Physiotherapy practice patterns for patients undergoing surgery for lung cancer: a survey of hospitals in Australia and New Zealand

BACKGROUND

There has been a recent increase in the research available to guide physiotherapy management of patients who require surgical resection for lung cancer. It is unclear whether this evidence has influenced clinical practice.

AIM

To describe physiotherapy practice patterns in the preoperative and postoperative management of patients who undergo surgical resection for lung cancer.

METHODS

Physiotherapists involved in the management of patients who require surgical resection for lung cancer at hospitals across Australia and New Zealand were mailed a purpose-designed questionnaire.

RESULTS

The response rate was 91% (43/47). Prior to surgery, 40% (n = 17) of the respondents indicated that patients were not assessed by a physiotherapist. In most hospitals (n = 39; 91%), patients did not participate in supervised exercise training before surgery. Most commonly, physiotherapy was commenced on the day following surgery (n = 39; 91%), with walking-based exercise being the treatment that was most frequently implemented in all patients (n = 40; 93%). Seventy-two per cent of respondents referred less than 25% of patients to pulmonary rehabilitation on discharge from hospital. Physiotherapy assessment and treatment choices were influenced predominantly by established practice in the hospital and personal experience rather than research findings.

CONCLUSION

In people who undergo surgical resection for lung cancer, physiotherapy services focused on reducing or preventing postoperative pulmonary complications. Despite recent data suggesting that exercise training is beneficial in this population, our data indicate that referral to pulmonary rehabilitation was uncommon.

Low cost and batteryless sensor-enabled radio frequency identification tag based approaches to identify patient bed entry and exit posture transitions

INTRODUCTION

Falls in hospitals and residential care facilities commonly occur near the bed. The aim of this study was to investigate the accuracy of a continuously wearable, batteryless, low power and low cost monitoring device (Wearable Wireless Identification and Sensing Platform) with a single kinematic sensor capable of real-time monitoring to automatically detect bed entry and exit events.

MATERIALS AND METHODS

Three dimensional acceleration readings and the strength of the transmitted signal from the WISP was interpreted to identify bed exit events and sensitivity, specificity and Receiving Operator Curves (ROC) were determined.

RESULTS

The sensor located over sternum method performed best with sensitivity and specificity values of 92.8% and 97.5% respectively for detecting bed entry and values of 90.4% and 93.80% respectively for bed exit. On the other hand, the sensor-on-mattress algorithm achieved sensitivity and specificity values of 84.2% and 97.4% respectively for bed entry and 79% and 97.4% for bed exit detection.

CONCLUSION

The WISP located over the sternum method is the preferred method to detect bed entry and exit. However, further work in frail older people is required to confirm the performance of this method.

Somatic CALR mutations in myeloproliferative neoplasms with nonmutated JAK2

BACKGROUND

Somatic mutations in the Janus kinase 2 gene (JAK2) occur in many myeloproliferative neoplasms, but the molecular pathogenesis of myeloproliferative neoplasms with nonmutated JAK2 is obscure, and the diagnosis of these neoplasms remains a challenge.

METHODS

We performed exome sequencing of samples obtained from 151 patients with myeloproliferative neoplasms. The mutation status of the gene encoding calreticulin (CALR) was assessed in an additional 1345 hematologic cancers, 1517 other cancers, and 550 controls. We established phylogenetic trees using hematopoietic colonies. We assessed calreticulin subcellular localization using immunofluorescence and flow cytometry.

RESULTS

Exome sequencing identified 1498 mutations in 151 patients, with medians of 6.5, 6.5, and 13.0 mutations per patient in samples of polycythemia vera, essential thrombocythemia, and myelofibrosis, respectively. Somatic CALR mutations were found in 70 to 84% of samples of myeloproliferative neoplasms with nonmutated JAK2, in 8% of myelodysplasia samples, in occasional samples of other myeloid cancers, and in none of the other cancers. A total of 148 CALR mutations were identified with 19 distinct variants. Mutations were located in exon 9 and generated a +1 base-pair frameshift, which would result in a mutant protein with a novel C-terminal. Mutant calreticulin was observed in the endoplasmic reticulum without increased cell-surface or Golgi accumulation. Patients with myeloproliferative neoplasms carrying CALR mutations presented with higher platelet counts and lower hemoglobin levels than patients with mutated JAK2. Mutation of CALR was detected in hematopoietic stem and progenitor cells. Clonal analyses showed CALR mutations in the earliest phylogenetic node, a finding consistent with its role as an initiating mutation in some patients.

CONCLUSIONS

Somatic mutations in the endoplasmic reticulum chaperone CALR were found in a majority of patients with myeloproliferative neoplasms with nonmutated JAK2. (Funded by the Kay Kendall Leukaemia Fund and others.).

Differences in the perceived role of the healthcare provider in delivering vascular health checks: a Q methodology study

BACKGROUND

The UK Department of Health introduced the National Health Service (NHS) Health Check Programme in April 2009 in an attempt to improve primary and secondary prevention of cardiovascular disease in the UK population and to reduce health inequalities. Healthcare professionals' attitudes towards giving lifestyle advice will influence how they interact with patients during consultations. We therefore sought to identify the attitudes of primary care healthcare professionals towards the delivery of lifestyle advice in the context of the NHS Health Check Programme.

METHODS

Fifty-two primary care healthcare professionals undertook a Q sort with 36 statements that represented a range of viewpoints about the importance of lifestyle change, medication, giving lifestyle advice in the primary care setting, and the individual, social and material factors that might impact on lifestyle related behaviour change. Sorts were analysed by-person using principal components analysis and varimax rotation.

RESULTS

Five statistically independent factors (accounts) reflected distinct views on the topic. Account 1 was supportive of initiatives like the NHS Health Check, and emphasised the importance of professionals working collaboratively with patients to facilitate lifestyle change. Account 2 expressed views on the potential overuse of statin medication and placed responsibility for lifestyle change with the patient. Account 3 viewed the healthcare professional role to be one of educator, emphasising the provision of information. Account 4 perceived lifestyle change to be difficult for patients and emphasised the need for healthcare professionals to be role models. Account 5 was inconsistent about the value of lifestyle change, or the role of healthcare professionals in promoting it, a finding that may be due to ambivalence about the health check or to lack of engagement with the Q sort task. We found no strong associations between any of the factors and, gender, role, age or ethnicity.

CONCLUSIONS

Our findings suggest that healthcare professionals hold viewpoints that may influence how they interact with patients during health checks. When implementing programmes like the NHS Health Check, it would be useful to take healthcare professionals' views into account. Attitudes and beliefs could be explored during training sessions, for example.

Trade-Offs between female food acquisition and child care among hiwi and ache foragers

Even though female food acquisition is an area of considerable interest in hunter-gatherer research, the ecological determinants of women's economic decisions in these populations are still poorly understood. The literature on female foraging behavior indicates that there is considerable variation within and across foraging societies in the amount of time that women spend foraging and in the amount and types of food that they acquire. It is possible that this heterogeneity reflects variation in the trade-offs between time spent in food acquisition and child care activities that women face in different groups of hunter-gatherers. In this paper we discuss the fitness trade-offs between food acquisition and child care that Hiwi and Ache women foragers might face. Multiple regression analyses show that in both populations the daily food acquisition of a woman's spouse is negatively related to female foraging effort. In addition, nursing mothers spend less time foraging and acquire less food than do nonnursing women. As the number of dependents that a woman has increases, however, women also increase foraging time and the amount of food they acquire. Some interesting exceptions to these general trends are as follows: (a) differences in foraging effort between nursing and nonnursing women are less pronounced when fruits and roots are in season than in other seasons of the year; (b) foraging return rates decrease for Ache women as their numbers of dependents increase; and (c) among Ache women, the positive effect of number of dependents on foraging behavior is less pronounced when fruits are in season than at other times of the year. Lastly, in the Hiwi sample we found that postreproductive women work considerably harder than women of reproductive age in the root season but not in other seasons of the year. We discuss how ecological variation in constraints, the number of health insults to children that Hiwi and Ache mothers can avoid, and the fitness benefits they can gain from spending time in food acquisition and child care might account for differences and similarities in the foraging behaviors of subgroups of Hiwi and Ache mothers across different seasons of the year. Valid tests of the explanations we propose will require considerable effort to measure the relationship between maternal food acquisition, child care, and adverse health outcomes in offspring.

Significant decline in Galactomannan Signal during storage of clinical serum samples

Galactomannan (GM) is widely used for detection of invasive aspergillosis in high-risk haemato-oncology patients. Recent publications have reported a lack of repeatability of GM detection. The objective of this retrospective study was to assess the repeatability of GM levels during storage of clinical samples. In a GM screening strategy, positive sera were repeat tested as per manufacturer’s recommendations. Short-term (ST) storage of samples was at +4 °C while long-term (LT) storage was at −80 °C. Bronchoalveolar (BAL) fluid was also repeating tested after ST storage and LT storage. Wilcoxon Signed Ranks Test was employed to assess the repeatability of GM levels. In a subset of 14 GM positive sera, repeat testing was performed on both the original serum and ethylenediaminetetraacetic acid (EDTA) pre-treated sample. There was a significant reduction in GM signals on repeat testing following ST storage (median GM index: 0.65 vs. 0.19; p < 0.001) and LT storage (median GM index: 0.56 vs. 0.10; p < 0.001) of serum samples. Of samples that were initially GM positive, an average GM index reduction of 50% was seen, with approximately two-thirds becoming GM negative on repeat testing of the same sample. In contrast, GM signal loss was not seen on repeat testing of BAL fluid following ST or LT storage. When GM positive serum samples were repeat tested using EDTA pre-treated serum from the first step of the testing protocol, all samples remained GM positive. In contrast, when the same samples were repeat tested from the original collected serum, 9 samples (64%) became GM negative. The significant reduction in GM signals during ST and LT storage of serum samples has implications for clinical management. Although the reasons for GM decline are unknown, they occur prior to the EDTA pre-treatment stage, indicating that the time from phlebotomy to testing should be minimized. BAL fluid GM index values remain stable.

Effect of ribotype on all-cause mortality following Clostridium difficile infection

BACKGROUND

Clostridium difficile infection (CDI) is significantly associated with subsequent all-cause mortality. Although a number of studies have investigated mortality associated with CDI, few have compared all-cause mortality between ribotypes.

AIM

We aimed to estimate all-cause mortality following CDI and to investigate the relationship between mortality, ribotype and other available variables.

METHODS

We undertook a retrospective cohort study. All patients with toxin-positive CDI in North East England between July 2009 and June 2011 were matched to death registration data. Differences in all-cause 30-day case fatality were explored using Poisson regression with robust error variances. For survival analysis, an accelerated failure time model with generalized gamma distribution was chosen.

FINDINGS

In total, 1426 patients were included. All-cause case fatality was 10.2%, 16.4%, 25.7% and 38.1% at 7, 14, 30 and 90 days respectively. In multivariate analysis, ribotype 027 (risk ratio: 1.34; 95% confidence interval: 1.02-1.75) and ribotype 015 (0.46; 0.26-0.82) were significantly associated with higher and lower all-cause 30-day case fatality rates, respectively. In survival analysis, only ribotype 015 had significantly lower predicted mortality (P = 0.008). Patients whose infection was hospital-acquired had significantly higher predicted mortality (P < 0.001).

CONCLUSION

This is the first population-based study of comparative mortality between multiple ribotypes. Our study identified a high rate of all-cause mortality following CDI. We found evidence of variability in mortality between ribotypes in this cohort with mortality significantly higher for ribotype 027 at 30 days following diagnosis and significantly lower for ribotype 015.

Mumps virus encephalomyelitis in a 19-year old male patient with an undefined severe combined immunodeficiency post-haematopoietic bone marrow transplantation: a rare fatal complication

We describe a rare case of fatal mumps encephalomyelitis occurring in 19-year old male following matched unrelated donor peripheral blood haematopoietic stem cell transplantation (HSCT). The indication for HSCT was for an undefined form of severe combined immunodeficiency (SCID). Molecular typing of the mumps viral RNA isolated from neural tissue indicated that the infection was acquired at the time of a mumps outbreak in England and Wales that occurred between 2004 and 2006. This case highlights the importance of considering mumps in the differential diagnosis of central nervous system infection in highly immunosuppressed patients.

The potential impact of washing machines on laundry malodour generation

A multidisciplinary approach has been adopted to investigate and identify the source of malodour in washing machines and the potential for cross-contamination of laundry. Four washing machines were olfactively graded, and the number of colony-forming units (CFUs) bacteria was determined in four specific locations. Then, samples of terry-towel and fleece were washed, without the use of detergent, in the machines, and the occurrence of malodour over a 52-h period was assessed. Analysis of the scrapings from the four locations in the two malodorous machines identified a plethora of volatile organic compounds (VOCs) by either olfactory detection or mass spectral identification post-gas chromatographic separation. In addition, microbiological analysis from the swabs from the four locations within all four washing machines was carried out. Quantitative analysis of VOCs from 66 microbiological isolates from either the washing machines or fabrics was carried out. In total, 10 VOCs were identified: dimethyl disulfide, 3-methyl-1-butanol, 2,4-dithiapentane, dimethyl trisulfide, 2-tridecanone, indole, 2-phenylethanol, isovaleric acid, isobutyric acid and 1-undecene.

Formation and stability of impurity "snakes" in tokamak plasmas

New observations of the formation and dynamics of long-lived impurity-induced helical "snake" modes in tokamak plasmas have recently been carried out on Alcator C-Mod. The snakes form as an asymmetry in the impurity ion density that undergoes a seamless transition from a small helically displaced density to a large crescent-shaped helical structure inside q<1, with a regularly sawtoothing core. The observations show that the conditions for the formation and persistence of a snake cannot be explained by plasma pressure alone. Instead, many features arise naturally from nonlinear interactions in a 3D MHD model that separately evolves the plasma density and temperature.

Further developments in indirect mortality estimation

Summary A variety of indirect estimators of mortality; survival of children by marriage duration of mother, survival of first spouse by marriage duration and by age, maternal orphanhood, and survival of siblings, are investigated by the use of a wide range of model fertility and mortality situations. Survival probabilities are then related by regression analysis to the proportions with a particular characteristic, to yield an equation which can then be used to estimate the survival probability in a population. Maternal orphanhood and survival of first spouse by age have already shown themselves to be useful, and the new developments are only simplifications of the existing methodology. Survival of first spouse by duration of marriage, and survival of siblings are, however, new methods which have yet to be justified by field experience. In conclusion, the features common to all indirect mortality estimation procedures are outlined, and the direction future developments may take in response to gradually improving data quality is suggested.

Molybdenum emission from impurity-induced m = 1 snake-modes on the Alcator C-Mod tokamak

A suite of novel high-resolution spectroscopic imaging diagnostics has facilitated the identification and localization of molybdenum impurities as the main species during the formation and lifetime of m = 1 impurity-induced snake-modes on Alcator C-Mod. Such measurements made it possible to infer, for the first time, the perturbed radiated power density profiles from which the impurity density can be deduced.

Epidemiological survey of Clostridium difficile ribotypes in the North East of England during an 18-month period

During an 18-month period, 1606 stool specimens from laboratory-confirmed cases of Clostridium difficile infection in the North East of England were ribotyped using unrestricted polymerase chain reaction. Of these, 87.6% grew C. difficile on culture; 70% had one of 10 recognizable ribotypes of which 001, 106 and 027 were the most prevalent. The proportions of ribotypes 002 and 015 declined during the study period, whereas ribotypes 016 and 023 increased. Ribotype 005 was significantly more numerous in males and ribotype 027 was associated with significantly higher mean age. Our findings differ from national data derived from more selective testing.

P4-01-04: Effects of CYP2D6 Phenotype and Drug Adherence on Tamoxifen Metabolite Levels

Background

Although the activity of cytochrome P450 2D6 (CYP2D6), the enzyme responsible for conversion of tamoxifen (TAM) to its most important active metabolite endoxifen, varies significantly with genotype. Routine genotype testing in patients on TAM has recently been discouraged. Conflicting results in publications regarding the prognostic utility of this test remain unexplained. Confounding factors could be lack of predicted correlation between CYP2D6 genotype and TAM active metabolites, or variability of patient compliance

Methods: Consecutive breast cancer patients on TAM were asked to enroll in a study to examine the relationship between CYP 2D6 phenotype, patient-reported treatment adherence, and TAM metabolites levels. Patients were genotyped for CYP2D6 polymorphisms using long-range PCR allele-specific amplification and single-nucleotide primer extension assay. From the genotypes, four phenotype groups were defined: Ultra rapid Metabolizer (UM), Extensive Metabolizer (EM), Intermediate Metabolizer (IM) and Poor Metabolizer (PM). Plasma was collected after at least 6 weeks of TAM (20 mg daily). The parent drug TAM, as well as 4-hydroxy N-desmethyl tamoxifen (endoxifen), 4 hydroxy tamoxifen (4OHtam) and N-desmethyl-tamoxifen (NDtam), were determined by Liquid Chromatography tandem mass-spectrometry (LC-MS/MS). Patients also completed a questionnaire about ethinicity, side effects, concurrent medications and tamoxifen adherence. Correlation between metabolite/TAM ratio and phenotype was tested by Spearman correlation test. Relationship between metabolite levels and adherence was tested by Wilcoxon rank sum test. Chi square test was used to compare proportions.

Results: Of the 100 patients enrolled there were 62 Caucasians, 25 Asians, 4 Africans and 6 Unknown. We found a strong correlation between ratio of endoxifen/TAM and phenotype (p &lt;.0001) (Table 1) Over a 2 week period 68 never missed a TAM dose, 25 missed 1–2 times, 2 missed 3–5 times and 2 &gt; 5times (2 missing data). In EM group we found significantly lower levels of TAM (p &lt;.0001), NDtam (p=.008), 4OHtam (p=.003) in less adherent patients. A trend to decreased levels was also shown for endoxifen (p=.081). No associations were found between adherence or phenotype activity and side effects.