Examining the sources of occupational stress in an emergency department

BACKGROUND

Previous work has established that health care staff, in particular emergency department (ED) personnel, experience significant occupational stress but the underlying stressors have not been well quantified. Such data inform interventions that can reduce cases of occupational mental illness, burnout, staff turnover and early retirement associated with cumulative stress.

AIMS

To develop, implement and evaluate a questionnaire examining the origins of occupational stress in the ED.

METHODS

A questionnaire co-designed by an occupational health practitioner and ED management administered to nursing, medical and support staff in the ED of a large English teaching hospital in 2015. The questionnaire assessed participants' demographic characteristics and perceptions of stress across three dimensions (demand-control-support, effort-reward and organizational justice). Work-related stressors in ED staff were compared with those of an unmatched control group from the acute ear, nose and throat (ENT) and neurology directorate.

RESULTS

A total of 104 (59%) ED staff returned questionnaires compared to 72 staff (67%) from the acute ENT/neurology directorate. The ED respondents indicated lower levels of job autonomy, management support and involvement in organizational change, but not work demand. High levels of effort-reward imbalance and organizational injustice were reported by both groups.

CONCLUSIONS

Our findings suggest that internal ED interventions to improve workers' job control, increase support from management and involvement in organizational change may reduce work stress. The high levels of effort-reward imbalance and organizational injustice reported by both groups may indicate that wider interventions beyond the ED are also needed to address these issues.

Tolerability and Clinical Activity of Post-Transplantation Azacitidine in Patients Allografted for Acute Myeloid Leukemia Treated on the RICAZA Trial

Disease relapse is the major causes of treatment failure after allogeneic stem cell transplantation (SCT) in patients with acute myeloid leukemia (AML). As well as demonstrating significant clinical activity in AML, azacitidine (AZA) upregulates putative tumor antigens, inducing a CD8(+) T cell response with the potential to augment a graft-versus-leukemia effect. We, therefore, studied the feasibility and clinical sequelae of the administration of AZA during the first year after transplantation in 51 patients with AML undergoing allogeneic SCT. Fourteen patients did not commence AZA either because of transplantation complications or withdrawal of consent. Thirty-seven patients commenced AZA at a median of 54 days (range, 40 to 194 days) after transplantation, which was well tolerated in the majority of patients. Thirty-one patients completed 3 or more cycles of AZA. Sixteen patients relapsed at a median time of 8 months after transplantation. No patient developed extensive chronic graft-versus-host disease. The induction of a post-transplantation CD8(+) T cell response to 1 or more tumor-specific peptides was studied in 28 patients. Induction of a CD8(+) T cell response was associated with a reduced risk of disease relapse (hazard ratio [HR], .30; 95% confidence interval [CI], .10 to .85; P = .02) and improved relapse-free survival (HR, .29; 95% CI, .10 to .83; P = .02) taking into account death as a competing risk. In conclusion, AZA is well tolerated after transplantation and appears to have the capacity to reduce the relapse risk in patients who demonstrate a CD8(+) T cell response to tumor antigens. These observations require confirmation in a prospective clinical trial.

REpeated AutoLogous Infusions of STem cells In Cirrhosis (REALISTIC): a multicentre, phase II, open-label, randomised controlled trial of repeated autologous infusions of granulocyte colony-stimulating factor (GCSF) mobilised CD133+ bone marrow stem cells in patients with cirrhosis. A study protocol for a randomised controlled trial

INTRODUCTION

Liver disease mortality and morbidity are rapidly rising and liver transplantation is limited by organ availability. Small scale human studies have shown that stem cell therapy is safe and feasible and has suggested clinical benefit. No published studies have yet examined the effect of stem cell therapy in a randomised controlled trial and evaluated the effect of repeated therapy.

METHODS AND ANALYSIS

Patients with liver cirrhosis will be randomised to one of three trial groups: group 1: Control group, Standard conservative management; group 2 treatment: granulocyte colony-stimulating factor (G-CSF; lenograstim) 15 µg/kg body weight daily on days 1-5; group 3 treatment: G-CSF 15 µg/kg body weight daily on days 1-5 followed by leukapheresis, isolation and aliquoting of CD133+ cells. Patients will receive an infusion of freshly isolated CD133+ cells immediately and frozen doses at days 30 and 60 via peripheral vein (0.2×10(6) cells/kg for each of the three doses). Primary objective is to demonstrate an improvement in the severity of liver disease over 3 months using either G-CSF alone or G-CSF followed by repeated infusions of haematopoietic stem cells compared with standard conservative management. The trial is powered to answer two hypotheses of each treatment compared to control but not powered to detect smaller expected differences between the two treatment groups. As such, the overall α=0.05 for the trial is split equally between the two hypotheses. Conventionally, to detect a relevant standardised effect size of 0.8 point reduction in Model for End-stage Liver Disease score using two-sided α=0.05(overall α=0.1 split equally between the two hypotheses) and 80% power requires 27 participants to be randomised per group (81 participants in total).

ETHICS AND DISSEMINATION

The trial is registered at Current Controlled Trials on 18 November 2009 (ISRCTN number 91288089, EuDRACT number 2009-010335-41). The findings of this trial will be disseminated to patients and through peer-reviewed publications and international presentations.

Challenges of clinical trial design for targeted agents against pediatric leukemias

The past 40 years have seen significant improvements in both event-free and overall survival for children with acute lymphoblastic and acute myeloid leukemia (ALL and AML, respectively). Serial national and international clinical trials have optimized the use of conventional chemotherapeutic drugs and, along with improvements in supportive care that have enabled the delivery of more intensive regimens, have been responsible for the major improvements in patient outcome seen over the past few decades. However, the benefits of dose intensification have likely now been maximized, and over the same period, the identification of new cytotoxic drugs has been limited. Therefore, challenges remain if survival is to be improved further. In pediatric ALL, 5-year-survival rates of over 85% have been achieved with risk-stratified therapy, but a notable minority of patients will still not be cured. In pediatric AML, different challenges remain. A slower improvement in overall survival has taken place in this patient population. Despite the obvious morphological heterogeneity of AML blasts, biological stratification is comparatively limited, and translation into risk-stratified therapeutic approaches has only best characterized by the use of retinoic acid for t(15;17)-positive AML. Even where prognostic markers have been identified, limited therapeutic options or multi-drug resistance of AML blasts has limited the impact on patient benefit. For both, the acute morbidities of current treatment remain significant and may be life-threatening alone. In addition, the Childhood Cancer Survivor Study (CCSS) highlighted many leukemia survivors develop one or more chronic medical conditions attributable to treatment (1, 2). As the biology of leukemogenesis has become better understood, key molecules and intracellular pathways have been identified that offer the possibility of targeting directly the leukemia cells while sparing normal cells. Consequently, there is now a drive to develop novel leukemia-specific or "targeted" therapies. These new classes of drugs will have mechanisms of action, toxicities, and therapeutic indices quite different from conventional cytotoxic drugs previously encountered, thus rendering current clinical trial methodologies inappropriate. Clinical trial methods will need to be adapted to accommodate these features of these new classes of drugs. This review will address the challenges and some of the techniques for developing clinical trials for targeted therapies.

Screened selection design for randomised phase II oncology trials: an example in chronic lymphocytic leukaemia

BACKGROUND

As there are limited patients for chronic lymphocytic leukaemia trials, it is important that statistical methodologies in Phase II efficiently select regimens for subsequent evaluation in larger-scale Phase III trials.

METHODS

We propose the screened selection design (SSD), which is a practical multi-stage, randomised Phase II design for two experimental arms. Activity is first evaluated by applying Simon's two-stage design (1989) on each arm. If both are active, the play-the-winner selection strategy proposed by Simon, Wittes and Ellenberg (SWE) (1985) is applied to select the superior arm. A variant of the design, Modified SSD, also allows the arm with the higher response rates to be recommended only if its activity rate is greater by a clinically-relevant value. The operating characteristics are explored via a simulation study and compared to a Bayesian Selection approach.

RESULTS

Simulations showed that with the proposed SSD, it is possible to retain the sample size as required in SWE and obtain similar probabilities of selecting the correct superior arm of at least 90%; with the additional attractive benefit of reducing the probability of selecting ineffective arms. This approach is comparable to a Bayesian Selection Strategy. The Modified SSD performs substantially better than the other designs in selecting neither arm if the underlying rates for both arms are desirable but equivalent, allowing for other factors to be considered in the decision making process. Though its probability of correctly selecting a superior arm might be reduced, it still performs reasonably well. It also reduces the probability of selecting an inferior arm.

CONCLUSIONS

SSD provides an easy to implement randomised Phase II design that selects the most promising treatment that has shown sufficient evidence of activity, with available R codes to evaluate its operating characteristics.

Association between long-term exposure to air pollution and specific causes of mortality in Scotland

OBJECTIVE

This study investigated the association between long-term exposure to black smoke (BS) air pollution and mortality in two related Scottish cohorts with 25 years of follow-up.

METHODS

Risk factors were collected during 1970-1976 for 15331 and 6680 participants in the Renfrew/Paisley and Collaborative cohorts respectively. Exposure to BS during 1970-1979 was estimated by inverse-distance weighted averages of observed concentrations at monitoring sites and by two alternative spatial modelling approaches which included local air quality predictors (LAQP).

RESULTS

Consistent BS-mortality associations (per 10 μg m(-3) increment in 10-year average BS) were observed in the Renfrew/Paisley cohort using LAQP-based exposure models (all-cause mortality HR 1.10 (95% CI 1.04 to 1.17); cardiovascular HR 1.11 (1.01 to 1.22); ischaemic heart disease HR 1.13 (1.02 to 1.25); respiratory HR 1.26 (1.02 to 1.28)). The associations were largely unaffected by additional adjustment for area-level deprivation category. A less consistent and generally implausible pattern of cause-specific BS-mortality associations was found for inverse-distance averaging of BS concentrations at nearby monitoring sites. BS-mortality associations in the Collaborative cohort were weaker and not statistically significant.

CONCLUSIONS

The association between mortality and long-term exposure to BS observed in the Renfrew/Paisley cohort is consistent with hypotheses of how air pollution may affect human health. The dissimilarity in pollution-mortality associations for different exposure models highlights the critical importance of reliable estimation of exposures on intraurban spatial scales to avoid potential misclassification bias.

A comparison of short-term and long-term air pollution exposure associations with mortality in two cohorts in Scotland

BACKGROUND

Air pollution-mortality risk estimates are generally larger at longer-term, compared with short-term, exposure time scales.

OBJECTIVE

We compared associations between short-term exposure to black smoke (BS) and mortality with long-term exposure-mortality associations in cohort participants and with short-term exposure-mortality associations in the general population from which the cohorts were selected.

METHODS

We assessed short-to-medium-term exposure-mortality associations in the Renfrew-Paisley and Collaborative cohorts (using nested case-control data sets), and compared them with long-term exposure-mortality associations (using a multilevel spatiotemporal exposure model and survival analyses) and short-to-medium-term exposure-mortality associations in the general population (using time-series analyses).

RESULTS

For the Renfrew-Paisley cohort (15,331 participants), BS exposure-mortality associations were observed in nested case-control analyses that accounted for spatial variations in pollution exposure and individual-level risk factors. These cohort-based associations were consistently greater than associations estimated in time-series analyses using a single monitoring site to represent general population exposure {e.g., 1.8% [95% confidence interval (CI): 0.1, 3.4%] vs. 0.2% (95% CI: 0.0, 0.4%) increases in mortality associated with 10-μg/m³ increases in 3-day lag BS, respectively}. Exposure-mortality associations were of larger magnitude for longer exposure periods [e.g., 3.4% (95% CI: -0.7, 7.7%) and 0.9% (95% CI: 0.3, 1.5%) increases in all-cause mortality associated with 10-μg/m³ increases in 31-day BS in case-control and time-series analyses, respectively; and 10% (95% CI: 4, 17%) increase in all-cause mortality associated with a 10-μg/m³ increase in geometic mean BS for 1970-1979, in survival analysis].

CONCLUSIONS

After adjusting for individual-level exposure and potential confounders, short-term exposure-mortality associations in cohort participants were of greater magnitude than in comparable general population time-series study analyses. However, short-term exposure-mortality associations were substantially lower than equivalent long-term associations, which is consistent with the possibility of larger, more persistent cumulative effects from long-term exposures.

What Undergraduate Factors Influence Medical Students When Making Their Choice of Post Graduate Career?

Objectives:

To determine what factors final year medical students consider when deciding upon their future post graduate career and to what extent each factor influences their decision.

Methods:

150 final year medical students were asked to complete an anonymous questionnaire relating to factors relating to their future career choice. Students were asked to rate each factor according to the level of importance or influence it exerted when choosing a post graduate career. A simple visual analogue scale from 1 to 10 was utilised with 10 being most influential.

Results:

The most significant factors influencing final year medical students in their career choice were clinical mentors and specialty themed PBL cases with scores of 6.8 and 6.5 out of a maximum of 10. Clinical exposure exerted the weakest influence with a mean score of 2.5.

Conclusion:

Various factors influence the future career choice of final year medical students to a differing extent. In order to promote Urology as a favourable career choice in this cohort, a concerted and coherent effort should be made at national level to engage medical students and promote the specialty.

Maternal fructose intake during pregnancy and lactation alters placental growth and leads to sex-specific changes in fetal and neonatal endocrine function

The effects of maternal fructose intake on offspring health remain largely unknown, despite the marked increase in consumption of sweetened beverages that has paralleled the obesity epidemic. The present study investigated the impact of maternal fructose intake on placental, fetal, and neonatal development. Female Wistar rats were time-mated and allocated to receive either water [control (CONT)] or fructose solution designed to provide 20% of caloric intake from fructose (FR). FR was administered from d 1 of pregnancy until postnatal day (P) 10. All dams had ad libitum access to standard laboratory chow and water. Dams and offspring were killed at embryonic day (E) 21 and P10. FR dams demonstrated increased total caloric intake and maternal hyperinsulinemia at E21 as well as increased maternal plasma fructose levels at E21 and P10. FR intake did not alter maternal blood glucose, β-hydroxybutyrate (BHB), or electrolyte levels at either time point. Fetal weights at E21 were unchanged, although placental weights were reduced in FR female but not FR male fetuses. Plasma leptin, fructose, and blood glucose levels were increased and BHB levels decreased in FR female but not male fetuses. Plasma insulin levels were not different between CONT and FR groups. Male and female FR neonates had higher plasma fructose levels and were hypoinsulinemic but euglycemic at P10 compared with CONT. Blood BHB levels were increased in FR male neonates but not females at P10. P10 plasma leptin levels were not different between groups. Stomach content leptin levels were increased in all FR offspring at P10, but no differences in stomach content insulin or fructose levels were observed. This study reports for the first time that maternal FR intake resulted in sex-specific changes in offspring development, whereby females appear more vulnerable to metabolic compromise during neonatal life. Independent follow-up studies are essential to investigate the long-term consequences of maternal FR consumption on offspring health.

Targeted intervention reduces refracture rates in patients with incident non-vertebral osteoporotic fractures: a 4-year prospective controlled study

In the present prospective controlled observational study, we investigated the effect of a coordinated intervention program on 4-year refracture rates in patients with recent osteoporotic fractures. Compared to standard care, targeted identification, and management significantly reduced the risk of refracture by more than 80%.

INTRODUCTION

The risk of refracture following an incident osteoporotic fracture is high. Despite the availability of treatments that reduce refracture and mortality rates, most patients with minimal trauma fracture (MTF) are not managed appropriately. The present prospective controlled observational study investigated the effect of a coordinated intervention program on 4-year refracture rates and time to refracture in patients with recent osteoporotic fractures.

METHODS

Patients presenting with a non-vertebral MTF were actively identified and offered referral to a dedicated intervention program. Patients attending the clinic underwent a standardized set of investigations, were treated as indicated and reviewed at 12-monthly intervals ('MTF group'). Patients who elected to follow-up with their primary care physician were assigned to the concurrent control group.

RESULTS

Groups were balanced for baseline anthropometric, socio-economic, and clinical risk factors. Over 4 years, 10 out of 246 patients (4.1%) in the MTF group and 31 of 157 patients (19.7%) in the control group suffered a new fracture, with a median time to refracture of 26 and 16 months, respectively (p < 0.01). Compared to the intervention group, the risk of refracture was increased by 5.3-fold in the control group (95% CI: 2.8-12.2, p < 0.01), and remained elevated (HR 5.63, 95%CI 2.73-11.6, p < 0.01) after adjustment for other significant predictors of refracture such as age and body weight.

CONCLUSIONS

In patients presenting with a minimal trauma non-vertebral fracture, active identification and management significantly reduces the risk of refracture (Australian New Zealand Clinical Trials Registry ACTRN 12606000108516).

In situ identification of follicles in ovarian cortex as a tool for quantifying follicle density, viability and developmental potential in strategies to preserve female fertility

BACKGROUND

Ovarian tissue cryopreservation, in combination with autotransplantation or long-term culture, has been proposed as a means of fertility preservation. However follicle density within ovarian cortex has a profound impact on the success of in vivo and in vitro systems designed to support follicle growth and restore fertility. The objective of this study was to investigate the dye neutral red (NR) as a tool to quantify follicle density in situ, without compromising follicle viability and developmental potential.

METHODS

In the first experimental series thin slices of cryopreserved and fresh ovine cortical tissue were incubated in 50 μg/ml NR and assessed for the presence of red colouration. Slices were then used for follicular structure isolation and viability evaluation using 5-(and 6)-carboxyfluoresceindiacetate succinimidylester (CFDA-SE), or prepared histologically for follicle counting or evaluation of apoptosis via terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labelling (TUNEL). An additional subset of slices were cultured for 8 days, followed by re-evaluation of follicle viability. NR staining was further assessed in a pilot study using thin slices of cryopreserved human ovarian tissue donated by 17 patients undergoing laparoscopic sterilisation or elective Caesarean section.

RESULTS

In both ovine and human ovarian cortex NR concentrated in follicular structures within weakly stained stroma. NR colouration was observed in 41.7 ± 4.6% of cryopreserved and 49.3 ± 6.5% of the fresh ovine tissue slices, and NR staining was consistently predictive of the presence of follicles. Non-stained ovine slices contained highly apoptotic follicles, while lower levels of apoptosis were observed in NR positive slices, indicating preferential detection of viable follicles by NR. Following culture the majority of ovine slices re-stained with NR, no significant increases in the levels of apoptosis were observed and 94.6 ± 3.1% of follicles were viable by CFDA-SE. In the human study, NR identified follicles in 19.3 ± 3.7% of tissue slices, and follicle density tended to decrease with advancing patient age.

CONCLUSIONS

NR predicts viable follicle density in situ in slices of ovine and human ovarian cortex. Furthermore incubation of tissue in NR prior to culture does not compromise subsequent follicle survival in vitro, indicating the potential suitability of this approach in fertility preservation regimes.

The effectiveness of walking as an intervention for low back pain: a systematic review

As current low back pain (LBP) guidelines do not specifically advocate walking as an intervention, this review has explored for the effectiveness of walking in managing acute and chronic LBP. CINAHL, Medline, AMED, EMBASE, PubMed, Cochrane and Scopus databases, as well as a hand search of reference lists of retrieved articles, were searched. The search was restricted to studies in the English language. Studies were included when walking was identified as an intervention. Four studies met inclusion criteria, and were assessed with a quality checklist. Three lower ranked studies reported a reduction in LBP from a walking intervention, while the highest ranked study observed no effect. Heterogeneity of study design made it difficult to draw comparisons between studies. There is only low-moderate evidence for walking as an effective intervention strategy for LBP. Further investigation is required to investigate the strength of effect for walking as a primary intervention in the management of acute and chronic LBP.

Carboplatin, ifosfamide, and mesna (CIM) for the treatment of gynecological carcinosarcoma

e16539

Background: A GOG trial comparing cisplatin/ifosfamide/mesna chemotherapy versus whole abdominal irradiation for FIGO stages I-IV carcinosarcoma (CS) showed an estimated median survival (MS) of 50 months for chemotherapy but high toxicity. This study investigates the efficacy and tolerability of a novel regimen using carboplatin AUC 5, ifosfamide 3 g/m2 and mesna 1 g/m2 (CIM) in both the adjuvant and metastatic setting. Methods: Retrospective analysis of women with CS treated from May 1997-May 2007 with CIM (group 1) versus other chemotherapy regimens (group 2). Toxicity was graded according to the Common Toxicity Criteria and MS estimated using the Kaplan-Meier method. Results: Of 51 eligible women (median age 71 years) 35 (69%) had stage 3 or 4 disease. 35/51 (69%) received chemotherapy; 2 with stage 1c disease received pelvic radiotherapy (pRT) alone whilst the remaining 14 were unfit for any treatment. Median follow-up for the treated patients is 45 months. 11/35 patients (31%) received CIM as first-line chemotherapy. Other regimens included: carboplatin (n = 14); carboplatin/paclitaxel (n = 3); carboplatin/epirubicin (n = 3); carboplatin/doxorubicin (n = 2); doxorubicin/ifosfamide (n = 1); cisplatin/ifosfamide (n = 1). 20/35 (57%) received adjuvant chemotherapy (AC) of which 8 received CIM; 11/20 patients also received adjuvant pRT. MS in the CIM AC group is 54.7 months compared to 37.4 months for other regimens. 3/8 patients (37.5%) in the CIM arm developed recurrent disease compared to 9/12 (75%) for other regimens. 4/16 patients received CIM as first- or second-line palliative chemotherapy. All patients responded of whom 2 achieved clinical and radiological complete response (CR). One woman subsequently relapsed and achieved a second CR with CIM. MS for all chemotherapy-treated patients is 54.7 months (group 1) versus 20.6 months (group 2) (p = 0.07). No patients in group 1 experienced any grade 3/4 toxicity and all patients completed the prescribed treatment. There were 2 unexpected treatment-related deaths in group 2, one of whom received carboplatin/paclitaxel and the other carboplatin/epirubicin. Conclusions: CIM appears to be efficacious and well tolerated in the treatment of CS and merits further investigation in clinical trials.

No significant financial relationships to disclose.

Acute small bowel toxicity and preoperative chemoradiotherapy for rectal cancer: investigating dose-volume relationships and role for inverse planning

PURPOSE

The relationship between volume of irradiated small bowel (VSB) and acute toxicity in rectal cancer radiotherapy is poorly quantified, particularly in patients receiving concurrent preoperative chemoradiotherapy. Using treatment planning data, we studied a series of such patients.

METHODS AND MATERIALS

Details of 41 patients with locally advanced rectal cancer were reviewed. All received 45 Gy in 25 fractions over 5 weeks, 3-4 fields three-dimensional conformal radiotherapy with daily 5-fluorouracil and folinic acid during Weeks 1 and 5. Toxicity was assessed prospectively in a weekly clinic. Using computed tomography planning software, the VSB was determined at 5 Gy dose intervals (V5, V10, etc.). Eight patients with maximal VSB had dosimetry and radiobiological modeling outcomes compared between inverse and conformal three-dimensional planning.

RESULTS

VSB correlated strongly with diarrheal severity at every dose level (p<0.03), with strongest correlation at lowest doses. Median VSB differed significantly between patients experiencing Grade 0-1 and Grade 2-4 diarrhea (p<or=0.05). No correlation was found with anorexia, nausea, vomiting, abdominal cramps, age, body mass index, sex, tumor position, or number of fields. Analysis of 8 patients showed that inverse planning reduced median dose to small bowel by 5.1 Gy (p=0.008) and calculated late normal tissue complication probability (NTCP) by 67% (p=0.016). We constructed a model using mathematical analysis to predict for acute diarrhea occurring at V5 and V15.

CONCLUSIONS

A strong dose-volume relationship exists between VSB and acute diarrhea at all dose levels during preoperative chemoradiotherapy. Our constructed model may be useful in predicting toxicity, and this has been derived without the confounding influence of surgical excision on bowel function. Inverse planning can reduce calculated dose to small bowel and late NTCP, and its clinical role warrants further investigation.

Acute Supraclavicular Skin Toxicity in Patients Undergoing Radiotherapy for Breast Cancer: An Evaluation of the ‘T’-Grip Method of Patient Positioning

AIMS

Supraclavicular fossa (SCF) radiotherapy plays an important part in the adjuvant management of breast cancer but data on acute radiotherapy toxicity are lacking, particularly when differing patient treatment positions are used to allow computed tomography planning or to reduce cardiac doses.

MATERIALS AND METHODS

We evaluated SCF and breast/chest wall acute skin toxicity in a cohort of 92 women with breast cancer, who were planned in a 'T'-grip (n = 72) or 90 degrees-grip (n = 20) position, while 'on treatment' and at 6 weeks. The modified Radiation Therapy Oncology Group (RTOG) criteria were used to score toxicity. Data on age, body mass index, smoking history, type of breast operation, prior chemotherapy, radiation dose, number of fields and field size were recorded and correlated with outcome.

RESULTS

Maximum SCF reaction score was RTOG 2a, with no moist desquamation observed. SCF reactions were less severe compared with chest wall reactions and no worse than breast reactions. There was significant resolution of toxicity at 6 weeks. SCF radiotherapy in 'T'-grip patients was well tolerated and no worse than the 90 degees-grip group. Pain scores and sore throat occurrences were minimal. Univariate and multivariate analyses showed that smoking was associated with worsening SCF toxicity (odds ratio [OR] 2.92; P = 0.045) and delayed healing. Incremental SCF dose worsened toxicity (OR 3.65; P = 0.023). Smoking worsened breast but not chest wall toxicity.

CONCLUSIONS

SCF radiotherapy was at least as well tolerated as breast radiotherapy and better tolerated than chest wall radiotherapy. The 'T'-grip position did not affect toxicity negatively. Smoking and radiation dose affected SCF toxicity.

Dynamic EBV gene loads in renal, hepatic, and cardiothoracic transplant recipients as determined by real-time PCR light cycler

BACKGROUND

Epstein-Barr virus (EBV) is recognised as one of the causative agents for most cases of post-transplant lymphoproliferative disease (PTLD). Elevated levels of EBV DNA are known to be associated with the onset of PTLD, but little information is available regarding how EBV loads change with time in asymptomatic transplant recipients following transplantation. Our aims were to study the trend of EBV loads in renal (RTx), hepatic, and cardiothoracic transplant recipients and to compare their EBV loads with other healthy and patient controls.

METHODS

A prospective study was performed using a real-time TaqMan polymerase chain reaction technique to measure EBV DNA loads from three types of organ transplant recipients and haemodialysis patients (HD). Their results were then compared with those from the healthy controls (HC); monospot test negative (MN-) and infectious mononucleosis positive (IM+) patients; patients who were previously treated for PTLD (pPTLD); those who were currently diagnosed to have PTLD (PTLD+); and patients who had a stable renal, hepatic, or cardiothoracic graft for more than a year.

RESULTS

Post-transplant EBV loads were significantly higher than the pre-transplant levels. Asymptomatic transplant recipients were differentiated from the PTLD+group at 600 genome copies of EBV/mug DNA, and from IM+group at 100 genome copies. Both HC and MN- groups had significantly lower EBV loads than the three transplant groups. The dynamic change of EBV loads in RTx was greater in the first post-transplant month when compared with the HD group. All transplant recipients had transient rises of EBV loads whereas EBV load continued to rise in one suspected PTLD patient.

CONCLUSIONS

Asymptomatic transplant recipients had higher baseline post-transplant EBV levels than the non-transplant and MN- groups. The rising post-transplant EBV load in these transplant recipients did not seem to be sustained for longer than 2 weeks. However, in a PTLD+patient the rising EBV load continued over a period of 4 weeks. Hence, the dynamic pattern of EBV loads is more important than absolute EBV DNA measurements alone in identifying those who might go on to develop PTLD.

In vitro biological characteristics of human cord blood-derived megakaryocytes

INTRODUCTION

Umbilical cord blood (CB) has been used as an alternative source for haematopoietic stem cell transplantation (HSCT) in recent years. However, delayed platelet recovery is frequently associated with CB HSCT. Megakaryocytes (Mk) are the specialised precursors of platelets and they are among the rarest haemopoietic cell types. Despite the rapid expansion of our knowledge of megakaryopoiesis in recent years, many questions, such as the molecular regulatory mechanisms in Mk differentiation and maturation, platelet formation and release, remain unanswered in CB-derived megakaryopoiesis. Variations can be seen from the literature by individual investigators using different approaches for Mk-specific differentiation and maturation induction. The development of in vitro culture methods to obtain sufficient numbers of Mks from readily available haematopoietic stem cells is of value for both basic research and clinical applications.

MATERIALS AND METHODS

The CD34+ cells from cord blood samples were cultured in serum-free medium with haematopoietic growth factors (GFs), such as IL-3, stem cell factor (SCF), and thrombopoietin (Tpo). The differentiation of Mk was monitored using Mk- and platelet-specific monoclonal antibodies and flow cytometric analysis. The morphology of the cultured cells was studied by both light and electronic microscopy (LM and EM). The involvement of the human Notch gene family members was studied by real time-polymerase chain reaction (RT-PCR). Maturation of the cultured Mks was studied using flow cytometric analysis for both platelet-specific surface markers and enodomitosis. Platelet activation was assessed in the cytoplasmic fragments harvested from the cultures.

RESULTS

Specific Mk differentiation of >70% resulted from a 2-step culture approach using IL-3, SCF and Tpo for 7 days followed by Tpo only for another 14 days. RT-PCR showed high-level expression of both Notch-1 and its ligand, Jagged-1, in the cultured Mks. Limited levels of polyploidy (>4N, endomitosis, EnM) were observed in the cultured Mks. The results also showed that the cytoplasmic fragments from the cultures responded to platelet activation reagents, including ADP and collagen, marked by upregulation of platelet-specific activation markers, such as CD62P (P-selectin) and PAC-1 (gpalphaIIbbeta3).

CONCLUSION

The methods used in this study are specific for differentiation of Mk from CB CD34+ cell, which can partially mature and produce functional platelets in vitro. This approach for human Mk differentiation could be further optimised and may be adapted on larger scales for clinical purposes.

Investigating the infertile couple

INTRODUCTION

Investigations play a pivotal role in the workup for infertility. The results must be interpreted carefully as these assess dynamic function. Evidence-based guidelines are useful in the selection of appropriate tests.

MATERIALS AND METHODS

A review of current evidence-based guidelines for the investigation and management of the infertile couple is undertaken.

RESULTS

The main areas that correlate with fecundability are ovulatory function, tubal patency and semen analysis.

CONCLUSION

The appropriate selection of investigations based on problem areas identified by history and physical examination would guide the physician in the management of the infertile couple.

Pregnancy following embolisation of uterine arteriovenous malformation--a case report

INTRODUCTION

Pregnancy following successful embolisation of a uterine arteriovenous malformation (AVM) is rare. Hypovascularity of treated areas affecting placentation and fetal growth has been postulated to be the cause for adverse pregnancy outcomes.

CLINICAL PICTURE

A 37-year-old multiparous lady presented with anaemia from repeated heavy vaginal bleeding from an iatrogenic uterine AVM. This was diagnosed with power Doppler ultrasonography and embolised after pelvis angiography with hystoacryl and lipiodol. Following this she had a spontaneous pregnancy with a normal outcome.

CONCLUSION

There are no distinguishing clinical features of a uterine AVM. An index of suspicion and power Doppler sonography help in reaching a diagnosis. Dilatation and curettage should be avoided as this can precipitate torrential vaginal bleeding.

Use of real-time PCR to measure Epstein-Barr virus genomes in whole blood

The measurement of the Epstein-Barr viral load in peripheral blood has been recognised as an important way of monitoring the response to treatment in patients with Epstein-Barr virus (EBV)-related malignancies. In particular, EBV load in transplant recipients can be used as a predictive parameter for Post-transplant Lymphoproliferative Disorder (PTLD). The aim was to develop a rapid and reliable PCR protocol for the quantification of the cell-associated EBV genome. Real-time PCR using TaqMan methodology was established. This technique was applied to determine the EBV load in various study groups including healthy controls, transplant recipients, patients on haemodialysis, and patients with infectious mononucleosis. The baseline level of EBV genomes in the immunosuppressed renal transplant recipients was significantly different from that in the healthy controls.

Tolerability of bolus versus continuous gastric feeding in brain-injured patients

Brain injured patients may exhibit altered gastric emptying; thus, some believe post-pyloric feeding to be tolerated better than gastric feeding. Reliable post-pylorus access can be difficult to obtain, so gastric feeding remains the preferred route for administering nutrition. Feeding intolerance may be associated with increased complications and costs. We sought to compare bolus (B) versus continuous (C) gastric feeding in brain injured patients. This retrospective cohort study was carried out at a neurological/neurosurgical intensive care unit at a Level 1 trauma and tertiary referral center. Our subjects were 152 consecutive patients over two years. Use of B or C feedings was based on clinicians' preferences. Abdominal examination and gastric residuals (> 75 mL over four hours) defined feeding intolerance (FI). Putative risks for FI were compared between the groups. Demographic characteristics were similar between groups B (n = 86) and C (n = 66). Feeding intolerance occurred more often in group B than in group C (60.5% vs. 37.9%, p = 0.009). Group C patients achieved 75% of nutritional goals faster than group B patients (median 3.3 vs. 4.6 days; p = 0.03). Prokinetic agent use was similar between the groups and did not reduce the time to achieve nutritional goals. There was a trend towards a reduction in the incidence of infections in group C (p = 0.05). Independent predictors of FI included: sucralfate (OR 2.3), propofol (OR 2.1), pentobarbital (OR 3.9) or paralytic (OR 3) use; older age (OR 5); days receiving mechanical ventilation (OR 1.2); and admission diagnosis of either intracerebral hemorrhage (OR 2.2) or ischemic stroke (OR 1.9). Continuous gastric feeding is better tolerated than B feedings in patients with acute brain injuries. Use of prokinetic agents did not affect time to achievement of nutritional goals. Use of common medications including sucralfate and propofol were associated with FI.

Temperature-entropy formulation of thermoelectric thermodynamic cycles

A temperature-entropy formulation is derived for thermoelectric devices. Thermoelectric chiller and generator cycles can then be cast in the same irreversible thermodynamics framework commonly applied to conventional large-scale cooling and power generation equipment, including a transparent identification of the principal energy flows and performance bottlenecks (dissipation). Distinct differences in chiller versus generator mode are highlighted and illustrated with data from commercial thermoelectric units.

Effect of whole-body (18)F-FDG PET imaging on clinical staging and management of patients with malignant lymphoma

Correct staging is important in selecting the appropriate treatment for lymphoma patients. PET imaging with (18)F-FDG is useful for staging of lymphoma as well as for monitoring of therapy. However, to our knowledge, the clinical impact of PET on staging and management of lymphoma patients has not been reported.

METHODS

Standardized questionnaires were mailed to referring physicians asking them whether and how the results of PET imaging had influenced clinical staging and management of the disease in their patients. Management changes, when present, were classified as intermodality (e.g., medical to surgical, surgical to radiation, medical to no treatment) or intramodality (e.g., altered medical, surgical, or radiotherapy approach).

RESULTS

The referring physicians returned 52 of 108 questionnaires (48.1%). Physicians indicated that PET led to a change in the clinical stage in 44% of patients: 21% were upstaged and 23% were downstaged. Findings of the PET examination resulted in intermodality changes in management in 42% of patients, in intramodality changes in 10%, and in a combination of the management changes in 10%. Other, not further specified, treatment changes were reported in 6% of patients. PET did not result in any management changes in only 32% of patients.

CONCLUSION

This survey-based study of referring physicians indicates that FDG PET has a major impact on the management of lymphoma patients, contributing to changes in clinical stage in 44% and changes in treatment in >60% of cases.

Clinical management of PCOS

The polycystic ovary syndrome (PCOS) is a heterogeneous condition with genetic predisposition. It is characterized by a myriad of symptoms including oligomenorrhea or amenorrhea, anovulation or infertility, hirsutism or acne. Insulin resistance appears to be an important factor in PCOS though the lack of an etiology has led to symptom oriented therapy which includes lifestyle modification, the use of cyclical progestagens and antiandrogens. Ovulation induction by drug therapy and ovarian drilling aims to treat subfertility in women with PCOS. Therapeutic approaches to PCOS remain an ongoing source of debate. Insulin sensitizing agents may bring new hope in therapy. Future research is aimed at shedding light on the pathophysiology so as to optimize treatment of women with PCOS.

Corneal temperature reversal after storage in Chen medium compared with Optisol GS

PURPOSE

To compare corneal endothelial cell function by measuring corneal thickness during temperature reversal between corneas stored in two different storage media, Optisol GS and Chen Medium (CM).

METHODS

Twenty paired corneas from 10 human donors were randomly assigned for storage at 4 degrees C in Optisol GS (10 corneas) or CM (10 corneas). The storage media were masked, and measurements were done in a masked fashion. After storage for 48 hours, corneal thickness was measured by ultrasonic pachymetry at 2-hour intervals for 12 hours, during which time the corneas were perfused with BSS (balanced salt solution) Plus at 37 degrees C. Scanning electron microscopy of two pairs of corneas from two donors was performed to assess ultrastructural change after 12 hours of warming.

RESULTS

Corneal thickness decreased during the first 4 hours of the warming period and then increased during the 6-to 12-hour warming period. These changes in corneal thickness over time were similar for the two storage media (p = 0.212). Scanning electron microscopy showed greater amounts of endothelial cell disruption in Optisol GS-stored corneas than those stored in CM after 12 hours of warming and perfusion.

CONCLUSIONS

The endothelial pump of corneas stored in CM appear to be as well-preserved as those stored in Optisol GS, although greater endothelial disruption may be present with Optisol GS by scanning electron microscopy. Further studies are required to compare the clinical effectiveness of these two media.

Variability in CD34+ cell counts in umbilical cord blood: implications for cord blood transplants

OBJECTIVE

To determine if total nucleated cell counts alone are sufficient for predicting the efficacy of cord blood units for transplant from neonatal umbilical cord blood samples.

METHODS

Umbilical cord blood samples were collected from 200 mothers at delivery and the cord blood units processed. The total nucleated cells and CD34+ cells were enumerated and compared for each sample.

RESULTS

Despite an apparent linear correlation between total nucleated cell counts and CD34+ cell counts, each group of total nucleated cell counts demonstrated a high degree of variation in CD34+ cell counts and could be as low as 0.1% of total nucleated cell counts.

CONCLUSIONS

Large variations in CD34+ cell counts per total nucleated cell count are present for cord blood units from neonatal umbilical cord samples. Hence a CD34+ cell count for each cord blood unit would improve selection of samples for transplant.

Ontogeny: the evolution of an oocyte

The physiology of oocyte development, maturation, and selection forms the basis for understanding ovarian follicle dynamics, reproductive function and ovulation induction. The number of ovarian follicles with which women are invested from birth and the rate of decline determine their reproductive lifespan. The processes of atresia and apoptosis constantly deplete this finite store. The initiation of follicle growth involves complex chemical signaling and ensures that a cohort of follicles is prepared for recruitment monthly. The effects of gonadotrophins, autocrine signals, and the degree of vascularization further determine dominance and the selection of an oocyte for ovulation.

Prevention of mechanical stretch-induced endothelial and smooth muscle cell injury in experimental vein grafts

Vein grafts are subject to increased tensile stress due to exposure to arterial blood pressure, which has been hypothesized to induce endothelial cell (EC) and smooth muscle cell (SMC) injury. This study was designed to verify this hypothesis and to develop a tissue engineering approach that can be used to prevent these pathological events. Two experimental models were created in rats to achieve these goals: (1) a nonengineered vein graft with increased tensile stress, which was created by grafting a jugular vein into the abdominal aorta using a conventional end-to-end anastomotic technique; and (2) an engineered vein graft with reduced tensile stress, which was created by restricting a vein graft into a cylindrical sheath constructed using a polytetrafluoroethylene membrane. The integrity of ECs in these models was examined by using a silver nitrate staining method, and the integrity of SMCs was assessed by using a fluorescein phalloidin-labeling technique. It was found that nonengineered vein grafts were associated with early EC denudation with a change in EC coverage from 100 percent in normal jugular veins to 36 +/- 10, 28 +/- 12, 18 +/- 9, 44 +/- 15, 80 +/- 13, and 97 +/- 6 percent at 1 and 6 hours and 1, 5, 10, and 30 days, respectively. Similarly, rapid SMC actin filament degradation was found during the early period with a change in SMC coverage from approximately 94 percent in normal jugular veins to 80 +/- 10, 41 +/- 17, 25 +/- 9, 51 +/- 15, 79 +/- 15, 98 +/- 2 percent at 1 and 6 hours and 1, 5, 10, and 30 days, respectively, in nonengineered vein grafts. In engineered vein grafts with reduced tensile stress, EC denudation and SMC actin filament degradation were prevented significantly. These results suggested that mechanical stretch due to increased tensile stress contributed to EC and SMC injury in experimental vein grafts, and these pathological events could be partially prevented when tensile stress was reduced by using a biomechanical engineering approach.

Consumption of foods from the WIC food packages of Chinese prenatal patients on the US west coast

OBJECTIVE

To assess consumption of foods from food packages provided by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) among 80 Chinese prenatal WIC recipients living in Oakland or San Francisco, Calif.

DESIGN

During a single interview, a food frequency questionnaire was used to assess WIC food consumption by the prenatal patients for the period before and after receipt of WIC vouchers.

SETTING

The study was conducted at Asian Health Services, Oakland, and the Chinatown Public Health Center of the San Francisco Department of Public Health in California.

SUBJECTS

Eighty low-income Chinese prenatal women with limited education and limited ability to speak English, aged 21 to 43 years, with gestational stages of 15 to 38 weeks.

STATISTICAL ANALYSES PERFORMED

Descriptive statistics (frequency and percent distribution) were used to report the findings of the study.

RESULTS

Subjects reported that before receiving WIC vouchers, milk, eggs, and juice were the only foods in their WIC food package that had been consumed frequently (> 5 times/week) in their daily diet. Other WIC foods, including cheese, peanut butter, dried beans, and hot and cold cereals, were consumed infrequently (0 to 1 time/month). Subjects reported that with the availability of WIC vouchers, milk, eggs, and juice remained frequently consumed with 81% to 100% of monthly supply as the most prevalent reported consumption rate. Dried beans and hot and cold cereals were also consumed frequently. Cheese remained poorly consumed (0% to 20% of the monthly supply). As many as 74 of 80 subjects stated that they had shared foods from their own WIC package, except milk, with their families. The use of any WIC foods provided to other children in the family was not assessed in this study.

APPLICATIONS

Data from this study indicate that most WIC foods were well used by Chinese prenatal patients. The most notable exception was cheese, which was poorly consumed. The ready consumption of milk by pregnant Chinese WIC recipients in this study suggests that milk may be readily consumed by these women, even though it is atypical of the Asian diet. The WIC food package for Chinese prenatal patients may be improved by omitting cheese and substituting more milk and/or foods such as tofu and dark green leafy vegetables.

Role of CYP2E1 in the pathogenesis of alcoholic liver disease: modifications by cAMP and ubiquitin-proteasome pathway

The ethanol inducible isoform of cytochrome P450, CYP2E1, may play a role in ethanol-induced liver injury. Therefore, the factors which govern CYP2E1 degradation and turnover were investigated. These factors include cAMP, ubiquitin, proteasomal enzymes and CYP2E1 mRNA. Rats fed ethanol or pair-fed isocaloric dextrose were pair-fed with rats fed ethanol or dextrose treated with cAMP for 2 months. The liver pathology, regenerative activity, fatty acid composition, NFkappaB activation, ubiquitin conjugates and proteasomal enzymes were measured as were the apoprotein levels of CYP2E1, CYP3A, CYP4A and mRNA levels for CYP2E1 and ubiquitin expression. The results showed, that the cAMP treatment ameliorated the increase liver fat storage and changes in the fatty acid composition in the livers of ethanol fed rats. Other histologic features of alcoholic liver disease were not changed. Western blot quantitation showed that the amount of ubiquitin and ubiquitin conjugates were markedly reduced by ethanol treatment. Similarly, ethanol decreased the level of ubiquitin mRNA. cAMP ameliorated the inhibition of the proteasomal enzyme proteolysis caused by ethanol feeding. The ethanol-induced increase in the CYP2E1 protein was partially inhibited by cAMP treatment. cAMP treatment decreased CYP2E1 mRNA levels in both ethanol-fed and pair fed control rats. Likewise NFkappaB activation was not increased by ethanol but cAMP reduced the level of NFkappaB activation. CAMP treatment also reduced CYP4A but not CYP3A. The results support the concept that cAMP treatment partially protects the liver from ethanol-induced fatty liver by reducing CYP2E1 induction through cAMP's effects on CYP2E1 synthesis.

Antiphospholipids and pregnancy--a review

The presence of antiphospholipid antibodies is associated with a clinical syndrome characterised by thrombocytopenia, recurrent arterial and venous thromboses and recurrent fetal loss. The etiology is unknown but leads to an abnormal autoimmune response. Platelet aggregation and thrombosis follow. The mainstay of treatment is low dose aspirin, heparin and corticosteroids.