An outcomes evaluation of an emergency department early pregnancy assessment service and early pregnancy assessment protocol

BACKGROUND

Complications in early pregnancy, such as threatened or actual miscarriage is a common occurrence resulting in many women presenting to the emergency department (ED). Early pregnancy service delivery models described in the literature vary in terms of approach, setting and outcomes. Our objective was to determine outcomes of women who presented to an Australian regional ED with diagnoses consistent with early pregnancy complications following the implementation of an early pregnancy assessment service (EPAS) and early pregnancy assessment protocol (EPAP) in July 2011.

METHODS

A descriptive, comparative (6 months before and after) study was undertaken. Data were extracted from the hospital ED information system and medical healthcare records. Outcome measures included: time to see a clinician, ED length of stay, admission rate, re-presentation rate, hospital admission and types of pathology tests ordered.

RESULTS

Over the 12 -month period, 584 ED presentations were made to the ED with complications of early pregnancy (268 PRE and 316 POST EPAS-EPAP). Outcomes that improved statistically and clinically following implementation included: time to see a clinician (decreased by 6 min from 35 to 29 min), admission rate (decreased 6% from 14.5% to 8.5%), increase in β-human chorionic gonadotrophin ordering by 10% (up to 80% POST), increase in ultrasound (USS) performed by 10% (up to 73% POST) and increase in pain score documentation by 23% (up to 36% POST).

CONCLUSIONS

The results indicate that patient and service delivery improvements can be achieved following the implementation of targeted service delivery models such as EPAS and EPAP in the ED.

Combined enrichment of neuromelanin granules and synaptosomes from human substantia nigra pars compacta tissue for proteomic analysis

This article gives a detailed description of a protocol using density gradient centrifugation for the enrichment of neuromelanin granules and synaptosomes from low amounts (≥0.15g) of human substantia nigra pars compacta tissue. This has a great advantage compared to already existing methods as it allows for the first time (i) a combined enrichment of neuromelanin granules and synaptosomes and (ii) just minimal amounts of tissue necessary to enable donor specific analysis. Individual specimens were classified as control or diseased according to clinical evaluation and neuropathological examination. For the enrichment of synaptosomes and neuromelanin granules from the same tissue sample density gradient centrifugations using Percoll® and Iodixanol were performed. The purity of resulting fractions was checked by transmission electron microscopy. We were able to establish a reproducible and easy to handle protocol combining two different density gradient centrifugations: using an Iodixanol gradient neuromelanin granules were enriched and in parallel, from the same sample, a fraction of synaptosomes with high purity using a Percoll® gradient was obtained. Our subfractionation strategy will enable a subsequent in depth proteomic characterization of neurodegenerative processes in the substantia nigra pars compacta in patients with Parkinson's disease and dementia with Lewy bodies compared to appropriate controls.

BIOLOGICAL SIGNIFICANCE

Key features of Parkinson's disease are the degeneration of dopaminergic neurons in the substantia nigra pars compacta, an associated loss of the brain pigment neuromelanin and a resulting impairment of the neuronal network. The accumulation of iron binding neuromelanin granules is age- and disease-dependent and disease specific alterations could affect the neuronal iron homeostasis leading to oxidative stress induced cell death. The focus of the described method is the analysis of neuromelanin granules as well as axonal cell-endings of nerve cells (synaptosomes) of individual donors (control and diseased). It is the basis for the identification of disease-relevant changes in the iron homeostasis and the generation of new insight into altered protein compositions or regulations which might lead to disturbed communications between nerve cells resulting in pathogenic processes.

Preventing type 2 diabetes after gestational diabetes: women's experiences and implications for diabetes prevention interventions

AIMS

To explore factors influencing post-natal health behaviours following the experience of gestational diabetes, and to elicit women's views about the feasibility of lifestyle intervention to prevent diabetes during the first 2 years after childbirth.

METHODS

Qualitative study using semi-structured interviews with women who had gestational diabetes. In phase 1 (31 women), interviews explored the experience of gestational diabetes, ideas about future risk of diabetes and factors influencing post-natal health-related behaviours. Statements were developed summarizing women's views of lifestyle change to prevent diabetes. In phase 2 (14 women), interviews explored how the passage of time had contributed to changes in health behaviour, and the statements were used to develop views about diabetes interventions.

RESULTS

Women were aware of their risk of developing diabetes, but did not always act on such knowledge. Pregnancy motivated behaviour changes to benefit the unborn child, but after delivery these changes were often not maintained. Tiredness, maternal attachment and childcare demands were prominent barriers in the early post-natal months. Later, work, family and child development became more significant barriers. Many women became more receptive to healthy eating messages around the time of weaning. Women were positive about long-term support for self-management to reduce their diabetes risk.

CONCLUSIONS

There is potential to reduce the risk of Type 2 diabetes post-natally among women with gestational diabetes. Interventions need to be developed that take into account contextual factors and competing demands, are flexible and respond to women's individual circumstances. Randomized trials of such interventions are warranted.

Inhibition of vascular permeability by antisense-mediated inhibition of plasma kallikrein and coagulation factor 12

Hereditary angioedema (HAE) is a rare disorder characterized by recurrent, acute, and painful episodes of swelling involving multiple tissues. Deficiency or malfunction of the serine protease inhibitor C1 esterase inhibitor (C1-INH) results in HAE types 1 and 2, respectively, whereas mutations in coagulation factor 12 (f12) have been associated with HAE type 3. C1-INH is the primary inhibitor of multiple plasma cascade pathways known to be altered in HAE patients, including the complement, fibrinolytic, coagulation, and kinin-kallikrein pathways. We have selectively inhibited several components of both the kinin-kallikrein system and the coagulation cascades with potent and selective antisense oligonucleotides (ASOs) to investigate their relative contributions to vascular permeability. We have also developed ASO inhibitors of C1-INH and characterized their effects on vascular permeability in mice as an inducible model of HAE. Our studies demonstrate that ASO-mediated reduction in C1-INH plasma levels results in increased vascular permeability and that inhibition of proteases of the kinin-kallikrein system, either f12 or prekallikrein (PKK) reverse the effects of C1-INH depletion with similar effects on both basal and angiotensin converting enzyme (ACE) inhibitor-induced permeability. In contrast, inhibition of coagulation factors 11 (f11) or 7 (f7) had no effect. These results suggest that the vascular defects observed in C1-INH deficiency are dependent on the kinin-kallikrein system proteases f12 and PKK, and not mediated through the coagulation pathways. In addition, our results highlight a novel therapeutic modality that can potentially be employed prophylactically to prevent attacks in HAE patients.

Preparing fathers for the transition to parenthood: recommendations for the content of antenatal education

Fathers now provide more care for their babies and children than they have in the past, and a large body of evidence supports the important role that father involvement plays in determining child and family outcomes. Fathers have also become the primary source of informal support for most mothers and it is now customary for fathers to attend antenatal education in this supporting role. However, many fathers remain unprepared for their personal transition to parenthood and this has important implications for all of the family. Antenatal education is likely to be more effective for fathers when it addresses fathers' needs but the literature is unclear about what fathers need to know. This paper presents evidence-based recommendations for core subject matter to be addressed when preparing men for the important challenges of new fatherhood.

Conversion from cyclosporine to everolimus at 4.5 months posttransplant: 3-year results from the randomized ZEUS study

The long-term effect of conversion from calcineurin inhibitor (CNI) therapy to an mTOR inhibitor requires clarification. Following completion of the 12-month, open-label, multicenter ZEUS study, in which 300 kidney transplant recipients were randomized to continue cyclosporine (CsA) or convert to everolimus at 4.5 months posttransplant, outcomes were assessed at month 36 (n = 284; 94.7%). CNI therapy was reintroduced in 28.4% of everolimus patients by month 36. The primary efficacy endpoint, estimated glomerular filtration rate (Nankivell, ANCOVA) was significantly higher with everolimus versus the CsA group at month 24 (7.6 mL/min/1.73 m(2) , 95%CI 4.3, 11.0 mL/min/1.73 m(2) ; p < 0.001) and month 36 (7.5 mL/min/1.73 m(2) , 95%CI 3.6, 11.4 mL/min/1.73 m(2) ; p < 0.001). The incidence of biopsy-proven acute rejection from randomization to month 36 was 13.0% in the everolimus arm and 4.8% in the CsA arm (p = 0.015). Patient and graft survival, as well as incidences of malignancy, severe infections and hospitalization, were similar between groups. Kidney transplant patients who are converted from CsA to everolimus at month 4.5 and who remain on everolimus thereafter may achieve a significant improvement in renal function that is maintained to 3 years. There was a significantly higher rate of rejection in the everolimus arm but this did not exert a deleterious effect by 3 years posttransplant.

Abstract 2951: Potent antisense pharmacology of highly optimized antisense oligonucleotides in multiple transgenic, spontaneous and patient derived xenograft models of cancer reveals antitumor activity for the non-coding RNA MALAT-1

Antisense technology holds great promise as a novel drug discovery platform that can rapidly translate discoveries from cancer genomics into highly selective therapeutics. Antisense oligonucleotices (ASOs) are particularly attractive, as they can be applied to difficult to drug target classes currently not tractable by other therapeutic modalities. Recent clinical demonstration of activity for ASOs in cancer patients supports the potential of this drug class, however, challenges in demonstrating robust antisense pharmacology in preclinical cancer models has slowed the progress of this technology as cancer therapeutics. Here we have employed a high resolution in-situ hybridization-based methodology (QuantigeneTM) among other detection methods, to demonstrate visually and quantitatively the activity of systemically administered, high potency next generation antisense oligonucleotides, in multiple preclinical cancer models. Cancer models evaluated include, transgenic models, chemically induced tumor, genetically predisposed mouse strains, cell line derived xenograft and patient derived xenograft models. As a test antisense target RNA sequence we chose the non-coding RNA MALAT1 (also called NEAT2) because it is ubiquitously expressed at high levels in most cell types and thus RNA levels could be readily visualize at the cellular level by Quantigene method. In addition, as MALAT-1 is overexpressed in many human tumors it also had the potential to be a therapeutically relevant target. We screened &gt;1000 ASO sequences in vitro and identified highly potent mouse and mouse/human cross reactive MALAT-1 ASOs that reduced target RNA in cells in culture with IC50 values in the low nanomalor range (10-50 nM), without any lipid mediated delivery vehicles (ASO free uptake). Systemic delivery (s.c. administration of ASOs formulated in saline) of MALAT1 ASOs in vivo were well tolerated in all animals tested, and reduced target RNA by 70–&gt;90% in the tumor cells of APC/min- mice, prostate tumor cells of the TRAMP model, DEN-induced HCC tumors as well as in the tumor cells of several human tumor xenograft models and in a patient derived NSCLC primary tumor explants model. Interestingly, MALAT-1 inhibition by ASOs was also associated with significant antitumor effects including inhibition of tumor formation and decreased BrdU positive cells in the polyps of APC/min- mice, decrease tumor growth in TRAMP prostate tumors and DEN HCC tumors and significant tumor growth delays in several xenograft and human tumor explant models. These data demonstrate unequivocal, potent, ASO mediated antisense activity of highly optimized next generation ASOs targeting MALAT-1 by systemic administration and highlight a previously uncharacterized role of the ncRNA MALAT1 as regulator of tumor growth in vivo.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 2951. doi:1538-7445.AM2012-2951

Effect of signalment on the presentation of canine patients suffering from cranial cruciate ligament disease

OBJECTIVE

To determine the effect of signalment on the incidence and presentation of patients suffering from cranial cruciate ligament disease.

METHODS

Data relating to 426 dogs (44 breeds) that met specific selection criteria were obtained from the hospital archive (2002 to 2008). Cases were followed up for 2 years.

RESULTS

The breeds most commonly presented with cranial cruciate ligament disease were Labrador retriever (16%), Rottweiler (15%), golden retriever (12%) and boxer (9%). Rottweilers were significantly more likely (69%; P=0·05) to develop and present with (50%; P=0·03) bilateral cranial cruciate ligament disease. Rottweilers presenting with cranial cruciate ligament disease were significantly younger (median 977 days; P<0·0001) than other breeds; golden retrievers being significantly older at presentation (median 1994 days; P=0·004). Neither sex nor neutered status significantly affected the incidence of developing (P=0·77 and P=0·30, respectively) or presenting with (P=0·62 and P=0·35, respectively) bilateral cranial cruciate ligament disease. Entire dogs were significantly younger than neutered dogs at presentation (P=0·0004). Entire female dogs presented significantly younger than neutered females (P=0·0002), entire males (P=0·01) and neutered males (P=0·0001).

CLINICAL SIGNIFICANCE

Breed affects the incidence of developing and presenting with bilateral cranial cruciate ligament disease. Breed and sex both affect the age that patients present with cranial cruciate ligament disease.

Abstract B23: Selective inhibition of a long non-coding RNA (lncRNA), MALAT1 by antisense oligonucleotides results in significant anti-tumor effects in a variety of preclinical cancer models

An increasing body of evidence supports the notion that long noncoding RNAs (lncRNAs) play important roles in diseases including cancer. MALAT1 (also called NEAT2) was originally identified in tumors of highly metastatic non-small cell lung cancer (NSCLC), however, the functional role of MALAT1 in carcinogenesis has remained largely unknown. However, MALAT1 is highly expressed in various types of cancer and is implicated in the regulation of alternative splicing. To determine if MALAT1 constitutes an important driver of tumor growth in vivo, we developed potent antisense oligonucleotides (ASOs) that were able to achieve strong inhibition of MALAT1 in the tumor cells of a variety of preclinical models following systemic delivery. MALAT1 ASOs were well tolerated in rodents at doses leading to &gt;95% inhibition of MALAT1 RNA in the liver. Inhibition of MALAT1 expression in tumor and tumor-associated stromal cells was determined by both q-RT-PCR using species-specific probe/primer sets and/or in situ ‘viewRNA’ technology, where target knockdown can be visualized on a cell by cell basis. Systemic administration of mouse MALAT1 ASOs resulted in a decrease in the numbers of polyps and proliferation index (BrdU (+)) in the small intestine of Apcmin mouse model of colon cancer and correlated well with MALAT1 inhibition in the polyps. Mouse MALAT1 ASOs were also effective in a DEN-induced HCC model, where ASO treatment reduced the target RNA ~ 90% in tumor cells with a concomitant decrease in tumor numbers, while control ASO had no effects on either measure. In addition, higher expression of MALAT1 in non-treated tumors compared to adjacent normal hepatocytes was also clearly visualized by the in situ ‘view RNA’ method. Furthermore, MALAT1 ASO significantly delayed tumor growth in C26 colon cancer and reduced tumor size in TRAMP mouse model of prostate cancer, where the target RNA was decreased by 80% in tumor cells. In a human NSCLC patient-derived xenograft model, both significant MALAT1 RNA reduction and a delay in tumor growth were achieved after MALAT1 ASO treatment. The effects of MALAT1 downregulation by ASO were not limited to the inhibition of tumor growth alone. MALAT1 ASO treatment not only inhibited the growth of primary tumors in the EBC-1 human NSCLC xenograft model, but also resulted in a decrease in lung metastasis as measured by micro CT scanning. Furthermore, cross-species MALAT1 ASOs greatly improved the survival of animals bearing Hep3B human hepatocellular carcinoma (HCC) tumor orthotopically (48.5 days with control ASO vs 88 days with MALAT1 ASO, p=0.005). Taken together, these results demonstrate previously undiscovered roles of MALAT1 as an important regulator in vivo tumor growth and metastasis and suggest that selective inhibition of MALAT1 by ASO could have therapeutic value for the cancer treatment.

Citation Format: Jeff Hsu, Guobin He, Gourab Bhattacharjee, Tianyuan Zhou, Chris May, Xiaokun Xiao, Gene Hung, Brett P. Monia, A. Robert MacLeod, Youngsoo Kim. Selective inhibition of a long non-coding RNA (lncRNA), MALAT1 by antisense oligonucleotides results in significant anti-tumor effects in a variety of preclinical cancer models [abstract]. In: Proceedings of the AACR Special Conference on Noncoding RNAs and Cancer; 2012 Jan 8-11; Miami Beach, FL. Philadelphia (PA): AACR; Cancer Res 2012;72(2 Suppl):Abstract nr B23.

Models of transitional care for young people with complex health needs: a scoping review

BACKGROUND

Young people with complex healthcare needs (CHNs) face the challenge of transferring from child to adult health services. This study sought to identify successful models of transitional care for young people with CHNs. Three conditions were used as exemplars: cerebral palsy, autism spectrum disorders and diabetes.

METHODS

Scoping review: using search terms concerning transitional care, four databases were systematically searched for papers published in English between 1980 and April 2010. Additional informal search methods included recommendations from colleagues working with young people with each of the three conditions and making contact with clinical and research teams with expertise in transitional care. Inclusion and exclusion criteria were applied to define the papers selected for review. A separate review of policy documents, adolescent health and transition literature was also undertaken; 10 common summary categories for the components of high-quality services were identified. All papers were coded using a framework analysis which evaluated the data in two ways using the 10 transition categories and four elements of Normalization Process Theory that are important for successful implementation and integration of healthcare interventions.

RESULTS

Nineteen papers were selected for review. A very limited literature of models of service provision was identified for young people with cerebral palsy and diabetes. No models were identified for young people with autism spectrum disorders. Furthermore most publications were either descriptions of new service provision or time-limited pilot studies with little service evaluation or consideration of key elements of effective implementation.

CONCLUSIONS

Despite agreement about the importance of effective transitional care, there is a paucity of evidence to inform best practice about both the process of and what constitutes effective transitional care. There is therefore an urgent need for research to evaluate current transitional care practices for young people with CHNs.

Higher efficacy of letrozole in combination with trastuzumab compared to letrozole monotherapy as first-line treatment in patients with HER2-positive, hormone-receptor-positive metastatic breast cancer - results of the eLEcTRA trial

The eLEcTRA trial compared efficacy and safety of letrozole combined with trastuzumab to letrozole alone in patients with HER2 and hormone receptor (HR) positive metastatic breast cancer (MBC). Patients were randomized to either letrozole alone (arm A, n = 31) or letrozole plus trastuzumab (arm B, n = 26) as first-line treatment. Additional 35 patients with HER2 negative and HR positive tumors received letrozole alone (arm C). Median time to progression in arm A was 3.3 months compared to 14.1 months in arm B (hazard ratio 0.67; p = 0.23) and 15.2 months in arm C (hazard ratio 0.71; p = 0.03). Clinical benefit rate was 39% for arm A compared to 65% in arm B (odds ratio 2.99, 95% CI 1.01-8.84) and 77% in arm C (odds ratio 5.34, 95% CI 1.83-15.58). The eLEcTRA trial showed that the combination of letrozole and trastuzumab is a safe and effective treatment option for patients with HER2 positive and HR positive MBC.

Clinically driven design of multi-scale cancer models: the ContraCancrum project paradigm

The challenge of modelling cancer presents a major opportunity to improve our ability to reduce mortality from malignant neoplasms, improve treatments and meet the demands associated with the individualization of care needs. This is the central motivation behind the ContraCancrum project. By developing integrated multi-scale cancer models, ContraCancrum is expected to contribute to the advancement of in silico oncology through the optimization of cancer treatment in the patient-individualized context by simulating the response to various therapeutic regimens. The aim of the present paper is to describe a novel paradigm for designing clinically driven multi-scale cancer modelling by bringing together basic science and information technology modules. In addition, the integration of the multi-scale tumour modelling components has led to novel concepts of personalized clinical decision support in the context of predictive oncology, as is also discussed in the paper. Since clinical adaptation is an inelastic prerequisite, a long-term clinical adaptation procedure of the models has been initiated for two tumour types, namely non-small cell lung cancer and glioblastoma multiforme; its current status is briefly summarized.