Dissecting Genetic Resistance to Fire Blight in Three Pear Populations

Fire blight, caused by the bacterial pathogen Erwinia amylovora, is a persistent problem for pear (Pyrus spp.) growers in the United States. Growing resistant cultivars is one of the best options for managing fire blight. The cultivars Potomac and Old Home and the selection NJA2R59T69 display resistance to fire blight. As such, three mapping populations (El Dorado × Potomac, Old Home × Bartlett, and NJA2R59T69 × Bartlett) were developed to identify genomic regions associated with resistance to fire blight. Progeny were phenotyped during 2017 and 2018 by inoculating multiple actively growing shoots of field-grown seedling trees with E. amylovora isolate E153n via the cut-leaf method. Genotyping was conducted using the recently developed Axiom Pear 70 K Genotyping Array and chromosomal linkage groups were created for each population. An integrated two-way pseudo-testcross approach was used to map quantitative trait loci (QTLs). Resistance QTLs were identified on chromosome 2 for each population. The QTLs identified in the El Dorado × Potomac and Old Home × Bartlett populations are in the same region as QTLs that were previously identified in Harrow Sweet and Moonglow. The QTL in NJA2R59T69 mapped proximally to the previously identified QTLs and originated from an unknown Asian or occidental source. Future research will focus on further characterizing the resistance regions and developing tools for DNA-informed breeding.

6 Perioperative Urinary Catheterisation in Hip Fracture Patients

Introduction

There are currently no national guidelines, in the UK, advising when to catheterize hip fracture patients and when to trial without a catheter (TWOC). We audited the practice in a UK teaching hospital where there is a consultants’ consensus that all patients should be catheterized on the day of admission (or day of surgery; which is usually within 36 hours of admission) and TWOC as soon as possible within 72 hours postoperatively. We also correlated delays in TWOC with urinary tract infection (UTI) rates.

Methods

Audit of consecutive hip fracture patients who had undergone surgery. Patients who had long term indwelling urinary catheter were excluded. Data collected include: demographics and date and time of admission, catheterisation, operation and TWOC, also duration of catheter post operatively, reason if TWOC delayed and whether the patient had a UTI.

Results

43 patients were included; 30 males and 13 females with a mean age of 82.9 and 83.9 years respectively. Urinary catheters were inserted in 100% of patients preoperatively. Overall 23% of patients had a UTI. There were more UTIs with prolonged catheterization. The results are summarised in the table. The reason for delaying a TWOC was not documented in any of patients’ notes.

Discussion

The low rate of TWOC within 72 hours can be attributed to:Lack of clear guidelinesReluctance to have a TWOC for older patients with poor postoperative mobility with concerns regarding inability to reach the toilet timely.Reluctance to have a TWOC for those who did not open their bowels postoperatively.Time and resources pressure.

Conclusion and recommendations

National guidelines for urinary catheterisation in hip fracture patients are needed meanwhile Orthopaedic Department guidelines will improve the care in these patients. Patients should have a urinary catheter “passport” documenting the date of insertion, expected date of TWOC and the reasons for delaying TWOC. It is important to educate the team about the importance of TWOC as early as possible and improve communication.

Variation in menopausal vasomotor symptoms outcomes in clinical trials: a systematic review

BACKGROUND

There is substantial variation in how menopausal vasomotor symptoms are reported and measured among intervention studies. This has prevented meaningful comparisons between treatments and limited data synthesis.

OBJECTIVES

To review systematically the outcome reporting and measures used to assess menopausal vasomotor symptoms from randomised controlled trials of treatments.

SEARCH STRATEGY

We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from inception to May 2018.

SELECTION CRITERIA

Randomised controlled trials with a primary outcome of menopausal vasomotor symptoms in women and a sample size of at least 20 women per study arm.

DATA COLLECTION AND ANALYSIS

Data about study characteristics, primary vasomotor-related outcomes and methods of measuring them.

MAIN RESULTS

The search identified 5591 studies, 214 of which were included. Forty-nine different primary reported outcomes were identified for vasomotor symptoms and 16 different tools had been used to measure these outcomes. The most commonly reported outcomes were frequency (97/214), severity (116/214), and intensity (28/114) of vasomotor symptoms or a composite of these outcomes (68/214). There was little consistency in how the frequency and severity/intensity of vasomotor symptoms were defined.

CONCLUSIONS

There is substantial variation in how menopausal vasomotor symptoms have been reported and measured in treatment trials. Future studies should include standardised outcome measures which reflect the priorities of patients, clinicians, and researchers. This is most effectively achieved through the development of a Core Outcome Set. This systematic review is the first step towards development of a Core Outcome Set for menopausal vasomotor symptoms.

TWEETABLE SUMMARY

Menopausal hot flushes and night sweats have been reported in 49 different ways in clinical research. A core outcome set is urgently required.

A future for all to INHERIT: taking integrated action on the environment, health and equity

Key messages

The urgent need to address the environmental crisis presents an opportunity to simultaneously manage closely related societal challenges linked to health and equity. Public health actors can play a key role by bringing together the sectors, evidence and examples to instigate change, around the common interest of promoting human, which depends on planetary, health.

Policies for tackling health inequities in migrants in an irregular situation: learning from Italy

Issue

With increasing of numbers of people moving in Europe and around the world, the health of migrants has become a key global public-health issue. Migrants in an irregular situation (MIS) represent an important part of the migration phenomenon, whether they have become irregular by entering a country without authorisation or by overstaying a visa, including whose applied unsuccessfully for asylum.

Description of the problem

Overstaying of visas is not unusual in EU countries and during 2015 and 2016 in particular, many countries experienced a large number of unauthorised entrants. Health policies for MIS are increasingly a matter of concern. Using the 2015 Migrant Integration Policy Index Health strand (MIPEX HS) it is possible to conduct an analysis of health policies, focusing on access to health services by MIS.

Results

Among the 34 European countries covered by the MIPEX HS, Italy’s overall score of 65 is exceeded only by Switzerland (70) and Norway (67). Averaging the indicators of access for MIS, Italy obtains the highest score (83), followed by Denmark, France, the Netherlands, Romania, Spain, Sweden and Switzerland with 67. Its score for legal entitlements to health care is 75 (the same as Sweden), while reporting of MIS to the immigration authorities is prohibited and there are no sanctions against helping them. However, legislation introduced by the new government in 2018 has restricted some of their rights.

Lessons

Current migration to Europe requires dealing with short-term health needs as well as strengthening public health and health systems in the long term. This presentation will discuss the lessons that can be learned from the comparative analysis of health policies for MIS using the MIPEX HS.

Key messages

Affordable health care is a human right, which should not be denied to any migrant. Policy analysis plays a key role in identifying interventions for promoting health equity.

Association of Expectations of Training With Attrition in General Surgery Residents

Importance

Attrition from general surgery training is highest during internship. Whether the expectations and attitudes of new trainees affect their subsequent risk of attrition is unknown.

Objective

To identify the expectations of general surgery residency associated with attrition from training.

Design, Setting, and Participants

This prospective observational cohort study included categorical general surgery interns entering training in the 2007-2008 academic year. Residents were surveyed regarding their expectations of training and of life as an attending at the start of their intern year (June 1 to August 31, 2007). Expectations were grouped into factors by principal component analysis, and a multivariable model was created using these factors in addition to known demographic and program characteristics associated with attrition. Follow-up was completed on December 31, 2016.

Main Outcomes and Measures

Attrition from training was determined by linkage to American Board of Surgery resident files through 2016, allowing 8 additional years of follow-up.

Results

Of 1048 categorical surgery interns in the study period, 870 took the survey (83.0% response rate), and 828 had complete information available for analysis (524 men [63.3%], 303 women [36.6%], and 1 missing information [0.1%]). Most were white (569 [69.1%]) and at academic programs (500 [60.4%]). Six hundred sixty-six residents (80.4%) completed training. Principal component analysis generated 6 factors. On adjusted analysis, 2 factors were associated with attrition. Interns who choose their residency based on program reputation (factor 2) were more likely to drop out (odds ratio, 1.08; 95% CI, 1.01-1.15). Interns who expected as an attending to work more than 80 hours per week, to have a stressful life, and to be the subject of malpractice litigation (career life expectation [factor 6]) were less likely to drop out (odds ratio, 0.90; 95% CI, 0.82-0.98).

Conclusions and Relevance

Interns with realistic expectations of the demands of residency and life as an attending may be more likely to complete training. Medical students and residents entering training should be given clear guidance in what to expect as a surgery resident.

The evolution of donation after circulatory death renal transplantation: a decade of experience

BACKGROUND

This study compared long-term outcomes of renal transplantation from donors following donation after circulatory death (DCD) with those following donation after brain death (DBD) from one of the largest centres in the UK.

METHOD

Recipients of renal transplants from deceased donors between 2002 and 2014 were identified from a prospectively maintained database. Outcomes were compared between DCD (468) and DBD (905) donors and between standard criteria donors (SCDs) and extended criteria donors (ECDs).

RESULTS

Graft survival (GS) and patient survival (PS) from DCD and DBD donors were comparable up to 10 years (GS: 61 versus 55%, P = 0.780; PS: 78 versus 71%, P = 0.285, respectively). Graft function was comparable after 3 months. GS and function were worse in the ECD groups, with no difference between EC-DBD and EC-DCD. PS in the ECD groups was worse than the SCD groups and PS in the EC-DCD group was worse than in the EC-DBD group. DCD donors were an independent risk factor for delayed graft function. Post-operative complications and EC-DCD donation were independent risk factors for reduced GS and PS.

CONCLUSION

This study supports the use of DCD renal grafts with comparable long-term survival and function to DBD grafts. The use of EC-DCD grafts is justified in selected recipients and provides acceptable function and survival advantages over dialysis.

Association of Time to Attrition in Surgical Residency With Individual Resident and Programmatic Factors

Importance

Attrition in general surgery residency remains high, and attrition that occurs in the later years is the most worrisome. Although several studies have retrospectively investigated the timing of attrition, no study to date has prospectively evaluated a national cohort of residents to understand which residents are at risk for attrition and at what point during residency.

Objective

To prospectively evaluate individual resident and programmatic factors associated with the timing of attrition during general surgery residency.

Design, Setting, and Participants

This longitudinal, national cohort study administered a survey to all categorical general surgery interns from the class of 2007-2008 during their first 30 days of residency and linked the data with 9-year follow-up data assessing program completion. Data were collected from June 1, 2007, through June 30, 2016.

Main Outcomes and Measures

Kaplan-Meier curves evaluating time to attrition during the 9 years after the start of residency.

Results

Among our sample of 836 residents (306 women [36.6%] and 528 men [63.2%]; gender unknown in 2), cumulative survival analysis demonstrated overall attrition for the cohort of 20.8% (n = 164). Attrition was highest in the first postgraduate year (67.6% [n = 111]; absolute rate, 13.3%) but continued during the next 6 years, albeit at a lower rate. Beginning in the first year, survival analysis demonstrated higher attrition among Hispanic compared with non-Hispanic residents (21.1% vs 12.4%; P = .04) and at military programs compared with academic or community programs after year 1 (32.3% vs 11.0% or 13.5%; P = .01). Beginning in year 4 of residency, higher attrition was encountered among women compared with men (23.3% vs 17.4%; P = .05); at year 5, at large compared with small programs (26.0% vs 18.4%; P = .04). Race and program location were not associated with attrition.

Conclusions and Relevance

Although attrition was highest during the internship year, late attrition persists, particularly among women and among residents in large programs. These results provide a framework for timing of interventions in graduate surgical training that target residents most at risk for late attrition.

Associations Between Serum Bone Biomarkers in Early Breast Cancer and Development of Bone Metastasis: Results From the AZURE (BIG01/04) Trial

Background

Adjuvant therapies can prevent/delay bone metastasis development in breast cancer. We investigated whether serum bone turnover markers in early disease have clinical utility in identifying patients with a high risk of developing bone metastasis.

Methods

Markers of bone formation (N-terminal propeptide of type-1 collagen [P1NP]) and bone resorption (C-telopeptide of type-1 collagen [CTX], pyridinoline cross-linked carboxy-terminal telopeptide of type-1 collagen [1-CTP]) were measured in baseline (pretreatment blood samples from 872 patients from a large randomized trial of adjuvant zoledronic acid (AZURE-ISRCTN79831382) in early breast cancer. Cox proportional hazards regression and cumulative incidence functions (adjusted for factors having a statistically significant effect on outcome) were used to investigate prognostic and predictive associations between recurrence events, bone marker levels, and clinical variables. All statistical tests were two-sided.

Results

When considered as continuous variables (log transformed), P1NP, CTX, and 1-CTP were each prognostic for future bone recurrence at any time (P = .006, P = .009, P = .008, respectively). Harrell’s c-indices were a P1NP of 0.57 (95% confidence interval [CI] = 0.51 to 0.63), CTX of 0.57 (95% CI = 0.51 to 0.62), and 1-CTP of 0.57 (95% CI = 0.52 to 0.63). In categorical analyses based on the normal range, high baseline P1NP (>70 ng/mL) and CTX (>0.299 ng/mL), but not 1-CTP (>4.2 ng/mL), were also prognostic for future bone recurrence (P = .03, P = .03, P = .10, respectively). None of the markers were prognostic for overall distant recurrence; that is, they were bone metastasis specific, and none of the markers were predictive of treatment benefit from zoledronic acid.

Conclusions

Serum P1NP, CTX, and 1-CTP are clinically useful, easily measured markers that show good prognostic ability (though low-to-moderate discrimination) for bone-specific recurrence and are worthy of further study.

‘Adrenal incidentalomas’; Rationalising assessment in the urology multi-disciplinary team meeting

The combination of an aging population and the continual technological advances in modern imaging techniques have contributed to the increased detection of asymptomatic incidental lesions. The definition of an adrenal ‘incidentaloma’ is an asymptomatic lesion (⩾1 cm) detected on imaging following a suspected alternative primary diagnosis. The majority of these adrenal incidentalomas, may be benign and non-functioning, however, a proportion of these lesions may be either malignant or ‘hyperfunctioning’ (hormone-producing). As such, these incidental and asymptomatic lesions can provide the urologist with a diagnostic dilemma. In this article we aim to review the current literature with reference to common clinical scenarios often encountered as part of the urology multi-disciplinary team meeting. The overall aim is to rationalise and standardise an approach to these often challenging scenarios.

Autoimmunity and Benefit from Trastuzumab Treatment in Breast Cancer: Results from the HERA Trial

BACKGROUND/AIM

This study sought to determine whether an autoimmune background could identify patients with HER2-positive early breast cancer (EBC) who derive differential benefit from primary adjuvant trastuzumab-based therapy.

PATIENTS AND METHODS

HERA is an international randomized trial of 5,102 women with HER2-positive EBC, who were enrolled to either receive adjuvant trastuzumab or not. In this exploratory analysis, the interaction between autoimmune history and the magnitude of trastuzumab benefit was evaluated.

RESULTS

A total of 5,099 patients were included in the current analysis. Among them, 325 patients (6.4%) had autoimmune disease history, 295 of whom had active disease. Patients were randomly assigned to trastuzumab or no-trastuzumab groups. Similar reductions in the risk of events in patients with and without autoimmune history were observed (interaction p=0.95 for disease-free survival, and p=0.62 for overall survival).

CONCLUSION

No evidence of a differential benefit from trastuzumab in patients with a medical history of autoimmune disease was found.

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.

Inhibition of apoptosis exacerbates fatigue-damage tendon injuries in an in vivo rat model

Tendinopathy is a common and progressive musculoskeletal disease. Increased apoptosis is an end-stage tendinopathy manifestation, but its contribution to the pathology of the disease is unknown. A previously established in vivo model of fatigue damage accumulation shows that increased apoptosis is correlated with the severity of induced tendon damage, even in early onset of the disease, supporting its implication in the pathogenesis of the disease. Consequently, this study aimed to determine: (1) whether apoptosis could be inhibited after fatigue damage and (2) whether its inhibition could lead to remodeling of the extracellular matrix (ECM) and pericellular matrix (PCM), to ultimately improve the mechanical properties of fatigue-damaged tendons. The working hypothesis was that, despite the low vascular nature of the tendon, apoptosis would be inhibited, prompting increased production of matrix proteins and restoring tendon mechanical properties. Rats received 2 or 5 d of systemic pan-caspase inhibitor (Q-VD-OPh) or dimethyl sulfoxide (DMSO) carrier control injections starting immediately prior to fatigue loading and were sacrificed at days 7 and 14 post-fatigue-loading. Systemic pan-caspase inhibition for 2 d led to a surprising increase in apoptosis, but inhibition for 5 d increased the population of live cells that could repair the fatigue damage. Further analysis of the 5 d group showed that effective inhibition led to an increased population of cells producing ECM and PCM proteins, although typically in conjunction with oxidative stress markers. Ultimately, inhibition of apoptosis led to further deterioration in mechanical properties of fatigue-damaged tendons.

Gene Expression Meta-Analysis of Potential Metastatic Breast Cancer Markers

Background:

Breast cancer metastasis is a highly prevalent cause of death for European females. DNA microarray analysis has established that primary tumors, which remain localized, differ in gene expression from those that metastasize. Cross-analysis of these studies allow to revile the differences that may be used as predictive in the disease prognosis and therapy.

Objective:

The aim of the project was to validate suggested prognostic and therapeutic markers using meta-analysis of data on gene expression in metastatic and primary breast cancer tumors.

Method:

Data on relative gene expression values from 12 studies on primary breast cancer and breast cancer metastasis were retrieved from Genevestigator (Nebion) database. The results of the data meta-analysis were compared with results of literature mining for suggested metastatic breast cancer markers and vectors and consistency of their reported differential expression.

Results:

Our analysis suggested that transcriptional expression of the COX2 gene is significantly downregulated in metastatic tissue compared to normal breast tissue, but is not downregulated in primary tumors compared with normal breast tissue and may be used as a differential marker in metastatic breast cancer diagnostics. RRM2 gene expression decreases in metastases when compared to primary breast cancer and could be suggested as a marker to trace breast cancer evolution. Our study also supports MMP1, VCAM1, FZD3, VEGFC, FOXM1 and MUC1 as breast cancer onset markers, as these genes demonstrate significant differential expression in breast neoplasms compared with normal breast tissue.

Conclusion:

COX2 and RRM2 are suggested to be prominent markers for breast cancer metastasis. The crosstalk between upstream regulators of genes differentially expressed in primary breast tumors and metastasis also suggests pathways involving p53, ER1, ERB-B2, TNF and WNT, as the most promising regulators that may be considered for new complex drug therapeutic interventions in breast cancer metastatic progression.

Abattoir surveillance of Sarcocystis spp., Cysticercosis ovis and Echinococcus granulosus in Tasmanian slaughter sheep, 2007-2013

OBJECTIVE

To estimate the prevalence of macroscopic Sarcocystis spp., Cysticercus ovis and Echinococcus granulosus recorded at routine postmortem inspection of Tasmanian slaughter sheep during 2007 to 2013.

METHODS

A retrospective analysis of routine postmortem meat inspection data maintained on 352,325 Tasmanian adult slaughter sheep inspected across nine abattoirs in Tasmania, Victoria and South Australia as part of the National Sheep Health Monitoring Project (NSHMP).

RESULTS

During the period 1 September 2007 to 30 June 2013, the estimated prevalence of macroscopic Sarcocystis spp. was 14.3%, C. ovis was 3.2% and E. granulosus was 0.01%. Mean Sarcocystis spp. line prevalence ranged from 0% to 33.5%. Significant between-abattoir differences in the level of sarcosporidiosis (P < 0.001) and C. ovis were found (P < 0.001). Overall, very low levels of hydatidosis were recorded throughout the surveillance period. Predicted within-line prevalence of macroscopic sarcocysts in animals coming from a known/recorded local government area (LGA) (P < 0.001) was lower than that of lines where the LGA was unknown or not recorded. A higher prevalence of sarcocystosis was recorded in lines of sheep aged ≥ 2 years compared with those < 2 years (P < 0.001).

CONCLUSION

Reasons for the significant between-abattoir differences in recorded levels of ovine sarcosporidiosis and cysticercosis remain unknown, but may represent sampling bias, with subsets of slaughter sheep going to abattoirs with different tiers or access to markets. Further investigation into apparent differences, including epidemiological studies of properties with high lesion prevalence, comparing meat inspector diagnostic sensitivity, assessing the effect of line speed and tiers and market access in different abattoirs, may be useful.

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.