'PartBreCon' study. A UK multicentre retrospective cohort study to assess outcomes following PARTial BREast reCONstruction with chest wall perforator flaps

BACKGROUND

Partial breast reconstruction with a pedicled chest wall perforator flap (CWPF) enables breast conservation in a higher tumour: breast volume ratio scenario. Since there is limited evidence, this retrospective cohort study aimed to ascertain immediate (30-days) and medium-term (follow-up duration) surgical outcomes.

METHODS

STROBE-compliant protocol ascertained CWPF outcomes between March 2011-March 2021. UK centres known to perform CWPF were invited to participate if they performed at least 10 cases. Data were retrospectively collected, including patient demographics, tumour and treatment characteristics, and surgical and oncological outcomes. Statistical analysis (R™) included multivariable logistic regression and sensitivity analysis.

RESULTS

Across 15 centres, 507 patients with median age (54 years, IQR; 48-62), body mass index (25.4 kg/m2, IQR; 22.5-29), tumour size (26 mm, IQR; 18-35), and specimen weight (62 g, IQR; 40-92) had following flap types: LiCAP (54.1%, n = 273), MiCAP/AiCAP (19.6%, n = 99), LiCAP + LTAP (19.8%, n = 100) and TDAP (2.2%, n = 11). 30-days complication rates were in 12%: haematoma (4.3%, n = 22), wound infection (4.3%, n = 22), delayed wound healing (2.8%, n = 14) and flap loss (0.6%, n = 3; 1 full) leading to readmissions (2.6%, n = 13) and re-operations (2.6%, n = 13). Positive margins (n = 88, 17.7%) led to 15.9% (n = 79) re-excisions, including 7.5% (n = 37) at the planned 2nd of 2-stage surgery and 1.8% (n = 9) mastectomy. At median 23 months (IQR; 11-39) follow-up, there were 1.2% (n = 6) symmetrisations; recurrences: local (1%), regional/nodal (0.6%) and distant (3.2%).

CONCLUSIONS

This large multicentre cohort study demonstrates acceptable complication and margin re-excision rates. CWPF extends the range of breast conservation techniques. Further studies are required for long-term oncological outcomes.

Expanding the phenotype of Bruck syndrome: Severe limb deformity, arthrogryposis, congenital cardiac disease and pulmonary hemorrhage

Bruck syndrome is a rare collagen disorder with autosomal recessive inheritance caused by pathogenic variants in either FKBP10 or PLOD2 genes. It is characterized by bone fragility and fractures similar in severity and variability to osteogenesis-imperfecta as well as congenital joint contractures. This article describes an infant with a homozygous (partial) gene deletion of PLOD2 that includes the start codon and would be expected to lead to nonfunctional protein product. The infant had a severe phenotype of Bruck syndrome and is the only reported case of Bruck syndrome with congenital cardiac disease (triscuspid valve dysplasia with severe regurgitation, mitral valve prolapses with moderate regurgitation, and pulmonary hypertension) and pulmonary hemorrhage. We hypothesize that the additional feature of congenital cardiac disease in this case was due to the underlying defect in type I collagen, and that the pulmonary hemorrhage was multifactorial, with underlying vessel fragility, rib fractures, and high pulmonary pressures likely to be major contributing factors. Management was largely supportive with the use of bisphosphonates to assist in pain management. Care was complicated by comorbid cardiopulmonary compromise, limited evidence-base guiding care, and difficulties in discussing end-of-life care.

Improved definition of growing pains: A common familial primary pain disorder of early childhood

Background

Commonly applied diagnostic criteria for growing pains (GP) have evolved without determination by an authoritative representative body. GP and restless legs syndrome (RLS) share anatomical, distributional, temporal, and other clinical features and are associated in individuals over time, in families, and in population samples. In this study, we tested the hypothesis that GP, diagnosed by widely used criteria, is confounded by cases of painful restless legs syndrome (RLS‐Painful).

Methods

A twin family study of genetic influence and associations of GP using questionnaires was administered by Twins Research Australia. Twins (3–18 years; monozygous 503, dizygous 513), their oldest siblings, mothers, and fathers were randomly selected from the twin registry. Family members completed the questionnaires assessing lifetime prevalence of GP by commonly applied criteria and covariates including the history of iron deficiency and pediatric pain disorders. A GP‐Specific phenotype was defined as GP without urge to move the legs. We determined similarities in twin pairs for the GP and GP‐Specific phenotypes, family associations, and estimated familial and individual‐specific associations for each phenotype.

Results

Lifetime prevalence was one‐third lower for GP‐Specific than for GP among the twin and family members. Monozygous twin pairs were more similar than dizygous twin pairs for GP and for the derived GP‐Specific phenotype by three methods, consistent with genetic influence. There were familial associations, but the essential evidence for genetic influence was the twin‐cotwin data. GP was associated, in multivariable analyses, with migraine, headaches, recurrent abdominal pain, and iron deficiency, while GP‐Specific associations were limited to migraine and headaches.

Conclusions

GP is hybrid, one‐third of cases having symptoms and associations of RLS, necessarily RLS‐Painful. GP‐Specific (without symptoms and associations of RLS) could have a genetic etiology. We propose new criteria to facilitate etiological and therapeutic research.

Growing pains, a highly prevalent primary pain disorder of childhood, has been associated with restless legs syndrome in individuals over time, in families and in population samples. This conundrum has been clarified by the evidence in this twin family study that growing pains, as previously defined, has been confounded by symptoms of restless legs syndrome. An exclusion clause of urge to move the legs has resulted in criteria for a purer phenotype which retains evidence of heritability.

Standardized practices for RNA diagnostics using clinically accessible specimens reclassifies 75% of putative splicing variants

PURPOSE

Genetic variants causing aberrant premessenger RNA splicing are increasingly being recognized as causal variants in genetic disorders. In this study, we devise standardized practices for polymerase chain reaction (PCR)-based RNA diagnostics using clinically accessible specimens (blood, fibroblasts, urothelia, biopsy).

METHODS

A total of 74 families with diverse monogenic conditions (31% prenatal-congenital onset, 47% early childhood, and 22% teenage-adult onset) were triaged into PCR-based RNA testing, with comparative RNA sequencing for 19 cases.

RESULTS

Informative RNA assay data were obtained for 96% of cases, enabling variant reclassification for 75% variants that can be used for genetic counseling (71%), to inform clinical care (32%) and prenatal counseling (41%). Variant-associated mis-splicing was highly reproducible for 28 cases with samples from ≥2 affected individuals or heterozygotes and 10 cases with ≥2 biospecimens. PCR amplicons encompassing another segregated heterozygous variant was vital for clinical interpretation of 22 of 79 variants to phase RNA splicing events and discern complete from partial mis-splicing.

CONCLUSION

RNA diagnostics enabled provision of a genetic diagnosis for 64% of recruited cases. PCR-based RNA diagnostics has capacity to analyze 81.3% of clinically significant genes, with long amplicons providing an advantage over RNA sequencing to phase RNA splicing events. The Australasian Consortium for RNA Diagnostics (SpliceACORD) provide clinically-endorsed, standardized protocols and recommendations for interpreting RNA assay data.

Clinically Responsive Genomic Analysis Pipelines: Elements to Improve Detection Rate and Efficiency

Massively parallel sequencing has markedly improved mendelian diagnostic rates. This study assessed the effects of custom alterations to a diagnostic genomic bioinformatic pipeline in response to clinical need and derived practice recommendations relative to diagnostic rates and efficiency. The Genomic Annotation and Interpretation Application (GAIA) bioinformatics pipeline was designed to detect panel, exome, and genome sample integrity and prioritize gene variants in mendelian disorders. Reanalysis of selected negative cases was performed after improvements to the pipeline. GAIA improvements and their effect on sensitivity are described, including addition of a PubMed search for gene-disease associations not in the Online Mendelian Inheritance of Man database, inclusion of a process for calling low-quality variants (known as QPatch), and gene symbol nomenclature consistency checking. The new pipeline increased the diagnostic rate and reduced staff costs, resulting in a saving of US$844.34 per additional diagnosis. Recommendations for genomic analysis pipeline requirements are summarized. Clinically responsive bioinformatics pipeline improvements increase diagnostic sensitivity and increase cost-effectiveness.

771 Shaping the Virtual Learning Environment: Emojis As A Novel Feedback Modality for Content Delivery in Postgraduate Medical Education

Introduction

Postgraduate medical education in the wake of a pandemic has sparked creativity, evolving novel platforms concordant with socially distanced learning. Inevitably, evaluation is critical in navigating improvements in content delivery. However, as culture continues to shift away from didactic teaching, students are at risk of ‘feedback overload’. We propose a novel emoji scale to facilitate rapid appraisal.

Method

A three-point emoji scale was developed within the novel virtual learning environment for core surgical training in the West Midlands. Engagement with the emoji system was assessed and correlated with conventional post-course questionnaires.

Results

The novel emoji system provided a rapid mechanism for trainees to express opinion on individual modules immediately following completion. Parallels to social media meant this modality felt familiar to trainees. Simplification of feedback permitted prompt, targeted review of modules for improvement, as opposed to laborious collection and analysis of standard post-course questionnaires. Literature review revealed limited research regarding similar emoji-based responses, or the validity of Likert or free-text based feedback systems.

Conclusion

As virtual learning evolves following COVID-19, feedback systems help guide evolution. Emoji-based feedback may provide the key to prompt, accessible evaluation of VLE platforms.

11 A Sequential Simulation Experience for Interim Foundation Doctors and Analysis of Preparedness to Practice Early

Introduction

Covid-19 necessitated the early graduation of medical students to join the healthcare workforce as Foundation Interim Year 1 (FiY1) doctors. A sequential simulation session was implemented to improve and assess FiY1 preparedness towards approaching deteriorating patients.

Method

12 FiY1 doctors participated in the session containing three sequential major stations: complex new admission, ward-based management, and acute deterioration. Participants interpreted investigations, performed examinations, created management plans, and escalated using a pager.

Results

There was a significant improvement in preparedness for giving treatment (median(IQR): pre-simulation 3(3-4) vs. post-simulation 4(4-4.75); p = 0.04) and paperwork (2(2-3.75) vs. 4(3.25-4.75); p = 0.03). Following four weeks of FiY1 participants demonstrated significant improvement in preparedness for giving treatment (median(IQR): pre-simulation 3(3-4) vs. post-FiY1 4.5(4-5); p = 0.01), communication and teamworking (4(3.25-4.75) vs. 5(5-5.75); p = 0.01), and paperwork (2(2-3.75) vs. 5(5-5); p = 0.01). The FiY1 programme improved integration within teams and facilitated training whilst medical school placements left participants feeling apprehensive and unprepared to practice.

Conclusions

This session provided an engaging method of increasing preparedness towards common challenges new physicians face. This study suggests future senior medical student apprenticeships should give the same investment, opportunities, and responsibilities as that of the FiY1 programme.

Using preoperative three-dimensional endoanal ultrasound to determine operative procedure in patients with perianal fistulas

AIM

Accurate preoperative identification of perianal fistula tracts and internal openings can facilitate the choice of surgical procedure and may lead to improved healing rates. Our aim was to explore the effectiveness of three-dimensional endoanal ultrasound (3D-EAUS) in determining the type of perianal fistula and planning operative management.

METHOD

This was a cohort longitudinal study. Patients with perianal fistulas from January 2017 to January 2018 who underwent 3D-EAUS and subsequent surgery were included. Intra-operative findings were considered as standard for comparison with clinical examination and 3D-EAUS findings. The primary outcome measure was to evaluate the concordance between 3D-EAUS and intra-operative findings and the secondary outcome measure was healing rates.

RESULTS

Sixty-eight patients with a mean age of 43.1 ± 14.1 years were included. Twenty-eight patients had inter-sphincteric (41.2%) and 40 (14 high and 26 low) trans-sphincteric fistulas (58.8%). 3D-EAUS, clinical examination and intra-operative exploration could predict the location of internal openings in 62/68 (91.2%), 48/68 (70.5%) and 56/68 (82.4%) patients, respectively. Hydrogen peroxide (H₂O₂)-enhanced 3D-EAUS accurately predicted the location of internal openings when compared with 3D-EAUS without H₂O₂ (concordance K = 0.963, P = 0.05). High concordance rates were seen between intra-operative and 3D-EAUS findings on the type of perianal fistula. No significant difference was seen between the suggested surgical treatment based on 3D-EAUS and the eventual surgical treatment (P > 0.05). Study limitations were the small sample size and lack of randomization.

CONCLUSION

3D-EAUS may be considered as a first-line investigation for patients with perianal fistulas because of high concordance with intra-operative assessment and facilitation of surgical planning.

A laboratory-based evaluation of tube blocking and microbial risks associated with one blended enteral feed recipe

BACKGROUND

Concerns associated with blended enteral feeds include the risk of blocked tubes and microbial contamination, although the available evidence is limited. The present laboratory-based investigation aimed to examine these risks in a blended feed providing a nutritionally adequate intake for a hypothetical patient.

METHODS

A one-blended feed recipe was made using three different methods (professional, jug and stick blenders) and three storage procedures. Feed samples were syringed via 10-, 12- and 14-French (Fr) enteral feeding tubes and both blockages and the time taken were recorded. Feed samples were diluted, plated on agars, incubated and bacterial colony-forming units (CFU) counted. After storage at -80 °C, identification was undertaken using 16S rRNA polymerase chain reaction sequencing.

RESULTS

Two blockages occurred during 27 administrations of feed made using a professional blender, although they were resolved with a water flush. No blockages occurred with the 14-Fr tube and administration was quicker with wider tubes (P < 0.00001). There was no significant difference between the total bacterial CFU of feeds prepared using different methods (P = 0.771) or stored differently. The genus of bacteria identified included Enterococcus, Bacillus, lactose-fermenting Enterobacteriaceae, Pseudomonas and Staphylococcus. Pathogens, such as Clostridium spp., Salmonella spp. and Vibrio spp., were not identified by phenotypic tests used. Sequencing identified Escherichia coli, Shigella spp., Streptococcus lutetiensis and Staphylococcus epidermidis.

CONCLUSIONS

The present study found no risk of tube blockages when one blended feed recipe made using three methods was delivered via a 14-Fr tube. There is concern about bacterial contamination, although this was not influenced by the methods of preparation or storage used in the present study.

Proof-of-Concept Study for an Enhanced Surrogate Marker of Endothelial Function in Diabetes

Diabetes mellitus affects distal small vessels earlier and to a greater extent than proximal vessels. Vascular disease starts from activation of the endothelial cells, which if prolonged may lead to reduced distensibility of the vessel when maximally stimulated. Hence a device which measures distensibility of a distal vessel should be a good biomarker for subclinical disease. We have developed a device capable of measuring reactive hyperaemia induced changes in the radial artery flow, volumetric changes and accompanying effects on the vessel wall. The measurement is based on the magnetic flux disturbance upon haemodynamic modulation as blood flows through a uniformly applied magnetic field, and generates what we have termed the radial artery maximum distensibility index (RA-MDI). In a proof-of-concept study we found significant correlations between RA-MDI and cardiovascular risk factors, scoring systems and carotid artery intima-media thickness. Further large scale prospective studies need to be conducted to ascertain the correlations with cardiovascular events.

Body dysmorphic disorder in patients undergoing septorhinoplasty surgery: should we be performing routine screening?

OBJECTIVE

Body dysmorphic disorder (BDD) is defined as having a preoccupation with a perceived flaw in one's appearance, which appears slight to others and significantly interferes with a person's functioning. When undetected in septorhinoplasty patients, it will often lead to poor outcomes.

DESIGN

We performed a prospective cohort study to determine the prevalence of BDD in our patients and whether surgical correction could be considered.

SETTING AND PARTICIPANTS

We recruited 34 patients being considered for septorhinoplasty in a tertiary referral rhinology clinic and a control group of 50 from the otology clinic giving a total of 84.

MAIN OUTCOME MEASURES

Participants completed the Body Dysmorphic Disorder Questionnaire (BDDQ), the sino-nasal outcome test-23 (SNOT-23) and underwent nasal inspiratory peak flow (NIPF). Those found to be at high risk for BDD were referred to a clinical psychologist.

RESULTS

Of the septorhinoplasty patients, 11 (32%) were high risk for BDD. Following psychological assessment, 7 (63%) patients were felt to be unsuitable for surgery and were offered psychological therapy. SNOT-23 scores were significantly higher in the BDD group indicating a negative impact on quality of life. NIPF readings were not significantly different in the BDD group compared to the control group.

CONCLUSIONS

The BDDQ is a valid tool for identifying patients at risk of BDD. A close working relationship with clinical psychology has been advantageous to help the selection process of candidates for surgery when there is a high risk of BDD.

Prolonged hypocalcemia following denosumab therapy in metastatic hormone refractory prostate cancer

Prostate cancer is a leading cause of cancer death, frequently associated with widespread bone metastases. We report two cases of hypocalcemia following the first dose of denosumab in metastatic hormone refractory prostate cancer, the first case requiring 26 days of intravenous calcium therapy. This is the first report of prolonged hypocalcemia following denosumab in a patient with normal renal function.

AGE-INDEPENDENT CORRELATION OF OPTICALLY DETERMINED THORACIC KYPHOSIS WITH LUMBAR SPINE BONE MINERAL DENSITY

The thoracic spine is susceptible to age-related increases in the sagittal curve, a process which is accentuated in osteoporosis. Previous studies have demonstrated an association between low vertebral bone mineral density (BMD) and accentuation of kyphosis. However, concerns of ionizing radiation associated with radiographic evaluation of osteoporotic fracture risks create a demand for alternative noninvasive detection methods. Back shape, and in particular the thoracic kyphosis, may act as a surrogate for bone density and complement methods of screening individuals for osteoporosis or monitoring progression. The aim of this prospective study is to establish the statistical association of mean lumbar spine BMD and the age-independent BMD Z-score with kyphosis, measured from noninvasive, rasterstereographic analysis of back shape. Back shape imaging of 42 females was performed following routine lumbar bone densitometry using dual energy X-ray absorptiometry. Kyphosis parameters derived from an optical back shape imaging system were correlated, using simple linear regression models, against mean lumbar BMD and BMD Z-scores. Moderate associations were noted between lumbar BMD and thoracic kyphosis (r=0.63 to 0.71, p<0.0001). The trend was still evident when correlating kyphosis against BMD Z-scores (r=0.57 to 0.68, p<0.0001). These data confirm earlier studies comparing radiographic indices of thoracic curvature with vertebral BMD, and suggest potential application of noninvasive back shape imaging to assist in the screening of individuals at risk of spinal osteoporosis, particularly in younger populations.

Vaccination of poultry workers: delivery and uptake of seasonal influenza immunization

Avian influenza is a highly infectious disease in poultry and although the risk of human infection is low, concerns exist that it could evolve into a new human strain of pandemic potential if reassortment with a human influenza virus occurs. In January 2007, the UK government introduced a programme to vaccinate poultry workers to reduce the potential of such an event. This study evaluates the delivery, uptake and costs of the programme in three counties of England. A questionnaire survey was completed by consultants in public health in all the Primary Care Trusts in Norfolk, Suffolk and Cambridgeshire in May 2007. The delivery of the programme varied between Primary Care Trusts, including being delivered in some cases by clinics in primary care, by general practitioners and occupational health services in others. The uptake of vaccination was low ranging from 7% to 29% at a cost of £29 to £132 per person vaccinated. Vaccination of poultry workers as a public health measure to prevent an influenza pandemic is likely to be ineffective with the level of coverage found in this evaluation in our region.

Elevated serum PTH is independently associated with poor outcomes in older patients with hip fracture and vitamin D inadequacy

To determine whether serum 25(OH)D and/or PTH levels in older patients with hip fracture (HF) could predict short-term clinical outcomes, we conducted a prospective observational study of 287 consecutive HF patients (mean age 81.9 + or - 7.5 [SD] years, 72% females). The prevalence of vitamin D inadequacy (25[OH]D < 80 nmol/l) was 97.1%, that of vitamin D deficiency (25[OH]D < 50 nmol/l) was 79.8%, and that of elevated PTH level (>6.8 pmol/l) was 35.5%. After adjustment for age and sex, PTH was significantly associated with in-hospital mortality (OR = 1.12, 95% CI 10.5-1.20, P < 0.001), myocardial injury (OR = 1.05, 95% CI 1.03-1.15, P = 0.002), prolonged length of stay (LOS > or = 20 days; OR = 1.05, 95% CI 1.01-1.06, P = 0.044), and being discharged to institutional care (OR = 1.07, 95% CI 1.01-1.18, P = 0.48). Secondary hyperparathyroidism (SHPT), but not vitamin D deficiency, was associated with older age, a higher prevalence of trochanteric fracture, coronary artery disease, hypertension, previous stroke, renal impairment, increased levels of serum osteocalcin, bone-specific alkaline phosphatase, and adiponectin as well as a significantly higher in-hospital mortality (11.8 vs. 0.54%, P = 0.001), perioperative myocardial injury (32.7 vs. 22.5%, P = 0.043), LOS > or = 20 days (40.2 vs. 26.9%, P = 0.017), and being discharged to institutional care (29.5 vs. 14.6%, P = 0.019). In multivariate regression analyses, SHPT was strongly associated with in-hospital mortality and LOS > or = 20 days. We conclude that elevated PTH (but not vitamin D deficiency per se) is a strong independent predictor of poor outcomes in older patients.

E. coli O157 phage type 21/28 outbreak in North Cumbria associated with pasteurized milk

In March 1999, a large community outbreak of Escherichia coli O157 infection occurred in North Cumbria. A total of 114 individuals were reported to the Outbreak Control Team (OCT); 88 had laboratory confirmed E. coli O157. Twenty-eight (32%) of the confirmed cases were admitted to hospital, including three children (3.4%) with haemolytic uraemic syndrome. There were no deaths. A case-control study found that illness was strongly associated with drinking pasteurized milk from a local farm (P = <0.0001) on single variable analysis. Microbiological investigations at the farm revealed E. coli O157 phage type (PT) 21/28 VT 2 which was indistinguishable from the human isolates by pulsed field gel electrophoresis. At the time of occurrence this was the largest E. coli O157 outbreak in England and Wales and the first E. coli O157 PT 21/28 VT 2 outbreak associated with pasteurized milk. This outbreak highlights lessons to be learnt regarding on-farm pasteurization.

Magnetic resonance-based vertebral morphometry of the thoracic spine: age, gender and level-specific influences

OBJECTIVE

The aim of this study was to examine age, gender, and segmental trends in thoracic vertebral body shape, utilising thoracic spine magnetic resonance images involving an age range spanning the life span.

DESIGN

A quantitative, cross-sectional, retrospective study design involving a sample of convenience.

BACKGROUND

Thoracic vertebral shape data are commonly derived from radiographic resources. The non-ionising properties of magnetic resonance imaging and availability of digital data for image analysis suggest potential for MR-based morphometric studies. For the thoracic spine, there is limited vertebral shape data on males, while few studies have examined the pattern of age-related changes across the life span.

METHODS

Morphometry was performed on 220 mid sagittal T1-weighted MR images using image analysis software. Three indices of vertebral shape were utilised: the antero-posterior height ratio or anterior wedge index, mid-posterior height ratio or biconcavity index, and ratio of posterior vertebral height to mid antero-posterior diameter or compression index.

RESULTS

Different segmental patterns were noted for the vertebral shape indices. Significantly lower mean values were noted in males for the compression index. Age trends were significant, with a linear age-related decline demonstrated for the anterior wedge and biconcavity indices, and a quadratic trend noted for the compression index.

CONCLUSIONS

Thoracic vertebral body shape may be uniquely described using specific shape indices, for examining various segmental, gender and age-associated changes.

RELEVANCE

These results suggest the importance of defining specific reference criteria for thoracic vertebral body shape indices, particularly age-related data encompassing a wide age range. Magnetic resonance studies enable interpretation of vertebral shape data in relation to the wide spectrum of pathologies afflicting the thoracic spine, without the concerns of ionising radiation.

Relation between morbidity and current treatment in patients who present with acute asthma to polyclinics

BACKGROUND

It has been suggested that resources for asthma intervention should be focused mainly on patients in the community who experience a high burden of disease. These are who patients who have acute exacerbations which require urgent treatment.

AIM

To assess the morbidity and identify deficiencies in the treatment of patients who present for urgent treatment of acute exacerbations to primary care clinics.

PATIENTS

Adult patients who received urgent treatment for acute exacerbation of bronchial asthma

SETTING

4 primary care polyclinics.

METHODS

A cross-sectional survey of consecutive patients which related regular preventive treatment to current asthma activity. Poor asthma control was defined as step 2 or higher (American National Asthma Education and Prevention Program, report II, 1997) or > or = 2 emergency room visits in 6 months.

RESULTS

There were 116 patients of whom 53% were women. The mean (SD) age was 45(15) years and duration of current exacerbation 3 (3) days. The acute symptoms were successfully treated in 93% of patients. Quick relief medication was used regularly in 91% and inhaled corticosteroids (ICS) in 55%. Oral salbutamol was prescribed in 14% of patients. The asthma was poorly controlled in 54%. In the poorly controlled group 33% were not on regular ICS treatment and 64% were not receiving "add on" medication.

CONCLUSIONS

Patients treated for acute asthma in primary care clinics: (1) were older and had less acutely severe exacerbations than those who presented to emergency rooms, (2) over half had poorly controlled asthma and (3) a third of patients with poor asthma control were inadequately treated.

A comparison of three methods for measuring thoracic kyphosis: implications for clinical studies

OBJECTIVES

To compare the Cobb technique for measuring kyphosis with an alternative Cobb method and a computer-assisted curve assessment technique, and to examine the influence of vertebral body and disc shape on kyphosis.

METHODS

Kyphosis measurements were derived from 93 lateral spinal radiographs or sagittal computed tomography images of cadaveric spines, using: (i) a computer-assisted method for estimating radius of curvature; (ii) the traditional Cobb method; and (iii) an alternative Cobb method. Regression models were applied for agreement analyses, and to examine the relative contribution of vertebral body and disc shape on the extent of curvature. Results and conclusions. Strong associations existed between curvature and angle data derived from the three methods, confirming the clinical utility of these techniques for the quantification of thoracic kyphosis. However, the traditional Cobb method tended to overestimate kyphosis in the presence of vertebral body end-plate deformation. The degree of kyphosis was strongly reflective of the extent of deformity of the vertebral bodies, and to a lesser extent the shape of the thoracic discs.

Sites on the cytoplasmic region of phospholamban involved in interaction with the calcium-activated ATPase of the sarcoplasmic reticulum

Proton NMR studies have shown that when a peptide corresponding to the N-terminal region of phospholamban, PLB(1-20), interacts with the Ca2+ATPase of the sarcoplasmic reticulum, SERCA1a, docking involves the whole length of the peptide. Phosphorylation of Ser16 reduced the affinity of the peptide for the pump by predominantly affecting the interaction with the C-terminal residues of PLB(1-20). In the phosphorylated peptide weakened interaction occurs with residues at the N-terminus of PLB(1-20). PLB(1-20) is shown to interact with a peptide corresponding to residues 378-405 located in the cytoplasmic region of SERCA2a and related isoforms. This interaction involves the C-terminal regions of both peptides and corresponds to that affected by phosphorylation. The data provide direct structural evidence for complex formation involving residues 1-20 of PLB. They also suggest that phospholamban residues 1-20 straddle separate segments of the cytoplasmic domain of SERCA with the N-terminus of PLB associated with a region other than that corresponding to SERCA2a(378-405).

The relative influence of vertebral body and intervertebral disc shape on thoracic kyphosis

OBJECTIVE

The aim of this study was to quantify the morphology or shape of thoracic vertebral bodies and intervertebral discs, and to examine the ex vivo association of thoracic kyphosis with these shape parameters.

DESIGN

A quantitative, retrospective study design was applied to define vertebral body and disc influences on thoracic kyphosis.

BACKGROUND

Age-related progression of thoracic kyphosis is a well-defined process that is influenced by the morphology of vertebral bodies. However, little is known about the contribution of intervertebral disc shape to the thoracic curvature.

METHODS

Vertebral and disc morphology, as represented by antero-posterior height ratios, were quantified in 93 lateral spine radiographs and midsagittal computed tomography films of ex vivo spines. Kyphosis was indicated by the Cobb angle. Linear and stepwise regression were applied to examine relationships for cumulative (T1-T12) and regional (T4-T9) analyses.

RESULTS

Vertebral morphology was highly predictive of thoracic curvature, while a poorer association was noted for disc morphology. The combined influence of both accounted for >85% of the variability in kyphosis. There was a trend for a more pronounced anterior wedge configuration of the midthoracic vertebral bodies and discs. Higher associations between variables were also noted in this region.

CONCLUSIONS

The normal kyphosis of the thoracic spine reflects the morphological adaptation of both the vertebral bodies and intervertebral discs.

RELEVANCE

This study contributes new data on the thoracic spine, particularly the characteristics of thoracic discs and their contribution to kyphosis genesis. Future directions for morphology studies should encompass more detailed examination of the thoracic discs and greater emphasis on the midthoracic segments, considering the prevalence of osteoporosis related fractures and subsequent deformity at these levels.

Assessment of metered dose inhaler technique in family health service patients in Singapore

OBJECTIVE

To assess the metered-dose inhaler technique in polyclinic patients with chronic lung disease.

METHOD

A cross-sectional study was conducted in three polyclinics. The inhalation technique was assessed in six steps.

RESULTS

Only 7.1% of patients could perform all six steps correctly. Percentage of patients performing each of the following steps correctly were: preparation (89.1%), exhalation (53.8%), lip closure (69.2%), inhalation (57.7%), breath-holding (32.1%) and puff interval (35.4%).

CONCLUSION

This study showed a high incidence of incorrect usage of metered dose inhaler amongst polyclinic patients.

A school and community outbreak of influenza A

In May 1995 a department of public health medicine was informed of an outbreak of respiratory and gastrointestinal illness in a local school. Eighty-three pupils and staff were affected out of a total of 247 people--an attack rate of 34%. The outbreak was investigated, control measures were instigated, and the outbreak subsided. Pupils and staff were surveyed and faecal specimens were collected. Blood specimens from a sample of pupils were examined serologically. No organisms were isolated from faecal specimens. Nine of the 18 blood specimens taken showed raised antibody titres against influenza A. This labour intensive investigation revealed a community outbreak of influenza A. Investigations in schools can be useful in community surveillance.

A framework for commissioning services for people with learning disabilities

The needs of people who have global developmental learning disabilities (mental handicap) are complex and lifelong. Unless social and health service commissioners agree a framework for conceptualizing their need, there is a danger that services could become fragmented. This paper uses the World Health Organization's model of disabilities to put in context these needs. Using this model it is logical for health services to focus on (1) ensuring access to the full range of primary and secondary health services, (2) reducing the occurrence and severity of intellectual and associated impairments and (3) ensuring the provision of assessment and treatment of behaviour disorders and associated mental health problems. Some of these inputs are required before birth and in early childhood, but a number of people will require health services throughout life because of the presence of other disabilities or continuing behaviour and/or mental health problems. At school age, the education authority should provide the lead in ensuring the best physical and social learning environment. All children with learning disabilities will be socially disadvantaged in adulthood unless they are provided with opportunities for social integration, continuing education, skills training, employment and normal living facilities which meet their needs. Although there appears a logical shift in agencies' responsibilities as children with intellectual impairment progress through life, there is considerable diversity within this group and care can only be effectively provided on the basis of a sophisticated assessment of individual need and provision of integrated care.

Dihalocarbene insertions into carbon-hydrogen bonds of hydrocarbons and ethers

Fair to moderate yields of insertion products of dichloro- and dibromo- carbenes can be achieved from aqueous reaction mixtures using the phase transfer method. Insertions are very selective; benzylic, tertiary C-H bonds of hydrocarbons and α-C-H bonds of ethers are particularly reactive. The convenience of this method makes it potentially attractive for certain synthetic applications.