Nebulised recombinant activated factor VII (rFVIIa) does not attenuate the haemorrhagic effects of blast lung injury

Introduction

Primary blast lung injury causes intrapulmonary haemorrhage. A number of case reports have suggested the efficacy of recombinant activated factor VII (rFVIIa) in the treatment of diffuse alveolar haemorrhage from a range of medical causes, but its efficacy in blast lung is unknown. The aim of this study was to investigate whether nebulised rFVIIa attenuates the haemorrhagic effects of blast lung injury in an animal model.

Methods

Terminally anaesthetised rabbits subjected to blast lung injury were randomised to receive either rFVIIa or placebo via a nebuliser. The primary outcome was the level of blood iron–transferrin complex, a marker of the extent of blast lung injury, analysed using low temperature electron paramagnetic resonance spectroscopy.

Results

Blast exposure led to a significant fall in iron-bound transferrin in both groups of animals (p<0.001), which remained depressed during the study. There were no significant differences in iron–transferrin between the rFVIIa and placebo treatment groups over the duration of the study (p=0.081), and there was no trend towards elevated iron–transferrin in the rFVIIa-treated group once drug treatment had started. There was suggestive evidence of systemic absorption of rFVIIa given via the inhaled route.

Conclusion

A single dose of nebulised rFVIIa did not attenuate pulmonary haemorrhage in a rabbit model of blast lung injury. As there was some evidence of systemic absorption, the inhaled route does not avoid the concern about potential thromboembolic complications from administration of rFVIIa.

Music for Wellness: An 8-Week Study of the Psychosocial Effects of Music Therapy on Cancer Patients

Background: Music therapy offers patients a way to address the psycho-social impacts of a cancer diagnosis and treatment. Research suggests that complementary therapies, such as music and art therapy, provide an opportunity for patients to express their emotions and make meaning of their experiences, as well as providing social connections to other patients. A better understanding of the specific benefits that may be achieved from these programs and the mechanism through which this might occur will help us better tailor services to patients' needs. While an increasing number of cancer care centers now offer complementary therapies as a way to support patients with cancer, there are few prospective evaluations that examine the benefits derived from program completion beyond patient satisfaction measures. Aim: The aim of this project is to examine the impact of music therapy on specific patient reported outcomes and the factors that influence how and why this occurs. Methods: Participants in an 8-week group music therapy program will be asked to complete a suite of measures prior to program commencement, and at 1-week and 1-month postprogram completion. Measures include core constructs of well-being such as distress, quality of life and symptom severity, as well as constructs specifically targeted by the music therapy program, such as meaning making, emotional expression and social connectedness. A waitlist control will provide comparison data at comparable time-points. Results: The music therapy program will run from April-May 2018, with the postprogram evaluation being completed in June 2018. Preliminary data will be presented and the suitability of this method will be considered. Conclusion: In the context of a comprehensive cancer center in Victoria, Australia, we will present data on the effectiveness of a music therapy program for addressing patients' well-being. We will discuss implications for the provision of supportive care for cancer patients and survivors and how the design of future programs might be tailored to achieve key outcomes.

Women's Cancer Screening in Haiti: Increasing Access by Bringing Services to the Workplace

Background: Cervical cancer is the leading cause of cancer-related death in Haiti yet the country does not provide sufficient screening. Working class women in Haiti are less likely to receive cancer screening or education than the poorest quartile of women. This is an untouched demographic not necessarily because of financial burdens but because most women work 6 days weekly and lack the time to seek healthcare and appropriate screening. Innovating Health International (IHI) and Share Hope recently implemented a cancer screening program using vaginal HPV self-swabs and clinical breast exams for working class women in Port-au-Prince. Aim: To not only bring much needed cervical cancer education, screening and treatment to an unreached demographic but also to assess the plausibility and acceptance by female factory workers to receive routine screening and treatment in clinics that reside within the workplace. Methods: The project began in September 2017 and will run for 12 months with plans to screen 4000 women with vaginal HPV swabs (QIAGEN careHPV) and clinical breast exams. Nurses perform clinical breast exam, teach self-breast exam, and instruct patients how to perform vaginal self-swab in the factory infirmary. Inclusion criteria for women include age 30 to 50 years. Women who screen positive for HPV will then be followed with visual inspection of the cervix with acetic acid (VIA) and thermocoagulation. Those who have suspicious masses in their breast have a breast ultrasound performed at the factory clinic. A smaller percentage of women with advanced disease will be referred to outside gynecology clinics. Results: Data collection is half-way completed and we´ll present full data in October. Over 3122 women have participated and received education on women's health issues during their lunch hour at the factories. Of all those sensitized, 2691 or 86.1% chose to have clinical breast exam. Of those who are eligible for HPV screening, 1948 or 93.8% of those eligible accepted testing. Of those tested, 344 or 16% were HPV-positive and all but a 5 completed VIA. For women who are HPV-positive, 69 or 20% were also VIA positive. All HPV-positive women received thermocoagulation except for 2, who were referred for colposcopy and loop electrocautery excisional procedure. There were 141 women who had a positive clinical breast exam and underwent breast ultrasound with only 2 requiring a biopsy. Conclusion: We seek to expand access to cervical cancer screening for the rural and working poor through using mobile health technologies coupled with community-based education and screening. HPV-positive women can undergo treatment by a traveling nurse with portable thermocoagulation therapy where they live or work, without the need to travel or leave work. With no doctor, no electricity, no pelvic exam for most women, and no stable infrastructure, we can screen women in rural areas and the working poor at their place of employment.

Triaging for Supportive Care Services: Do People Want and Accept Referral?

Background: Distress is the 6th vital sign in cancer yet it is only assessed in an ad hoc way in most cancer services. The Distress Thermometer (DT) and the associated Problem Checklist (PC) are the most widely available tools although few studies report on how they are used to effectively triage services. Aim: To explore the link between distress assessment, problem identification, referral to specific supportive care services by staff, and service uptake by cancer patients and survivors among a sample of people attending a major cancer hospital in Victoria Australia. Methods: A secondary analysis of quality assurance audit data were undertaken using data collected from patient medical records between January 2013 and June 2014. Data extracted were; age, sex, post code, language spoken, disease and treatment information, distress as measured by the DT and problems as identified by the PC. For the current study the focus was on the number of referrals offered and the number accepted or declined. The type of services referred to was also examined. Results: Data were collected for 877 patients although missing data resulted in a final sample size of 853. Only data associated with the first DT of each patient are presented. 729 patients (86%) participated in distress screening. The distress threshold of 4 was reported by 50% of participants, highlighting the prevalence of distress requiring support. This 50% reported an average of 9 problems on the PC, many of which came from the physical domain, with 91% reporting at least 1 physical problem. Other problems reported were emotional (74% of the sample); practical (24%), family (14%) and spiritual (2%). Referral data, which was available for 614 people, indicated that over 60% (372) were offered at least one referral. Referral offer was significantly predicted by DT score, and number of problems reported. Acceptance was significantly related to total number of problems, treatment type, and type of referral; referral for physical treatment was most likely to be accepted (87%) whereas referral for emotional support was least likely (53%). Conclusion: Routine distress screening and problem identification are critical to triaging to supportive care services. In a tertiary care setting, not all people will be screened or will want to be screened; not all people will be referred to services; and not all people will accept referral. Nonetheless, problems are extensive with most survivors reporting experiencing several problems. Despite a focus on the physical, these problems extend to other domains, including the emotional, and it is important that services are available to support these needs.

Chemical and structural data of (1,2,3-triazol-4-yl)pyridine-containing coordination compounds

The data presented in this paper are related to the research article entitled “Novel dichloro(bis{2-[1-(4-methylphenyl)-1H-1,2,3-triazol-4-yl-κN³]pyridine-κN})metal(II) coordination compounds of seven transition metals (Mn, Fe, Co, Ni, Cu, Zn and Cd)” (Conradie et al., 2018) [1]. This paper presents characterization and structural data of the 2-(1-(4-methyl-phenyl)-1H-1,2,3-triazol-1-yl)pyridine ligand (L²) (Tawfiq et al., 2014) [2] as well as seven dichloro(bis{2-[1-(4-methylphenyl)-1H-1,2,3-triazol-4-yl-κN³]pyridine-κN})metal(II) coordination compounds, [M(L²)₂Cl₂], all containing the same ligand but coordinated to different metal ions. The data illustrate the shift in IR, UV/VIS, and NMR (for diamagnetic complexes) peaks when L is coordinated to the metals, as well as the influence of the different metals on the peak positions. Solid state structural data is presented for M = Ni and Zn, while density functional theory calculated energies, structures and optimized coordinates are provided for the lowest energy cis and trans conformations for L² as well as [M(L²)₂Cl₂] with M = Mn, Fe, Co, Ni, Cu, Zn and Cd.

Benefits and risks of adjuvant treatment with zoledronic acid in stage II/III breast cancer. 10 years follow-up of the AZURE randomized clinical trial (BIG 01/04)

Adjuvant bisphosphonates improve disease outcomes in postmenopausal early breast cancer (EBC) but the long-term effects are poorly described. The AZURE trial (ISRCTN79831382) was designed to determine whether adjuvant zoledronic acid (ZOL) improves disease outcomes in EBC. Previous analyses showed no effect on overall outcomes but identified benefits in postmenopausal women. Here we present the long-term risks and benefits of adjuvant ZOL with 10-years follow-up.

Patients and methods

3360 patients with stage II/III breast cancer were included in an academic, international, phase III, randomized, open label trial. Patients were followed up on a regular schedule until 10 years. Patients were randomized on a 1:1 basis to standard adjuvant systemic therapy +/− intravenous ZOL 4 mg every 3–4 weeks x6, and then at reduced frequency to complete 5 years treatment. The primary outcome was disease free survival (DFS). Secondary outcomes included invasive DFS (IDFS), overall survival (OS), sites of recurrence, skeletal morbidity and treatment outcomes according to primary tumor amplification of the transcription factor, MAF. Pre-planned subgroup analyses focused on interactions between menopausal status and treatment effects.

Results

With a median follow up of 117 months [IQR 70.4–120.4), DFS and IDFS were similar in both arms (HR_DFS= 0.94, 95%CI = 0.84–1.06, p = 0.340; HR_IDFS= 0.91, 95%CI = 0.82–1.02, p = 0.116). However, outcomes remain improved with ZOL in postmenopausal women (HR_DFS= 0.82, 95%CI = 0.67–1.00; HR_IDFS= 0.78, 95%CI = 0.64–0.94). In the 79% of tested women with a MAF FISH negative tumor, ZOL improved IDFS (HR_IDFS= 0.75, 95%CI = 0.58–0.97) and OS HR_OS= 0.69, 95%CI = 0.50–0.94), irrespective of menopause. ZOL did not improve disease outcomes in MAF FISH + tumors. Bone metastases as a first DFS recurrence (B_DFS) were reduced with ZOL (HR_B-DFS= 0.76, 95%CI = 0.63–0.92, p = 0.005). ZOL reduced skeletal morbidity with fewer fractures and skeletal events after disease recurrence. 30 cases of osteonecrosis of the jaw in the ZOL arm (1.8%) have occurred.

Conclusions

Disease benefits with adjuvant ZOL in postmenopausal early breast cancer persist at 10 years of follow-up. The biomarker MAF identified a patient subgroup that derived benefit from ZOL irrespective of menopausal status.

Adjuvant zoledronic acid reduces fractures in breast cancer patients; an AZURE (BIG 01/04) study

The fracture impact of adjuvant bisphosphonates in breast cancer is not defined with most trials reporting changes in bone mineral density as a surrogate. The AZURE trial (ISRCTN79831382) evaluated the impact of adjuvant zoledronic acid (ZOL) on fractures. The AZURE trial is an academic, multi-centre, randomised phase III study evaluating the addition of ZOL 4 mg to standard therapy (neo/adjuvant chemotherapy and/or endocrine therapy) for 5 years (administered by intravenous (iv) infusion every 3-4 weeks for 6 doses, then 3 monthly × 8 and 6 monthly × 5) in patients with stage II/III early breast cancer. Fracture data collected as part of skeletal-related adverse event reporting were analysed after a median of 84.2 months of follow-up and 966 disease-free survival (DFS) events. We assessed number of fractures, time-to-first fracture and the incidence of fractures before and after disease recurrence. Two hundred forty-four patients reported ≥1 fracture, 140 (8.3%) in the control arm (171 fractures) and 104 (6.2%) in the ZOL arm (120 fractures). Of the 291 fractures reported, 207 fractures occurred in the absence of recurrence (control 111, ZOL 96), 80 after recurrence (control 59, ZOL 21). The 5-year fracture rate was reduced from 5.9% (95%CI 4.8, 7.1%; control) to 3.8% (95%CI 2.9, 4.7%) with ZOL. ZOL significantly increased time-to-first fracture (HR 0.69, 95%CI 0.53-0.90; P = 0.0053) but the majority of fracture prevention benefit occurred after a DFS event (HR 0.3; 95%CI 0.17, 0.53; P < 0.001). Fracture benefits from ZOL were similar across menopausal sub-groups. In conclusion, adjuvant ZOL reduced the risk of clinical fractures, the majority of this protection occurred after disease recurrence.

Effectiveness of Early Hematopoietic Stem Cell Transplantation in Preventing Neurocognitive Decline in Mucopolysaccharidosis Type II: A Case Series

The early progressive form of the X-linked disorder, Hunter syndrome or mucopolysaccharidosis type II (MPS II) (OMIM #309900), is characterized by cognitive decline, and pulmonary and cardiac complications that often cause death before 20 years of age. Deficiency of the lysosomal enzyme, iduronate-2-sulfatase (EC 3.1.6.13) results in deposition of the glycosaminoglycans, dermatan, and heparan sulfate in various tissues. In recent years, enzyme replacement therapy (ERT) has become the mainstay of treatment, but is expensive and ineffective in arresting cognitive decline. Hematopoietic stem cell transplantation (HSCT) also provides enzyme replacement, and may be effective in stabilizing neurocognitive function if initiated early, though data are limited. We present a case series of four patients who demonstrated neurocognitive stabilization with early HSCT. HSCT is a potentially underutilized treatment strategy for select groups of MPS II patients.

Connecting the dots between breast cancer, obesity and alcohol consumption in middle-aged women: ecological and case control studies

Background

Breast cancer (BC) incidence in Australian women aged 45 to 64 years (‘middle-aged’) has tripled in the past 50 years, along with increasing alcohol consumption and obesity in middle-age women. Alcohol and obesity have been individually associated with BC but little is known about how these factors might interact. Chronic psychological stress has been associated with, but not causally linked to, BC. Here, alcohol could represent the ‘missing link’ – reflecting self-medication. Using an exploratory cross-sectional design, we investigated inter-correlations of alcohol intake and overweight/obesity and their association with BC incidence in middle-aged women. We also explored the role of stress and various lifestyle factors in these relationships.

Methods

We analysed population data on BC incidence, alcohol consumption, overweight/obesity, and psychological stress. A case control study was conducted using an online survey. Cases (n = 80) were diagnosed with BC and controls (n = 235) were women in the same age range with no BC history. Participants reported lifestyle data (including alcohol consumption, weight history) over consecutive 10-year life periods. Data were analysed using a range of bivariate and multivariate techniques including correlation matrices, multivariate binomial regressions and multilevel logistic regression.

Results

Ecological inter-correlations were found between BC and alcohol consumption and between BC and obesity but not between other variables in the matrix. Strong pairwise correlations were found between stress and alcohol and between stress and obesity.

BMI tended to be higher in cases relative to controls across reported life history. Alcohol consumption was not associated with case-control status. Few correlations were found between lifestyle factors and stress, although smoking and alcohol consumption were correlated in some periods. Obesity occurring during the ages of 31 to 40 years emerged as an independent predictor of BC (OR 3.5 95% CI: 1.3–9.4).

Conclusions

This study provides ecological evidence correlating obesity and alcohol consumption with BC incidence. Case-control findings suggest lifetime BMI may be important with particular risk associated with obesity prior to 40 years of age. Stress was ecologically linked to alcohol and obesity but not to BC incidence and was differentially correlated with alcohol and smoking among cases and controls. Our findings support prevention efforts targeting weight in women below 40 years of age and, potentially, lifelong alcohol consumption to reduce BC risk in middle-aged women.

Mental health inpatients' and staff members' suggestions for reducing physical restraint: A qualitative study

WHAT IS KNOWN ON THE SUBJECT?: Restraint has negative psychological, physical and relational consequences for mental health patients and staff. Restraint reduction interventions have been developed (e.g., "Safewards"). Limited qualitative research has explored suggestions on how to reduce physical restraint (and feasibility issues with implementing interventions) from those directly involved. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: This paper explores mental health patients' and staff members' suggestions for reducing physical restraint, whilst addressing barriers to implementing these. Findings centred on four themes: improving communication and relationships; staffing factors; environment and space; and activities and distraction. Not all suggestions are addressed by currently available interventions. Barriers to implementation were identified, centring on a lack of time and/or resources; with the provision of more time for staff to spend with patients and implement interventions seen as essential to reducing physical restraint. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Improving communication and relationships between staff/patients, making staffing-related changes, improving ward environments and providing patient activities are central to restraint reduction in mental healthcare. Fundamental issues related to understaffing, high staff turnover, and lack of time and resources need addressing in order for suggestions to be successfully implemented.

ABSTRACT

Introduction Physical restraint has negative consequences for all involved, and international calls for its reduction have emerged. Some restraint reduction interventions have been developed, but limited qualitative research explores suggestions on how to reduce physical restraint (and feasibility issues with implementation) from those directly involved. Aims To explore mental health patients' and staff members' suggestions for reducing physical restraint. Methods Interviews were conducted with 13 inpatients and 22 staff members with experience of restraint on adult mental health inpatient wards in one UK National Health Service Trust. Results Findings centred on four overarching themes: improving communication and relationships between staff/patients; making staff-related changes; improving ward environments/spaces; and having more activities. However, concerns were raised around practicalities/feasibility of their implementation. Discussion Continued research is needed into best ways to reduce physical restraint, with an emphasis on feasibility/practicality and how to make time in busy ward environments. Implications for Practice Improving communication and relationships between staff/patients, making staffing-related changes, improving ward environments and providing patient activities are central to restraint reduction in mental healthcare. However, fundamental issues related to understaffing, high staff turnover and lack of time/resources need addressing in order for these suggestions to be successfully implemented.

Survival of Arteriovenous Fistula for Dialysis at Different Centers in the North of England

Background

Renal failure patients rely on their vascular access for hemodialysis. Surgery for construction of arteriovenous fistulae is provided by a range of specialists. The aim of this review was to assess the survival of arteriovenous fistulae for hemodialysis patients in different centers of Northern England.

Methods

Data was collected on 473 hemodialysis patients in the North of England. Risk factors for failure were determined for each patient (age, sex, diabetes), together with their current mode of dialysis and history of surgical access procedures. This was expressed against their duration of dialysis. The dialysis units were then compared for fistula survival using the Kaplan Meier method.

Results

68.3% (323) patients were dialysed through via arteriovenous fistulae and 31.7% (150) via neck line. Overall fistula survival rates were 85.1% at 1 year, 82.5% at 2 years and 72.7% at 3 years. The best 1 year survival was 91.6% and worst 76.1%. These were 74.4% and 53.1% at 5 years and 74.4% and 29.5% at 10 years; these differences were highly statistically significant (p=0.0033).

Conclusion

Though graft survival is affected by many things, surgical training in access surgery is not mandatory and a review of surgical practice is urgently needed.

Jahn–Teller distortion in 2-pyridyl-(1,2,3)-triazole-containing copper(ii) compounds

Octahedral copper(ii) compounds, containing two 2-pyridyl-(1,2,3)-triazole ligands as well as two Cl ions, exhibit elongation Jahn–Teller distortion.

Coordination of radiologic and clinical care reduces the wait time to breast cancer diagnosis

BACKGROUND

In 2009, a Rapid Access Breast Clinic (rabc) was opened at our urban hospital. Compared with the traditional system (ts), the navigated care through the clinic was associated with a significantly shorter time to surgical consultation. Since 2009, many radiology facilities have introduced facilitated-care pathways for patients with breast pathology. Our objective was to determine if that change in diagnostic imaging pathways had eliminated the advantage in time to care previously shown for the rabc.

METHODS

All patients seen in the rabc and the office-based ts in November-December 2012 were included in the analysis. A retrospective chart review tabulated demographic, surgeon, pathology, and radiologic data, including time intervals to care for all patients. The results were compared with data from 2009.

RESULTS

In 2012, time from presentation to surgical consultation was less for the rabc group than for the ts group (36 days vs. 73 days, p < 0.001) for both malignant (31 days vs. 55 days, p = 0.008) and benign diagnoses (43 days vs. 79 days, p < 0.001). Comparing the 2012 results with results from 2009, a decline in mean wait time was observed for the ts group (86 days vs. 73 days, p = 0.02). Compared with patients having investigations in the ts, rabc patients with cancer were more likely to undergo surgery within 60 days of presentation (33% vs. 15%, p = 0.04).

CONCLUSIONS

The coordination of radiology and clinical care reduces wait times for diagnosis and surgery in breast cancer. To achieve recommended targets, we recommend implementation of more systematic coordination of care for a breast cancer diagnosis and of navigation to surgeons for patients needing surgical care.