (SSBS)

This study examined the effects of a liquid meal on cholecystokinin (CCK) secretion in patients with severe short bowel syndrome (SSBS) receiving home total parenteral nutrition (TPN) support for 5-19 years after massive small bowel resection. Five patients with SSBS due to superior mesenteric artery or vein thrombosis were included. Five healthy volunteers served as controls. Blood was drawn before and 1 hr following consumption of 250 ml of a liquid diet containing 232 kcal with 8 g fat and 8 g protein. Plasma CCK activity was evaluated by amylase bioassay. All patients had stable weight with a normal BMI and serum albumin level, although there were mild abnormalities in their liver function tests. CCK secretion after stimulation was significantly decreased in patients. These results suggest that reduction in intestinal length influences CCK secretion in response to meal stimulation in SSBS patients.

[Breast carcinoma diagnosed in mammographic screening incidentally. Research on the radiologic signs in prior mammograms]

PURPOSE

To determine how many cancers screen-detected at subsequent rounds were already visible on previous screening mammograms, and to study their radiological features.

MATERIALS AND METHODS

The previous screening mammograms of 100 women who had cancers screen-detected at subsequent rounds (group A), and the negative screening mammograms of 200 women (group B) who had a further negative screening test two years later, were mixed for a new reading. The two groups were similar for age and year of examination. These films were blindly reviewed by 5 radiologists. Then, mammograms were reviewed retrospectively, with knowledge of subsequent diagnostic results. Finally the A group findings were classified as: 1) true negative: no radiological signs; 2) minimal sign: a nonspecific abnormality is retrospectively visible at the site of subsequent cancer; 3) false negative: "she should have been recalled"; 4) misdiagnosis at assessment: the woman had been recalled, but the cancer was missed after the assessment procedures.

RESULTS

60% of cases were true negatives, 29% were minimal signs, 9% were false negative and 2% were misdiagnosed at assessment. The most common radiological sign found among false negative cases was an architectural distortion: opacities and calcifications were more frequent among minimal signs. Only 10 of 40 cancers retrospectively visible on previous mammograms had reached stage II at diagnosis. At blinded review, the radiologists found false abnormalities in a considerable number of healthy women (average: 29%).

DISCUSSION AND CONCLUSIONS

Our study shows that mammography sensitivity can be improved. Cancer radiological signs may go undetected due to difficult interpretation (opacities, calcifications) or perception (architectural distortions). The use of a low threshold of suspicion (as in a reading test) in real screening might permit to detect more cancers (most of them, however, would not reach advanced stages at subsequent rounds), but might also lead to many unnecessary assessments and, probably, to some benign biopsies in healthy women. In conclusion, an attempt at improving mammography sensitivity by lowering the threshold of suspicion can not be directly recommended due to the considerable negative effects related to a loss in specificity. A reading test similar to the one presented in our study would be a useful training procedure for radiologists who are involved in a screening program.

Incidence, prognosis, and etiology of end-stage liver disease in patients receiving home total parenteral nutrition

BACKGROUND

Elevations in liver function tests have been reported in patients receiving total parenteral nutrition (TPN). The clinical aspects of end-stage liver disease (ESLD) associated with the prolonged use of home TPN have not been fully clarified. In previous series patients with duodenocolostomies appeared to be at higher risk than persons with some jejunum or ileum remaining in situ.

METHODS

The records of 42 patients treated with home TPN for more than 1 year were examined. This constituted 283 person-years of home TPN. Patients with duodenocolostomies were examined as a separate group on the basis of the literature experience.

RESULTS

Six of 42 patients who received chronic home TPN had ESLD with 100% subsequent mortality, at an average of 10.8 +/- 7.1 months after the initial bilirubin elevation. Thirteen of 42 patients had superior mesenteric artery or vein thrombosis (SMT) leading to duodenocolostomy. In 8 of these 13 patients with SMT and underlying inflammatory or malignant disorder, 2 had ESLD. The remaining 5 SMT patients who had only minimal liver enzyme elevation over 13.6 +/- 6.7 (range 3 to 19) years of home TPN were significantly younger (36 +/- 7 years vs 64 +/- 13 years) and did not have underlying inflammation either by clinical diagnosis or as reflected in the high normal serum albumin level (> or = 4.0 g/dL). Despite their extreme short bowel syndrome and long exposure to home TPN, ESLD did not develop.

CONCLUSIONS

Approximately 15% of patients who receive prolonged TPN have ESLD with a high rate of morbidity and mortality. The combination of chronic inflammation and the short bowel syndrome appears to be necessary for the development of ESLD with prolonged home TPN.

Irritable bowel syndrome and recurrent abdominal pain. A comparative review

Clinical findings on irritable bowel syndrome in adults and recurrent abdominal pain in children are reviewed to determine if what is known about each disorder can illuminate our understanding of the other. The evidence reveals striking similarities between the disorders in prevalence, course, medical and psychiatric comorbidity, family medical and psychiatric history, and association with life events. Continuity between the two disorders is also suggested by the results of follow-up and follow-back studies. The review shows the importance of a developmental perspective for understanding functional bowel disorders in adults and points to areas where further research would be useful.

[Ultrasonography contrast media Levovist and power Doppler in the study of the breast. Methodology, vascular morphology and automatic enhancement quantification with wash-in and wash-out curves]

PURPOSE

To define the technique for contrast-enhanced power Doppler US studies of breast lesions and to identify possible clinical applications.

MATERIAL AND METHODS

We studied 51 breast lesions detected at mammography and confirmed at cytology and/or surgical biopsy; 15 were benign lesions and 36 carcinomas, namely 14 T1ab, 29 T1c and 8 T2. We found 14 masses with regular margins, 28 with irregular margins, 1 asymmetric density, 2 architectural distortions and 6 clustered calcifications. US studies were performed with an AU5 Harmonic unit (Esaote Biomedica, Genoa, Italy) equipped with a software for online image storage, analysis and automatic quantification of US signal intensity changes after contrast agent injection, namely wash-in and wash-out contrast enhancement curves. The echocontrast agent Levovist (Schering AG, Berlin, Germany), 4.0 g preparation, was administered by i.v. injection (cubital vein) in two times at a concentration of 400 mg/mL. The first 4 mL of Levovist suspension were injected as a bolus at approximately .5 mL/s to evaluate lesion vascularization and choose the best scanning plane for wash-in and wash-out quantification. The remaining 6 mL of Levovist suspension were injected at approximately 1.0 mL/s and dedicated to wash-in and wash-out recording.

RESULTS

The region of interest could not be identified in 2 of 6 calcifications. After Levovist administration, signal enhancement was seen in 36 lesions. Nonsignificant curves were obtained in 7 fibroadenomas, 1 fibrocystic mastopathy and 5 carcinomas. Pathology diagnosed an in situ component around the lesion core (true positives) in 12 carcinomas with perilesional vessels and also 3 more carcinomas with perilesional foci in situ missed at contrast-enhanced US (false negatives). The wash-in/wash-out curves of 30 carcinomas differed from those of the 6 fibroadenomas, in that the former had faster wash-in and an earlier enhancement peak, as well as longer enhancement than the latter. Moreover, fibroadenoma curves are regularly increasing, with moderate variations. As for wash-out, carcinomas exhibited three main patterns, namely a monophasic, a polyphasic and a plateau pattern.

DISCUSSION

The pattern of enhancement curves in fibroadenomas is related to straight and regular vessels, while arteriovenous shunts in carcinomas cause early signal intensity peaks. Wash-out is longer in carcinomas than in fibroadenomas because the former present anarchic and tortuous vessels with slow flows.

CONCLUSIONS

Levovist enhanced US is a complementary test to study known breast lesions which permits the differential diagnosis of carcinomas and fibroadenomas. Our results justify a larger clinical trial to assess the role of this technique for diagnosis, prognosis and staging purposes.

Colonization with broad-spectrum cephalosporin-resistant gram-negative bacilli in intensive care units during a nonoutbreak period: prevalence, risk factors, and rate of infection

OBJECTIVE

To define the epidemiology of broad-spectrum cephalosporin-resistant gram-negative bacilli in intensive care units (ICUs) during a nonoutbreak period, including the prevalence, the risk factors for colonization, the frequency of acquisition, and the rate of infection.

DESIGN

Prospective cohort study.

SETTING

Tertiary care hospital.

PATIENTS

Consecutive patients admitted to two surgical ICUs.

MAIN OUTCOME MEASUREMENTS

Serial patient surveillance cultures screened for ceftazidime (CAZ) resistance, antibiotic and hospital exposure, and infections.

RESULTS

Of the 333 patients enrolled, 60 (18%) were colonized with CAZ-resistant gram-negative bacilli (CAZ-RGN) at admission. Clinical cultures detected CAZ-RGN in only 5% (3/60) of these patients. By using logistic regression, CAZ-RGN colonization was associated with duration of exposure to cefazolin (odds ratio, 10.3; p < or = .006) and to broad-spectrum cephalosporins/penicillins (odds ratio, 2; p < or = .03), Acute Physiology and Chronic Health Evaluation III score (odds ratio, 1.2; p < or = .008), and previous hospitalization (odds ratio, 3.1; p < or = .006). Of the 100 patients who remained in the surgical ICU for > or = 3 days, 26% acquired a CAZ-RGN. Of the 14 infections caused by CAZ-RGN, 11 (79%) were attributable to the same species present in surveillance cultures at admission to the surgical ICU.

CONCLUSIONS

Colonization with CAZ-RGN was common and was usually not recognized by clinical cultures. Most patients colonized or infected with CAZ-RGN had positive surveillance cultures at the time of admission to the surgical ICU, suggesting that acquisition frequently occurred in other wards and institutions. Patients exposed to first-generation cephalosporins, as well as broad-spectrum cephalosporins/penicillins, were at high risk of colonization with CAZ-RGN. Empirical treatment of nosocomial gram-negative infections with broad-spectrum cephalosporins, especially in the critically ill patient, should be reconsidered.

Depression in pediatric chronic illness. A diathesis-stress model

Depression in pediatric chronic illness has been receiving increasing attention in recent years. Studies to date have typically focused on characteristics of illness as the major determinants of the development of depression, but characteristics of the child have received less attention. This review suggests that a diathesis-stress model can be a fruitful heuristic that would incorporate illness characteristics and attributes of the child and environmental effects in an overall framework to guide future research and treatment.

The Limerick Leg-Ulcer Project: early results

Nurse led clinics in joint hospital and community settings are now being advocated as the most effective and economic way of dealing with leg ulcers. However, little information exists on the profile and outcome of patients with venous ulcers treated either in the community or in the hospital setting. Over a 2 yr period we assessed 134 patients with leg ulcers of whom 122 were deemed suitable for compression bandaging therapy. Thirty-four patients (28 per cent) were treated by the newly developed community service and 88 (72 per cent) were treated at the hospital clinic. Our overall healing rate for venous ulcers was 50 per cent @ 40 weeks. This probably reflects the long duration (48 per cent > 2 yr) and large size (0.5-600 cm2) of ulcer prior to treatment. There were no differences in outcome between hospital (50 per cent @ 40 weeks) and community (35 per cent @ 40 weeks) based treatment (p > 0.05). We conclude that most venous ulcers can be effectively treated in the community and resources should be provided to achieve this goal.

A group treatment approach to failure to toilet train: the case of Max

Toilet training is a major developmental milestone for children and parents. Accurate statistics on the prevalence of toilet-training failure do not exist; however, it is estimated that approximately 4% of 4-year-olds are not bowel trained. A number of biopsychosocial and developmental factors can interfere with toilet training. Frequently, a cycle of withholding and constipation with painful bowel movements and/or overflow incontinence ensues. A case study of a 4-year-old boy with encopresis and pervasive developmental disorder will highlight an interdisciplinary team's approach to helping children (4-6 years old) toilet train. Along with individual patient care management, parents and children attended (separately) a six-session medical and psychoeducational group called "Toilet School." This group model employs the principles of behavior modification, the concepts of children's preoperational thinking, and a philosophy of care that values collaborative relationships between caregivers and families.

Effects of human recombinant growth hormone (rhGH) on inflammatory responses in patients undergoing abdominal aortic aneurysm repair

BACKGROUND

Human recombinant growth hormone (rhGH) has been shown to increase skeletal muscle protein synthesis and improve nitrogen balance in critically ill patients and those undergoing surgery. rhGH effects on hepatic protein turnover in critically ill patients are less clearly understood.

OBJECTIVE

To examine rhGH effects on hepatic acute phase protein responses and inflammatory cytokine release in patients undergoing major surgery.

DESIGN

Prospective double blind randomised trial.

SETTING

Tertiary referral university teaching hospital.

PATIENTS

Patients undergoing elective abdominal aortic aneurysm repair.

INTERVENTION

Patients received rhGH (Genotropin, 0.3 IU/kg per day, n = 8) or placebo (n = 10) for 6 days prior to surgery.

RESULTS

Blood levels of growth hormone (GH) and insulin-like growth factor (IGF-1) were measured following rhGH treatment and C-reactive protein (CRP), serum amyloid A (SAA) and the cytokines interleukin-6 (IL-6) and the IL-1 receptor antagonist (IL-1ra) were measured for up to 24 h following surgery. Significant increases in plasma rhGH (0.84 +/- 0.3, mean (sem) versus 52 +/- 20 mU/l, p < 0.0008) and IGF-1 levels (119 +/- 13 versus 644 +/- 110 ng/ml, p < 0.0001) were seen prior to surgery following rhGH administration. No differences in acute phase protein or cytokine levels were seen following surgery in patients receiving rhGH.

CONCLUSIONS

These results indicate that pre-operative administration of rhGH does not alter acute phase protein or inflammatory cytokine release in response to major surgery.

The effects of 13-cis retinoic acid and interferon-alpha in chronic myelogenous leukemia cells in vivo in patients

The effects of the administration of a 3-day course of 13-cis retinoic acid in combination with interferon a [RA/IFN] on the leukemia cells was measured in vivo in 43 patients with chronic myelogenous leukemia. The administration of RA/IFN was associated with a significant fall in the white blood cell count of patients with chronic-phase disease and with a fall in the percentage S-phase cells in CML patients regardless of the stage of their leukemia. In two thirds of the patients studied the administration of RA/IFN was also associated with an increase in marrow apoptosis. The cytokine combination also suppressed bcl-2 and myc expression in a minority of patients and such expression appears to be associated with response to a treatment regimen which includes RA/IFN. These studies are the first to directly assess the effects of the combination of RA/IFN on chronic myelogenous leukemia cells in vivo in patients. These effects, if seen in other malignant diseases, could account for the therapeutic benefit which has been associated with the administration of this combination of biological agents to patients with malignant disease.