Identifying and prioritising unanswered research questions for people with hyperacusis: James Lind Alliance Hyperacusis Priority Setting Partnership

OBJECTIVE

To determine research priorities in hyperacusis that key stakeholders agree are the most important.

DESIGN/SETTING

A priority setting partnership using two international surveys, and a UK prioritisation workshop, adhering to the six-staged methodology outlined by the James Lind Alliance.

PARTICIPANTS

People with lived experience of hyperacusis, parents/carers, family and friends, educational professionals and healthcare professionals who support and/or treat adults and children who experience hyperacusis, including but not limited to surgeons, audiologists, psychologists and hearing therapists.

METHODS

The priority setting partnership was conducted from August 2017 to July 2018. An international identification survey asked respondents to submit any questions/uncertainties about hyperacusis. Uncertainties were categorised, refined and rephrased into representative indicative questions using thematic analysis techniques. These questions were verified as 'unanswered' through searches of current evidence. A second international survey asked respondents to vote for their top 10 priority questions. A shortlist of questions that represented votes from all stakeholder groups was prioritised into a top 10 at the final prioritisation workshop (UK).

RESULTS

In the identification survey, 312 respondents submitted 2730 uncertainties. Of those uncertainties, 593 were removed as out of scope, and the remaining were refined into 85 indicative questions. None of the indicative questions had already been answered in research. The second survey collected votes from 327 respondents, which resulted in a shortlist of 28 representative questions for the final workshop. Consensus was reached on the top 10 priorities for future research, including identifying causes and underlying mechanisms, effective management and training for healthcare professionals.

CONCLUSIONS

These priorities were identified and shaped by people with lived experience, parents/carers and healthcare professionals, and as such are an essential resource for directing future research in hyperacusis. Researchers and funders should focus on addressing these priorities.

Relative Contributions of Extracellular and Internalized Bacteria to Early Macrophage Proinflammatory Responses to Streptococcus pneumoniae

Both intracellular immune sensing and extracellular innate immune sensing have been implicated in initiating macrophage proinflammatory cytokine responses to Streptococcus pneumoniae The S. pneumoniae capsule, a major virulence determinant, prevents phagocytosis, and we hypothesized that this would reduce activation of host innate inflammatory responses by preventing activation of intracellular proinflammatory signaling pathways. We investigated this hypothesis in human monocyte-derived macrophages stimulated with encapsulated or isogenic unencapsulated mutant S. pneumoniae Unexpectedly, despite strongly inhibiting bacterial internalization, the capsule resulted in enhanced inflammatory cytokine production by macrophages infected with S. pneumoniae Experiments using purified capsule material and a Streptococcus mitis mutant expressing an S. pneumoniae serotype 4 capsule indicated these differences required whole bacteria and were not due to proinflammatory effects of the capsule itself. Transcriptional profiling demonstrated relatively few differences in macrophage gene expression profiles between infections with encapsulated S. pneumoniae and those with unencapsulated S. pneumoniae, largely limited to reduced expression of proinflammatory genes in response to unencapsulated bacteria, predicted to be due to reduced activation of the NF-κB family of transcription factors. Blocking S. pneumoniae internalization using cytochalasin D had minimal effects on the inflammatory response to S. pneumoniae Experiments using murine macrophages indicated that the affected genes were dependent on Toll-like receptor 2 (TLR2) activation, although not through direct stimulation of TLR2 by capsule polysaccharide. Our data demonstrate that the early macrophage proinflammatory response to S. pneumoniae is mainly dependent on extracellular bacteria and reveal an unexpected proinflammatory effect of encapsulated S. pneumoniae that could contribute to disease pathogenesis.IMPORTANCE Multiple extra- and intracellular innate immune receptors have been identified that recognize Streptococcus pneumoniae, but the relative contributions of intra- versus extracellular bacteria to the inflammatory response were unknown. We have shown that intracellular S. pneumoniae contributes surprisingly little to the inflammatory responses, with production of important proinflammatory cytokines largely dependent on extracellular bacteria. Furthermore, although we expected the S. pneumoniae polysaccharide capsule to block activation of the host immune system by reducing bacterial internalization and therefore activation of intracellular innate immune receptors, there was an increased inflammatory response to encapsulated compared to unencapsulated bacteria, which is likely to contribute to disease pathogenesis.

Lung Defense through IL-8 Carries a Cost of Chronic Lung Remodeling and Impaired Function

IL-8-dependent inflammation is a hallmark of host lung innate immunity to bacterial pathogens, yet in many human lung diseases, including chronic obstructive pulmonary disease, bronchiectasis, and pulmonary fibrosis, there are progressive, irreversible, pathological changes associated with elevated levels of IL-8 in the lung. To better understand the duality of IL-8-dependent host immunity to bacterial infection and lung pathology, we expressed human IL-8 transgenically in murine bronchial epithelium, and investigated the impact of overexpression on lung bacterial clearance, host immunity, and lung pathology and function. Persistent IL-8 expression in bronchial epithelium resulted in neutrophilia, neutrophil maturation and activation, and chemotaxis. There was enhanced protection against challenge with Pseudomonas aeruginosa, and significant changes in baseline expression of innate and adaptive immunity transcripts for Ccl5, Tlr6, IL-2, and Tlr1. There was increased expression of Tbet and Foxp3 in response to the Pseudomonas antigen OprF, indicating a regulatory T-cell phenotype. However, this enhanced bacterial immunity came at a high price of progressive lung remodeling, with increased inflammation, mucus hypersecretion, and fibrosis. There was increased expression of Ccl3 and reduced expression of Claudin 18 and F11r, with damage to epithelial organization leading to leaky tight junctions, all of which resulted in impaired lung function with reduced compliance, increased resistance, and bronchial hyperreactivity as measured by whole-body plethysmography. These results show that IL-8 overexpression in the bronchial epithelium benefits lung immunity to bacterial infection, but specifically drives lung damage through persistent inflammation, lung remodeling, and damaged tight junctions, leading to impaired lung function.

Diagnostic and prognostic value of delayed Gadolinium Enhanced Magnetic Resonance Imaging of Cartilage (dGEMRIC) in early osteoarthritis of the hip

BACKGROUND

Delayed Gadolinium Enhanced Magnetic Resonance Imaging of Cartilage (dGEMRIC) can detect glycosaminoglycan loss in the acetabular cartilage of asymptomatic individuals with cam morphology. The aims of this study were to explore the relationship between cam morphology and dGEMRIC values, and to explore whether baseline dGEMRIC can predict the development of radiographic hip osteoarthritis.

METHODS

Prospective cohort (SibKids) study with clinical, radiographic, and MRI assessment at baseline and five-year follow-up (n = 34). The dGEMRIC values of cartilage regions were correlated with measures of cam morphology. Receiver operating characteristic (ROC) analysis was applied to baseline variables to predict radiographic loss of joint space width.

RESULTS

Superolateral acetabular cartilage dGEMRIC values were significantly lower in participants with cam morphology (P < 0.001), defined as an alpha angle greater than 60°. There was a negative correlation between alpha angle and the dGEMRIC value of adjacent acetabular cartilage. This relationship was strongest superoanteriorly (r = -0.697 P < 0.001). There was a positive correlation between baseline dGEMRIC and the magnitude of joint space width narrowing (r = 0.398 P = 0.030). ROC analysis of combined baseline variables (positive impingement test, alpha angle, dGEMRIC ratio) gave an Area Under the Curve (AUC) of 0.75 for predicting joint space width narrowing greater than 0.5 mm within 5 years.

CONCLUSIONS

The size and position of cam morphology determines the severity and location of progressive cartilage damage, supporting the biomechanical aetiology of femoroacetabular impingement. Baseline dGEMRIC is able to predict the development of radiographic osteoarthritis. Compositional MRI offers the potential to identify patients who may benefit from early intervention to prevent the development of osteoarthritis.

TLR-mediated inflammatory responses to Streptococcus pneumoniae are highly dependent on surface expression of bacterial lipoproteins

Streptococcus pneumoniae infections induce inflammatory responses that contribute toward both disease pathogenesis and immunity, but the host–pathogen interactions that mediate these effects are poorly defined. We used the surface lipoprotein-deficient ∆lgt pneumococcal mutant strain to test the hypothesis that lipoproteins are key determinants of TLR-mediated immune responses to S. pneumoniae. We show using reporter assays that TLR2 signaling is dependent on pneumococcal lipoproteins, and that macrophage NF-κB activation and TNF-α release were reduced in response to the ∆lgt strain. Differences in TNF-α responses between Δlgt and wild-type bacteria were abrogated for macrophages from TLR2- but not TLR4-deficient mice. Transcriptional profiling of human macrophages revealed attenuated TLR2-associated responses to ∆lgt S. pneumoniae, comprising many NF-κB–regulated proinflammatory cytokine and chemokine genes. Importantly, non-TLR2–associated responses were preserved. Experiments using leukocytes from IL-1R–associated kinase-4–deficient patients and a mouse pneumonia model confirmed that proinflammatory responses were lipoprotein dependent. Our data suggest that leukocyte responses to bacterial lipoproteins are required for TLR2- and IL-1R–associated kinase-4–mediated inflammatory responses to S. pneumoniae.

Light-curing Time and Aging Effects on the Nanomechanical Properties of Methacrylate- and Silorane-based Restorations

The aim of this study was to assess the influence of light-curing time on the nanohardness (H) and reduced elastic modulus (Er) of components (underlying dentin, hybrid layer, adhesive, and composite) of methacrylate- and silorane-based restorations after 24 hours and six months of storage. Class II slot preparations were carried out in human molars (n=3) and restored with methacrylate (Clearfil SE Bond [Kuraray] + Filtek Z250 [3M ESPE]) or silorane (LS restorative system [3M ESPE]) restorative systems and light-cured using light-emitting diode at 1390 mW/cm2 for the recommended manufacturers' time or double time. Restorations were sectioned, and bonded dentin-resin interfaces were embedded in epoxy resin and polished for evaluation with a Berkovich fluid cell tip (TI 700 Ubi-1 nanoindenter, Hysitron). Data were statistically analyzed by analysis of variance and Tukey's test (alpha=0.05). Overall, the H and Er values were higher for methacrylate-based restorations than for silorane materials (p≤0.05), an increase in curing time did not improve the H and Er of the bonded interface components of either material (p&gt;0.05), and aging significantly decreased the mechanical properties of interface components of both resin-based restorative systems (p≤0.05). In general, nanomechanical properties decreased after six months of storage, the methacrylate restorative system exhibited higher H and Er than silorane, and light-curing time did not influence the properties tested.

Genetic evaluation of crossbred lamb production. 3. Growth and carcass performance of second-cross lambs

This study evaluated the growth and carcass performance of second-cross lambs that were the progeny of common terminal sires and a range of first-cross ewes. The first-cross ewes were the progeny of 91 industry sires from several maternal breeds including the Border Leicester, East Friesian, Finnsheep, Coopworth, White Suffolk, Corriedale, and Booroola Leicester breeds. The first-cross ewes were generated at 3 sites over 3 years, and 3 common maternal sires were used at each site and each year to provide genetic links for combined analysis. The 2726 first-cross ewes were mated naturally to common terminal sires for 3 years at each site to quantify the variation in maternal genetics on the performance of 11 341 second-cross cross lambs. The birthweight, weaning weight (at an average age of 100 days) and post-weaning weight (at an average age of 200 days) of the second-cross lambs were analysed using mixed-model procedures. The lambs were slaughtered (n = 8878) at an average target carcass weight of 22 kg and dressing yield, carcass fat, muscle, meat colour, and meat pH were analysed. Crossbred ewe breed (the maternal grand sire breed) was significant for birthweight (range of 0.9 kg), weaning weight (range 4.4 kg) and post-weaning weight (range 4.6 kg). Type of birth and rearing, age of dam, and sex effects were significant for all liveweights. Ewe breed was significant for hot carcass weight, carcass fat levels, and muscle dimensions, but not for meat colour and ultimate meat pH. There was a significant difference between wether and ewe lamb carcasses for most traits, with other fixed effects generally being small when carcass weight was included as a covariate. Lamb carcasses from East Friesian-cross ewes were very lean compared with carcasses from all other ewe breeds (~2 mm lower fat depth at the GR site at 22 kg carcass weight). This comprehensive study of maternal sire breeds provides an opportunity to exploit between-breed variation for some maternal growth and carcass traits. There was, however, considerable overlap among breeds and opportunities exist for additional improvement by exploiting between-maternal sire genetic variance. The role of improved growth and carcass performance in profitability of prime lamb enterprises is discussed.

Assessment of Iowa farmers' perceptions about auger safety

A survey of Iowa farmers was conducted to assess the farmers' perceptions and beliefs regarding auger safety and how these perceptions are put into practice. A questionnaire was designed to obtain information on the following auger-related topics: recognition of safe practices and appropriate shielding, personal practices and behaviors, risk perception, and personal beliefs. A random sample of 400 Iowa farmers (arrayed by county) was selected to be representative of Iowa farms. The response to the mailed survey was 23%. Some returned surveys were eliminated because the respondent was retired or did not own/operate augers, resulting in 57 usable questionnaires. Survey responses indicate that the majority of Iowa farmers who participated in this study can correctly identify appropriate shielding for auger intake that meet or exceed ASAE standards. Survey responses suggest that it is common practice in Iowa for youth (age 13 to 19) to operate augers. Iowa farmers in this study perceive the most important contributing factors to auger-related injuries to be operating an auger without shielding, failure to pay attention on the job, moving augers in a raised position, and using hand or feet to redirect the flow of grain. Survey results also indicate that carelessness is perceived to be the leading cause of auger-related injuries, and that auger related injuries can be avoided by having respect for the equipment, being careful, and using common sense. The results also show that the Iowa farmers who participated in this study commonly perform auger-related practices (e.g., moving an auger in a raised position) that they identify as being unsafe.

Welcome back, tax and spend?

The Chancellor, Gordon Brown’s promise to give the NHS an extra £1billion next year and his hint that higher taxation is the only way to improve funding of the NHS will have sent a shiver of excitement through sections of the health-care community. For many, it will seem a long-awaited vindication of their decision to vote Labour in 1997. The Government seems to have grasped the nettle of taxation for health which many people have supported for years. It seems that there may soon be a dependable source of funding for the grand ideals outlined in the NHS Plan.

Free nursing care for all - a half-hearted gesture

Since 1st October, changes have been implemented in who pays for nursing care for residents in long-term care in England. The move has been cautiously welcomed by charities working with older residents as a step in the right direction, but many still have reservations about the new system. Chief among them is that the new funding arrangements fall well short of the recommendations of Royal Commission on Long Term Care (RCLTC).

Community nursing research on the up

Community nursing research is not a new discipline, but I think it is true to say that the emergence of primary care at the heart of the health service in recent years has been a tremendous spur to development. A recent symposium in London, organized by the charity International Conferences in Community Health Care Nursing Research, raised a number of key questions, among them ‘what should community nurses research?’, ‘how should they research?’ and ‘how should they share their research?’. Clearly I have a vested interest in the last question – it benefits BJCN (and its readers) to be chosen as a means of disseminating research – but the first two questions produced some useful insights.

Sexual health is no laughing matter

Twenty years after HIV was first identified as the cause of the syndrome now known as AIDS, and despite millions of pounds spent on awareness campaigns and a decade of stability, the UK’s rate of HIV infection has seen a sharp rise. This must be depressing news for people engaged in sexual health education, but it has spurred the government into action. In July the Department of Health published the first National Strategy on Sexual Health and HIV for England. Hopefully the rest of the UK will soon follow suit.

Walk-in centres: not yet on a firm footing

The Kings Fund has recently completed an evaluation of the nine trial NHS walk-in centres in London (Mountford and Rosen, 2001). Although the report highlights a number of problems which will need to be overcome if the scheme is to be rolled out nationally, it seems to provide support for the extension of the nursing role in primary care.

A challenge to the new government: be radical

By the time this journal hits your doorstep, the election will be old news, and the new government will have started enacting whatever transformations in policy they have promised during the election campaign. If, as current predictions indicate, Labour is swept to power with another significant majority, it seems likely that they will have at least another two terms in which to effect their policies. After 18 years of Conservative government, many would once have relished the prospect of a longlived centre-left government. This is no longer the case – despite a commanding lead in the opinion polls, it is hard to find people who do not have a word to say against New Labour.

Making the most of very little

Tuesday 5 June saw the 20th anniversary of the first published account of the disease which would come to be known as HIV/AIDS. The story of its rapid and devastating global spread since then will be familiar to most people. In Britain and much of Western Europe, the disease is no longer the great cause for concern it once was. In the UK there have only been a few tens of thousands of HIV infections, and the panic of the early years of the epidemic has been replaced by complacency, as a result of which infection rates are increasing again after several years of decline. Yet elsewhere the epidemic rages unabated.

Action is required on out-of-hours care

The UK is gripped by election fever at the moment, and all government business has been put on hold until after the election on 7 June. So it is not surprising that an announcement made by the Department of Health on 1 May should have received little coverage outside the nursing press.

There's no alternative to taxation

Primary care nursing is – like the health service as a whole – in a state of flux. As the focus of health care shifts more and more towards the primary sector, changes are being enacted that will eventually lead to the dissolution of traditional professional boundaries. This is intended to encourage the development of fully integrated primary care teams, and more responsive care for all.

Congress shows changing face of palliative care

The 7th congress of the European Association for Palliative Care in Palermo, Sicily offered not only a break from the dismal British weather, but also a snapshot of the current state of palliative care in Europe and beyond. The picture presented was of a healthy, mature and confident discipline, which can encompass professionals from a wide range of backgrounds: medicine, nursing, social care, pastoral care. Over 450 posters and 260 presentations highlighted the diversity of palliative care practice, which perhaps more than any other specialty reflects the prevailing views of society in the country in which it is practised. Nowhere is this more obvious than in the ethics of palliative care.

Health inequalities in the firing line

Health Secretary Alan Milburn has announced plans to aggressively tackle health inequalities in England. Targets to be set by the Department of Health (DoH) will focus on reducing infant mortality and premature adult death in the poorest regions of the country. Much of the responsibility for meeting these targets will inevitably fall on primary care, with nurses in the vanguard.

Violence in the NHS: take precautions

The Government recently announced the latest figures for violent attacks on NHS staff, and there has been a predictable media outcry. NHS trusts have recorded an average 20% increase in violent incidents between 1999 and 2000. Government plans for a 20% reduction in violence towards NHS staff by April 2001 are clearly not going according to plan. Numerous reports in recent years have pointed to an inexorable rise in the frequency and severity of violence towards health-care staff: according to Unison in Scotland, NHS staff there have seen a four-fold increase in violent attacks in the last 4 years. The Department of Health has estimated that there are 65 000 recorded incidents of violence against NHS staff every year. Although ambulance staff are currently being used to highlight these figures to the public, community health trusts bear the brunt of these attacks with twice the number of incidents than acute trusts.

Reality bites on Big Brother

Unlikely as it may have seemed at the beginning, Big Brother ended by highlighting the uncomfortable reality that is healthcare rationing in the UK. Dismissed by the more cynical among us as a game-winning ploy, Craig’s donation of his prize money to provide a heart-and-lung transplant in the US for his best friend’s cousin with Down’s syndrome turned out to be genuine.

The information technology challenge for the NHS

One cannot turn a corner these days without seeing a poster for a new website. Television is awash with dot.com advertisements. One-quarter of UK homes have access to the internet (Office of National Statistics, 2000). We have entered the information technology age. How is the NHS coping with it?

Orthodontic therapists--the current situation

The promise of the U.K. being allowed to use auxiliary help in orthodontics is slowly gaining momentum. At long last, key factors are under discussion, such as permitted duties, length of training, etc. This article describes the present situation and highlights the disappointing rate of progress

Assessment of the condition of Iowa augers, auger-related injuries, and farmers' perceptions about auger-related injuries

This study provides an insight into auger-related injuries, Iowa farmers' perceptions of auger-related injuries and the condition of augers used in Iowa agriculture. Specific auger-related injury data (437 records) from the Iowa Department of Public Health (IDPH) was examined and interpreted. The most likely body part injured was the finger and 11:00 A.M., 3:00 P.M., and 5:00 P.M. were the times of the day with the highest number of injuries reported. In addition, a survey was administered to 400 farmers to ascertain their awareness of auger-related injuries and to determine the condition of their augers. Farmers' perceptions of what body part is most likely to be injured by an auger and the level of severity expected from those injuries coincided with injury records from 1993 to 1997. A total 34% of the primary and secondary augers reported were unshielded or without guarding. This assessment provides insight for development of intervention countermeasures to reduce auger-related injuries.

Tuberculosis: a challenge for community nurses

Tuberculosis (TB), the ‘Great White Plague’ of the 19th century, is reemerging onto the healthcare agenda. Worldwide, TB kills more people than any other infection (World Health Organization, 1994). In the UK, a rapid decline in TB notifications followed the introduction of various public health programmes initiated in the 1940s and 1950s. From the 1960s onwards however, the decline slowed with the immigration to the UK of large numbers of people from TB-endemic areas of the world such as the Indian subcontinent, where TB control programmes had been only partially successful or did not exist.

Patterns of cortisol and adrenaline variation in Australian aboriginal communities of the Kimberley region

Urinary cortisol and adrenaline excretion rates were measured in three Australian Aboriginal communities in the Kimberley region in the north-west of the country. The three communities, Derby, Kalumburu and Kupungarri, differ in size and remoteness and some lifestyle parameters. Cortisol excretion rate is associated with age and urine flow rate, but there is no association with smoking or the consumption of alcohol. All three communities show very high cortisol excretion rates compared to a sample of UK (Oxford) residents and there are also differences between the three communities. Adrenaline excretion rate also shows associations with age and urine flow rate, but not with smoking. Aboriginal people in the Kimberley region excrete adrenaline at a slightly higher rate than that found in Oxford, which itself is high by world standards. There are no marked differences between communities in their adrenaline excretion rates. Alcohol drinkers in Derby, where alcohol is freely available, have higher adrenaline output than non-drinkers.

Some determinants of population variation in cortisol levels in a British urban community

Urinary cortisol excretion rates were determined from three urine samples given over 2 days, a rest day and a working day, by 51 men and 50 women. Each subject also completed a questionnaire relating to life style factors and to perceived levels of stress, busyness and happiness on each day. In men, an association between raised cortisol and high levels of stress was found. In women, high levels of busyness were associated with low cortisol excretion rates. The subjective experiences measured accounted for around 10-20% of cortisol variation in this naturalistic setting.