Prognostic factors in renal cell carcinoma: association of preoperative sodium concentration with survival.

PURPOSE: Conventional renal cell carcinoma (RCC) has a variable natural history, and determining individual prognosis is important to guide management. We have examined the prognostic significance of a large number of hematologic and biochemical variables, as well as traditional tumor-related factors in patients with RCC. EXPERIMENTAL DESIGN: Patients undergoing nephrectomy for newly diagnosed RCC between September 1998 and March 2005 were invited to participate. Clinical, pathologic, and laboratory data were recorded in each case, and immunophenotyping was carried out on a subset of patients. A planned subset analysis of patients presenting with N0M0 disease was done. RESULTS: Two hundred twelve patients with RCC formed the study population. In addition to tumor-related factors, multivariate analyses revealed preoperative serum sodium concentration to be independently and significantly associated with overall survival and disease-free survival when considered as both a continuous variable and when dichotomized to above and below the median value [139 mmol/L; reference range 135-145 mmol/L, hazard ratio 0.44, 95% confidence interval (95% CI) 0.22-0.88, P = 0.014]. Five-year overall survival estimates for patients above and below the median serum sodium were 67.6% (95% CI 54.2-80.9) and 44.3% (95% CI 32.8-55.8), respectively. These findings persisted in the N0M0 subgroup analysis. CONCLUSIONS: We have confirmed the prognostic value of traditional tumor-related factors but, to our knowledge, these are the first data to show that low preoperative sodium concentration may be an important factor associated with reduced survival in patients with RCC, suggesting that serum sodium should be considered with established prognostic variables in modeling survival in RCC.     

Novel mucosal vaccines generated by genetic conjugation of heterologous proteins to pneumolysin (PLY) from Streptococcus pneumoniae

Induction of immunity at mucosal surfaces is thought to be an essential feature in the protection of the host against the many pathogens that gain access through these surfaces. Here we describe how strong local and systemic immune responses can be generated when proteins are genetically conjugated to pneumolysin (PLY) from Streptococcus pneumoniae. Using green fluorescent protein (eGFP) and PsaA from S. pneumoniae, we have shown that genetic fusion (eGFPPLY and PsaAPLY) is essential to ensure high levels of antigen specific IgG and IgA in the serum and at mucosal surfaces. This form of vaccination is highly effective with antigen specific antibodies detected after a single dose of nanogram quantities of the conjugated proteins. In addition, generation of a non-toxic variant (eGFPΔ6PLY) indicated that while the toxic activity of PLY was not essential for adjuvanticity, it contributed to the magnitude of the response generated. Whilst vaccination with the PsaAPLY fusion proteins did not protect the animals from challenge, these studies confirm the utility of pneumolysin to act as a novel mucosal adjuvant to substantially increase the local and systemic humoral response to genetically fused protein antigens.     

Identification and Characterisation of Pseudomonas 16S Ribosomal DNA from Ileal Biopsies of Children with Crohn's Disease

Molecular analysis of bacterial 16S rRNA genes has made a significant contribution to the identification and characterisation of bacterial flora in the human gut. In particular, this methodology has helped characterise bacterial families implicated in the aetiology of inflammatory bowel disease (IBD). In this study we have used a genus specific bacterial 16S PCR to investigate the prevalence and diversity of Pseudomonas species derived from the ileum of children with Crohn's disease (CD), and from control children with non-inflammatory bowel disease (non-IBD) undergoing their initial endoscopic examination. Fifty eight percent of CD patients (18/32) were positive using the Pseudomonas PCR, while significantly fewer children in the non-IBD group, 33% (12/36), were PCR positive for Pseudomonas (p<0.05, Fischer's exact test). Pseudomonas specific 16S PCR products from 13 CD and 12 non-IBD children were cloned and sequenced. Five hundred and eighty one sequences were generated and used for the comparative analysis of Pseudomonas diversity between CD and non-IBD patients. Pseudomonas species were less diverse in CD patients compared with non-IBD patients. In particular P.aeruginosa was only identified in non-IBD patients.     

Zero tolerance: A policy in conflict with current opinion on aggression and violence management in health care

Aggression and violence are common in the emergency department setting. In recent years, there has been a greater recognition of this problem with State Governments in Australia responding with zero tolerance policies. This paper examines the current recommendations from nursing and medical literature with regard to the minimisation and management of aggression and violence in health care. A consistent theme throughout the literature is that early recognition and use of de-escalation strategies aimed at diffusing a volatile situation is the preferred approach. Use of restraint and a zero tolerance approach are last resort measures. It is important to have practical policies, protocols and procedures in place to manage aggression and violence in the emergency department. An emphasis on training and skill development, particularly communication and negotiation strategies, is imperative for all health care professionals.     

Preparedness of emergency departments in northwest England for managing chemical incidents: a structured interview survey

Background

Ocular injuries are common in survivors of terror incidents that involve the use of explosive materials. These explosives are commonly of a High Explosive type (HE) and may be fashioned into improvised explosive devices (IED) that incorporate additional materials to maximise trauma and injuries. Serial IED explosions have occurred in commuter trains in several cities including London and Madrid but data on ocular injuries is limited. We report the ocular injuries of the survivors of a series of IED explosions in crowded commuter trains.

Methods

28 patients (56 eyes, 28 male, ages ranging from 22 to 52 years (mean 35.27 years) were screened in the triage area or the Intensive Care Unit (ICU). Testing included bedside visual acuity testing, torchlight examination of the anterior segment and dilated (or if necessary, undilated) fundus examination. Selected patients underwent B-scan examination, magnetic resonance imaging of the brain, orbits and the optic nerves or visual evoked potential assessment. The injuries, investigations and procedures were entered into the patient's case sheet as well as into a standardised format suggested by the Indian eye injury registry (IER).

Results

16 of 28 patients (57.1%) had ocular injuries whereas 12 (42.8%) were found to be normal. Injuries were seen unilaterally in 10 patients and bilaterally in six yielding a total of 22 injured eyes. The common injuries were periorbital haemorrhages (09 eyes, 40%); first or second degree burns to the upper or lower lids (seen in 07 eyes, 31.8 %) and corneal injuries (seen in 08 eyes, 36.3%). Open globe injuries were seen in two eyes of two patients (09%). One patient (4.5%) had a traumatic optic neuropathy.

Conclusion

Ophthalmologists and traumatologists should be aware of these patterns of ocular injuries. Protocols need to include the screening of large numbers of patients in a short time, diagnostic tests (B scan, visual evoked potential (VEP) etc) and early surgery preferably at the initial triage itself as most of the serious injuries in our studies had been missed or not treated at an initial assessment.     

Services for children with developmental co-ordination disorder: an evaluation against best practice principles

Purpose: The National Health Service in Scotland published a best practice framework to support occupational therapists and physiotherapists to deliver effective services for children with developmental co-ordination disorder (DCD); however, adherence is variable. To highlight areas for development, this study compared the care pathway within a paediatric DCD service against the NHS Scotland framework. Methods: A partnership of researchers and clinicians based in the United Kingdom conducted a qualitative study with 37 participants (N?=?13 interview participants, N?=?24 workshop participants). In-depth interviews and/or workshops were used to map the DCD service against the NHS framework. Identified gaps were aligned with four key stages of the care pathway. Qualitative analysis software was used to analyse the data. Results: Core principles to guide future development were identified for each phase of the pathway. These core principles related to the NHS framework and focused on issues such as involving the family, defining clear pathways and enhancing children’s participation. Participants identified potential strategies for service improvement such as developing community-based interventions and information provision. Conclusion: Challenges when providing services for children with DCD include confusing service pathways and poor partnership working. It is, therefore, important that clinicians utilise collaborative working strategies that support children’s participation.

• Implications for Rehabilitation

• There are numerous challenges related to the implementation of best practice principles into the provision of therapy services for children with developmental coordination disorder (DCD).

• It is important that AHPs seek ways of engaging parents and educational professionals at all stages of the care pathway in order to ensure optimum service provision for the child.

• Addressing participation is an important aspect and community-based strategies may be particularly beneficial, both as a preventative activity and as an intervention approach.

     

“You’ve got to breathe,you know” – asthma patients and carers’ perceptions around purchase and use of asthma preventer medicines

Objective : To explore influences on patients’ purchase and use of asthma preventer medicines and the perceived acceptability of financial incentives via reduced patient co‐payments. Methods : Semi‐structured telephone or face‐to‐face interviews were conducted with adults and carers of children with asthma. Interviews were recorded, transcribed verbatim and coded. Data were analysed using thematic analysis via grounded theory. Results : Twenty‐four adults and 20 carers for children aged 3–17 years with asthma were interviewed. For medicines choice, most participants did not consider themselves the primary decision‐maker; cost of medicines was an issue for some, but effectiveness was described as more important. For adherence, cost, side‐effects, perceived benefit and patient behaviours were important. Conclusions : Patient barriers to adherence with asthma preventer medicines including cost are ongoing. Healthcare professionals need to encourage empathic discussion with patients about cost issues. Implications for public health : Asthma patients and carers could benefit from greater involvement and respect within shared decision‐making. Healthcare professionals should be aware that cost may be a barrier for patient adherence, and provided with information about the relative costs of guideline‐recommended asthma medicines. Patients and healthcare professionals need education around the efficacy of ICS‐alone treatment and the rationale behind co‐payments, for initiatives around quality use of medicines to succeed.