Anxiety, Disability, and Pain Predict Outcomes of Complex Regional Pain Syndrome: An 8-year Follow-up of a Prospective Cohort

Factors contributing to the varied outcomes of complex regional pain syndrome (CRPS) are not well known. This study aimed to determine whether baseline psychological factors, pain, and disability influence long-term CRPS outcomes. We conducted an 8-year follow-up from a previous prospective study of CRPS outcomes. Sixty-six people diagnosed with acute CRPS were previously assessed at baseline, 6 months, and 12 months and in the current study, 45 were followed up after 8 years. At each timepoint, we measured signs and symptoms of CRPS, pain, disability, and psychological factors. Mixed-model repeated measures were used to identify baseline predictors of CRPS severity, pain, and disability at 8 years. Predictors of greater CRPS severity at 8 years were female sex, greater baseline disability, and greater baseline pain. Predictors of greater pain at 8 years were greater baseline anxiety and disability. The only predictor of greater disability at 8 years was greater baseline pain. Findings suggest CRPS is best understood from a biopsychosocial perspective, and baseline anxiety, pain, and disability may influence the trajectory of CRPS outcomes as far as 8 years later. These variables could be used to identify those at risk of poor outcomes or form targets for early interventions. PERSPECTIVE: This paper presents the findings of the first study to prospectively investigate predictors of CRPS outcomes over 8 years. Baseline anxiety, pain, and disability predicted greater CRPS severity, pain, and disability over 8 years. These factors could identify those at risk of poor outcomes or form targets for early interventions.

Use of public sector diabetes eye services in New Zealand 2006-2019: Analysis of national routinely collected datasets

OBJECTIVE

To assess diabetes eye service use in New Zealand among people aged ≥15 years by estimating service attendance, biennial screening rate, and disparities in the use of screening and treatment services.

METHODS

We obtained Ministry of Health data from the National Non-Admitted Patient Collection on diabetes eye service events between 1 July 2006 and 31 December 2019 and sociodemographic and mortality data from the Virtual Diabetes Register and linked these using a unique patient identifier (encrypted National Health Index). We 1) summarized attendance at retinal screening and ophthalmology services, 2) calculated biennial and triennial screening rate, 3) summarized treatment with laser and anti-VEGF and used log-binomial regression to examine associations of all of these with age group, ethnicity, and area-level deprivation.

RESULTS

In total, 245,844 people aged ≥15 years had at least one diabetes eye service appointment attended or scheduled; half of these (n = 125,821, 51.2%) attended only retinal screening, one-sixth attended only ophthalmology (n = 35,883, 14.6%) and one-third attended both (n = 78,300, 31.8%). The biennial retinal screening rate was 62.1%, with large regional variation (73.9% in Southern District to 29.2% in West Coast). Compared with NZ Europeans, Māori were approximately twice as likely to never receive diabetes eye care or to access ophthalmology when referred from retinal screening, 9% relatively less likely to receive biennial screening and received the fewest anti-VEGF injections when treatment was commenced. Disparities in service access were also present for Pacific Peoples compared to NZ Europeans, younger and older age groups compared to those aged 50-59 years and those living in areas with higher deprivation.

CONCLUSIONS

Access to diabetes eye care is suboptimal, with substantial disparity between age groups, ethnicity groups, area level deprivation quintile and across districts. Efforts to improve access to and quality of diabetes eye care services must include strengthening data collection and monitoring.

Pre-sleep cognitive arousal exacerbates sleep disturbance in chronic pain: an exploratory daily diary and actigraphy study

OBJECTIVES

Insomnia is commonly comorbid with chronic pain, and typically leads to worse outcomes. Two factors that could contribute to a cycle of pain and sleeplessness are pre-sleep cognitive arousal (repetitive thought processes) and low mood. This study aimed to examine how pain, sleep disturbance, mood, and pre-sleep cognitive arousal inter-relate, to determine whether low mood or pre-sleep cognitive arousal contribute to a vicious cycle of pain and insomnia.

METHODS

Forty seven chronic pain patients completed twice daily diary measures and actigraphy for one week. Analyses investigated the temporal and directional relationships between pain intensity, sleep quality, time awake after sleep onset, anhedonic and dysphoric mood, and pre-sleep cognitive arousal. Fluctuations in predictor variables were used to predict outcome variables the following morning using mixed-effects modelling.

RESULTS

For people with chronic pain, an evening with greater pre-sleep cognitive arousal (relative to normal) led to a night of poorer sleep (measured objectively and subjectively), lower mood in the morning, and a greater misperception of sleep (underestimating sleep). A night of poorer sleep quality led to greater pain the following morning. Fluctuations in pain intensity and depression did not have a significant influence on subsequent sleep.

CONCLUSIONS

For people with chronic pain, cognitive arousal may be a key variable exacerbating insomnia, which in turn heightens pain. Future studies could target cognitive arousal to assess effects on sleep and pain outcomes.

Parental satisfaction with an advanced audiology-led triage service in paediatric ENT outpatient clinics

OBJECTIVE

The advanced audiology-led service is designed to triage and manage children who are referred to Ear Nose and Throat (ENT) outpatient services with middle ear or hearing concerns. This service has resulted in shorter waiting times for children to receive ENT treatment, and improved ENT capacity. The aim of this study was to explore parental satisfaction with the advanced audiology-led ENT service and to determine if there were cultural or process factors affecting satisfaction.

DESIGN

Prospective cross-sectional study using a modified Visit-Specific Satisfaction Questionnaire (VSQ-9) survey.

STUDY SAMPLE

One hundred and thirteen parents of children consecutively attending a first appointment in the advanced audiology-led service recruited between October 2016 and October 2017.

RESULTS

There were a total of 100 valid responses (rate of 88.5%). The survey showed high levels of satisfaction. Satisfaction scores were significantly higher for items related to interactions with the audiologist compared to items related to waiting times. There were no differences in satisfaction across cultural groups. Parents were equally satisfied with the service whether their child was managed independently by the audiologist or required another appointment for medical input.

CONCLUSIONS

The advanced audiology-led service had high levels of satisfaction from parents attending with their children.

Can an advanced audiology-led service reduce waiting times for paediatric ear nose and throat outpatient services?

AIM

Children with middle ear disease often experience lengthy delays waiting for outpatient paediatric ear nose and throat (ENT) services. This study aimed to investigate whether an alternative service delivery model using audiologists working in an expanded scope of practice reduced waiting times for children to access such services.

METHODS

A total of 131 children consecutively referred to a large ENT outpatient service in Queensland, Australia, for middle ear and hearing concerns were prospectively allocated to either a standard ENT service or an advanced audiology (AA)-led service. Waiting times and attendance rates were collected and compared between the two patient groups.

RESULTS

The median waiting time from referral to first offered appointment was 96 days for children in the AA-led service versus 417.5 days for children in the standard ENT service. Seventy-nine percent of children in the AA-led service attended their first offered appointment versus 61% in the standard ENT service. For children receiving grommets, the median waiting time from initial referral to grommet insertion was 226 days for children in the AA-led service versus 627 days for children in the standard ENT service.

CONCLUSION

The AA-led service was an effective alternative pathway to reduce waiting times for children referred to ENT services with middle ear and hearing concerns.

Vaccine-Preventable Disease-Associated Hospitalisations Among Migrant and Non-migrant Children in New Zealand

Migrants may experience a higher burden of vaccine-preventable disease (VPD)-associated hospitalisations compared to the host population. A retrospective cohort study from 2006 to 2015 was conducted that linked de-identified data from government sources using Statistic NZ's Integrated Data Infrastructure. VPD-related hospitalisations were compared between three cohorts of children from birth to 5 years old: foreign-born children who migrated to NZ, children born in NZ of recent migrant mothers, and a comparator group of children born in NZ without a recent migration background. VPD-related hospitalisation rates were higher among NZ-born non-migrant children compared to NZ-born migrant and foreign-born children for all of the diseases of interest. For instance, 5.21% of NZ-born non-migrant children were hospitalised at least once due to all-cause gastroenteritis compared to 4.47% of NZ-born migrant children and only 1.13% of foreign-born migrant children. The overall hospitalisation rate for NZ-born non-migrant children was 3495 hospitalisations per 100,000 person years. Among children with migrant backgrounds, higher hospitalisation rates were noted among those of Pacific ethnicity and those with refugee backgrounds. Those arriving on Pacific visa schemes were hospitalised at rates ranging from 2644/100,000 person years among foreign-born migrant children and 4839/100,000 person years among NZ-born migrant children. Foreign-born quota refugee children and NZ-born children of quota refugee mothers were hospitalised at a rate of 4000-5000/100,000 person years. It is important to disaggregate migrant data to improve our understanding of migrant health. Children need to be age-appropriately vaccinated, and other individual and environmental factors addressed, to reduce the risk of infectious diseases.

A Signal Through the Noise: Do Professionalism Concerns Impact the Decision Making of Competence Committees?

PURPOSE

To characterize how professionalism concerns influence individual reviewers' decisions about resident progression using simulated competence committee (CC) reviews.

METHOD

In April 2017, the authors conducted a survey of 25 Royal College of Physicians and Surgeons of Canada emergency medicine residency program directors and senior faculty who were likely to function as members of a CC (or equivalent) at their institution. Participants took a survey with 12 resident portfolios, each containing hypothetical formative and summative assessments. Six portfolios represented residents progressing as expected (PAE) and 6 represented residents not progressing as expected (NPAE). A professionalism variable (PV) was developed for each portfolio. Two counterbalanced surveys were developed in which 6 portfolios contained a PV and 6 portfolios did not (for each PV condition, 3 portfolios represented residents PAE and 3 represented residents NPAE). Participants were asked to make progression decisions based on each portfolio.

RESULTS

Without PVs, the consistency of participants giving scores of 1 or 2 (i.e., little or no need for educational intervention) to residents PAE and to those NPAE was 92% and 10%, respectively. When a PV was added, the consistency decreased by 34% for residents PAE and increased by 4% for those NPAE (P = .01).

CONCLUSIONS

When reviewing a simulated resident portfolio, individual reviewer scores for residents PAE were responsive to the addition of professionalism concerns. Considering this, educators using a CC should have a system to report, collect, and document professionalism issues.

Survey of Barriers and Facilitators to Engagement in a Multidisciplinary Healthy Lifestyles Program for Children

OBJECTIVE

To understand facilitators and barriers to engagement in a multidisciplinary assessment and intervention program for children and adolescents with obesity, particularly for Māori, the Indigenous people of New Zealand.

METHODS

Whānau Pakari participants and caregivers (n = 71, 21% response rate) referred to the family-based healthy lifestyles program in Taranaki, New Zealand, were asked to participate in a confidential survey, which collected self-reported attendance levels and agreement with statements around service accessibility and appropriateness and open-text comments identifying barriers and facilitators to attendance.

RESULTS

Self-reported attendance levels were higher when respondents reported sessions to be conveniently located (P = .03) and lower when respondents considered other priorities as more important for their family (P = .02). Māori more frequently reported that past experiences of health care influenced their decision to attend (P = .03). Facilitators included perceived convenience of the program, parental motivation to improve child health, and ongoing support from the program.

CONCLUSIONS AND IMPLICATIONS

Program convenience and parental and/or self-motivation to improve health were facilitators of attendance. Further research is required to understand the relationship between past experiences with health care and subsequent engagement with services.

Global trends in ultraprocessed food and drink product sales and their association with adult body mass index trajectories

This study evaluated global trends in ultraprocessed food and drink (UPFD) volume sales/capita and associations with adult body mass index (BMI) trajectories. Total food/drink volume sales/capita from Euromonitor for 80 countries (2002-2016) were matched to mean adult BMI from the NCD Risk Factor Collaboration (2002-2014). Products were classified as UPFD/non-UPFD according to the NOVA classification system. Mixed models for repeated measures were used to analyse associations between UPFD volume sales/capita and adult BMI trajectories, controlling for confounding factors. The increase in UPF volume sales was highest for South and Southeast Asia (67.3%) and North Africa and the Middle East (57.6%), while for UPD, the increase was highest for South and Southeast Asia (120.0%) and Africa (70.7%). In 2016, baked goods were the biggest contributor to UPF volume sales (13.1%-44.5%), while carbonated drinks were the biggest contributor to UPD volume sales (40.2%-86.0%). For every standard deviation increase (51 kg/capita, 2002) in UPD volume sales, mean BMI increased by 0.195 kg/m² for men (P < .001) and 0.072 kg/m² for women (P = .003). For every standard deviation (40 kg/capita, 2002) increase in UPF volume sales, mean BMI increased by 0.316 kg/m² for men (P < .001), while the association was not significant for women. Increases in UPFD volume sales/capita were positively associated with population-level BMI trajectories.

Divide and conquer: A perspective on biochips for single-cell and rare-molecule analysis by next-generation sequencing

Recent advances in biochip technologies that connect next-generation sequencing (NGS) to real-world problems have facilitated breakthroughs in science and medicine. Because biochip technologies are themselves used in sequencing technologies, the main strengths of biochips lie in their scalability and throughput. Through the advantages of biochips, NGS has facilitated groundbreaking scientific discoveries and technical breakthroughs in medicine. However, all current NGS platforms require nucleic acids to be prepared in a certain range of concentrations, making it difficult to analyze biological systems of interest. In particular, many of the most interesting questions in biology and medicine, including single-cell and rare-molecule analysis, require strategic preparation of biological samples in order to be answered. Answering these questions is important because each cell is different and exists in a complex biological system. Therefore, biochip platforms for single-cell or rare-molecule analyses by NGS, which allow convenient preparation of nucleic acids from biological systems, have been developed. Utilizing the advantages of miniaturizing reaction volumes of biological samples, biochip technologies have been applied to diverse fields, from single-cell analysis to liquid biopsy. From this perspective, here, we first review current state-of-the-art biochip technologies, divided into two broad categories: microfluidic- and micromanipulation-based methods. Then, we provide insights into how future biochip systems will aid some of the most important biological and medical applications that require NGS. Based on current and future biochip technologies, we envision that NGS will come ever closer to solving more real-world scientific and medical problems.

Effect of a text message intervention on alcohol-related harms and behaviours: secondary outcomes of a randomised controlled trial

OBJECTIVE

Mobile Health approaches show promise as a delivery mode for alcohol screening and brief intervention. The 'YourCall' trial evaluated the effect of a low-intensity mobile phone text message brief intervention compared with usual care on hazardous drinking and alcohol-related harms among injured adults. This paper extends our previously published primary outcome analysis which revealed a significant reduction in hazardous drinking associated with the intervention at 3 months, with the effect maintained across 12 months follow-up. The objective of the current study was to evaluate the effect of the intervention on alcohol-related harms and troubles and help-seeking behaviours (secondary outcomes) at 12-months follow-up.

RESULTS

A parallel two-group, single-blind, randomised controlled trial was conducted in 598 injured inpatients aged 16-69 years identified as having medium-risk hazardous drinking. Logistic regression models applied to 12-month follow-up data showed no significant differences between intervention and control groups in self-reported alcohol-related harms and troubles and help-seeking behaviours. Although this text message intervention led to a significant reduction in hazardous alcohol consumption (previously published primary outcome), changes in self-reported alcohol-related harms and troubles and help seeking behaviours at 12-months follow up (secondary outcomes) were small and non-significant.

TRIAL REGISTRATION

ACTRN12612001220853. Retrospectively registered 19 November 2012.

STRIDER NZAus: a multicentre randomised controlled trial of sildenafil therapy in early-onset fetal growth restriction

OBJECTIVE

To assess the effect of maternal sildenafil therapy on fetal growth in pregnancies with early-onset fetal growth restriction.

DESIGN

A randomised placebo-controlled trial.

SETTING

Thirteen maternal-fetal medicine units across New Zealand and Australia.

POPULATION

Women with singleton pregnancies affected by fetal growth restriction at 22⁺⁰ to 29⁺⁶ weeks.

METHODS

Women were randomised to oral administration of 25 mg sildenafil citrate or visually matching placebo three times daily until 32⁺⁰ weeks, birth or fetal death (whichever occurred first).

MAIN OUTCOME MEASURES

The primary outcome was the proportion of pregnancies with an increase in fetal growth velocity. Secondary outcomes included live birth, survival to hospital discharge free of major neonatal morbidity and pre-eclampsia.

RESULTS

Sildenafil did not affect the proportion of pregnancies with an increase in fetal growth velocity; 32/61 (52.5%) sildenafil-treated, 39/57 (68.4%) placebo-treated [adjusted odds ratio (OR) 0.49, 95% CI 0.23-1.05] and had no effect on abdominal circumference Z-scores (P = 0.61). Sildenafil use was associated with a lower mean uterine artery pulsatility index after 48 hours of treatment (1.56 versus 1.81; P = 0.02). The live birth rate was 56/63 (88.9%) for sildenafil-treated and 47/59 (79.7%) for placebo-treated (adjusted OR 2.50, 95% CI 0.80-7.79); survival to hospital discharge free of major neonatal morbidity was 42/63 (66.7%) for sildenafil-treated and 33/59 (55.9%) for placebo-treated (adjusted OR 1.93, 95% CI 0.84-4.45); and new-onset pre-eclampsia was 9/51 (17.7%) for sildenafil-treated and 14/55 (25.5%) for placebo-treated (OR 0.67, 95% CI 0.26-1.75).

CONCLUSIONS

Maternal sildenafil use had no effect on fetal growth velocity. Prospectively planned meta-analyses will determine whether sildenafil exerts other effects on maternal and fetal/neonatal wellbeing.

TWEETABLE ABSTRACT

Maternal sildenafil use has no beneficial effect on growth in early-onset FGR, but also no evidence of harm.

Continuous support during labour in childbirth: a Cross-Sectional study in a university teaching hospital in Shanghai, China

BACKGROUND

Fear or anxiety could result in adverse consequences on the course of labour. To date, family members are still not permitted in the delivery rooms in the majority of hospitals in China, and continuous support from hospital professional staff is also limited. This study aimed to evaluate the benefits of continuous support by family members and hospital professional staff during labour in China.

METHODS

In this Cross-Sectional study, 362 primiparous pregnancies who self-requested to receive continuous or one to one support with vaginal delivery and 362 primiparous pregnant women with routine hospital maternal care were included from a university teaching hospital. Data on the length of labour, postpartum haemorrhage (PPH), use of pain relief, use of oxytocin, fetal distress, emergency caesarean section and apgar score at 1 and 5 min were retrospectively collected from hospital medical data-base and compared between the two groups.

RESULTS

Multiple linear regressions adjusting for maternal age, BMI and birth weight, revealed the estimated length of labour for women with routine hospital maternal care was 2.03 times (95%CI 1.86 to 2.21) the duration of women with supportive care (median time, 3.05 h vs 1.5 h). In addition, Fisher's exact test showed the emergency caesarean section rate was significantly lower in women with supportive care compared to women with routine hospital maternal care (3.3% vs 24%).

CONCLUSION

Our results suggest that continuous support from family members together with hospital professional staff should be considered as part of intrapartum care in hospitals in China.

Body Mass Index is Negatively Associated with Endometrial Cancer Stage, Regardless of Subtype and Menopausal Status

Objective: Obesity is one of the common risk factors for developing of endometrial cancer and is negatively associated with its survival, although this result is controversial. Endometrial cancer stages range from stage I, which has better clinical outcomes to stage IV, which has poorer clinical outcomes. Endometrial cancer traditionally divides into type 1 and type 2 dependent on histology which has different clinical outcomes. In this study we investigated whether obesity is associated with the stages of endometrial cancer taking into account subtypes of cancer and menopausal status.

Methods: Data on 1,104 women with endometrial cancer were retrospectively collected from the largest women's hospital in China and analysed. Data included age at diagnosis, body mass index (BMI), histology of cancer and menopausal status.

Results: The BMI in patients with stage I endometrial cancer was significantly higher than that in patients with stage II or III or IV (p=0.0001). However, there was no statistical difference in BMI between patients with stage II, and stage III endometrial cancer. This negative association was persisted with type 1 and type 2 endometrial cancer (p=0.1989) and premenopausal and post-menopausal status (p=0.4342). In addition, the proportion of over-weight or obese women in type1 endometrial cancer with stage I was not different to type 2 endometrial cancer with stage I.

Conclusion: Our data demonstrate that BMI is negatively associated with endometrial cancer in early stage regardless of subtypes of cancer, menopausal status and obesity may be also a potential risk factor for developing type 2 endometrial cancer.

Exploring immunisation inequities among migrant and refugee children in New Zealand

Migrants may experience immunisation inequities compared with the host population related to barriers with accessing immunisations in their home countries, while migrating and/or post-arrival. This retrospective cohort study explored vaccination rates among migrant and non-migrant children in New Zealand (NZ). Linked de-identified data from various government sources from 1 January 2006 to 31 December 2015 were analysed using Statistic NZ's Integrated Data Infrastructure. Vaccination rates were compared between three cohorts of children aged up to 5 years: foreign-born children who migrated to NZ; children born in NZ of migrant mothers; and a comparator group of children born in NZ to non-migrant mothers. Less than half of foreign-born children (46%) had a record in the NZ National Immunisation Register compared with 95% and 96% among migrant and non-migrant NZ-born children, respectively. Foreign-born migrant children had lower age-appropriate reported vaccination rates by vaccine of interest, ethnicity and visa category compared with NZ-born children. Migrant children from Pacific ethnicities had lower reported coverage than other ethnicities. High rates of not age-appropriately vaccinated were noted among foreign-born children on refugee, Pacific and humanitarian visa schemes. This study highlights possible shortfalls around immunisation data, particularly about recording vaccinations given overseas for foreign-born children, and potential challenges around engagement with immunisation services for migrant children. However, results highlight the successful engagement of quota refugee children as part of NZ's refugee orientation programme. It is important to monitor vaccination coverage by migrant and refugee background to inform improvements to policy and practice for wider population health benefits.

Non-thermalization in trapped atomic ion spin chains

Linear arrays of trapped and laser-cooled atomic ions are a versatile platform for studying strongly interacting many-body quantum systems. Effective spins are encoded in long-lived electronic levels of each ion and made to interact through laser-mediated optical dipole forces. The advantages of experiments with cold trapped ions, including high spatio-temporal resolution, decoupling from the external environment and control over the system Hamiltonian, are used to measure quantum effects not always accessible in natural condensed matter samples. In this review, we highlight recent work using trapped ions to explore a variety of non-ergodic phenomena in long-range interacting spin models, effects that are heralded by the memory of out-of-equilibrium initial conditions. We observe long-lived memory in static magnetizations for quenched many-body localization and prethermalization, while memory is preserved in the periodic oscillations of a driven discrete time crystal state.This article is part of the themed issue 'Breakdown of ergodicity in quantum systems: from solids to synthetic matter'.

Changes in clinical disease activity are weakly linked to changes in MRI inflammation on treat-to-target escalation of therapy in rheumatoid arthritis

Background

Rheumatoid arthritis (RA) treat-to-target (T2T) regimens often use the disease activity score (28 joints) incorporating C-reactive protein (DAS28_CRP) as an outcome measure. We compared changes in the DAS28_CRP with changes in magnetic resonance imaging (MRI) inflammation on treatment escalation.

Methods

Eighty seropositive RA patients with active disease were enrolled. Group A (N = 57) escalated to another conventional disease-modifying therapy (cDMARD) combination, and Group B (N = 23) to anti-TNF therapy/cDMARDs. Contrast-enhanced 3T-MRI wrist scans were obtained before and 4 months after regimen change. Scan pairs were scored for inflammation (MRI(i)) and damage. Disease activity was assessed using the DAS28_CRP.

Results

Eighty patients were enrolled and 66 MRI scan pairs were available for analysis. Intra-reader reliability was high: intraclass correlation coefficient (average) 0.89 (0.56–0.97). ΔDAS28_CRP did not differ between groups: Group A, −0.94 (−3.30, 1.61); Group B, −1.53 (−3.59, 0.56) (p = 0.45). ΔMRI(i) also did not differ: Group A, 0 (−25, 10); Group B, −1 (−15, 28) (p = 0.12). Combining groups, ΔMRI(i) correlated weakly with ΔDAS28_CRP (Spearman’s 0.36, p = 0.003). Using multiple linear regression analysis adjusting for confounders, ΔDAS28_CRP was associated with ΔMRI(i) (p = 0.056). Of the individual MRI measures, only Δtenosynovitis correlated with ΔDAS28_CRP (Spearman’s 0.33, p = 0.007). ΔMRI(i) was negatively associated with the MRI erosion score at entry (p = 0.0052).

Conclusions

We report the first study investigating the link between changes in clinical and imaging inflammation in a real-world RA cohort escalating to conventional and biologic DMARDs. The association was significant but relatively weak, suggesting that MRI targets cannot yet be advocated as outcomes for T2T escalation.

Trial registration

ANZCTR 12614000895684. Registered 22 August 2014.

SHARPSports mental Health Awareness Research Project: Prevalence and risk factors of depressive symptoms and life stress in elite athletes

OBJECTIVES

Our study aims to estimate the prevalence of symptoms of depression and daily life hassles in elite athletes.

DESIGN

A cross-sectional prospective epidemiological study design.

METHODS

An online anonymous survey was administered during a 2-month period from May to July 2015. Athletes 18 years of age (or older) who were members of the High Performance Sport New Zealand programme were invited to participate. Of 370 potential participants, 187 completed responses were received (51%). Symptoms of depression were measured by the Centre for Epidemiological Studies Depression Scale-Revised (CESD-R). Life stress was measured by the Daily Hassles Questionnaire.

RESULTS

Overall 21% (n=39) of participants reported symptoms consistent with depression. Only 2 of the 39 athletes were currently taking an anti-depressant medication. Those contemplating retirement, partaking in individual sport, and who were less than 25 years old had significantly increased odds of experiencing depression. Reported life stressors were higher in females, in those who play an individual sport and those in a centralised programme. There was a significant correlation between higher levels of life stress and experiencing depressive symptoms.

CONCLUSIONS

This study highlights that depressive symptoms are prevalent in elite athletes with multiple potential risk factors identified including high life stress. These variables warrant further exploration to enable the early identification of athletes with depressive symptoms, screening and support for elite athletes.

Effective cataract surgical coverage: An indicator for measuring quality-of-care in the context of Universal Health Coverage

OBJECTIVE

To define and demonstrate effective cataract surgical coverage (eCSC), a candidate UHC indicator that combines a coverage measure (cataract surgical coverage, CSC) with quality (post-operative visual outcome).

METHODS

All Rapid Assessment of Avoidable Blindness (RAAB) surveys with datasets on the online RAAB Repository on April 1 2016 were downloaded. The most recent study from each country was included. By country, cataract surgical outcome (CSOGood, 6/18 or better; CSOPoor, worse than 6/60), CSC (operated cataract as a proportion of operable plus operated cataract) and eCSC (operated cataract and a good outcome as a proportion of operable plus operated cataract) were calculated. The association between CSC and CSO was assessed by linear regression. Gender inequality in CSC and eCSC was calculated.

FINDINGS

Datasets from 20 countries were included (2005-2013; 67,337 participants; 5,474 cataract surgeries). Median CSC was 53.7% (inter-quartile range[IQR] 46.1-66.6%), CSOGood was 58.9% (IQR 53.7-67.6%) and CSOPoor was 17.7% (IQR 11.3-21.1%). Coverage and quality of cataract surgery were moderately associated-every 1% CSC increase was associated with a 0.46% CSOGood increase and 0.28% CSOPoor decrease. Median eCSC was 36.7% (IQR 30.2-50.6%), approximately one-third lower than the median CSC. Women tended to fare worse than men, and gender inequality was slightly higher for eCSC (4.6% IQR 0.5-7.1%) than for CSC (median 2.3% IQR -1.5-11.6%).

CONCLUSION

eCSC allows monitoring of quality in conjunction with coverage of cataract surgery. In the surveys analysed, on average 36.7% of people who could benefit from cataract surgery had undergone surgery and obtained a good visual outcome.

Enoxaparin for the prevention of preeclampsia and intrauterine growth restriction in women with a history: a randomized trial

BACKGROUND

Preeclampsia and small-for-gestational-age pregnancy are major causes of maternal and perinatal morbidity and mortality. Women with a previous pregnancy affected by these conditions are at an increased risk of recurrence in a future pregnancy. Past trials evaluating the effect of low-molecular-weight heparin for the prevention of recurrence of preeclampsia and small-for-gestational-age pregnancy have shown conflicting results with high levels of heterogeneity displayed when trials were compared.

OBJECTIVE

We sought to assess the effectiveness of enoxaparin in addition to high-risk care for the prevention of preeclampsia and small-for-gestational-age pregnancy in women with a history of these conditions.

STUDY DESIGN

This was an open-label randomized controlled trial in 5 tertiary care centers in 3 countries. Women with a viable singleton pregnancy were invited to participate between >6⁺⁰ and <16⁺⁰ weeks if deemed to be at high risk of preeclampsia and/or small for gestational age based on their obstetric history. Eligible participants were randomly assigned in a 1-to-1 ratio to standard high-risk care or standard high-risk care plus enoxaparin 40 mg (4000 IU) by subcutaneous injection daily from recruitment until 36⁺⁰ weeks or delivery, whichever occurred sooner. Standard high-risk care was defined as care coordinated by a high-risk antenatal clinic service, aspirin 100 mg daily until 36⁺⁰ weeks, and-for women with prior preeclampsia-calcium 1000-1500 mg daily until 36⁺⁰ weeks. In a subgroup of participants serum samples were taken at recruitment and at 20 and 30 weeks' gestation and later analyzed for soluble fms-like tyrosine kinase-1, soluble endoglin, endothelin-1, placental growth factor, and soluble vascular cell adhesion molecule 1. The primary outcome was a composite of preeclampsia and/or small-for-gestational-age <5th customized birthweight percentile. All data were analyzed on an intention-to-treat basis. The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12609000699268).

RESULTS

Between July 26, 2010, and Oct. 28, 2015, a total of 156 participants were enrolled and included in the analysis. In all, 149 participants were included in the outcome analysis (72 receiving standard high-risk care plus enoxaparin and 77 receiving standard high-risk care only). Seven women who miscarried <16 weeks' gestation were excluded. The majority of participants (151/156, 97%) received aspirin. The addition of enoxaparin had no effect on the rate of preeclampsia and/or small-for-gestational-age <5th customized birthweight percentile: enoxaparin 18/72 (25%) vs no enoxaparin 17/77 (22.1%) (odds ratio, 1.19; 95% confidence interval, 0.53-2.64). There was also no difference in any of the secondary outcome measures. Levels of soluble fms-like tyrosine kinase-1 and soluble endoglin increased among those who developed preeclampsia, but there was no difference in levels of these antiangiogenic factors (nor any of the other serum analytes measured) among those treated with enoxaparin compared to those receiving standard high-risk care only.

CONCLUSION

The use of enoxaparin in addition to standard high-risk care does not reduce the risk of recurrence of preeclampsia and small-for-gestational-age infants in a subsequent pregnancy.

Inequality in cataract blindness and services: moving beyond unidimensional analyses of social position

OBJECTIVE

Inequalities in cataract blindness are well known, but data are rarely disaggregated to explore the combined effects of a range of axes describing social disadvantage. We examined inequalities in cataract blindness and services at the intersection of three social axes.

METHODS

Three dichotomous social variables (sex (male/female); place of residence (urban/rural); literacy (literate/illiterate)) from cross-sectional national blindness surveys in Pakistan (2001-2004; n=16 507) and Nigeria (2005-2007; n=13 591) were used to construct eight subgroups, with disadvantaged subgroups selected a priori (ie, women, rural dwellers, illiterate). In each data set, the social distribution of cataract blindness, cataract surgical coverage (CSC) and effective cataract surgical coverage (eCSC) were examined. Inequalities were assessed comparing the best-off and worst-off subgroups using rate differences and rate ratios (RRs). Logistic regression was used to assess cumulative effects of multiple disadvantage.

RESULTS

Disadvantaged subgroups experienced higher prevalence of cataract blindness, lower CSC and lower eCSC in both countries. A social gradient was present for CSC and eCSC, with coverage increasing as social position improved. Relative inequality in eCSC was approximately twice as high as CSC (Pakistan: eCSC RR 2.7 vs CSC RR 1.3; Nigeria: eCSC RR 8.7 vs CSC RR 4.1). Cumulative disadvantage was observed for all outcomes, deteriorating further with each additional axis along which disadvantage was experienced.

CONCLUSIONS

Each outcome tended to be worse with the addition of each layer of social disadvantage. Illiterate, rural women fared worst in both settings. Moving beyond unidimensional analyses of social position identified subgroups in most need; this permits a more nuanced response to addressing the inequitable distribution of cataract blindness.

Prevalence of diabetic retinopathy at first presentation to the retinal screening service in the greater Wellington region of New Zealand 2006-2015, and implications for models of retinal screening

AIM

To describe the prevalence of diabetic retinopathy (DR) in patients at first presentation for diabetic retinal screening in the greater Wellington region with the intent of service evaluation.

METHODS

This is a retrospective study using data collected from patients newly referred for diabetic retinal screening between 2006-2015 (prevalence analysis, n=12667). The prevalence of DR was calculated by gender, ethnicity, age, type of diabetes and glycaemic control (HbA1c). Chi-square test and multiple logistic regression was used for data analysis.

RESULTS

The prevalence of any DR was 22.5% (n=2852) (non-sight-threatening (NST-DR) n=2562, 20.2%, sight-threatening (ST-DR) n=290, 2.3%). Type 1 diabetes and poor HbA1c control were strongly associated with any degree of DR. Old-age (>65 years), and Asian and Pacific Island (PI) ethnicity had moderately greater odds compared with European. Male gender had marginally increased odds for any DR.

CONCLUSION

This study identified a large proportion (97.7%) of patients (no DR n=9815, 77.5%, NST-DR n=2562, 20.2%) who can be managed in the community by appropriately supported primary care providers, and do not require referral to secondary care ophthalmology. In addition to early detection of ST-DR (2.3%), retinal screening is an early opportunity for education of patients with no DR or NST-DR.

Higher Expression of ERCC1 May Be Associated with Resistance to Adjuvant Platinum-Based Chemotherapy in Gastric Cancer

Potential predictive biomarker(s) to respond to chemotherapy in gastric cancer are unclear. Excision repair cross-complementing 1 (ERCC1), a DNA repair enzyme, is associated with clinical outcomes in gastric cancer. Here, we investigated the expression of ERCC1 in gastric cancer with platinum-based chemotherapy after surgery, and the association between ERCC1 expression and clinical parameters was analyzed. Our data showed that high levels of ERCC1 expression were positively associated with resistance to platinum-based chemotherapy but not with lymph node metastasis and pathological stage. In addition, patients with resistance to platinum-based chemotherapy probably had lymph node metastasis and pathological stage.

To move or not to move? Exploring the relationship between residential mobility, risk of cardiovascular disease and ethnicity in New Zealand

Residential mobility can have negative impacts on health, with some studies finding that residential mobility can contribute to widening health gradients in the population. However, ethnically differentiated experiences of residential mobility and the relationship with health are neglected in the literature. To examine the relationship between residential mobility, risk of cardiovascular disease (CVD) and ethnicity, we constructed a cohort of 2,077,470 participants aged 30 + resident in New Zealand using encrypted National Health Index (eNHI) numbers linked to individual level routinely recorded data. Using binary logistic regression, we model the risk of CVD for the population stratified by ethnic group according to mover status, baseline deprivation and transitions between deprivation statuses. We show that the relationship between residential mobility and CVD varies between ethnic groups and is strongly influenced by the inter-relationship between residential mobility and deprivation mobility. Whilst residential mobility is an important determinant of CVD, much of the variation between ethnic groups is explained by contrasting deprivation experiences. To reduce inequalities in CVD within New Zealand, policies must focus on residentially mobile Māori, Pacific and South Asian populations who already have a heightened risk of CVD living in more deprived areas.

Determinants of physical health in frail older people: the importance of self-efficacy

Objective: There is continued uncertainty regarding the strength of association between performance-based and self-report measures of physical functioning, and of their relationship to self-efficacy and health-related quality of life (HRQoL). This study assessed the inter-relationships between such measures, and the predictors of ‘physical’ aspects of HRQoL in frail older patients.

Design: We used statistical models to determine the predictors of ‘physical’ HRQoL, according to the physical component summary score and the physical functioning domain of the 36-item short form (SF-36) questionnaire.

Setting: Patients were recruited from hospitals in Australia and New Zealand and followed up in their homes.

Subjects: Two hundred and forty-three frail older patients.

Main measures: Physical functioning was assessed using three performance-based measures (Timed Up and Go Test, gait speed and the Berg Balance Scale) and five self-report measures, including the modified falls self-efficacy scale, at three and six months after registration.

Results: A moderate association (r=0.48=0.55) was found between each of the performance-based and self-report measures, including the SF-36 physical component summary score. Multiple linear regression analyses showed that the performance-based measures and falls self-efficacy predicted 33% of the SF-36 physical component summary score. Falls self-efficacy was the single highest predictor of both the SF-36 physical component summary score and SF-36 physical functioning domain. A curvilinear relationship was found between the SF-36 physical functioning domain and two variables: falls self-efficacy and the Berg Balance Scale.

Conclusions: Although performance-based and self-report measures provide complementary but distinct measures of physical function, psychosocial factors such as self-efficacy have a strong influence on the HRQoL of frail older people.

Overt Visual Attention in Parkinson's Disease

The ability of Parkinsonian (PD) patients to control overt visual attention was investigated, by measuring reaction time to a visual stimulus presented at different distances (1.5 deg, 6 deg, and 12 deg) and directions (left or right) from a central fixation point. Prior to the onset of the target stimulus (a square), a cue stimulus appeared just above the fixation point. With equal probability, the arrow pointed to the left, or to the right, or was ambiguous (with two heads). On 20% of their presentations, the left and right arrows pointed in the direction opposite to where the target was to appear. Subjects were informed that 20% of cues would be misleading, and correcting lenses were used to optimise their visual acuity. In previous work with a similar paradigm, only one target eccentricity was used, and subjects were not refracted, leaving open the possibility that PD subjects had more difficulty in seeing the cues and targets.

The eight PD subjects had longer reaction times than age-matched normal controls (and were relatively slower for the more eccentric targets), but made fewer errors in all conditions. In particular, they were more accurate than the controls on the presentations when the cue was misleading or ambiguous, suggesting that the PD group were ignoring the cue. It seems unlikely that the subjects discriminate the direction of the cues, given the use of optical correction, and they reported seeing the cues. Our data are consistent with those of other workers who have described a similar ‘disengagement of attention’ in PD (Clark et al, 1989 Neuropsychologia27 131 – 140) and attributed it to decreased catecholaminergic activity following destruction of midbrain structures (Wright et al, 1990 Neuropsychologia28 151 – 159).

Hospital Re-Admissions: An Empirical Analysis of Quality Management in Taiwan

This retrospective study uses discharge-level data to analyse and assess the situation of re-admissions within 15 days of discharge, for quality evaluation. The re-admission rate of the study period was 3.22%. Among those re-admission cases, 45.7% patients were re-admitted within five days of discharge, and 33.5% cases returned to hospital six to 10 days after discharge. The average length of stays of re-admissions (9.86 days for previous stay and 8.10 days for re-admitted stay) were both longer than the hospital's overall average (7.63 days) at the same period. Paediatric patients comprised the greatest number of re-admissions. Re-admissions were more likely to have higher percentage of emergency admission. Significant relationships were found between factors for re-admissions and patient characteristics (e.g. age and insurance status), admitted department, and diagnosis. Further investigation and strategies, combined with the application of severity adjustment technique to better monitor and avoid unnecessary re-admissions, need to be developed.

Body Mass Index Is Positively Associated with Endometrial Cancer in Chinese Women, Especially Prior to Menopause

Objective: Obesity is a well-known risk factor for developing endometrial cancer. However, the incidence and survival rate of endometrial cancer are associated with ethnicity and geographical area. In addition, whether menopausal status is associated with developing endometrial cancer in obese women and whether obesity is associated with subtypes of endometrial cancer have not been fully investigated. Here, we investigated the effect of BMI on developing endometrial cancer in Chinese women taking into account menopausal status and cancer subtypes.

Methods: Data on 1,127 women with endometrial cancer including body mass index (BMI), age at diagnosis, parity, menopausal status and cancer subtype were collected from the largest obstetrics & gynaecology hospital in China and analysed.

Results: After adjusting for age and parity, the odds for developing endometrial cancer in overweight or obese perimenopausal women was significantly higher than that in women with normal weight (OR=2.6 with 95%CI:1.9-3.5, and OR=3.5 with 95%CI: 2.2-5.4, respectively). The odds of developing endometrial cancer in overweight postmenopausal women were significantly higher than that in women who were normal weight (OR=2.4 with 95%CI: 1.8-3.1), however this was not the case for obese postmenopausal women. We further found that BMI, menopausal status, age and parity were not associated with subtypes of endometrial cancer.

Conclusion: Our data demonstrate that obesity is positively associated with the incidence of developing endometrial cancer in Chinese women, with more significant effects in perimenopausal women.

The Reduction in Circulating Melatonin Level May Contribute to the Pathogenesis of Ovarian Cancer: A Retrospective Study

Ovarian cancer is the third most common gynaecological malignancy. Changes in circadian rhythms such as bright light exposure may affect female reproductive physiology. Night shift work is associated with higher risks of developing gynaecological cancers. In addition, the season of birth is also suggested as an important environmental risk factor for developing gynaecological cancers. Melatonin may play an important role in this association as a marker of circadian rhythms. Serum from 96 women with ovarian cancer and 40 healthy women were collected and the level of melatonin was measured. In addition 277 women with ovarian cancer and 1076 controls were retrospectively collected for season of birth analysis over seven years. The serum levels of melatonin were significantly lower in women with ovarian cancer compared with healthy women (p<0.05). However there was no difference in melatonin levels in perimenopausal and postmenopausal patients. In addition, there is no statistically significant difference in seasonal distribution of birth between ovarian cancer patients and the control group. The melatonin levels in ovarian cancer patients and controls were not associated with the season of birth. Our results demonstrate the lower serum levels of melatonin in ovarian cancer patients which may contribute to the pathogenesis of ovarian cancer. The incidence of ovarian cancer was not associated with the season of birth. The serum levels of melatonin do not appear to be associated with season of birth in ovarian cancer patients.

Abstract P1-02-01: Genomic analysis of single cells isolated by a pulse laser retrieval system

Background: Isolating tumor cells of interest and harvesting histologically pure samples is important for genomic studies. Laser capture microdissection (LCM) is an established method to obtain such purified cell populations for various applications including DNA, gene expression, and single cell analyses. However, LCM possesses problems such as limited optical resolution, cell fragmentation from dissection, and adherence of adjacent tissue to the cells which interrupts with single cell isolation from tissue sections. To overcome these obstacles, we developed a high-throughput pulse laser retrieval system which uses a wavelength that minimizes damage to the cellular content and is processed with a sacrificial layer that provides applicable optical resolution. The aim of this study was to evaluate the performance of the pulse laser retrieval system to provide appropriate samples for genomic analysis using breast cancer tissue.

Methods: An indium tin oxide (ITO) coated glass slide was prepared using fresh frozen breast cancer tissue sections of 4㎛ thickness and stained by hematoxylin and eosin. The slide was mounted on the cell isolation machine and imaging was performed with a charge-coupled device camera using a 20× lens. Following identification of the target cells by a pathologist, nano-second pulsed laser (wavelength= 1064nm) was irradiated on the target. Isolated cells were collected in a polymerase chain reaction tube and whole genome amplification (WGA) was carried out using Illustra GenomiPhi V2 DNA Amplification Kit (GE Healthcare Life Sciences, Pittsburgh, PA, USA). Amplified genomic DNA was fragmented and Illumina sequencing libraries were constructed. Sequencing was carried out to generate data with 0.1∼0.2× depth throughout the whole genome for each sample. Copy number variation (CNV) was analyzed by the Variable binning algorithm.

Results: Whole genome amplification was performed using bulk tissue and 10 captured single cells from the same specimen. No difference in amplification coverage was observed between the two samples. A CNV analysis of captured single cells revealed similar CNV profiles with those in a matched bulk tumor. Whole exome sequencing (WES) of captured single cells yielded a variant frequency of 15% at a read depth of 15× and 50M base coverage, compared to 0% at 100× and 50M for WES using bulk tumor and 0.5% at 1200× and 100K for targeted sequencing using bulk tumor. Laser capture was performed for DCIS and stromal cells from the same slide. CNV analysis of the two samples showed minimal CNV in normal stromal cells in contrast to DCIS where multiple CNVs were observed.

Conclusions: Newly developed pulse laser retrieval system is suitable for capturing single cells for genomic analysis of breast cancer. WGA, WES, and CNV analysis was successfully carried out using the captured single cells and showed no difference in profile compared to those performed with bulk tissue. This method may have the potential to replace LCM for certain applications such as single cell analyses.

Citation Format: Lee H-B, Kim S, Lee K-M, Jung Y, Lee AC, Kim J, Bae S, Ryu HS, Yoo T-K, Moon H-G, Noh D-Y, Kwon S, Han W. Genomic analysis of single cells isolated by a pulse laser retrieval system. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-02-01.

Associations between body mass index and maternal weight gain on the delivery of LGA infants in Chinese women with gestational diabetes mellitus

BACKGROUND

Women with gestational diabetes mellitus (GDM) are at increased risk for maternal and fetal complications including delivery of large for gestational age (LGA) infants. Maternal body mass index (BMI) and excessive weight gain during pregnancy are associated with delivery of LGA infants. However, whether maternal BMI and weight gain are associated with LGA infants in women with GDM is unclear.

BASIC PROCEDURES

Data on 1049 pregnant women who developed GDM were collected from a university teaching hospital in China and retrospectively analyzed. Data included maternal BMI, weight gain, incidence of LGA and gestational week at diagnosis.

MAIN FINDINGS

The incidence of LGA infants was significantly associated with maternal BMI (p=0.0002) in women with GDM. The odds of delivery of LGA for obese or overweight pregnant women are 3.8 or 2 times more than normal weight pregnant women. The incidence of LGA infants was also significantly associated with maternal weight gain in women with GDM. The odds ratio of delivery of LGA for pregnant women with excessive weight gain was 3.3 times more than pregnant women with normal weight gain. The effect of weight gain was not significantly different between different maternal BMI.

PRINCIPAL CONCLUSION

The incidence of delivery of LGA infants in Chinese women with GDM who were overweight or obese is higher than Caucasians, Hispanic, and Asian-Americans. The effects of maternal BMI and weight gain on the delivery of LGA infants by women with GDM are additive.

The projected burden of hearing loss in New Zealand (2011-2061) and the implications for the hearing health workforce

BACKGROUND

There is considerable evidence that New Zealand's population is ageing. For example, the median age increased from 29 years in 1951 to 37 years in 2011-12, and will likely increase to 44 years by 2061. While the implications of an ageing population have been studied, to date there is no study investigating the impacts that population ageing will have on hearing health in New Zealand.

AIM

To explore the changing population structure and estimate the burden of hearing loss in New Zealand between 2011 and 2061.

METHODS

Using three alternative population projections from Statistics New Zealand, we quantify the likely distribution of the population between 2011 and 2061 by age and sex. Published estimates of hearing loss stratified by age and severity of hearing loss were then applied to the population projections to highlight the potential impact that population ageing will have on hearing loss in New Zealand in the next 50 years.

RESULTS

We estimated that there were 330,269 people aged ≥14 years with hearing loss and this would increase to 449,453 in 2061. Overall, males have a higher prevalence of hearing loss than females, and while the prevalence of hearing loss among those aged 14-49 years is expected to decrease, the prevalence among the population aged ≥70 years is expected to double between 2011 and 2061.

CONCLUSION

Age, sex and geographical variations in hearing loss are expected in the next 50 years. Further research into ethnic and variations in hearing loss will be instrumental in targeting the future hearing health workforce required to accommodate these increases.

Cochlear ablation effects on amino acid levels in the chinchilla cochlear nucleus

Inner ear damage can lead to hearing disorders, including tinnitus, hyperacusis, and hearing loss. We measured the effects of severe inner ear damage, produced by cochlear ablation, on the levels and distributions of amino acids in the first brain center of the auditory system, the cochlear nucleus. Measurements were also made for its projection pathways and the superior olivary nuclei. Cochlear ablation produces complete degeneration of the auditory nerve, which provides a baseline for interpreting the effects of partial damage to the inner ear, such as that from ototoxic drugs or intense sound. Amino acids play a critical role in neural function, including neurotransmission, neuromodulation, cellular metabolism, and protein construction. They include major neurotransmitters of the brain - glutamate, glycine, and γ-aminobutyrate (GABA) - as well as others closely related to their metabolism and/or functions - aspartate, glutamine, and taurine. Since the effects of inner ear damage develop over time, we measured the changes in amino acid levels at various survival times after cochlear ablation. Glutamate and aspartate levels decreased by 2weeks in the ipsilateral ventral cochlear nucleus and deep layer of the dorsal cochlear nucleus, with the largest decreases in the posteroventral cochlear nucleus (PVCN): 66% for glutamate and 63% for aspartate. Aspartate levels also decreased in the lateral part of the ipsilateral trapezoid body, by as much as 50%, suggesting a transneuronal effect. GABA and glycine levels showed some bilateral decreases, especially in the PVCN. These results may represent the state of amino acid metabolism in the cochlear nucleus of humans after removal of eighth nerve tumors, which may adversely result in destruction of the auditory nerve. Measurement of chemical changes following inner ear damage may increase understanding of the pathogenesis of hearing impairments and enable improvements in their diagnosis and treatment.

Movers and stayers: The geography of residential mobility and CVD hospitalisations in Auckland, New Zealand

The association between area-level disadvantage and health and social outcomes is unequivocal. However, less is known about the health impact of residential mobility, particularly at intra-urban scales. We used an encrypted National Health Index (eNHI) number to link individual-level data recorded in routine national health databases to construct a cohort of 641,532 participants aged 30+ years to investigate the association between moving and CVD hospitalisations in Auckland, New Zealand. Residential mobility was measured for participants according to changes in the census Meshblock of usual residence, obtained from the Primary Health Organisation (PHO) database for every calendar quarter between 1/1/2006 and 31/12/2012. The NZDep2006 area deprivation score at the start and end of a participant's inclusion in the study was used to measure deprivation mobility. We investigated the relative risk of movers being hospitalised for CVD relative to stayers using multi-variable binomial regression models, controlling for age, gender, deprivation and ethnicity. Considered together, movers were 1.22 (1.19-1.26) times more likely than stayers to be hospitalised for CVD. Using the 5×5 deprivation origin-destination matrix to model a patient's risk of CVD based on upward, downward or sideways deprivation mobility, movers within the least deprived (NZDep2006 Quintile 1) areas were 10% less likely than stayers to be hospitalised for CVD, while movers within the most deprived (NZDep2006 Q5) areas were 45% more likely than stayers to have had their first CVD hospitalisation in 2006-2012 (RR: 1.45 [1.35-1.55]). Participants who moved upward also had higher relative risks of having a CVD event, although their risk was less than those observed for participants experiencing downward deprivation mobility. This research suggests that residential mobility is an important determinant of CVD in Auckland. Further investigation is required to determine the impact moving has on the risk of CVD by ethnicity.

MRI osteitis predicts cartilage damage at the wrist in RA: a three-year prospective 3T MRI study examining cartilage damage

Introduction

Cartilage damage impacts on patient disability in rheumatoid arthritis (RA). The aims of this magnetic resonance imaging (MRI) study were to investigate cartilage damage over three years and determine predictive factors.

Methods

A total of 38 RA patients and 22 controls were enrolled at t = 0 (2009). After 3 years, clinical and MRI data were available in 28 patients and 15 controls. 3T MRI scans were scored for cartilage damage, bone erosion, synovitis and osteitis. A model was developed to predict cartilage damage from baseline parameters.

Results

Inter-reader reliability for the Auckland MRI cartilage score (AMRICS) was high for status scores; intraclass correlation coefficient (ICC), 0.90 (0.81 to 0.95) and moderate for change scores (ICC 0.58 (0.24 to 0.77)). AMRICS scores correlated with the Outcome MEasures in Rheumatoid Arthritis Clinical Trials (OMERACT) MRI joint space narrowing (jsn) and X-Ray (XR) jsn scores (r =0.96, P < 0.0001 and 0.80, P < 0.0001, respectively). AMRICS change scores were greater for RA patients than controls (P = 0.06 and P = 0.04 for the two readers). Using linear regression, baseline MRI cartilage, synovitis and osteitis scores predicted the three-year AMRICS (R² = 0.67, 0.37 and 0.39, respectively). A multiple linear regression model predicted the three-year AMRICS (R² = 0.78). Baseline radial osteitis predicted increased cartilage scores at the radiolunate and radioscaphoid joints, P = 0.0001 and 0.0012, respectively and synovitis at radioulnar, radiocarpal and intercarpal-carpometacarpal joints also influenced three-year cartilage scores (P-values of 0.001, 0.04 and 0.01, respectively).

Conclusions

MRI cartilage damage progression is preceded by osteitis and synovitis but is most influenced by pre-existing cartilage damage suggesting primacy of the cartilage damage pathway in certain patients.

P3-12-04: Involved Anterior Margins after Breast Conserving Surgery: Is Re-Excision Required?

Background: Complete tumour excision in breast conserving surgery (BCS) is critical for successful treatment; involved circumferential resection margins are associated with increased disease recurrence. However, the importance of an involved anterior margin is less clear. The purpose of this study was to audit an aggressive approach to involved anterior margins and hence assess whether anterior margin re-excision yields clinical benefit.

Material and Methods: A retrospective case note and pathology review was performed for all patients who underwent BCS between 2006 and 2010 through a single cancer centre. An involved margin was defined as &lt;1mm clearance of invasive or in situ breast cancer. Results: 1667 patients underwent BCS for invasive and/or in-situ disease, of whom 114 (6.8%) underwent re-excision, most commonly for mixed invasive and in-situ pathology. The annual re-excision rate rose significantly (p&lt;0.001), with no change in whole tumour diameter, specimen weight or specimen volume. A total of 170 involved margins were identified: most commonly the anterior margin (59 margins, 30.6%) followed by the posterior (39 22.9%) or inferior (31, 18.3%) margin. Patients with anterior margin involvement were more likely to have grade 3 invasive disease (p=0.0323) but less likely to have residual disease found at re-excision (2/49 vs. 32/101 margins, p=0.0033); there were no differences when in-situ characteristics were compared.

Conclusions: Re-excision of involved anterior margins rarely excises residual disease and may be unnecessary. Multidisciplinary teams should consider whether further therapy for an involved anterior margin is required on a patient by patient basis.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-12-04.

Attributes of response in depressed patients switched to treatment with duloxetine

BACKGROUND

This study was designed to assess clinical and functional outcomes associated with switching to duloxetine treatment in patients with major depressive disorder (MDD) experiencing emotional and painful physical symptoms in their current episode.

METHODS

In this 8-week, multinational, multicentre, single-arm, open-label clinical trial, 242 MDD patients were switched to duloxetine 60 mg/day after selective serotonin reuptake inhibitor (SSRI) or serotonin and norepinephrine reuptake inhibitor (SNRI) treatment. The primary analysis compared mean change from baseline in Brief Pain Inventory-Modified Short Form (BPI-SF) interference score between initial responders [≥ 50% reduction from baseline on the 17-item Hamilton Depression Rating Scale (HAMD(17)) Maier subscale] and initial non-responders after 4 weeks. Initial responders continued with duloxetine 60 mg/day. Initial non-responders received duloxetine 120 mg/day for the remaining 4 weeks. Depression, pain, anxiety and functional outcomes were also compared after 8 weeks.

RESULTS

BPI-SF interference decreased from baseline in initial responders (n = 108) and initial non-responders (n = 85) after 4 weeks of duloxetine treatment, with greater reductions in initial responders [BPI-SF mean difference in reduction: 1.01 (95% CI 0.42-1.61); p < 0.001]. Reductions in pain interference favouring initial responders were also apparent after 8 weeks [0.68 (95% CI: 0.03-1.33); p = 0.042]. Depression, pain, anxiety and function improved over 8 weeks across patient groups.

CONCLUSIONS

Elements of core mood and pain are important residual symptoms following poor treatment response in MDD. Early improvement in these symptoms after switching to duloxetine indicated an increased chance of functional recovery.

Pharmacological effects of cannabinoids on the Caco-2 cell culture model of intestinal permeability

Activation of cannabinoid receptors decreases emesis, inflammation, gastric acid secretion, and intestinal motility. However, the effects of cannabinoids on intestinal permeability have not yet been established. The aim of the present study is to examine the effects of cannabinoids on intestinal permeability in an in vitro model. Caco-2 cells were grown until fully confluent on inserts in 12-well plates. Transepithelial electrical resistance (TEER) measurements were made as a measure of permeability. EDTA (50 μM) was applied to reversibly increase permeability (reduce TEER). The effects of cannabinoids on permeability in combination with EDTA, or alone, were assessed. Potential target sites of action were investigated using antagonists of the cannabinoid (CB)(1) receptor, CB(2) receptor, transient receptor potential vanilloid subtype 1 (TRPV1), peroxisome proliferator-activated receptor (PPAR)γ, PPARα, and a proposed cannabinoid receptor. When applied to the apical or basolateral membrane of Caco-2 cells, Δ(9)-tetrahydrocannabinol (THC) and cannabidiol (CBD) enhanced the speed of recovery of EDTA-induced increased permeability. This effect was sensitive to cannabinoid CB(1) receptor antagonism only. Apical application of endocannabinoids caused increased permeability, sensitive to cannabinoid CB(1) receptor antagonism. By contrast, when endocannabinoids were applied basolaterally, they enhanced the recovery of EDTA-induced increased permeability, and this involved additional activation of TRPV1. All cannabinoids tested increased the mRNA of the tight junction protein zona occludens-1, but only endocannabinoids also decreased the mRNA of claudin-1. These findings suggest that endocannabinoids may play a role in modulating intestinal permeability and that plant-derived cannabinoids, such as THC and CBD, may have therapeutic potential in conditions associated with abnormally permeable intestinal epithelium.

Bruises, blood coagulation tests and the battered child syndrome

Cutaneous bruises are a common symptom and a sign of injury and blood coagulation disorders in childhood. A carefully-taken history, coupled with a thorough physical examination, would lead to the diagnosis, or guide the clinician to the necessary laboratory investigations. Most children suffering from non-accidental injury can have their diagnosis established on clinical grounds alone and do not require laboratory investigation. An initial screening with full blood counts, prothrombin time and activated partial thromboplastin time will be adequate in most cases if laboratory investigation is indicated, but the clinician must be aware of the limitations of these tests. The finding of an abnormal coagulation test does not exclude child abuse as it can be a consequence of maltreatment, or the two conditions may coexist. Whenever necessary, the opinion of a haematologist should be sought in order to obtain an accurate diagnosis, which is essential for subsequent management and the prevention of further injury in the case of child abuse.

The selective use of magnetic resonance cholangiopancreatography in the imaging of the axial biliary tree in patients with acute gallstone pancreatitis

BACKGROUND

Magnetic resonance cholangiopancreatography (MRCP) is an emerging modality in the management of acute gallstone pancreatitis (AGP). The aim of this study was to assess the impact following the introduction of MRCP in the management of AGP in a tertiary referral unit.

METHODS

Patients presenting with AGP from January 2002 to December 2004 were reviewed to assess the impact of the introduction of MRCP in June 2003. The indication for MRCP was suspected common bile duct (CBD) stones in the absence of biliary sepsis. Definitive treatment for AGP was laparoscopic cholecystectomy, with endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy reserved for patients unfit for cholecystectomy and those with biliary sepsis.

RESULTS

249 patients were identified of whom 36 (14.5%) underwent ERCP and sphincterotomy as definitive treatment. 96 patients with a non-dilated CBD and normal or resolving liver function tests proceeded to laparosocopic cholecystectomy and intraoperative cholangiogram (IOC), 8 (8.5%) of whom had CBD stones intraoperatively. Eleven patients underwent cholecystectomy during pancreatic necrosectomy. Of those undergoing preoperative diagnostic biliary tract imaging, ERCP was undertaken in 57 patients and MRCP in 49 patients. There was no significant difference in serum bilirubin levels [ERCP 43 mmol/l (18-204) vs. MRCP 39 mmol/l (24-180), p = NS] or the proportion of patients with CBD stones [ERCP 10 (17.5%) vs. MRCP 7 (14.2%), p = NS] between the two groups. Patients who underwent MRCP had a shorter median hospital stay [MRCP 5 days (range: 3-14) vs. ERCP 9 days (range: 4-20), p < 0.01] and higher rate of cholecystectomy during the index admission (MRCP 83.3% vs. ERCP 67.2%, p < 0.05). There was a high degree of correlation between preoperative MRCP results and findings of subsequent IOC or therapeutic ERCP (area under ROC curve: 0.94).

CONCLUSIONS

MRCP is an accurate modality for imaging the axial biliary tree in patients with AGP. Selective use of MRCP reduces the need for ERCP and results in shorter hospital stay. and IAP.

Prognostic factors in patients undergoing surgery for severe necrotizing pancreatitis

Pancreatic necrosectomy remains an important treatment modality for the management of infected pancreatic necrosis but is associated with significant mortality. The aim of this study was to identify factors associated with mortality following pancreatic necrosectomy. Patients who underwent pancreatic necrosectomy from January 1995 to December 2004 were reviewed. The association between admission, preoperative and postoperative variables, and mortality was assessed using logistic regression analysis. A total of 1248 patients presented with acute pancreatitis, of whom 94 (7.5%) underwent pancreatic necrosectomy (51 men, 43 women). The preoperative median Acute Physiology, Age, and Chronic Health Evaluation (APACHE II) score was 9 (range 2-19). The median cumulative organ dysfunction score was 2 (0-9) preoperatively and 4 (1-11) postoperatively. In all, 23 patients (24.5%) died. Those who died were older than the survivors; the ages (median and range) were 69 years (40-80 years) versus 52 years (19-79 years) (p < 0.05). They also had higher admission APACHE II scores (median and range): 14 (12-19) versus 9 (2-22) (p < 0.001). There were significant associations between preoperative (p < 0.01) and postoperative (p < 0.01) Marshall scores and mortality following pancreatic necrosectomy. The presence of the systemic inflammatory response syndrome (SIRS) during the first 48 hours (p < 0.01) and the time between presentation and necrosectomy (p < 0.01) were independent predictors of survival. Pancreatic necrosectomy is associated with higher mortality in patients with increased APACHE II scores, early persistent SIRS, and unresolved multiorgan dysfunction. Necrosectomy is associated with poorer outcome when performed within 2 weeks of presentation.

Identification of susceptibility and protective major histocompatibility complex haplotypes in canine diabetes mellitus

Diabetes mellitus occurs spontaneously in dogs, which is believed to have an autoimmune component and to be a model of human latent autoimmune diabetes of adults (LADA). Some dog breeds (e.g. Samoyed) are particularly predisposed, whereas others (e.g. Boxer) are highly resistant. With the completion of the Dog Genome Assembly, comparative genomic studies of complex diseases in dogs, including diabetes, could provide an important investigative approach into such disorders. Type 1 diabetes in humans is strongly associated with major histocompatibility complex (MHC) class II polymorphisms. We have investigated whether canine dog leucocyte antigen (DLA) class II haplotypes are associated with diabetes. DNA from 460 cases and 1047 controls were genotyped for DLA-DRB1, DLA-DQA1 and DLA-DQB1 using sequence-based typing. Three DLA haplotypes, DRB1*009/DQA1*001/DQB1*008, DRB1*015/DQA1*0061/DQB1*023 and DRB1*002/DQA1*009/DQB1*001, were found at significantly increased frequency in cases with diabetes compared with controls. One DLA-DQ haplotype, DQA1*004/DQB1*013, was significantly reduced in cases with diabetes. Further analysis showed that DQA1 alleles carrying arginine at codon 55 of DQA1 were increased in dogs with diabetes. To our knowledge, this is the first report of a comparative study of MHC and diabetes in a non-rodent species. Since no laboratory model of LADA exists and dogs and humans share similar environments, further research into canine diabetes is warranted.

Spectral characterization of yeast cells with an epitaxy-based UV-Vis optical sensor

The optical spectra of yeast cells in phosphate buffer saline (PBS) were analyzed with an optical UV-vis sensor based on a shallow p(+)n junction realized in a low doped n-type epitaxial silicon layer grown on a strongly doped n(+) substrate. The presence of the n/n(+) interface allows a significantly enhanced sensitivity, due to an increased collection of carriers photogenerated both by short and large wavelengths in the range 250...800 nm. In our experiments the optical absorption of yeast cells was investigated in the wavelength range 250...500 nm as a function of the cells concentration in PBS in the range of 6 x 10(6)-2 x 10(8) cells/ml. The main absorption peaks were found at 310, 350, 400 and 427 nm, respectively. A significant red shift of the wide absorption band at 427 nm has been observed when increasing cell concentration. This red shift behaviour was nonlinear, with saturation observed for yeast concentrations larger than 5 x 10(7) cells/ml. The half-peak bandwidth of this peak also showed a most significant nonlinear variation. These findings suggest that monitoring the parameters of the absorption band at 427 nm versus cells concentration could be used, e.g. using a dedicated integrated spectrometric microsystem, for fast quantitative measurements of yeast cell concentrations in various bio-samples, with possible applications in the food industry.

Intraoperative touch imprint cytology for the diagnosis of sentinel lymph node metastases in breast cancer

Background

Intraoperative detection of sentinel lymph node (SLN) metastases enables the surgeon to take an immediate decision to proceed to completion axillary lymph node dissection (ALND). The aim of this study was to determine the accuracy of touch imprint cytology (TIC) for the diagnosis of SLN metastases in sentinel nodes from women with breast cancer.

Methods

Touch imprints from 235 sentinel nodes in 133 women with breast cancer were diagnosed by cytopathology and compared with definitive histopathology results. After a feasibility study, a real-time study was performed with the surgeon proceeding to ALND based on the TIC diagnosis. The clinical opinion of the operating surgeon as to whether the SLN appeared to contain metastases was recorded, as was the time taken for the result to be available.

Results

TIC detected metastases with a sensitivity of 81·1 per cent and a specificity of 100 per cent. False-negative TIC diagnoses were associated with micrometastases and lobular carcinoma. The majority of false-negative diagnoses were due to sampling rather than interpretation errors. Clinical assessment of sentinel nodes had a sensitivity of 64·3 per cent and a specificity of 87·6 per cent.

Conclusion

TIC is feasible and enables the rapid diagnosis of SLN metastases with an acceptable accuracy for clinical use in ductal carcinoma of the breast.

Electromechanical effects on tether formation from lipid membranes: a theoretical analysis

The material properties of biomembranes can be measured by forming a tether, a thin bilayer tube that extends from the membrane surface. Recent experiments have demonstrated that the force required to maintain a tether is sensitive to the transmembrane potential. As a first approach towards understanding this phenomenon, a thermodynamic analysis of the influence of electrical fields on tether formation from an aspirated lipid vesicle is developed. The analysis considers contributions from Maxwell stresses as well as two forms of electromechanical coupling: coupling between the electric field and curvature strain (flexoelectric coupling) and between the electric field and areal strain (piezoelectric coupling). Predictions of equilibrium tether conformations are obtained numerically. For expected values of the dimensionless coupling parameters, flexoelectric coupling alters the force required to form a tether of a given length, while piezoelectric coupling and Maxwell forces do not greatly change the force versus tether length behavior. The results of this analysis indicate that tether experiments have the potential to characterize electromechanical coupling in both synthetic and cellular membranes.

Detection of allelic variants of the canine IGHA gene by fluorescence resonance energy transfer melting temperature examination

The fluorescence resonance energy transfer (FRET) dual hybridisation probe system has been used for the detection of the accumulation of target DNA during real-time PCR and for the identification of nucleotide polymorphisms through examination of melt curves. This system involves the use of two oligonucleotide probes which are located close to each other and are complementary to an internal segment of a target DNA of interest. Four allelic variants of the gene encoding the hinge region of the immunoglobulin A (IgA) heavy chain (IGHA) have been so far identified in the dog and this variability is due to a combination of single nucleotide polymorphisms and insertion/deletion of nucleic acid motifs. An individual dog may be homozygous or heterozygous for these allelic variants. The purpose of this study was to develop a FRET-based dual probe melting temperature assay to identify the alleles present within an individual dog and to use this assay to determine the frequency of the four allelic variants in different breeds within the canine population. A single pair of oligonucleotide probes were designed that were able to discriminate between the four allelic variants in both homozygous and heterozygous individuals. The genotype of 96 DNA samples obtained from various purebreeds of dogs was determined using this FRET assay. The frequency of each allele differed between the breed groups. The results of this study indicate that it is possible to distinguish relatively complex gene polymorphisms using a single set of oligonucleotide probes. Furthermore, any future comparison of IGHA genotypes between normal and diseased dog populations must take into account the breed variation in allelic frequency.