Consultants in Scotland: survey of educational qualifications, experience and needs of Scottish consultants

AIMS

To survey Scotland's NHS consultants regarding their teaching roles; educational qualifications/training; attitudes to educational qualifications; perceptions of health boards' attitudes to educational activities; usefulness of various educational courses and preferred delivery methods.

METHODS

Postal questionnaire (n=3615).

RESULTS

Sixty two percent response rate (n=2246). 98% had one or more roles in education/training. 54% spent more time in educational roles than job-plan allocations. 6% had educational qualifications. 30% rated educational qualifications valuable to their educational role; 21% to their career. 48% had not attended any educational training. 19% of respondents rated their health board as supportive of their educational activities. Respondents rated dealing with underperforming students (74%), dealing with challenging behaviour (63%), appraising students (63%), trainee assessment (61%) and feedback (58%) as the most useful topics.

CONCLUSIONS

Scottish consultant involvement in educational activities is virtually universal but consultants perceive they need more time than allocated in job plans. Most consultants had no teaching qualifications. Nearly half had no formal training for educational activities. Educational qualifications were valued by a minority regarding both career development and educational activities. Increased access to staff development for teaching is required as NHS sources are not meeting the need for teacher training of consultant staff.

The effect of education and home safety equipment on childhood thermal injury prevention: meta-analysis and meta-regression

OBJECTIVE

To evaluate whether home safety education and safety equipment provision increases thermal injury prevention practices or reduces thermal injury rates and whether the effect of interventions differs by social group.

METHODS

Systematic review and meta-analysis using individual participant data (IPD) evaluating home safety education with or without provision of free or discounted safety equipment provided to children or young people aged 0-19 years.

MAIN OUTCOME MEASURES

possession of functional smoke alarm, fitted fireguard and fire extinguisher; keeping hot drinks or food and keeping matches or lighters out of reach; having a safe hot water temperature and rate of medically attended thermal injuries.

RESULTS

Home safety interventions were effective in increasing the proportion of families with a functional smoke alarm (odds ratio (OR) 1.83, 95% CI 1.22 to 2.74) and with a safe hot tap water temperature (OR 1.35, 95% CI 1.01 to 1.80). There was some evidence they increased possession of fitted fireguards (OR 1.39, 95% CI 1.00 to 1.94), but there was a lack of evidence that interventions reduced medically attended thermal injury rates (incident rate ratio (IRR) 1.12, 95% CI 0.81 to 1.56). There was no consistent evidence that the effectiveness of interventions varied by social group.

CONCLUSIONS

Home safety education, especially with the provision of safety equipment, is effective in increasing some thermal injury prevention practices, but there is insufficient evidence to show whether this also reduces injury rates.

PIK3CA mutation analysis in recurrent breast cancer

11041

Background: Mutations in PIK3CA (encoding p110α catalytic subunit of phosphatidylinositol-3-kinase) are among the most common genetic events identified in breast cancer but the role of these mutations in determining the clinical course of the disease is uncertain. Furthermore the frequency of PIK3CA mutation in metastatic breast cancer samples has not been adequately studied but is an important concern in the design of studies with novel agents designed to inhibit mutant PIK3CA. Methods: We have established a tumor banking protocol for patients (pts) with metastatic breast cancer. In this study, we performed a mutational analysis of exons 9 (HD) and 20 (KD) of the PIK3CA using tumor DNA obtained from pts with recurrent disease and correlated mutational status with clinicopathological features and prognosis. Results: Biopsies were obtained from sites of recurrence in 51 pts with stage 4 disease. The median F/U was 44 (range: 0.9–239) months and death has occurred in 66%. Mutations in PIK3CA were identified in 24.5% (11.3% in HD and 13.2% in KD). PIK3CA mutation was significantly correlated with lower tumor grade (47% in grade 1/2 vs 8% in grade 3, p=0.004), positive ER (35% in ER+ vs 5% in ER-, p=0.017), and PR (37% in PR+ vs 5% in PR-, p=0.011). Overall survival (OS) was 139.5 and 53.7 months for mutation- and non-mutation- carriers respectively (p=0.014). Conclusions: About one quarter of pts with recurrent/advanced breast cancer carry PIK3CA mutations in samples of recurrent disease, which correlated with positive ER/PR status and a more indolent clinical course. These patients are good candidates for experimental protocols that combine endocrine agents with PI3 kinase inhibitors but the slower kinetics of disease progression in PIK3CA mutation carriers may have to be taken into account for statistical designs and power size calculations.

No significant financial relationships to disclose.

Communicating genetics research results to families: problems arising when the patient participant is deceased

OBJECTIVES

This study explores communication within families of clinically significant genetics research results, after the death of the patient participant. BRCA2 mutations were found in several men after their death from prostate cancer. Spouses were given the results in a genetic counselling session and asked to inform relatives.

METHODS

Cross-sectional, qualitative exploratory study. Interviews with 13 relatives, including informers and recipients of the information, were analysed using interpretative phenomenological analysis.

RESULTS

Dissemination was hampered when communication channels between relatives were limited, because of family rifts or socially distant or problematic relationships. When informing other branches of the family, relatives approached individuals in the generation of the deceased man, regardless of their risk status, who were then responsible for informing younger relatives. Most people informed by a relative did not seek genetic counselling. The informing relative may not have sufficient authority for the information either to be taken seriously or to challenge individual constructions about the aetiology of cancer. This impeded information transmission to further at-risk relatives. Most participants knew of relatives who had not been told about their cancer risk.

CONCLUSIONS

The implications of this limited efficiency of information transfer among relatives are discussed in the context of a potential role for genetics services in contacting at-risk relatives directly.

CORNA: testing gene lists for regulation by microRNAs

MOTIVATION

With the increasing use of post-genomics techniques to examine a wide variety of biological systems in laboratories throughout the world, scientists are often presented with lists of genes that they must make sense of. A consistently challenging problem is that of defining co-regulated genes within those gene lists. In recent years, microRNAs have emerged as a mechanism for regulating several cellular processes. In this article, we report on how gene lists and microRNA targets data may be integrated to test for significant associations between gene lists and microRNAs.

RESULTS

We discuss CORNA, a package written in R and released under the GNU GPL, which allows users to test gene lists for significant microRNA-target associations using one of three separate statistical tests, to link microRNA targets to functional annotation and to visualize quantitative data associated with those data.

AVAILABILITY

CORNA is available as an R package from http://corna.sf.net.

Detection of adverse events in a Scottish hospital using a consensus-based methodology

OBJECTIVE

To determine, using a consensus based methodology, the rate and nature of adverse events (AEs) among patients admitted to acute medicine, acute surgery and obstetrics in a large teaching hospital in Scotland.

METHODS

Retrospective case-note review of 450 medical, nursing and medication records to identify and classify adverse events. For 354 patients whose length of stay was greater than 24 hours, the overall adverse event rate was 7.9% which ranged from 0% in obstetrics, 7.2% in acute medicine to 13% in acute surgery. Among all AEs, 43% were deemed preventable by a consensus group and 59% of the AEs contributed to a proportion of the patients' hospital stay or led to hospital readmission. Whilst nurse identification of adverse events was highly specific (94%), its sensitivity was poor (43%). Only 10% of the identified AEs were identified by the hospital's voluntary reporting system for adverse events. The estimated additional cost of adverse events in terms of bed days was ł69,189 which if extrapolated Scotland-wide could cost ł297 million per annum.

CONCLUSIONS

This study supports the need to continue the traditional retrospective record review to identify adverse events. The current hospital-based reporting of adverse events does not provide a complete measure of adverse events and needs to be complemented by other measures.

TWIST1 and PITX2 expression in bone marrow of women with clinical stage II/III breast cancer identifies patients at risk for the development of early metastatic disease

Abstract #108

Background: The presence of disseminated tumor cells (DTCs) in bone marrow of women with newly diagnosed breast cancer has been associated with increased risk of recurrent disease development. We have previously described a 67-gene signature associated with the presence of DTCs using gene array analysis after immunomagnetic enrichment of these cells and found that the expression of one of the 67-genes in bone marrow of breast cancer patients, TWIST1, correlated with the development of early recurrent disease. We have now tested the remaining genes in the 67-gene signature for correlation with the development of recurrent disease. Our goal is to identify genes associated with DTCs with high metastatic potential for early detection and intervention.
 Methods: Expression of each of the 67 genes was analyzed using qRT-PCR in a breast cancer cell lines (MCF7, SKBR3, MDA/MB 231) diluted into normal human bone marrow at varying concentrations. Levels of expression in the breast cancer cells and in human bone marrow were quantitated. Genes with high expression in breast cancer cell lines and no observed expression in normal human bone marrow were further tested by qRT-PCR for expression in a validation set of bone marrows comprised of 50 specimens collected from 30 patients with clinical stage II/III breast cancer prior to any treatment. Thirteen of these patients developed recurrent disease within 16 months.
 Results: Within the 67 gene signature, 5 genes were identified that were highly expressed in breast cancer cell lines and had no detectable expression in normal human bone marrow. Expression of the 5 genes as well as keratin 19 were examined in the validation set of bone marrows. PITX2 was expressed in the bone marrow of 5 of the 13 patients who recurred within one year. Only expression of TWIST1 and PITX2 were found to correlate with the time to development of early recurrent disease (p <0.0001 and 0.0002 respectively).
 Conclusion: We have found that the expression of TWIST1 and PITX2 in the bone marrow of breast cancer patients prior to any treatment identifies patients at risk of early distant disease recurrence. These genes are not expressed in normal human bone marrow. Both are transcription factors involved in the embryonic development and appear to be expressed by DTCs with high metastatic potential. Expression of TWIST1 and PITX2 may prove to be excellent markers for identifying women at high risk for distant relapse and lead to new targets for chemotherapeutic intervention.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 108.

Burden of cervical cancer in the United States, 1998-2003

BACKGROUND

Recent interest in human papillomavirus (HPV)-associated cancers and the availability of several years of data covering 83% of the US population prompted this descriptive assessment of cervical cancer incidence and mortality in the US during the years 1998 through 2003. This article provides a baseline for monitoring the impact of the HPV vaccine on the burden of cervical cancer over time.

METHODS

Data from 2 federal cancer surveillance programs, the Centers for Disease Control and Prevention (CDC)'s National Program of Cancer Registries and the National Cancer Institiute's Surveillance, Epidemiology, and End Results Program, were used to examine cervical cancer incidence by race, Hispanic ethnicity, histology, stage, and US census region. Data from the CDC's National Center for Health Statistics were used to examine cervical cancer mortality by race, Hispanic ethnicity, and US census region.

RESULTS

The incidence rate of invasive cervical cancer was 8.9 per 100,000 women during 1998 through 2003. Greater than 70% of all cervical carcinomas were squamous cell type, and nearly 20% were adenocarcinomas. Cervical carcinoma incidence rates were increased for black women compared with white women and for Hispanic women compared with non-Hispanic women. Hispanic women had increased rates of adenocarcinomas compared with non-Hispanic women. The South had increased incidence and mortality rates compared with the Northeast.

CONCLUSIONS

Disparities by race/ethnicity and region persist in the burden of cervical cancer in the US. Comprehensive screening and vaccination programs, as well as improved surveillance, will be essential if this burden is to be reduced in the future.

Using population-based cancer registry data to assess the burden of human papillomavirus-associated cancers in the United States: overview of methods

Increased attention to human papillomavirus (HPV)-associated cancers in light of the recent release of an HPV vaccine, as well as increased availability of cancer registry data that now include reporting from a large proportion of the US population, prompted the current assessment of HPV-associated cancers. This article describes methods used to assess the burden of HPV-associated cervical, vulvar, vaginal, penile, anal, and oral cavity/oropharyngeal cancers in the United States during 1998 through 2003 using cancer registry data, and it provides a brief overview of the epidemiology of these cancers.

Incidence of in situ and invasive vulvar cancer in the US, 1998-2003

BACKGROUND

The human papillomavirus (HPV) vaccine has been shown to prevent precancerous lesions of the vulva with the potential to prevent a percentage of vulvar cancers. To provide a baseline picture before HPV vaccine implementation, the authors described vulvar cancer epidemiology by age, race, ethnicity, and histology in the US.

METHODS

The authors examined incidence data from 39 population-based cancer registries that met high-quality data standards from 1998 to 2003, covering approximately 83% of the US population. They limited their analysis to in situ and invasive vulvar squamous cell carcinomas (SCCs). In situ vulvar cancers did not include vulvar intraepithelial neoplasia type 3 (VIN 3).

RESULTS

SCC accounted for 77% of in situ cases and 75% of invasive vulvar cancers, an annual burden of 1498 in situ and 2266 invasive SCC vulvar cancers. Greater than 75% of the in situ and invasive SCCs had no specific histology identified. White women had the highest rates of vulvar cancer; the incidence rates of invasive vulvar SCC among black women and Hispanic women were approximately one-third lower than for their counterparts (white women and non-Hispanic women, respectively). For women aged <50 years, the age-specific rates of invasive SCC were approximately the same among whites and blacks. Increases in rates after age 50 years, however, were noted to be more rapid among white than among black women.

CONCLUSIONS

Distinct age-specific incidence rate patterns of invasive vulvar SCC by race and ethnicity and the higher incidence rates observed among white women compared with women of other races and ethnicities were opposite to patterns noted for cervical cancer. Underestimations of the burden of in situ vulvar cancers were a result of the inability to examine VIN 3 in the authors' data. Encouragement of cancer registries to report and submit VIN 3 data and more research on data quality will allow a thorough assessment of the impact of HPV vaccine by providing a basis for examining the true burden and quality of these precancerous vulvar tumors. Increased documentation of histologic subtypes in pathology reports and in cancer registry data can help differentiate the burden ofHPV-associated types from non-HPV-associated types of vulvar cancers.

The use of cognitive behavioural therapy techniques for anxiety and depression in hospice patients: a feasibility study

Anxiety and depression are common in palliative care patients. Cognitive behavioural therapy (CBT) has been recommended as one possible treatment, and it has been suggested that non-mental health professionals may be able to treat milder disorders with CBT. The aim of this study was to assess whether the use of CBT techniques in hospice patients is an acceptable intervention, and whether a palliative care professional with short CBT training can usefully apply such techniques. A feasibility study of a brief CBT intervention following training was conducted. Qualitative analysis was carried out on patient feedback from semi-structured interviews. Hospital Anxiety and Depression Scale scores pre-and post-intervention were analysed statistically. Eleven patients completed a short course using CBT techniques. The intervention was acceptable for 10 patients. One patient found it unacceptable due to advanced disease, lethargy and severe depression. Anxiety or depression symptoms were helped in eight patients. This study showed that a palliative care professional with short training in CBT was usefully able to apply CBT techniques to hospice patients with mild-to-moderate anxiety or depression.

Effect of education and safety equipment on poisoning-prevention practices and poisoning: systematic review, meta-analysis and meta-regression

OBJECTIVE

To assess (a) the effect of home safety education and the provision of safety equipment on poison-prevention practices and poisoning rates, and (b) whether the effect of interventions differs by social group.

DATA SOURCES

Medline, Embase, Cinahl, ASSIA, Psychinfo, Web of Science, plus other electronic sources and hand searching of conference abstracts and reference lists. Authors of included studies were asked to supply individual participant data.

REVIEW METHODS

Randomised controlled trials, non-randomised controlled trials and controlled before-and-after studies, with participants aged </=19 years, providing home safety education with or without free or subsidised safety equipment and reporting poison-prevention practices or poisoning incidents were included. Pooled odds ratios and pooled rate ratios were estimated, and meta-regression estimated intervention effects by child age, gender and social variables.

RESULTS

Home safety interventions increased safe storage of medicines (OR 1.57, 95% CI 1.22 to 2.02) and cleaning products (OR 1.63, 95% CI 1.22 to 2.17), the possession of syrup of ipecac (OR 3.34, 95% CI 1.50 to 7.41), and having poison control centre numbers accessible (OR 3.67, 95% CI 1.84 to 7.33). There was a lack of evidence on poisoning rates (rate ratio 1.03, 95% CI 0.78 to 1.36) and no consistent evidence that intervention effects differed by child age, gender or social group.

CONCLUSIONS

Home safety education and the provision of safety equipment improve poison-prevention practices, but the impact on poisoning rates is unclear. Such interventions are unlikely to widen inequalities in childhood poisoning-prevention practices.

Finite element modelling of the Ilizarov external fixation system

This study describes a computational method for predicting the mechanical response of any configuration of the Ilizarov external fixation system. Mechanical testing of each of the individual components (ring, threaded rod, and wire) of the Ilizarov system was used to determine the stiffness of each component. Finite element (FE) analysis was then used to model each of the individual components. Each model was tuned to match the mechanical testing. A modular FE modelling system, using a master input file, was then developed where the tuned FE models of the individual components could be generated, positioned, and interconnected to replicate a range of fixator configurations. The results showed that the stiffness predications from the FE modelling of the fixator configurations were consistently 10 per cent higher than the stiffness values obtained from the mechanical testing. The FE modelling system can be used to predict the characteristic response of the fixator configurations and clearly shows the relative changes in that response for variations in the number of components used.

Upregulation of protein S by progestins

BACKGROUND

Users of progestin-only contraceptives have raised protein S (PS) levels compared with baseline. This contrasts with the reduction in PS levels observed in users of combined oral contraceptives, which contain both a progestin and an estrogen.

OBJECTIVES

To determine the effect of progesterone and other progestin isoforms on the expression of PS and to describe the mechanism involved.

METHODS

Promoter activity of the PROS1 gene that encodes PS was assessed in vitro using breast and liver carcinoma cell lines grown in the presence of various progestins, with and without the addition of excess progesterone receptors. An electromobility shift assay (EMSA) was also performed to identify the progesterone receptor binding element.

RESULTS

PROS1 transcriptional levels were directly upregulated by 25% by progesterone via a mechanism that was progesterone receptor isoform B (PR-B)-dependent. The process was blocked by the progesterone receptor modulator RU486. Results for the EMSA demonstrated that a probe comprising nucleotides -397 to -417 of the PROS1 promoter bound to ligand-activated PR-B, suggesting that the domain is a progesterone response element (PRE). The type of progestin isoform greatly influenced the level of PROS1 promoter upregulation, with medroxyprogesterone able to stimulate a > 2-fold stronger response compared with progesterone.

CONCLUSIONS

The PROS1 promoter is responsive to progesterone and other progestins via a mechanism involving PR-B interacting with a PRE. The type of progestin is important as some elicit stronger upregulatory effects than others, which may influence the choice of progestin used for hormonal contraception by PS-deficient individuals.

Oral versus intra-vaginal imidazole and triazole anti-fungal treatment of uncomplicated vulvovaginal candidiasis (thrush)

BACKGROUND

Anti-fungals are available for oral and intra-vaginal treatment of uncomplicated vulvovaginal candidiasis (thrush).

OBJECTIVES

The primary objective of this review was to assess the relative effectiveness of oral versus intra-vaginal anti-fungals for the treatment of uncomplicated vulvovaginal candidiasis. The secondary objectives of the review were to assess the cost-effectiveness, safety and patient preference of oral versus intra-vaginal anti-fungals.

SEARCH STRATEGY

The following sources were searched for the original review: The Cochrane Library (Issue 4, 1999), MEDLINE (January 1985 to May 2000), EMBASE (January 1980 to January 2000) and the Cochrane Sexually Transmitted Disease (STD) Group Specialised Register of Controlled Trials. The manufacturers of anti-fungals available in the UK were contacted. For the update, CENTRAL (January 2000 to August 2006), PUBMED (January 2000 to August 2006), EMBASE (January 2000 to August 2006) and the Cochrane STD Group Specialised Register were searched in August 2006. The reference lists of retrieved articles were reviewed manually.

SELECTION CRITERIA

Randomised controlled trials published in any language. Trials had to compare at least one oral anti-fungal with one intra-vaginal anti-fungal. Women (aged 16 years or over) with uncomplicated vulvovaginal candidiasis. The diagnosis of vulvovaginal candidiasis to be made mycologically (i.e. a positive culture and / or microscopy for yeast). Trials were excluded if they solely involved subjects who were HIV positive, immunocompromised, pregnant, breast feeding or diabetic. The primary outcome measure was clinical cure.

DATA COLLECTION AND ANALYSIS

Two reviewers screened titles and abstracts of the electronic search results and full text of potentially relevant papers. Independent duplicate abstraction was performed by two reviewers. Disagreements regarding trial inclusion or data abstraction were resolved by discussion between the reviewers. Odds ratios were pooled using the fixed effects models (except for two analyses when random effects models were used because of potentially important heterogeneity).

MAIN RESULTS

Two new trials reporting three comparisons were found in the update. Nineteen trials are included in the review, reporting 22 oral versus intra-vaginal anti-fungal comparisons. No statistically significant differences were shown between oral and intra-vaginal anti-fungal treatment for clinical cure at short term (OR 0.94, 95% CI, 0.75 to 1.17) and long term (OR 1.07, 95% CI, 0.82 to 1.41) follow-up. No statistically significant differences for mycological cure were observed between oral and intra-vaginal treatment at short term (OR 1.15, 95% CI, 0.94 to 1.42). There was a statistically significant difference for long term follow-up (OR 1.29, 95% CI, 1.05 to 1.60) in favour of oral treatment, however the clinical significance of this result is uncertain. Two trials each reported one withdrawal from treatment due to an adverse reaction. Treatment preference data were poorly reported.

AUTHORS' CONCLUSIONS

No statistically significant differences were observed in clinical cure rates of anti-fungals administered by the oral and intra-vaginal routes for the treatment of uncomplicated vaginal candidiasis. No definitive conclusion can be made regarding the relative safety of oral and intra-vaginal anti-fungals for uncomplicated vaginal candidiasis. The decision to prescribe or recommend the purchase of an anti-fungal for oral or intra-vaginal administration should take into consideration: safety, cost and treatment preference. Unless there is a previous history of adverse reaction to one route of administration or contraindications, women who are purchasing their own treatment should be given full information about the characteristics and costs of treatment to make their own decision. If health services are paying the treatment cost, decision-makers should consider whether the higher cost of some oral anti-fungals is worth the gain in convenience, if this is the patient's preference.

Administration of hepatitis A vaccine at 6 and 12 months of age concomitantly with hexavalent (DTaP-IPV-PRP approximately T-HBs) combination vaccine

BACKGROUND

Administration of two doses of hepatitis A (HA) vaccine to children > or = 2 years of age has been shown to be protective. The present study assessed whether HA vaccine can be administered as early as 6 months of age and whether it can be administered concomitantly with a hexavalent (HV) vaccine at this age.

METHODS

In an open label, randomized, parallel group study, the liquid HV vaccine (HEXAVAC) (diphtheria, tetanus, 2-component acellular pertussis, inactivated poliomyelitis vaccine, Haemophilus influenzae type b conjugated to tetanus protein and hepatitis B) was administered at 2, 4, 6, and 12 months of age to all children. HA vaccine (VAQTA) was given at 7 and 13 months in the separate administration group (Group 1) and at 6 and 12 months in the concomitant administration group (Group 2). Serum samples were obtained at 2, 7, 12, and 14 months in Group 1 and at 2, 7, 12, and 13 months in Group 2. The primary immunogenicity outcomes were the seroconversion rates for HA 1 month after the second dose of HA vaccine in initially seronegative subjects, and the seroconversion rates for each HV antigen 1 month after the third dose of the HV vaccine (both at 7 months of age).

RESULTS

HA seropositivity rates 1 month after the second dose were 100% in both groups, regardless of initial serostatus. The responses to each HV antigen 1 month after the third dose were similar in both groups. The vaccines were generally well tolerated in both groups regardless of vaccine(s) administered.

CONCLUSIONS

A schedule of two doses of HA vaccine, 6 months apart beginning at 6 months of age is highly immunogenic and well tolerated when administered alone or concomitantly with HV vaccine at 6 and 12 months of age.

WITHDRAWN: Non-aspirin, non-steroidal anti-inflammatory drugs for treating osteoarthritis of the knee

BACKGROUND

Osteoarthritis(OA) is the most common rheumatic disease. Simple analgesics are now accepted as the appropriate first line pharmacological treatment of uncomplicated OA. Non-aspirin NSAIDs are licensed for the relief of pain and inflammation arising from rheumatic disease.

OBJECTIVES

To determine whether there is a difference in the relative efficacy of individual non-steroidal anti-inflammatory drugs (NSAIDs) when used in the management of osteoarthritis (OA) of the knee.

SEARCH STRATEGY

We searched Medline (1966-1995) and Bids Embase (Jan-Dec, 1980-1995). The searches were limited to publications in the English language, and were last performed in November 1996. We used modified Cochrane Collaboration search strategy to identify all randomised controlled trials. The MeSH heading "osteoarthritis" was combined with the generic names of the 17 non-aspirin NSAIDs licensed in the UK for the management of OA in general practice. The search of Embase used the term "osteoarthritis" if present in the abstract, title or keywords, and was combined with the generic names of the 17 non-aspirin NSAIDs, only if they were mentioned in the title, abstract or keywords.

SELECTION CRITERIA

All double blind, randomised controlled trials, in the English language, comparing the efficacy of two non-aspirin NSAIDs in the management of osteoarthritis of the knee, were selected. Only trials with subjects aged 16 years and over, with clinical and/or radiological confirmation of the diagnosis of OA knee were included. Studies which compared one "trial" NSAID with one "reference" NSAID were included provided they were non-aspirin NSAIDs available in the UK and were licensed for the treatment of OA by general practitioners. Trials which were placebo-controlled and which also involved the comparison of two NSAIDs were also included.

DATA COLLECTION AND ANALYSIS

The methodological design of each study was scored according to a pre-determined system. The three main outcome measures of pain, physical function and patient global assessment were chosen based on the core set agreed upon by OMERACT (Outcome Measures in Rheumatology Clinical Trials). These were used to determine the power of each trial. The equivalency of NSAID doses was calculated using the percentage of the recommended maximum daily dose. Sample size estimates for the detection of clinically relevant changes in outcome measures used in the assessment of OA knee were used for power calculations. These calculations were performed to determine whether the trials were of a sufficient size to detect clinically relevant differences which were statistically significant. The calculations incorporate estimates of standard deviation, and minimum, median and maximum differences (delta) between drugs which are deemed to be clinically important. The number of "withdrawals due to lack of efficacy" was also selected as an outcome measure for this review. The Peto odds ratio and 95% confidence intervals were calculated where possible. The results of studies which compared the same trial and reference NSAIDs were combined where possible.

MAIN RESULTS

Of the 1151 trials identified by the search strategy, 22 involved knee osteoarthritis only. Sixteen of these trials fulfilled the inclusion criteria and were entered in the review. Eight NSAIDs were represented in these trials. Etodolac was represented in 11 trials. The reference NSAID in these trials was piroxicam (n=3), naproxen(n=3), diclofenac (n=3), indomethacin (n=1), and, nabumetone (n=1). The reported methodological design of the trials was poor, with a median score of 3 (out of a maximum of 8). The results of the trials comparing the same trial and reference NSAIDs were pooled for the outcome "withdrawal due to lack of efficacy". For the comparison, etodolac versus piroxicam, the odds ratio favoured etodolac i.e. patients receiving etodolac were less likely to withdraw due to lack of efficacy. The dose of etodolac used in each of these three studies, however, was greater than the corresponding dose of piroxicam (based on percentage maximum daily dose). The significance of these results is therefore questionable. For the comparisons etodolac versus diclofenac, and etodolac versus naproxen, there were no clear differences between treatments. In one study [Bellamy 1993], a statistically significant difference was detected between treatments with regard to withdrawals due to lack of efficacy. In this trial, which compared equivalent NSAID doses, diclofenac was the favoured NSAID compared to tenoxicam(p=0.04). Two studies showed a statistical difference in patient global assessment of condition, which favoured the trial NSAID. In both cases the trial NSAID was etodolac, used in doses approximately 25-44% greater than the reference NSAID. Two studies showed a statistically significant difference in pain relief between NSAIDs. The trial NSAID in both cases was again etodolac but the doses exceeded those of the reference NSAIDs.

AUTHORS' CONCLUSIONS

In spite of the large number of publications in this area, there are few randomized controlled trials. Furthermore, most trials comparing two or more NSAIDs suffer from substantial design errors. From the results of this review it is concluded that no substantial evidence is available related to efficacy, to distinguish between equivalent recommended doses of NSAIDs. Had studies employed appropriate doses of comparator drug, most would have been sufficiently powerful to detect clinically important differences in efficacy. As differences in efficacy between NSAIDs have not been recorded, the selection of an NSAID for prescription for OA knee should be based upon relative safety, patient acceptability and cost.

Use of tumor gene expression signatures and drug-induced changes to discriminate early response in human breast cancer

2524

Background: To elucidate the genomics of tumor responses to different classes of chemotherapy, we analyzed breast cancer gene expression before and after in vivo treatment with adriamycin or docetaxel. Methods: Tumor biopsies were obtained before and 3 weeks after one chemotherapy cycle and tumor RNA amplified and hybridized on the Affymetrix HG-U133+2 array containing 33,000 genes. Results: Pre- and post-treatment tumors from 46 chemonaive patients with unresectable breast cancers were studied, of which 24 and 22 respectively received adriamycin and docetaxel in the first cycle, and 14 in each group had early response sensitive tumors (=25% shrinkage after 1 cycle). Comparison of our baseline gene signatures with drug-specific panels generated in vitro (Nevins, Nat Med 2006,12:1294) revealed 12 and 2 common genes (p<0.05) that predicted for adriamycin and docetaxel response respectively, with the 12 common adriamycin-response gene panel correctly predicting response in 76% of patients. Analysis of the relative change in tumor gene expression (ratio of post- and pre-treatment differential values to pre-treatment values) in our dataset revealed adriamycin to up- or down- regulate 209 transcripts (p<0.005) including genes that encode for nuclear protein, cell cycle regulation, aminopeptidases, and Ankyrin repeats, while docetaxel up- or down-regulated 469 transcripts (p<0.005) including genes that encode for extracellular matrix, transmembrane signaling, endocytosis, EGF-like calcium binding, tubulin and actin binding functions. Adriamycin and docetaxel concordantly up- or down-regulated 269 transcripts (p<0.01) that may be common response markers, including genes involved in cell cycle proliferation, mitosis, DNA damage, and carboxypeptidase activities. Adriamycin and docetaxel differentially induced 92 transcripts (p<0.01) that distinguished between the two drugs with 96% accuracy. 27 adriamycin- and 100 docetaxel-induced transcripts (p<0.005) predicted response to each drug with >90% accuracy. Conclusions: Drug-specific genomic changes can predict clinical response, and may yield insights to targets to overcome drug resistance.

No significant financial relationships to disclose.

Disclosure of genetics research results after the death of the patient participant: a qualitative study of the impact on relatives

When a gene mutation is identified in a research study following the death of the study participant, it is not clear whether such information should be made available to relatives. We report here an evaluation of the impact on relatives of being informed of study results that detected pathogenic BRCA2 mutations in a male relative, now deceased, who had early onset (under the age of 55) prostate cancer. The breast and ovarian cancer risk was unknown to the living relatives. Qualitative analysis of interviews with thirteen relatives indicated that those who had a higher risk perception, resulting from an awareness of cancer family history or experiential knowledge of cancer in their family, tended to adjust more easily to the results. All participants believed that genetics research results of clinical significance should be fed back to relatives. Those who were fully aware of the BRCA2 results and implications for themselves felt they had benefited from the information, irrespective of whether or not they had elected for genetic testing, because of the consequent availability of surveillance programs. Initial anxiety upon learning about the BRCA2 result was alleviated by genetic counselling. Factors influencing those who have not engaged with the information included scepticism related to the relative who attempted to inform them, young age and fear of cancer. Those who had not sought genetic counselling did not attempt further dissemination, and some were not undergoing regular screening. Implications for informed consent in genetics research programs, and the requirement for genetic counselling when research results are disclosed, are discussed.

Predictive genetic testing for BRCA1/2 in a UK clinical cohort: three-year follow-up

This prospective multicentre study assesses long-term impact of genetic testing for breast/ovarian cancer predisposition in a clinical cohort. Areas evaluated include risk management, distress and insurance problems 3 years post-testing. Participants are adults unaffected with cancer from families with a known BRCA1/2 mutation. One hundred and ninety-three out of 285 (70% response) participants at nine UK clinical genetics centres completed assessments at 3 years: 80% female; 37% carriers of a BRCA1/2 mutation. In the 3 years, post-genetic testing carriers reported more risk management activities than non-carriers. Fifty-five per cent of female carriers opted for risk reducing surgery; 43% oophorectomy; and 34% mastectomy. Eighty-nine per cent had mammograms compared with 47% non-carriers. Thirty-six per cent non-carriers > or =50 years did not have a mammogram post-test. Twenty-two per cent male carriers had colorectal and 44% prostate screening compared with 5 and 19% non-carriers respectively. Seven per cent carriers and 1% non-carriers developed cancer. Distress levels did not differ in carriers and non-carriers at 3-year follow-up. Forty per cent of female carriers reported difficulties with life and/or health insurance. Given the return to pre-test levels of concern among female non-carriers at 3 years and a substantial minority not engaging in recommended screening, there appears to be a need to help some women understand the meaning of their genetic status.

Home safety education and provision of safety equipment for injury prevention

BACKGROUND

In industrialised countries injuries are the leading cause of childhood death and steep social gradients exist in child injury mortality and morbidity. The majority of injuries in pre-school children occur at home, but there is little meta-analytic evidence that child home safety interventions improve a range of safety practices or reduce injury rates and little evidence on their effect by social group.

OBJECTIVES

We evaluated the effectiveness of home safety education, with or without the provision of low cost, discounted or free equipment in increasing home safety practices or reducing child injury rates and whether the effect varied by social group.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, CINAHL, DARE, ASSIA, Psychinfo and Web of Science, plus a range of relevant web sites, conference proceedings and bibliographies. We contacted authors of included studies and surveyed a range of organisations.

SELECTION CRITERIA

Randomised controlled trials (RCTs), non-randomised controlled trials and controlled before and after studies where home safety education with or without the provision of safety equipment was provided to those aged 19 years and under, which reported safety practices, possession of safety equipment or injury.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. We attempted to obtain individual participant level data (IPD) for all included studies and summary data and IPD were simultaneoulsy combined in meta-regressions by social and demographic variables.

MAIN RESULTS

Eighty studies were included; 37 of which were included in at least one meta-analysis. Twenty-three (62%) were RCTs and 12 (32%) included in the meta-analysis provided IPD. Home safety education was effective in increasing the proportion of families with safe hot tap water temperatures (OR 1.35, 95% CI 1.01 to 180), functional smoke alarms (OR 1.85, 95% CI 1.24 to 2.75), storing medicines (OR 1.58, 95% CI 1.18 to 2.13) and cleaning products (OR 1.63, 95% CI 1.22 to 2.17) out of reach, syrup of ipecac (OR 3.34, 95% CI 1.50 to 7.44) and poison control centre numbers accessible (OR 3.66, 95% CI 1.84 to 7.27), fitted stair gates (1.26, 95% CI 1.05 to 1.51), socket covers on unused sockets (OR 3.73, 95% CI 1.48 to 9.39) and storing sharp objects out of reach (OR 1.52, 95% CI 1.01 to 2.29). There was a lack of evidence that interventions reduced rates of thermal injuries, poisoning or a range of injuries. There was no consistent evidence that interventions were less effective in families whose children were at greater risk of injury.

AUTHORS' CONCLUSIONS

Home safety education provided most commonly as one-to-one, face-to-face education, in a clinical setting or at home, especially with the provision of safety equipment is effective in increasing a range of safety practices. There is a lack of evidence regarding its impact on child injury rates. There was no consistent evidence that home safety education, with or without the provision of safety equipment was less effective in those at greater risk of injury.

The EORTC QLQ-HDC29: A supplementary module assessing the quality of life during and after high-dose chemotherapy and stem cell transplantation

High-dose chemotherapy followed by haematopoietic stem cell transplantation can be associated with high physical and emotional distress levels and reduced quality of life. Systematic prospective measurement of impact of therapy on patient quality of life can aid treatment choices and provide better patient information. We describe the development of a high-dose chemotherapy questionnaire module to supplement the European Organisation for Research and Treatment of Cancer Core Questionnaire (EORTC QLQ-C30). Phases 1-3 of module development were conducted in United Kingdom, Germany, Austria and Norway, according to EORTC QOL Group guidelines. Forty-eight quality of life (QOL) issues were generated from the literature searches and interviews with health care professionals (n=24) and patients (n=92). This produced a 50 item provisional module. Further testing in 169 patients resulted in the QLQ-HDC29 module, containing 29 items, conceptualised into six multi-item scales and eight single items. The EORTC QLQ-C30, supplemented by QLQ-HDC29 will provide a comprehensive QOL measure for the international clinical trials of high-dose chemotherapy.

Preptin, another peptide product of the pancreatic beta-cell, is osteogenic in vitro and in vivo

Several hormones that regulate nutritional status also impact on bone metabolism. Preptin is a recently isolated 34-amino acid peptide hormone that is cosecreted with insulin and amylin from the pancreatic beta-cells. Preptin corresponds to Asp(69)-Leu(102) of pro-IGF-II. Increased circulating levels of a pro-IGF-II peptide complexed with IGF-binding protein-2 have been implicated in the high bone mass phenotype observed in patients with chronic hepatitis C infection. We have assessed preptin's activities on bone. Preptin dose-dependently stimulated the proliferation (cell number and DNA synthesis) of primary fetal rat osteoblasts and osteoblast-like cell lines at periphysiological concentrations (>10(-11) M). In addition, thymidine incorporation was stimulated in murine neonatal calvarial organ culture, likely reflecting the proliferation of cells from the osteoblast lineage. Preptin did not affect bone resorption in this model. Preptin induced phosphorylation of p42/p44 MAP kinases in osteoblastic cells in a dose-dependent manner (10(-8)-10(-10) M), and its proliferative effects on primary osteoblasts were blocked by MAP kinase kinase inhibitors. Preptin also reduced osteoblast apoptosis induced by serum deprivation, reducing the number of apoptotic cells by >20%. In vivo administration of preptin increased bone area and mineralizing surface in adult mice. These data demonstrate that preptin, which is cosecreted from the pancreatic beta-cell with amylin and insulin, is anabolic to bone and may contribute to the preservation of bone mass observed in hyperinsulinemic states such as obesity.

Cytokine expression profiles of bovine lymph nodes: effects of Mycobacterium bovis infection and bacille Calmette-Guérin vaccination

Cytokine expression in lymph nodes from cattle inoculated intranasally with Mycobacterium bovis was compared to that of non-infected animals using real-time polymerase chain reaction. The effect of M. bovis infection, 4 months post-challenge, was to suppress the expression of anti-inflammatory cytokines interleukin (IL)-4 and IL-10 as well as the pro-inflammatory cytokines tumour necrosis factor (TNF) and IL-6. Expression of interferon (IFN)-gamma and IL-12 was maintained. Animals vaccinated with bacille Calmette-Guérin responded differently to challenge with M. bovis. In particular, no decrease in expression of IL-4 or IL-6 was observed following challenge of vaccinated animals and decreased IFN-gamma was detected. Also, vaccinated animals had higher levels of IL-4 and IL-10 transcripts compared to unvaccinated animals following challenge. These changes in cytokine expression levels led to a significant shift in the IFN-gamma/IL-4 or IFN-gamma/IL-10 ratio within the lymph node following challenge. Challenged animals generally showed a strong Th1 bias that was not seen in animals vaccinated prior to challenge. An inverse correlation between the level of pathology and bacterial load within the lymph node and the expression of IL-4, IL-10 and TNF was also observed. These results suggest that in the lymph nodes of cattle with established tuberculosis and a persisting bacterial infection, maintenance of the pro-inflammatory response in combination with a suppressed anti-inflammatory response may control the infection but contribute to host-induced tissue damage. Vaccination, which reduces the bacterial load and consequently the IFN-gamma response, may result in less suppression of anti-inflammatory cytokines.

Reversal of adverse effects of neoadjuvant chemotherapy on bone turnover in pre- and post-menopausal women with zoledronic acid

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Background: Ovarian failure secondary to adjuvant chemotherapy is known to have an adverse effect on bone mineral density and to increase bone turnover markers. The effects of chemotherapy with growth factor support in the absence of hormonal changes have not been described. The impact of zoledronic acid on these changes was also explored. Methods: We evaluated bone turnover markers in 82 women undergoing neoadjuvant chemotherapy for localized stage II/III breast cancer at initial diagnosis prior to treatment and after 4 cycles of epirubicin (75mg/m2)-docetaxel (75mg/m2) with pegylated G-CSF support with or without zoledronic acid. 47% of patients were post-menopausal and all groups were balanced for other variables. Women were randomized to receive zoledronic acid 4 mg IV every 3 weeks concurrently with chemotherapy (n=41) versus no bisphosphonate treatment (n=41). Bone turnover markers included: urinary N-telopeptide (NTx), serum bone specific alkaline phosphatase (BAP)and osteocalcin (OSTEO). Results: Women, regardless of menopausal status, who received no bisphosphonate had statistically significant increases in NTx, from baseline after 3 months of neoadjuvant chemotherapy using multivariable mixed repeated measures (p=0.0213). Women who received zoledronic acid concurrently with neoadjuvant chemotherapy had statistically significant decreases in NTx (p<0.0001), BAP (p<0.0001) and OSTEO (p=0.0295) from baseline. This is the first demonstration that anthracycline-taxane chemotherapy with growth factor support increased bone turnover markers in both post-menopausal and pre-menopausal women independent of hormone therapy, radiation therapy and surgery. Conclusions: Neoadjuvant chemotherapy with anthracycline- taxane and growth factor support increased bone resorption markers in both post-menopausal and pre-menopausal women. Zoledronic acid given concurrently with each cycle of chemotherapy reversed this increase in bone turnover markers.

No significant financial relationships to disclose.

Lactoferrin and bone; structure–activity relationshipsThis paper is one of a selection of papers published in this Special Issue, entitled 7th International Conference on Lactoferrin: Structure, Function, and Applications, and has undergone the Journal's usual peer review process

The maintenance of the mechanical integrity of the skeleton depends on bone remodeling, the well-coordinated balance between bone formation by osteoblasts and bone resorption by osteoclasts. The coupled action of osteoblasts and osteoclasts is regulated by the action of many local and circulating hormones and factors as well as central regulation by a neurological mechanism. We have previously shown that lactoferrin can promote bone growth. At physiological concentrations, lactoferrin potently stimulates the proliferation and differentiation of primary osteoblasts and acts as a survival factor. Lactoferrin also affects osteoclasts, potently inhibiting their formation. In vivo, local injection of lactoferrin results in substantial increases in bone formation and bone area. In a critical bone-defect model in vivo, lactoferrin was also seen to promote bone growth. The mitogenic effect of lactoferrin in osteoblast-like cells is mediated mainly through low-density lipoprotein-receptor protein-1 (LRP1), a member of the low-density lipoprotein-receptor-related proteins that are primarily known as endocytic receptors; however, LRP1 is not necessary for the anti-apoptotic actions of lactoferrin. Lactoferrin also induces the activation of p42/44 mitogen-activated protein kinase (MAPK) signalling and the PI3-kinase-dependent phosphorylation of Akt in osteoblasts. In this study, we examined other properties of lactoferrin and the way they affect osteogenic activity. The degree of glycosylation, iron-binding, and the structure–activity relationships indicate that lactoferrin maintains osteogenic activity in deglycosylated, holo, and apo forms, and in with various small fragments of the molecule. These data suggest that lactoferrin signals through more than 1 membrane-bound receptor to produce its anabolic skeletal effects, and that it signals through diverse pathways. We conclude that lactoferrin might have a physiological role in bone growth and healing and a potential therapeutic role as an anabolic factor in osteoporosis.

Does genetic counseling have any impact on management of breast cancer risk?

Despite there being an increasing literature on the impact of cancer genetic counseling on risk perception and mental health, there is a lack of data describing impact on risk management. Genetic counseling and testing for cancer predisposition genes aims to improve the future health of those at high risk through appropriate surveillance and screening. However, management of breast cancer risk in women with a family history of this disease is an area of controversy. Counseling services may recommend specific risk management options to women, who then rely on their local screening service to make provision. This study investigated the impact of genetic counseling on management of breast cancer risk in women attending Cancer Family Clinics. A total of 293 women attending four genetic clinics were enrolled. Rates of breast self-examination, clinical breast examination, mammography, biopsy, detected cancers, and other screenings were documented. Participants' perceived benefits and barriers to mammography were assessed along with cancer worry. Results show that rates of mammography, clinical breast examination, and breast self-examination were increased following clinic attendance (p < 0.001). Women in the under 35 age-group had limited access to screening. Rates for biopsy and detected cancers were low. Women reported positive attitudes to mammography, with few reported barriers. Contrary to previous studies, there was no evidence that anxiety about breast cancer impedes uptake of health surveillance methods. Genetic counseling had a positive impact on management of breast cancer risk. Whether this translates into future health gains remains to be established.

Interchangeability of Hepatitis A boosters, Avaxim® and Vaqta®, in healthy adults following a primary dose of the combined typhoid/Hepatitis A vaccine Viatim®

This study investigated the suitability of Avaxim and Vaqta as Hepatitis A booster vaccines 6 months after priming with the combined Hepatitis A/typhoid vaccine, Viatim. One hundred and twenty adults were randomly assigned to one of the three groups. Group A (reference group) received Avaxim then Avaxim (n = 40), Group B received Viatim then Avaxim (n = 41) and Group C received Viatim then Vaqta (n = 39). One month after booster vaccination, anti-Hepatitis A virus (anti-HAV) antibodies geometric mean concentrations (GMC) of subjects primed with Viatim were non-inferior to the group primed and boosted with the monovalent Hepatitis A vaccine Avaxim. Anti-Salmonella typhi capsular polysaccharide virulence antigen (anti-Vi) GMCs in groups primed with Viatim were protective and all vaccines were well-tolerated. Therefore, Viatim may be used as a primary HAV vaccine with either Avaxim or Vaqta as Hepatitis A boosters and it will provide the same protection as two doses of Avaxim.

The feasibility and results of a population-based approach to evaluating prostate-specific antigen screening for prostate cancer in men with a raised familial risk

The feasibility of a population-based evaluation of screening for prostate cancer in men with a raised familial risk was investigated by studying reasons for non-participation and uptake rates according to postal recruitment and clinic contact. The levels of prostate-specific antigen (PSA) and the positive predictive values (PPV) for cancer in men referred with a raised PSA and in those biopsied were analysed. First-degree male relatives (FDRs) were identified through index cases (ICs): patients living in two regions of England and diagnosed with prostate cancer at age ⩽65 years from 1998 to 2004. First-degree relatives were eligible if they were aged 45–69 years, living in the UK and had no prior diagnosis of prostate cancer. Postal recruitment was low (45 of 1687 ICs agreed to their FDR being contacted: 2.7%) but this was partly due to ICs not having eligible FDRs. A third of ICs in clinic had eligible FDRs and 49% (192 out of 389) agreed to their FDR(s) being contacted. Of 220 eligible FDRs who initially consented, 170 (77.3%) had a new PSA test taken and 32 (14.5%) provided a previous PSA result. Among the 170 PSA tests, 10% (17) were ⩾4 ng ml⁻¹ and 13.5% (23) tests above the age-related cutoffs. In 21 men referred, five were diagnosed with prostate cancer (PPV 24%; 95% CI 8, 47). To study further the effects of screening, patients with a raised familial risk should be counselled in clinic about screening of relatives and data routinely recorded so that the effects of screening on high-risk groups can be studied.

Gene expression patterns in advanced human cervical cancer

The purpose of this study was to evaluate gene expression patterns in human cervical tumors by extent of lymph node metastases at diagnosis. Pretreatment whole-body fluorodeoxyglucose-positron emission tomography (FDG-PET) imaging was performed in eight patients with invasive squamous cell carcinoma of the cervix to evaluate the extent of lymph nodes metastases. Pretreatment tumor tissue samples were subjected to laser-capture microdissection, and isolated RNA was linearly amplified and hybridized to Affymetrix Human U95A GeneChip microarrays. Molecular FDG-PET imaging revealed that three patients had lymph node involvement in the supraclavicular region and five patients did not. Microarray data were segregated into two groups based on the extent of regional lymph node involvement. Supervised clustering analysis identified 75 of about 12,000 gene transcripts represented on the array whose average expression was at least threefold different. We identified 12 of the 75 transcripts that demonstrated a statistically significant difference in expression between the two patient groups (P < 0.05). Five transcripts were upregulated and seven downregulated. Both overall and cause-specific survivals were different between these two patient groups (P= 0.006). This limited data set identified candidate biomarkers of extent of lymph node metastases that correlated with poor survival outcome.

Feasibility of familial PSA screening: psychosocial issues and screening adherence

This study examined factors that predict psychological morbidity and screening adherence in first-degree relatives (FDRs) taking part in a familial PSA screening study. Prostate cancer patients (index cases - ICs) who gave consent for their FDRs to be contacted for a familial PSA screening study to contact their FDRs were also asked permission to invite these FDRs into a linked psychosocial study. Participants were assessed on measures of psychological morbidity (including the General Health Questionnaire; Cancer Worry Scale; Health Anxiety Questionnaire; Impact of Events Scale); and perceived benefits and barriers, knowledge; perceived risk/susceptibility; family history; and socio-demographics. Of 255 ICs, 155 (61%) consented to their FDRs being contacted. Of 207 FDRs approached, 128 (62%) consented and completed questionnaires. Multivariate logistic regression revealed that health anxiety, perceived risk and subjective stress predicted higher cancer worry (P = 0.05). Measures of psychological morbidity did not predict screening adherence. Only past screening behaviour reliably predicted adherence to familial screening (P = 0.05). First-degree relatives entering the linked familial PSA screening programme do not, in general, have high levels of psychological morbidity. However, a small number of men exhibited psychological distress.

Factors associated with emotional and behavioural problems among school age children of breast cancer patients

To identify factors linked with emotional and behavioural problems in school age (6- to 17-year-old) children of women with breast cancer. Reports of children's emotional and behavioural problems were obtained from patient mothers, their healthy partners, the children's teacher and adolescents using the Child Behaviour Checklist and Mental Health subscale of the Child Health Questionnaire. Parents reported on their own level of depression and, for patients only, their quality of life. Family functioning was assessed using the Family Assessment Device and Cohesion subscale of the Family Environment Scale. Using a cross-sectional within groups design, assessments were obtained (N=107 families) where the patients were 3-36 months postdiagnosis. Risk of problems in children were linked with low levels of family cohesion, low affective responsiveness and parental over-involvement as reported by both child and mother. Adolescents reported family communication issues, which were associated with externalising behaviour problems. Maternal depression was related to child internalising problems, particularly in girls. Whether the mother was currently on or off chemotherapy was not associated with child problems nor was time since cancer diagnosis. These findings held across child age. Where mothers have early stage breast cancer, a substantial minority of their school-aged children have emotional and behavioural problems. Such cases are characterised by the existence of maternal depression and poor family communication, rather than by the mother's treatment status or time since diagnosis. Targeted treatments, which focus on maternal depression and family communication may benefit the children and, through improved relationships, enhance the patients' quality of life.

Distribution of Streptococcus pneumoniae serotypes responsible for penicillin resistance and the potential role of new conjugate vaccines in New Caledonia

Invasive pneumococcal disease is a significant cause of morbidity and mortality worldwide. The aim of this study was to establish the serotypes responsible for pneumococcal disease and the serotypes responsible for penicillin resistance in Noumea, New Caledonia. Isolates of Streptococcus pneumoniae from all body sites referred to the Microbiology Department of the Pasteur Institute in New Caledonia between May 1999 and May 2001 had serotyping and susceptibility testing performed. Basic demographic data on patients were also collected. A total of 298 isolates were included in the study. The most common serotypes were types 1 (20%), 23F (10%), 12F (8%), 19F (8%), and 6B (5%). The serotype distribution differed significantly with age, site of collection, and ethnicity. Overall, 280 of 298 (94%) of the isolates had serogroups that are included in the 23-valent vaccine. However, only 14 of 20 (70%) of the isolates associated with invasive disease from children younger than 5 years of age and 26 of 113 (23%) of invasive isolates from patients more than 5 years of age were included in the new 7-valent conjugate vaccine. Overall, reduced susceptibility to penicillin was found in 43 of 298 (14.4%) of the isolates, with 13% falling into the intermediate resistance category and only 5 (2%) being high-level resistant. A higher prevalence of penicillin resistance occurred in younger age groups and in European patients and involved specifically certain serotypes. The 7-valent conjugate pneumococcal vaccine has potential benefit for the New Caledonian population under 5 years of age and should be considered for future vaccines schedules.

Men's decision-making about predictive BRCA1/2 testing: the role of family

Men who have a family history of breast and/or ovarian cancer may be offered a predictive genetic test to determine whether or not they carry the family specific BRCA1/2 mutation. Male carriers may be at increased risk of breast and prostate cancers. Relatively little is known about at-risk men's decision-making about BRCA1/2 testing. This qualitative study explores the influences on male patients' genetic test decisions. Twenty-nine in-depth interviews were undertaken with both carrier and noncarrier men and immediate family members (17 male patients, 8 female partners, and 4 adult children). These explored family members' experiences of cancer and genetic testing, decision-making about testing, family support, communication of test results within the family, risk perception and risk management. Implicit influences on men's testing decisions such as familial obligations are examined. The extent to which other family members--partners and adult children--were involved in testing decisions is also described. It is demonstrated that mothers of potential mutation carriers not only perceive themselves as having a right to be involved in making this decision, but also were perceived by their male partners as having a legitimate role to play in decision-making. There was evidence that (adult) children were excluded from the decision-making, and some expressed resentment about this. The implications of these findings for the practice of genetic counseling are discussed.

Influenza related hospitalisations in Sydney, New South Wales, Australia

BACKGROUND

Routine influenza vaccination for children aged 6-23 months has recently been recommended in the United States. Accurate assessment of influenza related burden of illness in children could support similar recommendations in other settings. However, routinely available data underestimate the role of influenza in causing hospitalisation, and indirect estimation methods face difficulties controlling for the concurrent circulation of respiratory syncytial virus (RSV). Recent studies from Hong Kong and the United States have used differing methods to estimate the true burden of influenza related hospitalisation, with disparate results.

METHODS

Retrospective population based study of children less than 18 years of age from Sydney, Australia, 1994 to 2001. Using two previously reported methods, estimates of annual hospitalisation rates attributable to influenza were derived by comparison of mean hospitalisation rates for acute respiratory disease during periods of high influenza activity and low RSV activity (defined using virological surveillance data) and periods where both influenza and RSV activity were low. These estimates were compared to rates of hospitalisation where influenza was recorded as the principal discharge diagnosis.

RESULTS

Hospitalisation rates attributable to influenza were up to 11 times higher, depending on the age group and method used, compared to rates calculated from principal discharge diagnosis codes.

CONCLUSIONS

Although there remains considerable uncertainty in estimating influenza related morbidity by methods using excess hospitalisations, even minimum estimates of disease burden warrant consideration of routine influenza immunisation for all children less than 2 years of age. Such estimates, derived from principal discharge diagnosis codes, are available in most settings.

The association of respiratory viruses, temperature, and other climatic parameters with the incidence of invasive pneumococcal disease in Sydney, Australia

BACKGROUND

Increases in incidence of invasive pneumococcal disease (IPD) during the colder months of the year in temperate regions are well recognized, but few detailed studies of possible interactions are available. We examined the relationship between virus activity, climatic parameters, and IPD during a winter in which there were separate peak incidences of influenza and respiratory syncytial virus (RSV) infection.

METHODS

We performed an ecological study that correlated population-based data on IPD and respiratory virus activity in the year 2000 in metropolitan New South Wales, Australia, with climatic parameters, including weekly mean maximum and minimum temperature, relative humidity, rainfall, and wind speed.

RESULTS

In children, RSV activity was significantly positively correlated with IPD activity (r = 0.578; P = .002) but not with influenza virus activity. There was a weak inverse relationship between parainfluenza virus activity and IPD activity (r = -0.401; P = .043) and a stronger inverse relationship between weekly mean maximum temperature (r = -0.458; P = .001), weekly mean minimum temperature (r = -0.437; P = .001), and IPD activity. In adults, there was no significant correlation between RSV or influenza virus activity alone and IPD, but the combination of RSV and influenza was significantly correlated with IPD (r = 0.481; P = .013).

CONCLUSIONS

This study suggests that RSV infection and influenza contribute to IPD incidence peaks differently for children than for adults. Data from other geographic areas and more rigorous study designs are required to confirm these findings.

Long-term outcomes of laparoscopic surgery for colorectal cancer

Multiple reports have outlined the potential benefits of the laparoscopic approach to colon surgery. Recently, randomized control trials have demonstrated the safety of applying these techniques to colorectal cancer. This study examined the long-term follow-up assessment of patients after laparoscopic colorectal cancer resections and compared them with a large prospective database of open resections. A total of 231 resections were performed for adenocarcinoma of the colon or rectum between 1992 and 2004. Of these 231 resections, 93 were rectal (40.3%) and 138 were colonic (59.7%). A total of 8 (3.2%) of the resections were performed as emergencies, and 27 (11.7%) were converted to open surgery. The mean follow-up period was 35.84 months (range, 0-132 months). The disease recurred in 51 of the patients (22.1%) before death, involving 14 (6.1%) local and 37 (16%) distant recurrences. Only two patients had wound recurrences (0.8%), and both patients had widespread peritoneal recurrence at the time of diagnosis. The overall survival rate was 65.3% at 60 months and 60.3% at 120 months. The disease-free survival rate was 58% at 60 months and 56% at 120 months. Laparoscopic techniques can be applied to a wide range of colorectal malignancies without sacrificing oncologic results during a long-term follow-up period.