Modelling the health impact of environmentally sustainable dietary scenarios in the UK

BACKGROUND/OBJECTIVES:

Food is responsible for around one-fifth of all greenhouse gas (GHG) emissions from products consumed in the UK, the largest contributor of which is meat and dairy. The Committee on Climate Change have modelled the impact on GHG emissions of three dietary scenarios for food consumption in the UK. This paper models the impact of the three scenarios on mortality from cardiovascular disease and cancer.

SUBJECTS/METHODS:

A previously published model (DIETRON) was used. The three scenarios were parameterised by fruit and vegetables, fibre, total fat, saturated fat, monounsaturated fatty acids, polyunsaturated fatty acids, cholesterol and salt using the 2008 Family Food Survey. A Monte Carlo simulation generated 95% credible intervals.

RESULTS:

Scenario 1 (50% reduction in meat and dairy replaced by fruit, vegetables and cereals: 19% reduction in GHG emissions) resulted in 36 910 (30 192 to 43 592) deaths delayed or averted per year. Scenario 2 (75% reduction in cow and sheep meat replaced by pigs and poultry: 9% reduction in GHG emissions) resulted in 1999 (1739 to 2389) deaths delayed or averted. Scenario 3 (50% reduction in pigs and poultry replaced with fruit, vegetables and cereals: 3% reduction in GHG emissions) resulted in 9297 (7288 to 11 301) deaths delayed or averted.

CONCLUSION:

Modelled results suggest that public health and climate change dietary goals are in broad alignment with the largest results in both domains occurring when consumption of all meat and dairy products are reduced. Further work in real-life settings is needed to confirm these results.

P3-07-33: Are Single Node Metastases More Common in Patients with Breast Cancer in the Sentinel Node Era?

Background: The axillary recurrence rate after axillary lymph node dissection has been reported as approximately 3%. Since the introduction of sentinel node biopsy (SNB), it has become apparent that, there is a significant decrease in axillary recurrence, ranging from 0.26% to 0.9% in published literature. One of the concerns that arises from this data is that, the sentinel node may have been missed when routine axillary node clearance were being performed. The aim of this study was to compare the results of a cohort of patients who had an axillary staging procedure prior to the introduction of SNB (axillary clearance) with patients after the introduction of SNB in relation to the number who had only one positive node in the axilla.

Methods: From June 2003 to November 2010 data was collected on demographics, histopathology and procedure performed. All patients with invasive breast cancer prior to April 2005 had an axillary node clearance (ANC) with either wide local excision or mastectomy. Since April 2005 all patients with invasive breast cancer had a SNB and patients with a positive sentinel node (SN) underwent ANC. Patients with a negative SNB had no further axillary surgery.

Results: 702 patients had axillary node surgery between June 2003 and November 2010. 251 patients had axillary node clearance (pre SN period) and 451 had SNB (SN period). Average age was 57 years. 509 patients (156 in pre SNB period and 353 in post SNB period) had no nodal metastases. Amongst the 193 node positive patients, 100 had single node involvement. In the pre SNB period 33 (34.7%) patients had single node involvement, compared to 67 (68.3%) in SNB period. The histopathological type of cancer did not vary significantly between the one node positive, multiple node positive and node negative groups.

Conclusion: Our study confirms a significant rise in patients with a single node positive in the sentinel node period. This could be due to the SLN being “missed” during surgery when an axillary node clearance was performed, which would explain the reported higher axillary recurrence rates in the pre sentinel node period compared to the sentinel node period. Another possibility is that the SN is undergoing more detailed histopathological assessment as there are fewer number of lymph nodes to be examined.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-33.

P3-07-38: Selective Omission of Blue Dye in Patients Undergoing Sentinel Lymph Node Biopsy for Breast Cancer

Background

Combined blue dye and radioisotope colloid injection with scintigraphy is standard practice for mapping and biopsy of sentinel lymph node in breast cancer within the UK. Whilst this combination aids sentinel node detection rate, blue dye has a number of possible adverse effects including anaphylaxis (reported as 1–3% of patients), semi-permanent skin tattooing and staining of bodily fluids which may cause distress for the unwary patient. It can also cause obscuration of the operating field, making identification and dissection of planes more difficult.

Methods: Patients undergoing sentinel lymph node biopsy (SLNB) using either a combination of blue dye and radioactive colloid, or radioactive colloid alone during a 14 month period were compared for identification rate, node harvest number and final positive rate. A total of 122 axillary sentinel node biopsies in 121 patients were identified. All patients scheduled for sentinel lymph node biopsy had intradermal injection of radiocolloid and lymphoscintigram preoperatively and were checked for radioactive intensity with gamma probe on the table before draping for surgery. Patients with good signal proceeded to surgery without blue dye. Those with more than 3 nodes (n=9), radioisotope skin contamination (n=2), absent signal on scintigraphy (n=7) and/or with weak pre-operative radioactive signal (n=22) were given 2 millilitres of patent V dye subdermally in the periareolar region. Sentinel node biopsy then proceeded in the standard fashion. Data was also collected from the year prior to be used as a control group, where the combination of blue dye and radioisotope was used for all patients (n=90), and compared with the group receiving radioisotope alone.

Results: The rate of identification for single agent and dual agent was 100% and 97.5% respectively, with no significant difference in mean node harvest using radioisotope alone (1.80) as compared to combined technique (1.87 p= 0.88, 95%CI −0.39 to 0.34). There was no significant difference in the number of patients with positive nodes on final histology when using single agent (13 (14%)) when compared to the dual agent technique (10 (25%) p=0.21). There was also no difference in the rate or number of node harvest in the group who underwent the single agent technique when compared to the control group (100% identification, mean harvest 1.84, p=0.77, 95% CI −0.36 to 0.27), with no difference in node positivity (16 (17%) p=0.68). No intra operative adverse reaction was reported in any of the groups.

Discussion: This study has shown no significant difference in the localisation rate when selectively omitting blue dye in suitable patients compared to the combined technique. This may be due to significant operator experience or change in the method of radioisotope injection since initial studies were performed. In this study, 86 out of 126 SLNB proceeded without blue dye, meaning not only a reduction in the number of patients with minor adverse effects, but also a potential reduction in severe adverse reaction of 68% or 2 patients per year within this breast unit.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-38.

P3-07-31: Intra-Operative Assessment of Sentinel Lymph Nodes in Breast Cancer with Touch Imprint Cytology (TIC) in 460 Consecutive Patients

Background

Sentinel node biopsy (SNB) accurately predicts the axillary lymph node status in patients with breast cancer. The sentinel lymph node (SLN) is evaluated by routine histology, requiring 3–5 days for the results and a second operation if the SLN is positive. However a second operation can be avoided if a reliable intraoperative assessment of the SLN was available. The techniques used for intra-operative assessment of the SLN include frozen section, touch imprint cytology (TIC) and more recently molecular biology assays. The aim of this study was to evaluate the accuracy of TIC in the assessment of the SLN.

Methods: A prospective study to include 460 patients with breast cancer who underwent SNB and had the sentinel node assessed intra-operatively with TIC. The SLN was bisected and a touch imprint was made on to a slide. The imprint was stained with Giemsa stain. Permanent sections were evaluated with H&E and immunohistochemical staining. The TIC results were compared with the final histology of the SLN.

Results: 766 SLN's were harvested from 460 patients (Mean - 1.66). Of the 460 patients, TIC was falsely negative in 50(24%) patients. No patients had false positive results. Negative predictive value was 87%. The accuracy rate was 89%. 94 patients were positive on histology. TIC was positive in 44 patients and negative in 50. The sensitivity, specificity and positive predictive value of TIC was 47%, 100% and 100% respectively. By acting on the results of TIC, 44 patients (47%) had an axillary clearance at the primary operation and were thus spared a second operation.

Conclusion: TIC in our cohort of 460 patients and 766 sentinel lymph nodes had an accuracy rate of 89% and specificity of 100%. Our study compares favourably with published literature, confirming that TIC is a simple, quick, reliable and reproducible technique that can be used for intra operative assessment of the SLN. A sensitivity of 47% means that about half of the SLN positive patients were spared a second operation. We had hoped that with more experience, our sensitivity would improve but since this has not been the case we are now moving towards molecular biology assays (OSNA) to assess the SN intra-operatively.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-31.

The Wellness Planner: empowerment, quality of life, and continuity of care in mental illness

Coordination of mental health services has often been a challenge from the user's point of view. Resulting gaps in care can lead to increased use of crisis services, more frequent hospitalization, and impaired quality of life. This study examined an innovative approach to building an individual's self-care capacities by testing the use of a wellness intervention: an adaptation of a client-held medical record/crisis plan in booklet form. Fifty individuals using community mental health services were recruited. Using a pretest-posttest design, participants completed measures of empowerment, continuity of care, quality of life, and satisfaction with services at the start of and again following 3 months of using the booklet. The booklet, referred to as the Wellness Planner, included components that have been empirically demonstrated as effective, such as crisis planning, goal setting, and resource planning. For the 42 individuals who completed the study, statistically significant increases were seen in empowerment, continuity of care, and satisfaction with services after 3 months of using the Wellness Planner. Qualitative data further demonstrated positive acceptance of the booklet by the users. Findings of the study suggest that the use of such a booklet could not only have a positive impact on the recovery of individuals but could also have utility within the mental health system. Since the completion of this study, the Winnipeg Regional Health Authority has adopted the booklet for use within all its adult mental health programs. Future research will focus on the impact of the booklet on system-wide indicators such as service utilization and readmission rates.

Calibration of a simple model for waste stabilisation pond performance in seasonal climates

The paper describes the calibration of a model for waste stabilisation pond (WSP) performance in seasonal climates, based on the use of readily available climate data sets. Calibration data were taken from a wide geographical area of Canada and the USA, including coastal and moderately seasonal sites. Good agreement with measured values was shown using a biochemical oxygen demand (BOD) decay constant of 0.3 day(-1) for facultative ponds and 0.07-0.1 day(-1) for storage/maturation ponds with a temperature-related Arrhenius constant of 1.05, and a fixed BOD decay constant of 0.007 day(-1) at water temperatures below 0 °C. The results suggested that such models could potentially be used as the basis for WSP design guidelines tailored to a wide range of climatic conditions.

Abstract P1-01-01: Learning Sentinel Node Biopsy in the UK: Results of the NEW START Training Program

Background: NEW START-a structured, validated multi-professional surgical training programme, was established to allow rapid transfer of appropriate knowledge and technical skills to ensure safe and competent practice of sentinel lymph node biopsy (SLNB) across the UK.

Methods: Multi-professional teams attended a theory/skills-lab course delivering a standardized educational package, following which they performed SLNB in 30 consecutive patients, either concurrently with their standard axillary staging procedure — mentorship training model-or as stand-alone SLNB — apprenticeship training model. An accredited NEW START trainer mentored the first 5 procedures in the participants’ hospital, or all 30 if stand-alone. Validation standards were a localization rate of ≥90% and in the mentorship program where a minimum of 10 cases were node positive, a false-negative rate of ≥10%. SLNB was performed according to a standardised protocol using the combined technique of isotope (0.05-0.1ml of 99mTc-albumin colloid — Nanocoll®) and blue dye (Patent blue V) injected into the tumour quadrant peri-areolar tissue. Isotope was injected intra-dermally and static scintigraphic images were obtained, blue dye was injected sub-dermally after anaesthetic induction.

Results: From October 2004 to December 2008, 210 SLNB naive surgeons, in 103 centres, performed 6,685 SLNB procedures of which 31% (2,098/6,685) were node positive. The mentorship training model was followed in 87% (5,849/6,685). Scintigraphy identified axillary lymph node drainage in 85% (5,564/6,511) with an overall SLN localization rate of 98.9% (6,610/6,685, 95% CI 98.6% to 99.1%). Node positivity was higher (P<0.001) for failed (58.7%, 44/75) than successful (31.1%, 2054/6610) localizations. The mentorship false negative rate (FNR) was 8.9% (163/1821, 95% CI 7.7% to 10.4%). The median SLN yield was 2.0 (range 1-11).

SLN localization and FNR improved with surgeon caseload so that after 20 procedures the FNR fell below 10% but no statistically significant learning curve was identified. The FNR patients who had one SLN harvested was 14.8%. The FNR rate declined to 9.4%, 6.3%, 4.5% and 4.0% for those patients with 2, 3, 4 and more than 4 SLNs removed.

Conclusion: NEW START demonstrates that a standardized injection protocol and structured multi-professional training can abolish learning curves so ensuring patient safety during national adoption of a new technique. Tumor quadrant injection using both isotope and dye has a high localization rate and low false-negative rate. Failed localization indicates higher probability of axillary nodal involvement. It is not necessary to remove more than 4 SLNs to achieve a FNR of less than 5%.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-01.

Subjective distress predicts treatment seeking for depression, bipolar, anxiety, panic, neurasthenia and insomnia severity spectra

OBJECTIVE

To examine correlates of mental health treatment seeking such as gender, diagnosis, impairment, distress and mastery.

METHOD

Longitudinal epidemiological data from the Zurich Study of common psychiatric syndromes, including unipolar and bipolar depression, panic, anxiety, neurasthenia and insomnia, were utilized. In longitudinal Generalized Estimating Equations, treatment seeking was regressed on measures of subjective distress and impairment, childhood family problems, mastery and number of comorbid diagnoses.

RESULTS

Approximately half of all treated participants across all six syndromes suffered from subthreshold disorders. Meeting full or subthreshold diagnostic criteria was associated with treatment seeking for insomnia. Being female was associated with treatment seeking for depression. The only variable highly and consistently associated with treatment seeking, across all syndromes, was subjective distress. Treated participants reported high levels of distress, work and social impairment in both diagnostic and subthreshold groups.

CONCLUSION

Subjective distress may be a better indicator of treatment seeking than symptom count.

Seat-belt trauma of the breast in a pregnant woman causing milk-duct injury: a case report and review of the literature

Injury to the milk-duct following a road traffic accident has not been reported in the literature. This case report describes a 25-year-old postpartum lady with massive swelling of the breast due to milk-duct injury and collection of milk within the breast. We describe the possible mechanism of milk-duct injury, its presentation and management, and also review the literature on seat-belt injury to the breast.

Perceptions and needs of parents during a young adult's first psychiatric hospitalization: "we're all on this little island and we're going to drown real soon"

A young person's first psychiatric hospitalization can present a crisis for the family. This initial contact with the mental health care system and health care providers, whether positive or negative, has the potential to set the foundation for all future interactions. The purpose of this study was to examine the impact of a young person's first hospitalization on his or her parents and to determine the parents' perspectives on their own emotional and practical support needs. Ten parents (nine mothers and one father) of a young person aged 18 to 25 were recruited through local support groups and by snowball sampling. Based on Aguilera and Messick's (1986) crisis theory, participants were asked about their perception of the event, coping methods they used, and support systems they engaged while their adult child was hospitalized. Six themes were identified: feeling relief about receiving a diagnosis; shock and disbelief associated with the diagnosis of a mental illness; isolation associated with the stigma of mental illness; feeling excluded during the discharge process; and grieving for the loss associated with an altered future. The results revealed that participants received their support from family, friends, and support groups and did not find mental health care providers to be helpful or supportive. The participants provided recommendations for those who work with families experiencing the crisis of a first psychiatric hospitalization.

Intra-Operative Assessment of Sentinel Lymph Nodes with Touch Imprint Cytology – Experience on 232 Patients with Breast Cancer

IntroductionSentinel lymph nodes (SLNs) are generally evaluated by histology which takes about 3-5 days and axillary clearance is then carried out if SLN is positive for metastasis. This second operation to perform axillary clearance can be avoided, if a reliable intraoperative assessment is available. This will allow the surgeon to proceed to axillary clearance during the primary operation if intra-operative assessment of SLNs is positive. Touch imprint cytology (TIC), is a relatively new technique for intraoperative assessment. This study aimed to evaluate the accuracy and feasibility of TIC in our practice.MethodsThis was a prospective study of 232 patients with breast cancer. SLN biopsy was performed first and sent for TIC while surgeon proceeded with wide local excision or mastectomy. In pathology, nodes less than 5mm were bisected and others were sliced at 2mm intervals.Each cut surface was touched onto a slide allowing the weight of the node to release the cells onto the slide. The slides were assessed by dedicated breast pathologists and the results telephoned to theatre. If TIC was positive, axillary clearance was performed. Permanent histological sections were evaluated with hematoxylin and eosin stain and immuno-histochemical staining. The TIC results were compared with the final histology of the SLN. We calculated the accuracy, sensitivity, specificity, positive predictive and negative predictive value of TIC. The time required for intra-operative assessment was recorded prospectively in the last 30 patients. We also calculated the percentage of patients who were spared from having a second operation for axillary clearance based on the results of TIC.ResultsAccuracy of TIC was 90%. Sensitivity and specificity was 54% and 100% respectively. Positive and negative predictive value was 100% and 88% respectively. On final histology, 52 patients (22%) were node positive. TIC diagnosed metastasis in 28(54%) patients (95% Confidence Interval 0.39-0.67). Thus 28 patients (54%) avoided a second operation. Among patients with falsely negative TIC, micrometastasis was seen in 6/24(25%) patients and isolated tumour cells in 1/24(4%) patient. Average time from harvesting of the nodes to receiving of result of the TIC for each patient was 32 minutes (range 15-53). This was proportional to the number of nodes sent. Average time taken by cytopathologist was 15 minutes. Prolongation of operation time was seen in only 22% patients on an average by 7 minutes (range 2-15).ConclusionsTIC is a simple and feasible technique with prolongation of operation time seen in only 22% patients on an average by 7 minutes. It is a reliable technique with an accuracy of 90%. No patient was subjected to unnecessary axillary clearance. Patients should however be counseled preoperatively about chance of false negative results on TIC and need for a second operation. TIC avoided a second operation for axillary lymph node clearance in 54% patients and thus also avoided delay in the adjuvant treatment of these patients.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1030.

The relationship between early suicide behaviors and mental health: results from a nine-year panel study

This paper employs community-level data to examine the relationship between suicide behaviors, measured at age eleven, and two mental health outcomes assessed nine-years later. Specifically, we assess the role and significance of suicide ideation and suicide attempts in substance dependence and depressive symptomatology. We evaluate these linkages in the context of two hypothesized mediators: exposure to social stress and T-1 depressive symptoms. Results indicate suicide ideation and attempts are significant predictors of later mental health problems. However, controlling for T-1 depression and stress exposure explains away the relationship between suicide attempts and later mental health. In contrast, suicide ideation remained a robust predictor of depression and drug dependence. The implications of these findings are discussed.