The SelfSTarT intervention for low back pain patients presenting to first contact physiotherapists: A mixed methods service evaluation.

INTRODUCTION: Globally, back pain is the leading cause of years of disability. In the United Kingdom, over 20 million people live with musculoskeletal (MSK) pain, with low back pain being one of the most common causes. National strategies promote self-management and the use of digital technologies to empower populations. AIMS: To evaluate the uptake and impact of providing the SelfSTart approach (STarT Back and SelfBACK App) when delivered by a First Contact Physiotherapist (FCP) to people presenting with low back pain in primary care. METHODS: Patients presenting with a new episode of low back pain underwent routine assessment and completion of a STarT Back questionnaire. Patients with low/medium scores were offered the SelfBACK App. A control population was provided by the MIDAS-GP study. Patient Experience, outcome measures, healthcare utilisation and retention were captured through the app and clinical systems (EMIS). Interviews with five FCPs explored the experiences of using the SelfSTart approach. RESULTS: SelfSTarT was taken up by almost half (48%) of those to whom it was offered. Compared to MIDAS-GP, users were more likely to be younger, male, in work, and with higher health literacy. SelfSTarT users reported significant improved experiences relating to receiving an agreed care plan and receiving sufficient information. There were no significant differences in treatments offered. FCPs were positive about the app and felt it had value but wanted feedback on patient progress. They recognised that a digital solution would not be suitable for all. CONCLUSION: This approach offers an opportunity to empower and support self-management, using robustly evaluated digital technology.

Detection of human papillomavirus in oral lesions using commercially developed typing kits.

Biopsy material from 20 oral lesions (19 condylomas and 1 squamous papilloma) previously shown to contain human papillomavirus (HPV) 6 and HPV 11 sequences by in situ hybridization were examined using 3 commercially available HPV typing kits. Sensitivity and specificity were compared with in-house methods. Previous in situ hybridization had detected HPV 6b in 11 (55%) of the biopsies, HPV 6 and 11 in 7 (53%) and HPV 11 alone in 1 biopsy. Only one of the commercial assays (assay 1) detected HPV in all 20 biopsies (11 positive for HPV 6b only, 1 for HPV 11 only and 7 for HPV 6b and 11). The wide spectrum probe of assay 2 detected HPV in only 10 (50%) of the biopsies, and in a further 2 biopsies the hybridization results were difficult to interpret because of background staining. Assay 3 used a combined HPV 6/11 probe and detected HPV in 15 (75%) of the biopsies. Clear hybridization signals were demonstrated in the intermediate and upper layers only of squamous epithelium, as expected from the known association of HPV replication with epithelium differentiation. In most specimens background levels were not a problem, and all commercial assays were easy to use. The findings are discussed in the context of the digestion procedures, sensitivity of the probes provided and the conditions of hybridization, all of which would influence the detection of HPV.

Detection of Epstein-Barr virus and human papillomavirus type 16 DNA in hairy leukoplakia by in situ hybridisation and the polymerase chain reaction.

Demonstration of Epstein-Barr virus (EBV) is considered desirable for the accurate diagnosis of hairy leukoplakia (HL). Previous studies have reported possible associations with human papillomavirus (HPV) infection although this is not a universal finding. Presence of EBV and HPV 16 was examined in biopsy specimens from 18 cases of HL and ten control specimens by in situ hybridisation using digoxigenin-labelled synthetic oligonucleotide probes and by the polymerase chain reaction (PCR). The presence of EBV was demonstrated in 12 cases by both techniques. Of the remaining six cases EBV could be detected in three by in situ hybridisation but not by PCR; EBV was not detected by either method in a further three cases. All samples were negative for HPV 16 by both techniques under conditions of high stringency, although when stringency of in situ hybridisation was reduced, four samples appeared to harbour HPV DNA sequences. This study provides further evidence to support the role of EBV in the pathogenesis of HL and suggests that HPV 16 is not regularly encountered.

Hairy leukoplakia in an HIV-negative, nonimmunosuppressed patient.

Oral hairy leukoplakia is an Epstein-Barr virus-associated lesion that is considered to be a marker of immunosuppression. We report a case of oral hairy leukoplakia in a healthy nonimmunosuppressed elderly patient with no evidence of HIV infection on repeated investigation. This report has important implications on our understanding of the significance of this lesion.

Plasminogen activators in normal and malignant oral epithelium in vivo and in vitro.

Urokinase-type (uPA) and tissue-type (tPA) plasminogen activators were identified by fibrinolytic autography in the sulcus epithelium of human gingival mucosa but not in the orthokeratinized gingival epithelium. Fibrinolytic activity was present only over blood vessels in frozen sections of oral squamous cell carcinomas, the malignant epithelial cells showing no plasminogen activator activity. Plasminogen activators could not be demonstrated in either the sulcus or gingival epithelium by immunofluorescence, but both uPA and tPA were found in occasional squamous carcinoma cells. Fibrinolytic activity of culture fluids from epithelial explants grown in vitro from human gingival mucosa showed marked variation, but activity was much higher in the culture supernatants than in the cell lysates. Fibrinolytic activity of culture fluids from epithelial explants of squamous cell carcinomas was low both in supernatants and lysates. Zymogram overlays of sodium dodecyl sulphate-polyacrylamide electrophoretic gels from culture supernatants showed that the low fibrinolytic activity of culture supernatants of oral squamous cell carcinomas was due to the associated presence of plasminogen activator inhibitors. The fibrinolytic activity in the zymogram was due predominantly to uPA but some lysis was due also to tPA.

Multifocal hairy leukoplakia associated with Kaposi's sarcoma.

An HIV-seropositive patient presented with multifocal lesions of both hairy leukoplakia and Kaposi's sarcoma, hairy leukoplakia being present in the epithelium covering the Kaposi's sarcoma lesions. The findings suggest that hairy leukoplakia in immunocompromised patients is both more common and more widely distributed than is generally recognised.

Epstein-Barr virus gene expression and epithelial cell differentiation in oral hairy leukoplakia.

Hairy leukoplakia (HL) is an Epstein-Barr (EB) virus related lesion of oral mucosa that is principally associated with human immunodeficiency virus-induced immunosuppression. To understand the nature of EB virus involvement in these lesions, this study compares the distribution of EB virus DNA and EB viral gene products with the pattern of keratinocyte differentiation in 12 lateral tongue biopsies of HL. Evidence of replicating EB viral infection and abundant virus production was demonstrated in the superficial epithelium of most (92%) samples by means of in situ hybridization and immunocytochemical techniques. Epstein-Barr virus latent membrane protein also was identified in 45% of samples, suggesting that this viral gene product, which is usually associated with EB virus latent infection, may be transiently expressed during viral replication in HL epithelium. The absence of detectable EB virus involvement in basal keratinocytes, however, fails to support the theory that latent infection occurs in basal epithelium. From this study, EB viral gene expression in HL appears to be linked with epithelial maturation. Conversely, the normal patterns of keratinocyte differentiation in these lesions do not appear to be appreciably altered by association with EB virus.

Fine needle cutting biopsy of lesions of the head and neck.

One hundred and twenty-four fine needle cutting biopsies of lesions of the head and neck have been carried out over the last 7 years. While the overall accuracy of diagnosis was 79%, the accuracy of the 43 biopsies carried out during the last 2 years was 93%. These results compare very favourably with published results of the accuracy of fine needle aspiration cytology.

Application of molecular techniques in the rapid diagnosis of EBV-associated oral hairy leukoplakia.

A rapid method for the detection of EBV-DNA in paraffin sections of lesions of oral hairy leukoplakia (OHL) is described. The method makes use of advances in molecular technology, including the use of synthetic oligonucleotides with digoxigenin labelling in an in situ hybridisation (ISH) reaction, which can be completed in 24 h. Using this method, sections from 15 of 17 patients clinically diagnosed as having OHL contained readily detectable EBV-DNA in small foci along the upper layers of the stratum spinosum. The sections examined from the two remaining patients appeared to be EBV-DNA negative but both patients were on AZT therapy and one was in addition receiving acyclovir.

Hairy leukoplakia--a histological study.

Hairy leukoplakia is a recently described oral mucosal condition seen in immunosuppressed individuals, usually in association with HIV infection, when it is thought to be a sign of decreasing immunocompetence. It probably results from reactivation of infection by Epstein-Barr virus (EBV) and usually presents as bilateral white patches on the lateral borders of the tongue. From a histological study of 20 cases we have found that the typical appearance of hairy leukoplakia is of acanthotic, hyperparakeratinized epithelium with Candida hyphae sometimes present in the parakeratin. A band of EBV infected, koilocyte-like cells is present in the upper part of the prickle cell layers, these cells being swollen and pale staining, with prominent cell borders and perinuclear vacuoles. There is a paucity of inflammation in both the epithelium and lamina propria. An atypical appearance shows the koilocyte-like cells lying isolated or in small groups, irregularly arranged in the prickle cell layer and without a hyperparakeratinized surface. Diagnosis of hairy leukoplakia should normally be confirmed by demonstrating EBV in the koilocyte-like cells by immunocytochemistry or DNA in situ hybridization.

Aluminium leaching and fluoride.

Aluminium leaching from cooking utensils is a source of dietary aluminium and there are differing reports in the literature concerning the effects of fluoride ions on aluminium leaching. This paper reports that aluminium leaching may be increased by around 5% when fluoride ion at 1 mg/litre is present. More dramatic increases in aluminium leaching occur if the fluoride ion concentration is increased to 20 mg/litre, but this would rarely, if ever, be found in a culinary situation. At fluoride ion concentrations likely to be encountered in cooking, the increased leaching due to fluoride is very small in relation to the effects of pH on aluminium leaching.

Preparation of the bowel before elective surgery using a polyethylene glycol solution at home and in hospital compared with conventional preparation using magnesium sulphate.

Bowel preparation by conventional methods is time-consuming and unpleasant for both patient and staff. In addition, it requires admission to hospital several days before surgery. Preparation using oral polyethylene glycol solution is more acceptable and can easily be adapted so that the patient can perform the procedure at home before admission to hospital. In a prospective series we have compared the efficacy of preparation at home using polyethylene glycol with similar preparation in hospital and with a standard bowel preparation based on magnesium sulphate. Preparation was better after polyethylene glycol and this was significant when performed at home (P less than 0.01). There was no effect on either electrolytes or haematological parameters, but polyethylene glycol did result in a rise in the number of colonic Streptococcus faecalis seen. This rise was not seen with magnesium sulphate (P less than 0.001).

Is intravenous cholangiography an alternative to the routine per-operative cholangiogram?

Ultrasonography, although an accurate method of detecting stones within the gall bladder, is unreliable for the detection of bile duct stones for which per-operative cholangiography remains the standard investigation. Fifty seven patients undergoing elective cholecystectomy had both a pre-operative intravenous cholangiogram and per-operative cholangiography. The pre-operative investigation is shown to be at least as effective in the detection of common bile duct stones and only missed a duct stone in one patient. The substitution of pre-operative intravenous cholangiography for routine per-operative cholangiography would result in a significant reduction in operating time, may provide advance knowledge on the biliary anatomy and would allow advance planning of the likely procedure. It is suggested that pre-operative intravenous cholangiography, carried out on the day of admission, should be considered as a preferred alternative investigation to per-operative cholangiography.

Haemorrhoids treated by cryotherapy: a critical analysis.

One hundred and four patients with second, third degree or thrombosed prolapsed piles, treated by cryotherapy, were studied pre- and postoperatively. A computer analysis was made of all relevant data such as pile mass, freezing time and results of treatment. The method, which is easy to perform and cost effective, is aided by the use of a specially insulated speculum. To minimise complications such as pain and haemorrhage the ice-ball should be limited to the mucosal part of the haemorrhoid alone. Careful selection of patients will produce good results and a low recurrent rate. It is suggested that valium, fortral and, where necessary, a local anaesthetic should be used and that the patients remain in hospital for one night.

Experimental oral infection of mice with a pathogenic and a non-pathogenic strain of the yeast Candida albicans.

Oral infection by Candida albicans is thought to be related more to host susceptibility than to virulence of the organism. Using a mouse model of oral candidosis, differences in colonization and infection between two strains of C. albicans were demonstrated.

Radical surgery for pilonidal sinus.

Pilonidal sinus disease in 72 patients was treated by radical excision and primary wound closure and the results compared with those other currently practised techniques. A number of factors have been examined in an attempt to identify a group of patients in whom the risk of delayed healing is high.