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The COG-UK hospital-onset COVID-19 infection (HOCI) trial evaluated the impact of SARS-CoV-2 whole-genome sequencing (WGS) on acute infection, prevention, and control (IPC) investigation of nosocomial transmission within hospitals. To estimate the cost implications of using the information from the sequencing reporting tool (SRT), used to determine likelihood of nosocomial infection in IPC practice. A micro-costing approach for SARS-CoV-2 WGS was conducted. Data on IPC management resource use and costs were collected from interviews with IPC teams from 14 participating sites and used to assign cost estimates for IPC activities as collected in the trial. Activities included IPC-specific actions following a suspicion of healthcare-associated infection (HAI) or outbreak, as well as changes to practice following the return of data via SRT. The mean per-sample costs of SARS-CoV-2 sequencing were estimated at £77.10 for rapid and £66.94 for longer turnaround phases. Over the three-month interventional phases, the total management costs of IPC-defined HAIs and outbreak events across the sites were estimated at £225,070 and £416,447, respectively. The main cost drivers were bed-days lost due to ward closures because of outbreaks, followed by outbreak meetings and bed-days lost due to cohorting contacts. Actioning SRTs, the cost of HAIs increased by £5,178 due to unidentified cases and the cost of outbreaks decreased by £11,246 as SRTs excluded hospital outbreaks. Although SARS-CoV-2 WGS adds to the total IPC management cost, additional information provided could balance out the additional cost, depending on identified design improvements and effective deployment. [ABSTRACT FROM AUTHOR]

Background: Barriers to rapid return of sequencing results can affect the utility of sequence data for infection prevention and control decisions.Aim: To undertake a mixed-methods analysis to identify challenges that sites faced in achieving a rapid turnaround time (TAT) in the COVID-19 Genomics UK Hospital-Onset COVID-19 Infection (COG-UK HOCI) study.Methods: For the quantitative analysis, timepoints relating to different stages of the sequencing process were extracted from both the COG-UK HOCI study dataset and surveys of study sites. Qualitative data relating to the barriers and facilitators to achieving rapid TATs were included from thematic analysis.Findings: The overall TAT, from sample collection to receipt of sequence report by infection control teams, varied between sites (median 5.1 days, range 3.0-29.0 days). Most variation was seen between reporting of a positive COVID-19 polymerase chain reaction (PCR) result to sequence report generation (median 4.0 days, range 2.3-27.0 days). On deeper analysis, most of this variability was accounted for by differences in the delay between the COVID-19 PCR result and arrival of the sample at the sequencing laboratory (median 20.8 h, range 16.0-88.7 h). Qualitative analyses suggest that closer proximity of sequencing laboratories to diagnostic laboratories, increased staff flexibility and regular transport times facilitated a shorter TAT.Conclusion: Integration of pathogen sequencing into diagnostic laboratories may help to improve sequencing TAT to allow sequence data to be of tangible value to infection control practice. Adding a quality control step upstream to increase capacity further down the workflow may also optimize TAT if lower quality samples are removed at an earlier stage. [ABSTRACT FROM AUTHOR]

COVID-19 has accelerated a reliance on virtual technology for the delivery of postgraduate surgical education. We sought to develop a regional teaching programme with robust quality assurance. Webinars were delivered on a weekly basis by subspecialty experts using Zoom™ augmented with interactive polling software. Trainee feedback comprised Likert item rating on content and delivery, free text comments and self-assessed confidence levels using visual analogue scale (VAS) scores. A focus group was also convened and transcripts assessed with grounded theory analysis. Likert items revealed 442 (93.2%) positive responses regarding content and 642 (96.7%) positive responses regarding trainer delivery. There were statistically significant improvements in VAS scores across all programme content. Key themes from the focus group analysis were the pragmatics of delivering online education, issues surrounding trainer interactivity in the virtual world, the identification of the FRCS as a driving factor and a desire for case-based content and pre-learning of information (the 'flipped classroom'). We are continuing to be reactive to trainee feedback in developing our online learning programme which will also include a regional Moodle-based virtual learning environment (VLE), the subject of future educational research in our region. [ABSTRACT FROM AUTHOR]

Education and training strategies in Therapeutic Radiography are challenged in recruiting and retaining students in the profession. Clinical oncology centres are often viewed as stressful environments for students due to rapid advances in technology and reported bullying and harassment. Educators continue to work with clinical partners in developing strategies to promote resilience and reduce negative attitudes. The overall aim of this project was to explore the use of Triple R sessions as a new method of student reflection. The Review, Reflect and Re-focus (Triple R) sessions were designed to enable students to learn from their clinical experiences and; apply their understanding and positivity when they return to clinical placement. Eleven sessions were completed across 7 student cohorts in one academic year. Qualitative data was collected from feedback forms, as well as academic field notes, and analysed thematically. Two main themes focused on: (1) staff interactions and (2) student expectations. Results showed that Triple R sessions were helpful in drawing out the experiences of students in a positive way to reflect on their own development. The sessions enabled critical self-analysis and improved problem-solving skills, particularly evident during peer discussions. Triple R sessions explored the influence of a positive approach on students' perceptions of their overall placement. Evaluation of the data indicated that, following academic and peer discussion, students' perceptions tended to be a more positive overall view of their placement. Triple R sessions can be used in academic and clinical environments to enable positive student interactions. [ABSTRACT FROM AUTHOR]

Highlights • Minor, acute wounds are often left untreated resulting in a dry wound environment and crust formation. • Novel wound healing ointment supports rapid re-epithelization of acute wounds. • Novel wound healing ointment promotes accelerated improved wound healing. • Acute, superficial wounds benefit from moist wound healing conditions. Abstract Objective Moist wound healing conditions are beneficial in a professional wound care setting as well as for self-treatment of acute, superficial wounds. The purpose of this randomized, controlled, investigator-blinded investigation was to determine the local tolerability, wound healing efficacy and cosmetic outcome of a novel wound healing ointment in an intra-individual comparison of 4 treatment regimens in an abrasive wound model. Methods Standardized abrasive wounds were induced on the inner forearms of 30 healthy subjects and 4 treatment regimens were randomly allocated to test areas (wound healing ointment covered with standard first aid dressing, wound healing ointment covered with gauze, standard first aid dressing alone, untreated area covered with gauze). Wounds were treated once daily for 11 days. Local tolerability and wound healing were assessed using visual scoring and digital photography on 5 different days. The cosmetic outcome was evaluated on a follow-up visit on Day 31. Results The wound healing ointment exhibited excellent local tolerability with superior assessments in comparison to treatment utilizing only dressings without ointment. Significant differences between AUC values for re-epithelization and overall wound healing efficacy were demonstrated in favor of treatment with the wound healing ointment in comparison to dry wound healing conditions. Wounds treated with the wound healing ointment showed a faster onset of healing and the cosmetic outcome was rated as being superior for the wound healing ointment both by the investigator and the subject. Conclusion Superficial cutaneous wounds treated with the novel wound healing ointment displayed a significant improvement of wound healing with an earlier onset of re-epithelization, faster wound closure and a better cosmetic outcome. Clinically relevant accelerated wound healing compared to traditional dry healing could be shown demonstrating the benefits of moist wound healing conditions also in the treatment of minor, superficial wounds (Clinical trial identification number: EUDAMED_CIV 17-04-019364). [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Ophthalmology is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Measures of patient-reported quality of life (QoL) are increasingly being used to tailor services that are funded by Clinical Commissioning Groups (CCG) in England. Mandibular osteotomies may result in altered sensation of the lower lip, but we know of limited evidence about the resulting effect on QoL. The modified Bristol orthognathic patient outcomes questionnaire was given to patients who had mandibular osteotomies at the Queen Elizabeth Hospital, Birmingham, between March 2006 and April 2016. Questionnaires were collected at the final orthognathic postoperative appointment. The significance of the difference in QoL between those who had altered sensation of the lower lip and those who did not was compared using a two-tailed t test. During this period 170 patients had mandibular orthognathic operations. Completed questionnaires were received from 117 of those patients (69%) during this period, after a follow up of about six months. We found no significant difference between the perceived benefits of treatment between the 41 who had altered sensation and the 74 who did not (p = 0.30). Only 5/41 who reported residual numbness six months postoperatively stated that they would not choose to have the same treatment again. In conclusion, orthognathic surgery results in an appreciable improvement in QoL and should continue to be funded by CCG in England. Contrary to the perception of some clinicians, those patients with residual numbness of the lip did not have significantly poorer QoL. Future interpretation of the data will be improved if they are collected both before and after the operation. [ABSTRACT FROM AUTHOR]

Previous studies have compared the outcomes after open and endoscopic excision of an os trigonum in patients of mixed professions. No studies have compared the differences in outcomes between the 2 procedures in elite ballet dancers. From October 2005 to February 2010, 35 professional ballet dancers underwent excision of a symptomatic os trigonum of the ankle after a failed period of nonoperative treatment. Of the 35 patients, 13 (37.1%) underwent endoscopic excision and 22 (62.9%) open excision. We compared the outcomes, complications, and time to return to dancing. The open excision group experienced a significantly greater incidence of flexor hallucis longus tendon decompression compared with the endoscopic group. The endoscopic release group returned to full dance earlier at a mean of 9.8 (range 6.5 to 16.1) weeks and those undergoing open excision returned to full dance at a mean of 14.9 (range 9 to 20) weeks ( p = .001). No major complications developed in either group, such as deep infection or nerve or vessel injury. We have concluded that both techniques are safe and effective in the treatment of symptomatic os trigonum in professional ballet dancers. Endoscopic excision of the os trigonum offers a more rapid return to full dance compared with open excision. [ABSTRACT FROM AUTHOR]

The Lawrence Berkeley National Laboratory Population Impact Assessment Modeling Framework (PIAMF) was expanded to enable determination of indoor PM 2.5 concentrations and exposures in a set of 50,000 homes representing the US housing stock. A mass-balance model is used to calculate time-dependent pollutant concentrations within each home. The model includes size- and species-dependent removal mechanisms. The particle model was applied to the housing samples of the Relationship of Indoor, Outdoor, and Personal Air (RIOPA) and The Detroit Exposure and Aerosol Research Study (DEARS) studies to compare model- and measurement-based estimates of indoor PM 2.5 of outdoor origin. Model-derived distributions of infiltration factors (ratio of indoor PM 2.5 of outdoor origin to outdoor PM 2.5 ) are compared to measurement-based distributions obtained in studies conducted in 11 US cities. [ABSTRACT FROM AUTHOR]

Anthropogenic underwater noise is now recognized as a world-wide problem, and recent studies have shown a broad range of negative effects in a variety of taxa. Underwater noise from shipping is increasingly recognized as a significant and pervasive pollutant with the potential to impact marine ecosystems on a global scale. We reviewed six regional case studies as examples of recent research and management activities relating to ocean noise in a variety of taxonomic groups, locations, and approaches. However, as no six projects could ever cover all taxa, sites and noise sources, a brief bibliometric analysis places these case studies into the broader historical and topical context of the peer-reviewed ocean noise literature as a whole. The case studies highlighted emerging knowledge of impacts, including the ways that non-injurious effects can still accumulate at the population level, and detailed approaches to guide ocean noise management. They build a compelling case that a number of anthropogenic noise types can affect a variety of marine taxa. Meanwhile, the bibliometric analyses revealed an increasing diversity of ocean noise topics covered and journal outlets since the 1940s. This could be seen in terms of both the expansion of the literature from more physical interests to ecological impacts of noise, management and policy, and consideration of a widening range of taxa. However, if our scientific knowledge base is ever to get ahead of the curve of rapid industrialization of the ocean, we are going to have to identify naïve populations and relatively pristine seas, and construct mechanistic models, so that we can predict impacts before they occur, and guide effective mitigation for the most vulnerable populations. [ABSTRACT FROM AUTHOR]

Milk samples from individual cows producing small (148-155 nm) or large (177-222 nm) casein micelles were selected to investigate the relationship between the individual casein proteins, specifically κ- and β-casein phenotypes, and casein micelle size. Only κ-casein AA and β-casein A¹A¹, A¹A² and A²A² phenotypes were found in the large casein micelle group. Among the small micelle group, both κ-casein and β-casein phenotypes were more diverse. κ-Casein AB was the dominant phenotype, and 3 combinations (AA, AB, and BB) were present in the small casein micelle group. A considerable mix of β-casein phenotypes was found, including B and I variants, which were only found in the small casein micelle group. The relative amount of κ-casein to total casein was significantly higher in the small micelle group, and the nonglycosylated and glycosylated κ-casein contents were higher in the milks with small casein micelles (primarily with κ-casein AB and BB variants) compared with the large micelle group. The ratio of glycosylated to nonglycosylated κ-casein was higher in the milks with small casein micelles compared with the milks with large casein micelles. This suggests that although the amount of κ-casein (both glycosylated and nonglycosylated) is associated with micelle size, an increased proportion of glycosylated κ-casein could be a more important and favorable factor for small micelle size. This suggests that the increased spatial requirement due to addition of the glycosyl group with increasing extent of glycosylation of κ-casein is one mechanism that controls casein micelle assembly and growth. In addition, increased electrostatic repulsion due to the sialyl residues on the glycosyl group could be a contributory factor. [ABSTRACT FROM AUTHOR]

The clinic-specific public reporting of assisted reproductive technology (ART) outcomes has been mandated by Federal law since 1992. As of late, a series of scientific and medical advances have all but deconstructed ART practice patterns thereby demanding that current reporting platforms be reevaluated for their continued ability to afford the public with credible and understandable estimates of conception per initiated cycle. In this Clinical Opinion , we trace the history of the public reporting of ART, describe the recently modified (present day) reporting platform, and explore potential future improvements thereof. [ABSTRACT FROM AUTHOR]

P047 - Real-world study on HR+, HER2-, node-positive, high-risk early breast cancer (EBC) in France: patient profiles, management and treatment patterns. [Extracted from the article]

Summary: Background and aims: The initial disturbance of insulin resistance seems to focus on adipose tissue is a dynamic organ involved in many physiological and metabolic processes. Expresses and secretes a variety of active peptides, adipocytokines. To evaluate the prevalence of insulin-resistance in an healthy urban middle age population and to explore the role of adiponectin, inflammatory biomarkers (hs-CRP) and traditional cardiovascular risk factors as predictors of the insulin-resistance state. Materials and methods: We studied of 176 participants (117 women and 59 men, 25–74 years), individuals with diabetes, hypothyroidism or hyperthyroidism, infectious disease, renal, or hepatic neoplasms and pregnant women were excluded. We evaluated glucose, insulin, adiponectin and hs-CRP. Results: We found that 17.2% of individuals presented insulin-resistance. Correlation was found between waist circumference, body mass index, blood pressure and HOMA index (p <0.01). Adiponectin was associated with the insulin-resistance (p <0.001) but not hs-CRP. Adiponectin (β =0.385, p =0.004) and waist circumference (β =0.116, p =0.02) were predictors of IR only in women, meanwhile none of the analyzed biomarkers predicted insulin-resistance in men. Besides, postmenopausal women presented higher adiponectin levels than premenopausal 7.63 (4.46–9.58) vs 5.50 (3.83–7.40) μg/ml, p =0.01. Conclusions: Adiponectin and waist circumference are important predictors of insulin-resistance even in healthy non-diabetic women, they may open a new opportunity to improve current risk estimation. [Copyright &y& Elsevier]

Summary: Objective: To correlate meniscal T2* relaxation times using ultra-short echo time (UTE) magnetic resonance imaging (MRI) with quantitative microscopic methods, and to determine the effect of meniscal repair on post-operative cartilage T2 values. Design: A medial meniscal tear was created and repaired in the anterior horn of one limb of 28 crossbred mature ewes. MR scans for morphological evaluation, meniscal T2* values, and cartilage T2 values were acquired at 0, 4 and 8 months post-operatively for the Tear and Non-Op limb. Samples of menisci from both limbs were analyzed using multiphoton microscopy (MPM) analysis and biomechanical testing. Results: Significantly prolonged meniscal T2* values were found in repaired limbs than in control limbs, P < 0.0001. No regional differences of T2* were detected for either the repaired or control limbs in the anterior horn. Repaired limbs had prolonged cartilage T2 values, primarily anteriorly, and tended to have lower biomechanical force to failure at 8 months than Non-Op limbs. MPM autofluorescence and second harmonic generation data correlated with T2* values at 8 months (ρ = −0.48, P = 0.06). Conclusions: T2* mapping is sensitive to detecting temporal and zonal differences of meniscal structure and composition. Meniscal MPM and cartilage T2 values indicate changes in tissue integrity in the presence of meniscal repair. [Copyright &y& Elsevier]

During the past two decades, research on ceramic scaffolds for bone regeneration has progressed rapidly; however, currently available porous scaffolds remain unsuitable for load-bearing applications. The key to success is to apply microstructural design strategies to develop ceramic scaffolds with mechanical properties approaching those of bone. Here we report on the development of a unique microstructurally designed ceramic scaffold, strontium–hardystonite–gahnite (Sr–HT–gahnite), with 85% porosity, 500μm pore size, a competitive compressive strength of 4.1±0.3MPa and a compressive modulus of 170±20MPa. The in vitro biocompatibility of the scaffolds was studied using primary human bone-derived cells. The ability of Sr–HT–gahnite scaffolds to repair critical-sized bone defects was also investigated in a rabbit radius under normal load, with β-tricalcium phosphate/hydroxyapatite scaffolds used in the control group. Studies with primary human osteoblast cultures confirmed the bioactivity of these scaffolds, and regeneration of rabbit radial critical defects demonstrated that this material induces new bone defect bridging, with clear evidence of regeneration of original radial architecture and bone marrow environment. [ABSTRACT FROM AUTHOR]

Abstract: This is the first reported study to prepare highly porous baghdadite (Ca3ZrSi2O9) scaffolds with and without surface modification and investigate their ability to repair critical-sized bone defects in a rabbit radius under normal load. The modification was carried out to improve the mechanical properties of the baghdadite scaffolds (particularly to address their brittleness) by coating their surfaces with a thin layer (∼400nm) of polycaprolactone (PCL)/bioactive glass nanoparticles (nBGs). The β-tricalcium phosphate/hydroxyapatite (TCP/HA) scaffolds with and without modification were used as the control groups. All of the tested scaffolds had an open and interconnected porous structure with a porosity of ∼85% and average pore size of 500μm. The scaffolds (six per scaffold type and size of 4mm×4mm×15mm) were implanted (press-fit) into the rabbit radial segmental defects for 12weeks. Micro-computed tomography and histological evaluations were used to determine bone ingrowth, bone quality, and implant integration after 12weeks of healing. Extensive new bone formation with complete bridging of the radial defect was evident with the baghdadite scaffolds (modified/unmodified) at the periphery and in close proximity to the ceramics within the pores, in contrast to TCP/HA scaffolds (modified/unmodified), where bone tended to grow between the ulna adjacent to the implant edge. Although the modification of the baghdadite scaffolds significantly improved their mechanical properties, it did not show any significant effect on in vivo bone formation. Our findings suggest that baghdadite scaffolds with and without modification can serve as a potential material to repair critical sized bone defects. [Copyright &y& Elsevier]

Background: Mental stress-induced myocardial ischemia (MSIMI) is common in patients with clinically stable coronary heart disease (CHD) and is associated with poor outcomes. Depression is a risk factor of MSIMI. The REMIT trial investigates whether selective serotonin reuptake inhibitor (SSRI) treatment can improve MSIMI. The rationale and outline of the study are described.Method: In this single-center randomized clinical trial, adult patients with clinically stable CHD are recruited for baseline mental and exercise stress testing assessed by echocardiography. In addition, psychometric questionnaires are administered, and blood samples are collected for platelet activity analysis. Patients who demonstrate MSIMI, defined by new abnormal wall motion, ejection fraction reduction ≥8%, and/or development of ischemic ST change in electrocardiogram during mental stress testing, are randomized at a 1:1 ratio to escitalopram or placebo for 6 weeks. Approximately 120 patients with MSIMI are enrolled in the trial. The stress testing, platelet activity assessment, and psychometric questionnaires are repeated at the end of the 6-week intervention. The hypothesis of the study is that SSRI treatment improves MSIMI via mood regulation and modification of platelet activity.Conclusion: The REMIT study examines the effect of SSRI on MSIMI in vulnerable patients with CHD and probes some potential underlying mechanisms. [ABSTRACT FROM AUTHOR]

Acute coronary syndrome (ACS) affects many aspects of female and male survivors' lives. This prospective longitudinal study explored gender differences in 100 patients hospitalized with ACS and 1 month follow-up. There were no significant differences in depressive symptoms (DS) by gender. However, significantly more females than males had a history of depression and reported being prescribed and taking antidepressants. Considering that 18 nonrespondents had higher DS at Time 1 than the did the others, DS at Time 2 could have been higher given that patients who are depressed tended not to respond at Time 2. Therefore, health care providers need to pay more attention to DS in ACS survivors, especially women whose early recovery experience might be different from men. ©2010 Elsevier Inc. All rights reserved.Copyright © 2010 by Elsevier Inc. [ABSTRACT FROM AUTHOR]

Abstract: Lithium is the ‘gold standard’ of the many drug treatments used in bipolar disorder. It has efficacy in the treatment of mania, prophylaxis against manic relapses, and, to a lesser extent, prophylaxis against depressive relapses. It decreases suicidal risk. Blood monitoring of lithium is essential. In addition to side effects, problems include rebound mania on abrupt cessation of lithium and teratogenetic risks. Carbamazepine, valproate, and lamotrigine are anticonvulsants with an evidence base in bipolar disorder. Carbamazepine is anti-manic, but is poorly tolerated and associated with many pharmacokinetic interactions. Valproate is also anti-manic and is prophylactic, especially against mania, but its antidepressant effects in bipolar disorder are unclear. It is associated with many problems when used during pregnancy, and should be avoided in women of childbearing potential. Lamotrigine is not licensed for use in bipolar disorder in the UK, but has some evidence for effectiveness in bipolar depression and, more particularly, prophylaxis against depressive relapse. It must be introduced slowly to avoid dangerous skin reactions. Other anticonvulsants have no evidence supporting their use. Antipsychotics, including the atypicals, are effective in treating mania. Olanzapine and aripiprazole are also licensed for continuation treatment in acute responders. Quetiapine has evidence for effectiveness in both bipolar mania and bipolar depression. The efficacy of antidepressants in bipolar disorder is unclear. Tricyclic antidepressants and mono-amine oxidase inhibitors should probably be avoided, owing to a possible risk of switching to mania. In general, antidepressants should be used in conjunction with a mood stabilizer and for the shortest period necessary. [Copyright &y& Elsevier]

Abstract: Unipolar affective disorder, or depression, is the one of the leading causes of disability worldwide and its effective management is a high priority. Treatment is required whether or not the illness is seen as ‘reactive’ to circumstances or understandable. Guidelines for its management have been produced by the National Institute for Health and Clinical Excellence (NICE) and the British Association for Psychopharmacology (BAP). These recommend rating the severity of the illness and using this as a guide for treatment. For less severe depression, antidepressants are recommended only when a patient fails to respond to other interventions or there is a history of more severe depression. For moderate-to-severe depression, antidepressants such as citalopram or fluoxetine are recommended as first-line treatments. The management of treatment-resistant depression (failure to respond to two adequate courses of antidepressants) is complex. NICE includes recommendations to consider augmentation of an antidepressant with cognitive behavioural therapy or lithium, monotherapy with venlafaxine or phenelzine (the latter particularly for atypical depression), and the combination of mirtazapine plus a selective serotonin reuptake inhibitor. BAP guidelines also include consideration of atypical antipsychotic or tri-iodothyronine augmentation of antidepressants. Other strategies have limited data supporting them and are not recommended, or are for use only in specialist centres. [Copyright &y& Elsevier]

During the manufacture of skim milk powder, many important alterations to the casein micelles occur. This study investigates the nature and cause of these alterations and their reversibility upon reconstitution of the powders in water. Samples of skim milk and powder were taken at different stages of commercial production of low-, medium-, and high-heat powders. The nature and composition of the casein micelles were analyzed using a variety of analytical techniques including photon correlation spectroscopy, transmission electron microscopy, turbidity, and protein electrophoresis. It was found that during heat treatment, whey proteins are denatured and become attached to the casein micelles, resulting in larger micelles and more turbid milk. The extent of whey protein attachment to the micelles is directly related to the severity of the heat treatment. It also appeared that whey proteins denatured during heat treatment may continue to attach to casein micelles during water removal (evaporation and spray-drying). The process of water removal causes casein and Ca in the serum to become increasingly associated with the micelles. This results in much larger, denser micelles, increasing the turbidity while decreasing the viscosity of the milk. During reconstitution, the native equilibrium between colloidal Ca and serum Ca is slowly reestablished. The reequilibration of the caseins and detachment of the whey proteins occur even more slowly. The rate of reequilibration does not appear to be influenced by shear or temperature in the range of 4 to 40°C. [ABSTRACT FROM AUTHOR]

Abstract: Many drug treatments are used in bipolar disorder. Lithium is the gold standard. It has efficacy in the treatment of mania, prophylaxis against manic relapses, and to a lesser extent prophylaxis against depressive relapses. It has been shown to decrease suicidal risk. Therapeutic blood monitoring of lithium is necessary. In addition to side effects, problems include rebound mania on abrupt secession of lithium, and teratogenetic risks. Carbamazepine, valproate and lamotrigine are anticonvulsants with an evidence base in bipolar disorder. Carbamazepine is anti-manic but poorly tolerated and associated with many pharmacokinetic interactions. Valproate is also anti-manic and has some data suggesting it is anti-depressant in bipolar disorder and is prophylactic, especially against mania. It is associated with many problems if used during pregnancy and this should be avoided if possible. Lamotrigine is not licensed for use in the treatment of bipolar disorder in the UK but has some evidence for effectiveness against bipolar depression or more particularly prophylaxis against depressive relapse. It must be introduced slowly to avoid dangerous skin reactions. Other anticonvulsants have no evidence supporting their use. Antipsychotics, including the atypicals, are effective in treating mania. Olanzapine is also licensed for long-term prophylaxis and quetiapine has evidence for effectiveness in treating bipolar depression. Antidepressants, especially tricylcics and MAOIs, should be avoided due to risks of switching to mania. In general if an antidepressant is used it should ideally be an SSRI and using in conjuncture with a mood stabiliser and for the shortest period necessary. [Copyright &y& Elsevier]

Abstract: Unipolar affective disorder, or depression, is the one of the leading causes of disability worldwide and its effective management is a high priority. Treatment is required whether or not the illness is seen as “reactive” to circumstances or understandable. Guidelines for its management have been produced by the National Institute for Clinical Excellence (NICE). These recommend rating the severity of the illness using the International Classification for Diseases 10th edition (ICD-10). For mild depression, antidepressants are only recommended if a patient fails to respond to other interventions or there is a history of more severe depression. For moderate to severe depression, citalopram or fluoxetine are recommended as first line treatments. Alternatives if a patient fails to respond to these are mirtazepine, reboxetine, moclobemide and lofepramine. The management of treatment resistant depression (TRD – failure to respond to two adequate courses of antidepressants) is complex. NICE include recommendations to consider augmentation of an antidepressant with cognitive behavioural therapy or lithium, monotherapy with venlafaxine or phenelzine (the latter particularly for atypical depression), and the combination of mirtazepine plus a selective serotonin reuptake inhibitor (SSRI). Other strategies have limited data supporting them or are not recommended. [Copyright &y& Elsevier]

Abstract: Prostaglandin (PG) F2α has been shown to contribute to the anabolic events in skeletal muscle. We measured the skeletal muscle interstitial concentration of PGF2α at rest and following a standard bout of resistance exercise in eight young (27±2 year) and eight old (75±4 year) men. Interstitial PGF2α concentration was determined from microdialysate samples obtained from two microdialysis probes placed in the vastus lateralis. Microdialysates were collected 1h pre- and 5–6, 8–9, and 24–25h postexercise. The exercise bout consisted of 4 exercises (3 sets of 8 replications at 80% 1RM per exercise) emphasizing the quadriceps. Interstitial PGF2α levels were not different (P>0.05) between young and old at rest (1.50±0.35 vs. 1.52±0.30ngml−1) or at any time point following the resistance exercise bout. For the young and old combined there was a change (P<0.05) in PGF2α levels at 5–6h (93%) and 8–9h (95%), which had returned to preexercise levels by 24–25h. These results show that PGF2α is increased in skeletal muscle following a standard bout of resistance exercise and aging does not alter interstitial levels of this PG at rest or after exercise. These data, coupled with previous findings, suggest that the anabolic factor PGF2α should be considered when discussing the complex processes that regulate muscle mass in young and old individuals. [Copyright &y& Elsevier]

Objective: This study was designed to assess the understanding of primary care physicians who practice in the state of Florida of the risks and benefits of hormone replacement therapy as described in the Women's Health Initiative clinical trial. Study design: All primary care physicians in the state of Florida, including family practice, internal medicine, and Ob/Gyn were identified and mailed an anonymous survey asking about their understanding of the risks and benefits of hormone replacement therapy (HRT), including heart disease, breast cancer, osteoporotic fractures, colon cancer, stroke, and death. Univariate statistics stratified by specialty were performed with Kruskal-Wallis one-way analysis of variance. Results: Six thousand one hundred twenty-five surveys were mailed, with the return of 600 completed surveys, including 203 Ob/Gyn, 145 internal medicine, 219 family practice, and 33 other. Overall, Ob/Gyns had a more positive view of HRT, and internal medicine had a relatively negative view of HRT. In general, respondents overestimated the risk attributable to hormone replacement therapy. Ob/Gyns were significantly more likely to provide accurate assessments of these risks and benefits compared with the other specialties. Respondents correctly identified the magnitude of risks and benefits 28% of the time, 67% of the time overestimated risks and benefits, and 5% of the time misunderstood the direction of risk vs benefit of HRT. Conclusion: This study suggests that the findings of the Women's Health Initiative are misunderstood by the majority of primary care specialists, although Ob/Gyns have a better understanding of the risks and benefits compared to other specialties. We hypothesize that respondents that overestimate the increase or decrease in risk were making the error of confusing relative risk with absolute risk difference. There is a great need for physician education about the attributable risks and benefits of HRT. [ABSTRACT FROM AUTHOR]

In April 1998, a holding lagoon containing pyrite ore processing waste rich in arsenic, failed and released 5–6 millionm3 of highly polluting sludge and acidic water. Over 2700ha of the internationally important Doñana National and Natural Parks were contaminated. The area of Natural Park to sustain the greatest impact was known as the Entremuros. This paper presents 0–5cm soil monitoring data from the Entremuros, from sampling campaigns 6 and 18 months after the disaster; as well as macrophyte root, rhizome and stem data from samples taken 18 months after the spill. Results show a clear, decreasing, north–south arsenic soil pollution trend, both 6 and 18 months after the spill, and suggest a small reduction in total soil arsenic levels occurred over time; although a significant increase in extractable arsenic is also noted. The two macrophytes (Typha dominguensis and Scirpus maritimus) studied herein are not accumulating arsenic in stem parts, however, accumulation of arsenic on iron plaque on the roots of these plants may be occurring. Further work is recommended in order to determine the ecotoxicological significance of this process in relation to the avian food-chains of Doñana, and elsewhere. [Copyright &y& Elsevier]

BACKGROUND: Military hospitals currently use gestational age-specific growth curves based on data collected in Denver, Colo, from 1948 to 1961. A number of population and environmental factors and medical practice changes may make these curves nonrepresentative. OBJECTIVE: Determine if presently used growth curves represent norms for infants born in military hospitals and create new curves for use in military hospitals. METHODS: Data were collected from medical records of tertiary- and primary-care military hospitals. We created growth curves created for birth weight, length, and head circumference and compared these curves at gestational ages 23-42 weeks to previously published norms and to 1998 national vital statistics. Racial and ethnic differences between groups were compared. A retrospective analysis of blood-glucose measurements for healthy term infants was performed to identify potential safety issues. RESULTS: Significant increases in growth parameters were noted for infants born in military hospitals. Specific racial and ethnic groups within the military also had an increase when compared with these groups in the United States as a whole. Less than 1% of infants classified as large for gestational age (LGA) according by old standards but average for gestational age (AGA) according to new curves experienced hypoglycemia. CONCLUSION: Published growth curves may not represent infants born in military hospitals. Term infants born in military hospitals as a group and in racial and ethnic subgroups are larger than term infants born in US civilian hospitals. Prospective use of curves will help to validate their long-term applicability in military and civilian nurseries. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to determine if use of a Gonadotropin releasing hormone (GnRH) antagonist, Ganirelix (Antagon), can improve pregnancy rates during superovulation with recombinant follicle-stimulating hormone (rFSH) followed by intrauterine insemination (IUI). Study design: This was a multicenter, prospective, randomized, open-label, assessor-blind, controlled trial of females (n = 54), ages 18 to 39 undergoing superovulation/IUI with up to 4 cycles of superovulation/IUI without Ganirelix (n = 66), or up to 4 cycles of superovulation/IUI with the addition of Ganirelix (n = 52). Results: No statistically significant difference in clinical pregnancy rates per cycle initiated was found for patients in the treatment or control group (12% vs 7%, P = .29). Other variables assessed, including endometrial thickness, size of follicles, peak serum estradiol levels, mid-lutea progesterone levels, and total vials of rFSH used also showed no statistically significant difference. Conclusion: Superovulation/IUI cycles using Ganirelix produce similar pregnancy rates when compared with cycles not using a GnRH antagonist, although there is a trend towards better pregnancy rates in cycles with Ganirelix. [ABSTRACT FROM AUTHOR]

Objective: Our purpose was to assess the efficacy of two recombinant follicle-stimulating hormones, follitropin beta (Follistim, Organon, West Orange, NJ) and follitropin alfa (Gonal F, Serono, Norwell, Mass) on pregnancy rates in varying age groups of women undergoing in vitro fertilization (IVF).Study Design: Three hundred sixty-five IVF cycles were retrospectively compared, 233 by use of follitropin beta and 132 by use of follitropin alfa, both after gonadotropin-releasing hormone agonist down-regulation. Assignment to each medication was indiscriminate. The primary outcome measured was pregnancy evidenced by fetal heartbeat on ultrasonography. Secondary outcomes included days of stimulation, ampules per patient cycle, estradiol level on the day of human chorionic gonadotropin administration, total follicles present on the day of human chorionic gonadotropin administration, follicles greater than 14 mm, oocytes retrieved, mature eggs, fertilization rate, and embryos transferred. Outcomes were stratified by age, including women less than 36 years old, 36 to 39 years old, and more than 39 years old.Results: There was no significant difference between follitropin beta and follitropin alfa in either the primary or secondary outcomes, although the pregnancy rate was significantly decreased with advancing age.Conclusion: Success rates are similar, when stratified by age, in women undergoing IVF with either follitropin beta or follitropin alfa. [ABSTRACT FROM AUTHOR]

Assesses the effect of multiple factors that influence the success rate and time to conception among couples undergoing donor sperm insemination. Impact of maternal age on the cycle pregnancy rate; Factors that influence the outcome of donor intrauterine insemination cycles; Effect of history on fecundity rates.

Abstract: The author discusses a new role for stereolithic models in the management of complex mandibular fractures with reference to two case studies. [Copyright &y& Elsevier]

Clinical audit is a sustained cyclical quality improvement process seeking to improve patient care and outcomes by evaluating services against explicit standards and implementing necessary changes. National audits aim to improve population-level clinical care by identifying unwarranted variations and making recommendations for clinicians, managers and service commissioners. The National Clinical Audit of Anxiety and Depression aimed to improve clinical care for people admitted to English hospitals for treatment of anxiety and depression, to provide comparative data on quality of care, and to support local quality improvement initiatives by identifying and sharing examples of best practice. Thirteen standards were developed based on NICE guidelines, literature review and feedback from a steering committee and reference group of service users and carers. All providers of NHS inpatient mental health services in England were asked to submit details of between 20 and 100 eligible service users/patients admitted between April 2017 and September 2018. To ascertain data reliability, participating services re-audited 5 sets of case-notes with a second auditor, and the coordinating team checked 10 randomly-selected sets of case-notes from 3 services, also selected at random. The reference group and steering committee identified key findings and developed a series of recommendations, which were discussed in regional quality improvement workshops and on-line webinars. Data from 3795 case notes were analysed. A sizeable proportion of records indicated that at least one important aspect of initial assessment was not documented. Many service users/patients who could have benefited from an intervention targeted at optimising physical health did not receive it. Only a minority (39%) were referred for psychological therapy. Use of outcome measures varied considerably but no single outcome measure was being used routinely. Most individuals had a care plan recorded in the notes, but a review date was documented in only two-thirds, and almost half of individuals had not received a copy. There was considerable variation between English mental health services across many variables, and much scope for improvement. Clinicians should ensure that care plans are developed collaboratively with service users/patients and identified carers should be provided with information about support services. Health services should investigate the reasons for low referral rates for psychological therapies. Clinicians should ensure all service users have jointly developed crisis plans in place at discharge. Service managers should agree outcome measures to evaluate the treatment provided and clinicians should use these measures at initial assessment and review appointments. The implementation of such changes provides an opportunity for collaborative research into mental health service delivery and quality. • NCAAD examined performance of all English mental health services against 13 specified care quality standards for inpatients • Audit of the care of 3795 individuals identified sub-optimal performance in many domains from initial assessment to discharge • The findings provide an evidence base for a series of recommendations for individual care and mental health service delivery [ABSTRACT FROM AUTHOR]

Introduction The purpose of this article is to highlight the importance of assessing health literacy in the radiotherapy department and to discuss the challenges in practice. The paper aims to identify factors to facilitate improved access to, and understanding of, health information for patients with low health literacy. Methods A literature search was conducted using PubMed, CINAHL, Medline and Cochrane library. Non English language studies and non-healthcare related studies were excluded. Results The search identified 9 articles relevant to assessment of low literacy and 16 articles that address communication skills and low literacy. Four key themes were identified from the selected articles: • Identifying low literacy • Communication strategies • Assessing Understanding • Use of supportive technology Conclusion Current health literacy screening tools as a means of identifying patients with low literacy are not suitable for use in the radiotherapy department. Patient factors such as age, socioeconomic status, and education level, as well as the use of patient's evasion techniques can indicate low literacy. To address limited literacy skills, speaking in plain English, encouraging patients to ask questions and assessing patient's understanding are important methods to promote effective communication of information in patients with low literacy skills. [ABSTRACT FROM AUTHOR]

Introduction Adherence to standard infection control precautions (SICP) by radiographers is critical in combating healthcare associated infections (HAIs). Therefore, radiographers need to have adequate knowledge and practices of infection control if they are to contain the magnitude of HAIs. Methods Purposive, all-inclusive sampling was used to recruit 62 radiographers from four government referral hospital in Malawi. Radiographers' knowledge and practices of infection control were determined using a self-administered questionnaire. Data collection was carried out in January 2017. Descriptive (e.g. mean and standard deviation) and inferential (Chi 2 test) statistics were generated using an MS Excel VBA application. Results The majority of the respondents (84%) were between 20 and 39 years of age. The study results revealed that radiographers in the four hospitals had mean infection control score (percentage) of 76.8 ± 12.6 for knowledge and a mean infection control score of 65.3 ± 16.1 for practice. A slight significant association between age and knowledge (p < 0.05; Cramer's V 0.26) was found in that radiographers between 40 and 59 years of age (majority of the sample) obtained higher knowledge scores than those 20–39 years of age. Conclusion Given the results, further training is required regarding infection control among radiographers in radiology departments in Malawi. A guideline for infection control, specifically contextualised to be used by radiographers in radiology departments in Malawi, should be developed and implemented to enhance adherence to SICP in these departments. [ABSTRACT FROM AUTHOR]