Survivorship care plans and information for rural cancer survivors

PURPOSE

The purpose of the study was to investigate the amount and type of survivorship care information received by cancer survivors living in rural Australia and whether this varies according to demographic factors or cancer type.

METHODS

Self-reported receipt of a survivorship care plan (SCP) and information on various aspects of survivorship care (e.g., managing side effects, healthy lifestyles, psychosocial advice and monitoring for recurrence) were collected from 215 cancer survivors who had returned home to a rural area in Queensland Australia after receiving cancer treatment in a major city within the previous 5 years (72% in the previous 12 months). Logistic regression was used to assess for differences across demographic factors and cancer type.

RESULTS

Only 35% of participants reported receiving a SCP and proportions of those reporting the receipt of specific information varied from 74% for information on short-term side effects to less than 30% for information on finances, chemoprevention and monitoring for signs of recurrence. No significant differences were found in the receipt of survivorship care information across demographic factors or cancer type.

CONCLUSIONS

Findings suggest that cancer survivors living in rural areas are not consistently provided with adequate survivorship care information, particularly that pertaining to long-term health and recovery.

IMPLICATIONS FOR CANCER SURVIVORS

Without improved systems for delivering survivorship care information to patients returning home to rural communities after treatment, these cancer survivors risk missing out on necessary information and advice to maintain their health, wellbeing and long-term recovery.

Mental health symptoms in children and adolescents during COVID-19 in Australia

OBJECTIVE

COVID-19 has led to disruptions to the lives of Australian families through social distancing, school closures, a temporary move to home-based online learning, and effective lockdown. Understanding the effects on child and adolescent mental health is important to inform policies to support communities as they continue to face the pandemic and future crises. This paper sought to report on mental health symptoms in Australian children and adolescents during the initial stages of the pandemic (May to November 2020) and to examine their association with child/family characteristics and exposure to the broad COVID-19 environment.

METHODS

An online baseline survey was completed by 1327 parents and carers of Australian children aged 4 to 17 years. Parents/carers reported on their child's mental health using five measures, including emotional symptoms, conduct problems, hyperactivity/inattention, anxiety symptoms and depressive symptoms. Child/family characteristics and COVID-related variables were measured.

RESULTS

Overall, 30.5%, 26.3% and 9.5% of our sample scored in the high to very high range for emotional symptoms, conduct problems and hyperactivity/inattention, respectively. Similarly, 20.2% and 20.4% of our sample scored in the clinical range for anxiety symptoms and depressive symptoms, respectively. A child's pre-existing mental health diagnosis, neurodevelopmental condition and chronic illness significantly predicted parent-reported child and adolescent mental health symptoms. Parental mental health symptoms, having a close contact with COVID-19 and applying for government financial assistance during COVID-19, were significantly associated with child and adolescent mental health symptoms.

CONCLUSION

Our findings show that Australian children and adolescents experienced considerable levels of mental health symptoms during the initial phase of COVID-19. This highlights the need for targeted and effective support for affected youth, particularly for those with pre-existing vulnerabilities.

Increased Ion Temperature and Neutron Yield Observed in Magnetized Indirectly Driven D_{2}-Filled Capsule Implosions on the National Ignition Facility

The application of an external 26 Tesla axial magnetic field to a D_{2} gas-filled capsule indirectly driven on the National Ignition Facility is observed to increase the ion temperature by 40% and the neutron yield by a factor of 3.2 in a hot spot with areal density and temperature approaching what is required for fusion ignition [1]. The improvements are determined from energy spectral measurements of the 2.45 MeV neutrons from the D(d,n)^{3}He reaction, and the compressed central core B field is estimated to be ∼4.9  kT using the 14.1 MeV secondary neutrons from the D(T,n)^{4}He reactions. The experiments use a 30 kV pulsed-power system to deliver a ∼3  μs current pulse to a solenoidal coil wrapped around a novel high-electrical-resistivity AuTa_{4} hohlraum. Radiation magnetohydrodynamic simulations are consistent with the experiment.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Trajectories of Change in an Open-access Internet-Based Cognitive Behavior Program for Childhood and Adolescent Anxiety: Open Trial

BACKGROUND

Although evidence bolstering the efficacy of internet-based cognitive behavioral therapy (iCBT) for treating childhood anxiety has been growing continuously, there is scant empirical research investigating the timing of benefits made in iCBT programs (eg, early or delayed).

OBJECTIVE

This study aims to examine the patterns of symptom trajectories (changes in anxiety) across an iCBT program for anxiety (BRAVE Self-Help).

METHODS

This study's participants included 10,366 Australian youth aged 7 to 17 years (4140 children aged 7-12 years; 6226 adolescents aged 12-17 years) with elevated anxiety who registered for the BRAVE Self-Help program. Participants self-reported their anxiety symptoms at baseline or session 1 and then at the commencement of each subsequent session.

RESULTS

The results show that young people completing the BRAVE Self-Help program tend to fall into two trajectory classes that can be reliably identified in terms of high versus moderate baseline levels of anxiety and subsequent reduction in symptoms. Both high and moderate anxiety severity trajectory classes showed significant reductions in anxiety, with the greatest level of change being achieved within the first six sessions for both classes. However, those in the moderate anxiety severity class tended to show reductions in anxiety symptoms to levels below the elevated range, whereas those in the high symptom group tended to remain in the elevated range despite improvements.

CONCLUSIONS

These findings suggest that those in the high severity group who do not respond well to iCBT on a self-help basis may benefit from the additional support provided alongside the program or a stepped-care approach where progress is monitored and support can be provided as necessary.

213 A Novel, Cost-Effective and Convenient Model for Simulating Facial Wound Repair

Introduction

We describe the use of a novel synthetic simulation pad for learning complex facial wound management including local flaps. The simulation pad is a cost effective and convenient model of facial wounds. We have compared the use of animal tissue to the simulation pad in the context of a workshop for surgical trainees and collected feedback from delegates.

Methods

Feedback was collected from 14 of 16 attending delegates.

Results

It was clear from feedback that animal tissue is not an ideal model of facial wounds with 71% of delegates stating that they did not consider it to be high-fidelity. The synthetic pad was rated more favourably with 100% of delegates reporting that it was a valuable exercise and well designed for local flaps.

Conclusions

It is imperative that training opportunities are high quality and useful to clinical practice. Techniques learnt in the context of a course or workshop are more valuable where targeted practice may occur following learning. The use of a synthetic pad is more amenable to continued practice where it may be taken home following a workshop. Feedback from this event suggests a well-designed synthetic pad is more useful than animal tissue in learning local flaps.

The junior trainee group 'Buddy Scheme'

The ethos of the junior trainees' group is to facilitate peer support, an important complement to pursuing our speciality of oral and maxillofacial surgery. Launched in September 2020, the Buddy Scheme enables peer-matching. Results demonstrate this scheme has successfully provided additional support for second-degree applicants. With further help from our senior colleagues, our ambition is to expand this scheme in 2021.

Cancer-related help-seeking in cancer survivors living in regional and remote Australia

OBJECTIVES

To measure rates of detection via screening, perceived self-imposed delays in seeking medical attention, and support seeking in a sample of regional and remote people with a cancer diagnosis and to test whether an association exists between these behaviours and minimising problems and resignation, a need for self-control and reliance and fatalism. Correlations and binary logistic regressions were conducted to test the associations between demographic characteristics, attitudes and behaviours.

RESULTS

Females were more likely to have had their cancer detected via screening (OR = 10.02, CI = 3.49-28.78). Younger participants (r = -0.103, p = 0.009) were slightly more likely to seek at least one form of support and online support was sought more often by younger patients (r = -0.269, p < 0.001), females (r = 0.152, p < 0.001), those from higher socio-economic (SES) areas (r = 0.100, p = 0.012), and those with higher education levels (r = 0.247, p < 0.001). Younger (r = -0.161, p < 0.001), and female (r = 0.82, p = 0.013), participants were also slightly more likely to seek support specifically through cancer support groups. No significant relationships between minimising problems and resignation, needs for control and self-reliance or fatalism and detection via screening, support seeking, or perceived self-imposed delays to seeking medical attention were apparent, with the exception that those with higher fatalism (predetermined health) were slightly less likely to report seeking support or information online (OR = 0.79, CI = 0.65-0.95) and slightly more likely to report using Cancer Council's support services (OR = 1.24, CI = 1.02-1.52).

CONCLUSIONS

Strategies to improve the accessibility and appropriateness of support available for regional and remote cancer patients should consider interventions that remove barriers to access associated with age, gender, and education as opposed to those which address the attitudinal traits measured here.

Are National Cancer Control Indicators for patient experiences being met in regional and remote Australia? A cross-sectional study of cancer survivors who travelled for treatment

OBJECTIVE

To examine the health services experience of patients with cancer from regional and remote Australia using the Australian National Cancer Control Indicators (NCCI) guidelines as an assessment framework.

DESIGN

Cross-sectional.

SETTING

Queensland non-for-profit cancer accommodation lodges.

PARTICIPANTS

Participants were patients with cancer who travelled for treatment from rural and remote Queensland to major urban centres (n=518; age mean=64.6, SD=11.18).

OUTCOME MEASURES

Assessments included NCCI patient indicators, quality of life (QoL), psychological distress and unmet supportive care needs.

RESULTS

The frequency at which NCCI indicators were met ranged from 37.5% for receiving an assessment and care plan to 97.3% for understanding explanations about diagnosis. Geographical considerations did not impact patient experience, whereas middle school educated participants were more likely than those with senior-level education or higher to receive an assessment and care plan (OR=1.90, 95% CI 1.23 to 2.91) and to report having their views on treatment taken into account (OR=2.22, 95% CI 1.49 to 3.33). Patients with breast or prostate cancer reported better communication and patient involvement and information and services provision (r=p<0.001) compared with those with skin and head and neck cancer. When compared with information and service provision, communication and patient involvement showed stronger positive associations with QoL (z=2.03, p=0.042), psychosocial (z=2.05, p=0.040) and patient care (z=2.00, p=0.046) outcomes.

CONCLUSION

The patient care experience varies across the NCCI indicators by sociodemographic and clinical factors that likely reflect healthcare system biases. Perceptions about communication and involvement appear most critical for optimal outcomes and should be a priority action area for cancer control.

Three changes to reduce the loss of dual degree trainees from OMFS national specialty selection in the UK: evidence based proposals

The training pathway for oral and maxillofacial surgery (OMFS) has remained relatively stable for around 30 years. Circumstances surrounding the training pathway have changed including the priorities of individuals considering entering OMFS training. Run-through Specialty Training (ST1) OMFS posts (which include core surgical training) are oversubscribed while direct entry to Specialty Training (ST3) OMFS specialty recruitment rounds have unfilled posts, including places declined by appointable candidates. As part of a project to refine and improve OMFS recruitment and retention, data drawn from the British Association of Oral and Maxillofacial Surgeons (BAOMS) and the OMFS National Selection administering Deanery, Health Education England South West were scrutinised. Numbers of students starting second undergraduate degrees (medicine or dentistry) to pursue an OMFS career are increasing. Of a total of 43 candidates deemed appointable at OMFS ST1 selection but not offered an available post, 16 did not subsequently apply for ST3 selection. In the period studied (2015-20), of a total of 116 unfilled ST3 posts, 39 remained vacant because appointable candidates declined the available posts (33%). Appropriate changes to the current national selection processes could help address the perceived OMFS ST recruitment problems. By increasing the number of available ST1 posts, widening the window during which appointable candidates can continue into training and increasing prior experience recognition (including creating benchmarking processes prior to ST). These 3 clear, fair and transparent changes could reduce the current levels of attrition.

Online physical activity and sedentary behaviour information for cancer survivors

PURPOSE

The purpose of this study is to assess the prevalence, content, and nature of information and/or advice regarding physical activity and sedentary behaviour available online for cancer survivors.

METHODS

A search strategy was designed to identify website links that were most likely to be accessed by cancer survivors, living in five English speaking nations, looking for information about maintaining and improving health after a cancer diagnosis. All content pertaining to physical activity and sedentary behaviour was extracted, and proportions of website links containing key information were calculated. Content analysis was performed on the data to describe the nature of information provided.

RESULTS

Of the 394 website links reviewed, 73.4% contained information about physical activity; however, most websites did not detail recommendations, strategies and potential risks of engaging in physical activity. Less than 10% of the links reviewed contained information about sedentary behaviour. Results varied according to website and cancer type.

CONCLUSIONS

Although the importance of physical activity is frequently mentioned, online content on the subject lacks comprehensive, specific advice. Health advice online for cancer survivors regarding the importance of avoiding sedentary behaviour is scarce with little to no detail on how to achieve this.

IMPLICATION OF CANCER SURVIVORS

Until website conveners improve the comprehensiveness and specificity of the information they provide, cancer survivors may find it difficult to find, via the Internet, the advice required to properly guide and facilitate their safe participation in physical activity and avoidance of sedentary behaviour.

Geographical Variations in the Clinical Management of Colorectal Cancer in Australia: A Systematic Review

Background: Colorectal cancer (CRC) presents considerable health, economic, and societal burden, and Australia has one of the highest incidence rates of this disease. Over a third of the Australian population live in nonmetropolitan areas and research has shown that they experience a range of health disadvantages that result in a higher disease burden and lower life expectancy. One of the main contributors of poorer CRC outcomes in rural Australia may be limited access to treatment facilities and optimal care; however, the extent to which geographical disparities exist in CRC management has not been systematically explored. Aim: To understand the nature of geographical variations in the clinical management and treatment of CRC (including surgery, chemotherapy, and radiotherapy) in Australia, incorporating clinical reports as well as peer-reviewed literature. Methods: A systematic review of published and gray literature was conducted. Five databases (CINAHL, PubMed, Embase, ProQuest, and Informit) were searched for articles published in English from 1990 to 2018. Studies were included if they assessed differences in clinical management according to geographical location; focused on CRC patients; and were conducted in Australia. Included studies were critically appraised using a modified Newcastle-Ottawa Scale. PRISMA systematic review reporting methods were applied. Results: Only 17 articles met inclusion criteria. All were of high (53%) or moderate (47%) quality. The evidence available may suggest that patients in nonmetropolitan areas are more likely to experience delays in surgery and are less likely to receive chemotherapy for stage III colon cancer and adjuvant radiotherapy for rectal cancer. Conclusion: The present review found limited information on clinical management across geographic regions in Australia and the synthesis highlights significant issues both for data collection and reporting at the population level. Where geographical disparities exist, these may be due to a combination of patient and system factors reflective of location. Population-level data regarding clinical management and treatment of CRC needs to be routinely collected to better understand geographical variations and inform future guidelines and policy.

Geographical Variations in the Clinical Management of Colorectal Cancer in Australia: A Systematic Review

Background

In Australia, cancer survival is significantly lower in non-metropolitan compared to metropolitan areas. Our objective was to evaluate the evidence on geographical variations in the clinical management and treatment of colorectal cancer (CRC).

Methods

A systematic review of published and gray literature was conducted. Five databases (CINAHL, PubMed, Embase, ProQuest, and Informit) were searched for articles published in English from 1990 to 2018. Studies were included if they assessed differences in clinical management according to geographical location; focused on CRC patients; and were conducted in Australia. Included studies were critically appraised using a modified Newcastle–Ottawa Scale. PRISMA systematic review reporting methods were applied.

Results

17 articles met inclusion criteria. All were of high (53%) or moderate (47%) quality. The evidence available may suggest that patients in non-metropolitan areas are more likely to experience delays in surgery and are less likely to receive chemotherapy for stage III colon cancer and adjuvant radiotherapy for rectal cancer.

Conclusion

The present review found limited information on clinical management across geographic regions in Australia and the synthesis highlights significant issues both for data collection and reporting at the population level, and for future research in the area of geographic variation. Where geographical disparities exist, these may be due to a combination of patient and system factors reflective of location. It is recommended that population-level data regarding clinical management of CRC be routinely collected to better understand geographical variations and inform future guidelines and policy.

Attitudes Toward e-Mental Health Services in a Community Sample of Adults: Online Survey

BACKGROUND

Despite evidence that e-mental health services are effective, consumer preferences still appear to be in favor of face-to-face services. However, the theory of planned behavior (TPB) suggests that cognitive intentions are more proximal to behavior and thus may have a more direct influence on service use. Investigating individual characteristics that influence both preferences and intentions to use e-mental health services is important for better understanding factors that might impede or facilitate the use of these services.

OBJECTIVE

This study explores predictors of preferences and intentions to access e-mental health services relative to face-to-face services. Five domains were investigated (demographics, technology factors, personality, psychopathology, and beliefs), identified from previous studies and informed by the Internet interventions model. We expected that more participants would report intentions to use e-mental health services relative to reported preferences for this type of support and that these 5 domains would be significantly associated with both intentions and preferences toward online services.

METHODS

A mixed sample of 308 community members and university students was recruited through social media and the host institution in Australia. Ages ranged between 17 and 68 years, and 82.5% (254/308) were female. Respondents completed an online survey. Chi-square analysis and t tests were used to explore group differences, and logistic regression models were employed to explore factors predicting preferences and intentions.

RESULTS

Most respondents (85.7%, 264/308) preferred face-to-face services over e-mental health services. Relative to preferences, a larger proportion of respondents (39.6%, 122/308) endorsed intentions to use e-mental health services if experiencing mental health difficulties in the future. In terms of the 5 predictor domains, 95% CIs of odds ratios (OR) derived from bootstrapped standard errors suggested that prior experience with online services significantly predicted intentions to use self-help (95% CI 2.08-16.24) and therapist-assisted (95% CI 1.71-11.90) online services in future. Being older predicted increased intentions to use therapist-assisted online services in future (95% CI 1.01-1.06), as did more confidence using computers and the Internet (95% CI 1.06-2.69). Technology confidence was also found to predict greater preference for online services versus face-to-face options (95% CI 1.24-4.82), whereas higher doctor-related locus of control, or LOC (95% CI 0.76-0.95), and extraversion (95% CI 0.88-1.00) were predictive of lower likelihood of preferring online services relative to face-to-face services.

CONCLUSIONS

Despite generally low reported preferences toward e-mental health services, intentions to access these services are higher, raising the question of how to best encourage translation of intentions into behavior (ie, actual use of programs). Strategies designed to ease people into new Internet-based mental health programs (to enhance confidence and familiarity) may be important for increasing the likelihood that they will return to such programs later.

The association between anthropometric measures and lung function in a population-based study of Canadian adults

BACKGROUND

Decreased lung function has health impacts beyond diagnosable lung disease. It is therefore important to understand the factors that may influence even small changes in lung function including obesity, physical fitness and physical activity. The aim of this study was to determine the anthropometric measure most useful in examining the association with lung function and to determine how physical activity and physical fitness influence this association.

METHODS

The current study used cross-sectional data on 4662 adults aged 40-79 years from the Canadian Health Measures Survey Cycles 1 and 2. Linear regression models were used to examine the association between the anthropometric and lung function measures (forced expiratory volume in 1 s [FEV₁] and forced vital capacity [FVC]); R² values were compared among models. Physical fitness and physical activity terms were added to the models and potential confounding was assessed.

RESULTS

Models using sum of 5 skinfolds and waist circumference consistently had the highest R² values for FEV₁ and FVC, while models using body mass index consistently had among the lowest R² values for FEV₁ and FVC and for men and women. Physical activity and physical fitness were confounders of the relationships between waist circumference and the lung function measures. Waist circumference remained a significant predictor of FVC but not FEV₁ after adjustment for physical activity or physical fitness.

CONCLUSIONS

Waist circumference is an important predictor of lung function. Physical activity and physical fitness should be considered as potential confounders of the relationship between anthropometric measures and lung function.

The relationship between attachment style and placement of parents in adults' attachment networks over time

Using a bull's-eye hierarchical mapping technique (HMT), the present study examined placement of parents in adults' attachment networks over time. We hypothesized that attachment style would predict distance at which network members (mother, father, and romantic partner) would be placed from the core-self over time. Participants completed the HMT on two occasions, 12 months apart. Concurrently and over time, fathers were placed further from the core-self than mothers. Attachment style explained unique variance, beyond that accounted for by individual and relationship characteristics. Specifically, network members with whom participants reported greater attachment insecurity were placed further from the core-self concurrently. Mothers with whom participants reported greater attachment insecurity were placed further from the core-self over time. Unsatisfactory attachment relationships with father and partner and those marked by higher attachment insecurity were more likely to be excluded from attachment networks over time. Findings suggest that attachment style, relationship quality, romantic relationship status, and parents' marital status determine the placement of parents in adults' attachment networks.

Isolated language impairment as the primary presentation of sporadic Creutzfeldt Jakob Disease

OBJECTIVES

Sporadic Creutzfeldt Jakob Disease (sCJD) is a neurodegenerative disorder that typically presents as a rapidly progressive encephalopathy associated with various neurological features, culminating in akinetic mutism and death. Atypical cases, presenting with an isolated focal may cause diagnostic confusion. We described a series of patients with sCJD presenting with isolated language impairment.

MATERIALS & METHODS

We report a patient with sCJD referred to the NCJDRSU, who presented with isolated language impairment and subsequently identified all cases of sporadic CJD on the NCJDRSU database (covering the years 1990-2012) with an isolated language impairment presentation.

RESULTS

Nineteen patients (11 females) with sCJD (1.19% of all patients) had an isolated language disorder of at least 2 weeks duration as the first neurological symptom pattern. Mean age at onset was 68.28 years. No specific pattern of language affection was seen in these patients. Further progression usually affected more than one neurological domain, with all patients eventually developing cognitive decline and myoclonic jerks. The median duration of illness was 4 months. CSF 14.3.3 was positive and S100b level was elevated in all patients in whom it was performed. EEG and MRI showed typical features of sCJD in six patients each. Most patients showed MM genotype of PRNP codon 129.

CONCLUSION

This study highlights the fact that isolated aphasia can be the first neurological symptom approximately in 1% of patients with sCJD. The diagnosis is usually made with appearance of other clinical features and investigation results, but in a small minority, these may not be apparent for relatively long periods.

Gene expression analysis in RA: towards personalized medicine

Gene expression has recently been at the forefront of advance in personalized medicine, notably in the field of cancer and transplantation, providing a rational for a similar approach in rheumatoid arthritis (RA). RA is a prototypic inflammatory autoimmune disease with a poorly understood etiopathogenesis. Inflammation is the main feature of RA; however, many biological processes are involved at different stages of the disease. Gene expression signatures offer management tools to meet the current needs for personalization of RA patients' care. This review analyses currently available information with respect to RA diagnostic, prognostic and prediction of response to therapy with a view to highlight the abundance of data, whose comparison is often inconclusive due to the mixed use of material source, experimental methodologies and analysis tools, reinforcing the need for harmonization if gene expression signatures are to become a useful clinical tool in personalized medicine for RA patients.

Muscle composition and fatty acid profile in lambs fattened in drylot or pasture

The effects of two fattening systems on muscle composition and fatty acid profile were determined in an experiment using samples of the longissimus dorsi (LD) muscle of 24 ram lambs (slaughter weight 29-31kg). The fattening systems were: (i) drylot (a mixture of maize, soybean, wheat and minerals) and (ii) grazing (Cynodon dactylon). The lambs fattened in the drylot system presented higher fat levels (p<0.01), but lower concentrations of moisture (p<0.01) and cholesterol (p<0.05). The lipid content presented a negative correlation with moisture and protein. In lambs fattened in the drylot system increasing levels of fatness of LD muscle were associated with a decrease (p<0.05) in myristic and palmitic acids, but myristic, palmitic and linoleic acids increased (p<0.05) as the cholesterol levels of the muscles increased.

Acute Cerebrovascular Disease in the Young

Background and Purpose—

Strokes have especially devastating implications if they occur early in life; however, only limited information exists on the characteristics of acute cerebrovascular disease in young adults. Although risk factors and manifestation of atherosclerosis are commonly associated with stroke in the elderly, recent data suggests different causes for stroke in the young. We initiated the prospective, multinational European study Stroke in Young Fabry Patients (sifap) to characterize a cohort of young stroke patients.

Methods—

Overall, 5023 patients aged 18 to 55 years with the diagnosis of ischemic stroke (3396), hemorrhagic stroke (271), transient ischemic attack (1071) were enrolled in 15 European countries and 47 centers between April 2007 and January 2010 undergoing a detailed, standardized, clinical, laboratory, and radiological protocol.

Results—

Median age in the overall cohort was 46 years. Definite Fabry disease was diagnosed in 0.5% (95% confidence interval, 0.4%–0.8%; n=27) of all patients; and probable Fabry disease in additional 18 patients. Males dominated the study population (2962/59%) whereas females outnumbered men (65.3%) among the youngest patients (18–24 years). About 80.5% of the patients had a first stroke. Silent infarcts on magnetic resonance imaging were seen in 20% of patients with a first-ever stroke, and in 11.4% of patients with transient ischemic attack and no history of a previous cerebrovascular event. The most common causes of ischemic stroke were large artery atherosclerosis (18.6%) and dissection (9.9%).

Conclusions—

Definite Fabry disease occurs in 0.5% and probable Fabry disease in further 0.4% of young stroke patients. Silent infarcts, white matter intensities, and classical risk factors were highly prevalent, emphasizing the need for new early preventive strategies.

Clinical Trial Registration Information—

URL: http://www.clinicaltrials.gov .Unique identifier: NCT00414583

Clinical efficacy and safety of a water-soluble micellar paclitaxel (Paccal Vet) in canine mastocytomas

OBJECTIVE

To determine the clinical efficacy and safety of a cremophor-free formulation of paclitaxel (Paccal Vet, Oasmia Pharmaceuticals) in dogs with mast cell tumours.

METHODS

Paccal Vet was administered at a median dose of 145 (range, 135 to 150) mg/m(2) intravenously once every 21 days for three cycles to 29 dogs with macroscopic grade 2 or 3 mast cell tumour. Efficacy was assessed by tumour response (Response Evaluation Criteria in Solid Tumours version 1.0) and performance status score. Progression-free survival, quality of life and safety/adverse events were also evaluated. Clinical safety was assessed by clinicopathological analyses and recording of adverse events.

RESULTS

Complete or partial response was observed in 59% of dogs. Performance status score remained constant or improved for 20 dogs and decreased by one grade for 9 dogs. Median time to progression was 247 (range, 42 to 268) days. Expected, transient frequently subclinical adverse events (primarily grade 3/4 neutropenia and grade 1/2 leukopenia) were observed in the majority of dogs. Nine dogs were euthanased and one dog died due to disease progression.

CLINICAL SIGNIFICANCE

Paccal Vet appears to be a clinically safe and effective treatment for canine mast cell tumours. Further controlled confirmatory investigation is warranted.

Novel methods of myocardial protection and de-airing for complex descending aortic aneurysm surgery

A 64-year-old male who had previously undergone an aortic valve replacement and replacement of the ascending aorta presented with an 8 cm descending aortic aneurysm. A left thoracotomy was required to allow replacement of the aorta. However, due to longitudinal as well as transverse expansion, visualisation of the aortic arch was compromised, preventing cross-clamping of the proximal aorta. Cardiopulmonary bypass and deep hypothermic circulatory arrest were, therefore, required. An unusual method of cardioplegia delivery was used for myocardial protection, utilising a Foley catheter under direct vision as an alternative to more expensive percutaneous peripheral endoclamp devices. We also describe an unusual cardiopulmonary bypass circuit, with the dual use of a left atrial cannula for venting and also for re-establishing perfusion during de-airing.

Kavalactone pharmacophores for major cellular drug targets

A number of studies have identified differential kavalactone activity against a variety of molecular targets, including P-glycoprotein (Pgp), platelet monoamine oxidase (MAO-B), transcription factor binding domains, pregnane X (PXR) and GABA receptors, and cytochrome P450 and cyclo-oxygenase (COX) enzymes. The molecular structure of the kavalactones possesses a pharmacophore for several of these targets. In most cases, conformational stability is more significant than the substituents present. The analysis of these pharmacophores provides important insights for future medicinal chemistry-based approaches to kavalactone-type drugs.

Kavalactones Yangonin and Methysticin induce apoptosis in human hepatocytes (HepG2) in vitro

While cases of severe kava hepatotoxicity have been reported, studies examining the toxicity of individual kavalactones are limited. The present study examined the in vitro hepatotoxicity of kavain, methysticin and yangonin on human hepatocytes (HepG2) and the possible mechanism(s) involved. Cytotoxicity was assessed using lactate dehydrogenase (LDH) and ethidium bromide (EB) assays. The mode of cell death was analysed with acridine orange/ethidium bromide dual staining with fluorescence microscopy. Glutathione oxidation was measured using the ortho-phthalaldehyde (OPT) fluorescence assay. Kavain had minimal cytotoxicity, methysticin showed moderate concentration-dependent toxicity and yangonin displayed marked toxicity with ~ 40% reduction in viability in the EB assay. Acridine orange/ethidium bromide staining showed the predominant mode of cell death was apoptosis rather than necrosis. No significant changes were observed in glutathione levels, excluding this as the primary mechanism of cell death in this model. Further studies may elucidate the precise apoptotic pathways responsible and whether toxic kavalactone metabolites are involved.

Sequential microarray to identify timing of molecular responses to Haemonchus contortus infection in sheep

Anthelmintics are currently the most common method of worm control. The emergence of worms with multiple-drug resistance and issues of residues in the food chain make alternative parasite control measures a priority. To develop improved and sustainable methods for controlling Haemonchus contortus such as genetic selection of resistant sheep, a better understanding of the host-parasite relationship is required. A trial was undertaken using sheep surgically implanted with abomasal fistulas to enable sequential biopsy of the abomasal mucosa during trickle infection with two strains of H. contortus. These were ivermectin-resistant CAVR and ivermectin-sensitive McMaster. From a gross parasitology perspective, this approach enabled the effect of developing immunity to be observed on both the establishment and maturation of two CAVR doses within and between groups. Since the only difference in parasite treatment between the groups was the staggering of the two CAVR doses, microarray results from biopsies taken on the same day in different groups were combined and compared between different biopsy dates to observe differential gene transcription over time. Differential gene transcription was detected by comparing transcription in our array data between different biopsy dates using a low P value screen (P<0.01) and by compiling a list of 82 immunoparasitology-related genes and examining transcription in this list with a higher P value screen (P<0.05). Our microarray data were validated in silico by comparison with intelectin 2, trefoil factor 3, calcium activated chloride channel and mucin 5 from other gene transcription studies and with phenotypic data such as the response by gammadelta T cells and immunoglobulins to H. contortus. The first four genes are involved in non-specific responses to infection and mucosal healing. These were upregulated at the early time points and intelectin 2 remained prominent throughout the trial. As the trial progressed, immunoglobulin genes became strongly upregulated. These included IgCgamma IgG2a heavy chain constant region, IGHE immunoglobulin heavy constant epsilon and IGHM immunoglobulin heavy constant mu.

Genomic analyses of Haemonchus contortus infection in sheep: abomasal fistulation and two Haemonchus strains do not substantially confound host gene expression in microarrays

To determine whether fistulation and differing strains of Haemonchus contortus complicate genome analysis of the host response to infection, two pilot experiments examined parasite development and gene expression in the abomasal mucosa of parasitised sheep. No significant differentially-expressed genes were detected in a comparison between ivermectin-susceptible McMaster and ivermectin-resistant CAVR strains of H. contortus. This demonstrated that the sheep response was not significantly altered by the ivermectin-resistance status of the parasite. However, sheep infected with McMaster strain had a significantly lower proportion of larvae and a higher mean FEC at post-mortem than sheep infected with CAVR, suggesting that McMaster larvae advance to patency faster than CAVR larvae. Abomasal fistulation resulted in significant upregulation of three genes and significant downregulation of two genes. Fistulated sheep had significantly lower FEC than the other groups but the proportion of larvae at post-mortem was not significantly different to other groups infected with the same strain (CAVR). Hence fistulation does not alter establishment of the CAVR isolate, but may slow its progression to patency. The observation that different H. contortus strains and abomasal fistulation induced minimal changes in mucosal gene expression validated the design of a subsequent experiment (manuscript in preparation) where sequential biopsies taken during infection were analysed by microarray to describe the molecular responses which inhibit larval establishment.

Expression of p16, CD95, CD95L and Helix pomatia agglutinin in relapsing and nonrelapsing very thin melanoma

BACKGROUND

The incidence of malignant melanoma is increasing worldwide and patients are being diagnosed earlier with thinner primary lesions. Most patients with very thin melanoma (Breslow thickness < 0.76 mm) are cured by surgery but 2-18% relapse locally or with distant metastases.

OBJECTIVES

The objective of this study was to establish potential new prognostic markers in very thin melanoma.

METHODS

We identified a group of subjects with relapsing very thin primary cutaneous melanoma and a matched control group who had not relapsed. We investigated the expression of p16, Helix pomatia agglutinin (HPA), CD95 and CD95 ligand (CD95L) by immunohistochemistry on paraffin-embedded tissue sections from the subject group, their subsequent metastases and the control group.

RESULTS

Reduced p16 expression was significantly associated with relapse in very thin melanoma (P = 0.0129). Loss of p16 expression was also found in 76% of metastases. There was no significant association between HPA, CD95 or CD95L expression and subsequent relapse.

CONCLUSIONS

This work is the first to show a significant loss of p16 in relapsing very thin melanoma.

Androgen decreases osteoprotegerin expression in prostate cancer cells

Osteoprotegerin (OPG), a key regulator of bone resorption, is hypothesized to have a role in prostate cancer (CaP) bone metastasis. As advanced CaP is treated by androgen ablation, we examined if androgen modulates OPG expression by CaP cell lines in vitro. Basal levels of secreted OPG protein were significantly greater in androgen-independent PC-3 cells compared with androgen-responsive LNCaP-FGC cells (P<0.001); OPG was not detected in the androgen-responsive CaP cell lines LAPC-4 or DuCaP. Treatment with 5alpha-dihydrotestosterone (5alpha-DHT) significantly decreased OPG protein levels in both PC-3 and LNCaP-FGC, with maximal suppression using 10(-9)-10(-7) M 5alpha-DHT in PC-3 (P<0.01; day 3), and using 10(-10)-10(-9) M 5alpha-DHT in LNCaP-FGC cells (P<0.01; day 6). OPG messenger RNA levels were not significantly altered by this 5alpha-DHT treatment. Co-treatment with 10(-6) M flutamide blocked 5alpha-DHT inhibition of OPG protein expression in LNCaP-FGC cells. These data suggest that androgen may modulate OPG protein levels in CaP cell lines in vitro using a post-transcriptional mechanism.

Clinico-pathological features of relapsing very thin melanoma

In the UK the incidence of malignant melanoma is increasing and more patients with thinner primary lesions are diagnosed earlier. Most patients with very thin melanoma (< 0.76 mm Breslow thickness) are cured by surgical excision, however, 2-18% relapse over 0-11 years with local or distant metastatic disease and may die. There are still no recognized prognostic or predictive, clinical, serological or molecular markers that accurately determine which of these very thin melanoma will relapse: the Breslow thickness remains the single most important prognostic factor for melanoma in general. Improved prognostic indicators are therefore needed for this rare, but important, unusually aggressive group, to better direct new invasive and expensive investigations and treatment. This article reviews the clinical and histological aspects of relapsing very thin melanoma and discusses the findings of several recent studies, including our own. There is no clinical or biological evidence to support either wide surgical excision or sentinel node biopsy in these patients.

Functional formation of domain V of the poliovirus noncoding region: significance of unpaired bases

Previously we have shown that polioviruses with mutations that disrupt the predicted secondary structure of the 5' noncoding region of domain V are temperature sensitive for growth. Non-temperature-sensitive revertant viruses had mutations that re-formed secondary structure by a direct back mutation of changes in the opposite strand. We mutated unpaired regions and selected revertants of viruses with single base deletions, where no obvious back mutation was available in order to gain information on secondary structure. Results indicated that conservation of length of a three base loop between two double-stranded stems was essential for a functional domain V to form. The requirement for the unpaired "hinge" base at 484 which is implicated in the attenuation of Sabin 2 was also confirmed. Results also underline the necessity for functional folding over local secondary structure stability.

The potential for eye bank limbal rings to generate cultured corneal epithelial allografts

PURPOSE

Patients with severe limbal deficiencies are unable to maintain a stable corneal surface. If sheets of cultured allogeneic corneal epithelium could be prepared from eye banked corneal limbal rings, which are normally discarded after keratoplasty, the sheets may be beneficial for grafting onto patients with limbal stem cell deficiencies.

METHOD

Biopsies of limbal tissue (2-3 mm2) removed from organ-cultured corneal limbal rings or from fresh whole globes were either trypsinized or set up as explants to assess their potential for corneal epithelial cell production.

RESULTS

Several biopsies were taken from each of 21 organ-cultured limbal rings and 10 fresh cadaveric globes. Cultures were generated from every cadaveric eye (10/10), although not all biopsies from the same eye gave rise to cultures. Confluent sheets of cultured cells were also produced successfully from limbal rings that had been in organ culture for up to 25 days, but the success rate from limbal ring material was variable (14/21). An analysis of parameters associated with each limbal ring was carried out in an attempt to identify the reasons for the different efficiencies of epithelial production. No obvious single parameter correlation was detected, although there was a trend to poorer efficiency with increased donor age.

CONCLUSIONS

Confluent sheets of cultured corneal epithelial cells, suitable for grafting, can be produced from limbal tissue taken from eye bank organ-cultured corneas, although it takes longer, on average, to reach confluence (17-21 days) than an equivalent sample from a fresh eye (9-12 days).

Experimental observations in the rat on the influence of cadmium on skin wound repair

Wound healing in the skin depends upon the availability of appropriate trace metals as enzyme cofactors and structural components in tissue repair. The present study forms part of a series of experimental investigations to examine the influence of xenobiotic elements with no known nutritional function and which are known to compete with essential trace metals. It was designed to investigate further the importance of trace metals in wound healing as an aid to wound management and to identify mechanisms of nonhealing which constitute a major problem in human medicine. Surgically induced skin wounds in young adult male Wistar rats were exposed topically to 0.2 ml of 0.01, 0.10 or 1.0% cadmium chloride (aq.) daily for up to 10 days. Control wounds received de-ionized water only. Wounds exposed to cadmium chloride at 0.01 or 0.10% healed in a similar fashion to controls and exhibited a comparable histological profile with metallothionein distribution. Wounds receiving 1.0% cadmium chloride failed to heal or fully re-epithelialize within 7 days and animals were humanely killed. They showed a persistent mass of inflammatory cell infiltration, oedema, wound debris and aberrant epidermal cell growth. Metallothionein concentrations in the epidermis and fibroblasts of the papillary dermis increased greatly by 5 days postwounding and remained high through the observation period. Cadmium was identified in the liver, kidney and wound sites. In the wound, 1.0% cadmium chloride induced statistically significant (P > 0.001) changes in local concentrations of zinc and calcium at key stages in the healing process, and as a consequence disturbed the trace metal balance necessary for normal wound repair. Zinc levels were increased twofold after 7 days, but calcium was markedly reduced. Local changes in the distribution of metallothionein indicate interaction of cadmium and trace metal carrier proteins as a probable mechanism for impaired wound healing. The cytotoxicity of cadmium is considered to be largely responsible.

HLA-C and guttate psoriasis

BACKGROUND

Psoriasis is a heterogeneous disease in its clinical expression. Both genetic and environmental factors are thought to contribute to the pathogenesis of the inflammatory and hyperproliferative components of the typical skin lesions. Predisposing genetic influences include associations with human leucocyte antigens (HLA) of which that with HLA-Cw6 is the strongest. Guttate psoriasis is a specific clinical manifestation of psoriasis frequently associated with group A beta-haemolytic streptococcal throat infection.

OBJECTIVES

We set out to determine whether further clinical subdivision of psoriasis is associated with tighter correlation with HLA-C alleles.

PATIENTS/METHODS

We determined the HLA-C locus genotype of 29 caucasian patients with guttate psoriasis presenting consecutively with guttate psoriasis associated with a history of a sore throat and/or an antistreptolysin O titre > 200 IU mL-1. Polymerase chain reaction typing using sequence-specific primers was used to detect all known HLA-C alleles. These data were compared with a control population of 604 random caucasian cadaver donors.

RESULTS

All patients (100%) with guttate psoriasis carried the Cw*0602 allele compared with 20% of the control population (odds ratio = infinity; 95% confidence limits 25.00-infinity; Pcorrected < 0.0000002).

CONCLUSIONS

This result is consistent with HLA-Cw*0602 playing a part directly in the pathogenesis of guttate psoriasis.