Clinicians underestimate gastrointestinal symptoms and overestimate quality of life in renal transplant recipients: a multinational survey of nephrologists

Gastrointestinal (GI) symptoms are common in renal transplant recipients and are associated with impaired health-related quality of life (HRQoL). We investigated clinician attitudes to GI symptoms and HRQoL in these patients by surveying 145 nephrologists from Sweden, Denmark, Finland, and Norway. In total, 79 clinicians responded. They estimated that 20% of their patients experienced GI discomfort and that 36% had impaired HRQoL. We previously conducted a survey of the renal transplant recipients treated by these clinicians, in which 92% reported troublesome GI symptoms and 53% had impaired HRQoL compared with the general population. Nephrologists were more likely to manage GI symptoms by reducing immunosuppressant dose (87%) than by switching medication to one with fewer GI side effects (66%). We conclude that clinicians appear to underestimate the prevalence of GI symptoms and impaired HRQoL. Improving patient-clinician communication could lead to more informed management, resulting in better HRQoL and increased graft survival.     

Histologically verified bone wax (beeswax) granuloma after median sternotomy in 17 of 18 autopsy cases

AIM: To evaluate the sternum from ordinary or forensic autopsy cases with a midline sternal cutaneous scar macro- and microscopically and using computed tomography (CT) to detect if the haemostatic bone sealant bone wax (beeswax) had been applied after median sternotomy and if the bone wax had elicited inflammation. METHODS: During a 3-year period, the sterna of 18 consecutive cadavers (15 ordinary autopsies, 3 forensic) who prior to death had undergone surgery with median sternotomy were examined macro- and microscopically and with CT. In addition, one virgin sternum was smeared with bone wax at the upper half after bench sternotomy, sutured and examined with CT. Unused bone wax was examined with CT for attenuation measurements. RESULTS: Macroscopically, bone wax was seen in 17 of 18 sterna. Acute inflammation was found in one, chronic inflammation and foreign body multinucleated giant cells were seen around the bone wax in 17 sterna. No inflammation was found in one. CT could only detect foci in the operated sterna with attenuation values from -45 to +20 Hounsfield units (HU) and values about -80 HU were found in the virgin sternum. Unused bone wax measured about -100 HU. CONCLUSIONS: Bone wax is non-resorbable and induces chronic inflammation in the operated sternum up to 10 years after application. Measurement of Hounsfield units with CT of the operated sterna could not verify bone wax granuloma.     

The impact of the COVID-19 pandemic on the mental health of healthcare workers: study protocol for the COVID-19 HEalth caRe wOrkErS (HEROES) study

Background

Preliminary country-specific reports suggest that the COVID-19 pandemic has a negative impact on the mental health of the healthcare workforce. In this paper, we summarize the protocol of the COVID-19 HEalth caRe wOrkErS (HEROES) study, an ongoing, global initiative, aimed to describe and track longitudinal trajectories of mental health symptoms and disorders among health care workers at different phases of the pandemic across a wide range of countries in Latin America, Europe, Africa, Middle-East, and Asia.

Methods

Participants from various settings, including primary care clinics, hospitals, nursing homes, and mental health facilities, are being enrolled. In 26 countries, we are using a similar study design with harmonized measures to capture data on COVID-19 related exposures and variables of interest during two years of follow-up. Exposures include potential stressors related to working in healthcare during the COVID-19 pandemic, as well as sociodemographic and clinical factors. Primary outcomes of interest include mental health variables such as psychological distress, depressive symptoms, and posttraumatic stress disorders. Other domains of interest include potentially mediating or moderating influences such as workplace conditions, trust in the government, and the country’s income level.

Results

As of August 2021, ~ 34,000 health workers have been recruited. A general characterization of the recruited samples by sociodemographic and workplace variables is presented. Most participating countries have identified several health facilities where they can identify denominators and attain acceptable response rates. Of the 26 countries, 22 are collecting data and 2 plan to start shortly.

Conclusions

This is one of the most extensive global studies on the mental health of healthcare workers during the COVID-19 pandemic, including a variety of countries with diverse economic realities and different levels of severity of pandemic and management. Moreover, unlike most previous studies, we included workers (clinical and non-clinical staff) in a wide range of settings.

     

Long-term follow-up of patellar tendon grafts or hamstring tendon grafts in endoscopic ACL reconstructions

Purpose

Several studies compare the short- and long-term results of anterior cruciate ligament (ACL) reconstruction using bone-patellar tendon-bone (BPTB) graft or double-looped semitendinosus and gracilis (DLSG) graft. However, no studies evaluate the long-term results of BPTB grafts fixed with metal interference screws and DLSG grafts fixed with the Bone Mulch Screw and the Washer Loc. This prospective randomized multicentre study has the null hypothesis that there is no difference in long-term outcome between the two procedures.

Methods

A total of 114 patients with a symptomatic ACL rupture were randomized to reconstruction with either a BPTB graft (N = 58) or a DLSG graft (N = 56). Follow-up was conducted after one, two and seven years. At the seven-year follow-up, 102 of the 114 patients (89%) were available for evaluation; however, 16 of these by telephone-interview only.

Results

Ten patients in the BPTB group and 19 patients in the DLSG group underwent additional knee surgery (P = 0.048), two and three, respectively, of these were ACL revisions (n.s.). The total flexion work was lower in the DLSG group (P = 0.001). The mean peak flexion torque and extension work, however, showed no difference between the groups. No significant differences were found between the groups regarding the Tegner activity score, the Lysholm functional score, the Knee injury and osteoarthritis outcome score (KOOS), subjective knee function, anterior knee pain or mobility. There was no significant difference in laxity between the groups on the Lachman test or the KT-1,000 maximum manual force test.

Conclusions

Both grafts and fixation methods resulted in satisfactory subjective outcome and objective stability. Both these methods can therefore be considered as suitable alternatives for ACL reconstructions.

Level of evidence

II.     

Role of estrogen receptor in regulation of polycyclic aromatic hydrocarbon metabolic activation in lung

Epidemiological and biochemical studies have indicated that females may be at greater risk of smoking associated lung cancer compared with males. Among lung cancer patients, female smokers have been found to have higher levels of PAH-related DNA adducts and CYP1A1 gene expression in their normal lung tissue compared to male smokers. A possible role of steroid hormones in these sex differences via interactions between aryl hydrocarbon receptor and estrogen receptor mediated cellular effects has been suggested. In the present study the impact of the estrogen receptor (ERalpha) on CYP1A1 and CYP1B1 gene expression was studied in vitro in human bronchial epithelial cells. Transient transfection of the BEP2D cell line with ERalpha influenced neither constitutive expression of CYP1A1 or CYP1B1 nor induction of these genes by TCDD as measured by real-time RT-PCR. ERalpha had no effect on the constitutive or TCDD-induced enzymatic activity of CYP1A1 (EROD). We also studied the effect of steroid hormones on lung PAH metabolic activation in A/J mice. Intact and ovariectomized female mice were orally exposed to a single dose of benzo[a]pyrene. Ovariectomy did not influence the levels of either benzo[a]pyrene-derived protein or DNA adducts in the lung tissue measured by HPLC and 32P-postlabeling, respectively. In conclusion, the present data do not support the hypothesis of a role of estrogen or the ERalpha in regulating the metabolic activation of polycyclic aromatic hydrocarbons in lung.     

Upper airway inflammation in waste handlers exposed to bioaerosols

Aims: To examine work associated upper airway inflammation in 31 waste handlers, and to correlate these findings with personally monitored exposure to different bioaerosol components.

Methods: Cell differentials, interleukin 8 (IL-8), myeloperoxidase (MPO), and eosinophilic cationic protein (ECP) were examined in NAL (nasal lavage), and swelling of the nasal mucosa was determined by acoustic rhinometry before work start on Monday and the following Thursday. Bioaerosol exposure was determined by personal full shift exposure measurements on Monday, Tuesday, and Wednesday and analysed for total bacteria, fungal spores, endotoxin, and ß(1→3)-glucans.

Results: The increased percentage of neutrophils from Monday (28%) to Thursday (46%) correlated with increases in ECP (r_S = 0.71, p < 0.001) and MPO (r_S = 0.38, p < 0.05), and showed a close to significant correlation with nasal swelling (r_S = -0.55, p = 0.07). The Thursday levels of neutrophils, MPO, and IL-8 were associated with the exposure to fungal spores (range 0–2.0 x 10⁶/m³) and endotoxin (range 4–183 EU/m³) measured the day before, and the median exposure to ß(1→3)-glucans (range 3–217 ng/m³), respectively (r_S = 0.47–0.54, p < 0.01). Swelling of the nasal mucosa was associated with the fungal spore and ß(1→3)-glucan exposure (r_S = 0.58–0.59, p < 0.05).

Conclusion: These results are based on a relatively small population, and conclusions must be drawn with care. The results suggested that a moderate exposure to fungal spores, endotoxins, and ß(1→3)-glucans during waste handling induced upper airway inflammation dominated by neutrophil infiltration and swelling of the nasal mucosa.