Polarimetry diagnostic on OMEGA EP using a 10-ps, 263-nm probe beam

A polarimetry diagnostic was built and characterized for magnetic-field measurements in laser-plasma experiments on the OMEGA EP laser. This diagnostic was built into the existing 4ω (263-nm) probe system that employs a 10-ps laser pulse collected with an f/4 imaging system. The diagnostic measures the rotation of the probe beam's polarization. The polarimeter uses a Wollaston prism to split the probe beam into orthogonal polarization components. Spatially localized intensity variations between images indicate polarization rotation. Magnetic fields can be calculated by combining the polarimetry data with the measured plasma density profile obtained from angular filter refractometry.

Abstract 3388: The CD44s splice isoform is essential for breast tumor initiating cell properties

Tumor initiating cells (TICs) constitute a small fraction of tumor cells that display stem cell characteristics, including the ability to self-renew and generate heterogeneous tumors. A CD44+/CD24- profile has been widely used to identify TICs in a variety of tumors. However, it has remained unknown whether CD44 is functionally required for TICs and whether a specific CD44 isoform is enriched in TICs. Here, we report that the CD44s isoform is the major splice isoform expressed in a CD44+/CD24- breast stem cell population. Functionally, CD44s is required for expression of a breast stem cell (BSC) gene signature and is essential for mammosphere formation. Modulation of CD44 alternative splicing by the splicing regulator ESRP1 prevents CD44s production and, in turn, inhibits mammosphere formation and expression of the BSC signature. Furthermore, CD44s is required for limiting numbers of TICs to form tumors in an animal model of breast cancer progression. Together, these data illustrate that the CD44s splice isoform is enriched in CD44+/CD24- breast stem cells and serves as an important regulator of stem cell properties. Our results also suggest that CD44s-dependent TIC properties can be controlled at the level of alternative splicing by splicing factors that regulate production of specific CD44 isoforms.

Citation Format: Rhonda Brown, Sali Liu, Lauren Reinke, Chonghui Cheng. The CD44s splice isoform is essential for breast tumor initiating cell properties. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 3388. doi:10.1158/1538-7445.AM2014-3388

Quality care outcomes following transitional care interventions for older people from hospital to home: a systematic review

BACKGROUND

Provision of high quality transitional care is a challenge for health care providers in many western countries. This systematic review was conducted to (1) identify and synthesise research, using randomised control trial designs, on the quality of transitional care interventions compared with standard hospital discharge for older people with chronic illnesses, and (2) make recommendations for research and practice.

METHODS

Eight databases were searched; CINAHL, Psychinfo, Medline, Proquest, Academic Search Complete, Masterfile Premier, SocIndex, Humanities and Social Sciences Collection, in addition to the Cochrane Collaboration, Joanna Briggs Institute and Google Scholar. Results were screened to identify peer reviewed journal articles reporting analysis of quality indicator outcomes in relation to a transitional care intervention involving discharge care in hospital and follow-up support in the home. Studies were limited to those published between January 1990 and May 2013. Study participants included people 60 years of age or older living in their own homes who were undergoing care transitions from hospital to home. Data relating to study characteristics and research findings were extracted from the included articles. Two reviewers independently assessed studies for risk of bias.

RESULTS

Twelve articles met the inclusion criteria. Transitional care interventions reported in most studies reduced re-hospitalizations, with the exception of general practitioner and primary care nurse models. All 12 studies included outcome measures of re-hospitalization and length of stay indicating a quality focus on effectiveness, efficiency, and safety/risk. Patient satisfaction was assessed in six of the 12 studies and was mostly found to be high. Other outcomes reflecting person and family centred care were limited including those pertaining to the patient and carer experience, carer burden and support, and emotional support for older people and their carers. Limited outcome measures were reported reflecting timeliness, equity, efficiencies for community providers, and symptom management.

CONCLUSIONS

Gaps in the evidence base were apparent in the quality domains of timeliness, equity, efficiencies for community providers, effectiveness/symptom management, and domains of person and family centred care. Further research that involves the person and their family/caregiver in transitional care interventions is needed.

Prostate cancer cell malignancy via modulation of HIF-1α pathway with isoflurane and propofol alone and in combination

Background:

Surgery is considered to be the first line treatment for solid tumours. Recently, retrospective studies reported that general anaesthesia was associated with worse long-term cancer-free survival when compared with regional anaesthesia. This has important clinical implications; however, the mechanisms underlying those observations remain unclear. We aim to investigate the effect of anaesthetics isoflurane and propofol on prostate cancer malignancy.

Methods:

Prostate cancer (PC3) cell line was exposed to commonly used anaesthetic isoflurane and propofol. Malignant potential was assessed through evaluation of expression level of hypoxia-inducible factor-1α (HIF-1α) and its downstream effectors, cell proliferation and migration as well as development of chemoresistance.

Results:

We demonstrated that isoflurane, at a clinically relevant concentration induced upregulation of HIF-1α and its downstream effectors in PC3 cell line. Consequently, cancer cell characteristics associated with malignancy were enhanced, with an increase of proliferation and migration, as well as development of chemoresistance. Inhibition of HIF-1α neosynthesis through upper pathway blocking by a PI-3K-Akt inhibitor or HIF-1α siRNA abolished isoflurane-induced effects. In contrast, the intravenous anaesthetic propofol inhibited HIF-1α activation induced by hypoxia or CoCl₂. Propofol also prevented isoflurane-induced HIF-1α activation, and partially reduced cancer cell malignant activities.

Conclusions:

Our findings suggest that modulation of HIF-1α activity by anaesthetics may affect cancer recurrence following surgery. If our data were to be extrapolated to the clinical setting, isoflurane but not propofol should be avoided for use in cancer surgery. Further work involving in vivo models and clinical trials is urgently needed to determine the optimal anaesthetic regimen for cancer patients.

Can consultation skills training change doctors' behaviour to increase involvement of patients in making decisions about standard treatment and clinical trials: a randomized controlled trial

BACKGROUND

Informed consent is required for both standard cancer treatments and experimental cancer treatments in a clinical trial. Effective and sensitive physician-patient communication about informed consent is difficult to achieve. Our aim was to train doctors in clear, collaborative and ethical communication about informed consent and evaluate the impact of training on doctor behaviour, stress and satisfaction.

PARTICIPANTS AND METHODS

Participants were 21 oncologists from 10 Australian/New Zealand (ANZ) centres and 41 oncologists from 10 Swiss/German/Austrian (SGA) centres. Oncologists were randomized to participate in a 1-day workshop or not. Patients were recruited before and after the training. Doctors were asked to submit 1-2 audiotaped consultations before and after training. Doctors completed outcome measures before and after completing the post-training cohort recruitment.

RESULTS

Ninety-five consultation interactions were audiotaped. Doctors strongly endorsed the training. ANZ intervention doctors demonstrated a significant increase in collaborative communication (P = 0.03). There was no effect of training on other doctor behaviours. Trained doctors did not demonstrate reduced stress and burnout. Patient outcomes are presented elsewhere.

CONCLUSIONS

Training can improve some aspects of the process of obtaining informed consent. Methods to increase the impact of training are required and may include longer training and more intensive follow-up.

Is it helpful to give older people with cancer the same chance at rehabilitation as older general medical patients?

Although the complexity of age combined with a cancer diagnosis can result in unmet supportive care needs there are seldom resources to assess or address such needs for older people with cancer (OPWC). The purpose of this project was to trial a service to improve the care for OPWC through (1) an expanded supportive care screening process and (2) capacity building of subacute ambulatory care services (SACS) staff to increase referrals to community-based rehabilitation.

METHODS/DESIGN

Collaboration between allied health (AH) staff at an inner city general hospital with a large cancer service, a cancer specialist hospital, and a SACS service in Melbourne, Australia, developed an AH geriatric screening assessment (GSA) tool. Parallel to this process training was provided to SACS staff in relation to working with OPWC. Although close to one half (44%) of SACS staff who participated in this program (n = 22) had over 6 years' experience, 32% had not worked with OPWC. Prior to training, 81% did not feel confident in their knowledge about working with this cohort. After their training 72% were more confident about normal aging and implications for care of OPWC. Of the 491 patients screened, 80% were older than age 65, however, only 25 resided in the SACS catchment area. More than one third of these did not have clear rehabilitation needs, and the remainder were not referred due to ongoing medical issues. Less than one half of the patients in the catchment area were discussed in a Multi-disciplinary Meeting (MDM) but all were referred to allied health and assessed using the GSA. Although this project did not result in referrals of OPWC to SACS the training program for SACS staff was a success and allied health assessments were improved to include GSA factors. The complexity of care for OPWC was further highlighted through interviews with staff involved with the study.

A randomised, phase II trial of the DNA-hypomethylating agent 5-aza-2'-deoxycytidine (decitabine) in combination with carboplatin vs carboplatin alone in patients with recurrent, partially platinum-sensitive ovarian cancer

BACKGROUND

Our previous laboratory and clinical data suggested that one mechanism underlying the development of platinum resistance in ovarian cancer is the acquisition of DNA methylation. We therefore tested the hypothesis that the DNA hypomethylating agent 5-aza-2'-deoxycytodine (decitabine) can reverse resistance to carboplatin in women with relapsed ovarian cancer.

METHODS

Patients progressing 6-12 months after previous platinum therapy were randomised to decitabine on day 1 and carboplatin (AUC 6) on day 8, every 28 days or carboplatin alone. The primary objective was response rate in patients with methylated hMLH1 tumour DNA in plasma.

RESULTS

After a pre-defined interim analysis, the study closed due to lack of efficacy and poor treatment deliverability in 15 patients treated with the combination. Responses by GCIG criteria were 9 out of 14 vs 3 out of 15 and by RECIST were 6 out of 13 vs 1 out of 12 for carboplatin and carboplatin/decitabine, respectively. Grade 3/4 neutropenia was more common with the combination (60% vs 15.4%) as was G2/3 carboplatin hypersensitivity (47% vs 21%).

CONCLUSIONS

With this schedule, the addition of decitabine appears to reduce rather than increase the efficacy of carboplatin in partially platinum-sensitive ovarian cancer and is difficult to deliver. Patient-selection strategies, different schedules and other demethylating agents should be considered in future combination studies.

The impact of age and chronic kidney disease on secondary prevention post-primary percutaneous coronary intervention

OBJECTIVE

Historical data suggest elderly patients and those with chronic kidney disease (CKD) receive suboptimal secondary prevention following myocardial infarction (MI). We evaluated the impact of age and CKD on secondary prevention following primary percutaneous coronary intervention (PPCI) in a contemporary unselected cohort.

DESIGN

We studied 1169 consecutive patients from five UK centres receiving PPCI for ST elevation MI, with use of evidence-based secondary prevention at discharge assessed by age (<60, 60-75 and >75 years) and estimated glomerular filtration rate (eGFR). Follow-up prescribing practice was assessed in 567 patients.

RESULTS

One-fifth of patients receiving PPCI were >75 years. This group received fewer secondary prevention drugs at discharge compared to younger patients (P < 0.01 for β-blockers, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARB) and statins). By 6 weeks post-PPCI, there was a small drop-off in evidence-based therapy; β-blocker and statin use in those >75 years fell from 90% to 86% and 96% to 93%, respectively. CKD (eGFR<60 ml/min/1.73 m(2)) was seen in 17.6%. Declining renal function was associated with age, female sex and lower use of ACE inhibitor/ARB. At discharge 83.5% of patients with eGFR<60 ml/min/1.73 m(2) were receiving ACE inhibitors/ARB, dropping to 77.5% at 6 weeks (compared with 95% and 92%, respectively, in patients with eGFR >60 ml/min/1.73 m(2)).

CONCLUSION

The uptake of secondary prevention medication is high following PPCI in the UK, even in the elderly and in those with renal dysfunction. A focus on strategies to improve up-titration and continuation of drugs following discharge is required.

Climate Change and Nutrition: Creating a Climate for Nutrition Security

Background

Climate change further exacerbates the enormous existing burden of undernutrition. It affects food and nutrition security and undermines current efforts to reduce hunger and promote nutrition. Undernutrition in turn undermines climate resilience and the coping strategies of vulnerable populations.

Objectives

The objectives of this paper are to identify and undertake a cross-sectoral analysis of the impacts of climate change on nutrition security and the existing mechanisms, strategies, and policies to address them.

Methods

A cross-sectoral analysis of the impacts of climate change on nutrition security and the mechanisms and policies to address them was guided by an analytical framework focused on the three ‘underlying causes’ of undernutrition: 1) household food access, 2) maternal and child care and feeding practices, 3) environmental health and health access. The analytical framework includes the interactions of the three underlying causes of undernutrition with climate change, vulnerability, adaptation and mitigation.

Results

Within broad efforts on climate change mitigation and adaptation and climate-resilient development, a combination of nutrition-sensitive adaptation and mitigation measures, climate-resilient and nutrition-sensitive agricultural development, social protection, improved maternal and child care and health, nutrition-sensitive risk reduction and management, community development measures, nutrition-smart investments, increased policy coherence, and institutional and cross-sectoral collaboration are proposed as a means to address the impacts of climate change to food and nutrition security. This paper proposes policy directions to address nutrition in the climate change agenda and recommendations for consideration by the UN Framework Convention on Climate Change (UNFCCC).

Conclusions

Nutrition and health stakeholders need to be engaged in key climate change adaptation and mitigation initiatives, including science-based assessment by the Intergovernmental Panel on Climate Change (IPCC), and policies and actions formulated by the UN Framework Convention on Climate Change (UNFCCC). Improved multi-sectoral coordination and political will is required to integrate nutrition-sensitive actions into climate-resilient sustainable development efforts in the UNFCCC work and in the post 2015 development agenda. Placing human rights at the center of strategies to mitigate and adapt to the impacts of climate change and international solidarity is essential to advance sustainable development and to create a climate for nutrition security.

Evaluation of Erytra® fully automated analyser for Routine Use in Transfusion Laboratory

OBJECTIVE

To evaluate efficiency and performance of Erytra® analyser in comparison to the reference platform of the NBT immunohaematology laboratory (Bio-Rad ID-System).

BACKGROUND

Moving to automation or semi-automation is a major focus of transfusion centres. The Erytra® (Grifols) is a new fully automated walk-away analyser with high volume processing capacity for pre-transfusion testing, designed to be used with the unique 8-column DG Gel® cards.

STUDY DESIGN AND METHODS

A total of 2201 immunohaematological tests (1041 ABO/D grouping, 1041 antibody screening, 51 antibody identification, 45 newborns (ABO/D and DAT) and 23 crossmatches were performed on 1160 donor/patient whole blood samples. Erytra®'s performance was assessed by means of a stress test replicating the routine work of a hospital laboratory.

RESULTS

Concordant results between the Erytra® and the reference method were obtained in 2195 (99·73 %) of the tests. There were only three discrepancies out of 6246 reactions (0·05%) in ABO/D grouping, all in the reverse group which did not mislead to group identification. Of the 1041 samples screened for antibody presence, Erytra® detected all the relevant antibodies [9 not detected weak prophylactic anti-D were determined to be clinically nonsignificant (<0·1 IU mL(-1) )] while Bio-Rad ID-System missed one anti-e and one anti-Jk(a) . Concordance for D grouping, crossmatching and newborns was 100%. Results of the simulated stress test exercise highlighted the capacity of Erytra® for absorbing into 4 h workloads equivalent to 24 h of routine.

CONCLUSIONS

Grifols' Erytra® analyser showed reliable high sensitivity, velocity and capacity to cope with high workload in the immunohaematology laboratory routine.

Doctors' experience of stress during simulated bad news consultations

OBJECTIVE

Breaking bad news (BBN) is a core component of medicine. Psychophysiological studies confirm the subjective reports of doctors that BBN is a stressful experience. This study investigated doctors' physiological stress responses prior to and during two simulated bad news consultations.

METHODS

Thirty-one doctors participated in a speech-interaction task and two simulated BBN consultations. Heart rate (HR) and skin conductance (SC) were recorded using consecutive 30-s epochs during each of the interactions. The simulations were video recorded.

RESULTS

Most doctors showed an early anticipatory increase in HR and SC that peaked during the reading of the case history prior to the BBN consultations. Most doctors then experienced a brief and relatively small stress response. However, about one-third of the doctors showed a significant and sustained stress response.

CONCLUSIONS

The results suggest that most doctors were cognitively engaged with the BBN tasks, however, a small proportion of doctors might have focused more on their own internal feelings and less on these contextual features.

PRACTICE IMPLICATIONS

In regards to training medical students and doctors, these results suggest that there is a need to focus more on the impact of these encounters on the doctors, not just their performance during these encounters.

Association of somatic DNA methylation variability with progression-free survival and toxicity in ovarian cancer patients

BACKGROUND

We have addressed whether inter-individual methylation variation in somatic (white blood cells, WBCs) DNA of ovarian cancer patients provides potential for prognostic and/or pharmacoepigenetic stratification.

PATIENTS AND METHODS

WBC DNA methylation was analysed by bisulphite pyrosequencing at ataxia telangiectasia mutated (ATM), estrogen receptor 1 (ESR1), progesterone receptor (PGR), mutL homologue 1 (MLH1), breast cancer susceptibility gene (BRCA1), secreted frizzled-related protein 1 (SFRP1), stratifin (SFN), retinoic acid receptor beta (RARB) loci and the repetitive element LINE1 in 880 SCOTROC1 trial patients [paclitaxel (Taxol)-carboplatin versus docetaxel (Taxotere)-carboplatin as primary chemotherapy for stage Ic-IV epithelial ovarian cancer].

RESULTS

We observed no significant associations (P < 0.005, after correction for multiple testing) for progression-free survival (PFS) using test and validation sets. However, we did identify mean SFN methylation associated with PFS (hazard ratio, HR = 1.01 per 1% increase in methylation, q = 0.028); particularly in the paclitaxel (HR = 1.01, q = 0.006), but not in the docetaxel arm in stratified analyses. Furthermore, higher methylation within the ESR1 gene was associated with CA125 response (odds ratio, OR = 1.06, q = 0.04) and with neuropathy (HR = 0.95, q = 0.002), but only in the paclitaxel arm of the trial.

CONCLUSIONS

This is the first study linking DNA methylation variability in WBC to clinical outcomes for any tumour type; the data generated on novel prognostic and pharmacoepigenetic DNA methylation biomarkers in the circulation now need independent further evaluation.

Internal Carotid Artery Occlusion

Objective:

To determine the incidence of recanalization of the occluded internal carotid artery (ICA) and establish its natural history.

Methods:

Patients with duplex-confirmed ICA occlusions were identified, and a subgroup offered repeat scanning. The antemortem condition and cause of death of patients who died were recorded.

Results:

Of 153 patients identified, 77 underwent follow-up at a median of 35 months (interquartile range [IQR]: 14-61).In all, 8 (10.3%) demonstrated recanalization at a median of 53 months (IQR: 35-114). Of 8, 7 underwent carotid endarterectomy with histopathological confirmation of recanalization. Of the 153 patients, 45 (29%) had further neurological events, and 38 (25%) were within the territory of the occluded ICA. In all, 76 patients died, and of the 53 with a confirmed cause of death, 12 (23%) were attributed to a cerebrovascular accident corresponding to the territory of the occluded artery.

Conclusion:

Recanalization of ICA occlusion is common and leads to significant neurological events. Duplex ultrasound follow-up appears mandatory.

The impact of thunderstorm asthma on emergency department attendances across London during July 2013

BACKGROUND

This study illustrates the potential of using emergency department attendance data, routinely accessed as part of a national syndromic surveillance system, to monitor the impact of thunderstorm asthma.

METHODS

The Emergency Department Syndromic Surveillance System (EDSSS) routinely monitors anonymised attendance data on a daily basis across a sentinel network of 35 emergency departments. Attendance data for asthma, wheeze and difficulty breathing are analysed on a daily basis.

RESULTS

A statistically significant spike in asthma attendances in two EDSSS emergency departments in London was detected on 23 July 2013, coinciding with a series of large violent thunderstorms across southern England. There was also an increase in the reported severity of these attendances.

CONCLUSIONS

This preliminary report illustrates the potential of the EDSSS to monitor the impact of thunderstorms on emergency department asthma attendances. Further work will focus on how this system can be used to quantify the impact on emergency departments, thus potentially improving resource planning and also adding to the thunderstorm asthma evidence-base.

Review of processing and analysis methods for DNA methylation array data

The promise of epigenome-wide association studies and cancer-specific somatic DNA methylation changes in improving our understanding of cancer, coupled with the decreasing cost and increasing coverage of DNA methylation microarrays, has brought about a surge in the use of these technologies. Here, we aim to provide both a review of issues encountered in the processing and analysis of array-based DNA methylation data and a summary of the advantages of recent approaches proposed for handling those issues, focusing on approaches publicly available in open-source environments such as R and Bioconductor. We hope that the processing tools and analysis flowchart described herein will facilitate researchers to effectively use these powerful DNA methylation array-based platforms, thereby advancing our understanding of human health and disease.

Long-term survival in multiple myeloma is associated with a distinct immunological profile, which includes proliferative cytotoxic T-cell clones and a favourable Treg/Th17 balance

Despite improved outcomes in multiple myeloma (MM), a cure remains elusive. However, even before the current therapeutic era, 5% of patients survived >10 years and we propose that immune factors contribute to this longer survival. We identified patients attending our clinic, who had survived >10 years (n=20) and analysed their blood for the presence of T-cell clones, T-regulatory cells (Tregs) and T helper 17 (Th17) cells. These results were compared with MM patients with shorter follow-up and age-matched healthy control donors. The frequency of cytotoxic T-cell clonal expansions in patients with <10 years follow-up (MM patients) was 54% (n=144), whereas it was 100% (n=19/19) in the long-survivors (LTS-MM). T-cell clones from MM patients proliferated poorly in vitro, whereas those from LTS-MM patients proliferated readily (median proliferations 6.1% and 61.5%, respectively (P<0.0001)). In addition, we found significantly higher Th17 cells and lower Tregs in the LTS-MM group when compared with the MM group. These results indicate that long-term survival in MM is associated with a distinct immunological profile, which is consistent with decreased immune suppression.

Estimating cancer risk in relation to tritium exposure from routine operation of a nuclear-generating station in Pickering, Ontario

Introduction

Evidence suggests that current levels of tritium emissions from CANDU reactors in Canada are not related to adverse health effects. However, these studies lack tritium-specific dose data and have small numbers of cases. The purpose of our study was to determine whether tritium emitted from a nuclear-generating station during routine operation is associated with risk of cancer in Pickering, Ontario.

Methods

A retrospective cohort was formed through linkage of Pickering and north Oshawa residents (1985) to incident cancer cases (1985–2005). We examined all sites combined, leukemia, lung, thyroid and childhood cancers (6–19 years) for males and females as well as female breast cancer. Tritium estimates were based on an atmospheric dispersion model, incorporating characteristics of annual tritium emissions and meteorology. Tritium concentration estimates were assigned to each cohort member based on exact location of residence. Person-years analysis was used to determine whether observed cancer cases were higher than expected. Cox proportional hazards regression was used to determine whether tritium was associated with radiation-sensitive cancers in Pickering.

Results

Person-years analysis showed female childhood cancer cases to be significantly higher than expected (standardized incidence ratio [SIR] = 1.99, 95% confidence interval [CI]: 1.08–3.38). The issue of multiple comparisons is the most likely explanation for this finding. Cox models revealed that female lung cancer was significantly higher in Pickering versus north Oshawa (HR = 2.34, 95% CI: 1.23–4.46) and that tritium was not associated with increased risk. The improved methodology used in this study adds to our understanding of cancer risks associated with low-dose tritium exposure.

Conclusion

Tritium estimates were not associated with increased risk of radiation-sensitive cancers in Pickering.

Operator training requirements and diagnostic accuracy of Fibroscan in routine clinical practice

BACKGROUND

Fibroscan is a quick, non-invasive technique used to measure liver stiffness (kPa), which correlates with fibrosis. To achieve a valid liver stiffness evaluation (LSE) the operator must obtain all the following three criteria: (1) ≥10 successful liver stiffness measurements; (2) IQR/median ratio <0.30 and (3) ≥60% measurement success rate.

OBJECTIVES

To assess the operator training requirements and the importance of adhering to the LSE validity criteria in routine clinical practice.

METHODS

We retrospectively analysed the LSE validity rates of 2311 Fibroscans performed (1 August 2008 to 31 July 2011) in our tertiary liver outpatients department at the University Hospital Birmingham, UK. The diagnostic accuracy of Fibroscan was assessed in 153 patients, by comparing LSE (valid and invalid) with the modified Ishak fibrosis stage on liver biopsy.

RESULTS

Learning curve analysis highlighted that the greatest improvement in validity of LSE rates occurs in the operator's first 10 Fibroscans, reaching 64.7% validity by the 50th Fibroscan. The correlation between LSE and the fibrosis stage on liver biopsy was superior in patients with a valid LSE (n=97) compared with those with an invalid LSE (n=56) (rs 0.577 vs 0.259; p=0.022). Area under receiving operating characteristics for significant fibrosis was greater when LSE was valid (0.83 vs 0.66; p=0.048). Using an LSE cut-off of 8 kPa, the negative predictive value of valid LSE was superior to invalid LSE for the detection of significant (84% vs 71%) and advanced fibrosis (100% vs 93%).

CONCLUSIONS

Fibroscan requires minimal operator training (≥10 observed on patients), and when a valid LSE is obtained, it is an accurate tool for excluding advanced liver fibrosis. To ensure the diagnostic accuracy of Fibroscan it is essential that the recommended LSE validity criteria are adhered to in routine clinical practice.

Can patients or clinicians predict the severity or duration of an acute upper respiratory infection?

PURPOSE

Acute upper respiratory infections (URI) are the second most common diagnosis in primary care offices. As treatments have limited effectiveness, patient counseling regarding expectations for the course of the URI is an important aspect of care. It is unknown how accurate patients, clinicians or questionnaires such as the Wisconsin Upper Respiratory Symptom Survey (WURSS) instrument are at predicting URI severity and duration, and whether these predictions should be used to counsel patients.

METHODS

Seven hundred and nineteen individuals with recent onset cold in community clinic settings participated. Participants and clinicians predicted the severity and duration of the URI and participants completed the WURSS instrument at initial visit. Subsequent URI global severity was calculated as area under the curve using an average of twice-daily WURSS-21 self-reports as the y-axis and illness duration as the x-axis. URI duration was determined by self-report of beginning and end of illness. Linear regression analysis was used to correlate baseline predictions with subsequent outcomes. Analyses by gender, age and income were also performed.

RESULTS

There was no significant association between participant and clinician predictions of severity or duration. Initial WURSS values explained 0.119 (95% CI: 0.074-0.163) of the variance in subsequent severity outcomes. There were no significant differences in associations by age, gender or income.

CONCLUSIONS

Clinicians should not use their predictive assessments or their patients' predictions when advising patients on the expected course of a URI. This study also suggests that the WURSS instrument could give some predictive information, but whether this is clinically useful is uncertain.

Influence of oxygenated organic aerosols (OOAs) on the oxidative potential of diesel and biodiesel particulate matter

Generally, the magnitude of pollutant emissions from diesel engines running on biodiesel fuel is ultimately coupled to the structure of the fuel's constituent molecules. Previous studies demonstrated the relationship between the organic fraction of particulate matter (PM) and its oxidative potential. Herein, emissions from a diesel engine running on different biofuels were analyzed in more detail to explore the role that different organic fractions play in the measured oxidative potential. In this work, a more detailed chemical analysis of biofuel PM was undertaken using a compact time of flight aerosol mass spectrometer (c-ToF AMS). This enabled a better identification of the different organic fractions that contribute to the overall measured oxidative potentials. The concentration of reactive oxygen species (ROS) was measured using a profluorescent nitroxide molecular probe 9-(1,1,3,3-tetramethylisoindolin-2-yloxyl-5-ethynyl)-10-(phenylethynyl)anthracene (BPEAnit). Therefore, the oxidative potential of the PM, measured through the ROS content, although proportional to the total organic content in certain cases, shows a much higher correlation with the oxygenated organic fraction as measured by the c-ToF AMS. This highlights the importance of knowing the surface chemistry of particles for assessing their health impacts. It also sheds light onto new aspects of particulate emissions that should be taken into account when establishing relevant metrics for assessing health implications of replacing diesel with alternative fuels.

Patient-doctor agreement on recall of clinical trial discussion across cultures

BACKGROUND

The purpose was to investigate patient-doctor agreement on clinical trial discussion cross-culturally.

METHODS

In the International Breast Cancer Study Group Trial 33-03 on shared decision-making for early breast cancer in Australian/New Zealand (ANZ) and Swiss/German/Austrian (SGA) centers, doctor and patient characteristics plus doctor stress and burnout were assessed. Within 2 weeks post-consultation about treatment options, the doctor and patient reported independently, whether a trial was discussed. Odds ratios of agreement for covariables were estimated by generalized estimating equations for each language cohort, with doctor as a random effect.

RESULTS

In ANZ, 21 doctors and 339 patients were eligible; in SGA, 41 doctors and 427 patients. In cases where the doctor indicated 'no trial discussed', 82% of both ANZ and SGA patients agreed; if the doctor indicated 'trial discussed', 50% of ANZ and 38% of SGA patients agreed, respectively. Factors associated with higher agreement were: low tumor grade and fewer patients recruited into clinical trials in SGA; public institution, patient born in ANZ (versus other), higher doctor depersonalization and personal accomplishment in ANZ.

CONCLUSION

There is discordance between oncologists and their patients regarding clinical trial discussion, particularly when the doctor indicates that a trial was discussed. Factors contributing to this agreement vary by culture.

Water scarcity and institutional change: lessons in adaptive governance from the drought experience of Perth, Western Australia

Urban water systems will be increasingly challenged under future climates and global pressures. Meeting challenges by reconfiguring water systems to integrate supplies and deliver multifunctional uses is technically well described. Adjusting the institutions that frame the management of these systems is not well operationalized in practice or conceptualized in theory. This study seeks to address this gap through an institutional analysis of Perth, Australia, a city where drought crisis has put under pressure both management practices and the institutional setting that underlies them. The study found that while trusted practices moderated water scarcity, the stability of the institutional setting may not facilitate a shift toward adaptable institutional configurations suited to future conditions. The results identified three key ingredients for a flexible institutional setting: (i) feedbacks in the system through better information management, (ii) reflexive dialogue and strategic use of projects to generate greater learning opportunities, and (iii) policy level support for sector-wide collaboration through progressive agendas, incentives for innovation and capacity building in stakeholder and community engagement. Further, the results suggest that a deeper understanding of institutional dynamics is needed to enable adaptive governance. The paper provides an analytical framework for diagnosing how greater adaptive capacity might be mobilized through influencing these dynamics.

Chromatin H3K27me3/H3K4me3 histone marks define gene sets in high-grade serous ovarian cancer that distinguish malignant, tumour-sustaining and chemo-resistant ovarian tumour cells

In embryonic stem (ES) cells, bivalent chromatin domains containing H3K4me3 and H3K27me3 marks silence developmental genes, while keeping them poised for activation following differentiation. We have identified gene sets associated with H3K27me3 and H3K4me3 marks at transcription start sites in a high-grade ovarian serous tumour and examined their association with epigenetic silencing and malignant progression. This revealed novel silenced bivalent marked genes, not described previously for ES cells, which are significantly enriched for the PI3K (P<10(-7)) and TGF-β signalling pathways (P<10(-5)). We matched histone marked gene sets to gene expression sets of eight normal fallopian tubes and 499 high-grade serous malignant ovarian samples. This revealed a significant decrease in gene expression for the H3K27me3 and bivalent gene sets in malignant tissue. We then correlated H3K27me3 and bivalent gene sets to gene expression data of ovarian tumour 'stem cell-like' sustaining cells versus non-sustaining cells. This showed a significantly lower expression for the H3K27me3 and bivalent gene sets in the tumour-sustaining cells. Similarly, comparison of matched chemo-sensitive and chemo-resistant ovarian cell lines showed a significantly lower expression of H3K27me3/bivalent marked genes in the chemo-resistant compared with the chemo-sensitive cell line. Our analysis supports the hypothesis that bivalent marks are associated with epigenetic silencing in ovarian cancer. However it also suggests that additional tumour specific bivalent marks, to those known in ES cells, are present in tumours and may potentially influence the subsequent development of drug resistance and tumour progression.

Communication pathways in community aged care: an Australian study

BACKGROUND

Health and social care practitioners collaborate in discharge planning for older people. Difficulties securing timely and quality discharge information and unclear role boundaries can be challenging. There are limited reports in the literature describing community-based practitioners' roles communicating client information.

AIM

To describe the roles of community-based practitioners in communication of older clients' information in an Australian context.

DESIGN

A descriptive and exploratory qualitative research design was applied.

METHODS

Four focus groups were conducted in 2009 with a small sample (n = 16) of district nurses, practice nurses and aged care case managers.

RESULTS

All participants described communication as a core characteristic of their role focused on minimising risks for older people. Participants valued dialogue with other health and social care providers in real time with an emphasis on telephone communication, face-to-face meetings, and case conferences. Telephone communication was considered important where there was an urgent need to problem solve. Written communication was noted as less effective.

CONCLUSIONS

There is an increasing need for stronger models of communication in community-based settings to facilitate safe, efficient and sustainable health and social outcomes for older people.

IMPLICATIONS FOR PRACTICE

There is limited available research with this focus to guide practice. Findings from this exploratory study indicate a number of important areas for further research: (i) to understand how communication feedback systems and pathways between community and inpatient providers could improve information exchange and (ii) to describe community nurses' roles in communication and medication risks for older people.

Biliary and portal vein strictures following treatment of Hodgkin's lymphoma

Treatment of abdominal lymphoma can be associated with bowel stricture or perforation. Rarely, the common bile duct or portal vein can be involved. This is the first case of stricture formation of both the portal vein and common bile duct in a patient following successful treatment of lymphoma. The development of extensive hilar varices rendered surgical management high risk. A staged approach to treatment was used. First, a percutaneous portal vein stent was placed, resulting in resolution of the hilar varices. This was followed by a surgical hepaticojejunostomy, performed without complication. Gastrointestinal complications are rare following treatment of lymphoma but may affect a variety of sites. The safe and effective treatment of this case highlights the benefit of a multidisciplinary approach to complex medical and surgical problems.