Cancer diagnostic assessment programs: standards for the organization of care in Ontario

Background

Improving access to better, more efficient, and rapid cancer diagnosis is a necessary component of a high-quality cancer system. How diagnostic services ought to be organized, structured, and evaluated is less understood and studied. Our objective was to address this gap.

Methods

As a quality initiative of Cancer Care Ontario’s Program in Evidence-Based Care, the Diagnostic Assessment Standards Panel, with representation from clinical oncology experts, institutional and clinical administrative leaders, health service researchers, and methodologists, conducted a systematic review and a targeted environmental scan of the unpublished literature. Standards were developed based on expert consensus opinion informed by the identified evidence. Through external review, clinicians and administrators across Ontario were given the opportunity to provide feedback.

Results

The body of evidence consists of thirty-five published studies and fifteen unpublished guidance documents. The evidence and consensus opinion consistently favoured an organized, centralized system with multidisciplinary team membership as the optimal approach for the delivery of diagnostic cancer assessment services. Independent external stakeholders agreed (with higher mean values, maximum 5, indicating stronger agreement) that dap standards are needed (mean: 4.6), that standards should be formally approved (mean: 4.3), and importantly, that standards reflect an effective approach that will lead to quality improvements in the cancer system (mean: 4.5) and in patient care (mean: 4.3).

Interpretation

Based on the best available evidence, standards for the organization of daps are offered. There is clear need to integrate formal and comprehensive evaluation strategies with the implementation of the standards to advance this field.

339 BIOENGINEERING OF THE MAMMARY GLAND OF LIVESTOCK: INCREASED PROPEPTIDE PROCESSING OF FACTOR IX IN THE MILK OF TRANSGENIC PIGS BY CO-EXPRESSION OF FURIN

Coagulation Factor IX is a vital protein that plays an important role in the blood coagulation cascade. Hereditary deficiency in the Factor IX gene can result in hemophilia type B, the second most common hemophilia. The milk of transgenic livestock can be an efficient vehicle for producing complex, post-translationally modified blood proteins. The advantages include decreased pathogen risk as well as 100-fold or more production efficiency over blood fractionation and cell culture biotechnology. Although the mammary gland can make many of the complex post-translational modifications necessary for biological function of blood proteins, improvements in propeptide cleavage and decreased proteolytic degradation are desirable. To explore the possibility of producing bioactive human Factor IX protein in pig milk, male and female Landrace fetal fibroblast cells were co-transfected by electroporation with 3 different transgene constructs, Factor IX (FIX), Furin, and SERPINA1. The SERPINA1 construct (containing a Neo selectable marker) was delivered into fetal fibroblasts at a 10-fold-lower molar concentration than the other 2 constructs. Following selection in Geneticin, the presence of all 3 genes was verified by PCR and then cells were used as donors for somatic cell nuclear transfer. Thirteen F0 female piglets from 3 potential different integrations were delivered, and 6 piglets were validated by PCR to be positive for all 3 genes. Among the 6 transgenic pigs, 3 are healthy and able to reach puberty. Milk was collected by induced lactation from 2 gilts. A short murine whey acidic protein promoter-Furin gene was used to limit Furin to the lowest levels needed for pro-FIX processing. Furin was expressed to increase propeptide cleavage efficiency, with the result being complete processing of pro-FIX to FIX at ∼0.3 g L–1 pro-FIX. Total FIX levels were ∼1 g L–1. SERPINA1 was also co-expressed at ∼1 g L–1 or more and this serine protease inhibitor did not seem to inhibit furin processing of the pro-FIX. Fifteen F0 male piglets from 3 potential different integration sites were delivered and all of them were positive for all 3 genes. Four F0 males were chosen to breed with wild-type females, and 5 litters of F1 piglets were born. Of 63 F1 piglets, 22 were tri-transgenic and 3 were di-transgenic (only carrying FIX and Furin). Two F1 females were mated with wild-type males, are confirmed to be pregnant, and will be used to determine the expression level and bioactivity of the Factor IX protein in the milk. Funded by the NIH NCRR (RR018877) and R01 HL078944.

Excess lung function decline in gold miners following pulmonary tuberculosis

BACKGROUND

Few if any studies of the association between pulmonary tuberculosis (TB) and lung function loss have had access to premorbid lung function values.

METHODS

Using a retrospective cohort design, the study recruited employed South African gold miners who had undergone a pulmonary function test (PFT) between January 1995 and August 1996. The 'exposed' group comprised 185 miners treated for pulmonary TB after the initial PFT and the 'unexposed' group comprised 185 age-matched miners without TB. All participants had a follow-up PFT between April and June 2000. The outcome of interest was decline in lung function during the follow-up period as measured by forced vital capacity (FVC) and forced expiratory volume in 1 s(FEV(1)).

RESULTS

After controlling for age, height, baseline lung function, silicosis, years of employment, smoking and other respiratory diagnoses, pulmonary TB during the follow-up period was associated with a mean excess loss of 40.3 ml/year in FEV(1) (95% CI 25.4 to 55.1) and 42.7 ml/year in FVC (95% CI 27.0 to 58.5). Lung function loss was greater among those with more severe or later clinical presentation of TB. Breathlessness was twice as common among TB cases (OR 2.20, 95% CI 1.18 to 4.11).

CONCLUSION

There is a need for greater clinical recognition of the long-term respiratory consequences of treated pulmonary TB. Early detection of TB would help to reduce these sequelae and remains a priority, particularly in a workforce already subject to silica dust disease. However, strategies such as dust control, worker education about TB and dust and TB preventive therapy are also needed to avert the disease itself.

Pattern recognition in coupled chemical kinetic systems

A network of open, bistable reaction systems coupled by mass transfer is simulated. The mass transfer rates are determined by a Hebb-type rule, and the programmable network can store patterns of high and low concentrations in each bistable system. In a parallel computation, the network recognizes patterns similar, but not necessarily identical, to stored patterns.

Benzodiazepine use among heroin users in Sydney: patterns of use, availability and procurement

A sample of 210 heroin users who had used benzodiazepines during the preceding 6 months were interviewed about their benzodiazepine use. Forty-one percent of the sample reported having used benzodiazepines more than once a week during the 6 months preceding interview. Forty-eight percent had injected benzodiazepines, with 17% having done so during the preceding 6 months. Eleven percent of the sample reported having experienced convulsions when attempting detoxification from benzodiazepines. The majority of subjects (86%) indicated that benzodiazepines are easy or very easy to obtain. Only a third of the sample reported obtaining benzodiazepines exclusively through a doctor in the last 6 months. Over a half of the sample indicated that they had given or sold benzodiazepines to someone during that time. Diazepam was considered by subjects to be the easiest benzodiazepine to procure. Doctors should avoid the prescription of benzodiazepines to injecting drug users, particularly the more readily injectable drug temazepam. Given the widespread use of benzodiazepines by injection, research needs to examine the harm associated with the parenteral use of these drugs.

Assessing compliance with practice treatment guidelines by treatment centers and the reasons for noncompliance

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Background: Cancer Care Ontario (CCO) is the chief advisor on cancer care to the government of Ontario, a province with a population of more than 12 million. One of the many roles of CCO is to develop evidence based consensus-derived treatment practice guidelines for all major cancer types, through its Program in Evidence-based Care (PEBC). To determine province-wide compliance with these guidelines, a pilot project assessed the proportion of patients with stage III colon cancer (CC) treated in concordance with the corresponding treatment guideline. Initial results are made available to the regional cancer centers (RCC) in the province and to the public through web based Cancer Systems Quality Index (CSQI, http://www.cancercare.on.ca/qualityindex2007/ ). Methods: The guideline (http://www.cancercare.on.ca/pdf/pebc2–29s.pdf) states that patients with resected stage 3 CC will have adjuvant fluoropyrimidine-based chemotherapy within eight weeks of resection. Patients at each of 11 RCC who presented in 2007/2008 with stage III CC and the proportion treated according to the guidelines were identified. Individual charts of those patients who were not treated according to guideline were reviewed to determine the reason. Results: Across eight RCC with complete chart results to date 376 patients with stage 3 CC were identified, 244 (65%, range 47% to 72%) treated in concordance with the guideline, including 13% treated with capecitabine and 6% on clinical trials. The reasons for non-concordance of the 132 remaining cases were: age and co morbid conditions 48 (13%), patient choice 36 (10%), referred for treatment outside the RCC system 16 (4%), stage incorrect and other 32 (9%). Conclusions: Adjuvant chemotherapy treatment of stage III CC at the RCC across the Province of Ontario was concordant with the guideline in the majority of patients, and appropriate clinical reasons for non-compliance were identified. Data from all 11 RCC will be presented along with concordance within the eight-week time frame stated in the guideline . Refinement in province-wide data collection and interpretation will allow results from this pilot to be expanded to other PEBC practice guidelines for dissemination through the CSQI.

No significant financial relationships to disclose.

2008 European Guideline on HIV testing

Testing for HIV is one of the cornerstones in the combat against HIV infection. The 2008 European Guideline on HIV Testing provides advice on testing for HIV infection in individuals aged 16 years and older who have sought evaluation and treatment at sexually transmitted infection services for dermatovenereology clinics across Europe. Its aim is to provide practical guidance to clinicians in these settings who undertake HIV testing and suggest appropriate standards for the audit of service provision.

A multilevel analysis of condom use among adolescents in the European Union

OBJECTIVES

This study examined which individual and national factors affect condom use among adolescents.

STUDY DESIGN

Multilevel analysis.

METHODS

This study reviewed the data on bullying, alcohol use and condom use provided by 18 European countries and subnational entities in the Health Behaviour in School-Aged Children survey. Another eight contextual variables were also analysed. Three multilevel logistic regression models were applied consecutively (analysing for crude geographical and school variance in condom use, adjusting for gender and adjusting all variables for one another).

RESULTS

Among the 15-year-olds studied, 7.0% of the total variance in condom use was explained by school-related factors (intraschool-level correlation) and 5.8% by national/subnational factors. In the empty model, condom use was significantly associated with gender, alcohol consumption, predominant national religion and national prevalence of human immunodeficiency virus (HIV). In the full model, there was also a significant association with the Human Development Index ranking, gross domestic product, Gini coefficient and the Gender-related Development Index.

CONCLUSIONS

This study suggests that while alcohol, gender, human development level, income, religion and HIV prevalence affect condom use in young Europeans, these factors do not explain all or even most of the variation. Nonetheless, since some of these factors are not traditionally associated with young people's sexual and reproductive health, these findings should enable more nuanced health policy programming.

289 COOPERATIVE EXPRESSION OF PLURIPOTENCY-RELATED GENES AND NEURAL CREST MARKER GENES IN PORCINE GFP-TRANSGENIC SKIN-DERIVED PROGENITORS

Recently neural crest derived multipotent progenitors from skin have attracted much attention as the skin may provide an accessible, autologous source of stem cells available with therapeutic potential (Toma JG et al. 2001 Nat. Cell Biol. 3, 778–784). The multipotent property of stem cells could be tracked back to the expression of specific marker genes that are exclusively expressed in multipotent stem cells rather than any other types of differentiated cells. Here we demonstrate the property of multipotency and neural crest origin of porcine GFP-transgenic skin derived progenitors (termed pSKP) in vitro by marker gene expression analysis. The pSKP cells were isolated from the back skin of GFP transgenic fetuses by serum-free selection culture in the presence of EGF (20 ng mL–1) and bFGF (40 ng mL–1), and developed into spheres in 1–2 weeks (Dyce PW et al. 2004 Biochem. Biophy. Res. Commun. 316, 651–658). Three groups of RT-PCR primers were used on total RNA from purified pSKP cells: pluripotency related genes (Oct4, Sox2, Nanog, Stat3), neural crest marker genes (p75NGFR, Slug, Twist, Pax3, Sox9, Sox10) and lineage specific genes (GFAP, tubulin β-III, leptin). Expression of both pluripotency related genes and neural crest marker genes were detected in undifferentiated pSKP cells. In addition, transcripts for fibronectin, vimentin and nestin (neural stem cell marker) were also present. The percentage of positive cells for Oct4, fibronection and vimentin were 12.3%, 67.9% and 53.7% respectively. Differentiation assays showed the appearance of tubulin β-III positive (39.4%) and GFAP-positive (42.6%) cells in cultures by immunocytochemistry, which share the characteristics of neurons and glial cells, respectively. Thus, we confirm the multiple lineage potentials and neural crest origin of pSKP cells in the level of marker gene expression. This work was funded by National Institutes of Health National Center for Research Resources RR013438.

Relief of severe retro-orbital pain and vision improvement after optic-nerve decompression in polyostotic fibrous dysplasia: case report and review of the literature

INTRODUCTION

We describe a case of a 9-year-old girl who developed progressive severe retro-orbital pain and partial visual loss in association with left optic-nerve compression due to polyostotic fibrous dysplasia of the skull.

MATERIALS AND METHODS

Intradural decompression of the optic nerve resulted in immediate and complete resolution of the pain as well as a vast visual improvement.

CONCLUSION

In cases of fibrous dysplasia of the skull with evidence of optic-nerve compression, relief of retro-orbital pain should be an additional consideration when deciding to proceed with surgical management.

Parents and nurses during the immunization of children--where is the power? A conversation analysis

BACKGROUND

Best practice for health care practitioners is considered patient-centred approaches which empower patients. Immunization of young children requires maintaining this approach while retaining professional management.

OBJECTIVE

The objectives were to assess situations within the immunization event with discordance between health provider and caregiver and evaluate strategies used to empowering parents while obtaining the desired clinical outcome.

METHODS

This was a qualitative study nested within a larger study of immunization rates in 124 randomly selected primary care practices. Interactions between immunizing practice nurses, caregivers and children were videotaped and transcribed and underwent conversation analysis. Six purposively sampled primary care practices in Auckland, New Zealand, served as the setting. The participants were eight practice nurses immunizing 10 children and their parents. Normative pattern of interactions and 'deviant cases' involving discordance between nurse and parent.

RESULTS

A total of 168 minutes of video-recorded conversation from 10 immunization sessions provided strong 'typical' pattern and equally striking 'deviant cases'. Parents mostly treated nurses as 'experts' and accepted asymmetry of knowledge over medical matters. Nurses demonstrated skilful strategies in delineating their area of medical expertise from areas in which patients are expert-their knowledge of themselves and their children.

CONCLUSION

While patient centredness and empowering patients are contemporary goals of primary health care delivery, these attributes are not precisely defined. Patients may wish to be informed, but many trust their health professionals to direct their decision making. Although health professionals may impart as much knowledge as they can, asymmetry of knowledge remains. However, patients hold expertise beyond their clinical situation in the social and economic world in which they live.

Green frequency-doubled laser-beam propagation in high-temperature hohlraum plasmas

We demonstrate propagation and small backscatter losses of a frequency-doubled (2omega) laser beam interacting with inertial confinement fusion hohlraum plasmas. The electron temperature of 3.3 keV, approximately a factor of 2 higher than achieved in previous experiments with open geometry targets, approaches plasma conditions of high-fusion yield hohlraums. In this new temperature regime, we measure 2omega laser-beam transmission approaching 80% with simultaneous backscattering losses of less than 10%. These findings suggest that good laser coupling into fusion hohlraums using 2omega light is possible.

What influences intention to become a postgraduate trainer?

OBJECTIVE

Only a small proportion of eligible dentists become dental vocational trainers. The aim of this study was to apply Social Cognitive Theory to further an understanding of beliefs underpinning intention to become a dental vocational trainer.

SUBJECTS

Primary care dentists.

DESIGN

A self-administered questionnaire was distributed at all continuing professional development courses during November 2004 regardless of course enrolment numbers, content or duration.

OUTCOME MEASURE

Intention to train. Predictive measures Attitude toward being a trainer, attitude toward attending the trainer course, and confidence in ability to train (training self-efficacy).

RESULTS

Of the 316 respondents, 47% intended never to train. Training self-efficacy accounted for the majority of variance in intention to train (15%, step 1) with attitude to training accounting for a further 4% (step 2) (Hosmer and Lemeshow test: Chi-square = 7.36, df = 8, p = 0.498; 95% CI for EXP(b): training self-efficacy = 1.38-2.06, attitude = 1.17-2.08). Attitude to the trainer course did not enter the regression model. The most influential belief relating to intention to train was confidence in teaching, and for intention never to train was evaluating a trainee's skills. Both intenders and non-intenders believed training and attending training courses would be time-consuming and financially costly, suggesting these are not primary factors in making the decision to become a trainer.

CONCLUSIONS

Using a psychological model provided a starting point for understanding intention to become a vocational trainer and a rationale for the format of future interventions. Results suggest intention to train may be influenced by targeting dentists' confidence in teaching and performing evaluative aspects of training.

Targeting FGF19 inhibits tumor growth in colon cancer xenograft and FGF19 transgenic hepatocellular carcinoma models

Although fibroblast growth factor 19 (FGF19) can promote liver carcinogenesis in mice its involvement in human cancer is not well characterized. Here we report that FGF19 and its cognate receptor FGF receptor 4 (FGFR4) are coexpressed in primary human liver, lung and colon tumors and in a subset of human colon cancer cell lines. To test the importance of FGF19 for tumor growth, we developed an anti-FGF19 monoclonal antibody that selectively blocks the interaction of FGF19 with FGFR4. This antibody abolished FGF19-mediated activity in vitro and inhibited growth of colon tumor xenografts in vivo and effectively prevented hepatocellular carcinomas in FGF19 transgenic mice. The efficacy of the antibody in these models was linked to inhibition of FGF19-dependent activation of FGFR4, FRS2, ERK and beta-catenin. These findings suggest that the inactivation of FGF19 could be beneficial for the treatment of colon cancer, liver cancer and other malignancies involving interaction of FGF19 and FGFR4.

Species connectivities and reaction mechanisms from neutral response experiments

We develop a new method for obtaining connectivity data for nonlinear reaction networks, based on linear response experiments. In our approach the linear response is not the result of an approximation procedure but is due to the appropriate design of the response experiments, that is (1) they are carried out with the preservation of constant values for the total (labeled plus unlabeled) input and output fluxes and (2) the labeled compounds obey a neutrality condition (i.e., they have practically the same kinetic and transport properties as the unlabeled compounds). Under these circumstances the linear response equations hold even though the kinetics of the process is highly nonlinear. On the basis of this linear response law, we develop a method for evaluating reaction connectivities in biochemical networks from stationary response experiments. Given a system in a stationary regime, a pulse of a labeled species is introduced (with conservation of the total flux) and then the response of all the species of the network is recorded. The mechanistic information is contained in a connectivity matrix, K, which can be evaluated from the response data by means of differential as well as integral methods. The approach does not require any prior knowledge of the reaction mechanism. We carried out a numerical study of the method, based on a two-step procedure. Starting from a known reaction mechanism, we generated response data sets, to which we add noise; then, we use the noisy data sets for retrieving the connectivity matrix. The calculations were done with two programs written in Mathematica: the urea cycle and the upper part of glycolysis are used as sample biochemical networks. Given enough computer power, there are no limitations concerning the number of species involved in the response experiments; on current desktop systems processing responses of teens of species would take a few hours. The method is limited by the occurrence of experimental errors: if experimental errors in the evaluation of fluxes are larger than 10%, the method may fail to reproduce the correct values of some elements of the connectivity matrix.