Botulinum toxin A for treatment of allodynia of complex regional pain syndrome: a pilot study

OBJECTIVE

To investigate the efficacy and tolerability of Botulinum toxin A (BoNT-A) in allodynia of patients with complex regional pain syndrome.

DESIGN

A total of 14 patients were studied. Eight patients were participants of a randomized, prospective, double-blind, placebo-controlled protocol. Six patients were studied prospectively in an open-label protocol. Patients were rated at baseline and at 3 weeks and 2 months after BoNT-A administration. Ratings included brief pain inventory, McGill pain questionnaire, clinical pain impact questionnaire, quantitative skin sensory test, sleep satisfaction scale, and patient global satisfaction scale. BoNT-A was injected intradermally and subcutaneously, five units/site into the allodynic area (total dose 40-200 units).

RESULTS

None of the patients with allodynia showed a significant response after treatment. The treatment was painful and poorly tolerated.

CONCLUSION

Intrademal and subcutaneous administration of BoNT-A into the allodynic skin of the patients with complex regional pain syndrome (CRPS) failed to improve pain and was poorly tolerated.

It's not all swine flu...are we missing opportunities to diagnose primary HIV infection in patients with flu symptoms?

The advantages of diagnosis of primary HIV infection (PHI) for the individual and public health are well documented. However, symptoms of HIV seroconversion are often not recognized by health-care professionals. Also, symptomatic patients themselves often do not present to health-care services. With the emergence of H1N1 infection, many patients with flu-like symptoms are seeking medical advice. Currently in the UK, the management of H1N1 is in the treatment phase, that is, patients are diagnosed and treated for H1N1 influenza based on clinical observation rather than laboratory testing. Symptoms of H1N1 infection are often similar to those of PHI. We present two cases of men who have sex with men from Brighton, UK presenting to general practice and accident and emergency with flu-like symptoms. Both were initially diagnosed on clinical grounds with H1N1 infection and treated empirically with antivirals but were later confirmed to, in fact, have symptomatic PHI. It is important in high-risk patients with flu symptoms attributed to swine flu infection, that PHI is also considered and excluded.

A pilot qualitative analysis of the psychosocial factors which drive young people to decline chlamydia testing in the UK: implications for health promotion and screening

The main objectives of this study are to investigate the psychosocial issues for young people who decline chlamydia testing as part of the national chlamydia screening programme in the UK and to consider the implications for future opportunistic screening. Transcripts of qualitative semi-structured interviews were analysed using interpretative phenomenological analysis to identify themes. The study involved 14 young people aged 16–24 years who declined chlamydia tests in non-health-care settings as part of the chlamydia screening programme. The study was conducted in educational settings where chlamydia screening is available. Four interlinked themes were identified: stigmatization of young people with chlamydia and who take a test, the feeling of embarrassment, their perception of risk and their beliefs of what the test involves. These beliefs and feelings were pervasive and negatively affected their personal decisions of having a test. In conclusion, understanding psychosocial cultural phenomena in the context of screening programmes for sexually transmitted infections (STIs) in young people are important for their success. Chlamydia and STIs remain stigmatized; testing is poorly understood and embarrassing for young people, which impacts the poor uptake for opportunistic screening. Strategies are needed to normalize and de-stigmatize chlamydia and the chlamydia test.

The prevalence of urethral and rectal Mycoplasma genitalium and its associations in men who have sex with men attending a genitourinary medicine clinic

OBJECTIVES

To determine the prevalence of rectal and urethral Mycoplasma genitalium (MG) in men who have sex with men (MSM) attending a genitourinary medicine clinic and to measure its associations with symptoms, clinical signs, sexual behaviour and concomitant sexually transmitted infections (STI).

METHODS

MSM attending for STI screening were tested for MG using a real-time PCR assay that targets the MgPa gene. Data were collected on demographics, sexual behaviour, past STI history and clinical symptoms and signs.

RESULTS

849 first-void urine and rectal specimens were collected from 438 MSM. The overall prevalence of MG in MSM was 6.6% with first-void urine positivity of 2.7% and rectal positivity of 4.4%. MG was significantly associated with HIV positivity (OR 7.6, 95% CI 3.2 to 18.7, p<0.001) in contrast to Chlamydia trachomatis (OR 1.5, 95% CI 0.5 to 4.1, p=0.4) and Neisseria gonorrhoeae (OR 1.7, 95% CI 0.7 to 3.8, p=0.194). MG was more prevalent than C trachomatis (p=0.15) and N gonorrhoeae (p=0.02) in this subgroup of HIV-positive MSM. Urethral infection was associated with dysuria (p<0.001) but there was no association between rectal infection and anorectal symptoms or signs.

CONCLUSION

Rates of MG are much higher in HIV-positive MSM than HIV-negative MSM at both urethral and rectal sites, and MG is more prevalent in HIV-positive MSM than other bacterial STI. Although the subclinical nature of MG in the rectum questions its significance, the high prevalence seen at this site could be a potential source of onward urethral transmission. Future work should assess the need for appropriate screening and treatment of MG infection in MSM, particularly those with HIV infection and high-risk sexual behaviour.

Botulinum neurotoxin-A for treatment of refractory neck pain: a randomized, double-blind study

OBJECTIVE

To investigate the efficacy and tolerability of Botulinum neurotoxin-A (BoNT-A) in the patients with refractory neck pain.

BACKGROUND

An analgesic effect is suggested for BoNT-A by a number of animal studies. Two blinded studies suggested efficacy of BoNT-A in a chronic neck pain.

METHODS

Forty-seven subjects were enrolled in a prospective, double-blind, placebo-controlled study. A total of 150 to 300 units of BoNT-A were injected into the neck and shoulder muscles based on pain localization. Subjects completed the visual analog scale (VAS), Pain Frequency Questionnaire and the Modified Oswestry Pain Questionnaire (MOPQ) at baseline, 3 and 8 weeks after the treatment. The primary outcomes consisted of: 1) > or =50% improvement on the VAS; and 2) > or =30% reduction in pain day frequency. The secondary outcome was an improvement of ADL in MOPQ. Excellent responders (ERs) were those who met all three outcomes.

RESULTS

At 2 months, a significant reduction in the mean VAS (pain intensity) was noted in the BoNT-A group compared with the placebo (P = 0.0018, CI 95% from 2.51 to 7.89). At 2 months, there were six ERs in the BoNT-A group and one ER in the placebo group (P = 0.0152).

CONCLUSION

Administration of BoNT-A into the neck and shoulder muscles for treatment of chronic refractory neck pain met one of the two primary outcomes: reduction in pain intensity. More ERs were noted in the Botox group.

Relationships between leisure-time energy expenditure and individual coping strategies for shift-work

A total of 13 to 14% of European and North American workers are involved in shift work. The present aim is to explore the relationships between coping strategies adopted by shift workers and their leisure-time energy expenditure. Twenty-four female and 71 male shift workers (mean +/- SD age: 37 +/- 9 years) completed an adapted version of the Standard Shift-work Index (SSI), together with a leisure-time physical activity questionnaire. Predictors of age, time spent in shift work, gender, marital status and the various shift-work coping indices were explored with step-wise multiple regression. Leisure-time energy expenditure over a 14-d period was entered as the outcome variable. Gender (beta = 7168.9 kJ/week, p = 0.023) and time spent in shift work (beta = 26.36 kJ/week, p = 0.051) were found to be predictors of energy expenditure, with the most experienced, male shift workers expending the most energy during leisure-time. Overall 'disengagement' coping scores from the SSI were positively related to leisure-time energy expenditure (beta = 956.27 kJ/week, p = 0.054). In males, disengagement of sleep problems (beta = -1078.1 kJ/week, p = 0.086) was found to be negatively correlated to energy expenditure, whereas disengagement of domestic-related problems was found to be positively related to energy expenditure (beta = 1961.92 kJ/week, p = 0.001). These relations were not found in female shift workers (p = 0.762). These data suggest that experienced male shift workers participate in the most leisure-time physical activity. These people 'disengage' more from their domestic-related problems, but less from their sleep-related problems. It is recommended that physical activity interventions for shift workers should be designed with careful consideration of individual domestic responsibilities and perceived disruption to sleep.

Self-taken pharyngeal and rectal swabs are appropriate for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae in asymptomatic men who have sex with men

INTRODUCTION

Self-taken specimens from men who have sex with men (MSM) could be important in reducing high levels of demand on sexual health services. The performance of self-taken specimens for the detection of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) from both pharyngeal and rectal sites in asymptomatic MSM was assessed.

METHODS

MSM were examined according to clinic protocol: a rectal and pharyngeal swab for GC culture and a rectal swab for the CT strand displacement assay. An extra set of nurse-taken and self-taken pharyngeal and rectal specimens were also requested and were tested using the Aptima Combo 2 assay and the result compared with the routine clinic result, which was considered the gold standard.

RESULTS

A total of 272 MSM was recruited and the sensitivity and specificity of nurse-taken and patient-taken swabs, respectively, was as follows: rectal GC: 94.9% and 90.1% (nurse); 92.3% and 87.9% (patient); pharyngeal GC: 88.2% and 91.8% (nurse); 100% and 87.8% (patient); rectal CT: 80.0% and 99.6% (nurse); 91.4% and 98.2% (patient). No significant difference in sensitivity or specificity was observed between the nurse-taken and the patient-taken rectal swabs for either GC or CT. For the detection of GC from the pharynx, comparable sensitivities were achieved between nurse-taken and patient-taken swabs (p = 0.5); however, a significant difference in specificity was observed (p = 0.006). This was due to a higher number of false GC-positive self-taken pharyngeal swabs from patients with high rates (90.9%; 10/11) of confirmed concurrent GC infection in different anatomical sites.

CONCLUSIONS

MSM are able to collect self-taken rectal and pharyngeal swabs that are comparable to those taken by clinicians.

Diagnostic utility of urethral smears in predicting urethral chlamydia in HIV-infected men

We collected data from 218 HIV-infected men to assess the usefulness of the urethral smear and symptoms in predicting Chlamydia trachomatis infection. Prevalence of urethral chlamydia was 9%. A polymorphonuclear leucocyte (PMNL) count ≥5 was 73% sensitive and 71% specific for C. trachomatis infection. Adjusted odds ratio for risk of chlamydial infection was significant for urethral irritation (7.48; 1.54–36.4), a PMNL count of 20 or more (9.83; 2.52–8.4) and a PMNL count of 5–19 (4.10; 1.34–12.5). We had to perform 50 urethral smears in HIV-positive men without symptoms to treat one case of C. trachomatis at the time of visit. Findings suggest that the presence of symptoms, in particular urethral irritation may be associated with chlamydial urethritis and that the higher the urethral PMNL count, the more likely it is for C. trachomatis to be detected. The findings in this study also lend further support to recent guidelines that urethral microscopy is not useful in asymptomatic men and hence should be abandoned.

Estimates of historical exposures by phase contrast and transmission electron microscopy in North Carolina USA asbestos textile plants

OBJECTIVES

To develop a job-exposure matrix (JEM) for fibre exposures in three asbestos textile plants and to develop estimates of fibre size-specific exposures.

METHODS

Historical dust samples from three North Carolina, USA asbestos textile plants were obtained. Plant specific samples were used to express impinger dust concentrations as fibre concentrations by phase contract microscopy (PCM). Mixed models were used to estimate PCM exposures by plant, department, job and calendar time. Archived membrane filter samples were analysed by transmission electron microscopy (TEM) to determine the bivariate diameter/length distribution of airborne fibres by plant and operation.

RESULTS

PCM fibre levels estimated from the models were very high in the 1930s, with some operations having in excess of 200 fibres/ml, and decreased appreciably over time. TEM results for 77 airborne dust samples found that only a small proportion of airborne fibres were measured by PCM (>0.25 microm in diameter and >5 microm in length) and the proportion varied considerably by plant and operation (range 2.9% to 10.0%). The bivariate diameter/length distribution of airborne fibres demonstrated a relatively high degree of variability by plant and operation. PCM adjustment factors also varied substantially across plants and operations.

CONCLUSIONS

These data provide new information concerning airborne fibre levels and characteristics in three historically important asbestos textile plants. PCM concentrations were high in the early years and TEM data demonstrate that the vast majority of airborne fibres inhaled by the workers were shorter than 5 microm in length, and thus not included in the PCM-based fibre counts.

Self-sampling for oropharyngeal and rectal specimens to screen for sexually transmitted infections: acceptability among men who have sex with men

OBJECTIVES

To explore the feasibility and acceptability of self-sampling for oropharyngeal and rectal specimens to screen for sexually transmitted infections (STIs) among men who have sex with men (MSM). Participant's willingness to self-sample at home was also explored.

METHODS

Participants of a study to evaluate the sensitivity and specificity of self versus nurse taken oropharyngeal and rectal specimens were surveyed to assess the feasibility and acceptability of self-sampling using specimen collection methods (gargle, OraSure mouth pad to collect oropharyngeal specimens and APTIMA unisex swabs to collect rectal and pharyngeal specimens). Acceptability was measured using a five-point Likert-type response scale (for example, 1 = strongly disagree; 5 = strongly agree). Open-ended questions explored participants' experiences of self-sampling.

RESULTS

Of 334 eligible MSM, 301 (90%) participated in the study. Altogether, 301 participants self-sampled using gargle and rectal and pharyngeal swabs and 288 using mouth pad. Complete questionnaire data from 274 participants showed that feasibility and acceptability of self-sampling using gargle and mouth pad was higher (92%) than pharyngeal swabs (76%). Rectal swabs were acceptable to 82% participants. Despite some discomfort and difficulty in using swabs, 76% were willing to use all four methods for self-sampling in the future. Home sampling was acceptable (84%) as it was perceived to be less intrusive and more convenient than a clinic visit and likely to reduce genitourinary medicine (GUM) waiting time.

CONCLUSIONS

Self-sampling for rectal and oropharyngeal specimens is feasible and acceptable to MSM. Self-sampling can be offered as an alternative to clinic-based testing and has the potential to improve choice, access and uptake of screening for STIs.

Prospective study of bone scintigraphy as a staging investigation for oesophageal carcinoma

BACKGROUND

About 10 per cent of patients undergoing radical oesophagectomy for transmural (T3) carcinoma with lymph node involvement (N1) develop symptomatic bone metastases within 12 months of surgery. The aim of this study was to evaluate the introduction of targeted preoperative bone scintigraphy.

METHODS

Of 790 patients with oesophageal carcinoma staged between December 2000 and December 2004, 189 were eligible for potentially curative treatment. (99m)Tc-labelled hydroxymethylene diphosphonate bone scintigraphy was performed in those with stage T3 N1 disease (identified by computed tomography and endoscopic ultrasonography) who were suitable for radical treatment.

RESULTS

A total of 115 patients had bone scintigraphy. The histological diagnosis was adenocarcinoma in 82 patients and squamous cell carcinoma in 33. Bone scintigraphy was normal or showed degenerative changes in 93 patients, and abnormal requiring further investigation in 22. Plain radiography, magnetic resonance imaging and biopsy confirmed the presence of bone metastases in 11 patients (9.6 per cent).

CONCLUSION

Bone is frequently the first site of identifiable distant metastatic spread, and bone scintigraphy is recommended to exclude metastatic disease before radical treatment of advanced oesophageal carcinoma.

Evidence for a novel functional role of cannabinoid CB(2) receptors in the thalamus of neuropathic rats

Cannabinoid CB₁ receptors have analgesic effects in models of neuropathic pain, but can also produce psychoactive side-effects. A supraspinal location of CB₂ receptors has recently been described. CB₂ agonists are also antinociceptive, although the functional role of supraspinal CB₂ receptors in the control of nociception is unknown. Herein, we provide evidence that CB₂ receptors in the thalamus play a functional role in the modulation of responses of neurons in the ventral posterior nucleus (VPL) of the thalamus in neuropathic, but not sham-operated, rats. Spontaneous and mechanically evoked activity of VPL neurons was recorded with a multichannel electrode array in anaesthetized spinal nerve-ligated (SNL) rats and compared to sham-operated rats. Intra-VPL administration of the CB₂ agonist JWH-133 (30 ng in 500 nL) significantly reduced spontaneous (P < 0.05), non-noxious (P < 0.001) and noxious (P < 0.01) mechanically evoked responses of VPL neurons in SNL rats, but not in sham-operated rats. Inhibitory effects of JWH-133 on spontaneous (P < 0.01) and noxious-evoked (P < 0.001) responses of neurons were blocked by the CB₂ antagonist SR144528. Local administration of SR144528 alone did not alter spontaneous or evoked responses of VPL neurons, but increased burst activity of VPL neurons in SNL rats. There were, however, no differences in levels of the endocannabinoids anandamide and 2AG in the thalamus of SNL and sham-operated rats. These data suggest that supraspinal CB₂ receptors in the thalamus may contribute to the modulation of neuropathic pain responses.

Population-based research on occupational and environmental factors for leukemia and non-Hodgkin's lymphoma: the Northern Germany Leukemia and Lymphoma Study (NLL)

BACKGROUND

The Northern Germany Leukemia and Lymphoma Study (NLL) is a population-based study designed to provide a quantitative basis for investigations into occupational and environmental risk factors for leukemia and lymphoma.

METHODS

All incident cases of leukemia and lymphoma diagnosed between 1/1/1986 and 12/31/1998 in six counties in Northern Germany were actively ascertained. Controls were selected from population registries. Use of pesticides, sources of food supply, time spent at home and work, medical and family history were assessed via face-to-face interview. This self-reported information was used in conjunction with direct environmental measurements of pesticides in household dust and electromagnetic fields (EMFs). In addition, geographical information system (GIS) data were used to derive estimates of environmental exposure to pesticides, EMFs associated with transmission lines, and ionizing radiation from routine nuclear power reactor operations. Occupational exposure assessment was based on lifetime work history. For each job, information on branch of industry, company, job description, and duration of employment were ascertained.

RESULTS

Fourteen hundred thirty cases and 3041 controls were recruited. Lifetime residential and workplace histories totaled 49,628 addresses. Occupational exposure to pesticides was reported by 15% of the male participants (women: 16%). Four percent of the men (women: 8%) were occupationally exposed to ionizing radiation for >or=1 year over their lifetime. Sixty four percent of the participants had lived in the vicinity (20 km) of a nuclear power plant in operation.

CONCLUSIONS

The NLL illustrates the successful application of innovative methods to simultaneously assess occupational and environmental risk factors for leukemia and lymphoma including radiological hazards, pesticides, and EMFs.

Waking at night to smoke as a marker for tobacco dependence: patient characteristics and relationship to treatment outcome

AIM

This study aimed to describe the characteristics of treatment-seeking patients who wake at night to smoke (night-smoking), identify factors that may be associated with night-smoking, and assess the association between night-smoking and treatment outcome.

METHODS

A total of 2312 consecutive eligible cigarette smokers who sought treatment at a specialist tobacco-dependence clinic declared a Target Quit Date, provided baseline information at assessment, and were then followed-up 4 and 26 weeks after their target quit date.

RESULTS

Of the total sample, 51.1% were identified as night-smokers and 25.1% reported smoking abstinence at 26-week follow-up. Night-smoking was associated with a number of other patient characteristics, including African-American race or Hispanic ethnicity, having smoking-related medical symptoms, having been treated for a behavioural health problem, smoking mentholated cigarettes, smoking within 30 min of waking in the morning, increased cigarettes smoked per day, and not having private health insurance. In multivariate analyses, night-smoking at assessment remained a significant predictor of smoking at 26-week follow-up when controlling for other factors associated with treatment outcome (adjusted odds ratio: 0.77, 95% confidence interval: 0.62-0.96). Night-smokers also experienced a shorter average time to relapse (38.5 vs. 56 days, p<0.0001).

CONCLUSIONS

Several socioeconomic and tobacco use characteristics are shared among patients who wake at night to smoke. This behaviour can be assessed by a simple question and used as a marker for tobacco dependence and as an indicator that more intensive and sustained treatment may be required.

Endocannabinoid metabolism and uptake: novel targets for neuropathic and inflammatory pain

Cannabinoid CB1 and CB2 receptors are located at key sites involved in the relaying and processing of noxious inputs. Both CB1 and CB2 receptor agonists have analgesic effects in a range of models of inflammatory and neuropathic pain. Importantly, clinical trials of cannabis-based medicines indicate that the pre-clinical effects of cannabinoid agonists may translate into therapeutic potential in humans. One of the areas of concern with this pharmacological approach is that CB1 receptors have a widespread distribution in the brain and that global activation of CB1 receptors is associated with adverse side effects. Studies of the endogenous cannabinoids (endocannabinoids) have demonstrated that they are present in most tissues and that in some pain states, such as neuropathic pain, levels of endocannabinoids are elevated at key sites involved in pain processing. An alternative approach that can be used to harness the potential therapeutic effects of cannabinoids is to maximise the effects of the endocannabinoids, the actions of which are terminated by re-uptake and metabolism by various enzymes, including fatty acid amide hydrolase (FAAH), monoacylglycerol lipase (MAGL) and cyclooxygenase type 2 (COX2). Preventing the metabolism, or uptake, of endocannabinoids elevates levels of these lipid compounds in tissue and produces behavioural analgesia in models of acute pain. Herein we review recent studies of the effects of inhibition of metabolism of endocannabinoids versus uptake of endocannabinoids on nociceptive processing in models of inflammatory and neuropathic pain.

Inhalation of toluene diisocyanate vapor induces allergic rhinitis in mice

Diisocyanates are the leading cause of occupational asthma, and epidemiological evidence suggests that occupational rhinitis is a comorbid and preceding condition in patients who develop asthma. The goal of the present studies was to develop and characterize a murine model of toluene diisocyanate (TDI)-induced rhinitis. Female C57BL/6 mice were exposed to workplace-relevant concentrations of TDI vapor via inhalation for 4 h/day for 12 days with or without a 2-wk rest period and TDI challenge. Mice exposed 12 consecutive weekdays to 50 parts per billion TDI vapor showed elevated total serum IgE and increased TDI-specific IgG titers. Breathing rates were decreased corresponding with increased inspiratory time. TDI exposure elevated IL-4, IL-5, IL-13, and IFN-gamma mRNA expression in the nasal mucosa, suggesting a mixed Th1/Th2 immune response. Expressions of mRNA for proinflammatory cytokines and adhesion molecules were also up-regulated. These cytokine changes corresponded with a marked influx of inflammatory cells into the nasal mucosa, eosinophils being the predominant cell type. Removal from exposure for 2 wk resulted in reduced Ab production, cytokine mRNA expression, and cellular inflammation. Subsequent challenge with 50 parts per billion TDI vapor resulted in robust up-regulation of Ab production, cytokine gene expression, as well as eosinophilic inflammation in the nasal mucosa. There were no associated changes in the lung. The present model shows that TDI inhalation induces immune-mediated allergic rhinitis, displaying the major features observed in human disease. Future studies will use this model to define disease mechanisms and examine the temporal/dose relationship between TDI-induced rhinitis and asthma.

Carbonic anhydrase IX expression and outcome after radiotherapy for muscle-invasive bladder cancer

AIMS

Carbonic anhydrase IX (CA IX) expression has been described as an endogenous marker of hypoxia in solid neoplasms. Furthermore, CA IX expression has been associated with an aggressive phenotype and resistance to radiotherapy. We assessed the prognostic significance of CA IX expression in patients with muscle-invasive bladder cancer treated with radiotherapy.

MATERIALS AND METHODS

A standard immunohistochemistry technique was used to show CA IX expression in 110 muscle-invasive bladder tumours treated with radiotherapy. Clinicopathological data were obtained from medical case notes.

RESULTS

CA IX immunostaining was detected in 89 ( approximately 81%) patients. Staining was predominantly membranous, with areas of concurrent cytoplasmic and nuclear staining and was abundant in luminal and perinecrotic areas. No significant correlation was shown between the overall CA IX status and the initial response to radiotherapy, 5-year bladder cancer-specific survival or the time to local recurrence.

CONCLUSIONS

The distribution of CA IX expression in paraffin-embedded tissue sections seen in this series is consistent with previous studies in bladder cancer, but does not provide significant prognostic information with respect to the response to radiotherapy at 3 months and disease-specific survival after radical radiotherapy.

47. Evaluation of new implementation strategies, program effectiveness and dissemination of new pedagogical knowledge: Centre for faculty development's stepping stones teaching certificate program

This evaluation of the integrated Stepping Stones (SS) Teaching Certificate program, including its instructional development (workshops) and theory review (journal club) components, will inform further program development. Results of this project will also add to the limited amount of scholarly work in the area of faculty development program evaluation. Faculty development literature in the area of organized program assessment reveals use of either quantitative OR qualitative methods. In this project, a novel method combining both techniques was used to explore program impact. Participants completed 2 questionnaires to identify skill-set knowledge gaps in teaching effectiveness. Pre- and post-program quantitative gaps were generated. Focus groups were used for qualitative exploration. Areas explored pre-program included: a) motives for enrollment, b) program expectations and c) prior teaching preparation. Post-program discussion explored: the impact of the program on a) participant’s perceived gaps, b) teaching behaviour change, and c) its influence on their career in education. We believed the program’s interprofessional environment would foster development of a learning community having impact on faculty knowledge, skills and attitudes related to teaching, and potentially elicit behavioural change in teaching practices. Results from a 2004-2005 cohort of participants have identified a variety of benefits for faculty and their teaching practice. Results from a second separate cohort, 2005-2006 participants, validated the initial findings. Remarkable harmonization in the results of the qualitative analysis between the two cohort samples was evident. Statistically significant differences (p < 0.05) were found in each of the domains examined qualitatively. Both qualitative and quantitatively, program effectiveness was demonstrated immediately following completion of the program. Follow up to assess the sustainability of the effects is ongoing. The analysis of the quantitative discrepancy (gaps) data has lead to a possible technique to assist in identifying unperceived educational needs. McLeod PJ, Steinert Y, Nasmith L, Conochie L. Faculty Development in Canadian medical schools: a 10-year update. CMAJ 1997; 156(10):1419-23. Hewson MG, Copeland HL, Fishleder AJ. What’s the use of faculty development? Program evaluation using retrospective self-assessments and independent performance ratings. Teach Learn Med 2001; 13(3):153-60. Moore EM. A Framework for Outcomes Evaluation in the Continuing Development of Physicians, in: The Continuing Professional Development of Physicians. Eds. Davis D, Barnes BE, Fox R. AMA Press, 2003.

Assessment of medication safety in the outpatient setting

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Background: US Oncology provides the pharmacy and drug infusion support for over 700 medical oncologists and hematologists. As such medication safety is a principle concern for the delivery of quality care. As described earlier, a survey of affiliated practices indicated three areas of concern: 1) no uniform reporting mechanism, 2) no standard double check mechanism, and 3) variable inclusion of medication safety procedures and reporting into practice operations. This report describes the first three years experience and proposals for continuing improvement. Methods: An online reporting tool was made available to all practices. 337 practice sites and 35 practice groups were monitored. The first hour of chemotherapy (1HC) was used as the denominator for all occurrence calculations. All reporting was voluntary. Occurrences were rated as to severity, from 1 (error detected before any steps towards completion) to 7 (error resulting in death of the patient). The occurrences were categorized according to process, either in prescribing, calculation of doses, lab or allergy issues, or matching the mixed dose to the order or in administering a mixed dose. In each circumstance a near miss or failure to double check was determined. The total experience for the network was determined for 2004 and 2005 with projected data for 2006. Results: The 1HC numbers used as denominators are: 2004–534,542: 2005–534,606: 2006 –542,000. Occurrences with error rates were: 2004 –1,723 (0.32%), 2005 –2,467 (0.46%), 2006 –2,653 (0.49%). The percent practices participating were 70%, 83% and 75% for 2004, 2005 and 2006 respectively. When considering only reporting practices the occurrence rates were: 2004 –0.45%, 2005–0.55%, 2006–0.65%. The percent occurrences with temporary or permanent harm to the patient dropped from 19% in 2004 to 16% in 2006. A failure to double check was a contributing factor in 57% in 2004, 42% in 2006. Conclusions: An anonymous reporting mechanism resulted in an increase in occurrence reporting. An education program led to fewer failures to double check and a decrease in events causing harm to patients. Next steps include enhanced feedback to practices and the use of an EHR to improve processes. The malpractice environment in some areas inhibits reporting.

No significant financial relationships to disclose.

Platinum and taxane intraperitoneal chemotherapy after secondary cytoreductive surgery for recurrent ovarian carcinoma

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Background: Intraperitoneal chemotherapy (IP) after primary optimal debulking for advanced stage epithelial ovarian carcinoma improves survival. The objective of this research is to describe our experience with IP taxane and platinum chemotherapy after optimal secondary cytoreductive surgery in patients with platinum-sensitive recurrent ovarian cancer. Methods: We retrospectively reviewed charts from January 2006 to January 2007 and identified approximately 30 patients who received IP chemotherapy for optimally debulked advanced ovarian carcinoma. Of these patients, 8 were treated at first recurrence with cytoreductive surgery followed by second-line IP chemotherapy with intravenous docetaxel (70 mg/m2) and IP cisplatin (75–85 mg/m2) on day 1 and IP paclitaxel (60 mg/m2) on day 8, every 21 days. Results: The median disease free interval from completion of initial chemotherapy to recurrence was 19 months. All patients who underwent secondary cytoreductive surgery were considered optimally debulked (less than 1 cm residual disease), with 6 patients having no residual disease. One patient required rectal resection and another patient had ileocecal resection without a protective ostomy. All patients had insertion of an intraperitoneal venous access device for infusion of IP chemotherapy at the time of cytoreduction. While four patients have completed all 6 cycles of IP chemotherapy, one patient completed only 3 cycles due to catheter related toxicity requiring removal of the port (abdominal pain). This patient did not undergo concurrent bowel surgery. In addition, two patients have completed 3 cycles and two patients are currently scheduled to begin IP chemotherapy. Only two patients experienced grade 3 or 4 neutropenia. No other grade 3 or 4 toxicities were identified. A median of 5 cycles (range 2–5 cycles) was required to achieve a CA125 nadir. Complete clinical response was obtained in all patients at a median follow up of 9 months (range 4–10 months). Conclusions: In optimally debulked, platinum-sensitive patients following secondary cytoreductive surgery for recurrent ovarian cancer, intraperitoneal taxane and platinum chemotherapy is feasible with acceptable toxicity and provides another option for treatment.

No significant financial relationships to disclose.

AutoCSA, an algorithm for high throughput DNA sequence variant detection in cancer genomes

The undertaking of large-scale DNA sequencing screens for somatic variants in human cancers requires accurate and rapid processing of traces for variants. Due to their often aneuploid nature and admixed normal tissue, heterozygous variants found in primary cancers are often subtle and difficult to detect. To address these issues, we have developed a mutation detection algorithm, AutoCSA, specifically optimized for the high throughput screening of cancer samples.

Use of Botanicals in Food Supplements

BACKGROUND/AIMS

In the European Union, an elaborate legal framework regulates botanical products both under food and medicinal law. The decision as to which legal framework applies to an individual product may differ between the Member States. In the case of botanical food supplements, all food law provisions apply to their manufacturing, composition and marketing, including the new claims legislation.

METHODS

Elements from EU and national law, scientific and other publications are brought together to investigate how to clarify the differentiation between the use of botanicals for medicinal and health-promoting purposes on a scientific basis.

RESULTS

Guidance on the safety assessment and quality evaluation of botanicals is proposed in light of the different approaches described in the scientific literature with particular attention to the concept of long-term use as an integral part of safety evaluation. Guidance on claims substantiation is also included, taking into consideration the proposed legislation, the concept of long-term experience and grading of evidence.

CONCLUSIONS

A model for safety and efficacy assessment of botanical food supplements in the EU is proposed, and should be taken into consideration in the development of legislation and scientific research on botanicals.

Craniofacial surgery for orbital malformations

Paediatric craniofacial surgery is a highly specialised field requiring a multidisciplinary team input. Orbital and ocular involvement is relatively common in craniofacial patients. This is more in syndromic patients. In nonsyndromic patients, orbital involvement is common in frontal plagiocephaly and trigonocephaly. The management of these conditions requires close working between the craniofacial surgeon and ophthalmologist. An outline of the management of these deformities is discussed.

Symptomatic venous thromboembolism after orthognathic operations: An audit

We report the incidence of symptomatic venous thromboembolism confirmed by venography after 129 consecutive orthognathic operations between 1998 and 2002. Two patients developed deep vein thromboses (DVT) and there were no symptomatic pulmonary emboli.

Predictors of recurrent stroke in African Americans

BACKGROUND

Stroke incidence and mortality are disproportionately higher among African Americans than among whites.

OBJECTIVE

To describe the recurrent stroke characteristics and determine the predictability of known vascular risk factors for stroke recurrence in African Americans.

METHODS

The authors followed 1,809 African Americans in the African-American Antiplatelet Stroke Prevention Study with recent noncardioembolic ischemic stroke for recurrent stroke, recurrent stroke subtype, and disability.

RESULTS

Of the subjects, 10.6% experienced a recurrent stroke during follow-up. The mean interval between eligibility and recurrent stroke was 325 days (median 287 days, SD = 224 days). Stroke recurrence resulted in an average 1.5-point increase in the National Institute of Health Stroke Scale (p < 0.001) and a 3.5-point decrease in modified Barthel Index (p < 0.001). Of previously nondisabled subjects, 48% became disabled or died after stroke recurrence (p < 0.0001). Longitudinal analysis resulted in a hazard for recurrent stroke for each 10-mm Hg increase in systolic blood pressure of 1.103 (95% CI: 1.031 to 1.179, p = 0.004), pulse pressure 1.123 (95% CI: 1.041 to 1.213, p = 0.003), and mean arterial pressure 1.123 (95% CI: 1.001 to 1.260, p = 0.048). Multivariate analysis revealed increases in the recurrent stroke hazard for increases in baseline Glasgow Outcome Score (1.449, 95% CI: 1.071 to 1.961, p = 0.016) and increases in longitudinal pulse pressure (1.009, 95% CI: 1.001 to 1.017, p = 0.029).

CONCLUSION

Recurrent stroke leads to disability and disability predicts recurrent stroke. Hypertension is the most predictive modifiable stroke risk factor.

The development of an outpatient chemotherapy medication safety program

16005

Background: Through Institute of Medicine publications (To Err is Human) and through the public experience of a major cancer center, chemotherapy safety has been of concern. US Oncology, Inc. (USON) is the nations largest oncology management company, associated with over 900 medical, radiation, gynecologic and pediatric oncologists. In 2004 USON undertook a quality initiative with a principal objective a system-wide approach to medication safety. Methods: Medication safety was identified as a principal concern by a combined clinical/management committee. A questionnaire was prepared for each practice site to differentiate high performing practices in regards to variances from lower performing practices. 8 high performing practices and 8 lower performing practices were physically evaluated by team members. Neither the questionnaire nor onsite evaluation reliably differentiated quality processes. Three issues became apparent: no uniform reporting mechanism, multiple “double-check” interpretations and variable inclusion of medication safety into practice operations. The safety team undertook these first two issues. An online reporting tool was developed. “Double-check” was defined and processes mapped. Results: The team chose 1st hour of chemotherapy as the denominator for medication occurrence reporting. An online reporting tool was developed with now 1 year of experience. 83% of practice sites are reporting, accounting for 445,148 1st hours of chemotherapy. The occurrence rate is 0.66%. Of the total 0.13% is adverse drug reaction, 0.10% is near miss, 0.08% is miscalculation of dose, 0.05% is the wrong dose. Injury to a patient is a very rare event. Conclusions: The development of a culture of quality in an organization with affiliations of national scope is a formidable undertaking. These initial numbers have no comparative measure, as this is self-reporting using a novel denominator. However, there are within the network similar groups for comparison. The challenge continues to be developing a culture of reporting with systematic integration of those reports and quality processes into the fabric of the practice.

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The inter-relationship of hypoxia and phospho-Akt in the pathobiology of malignant pleural mesothelioma

17057

Background: Poor outcomes with conventional oncological treatments for malignant pleural mesothelioma (MPM) have driven the imperative to advance understanding of the disease pathobiology. Carbonic Anhydrase (CA)-IX is a surrogate marker of hypoxia over-expressed in solid tumours. Protein Kinase B, or Akt, known to have important intracellular roles including resistance to apoptosis, is activated in human malignancies and upregulated in hypoxic conditions. This study examined the expression of CA-IX and phosphorylated Akt (pAkt) in tumour samples from patients with MPM, correlating expression with established prognostic factors. The role of pAkt in the survival of an MPM cell line exposed to hypoxic conditions was also examined. Methods: Full local regional ethics committee approval was obtained for this work. Tumour samples from 200 patients with MPM were stained using pAkt and CA-IX specific antibodies. The effect of hypoxia on Akt and pAkt was evaluated in the JU77 mesothelioma cell line in the presence or absence of the phosphatidylinositol-3-kinase inhibitor, LY294002. Results: There was a positive association between the level of CA-IX and pAkt staining, implying that intra-tumoural hypoxia may be a stimulus for Akt phosphorylation. On multivariate analysis increased expression of nuclear pAkt was found to be associated with a poor survival. In-vitro cell culture work showed that, although pAkt is expressed in normoxic conditions in the JU77 cell line, the rates of apoptosis were significantly increased in hypoxic conditions when the phosphorylation of Akt was blocked by LY294002. Conclusions: This work provides evidence for the anti-apoptotic role of pAkt in hypoxic conditions in solid human malignancies. Phospho-Akt may represent a novel therapeutic target in MPM.

No significant financial relationships to disclose.