Effectiveness of QUICATOUCH: a computerised touch screen evaluation for pain and distress in ambulatory oncology patients in Newcastle, Australia

OBJECTIVE

To describe the change in pain and distress over time to demonstrate the effectiveness of the QUICATOUCH program in an outpatient oncology population.

METHODS

Descriptive study of the first 29 months of the QUICATOUCH program (13 736 assessments for 5775 patients). A longitudinal cohort design was used to examine the patients with three or more assessments (8129 assessments for 1778 patients). Effectiveness of this complex intervention (repeated assessment, clinician report and referral to speciality psycho-oncology service) was examined using: reduction in proportion over threshold for pain and distress, predictors of mean pain and distress scores and comparison of the number of new patients treated by the psycho-oncology service during the study and in the preceding 29 months.

RESULTS

Pain and distress declined during the study. The risk of being over threshold at endpoint was reduced for pain (odds ratio (OR) 0.70, confidence interval (CI) 95% 0.60-0.81) and for distress (OR 0.58 CI 95% 0.49-0.68) with baseline as referent level. Three variables predicted the mean pain: clinic type, current radiotherapy treatment and distress score; and five predicted mean distress: time, gender, clinic type, age and pain score. There was an increase of 40% (533v747) in new patients treated by the psycho-oncology service.

CONCLUSIONS

The QUICATOUCH assessment for pain and distress was implemented into usual clinical practice with reasonable coverage of patients for modest cost. It was effective in monitoring the patients over time, contributed to a reduction in pain and distress, whilst appropriately increasing the number of new patients reaching psychological treatment as part of the clinical service.

Effects of the interactions of classical swine fever virus Core protein with proteins of the SUMOylation pathway on virulence in swine

Here we have identified host cell proteins involved with the cellular SUMOylation pathway, SUMO-1 (small ubiquitin-like modifier) and UBC9, a SUMO-1 conjugating enzyme that interact with classical swine fever virus (CSFV) Core protein. Five highly conserved lysine residues (K179, K180, K220, K221, and K246) within the CSFV Core were identified as putative SUMOylation sites. Analysis of these interactions showed that K179A, K180A, and K221A substitutions disrupt Core-SUMO-1 binding, while K220A substitution precludes Core-UBC9 binding. In vivo, Core mutant viruses (K179A, K180A, K220A, K221A) and (K220A, K221A) harboring those substitutions were attenuated in swine. These data shows a clear correlation between the disruption of Core protein binding to SUMO-1 and UBC9 and CSFV attenuation. Overall, these data suggest that the interaction of Core with the cellular SUMOylation pathway plays a significant role in the CSFV growth cycle in vivo.

Associations between exercise-induced pulmonary haemorrhage, right ventricular dimensions and atrioventricular valve regurgitation in conditioned National Hunt racehorses

REASONS FOR PERFORMING STUDY

Exercise-induced pulmonary haemorrhage (EIPH) and tricuspid (TR) and mitral valve regurgitation (MR) are conditions with high prevalence in conditioned Thoroughbreds. Stress failure of pulmonary capillaries, leading to EIPH, is most likely when pulmonary vascular pressure is increased, and mitral regurgitation can result in pulmonary venous hypertension.

HYPOTHESIS

There might be an association between MR and EIPH and the right ventricle (RV) of horses known to suffer repeated episodes of EIPH, as their hearts would be subject to higher pulmonary vascular pressures and cardiac output during training and hence increased RV afterload and preload.

METHODS

An echocardiographic and auscultation study was conducted in 121 race-fit National Hunt Thoroughbreds. Cardiac auscultation and echocardiography were performed. A guided M-mode image of the RV just below the tricuspid valve was obtained from a right parasternal location and colour flow Doppler (CFD) used to interrogate the tricuspid valve and right atrium. The mitral valve was similarly examined from the left hemithorax. Severity of TR and MR by CFD was graded. Binary data on EIPH, based on whether the horse was perceived to have a clinically significant problem with EIPH, were determined retrospectively for each horse by the horses' primary care veterinary surgeon from medical and other records. Data were analysed using a standard logistic regression analysis approach.

RESULTS

EIPH was significantly and positively associated with the systolic and diastolic dimensions of the RV (P = 0.017 and 0.011 respectively) and this association was not sensitive to the effects of age or weight. There were no significant associations between EIPH and TR or MR by auscultation or CFD (TR: auscultation P = 0.1; CFD P = 0.2 and MR: auscultation P = 0.07; CFD P = 0.37).

CONCLUSIONS AND CLINICAL RELEVANCE

This study was limited by the method used to classify EIPH, but there was no association between EIPH and horse age, weight, TR or MR in this population of Thoroughbreds. Nevertheless, RV internal dimension was greater in horses obviously affected by EIPH, suggesting that factors resulting in EIPH may directly or indirectly affect RV remodelling in athletic horses.

Measurements of right ventricular internal dimensions and their relationships to severity of tricuspid valve regurgitation in National Hunt Thoroughbreds

REASONS FOR PERFORMING STUDY

The effect of tricuspid valve regurgitation (TR) in right ventricular (RV) chamber size has not been reported.

METHODS

An echocardiographic and auscultation study was conducted on 394 race-fit National Hunt Thoroughbreds (TBs) in 4 training yards. Auscultation was performed on each horse and audible murmurs of TR graded using a 1-6 scale. Echocardiography was also performed and standard, 2-dimensional (2D), short (SA) and long axis (LA) images of the RV obtained from a right parasternal location. An m-mode image was recorded from an SA view of the RV just below the level of the tricuspid valve. Colour flow Doppler (CFD) echocardiography was used to interrogate the tricuspid valve and right atrium. If retrograde flow was visible, representative recordings were also acquired. Severity of TR by CFD was graded using a subjective 1-9 scale. Measurements of RV chamber size in systole and diastole were made from archived 2D, LA, SA and m-mode images by a single observer unaware of the auscultation and CFD findings. To determine day-to-day repeatability of RV measurements from each imaging plane and of TR by CFD, 5 horses were examined on 5 consecutive days using an identical echocardiographic protocol. Images from 30 horses in the original dataset were also measured on a second occasion to determine the intra-observer repeatability.

RESULTS

There were significant positive correlations between the severity of TR by CFD and RV internal diameter from each image plane. In contrast, there were no significant associations between grade of TR by auscultation and any RV dimension. Data also showed that only RV measurements derived from M-mode images have acceptable intraobserver repeatability and similarly the M-mode measurements had the best overall day-to-day repeatability.

CONCLUSIONS AND CLINICAL RELEVANCE

Data showed that TR assessed by CFD was positively associated with the diastolic and systolic dimensions of the RV, but failed to demonstrate a positive association between the presence of a murmur of TR and RV chamber size. M-mode and 2D echocardiography provided moderately reliable and repeatable methods for obtaining measurements of RV internal dimensions. M-mode images provide the most reliable and repeatable measurements, particularly for less experienced operators.

Risk factors for epistaxis on British racecourses: evidence for locomotory impact-induced trauma contributing to the aetiology of exercise-induced pulmonary haemorrhage

REASONS FOR PERFORMING STUDY

The proposed biological mechanisms for exercise-induced pulmonary haemorrhage (EIPH) are many and varied. Better knowledge of risk factors should lead to achievable measures to reduce the incidence.

OBJECTIVES

To identify risk factors associated with epistaxis following racing in UK Thoroughbreds, to gain possible insights into the pathogenesis of the condition and to investigate the association between epistaxis and race finishing position.

METHODS

The association of epistaxis occurring on UK racecourses between 1996 and 1998 with a wide range of race-, horse- and start-level variables was examined in multivariable mixed effect logistic regression analyses. Four multivariable analyses were conducted, one for all race types considered collectively and one each for flat, hurdle and steeplechase race types considered separately.

RESULTS

Risk of epistaxis was significantly increased for hurdle and steeplechase race types compared to both flat and National Hunt flat races. In 3 of the 4 final models, there was a significant biological trend for increasing risk of epistaxis with increasing ground hardness ('going') and accumulated years spent racing. However, in flat races epistaxis was such a rare outcome (0.33 cases per 1000 starts) that this subset analysis had insufficient power to measure the detectable effect of 'going' as statistically significant. Horses with epistaxis were significantly more likely to have a poorer finishing position than those without blood at the nostrils.

CONCLUSIONS

Findings were consistent with the theory that locomotory impact-induced trauma contributes to exercise-induced epistaxis. Further validation of this hypothesis through application of similar methods to endoscopically visible EIPH and through biomechanical studies is warranted.

POTENTIAL RELEVANCE

Knowledge of significant risk factors should allow formulation of practical measures, such as track watering, to reduce the risks of EIPH and epistaxis in racehorses.

The use of the Oxford hip and knee scores

The Oxford hip and knee scores have been extensively used since they were first described in 1996 and 1998. During this time, they have been modified and used for many different purposes. This paper describes how they should be used and seeks to clarify areas of confusion.

Objective Analysis of Tomographic Ventilation–Perfusion Scintigraphy in Pulmonary Embolism

RATIONALE

Ventilation-perfusion scintigraphy is highly sensitive for pulmonary embolism (PE), but its clinical usefulness is limited by its nondiagnostic rate. Objective analysis of single photon emission computed tomography (SPECT) three-dimensional scintigraphy may improve its diagnostic performance compared with subjective interpretation.

OBJECTIVES

To determine the diagnostic accuracy of objective SPECT analysis in PE.

METHODS

We determined the ventilation/perfusion (V(.)/Q(.)) relationship using SPECT scintigraphy in a retrospective cohort of 73 patients. Measures of V(.)/Q(.) heterogeneity (logSD(Q(.)), logSD(V(.)), logSD(VQR)), including a novel parameter, the weighted median V(.)/Q(.) value, were calculated. Using receiver operating characteristic (ROC) analysis, each parameter's diagnostic accuracy was determined. The weighted median V(.)/Q(.) value was then assessed prospectively in a second cohort of 50 patients.

MEASUREMENTS AND MAIN RESULTS

In cohort 1, all parameters of V(.)/Q(.) heterogeneity were higher in patients with PE (p < 0.002). The weighted median V(.)/Q(.) had the highest area under the ROC curve (0.93; 95% confidence interval, 0.87-0.98). When applied to the prospective cohort, the area under the ROC curve was 0.87 (95% confidence interval, 0.75-0.99), with diagnostic cutoff values having negative and positive predictive values of 96 and 83%, respectively. In the retrospective and prospective cohorts, 82 and 73% of initially reported intermediate or low probability scans had diagnostic weighted median V(.)/Q(.) values, with 90 and 100% accuracy, respectively.

CONCLUSIONS

Objective analysis of SPECT scintigraphy has a high diagnostic accuracy in patients with suspected PE. Objective analysis has the potential to reduce the number of nondiagnostic scan results, and may be useful for quantifying V(.)/Q(.) mismatch in other pulmonary disorders.

An echocardiographic and auscultation study of right heart responses to training in young national hunt thoroughbred horses

REASONS FOR PERFORMING STUDY

There are few data available to determine the effect of training on cardiac valve function.

OBJECTIVES

To investigate the effect of commercial race training on right ventricular (RV) and tricuspid valve function in an untrained group of National Hunt Thoroughbreds (TB).

MATERIAL AND METHODS

Cardiac auscultation, guided M-mode echocardiography of the RV, and colour flow Doppler (CFD) tricuspid valve and right atrium were performed in 90 TB horses (age 2-7 years) 1998-2003. Forty horses were examined at least once and 48 horses were examined on at least 2 occasions. Examinations were then classified as: i) before commencement of race training, ii) after cantering exercise had been sustained for a period of 8-12 weeks and iii) at full race fitness. Tricuspid valve regurgitation (TR) murmurs were graded on a 1-6 scale and CFD echocardiography TR signals were graded on a 1-9 scale. Right ventricular internal diameter (RVID) in diastole and systole (RVIDd and RVIDs) was measured by guided M-mode. Associations between continuous RVID and TR measures and explanatory covariates of weight, age, heart rate, yard and stage of training were examined using general linear mixed models with horse-level random effects.

RESULTS

On average, RVIDd and RVIDs increased by 0.08 and 0.1 cm, respectively, per year increase in age (P = 0.1 and 0.02) and by 0.3 and 0.4 cm, respectively between pretraining and race fitness (P = 0.07 and 0.005). Tricuspid regurgitation score by colour flow Doppler increased by 0.6/year with age (P<0.0001) and by 1.8 between pretraining and race fitness (P<0.0001). No significant associations were found between any outcomes and weight, heart rate and training yard. Due to the high level of colinearity between age and training, multivariable models including both terms were not interpretable.

CONCLUSIONS AND CLINICAL RELEVANCE

Athletic training of horses exerts independent effects on both severity and prevalence of tricuspid valve incompetence. This effect should therefore be taken into account when examinations are performed. Dimensions of RV increase with age and training in TB horses in a manner that appears to be similar to that of the LV.

Hippocampal damage and memory impairments as possible early brain complications of type 2 diabetes

AIMS/HYPOTHESIS

There is evidence that type 2 diabetes mellitus is associated with cognitive impairment. Most studies investigating this association have evaluated elderly individuals, after many years of diabetes, who generally have poor glycaemic control and significant vascular disease. The aim of the current study was to investigate the early cognitive consequences and associated brain correlates of type 2 diabetes.

MATERIALS AND METHODS

With regard to cognition and brain measures, we compared 23 age-, sex- and education-matched control subjects with 23 mostly middle-aged individuals with relatively well-controlled diabetes of less than 10 years from the time of diagnosis.

RESULTS

We found deficits in hippocampal-based memory performance and preservation of other cognitive domains. Relative to control subjects, individuals with diabetes had reductions in brain volumes that were restricted to the hippocampus. There was an inverse relationship between glycaemic control and hippocampal volume; in multivariate regression analysis, HbA(1c) was the only significant predictor of hippocampal volume, accounting for 33% of the observed variance. Other variables commonly associated with type 2 diabetes, such as elevated BMI, hypertension or dyslipidaemia, did not independently contribute to the variance in hippocampal volume.

CONCLUSIONS/INTERPRETATION

These results suggest that the medial temporal lobe may be the first brain site affected by type 2 diabetes and that individuals in poorer metabolic control may be affected to a greater extent.

Wavelet-based feature extraction applied to small-angle x-ray scattering patterns from breast tissue: a tool for differentiating between tissue types

This paper reports on the application of wavelet decomposition to small-angle x-ray scattering (SAXS) patterns from human breast tissue produced by a synchrotron source. The pixel intensities of SAXS patterns of normal, benign and malignant tissue types were transformed into wavelet coefficients. Statistical analysis found significant differences between the wavelet coefficients describing the patterns produced by different tissue types. These differences were then correlated with position in the image and have been linked to the supra-molecular structural changes that occur in breast tissue in the presence of disease. Specifically, results indicate that there are significant differences between healthy and diseased tissues in the wavelet coefficients that describe the peaks produced by the axial d-spacing of collagen. These differences suggest that a useful classification tool could be based upon the spectral information within the axial peaks.

A comparison of survival models for assessing risk of racehorse fatality

Survival analysis was used to assess risk factors for fatal injuries on UK race courses. This allowed assessment of variation due to temporal horse-level effects, including previous racing intensity and historical distribution of race types, as well as race-level factors. Comparisons were made between measuring survival time as number of days and as number of races to injury from the first race. Two related models were presented for time as number of races to injury: a Cox regression model fitted using partial likelihood, with the Efron approximation to handling ties, and a discrete-time logit model fitted using maximum likelihood. The latter approach had the advantages of being computationally more efficient and enabling the testing of different functional forms for the dependence of hazard on time. Retrospective data were available from all race starts on the 59 courses in Britain from 1990 to the end of 1999, as analysed by . The analysis was conducted on the data for the 47,424 horses that had started racing in the UK: 538,895 starts with 1,228 fatal injuries. Horses starting racing abroad were excluded, but some included horses would have raced abroad at some stage during their racing career. The results for the selected models were broadly consistent with each other and with previously published studies. Steeplechase and hurdle races had a higher risk of fatal injury than flat races (relative hazards 1.5 and 1.7, respectively). Risk increased with the firmness of surface, age and race distance (reaching a plateau at 20 furlongs) and decreased with previous racing intensity (reaching a plateau after seven races run in the last 12 months). Horses running their first race of a new type were also found to be at higher risk (relative hazard 1.5). The main difference between the models for time as number of days and number of races concerned the role of age: age at race was identified as the more important factor in the latter model, whereas, age at first race was more significant in the former model.