External Beam Radiotherapy in the Treatment of Gastroenteropancreatic Neuroendocrine Tumours: A Systematic Review

AIMS

External beam radiotherapy (EBRT) is infrequently used to treat gastroenteropancreatic neuroendocrine tumours (GEPNETS), with little published data to date. We carried out a systematic review to assess the activity of EBRT for GEPNETS.

MATERIALS AND METHODS

Major databases were searched for papers including at least five patients treated with contemporary EBRT techniques. Eligible studies underwent dual independent review. The primary end points were response rate for lesions treated with definitive intent and recurrence-free survival for primary lesions treated with neoadjuvant or adjuvant intent.

RESULTS

Of 11 included studies (all retrospective), seven investigated pancreatic neuroendocrine tumours (PNETs, 100 patients, 14% grade 3) and four studies investigated extra-pancreatic neuroendocrine tumours (84 patients, 14% grade 3). Trials investigating PNETs administered a median of 50.4 Gy via three-dimensional conformal radiotherapy and intensity-modulated radiotherapy. EBRT was given with neoadjuvant or adjuvant intent in 56 patients, with a recurrence rate of 15%. For the 44 patients not undergoing surgery, the radiological response rate was 46%. Grade 3 + toxicity rates were 11% (acute) and 4% (late). Twelve patients with anorectal neuroendocrine carcinoma received 58 Gy to the primary tumour. Seventy-two patients were treated to sites of metastatic disease (34 bone, 27 brain, 11 soft tissue). Local and distant control were poorly reported. Overall survival ranged from 9 to 19 months. No studies in this group reported toxicity outcomes.

CONCLUSIONS

There are limited, retrospective data on the overall activity and safety of EBRT in GEPNETS. EBRT generally seems to be well tolerated in selected PNET patients with encouraging activity. Well-designed prospective studies in clearly defined populations are required to clarify the role of EBRT in neuroendocrine tumours.

Evaluation of three rapid oral fluid test devices on the screening of multiple drugs of abuse including ketamine

Rapid oral fluid testing (ROFT) devices have been extensively evaluated for their ability to detect common drugs of abuse; however, the performance of such devices on simultaneous screening for ketamine has been scarcely investigated. The present study evaluated three ROFT devices (DrugWipe^® 6S, Ora-Check^® and SalivaScreen^®) on the detection of ketamine, opiates, methamphetamine, cannabis, cocaine and MDMA. A liquid chromatography tandem mass spectrometry (LCMS) assay was firstly established and validated for confirmation analysis of the six types of drugs and/or their metabolites. In the field test, the three ROFT devices were tested on subjects recruited from substance abuse clinics/rehabilitation centre. Oral fluid was also collected using Quantisal^® for confirmation analysis. A total of 549 samples were collected in the study. LCMS analysis on 491 samples revealed the following drugs: codeine (55%), morphine (49%), heroin (40%), methamphetamine (35%), THC (8%), ketamine (4%) and cocaine (2%). No MDMA-positive cases were observed. Results showed that the overall specificity and accuracy were satisfactory and met the DRUID standard of >80% for all 3 devices. Ora-Check^® had poor sensitivities (ketamine 36%, methamphetamine 63%, opiates 53%, cocaine 60%, THC 0%). DrugWipe^® 6S showed good sensitivities in the methamphetamine (83%) and opiates (93%) tests but performed relatively poorly for ketamine (41%), cocaine (43%) and THC (22%). SalivaScreen^® also demonstrated good sensitivities in the methamphetamine (83%) and opiates (100%) tests, and had the highest sensitivity for ketamine (76%) and cocaine (71%); however, it failed to detect any of the 28 THC-positive cases. The test completion rate (proportion of tests completed with quality control passed) were: 52% (Ora-Check^®), 78% (SalivaScreen^®) and 99% (DrugWipe^® 6S).

Effect of the Factor V Leiden Mutation on the Clinical Expression of Severe Hemophilia A

To determine whether the factor V Leiden mutation is associated with decreased bleeding in individuals with severe hemophilia A, factor concentrate utilization, maximum annual number of bleeding episodes, and the prevalence of hemophilic arthropathy between carriers and non-carriers of the factor V Leiden mutation were compared. Heterozygosity for the factor V Leiden mutation was found in 6 of 137 subjects (4.4%). Carriers of the factor V Leiden mutation utilized less factor concentrate (geometric mean: 310 vs. 1185 units/kg/year) and had fewer bleeding episodes than non-carriers (proportion with 10 or fewer bleeding episodes in their worst year: 50 vs. 11%). However, the factor V Leiden mutation was not associated with the absence of arthropathy. The intron 22 inversion mutation of the factor VIII gene was tested for in a subgroup of 80 subjects, but it was not found to be a significant variable for any of the bleeding endpoints. The results of this small study are consistent with the hypothesis that the factor V Leiden mutation imparts a protective effect; however, a larger confirmatory study in which the factor VIII molecular defects can be controlled for is needed. Furthermore, most severe hemophiliacs who used fewer than 200 units/kg/year of factor concentrate or who had experienced 10 or fewer bleeding episodes per year did not carry the factor V Leiden mutation, suggesting that the proportion of severe hemophiliacs whose mild clinical course can be attributed to the factor V Leiden mutation is small.

Effective Healthcare Worker-Patient Communication in Hong Kong Accident and Emergency Departments

Introduction

This paper reports on research conducted within a Hong Kong (HK) accident and emergency department (AED), which investigated the effectiveness of health care worker-patient communication over the course of patients' journeys from triage to disposition.

Methods

The research combined qualitative and quantitative ethnographic methods with linguistically-oriented discourse analysis of audiotaped interactions between patients and health care workers. It involved: (1) observations, (2) semi-structured interviews with management and health care workers, (3) surveys with AED staff, (4) audio-recordings of 10 patients' journeys, and (5) follow-up interviews with patients.

Results

The paper described the typically complex communication networks involved in AED care. It then exemplified how certain communicative strategies, balancing the communication of medical knowledge with interpersonal communication, could be used to achieve positive healthcare outcomes. This was illustrated by a case study of one patient's journey through the AED, pinpointing health care workers' effective use of communication strategies, their effect on the patient's participation and subsequently the patient's understanding and evaluation of the care he received.

Conclusion

The high stress nature of AEDs inevitably poses challenges to communication. The results of this study, however, strongly suggest a correlation between health care workers' use of effective, interpersonally sensitive communication strategies and positive patient outcomes. Health care worker-patient communication that effectively balances interpersonal communication with the communication of medical expertise is integral to ensuring patients' participation in, understanding of, and satisfaction with their healthcare. These communication strategies should be required components in health care worker communication training. (Hong Kong j.emerg.med. 2015;22:69-83)

Paracetamoloverdose Presenting to an Accident & Emergency Department of a Regional Hospital in Hong Kong

We carried out a review of the patient resuscitation records and hospital notes of paracetamol overdose patients initially treated in the Accident and Emergency Department of Tuen Mun Hospital during the period starting from January 1998 to April 1999. Altogether there were 42 patients but 46 cases were recruited in the study because 4 patients had overdose twice. Ten (22%) were male, 36 (78%) were female and young female constituted the majority of the patients Forty-three cases (93%) took an overdose of paracetamol as a means of committing suicide and 20 cases (43%) ingested 10 grams or more of paracetamol. The most common provoking causes were adjustment disorder (18 cases, 39.1%) and acute stress reaction (8 cases 17.4%). The majority of the cases presented early and within 8 hours after the overdose. Two cases had impaired liver function, 3 had prolonged prothrombin time and 5 had transient metabolic acidaemia in the absence of liver failure. All patients recovered uneventfully. Forty one cases (89%) were given N-acetylcysteine (NAC) infusion, of these 6 had toxic paracetamol level, 24 had non-toxic level because NAC was given before the availability of paracetamol level in many cases and it was undetermined for the other 11 cases. Hypersensitivity reaction to NAC infusion was common (8 cases, 21%) but there was no long term sequelae. Highly variable approach in the use of NAC was noted, we suggest to set a clinical check-list for the management of paracetamol overdose especially concerning the time to check the serum level and the initiation of NAC.

Tribes and tribulations: interdisciplinary eHealth in providing services for people with a traumatic brain injury (TBI)

Background

eHealth has potential for supporting interdisciplinary care in contemporary traumatic brain injury (TBI) rehabilitation practice, yet little is known about whether this potential is being realised, or what needs to be done to further support its implementation. The purpose of this study was to explore health professionals’ experiences of, and attitudes towards eHealth technologies to support interdisciplinary practice within rehabilitation for people after TBI.

Methods

A qualitative study using narrative analysis was conducted. One individual interview and three focus groups were conducted with health professionals (n = 17) working in TBI rehabilitation in public and private healthcare settings across regional and metropolitan New South Wales, Australia.

Results

Narrative analysis revealed that participants held largely favourable views about eHealth and its potential to support interdisciplinary practice in TBI rehabilitation. However, participants encountered various issues related to (a) the design of, and access to electronic medical records, (b) technology, (c) eHealth implementation, and (d) information and communication technology processes that disconnected them from the work they needed to accomplish. In response, health professionals attempted to make the most of unsatisfactory eHealth systems and processes, but were still mostly unsuccessful in optimising the quality, efficiency, and client-centredness of their work.

Conclusions

Attention to sources of disconnection experienced by health professionals, specifically design of, and access to electronic health records, eHealth resourcing, and policies and procedures related to eHealth and interdisciplinary practice are required if the potential of eHealth for supporting interdisciplinary practice is to be realised.

Validation of the Chinese Version of the Revised Clinical Interview Schedule: Findings from Hong Kong Mental Morbidity Survey

This study aimed to assess the psychometric properties of the Chinese version of the Revised Clinical Interview Schedule (C-CIS-R), and explore its applicability as a diagnostic instrument for common mental disorders (CMDs) in Hong Kong. Its psychometric properties were evaluated among 140 patients and 161 healthy controls. In comparison to the diagnoses made by the Structured Clinical Interview for the DSM-IV, the C-CIS-R showed good criterion validity in diagnosing CMDs. The correlation of the total score of C-CIS-R with the 12-item General Health Questionnaire and Hospital Anxiety and Depression Scale was satisfactory, indicating favourable convergent validity as well. The inter-rater and test-retest reliability were also satisfactory. Receiver operating characteristic analyses suggested an optimal cut-off point of 11/12 for detecting diagnosable CMDs (sensitivity: 0.69; specificity: 0.93) and 17/18 for identifying a need for treatment (sensitivity: 0.70; specificity: 0.95). In conclusion, C-CIS-R is a valid diagnostic instrument for CMDs in a Chinese community. Its cut-off points for clinically significant symptoms and treatment needs among Chinese are identical to those adopted in the original English version.

The relationship between negative symptom subdomains and cognition

BACKGROUND

Negative symptoms and cognitive deficits in schizophrenia are partially overlapping. However, the nature of the relationship between negative symptoms and cognition remains equivocal. Recent reviews have demonstrated the presence of two negative symptom subdomains, diminished emotional expression (DEE) and avolition. In view of this, we sought to clarify the relationship between negative symptoms and cognitive domains.

METHOD

A total of 687 participants with schizophrenia were assessed on measures of psychopathology and cognition. Three cognitive factors, namely executive function, fluency/memory and speed/vigilance were computed from the cognitive tests. Confirmatory factor analysis was utilized to examine if a one-factor or two-factor negative model was applicable to our sample. Subsequently, the relationships between negative symptoms and cognition were examined using structural equation modeling.

RESULTS

Results demonstrated that the two-factor model fitted the data well. While negative symptoms were mildly to moderately associated with cognition, we found that DEE had unique associations with cognition compared to social avolition, contributing to the validity of the constructs and suggesting the possibility of common underlying substrates in negative symptoms and cognition.

CONCLUSIONS

Our study highlighted the need to classify DEE and social avolition separately as both are necessary in refining the complex relationship between negative symptoms and cognition as well as potentially guiding treatment and management of schizophrenia.

Oriented Division: Using T-Junctions to Determine Direction

Cell shape has long been thought to be the main cue for spindle positioning in mitotic cells, but new evidence suggests that, in the context of an epithelium, tricellular junctions encode positional information that helps orient mitotic spindles.

Emergence of homeostatic epithelial packing and stress dissipation through divisions oriented along the long cell axis

Cell division plays an important role in animal tissue morphogenesis, which depends, critically, on the orientation of divisions. In isolated adherent cells, the orientation of mitotic spindles is sensitive to interphase cell shape and the direction of extrinsic mechanical forces. In epithelia, the relative importance of these two factors is challenging to assess. To do this, we used suspended monolayers devoid of ECM, where divisions become oriented following a stretch, allowing the regulation and function of epithelial division orientation in stress relaxation to be characterized. Using this system, we found that divisions align better with the long, interphase cell axis than with the monolayer stress axis. Nevertheless, because the application of stretch induces a global realignment of interphase long axes along the direction of extension, this is sufficient to bias the orientation of divisions in the direction of stretch. Each division redistributes the mother cell mass along the axis of division. Thus, the global bias in division orientation enables cells to act collectively to redistribute mass along the axis of stretch, helping to return the monolayer to its resting state. Further, this behavior could be quantitatively reproduced using a model designed to assess the impact of autonomous changes in mitotic cell mechanics within a stretched monolayer. In summary, the propensity of cells to divide along their long axis preserves epithelial homeostasis by facilitating both stress relaxation and isotropic growth without the need for cells to read or transduce mechanical signals.

Refining the latent structure of neuropsychological performance in schizophrenia

BACKGROUND

Elucidating the cognitive architecture of schizophrenia promises to advance understanding of the clinical and biological substrates of the illness. Traditional cross-sectional neuropsychological approaches differentiate impaired from normal cognitive abilities but are limited in their ability to determine latent substructure. The current study examined the latent architecture of abnormal cognition in schizophrenia via a systematic approach.

METHOD

Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were carried out on a large neuropsychological dataset including the Brief Assessment of Cognition in Schizophrenia, Continuous Performance Test, Wisconsin Card Sorting Test, Benton Judgment of Line Orientation Test, and Wechsler Abbreviated Scale of Intelligence matrix reasoning derived from 1012 English-speaking ethnic Chinese healthy controls and 707 schizophrenia cases recruited from in- and out-patient clinics.

RESULTS

An initial six-factor model fit cognitive data in healthy and schizophrenia subjects. Further modeling, which accounted for methodological variance between tests, resulted in a three-factor model of executive functioning, vigilance/speed of processing and memory that appeared to best discriminate schizophrenia cases from controls. Factor analytic-derived g estimands and conventionally calculated g showed similar case-control discrimination. However, agreement analysis suggested systematic differences between both g indices.

CONCLUSIONS

Factor structures derived in the current study were broadly similar to those reported previously. However, factor structures between schizophrenia subjects and healthy controls were different. Roles of factor analytic-derived g estimands and conventional composite score g were further discussed. Cognitive structures underlying cognitive deficits in schizophrenia may prove useful for interrogating biological substrates and enriching effect sizes for subsequent work.

Reliability and validity of the Severity of Dependence Scale in a Chinese sample of treatment-seeking ketamine users

OBJECTIVE

Despite growing popularity of ketamine misuse in Asia, there is a lack of a validated instrument to measure the severity of ketamine dependence. Psychometric properties of Chinese Severity of Dependence Scale for ketamine (C-SDS-K) were examined in a sample of treatment-seeking ketamine users in Hong Kong.

METHODS

A total of 80 treatment-seeking ketamine users were recruited from 3 treatment centres. The C-SDS-K was administered to assess their severity of dependence on ketamine in the previous month. The diagnosis of their ketamine misuse as per the DSM-IV criteria, and the count of dependence criteria fulfilled in the previous month were determined by the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I).

RESULTS

The C-SDS-K showed high internal consistency (α = 0.74) and test-retest reliability (intraclass correlation coefficient = 0.95). Total score of C-SDS-K correlated positively with frequency (rs = 0.73, p < 0.001) and dose (rs = 0.89, p < 0.001) of ketamine use per week in the previous month, duration of regular ketamine use (rs = 0.28, p = 0.01), and the count of DSM-IV ketamine dependence criteria met in the previous month (rs = 0.84, p < 0.001). All items loaded strongly on a single factor (factor loading ≥ 0.60) in principal component analysis.

CONCLUSION

The findings support SDS as a reliable and valid tool for measuring the severity of dependence in the treatment-seeking population of Chinese ketamine users.

Deacetylation of the tumor suppressor protein PML regulates hydrogen peroxide-induced cell death

The promyelocytic leukemia protein (PML) is a tumor suppressor that is expressed at a low level in various cancers. Although post-translational modifications including SUMOylation, phosphorylation, and ubiquitination have been found to regulate the stability or activity of PML, little is known about the role of its acetylation in the control of cell survival. Here we demonstrate that acetylation of lysine 487 (K487) and SUMO1 conjugation of K490 at PML protein are mutually exclusive. We found that hydrogen peroxide (H₂O₂) promotes PML deacetylation and identified SIRT1 and SIRT5 as PML deacetylases. Both SIRT1 and SIRT5 are required for H₂O₂-mediated deacetylation of PML and accumulation of nuclear PML protein in HeLa cells. Knockdown of SIRT1 reduces the number of H₂O₂-induced PML-nuclear bodies (NBs) and increases the survival of HeLa cells. Ectopic expression of wild-type PML but not the K487R mutant rescues H₂O₂-induced cell death in SIRT1 knockdown cells. Furthermore, ectopic expression of wild-type SIRT5 but not a catalytic defective mutant can also restore H₂O₂-induced cell death in SIRT1 knockdown cells. Taken together, our findings reveal a novel regulatory mechanism in which SIRT1/SIRT5-mediated PML deacetylation plays a role in the regulation of cancer cell survival.