Cost impact of a non-invasive, portable device for patient self-administration of chronic migraine in a UK National Health Service setting

BACKGROUND

Chronic migraine (CM) is a neurological disorder associated with substantial disability. Botulinum toxin type A (Botox) is an approved and effective preventive treatment option for adult patients with CM. Transcranial magnetic stimulation (TMS) is an alternative treatment device delivering a brief pre-set magnetic pulse used for self-administration by the patient at home. Despite being available in a risk share scheme TMS is perceived to be more costly in the UK. The objective of this study was to analyse the incremental costs of TMS compared to Botox in refractory CM patients both for a UK individual funding request setting as well as for an average UK specialist center setting.

METHODS

Cost impact results were derived from a decision-tree model simulating treatment pathways over 1 year. Costs were applied from the most recently available UK data sources. Sensitivity analysis was performed for all variables.

RESULTS

Based on published utilisation data 45.5 % of CM patients would continuously receive Botox over 1 year, whereas 53.7 % of TMS patients would be still on treatment at the end of year one. Total costs of Botox treatment accrue to £2923 in an individual funding request NHS cost setting, whereas TMS treatment results in £1466 in the first year. Applying a time-based NHS cost setting expenditures accrue to £1747 for the Botox treatment and to £1361 for the TMS treatment. In both cost settings variation of cost assumptions did have a minor impact on the cost increment from Botox to TMS.

CONCLUSION

The current risk share based remuneration model of TMS allows the UK NHS to reimburse only the cost of those patients experiencing reduction in migraine days resulting in lower costs for treating migraine attacks. Treatment of chronic refractory migraine using TMS implies a substantial cost reduction potential for the management of chronic treatment of refractory migraine patients compared to conventional Botox treatment.

Longitudinal plasma metanephrines preceding pheochromocytoma diagnosis: a retrospective case-control serum repository study

OBJECTIVE

Plasma metanephrines (PMN) are highly sensitive for diagnosis of pheochromocytoma, but the natural history of PMN before pheochromocytoma diagnosis has not been previously described. The aim of the study was to compare the progression of PMN before pheochromocytoma diagnosis to matched healthy and essential hypertension disease controls.

DESIGN

A retrospective case-control Department of Defense Serum Repository (DoDSR) study.

METHODS

We performed a DoDSR study that compared three longitudinal pre-diagnostic PMN for 30 biopsy-proven pheochromocytoma cases to three longitudinal PMN for age, sex, race, and age of serum sample matched healthy and essential hypertension disease controls. Predominant metanephrine (MN) or normetanephrine (NMN) production was identified for each case and converted to a percentage of the upper limit of normal to allow analysis of all cases together. PMN were measured by Quest Diagnostics.

RESULTS

The predominant plasma metanephrine (PPM) was >100 and 300% of the upper limit of normal a median of 6.6 and 4.1 years before diagnosis respectively. A greater percentage of pheochromocytoma patients had a PPM >100 and >300% of the upper limit of normal compared with combined healthy and essential hypertension disease controls <2, 2-8, and >8 years prior to diagnosis. For patients with a baseline PPM 90-300% of the upper limit of normal, a 25% rate of rise per year was 100% specific for pheochromocytoma.

CONCLUSIONS

PPMs elevate years before diagnosis which suggests that delayed diagnoses are common. For mild PMN elevations, follow-up longitudinal PMN trends may provide a highly specific and economical diagnostic tool.

Changes in liver acceptance patterns after implementation of Share 35

The Share 35 policy was implemented June 2013. We sought to evaluate liver offer acceptance patterns of centers under this policy. We compared three 1-year eras (1, 2, and 3) before and 1 era (4) after the implementation date of the Share 35 policy (June 18, 2013). We evaluated all offers for liver-only recipients including only those offers for livers that were ultimately transplanted. Logistic regression was used to develop a liver acceptance model. In era 3, there were 4809 offers for Model for End-Stage Liver Disease (MELD) score ≥ 35 patients with 1071 acceptances (22.3%) and 10,141 offers and 1652 acceptances (16.3%) in era 4 (P < 0.001). In era 3, there were 42,954 offers for MELD score < 35 patients with 4181 acceptances (9.7%) and 44,137 offers and 3882 acceptances (8.8%) in era 4 (P < 0.001). The lower acceptance rate persisted across all United Network for Organ Sharing regions and was significantly less in regions 2, 3, 4, 5, and 7. Mean donor risk index was the same (1.3) for all eras for MELD scores ≥ 35 acceptances and the same (1.4) for MELD score < 35 acceptances. Refusal reasons did not vary throughout the eras. The adjusted odds ratio of accepting a liver for a MELD score of 35 + compared to a MELD score < 35 patient was 1.289 before the policy and 0.960 after policy implementation. In conclusion, the Share 35 policy has resulted in more offers to patients with MELD scores ≥ 35. Overall acceptance rates were significantly less compared to the same patient group before the policy implementation. Centers are less likely to accept a liver for a patient with a MELD score of 35 + after the policy change. Decreased donor acceptance rates could reflect more programmatic selectivity and ongoing donor and recipient matching.

Complications and Their Resolution in Recipients of Deceased and Living Donor Liver Transplants: Findings From the A2ALL Cohort Study

The purpose of this study was to explore long-term complications in recipients of deceased donor liver transplant (DDLT) and living donor liver transplant (LDLT) in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL). We analyzed 471 DDLTs and 565 LDLTs from 1998 to 2010 that were followed up to 10 years for 36 categories of complications. Probabilities of complications and their resolutions were estimated using the Kaplan-Meier method, and predictors were tested in Cox proportional hazards models. Median follow-up for DDLT and LDLT was 4.19 and 4.80 years, respectively. DDLT recipients were more likely to have hepatocellular carcinoma and higher disease severity, including Model for End-Stage Liver Disease score. Complications occurring with higher probability in LDLT included biliary-related complications and hepatic artery thrombosis. In DDLT, ascites, intra-abdominal bleeding, cardiac complications and pulmonary edema were significantly more probable. Development of chronic kidney disease stage 4 or 5 was less likely in LDLT recipients (hazard ratio [HR] 0.41, p = 0.02). DDLT and LDLT had similar risk of grade 4 complications (HR 0.89, p = 0.60), adjusted for other risk factors. Once a complication occurred, the time to resolution did not differ between LDLT and DDLT. Future efforts should be directed toward reducing the occurrence of complications after liver transplantation.

Serum lipid expression correlates with function and regeneration following living donor liver transplantation

Following living donor liver transplantation (LDLT; and unlike deceased donor liver transplantation [DDLT]), the liver must rapidly regenerate, and sometimes segmental graft dysfunction (SGD) is observed. Hepatic regeneration requires substantial de novo lipid synthesis, and we previously reported that expression of lipid-related genes is dysregulated in LDLT. Here, we compare serum lipid measurements in 41 LDLT recipients and 43 DDLT recipients at baseline and at serial posttransplant time points. In addition, we examined whether serum lipid/apolipoprotein (apo) levels correlate with the degree of liver regeneration (measured using percent volume increase [%VI] at 3 months) or SGD in LDLT recipients. In contrast to DDLT, lipid levels declined early after LDLT but returned to baseline by 30 days. The odds ratio (OR) for achieving robust regeneration (>90 %VI) was 2.53 (95% confidence interval [CI], 1.15-5.52) for every 1 mg/dL increase in serum apoE at 30 days. The OR of SGD for every year increase in donor age was 1.19 (95% CI, 1.02-1.39), and 0.61 for every 1 mg/dL increase in serum high-density lipoprotein cholesterol at 7 days (95% CI, 0.34-1.11). No associations were detected between preoperative serum lipids/apos in LDLT donors and SGD or %VI in recipients. In conclusion, we suggest that initiation of regeneration prevents the liver from participating fully in lipid transport and metabolism. Inability to meet systemic metabolic needs may result in compromised liver function and SGD. Certain serum lipid concentrations correlate with extent of liver regeneration and function.

Water extraction on Mars for an expanding human colony

In-situ water extraction is necessary for an extended human presence on Mars. This study looks at the water requirements of an expanding human colony on Mars and the general systems needed to supply that water from the martian atmosphere and regolith. The proposed combination of systems in order to supply the necessary water includes a system similar to Honeybee Robotics' Mobile In-Situ Water Extractor (MISWE) that uses convection, a system similar to MISWE but that directs microwave energy down a borehole, a greenhouse or hothouse type system, and a system similar to the Mars Atmospheric Resource Recovery System (MARRS). It is demonstrated that a large water extraction system that can take advantage of large deposits of water ice at site specific locations is necessary to keep up with the demands of a growing colony.

CHRNA5 risk variant predicts delayed smoking cessation and earlier lung cancer diagnosis--a meta-analysis

BACKGROUND

Recent meta-analyses show strong evidence of associations among genetic variants in CHRNA5 on chromosome 15q25, smoking quantity, and lung cancer. This meta-analysis tests whether the CHRNA5 variant rs16969968 predicts age of smoking cessation and age of lung cancer diagnosis.

METHODS

Meta-analyses examined associations between rs16969968, age of quitting smoking, and age of lung cancer diagnosis in 24 studies of European ancestry (n = 29 072). In each dataset, we used Cox regression models to evaluate the association between rs16969968 and the two primary phenotypes (age of smoking cessation among ever smokers and age of lung cancer diagnosis among lung cancer case patients) and the secondary phenotype of smoking duration. Heterogeneity across studies was assessed with the Cochran Q test. All statistical tests were two-sided.

RESULTS

The rs16969968 allele (A) was associated with a lower likelihood of smoking cessation (hazard ratio [HR] = 0.95, 95% confidence interval [CI] = 0.91 to 0.98, P = .0042), and the AA genotype was associated with a four-year delay in median age of quitting compared with the GG genotype. Among smokers with lung cancer diagnoses, the rs16969968 genotype (AA) was associated with a four-year earlier median age of diagnosis compared with the low-risk genotype (GG) (HR = 1.08, 95% CI = 1.04 to 1.12, P = 1.1*10(-5)).

CONCLUSION

These data support the clinical significance of the CHRNA5 variant rs16969968. It predicts delayed smoking cessation and an earlier age of lung cancer diagnosis in this meta-analysis. Given the existing evidence that this CHRNA5 variant predicts favorable response to cessation pharmacotherapy, these findings underscore the potential clinical and public health importance of rs16969968 in CHRNA5 in relation to smoking cessation success and lung cancer risk.

Degradation in urban air quality from construction activity and increased traffic arising from a road widening scheme

Road widening schemes in urban areas are often proposed as a solution to traffic congestion and as a means of stimulating economic growth. There is however clear evidence that new or expanded roads rapidly fill with either displaced or induced traffic, offsetting any short-term gains in eased traffic flows. What has not been addressed in any great detail is the impact of such schemes on air quality, with modelled impact predictions seldom validated by measurements after the expansion of road capacity. In this study we made use of a road widening project in London to investigate the impact on ambient air quality (particulate matter, NOX, NO2) during and after the completion of the road works. PM10 increased during the construction period up to 15 μg m(-3) during working hours compared to concentrations before the road works. A box modelling approach was used to determine a median emission factor of 0.0022 kg PM10 m(-2) month(-1), three times larger than that used in the UK emission inventory (0.0007 kg PM10 m(-2) month(-1)). Peaks of activity released 0.0130 kg PM10 m(-2) month(-1), three and eight times smaller than the peak values used in the European and US inventories. After the completion of the widening there was an increase in all pollutants from the road during rush hour: 2-4 μg m(-3) for PM10; 1 μg m(-3) for PM2.5; 40 and 8 μg m(-3) for NOX and NO2, respectively. NO2 EU Limit Value was breached after the road development illustrating a notable deterioration in residential air quality. Additionally, PM10, but not PM2.5, glutathione dependent oxidative potential increased after the road was widened consistent with an increase in pro-oxidant components in the coarse particle mode, related to vehicle abrasion processes. These increased air pollution indices were associated with an increase in the number of cars, taxis and LGVs.

A telephone reminder intervention to improve breast screening information and access

OBJECTIVES

In the UK, women aged 50-70 are offered breast cancer screening every three years. Screening participation rates in London have been particularly low. Low rates have been associated with low socio-economic status, and some ethnic groups have been observed to be underserved by cancer screening. This paper reports on a telephone reminder intervention in London Newham, an area of high deprivation and ethnic diversity.

STUDY DESIGN

Observational study of planned intervention.

METHODS

Women invited for breast screening were telephoned to confirm receipt of the invitation letter, remind invitees of their upcoming appointment, and to provide further information. Aggregate data at general practice level on invitation to and attendance at breast screening and on numbers reached by telephone were analysed by logistic regression.

RESULTS

For the 29 participating GP practices (10,928 invitees) overall uptake in 2010 was higher compared to the previous screening round in 2007 (67% vs. 51%; p < 0.001). On average 59% of invitees were reached by the reminder calls. A 10% increase in women reached resulted in an 8% increase in the odds of women attending their screening appointment (95% CI: 5%-11%), after adjusting for 2007 attendance rates. Practices with a higher proportion of South Asian women were associated with a larger uptake adjusted for 2007 uptake and population reached by the telephone intervention, (4% increase in odds of attendance per 10% increase in South Asian population, CI 1%-7%, p = 0.003) while practices with a higher proportion of black women were associated with a smaller uptake similarly adjusted. (11% decrease in odds of attendance per 10% increase in black population, CI 9%-16%, p < 0.001).

CONCLUSIONS

A language- and culture-sensitive programme of reminder calls substantially improved breast cancer screening uptake.

Abstract P5-07-03: The nuclear coactivator amplified in breast cancer 1 maintains tumor initiating cells during development of ductal carcinoma in situ

Introduction: Ductal Carcinoma In Situ (DCIS) has become the most diagnosed breast tumor type in North America. Amplified In Breast Cancer 1 (AIB1) is amplified in 5 to 10% of primary breast tumors. We have recently demonstrated that AIB1 causes development of DCIS lesions in the mammary gland of 30% of the AIB1 transgenic mice. Our laboratory has also shown that deletion of one allele of AIB1 prevents HER2-induced mammary tumor development in mice, suggesting a pivotal role of AIB1 during earlier stage of breast cancer. We hypothesize that AIB1-mediated pathways promote the transformation of the mammary epithelial cells and the alterations of the functional integrity of the mammary gland. By contrast, decrease in AIB1 functionality may result in prevented DCIS initiation and development.

Results: We show by immunohistochemistry that AIB1 is expressed at low levels in normal breast but is highly expressed in DCIS lesions. We investigated the impact of decreasing AIB1 expression on the early transformed MCFDCIS cell line. MCFDCIS cells generate multiacinar disorganized structures with filling of the lumen, loss of polarization and escape from the proliferative suppression. Reduction of AIB1 in human MCFDCIS cells restored a more normal mammary acinar structure with basement membrane in 3D growth in Matrigel. Then, we studied the effect of regulating AIB1 on the histopathology development of the DCIS lesions both prior to DCIS development or in existing MCFDCIS lesions in a xenograft mouse model by subcutaneously injecting MCFDCIS cells deficient or not in AIB1 into nude mice. The MCFDCIS xenografted tumors obtained reproduced the human breast cancer progression and displayed multiple comedo DCIS-like lesions. Decreased levels of AIB1 in MCFDCIS cells, inhibited tumor growth and led to smaller, necrotic lesions. To investigate how AIB1 affects initiation and progression of DCIS, we compared global gene expression changes in MCFDCIS cells +/-AIB1 shRNA in vitro using cDNA array analysis. Among the most significant expression changes observed were genes that are differentially expressed in Breast Cancer Initiating Cells (BCIC) including CD24 and members of the NOTCH signaling pathway (DLL1 and DLL3). We demonstrated by flow cytometric and immunohistochemical analysis that AIB1 reduction in MCFDCIS cells was correlated with significant reduction in the CD24-/CD44+ BCIC population, and a decrease in myoepithelial progenitor cells in the DCIS lesions in vitro and in vivo. Loss of AIB1 in MCFDCIS cells was also accompanied by a loss of expression of NOTCH 2, 3 and 4, JAG2, HES1, GATA3, HER2 and HER3 in vivo.

Conclusions: These data indicate that AIB1 plays a central role in the initiation and maintenance of DCIS and that reduction of AIB1 causes loss of BCIC, loss of components of the NOTCH, HER2 and HER3 signaling pathways and fewer DCIS myoepithelial progenitor cells in vivo. We propose that increased expression of AIB1, through maintenance of BCIC, facilitates formation of DCIS, a necessary step prior to development of invasive disease. Thus, targeting AIB1 may represent a new therapeutic paradigm especially for women with AIB1-positive primary tumor.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-07-03.

It is out of my hands: how deferring control to God can decrease quality of life for breast cancer patients

OBJECTIVE

This paper seeks to contribute to the understanding of how and why religion affects psychosocial health outcomes. We propose a theoretical model predicting that when women with breast cancer defer control to God they will experience fewer breast cancer related concerns. Deferring control to God, however, should also reduce the likelihood that they take a proactive coping approach, which will be exacerbated by lowered breast cancer concerns. We therefore predict that this passive coping style will ultimately result in lower levels of quality of life.

METHODS

Data were collected as part of a randomized clinical trial funded by the National Cancer Institute. A total of 192 women with breast cancer participated in a computer-mediated social support group. Deferring control to God statements were captured by using computer-aided content analysis of discussion posts. Psychosocial outcomes were measured using longitudinal survey data. Analysis was performed using structural equation modeling.

RESULTS

The results of our analysis largely confirm our mediation model for which we find significant model fit. As predicted, deferring control to God leads to lower levels of breast cancer concerns but also to more passive coping styles. Ultimately, deferring control to God can lead to lower levels of quality of life.

CONCLUSIONS

Our study demonstrates how and why religious coping can lead to both positive and negative psychosocial health outcomes. Health care practitioners should encourage patients who are relying on religion to keep their end of the bargain and maintain an active coping style.

The nuclear coactivator amplified in breast cancer 1 maintains tumor-initiating cells during development of ductal carcinoma in situ

The key molecular events required for the formation of Ductal Carcinoma in Situ (DCIS) and its progression to invasive breast carcinoma have not been defined. Here we show that the nuclear receptor coactivator Amplified In Breast cancer 1 (AIB1) is expressed at low levels in normal breast but is highly expressed in DCIS lesions. This is of significance since reduction of AIB1 in human MCFDCIS cells restored a more normal 3D mammary acinar structure. Reduction of AIB1 in MCFDCIS cells, both prior to DCIS development or in existing MCFDCIS lesions in vivo, inhibited tumor growth and led to smaller, necrotic lesions. AIB1 reduction in MCFDCIS cells was correlated with significant reduction in the CD24−/CD44+ Breast Cancer Initiating Cells (BCIC) population, and a decrease in myoepithelial progenitor cells in the DCIS lesions in vitro and in vivo. Loss of AIB1 in MCFDCIS cells was also accompanied by a loss of expression of NOTCH 2, 3 and 4, JAG2, HES1, GATA3, HER2 and HER3 in vivo. These signaling molecules have been associated with differentiation of breast epithelial progenitor cells. These data indicate that AIB1 plays a central role in the initiation and maintenance of DCIS and that reduction of AIB1 causes loss of BCIC, loss of components of the NOTCH, HER2 and HER3 signaling pathways and fewer DCIS myoepithelial progenitor cells in vivo. We propose that increased expression of AIB1, through maintenance of BCIC, facilitates formation of DCIS, a necessary step prior to development of invasive disease.

A delayed presentation of Boerhaave's syndrome with mediastinitis managed using the over-the-scope clip

Boerhaave syndrome is a spontaneous perforation of the oesophagus secondary to forceful emesis. Surgery has been advocated in delayed presentations of Boerhaave's syndrome with mediastinitis. The over-the-scope clip (OTSC) by OVESCO^® (Tubingen, Germany) has been used in the endoscopic management of gastrointestinal bleeds, fistulae and anastamotic leaks. We describe the successful endoscopic use of the OTSC in a delayed presentation of Boerhaave syndrome with mediastinitis. A 69-year-old gentleman underwent a computerised tomography scan, which demonstrated a lower oesophageal perforation and mediastinitis 7 days after admission, having presented with forceful emesis and chest discomfort. During endoscopy the defect was visualized and successfully closed using the OTSC. This resulted in a favourable outcome and is a technique not previously described in the literature to manage this condition.

Outcomes and native renal recovery following simultaneous liver-kidney transplantation

With the increase in patients having impaired renal function at liver transplant due to MELD, accurate predictors of posttransplant native renal recovery are needed to select candidates for simultaneous liver-kidney transplantation (SLK). Current UNOS guidelines rely on specific clinical criteria for SLK allocation. To examine these guidelines and other variables predicting nonrecovery, we analyzed 155 SLK recipients, focusing on a subset (n = 78) that had post-SLK native GFR (nGFR) determined by radionuclide renal scans. The 77 patients not having renal scans received a higher number of extended criteria donor organs and had worse posttransplant survival. Of the 78 renal scan patients, 31 met and 47 did not meet pre-SLK UNOS criteria. The UNOS criteria were more predictive than our institutional criteria for all nGFR recovery thresholds (20-40 mL/min), although at the most conservative cut-off (nGFR ≤ 20) it had low sensitivity (55.3%), specificity (75%), PPV (67.6%) and NPV (63.8%) for predicting post-SLK nonrecovery. On multivariate analysis, the only predictor of native renal nonrecovery (nGFR ≤ 20) was abnormal pre-SLK renal imaging (OR 3.85, CI 1.22-12.5). Our data support the need to refine SLK selection utilizing more definitive biomarkers and predictors of native renal recovery than current clinical criteria.

Adipose-Derived Regenerative Cells for the Treatment of Patients with Non-revascularisable Ischaemic Cardiomyopathy – The PRECISE Trial

Adipose-derived regenerative cells (ADRCs) continue to be evaluated for use in the treatment of patients with chronic heart failure, particularly in those refractory to, or not suitable for, currently available options. This population of cells has demonstrated the ability to facilitate wound repair through the restoration of blood flow in ischaemic conditions, reduction in inflammation and apoptosis, and regeneration of damaged tissue through stem cell differentiation into multiple cell lineages, including cardiac muscle. This approach is particularly useful in the repair or restoration of function to ischaemic tissues in patients where the body’s natural repair mechanisms have failed or been exhausted, such as patients with non-revascularisable, refractory heart failure. The use of ADRCs for these patients has numerous advantages. Primarily, the cells are accessed from a patient’s own tissue, minimising the risk of disease transmission or rejection. Further, the heterogeneity of the cells generates an orchestrated response that targets all phases of the wound healing process. Finally, the cells are readily accessible in real-time without the need for cell expansion, making it a virtually off-the-shelf therapy option. The Celution® System is a safe, GMP-compliant technology designed to automate the preparation of ADRCs at the patient’s bedside. It has been clinically validated for safety and feasibility in two completed cardiac trials; one for acute myocardial infarction and the other for chronic myocardial ischaemia. It is being further evaluated in two ongoing clinical trials for the same indications. In this article, a summary of 18-month follow-up data using the Celution technology for the treatment of patients with non-revascularisable, symptomatic, ischaemic cardiomyopathy will be presented. While additional studies are planned to confirm the efficacy of these cells in the cardiac setting, early clinical data shows promising trends towards the improvement of cardiac function and mortality rate using a technology that can potentially significantly reduce treatment costs compared to the current standard-of-care.

Potential Risk Estimation Drowning Index for Children (PREDIC): a pilot study from Matlab, Bangladesh

Childhood drowning is a major public health problem that has been neglected in many low- and middle-income countries. In Matlab, rural Bangladesh, more than 40% of child deaths aged 1-4 years are due to drowning.

AIM

The main objective of this paper was to develop and evaluate a childhood drowning risk prediction index.

METHODOLOGY

A literature review was carried out to document risk factors identified for childhood drowning in Bangladesh. The Newacheck model for special health care needs for children was adapted and applied to construct a childhood drowning risk index called "Potential Risk Estimation Drowning Index for Children" (PREDIC). Finally, the proposed PREDIC Index was applied to childhood drowning deaths and compared with the comparison group from children living in Matlab, Bangladesh. This pilot study used t-tests and Receiver Operating Characteristic (ROC) curve to analyze the results.

RESULTS

The PREDIC index was applied to 302 drowning deaths and 624 children 0-4 years old living in Matlab. The results of t-test indicate that the drowned children had a statistically (t=-8.58, p=0.0001) significant higher mean PREDIC score (6.01) than those in comparison group (5.26). Drowning cases had a PREDIC score of 6 or more for 68% of the children however, the comparison group had 43% of the children with score of 6 or more which was statistically significant (t=-7.36, p<0.001). The area under the curve for the Receiver Operating Characteristic curve was 0.662.

CONCLUSION

Index score construction was scientifically plausible; and the index is relatively complete, fairly accurate, and practical. The risk index can help identify and target high risk children with drowning prevention programs. PREDIC index needs to be further tested for its accuracy, feasibility and effectiveness in drowning risk reduction in Bangladesh and other countries.

Increased oxidative burden associated with traffic component of ambient particulate matter at roadside and urban background schools sites in London

As the incidence of respiratory and allergic symptoms has been reported to be increased in children attending schools in close proximity to busy roads, it was hypothesised that PM from roadside schools would display enhanced oxidative potential (OP). Two consecutive one-week air quality monitoring campaigns were conducted at seven school sampling sites, reflecting roadside and urban background in London. Chemical characteristics of size fractionated particulate matter (PM) samples were related to the capacity to drive biological oxidation reactions in a synthetic respiratory tract lining fluid. Contrary to hypothesised contrasts in particulate OP between school site types, no robust size-fractionated differences in OP were identified due high temporal variability in concentrations of PM components over the one-week sampling campaigns. For OP assessed both by ascorbate (OP(AA) m(-3)) and glutathione (OP(GSH) m(-3)) depletion, the highest OP per cubic metre of air was in the largest size fraction, PM(1.9-10.2). However, when expressed per unit mass of particles OP(AA) µg(-1) showed no significant dependence upon particle size, while OP(GSH) µg(-1) had a tendency to increase with increasing particle size, paralleling increased concentrations of Fe, Ba and Cu. The two OP metrics were not significantly correlated with one another, suggesting that the glutathione and ascorbate depletion assays respond to different components of the particles. Ascorbate depletion per unit mass did not show the same dependence as for GSH and it is possible that other trace metals (Zn, Ni, V) or organic components which are enriched in the finer particle fractions, or the greater surface area of smaller particles, counter-balance the redox activity of Fe, Ba and Cu in the coarse particles. Further work with longer-term sampling and a larger suite of analytes is advised in order to better elucidate the determinants of oxidative potential, and to fuller explore the contrasts between site types.

Explicating an evidence-based, theoretically informed, mobile technology-based system to improve outcomes for people in recovery for alcohol dependence

Post-treatment relapse to uncontrolled alcohol use is common. Currently available communication technology can use existing models for relapse prevention to cost-effectively improve long-term relapse prevention. This paper describes: (1) research-based elements of alcohol consumption-related relapse prevention and how they can be encompassed in self-determination theory (SDT) and Marlatt's cognitive behavioral relapse prevention model, (2) how technology could help address the needs of people seeking recovery, (3) a technology-based prototype, organized around sexual transmitted disease and Marlatt's model, and (4) how we are testing a system based on the ideas in this article and related ethical and operational considerations.

Comparing road traffic mortality rates from police-reported data and death registration data in China

OBJECTIVE

To compare death rates from road traffic injuries in China in 2002-2007 when derived from police-reported data versus death registration data.

METHODS

In China, police-recorded data are obtained from police records by means of a standardized, closed-ended data collection form; these data are published in the China statistical yearbook of communication and transportation. Official death registration data, on the other hand, are obtained from death certificates completed by physicians and are published in the China health statistics yearbook. We searched both sources for data on road traffic deaths in 2002-2007, used the χ(2) test to compare the mortality rates obtained, and performed linear regression to look for statistically significant trends in road traffic mortality over the period.

FINDINGS

For 2002-2007, the rate of death from road traffic injuries based on death registration data was about twice as high as the rate reported by the police. Linear regression showed a significant decrease of 27% (95% confidence interval, CI: 35-19) in the death rate over the period according to police sources but no significant change according to death registration data.

CONCLUSION

The widely-cited recent drop in road traffic mortality in China, based on police-reported data, may not reflect a genuine decrease. The quality of the data obtained from police reports, which drives decision-making by the Government of China and international organizations, needs to be investigated, monitored and improved.

[The role of the voltage-dependent anion channels in the outer membrane of mitochondria in the regulation of cellular metabolism]

The role of voltage-dependent anion channels (VDAC/porins) of the mitochondrial outer membrane in the regulation of cell metabolism is assessed using an experimental model of ethanol toxicity in cultured hepatocytes. It is demonstrated that ethanol inhibits the phosphorylating and the uncoupled mitochondrial respiration, decreases the accessibility of mitochondrial adenylate kinase in the intermembrane space, and suppresses ureagenic respiration in the cells. Treatment with digitonin at high concentrations (>80 μM)—which creates pores in the mitochondrial outer membrane, allowing bypass of closed VDAC—restores all the processes suppressed with ethanol. It is concluded that the effect of ethanol in hepatocytes leads to global loss of mitochondrial function because of closure of VDAC, which limits the free diffusion of metabolites into the intermembrane space. Our studies also reveal the role of VDAC in the regulation of liver-specific intracellular processes such as ureagenesis. The data obtained can be used in development of pharmaceuticals that would prevent VDAC closure in mitochondria of ethanol-oxidizing liver, thus protecting liver tissue from the hepatotoxic action of alcohol.

The neighborhood health exchange: developing a community partnership in residency

BACKGROUND

The current system of residency training focuses on the hospital setting, and resident exposure to the surrounding community is often limited. However, community interaction can play an important role in ambulatory training and in learning systems-based practice, a residency core competency. The goal of the Neighborhood Health Exchange was to develop a community partnership to provide internal medicine residents with an opportunity to interface with community members through a mutually beneficial educational experience.

METHODS

Internal medicine residents received training during their ambulatory block and participated in a voluntary field practicum designed to engage community members in discussions about their health. Community members participated in education sessions led by resident volunteers.

RESULTS

Resident volunteers completed a survey on their experiences. All residents stated that the opportunity to lead an exchange was very useful to their overall residency training. Eight exchanges were held with a total of 61 community participants, who completed a 3-question survey following the session. This survey asked about the level of material, the helpfulness of the exchanges, and opportunities for improvement. We received 46 completed surveys from community members: 91% stated that the material was presented "at the right level" and 93% stated that the presentations were somewhat or very helpful. Eighty percent gave positive and encouraging comments about the exchange.

CONCLUSION

Effective community partnerships involve assessing needs of the stakeholders, anticipating leadership turnover, and adapting the Neighborhood Health Exchange model to different groups. Community outreach can also enhance internal medicine ambulatory training experience, provide residents with patient counseling opportunities, and offer a novel method to enhance resident understanding of systems-based practice, especially within the larger community in which their patients live.

DonorNet and the potential effects on organ utilization

The evolution of communication as donor data flows from organ procurement organization to transplant centers has evolved with the incorporation of DonorNet 2007 into the UNet(SM) system. The ensuing study looks at DonorNet's impact on this process. We established defined time periods for comparison purposes. The study looked at match number for organ placement and overall organ utilization with a focus on ischemia time and graft outcomes. The results of the study demonstrate no significant change in the median match number of organ placement in liver or kidney transplantation. Changes in discard rates were varied amongst transplanted organs and there were noticeable changes in organ sharing with an increase in local allocation for kidney and liver and an ensuing decrease in regional and national distribution. There were no significant differences in the outcomes of livers and kidneys with low offer numbers compared with those with high offer numbers. Overall the study suggests a modest impact by DonorNet on organ placement and utilization, but a longer term study would need to be done to fully evaluate its impact.

What defines a transplant surgeon? A needs assessment for curricular development in transplant surgery fellowship training

This study compares the perceptions of transplant surgery program directors (PDs) and recent fellowship graduates (RFs) regarding the adequacy of training and relevancy to practice of specific curricular content items in fellowship training. Surveys were sent to all American Society of Transplant Surgery approved fellowship PDs and all RFs in practice <5 years. For operative procedures, the RFs considered the overall training to be less adequate than the PDs (p = 0.0117), while both groups considered the procedures listed to be relevant to practice (p = 0.8281). Regarding nonoperative patient care items, although RFs tended to rank many individual items lower, both groups generally agreed that the training was both adequate and relevant. For nonpatient care related items (i.e. transplant-related ethics, economics, research, etc.), both groups scored them low regarding their adequacy of training although RFs scored them significantly lower than PDs (p = 0.0006). Regarding their relevance to practice, while both groups considered these items relevant, RFs generally considered them more relevant than PDs. Therefore, although there is consensus on many items, significant differences exist between PDs and RFs regarding their perceptions of the adequacy of training and the relevance to practice of specific curriculum items in transplant surgery fellowship training.

A comparative analysis of transarterial downstaging for hepatocellular carcinoma: chemoembolization versus radioembolization

Chemoembolization and other ablative therapies are routinely utilized in downstaging from United Network for Organ Sharing (UNOS) T3 to T2, thus potentially making patients transplant candidates under the UNOS model for end-stage liver disease (MELD) upgrade for hepatocellular carcinoma (HCC). This study was undertaken to compare the downstaging efficacy of transarterial chemoembolization (TACE) versus transarterial radioembolization. Eighty-six patients were treated with either TACE (n = 43) or transarterial radioembolization with Yttrium-90 microspheres (TARE-Y90; n = 43). Median tumor size was similar (TACE: 5.7 cm, TARE-Y90: 5.6 cm). Partial response rates favored TARE-Y90 versus TACE (61% vs. 37%). Downstaging to UNOS T2 was achieved in 31% of TACE and 58% of TARE-Y90 patients. Time to progression according to UNOS criteria was similar for both groups (18.2 months for TACE vs. 33.3 months for TARE-Y90, p = 0.098). Event-free survival was significantly greater for TARE-Y90 than TACE (17.7 vs. 7.1 months, p = 0.0017). Overall survival favored TARE-Y90 compared to TACE (censored 35.7/18.7 months; p = 0.18; uncensored 41.6/19.2 months; p = 0.008). In conclusion, TARE-Y90 appears to outperform TACE for downstaging HCC from UNOS T3 to T2.

Perception versus reality?: Virtual crossmatch--how to overcome some of the technical and logistic limitations

The goal of this work was to evaluate concordance between (a) actual flow cytometric crossmatch (FCXM) that is performed by the OPO laboratory servicing our transplant center and (b) virtual XM (vXM) prediction based on antibody identification by solid-phase methods performed in our laboratory. A total of 1586 FCXM, performed between June 2007 and September 2008, between all potential deceased donors in our region and sera from patients awaiting kidney or kidney-pancreas transplant, listed at Northwestern Memorial Hospital were evaluated. A key finding of this analysis was the understanding that a thorough vXM cannot be performed in some donor/recipient pairs due to the lack of certain antibody profile data specific to the donor in question. Obtaining more in depth and stringent information regarding antibody specificities, we demonstrate an excellent sensitivity and specificity of the vXM assays- 86.1% and 96.8%, respectively, with a positive likelihood ratio and negative likelihood ratios of 26.9 and 0.14, respectively. The vXM can serve as an outstanding tool to predict HLA compatibility between donor and recipient, with the caveat that the presence/absence of all antibodies against the potential donor and their strength have been thoroughly investigated.

Cost and clinical consequence of antibiotic non-adherence in acute exacerbations of chronic bronchitis

OBJECTIVE

To quantify the impact of non-adherence on the clinical effectiveness of antibiotics for acute exacerbations of chronic bronchitis (AECB) and to estimate the economic consequences for Spain, Italy and the United States.

METHODS

Standard systematic reviewing procedures were followed to identify randomised controlled clinical trials of antibiotic treatment for acute respiratory tract infection for which adherence was reported. A decision-analytic model was then constructed to evaluate the impact of non-adherence to antibiotic treatment on clinical effectiveness and costs per AECB episode. The model compared the total treatment costs, cure rates and incremental costs per cure for a poor compliance group (PCG) against a good compliance group (GCG). Clinical and resource use estimates were from the published literature and physician surveys.

RESULTS

Twenty-five articles met the criteria of the systematic review, although only one reported treatment success by adherence status. The relative risk of clinical effectiveness if non-adherent was 0.75 (95%CI 0.73-0.78). Based on this single study, the model predicted that 16-29% more patients would be cured in the GCG vs. the PCG, and payers would save up to euro122, euro179 and US$141 per AECB episode in Spain, Italy and the United States, respectively.

CONCLUSIONS

Non-adherence to antibiotics for AECB may have an impact on clinical effectiveness, which is associated with increased costs.

A comparative analysis of transarterial downstaging for hepatocellular carcinoma: chemoembolization versus radioembolization

Chemoembolization and other ablative therapies are routinely utilized in downstaging from United Network for Organ Sharing (UNOS) T3 to T2, thus potentially making patients transplant candidates under the UNOS model for end-stage liver disease (MELD) upgrade for hepatocellular carcinoma (HCC). This study was undertaken to compare the downstaging efficacy of transarterial chemoembolization (TACE) versus transarterial radioembolization. Eighty-six patients were treated with either TACE (n = 43) or transarterial radioembolization with Yttrium-90 microspheres (TARE-Y90; n = 43). Median tumor size was similar (TACE: 5.7 cm, TARE-Y90: 5.6 cm). Partial response rates favored TARE-Y90 versus TACE (61% vs. 37%). Downstaging to UNOS T2 was achieved in 31% of TACE and 58% of TARE-Y90 patients. Time to progression according to UNOS criteria was similar for both groups (18.2 months for TACE vs. 33.3 months for TARE-Y90, p = 0.098). Event-free survival was significantly greater for TARE-Y90 than TACE (17.7 vs. 7.1 months, p = 0.0017). Overall survival favored TARE-Y90 compared to TACE (censored 35.7/18.7 months; p = 0.18; uncensored 41.6/19.2 months; p = 0.008). In conclusion, TARE-Y90 appears to outperform TACE for downstaging HCC from UNOS T3 to T2.