Pandemic lifeworlds: A segmentation analysis of public responsiveness to official communication about Covid-19 in England

Pandemics such as Covid-19 pose tremendous public health communication challenges in promoting protective behaviours, vaccination, and educating the public about risks. Segmenting audiences based on attitudes and behaviours is a means to increase the precision and potential effectiveness of such communication. The present study reports on such an audience segmentation effort for the population of England, sponsored by the United Kingdom Health Security Agency (UKHSA) and involving a collaboration of market research and academic experts. A cross-sectional online survey was conducted between 4 and 24 January 2022 with 5525 respondents (5178 used in our analyses) in England using market research opt-in panel. An additional 105 telephone interviews were conducted to sample persons without online or smartphone access. Respondents were quota sampled to be demographically representative. The primary analytic technique was k means cluster analysis, supplemented with other techniques including multi-dimensional scaling and use of respondent - as well as sample-standardized data when necessary to address differences in response set for some groups of respondents. Identified segments were profiled against demographic, behavioural self-report, attitudinal, and communication channel variables, with differences by segment tested for statistical significance. Seven segments were identified, including distinctly different groups of persons who tended toward a high level of compliance and several that were relatively low in compliance. The segments were characterized by distinctive patterns of demographics, attitudes, behaviours, trust in information sources, and communication channels preferred. Segments were further validated by comparing the segmentation variable versus a set of demographic variables as predictors of reported protective behaviours in the past two weeks and of vaccine refusal; the demographics together had about one-quarter the effect size of the single seven-level segment variable. With respect to managerial implications, different communication strategies for each segment are suggested for each segment, illustrating advantages of rich segmentation descriptions for understanding public health communication audiences. Strengths and weaknesses of the methods used are discussed, to help guide future efforts.

Application of multidisciplinary team conference for neuromodulation candidates facilitates patient selection and optimization

Introduction

Psychological evaluation is required by insurance companies in the United States prior to proceeding with a spinal cord stimulation or a dorsal root ganglion stimulation trial. Since January 2017, we implemented a Multidisciplinary Team Conference for Neuromodulation in our center to facilitate the collaboration between pain physicians and psychologists and to optimize screening of neuromodulation candidates. This study aims to report the impact of this team conference on improvement of neuromodulation outcome in our center.

Methods

Appropriateness of neuromodulation were discussed in the team conference after initial visit with the pain specialist and psychological evaluation. For this study, we prospectively and retrospectively collected data on neuromodulation candidates who went through the team conference and those who did not as controls.

Results

We discussed 461 patients in the team conference sessions from January 2017 to July 2023. Out of these, a spinal cord stimulator or a dorsal root ganglion stimulator trial was performed in 164 patients with 80.5% (132 cases) trial success rate leading to 140 implants. Out of these implants, 26 (18.6%) explanted and 21 (15%) required revision in 41 (29.3%) patients. We performed neuraxial neuromodulation trial for 70 patients without going through the team conference from January 2016 to July 2023 with a trial success rate of 45.7% (32 cases). In this group, 7 (21.9%) and 6 (18.8%) patients underwent explant and revision. The differences between the groups were statistically significant for trial success rate (odds ratio of 4.9 with p-value of <0.01) but not for explant (odds ratio of 0.8 with p-value of 0.627) or revision (odds ratio of 0.8 with p-value of 0.595).

Conclusion

Implementing Multidisciplinary Team Conference increased trial success rate in our center. Team conference provides therapeutic benefit for patients, and also provides the opportunity for an educational discussion for trainees.

Spherulitic Lead Calcium Apatite Minerals in Lead Water Pipes Exposed to Phosphate-Dosed Tap Water

Phosphate dosing is the principle strategy used in the United Kingdom to reduce the concentration of lead in tap waters supplied by lead water pipes. The mechanisms of phosphate-mediated lead control are not fully understood, but solid solutions of lead calcium apatite are thought to play an important role. This study investigated the microstructure of a lead pipe, supplied with high-alkalinity tap water, in which the lead calcium apatite crystals were spherulitic having rounded and dumb-bell-shaped morphologies. XRD, Fourier transform infrared spectroscopy, optical microscopy, Raman spectroscopy, scanning electron microscopy, and energy-dispersive spectroscopy showed that the lead pipe had a well-established inner layer of litharge; a middle layer containing lead calcium apatite spherulites, plumbonacrite, and some hydrocerussite; and an outer layer containing iron, lead, phosphorus, calcium, silicon, and aluminum. It was found that spherulitic lead calcium apatite could be grown in the laboratory by adding hydrocerussite to synthetic soft and hard water-containing phosphate, chloride, and citrate ions at pH 5.5 but not when the citrate was absent. This suggests that dissolved organic molecules might play a role in spherulite formation on lead water pipes. These molecules might inhibit the formation of lead calcium apatite, reducing the effectiveness of phosphate dosing in lead water pipes.

Comparison of an Antioxidant Source and Antioxidant Plus BCAA on Athletic Performance and Post Exercise Recovery of Horses

Antioxidant supplementation decreases postexercise oxidative stress but could also decrease muscle protein synthesis. This study compared the effects of three diets: low antioxidant (control, CON), high antioxidant (AO), and branched-chain amino acid high antioxidant (BCAO) supplementation on postexercise protein synthesis and oxidative stress. We hypothesized that supplementing antioxidants with branched-chain amino acids(BCAA) would reduce oxidative stress without hindering muscle protein synthesis. Eighteen mixed-breed polo horses (11 mares and 7 geldings, with age range between 5 and 18 years, were on CON diet for 30 days (from day -45 until day 0) and then were assigned to one of the treatments after the first lactate threshold test (day 0, LT). LT were also conducted on days 15 and 30 of supplemenation. Oxidative stress was assessed by measuring blood glutathione peroxidase, superoxide dismutase, and malondialdehyde concentrations before 2 and 4 hours after each LT. Muscle biopsies were taken before and 4 hours after each LT and analyzed for gene expression of protein synthesis by RTqPCR. Data were analyzed by ANOVA and compared by least-square means. A reduction in oxidative stress occurred over time (P < .05), from day 0 to day 30. An up-regulation in the abundance of muscle protein mRNA transcripts was found for CD36, CPT1, PDK4, MYF5, and MYOG (P < .05) after all lactate threshold tests, without a treatment effect. A treatment-by-exercise effect was observed for MYOD1 (P = .0041). Transcript abundance was upregulated in AO samples post exercise compared to other treatments. MYF6 exhibited a time-by-treatment effect (P = .045), where abundance increased more in AO samples from day 0 to day 15 and 30 compared to other treatments. Transcript abundance for metabolic and myogenic genes was upregulated in post exercise muscle samples with no advantage from supplementation of antioxidants with branched-chain amino acids compared to antioxidants alone.

288 EARLY SUPPORTED DISCHARGE AFTER STROKE IN THE COVID-19 PANDEMIC: A CONTAGIOUS SERVICE-DELIVERY MODEL

Background

Early Supported Discharge (ESD) after stroke is an internationally recognised model of best practice for patients with mild to moderate functional deficits after stroke. By end of 2021 there were nine stroke-specific ESD teams in operation in Ireland. This paper outlines the analysis of annual reports submitted by each site to the National Stroke Programme.

Methods

We completed data analysis of the 2020 and 2021 clinical activity of ESD teams, the functional outcomes achieved using the Functional Independence Measure/Functional Assessment Measure (FIM/FAM), and qualitative reporting from patients. Teams were also asked to report on team composition and service developments.

Results

Team composition and size varied, but all had some combination of Occupational Therapy, Physiotherapy, and Speech and Language Therapy. 764 patients received ESD after acute stroke in 2021, representing 24.7% of all patients discharged with stroke in participating sites. Activity increased by 39.9% from 2020 (n = 546), which was in turn an increase of 48% on the 2019 figure (n = 370). Although new sites were added in each year, the increased capacity alone does not account for the growth. All sites reported patient improvement on the extended FIM/FAM. Patient feedback was positive, with many reporting particularly on the benefits of receiving intervention in the home at a time when hospital visiting was restricted. Many sites also reported introducing telehealth to support delivery of ESD.

Conclusion

ESD after stroke continues to grow at pace in Ireland, proving resilient to the pressures of operating in a pandemic. It remains a highly acceptable model to patients, and growth during the pandemic may have been supported by increased capacity, new ways of working, and patients' desire for earlier discharge. Although all teams reported functional improvement among their patients, some sites are achieving greater gains, suggesting that further research into patient selection, treatment intensity and further embedding of telehealth is warranted.

Consensus clustering for Bayesian mixture models

BACKGROUND

Cluster analysis is an integral part of precision medicine and systems biology, used to define groups of patients or biomolecules. Consensus clustering is an ensemble approach that is widely used in these areas, which combines the output from multiple runs of a non-deterministic clustering algorithm. Here we consider the application of consensus clustering to a broad class of heuristic clustering algorithms that can be derived from Bayesian mixture models (and extensions thereof) by adopting an early stopping criterion when performing sampling-based inference for these models. While the resulting approach is non-Bayesian, it inherits the usual benefits of consensus clustering, particularly in terms of computational scalability and providing assessments of clustering stability/robustness.

RESULTS

In simulation studies, we show that our approach can successfully uncover the target clustering structure, while also exploring different plausible clusterings of the data. We show that, when a parallel computation environment is available, our approach offers significant reductions in runtime compared to performing sampling-based Bayesian inference for the underlying model, while retaining many of the practical benefits of the Bayesian approach, such as exploring different numbers of clusters. We propose a heuristic to decide upon ensemble size and the early stopping criterion, and then apply consensus clustering to a clustering algorithm derived from a Bayesian integrative clustering method. We use the resulting approach to perform an integrative analysis of three 'omics datasets for budding yeast and find clusters of co-expressed genes with shared regulatory proteins. We validate these clusters using data external to the analysis.

CONCLUSTIONS

Our approach can be used as a wrapper for essentially any existing sampling-based Bayesian clustering implementation, and enables meaningful clustering analyses to be performed using such implementations, even when computational Bayesian inference is not feasible, e.g. due to poor exploration of the target density (often as a result of increasing numbers of features) or a limited computational budget that does not along sufficient samples to drawn from a single chain. This enables researchers to straightforwardly extend the applicability of existing software to much larger datasets, including implementations of sophisticated models such as those that jointly model multiple datasets.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

British Journal of Surgery Society.

Autoimmunity Is a Significant Feature of Idiopathic Pulmonary Arterial Hypertension

Rationale: Autoimmunity is believed to play a role in idiopathic pulmonary arterial hypertension (IPAH). It is not clear whether this is causative or a bystander of disease and if it carries any prognostic or treatment significance. Objectives: To study autoimmunity in IPAH using a large cross-sectional cohort. Methods: Assessment of the circulating immune cell phenotype was undertaken using flow cytometry, and the profile of serum immunoglobulins was generated using a standardized multiplex array of 19 clinically validated autoantibodies in 473 cases and 946 control subjects. Additional glutathione S-transferase fusion array and ELISA data were used to identify a serum autoantibody to BMPR2 (bone morphogenetic protein receptor type 2). Clustering analyses and clinical correlations were used to determine associations between immunogenicity and clinical outcomes. Measurements and Main Results: Flow cytometric immune profiling demonstrates that IPAH is associated with an altered humoral immune response in addition to raised IgG3. Multiplexed autoantibodies were significantly raised in IPAH, and clustering demonstrated three distinct clusters: "high autoantibody," "low autoantibody," and a small "intermediate" cluster exhibiting high concentrations of ribonucleic protein complex. The high-autoantibody cluster had worse hemodynamics but improved survival. A small subset of patients demonstrated immunoglobulin reactivity to BMPR2. Conclusions: This study establishes aberrant immune regulation and presence of autoantibodies as key features in the profile of a significant proportion of patients with IPAH and is associated with clinical outcomes.

PSVII-13 Effects of corn supplementation on muscle microRNA profiles within horses

The objective of this study was to determine the effect of corn supplementation on muscle microRNA (miRNA) profiles. Twelve mares were blocked by weight and BCS and assigned to one of two treatments (6 hd/treatment): 1) control, (basal diet: 9 Kg/hd/d of chopped mixed grass hay and ad libitum mixed grass hay), 2) basal diet supplemented with 454 g/d steam flaked corn individually using feed bags. All mares were placed on the basal diet and in the same pen 14 days prior to the beginning of corn supplementation. Mares were weighed and BCS on d -7 and 28. Muscle biopsies of the gluteus medius were taken from all horses on d0 and d26. Muscle samples were analyzed using real time RT-qPCR for 277 endogenous miRNAs. Raw CT values were normalized with the geometric mean of three consistently appearing endogenous miRNAs. Sixteen miRNAs that consistently appeared in at least 8 horses including 3 relating to metabolic disorders appearing at d0, d26, or both were analyzed. Differential abundances of miRNAs using log transformed fold change and differences between BW and BCS of treatment groups were determined by ANOVA and LS means analysis. There was no difference between BW (P &lt; .05) and BCS (P &lt; .05) between the two treatment groups. Feeding corn lead to higher quantities (P &lt; .05) of mir 133a, 1515p, 6155p, 770, and 99b within muscle compared to control group. Lower quantities of mir 382 and 433 were found within muscle of horses fed corn compared to the control group (P &lt; .05). Based upon the results of this study corn supplementation appears to influence endogenous miRNA expression profiles within muscle of horses.

Vemurafenib in patients with BRAFV600 mutation-positive metastatic melanoma: final overall survival results of the randomized BRIM-3 study

Background

The BRIM-3 trial showed improved progression-free survival (PFS) and overall survival (OS) for vemurafenib compared with dacarbazine in treatment-naive patients with BRAFV600 mutation-positive metastatic melanoma. We present final OS data from BRIM-3.

Patients and methods

Patients were randomly assigned in a 1 : 1 ratio to receive vemurafenib (960 mg twice daily) or dacarbazine (1000 mg/m2 every 3 weeks). OS and PFS were co-primary end points. OS was assessed in the intention-to-treat population, with and without censoring of data for dacarbazine patients who crossed over to vemurafenib.

Results

Between 4 January 2010 and 16 December 2010, a total of 675 patients were randomized to vemurafenib (n = 337) or dacarbazine (n = 338, of whom 84 crossed over to vemurafenib). At the time of database lock (14 August 2015), median OS, censored at crossover, was significantly longer for vemurafenib than for dacarbazine {13.6 months [95% confidence interval (CI) 12.0-15.4] versus 9.7 months [95% CI 7.9-12.8; hazard ratio (HR) 0.81 [95% CI 0.67-0.98]; P = 0.03}, as was median OS without censoring at crossover [13.6 months (95% CI 12.0-15.4) versus 10.3 months (95% CI 9.1-12.8); HR 0.81 (95% CI 0.68-0.96); P = 0.01]. Kaplan-Meier estimates of OS rates for vemurafenib versus dacarbazine were 56% versus 46%, 30% versus 24%, 21% versus 19% and 17% versus 16% at 1, 2, 3 and 4 years, respectively. Overall, 173 of the 338 patients (51%) in the dacarbazine arm and 175 of the 337 (52%) of those in the vemurafenib arm received subsequent anticancer therapies, most commonly ipilimumab. Safety data were consistent with the primary analysis.

Conclusions

Vemurafenib continues to be associated with improved median OS in the BRIM-3 trial after extended follow-up. OS curves converged after ≈3 years, likely as a result of crossover from dacarbazine to vemurafenib and receipt of subsequent anticancer therapies.

ClinicalTrials.gov

NCT01006980.

Efficacy and safety of collagenase clostridium histolyticum for Dupuytren disease nodules: a randomized controlled trial

Background

To determine the safety and efficacy of collagenase clostridium histolyticum (CCH) injection for the treatment of palmar Dupuytren disease nodules.

Methods

In this 8-week, double-blind trial, palpable palmar nodules on one hand of adults with Dupuytren disease were selected for treatment. Patients were randomly assigned using an interactive web response system to receive a dose of 0.25 mg, 0.40 mg, or 0.60 mg (1:1:1 ratio) and then allocated to active treatment (CCH) or placebo (4:1 ratio). All patients and investigators were blinded to treatment. One injection was made in the selected nodule on Day 1. Caliper measurements of nodule length and width were performed at screening and at Weeks 4 and 8. Investigator-reported nodular consistency and hardness were evaluated at baseline and Weeks 1, 4, and 8. Investigator-rated patient improvement (1 [very much improved] to 7 [very much worse]) and patient satisfaction were assessed at study end.

Results

In the efficacy population (n = 74), percentage changes in area were significantly greater with CCH 0.40 mg (−80.1%, P = 0.0002) and CCH 0.60 mg (−78.2%, P = 0.0003), but not CCH 0.25 mg (−58.3%, P = 0.079), versus placebo (−42.2%) at post-treatment Week 8. Mean change in nodular consistency and hardness were significantly improved with CCH versus placebo at Weeks 4 and 8 (P ≤ 0.0139 for all). At Week 8, investigator global assessment of improvement was significantly greater with CCH 0.40 mg and 0.60 mg (P ≤ 0.0014) but not statistically significant with CCH 0.25 mg versus placebo (P = 0.13). Most patients were “very satisfied” or “quite satisfied” with CCH 0.40 mg and 0.60 mg. Contusion/bruising (50.0% to 59.1%) was the most common adverse event with CCH treatment.

Conclusion

In patients with Dupuytren disease, a single CCH injection significantly improved palmar nodule size and hardness. The safety of CCH was similar to that observed previously in patients with Dupuytren contracture.

Trial registration

ClinicalTrials.gov identifier: NCT02193828. Date of trial registration: July 2, 2014 to December 5, 2014

Using cognitive pre-testing methods in the development of a new evidenced-based pressure ulcer risk assessment instrument

Background

Variation in development methods of Pressure Ulcer Risk Assessment Instruments has led to inconsistent inclusion of risk factors and concerns about content validity. A new evidenced-based Risk Assessment Instrument, the Pressure Ulcer Risk Primary Or Secondary Evaluation Tool - PURPOSE-T was developed as part of a National Institute for Health Research (NIHR) funded Pressure Ulcer Research Programme (PURPOSE: RP-PG-0407-10056). This paper reports the pre-test phase to assess and improve PURPOSE-T acceptability, usability and confirm content validity.

Methods

A descriptive study incorporating cognitive pre-testing methods and integration of service user views was undertaken over 3 cycles comprising PURPOSE-T training, a focus group and one-to-one think-aloud interviews. Clinical nurses from 2 acute and 2 community NHS Trusts, were grouped according to job role. Focus group participants used 3 vignettes to complete PURPOSE-T assessments and then participated in the focus group. Think-aloud participants were interviewed during their completion of PURPOSE-T.

After each pre-test cycle analysis was undertaken and adjustment/improvements made to PURPOSE-T in an iterative process. This incorporated the use of descriptive statistics for data completeness and decision rule compliance and directed content analysis for interview and focus group data. Data were collected April 2012-June 2012.

Results

Thirty-four nurses participated in 3 pre-test cycles. Data from 3 focus groups, 12 think-aloud interviews incorporating 101 PURPOSE-T assessments led to changes to improve instrument content and design, flow and format, decision support and item-specific wording. Acceptability and usability were demonstrated by improved data completion and appropriate risk pathway allocation. The pre-test also confirmed content validity with clinical nurses.

Conclusions

The pre-test was an important step in the development of the preliminary PURPOSE-T and the methods used may have wider instrument development application. PURPOSE-T proposes a new approach to pressure ulcer risk assessment, incorporating a screening stage, the inclusion of skin status to distinguish between those who require primary prevention and those who require secondary prevention/treatment and the use of colour to support pathway allocation and decision making. Further clinical evaluation is planned to assess the reliability and validity of PURPOSE-T and it’s impact on care processes and patient outcomes.

Abnormalities of gait caused by ankle arthritis are improved by ankle arthrodesis

Aims

The surgical management of ankle arthritis with tibiotalar arthrodesis is known to alter gait, as compared with normal ankles. The purpose of this study was to assess post-operative gait function with gait before arthrodesis.

Patients and Methods

We prospectively studied 20 patients who underwent three-dimensional gait analysis before and after tibiotalar arthrodesis. Cadence, step length, walking velocity and total support time were assessed. Kinetic parameters, including the moment and power of the ankle in the sagittal plane and hip power were also recorded.

Results

Significant improvement was recorded across numerous parameters compared with pre-operative measurements. Temporal-spatial data demonstrated a significant increase in step length (p = 0.003) and velocity (p = < 0.001). Total support time decreased for the unaffected limb (p = 0.01). Kinematic results demonstrated that in the affected limb, total sagittal range of movement did not change significantly (p = 0.1259). However, the arc of movement had a near congruent shift with mean maximal dorsiflexion increasing from 5° (-17° to 16°) to 12° (5° to 18°) (p < 0.001) and mean maximal plantarflexion decreasing from 6.8° (6° to 21°) to 0.9° (-9° to 8°) (p = 0.003). Mean hip joint range of movement increased by 6° (-7° to 24°; p = 0.003). Kinetic results demonstrated no statistically significant change in ankle power (p = 0.1292). However, there was an increase in ankle moment (p = 0.04) and hip power (p = 0.01) in the surgically treated extremity. Sagittal plane range of movement was not reduced after tibiotalar fusion.

Conclusion

Although following tibiotalar arthrodesis the gait demonstrated never matched the gait shown in unaffected ankles, compared with the pre-operative analysis there was improvement in numerous temporal-spatial, kinematic, and kinetic measures. Cite this article: Bone Joint J 2016;98-B:1369–75.

The association between varicella (chickenpox) and group A streptococcus infections in historical perspective

OBJECTIVES

The aim of the research is to investigate the historical relationship between varicella and Streptococcus pyogenes infections. In the past few decades, varicella has been identified as a risk factor for invasive group A streptococcus infections. The question is whether this relationship also existed between varicella and scarlet fever in the historical era.

METHODS

The analysis begins with a search of historical medical reports on the relationship between varicella and scarlet fever epidemics in the late 19th and early 20th century, as well as in more recent empirical studies. Correlations and cross-correlations between varicella and scarlet fever are analyzed using weekly public health case reports from 1924 to 1932 for Boston, Chicago, New York City, and Philadelphia. Regression models are used to estimate the relationship between varicella and scarlet fever after controlling for seasonal forcing.

RESULTS

Historical records give limited support for a causal relationship between varicella and scarlet fever but indicate that these diseases often occurred close in time to each other. Likewise, statistical analysis shows that varicella and scarlet fever epidemics are closely aligned with each other, and varicella has a strong relationship with scarlet fever. The relationship is stronger than reported in any previous research on the two diseases.

CONCLUSION

The close correspondence of the two diseases likely depends on multiple factors, including seasonal forcing, a causal relationship, and co-infections. The results raise questions about whether this close relationship might have had a synergistic effect or a role in the evolution of S. pyogenes from the virulent, high incidence epidemics of the 19th century to the relatively benign scarlet fever of the 1950s.

Juries

A quick journey through prevention science (e.g., substance misuse prevention) and a comparison between online and offline risks, harm, and vulnerability in children suggests that new approaches and interventions are needed to promote Internet safety and minimise the new sources of risk associated with accessing the Internet. In this paper we present a new methodological approach to promote digital literacy and positively influence the way in which young people interact with the Internet: iRights Youth Juries. These juries offer a solution for the challenge of how to engage children and young people in activities that, rather than simply promoting Internet safety, aim to provide the knowledge and the confidence required for developing healthy digital citizens. This approach thus begins to move beyond the notion of the Internet as a simple cause of social change, approaching it instead as an opportunity to engage knowledgeably with the digital world and maximise citizenship.

The historical association between measles and pertussis: A case of immune suppression?

Objectives:

According to historical medical reports, many children with measles subsequently contracted pertussis, often with fatal results. The likelihood of a child contracting pertussis after a measles infection is increased by its immune-suppressing effects. This research aims to verify the historical reports.

Methods:

The analysis examines statistically the historical relationship between average measles and pertussis incidence rates in the United States from 1938 to 1954 at the state level and in average weekly rates. Analysis of incidence rates is cross-sectional at the state level using public health data.

Results:

The results show that, on average and over time, states with higher measles rates have higher pertussis rates, and the peaks and nadirs of average weekly incidence rates of pertussis lag measles by a delay of about 3–4 weeks, well within the duration of immune suppression. Measles and pertussis have similar geographical distributions.

Conclusion:

The research tentatively supports the hypothesis that because of its immune-suppressing effects, measles causes an increase in pertussis, but other factors may be involved. Epidemic models should give more attention to the possibility of immune suppression for diseases such as measles where that might be a risk factor. The findings reemphasize the importance of measles vaccination for the prevention of other diseases.

The Efficacy and Safety of Concurrent Collagenase Clostridium Histolyticum Injections for 2 Dupuytren Contractures in the Same Hand: A Prospective, Multicenter Study

PURPOSE

To evaluate efficacy and safety of concurrent administration of 2 collagenase clostridium histolyticum (CCH) injections to treat 2 joints in the same hand with Dupuytren fixed flexion contractures (FFCs).

METHODS

Patients with 2 or more contractures in the same hand caused by palpable cords participated in a 60-day, multicenter, open-label, phase 3b study. Two 0.58 mg CCH doses were injected into 1 or 2 cords in the same hand (1 injection per affected joint) during the same visit. Finger extension was performed approximately 24, 48, or 72 or more hours later. Changes in FFC and range of motion, incidence of clinical success (FFC ≤ 5°), and adverse events (AEs) were summarized.

RESULTS

The study enrolled 715 patients (725 treated joint pairs), and 714 patients (724 joint pairs) were analyzed for efficacy. At day 31, mean total FFC (sum of 2 treated joints) decreased 74%, from 98° to 27°. Mean total range of motion increased from 90° to 156°. The incidence of clinical success was 65% in metacarpophalangeal joints and 29% in proximal interphalangeal joints. Most treatment-related AEs were mild to moderate, resolving without intervention; the most common were swelling of treated extremity, contusion, and pain in extremity. The incidence of skin lacerations was 22% (160 of 715). Efficacy and safety were similar regardless of time to finger extension.

CONCLUSIONS

Collagenase clostridium histolyticum can be used to effectively treat 2 affected joints concurrently without a greater risk of AEs than treatment of a single joint, with the exception of skin laceration. The incidence of clinical success in this study after 1 injection per joint was comparable to phase 3 study results after 3 or more injections per joint. Two concurrent CCH injections may allow more rapid overall treatment of multiple affected joints, and the ability to vary the time between CCH injection and finger extension may allow physicians and patients greater flexibility with scheduling treatment.

Dupuytren Contracture Recurrence Following Treatment With Collagenase Clostridium histolyticum (CORDLESS [Collagenase Option for Reduction of Dupuytren Long-Term Evaluation of Safety Study]): 5-Year Data

PURPOSE

Collagenase Option for Reduction of Dupuytren Long-Term Evaluation of Safety Study was a 5-year noninterventional follow-up study to determine long-term efficacy and safety of collagenase clostridium histolyticum (CCH) treatment for Dupuytren contracture.

METHODS

Patients from previous CCH clinical studies were eligible. Enrolled patients were evaluated annually for contracture and safety at 2, 3, 4, and 5 years after their first injection (0.58 mg) of CCH. In successfully treated joints (≤ 5° contracture following CCH treatment), recurrence was defined as 20° or greater worsening (relative to day 30 after the last injection) with a palpable cord or any medical/surgical intervention to correct new/worsening contracture. A post hoc analysis was also conducted using a less stringent threshold (≥ 30° worsening) for comparison with criteria historically used to assess surgical treatment.

RESULTS

Of 950 eligible patients, 644 enrolled (1,081 treated joints). At year 5, 47% (291 of 623) of successfully treated joints had recurrence (≥ 20° worsening)-39% (178 of 451) of metacarpophalangeal and 66% (113 of 172) of proximal interphalangeal joints. At year 5, 32% (198 of 623) of successfully treated joints had 30° or greater worsening (metacarpophalangeal 26% [119 of 451] and proximal interphalangeal 46% [79 of 172] joints). Of 105 secondary interventions performed in the successfully treated joints, 47% (49 of 105) received fasciectomy, 30% (32 of 105) received additional CCH, and 23% (24 of 105) received other interventions. One mild adverse event was attributed to CCH treatment (skin atrophy [decreased ring finger circumference from thinning of Dupuytren tissue]). Antibodies to clostridial type I and/or II collagenase were found in 93% of patients, but over the 5 years of follow-up, this did not correspond to any reported clinical adverse events.

CONCLUSIONS

Five years after successful CCH treatment, the overall recurrence rate of 47% was comparable with published recurrence rates after surgical treatments, with one reported long-term treatment-related adverse event. Collagenase clostridium histolyticum injection proved to be an effective and safe treatment for Dupuytren contracture. For those receiving treatment during follow-up, both CCH and fasciectomy were elected options.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

A pragmatic randomized controlled trial to evaluate the effectiveness of a facilitated exercise intervention as a treatment for postnatal depression: the PAM-PeRS trial

BACKGROUND

Postnatal depression affects about 10-15% of women in the year after giving birth. Many women and healthcare professionals would like an effective and accessible non-pharmacological treatment for postnatal depression.

METHOD

Women who fulfilled the International Classification of Diseases (ICD)-10 criteria for major depression in the first 6 months postnatally were randomized to receive usual care plus a facilitated exercise intervention or usual care only. The intervention involved two face-to-face consultations and two telephone support calls with a physical activity facilitator over 6 months to support participants to engage in regular exercise. The primary outcome was symptoms of depression using the Edinburgh Postnatal Depression Scale (EPDS) at 6 months post-randomization. Secondary outcomes included EPDS score as a binary variable (recovered and improved) at 6 and 12 months post-randomization.

RESULTS

A total of 146 women were potentially eligible and 94 were randomized. Of these, 34% reported thoughts of self-harming at baseline. After adjusting for baseline EPDS, analyses revealed a -2.04 mean difference in EPDS score, favouring the exercise group [95% confidence interval (CI) -4.11 to 0.03, p = 0.05]. When also adjusting for pre-specified demographic variables the effect was larger and statistically significant (mean difference = -2.26, 95% CI -4.36 to -0.16, p = 0.03). Based on EPDS score a larger proportion of the intervention group was recovered (46.5% v. 23.8%, p = 0.03) compared with usual care at 6 months follow-up.

CONCLUSIONS

This trial shows that an exercise intervention that involved encouragement to exercise and to seek out social support to exercise may be an effective treatment for women with postnatal depression, including those with thoughts of self-harming.

The role of social media in reducing stigma and discrimination

This editorial explores the implications of social media practices whereby people with mental health problems share their experiences in online public spaces and challenge mental health stigma. Social media enable individuals to bring personal experience into the public domain with the potential to affect public attitudes and mainstream media. We draw tentative conclusions regarding the use of social media by campaigning organisations.

The effectiveness of exercise as treatment for vasomotor menopausal symptoms: randomised controlled trial

OBJECTIVE

To investigate the effectiveness of exercise as treatment for vasomotor menopausal symptoms.

DESIGN

Three-group randomised controlled trial, two exercise interventions and a control group.

SETTING

Primary Care, West Midlands UK.

POPULATION

Perimenopausal and postmenopausal women experiencing at least five hot flushes/night sweats per day and not taken MHT in previous 3 months were recruited from 23 general practices.

METHODS

Participants in both exercise interventions groups were offered two face-to-face consultations with a physical activity facilitator to support engagement in regular exercise. In addition, one exercise group received a menopause-specific information DVD and written materials to encourage regular exercise and the other exercise group was offered the opportunity to attend exercise social support groups in their communities. Interventions lasted 6 months.

MAIN OUTCOME MEASURE

The primary outcome was frequency of hot flushes/night sweats at 6-month up.

RESULTS

Two hundred and sixty-one women were randomised (n = 87 per group). Neither of the exercise intervention groups reported significantly less frequent hot flushes/night sweats per week than controls (exercise-DVD versus control: -8.9, 95% CI -20.0 to 2.2; exercise-social support versus control: -5.2, 95% CI -16.7 to 6.3).

CONCLUSIONS

This trial indicates that exercise is not an effective treatment for hot flushes/night sweats. Contrary to current clinical guidance, women should not be advised that exercise will relieve their vasomotor menopausal symptoms.

Efficacy and safety of concurrent collagenase clostridium histolyticum injections for multiple Dupuytren contractures

PURPOSE

To assess the safety and efficacy of 2 concurrent injections of collagenase clostridium histolyticum (CCH) in the same hand to treat multiple Dupuytren flexion contractures.

METHODS

In a multicenter, open-label phase IIIb study, 60 patients received two 0.58-mg CCH doses injected into cords affecting 2 joints in the same hand during 1 visit, followed by finger extension approximately 24 hours later. Efficacy at postinjection day 30 (change in flexion contracture and active range of motion, patient satisfaction, physician-rated improvement, and rates of clinical success [flexion contracture 5° or less]) and adverse events were summarized.

RESULTS

The concurrent injections were most commonly administered in cords affecting metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints on the same finger (47%) or 2 MCP joints on different fingers of the same hand (37%). Mean total (sum of the 2 treated joints) flexion contracture decreased 76%, from 87° to 24° (MCP joints: 86%; PIP joints: 66%). Mean total range of motion increased from 100° to 161°. Clinical success was 76% for MCP joints and 33% for PIP joints. Most patients were very satisfied (60%) or quite satisfied (28%) with treatment. Most investigators rated treated joints as very much improved (55%) or much improved (37%). The most common treatment-related adverse events (> 75% of patients) were contusion, pain in extremity, and edema peripheral (local edema). Most adverse events were mild to moderate in severity. Serious complications included 1 pulley rupture related to study medication and 1 flexor tendon rupture (following conclusion of the study). There were no systemic complications.

CONCLUSIONS

Results suggest that 2 affected joints can be effectively and safely treated with concurrent CCH injections. There was an increased incidence of some adverse events with concurrent treatment (pruritus, lymphadenopathy, blood blister, and skin laceration) compared with treatment of a single joint. High degrees of patient satisfaction and physician-rated improvement were reported.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Genetic structure of introduced populations: 120-year-old DNA footprint of historic introduction in an insular small mammal population

Wildlife populations have been introduced to new areas by people for centuries, but this human-mediated movement can disrupt natural patterns of genetic structure by altering patterns of gene flow. Insular populations are particularly prone to these influences due to limited opportunities for natural dispersal onto islands. Consequently, understanding how genetic patterns develop in island populations is important, particularly given that islands are frequently havens for protected wildlife. We examined the evolutionary origins and extent of genetic structure within the introduced island population of red squirrels (Sciurus vulgaris) on the Channel Island of Jersey using mitochondrial DNA (mtDNA) control region sequence and nuclear microsatellite genotypes. Our findings reveal two different genetic origins and a genetic architecture reflective of the introductions 120 years ago. Genetic structure is marked within the maternally inherited mtDNA, indicating slow dispersal of female squirrels. However, nuclear markers detected only weak genetic structure, indicating substantially greater male dispersal. Data from both mitochondrial and nuclear markers support historic records that squirrels from England were introduced to the west of the island and those from mainland Europe to the east. Although some level of dispersal and introgression across the island between the two introductions is evident, there has not yet been sufficient gene flow to erase this historic genetic "footprint." We also investigated if inbreeding has contributed to high observed levels of disease, but found no association. Genetic footprints of introductions can persist for considerable periods of time and beyond traditional timeframes of wildlife management.

Major element, trace element, nutrient, and radionuclide mobility in a mining by-product-amended soil

This study investigates the use of a mineral processing by-product, neutralized used acid (NUA), primarily composed of gypsum and Fe-oxyhydroxide, as a soil amendment. A 1489-d turf farm field trial assessed nutrient, trace element, and radionuclide mobility of a soil amended with ∼5% by mass to a depth of 15 cm of NUA. Average PO-P fluxes collected as subsoil leachates were 0.7 and 26.6 kg ha yr for NUA-amended and control sites, respectively, equating to a 97% reduction in PO-P loss after 434 kg P ha was applied. Total nitrogen fluxes in NUA-amended soil leachates were similarly reduced by 82%. Incorporation of NUA conferred major changes in leachate geochemistry with a diverse suite of trace elements depleted within NUA-amended leachates. Gypsum dissolution from NUA resulted in an increase from under- to oversaturation of the soil leachates for a range of Fe- and Ca-minerals including calcite and ferrihydrite, many of which have a well-documented ability to assimilate PO-P and trace elements. Isotopic analysis indicated little Pb addition from NUA. Both Sr and Nd isotope results revealed that NUA and added fertilizer became an important source of Ca to leachate and turf biomass. The NUA-amended soils retained a range of U-Th series radionuclides, with little evidence of transfer to soil leachate or turf biomass. Calculated radioactivity dose rates indicate only a small increment due to NUA amendment. With increased nutrient, trace element, and solute retention, and increased productivity, a range of potential agronomic benefits may be conferred by NUA amendment of soils, in addition to the potential to limit offsite nutrient loss and eutrophication.

Multiple concurrent collagenase clostridium histolyticum injections to Dupuytren's cords: an exploratory study

Background

Dupuytren’s contracture (DC) is a progressive fibroproliferative disorder characterized by development of nodules and collagen cords within the palmar fascia of the hand. Collagenase clostridium histolyticum (CCH) is currently approved in adults with DC for the nonsurgical treatment of a single palpable cord during a 30-day treatment cycle. This open-label pilot study was designed to examine the safety, efficacy, and multiple-dose pharmacokinetics of injecting two cords (affected joints) with multiple doses of CCH concurrently into the same hand in subjects with DC and multiple contractures.

Methods

Twelve subjects with DC were enrolled, each with ≥3 contractures caused by palpable cords. Efficacy assessments were taken 30 days after treatment and adverse events (AEs) were recorded throughout. In the first treatment period, all subjects were injected with a single dose of CCH (0.58 mg) into a single cord. The same subjects entered a second treatment period 30 days later, where two different cords (affected joints) were injected concurrently on the same hand. A finger extension procedure was performed 24 hours after each administration of CCH to disrupt the enzymatically weakened cord.

Results

For metacarpophalangeal (MP) joints, mean contracture reduction per joint treated was 29.0 ± 20.7 degrees following single injection vs 30.3 ± 10.9 degrees per treated joint following multiple injections. For proximal interphalangeal (PIP) joints, mean reduction in contracture was 30.7 ± 21.1 and 22.1 ± 4.9 degrees per treated joint, respectively, for the two periods. All patients (100%) were either “quite satisfied” or “very satisfied” following either treatment cycle. The most common treatment-related AEs were edema peripheral, contusion, and pain in the treated extremity; the differences in severity for local effects of the injections were minimal between treatment periods. No serious treatment-related AEs or systemic complications were reported.

Conclusion

These results provide preliminary evidence that two cords (affected joints) can be treated concurrently with CCH with similar efficacy and safety as cords treated individually in a sequential fashion. Multiple concurrent injections would eliminate the 30-day wait between single treatments and allow for rapid and effective treatment of patients with multiple affected joints, a significant advantage for both patient and physician.

Trial registration

Australian New Zealand Clinical Trials Registry #ACTRN12610001045000.

Injectable collagenase Clostridium histolyticum: a new nonsurgical treatment for Dupuytren's disease

PURPOSE

The Collagenase Option for the Reduction of Dupuytren's (CORD) II study investigated the efficacy and safety of injectable Xiaflex (collagenase clostridium histolyticum), in patients with Dupuytren's contracture.

METHODS

This was a prospective, randomized, placebo-controlled trial with 90-day double-blind and 9-month open-label phases. We randomized patients with contractures affecting metacarpophalangeal (MCP) or proximal interphalangeal (PIP) joints 2 to 1 to collagenase (0.58 mg) or placebo. Cords received a maximum of 3 injections. Cord disruption was attempted the day after injection using a standardized finger extension procedure. Primary end point was reduction in contracture to 0° to 5° of normal 30 days after the last injection.

RESULTS

We enrolled 66 patients; 45 cords (20 MCP to 25 PIP joints) received collagenase and 21 cords (11 MCP to 10 PIP joints) received placebo in the double-blind phase. Statistically significantly more cords injected with collagenase than placebo met the primary end point (44.4% vs 4.8%; p <. 001). The mean percentage decrease in degree of joint contracture from baseline to 30 days after last injection was 70.5% ± 29.2% in the collagenase group and 13.6% ± 26.1% in the placebo group (p < .001). The mean increase in range of motion was significantly greater in the collagenase (35.4° ± 17.8°) than in the placebo (7.6° ± 14.9°; p < .001) group. Efficacy after open-label treatment was similar to that after the double-blind phase: 50.7% of all joints achieved 0° to 5° of normal. More patients were satisfied with collagenase (p < .001). No joint had recurrence of contracture. One patient had a flexion pulley rupture and one patient underwent routine fasciectomy to address cord proliferation and sensory abnormality. No tendon ruptures or systemic allergic reactions were reported. Most adverse events were related to the injection or finger extension procedure.

CONCLUSIONS

Collagenase clostridium histolyticum is the first Food and Drug Administration-approved, nonsurgical treatment option for adult Dupuytren's contracture patients with a palpable cord that is highly effective and well tolerated.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Incorporating independent component analysis to Q-ball imaging for diffusion orientation distribution reconstruction

In this paper, we investigate the incorporation of independent component analysis (ICA) with Q-ball imaging (QBI) to extract information on the diffusion orientation distribution function (ODF) from an inner voxel. In our approach, the ICA algorithm is applied to a mixture of ODFs which are constructed based on the analytical QBI solution. The numerical simulation results demonstrate that the proposed ICA framework can not only successfully separate the diffusion ODF from the noisy diffusion data, but also achieves better performance compared with a QBI solution when the data has a low signal to noise ratio (SNR).

Navigational predictors in determining the necessity for collateral ligament release in total knee replacement

The requirement for release of collateral ligaments to achieve a stable, balanced total knee replacement has been reported to arise in about 50% to 100% of procedures. This wide range reflects a lack of standardised quantitative indicators to determine the necessity for a release. Using recent advances in computerised navigation, we describe two navigational predictors which provide quantitative measures that can be used to identify the need for release. The first was the ability to restore the mechanical axis before any bone resection was performed and the second was the discrepancy in the measured medial and lateral joint spaces after the tibial osteotomy, but before any femoral resection.

These predictors showed a significant association with the need for collateral ligament release (p < 0.001). The first predictor using the knee stress test in extension showed a sensitivity of 100% and a specificity of 98% and the second, the difference between medial and lateral gaps in millimetres, a sensitivity of 83% and a specificity of 95%. The use of the two navigational predictors meant that only ten of the 93 patients required collateral ligament release to achieve a stable, neutral knee.