Rural-Urban Variation in Time to Diagnosis and Treatment of Colorectal or Breast Cancer in Victoria, Australia

Background: Rural-urban disparities in cancer outcomes are found in many countries, though these vary by cancer type. In Victoria, Australia, survival is poorer for rural patients with colorectal cancer, but not breast cancer. Delayed diagnosis and treatment may contribute to disparities, but previous studies have not compared the timeliness of rural and urban pathways to treatment of these common cancers. Aim: We investigated whether time to diagnosis and treatment differed for rural and urban patients with colorectal or breast cancer in Victoria, Australia. Methods: Population-based, cross-sectional surveys examining events and dates on the pathway to treatment completed by patients aged ≥ 40 and approached within six months of diagnosis, their general practitioner (GP) and specialist. Data were collected from 2013 to 2014 as part of the International Cancer Benchmarking Partnership, Module 4. Six intervals were explored: patient (symptom to presentation), primary care (presentation to referral), diagnostic (presentation/screening to diagnosis), treatment (diagnosis to treatment), health system (presentation to treatment) and total intervals (symptom/screening to treatment). Rural-urban differences were examined for each cancer using quantile regression (50th, 75th and 90th percentiles) models including age, gender, health insurance and socioeconomic status. Results: 433 colorectal (48% rural) and 489 breast (42% rural) patients, 621 GPs and 370 specialists completed surveys. Compared with urban patients, symptomatic colorectal cancer patients from rural areas had a significantly longer total interval at all percentiles: 50th (18 days longer, 95% confidence interval (CI): 9-27), 75th (53, 95% CI: 47-59) 90th (44, 95% CI: 40-48). These patients also had longer health system intervals, ranging 7-85 days longer. This appeared mostly due to longer diagnostic intervals (range: 6-54 days longer). Results were similar when including screen-detected cases. In contrast, breast cancer intervals were similar for rural and urban patients, except the patient interval, which was shorter for rural patients. Conclusion: Consistent with variation in survival, we found longer total and diagnostic intervals for rural compared with urban patients with colorectal cancer, but not breast cancer. The lack of rural-urban differences observed for breast cancer suggest that inequities in the timeliness of colorectal cancer pathways can be ameliorated, and may improve clinical outcomes. Indeed, based on previous research, delays observed in this study could result in stage progression and hence reduced survival. From our results, interventions targeting the time from presentation to colorectal cancer diagnosis in rural populations should be pursued. Countries seeking to understand cancer disparities in their local context may also consider using a pathways approach to identify possible targets for policy intervention.

New Mitral Valve Annuloplasty Concept: Optimizing Annular Dynamics and Force Distribution

BACKGROUND

Temporal three-dimensional (3D) analysis of the mitral valve biomechanics has prompted a re-evaluation of surgical approaches and repair device designs to accommodate the natural dynamics of the valve. Such new designs strive to obtain lower annulus restraining forces, resulting in more natural leaflet and chordal stresses. A new annuloplasty system was evaluated using 3D motion and out-of-plane force analysis. It was hypothesized that this system would not impact the valve with adverse motion restrictions or high systolic annular forces compared to conventional flat rigid ring designs.

METHODS

In an acute porcine set-up, six 80 kg pigs were monitored before and after implantation of the new annuloplasty system consisting of two half-rings with a saddle-shaped outline. Valvular 3D dynamic geometry was obtained using sonomicrometry before and after annuloplasty system implantation. Strain gauges mounted on the commissural segments provided the annular restraining force distribution perpendicular to the annular plane.

RESULTS

The change in annular height to commissural width ratio from diastole to systole did not alter following implantation (p >0.05). Out-of-plane systolic restraining forces were 0.2 ± 0.1 N and 0.8 ± 0.3 N (mean ± SEM) in the posterior and anterior commissural segments, respectively, without any difference in-between (p >0.1). Forces in both commissural segments were significantly lowered compared to previous measurements with a flat and stiff mitral annuloplasty ring (p <0.01). Mitral annular septal-lateral distance, area, and circumference in the commissural segments were decreased after implantation (p <0.05). The cross-annular distance between the commissural segments and the lengths of the anterior and posterior annular segments did not change following implantation (p >0.05).

CONCLUSIONS

The new annuloplasty system design maintained annular 3D dynamics and provided a minimized out-of-plane restraining force distribution compared to earlier studies on flat rigid rings. This may have important implications in the selection of annuloplasty devices in order to increase repair durability.

Insights into the genetic architecture of morphological traits in two passerine bird species

Knowledge about the underlying genetic architecture of phenotypic traits is needed to understand and predict evolutionary dynamics. The number of causal loci, magnitude of the effects and location in the genome are, however, still largely unknown. Here, we use genome-wide single-nucleotide polymorphism (SNP) data from two large-scale data sets on house sparrows and collared flycatchers to examine the genetic architecture of different morphological traits (tarsus length, wing length, body mass, bill depth, bill length, total and visible badge size and white wing patches). Genomic heritabilities were estimated using relatedness calculated from SNPs. The proportion of variance captured by the SNPs (SNP-based heritability) was lower in house sparrows compared with collared flycatchers, as expected given marker density (6348 SNPs in house sparrows versus 38 689 SNPs in collared flycatchers). Indeed, after downsampling to similar SNP density and sample size, this estimate was no longer markedly different between species. Chromosome-partitioning analyses demonstrated that the proportion of variance explained by each chromosome was significantly positively related to the chromosome size for some traits and, generally, that larger chromosomes tended to explain proportionally more variation than smaller chromosomes. Finally, we found two genome-wide significant associations with very small-effect sizes. One SNP on chromosome 20 was associated with bill length in house sparrows and explained 1.2% of phenotypic variation (V_P), and one SNP on chromosome 4 was associated with tarsus length in collared flycatchers (3% of V_P). Although we cannot exclude the possibility of undetected large-effect loci, our results indicate a polygenic basis for morphological traits.

The genomic mosaicism of hybrid speciation

Hybridization is widespread in nature and, in some instances, can result in the formation of a new hybrid species. We investigate the genetic foundation of this poorly understood process through whole-genome analysis of the hybrid Italian sparrow and its progenitors. We find overall balanced yet heterogeneous levels of contribution from each parent species throughout the hybrid genome and identify areas of novel divergence in the hybrid species exhibiting signals consistent with balancing selection. High-divergence areas are disproportionately located on the Z chromosome and overrepresented in gene networks relating to key traits separating the focal species, which are likely involved in reproductive barriers and/or species-specific adaptations. Of special interest are genes and functional groups known to affect body patterning, beak morphology, and the immune system, which are important features of diversification and fitness. We show that a combination of mosaic parental inheritance and novel divergence within the hybrid lineage has facilitated the origin and maintenance of an avian hybrid species.

Assertive Interventions for First Episode Psychoses: The Danish Experience

Early Intervention services with team-based intensive case management and family involvement are superior to standard treatment in reducing psychotic and negative symptoms and comorbid substance abuse and improving social functioning and user satisfaction. The results of the OPUS-trial will be presented together with meta-analyses based on similar trials. The implementation of OPUS all over Denmark will be presented together with the Danish OPUS-fidelity study. Specialized elements are being are being developed such as inclusion of new methods in CBT for psychotic and negative symptoms, neurocognitive and social cognitive training programs, interventions for supported employment and focus on physical health. Results of long term follow-up studies indicate that the prognosis of first episode psychosis is very diverse with the extremes represented by one group being well functioning and able to quit medication without relapse; and another group having a long term chronic course of illness with a need for support to maintain daily activities. The Danish TAILOR-trial–testing dose reduction versus maintenance therapy will be presented. It will be of immense value to be able to intervene in risk groups identified in the premorbid phase, and there are few examples of ongoing trial for children of parent with schizophrenia and bipolar disorder.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

High-Throughput Fabrication of Nanocomplexes Using 3D-Printed Micromixers

3D printing allows a rapid and inexpensive manufacturing of custom made and prototype devices. Micromixers are used for rapid and controlled production of nanoparticles intended for therapeutic delivery. In this study, we demonstrate the fabrication of micromixers using computational design and 3D printing, which enable a continuous and industrial scale production of nanocomplexes formed by electrostatic complexation, using the polymers poly(diallyldimethylammonium chloride) and poly(sodium 4-styrenesulfonate). Several parameters including polymer concentration, flow rate, and flow ratio were systematically varied and their effect on the properties of nanocomplexes was studied and compared with nanocomplexes prepared by bulk mixing. Particles fabricated using this cost effective device were equally small and homogenous but more consistent and controllable in size compared with those prepared manually via bulk mixing. Moreover, each micromixer could process more than 2 liters per hour with unaffected performance and the setup could easily be scaled-up by aligning several micromixers in parallel. This demonstrates that 3D printing can be used to prepare disposable high-throughput micromixers for production of therapeutic nanoparticles.