Recommendations on multidisciplinary management of elective surgery in people with haemophilia.

Planning and undertaking elective surgery in people with haemophilia (PWH) is most effective with the involvement of a specialist and experienced multidisciplinary team (MDT) at a haemophilia treatment centre. However, despite extensive best practice guidelines for surgery in PWH, there may exist a gap between guidelines and practical application. For this consensus review, an expert multidisciplinary panel comprising surgeons, haematologists, nurses, physiotherapists and a dental expert was assembled to develop practical approaches to implement the principles of multidisciplinary management of elective surgery for PWH. Careful preoperative planning is paramount for successful elective surgery, including dental examinations, physical assessment and prehabilitation, laboratory testing and the development of haemostasis and pain management plans. A coordinator may be appointed from the MDT to ensure that critical tasks are performed and milestones met to enable surgery to proceed. At all stages, the patient and their parent/caregiver, where appropriate, should be consulted to ensure that their expectations and functional goals are realistic and can be achieved. The planning phase should ensure that surgery proceeds without incident, but the surgical team should be ready to handle unanticipated events. Similarly, the broader MDT must be made aware of events in surgery that may require postoperative plans to be changed. Postoperative rehabilitation should begin soon after surgery, with attention paid to management of haemostasis and pain. Surgery in patients with inhibitors requires even more careful preparation and should only be undertaken by an MDT experienced in this area, at a specialized haemophilia treatment centre with a comprehensive care model.

Autonomic modulation in resistance-trained individuals after acute resistance exercise.

The effects of different types of acute bouts of resistance exercise on autonomic modulation in individuals that are resistance-trained compared to untrained individuals are unknown. Seventeen untrained and 17 resistance-trained participants were assessed for autonomic modulation after various acute resistance exercise bouts. Electrocardiogram readings were collected at rest and 25 min after a control period, whole-, lower-, or upper-body acute bouts of resistance exercise. Heart rate variability and heart rate complexity were used to assess autonomic modulation. Participants were similar for age, height, weight and measures of body composition (p>0.05) and were different for measures of maximal strength (p<0.05). There were no differences (p>0.05) in autonomic modulation at rest between groups. Significant decreases (p<0.05) in parasympathetic modulation after the acute bouts of resistance exercise were noted. Sample entropy was not affected in the untrained group, but was significantly decreased after whole- (-17.5%) and upper-body exercise (-13.5%) in the resistance training group. The changes in sample entropy after lower-body resistance exercise were not significant (-15.7%; p=0.06). These data suggest that resistance exercise training further attenuates the parasympathetic responses to an acute bout of resistance training regardless of the modality compared to the untrained state.

The 3-year evolution of a preschool physical activity intervention through a collaborative partnership between research interventionists and preschool teachers.

Despite evidence that preschoolers spend the majority of their time in sedentary activities, few physical activity interventions have focused on preschool-age children. Health promotion interventions that can be integrated into the daily routines of a school or other setting are more likely to be implemented. The Study of Health and Activity in Preschool Environments employed a flexible approach to increasing physical activity opportunities in preschools' daily schedules through recess, indoor physical activity and physical activity integrated into academic lessons. Eight preschools were randomly assigned to receive the study's physical activity intervention. Teachers in these schools partnered with university-based interventionists across 3 years to design and implement a flexible and adaptive intervention. The intervention approach included trainings and workshops, site visits and feedback from intervention personnel, newsletters, and physical activity equipment and materials. Teachers reported a high acceptability of the intervention. The purpose of this article is to describe the evolution of a multi-component physical activity intervention in preschools, including (i) a description of the intervention components, (ii) an explanation of the intervention process and approach, and (iii) a report of teachers' perceptions of barriers to implementation.

Guidance on the dental management of patients with haemophilia and congenital bleeding disorders.

Recommendations for dental preventive strategies and treatment planning were originally developed through consensus meetings by the Scottish Oral Health Group for Medically Compromised Patients and published in 2003 as a Guideline. The United Kingdom Haemophilia Centre Doctors' Organisation (UKHCDO) Dental Working Party has updated these recommendations following the AGREE II approach (www.agreetrust.org), involving a literature search, a review of national and international guidelines and after seeking the opinions of haemophilia treaters in the United Kingdom by an online survey. Where possible, evidence from the literature is graded according to the 'GRADE' system (www.bcshguidelines.com/bsch_process/evidence_levels_and_grades_of_recommendations/43_grade.html); however, overall there is a lack of robust data and most studies have methodological limitations. The objective of this guidance, which is largely consensus-based, is to assist dental practitioners in primary and secondary care to provide routine dental care for patients of all ages with congenital bleeding diatheses in order to improve overall access to dental care. The guidance may not be appropriate in all cases and individual patient circumstances may dictate an alternative approach. Date for guideline review: May 2016.

Guidelines for the management of hemophilia.

Hemophilia is a rare disorder that is complex to diagnose and to manage. These evidence-based guidelines offer practical recommendations on the diagnosis and general management of hemophilia, as well as the management of complications including musculoskeletal issues, inhibitors, and transfusion-transmitted infections. By compiling these guidelines, the World Federation of Hemophilia aims to assist healthcare providers seeking to initiate and/or maintain hemophilia care programs, encourage practice harmonization around the world and, where recommendations lack adequate evidence, stimulate appropriate studies.

Terahertz emission by diffusion of carriers and metal-mask dipole inhibition of radiation.

Terahertz (THz) radiation can be generated by ultrafast photo-excitation of carriers in a semiconductor partly masked by a gold surface. A simulation of the effect taking into account the diffusion of carriers and the electric field shows that the total net current is approximately zero and cannot account for the THz radiation. Finite element modelling and analytic calculations indicate that the THz emission arises because the metal inhibits the radiation from part of the dipole population, thus creating an asymmetry and therefore a net current. Experimental investigations confirm the simulations and show that metal-mask dipole inhibition can be used to create THz emitters.

Preparation of reference strains for validation and comparison of mycoplasma testing methods.

AIMS: To optimize growth conditions for preparation of stocks of mycoplasma reference strains to obtain highly viable and disperse samples with low ratios of genomic copy (GC) number to that of colony forming units (CFU). These stocks are required for assessment of relative limits of detection (LOD) of alternative nucleic acid testing (NAT)-based methods in comparison to the conventional microbiological methods. METHODS AND RESULTS: A kinetics study was used to assess the changes in ratios between the numbers of GC and CFU at different growth phases of six different mycoplasma cultures Acholeplasma laidlawii, Mycoplasma gallisepticum, Mycoplasma arginini, Mycoplasma fermentans, Mycoplasma orale and Mycoplasma pneumoniae. All tested mycoplasmas demonstrated low GC/CFU ratios (≤ 10) within the log and early stationary growth phases. A significant increase in GC/CFU ratios was observed at the very late stationary and death phases, when the titre of cultures has declined. Similar patterns of GC/CFU profiles were observed for A. laidlawii and Myc. gallisepticum co-cultured with suspension of Chinese hamster ovary (CHO) cells. CONCLUSIONS: Tested mycoplasma strains harvested at the exponential-early stationary phases of growth demonstrated the lowest GC/CFU ratios and low propensity to form filamentous structures or aggregates under proposed conditions and can be used for the preparation of a mycoplasma reference panel for methods comparability study. SIGNIFICANCE AND IMPACT OF THE STUDY: This study shows that the preparation and use of viable mycoplasma reference strains with low CG/CFU ratios is the most reliable way to adequately evaluate the LOD of alternative NAT-based mycoplasma testing methods.

Effects of gonadectomy on performance in operant tasks measuring prefrontal cortical function in adult male rats.

Previous studies have shown that gonadectomy in adult male rats influences the acquisition and performance of spatial and other working memory tasks that depend in part on the medial prefrontal cortex and its dopamine innervation. Stimulated by previous findings that gonadectomy alters dopamine axon density in not only medial but several other prefrontal fields, the present studies asked whether gonadectomy might also broadly impact dopamine-dependent prefrontal functions, and whether these effects bore any relation to hormone modulation of mesoprefrontal dopamine afferents. Specifically, control, gonadectomized, and gonadectomized rats given estradiol or testosterone propionate were tested on a series of operant tasks that together measured medial prefrontal functions of spatial working memory, impulsivity and extradimensional set shifting and orbital prefrontal functions of reversal learning/perseveration and motivation. Afterwards, animals were sacrificed, their bulbospongiosus muscles were removed and weighed, their brains were processed for immunocytochemistry for the dopamine-synthesizing enzyme tyrosine hydroxylase, and axon densities were measured in orbital and medial prefrontal fields. Statistical evaluations of group effects on behavior and regression analyses comparing individual performance with muscle weights and axon density measures revealed androgen-reversible effects of gonadectomy on acquisition of spatial working memory and extradimensional set shifting that were correlated with bulbospongiosus weight and medial prefrontal dopamine axon density, estrogen-sensitive influences of gonadectomy on motivation and response withholding that were correlated with bulbospongiosus weight but not with dopamine innervation, and still other prefrontal functions, i.e., impulsivity, reversal learning, that were insensitive to gonadectomy and unrelated to gonadectomy-induced changes in muscle weight or prefrontal dopamine innervation.

Sodium reduction for hypertension prevention in overweight adults: further results from the Trials of Hypertension Prevention Phase II.

Sodium reduction is efficacious for primary prevention of hypertension, but the feasibility of achieving this effect is unclear. The objective of the paper is detailed analyses of adherence to and effects of the sodium reduction intervention among overweight adults in the Trials of Hypertension Prevention, Phase II. Sodium reduction (comprehensive education and counselling about how to reduce sodium intake) was tested vs no dietary intervention (usual care) for 36-48 months. A total of 956 white and 203 black adults, ages 30-54 years, with diastolic blood pressure 83-89 mmHg, systolic blood pressure (SBP) <140 mmHg, and body weight 110-165% of gender-specific standard weight were included in the study. At 36 months, urinary sodium excretion was 40.4 mmol/24 h (24.4%) lower in sodium reduction compared to usual care participants (P<0.0001), but only 21% of sodium reduction participants achieved the targeted level of sodium excretion below 80 mmol/24 h. Adherence was positively related to attendance at face-to-face contacts. Net decreases in SBP at 6, 18, and 36 months of 2.9 (P<0.001), 2.0 (P<0.001), and 1.3 (P=0.02) mmHg in sodium reduction vs usual care were associated with an overall 18% lower incidence of hypertension (P=0.048); were relatively unchanged by adjustment for ethnicity, gender, age, and baseline blood pressure, BMI, and sodium excretion; and were observed in both black and white men and women. From these beneficial but modest results with highly motivated and extensively counselled individuals, sodium reduction sufficient to favourably influence the population blood pressure distribution will be difficult to achieve without food supply changes.

Staphylococcal species in the oral cavity from patients in a regional burns unit.

The aim of this study was to perform a quantitative and qualitative analysis of oral carriage of staphylococci in a range of oral specimens from patients admitted to a regional burns unit. The study recruited 28 patients and reasons for admittance were: burns (46%), skin grafting (39%), lacerations (7%), scalding (4%) and necrotizing fasciitis (4%). No patient had smoke inhalation injuries or trauma to the oro-pharynx. There were five patients from whom methicillin-sensitive S. aureus (MRSA) could be detected in oral specimens. For three patients only the wound and oral specimens were positive for MRSA. In one patient only the oral specimens were positive for MRSA. There were five patients from whom methicillin-sensitive S. aureus (MRSA) could be detected in the oral specimens. In one patient only the oral specimens were positive for MSSA. Staphylococci could be recovered from the dental plaque, denture and toothbrush specimens with a mean count of 1.1 x 10(4)cfu/mL (range 20-5.3 x 10(4)), 5.4 x 10(3) (range 40-2.1 x 10(4)) and 264 cfu/mL (range 20-500), respectively. Both MSSA and MRSA could be recovered from these specimen types. In one patient only the toothbrush was positive for MRSA and all other oral specimens were negative. This study suggests that staphylococci are not infrequent colonizers of the oral cavity, and that this site may serve as a potential reservoir for transmission to other body sites.

The dental management of adult patients with haemophilia and other congenital bleeding disorders.

The management of adult dental patients with congenital bleeding disorders has caused a considerable number of problems to the dental profession. There is a need to simplify the process and identify what can be safely carried out on a 'shared care' basis in General Dental Practice or the Community Dental Service. Particular problems are discussed with special reference to those requiring hospital care. The Scottish Oral Health Group for Medically Compromised Patients has developed this clinical guidance in conjunction with the Scottish Haemophilia Directors. It is important that dental care is easily available for this group of patients, especially those living at some distance from the regional centres. The aim is to simplify planning dental care for this group of patients and remove a number of myths concerning their management. The hospital departments, both medical and dental, must be available for advice and to arrange for treatment that is inappropriate outside a specialist hospital.

Visual areas and spatial summation in human visual cortex.

Functional MRI measurements can securely partition the human posterior occipital lobe into retinotopically organized visual areas (V1, V2 and V3) with experiments that last only 30 min. Methods for identifying functional areas in the dorsal and ventral aspect of the human occipital cortex, however, have not achieved this level of precision; in fact, different laboratories have produced inconsistent reports concerning the visual areas in dorsal and ventral occipital lobe. We report four findings concerning the visual representation in dorsal regions of occipital cortex. First, cortex near area V3A contains a central field representation that is distinct from the foveal representation at the confluence of areas V1, V2 and V3. Second, adjacent to V3A there is a second visual area, V3B, which represents both the upper and lower quadrants. The central representation in V3B appears to merge with that of V3A, much as the central representations of V1/2/3 come together on the lateral margin of the posterior pole. Third, there is yet another dorsal representation of the central visual field. This representation falls in area V7, which includes a representation of both the upper and lower quadrants of the visual field. Fourth, based on visual field and spatial summation measurements, it appears that the receptive field properties of neurons in area V7 differ from those in areas V3A and V3B.

Long-term weight loss and changes in blood pressure: results of the Trials of Hypertension Prevention, phase II.

BACKGROUND: Weight loss appears to be an effective method for primary prevention of hypertension. However, the long-term effects of weight loss on blood pressure have not been extensively studied. OBJECTIVE: To present detailed results from the weight loss arm of Trials of Hypertension Prevention (TOHP) II. DESIGN: Multicenter, randomized dinical trial testing the efficacy of lifestyle interventions for reducing blood pressure over 3 to 4 years. Participants in TOHP II were randomly assigned to one of four groups. This report focuses only on participants assigned to the weight loss (n = 595) and usual care control (n = 596) groups. PATIENTS: Men and women 30 to 54 years of age who had nonmedicated diastolic blood pressure of 83 to 89 mm Hg and systolic blood pressure less than 140 mm Hg and were 110% to 165% of their ideal body weight at baseline. INTERVENTION: The weight loss intervention included a 3-year program of group meetings and individual counseling focused on dietary change, physical activity, and social support MEASUREMENTS: Weight and blood pressure data were collected every 6 months by staff who were blinded to treatment assignment RESULTS: Mean weight change from baseline in the intervention group was -4.4 kg at 6 months, -2.0 kg at 18 months, and -0.2 kg at 36 months. Mean weight change in the control group at the same time points was 0.1, 0.7, and 1.8 kg. Blood pressure was significantly lower in the intervention group than in the control group at 6, 18, and 36 months. The risk ratio for hypertension in the intervention group was 0.58 (95% CI, 0.36 to 0.94) at 6 months, 0.78 (CI, 0.62 to 1.00) at 18 months, and 0.81 (CI, 0.70 to 0.95) at 36 months. In subgroup analyses, intervention participants who lost at least 4.5 kg at 6 months and maintained this weight reduction for the next 30 months had the greatest reduction in blood pressure and a relative risk for hypertension of 0.35 (CI, 0.20 to 0.59). CONCLUSIONS: Clinically significant long-term reductions in blood pressure and reduced risk for hypertension can be achieved with even modest weight loss.

Flow characteristics of 3 unique ureteral stents: investigation of a Poiseuille flow pattern.

PURPOSE: The pattern of flow in the stented ureter (intraluminal and/or extra luminal) has only been defined for the standard pigtail stent. No data are available on stent flow for any specialty stents. To our knowledge we present the first investigation characterizing the type of flow through a stent (Poiseuille versus nonPoiseuille flow). MATERIALS AND METHODS: Flow was measured in an unstented ureter, a standard 7Fr double pigtail stent and the 7/3Fr Tail stent, 7Fr Spirastent and 14/7Fr endopyelotomy stent using a previously developed stent flow model. In vitro pressure flow studies were also done in nonfenestrated 14/7Fr, Tail and standard 7Fr stents. These stents were infused at a constant flow rate of 2 to 10 ml. per minute with monitoring of the corresponding pressure gradients. Resistance to flow was determined for these stents using pressure flow plots and Poiseuille's law. RESULTS: In vivo the 7Fr pigtail, 14/7Fr endopyelotomy and 7/3Fr Tail stents had statistically similar flow rates. Flow through each of these stents exceeded the flow through an unstented ureter. The Spirastent had the least flow in all categories tested. There was no correlation of Poiseuille flow parameters measured in vitro for nonfenestrated stents with in vivo stent flow. CONCLUSIONS: In stented ureters fluid drains through and around the stent regardless of its design. The flow characteristics of these 3 specialty stents were not predictable according to lumen or stent size. In vitro Poiseuille's flow did not correlate with in vivo stent flow.

Laparoscopic augmentation cystoplasty with different biodegradable grafts in an animal model.

PURPOSE: Recently a variety of biodegradable organic materials have been used for bladder wall replacement. We sought to study the effectiveness of 4 different types of biodegradable materials for bladder augmentation using laparoscopic techniques. MATERIALS AND METHODS: Thirty one minipigs underwent successful transperitoneal laparoscopic partial cystectomy and subsequent closure (6 control) or patch augmentation (25): porcine bowel acellular tissue matrix (ATM) (6), bovine pericardium (BPC) (6), human placental membranes (HPM) (6) or porcine small intestinal submucosa (SIS) (7). An intracorporeal suturing technique with the EndoStitch device (U.S. Surgical, Norwalk, CT) and Lapra-Ty clips (Ethicon, Enodsurgery Inc. Cincinnati, OH) was used to anastomose the graft to the bladder wall. Postoperatively, a urethral catheter was left for one week. Bladders were evaluated by cystoscopy at 6 and 12 weeks and harvested at 12 weeks. RESULTS: Grafts remained in place in all groups except for the BPC group, where all grafts failed to incorporate. For the ATM and SIS groups, at 6 weeks, there was mucosal coverage of the grafts without evidence of encrustation. In the control group, at 12 weeks, the bladder capacity was 23% less than preoperatively. In the ATM, HPM and SIS groups, at 12 weeks, the bladder capacities were larger than preoperatively by 16%, 51% and 43% respectively; also the grafts had contracted to 70%, 65%, and 60% of their original sizes, respectively. Histologically, there was patchy epithelialization of ATM and SIS grafts with a mixture of squamoid and transitional cell epithelia. The graft persisted as a well-vascularized fibrous band in HPM, ATM, and SIS without evidence of significant inflammatory response. CONCLUSION: A laparoscopic technique for partial bladder wall replacement using a free graft is feasible. The biodegradable grafts of ATM, HPM and SIS are tolerated by host bladder and are associated with predominantly only mucosal regeneration at 12 weeks post-operatively.