Faecal immunochemical testing (FIT): sources of result variation based on three years of routine testing of symptomatic patients in English primary care

Introduction: We aimed to determine the analytical capabilities of a commonly used faecal immunochemical test (FIT) to detect faecal haemoglobin (Hb) in symptomatic people attending primary care in the context of the English NICE DG30 guidance.Materials and Methods: Data obtained from independent verification studies and clinical testing of the HM-JACKarc FIT method in routine primary care practice were analysed to derive performance characteristics.Results: Detection capabilities for the FIT method were 0.5 µg/g (limit of blank), 1.3 µg/g (limit of detection) and 3.0 µg/g (limit of quantitation). Of 33 non-homogenized specimens, 31 (93.9%) analysed in triplicate were consistently categorized relative to 10 µg/g, compared to all 33 (100%) homogenized specimens. Imprecision was higher (median 27.8%, (range 20.5% to 48.6%)) in non-homogenized specimens than in homogenized specimens (10.2%, (7.0 to 13.5%)). Considerable variation was observed in sequential clinical specimens from individual patients but no positive or negative trend in specimen degradation was observed over time (p = 0.26).Discussion: The FIT immunoassay evaluated is capable of detecting faecal Hb at concentrations well below the DG30 threshold of 10 µg/g and is suitable for application in this context. The greatest practical challenge to FIT performance is reproducible sampling, the pre-analytical step associated with most variability. Further research should focus on reducing sampling variability, particularly as post-COVID-19 guidance recommends greater FIT utilization.

Premature hippocampus-dependent memory decline in middle-aged females of a genetic rat model of depression

Aging and major depressive disorder are risk factors for dementia, including Alzheimer's Disease (AD), but the mechanism(s) linking depression and dementia are not known. Both AD and depression show greater prevalence in women. We began to investigate this connection using females of the genetic model of depression, the inbred Wistar Kyoto More Immobile (WMI) rat. These rats consistently display depression-like behavior compared to the genetically close control, the Wistar Kyoto Less Immobile (WLI) strain. Hippocampus-dependent contextual fear memory did not differ between young WLI and WMI females, but, by middle-age, female WMIs showed memory deficits compared to same age WLIs. This deficit, measured as duration of freezing in the fear provoking-context was not related to activity differences between the strains prior to fear conditioning. Hippocampal expression of AD-related genes, such as amyloid precursor protein, amyloid beta 42, beta secretase, synucleins, total and dephosphorylated tau, and synaptophysin, did not differ between WLIs and WMIs in either age group. However, hippocampal transcript levels of catalase (Cat) and hippocampal and frontal cortex expression of insulin-like growth factor 2 (Igf2) and Igf2 receptor (Igf2r) paralleled fear memory differences between middle-aged WLIs and WMIs. This data suggests that chronic depression-like behavior that is present in this genetic model is a risk factor for early spatial memory decline in females. The molecular mechanisms of this early memory decline likely involve the interaction of aging processes with the genetic components responsible for the depression-like behavior in this model.

Using simulation to iteratively test and re-design a cognitive aid for use in the management of severe local anaesthetic toxicity

Introduction

Cognitive aids, such as a guideline for the management of severe local anaesthetic (LA) toxicity, are tools designed to help users complete a task. Human factors experts recommend the use of simulation to iteratively test and re-design these tools. The purpose of this study was to apply human factors engineering principles to the testing and iterative re-design of three existing cognitive aids used for the management of severe LA toxicity and to use these data to develop a ‘new’ cognitive aid.

Methods

Twenty anaesthetist–anaesthetic assistant pairs were randomised into four groups. Each of the first three groups received one of three different existing cognitive aids during a standardised simulated LA toxicity crisis. Postsimulation semistructured interviews were conducted to identify features beneficial and detrimental to the format and usability of the aid. Synthesis of the interview data with established checklist design recommendations resulted in a prototype aid, which was subjected to further testing and re-design by the fourth group (five more pairs) under the same conditions thus creating the final iteration of the new aid.

Results

Features of the new aid included a single-stream flowchart structure, single-sided, large-font design with colour contrast, simplified instructions and no need for calculations. This simplified tool contains only the information users reported as essential for the immediate crisis management.

Conclusions

Utilisation of formative usability testing and simulation-based user-centred design resulted in a visually very different cognitive aid and reinforces the importance of designing aids in the context in which they are to be used. Simplified tools may be more appropriate for use in emergencies but more detailed guidelines may be necessary for training, education and development of local standard operating procedures. Iterative simulation-based testing and re-design is likely to be of assistance when developing aids for other crises, and to eliminate design failure as a confounder when investigating the relationship between use of cognitive aids and performance.

A Clinically Relevant Closed-Head Model of Single and Repeat Concussive Injury in the Adult Rat Using a Controlled Cortical Impact Device

Repeat concussions (RC) can result in significant long-term neurological consequences and increased risk for neurodegenerative disease compared with single concussion (SC). Mechanisms underlying this difference are poorly understood and best elucidated using an animal model. To the best of our knowledge, there is no closed-head model in the adult rat using a commercially available device. We developed a novel and clinically relevant closed-head injury (CHI) model of both SC and RC in the adult rat using a controlled cortical impact (CCI) device. Adult rats received either a single or repeat CHI (three injuries, 48 h apart), and acute deficits in sensorimotor and locomotor function (foot fault; open field), memory (novel object), and anxiety (open field; corticosterone [CORT]) were measured. Assessment of cellular pathology was also conducted. Within the first week post-CHI, rats with SC or RC showed similar deficits in motor coordination, decreased locomotion, and higher resting CORT levels. Rats with an SC had memory deficits post-injury day (PID) 3 that recovered to sham levels by PID 7; however, rats with RC continued to show memory deficits. No obvious gross pathology was observed on the cortical surface or in coronal sections. Further examination showed thinning of the cortex and corpus callosum in RC animals compared with shams and increased axonal pathology in the corpus callosum of both SC and RC animals. Our data present a model of CHI that results in clinically relevant markers of concussion and an early differentiation between SC and RC.

Presenilin-1 Dependent Neurogenesis Regulates Hippocampal Learning and Memory

Presenilin-1 (PS1), the catalytic core of the aspartyl protease γ-secretase, regulates adult neurogenesis. However, it is not clear whether the role of neurogenesis in hippocampal learning and memory is PS1-dependent, or whether PS1 loss of function in adult hippocampal neurogenesis can cause learning and memory deficits. Here we show that downregulation of PS1 in hippocampal neural progenitor cells causes progressive deficits in pattern separation and novelty exploration. New granule neurons expressing reduced PS1 levels exhibit decreased dendritic branching and dendritic spines. Further, they exhibit reduced survival. Lastly, we show that PS1 effect on neurogenesis is mediated via β-catenin phosphorylation and notch signaling. Together, these observations suggest that impairments in adult neurogenesis induce learning and memory deficits and may play a role in the cognitive deficits observed in Alzheimer’s disease.

Neprilysin: an enzyme candidate to slow the progression of Alzheimer's disease

It is well established that the extracellular deposition of amyloid beta (Abeta) peptide plays a central role in the development of Alzheimer's disease (AD). Therefore, either preventing the accumulation of Abeta peptide in the brain or accelerating its clearance may slow the rate of AD onset. Neprilysin (NEP) is the dominant Abeta peptide-degrading enzyme in the brain; NEP becomes inactivated and down-regulated during both the early stages of AD and aging. In this study, we investigated the effect of human (h)NEP gene transfer to the brain in a mouse model of AD before the development of amyloid plaques, and assessed how this treatment modality affected the accumulation of Abeta peptide and associated pathogenetic changes (eg, inflammation, oxidative stress, and memory impairment). Overexpression of hNEP for 4 months in young APP/DeltaPS1 double-transgenic mice resulted in reduction in Abeta peptide levels, attenuation of amyloid load, oxidative stress, and inflammation, and improved spatial orientation. Moreover, the overall reduction in amyloidosis and associated pathogenetic changes in the brain resulted in decreased memory impairment by approximately 50%. These data suggest that restoring NEP levels in the brain at the early stages of AD is an effective strategy to prevent or attenuate disease progression.

Novel strategies for Alzheimer's disease treatment

Considerable progress has been made in recent years towards better understanding the pathogenesis of Alzheimer's disease (AD), a dementing neurodegenerative disorder that affects > 10 million individuals in the US and Europe combined. Recent studies suggest that alterations in the processing of amyloid precursor protein (APP), resulting in the accumulation of amyloid-beta protein (Abeta) and the formation of oligomers leads to synaptic damage and neurodegeneration. Therefore, strategies for treatment development have been focused on reducing Abeta accumulation using, among other approaches, antiaggregation molecules, regulators of the APP proteolysis and processing, reducing APP production (e.g., small-interfering RNA), and increasing Abeta clearance with antibodies, apolipoprotein E and Abeta-degrading enzymes (e.g., neprilysin). The main focus of this review is on novel treatments for AD with a special emphasis on delivering neuroprotective and antiamyloidogenic molecules by gene therapy and by promoting neurogenesis.

Stabilisation of crosslinked ultra-high molecular weight polyethylene (UHMW-PE)-acetabular components with alpha-tocopherol

A stabilisation of crosslinked ultra-high molecular weight polyethylene (UHMW-PE) with alpha-tocopherol (vitamin E) used for endoprostheses can increase its resistance against oxidative degradation remarkably. However, the method used for conventional UHMW-PE of adding alpha-tocopherol to the UHMW-PE powder before processing can not be applied for crosslinked UHMW-PE, since the alpha-tocopherol hinders the crosslinking process, which would be accompanied by a heavy degradation of this vitamin. The alpha-tocopherol has therefore to be added after the crosslinking process. This paper presents two methods for a stabilisation of finished products with alpha-tocopherol. In method 1, UHMW-PE-cubes (20 x 20 x 20 mm3) were stored in pure alpha-tocopherol under inert atmosphere at temperatures from 100 degrees C to 150 degrees C resulting in a high mass fraction of alpha-tocopherol in the edge zones. For further homogenisation, the cubes were stored in inert atmosphere at temperatures from 160 degrees C to 200 degrees C. In method 2, supercritical CO2 was used to incorporate the vitamin into the UHMW-PE. In an autoclave vessel, the cubes were treated with alpha-tocopherol dissolved in supercritical CO2 for several hours at temperatures from 100 degrees C to 170 degrees C. In both cases, the mass fraction of alpha-tocopherol was detected with the help of a FTIR-microscope. Both methods are well suited to stabilise crosslinked UHMW-PE with alpha-tocopherol. A stabilisation of the sensitive edge layer as well as a nearly homogenous distribution with varying alpha-tocopherol content may be realised by varying the process parameters. Using method 2, standard hip cups were stabilized nearly homogeneously with varying mass fraction of alpha-tocopherol. No oxidation of the UHMW-PE could be detected by infrared spectroscopy (FTIR) and HPLC studies showed a very low degradation of the alpha-tocopherol for both processes.