A Brief Overview of Neurosurgical Management for Breast Cancer Metastasis

Despite advances in chemotherapy and radiation, stage IV breast cancer presents a serious challenge to clinicians in light of the continued poor outcomes for patients. Stage IV breast cancer frequently metastasizes to the brain often necessitating neurosurgical intervention. The goals of the neurosurgeon are to adequately address metastatic disease to the central nervous system, limit morbidity for the patients, while preserving as much neurologic function as possible, and to help guide next steps regarding need for radiation and immunotherapy. In this review, we provide a background overview of the role of neurosurgery in managing stage IV metastatic breast cancer involving the brain, discuss what is known about brain metastasis, and highlight avenues for future study and investigation.

Short communication: Risk factors identified at arrival associated with average daily gain at a grain-fed veal facility: A prospective single cohort study

The primary objective of this prospective cohort study was to identify factors evaluated upon arrival at a grain-fed veal facility that were associated with increased growth. A secondary objective was to determine if the factors associated with average daily gain (ADG) varied between the pre- and postweaning periods. Calves were visually assessed and scored using a standardized health scoring system immediately upon arrival. They were also weighed and vaccinated, and had blood drawn from their jugular vein to determine their serum total protein level. Weights were taken on d 49 and 78 after arrival and were used to calculate ADG. Three mixed linear regression models were created to determine factors associated with ADG from 0 to 49 d after arrival, 0 to 78 d after arrival, and 49 to 78 d after arrival. A total of 998 calves were evaluated and weighed upon arrival; 636 and 915 of those calves were weighed at d 49 and d 78, respectively. Mean ADG were 610 g/d from 0 to 49 d after arrival, 860 g/d from 0 to 78 d after arrival, and 1,240 g/d from 49 to 78 d after arrival. In the model evaluating growth from 0 to 49 d, calves arriving at the facility with a higher body mass index (BMI) gained more weight per day than calves that arrived with a lower BMI. If calves arrived in the spring, they gained 201 g/d more than calves that arrived in the winter. For the period following weaning (d 49 to 78), BMI was also associated with growth. For every additional 1 g/cm² increase in BMI at arrival, calves gained an additional 1.55 g/d from d 49 to 78. Growth from arrival to d 78 was affected solely by BMI. For every 1 g/cm² increase in BMI at arrival, calves gained 1.23 g/d more during the entire observation period. Body mass index and season at arrival affected growth through the initial period at a grain-fed veal facility. Producers should consider these factors, especially BMI, when purchasing calves to maximize the calves' growth potential.

Risk factors identified on arrival associated with morbidity and mortality at a grain-fed veal facility: A prospective, single-cohort study

High levels of morbidity, mortality, and antimicrobial use are common in the veal industry. For the sustainability of the industry, it is important to address these challenges and determine factors that can be used to improve animal health and welfare. The objectives of this prospective observational cohort study were to describe the health status of calves on arrival at a grain-fed veal facility and determine characteristics that were associated with morbidity and mortality. On arrival, the calves were assessed for health abnormalities, weighed, measured for hip height and length from withers to lumbosacral junction, and had blood collected to determine serum total protein level. Body mass index (BMI) was calculated using weight on arrival divided by the sum of the calf's length from withers to lumbosacral junction and hip height. The calves were observed for 77 d after arrival, during which the producer was responsible for recording all antibiotic treatments and mortality. We built Cox proportional hazard models for morbidity and mortality variables. We created 2 morbidity models: 1 for calves that were treated <21 d after arrival at the facility, and 1 for calves that were treated during the 11 wk at the facility. From January to December 2017, 998 calves were evaluated on arrival at the veal rearing facility. A large proportion (68%) were treated with antibiotics in the first 21 d after arrival. The only explanatory variable in the final <21 d morbidity model was BMI: calves with a higher BMI had a lower hazard of being treated for disease in the first 21 d after arrival. A total of 872 calves (87%) were treated at least once over the 11-wk housing period. A calf arriving with a BMI >371.46 g/cm or a serum total protein between 5.8 and 6.2 g/dL had a lower level of morbidity during the observation period. Over the 11-wk housing period, 74 calves (7.5%) died. Calves that arrived at the facility with a fecal score of 2 or a rectal temperature between 38.9 and 39.1°C had a higher hazard of dying; calves that had a BMI of >371 g/cm were less likely to die than calves that had a BMI <330 g/cm. These results point to the importance of assessing calves on arrival at a veal facility as a measure of identifying those at high risk for morbidity and mortality.

Developing more participatory and accountable institutions for health: identifying health system research priorities for the Sustainable Development Goal-era

Health policy and systems research (HPSR) is vital to guiding global institutions, funders, policymakers, activists and implementers in developing and enacting strategies to achieve the Sustainable Development Goals. We undertook a multi-stage participatory process to identify priority research questions relevant to improving accountability within health systems. We conducted interviews (n = 54) and focus group discussions (n = 2) with policymakers from international and national bodies (ministries of health, other government agencies and technical support institutions) across the WHO regions. Respondents were asked to reflect on challenges and current policy discussions related to health systems accountability, and to identify their pressing research needs. We also conducted an overview of reviews (n = 34) to determine the current status of knowledge on health systems accountability and to identify any gaps. We extracted research questions from the policymaker interviews and focus groups (70 questions) and from the overview of reviews (112 questions), and synthesized these into 36 overarching questions. Using the online platform Co-Digital, we invited researchers from around the world to refine and then rank the questions according to research importance. The questions that emerged amongst the top priorities focused on political factors that mediate the adoption or effectiveness of accountability initiatives, processes and incentives that facilitate the acceptability of accountability mechanisms among frontline healthcare providers, and the national governance reforms and contexts that enhance provider accountability. The process revealed different underlying conceptions of social accountability and how best to promote it, with some researchers and policymakers focusing on specific interventions and others embracing a more systems-oriented approach to understanding accountability, the multiple forms that it can take, how these interact with each other and the importance of power and underlying social relations. The findings from this exercise identify HPSR funding priorities and future areas for evidence production and policy engagement.

How are gender inequalities facing India's one million ASHAs being addressed? Policy origins and adaptations for the world's largest all-female community health worker programme

BACKGROUND

India's accredited social health activist (ASHA) programme consists of almost one million female community health workers (CHWs). Launched in 2005, there is now an ASHA in almost every village and across many urban centres who support health system linkages and provide basic health education and care. This paper examines how the programme is seeking to address gender inequalities facing ASHAs, from the programme's policy origins to recent adaptations.

METHODS

We reviewed all publically available government documents (n = 96) as well as published academic literature (n = 122) on the ASHA programme. We also drew from the embedded knowledge of this paper's government-affiliated co-authors, triangulated with key informant interviews (n = 12). Data were analysed thematically through a gender lens.

RESULTS

Given that the initial impetus for the ASHA programme was to address reproductive and child health issues, policymakers viewed volunteer female health workers embedded in communities as best positioned to engage with beneficiaries. From these instrumentalist origins, where the programme was designed to meet health system demands, policy evolved to consider how the health system could better support ASHAs. Policy reforms included an increase in the number and regularity of incentivized tasks, social security measures, and government scholarships for higher education. Residential trainings were initiated to build empowering knowledge and facilitate ASHA solidarity. ASHAs were designated as secretaries of their village health committees, encouraging them to move beyond an all-female sphere and increasing their role in accountability initiatives. Measures to address gender based violence were also recently recommended. Despite these well-intended reforms and the positive gains realized, ongoing tensions and challenges related to their gendered social and employment status remain, requiring continued policy attention and adaptation.

CONCLUSIONS

Gender trade offs and complexities are inherent to sustaining CHW programmes at scale within challenging contexts of patriarchal norms, health system hierarchies, federal governance structures, and evolving aspirations, capacities, and demands from female CHWs. Although still grappling with significant gender inequalities, policy adaptations have increased ASHAs' access to income, knowledge, career progression, community leadership, and safety. Nonetheless, these transformative gains do not mark linear progress, but rather continued adaptations.

Prescribing patterns for psychotic and behavioural symptoms in dementia: a national survey

Aims and Method

To compare current prescribing practice for psychotic and behavioural symptoms in dementia with the available research. An anonymous questionnaire was sent to all members of the Faculty of Old Age Psychiatry, enquiring about preferred drug treatments.

Results

Classical antipsychotics were chosen by 50% for psychotic symptoms over atypical antipsychotics (43%) and were preferred for aggression (48%) and sexual disinhibition (55%). Antidepressants were favoured in treating anxiety (41%) and lability (45%).

Clinical Implications

Alternatives to classical antipsychotics, especially for behavioural symptoms, have yet to be researched satisfactorily. In view of the continued widespread use of classical antipsychotics and recent concerns about their safety, we call for this to be addressed.

Medico-legal implications of drug treatment in dementia: prescribing out of licence

AIMS AND METHOD

There is increasing evidence-based knowledge in the drug treatment of psychotic and behavioural symptoms in dementia, but drugs do not possess a formal licence for these indications. Drug companies, health authorities, NHS trusts and medical defence unions were asked for their advice on the medico-legal implications for the prescribing clinician.

RESULTS

Drug companies, health authorities, medical defence unions and NHS trusts are aware of out-of-licence prescribing and leave ultimate accountability with the clinician. A suggested best practice is that of obtaining the patient's consent.

CLINICAL IMPLICATIONS

Out-of-licence prescribing for psychotic and behavioural symptoms in dementia is widespread. This patient group may be unable to grant consent. The accountability of individual clinicians should be supported by more adequate medico-legal frameworks.

Posttraumatic stress disorder in the World Mental Health Surveys

BACKGROUND

Traumatic events are common globally; however, comprehensive population-based cross-national data on the epidemiology of posttraumatic stress disorder (PTSD), the paradigmatic trauma-related mental disorder, are lacking.

METHODS

Data were analyzed from 26 population surveys in the World Health Organization World Mental Health Surveys. A total of 71 083 respondents ages 18+ participated. The Composite International Diagnostic Interview assessed exposure to traumatic events as well as 30-day, 12-month, and lifetime PTSD. Respondents were also assessed for treatment in the 12 months preceding the survey. Age of onset distributions were examined by country income level. Associations of PTSD were examined with country income, world region, and respondent demographics.

RESULTS

The cross-national lifetime prevalence of PTSD was 3.9% in the total sample and 5.6% among the trauma exposed. Half of respondents with PTSD reported persistent symptoms. Treatment seeking in high-income countries (53.5%) was roughly double that in low-lower middle income (22.8%) and upper-middle income (28.7%) countries. Social disadvantage, including younger age, female sex, being unmarried, being less educated, having lower household income, and being unemployed, was associated with increased risk of lifetime PTSD among the trauma exposed.

CONCLUSIONS

PTSD is prevalent cross-nationally, with half of all global cases being persistent. Only half of those with severe PTSD report receiving any treatment and only a minority receive specialty mental health care. Striking disparities in PTSD treatment exist by country income level. Increasing access to effective treatment, especially in low- and middle-income countries, remains critical for reducing the population burden of PTSD.

ICORG 10-14: NEOadjuvant trial in Adenocarcinoma of the oEsophagus and oesophagoGastric junction International Study (Neo-AEGIS)

BACKGROUND

Neoadjuvant therapy is increasingly the standard of care in the management of locally advanced adenocarcinoma of the oesophagus and junction (AEG). In randomised controlled trials (RCTs), the MAGIC regimen of pre- and postoperative chemotherapy, and the CROSS regimen of preoperative chemotherapy combined with radiation, were superior to surgery only in RCTs that included AEG but were not powered on this cohort. No completed RCT has directly compared neoadjuvant or perioperative chemotherapy and neoadjuvant chemoradiation. The Neo-AEGIS trial, uniquely powered on AEG, and including comprehensive modern staging, compares both these regimens.

METHODS

This open label, multicentre, phase III RCT randomises patients (cT2-3, N0-3, M0) in a 1:1 fashion to receive CROSS protocol (Carboplatin and Paclitaxel with concurrent radiotherapy, 41.4Gy/23Fr, over 5 weeks). The power calculation is a 10% difference in favour of CROSS, powered at 80%, two-sided alpha level of 0.05, requiring 540 patients to be evaluable, 594 to be recruited if a 10% dropout is included (297 in each group). The primary endpoint is overall survival, with a minimum 3-year follow up. Secondary endpoints include: disease free survival, recurrence rates, clinical and pathological response rates, toxicities of induction regimens, post-operative pathology and tumour regression grade, operative in-hospital complications, and health-related quality of life. The trial also affords opportunities for establishing a bio-resource of pre-treatment and resected tumour, and translational research.

DISCUSSION

This RCT directly compares two established treatment regimens, and addresses whether radiation therapy positively impacts on overall survival compared with a standard perioperative chemotherapy regimen Sponsor: Irish Clinical Research Group (ICORG).

TRIAL REGISTRATION

NCT01726452 . Protocol 10-14. Date of registration 06/11/2012.

Mental disorders among college students in the World Health Organization World Mental Health Surveys

BACKGROUND

Although mental disorders are significant predictors of educational attainment throughout the entire educational career, most research on mental disorders among students has focused on the primary and secondary school years.

METHOD

The World Health Organization World Mental Health Surveys were used to examine the associations of mental disorders with college entry and attrition by comparing college students (n = 1572) and non-students in the same age range (18-22 years; n = 4178), including non-students who recently left college without graduating (n = 702) based on surveys in 21 countries (four low/lower-middle income, five upper-middle-income, one lower-middle or upper-middle at the times of two different surveys, and 11 high income). Lifetime and 12-month prevalence and age-of-onset of DSM-IV anxiety, mood, behavioral and substance disorders were assessed with the Composite International Diagnostic Interview (CIDI).

RESULTS

One-fifth (20.3%) of college students had 12-month DSM-IV/CIDI disorders; 83.1% of these cases had pre-matriculation onsets. Disorders with pre-matriculation onsets were more important than those with post-matriculation onsets in predicting subsequent college attrition, with substance disorders and, among women, major depression the most important such disorders. Only 16.4% of students with 12-month disorders received any 12-month healthcare treatment for their mental disorders.

CONCLUSIONS

Mental disorders are common among college students, have onsets that mostly occur prior to college entry, in the case of pre-matriculation disorders are associated with college attrition, and are typically untreated. Detection and effective treatment of these disorders early in the college career might reduce attrition and improve educational and psychosocial functioning.

Effects of long term treatment with high doses of odanacatib on bone mass, bone strength, and remodeling/modeling in newly ovariectomized monkeys

The objectives here were to evaluate the effects of odanacatib (ODN) at doses exceeding the clinical exposure on biomechanical properties of lumbar vertebrae (LV), hip and central femur (CF), and compare ODN to alendronate (ALN) on bone remodeling/modeling in ovariectomized (OVX) monkeys. Ten days post-surgery, animals were treated with vehicle (VEH), ODN-L (2mg/kg/day, p.o.), ODN-H (8/4mg/kg/day), or ALN (30μg/kg/week, s.c.) for 20months. An intact group was also included. ODN-L provided systemic exposures of 1.8-fold of clinical exposure. ODN-H started at 20-fold for 5.5months, and then reduced to 7.8-fold of clinical exposure, compared to ALN at approximated clinical exposure. From cross sectional analyses, LV density and peak load in ODN at both doses or ALN were not different from VEH or Intact. However, cortical thickness of femoral neck (FN) and CF in ODN were higher (21-34%, p<0.05) than VEH, due to smaller endocortical (Ec) perimeter of FN (10-11%; p<0.05) and CF (9-12%; ODN-L, p<0.05), and larger CF periosteal (Ps) perimeter (2-12%; ODN-H, p<0.001) versus VEH. ODN groups also showed slightly higher cortical porosity and Ps non-lamellar bone in CF. ODN-H treatment resulted in higher CF peak load (p<0.05) versus VEH. For all bone sites analyzed, a positive, linear relationship (r(2)=0.46-0.69, p<0.0001) of peak load to density or structural parameters was demonstrated. No treatment-related differences in the derived intrinsic strength properties were evidenced as compared between groups. ALN reduced all remodeling surfaces without affecting Ps modeling. Trabecular and intracortical remodeling were reduced in ODN groups, similar to ALN. Ec mineralizing surface in ODN-H trended to be lower than VEH by month 20, but Ec bone formation indices in ODN groups generally were not different from VEH. Ps modeling in ODN groups was significantly higher than other treatment groups. This study overall demonstrated the bone safety profile of ODN and its unique mechanism on cortical bone supporting the clinical application for osteoporosis treatment.

Is Signature Size Associated With Organ Donor Designation on Driver's Licenses?

INTRODUCTION

Previous studies suggest that large signature size is associated with narcissistic characteristics. By contrast, organ donation is an indicator of altruism. Because altruism and narcissism may be viewed as opposites, we sought to determine if smaller signature size is associated with willingness to be an organ donor.

METHODS

Using a cross-sectional study design, we reviewed the health records of 571 randomly selected primary care patients at a large urban safety-net medical system to obtain their demographic and medical characteristics. We also examined driver's licenses that were scanned into electronic health records as part of the patient registration process. We measured signature sizes and obtained the organ donor designation from these driver's licenses.

RESULTS

Overall, 256 (45%) patients were designated as donors on their driver's licenses. Signature size averaged 113.3 mm(2) but varied greatly across patients (10th percentile 49.1 mm(2), 90th percentile 226.1 mm(2)). On multivariate analysis, donor designation was positively associated with age 18-34 years, non-black race, having private insurance, and not having any comorbid conditions. However, signature size was not associated with organ donor designation.

CONCLUSIONS

Signature size is not associated with verified organ donor designation. Further work is needed to understand the relationship between personality types and willingness to be an organ donor.