Gastrointestinal toxicities following radiation therapy for localized prostate cancer

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Background: Radiation therapy (RAD) is commonly employed to treat localized prostate cancer; however, representative data regarding treatment related toxicities compared to conservative management (CM) is sparse.

Methods: We performed a population-based cohort study, using Medicare claims data linked to the Surveillance, Epidemiology, and End Results data, to evaluate gastrointestinal (GI) toxicities in men aged 65-85 years treated with either primary RAD or CM for T1-T2 prostate cancer diagnosed in 1992-2005. In this study, only GI toxicities requiring interventional procedures occurring after 6 months of cancer diagnosis were included. Competing risk models were used with the following covariates: year of diagnosis, comorbidity, age, tumor stage, cancer grade, hormone use within 1 year of diagnosis, region, race, poverty and marital status.

Results: Among 41,859 patients in this study, 28,021 patients received radiation therapy, 19,287 with external beam radiation therapy (EBRT) alone, and 5,138 with brachytherapy alone. The most common GI toxicity was GI bleeding or ulceration. GI toxicity rates were 6.1% after 3D-conformal therapy (3D-CRT), 2.8% after intensity modulated radiation therapy (IMRT), 2.6% after brachytherapy, 8.2% after proton therapy and 1.1% for CM patients. In the multivariate models, RAD group was associated with a higher hazard of GI toxicities (hazard ratio [HR] 4.68; 95% CI, 3, 93-5.58) than CM. Comparing to 3D-CRT, brachytherapy (HR 0.62; 95% CI, 0.51-0.75) and IMRT (HR 0.67; 95% CI, 0.55-0.82) are associated with a lower hazard of GI toxicities, while proton therapy is associated with a higher hazard of GI toxicities (HR 2.15; 95% CI, 1.45-3.17).

Conclusions: Radiation therapy is associated with a higher risk of GI toxicities than CM. Among different modalities of radiation therapy, protons therapy is associated with the highest risk of GI toxicities, followed by 3D-CRT, IMRT, and brachytherapy. The increased GI toxicities for patients with proton therapy may reflect a learning curve in the early years.

No significant financial relationships to disclose.

The establishment of stimulus control by instructions and by differential reinforcement

A repeated acquisition design was used to study the effects of instructions and differential reinforcement on the performance of complex chains by undergraduates. The chains required responding on a series of keys that corresponded to characters that appeared on a monitor. Each day, subjects performed a new chain in a learning session and later relearned the same chain in a test session. Experiment 1 replicated previous research by showing that instructional stimuli paired with the correct responses in the learning sessions, combined with differential reinforcement in both learning and test sessions, resulted in stimulus control by the characters in each link. Experiment 2 separated the effects of instructional stimuli and differential reinforcement, and showed that stimulus control by the characters could be established solely by differential reinforcement during the test sessions. Experiment 3 showed that when a rule specified the relation between learning and test sessions, some subjects performed accurately in the test sessions without exposure to any differential consequences. This rule apparently altered the stimulus control properties of the characters much as did differential reinforcement during testing. However, compared to differential reinforcement, the rule established stimulus control more quickly.

Assessment of dose from faecal measurement data

At AWE, an annual faecal sample forms part of the internal monitoring strategy for insoluble forms of plutonium. The setting of a derived investigation level (DIL) and assessment of doses from results for faecal samples can pose some difficulties in view of uncertainties related to: (a) the time and number of intakes during the monitoring period and (b) the result from a single sample. This paper uses Monte Carlo simulation to investigate the activity that would be expected in faeces following varying numbers of intake events during the monitoring period. The variation in faecal activity of a long-term excretor is also investigated. The implications of the results for the setting of the DIL and assessment of dose are discussed.

The impact of ice-skating injuries on orthopaedic admissions in a regional hospital

Since the opening of a temporary ice-rink in our hospital's catchment area, we have observed an increase in patients requiring in-patient treatment for orthopaedic intervention. The authors performed a prospective analysis of all patients admitted to our unit over a one-month period. Epidemiological data, wearing of protective gear and skater experience were collected. Fracture type, treatment required, average length of hospital stay and number of days missed from work was also recorded. Ice-skating injuries accounted for 7.7% of our total admissions over the study period. There was a significant variation noted in the types of fracture sustained ranging from comminuted fractures of the radial head to spiral fractures of the tibia. The average length of hospital stay was 2.6 days and average time missed from work was 6.1 weeks. This paper highlights the potential serious injuries that can occur in ice-skating and their impact on admissions to our orthopaedic unit.

Defining the needs of patients with intellectual disabilities in the high security psychiatric hospitals in England

BACKGROUND

Previous studies have suggested that a substantial proportion of the patients with intellectual disabilities (ID) in the high security psychiatric hospitals (HSPHs) should be transferred to more appropriate services to cater for their specific needs in the longer term.

METHOD

The individual and placement needs of high secure psychiatric patients detained under the legal category of mental impairment or severe mental impairment were assessed in a cross-sectional survey.

RESULTS

Patients had a large number of needs (on average 10.8), about a third of which were rated as unmet and therefore represented significant continuing problems. Approximately one-third of the sample could be moved out of HSPHs if appropriate alternatives were available. Factors associated with the continued need for high security included higher treatment and security needs, younger age, recent violent conduct and their index offence profile.

CONCLUSIONS

High security services are still required for a number of patients with ID. New and existing services need to be configured to meet specific profiles of need and provide long-term rehabilitation and specialist care.

DECLARATION OF INTEREST

This was part of a larger project funded by grants from the High Security Psychiatric Services Commissioning Board and Department of Health.

Theory of mind and mentalizing ability in antisocial personality disorders with and without psychopathy

BACKGROUND

The literature on Theory of Mind (ToM) in antisocial samples is limited despite evidence that the neural substrates of theory of mind task involve the same circuits implicated in the pathogenesis of antisocial behaviour.

METHOD

Eighty-nine male DSM-IV Antisocial Personality Disordered subjects (ASPDs) and 20 controls (matched for age and IQ) completed a battery of ToM tasks. The ASPD group was categorized into psychopathic and non-psychopathic groups based on a cut-off score of 18 on the Psychopathy Checklist: Screening Version.

RESULTS

There were no significant group (control v. psychopath v. non-psychopathic ASPD) differences on basic tests of ToM but both psychopathic and non-psychopathic ASPDs performed worse on subtle tests of mentalizing ability (faux pas tasks). ASPDs can detect and understand faux pas, but show an indifference to the impact of faux pas. On the face/eye task non-psychopathic ASPDs showed impairments in the recognition of basic emotions compared with controls and psychopathic ASPDs. For complex emotions, no significant group differences were detected largely due to task difficulty.

CONCLUSIONS

The deficits in mentalizing ability in ASPD are subtle. For the majority of criminals with ASPD and psychopathy ToM abilities are relatively intact and may have an adaptive function in maintaining a criminal lifestyle. Our findings suggest the key deficits appear to relate more to their lack of concern about the impact on potential victims than the inability to take a victim perspective. The findings tentatively also suggest that ASPDs with neurotic features may be more impaired in mentalizing ability than their low anxious psychopathic counterparts.

The Gene Ontology (GO) database and informatics resource

The Gene Ontology (GO) project (http://www. geneontology.org/) provides structured, controlled vocabularies and classifications that cover several domains of molecular and cellular biology and are freely available for community use in the annotation of genes, gene products and sequences. Many model organism databases and genome annotation groups use the GO and contribute their annotation sets to the GO resource. The GO database integrates the vocabularies and contributed annotations and provides full access to this information in several formats. Members of the GO Consortium continually work collectively, involving outside experts as needed, to expand and update the GO vocabularies. The GO Web resource also provides access to extensive documentation about the GO project and links to applications that use GO data for functional analyses.

Sprinting on a running track: a rare cause of a Lisfranc dislocation

We present a case report of a young man who sustained a serious foot injury while sprinting in a straight line. We discuss the management of these injuries and emphasise the importance of a high index of suspicion amongst orthopaedic, casualty and radiology trainees.

Response inhibition and impulsivity: an fMRI study

Aggressive, suicidal and violent behaviour have been associated with impulsive personality and difficulty in inhibiting responses. We used functional magnetic resonance imaging (fMRI) of the whole brain to examine the neural correlates of response inhibition in 19 normal subjects as they performed a Go/NoGo task. Subjects completed Eysenck's Impulsivity Scale, Barratt's Impulsivity Scale (BIS) and behavioural impulsivity tasks. Associations between blood oxygen level dependent (BOLD) response, trait impulsivity, task performance and National Adult Reading Test (NART) IQ were investigated. Neural response during response inhibition was most prominent in the right lateral orbitofrontal cortex. Responses were also seen in superior temporal gyrus, medial orbitofrontal cortex, cingulate gyrus, and inferior parietal lobule, predominantly on the right side. Subjects with greater scores on impulsivity scales and who made more errors had greater activation of paralimbic areas during response inhibition, while less impulsive individuals and those with least errors activated higher order association areas. Exploratory factor analysis of orbital activations, personality measures and errors of commission did not reveal a unitary dimension of impulsivity. However, the strong association between posterior orbital activation and Eysenck's impulsivity score on a single factor suggests that greater engagement of right orbitofrontal cortex was needed to maintain behavioural inhibition in impulsive individuals. Lower IQ was more important than impulsivity scores in determining errors of commission during the task. Neuroimaging of brain activity during the Go/NoGo task may be useful in understanding the functional neuroanatomy and associated neurochemistry of response inhibition. It may also allow study of the effects of physical and psychological interventions on response inhibition in clinical conditions such as antisocial personality disorder.

Violence risk assessment: combining actuarial and clinical information to structure clinical judgements for the formulation and management of risk

Throughout history most societies have assumed a link between mental disorder and violence to others. In recent times there has been increasing concern in the United Kingdom over law and order, specifically the risk of violence, and these issues are now high on the political and mental health agenda. Nurses and staff working in National Health Service Mental Health Service Trusts are the groups most at risk of violence. Many clinical decisions are based on risk. Mental health nurses play a pivotal role in the assessment and management of risk and it is argued that they need to adopt a clear structured approach to violence risk assessment and management, which is evidence-based. The advantages of clinical and actuarial approaches to risk assessment are briefly reviewed and a structured clinical judgement approach is proposed that combines these approaches. A method of linking the assessment process with the management plan via a risk formulation is discussed.

Comparative analysis of the complete genome sequences of Helicoverpa zea and Helicoverpa armigera single-nucleocapsid nucleopolyhedroviruses

The complete nucleotide sequence of Helicoverpa zea single-nucleocapsid nucleopolyhedrovirus (HzSNPV) has been determined (130869 bp) and compared to the nucleotide sequence of Helicoverpa armigera (Ha) SNPV. These two genomes are very similar in their nucleotide (97% identity) and amino acid (99% identity) sequences. The coding regions are much more conserved than the non-coding regions. In HzSNPV/HaSNPV, the 63 open reading frames (ORFs) present in all baculoviruses sequenced so far are much more conserved than other ORFs. HzSNPV has four additional small ORFs compared with HaSNPV, one of these (Hz42) being in a correct transcriptional context. The major differences between HzSNPV and HaSNPV are found in the sequence and organization of the homologous regions (hrs) and the baculovirus repeat ORFs (bro genes). The sequence identity between the HzSNPV and HaSNPV hrs ranges from 90% (hr1) to almost 100% (hr5) and the hrs differ in the presence/absence of one or more type A and/or B repeats. The three HzSNPV bro genes differ significantly from those in HaSNPV and may have been acquired independently in the ancestral past. The sequence data suggest strongly that HzSNPV and HaSNPV are variants of the same virus species, a conclusion that is supported by the physical and biological data.

Comparison between clinical and radiologic outcome measures after reconstruction of acetabular fractures

OBJECTIVES

To compare clinical and radiologic outcome measures in patients after reconstruction of acetabular fractures and to investigate whether an objective radiologic outcome could be used as a proxy for a clinical outcome.

DESIGN

Follow-up survey with retrospective analysis of consecutive case records.

PATIENTS AND INTERVENTION

Over a ten-year period, 201 consecutive patients had open reduction and internal fixation of acetabular fractures performed by a single surgeon. The outcome measures on 166 fractures were available for analysis when the twenty-six patients who were lost to follow-up and the fourteen patients who had salvage total hip replacement were excluded.

MAIN OUTCOME MEASUREMENTS

The assessment of patients was performed by one of two independent assessors, who used the Merle d'Aubigné (1954) clinical outcome score and a radiologic score of degenerative hip disease (Matta, 1994).

RESULTS

Although the overall correlation between the clinical and radiologic outcome grades was good (r = 0.63, p < 0.001), their agreement (i.e., the prediction of a specific clinical outcome by a corresponding radiologic one) was poor (Kappa = 0.24). The authors found that the clinical scoring system was difficult to apply specifically to acetabular trauma in 29 percent of fractures because of complications related to associated injuries. When the individual Merle d'Aubigné scores for pain, range of motion, and walking were correlated with the radiologic score, it was found that the walking score had a significant association with the radiologic score and the pain and range of movement scores.

CONCLUSIONS

The Merle d'Aubigné score has shortcomings as an outcome measure for acetabular fractures. Our aim to use a radiologic outcome as a proxy for this clinical grading system was not realized, but we propose that the patient's walking ability could be used as an objective local outcome measurement.

Serotonergic and cognitive impairment in impulsive aggressive personality disordered offenders: are there implications for treatment?

BACKGROUND

Reduced serotonin (5-HT) function and deficits on neuropsychological tasks have been separately reported in antisocial populations. We investigated whether these impairments are independent or associated factors underlying impulsivity in aggressive personality disordered (PD) offenders and healthy controls and whether there are associated changes in quantitative brain measures.

METHODS

This study reports on the findings from a sample of 51 PD offenders and 24 controls, recruited from maximum security psychiatric hospitals, who were characterized using the Special Hospital Assessment of Personality and Socialisation (SHAPS). Subjects underwent assessment of 5-HT function (prolactin response to D-fenfluramine challenge), neuropsychological testing and had a diagnostic MRI scan. Of this sample 19 controls and 24 patients also had quantitative measurement of frontal and temporal lobe volumes on magnetic resonance imaging (MRI).

RESULTS

Non-psychopathic (low-impulsive) aggressive PDs had enhanced 5-HT function compared with controls and highly impulsive aggressive psychopaths. Primary and secondary psychopaths had poorer executive/frontal, but not memory/temporal neuropsychological function than controls and non-psychopaths. There were no significant group differences in frontal or temporal lobe brain volumes. Although impulsivity and aggression are correlated constructs impulsivity appeared to be related to both executive function and 5-HT function, while aggression only correlated inversely with executive/frontal and memory/temporal function. 5-HT did not directly correlate with frontal or temporal volume or function.

CONCLUSION

Impulsivity appears to be contributed to by both impaired neuropsychological function and 5-HT function. Impaired neuropsychological function alone makes a contribution to aggression. Treatment needs to take account of the neuropsychological and biochemical deficits in this challenging population.

The genome of the natural genetic engineer Agrobacterium tumefaciens C58

The 5.67-megabase genome of the plant pathogen Agrobacterium tumefaciens C58 consists of a circular chromosome, a linear chromosome, and two plasmids. Extensive orthology and nucleotide colinearity between the genomes of A. tumefaciens and the plant symbiont Sinorhizobium meliloti suggest a recent evolutionary divergence. Their similarities include metabolic, transport, and regulatory systems that promote survival in the highly competitive rhizosphere; differences are apparent in their genome structure and virulence gene complement. Availability of the A. tumefaciens sequence will facilitate investigations into the molecular basis of pathogenesis and the evolutionary divergence of pathogenic and symbiotic lifestyles.

Staurojoenina and other symbionts in Neotermes from San Salvador Island, Bahamas

Staurojoenina, a conspicuous hypermastigote protist (undocumented in any Neotermes) and other hindgut symbionts are reported for the first time in Neotermes nr. jouteli, a dry-wood-eating termite (Kalotermitidae), from the red mangroves at the northeast corner of San Salvador Island. Other distinctive protists (Macrotrichomonas, Metadevescovina, two morphotypes of small trichomonads) and bacteria (Arthromitus-type filamentous spore-formers) symbionts were also found in this termite. This Staurojoenina sp. replete with epibiotic bacterial symbionts is not distinguished from previously described species of Staurojoenina.

Major histocompatibility complex class II-independent generation of neutralizing antibodies against T-cell-dependent Borrelia burgdorferi antigens presented by dendritic cells: regulation by NK and gammadelta T cells

We previously showed that adoptive transfer of Borrelia burgdorferi-pulsed dendritic cells (DCs) into syngeneic mice protects animals from challenge with tick-transmitted spirochetes. Here, we demonstrate that the protective immune response is antibody (Ab) dependent and does not require the presence of major histocompatibility complex (MHC) class II molecules on DCs. Mice sensitized with B. burgdorferi-pulsed MHC class II-deficient (MHC class II(-/-)) DCs mounted a humoral response against protective antigens, including B. burgdorferi outer surface protein A (OspA) and OspC. B-cell help for the generation of neutralizing anti-OspC immunoglobulin G Abs could be provided by gammadelta T cells. In contrast, anti-OspA Ab production required the presence of alphabeta T cells, although this pathway could be independent of MHC class II molecules on antigen-presenting cells. Moreover, depletion of NK cells prior to transfer of antigen-pulsed MHC class II(-/-) DCs resulted in significant increases in the levels of neutralizing Abs induced by DCs. Altogether, these data suggest that the initial interactions between DCs and innate immune cells, such as gammadelta and NK cells, can influence the generation of a protective humoral response against B. burgdorferi antigens.

Relationship between 5-HT function and impulsivity and aggression in male offenders with personality disorders

BACKGROUND

Reduced serotonergic (5-HT) function and elevated testosterone have been reported in aggressive populations.

AIMS

To investigate relationships between impulsivity, aggression, 5-HT function and testosterone in male offenders with personality disorders.

METHOD

Sixty male offenders with DSM-III-R personality disorders and 27 healthy staff controls were assessed using the Special Hospital Assessment of Personality and Socialisation (SHAPS), impulsivity and aggression ratings, d-fenfluramine challenge and plasma hormone concentrations.

RESULTS

The SHAPS non-psychopaths and those with schizoid personality disorders had enhanced 5-HT function (prolactin response to d-fenfluramine). Reduced 5-HT function was found in offenders with DSM-III-R borderline personality disorders and those with a history of repeated self-harm or alcohol misuse. The 5-HT function was inversely correlated more strongly with impulsivity than with aggression. Plasma testosterone correlated positively with aggressive acts. The SHAPS primary psychopaths had lower initial cortisol and higher testosterone concentrations than controls.

CONCLUSIONS

Future studies are needed to investigate regional brain 5-HT function.