Search

Introduction In Wessex Deanery, prior to the COVID-19 pandemic, Geriatric Medicine trainees from 10 NHS trusts attended face-to-face regional teaching sessions. In response to the pandemic, this teaching was suspended to reduce disruption in service provision and support social distancing. There was a clear need to reintroduce teaching for continued professional development and trainee progression. Methods In July 2020, Geriatric Medicine trainees in Wessex completed a questionnaire survey to identify their desire for socially distanced teaching and an acceptable format for delivery. Two half-day pilot teaching sessions via MS Teams were organised in September and October 2020. Trainees provided feedback via a questionnaire survey about the relevance and quality of teaching, and to identify any barriers to attendance. Subsequently, a monthly full-day virtual teaching programme was implemented. We reported reflections of our experiences on our trainee website to support future sessions. Results All trainees (n = 15) were eager for regional teaching to recommence through socially distanced education. Trainees had a preference for MS Teams, which can support interactive teaching. Attendance to the pilot sessions exceeded previous face-to-face sessions. 19 trainees attended the first session; 17 provided feedback. 28 trainees attended the second session; 12 provided feedback. Feedback was overwhelmingly positive; all reported the sessions were interesting and 82% (n = 14) that they would lead to changes in their practice. Some trainees expressed that full-day sessions would enhance curriculum coverage. 94% (n = 16) were positive of the virtual platform; it reduced travel and sessions could be recorded. Local trainees attended the second session in-person, which enhanced interactivity. Conclusion Virtual teaching has been successful in Wessex Deanery, with high attendance and positive feedback. Trainees can engage remotely without the need for travel and disruption. After the pandemic we hope to develop a regional teaching programme integrating virtual and face-to-face sessions to improve attendance and accessibility.

BackgroundThe increase in the number of available biologic agents for psoriasis has led to an urgent need to evaluate their associated risk of serious infections to help inform clinical decisions.MethodologyWe systematically searched PubMed, Medline, Embase, and Cochrane databases for biologics targeting TNF (adalimumab, etanercept, infliximab, certolizumab pegol), interleukin (IL)-12/23 (ustekinumab), IL-17A (secukinumab, ixekizumab), IL-17RA (brodalumab) and IL-23p19 (guselkumab, risankizumab, and tildrakizumab) for the primary outcome serious infections, at 10– 16 weeks, 1 year and 3 years. Peto’s method (fixed effect model) was used to estimate the pooled odds ratio (OR) in meta-analyses comparing biologics with one another, methotrexate, or placebo.ResultsForty-three publications (49 trials) consisting of 29,724 participants met our inclusion criteria. Serious infections across all studies were low (n=97) at 10–16 weeks and did not show an increased risk with biologic therapies compared with placebo. Seven head-to-head RCTs were identified, most of which showed no significant difference in the risk of serious infections at 10–16 weeks and at 1 year. Adalimumab was not associated with a significant increased risk of serious infections compared with methotrexate in children at 10–16 weeks.ConclusionsBiologics for psoriasis were not associated with an increased risk of serious infections compared with placebo or one another at 10–16 weeks. Longer-term, real-world data with larger sample sizes are warranted.

Effective agents to treat coronavirus infection are urgently required, not only to treat COVID-19, but to prepare for future outbreaks. Repurposed anti-virals such as remdesivir and human anti-inflammatories such as barcitinib have received emergency approval but their overall benefits remain unclear. Vaccines are the most promising prospect for COVID-19, but will need to be redeveloped for any future coronavirus outbreak. Protecting against future outbreaks requires the identification of targets that are conserved between coronavirus strains and amenable to drug discovery. Two such targets are the main protease (Mpro) and the papain-like protease (PLpro) which are essential for the coronavirus replication cycle. We describe the discovery of two non-antiviral therapeutic agents, the caspase-1 inhibitor SDZ 224015 and Tarloxotinib that target Mpro and PLpro, respectively. These were identified through extensive experimental screens of the drug repurposing ReFRAME library of 12,000 therapeutic agents. The caspase-1 inhibitor SDZ 224015, was found to be a potent irreversible inhibitor of Mpro (IC50 30 nM) while Tarloxotinib, a clinical stage epidermal growth factor receptor inhibitor, is a sub micromolar inhibitor of PLpro (IC50 300 nM, Ki 200 nM) and is the first reported PLpro inhibitor with drug-like properties. SDZ 224015 and Tarloxotinib have both undergone safety evaluation in humans and hence are candidates for COVID-19 clinical evaluation.

Increasing evidence suggests the pathogenesis of male genital lichen sclerosus (LS) is driven by chronic, occluded exposure of susceptible epithelium to the irritant effect of urine (1, 2). It is not clear how this can be extrapolated to females, however, the typical 'figure of eight' distribution seen in female genital LS suggests that urine could be implicated. This has not yet been robustly investigated.

There are concerns that immunomodulatory therapies may increase the risks of developing basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (SCC) in patients with moderate-severe psoriasis. A systematic review showed that psoriasis patients were significantly more likely to develop SCC than the general population, though included studies lacked adequate comparator cohorts and adjustment for relevant confounding factors including heterogeneity between BCC and SCC in association with phototherapy and immunomodulatory therapies and lacked data on newer biologic therapies. We therefore followed-up a large prospective patient cohort to determine whether the risks of developing BCC and SCC are increased in patients with psoriasis receiving biologic therapy compared with those treated with non-biologic systemic therapies only.

Background Lichen sclerosus (LS) is a scarring chronic inflammatory disease with a predilection for genital skin in both sexes. The aetiology of LS is controversial, but evidence increasingly suggests that the occluded exposure of susceptible epithelium to urine is involved in the pathogenesis of genital LS in males. This theory has not yet been robustly investigated in females. Objectives This review and meta‐analysis examined whether there is an association between urinary incontinence (UI) and genital lichen LS in females. Methods We performed a comprehensive search of MEDLINE, Embase and CINAHL to identify observational studies assessing the prevalence of UI in females with LS. DerSimonian and Laird random‐effects models were used to estimate the overall pooled prevalence and risk ratio compared to controls. Heterogeneity was assessed. Results In total, eight studies met the inclusion criteria and five studies were included in a meta‐analysis. Three studies were graded as moderate quality and five were poor. The pooled prevalence for UI in LS was 0.35 (95% confidence interval [CI] 0.13–0.58, I2 = 98.4%). The risk ratio of UI in LS was 0.97 (95% CI 0.53–1.75, I2 = 87.5%). Conclusion There appears to be no difference between patients with LS and those without LS in terms of UI. Studies are limited by clinical and methodological quality and heterogeneity is high. Well‐designed prospective studies are needed.

International audience; The Radio and Plasma Waves (RPW) instrument on the ESA Solar Orbiter mission is designed to measure in situ magnetic and electric fields and waves from the continuum up to several hundred kHz. The RPW also observes solar and heliospheric radio emissions up to 16 MHz. It was switched on and its antennae were successfully deployed two days after the launch of Solar Orbiter on February 10, 2020. Since then, the instrument has acquired enough data to make it possible to assess its performance and the electromagnetic disturbances it experiences. In this article, we assess its scientific performance and present the first RPW observations. In particular, we focus on a statistical analysis of the first observations of interplanetary dust by the instrument’s Thermal Noise Receiver. We also review the electro-magnetic disturbances that RPW suffers, especially those which potential users of the instrument data should be aware of before starting their research work.

Context.Solar Orbiter was launched on 10 February 2020 with the purpose of investigating solar and heliospheric physics using a payload of instruments designed for both remote and in situ studies. Similar to the recently launched Parker Solar Probe, and unlike earlier missions, Solar Orbiter carries instruments designed to measure low-frequency DC electric fields.Aims.In this paper, we assess the quality of the low-frequency DC electric field measured by the Radio and Plasma Waves instrument (RPW) on Solar Orbiter. In particular, we investigate the possibility of using Solar Orbiter’s DC electric and magnetic field data to estimate the solar wind speed.Methods.We used a deHoffmann-Teller (HT) analysis, based on measurements of the electric and magnetic fields, to find the velocity of solar wind current sheets, which minimises a single component of the electric field. By comparing the HT velocity to the proton velocity measured by the Proton and Alpha particle Sensor (PAS), we have developed a simple model for the effective antenna length,Leffof the E-field probes. We then used the HT method to estimate the speed of the solar wind.Results.Using the HT method, we find that the observed variations inEyare often in excellent agreement with the variations in the magnetic field. The magnitude ofEy, however, is uncertain due to the fact that theLeffdepends on the plasma environment. Here, we derive an empirical model relatingLeffto the Debye length, which we can use to improve the estimate ofEyand, consequently, the estimated solar wind speed.Conclusions.The low-frequency electric field provided by RPW is of high quality. Using the deHoffmann-Teller analysis, Solar Orbiter’s magnetic and electric field measurements can be used to estimate the solar wind speed when plasma data are unavailable.

Background The rapid expansion of psoriasis biologics has led to an urgent need to understand their relative efficacy and tolerability to inform treatment decisions better and, specifically, to inform guideline development. Objectives To update a 2017 meta‐analysis on the comparative efficacy and tolerability of biologic treatments for psoriasis. Methods We searched the MEDLINE, PubMed, Embase and Cochrane databases for randomized controlled trials (RCTs), published up to 7 September 2018, of 11 licensed, NICE‐approved biologics targeting tumour necrosis factor (adalimumab, etanercept, infliximab, certolizumab pegol), interleukin (IL)‐12/IL‐23p40 (ustekinumab), IL‐17A (secukinumab, ixekizumab), IL‐17RA (brodalumab) and IL‐23p19 (guselkumab, tildrakizumab, risankizumab). A frequentist network meta‐analysis ascertained direct or indirect evidence comparing biologics with one another, methotrexate or placebo. This was combined with hierarchical cluster analyses to consider efficacy (≥ 90% improvement in Psoriasis Area and Severity Index (PASI 90) or Physician’s Global Assessment 0 or 1; PASI 75; Dermatology Life Quality Index improvement) and tolerability (drug withdrawal due to adverse events) outcomes at 10–16 weeks, followed by assessments of study quality, heterogeneity and inconsistency. Results We identified 62 RCTs presenting data on direct comparisons (31 899 participants). All biologics were efficacious compared with placebo or methotrexate at 10–16 weeks. Hierarchical cluster analyses revealed that adalimumab, brodalumab, certolizumab pegol, guselkumab, risankizumab, secukinumab, tildrakizumab and ustekinumab were comparable with respect to high short‐term efficacy and tolerability. Infliximab and ixekizumab clustered together, with high short‐term efficacy but relatively lower tolerability than the other agents, although the number of drug withdrawal events across the network was low, so these findings should be treated with caution. Conclusions Using our methodology we found that most biologics cluster together with respect to short‐term efficacy and tolerability, and we did not identify any single agent as ‘best’. These data need to be interpreted in the context of longer‐term efficacy, effectiveness data, safety, posology and drug acquisition costs when making treatment decisions.

Background: Contamination with oral commensals and pathogenic microorganisms, and cross contamination between clinic and laboratory can occur. The amount of contamination has not been determined. Methods: Samples from different clinical and laboratory stages before and after disinfection (17 sites, 10 samples per stage) were collected. Laboratory surfaces and equipment were swabbed for 10 days (11 sites). Swabs were cultured for total mixed flora, Streptococci, Lactobacilli, Staphylococcus aureus, aerobic Gram-negative bacteria (AGNB) and Candida. Knowledge of infection control among staff and students was assessed. Results: Clinic: In total, 30&ndash, 40% of the samples overall were contaminated with mixed flora and Streptococci of &gt, 100 cfu/swab, &gt, 100 cfu of AGNB and Candida were present on 6% and 1% of samples, 2% contained &lt, 100 cfu of S. aureus. Laboratory: In total, 17&ndash, 48% of the samples overall were contaminated with mixed flora and Streptococci of &gt, 100 cfu of AGNB were present on 11% of samples, none contained &gt, 100 cfu of Candida. Disinfection significantly reduced the level of all organisms. Knowledge of infection control was sufficient, but compliance was poor. Conclusion: Although the count of mixed flora was high, potential pathogens such as S. aureus and Candida were low. In immunocompromised patients, this can become a problem.

Introduction: Older people represent nearly two-third of admissions to hospitals in the UK, and many are at high risk of poor healthcare outcomes including long length of stay and admission to care homes. Early identification of these patients would allow appropriate interventions to improve outcomes. It is unclear whether and how they are identified within current practice. The aim of this study was to define current practice with regard to the identification of older patients at high risk of poor healthcare outcomes. Methods: A random sample of 60 patients’ clinical records from five geriatric wards in one hospital were reviewed for evidence of risk assessments occurring routinely on admission. In addition, semi-structured interviews/focus groups were conducted with 22 healthcare staff across the study wards including: 7 nursing staff, 4 dieticians, 7 medical staff, and 4 therapists. Results: A number of risk-assessments take place routinely early on admission including, assessment of nutrition using Malnutrition Universal Screening Test (MUST) score (85% patients), recognition of dementia and delirium using (77%), risk of falls (95%), moving and handling assessment (85%), and pressure ulcers assessment (88%). However, there was no explicit tool to identify older patients at risk of poor healthcare outcomes. Qualitative data revealed that healthcare staff depend on “clinical judgement” to recognise high-risk patients based on detailed collateral history about patient’s general condition, reasons for admission, ability to manage at home and level of care needed, number of comorbidities, and patient’s engagement with therapy assist professional judgment. Yet, most often making such a judgment occurs several days after admission potentially delaying interventions. Conclusions: Although a number of risk assessments are used routinely on admission to geriatric wards, explicit identification of patients at risk of poor healthcare outcomes is missing. Staff rely on clinical judgement which often occurs later on admission potentially delaying interventions.

BACKGROUND: Treatment modifications, including dose-escalations, dose-reductions, switches, discontinuations and restarts of biologics may be necessary in the management of psoriasis but the patterns of usage are incompletely defined.OBJECTIVES: To examine the treatment utilisation patterns of adalimumab, etanercept and ustekinumab among biologic-naïve and non-naïve psoriasis patients enrolled in the British Association of Dermatologists Biologic Interventions Register (BADBIR).METHOD: The cohort study included adults with chronic plaque psoriasis who were followed-up for ≥12-months.Treatment modifications were assessed during the first year of therapy. The time-trend method, comparing the cumulative dose (CD) patients received to the recommended cumulative dose (RCD), was used to assess dosing patterns. Concomitant use of other systemic treatments was also examined.RESULTS: In total, 2980 patients (adalimumab:1675; etanercept:996; ustekinumab:309) were included; 79.2% were biologic-naïve. Over 12-months, 77.4% of patients continued the biologic, 2.6% restarted therapy after a break of ≥90-days, 2.5% discontinued, and 17.5% switched biologic therapy. Most patients (85.7%) received the RCD of the biologic, although 8.1% were exposed to a higher CD. In total, 749(25.1%) patients used conventional systemic therapies concomitantly with a biologic at some stage; methotrexate was used most commonly (458;61.2%). Of those using combination therapy, 454(60.6%) continued the use of the conventional systemic therapy for >120 days after the start of the biologic.CONCLUSION: More than one-third of patients experienced treatment modifications within the first year of initiating a biologic. Conventional systemic therapies, particularly methotrexate, were commonly used concurrently which should be considered when evaluating treatment response and adverse events to biologics in real-world observational studies. This article is protected by copyright. All rights reserved.

Background Guttate psoriasis is a distinctive acute form of psoriasis which characteristically occurs in children and young adults. Very little specific evidence-based guidance is available in standard texts to help make rational decisions about treatment options. Objectives To assess the effectiveness of treatments for guttate psoriasis. Search methods We searched the Cochrane Clinical Trials Register (Cochrane Library, Issue 3, 1999), Medline (1966- September 1999), Embase (1988-September 1999), Salford Database of Psoriasis Trials (to November 1999) and European Dermato-Epidemiology Network (EDEN) Psoriasis Trials Database (to November 1999) for terms GUTTATE and PSORIASIS. We also searched 100 unselected RCTs of psoriasis therapy and all 112 RCTs of phototherapy for psoriasis in the Salford Database of Psoriasis Trials for separate stratification for guttate psoriasis. Selection criteria Randomised trials in which patients with acute guttate psoriasis were randomised to different treatments, except those trials examining antistreptococcal interventions which are addressed in a separate Cochrane review. Data collection and analysis Two reviewers independently assessed trial eligibility and quality. Main results No published report could be found to support or to challenge current commonly used methods of management.Only one trial which met the selection criteria was identified. In this small study of 21 hospitalised patients with guttate psoriasis, intravenous infusion of an n-3 fatty acid rich lipid emulsion was compared with placebo emulsion containing n-6 fatty acids. The n-3 preparation appeared to be of some benefit for patients with guttate psoriasis. Authors' conclusions There is currently no firm evidence on which to base treatment of acute guttate psoriasis. Studies comparing standard treatment modalities, including phototherapy and topical regimens, are required to enable informed decisions on treatment choices to be made.

Chronic ulcerating lesions on the face are rarely seen in toddlers. Blistering disease, vasculitis, infections and self-mutilation due to neurometabolic disease can usually be excluded on clinical and histological grounds. In the absence of identifiable disease, such lesions are sometimes attributed to child abuse or fabricated illness. We describe three toddlers with chronic mid-face erosions, two from India and one from the UK. One had moderate developmental delay and one had had seizures. The lesions appeared to be self-inflicted, no underlying disease was identified and there was no suspicion of child abuse. Recognition of the same disease pattern in different continents implies a distinct pathological entity. The pattern closely resembles that seen in some patients with mutations in the pain-insensitivity genes PRDM12 and SCN11A. We suggest the term 'mid-face toddler excoriation syndrome' (MiTES) to acknowledge the existence of this condition, encourage further reports and help clarify the pathogenesis.

A comprehensive evaluation of the risk of serious infections in biologic therapies for psoriasis is lacking. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and prospective cohort studies reporting serious infections in people taking any licensed biologic therapy for psoriasis compared with those taking placebo, nonbiologic therapy, or other biologic therapies. The quality of the studies was assessed using Grading of Recommendations Assessment, Development and Evaluation criteria. No significant heterogeneity was detected in data from 32 RCTs (n = 13,359 participants) and one cohort study (n = 4,993 participants). In adults, low- to very-low-quality RCT data showed no significant difference between any biologic therapy and placebo at weeks 12–16 (overall pooled Peto odds ratio = 0.71, 95% confidence interval = 0.36–1.41) and weeks 20–30 (odds ratio = 2.27, 95% confidence interval = 0.45–11.49). No significant differences were found in any of the other comparisons in underpowered RCT data. Prospective cohort study data of low quality suggests that only adalimumab (adjusted hazard ratio [adjHR] = 2.52, 95% confidence interval = 1.47–4.32) was associated with a significantly higher risk of serious infection compared with retinoid and/or phototherapy in adults. No association between biologic therapies and serious infections in patients with psoriasis who were eligible for RCTs was detected. Further observational studies are needed to inform the uncertainty around this risk in the real world.

Background The persistence and effectiveness of systemic therapies for moderate-to-severe psoriasis in current clinical practice are poorly characterized. Objectives To systematically review observational studies investigating the persistence and effectiveness of acitretin, ciclosporin, fumaric acid esters (FAE) and methotrexate, involving at least 100 adult patients with moderate-to-severe psoriasis, exposed to therapy for ≥ 3 months. Methods MEDLINE, Embase, the Cochrane Library and PubMed were searched from 1 January 2007 to 1 November 2017 for observational studies reporting on persistence (therapy duration or the proportion of patients discontinuing therapy during follow-up) or effectiveness [improvements in Psoriasis Area and Severity Index (PASI) or Physician's Global Assessment (PGA)]. This review was registered with PROSPERO, number CRD42018099771. Results Of 411 identified studies, eight involving 4624 patients with psoriasis were included. Variations in the definitions and analyses of persistence and effectiveness outcomes prevented a meta-analysis from being conducted. One prospective multicentre study reported drug survival probabilities of 23% (ciclosporin), 42% (acitretin) and 50% (methotrexate) at 1 year. Effectiveness outcomes were not reported for either acitretin or ciclosporin. The persistence and effectiveness of FAE and methotrexate were better characterized, but mean discontinuation times ranged from 28 to 50 months for FAE and 7·7 to 22·3 months for methotrexate. At 12 months of follow-up, three studies reported that 76% (FAE), 53% (methotrexate) and 59% (methotrexate) of patients achieved ≥ 75% reduction in PASI, and one reported that 76% of FAE-exposed patients achieved a markedly improved or clear PGA. Conclusions The comparative persistence and effectiveness of acitretin, ciclosporin, FAE and methotrexate in real-world clinical practice in the past decade cannot be well described due to the inconsistency of the methods used.

BACKGROUND Lichen sclerosus (LS) is a chronic inflammatory dermatosis with a predilection for the anogenital region, which mainly affects prepubertal girls and postmenopausal women. The cause is unknown, but a number of potential aetiological factors have been identified. AIM To examine a cohort of patients with prepubertal-onset vulval LS (VLS) and assess baseline characteristics, clinical presentation, potential precipitating and predisposing factors, and response to treatment. METHODS Data were collected from case notes on patients aged

Background We present a distinctive type of acquired vascular proliferation, for which we propose the name of poikilodermatous plaque-like hemangioma. Objective The aim of this study was to summarize the clinical and histopathologic features in a case series of poikilodermatous plaque-like hemangioma. Methods Sixteen cases were identified from the routine clinical and referral practices of the authors. Clinical characteristics, including demographic details and clinical morphology, were collated. The salient histopathologic features, including immunohistochemical staining results, were summarized. Results The lesions were usually solitary erythematous-to-violaceous poikilodermatous plaques on the lower extremities and pelvic girdle, with an indolent clinical course. Mean age of affected patients was 72 (range 58-80) years, and there was a male predominance. Histology comprised a distinctive band-like proliferation of vascular channels suggestive of postcapillary venules within the superficial dermis with a background of fibrosis, edema, and loss of elastic fibers. Despite the clinical atrophic appearance, acanthosis was a frequent finding. Limitations Retrospective study. Conclusion Poikilodermatous plaque-like hemangioma is a distinctive and previously undescribed vascular proliferation defined by a constellation of consistent and reproducible clinical and histologic features.

Vertically sided offshore structures subjected to level ice are designed to withstand the effects of ice-induced vibrations. Such structures are, for example, offshore wind turbines on monopile foundations, multi-legged oil- and gas platforms or lighthouses. For the prediction of dynamic interaction between ice and structures, several phenomenological models exist. The main challenge with these models is the limited amount of data available for validation, which makes it difficult to determine their applicability. In this study, an attempt is made to validate one of the existing models. First, the parameters which define the ice in the model were derived from new model-scale experiments with a rigid rectangular structure. The model was subsequently applied to simulate the interaction between ice and two compliant rectangular structures with different structural properties. Finally, model-scale experiments were conducted for the two compliant structures. Results of the experiments and model were compared to assess the capability of the model to predict dynamic ice-structure interaction. Results show that the adopted approach allows for a definition of the input parameters of the model and accurate prediction of frequency lock-in and continuous brittle crushing for compliant structures. Intermittent crushing was not observed in the model-scale experiments due to the model-scale ice bending significantly during low ice speeds. As a consequence, the model could not be validated for this regime of interaction. The approach followed and challenges encountered during its application are discussed.

SummaryBackground Using a monoclonal antibody with greater affinity for IgE than omalizumab, we examined whether more complete suppression of IgE provided greater pharmacodynamic effects, including suppression of skin prick responses to allergen. Objective To explore the pharmacokinetics, pharmacodynamics and safety of QGE031 (ligelizumab), a novel high-affinity humanized monoclonal IgG1κ anti-IgE. Methods Preclinical assessments and two randomized, placebo-controlled, double-blind clinical trials were conducted in atopic subjects. The first trial administered single doses of QGE031 (0.1–10 mg/kg) or placebo intravenously, while the second trial administered two to four doses of QGE031 (0.2– 4 mg/kg) or placebo subcutaneously at 2-week intervals. Both trials included an open-label omalizumab arm. Results Sixty of 73 (82%) and 96 of 110 (87%) subjects completed the intravenous and subcutaneous studies, respectively. Exposure to QGE031 and its half-life depended on the QGE031 dose and serum IgE level. QGE031 had a biexponential pharmacokinetic profile after intravenous administration and a terminal half-life of approximately 20 days. QGE031 demonstrated dose- and time-dependent suppression of free IgE, basophil FceRI and basophil surface IgE superior in extent (free IgE and surface IgE) and duration to omalizumab. At Day 85, 6 weeks after the last dose, skin prick wheal responses to allergen were suppressed by > 95% and 41% in subjects treated subcutaneously with QGE031 (2 mg/kg) or omalizumab, respectively (P

Purpose It is known that distortions can occur during impression making and the pouring of casts, and that this distortion may produce inaccuracies of subsequent castings, especially long span castings for implant superstructures. The purpose of this study was to compare the ability of different impression materials to reproduce the positions of 5 implant analogues on a master model, in terms of their accuracy and the accuracy of a resultant cast, relative to the master model. Method The master model was a stainless steel model with 5 implant analogues. The impression materials used were impression plaster (Plastogum), a polyether (Impregum Penta), and two polyvinyl siloxane materials (Aquasil Monophase and Aquasil putty with light body wash). Five impressions were made with each impression material and cast in Satin stone under controlled conditions. The positions of the implants on the master model, the impression copings, and the implant analogues in the subsequent cast were measured using a co-ordinate measuring machine which measures within 4μm of accuracy. Results Statistical analysis using a one factor t-test indicated that distortion occurred in all the impression materials, but inconsistently. Aquasil Monophase reproduced the master model most accurately. Although there was no significant distortion between the Aquasil monophase impressions and the master model or between the impressions and their casts, there were distortions between the master model and the master cast, which highlighted the cumulative effects of the distortions. Impregum’s performance proved to be the most reliable in terms of predictability. Plastogum displayed cumulative distortion and with Aquasil putty with light body, these impression materials had the least reliability. Conclusions Some of the distortions observed are of clinical significance and likely to contribute to a lack of passive fit of any superstructure. The unpredictability of such distortions may mean that the future of accurate impressions and superstructures may lie in the digital world.

The emergence of guaranteed wage plans in the automobile industry, likely to spread to other fields in the near future, poses the problem of the relationship between such plans and the national Unemployment Insurance system in Canada. This article is an attempt to indicate, by a comparative analysis of Canadian and U.S. Unemployment Insurance systems, to what extent problems associated with U.S. unemployment insurance systems, and the possible integration of these systems with company supplemental unemployment benefit plans, are applicable to Canada., L'établissement du principe des « prestations d'assurance-chômage » sur le plan de l'entreprise dans l'industrie américaine de l'automobile, en juin dernier, de même que les pourparlers en cours entre les Ouvriers Unis de l'Automobile ( UAW-CIO ) et General Motors, au Canada, autour du salaire garanti, nous invitent à l'étude de ces divers plans dans leurs rapports avec le système canadien d'assurance-chômage.Ces plans — à l'enseigne plutôt vague du « salaire garanti » — possèdent un trait commun: ils visent à coordonner les services de l'assurance-chômage traditionnelle à des prestations additionnelles fournies par l'employeur en cas de chômage. L'assurance-chômage, en d'autres termes, deviendrait d'une certaine façon la responsabilité commune de l'État et de l'employeur.Il s'agit ici de déterminer, à partir d'une analyse comparative des systèmes canadien et américain d'assurance-chômage, dans quelle mesure les problèmes d'intégration des secteurs public et privé qui se posent aux États-Unis sont susceptibles de se retrouver, avec des modalités variables peut-être, au Canada,CARACTÉRISTIQUES DU SYSTÈME AMÉRICAIN D'ASSURANCE-CHÔMAGEDepuis plusieurs années, le système américain d'assurance-chômage est l'objet de critiques plutôt sévères en certains milieux. D'un État à l'autre, les systèmes manquent d'uniformité, car il appartient à chaque État de fixer le montant et la durée des prestations, de même que les conditions d'éligibilité et le mode d'administration du système. Les unions ouvrières s'en prennent particulièrement à la formule selon laquelle la cotisation de l'employeur varie en fonction des prestations de chômage qu'on a dû verser à ses employés. La participation de l'employeur est fonction du nombre des réclamations de chômage que font ses propres employés. Ainsi, le nombre des demandes favorablement accueillies étant réduit, la contribution de l'employeur en cause au fonds d'assurance-chômage s'en trouvera diminuée d'autant. Certains chefs syndicaux prétendent toutefois qu'en certains cas, des compagnies se sont opposées à des prestations d'assurance-chômage au bénéfice d'anciens employés — comme cela peut se faire aux États-Unis — afin de réduire le montant de leurs obligations à l'endroit du fonds.A l'encontre de cette diversité, le système canadien d'assurance-chômage s'applique uniformément à tout le pays, sous le contrôle de la Commission d'assurance-chômage. De ce chef, certains problèmes, réels aux États-Unis, s'éliminent d'eux-mêmes au Canada. Et qui plus est, l'employeur canadien paie chaque semaine pour chacun de ses employés une somme fixe en fonction de son salaire, et non pas, comme l'employeur américain, une contribution qui varie selon le nombre de prestations de chômage fournies à ses anciens employés.CERTAINS ASPECTS LÉGAUX DU SALAIRE GARANTI ET DE L'ASSURANCE-CHÔMAGEL'insertion du secteur privé dans le secteur public, en matière d'assurance-chômage se complique encore de difficultés légales, surtout au Canada. Ici, en effet, un ordre-en-conseil émis le 31 décembre 1954 stipule qu'un individu ne peut bénéficier de l'assurance-chômage s'il reçoit des prestations de son ancien employeur a) à condition de reprendre son service chez l'employeur sur demande, et b) sous forme de salaire garanti. Selon toute probabilité, les règlements du même ordre en vigueur aux États-Unis joueraient dans le même sens. Cependant, il n'existe là-bas rien d'aussi spécifique que l'ordre-en-conseil canadien mentionné plus haut; de sorte que certains États pourraient, sans modifier la législation, donner une nouvelle interprétation à certaines clauses déjà existantes, ce qui ne semble pas possible au Canada.Ce qui précède n'exclut évidemment pas la possibilité d'une modification de la réglementation en vigueur au Canada. Une telle modification ferait immédiatement sentir ses effets sur l'ensemble de l'économie canadienne, en vertu de l'unité même du système. Les États américains, de leur côté, pourraient modifier la loi ou lui donner une interprétation nouvelle afin de permettre à un employé de toucher son salaire garanti et de bénéficier également de l'assurance-chômage étatique. Certains États toutefois, pourraient interdire le cumul de ces deux sources durant la même semaine.L'ordre-en-conseil plus haut cité, dans son interdiction quant au cumul par le même individu des deux sources — assurance-chômage de l'État et « assurance-chômage » de l'employeur sous forme de salaire garanti — n'a peut-être pas toute la rigueur que les mots semblent lui prêter. Il se peut qu'en certaines circonstances ce texte restrictif ne s'applique pas aux plans imaginés conjointement par employeurs et unions, sans exclure les plans qui se fondent sur la formule adoptée par Ford, General Motors et UAW-CIO.Les éléments principaux de cette dernière formule se centrent autour du fait que l'employeur, en l'occurrence, subira une perte financière; à cause même de ce fait, il se peut que, d'après les clauses de la Loi de l'assurance-chômage, il ne s'agisse pas là d'une formule stricte de salaire garanti. Une telle interprétation aurait pour effet d'éliminer, par rapport à la formule de « salaire garanti » préconisée, l'article restrictif qui interdit le cumul des deux souces — État et employeur — par un individu en chômage.On applique les mots « salaire annuel garanti » à tellement de formules — parfois diamétralement opposées — que l'expression a beaucoup perdu en précision. Il conviendra donc d'étudier chaque plan à sa face même, sans égard pour son titre: ce faisant, il pourra fort bien arriver que tel employé protégé par tel plan de « salaire garanti » puisse bénéficier de l'assurance-chômage, alors que son voisin, sous un autre plan dit également de «salaire garanti», n'aura pas droit aux prestations de l'État en cas de chômage.DISPONIBILITÉ POUR TRAVAIL APPROPRIÉLe grand problème de compénétration des deux systèmes — assurance-chômage de l'État et « salaire garanti » de l'employeur — se situe autour de deux exigences contradictoires et péremptoires: d'une part, l'employeur, en retour du «salaire garanti », obtient de chaque employé la promesse que ce dernier retournera au travail aussitôt que lui, l'employeur, en aura besoin; d'autre part, la Loi de l'assurance-chômage stipule que le bénéficiaire doit être disponible pour tout travail approprié, et doit même normalement se chercher du travail. Il semble impossible de concilier ces deux exigences.Un élément possible de solution loge à l'enseigne de «l'intention », sujet bien délicat en matière légale. Ainsi, l'individu temporairement en chômage, qui n'a pas l'intention de demeurer disponible pour son ancien employeur et qui se cherche activement activement du travail ailleurs, aurait droit aux prestations d'assurance-chômage même s'il reçoit de son ancien employeur un salaire durant toute la période couverte par la garantie. L'employé en chômage qui, recevant le salaire garanti, s'attend à retourner à son ancien emploi aussitôt qu’on aura besoin de lui et ne se rend pas disponible pour un autre emploi, n'aurait pas droit aux prestations de l'État.LE COÛT DES PRESTATIONS DE CHÔMAGE AU NIVEAU DE L'ENTREPRISEL'intégration des deux formules d'assurance contre le chômage — celle de l'État et celle de l'employeur sous forme de « salaire garanti » — aura sa répercussion sur le coût d'un plan de salaire garanti dans une entreprise particulière. Dans la mesure où un chômeur touchera des prestations d'assurance-chômage, le coût pour l'employeur d'un plan de salaire garanti se trouvera diminué; ce coût, encore une fois, dépend pour beaucoup du niveau des prestations étatiques de chômage auxquelles les employés ont droit. Au Canada comme aux États-Unis, les prestations d'assurance-chômage représentent une proportion plus forte de salaires inférieurs que de salaires élevés. Si donc un employeur garantissait un salaire égal à la totalité ou à une certaine proportion du salaire hebdomadaire moyen d'un employé, ses déboursés — s'ajoutant à sa contribution au fonds d'assurance-chômage — varieraient en fonction de la structure des salaires de sa main-d'oeuvre.La durée des prestations varie également selon les réclamations de chaque individu. Si, par conséquent, le droit d'un individu aux prestations d'assurance-chômage devenait périmé avant l'échéance de la garantie faite par son employeur, celui-ci ne tirerait aucun avantage de l'existence du système étatique.MISE EN APPLICATION CONCOMITANTE DES DEUX SYSTÈMESIl ne fait pas de doute que l'intégration des deux systèmes — public et privé — de protection contre le chômage exigerait un surcroît d'efforts, et pour les administrateurs gouvernementaux et pour les représentants des entreprises en cause. D'autre part, la bonne marche en commun des deux systèmes pourrait exiger, de la part de la Commission d'assurance-chômage, un certain contrôle sur les divers plans de « salaire garanti » établis par les entreprises.Au point de vue purement administratif, il est essentiel que les plans de salaire garanti au niveau de l'entreprise reposent sur les mêmes règles d'éligibilité que celles utilisées par la Commission de l'assurance-chômage. Tout plan privé qui s'appuierait sur des principes et des règles indépendants ou ennemis de ceux du système fédéral d'assurance-chômage risquerait de mettre les officiers de la Commission dans une situation fâcheuse et incommode.CONCLUSIONL'entrée en scène de diverses formules de salaire garanti par l'employeur pose le problème de l'intégration de ces formules dans le système national d'assurance-chômage. Des modifications à la législation présente s'avèrent nécessaires et paraissent imminentes. Des problèmes administratifs se posent également, qui requièrent l'attention urgente des experts en la matière.

Summary Morphoea (localized scleroderma) is a cutaneous inflammatory condition characterized by the development of indurated and discoloured plaques. The histological features of morphoea typically include a superficial and deep perivascular and periadnexal chronic inflammatory infiltrate associated with variable degrees of dermal and/or subcutaneous sclerosis. The infiltrate is typically composed of lymphocytes, macrophages and conspicuous plasma cells. The early stages of morphoea may have a very prominent inflammatory infiltrate associated with subtle sclerosis. In addition, the inflammatory infiltrate may show a perineural and rarely intraneural distribution. We report two cases of morphoea that histologically showed plasma cell endoneuritis associated with subtle dermal sclerosis. These two cases highlight the potential for diagnostic confusion with infectious and inflammatory diseases, particularly leprosy and lupus.

Background There is a lack of published evidence for treatment and outcome measures for vulval erosive lichen planus (ELPV). Objectives To conduct a multicentre case note review to examine real-life management of ELPV comparing current U.K. practice against an agreed audit standard. Methods Criteria for standards of care for which to evaluate current service provision were set following communication with experts from the British Society for the Study of Vulval Disease. Participants from 10 U.K. centres included nine dermatologists and one gynaecologist who run specialist vulval clinics. Standards examined the documentation of disease severity/impact measures, the use of diagnostic biopsies, treatments used and assessment of treatment response. Results Audit data were collected from 172 patients. Documentation of symptoms/clinical findings was excellent (99%, 170/172). A schematic diagram was present in the notes of 87% (150/172). Patient-related disease impact measures including Dermatology Life Quality Index (3%, 6/172) or visual analogue scales (1%, 2/172) were less well documented. Biopsies were performed in 78% (135/172); 71% (96/135) showed histological features consistent with erosive lichen planus. Squamous cell carcinoma developed in four patients (two vulval, two oral) and vulval intraepithelial neoplasia in two further patients. Recommended first-line treatment with a very potent topical steroid was used in 75% (129/172) with improvement in 66% (85/129). Significant variation in second-line therapy was seen. Conclusions Wide variation in U.K. practice demonstrates the absence of standardized guidance for treating ELPV and the need for vulval-specific outcomes. This audit should act as a framework towards improving ELPV management and to plan future research in this area.

Introduction: falls are common in Parkinson’s disease, and a recognised research priority. This mixed methods study aimed to establish the experiences, needs and preferences of people with Parkinson’s (PwP) who fall, and their informal caregivers, for the effective self-management of falls. PwP with cognitive impairment (CI)/ dementia were included. Methods: PwP and caregivers completed questionnaires about fall history, fear of falling and caregiver burden. A purposive sub-sample participated in semi-structured interviews. Questionnaires were analysed through descriptive statistics, interviews were analysed through inductive thematic analysis. Results: 61 PwP and 56 caregivers completed questionnaires. Of these, 20 PwP and 18 caregivers were interviewed. Median number of falls in the last year was 4. 70% reported difficulty getting up from the floor, and caregivers often provided support. 71% of caregivers had high caregiver burden. Five themes emerged from the interviews: (1) establishing reasons for falls: attributions and perceptions; (2) coping and adaptation; (3) recognising and managing risks surrounding falling; (4) concerns and worries about consequences; (5) PwP and caregivers as case managers. There was heterogeneity of situations where PwP could feel unsteady or fall. Dyads often sought to identify the cause of falling; uncertainty could lead to frustration. Dyads displayed a range of problem and emotion-focused coping strategies. Caregivers played a key role in falls management, particularly in the setting of CI/dementia. There was often considerable impact on the relationship within the dyad, with loss of caregiver identity. Dyads could appear lost within the healthcare system, and be unsure of the role of healthcare professionals (HCPs) in falls management. Conclusions: dyads displayed variety in their experiences and unmet needs for successful falls management. Dyads require support in attributing reasons for falls and in communicating with HCPs. Results from this study will inform the development of a falls-based self-management guide for PwP and caregivers.

Background: cognitive impairment affects many people with Parkinson’s (PwP) and falling is also common. Falls can lead to a fear of falling (FOF) among PwP and high caregiver burden among their close relatives, both of which can be detrimental to an individual’s quality of life. The aim of this study was to examine whether FOF among PwP and caregiver burden in their relatives are affected by cognitive impairment. A secondary outcome was to determine whether FOF among PwP is associated with caregiver burden among their relatives. Methods: PwP and their caregivers were recruited through Parkinson’s UK support groups and data was collected in the form of questionnaires as part of a larger study. Cognitive impairment was self-reported. FOF was evaluated using the short Falls Efficacy Scale (FES – I) and caregiver burden was tested using the Zarit Burden Interview (ZBI). Data was analysed using SPSS – 24. Results: 61 PwP (mean age 74 years; 67% male; median time since diagnosis 10 years) and 56 caregivers were recruited. 13 PwP (21%) reported cognitive impairment. The median FOF score for all PwP was high at 14/28 (IQR 11, 20). FOF was significantly higher in PwP who had cognitive impairment compared to those without (21 vs 13, P = 0.02) and particularly related to dressing, bathing or showering, rising from a chair, reaching for an object and climbing stairs. Mean caregiver burden for all 56 caregivers was also high at 21/40 (SD = 9.6). It was significantly higher in caregivers of PwP with cognitive impairment compared to those without (27 vs 19, P = 0.007). Importantly, a correlation was found between FOF and caregiver burden in PwP with cognitive impairment (P = 0.06, r = 0.580) compared to those without (P = 0.996; r = 0.0001). Conclusion: PwP with cognitive impairment had an increased FOF and their caregivers reported a greater sense of caregiver burden. A correlation was found between FOF and caregiver burden among PwP living with cognitive impairment. These findings suggest that PwP with cognitive impairment and their carers should be offered additional support. However, this study was conducted with a small sample making generalisation to a wider population difficult and further research is needed.

A 17 year old boy with no previous history of skin disease was admitted to the medical ward with facial swelling and a widespread itchy, erythematous, papular rash (fig 1 …

A variety of mechanisms may cause intravascular coagulation. Fibrinolysis is nearly always secondary to the initial clotting. In the acute form, ICF is characterized by depletion of platelets and several coagulation factors together with active fibrinolysis. There is a decrease in Factors V and VIII because they are sensitive to coagulation. The stable coagulation factors may be decreased as well because after activation they are removed from the circulation by the liver and reticuloendothelial system. Severe bleeding is the usual accompaniment of the acute syndrome, which may also occur in cancer and infection of all types. The acute syndrome may also occur in prolonged, extensive operations, after transfusion of incompatible blood, heat stroke, acute injury, certain snake bites, and with the administration of certain drugs. The chronic syndrome of intravascular coagulation is much more common and is associated with many diseases, including collagen diseases or immune diseases and malignancy. Many patients with chronic intravascular coagulation have normal or even increased levels of coagulation factors, and these patients have no unusual bleeding. The diagnosis depends on the demonstration of circulating complex of "soluble" fibrin revealed by the ethanol gel and protamine sulfate gelation tests. The secondary fibrinolysis results in elevation of FSP. Many laboratories are investigating the use of other procedures in the diagnosis of intravascular coagulation, including fibrinopeptides A and B, the VIII:C VIIIR:AG ratio, antithrombin III, PF 4, beta-thromboglobulin, D dimer, urinary FSP, and fibrinogen chromatography.

On 26 February 2001, the Cluster spacecraft were outbound over the Northern Hemisphere, at approximately 12:00MLT, approaching the magnetosheath through the high-altitude (and exterior) cusp region. Due to macroscopic motions of the cusp, the spacecraft made multiple entries into the exterior cusp region before exiting into the magnetosheath, presenting an excellent opportunity to utilize the four spacecraft techniques available to the Cluster mission. We present and compare 2 methods of 4-spacecraft boundary analysis, one using PEACE data and one using FGM data. The comparison shows reasonable agreement between the techniques, as well as the expected "single spacecraft" plasma and magnetic signatures when associated with propagated IMF conditions. However, during periods of highly radial IMF (predominantly negative BX GSM), the 4-spacecraft boundary analysis reveals a dynamic and deformed cusp morphology.

Orf is caused by a parapoxvirus. In adults, it is commonly associated with specific occupations, whereas cases in children tend to be associated with household or recreational exposure. Spontaneous recovery usually occurs within 6 weeks. Infection in humans is believed to be through exposure to an infected animal or fomite. We present a case of a 13-month-old boy who was exposed to orf through his mother, a farmer, who had contracted the disease through administering medication to an infected animal. We believe that this may represent only the fifth case of human to human transmission of orf reported in the literature.

A sensor to measure rapidly changing pressures in an explosive air blast requires high bandwidth and high spatial resolution. For such an application a low-cost, electrically isolated sensor is particularly attractive. We describe an optical fibre-based pressure sensor that meets these requirements. The sensor is subjected to an experimental explosive-blast measurement test and the results are discussed with respect to the sensor performance and compared with a simple blast-wave model and conventional pressure transducers.

While most academic inquiry has focused on the new national government in postsocialist Poland, much of the responsibility for establishing democratic institutions and practices and a market economy has been delegated by Parliament (Sejm) to the local level. This has placed extreme stress on the local government arrangement. This study does two things: It examines Sejm's 1990 local government system as implemented in the city of Block and reveals a fractionated structure devoid of important executive authority. It also demonstrates how, in pursuing the city council's growth mandate, the mayor landed a Western clothing manufacturing plant in Plock and, in so doing, established business community linkages which contain key elements of an emerging urban regime.

The physiological mechanism of paradoxical pulse in cardiac tamponade remains controversial. In eight conscious dogs with intact pericardia, ultrasonic dimension transducers assessed biventricular geometry and volumes, while micromanometers measured right ventricular (RV), left ventricular (LV), pleural, and pericardial pressures. With normal inspiration, peak LV pressure fell by 7.7 +/- 1.3 mmHg at control and by 20.3 +/- 3.7 mmHg during tamponade (P < 0.001), consistent with the development of paradoxical pulse. At peak inspiration during tamponade, RV filling increased, the interventricular septum shifted leftward, transeptal pressure became negative, and LV septal arc length (l theta) became smaller than its respective unpreloaded value at maximal vena caval occlusion (l(o)). Analysis of stroke work (SW)-end-diastolic volume (EDV) and end-systolic pressure-volume coordinates at peak inspiration during tamponade revealed that end-systolic pressure was 19.1 +/- 10.2 mmHg below the baseline end-systolic pressure-volume curve (P < 0.01), and SW was 24.2 +/- 8.8% below the baseline SW-EDV curve (P < 0.01), indicating transient inspiratory LV dysfunction. It is proposed that inspiratory leftward interventricular septal shifting at low LV EDV during tamponade completely unloads the septum (l theta < l o), eliminates the septal contribution to global LV SW, results in transient inspiratory LV dysfunction, and contributes to the phenomenon of paradoxical pulse.

Managers living in the Jurassic past find it difficult or impossible to deal with changes demanded by today's environmentally challenged operational arena. The highly technical environmental issues were once thought to be the sole province of the individual with “environmental” in his or her job description. Environmental professionals spent most of their time learning all the regulatory constraints on the company's processes. Sharpening these technical skills has not prepared ESH managers to get things done with others from outside the environmental field. In this article, the author argues that managers must learn to use team empowerment to remain competitive and improve environmental performance.

Necrobiosis lipoidica is a well recognized but comparatively rare cutaneous complication of diabetes mellitus. The aetiology is probably multifactorial with microangiopathy, immune complex formation, abnormal collagen synthesis and breakdown, and altered haemostasis all thought to play a part. Necrobiosis lipoidica often proves very resistant to treatment. We report a case of a 44-year-old woman with ulcerated necrobiosis lipoidica that healed following grafting with a tissue-engineered living dermal tissue.

The heliospheric current sheet (HCS) is a permanent solar wind feature, with well predicted Earth passages, but it can be structured and its main orientation can be highly distorted. We report new observations from 2 spacecraft in the solar wind (supported by observations from 3 spacecraft in the nightside magnetosheath), showing an evolution across the Sun‐Earth line of large field reversals adjacent to the HCS. Contrary to a previously reported multi‐spacecraft event, this case shows that the field inversion structure cannot be assumed to be well preserved and close to planar on the scale of the magnetospheric cross‐section. However, both cases indicate the presence of field reversals in an away sector that is connected to the southern solar magnetic hemisphere but lies unexpectedly above a toward sector. Following the interpretation of the reversals as transient outflowing loops, associated initial flow deviations can be envisaged to account for the HCS deformations.

T-cell mediated inflammation plays an important role in the aetiology of psoriasis. We describe a case of severe recalcitrant psoriasis responding well to combined cyclosporin and basiliximab (Simulect(R) Novartis Pharmaceuticals UK Ltd), an interleukin-2 receptor (IL-2R; CD25) chimeric monoclonal antibody.

Right ventricular failure is a leading cause of death in patients who require the left ventricular assist device. Previous reports suggested right ventricular functional deterioration during left ventricular assist but lacked a method by which right ventricular function could be quantified adequately. This study examined the effects of left ventricular volume unloading on right ventricular systolic function by means of the stroke work/end-diastolic volume relationship, a load-insensitive index of myocardial performance. In 12 anesthetized open-chested dogs, right ventricular and left ventricular pressures were measured with micromanometers while ultrasonic dimension transducers measured left and right ventricular orthogonal diameters. Left ventricular unloading was accomplished with left atrial-to-femoral artery bypass with a centrifugal pump. Data were recorded during transient vena caval occlusion in the control state and with maximal left ventricular unloading by full support by the left ventricular assist device. Modified ellipsoidal geometry was used to calculate simultaneous biventricular volumes, and linear regression analysis of right ventricular stroke work versus end-diastolic volume was used to quantify right ventricular systolic function. Average slope and x intercept of this relationship under control conditions were 2.2 +/- 0.3 X 10(4) erg/ml and 10.7 +/- 5.0 ml, respectively. During full support by the left ventricular assist device (mean flow rate, 2.4 +/- 0.3 L/min), left ventricular end-diastolic volume decreased by 31% (p less than 0.01), left ventricular septal-free wall diameter decreased by 7% (p less than 0.001), and rate of rise of right ventricular peak positive pressure declined by 13% (p less than 0.05). The corresponding slope and x intercept of the right ventricular stroke work/end-diastolic volume relationship during full unloading of left ventricular assist device were 2.3 +/- 0.3 X 0.3 X 10(4) erg/ml and 14.3 +/- 4.8 ml, respectively; these values were not significantly different from control values (p greater than 0.5). Additionally, analysis of right ventricular end-diastolic pressure-volume relationships suggested improved right ventricular chamber compliance, although the effects were small and did not reach statistical significance (p = 0.10). These data imply that marked alterations in biventricular geometry accompanying left ventricular volume unloading by the left ventricular assist device in a normal heart do not significantly alter right ventricular performance characteristics.

Background: Maternal subclinical hypothyroidism is a cause of poor neurodevelopment outcome in the offspring. Although iodine deficiency is the most common cause of hypothyroidism world wide, there are no screening programmes for it in the United Kingdom where the population is assumed to be iodine replete. Objective: To determine the prevalence of reduced iodine intake by measuring urinary iodide concentrations in pregnant and non-pregnant women from the north east of England. Methods: Urinary iodide excretion (UIE) rate was estimated using inductively coupled mass spectrometry in 227 women at 15 weeks gestation and in 227 non-pregnant age matched controls. A reduced intake of iodine is indicated by a concentration in urine of less than 50 μg/l or less than 0.05 μg iodine/mmol creatinine. Results: Eight (3.5%) pregnant women and 13 (5.7%) controls had a reduced iodine/creatinine ratio. These values were higher when UIE was expressed as iodine concentration: 16 (7%) and 20 (8.8%) respectively. Ninety (40%) of the pregnant women had a UIE of 0.05–0.10, which is consistent with borderline deficiency. Conclusion: In this study, 3.5% of pregnant women had evidence of iodine deficiency, and 40% may be borderline deficient. Larger scale studies are required to estimate the true prevalence of iodine deficiency in the United Kingdom.