Advances in MRI for the evaluation of carotid atherosclerosis

Carotid artery atherosclerosis is an important source of mortality and morbidity in the Western world with significant socioeconomic implications. The quest for the early identification of the vulnerable carotid plaque is already in its third decade and traditional measures, such as the sonographic degree of stenosis, are not selective enough to distinguish those who would really benefit from a carotid endarterectomy. MRI of the carotid plaque enables the visualization of plaque composition and specific plaque components that have been linked to a higher risk of subsequent embolic events. Blood suppressed T1 and T2 weighted and proton density-weighted fast spin echo, gradient echo and time-of-flight sequences are typically used to quantify plaque components such as lipid-rich necrotic core, intraplaque haemorrhage, calcification and surface defects including erosion, disruption and ulceration. The purpose of this article is to review the most important recent advances in MRI technology to enable better diagnostic carotid imaging.

Using the Medical Research Council framework to develop a complex intervention to improve delivery of care for young people with type 1 diabetes

AIMS

We describe how we have used the development phase of the Medical Research Council (MRC) Guidelines to construct a complex intervention to improve physical and psychological health among young people (16-21 years) with Type 1 diabetes.

METHODS

We consulted previous reviews where available and conducted systematic searches of electronic databases to determine physical and mental health among the population, audited medical records, surveyed self-reported psychological health among our clinic population; and interviewed staff (n = 13), young people (n = 27) and parents (n = 18) about their views of current care.

RESULTS

Our audit (n = 96) confirmed a high HbA1c [86 mmol/mol (10.0%)] and one third (36.1%) reported significant eating problems. Young people did not attend 12% of their clinic appointments. Staff described difficulties communicating with young people who wanted staff to take account of their individual lifestyle when giving information.

CONCLUSION

Based on the findings of the systematic reviews and our audit, we concluded that there was sufficient evidence to justify development of a model of care specific to this age group. The components of the complex intervention include changes to standard care, an optional 5-day self-management course directed at young people and a separate family communication programme. The MRC Guidelines provided a valuable structure to guide development and evaluation of this intervention.

Prevalence of depression among young people with Type 1 diabetes: a systematic review

AIMS

  To determine: (1) prevalence of depression among young people with Type 1 diabetes compared with control groups or population norms; (2) implications of depression for HbA(1c) level; and (3) the relationship between history of depressive symptoms and future depressive symptoms.

BACKGROUND

  Among adults with Type 1 diabetes depression is higher than the general population, and has been associated with adverse implications for self-care and HbA(1c) level. The last published review of depression among young people with Type 1 diabetes only included studies up to 1999.

METHOD

  Systematic searches were conducted for articles published from January 1999 to December 2011 including young people (up to 25 years old) with Type 1 diabetes.

RESULTS

  Twenty-three articles met the inclusion criteria. Of five studies that reported prevalence of depression compared with control groups, three found no differences. Of the three studies that investigated prevalence of depression making reference to population norms, all three showed higher rates of depressive symptoms. Fourteen of 15 studies found associations between more depressive symptoms and higher HbA(1c) level either cross-sectionally or longitudinally. Past depressive symptoms were associated with later depressive symptoms.

CONCLUSIONS

  Current evidence is inconclusive about whether there is increased prevalence of depression among young adults with Type 1 diabetes, as established among adults, but those who are more depressed have higher HbA(1c) level. This review is limited by methodological problems and no identified work in the UK met the inclusion criteria. Given the adverse clinical outcomes, we conclude there is a case for routine mental health screening for young adults with Type 1 diabetes.

Eating problems in adolescents with Type 1 diabetes: a systematic review with meta-analysis

AIMS

We report a systematic review to determine (1) prevalence of eating problems compared with peers and (2) the association between eating problems and glycaemic control in young adults with Type 1 diabetes.

METHOD

  We conducted a systematic literature search via electronic databases and meta-analysis. Cohen's d (the mean difference score between Type 1 diabetes and comparison groups) was calculated for 13 studies that met inclusion criteria.

RESULTS

  Eating problems [both disordered eating behaviour (39.3 and 32.5%; d = 0.52, 95% CI 0.10-0.94) and eating disorders (7.0 and 2.8%; d = 0.46, 95% CI 0.10-0.81)] were more common in adolescents with Type 1 diabetes compared with peers and both were associated with poorer glycaemic control (d = 0.40, 95% CI 0.17-0.64). In restricted analyses involving measures adapted for diabetes, associations between eating problems and poorer glycaemic control remained (d = 0.54, 95% CI 0.32-0.76). Disordered eating behaviour (51.8 and 48.1%; d = 0.06, 95% CI -0.05 to 0.21) and eating disorders (6.4 and 3.0%; d = 0.43, 95% CI -0.06 to 0.91) were more common in adolescents with Type 1 diabetes compared with peers, but differences were non-significant.

CONCLUSIONS

  Eating problems are common among this age group. Future work in populations with Type 1 diabetes should develop sensitive measures of eating problems and interventions, and establish predictors of eating problems. Screening in clinics is recommended.

Working with young adults with Type 1 diabetes: views of a multidisciplinary care team and implications for service delivery

AIMS

Young adults with Type 1 diabetes experience difficulties achieving glucose targets. Clinic attendance can be poor, although health and self-care tend to be better among those who attend regularly. Our aims were to describe staff views about challenges working with this age-group (16-21 years).

METHODS

Semistructured interviews were conducted with 14 staff from Sheffield Teaching Hospitals diabetes care team. Interviews were audio-recorded, transcribed and analysed using thematic analysis.

RESULTS

Three main themes emerged. Unique challenges working with young adults included staff emotional burden, the low priority given to self-care by young adults and the complexity of the diabetes regimen. Working in a multidisciplinary team was complicated by differences in consultation styles, poor team cohesion and communication. An ideal service should include psychological support for the professional team, identification of key workers, and development of individualized care plans.

CONCLUSIONS

Staff differed in their views about how to achieve optimal management for young adults, but emphasized the need for greater patient-centred care and a range of interventions appropriate for individual levels of need. They also wanted to increase their own skills and confidence working with this age-group. While these results reflect the views of staff working in only one diabetes centre, they are likely to reflect the views of professionals delivering care to individuals of this age; replication is needed to determine their generalizability.

Where do hands go? An audit of sequential hand-touch events on a hospital ward

BACKGROUND

Reservoirs of pathogens could establish themselves at forgotten sites on a ward, posing a continued risk for transmission to patients via unwashed hands.

AIM

To track potential spread of organisms between surfaces and patients, and to gain a greater understanding into transmission pathways of pathogens during patient care.

METHODS

Hand-touch activities were audited covertly for 40 × 30 min sessions during summer and winter, and included hand hygiene on entry; contact with near-patient sites; patient contact; contact with clinical equipment; hand hygiene on exit; and contact with sites outside the room.

FINDINGS

There were 104 entries overall: 77 clinical staff (59 nurses; 18 doctors), 21 domestic staff, one pharmacist and five relatives. Hand-hygiene compliance among clinical staff before and after entry was 25% (38/154), with higher compliance during 20 summer periods [47%; 95% confidence interval (CI): 35.6-58.8] than during 20 winter periods (7%; 95% CI: 3.2-14.4; P < 0.0001). More than half of the staff (58%; 45/77) touched the patient. Staff were more likely to clean their hands prior to contact with a patient [odds ratio (OR): 3.44; 95% CI: 0.94-16.0); P = 0.059] and sites beside the patient (OR: 6.76; 95% CI: 1.40-65.77; P = 0.0067). Nearly half (48%; 37/77) handled patient notes and 25% touched the bed. Most frequently handled equipment inside the room were intravenous drip (30%) and blood pressure stand (13%), and computer (26%), notes trolley (23%) and telephone (21%) outside the room.

CONCLUSION

Hand-hygiene compliance remains poor during covert observation; understanding the most frequent interactions between hands and surfaces could target sites for cleaning.

P4-15-01: High Prevalence of Prospective Memory (PM) Impairment in Early Breast Cancer (EBC) Survivors within 1 Year of Adjuvant Chemotherapy Completion: Novel Findings Concerning Post Chemotherapy Cognitive Effects

Background Numerous studies have demonstrated that EBC survivors report more memory problems than healthy controls. However, evidence of impairment on objective tests of memory remains inconclusive. Past research has focussed exclusively on retrospective memory (remembering information from the past when asked to do so), but the complaints of EBC patients appear better described as “prospective memory” failures defined as forgetting to carry out in the future previously formed intentions. The effective performance of many day-to-day activities relies on PM and its impairment has negative consequences in everyday life. Despite its high ecological relevance, no study has evaluated PM functioning in EBC survivors. Consequently, we assessed the prevalence of PM impairment among EBC survivors in the year following completion of chemotherapy. Methods We undertook a cross sectional quantitative case-control study aiming to recruit 80 patients from the Ottawa Hospital Regional Cancer Centre and 80 matched healthy controls from the community. Patients were within 1 year of having completed a first course of chemotherapy. A standardized test of prospective memory (Memory for Intention Screening Test) was administered to both groups. Following the International Cognition and Cancer Task Force recommendation (2008), impairment was defined as a score that fell one standard deviation below the mean performance of the control group. Standardized measures of depression (CESD), anxiety (STAI) and fatigue (Fact-F) were also completed. Results Data are available on 36 patients and 18 controls. Age was well balanced between the groups (case-control mean age 54y vs. 51y, respectively, p=.204). Overall PM impairment was observed in 41% of the participants. More importantly, the rate of PM impairment was significantly higher in the EBC group than controls (53% vs 17%; p &lt; 0.005; odds ratio = 5.588; 95% CI=1.376 to 22.7). Multivariate logistic regression showed that PM performance was unaffected by age (p=0.459), depression (p=0.358), anxiety (p=0.512) or fatigue (p=0.595). Conclusions These preliminary findings provide further support for the hypothesis that breast cancer treatment can impair cognitive processes and yield new and important insights into the type of memory problems experienced by EBC survivors. They suggest that a significant proportion of patients exhibit deficits in PM, an aspect of memory involved in effective daily functioning. Our results also suggest that emotional distress and fatigue do not contribute to PM functioning. Further studies in this area should be directed at understanding the severity and duration of PM impairment. Acknowledging and studying this vexing problem in EBC survivors will aid in developing appropriate rehabilitation strategies.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-15-01.

Outcomes of patients presenting to a dedicated rapid access lung cancer clinic

We examined the outcomes of the first 500 patients referred to a dedicated Rapid Access Lung Cancer Clinic. A total of 206 patients (41.2%) were diagnosed with a thoracic malignancy; 179 had primary lung cancer and 27 had secondary or other thoracic cancers. Pulmonary nodules requiring ongoing surveillance were found in a further 79 patients (15.8%). Of those patients found to have primary lung cancer, 24 (13.4%) had Small Cell and 145 (81%) had Non Small Cell Lung Cancer. In patients with Non small cell tumours, 26 (21.1%) were stage 1, 14 (11.4%) stage II, 37 (30.1%) stage III and 46 (37.4%) stage IV at diagnosis. For the 129 patients (72%) in whom the thoracic MDT recommended active treatment, primary therapy was surgical resection in 44 (24.6%), combined chemoradiation in 31 patients (17.3%), chemotherapy alone in 39 (21.8%) and radiation in 15 (8.4%).

ACTH-secreting bronchial carcinoid: a diagnostic and therapeutic challenge

OBJECTIVE

We describe a case of Cushing's syndrome due to ectopic ACTH secretion, where the only potential source on conventional imaging was a tiny benign-appearing lung nodule, which failed to take up radiolabelled octreotide.

DESIGN AND METHODS

To determine whether the patient might respond to therapeutic administration of octreotide, a test dose was given.

RESULTS

Compared to ACTH and cortisol levels on a control day, the levels following the test dose of octreotide were lower. Subsequent therapeutic administration of subcutaneous octreotide normalised urine free cortisol, with symptomatic improvement, pending evaluation for surgery. Eventual resection of the lung nodule resulted in cure of hypercortisolism. Histological examination of the resected specimen confirmed bronchial carcinoid staining positive for ACTH.

CONCLUSIONS

This is one of the few cases described where ectopic ACTH secretion secondary to bronchial carcinoid responded to somatostatin analogue therapy. The case was also unusual in that the tumour responded despite not taking up radiolabelled octreotide.

Pyoderma gangrenosum manifesting as a cavitating lung lesion

We present a case of pyoderma gangrenosum (PG) mimicking a lung carcinoma. A 52-year-old woman presented with an unremitting cough. Computed tomography revealed a cavitating lung lesion. Bronchoscopy and biopsy were interpreted as squamous cell carcinoma. Following a staging mediastinoscopy, a sleeve lobectomy and chest-wall resection was performed. The pulmonary histopathological features suggested Wegener's granulomatosis; no malignancy was found. Three months postoperatively, wound breakdown led to dermatological review. A clinical diagnosis of cutaneous PG was made on the basis of the classic appearance of the surgical wounds and an ulcer on the upper back that had been present before surgery. The patient has been consistently negative for cytoplasmic-staining antineutrophil cytoplasmic antibodies, which supports the diagnosis of PG with cutaneous and pulmonary involvement. Lung manifestations of PG are rare. PG is amenable to systemic therapy. Pulmonary PG is a rare but important differential diagnosis that is not familiar to many physicians and surgeons in this type of presentation.

Phase II pilot study of neoadjuvant cetuximab in combination with cisplatin and gemcitabine in patients with resectable IB-IIIA non small cell lung cancer

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Background: Adjuvant and neoadjuvant chemotherapy play a role in optimising long term outcome of patients with resectable non small cell lung cancer (NSCLC). The epidermal growth factor receptor (EGFR) is a receptor tyrosine kinase which is overexpressed NSCLC. Cetuximab is a monoclonal antibody which attaches to the extracellular domain of the EGFR preventing ligand binding. Preclinical data and phase II evidence in advanced NSCLC suggest cetuximab potentiates the effect of conventional cytotoxic agents. Methods: Patients with histologically confirmed resectable stage IB-IIIA NSCLC and adequate end-organ function, giving informed written consent are eligible. Three weekly cycles of cisplatin 80 mg/m2 D1, gemcitabine 1250 mg/m2 D1,D8 and cetuximab loading dose of 400 mg/m2 on first infusion, thereafter weekly 250 mg/m2 are used. The primary endpoint is response rate (radiological and pathological). Secondary endpoints are safety and tolerability of the combination, resection rate following therapy, overall survival and relapse free survival. In addition, molecular prognostic and predictive biomarkers of response are being assessed. Sequential samples of tissue, plasma, serum and white blood cells are being collected before, during and after therapy on all patients. Results: 16 patients have been recruited to date. (10 men, 6 women). Median age 66 (range 29–76). 3 patients stage I, 4 patients, stage II, 9 patients stage III. 11 have completed treatment. Response (RECIST guidelines); PR - 6 patients, SD - 4 patients, PD - 1 patient. The most common toxicity was skin rash (100%). Grade 3/4 toxicities were neutropenia (73%), thrombocytopenia (45%). There were 2 grade 3 and 2 grade 4 cardiovascular toxicities in patients with significant co-morbid cardiovascular histories. Conclusion: The response rate is consistent with that established for neoadjuvant chemotherapy. Ongoing biomarker studies may identify those patients most likely to benefit from induction treatment.

No significant financial relationships to disclose.

Real-time PCR detection and quantification of vector trichodorid nematodes and Tobacco rattle virus

This report describes a novel diagnostic method for virus-vector trichodorid nematodes and associated Tobacco rattle virus (TRV) based on a real-time fluorogenic 5' nuclease PCR assay (TaqMan). Two independent primer/probe sets were designed targeting the 18S gene of the ribosomal cistron for the trichodorid species, Paratrichodorus pachydermus and Trichodorus similis. Assays using purified plasmid DNA containing clones of the 18S region and genomic DNA extracted from individuals from both nematode species displayed high specificity as no cros s-reaction was observed between the species or with two non-target trichodorid species Paratrichodorus anemones and Trichodorus primitivus. Relative quantification of target DNA present in unknown samples was performed by comparison of the fluorescence signals of the samples to those obtained from plasmid standard dilutions. Three primer/probe sets were also used to target TRV; one set for RNA1 and the two other sets for RNA2 of specific isolates (TRV-PpK20 and TRV-TpO1). Detection of both trichodorid species and TRV RNA1 and RNA2 from a single sample was achieved and field samples were used to demonstrate the potential of this assay to provide rapid, accurate and sensitive molecular information in relation to risk assessment in the field.