HIV testing and treatment in the antenatal care setting

Routine linked HIV antenatal screening, with "opt-out", was introduced at the Rotunda in January 1998. This paper reviews the screening and subsequent pregnancy management and outcome in HIV positive women from 1998 to 2006. During this time 225 women (280 pregnancies) were HIV positive and 194 women subsequently delivered at the Rotunda, representing 233 liveborn infants. Overall anti-HIV prevalence was 0.42%, increasing from 0.06% in 1998 to 0.57% in 2006. Of 233 livebirths, 111 (48%) were delivered by spontaneous vaginal delivery (SVD). HIV treatment was started pre-pregnancy in 14 (6%) pregnancies and antenatally in 208 (90%). The vertical transmission rate in mothers receiving >4 weeks of treatment was 0%. We conclude that routine antenatal HIV screening is effective and significantly benefits the health of mother and child.

Traveller health: prevalence of diabetes, pre diabetes and the metabolic syndrome

Irish Travellers are an ethnic minority group exposed to a myriad of social and health inequalities. Their current life expectancy equals that of the background population in the 1940s and one of the main causes of death is cardiovascular disease (CVD). There is a paucity of information on CVD risk factor assessment in the research literature in this population. This study assesses the prevalence of Diabetes, Pre-Diabetes and the Metabolic Syndrome (MetS) in a sample population from this community. Working with the Galway Traveller Movement, and following an overnight fast we measured fasting plasma glucose, HDL-cholesterol and Triglycerides. In addition weight, height, waist circumference (WC) and blood pressure (BP) were recorded. Of the 47 subjects, there were 4 (8.5%) participants identified as having diabetes, 5 (10.6%) pre-diabetes and 25 (53.2%) with the metabolic syndrome. The point prevalence of diabetes was calculated as 8.5%, pre-diabetes 10.6% and the metabolic syndrome 53.2%. In addition abdominal obesity was present in 70% and hypertension in 43%. Targeted screening for glucose abnormalities and traditional CVD risk factors is needed. Based on current literature, appropriate interventions might reasonably be expected to lower mortality and increase life expectancy.

Drilling systems for extraterrestrial subsurface exploration

Drilling consists of 2 processes: breaking the formation with a bit and removing the drilled cuttings. In rotary drilling, rotational speed and weight on bit are used to control drilling, and the optimization of these parameters can markedly improve drilling performance. Although fluids are used for cuttings removal in terrestrial drilling, most planetary drilling systems conduct dry drilling with an auger. Chip removal via water-ice sublimation (when excavating water-ice-bound formations at pressure below the triple point of water) and pneumatic systems are also possible. Pneumatic systems use the gas or vaporization products of a high-density liquid brought from Earth, gas provided by an in situ compressor, or combustion products of a monopropellant. Drill bits can be divided into coring bits, which excavate an annular shaped hole, and full-faced bits. While cylindrical cores are generally superior as scientific samples, and coring drills have better performance characteristics, full-faced bits are simpler systems because the handling of a core requires a very complex robotic mechanism. The greatest constraints to extraterrestrial drilling are (1) the extreme environmental conditions, such as temperature, dust, and pressure; (2) the light-time communications delay, which necessitates highly autonomous systems; and (3) the mission and science constraints, such as mass and power budgets and the types of drilled samples needed for scientific analysis. A classification scheme based on drilling depth is proposed. Each of the 4 depth categories (surface drills, 1-meter class drills, 10-meter class drills, and deep drills) has distinct technological profiles and scientific ramifications.

Limited ileo-caecal resection for localised Crohn's disease in childhood: Clinical outcome and predictors of further surgery

OBJECTIVES

To investigate the outcome of limited ileo-caecal resection in children with localised Crohn's disease (CD) and determine predictors of further surgery.

METHODS

Review of children diagnosed with CD and operated on for ileo-caecal disease from 1995 to 2005. Age at diagnosis, endoscopic disease distribution, indication for surgery, site of recurrence and date of last follow-up were recorded. Surgery required removal of only the ileo-caecal junction and caecal pole with removal of the minimum terminal ileal length.

RESULTS

Thirty seven children underwent intestinal resection. Time between primary operation and most recent follow-up was 3.8 years (range 1 month-8.8 years). Indications for surgery were obstruction/stricture (20), treatment-resistant disease (13) and abscess/perforation peritonitis (4). Follow-up was available in 32. Nine (28%) required re-laparotomy. Median time to second laparotomy was 12 months (range 4-58 months). Eighteen children required no endoscopies after surgery (median follow-up 3.4 years).

CONCLUSION

Most conservative surgery occurs about 2 years after diagnosis. About 1 in 4 children have a further laparotomy within 12 months. Over half of these require division of adhesions. Limited ileo-caecal resection for localized Crohn's disease is not associated with early peri-anastomotic recurrence. Developments in laparoscopic surgery are likely to further reduce complications from adhesions.

Why do consumers deviate from best microbiological food safety advice? An examination of ‘high-risk’ consumers on the island of Ireland

The objectives of this paper are 2-fold, firstly to profile and identify 'high risk' demographic groups on the island of Ireland and secondly to investigate, with these groups, their knowledge of microbiological food safety and the microbiological food safety handling and preparation behaviours they engage in. A representative survey (n=1025) was undertaken with quotas for age and social class. There was a total of 73 sampling points. Four 'high-risk' groups were identified using univariate analysis of variance: (1) 18-34 single males, non-students, without home economics training; (2) 18-24-year-old female homemakers without home economics training; (3) 45+ female homemakers with home economics training; and (4) 65+ males who are either widowed/divorced/separated (W/D/S). Time and financial constraints limited the number of groups (1/3/4), which could be qualitatively investigated in a meaningful way to 3. The findings indicated that these 'high-risk' groups were willing to engage in a range of behaviours that deviate from best practise guidelines. Personal (overconfidence; lack of interest), environmental (technological) and lifestyle (time and energy investment) characteristics were identified as the source cause of such deviating behaviour.

Oral mucositis is associated with increased resource use among patients receiving treatment for cancers of the head and neck

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Background: Oral mucositis (OM) is the oral manifestation of mucosal injury (MUI), and is a common, bothersome, and treatment-interrupting toxicity of chemoradiation therapy for squamous cell cancers (SCC) of the head and neck. Retrospective studies have reported that OM increases healthcare resource use. We present interim results of an international, multicenter, prospective study undertaken to characterize the clinical and economic burden of OM in patients with cancers of the oral cavity (OC), oropharynx (OP), larynx (L) and hypopharynx (HP). Methods: Patients (pts) with histologically proven SCC of the designated anatomical sites, whose planned treatment included full-cycle conventional or intensity modulated (IM) radiation therapy (RT) with or without chemotherapy, were enrolled at least one week prior to the start of treatment. Pts completed the Oral Mucositis Daily Questionnaire (OMDQ), a validated questionnaire developed to document patient-reported symptoms of OM and MUI including mouth and throat soreness (MTS), at baseline and daily throughout RT. MTS was assessed using a 5-point numeric rating scale, ranging from 0 (“no soreness”) to 4 (“extreme soreness”). Results: Of the first 61 pts to complete RT, 72% had cancers of the OC or OP, 49% received IMRT with concomitant chemotherapy, and 68% were male. 95% of pts reported OM symptoms (MTS>0); 80% had one or more scores =2. Pts with OC or OP cancers reported more symptoms than those with L or HP tumors (mean maximum score: 3.3 vs 2.8; p= 0.12). MTS scores were positively related to levels of resource use. Conclusions: Symptoms of radiation-induced OM are positively correlated with levels of resource utilization in patients with head and neck cancers.

No significant financial relationships to disclose.

[Table: see text]

A phase II study of preoperative chemotherapy with irinotecan(CPT) and cisplatin(CIS) for gastric cancer(NCI 5917): FDG-PET/CT predicts patient outcome

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Introduction: Preoperative chemotherapy is a standard option for the treatment of locally advanced gastric cancer(GC). FDG-PET scans have been examined to identify early treatment response in esophagus and GEJ adenocarcinoma. We evaluated the utility of an early change in FDG-PET/CT at several time points in predicting response to preoperative chemotherapy in gastric cancer. Methods: 42 pts with locally advanced GC(preoperative stage T2N+M0 or T3–4NanyM0) were treated with CPT 65 mg/m2 and CIS 30mg/m2 on day(d)1 and d8, every 21 days for 4 cycles. FDG-PET/CT scans were performed at baseline, and in FDG avid patients, again on d15 and d35. The primary objective was to demonstrate that a decrease in FDG-SUV discriminates treatment response. Response was defined pathologically based on microscopic inspection for residual cancer cells and fibrosis(Mandard, Cancer 1994). Disease free survival(DFS) and overall survival(OS) were secondary endpoints. Results: Pt characteristics are as follows: median age 59(35–77), KPS 90%(70–100%), 27 male, gastric:GEJ 31:11. Median follow up is 23.3 months, with median DFS 23.8 months(95%CI 14-infinity) and median OS 39.1 months(95%CI 31–39months). Surgical resection occurred at a median of 101 days from study initiation. Pathologic response correlates significantly with DFS(p=0.005) and with OS(p=0.01). Amongst 31 FDG avid pts, a drop in SUV from baseline to d35 significantly predicts pathologic response(p=0.007) and DFS(p=0.01), whereas the change at d15 does not. 45% decrease in SUV at d35 best distinguishes good from poor pathologic response. With this cutoff, median DFS has not been reached(eg.>23.3 months) for patients with good PET response, and is 14.4 months(95%CI 8.3-infinity) for poor PET responders, p=0.03. Conclusions: Following preoperative chemotherapy, pathologic response at the time of resection significantly correlates with DFS and OS. We confirm that FDG-PET/CT response predicts both pathologic response and DFS following preoperative chemotherapy for locally advanced GC, although at d35. An early PET response assessment provides an opportunity to change therapy in non responding patients, and is currently under investigation(supported by ASCO CDA).

No significant financial relationships to disclose.

Prospective assessment of short-term quality of life after total, distal or proximal gastrectomy for gastric cancer

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Background: Few studies have systematically examined the short-term quality of life (QOL) of patients undergoing gastrectomy for gastric cancer. This is due to a lack of consistent prospectively acquired baseline and early outcome measures. The purpose of the current study is to assess differences in QOL scores among patients within a year of curative distal (DG), proximal (PG) or total (TG) gastrectomy, using validated gastric cancer specific questionnaires. Methods: Patients undergoing curative gastrectomy were asked to prospectively complete preoperative, postoperative, 3, 6, and 12 month EORTC QLQ-C30 and STO22 questionnaires. We used analysis of covariance to compare differences in scores based on type of operation while adjusting for potential differences in baseline scores. Results: Patients undergoing DG (n=101), PG (n=20) or TG (n=49) were consented and interviewed. Data collection is complete on all patients through twelve months. In the immediate postoperative period, patients in all three surgical groups demonstrated worse scores in about half of the 23 function and symptom scales, compared to their preoperative scores. However, DG and TG patients had mostly returned to baseline by three to six months, while PG patients continued to remain below the baseline scores for many function and symptom scales over the entire twelve month period following surgery. PG patients had significantly poorer scores than DG and TG patients in reflux, nausea/vomiting, eating restrictions and anxiety scales, among others ( Table 1 ). Conclusion: This prospective study indicates that patients fared better after DG or TG than after PG in most function and symptom scales throughout the twelve month period following gastrectomy. Long term follow-up studies are required to see if these differences persist over time. Table 1 Mean change in score from preoperative baseline score (a negative value means return to baseline or better).

[Table: see text]

No significant financial relationships to disclose.

Galanin type 1 receptor knockout mice show altered responses to high-fat diet and glucose challenge

Galanin, a brain and pancreatic peptide with three receptor subtypes (GALR1, GALR2, and GALR3), is hypothesized to participate in energy homeostasis and glucoregulation. Hypothalamic galanin expression is induced by dietary fat, and intra-hypothalamic galanin administration has orexigenic/anabolic properties. Systemic galanin infusion alters glucoregulation in non-human species, partly through direct actions on pancreatic islets. However, the physiologic significance of endogenous galanin-GALR signaling is unclear. The present studies tested the hypotheses that GALR1 deficiency alters food intake and feed efficiency following switches to high-fat diet and that GALR1 deficiency alters whole-body glucose homeostasis. Adult, male GALR1 knockout (-/-), heterozygote (+/-), and C57BL/6J control (+/+) mice were studied. GALR1 deficiency impaired adaptation to a 3-day high-fat diet challenge, leading to increased food intake, feed efficiency and weight gain. However, during the following 2 weeks, GALR1 knockout mice decreased intake, consuming less daily energy than while maintained on low-fat diet and also than heterozygote littermates. Chow-maintained GALR1 knockout mice showed relative hyperglycemia in fed and d-glucose (i.p. 1.5 g/kg)-challenged states. GALR1 knockout mice showed normal food intake, feed efficiency and weight accrual on low-fat diets, normal fasted glucose levels, and normal glucose sensitivity to porcine insulin (i.p. 1 IU/kg) in vivo. The results support the hypotheses that galanin-GALR1 systems help adapt food intake and metabolism to changes in dietary fat and modulate glucose disposition in mice.

Initial experience with hand-assisted laparoscopic distal pancreatectomy

BACKGROUND

Hand-assisted laparoscopic distal pancreatectomy, with or without splenectomy, is gradually gaining acceptance, although its ultimate benefit is yet to be confirmed. This study aimed to report our initial experience with hand-assisted laparoscopic distal pancreatectomy.

METHODS

A retrospective review of a prospectively collected database including 17 patients during the period 2002-2004 was conducted. The median age was 60 years (range, 29-85 years), and the female-to-male ratio was 13:4. The preoperative diagnoses included benign and malignant conditions. Besides two to three ports, a hand port was placed in the upper midline to aid in dissection. The pancreas was divided with a stapler in all the patients, and drains were placed in 10 patients (70%).

RESULTS

One patient was found to be unresectable because of celiac artery involvement, and 2 of the remaining 16 patients underwent conversion to an open procedure. The median operating time was 196 min (range, 128-235 min). The mean tumor size was 4 cm (range, 2-7 cm), and the estimated blood loss was 125 ml (range, 50-1,250 ml). The median time to resumption of a regular diet was 3.5 days (range, 2-9 days), and the time to conversion to oral pain medications was 3 days (range, 2-9 days). The length of hospital stay was 5.5 days (range, 4-18 days), with a majority of the patients (11 patients, 78%) staying less than 7 days. There were no mortalities. The overall postoperative morbidity rate was 25%, and the morbidities consisted of pancreatic leak/fistula (2 patients, 14%) and fever (1 patient). The margins were negative in 10 (76%) of the relevant 13 patients. At a median follow-up period of 3.8 months (range, 5-14 months), 11 (84%) of 13 patients had no evidence of disease recurrence.

CONCLUSIONS

The minimally invasive approach to pancreatic disease is safe and technically feasible. Further large studies with longer follow-up periods are necessary to determine the role of laparoscopic surgery in the management of pancreatic disease.