Emergency short stay area improves access and flow in a rural hospital

OBJECTIVES

Shoalhaven District Memorial Hospital is a rural (MM3) 150-bed hospital in Nowra, New South Wales, whose ED has evolved to a FACEM-led model of care (MOC). It has never had an emergency short stay area (ESSA). The objective of the present study was to pilot an ESSA and determine whether this MOC would increase the operational performance of the ED.

METHODS

An ESSA was designed and delivered by emergency medicine medical, nursing and allied health practitioners. The study period was July-December 2021, with a seasonally matched retrospective cohort of records extracted for comparison (July-December 2020). Both took place within the context of the ongoing COVID-19 pandemic. The primary outcome measured was percentage of admitted patients meeting Emergency Treatment Performance (ETP). Secondary outcomes included discharge ETP, overall ED and inpatient length of stay (LOS), mortality and representation rates.

RESULTS

The admission ETP for patients after the implementation of the ESSA significantly increased, from 13.9% to 31.6% (χ2  = 288, P < 0.001). Discharge ETP significantly declined. There was no effect improvement on overall ETP. There was no change to mortality or representation rates. Average admission LOS decreased.

CONCLUSIONS

The introduction of the ESSA significantly improved the ETP of admitted patients. Ongoing refinement of the ESSA admission processes, as well as the lifting of certain COVID-19 restrictions, could show even greater improvements in this and other areas. Ongoing research in this field is necessary, as well as a more detailed cost-benefit analysis.

Time trade-off study to establish utility decrements in individuals with a spinal cord injury who perform intermittent catheterisation

AIMS

To generate utility decrements for three attributes associated with catheterisation for individuals with a spinal cord injury (SCI): the process of catheterisation, the physical impact of urinary tract infections (UTIs) and worry associated with hospitalisation.

MATERIALS AND METHODS

Health state vignettes comprising various levels of the three attributes were developed. Two cohorts of respondents, corresponding to people with SCIs and a sample broadly representative of the UK population, were presented with nine vignettes (three vignettes for the mild, moderate and severe health states in addition to a random set of six vignettes). It was assumed no or a nominal decrement was associated with the mild health state. Utility decrements were derived from analysing the data obtained from the online time trade-off (TTO). A proportion of the SCI cohort (n = 57) also completed the EQ-5D-5L questionnaire.

RESULTS

Utility decrements were generated using statistical models for the general population (n = 358), the SCI population (n = 48) and the two populations combined (merged model, n = 406). Results from the two cohorts showed minimal differences. For the merged model, SCI status was not statistically significant. All interaction terms, excluding SCI and the severe level of the physical attribute, were not statistically significant. Compared to the mild level, the greatest utility decrement calculated was the severe level of the emotional (worry) attribute (0.09, p < 0.001) for the SCI population. A significant decrement of 0.02 (p <0.001) was calculated for the moderate level of the emotional attribute for all models. The mean utility score for those with SCI having completed the EQ-5D-5L was 0.371.

LIMITATIONS

Modest sample size of respondents from the SCI population (n = 48).

CONCLUSIONS

Worry associated with hospitalisation had the greatest impact on patients' health-related quality of life (HRQoL). The catheterisation process, such as the lubrication and repositioning of the catheter, also impacted on patients' HRQoL.

Treatment outcomes of patients with Atopic Dermatitis (AD) treated with dupilumab through the Early Access to Medicines Scheme (EAMS) in the UK

BACKGROUND

Dupilumab, a monoclonal antibody against interleukin (IL)-4 receptor alpha that inhibits IL-4/IL-13 signalling is indicated in dermatology for the treatment of moderate-to-severe atopic dermatitis (AD) in adult and adolescent patients 12 years and older and severe AD in children 6-11 years, who are candidates for systemic therapy. Dupilumab received Early Access to Medicines Scheme (EAMS) approval for adults in March 2017.

OBJECTIVES

The purpose of this study was to assess the efficacy outcomes of treatment with dupilumab in EAMS.

METHODS

A retrospective analysis of adult patients enrolled in the dupilumab EAMS in the UK. Scores were assessed at baseline and follow up, including the Eczema Area and Severity Index (EASI), Investigator's Global Assessment Score (IGA) and Dermatology Life Quality Index (DLQI).

RESULTS

Data were available for 57 adult patients treated with dupilumab for at least 12 weeks; 73.6% of patients had received prior treatment with 3 or 4 immunosuppressants. Baseline scores for the EASI and DLQI were 27.93 (standard deviation, SD 13.09) and 18.26 (SD 6.18) respectively. AD severity scores showed statistically significant improvement at week 16±4 weeks (p <0.001 for all). The mean change in EASI was 14.13 points with 66.7% and 36.7% achieving a 50% (EASI-50) and 75% (EASI-75) improvement in EASI, respectively at 16^+/- 4 weeks. IGA scores improved by at least two categories for 75% patients. DLQI scores decreased by a mean of 9.0 points, with 80% patients demonstrating a MCID 4-point improvement. For 85% patients, clinicians rated the treatment response as being either 'better' (19%) or 'much better' (65%).

CONCLUSIONS

Dupilumab is associated with a significant and clinically relevant improvements in AD as measured by patient- and physician-reported outcome measures. Importantly, the clinical efficacy, despite the refractory disease of this EAMS cohort, is comparable to that previously reported in clinical trials.

Cancer information overload and multiple prevention behaviors

Background

Many people feel overwhelmed by the increasing amount of cancer-related material available in the information environment. Our aims was to evaluate the psychometric properties of the brief version of the cancer information overload (CIO) scale and to examine the association between CIO and multiple cancer prevention behaviors.

Methods

A large survey using a self-administered online questionnaire was proposed to all adult members of the Seintinelles, a French national non-profit organization. The psychometric properties of the CIO scale were evaluated. Measurement invariance across French and English languages was studied using an additional sample of 224 Australian cancer survivors from Register4. We also collected functional, communicative, and critical health literacy (FCCHL), deprivation (EPICES index), current smoking, alcohol misuse, frequent sunburns, and rare skin self-examination.

Results

Between June 16th and 30th 2016, 2 363 French participants answered the online questionnaire. The five-item CIO scale demonstrated the best balance between psychometric properties and number of items. It showed satisfactory internal consistency and adequate fit. No measurement invariance issue was found across age, gender, education level, and language groups.

CIO was increased among people with higher deprivation, lower education and a cancer information avoidant profile. In multivariate analyses, CIO was associated with tobacco use (OR = 1.05, 95%CI [1.00-1.10]), rare skin checks (OR = 1.05 [1.01-1.08]) and frequent sunburns (OR = 1.04 [1.01-1.07]), but not with alcohol misuse.

Conclusions

The 5-item CIO scale is ready to be used in French and English-speaking countries. The links observed between CIO and multiple prevention behaviors encourage further research in order to better characterize the psycho-cognitive and environmental phenomena at play. Efforts are needed to communicate adequately and empower citizens to limit the growing burden of cancer.

Key messages

The 5-item CIO scale is ready to be used in French and English-speaking countries. Efforts are needed to communicate adequately and empower citizens to limit the growing burden of cancer.

Psychological intervention (ConquerFear) for treating fear of cancer recurrence: mediators and moderators of treatment efficacy

PURPOSE

ConquerFear is an efficacious intervention for fear of cancer recurrence (FCR) that demonstrated greater improvements than an attention control (relaxation training) in a randomized controlled trial. This study aimed to determine mediators and moderators of the relative treatment efficacy of ConquerFear versus relaxation.

METHODS

One hundred and fifty-two cancer survivors completed 5 therapy sessions and outcome measures before and after intervention and at 6 months' follow-up. We examined theoretically relevant variables as potential mediators and moderators of treatment outcome. We hypothesized that metacognitions and intrusions would moderate and mediate the relationship between treatment group and FCR level at follow-up.

RESULTS

Only total FCR score at baseline moderated treatment outcome. Participants with higher levels of FCR benefited more from ConquerFear relative to relaxation on the primary outcome. Changes in metacognitions and intrusive thoughts about cancer during treatment partially mediated the relationship between treatment group and FCR.

CONCLUSIONS

These results show that ConquerFear is relatively more effective than relaxation for those with overall higher levels of FCR. The mediation analyses confirmed that the most likely mechanism of treatment efficacy was the reduction in unhelpful metacognitions and intrusive thoughts during treatment, consistent with the theoretical framework underpinning ConquerFear.

IMPLICATIONS FOR CANCER SURVIVORS

ConquerFear is a brief, effective treatment for FCR in cancer survivors with early-stage disease. The treatment works by reducing intrusive thoughts about cancer and changing beliefs about worry and is particularly helpful for people with moderate to severe FCR.

Margins and survival in oral cancer

In the surgical management of oral squamous cell carcinoma (SCC) we aim to resect the tumour with clear margins in all planes. The aim of this study was to identify and compare overall survival in a group of 591 patients who had resections, and to relate this to the clearance of margins at the tumour bed. We used life tables to calculate survival at one, two, three, five, and 10 years after diagnosis by margin (clear=5mm or more; close=2-5mm; and involved=less than 2mm). Kaplan-Meier curves were produced for the margins alone, which were defined as clear in 480 patients (81%), close in 63 (11%), and involved in 48 (8%). Five-year survival was 81%, 75%, and 54% for clear, close, and involved margins, respectively, which highlights the importance of clear margins for survival. There is a significant prognostic implication associated with close, and particularly with involved, margins.

Abstract P6-12-14: Quality of life and ability to work in patients at different disease stages of HER2+ breast cancer

OBJECTIVES: Health-related quality of life (HRQoL) and ability to work in patients treated for HER2+ early breast cancer (EBC) are poorly understood. This study compared HRQoL and ability to work in 3 HER2+ patient cohorts: EBC during adjuvant treatment, EBC after treatment, and metastatic disease (MBC).

METHODS: A cross-sectional observational cohort study of 299 female consenting patients with HER2+BC, from 14 UK secondary care centres. Group1 (n=89): receiving targeted HER2 therapy±chemotherapy for EBC; Group2 (n=108): in follow up post-targeted treatment for eBC; Group3 (n=102): MBC on treatment. Data collected between Dec 2016-Mar 2017: HRQoL, demographic and employment status data collected via patient-reported questionnaires (including EQ-5D-5L and Functional Assessment of Cancer Therapy [FACT-B]); clinical data collected from medical records. Inter-group differences were assessed using univariate Analysis of variance (ANOVA) and chi-square tests as appropriate. [NCT03099200].

RESULTS: Table1 shows patient demographics, disease characteristics, employment status, and EQ-5D-5L scores. Group1 and Group2 patients did not differ in overall health utility or visual analogue scale (VAS) scores. However, Group3 patients reported significantly poorer health utility than Group1 (p&lt;0.02) and Group2 (p&lt;0.001), and significantly worse VAS scores than Group2 (p&lt;0.001). Significantly fewer Group2 patients and more Group3 patients were unable to work (p&lt;0.003), and fewer Group3 patients were employed than expected (by chi-square, p&lt;0.003).

CONCLUSIONS: HRQoL in patients with EBC was similar whether on or off treatment, and better than those with MBC. HRQoL scores reported on the generic EQ-5D will be compared with those from the disease-specific FACT-B. A smaller proportion of patients with MBC were employed compared to the EBC groups, reflecting the impact of advanced disease. Fewer patients with EBC reported being unable to work than we expected, suggesting these patients maintain function.

Table1

 Group1 (n=89)Group2 (n=108)Group3 (n=102)Age (years)↑55 (11)58 (11)55 (11)Hormone receptor status¥Positive64 (72%)84 (78%)74 (73%)Negative25 (28%)24 (22%)26 (26%)Unknown0 (0%)0 (0%)2 (2%)Time since diagnosis (months)+EBC9 (6)45 (32) (n=103)80 (82) (n=71*)MBC--39 (36) (n=101)Employment status¥Employed45 (51%)55 (51%)28 (28%)§Not employed41 (46%)52 (48%)69 (68%)Retired22 (25%)39 (36%)33 (32%)Unable to work7 (8%)5 (5%)§27 (27%)§Other12 (14%)8 (7%)9 (9%)Unknown3 (3%)1 (1%)5 (5%)EQ-5D summary scoresVisual analogue scale72.7 (18.4)†77.0 (17.5)†65.8 (22.9)† (n=99)Utility value0.809 (0.170)† (n=86)0.818 (0.181)†0.695 (0.262)† (n=97)↑mean (standard deviation); ¥n (%); +median (interquartile range); *excludes 27/102 patients (27%) with de novo MBC. Bold text: observed differences between three groups at significance thresholds of ‡p&lt;0.05, §p&lt;0.003 or †p&lt;0.001. EBC/MBC: early/metastatic breast cancer. %s have been rounded so may not total 100%

Citation Format: Verrill M, Wardley A, Retzler J, Smith AB, McNicol D, Dando S, Tran I, Leslie I, Schmid P. Quality of life and ability to work in patients at different disease stages of HER2+ breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-14.

e-TC: Development and pilot testing of a web-based intervention to reduce anxiety and depression in survivors of testicular cancer

e-TC is an online intervention designed to address common psychosocial concerns of testicular cancer survivors. It aims to reduce anxiety, depression and fear of cancer recurrence by providing evidence-based information and psychological intervention. This paper details the development and pilot testing of e-TC. During pilot testing, 25 men (with varying psychological profiles) who had completed treatment for testicular cancer, 6 months to 5 years ago (which had not recurred), used e-TC over a 10-week period and provided quantitative and qualitative feedback on the feasibility and acceptability of the programme. Six men also completed a qualitative interview to provide detailed feedback on their experiences using e-TC. Fourteen men (56%) completed at least 80% of the programme. Participants reported a high level of satisfaction with the programme. Men's limited time was a barrier to programme use and completion, and participants suggested that men with a more recent diagnosis and a higher level of distress may be more likely to engage with the programme. e-TC appears to be a feasible and acceptable online intervention for survivors of testicular cancer. Findings from this study are currently being used to refine e-TC and guide the design of a larger efficacy study.

Achieving social justice for children: How can children's rights thinking make a difference?

This article draws on themes from the author's book, Children’s Rights: Toward Social Justice, that emerge from surveying children’s rights issues in different childhood contexts; the family, education, child protection, and health services. The author has selected five examples of application of children’s rights to a policy area and identified the implications for policy and practice. There are four core rights that cut across all children’s rights issues that are mentioned before discussing specific areas. First, children, regardless of race, sex, language, religion, disability, or class, are entitled to rights. In other words, all children should enjoy their rights and should not be discriminated against. Second, “the best interests of the child” should be “a primary consideration” in actions or decisions concerning children. Third, children have the right to survival and development. And fourth, children have the right to be consulted and have their views heard in matters that affect them.

Validated questionnaires on intimacy in patients who have had cancer

Problems with intimacy in patients with cancer of the head and neck may not be recognised. Our aim was to review published papers on patient-reported outcomes that record concerns about intimacy, sex, and function, to help develop a tool for use in head and neck cancer. We specifically looked for instruments with evidence of validation in patients with cancer, which could be used to identify problems with intimacy and sexuality. After evaluating 2563 papers, we identified 20 that satisfied our inclusion criteria, and these have been presented in a tabulated form. This review has shown the need to develop a questionnaire on intimacy that is specific to patients with cancer of the head and neck. It is an important issue that must be addressed by clinical and research teams, and will be done most effectively if it is linked to specific interventions.

Improving decision making about clinical trial participation - a randomised controlled trial of a decision aid for women considering participation in the IBIS-II breast cancer prevention trial

BACKGROUND

Decision aids may improve informed consent in clinical trial recruitment, but have not been evaluated in this context. This study investigated whether decision aids (DAs) can reduce decisional difficulties among women considering participation in the International Breast Cancer Intervention Study-II (IBIS-II) trial.

METHODS

The IBIS-II trial investigated breast cancer prevention with anastrazole in two cohorts: women with increased risk (Prevention), and women treated for ductal carcinoma in situ (DCIS). Australia, New Zealand and United Kingdom participants were randomised to receive a DA (DA group) or standard trial consent materials (control group). Questionnaires were completed after deciding about participation in IBIS-II (post decision) and 3 months later (follow-up).

RESULTS

Data from 112 Prevention and 34 DCIS participants were analysed post decision (73 DA; 73 control); 95 Prevention and 24 DCIS participants were analysed at follow-up (58 DA; 61 control). There was no effect on the primary outcome of decisional conflict. The DCIS-DA group had higher knowledge post decision, and the Prevention-DA group had lower decisional regret at follow-up.

CONCLUSIONS

This was the first study to evaluate a DA in the clinical trial setting. The results suggest DAs can potentially increase knowledge and reduce decisional regret about clinical trial participation.

Drug-specific laterality effects on frontal lobe activation of atomoxetine and methylphenidate in attention deficit hyperactivity disorder boys during working memory

BACKGROUND

The catecholamine reuptake inhibitors methylphenidate (MPH) and atomoxetine (ATX) are the most common treatments for attention deficit hyperactivity disorder (ADHD). This study compares the neurofunctional modulation and normalization effects of acute doses of MPH and ATX within medication-naive ADHD boys during working memory (WM).

METHOD

A total of 20 medication-naive ADHD boys underwent functional magnetic resonance imaging during a parametric WM n-back task three times, under a single clinical dose of either MPH, ATX or placebo in a randomized, double-blind, placebo-controlled, cross-over design. To test for normalization effects, brain activations in ADHD under each drug condition were compared with that of 20 age-matched healthy control boys.

RESULTS

Relative to healthy boys, ADHD boys under placebo showed impaired performance only under high WM load together with significant underactivation in the bilateral dorsolateral prefrontal cortex (DLPFC). Both drugs normalized the performance deficits relative to controls. ATX significantly enhanced right DLPFC activation relative to MPH within patients, and significantly normalized its underactivation relative to controls. MPH, by contrast, both relative to placebo and ATX, as well as relative to controls, upregulated the left inferior frontal cortex (IFC), but only during 2-back. Both drugs enhanced fronto-temporo-striatal activation in ADHD relative to control boys and deactivated the default-mode network, which were negatively associated with the reduced DLPFC activation and performance deficits, suggesting compensation effects.

CONCLUSIONS

The study shows both shared and drug-specific effects. ATX upregulated and normalized right DLPFC underactivation, while MPH upregulated left IFC activation, suggesting drug-specific laterality effects on prefrontal regions mediating WM.

Volatile components of scent material from cotton-top tamarin (Saguinus o. oedipus) : A chemical and behavioral study

The first chemical analysis of the volatile components of scent material from the cotton-top tamarin,Saguinus o. oedipus is presented. In contrast to our previous findings in saddle-back tamarins (Saguinus fuscicollis), the chemical composition of the scent marks is quite variable. Analysis of secretion expressed manually from different areas of the scent pads of sedated animals shows individual and regional variability. Only three components (squalene, cholesterol, andp-methoxybenzaldehyde) were found in all scent mark samples analyzed. However, suprapubic secretions obtained from one sedated female contained, in addition, 12 butyrate esters as well as five acetate esters which were homologous to the butyrates. The butyrate esters have been previously identified in scent material fromSaguinus fuscicollis. The variability of the composition of the scent material is discussed in relation to the scent-marking behavior of the cotton-top tamarins. Behavioral studies tested the ability of the cotton-top tamarins to discriminate between scent marks from conspecifics and scent marks from saddle-back tamarins. The group of 12 subjects discriminated between the scent marks from both species in choice tests during which they could freely contact the scent samples. However, when scent marks were presented under a screen, so that the subjects could smell but not contact the stimuli, no discrimination was shown. Four individuals displayed more interest in the screened scent stimuli than all other subjects. When these animals were tested in a second experiment for their ability to discriminate between material from the two species on the basis of only volatile cues, it became evident that they were able to do so. These results indicate that volatile cues alone enable the tamarins to recognize scent marks from conspecifics, but that additional cues perceived during contact with the scent are important for its full attractiveness and/or informational content.

Oleocanthal inhibits proliferation and MIP-1α expression in human multiple myeloma cells

Multiple myeloma (MM) is a plasma cell malignancy that causes devastating bone destruction by activating osteoclasts in the bone marrow milieu. MM is the second of all hematological malignancies. Thus, the search for new pharmacological weapons is under intensive investigation being MM a critically important public health goal. Recently, it has been demonstrated that macrophage inflammatory protein 1- alpha (MIP-1 α) is crucially involved in the development of osteolytic bone lesions in MM. Phenolic components of extra virgin olive oil are reported to have anti tumor activity. However, the underlying mechanisms and specific targets of extra virgin olive oil remain to be elucidated. In the present study, we investigated the effects of a recently isolated novel extra virgin olive oil polyphenol, oleocanthal, on the human multiple myeloma cell line ARH-77. Here we report that this natural compound has a remarkable in vitro activity by inhibiting MIP-1 α expression and secretion in MM cells. In addition, we also demonstrated that oleocanthal inhibits MM cells proliferation by inducing the activation of apoptosis mechanisms and by down-regulating ERK1/2 and AKT signal transduction pathways. This in vitro study suggests a therapeutic potential of oleocanthal in treating multiple myeloma.

Disorder-specific functional abnormalities during sustained attention in youth with Attention Deficit Hyperactivity Disorder (ADHD) and with autism

Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) are often comorbid and share behavioural-cognitive abnormalities in sustained attention. A key question is whether this shared cognitive phenotype is based on common or different underlying pathophysiologies. To elucidate this question, we compared 20 boys with ADHD to 20 age and IQ matched ASD and 20 healthy boys using functional magnetic resonance imaging (fMRI) during a parametrically modulated vigilance task with a progressively increasing load of sustained attention. ADHD and ASD boys had significantly reduced activation relative to controls in bilateral striato-thalamic regions, left dorsolateral prefrontal cortex (DLPFC) and superior parietal cortex. Both groups also displayed significantly increased precuneus activation relative to controls. Precuneus was negatively correlated with the DLPFC activation, and progressively more deactivated with increasing attention load in controls, but not patients, suggesting problems with deactivation of a task-related default mode network in both disorders. However, left DLPFC underactivation was significantly more pronounced in ADHD relative to ASD boys, which furthermore was associated with sustained performance measures that were only impaired in ADHD patients. ASD boys, on the other hand, had disorder-specific enhanced cerebellar activation relative to both ADHD and control boys, presumably reflecting compensation. The findings show that ADHD and ASD boys have both shared and disorder-specific abnormalities in brain function during sustained attention. Shared deficits were in fronto-striato-parietal activation and default mode suppression. Differences were a more severe DLPFC dysfunction in ADHD and a disorder-specific fronto-striato-cerebellar dysregulation in ASD.

Common and expected postmortem CT observations involving the brain: mimics of antemortem pathology

BACKGROUND AND PURPOSE

Postmortem imaging with CT or MR is emerging as an effective technique to augment forensic autopsy. Expected findings on postmortem imaging of the brain may mimic pathologic processes in the living brain, leading to potential misdiagnosis. The purpose of this study is to describe the array of CT findings that can be expected to be present within the brain after death.

MATERIALS AND METHODS

A retrospective review was performed using an anonymized data base of 33 postmortem head CTs with no evidence of trauma to the face or scalp. Head CTs were assessed for 1) loss of gray-white differentiation, 2) effacement of the ventricles and cisterns, 3) postmortem intravascular blood distribution, 4) presence of intracranial or intravascular air, and 5) an irregular appearance of the falx. Imaging findings were correlated with autopsy findings.

RESULTS

Visualization of the basal ganglia was noted in 30 (91%) subjects, and the cortical ribbon was appreciated in 14 (42%). The ventricles and cisterns were effaced in 19 (58%) cases. An "expected postmortem blood distribution" was seen in 27 (82%) instances. Intravascular air was present in 14 cases (42%). A "lumpy" falx was present in 20 cases (61%). In 4 cases of subdural or subarachnoid hemorrhage noted on autopsy, but not on CT, retrospective review confirmed that a true discrepancy between the radiology and pathology findings persisted.

CONCLUSIONS

Recognition of expected postmortem patterns is required before pathology can be accurately diagnosed. A limitation of CT virtual autopsy is the possibility of missing small blood collections.

A Clinical Study Comparing the Efficacy and Sensitivity of Home vs Combined Whitening

This randomized clinical study assessed efficacy in terms of color change and production of sensitivity after home whitening alone and home whitening supplemented with in-office bleaching. Thirty-six subjects (aged 19 to 58 years) were randomly assigned to one of three different treatment groups: (A) home whitening for two weeks, with 16% carbamide peroxide in custom-made trays; (B) home whitening for two weeks, with 16% carbamide peroxide in custom-made trays supplemented with in-office bleaching with 9% hydrogen peroxide (in the same trays); or (C) home whitening for two weeks, with 16% carbamide peroxide in custom-made trays supplemented with in-office bleaching with 27% hydrogen peroxide (in the same trays). The efficacy of tooth whitening was assessed by determining the color change associated with the six upper anterior teeth using a value-ordered shade guide. Sensitivity was self-assessed with the use of a visual analog scale (VAS). Tooth shade and sensitivity were assessed at the following points: pretreatment; immediately after the home whitening phase; immediately after the in-office phase (groups B and C); and one week post active treatment. At the one week follow-up visit, subjects in group A had a mean (SD) color change of 5.9 (1.83) (teeth were lighter) immediately after cessation of treatment (p&lt;0.01). Subjects in groups B and C experienced a greater change in mean (SD) shade immediately following their respective in-office treatments of 5.1 (1.53) and 5.4 (1.55). However, within one week, the shade of these teeth regressed to a similar degree to that achieved by subjects treated in group A. Overall, no significant difference in shade change or sensitivity was produced between the three groups. Investigators concluded that the in-office element of combined whitening produced no significant difference in tooth color or sensitivity when compared with home whitening alone.

Cambrian stalked echinoderms show unexpected plasticity of arm construction

Feeding arms carrying coelomic extensions of the theca are thought to be unique to crinoids among stemmed echinoderms. However, a new two-armed echinoderm from the earliest Middle Cambrian of Spain displays a highly unexpected morphology. X-ray microtomographic analysis of its arms shows they are polyplated in their proximal part with a dorsal series of uniserial elements enclosing a large coelomic lumen. Distally, the arm transforms into the more standard biserial structure of a blastozoan brachiole. Phylogenetic analysis demonstrates that this taxon lies basal to rhombiferans as sister-group to pleurocystitid and glyptocystitid blastozoans, drawing those clades deep into the Cambrian. We demonstrate that Cambrian echinoderms show surprising variability in the way their appendages are constructed, and that the appendages of at least some blastozoans arose as direct outgrowths of the body in much the same way as the arms of crinoids.

Modulation of protein-protein interactions as a therapeutic strategy for the treatment of neurodegenerative tauopathies

The recognition that malfunction of the microtubule (MT) associated protein tau is likely to play a defining role in the onset and/or progression of a number of neurodegenerative diseases, including Alzheimer's disease, has resulted in the initiation of drug discovery programs that target this protein. Tau is an endogenous MT-stabilizing agent that is highly expressed in the axons of neurons. The MT-stabilizing function of tau is essential for the axonal transport of proteins, neurotransmitters and other cellular constituents. Under pathological conditions, tau misfolding and aggregation results in axonal transport deficits that appear to have deleterious consequences for the affected neurons, leading to synapse dysfunction and, ultimately, neuronal loss. This review focuses on both progress and unresolved issues surrounding the development of novel therapeutics for the treatment of neurodegenerative tauopathies, which are based on (A) MT-stabilizing agents to compensate for the loss of normal tau function, and (B) small molecule inhibitors of tau aggregation.

Children as citizens and partners in strengthening communities

Children are citizens who are entitled to recognition, respect, and participation. Positioning children as citizens gives them the opportunity to play a role in solving fundamental problems and, in partnership with adults, strengthen their communities. Research on children's understanding of rights, responsibilities, and citizenship can build a platform for action. Numerous examples of projects are available in which children have been encouraged and supported to exercise their agency and put into practice the ideals of citizenship for the benefit of their communities. If children are to exercise their rights and responsibilities as citizens, change must occur in both adult and child cultures.

Asymmetrical lateral ventricular enlargement in Parkinson's disease

BACKGROUND

A recent case report suggested the presence of asymmetrical lateral ventricular enlargement associated with motor asymmetry in Parkinson's disease (PD). The current study explored these associations further.

METHODS

Magnetic resonance imaging (3T) scans were obtained on 17 PD and 15 healthy control subjects at baseline and 12-43 months later. Baseline and longitudinal lateral ventricular volumetric changes were compared between contralateral and ipsilateral ventricles in PD subjects relative to symptom onset side and in controls relative to their dominant hand. Correlations between changes in ventricular volume and United Parkinson's disease rating scale motor scores (UPDRS-III) whilst on medication were determined.

RESULTS

The lateral ventricle contralateral to symptom onset side displayed a faster rate of enlargement compared to the ipsilateral (P = 0.004) in PD subjects, with no such asymmetry detected (P = 0.312) in controls. There was a positive correlation between ventricular enlargement and worsening motor function assessed by UPDRS-III scores (r = 0.96, P < 0.001).

DISCUSSION

There is asymmetrical lateral ventricular enlargement that is associated with PD motor asymmetry and progression. Further studies are warranted to investigate the underlying mechanism(s), as well as the potential of using volumetric measurements as a marker for PD progression.

Maximum entropy and the state-variable approach to macroecology

The biodiversity scaling metrics widely studied in macroecology include the species-area relationship (SAR), the scale-dependent species-abundance distribution (SAD), the distribution of masses or metabolic energies of individuals within and across species, the abundance-energy or abundance-mass relationship across species, and the species-level occupancy distributions across space. We propose a theoretical framework for predicting the scaling forms of these and other metrics based on the state-variable concept and an analytical method derived from information theory. In statistical physics, a method of inference based on information entropy results in a complete macro-scale description of classical thermodynamic systems in terms of the state variables volume, temperature, and number of molecules. In analogy, we take the state variables of an ecosystem to be its total area, the total number of species within any specified taxonomic group in that area, the total number of individuals across those species, and the summed metabolic energy rate for all those individuals. In terms solely of ratios of those state variables, and without invoking any specific ecological mechanisms, we show that realistic functional forms for the macroecological metrics listed above are inferred based on information entropy. The Fisher log series SAD emerges naturally from the theory. The SAR is predicted to have negative curvature on a log-log plot, but as the ratio of the number of species to the number of individuals decreases, the SAR becomes better and better approximated by a power law, with the predicted slope z in the range of 0.14-0.20. Using the 3/4 power mass-metabolism scaling relation to relate energy requirements and measured body sizes, the Damuth scaling rule relating mass and abundance is also predicted by the theory. We argue that the predicted forms of the macroecological metrics are in reasonable agreement with the patterns observed from plant census data across habitats and spatial scales. While this is encouraging, given the absence of adjustable fitting parameters in the theory, we further argue that even small discrepancies between data and predictions can help identify ecological mechanisms that influence macroecological patterns.

Quality of life after liver resection for hepatobiliary malignancies

BACKGROUND

Few prospective longitudinal studies have used a validated quality of life (QOL) instrument in patients undergoing liver resection for hepatobiliary malignancy.

METHODS

Patients undergoing liver resection for hepatobiliary tumours in a 1-year period were enrolled. The cancer-specific European Organization for Research and Treatment of Cancer core questionnaire (EORTC QLQ-C30) was completed before operation, and at 6, 12 and 36-48 months after surgery. QOL over time was analysed in relation to several clinical factors.

RESULTS

A total of 103 patients were enrolled. Patient compliance was at least 75 per cent at all stages. Most functional scales and the global QOL scale showed a non-significant trend towards deterioration at 6 months and a return to preoperative level at 12 months. Physical functioning and dyspnoea deteriorated significantly at 6 months (P = 0.020 and P = 0.004 respectively) and did not recover by 12 months (P = 0.002 and P < 0.001 respectively). Pain and fatigue showed clinically significant deterioration over 12 months, which was not statistically significant. Survivors without recurrence at 36-48 months showed better QOL than those with recurrent disease.

CONCLUSION

Major liver resection is associated with acceptable QOL outcomes, and QOL continues to improve in the long term in those without recurrence.

Radiation dose-reduction strategies for neuroradiology CT protocols

Within the past 2 decades, the number of CT examinations performed has increased almost 10-fold. This is in large part due to advances in multidetector-row CT technology, which now allows faster image acquisition and improved isotropic imaging. The increased use, along with multidetector technique, has led to a significantly increased radiation dose to the patient from CT studies. This places increased responsibility on the radiologist to ensure that CT examinations are indicated and that the "as low as reasonably achievable" concept is adhered to. Neuroradiologists are familiar with factors that affect patient dose such as pitch, milliamperes, kilovolt peak (kVp), collimation, but with increasing attention being given to dose reduction, they are looking for additional ways to further reduce the radiation associated with their CT protocols. In response to increasing concern, CT manufacturers have developed dose-reduction tools, such as dose modulation, in which the tube current is adjusted along with the CT acquisition, according to patient's attenuation. This review will describe the available techniques for reducing dose associated with neuroradiologic CT imaging protocols.

The initial development of an item bank to assess and screen for psychological distress in cancer patients

Psychological distress is a common problem among cancer patients. Despite the large number of instruments that have been developed to assess distress, their utility remains disappointing. This study aimed to use Rasch models to develop an item-bank which would provide the basis for better means of assessing psychological distress in cancer patients.An item bank was developed from eight psychological distress questionnaires using Rasch analysis to link common items. Items from the questionnaires were added iteratively with common items as anchor points and misfitting items (infit mean square >1.3) removed, and unidimensionality assessed.A total of 4914 patients completed the questionnaires providing an initial pool of 83 items. Twenty items were removed resulting in a final pool of 63 items. Good fit was demonstrated and no additional factor structure was evident from the residuals. However, there was little overlap between item locations and person measures, since items mainly targeted higher levels of distress. The Rasch analysis allowed items to be pooled and generated a unidimensional instrument for measuring psychological distress in cancer patients. Additional items are required to more accurately assess patients across the whole continuum of psychological distress.

Rasch analysis of the dimensional structure of the Hospital Anxiety and Depression Scale

The Hospital Anxiety and Depression Scale (HADS) has been used extensively in cancer patients to identify psychological distress. Reports of the factor structure and screening performance of the instrument vary. Rasch models allow an assessment of the structure of a questionnaire by identifying item fit. Removal of misfitting items may improve both the dimensionality and efficacy of screening questionnaires. A Rasch analysis of the HADS-T and subscales was used to explore the factor structure, dimensionality and screening efficacy. A total of 1855 patients completed a touchscreen version of the HADS, including 381 patients who had received a psychiatric interview (SCAN/PSE). These data were analysed using Rasch models, and the screening efficacy at identifying cases of psychological distress and anxiety and depression evaluated. The results demonstrated that the structure of the HADS-T and subscales was unidimensional. Three items from the HADS-T, and one from each of the subscales demonstrated misfit. Screening efficacy for the HADS-T and subscales was modest. However, removal of misfitting items had little impact on screening, demonstrating that items could potentially be omitted, if required. The item range covered a narrow spectrum of psychological distress, predominantly higher levels of distress. Additional items have to be added if screening for moderate to mild distress is to be improved for cancer patients.

Determination of the absolute configurations of natural products via density functional theory calculations of optical rotation, electronic circular dichroism, and vibrational circular dichroism: the cytotoxic sesquiterpene natural products quadrone, suberosenone, suberosanone, and suberosenol A acetate

The determination of the absolute configurations (ACs) of chiral molecules using the chiroptical techniques of optical rotation (OR), electronic circular dichroism (ECD), and vibrational circular dichroism (VCD) has been revolutionized by the development of density functional theory (DFT) methods for the prediction of these properties. Here, we demonstrate the significance of these advances for the stereochemical characterization of natural products. Time-dependent DFT (TDDFT) calculations of the specific rotations, [alpha](D), of four cytotoxic natural products, quadrone (1), suberosenone (2), suberosanone (3), and suberosenol A acetate (4), are used to assign their ACs. TDDFT calculations of the ECD of 1 are used to assign its AC. The VCD spectrum of 1 is reported and also used, together with DFT calculations, to assign its AC. The ACs of 1 derived from its [alpha](D), ECD, and VCD are identical and in agreement with the AC previously determined via total synthesis. The previously undetermined ACs of 2-4, derived from their [alpha](D) values, have absolute configurations of their tricyclic cores identical to that of 1. Further studies of the ACs of these molecules using ECD and, especially, VCD are recommended to establish more definitively this finding. Our studies of the OR, ECD, and VCD of quadrone are the first to utilize DFT calculations of all three properties for the determination of the AC of a chiral natural product molecule.

Development and evaluation of an instrument to assess social difficulties in routine oncology practice

PURPOSE

To develop and preliminarily evaluate a Social Difficulties Inventory (SDI) for use in oncology practice.

METHODS

Item generation from patients (n = 96), staff (n = 49) and the literature. Questions constructed and pre-tested (n = 42) resulting in a 22-item questionnaire. Psychometric evaluation (n = 271) assessed frequency of endorsement, factor structure, summated scales and construct validity followed by randomisation to criterion validity or test-retest arms.

RESULTS

Items met preset frequency of endorsement criteria. Factor analysis revealed a four-factor structure, three clearly definable, (1) Physical ability, (2) Providing for the family and (3) Contact with others, explaining 45.8% variance. Summated scales developed from these demonstrated good reliability (Cronbach's alpha > 0.7) and were used to test and confirmed construct validity. Several comparators from the Life Events and Difficulties Schedule (LEDS) and Cancer Rehabilitation Evaluation System Short Form (CARES-SF) tested criterion validity and majority agreements were moderate to good. Test-retest reliability was good with most kappa values > 0.6. One item was eliminated resulting in a 21-item questionnaire.

CONCLUSION

The SDI is relevant and easy to understand. Initial psychometric evaluation was encouraging. Ongoing work to evaluate the clinical meaning and utility of the instrument and to examine the relationships between SDI scores and clinical outcomes will provide guidance about its usefulness as an assessment tool in routine oncology practice.

A practical synthesis of Nalpha-Fmoc-L-pyrazinylalanine via Schöllkopf's chiral auxiliary

A practical, gram-scale synthesis of L-pyrazinylalanine (Paa) is described, utilizing Schöllkopf's D-valine-derived bis-lactim ether chiral auxiliary.

Health rights in secondary schools: student and staff perspectives

This paper examines the perspectives of secondary school students and staff about the extent to which young people's health rights are catered for at school. The United Nations Convention on the Rights of the Child and the concept of Health-Promoting Schools encourage the provision of healthy school environments. A postal survey of secondary schools in New Zealand elicited responses from 821 Year 11 (15-16 year olds) students and 438 staff in 107 schools. Most students and staff reported that sources of health advice were available at their schools, but only a minority of students saw these sources as accessible or trustworthy. In every area of health promotion, students saw information and advice as less accessible than staff did. Most staff and students identified mental health problems such as depression as a source of concern in schools, but only a quarter of students (compared to half of staff) thought that this topic was covered during classtime. Students in lower-income schools reported the school environment as slightly less healthy than did students in high-income schools. The paper concludes that schools and policy makers should seek the voices and opinions of young people in order to improve effectiveness in catering for health rights.

Salvaging legacy data: mapping an obsolete medical nomenclature to a modern one

The Veterinary Medical Database (VMDB) is a repository containing abstracts of over six million case records from 24 veterinary colleges throughout the U.S. and Canada. These case record abstracts, spanning almost 40 years, represent a valuable resource for outcomes analysis and hypothesis generation. Database records are currently encoded using the Standard Nomenclature of Veterinary Diseases and Operations (SNVDO), a precoordinated, hierarchical coding system. SNVDO has not been updated since 1977 and is outdated and inadequate to express the current state of medical knowledge. We undertook to manually map a subset of the SNVDO codes to a modern medical nomenclature, SNOMED-RT (Version 1.0), and to evaluate the quality of the resultant mappings and the acceptability of the mapping method used. We found that the distribution of frequency of use of the SNVDO codes in the VMDB records is highly skewed, with a small number of codes accounting for a large percentage of the records. We targeted our mapping efforts on that subset of codes. We found that our targeted manual mapping of the SNVDO codes to SNOMED-RT codes was feasible and produced good quality results, based on separate evaluations performed by two domain experts. However, a significant proportion of the SNVDO codes could not be mapped to a single SNOMED-RT concept, necessitating construction of multiple-code post-coordinated terms. Additionally, this manual mapping was very labor-intensive.

Computer-based quality of life questionnaires may contribute to doctor-patient interactions in oncology

It is well recognized that oncologists should consider patients' quality of life and functioning when planning and delivering anticancer treatment, but a comprehensive assessment of how a patient feels requires a thorough inquiry. A standardized measurement of patients' quality of life may support clinicians in identifying important problems for discussion during the limited time of the medical consultations. The aim of this study was to assess the feasibility of computer-administered individual quality of life measurements in oncology clinics with immediate feedback of results to clinicians and to examine the impact of the information on consultations. The study employed a prospective non-randomized design with pre-test post-test within subjects comparisons and involved three medical oncologists and 28 cancer patients receiving chemotherapy. The intervention consisted of completion of quality of life questionnaires before the consultations and informing clinicians of the results. The main outcome measures were patients' perceptions of the content of baseline and intervention consultations and satisfaction with communication. A qualitative analysis of clinicians' interviews was performed. When clinicians had the quality of life results they enquired more often about daily activities (Z= -2.71, P=0.007), emotional problems (Z= -2.11, P=0.035) and work related issues (Z= -1.89, P=0.058). There was an increase in the number of issues discussed during the intervention consultation (Z= -1.89, P=0.059). Patients were highly satisfied with both consultations. The computer measurement was well accepted by patients who felt that the questionnaires were a useful tool to tell the doctors about their problems. The clinicians perceived that the quality of life data broadened the range of the clinical inquiry and helped them identify issues for discussion. Having symptoms and functional problems expressed quantitatively on a scale was useful for detection of change over time.

Pre- and postsynaptic actions of ATP on neurotransmission in rat submandibular ganglia

The pre- and postsynaptic actions of exogenously applied ATP were investigated in intact and dissociated parasympathetic neurones of rat submandibular ganglia. Nerve-evoked excitatory postsynaptic potentials (EPSPs) were not inhibited by the purinergic receptor antagonists, suramin and pyridoxal-phosphate-6-azophenyl-2',4'-disulphonic acid (PPADS), or the desensitising agonist, alpha,beta-methylene ATP. In contrast, EPSPs were abolished by the nicotinic acetylcholine receptor antagonists, hexamethonium and mecamylamine. Focal application of ATP (100 microM) had no effect on membrane potential of the postsynaptic neurone or on the amplitude of spontaneous EPSPs. Taken together, these results suggest the absence of functional purinergic (P2) receptors on the postganglionic neurone in situ. In contrast, focally applied ATP (100 microM) reversibly inhibited nerve-evoked EPSPs. Similarly, bath application of the non-hydrolysable analogue of ATP, ATP gamma S, reversibly depressed EPSPs amplitude. The inhibitory effects of ATP and ATP gamma S on nerve-evoked transmitter release were antagonised by bath application of either PPADS or suramin, suggesting ATP activates a presynaptic P2 purinoceptor to inhibit acetylcholine release from preganglionic nerves in the submandibular ganglia. In acutely dissociated postganglionic neurones from rat submandibular ganglia, focal application of ATP (100 microM) evoked an inward current and subsequent excitatory response and action potential firing, which was reversibly inhibited by PPADS (10 microM). The expression of P2X purinoceptors in wholemount and dissociated submandibular ganglion neurones was examined using polyclonal antibodies raised against the extracellular domain of six P2X purinoceptor subtypes (P2X(1-6)). In intact wholemount preparations, only the P2X(5) purinoceptor subtype was found to be expressed in the submandibular ganglion neurones and no P2X immunoreactivity was detected in the nerve fibres innervating the ganglion. Surprisingly, in dissociated submandibular ganglion neurones, high levels of P2X(2) and P2X(4) purinoceptors immunoreactivity were found on the cell surface. This increase in expression of P2X(2) and P2X(4) purinoceptors in dissociated submandibular neurones could explain the increased responsiveness of the neurones to exogenous ATP. We conclude that disruption of ganglionic transmission in vivo by either nerve damage or synaptic blockade may up-regulate P2X expression or availability and alter neuronal excitability.

First generation design, synthesis, and evaluation of azepine-based cryptophycin analogues

[structure: see text] Azepine-based cryptophycin mimics (+)-4 and (+)-5 have been designed and synthesized. Biological evaluation revealed modest in vitro activity against several human tumor cell lines, thereby supporting the utility of novel scaffolds for the design and synthesis of cryptophycin analogues.

Nodulisporic acid A synthetic studies. 2. Construction of an eastern hemisphere subtarget

In this, the second of two Letters, we describe an effective assembly of (+)-4, an eastern hemisphere subtarget comprising the FGH rings of (+)-nodulisporic acid A (1) (17 steps, 9% overall yield). Central to the synthesis is a Koga three-component conjugate addition-alkylation sequence which secures the trans orientation of the vicinal quaternary methyl groups. [reaction: see text]

Lituarine synthetic studies. An efficient, stereocontrolled construction of the common c(7-19) tricyclic spiroketal fragment

A highly efficient, stereocontrolled synthesis of (+)-4, the common C(7-19) tricyclic spiroketal fragment of the lituarines A, B, and C (1-3), has been achieved. Highlights of the synthesis include a remarkably facile 6-endo cyclization to access the C(8-12) pyran ring and a kinetically controlled acid-catalyzed spiroketalization. [reaction: see text]

Nodulisporic acid A synthetic studies. 1. Overall strategy and construction of a western hemisphere subtarget

In this, the first of two Letters, we outline our overall strategy for the construction of (+)-nodulisporic acid A (1), a representative member of a new class of indole diterpenes. In addition, we describe the efficient assembly of (-)-6, an advanced western hemisphere subtarget, comprising the ABC rings of (+)-nodulisporic acid A (1). The synthesis proceeded in 9% overall yield (longest linear sequence, 11 steps), exploiting a Shibasaki-Mori tandem transmetalation-cyclization to construct ring B. [reaction: see text]

Total synthesis of (+)-phorboxazole A exploiting the Petasis-Ferrier rearrangement

A highly convergent, stereocontrolled total synthesis of the potent antiproliferative agent (+)-phorboxazole A (1) has been achieved. Highlights of the synthesis include: modified Petasis-Ferrier rearrangements for assembly of both the C(11-15) and C(22-26) cis-tetrahydropyran rings; extension of the Julia olefination to the synthesis of enol ethers; the design, synthesis, and application of a novel bifunctional oxazole linchpin; and Stille coupling of a C(28) trimethyl stannane with a C(29) oxazole triflate. The longest linear sequence leading to (+)-phorboxazole A (1) was 27 steps, with an overall yield of 3%.

Stereospecific synthesis of beta-D-allopyranosides by dihydroxylation of beta-D-erythro-2,3-dideoxyhex-2-enopyranosides

The synthesis of 4,6-O-benzylidene-beta-D-erythro-2-3-dideoxyhex-2-enopyranosides and their osmium and ruthenium catalysed dihydroxylation reactions have been investigated. These reactions have been shown, for a range of monosaccharides and a disaccharide, to proceed stereospecifically to give beta-D-allopyranosides in moderate to excellent yield.

The relationship between Taxol and (+)-discodermolide: synthetic analogs and modeling studies

BACKGROUND

During the past decade, Taxol has assumed an important role in cancer chemotherapy. The search for novel compounds with a mechanism of action similar to that of Taxol, but with greater efficacy particularly in Taxol-resistant cells, has led to the isolation of new natural products. One such compound, (+)-discodermolide, although structurally distinct from Taxol, has a similar ability to stabilize microtubules. In addition, (+)-discodermolide is active in Taxol-resistant cell lines that overexpress P-glycoprotein, the multidrug-resistant transporter. Interestingly, (+)-discodermolide demonstrates a profound enhancement of the initiation process of microtubule polymerization compared to Taxol.

RESULTS

The synthesis of (+)-discodermolide analogs exploiting our highly efficient, triply convergent approach has permitted structure-activity relationship (SAR) studies. Small changes to the (+)-discodermolide structure resulted in a dramatic decrease in the ability of all four discodermolide analogs to initiate tubulin polymerization. Two of the analogs also demonstrated a decrease in total tubulin polymerization, while a change in the olefin geometry at the C8 position produced a significant decrease in cytotoxic activity.

CONCLUSIONS

The availability of (+)-discodermolide and the analogs, and the resultant SAR analysis, have permitted an exploration of the similarities and differences between (+)-discodermolide and Taxol. Docking of the X-ray/solution structure of (+)-discodermolide into the Taxol binding site of beta-tubulin revealed two possible binding modes (models I and II). The preferred pharmacophore model (I), in which the C19 side chain of (+)-discodermolide matches with the C2 benzoyl group of Taxol and the delta-lactone ring of (+)-discodermolide overlays with the C13 side chain of Taxol, concurred with the results of the SAR analysis.