Quantitative Characterization of α-Synuclein Aggregation in Living Cells through Automated Microfluidics Feedback Control

Aggregation of α-synuclein and formation of inclusions are hallmarks of Parkinson’s disease (PD). Aggregate formation is affected by cellular environment, but it has been studied almost exclusively in cell-free systems. We quantitatively analyzed α-synuclein inclusion formation and clearance in a yeast cell model of PD expressing either wild-type (WT) α-synuclein or the disease-associated A53T mutant from the galactose (Gal)-inducible promoter. A computer-controlled microfluidics device regulated α-synuclein in cells by means of closed-loop feedback control. We demonstrated that inclusion formation is strictly concentration dependent and that the aggregation threshold of the A53T mutant is about half of the WT α-synuclein (56%). We chemically modulated the proteasomal and autophagic pathways and demonstrated that autophagy is the main determinant of A53T α-synuclein inclusions’ clearance. In addition to proposing a technology to overcome current limitations in dynamically regulating protein expression levels, our results contribute to the biology of PD and have relevance for therapeutic applications.

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In silico feedback control enables regulation of α-synuclein expression in yeast

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α-Synuclein inclusion formation is strictly concentration, but not time, dependent

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The aggregation threshold of the α-synuclein A53T mutant is 56% of the wild-type

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Autophagy induction speeds up inclusion clearance in the A53T α-synuclein strain

The impact of participatory arts in promoting social relationships for older people within care homes

AIMS

Loneliness and social isolation negatively affect wellbeing and quality of life. Despite the proximity of others, older people living in care homes often experience loneliness and social isolation. The impact of participatory arts on wellbeing is widely acknowledged; however, relational impacts have received less attention. This article explores the impact of participatory arts in care homes on the social relationships between older people and older people and care staff.

METHODS

'Creative Journeys', an initiative led by Essex County Council, provides opportunities for older people living in care homes to participate in arts activities. In this study, three arts organisations (reminiscence arts, seated dance, and orchestral music participation) delivered participatory arts in three homes. Stage 1 of the research comprised mixed-methods case studies in each home. Stage 2 involved an online survey across care homes in Essex to provide a broader perspective, with follow-up interviews in three further homes, and a focus group with the arts organisations. Findings presented here focus on the qualitative data around the impact of participatory arts on the social relationships in care homes between older people and older people and care staff.

RESULTS

Participatory arts enhanced social relationships between older people and between older people and care staff in care homes. Through engagement in shared experiences leading to increased communication and interaction, participatory arts facilitated social connectedness between residents, and changed the relationship dynamics between older people and care staff, thus promoting reciprocity.

CONCLUSION

Participatory arts enable older people to express themselves creatively, and make meaningful contributions to their social relationships. Policy makers and those working in the care sector should consider including participatory arts as an integral and necessary component of quality care for older people living in care homes.

Prospective assessment of resection margin status following pancreaticoduodenectomy for pancreatic ductal adenocarcinoma after standardisation of margin definitions

BACKGROUND

Surgical resection remains the only curative treatment for pancreatic ductal adenocarcinoma (PDAC). The prognostic value of resection margin status following pancreatoduodenectomy (PD) remains controversial. Standardised pathological assessment increases positive margins but limited data is available on the significance of involved margins. We investigated the impact of resection margin status in PDAC on patient outcome.

METHOD

We identified all patients with PD for PDAC at one pancreatic cancer centre between August 2008 and December 2014. Demographic, operative, adjuvant therapeutic and survival data was obtained. Pathology data including resection margin status of specific anatomic margins was collected and analysed.

RESULTS

107 patients were included, all pathologically staged as T3 with 102 N1. 87.9% of patients were R1 of which 53.3% showed direct extension to the resection margin. Median survival for R0 patients versus R1<1 mm and R1 = 0 mm was 28.4 versus 15.4 and 25.1 versus 13.4 months. R1 = 0 mm status remained a predictor of poor outcome on multivariate analysis. Evaluation of individual margins (R1<1 mm) showed the SMV and SMA margins were associated with poorer overall survival. Multiple involved margins impacted negatively on outcome. SMA margin patient outcome with R1 = 1-1.9 mm was similar to R1=>2 mm.

CONCLUSION

Using an R1 definition of <1 mm and standardised pathology we demonstrate that R1 rates in PDAC can approach 90%. R1 = 0 mm remained an independent prognostic factor for overall survival. Using R1<1 mm we have shown that involvement of medial margins and multiple margins has significant negative impact on overall survival. We conclude that not all margin positivity has the same prognostic significance.

Regional anaesthesia practice for arteriovenous fistula formation surgery

We conducted a survey and semi‐structured qualitative interviews to investigate current anaesthetic practice for arteriovenous fistula formation surgery in the UK. Responses were received from 39 out of 59 vascular centres where arteriovenous access surgery is performed, a response rate of 66%. Thirty‐five centres reported routine use of brachial plexus blocks, but variation in anaesthetic skill‐mix and practice were observed. Interviews were conducted with 19 clinicians from 10 NHS Trusts including anaesthetists, vascular access and renal nurses, surgeons and nephrologists. Thematic analysis identified five key findings: (1) current anaesthetic practice showed that centres could be classified as ‘regional anaesthesia dominant’ or ‘local anaesthesia/mixed’; (2) decision making around mode of anaesthesia highlighted the key role of surgeons as frontline decision makers across both centre types; (3) perceived barriers and facilitators of regional block use included clinicians’ beliefs and preferences, resource considerations and patients’ treatment preferences; (4) anaesthetists’ preference for supraclavicular blocks emerged, alongside acknowledgement of varied practice; (5) there was widespread support for a future randomised controlled trial, although clinician equipoise issues and logistical/resource‐related concerns were viewed as potential challenges. The use of regional anaesthesia for arteriovenous fistula formation in the UK is varied and influenced by a multitude of factors. Despite the availability of anaesthetists capable of performing regional blocks, there are other limiting factors that influence the routine use of this technique. The study also highlighted the perceived need for a large multicentre, randomised controlled trial to provide an evidence base to inform current practice.

Characterising radium-226 particles from legacy contamination to support radiation dose assessments

Radioactive particles are physically discrete sources of radioactivity that have been released into the environment as a result of past emergencies, events and practices. As the release of radioactive particles is often unplanned, the source term has not been characterised, and the potential radiation doses have not been prospectively assessed. If a plausible exposure pathway exists, radioactive particles in the environment may present a hazard to the public depending on their radiological, physical and chemical characteristics. Given their physically discrete nature, standard assessment approaches such as dispersion and transfer modelling of liquid and gaseous radioactive releases, are not appropriate for radioactive particles. The challenge for national regulatory authorities is to calculate potential radiation doses from unplanned releases of radioactive particles into the environment, assess whether the doses are relevant to radiological protection and decide whether actions are required to reduce potential doses. To address this challenge, this paper presents the approach being adopted to radiologically, physically and chemically characterise Ra-226 particles from a contaminated legacy site using gamma spectrometry, optical macroscopy and SEM-EDS. The use of particle characterisation data to support radiation dose assessments is discussed and consideration is given to radioactive particles in the context of radiological protection.

Dynamics of genomic architecture during composite breed development in cattle

Some livestock breeds face the challenge of reduced genetic variation, increased inbreeding depression owing to genetic drift and selection. Hybridization can reverse these processes and increase levels of productivity and adaptation to various environmental stressors. Samples from American Brangus were used to evaluate the indicine/taurine composition through nine generations (~45 years) after the hybridization process was completed. The purpose was to determine how hybridization alters allelic combinations of a breed over time when genetic factors such as selection and drift are operating. Furthermore, we explored genomic regions with deviations from the expected composition from the progenitor breeds and related these regions to traits under selection. The Brangus composition deviated from the theoretical expectation, defined by the breed association, of 62.5% taurine, showing taurine composition to be 70.4 ± 0.6%. Taurine and indicine proportion were not consistent across chromosomes. Furthermore, these non‐uniform areas were found to be associated with traits that were probably under selection such as intermuscular fat and average daily gain. Interestingly, the sex chromosomes were predominantly taurine, which could be due to the composite being formed particularly in the final cross that resulted in progeny designated as purebred Brangus. This work demonstrated the process of new breed formation on a genomic level. It suggests that factors like genetic drift, selection and complementarity shift the genetic architecture into a uniquely different population. These findings are important to better understand how hybridization and crossbreeding systems shape the genetic architecture of composite populations.

Assessment of Intrafraction Motion of the Urinary Bladder Using Magnetic Resonance Imaging (cineMRI)

AIM

To assess the intrafraction motion of the urinary bladder and delineate the appropriate margin size for radiotherapy planning, for both the full and empty bladder.

MATERIALS AND METHODS

This was a single-site, single-arm study of 20 patients planned to undergo radical cystectomy for histologically confirmed muscle-invasive bladder cancer. Patients underwent magnetic resonance imaging (cineMRI) of the entire pelvis using a 3-Tesla system, prior to cystectomy. Patients first underwent a cineMRI with a full bladder, then voided and underwent a second MRI with an empty bladder. All MRI sequences were acquired over 18 min. We assessed the differences in bladder filling and subsequent bladder wall displacement, between the empty and full bladder, during a time period consistent with radiotherapy treatment delivery.

RESULTS

Twenty patients underwent cineMRI of the entire pelvis. The maximum mean directional displacements of the bladder walls over the 18 min duration of the scan for the empty bladders were 9.8 mm superiorly, 1.1 mm inferiorly, 2.39 mm anteriorly, 3.73 mm posteriorly, 2.74 mm to the left and 2.48 mm to the right. The maximal mean displacements for the full bladders were 9.2 mm superiorly, 1.1 mm inferiorly, 2.28 mm anteriorly, 1.08 mm posteriorly, 1.85 mm to the left and 1.73 mm to the right. Statistically significant differences were seen in the posterior, left and right displacements but were quantitatively small.

CONCLUSIONS

Intrafractional motion secondary to bladder filling showed minimal variation between the full and empty bladder. Similar clinical target volume to planning target volume margins can be applied for the delivery of radiotherapy for a full and empty bladder.

The TRAPP complex mediates secretion arrest induced by stress granule assembly

The TRAnsport Protein Particle (TRAPP) complex controls multiple membrane trafficking steps and is strategically positioned to mediate cell adaptation to diverse environmental conditions, including acute stress. We have identified the TRAPP complex as a component of a branch of the integrated stress response that impinges on the early secretory pathway. The TRAPP complex associates with and drives the recruitment of the COPII coat to stress granules (SGs) leading to vesiculation of the Golgi complex and arrest of ER export. The relocation of the TRAPP complex and COPII to SGs only occurs in cycling cells and is CDK1/2-dependent, being driven by the interaction of TRAPP with hnRNPK, a CDK substrate that associates with SGs when phosphorylated. In addition, CDK1/2 inhibition impairs TRAPP complex/COPII relocation to SGs while stabilizing them at ER exit sites. Importantly, the TRAPP complex controls the maturation of SGs. SGs that assemble in TRAPP-depleted cells are smaller and are no longer able to recruit RACK1 and Raptor, two TRAPP-interactive signaling proteins, sensitizing cells to stress-induced apoptosis.

Correlations between patient-perceived outcome and objectively-measured biomechanical change following Total Knee Replacement

BACKGROUND

Total Knee Replacement (TKR) surgery is being utilised in a younger, more active population with greater functional expectations. Understanding whether patient-perceived measures of function reflect objective biomechanical measures is critical in understanding whether functional limitations can be adequately captured within a clinical setting.

RESEARCH QUESTION

Do changes in objective gait biomechanics measures reflect patient-reported outcome measures at approximately 12 months following TKR surgery?

METHODS

Three-dimensional gait analysis was performed on 41 patients with OA who were scheduled for TKR surgery, 22 of which have returned for a (9-24 month) follow-up assessment. Principal Component Analysis was used to define features of variation between OA subjects and an additional 31 non-pathological control subjects. These were used to train the Cardiff Classifier, an objective classification technique, and subsequently quantify changes following TKR surgery. Patient-perceived changes were also assessed using the Oxford Knee Score (OKS), Knee Outcome Survey (KOS), and Pain Audit Collection System scores (PACS). Pearson and Spearman correlation coefficients were calculated to establish the relationship between changes in objectively-measured and perceived outcome.

RESULTS

Objective measures of biomechanical change were strongly correlated to changes in OKS(r=-0.695, p < 0.001) and KOS(r=-.810, p < 0.001) assessed outcomes. Pain (PACS) was only related to biomechanical function post-operatively (r=-.623, p = 0.003).

SIGNIFICANCE

In this biomechanics study, the relationship between changes in objective function and patient-reported measures pre to post TKR surgery is stronger than in studies which did not include biomechanics metrics. Quality of movement may hold more significance for a patient's perception of improvement than functional measures which consider only the time taken or distance travelled during functional activities.

Correction: Safety and utility of image-guided research biopsies in relapsed high-grade serous ovarian carcinoma-experience of the BriTROC consortium

This article was originally published under a CC BY NC SA License, but has now been made available under a CC BY 4.0 License.

A sea change in our view of overturning in the subpolar North Atlantic

To provide an observational basis for the Intergovernmental Panel on Climate Change projections of a slowing Atlantic meridional overturning circulation (MOC) in the 21st century, the Overturning in the Subpolar North Atlantic Program (OSNAP) observing system was launched in the summer of 2014. The first 21-month record reveals a highly variable overturning circulation responsible for the majority of the heat and freshwater transport across the OSNAP line. In a departure from the prevailing view that changes in deep water formation in the Labrador Sea dominate MOC variability, these results suggest that the conversion of warm, salty, shallow Atlantic waters into colder, fresher, deep waters that move southward in the Irminger and Iceland basins is largely responsible for overturning and its variability in the subpolar basin.

Impact on short-lived climate forcers (SLCFs) from a realistic land-use change scenario via changes in biogenic emissions

More than one quarter of natural forests have been cleared by humans to make way for other land-uses, with changes to forest cover projected to continue. The climate impact of land-use change (LUC) is dependent upon the relative strength of several biogeophysical and biogeochemical effects. In addition to affecting the surface albedo and exchanging carbon dioxide (CO₂) and moisture with the atmosphere, vegetation emits biogenic volatile organic compounds (BVOCs), altering the formation of short-lived climate forcers (SLCFs) including aerosol, ozone (O₃) and methane (CH₄). Once emitted, BVOCs are rapidly oxidised by O₃, and the hydroxyl (OH) and nitrate (NO₃) radicals. These oxidation reactions yield secondary organic products which are implicated in the formation and growth of aerosol particles and are estimated to have a negative radiative effect on the climate (i.e. a cooling). These reactions also deplete OH, increasing the atmospheric lifetime of CH₄, and directly affect concentrations of O₃; the latter two being greenhouse gases which impose a positive radiative effect (i.e. a warming) on the climate. Our previous work assessing idealised deforestation scenarios found a positive radiative effect due to changes in SLCFs; however, since the radiative effects associated with changes to SLCFs result from a combination of non-linear processes it may not be appropriate to scale radiative effects from complete deforestation scenarios according to the deforestation extent. Here we combine a land-surface model, a chemical transport model, a global aerosol model, and a radiative transfer model to assess the net radiative effect of changes in SLCFs due to historical LUC between the years 1850 and 2000.

Towards prevention of post-traumatic osteoarthritis: report from an international expert working group on considerations for the design and conduct of interventional studies following acute knee injury

OBJECTIVE

There are few guidelines for clinical trials of interventions for prevention of post-traumatic osteoarthritis (PTOA), reflecting challenges in this area. An international multi-disciplinary expert group including patients was convened to generate points to consider for the design and conduct of interventional studies following acute knee injury.

DESIGN

An evidence review on acute knee injury interventional studies to prevent PTOA was presented to the group, alongside overviews of challenges in this area, including potential targets, biomarkers and imaging. Working groups considered pre-identified key areas: eligibility criteria and outcomes, biomarkers, injury definition and intervention timing including multi-modality interventions. Consensus agreement within the group on points to consider was generated and is reported here after iterative review by all contributors.

RESULTS

The evidence review identified 37 studies. Study duration and outcomes varied widely and 70% examined surgical interventions. Considerations were grouped into three areas: justification of inclusion criteria including the classification of injury and participant age (as people over 35 may have pre-existing OA); careful consideration in the selection and timing of outcomes or biomarkers; definition of the intervention(s)/comparator(s) and the appropriate time-window for intervention (considerations may be particular to intervention type). Areas for further research included demonstrating the utility of patient-reported outcomes, biomarkers and imaging outcomes from ancillary/cohort studies in this area, and development of surrogate clinical trial endpoints that shorten the duration of clinical trials and are acceptable to regulatory agencies.

CONCLUSIONS

These considerations represent the first international consensus on the conduct of interventional studies following acute knee joint trauma.

Nebulised recombinant activated factor VII (rFVIIa) does not attenuate the haemorrhagic effects of blast lung injury

Introduction

Primary blast lung injury causes intrapulmonary haemorrhage. A number of case reports have suggested the efficacy of recombinant activated factor VII (rFVIIa) in the treatment of diffuse alveolar haemorrhage from a range of medical causes, but its efficacy in blast lung is unknown. The aim of this study was to investigate whether nebulised rFVIIa attenuates the haemorrhagic effects of blast lung injury in an animal model.

Methods

Terminally anaesthetised rabbits subjected to blast lung injury were randomised to receive either rFVIIa or placebo via a nebuliser. The primary outcome was the level of blood iron–transferrin complex, a marker of the extent of blast lung injury, analysed using low temperature electron paramagnetic resonance spectroscopy.

Results

Blast exposure led to a significant fall in iron-bound transferrin in both groups of animals (p<0.001), which remained depressed during the study. There were no significant differences in iron–transferrin between the rFVIIa and placebo treatment groups over the duration of the study (p=0.081), and there was no trend towards elevated iron–transferrin in the rFVIIa-treated group once drug treatment had started. There was suggestive evidence of systemic absorption of rFVIIa given via the inhaled route.

Conclusion

A single dose of nebulised rFVIIa did not attenuate pulmonary haemorrhage in a rabbit model of blast lung injury. As there was some evidence of systemic absorption, the inhaled route does not avoid the concern about potential thromboembolic complications from administration of rFVIIa.

Music for Wellness: An 8-Week Study of the Psychosocial Effects of Music Therapy on Cancer Patients

Background: Music therapy offers patients a way to address the psycho-social impacts of a cancer diagnosis and treatment. Research suggests that complementary therapies, such as music and art therapy, provide an opportunity for patients to express their emotions and make meaning of their experiences, as well as providing social connections to other patients. A better understanding of the specific benefits that may be achieved from these programs and the mechanism through which this might occur will help us better tailor services to patients' needs. While an increasing number of cancer care centers now offer complementary therapies as a way to support patients with cancer, there are few prospective evaluations that examine the benefits derived from program completion beyond patient satisfaction measures. Aim: The aim of this project is to examine the impact of music therapy on specific patient reported outcomes and the factors that influence how and why this occurs. Methods: Participants in an 8-week group music therapy program will be asked to complete a suite of measures prior to program commencement, and at 1-week and 1-month postprogram completion. Measures include core constructs of well-being such as distress, quality of life and symptom severity, as well as constructs specifically targeted by the music therapy program, such as meaning making, emotional expression and social connectedness. A waitlist control will provide comparison data at comparable time-points. Results: The music therapy program will run from April-May 2018, with the postprogram evaluation being completed in June 2018. Preliminary data will be presented and the suitability of this method will be considered. Conclusion: In the context of a comprehensive cancer center in Victoria, Australia, we will present data on the effectiveness of a music therapy program for addressing patients' well-being. We will discuss implications for the provision of supportive care for cancer patients and survivors and how the design of future programs might be tailored to achieve key outcomes.

Women's Cancer Screening in Haiti: Increasing Access by Bringing Services to the Workplace

Background: Cervical cancer is the leading cause of cancer-related death in Haiti yet the country does not provide sufficient screening. Working class women in Haiti are less likely to receive cancer screening or education than the poorest quartile of women. This is an untouched demographic not necessarily because of financial burdens but because most women work 6 days weekly and lack the time to seek healthcare and appropriate screening. Innovating Health International (IHI) and Share Hope recently implemented a cancer screening program using vaginal HPV self-swabs and clinical breast exams for working class women in Port-au-Prince. Aim: To not only bring much needed cervical cancer education, screening and treatment to an unreached demographic but also to assess the plausibility and acceptance by female factory workers to receive routine screening and treatment in clinics that reside within the workplace. Methods: The project began in September 2017 and will run for 12 months with plans to screen 4000 women with vaginal HPV swabs (QIAGEN careHPV) and clinical breast exams. Nurses perform clinical breast exam, teach self-breast exam, and instruct patients how to perform vaginal self-swab in the factory infirmary. Inclusion criteria for women include age 30 to 50 years. Women who screen positive for HPV will then be followed with visual inspection of the cervix with acetic acid (VIA) and thermocoagulation. Those who have suspicious masses in their breast have a breast ultrasound performed at the factory clinic. A smaller percentage of women with advanced disease will be referred to outside gynecology clinics. Results: Data collection is half-way completed and we´ll present full data in October. Over 3122 women have participated and received education on women's health issues during their lunch hour at the factories. Of all those sensitized, 2691 or 86.1% chose to have clinical breast exam. Of those who are eligible for HPV screening, 1948 or 93.8% of those eligible accepted testing. Of those tested, 344 or 16% were HPV-positive and all but a 5 completed VIA. For women who are HPV-positive, 69 or 20% were also VIA positive. All HPV-positive women received thermocoagulation except for 2, who were referred for colposcopy and loop electrocautery excisional procedure. There were 141 women who had a positive clinical breast exam and underwent breast ultrasound with only 2 requiring a biopsy. Conclusion: We seek to expand access to cervical cancer screening for the rural and working poor through using mobile health technologies coupled with community-based education and screening. HPV-positive women can undergo treatment by a traveling nurse with portable thermocoagulation therapy where they live or work, without the need to travel or leave work. With no doctor, no electricity, no pelvic exam for most women, and no stable infrastructure, we can screen women in rural areas and the working poor at their place of employment.

Triaging for Supportive Care Services: Do People Want and Accept Referral?

Background: Distress is the 6th vital sign in cancer yet it is only assessed in an ad hoc way in most cancer services. The Distress Thermometer (DT) and the associated Problem Checklist (PC) are the most widely available tools although few studies report on how they are used to effectively triage services. Aim: To explore the link between distress assessment, problem identification, referral to specific supportive care services by staff, and service uptake by cancer patients and survivors among a sample of people attending a major cancer hospital in Victoria Australia. Methods: A secondary analysis of quality assurance audit data were undertaken using data collected from patient medical records between January 2013 and June 2014. Data extracted were; age, sex, post code, language spoken, disease and treatment information, distress as measured by the DT and problems as identified by the PC. For the current study the focus was on the number of referrals offered and the number accepted or declined. The type of services referred to was also examined. Results: Data were collected for 877 patients although missing data resulted in a final sample size of 853. Only data associated with the first DT of each patient are presented. 729 patients (86%) participated in distress screening. The distress threshold of 4 was reported by 50% of participants, highlighting the prevalence of distress requiring support. This 50% reported an average of 9 problems on the PC, many of which came from the physical domain, with 91% reporting at least 1 physical problem. Other problems reported were emotional (74% of the sample); practical (24%), family (14%) and spiritual (2%). Referral data, which was available for 614 people, indicated that over 60% (372) were offered at least one referral. Referral offer was significantly predicted by DT score, and number of problems reported. Acceptance was significantly related to total number of problems, treatment type, and type of referral; referral for physical treatment was most likely to be accepted (87%) whereas referral for emotional support was least likely (53%). Conclusion: Routine distress screening and problem identification are critical to triaging to supportive care services. In a tertiary care setting, not all people will be screened or will want to be screened; not all people will be referred to services; and not all people will accept referral. Nonetheless, problems are extensive with most survivors reporting experiencing several problems. Despite a focus on the physical, these problems extend to other domains, including the emotional, and it is important that services are available to support these needs.

Chemical and structural data of (1,2,3-triazol-4-yl)pyridine-containing coordination compounds

The data presented in this paper are related to the research article entitled “Novel dichloro(bis{2-[1-(4-methylphenyl)-1H-1,2,3-triazol-4-yl-κN³]pyridine-κN})metal(II) coordination compounds of seven transition metals (Mn, Fe, Co, Ni, Cu, Zn and Cd)” (Conradie et al., 2018) [1]. This paper presents characterization and structural data of the 2-(1-(4-methyl-phenyl)-1H-1,2,3-triazol-1-yl)pyridine ligand (L²) (Tawfiq et al., 2014) [2] as well as seven dichloro(bis{2-[1-(4-methylphenyl)-1H-1,2,3-triazol-4-yl-κN³]pyridine-κN})metal(II) coordination compounds, [M(L²)₂Cl₂], all containing the same ligand but coordinated to different metal ions. The data illustrate the shift in IR, UV/VIS, and NMR (for diamagnetic complexes) peaks when L is coordinated to the metals, as well as the influence of the different metals on the peak positions. Solid state structural data is presented for M = Ni and Zn, while density functional theory calculated energies, structures and optimized coordinates are provided for the lowest energy cis and trans conformations for L² as well as [M(L²)₂Cl₂] with M = Mn, Fe, Co, Ni, Cu, Zn and Cd.

Benefits and risks of adjuvant treatment with zoledronic acid in stage II/III breast cancer. 10 years follow-up of the AZURE randomized clinical trial (BIG 01/04)

Adjuvant bisphosphonates improve disease outcomes in postmenopausal early breast cancer (EBC) but the long-term effects are poorly described. The AZURE trial (ISRCTN79831382) was designed to determine whether adjuvant zoledronic acid (ZOL) improves disease outcomes in EBC. Previous analyses showed no effect on overall outcomes but identified benefits in postmenopausal women. Here we present the long-term risks and benefits of adjuvant ZOL with 10-years follow-up.

Patients and methods

3360 patients with stage II/III breast cancer were included in an academic, international, phase III, randomized, open label trial. Patients were followed up on a regular schedule until 10 years. Patients were randomized on a 1:1 basis to standard adjuvant systemic therapy +/− intravenous ZOL 4 mg every 3–4 weeks x6, and then at reduced frequency to complete 5 years treatment. The primary outcome was disease free survival (DFS). Secondary outcomes included invasive DFS (IDFS), overall survival (OS), sites of recurrence, skeletal morbidity and treatment outcomes according to primary tumor amplification of the transcription factor, MAF. Pre-planned subgroup analyses focused on interactions between menopausal status and treatment effects.

Results

With a median follow up of 117 months [IQR 70.4–120.4), DFS and IDFS were similar in both arms (HR_DFS= 0.94, 95%CI = 0.84–1.06, p = 0.340; HR_IDFS= 0.91, 95%CI = 0.82–1.02, p = 0.116). However, outcomes remain improved with ZOL in postmenopausal women (HR_DFS= 0.82, 95%CI = 0.67–1.00; HR_IDFS= 0.78, 95%CI = 0.64–0.94). In the 79% of tested women with a MAF FISH negative tumor, ZOL improved IDFS (HR_IDFS= 0.75, 95%CI = 0.58–0.97) and OS HR_OS= 0.69, 95%CI = 0.50–0.94), irrespective of menopause. ZOL did not improve disease outcomes in MAF FISH + tumors. Bone metastases as a first DFS recurrence (B_DFS) were reduced with ZOL (HR_B-DFS= 0.76, 95%CI = 0.63–0.92, p = 0.005). ZOL reduced skeletal morbidity with fewer fractures and skeletal events after disease recurrence. 30 cases of osteonecrosis of the jaw in the ZOL arm (1.8%) have occurred.

Conclusions

Disease benefits with adjuvant ZOL in postmenopausal early breast cancer persist at 10 years of follow-up. The biomarker MAF identified a patient subgroup that derived benefit from ZOL irrespective of menopausal status.

Adjuvant zoledronic acid reduces fractures in breast cancer patients; an AZURE (BIG 01/04) study

The fracture impact of adjuvant bisphosphonates in breast cancer is not defined with most trials reporting changes in bone mineral density as a surrogate. The AZURE trial (ISRCTN79831382) evaluated the impact of adjuvant zoledronic acid (ZOL) on fractures. The AZURE trial is an academic, multi-centre, randomised phase III study evaluating the addition of ZOL 4 mg to standard therapy (neo/adjuvant chemotherapy and/or endocrine therapy) for 5 years (administered by intravenous (iv) infusion every 3-4 weeks for 6 doses, then 3 monthly × 8 and 6 monthly × 5) in patients with stage II/III early breast cancer. Fracture data collected as part of skeletal-related adverse event reporting were analysed after a median of 84.2 months of follow-up and 966 disease-free survival (DFS) events. We assessed number of fractures, time-to-first fracture and the incidence of fractures before and after disease recurrence. Two hundred forty-four patients reported ≥1 fracture, 140 (8.3%) in the control arm (171 fractures) and 104 (6.2%) in the ZOL arm (120 fractures). Of the 291 fractures reported, 207 fractures occurred in the absence of recurrence (control 111, ZOL 96), 80 after recurrence (control 59, ZOL 21). The 5-year fracture rate was reduced from 5.9% (95%CI 4.8, 7.1%; control) to 3.8% (95%CI 2.9, 4.7%) with ZOL. ZOL significantly increased time-to-first fracture (HR 0.69, 95%CI 0.53-0.90; P = 0.0053) but the majority of fracture prevention benefit occurred after a DFS event (HR 0.3; 95%CI 0.17, 0.53; P < 0.001). Fracture benefits from ZOL were similar across menopausal sub-groups. In conclusion, adjuvant ZOL reduced the risk of clinical fractures, the majority of this protection occurred after disease recurrence.

Effectiveness of Early Hematopoietic Stem Cell Transplantation in Preventing Neurocognitive Decline in Mucopolysaccharidosis Type II: A Case Series

The early progressive form of the X-linked disorder, Hunter syndrome or mucopolysaccharidosis type II (MPS II) (OMIM #309900), is characterized by cognitive decline, and pulmonary and cardiac complications that often cause death before 20 years of age. Deficiency of the lysosomal enzyme, iduronate-2-sulfatase (EC 3.1.6.13) results in deposition of the glycosaminoglycans, dermatan, and heparan sulfate in various tissues. In recent years, enzyme replacement therapy (ERT) has become the mainstay of treatment, but is expensive and ineffective in arresting cognitive decline. Hematopoietic stem cell transplantation (HSCT) also provides enzyme replacement, and may be effective in stabilizing neurocognitive function if initiated early, though data are limited. We present a case series of four patients who demonstrated neurocognitive stabilization with early HSCT. HSCT is a potentially underutilized treatment strategy for select groups of MPS II patients.

Connecting the dots between breast cancer, obesity and alcohol consumption in middle-aged women: ecological and case control studies

Background

Breast cancer (BC) incidence in Australian women aged 45 to 64 years (‘middle-aged’) has tripled in the past 50 years, along with increasing alcohol consumption and obesity in middle-age women. Alcohol and obesity have been individually associated with BC but little is known about how these factors might interact. Chronic psychological stress has been associated with, but not causally linked to, BC. Here, alcohol could represent the ‘missing link’ – reflecting self-medication. Using an exploratory cross-sectional design, we investigated inter-correlations of alcohol intake and overweight/obesity and their association with BC incidence in middle-aged women. We also explored the role of stress and various lifestyle factors in these relationships.

Methods

We analysed population data on BC incidence, alcohol consumption, overweight/obesity, and psychological stress. A case control study was conducted using an online survey. Cases (n = 80) were diagnosed with BC and controls (n = 235) were women in the same age range with no BC history. Participants reported lifestyle data (including alcohol consumption, weight history) over consecutive 10-year life periods. Data were analysed using a range of bivariate and multivariate techniques including correlation matrices, multivariate binomial regressions and multilevel logistic regression.

Results

Ecological inter-correlations were found between BC and alcohol consumption and between BC and obesity but not between other variables in the matrix. Strong pairwise correlations were found between stress and alcohol and between stress and obesity.

BMI tended to be higher in cases relative to controls across reported life history. Alcohol consumption was not associated with case-control status. Few correlations were found between lifestyle factors and stress, although smoking and alcohol consumption were correlated in some periods. Obesity occurring during the ages of 31 to 40 years emerged as an independent predictor of BC (OR 3.5 95% CI: 1.3–9.4).

Conclusions

This study provides ecological evidence correlating obesity and alcohol consumption with BC incidence. Case-control findings suggest lifetime BMI may be important with particular risk associated with obesity prior to 40 years of age. Stress was ecologically linked to alcohol and obesity but not to BC incidence and was differentially correlated with alcohol and smoking among cases and controls. Our findings support prevention efforts targeting weight in women below 40 years of age and, potentially, lifelong alcohol consumption to reduce BC risk in middle-aged women.

Mental health inpatients' and staff members' suggestions for reducing physical restraint: A qualitative study

WHAT IS KNOWN ON THE SUBJECT?: Restraint has negative psychological, physical and relational consequences for mental health patients and staff. Restraint reduction interventions have been developed (e.g., "Safewards"). Limited qualitative research has explored suggestions on how to reduce physical restraint (and feasibility issues with implementing interventions) from those directly involved. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: This paper explores mental health patients' and staff members' suggestions for reducing physical restraint, whilst addressing barriers to implementing these. Findings centred on four themes: improving communication and relationships; staffing factors; environment and space; and activities and distraction. Not all suggestions are addressed by currently available interventions. Barriers to implementation were identified, centring on a lack of time and/or resources; with the provision of more time for staff to spend with patients and implement interventions seen as essential to reducing physical restraint. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Improving communication and relationships between staff/patients, making staffing-related changes, improving ward environments and providing patient activities are central to restraint reduction in mental healthcare. Fundamental issues related to understaffing, high staff turnover, and lack of time and resources need addressing in order for suggestions to be successfully implemented.

ABSTRACT

Introduction Physical restraint has negative consequences for all involved, and international calls for its reduction have emerged. Some restraint reduction interventions have been developed, but limited qualitative research explores suggestions on how to reduce physical restraint (and feasibility issues with implementation) from those directly involved. Aims To explore mental health patients' and staff members' suggestions for reducing physical restraint. Methods Interviews were conducted with 13 inpatients and 22 staff members with experience of restraint on adult mental health inpatient wards in one UK National Health Service Trust. Results Findings centred on four overarching themes: improving communication and relationships between staff/patients; making staff-related changes; improving ward environments/spaces; and having more activities. However, concerns were raised around practicalities/feasibility of their implementation. Discussion Continued research is needed into best ways to reduce physical restraint, with an emphasis on feasibility/practicality and how to make time in busy ward environments. Implications for Practice Improving communication and relationships between staff/patients, making staffing-related changes, improving ward environments and providing patient activities are central to restraint reduction in mental healthcare. However, fundamental issues related to understaffing, high staff turnover and lack of time/resources need addressing in order for these suggestions to be successfully implemented.