Feeding forage or concentrates early in life influences rumen fermentation, metabolic response, immune function and growth of Wagyu × Friesian calves

Context Early life nutrition of calves influences their performance later in life. There is limited literature demonstrating the effects of rearing dairy calves in early life on milk with either exclusively forage or concentrate starter diets on metabolic and immune function and post-weaning growth and body composition on a pasture only diet. Aim This study evaluated the effects of feeding Wagyu × Holstein Friesian calves a forage starter (FS) or a concentrate starter (CS) for the first 14 weeks of rearing on rumen fermentation, blood metabolites, immune function, growth and body composition to Week 41. Methods Group-housed calves (Wagyu × Friesian, 10 calves per group, three groups per treatment) were fed milk (2 L per calf twice daily) until Week 7, then transitioned to once a day milk feeding until weaning by Week 9, with ad libitum access to either FS or CS. All calves were transferred to graze ryegrass pastures a week after transitioning to once daily milk feeding, with starter feeds removed gradually by Week 14. Thereafter, calves were reared together on pasture until Week 41. Results Solid feed intake was lower in FS than CS calves during the first 7 weeks. Total short chain fatty acids were lower, but acetate to propionate ratio and rumen pH were higher in FS than CS calves at Week 7, with no differences observed at Week 12 or 30. Plasma β-hydroxybutyrate an indicator of ketogenic ability of the rumen in developing calves was higher in FS vs CS calves at weaning. Further, FS calves had lower concentrations of circulating non-esterified fatty acids compared with CS calves at weaning. Compared with CS calves, FS calves grew slower for the first 14 weeks which was associated with lower plasma IGF-1 levels. However, FS calves had greater average daily gain after 14 weeks when on pasture and had similar plasma IGF-1 at 30 weeks and similar body weight and body composition (muscle and subcutaneous fat deposition) by Week 41 compared to CS calves. Conclusions These results indicate that offering a FS starter has better prepared calves for weaning onto pasture and potentially improved utilisation of forage post-weaning to achieve similar muscle and fat deposition and overall liveweight in both groups by 41 weeks. Implications Dairy beef calves can be successfully reared using forage as the only solid feed source without affecting their growth performance on pasture until 10 months of age. Rearing calves using forage will contribute to reducing the usage of concentrate feeds in pastoral dairy-beef production systems and provide an opportunity to fulfil the market requirements and standards for grain-free beef production.

A case-study of the experiences of junior medical officers in the emergency departments of a metropolitan hospital and rural hospital

OBJECTIVE

Increased exposure to post-graduate rural medical training is associated with increased likelihood of future rural practice. Training rotations in rural emergency departments provide a possible avenue for such exposure, but have been under-investigated. This study aimed to compare junior medical officers' emergency department experiences in a metropolitan and a rural hospital to inform rural health workforce initiatives.

DESIGN

Mixed-method case-study design.

SETTING

Two 10-week periods in the respective emergency departments.

PARTICIPANTS

Four junior medical officers at the rural site and 22 junior medical officers at the metropolitan hospital.

MAIN OUTCOME MEASURES

Caseloads extracted from electronic medical records and training experience.

RESULTS

Data were collected over 142 days. The average number of patients seen per day, per junior medical officer, was significantly higher at the rural hospital emergency department (7.2 patients per day) in comparison with the metropolitan hospital (4.3 patients per day). Junior medical officers at the rural hospital saw relatively more lower acuity patients. The seven junior medical officers who were interviewed provided consistently positive responses regarding their training experiences in both locations. This was particularly evident in the rural hospital and was attributed to one-on-one supervision.

CONCLUSIONS

Most junior medical officers agreed that their expectations for support and learning opportunities were met and/or exceeded. However, junior medical officers reported feeling more supported at the rural hospital due to direct contact and communication with senior medical officers. Placement in a smaller hospital emergency department did not disadvantage the junior medical officers' training in this case-study and provided a positive rural training experience. These findings support workforce policies which encourage rural hospital emergency department training.

Circulating tumor DNA as a potential marker of adjuvant chemotherapy benefit following surgery for localized pancreatic cancer

BACKGROUND

In early-stage pancreatic cancer, there are currently no biomarkers to guide selection of therapeutic options. This prospective biomarker trial evaluated the feasibility and potential clinical utility of circulating tumor DNA (ctDNA) analysis to inform adjuvant therapy decision making.

MATERIALS AND METHODS

Patients considered by the multidisciplinary team to have resectable pancreatic adenocarcinoma were enrolled. Pre- and post-operative samples for ctDNA analysis were collected. PCR-based-SafeSeqS assays were used to identify mutations at codon 12, 13 and 61 of KRAS in the primary pancreatic tumor and to detect ctDNA. Results of ctDNA analysis were correlated with CA19-9, recurrence-free and overall survival (OS). Patient management was per standard of care, blinded to ctDNA data.

RESULTS

Of 112 patients consented pre-operatively, 81 (72%) underwent resection. KRAS mutations were identified in 91% (38/42) of available tumor samples. Of available plasma samples (N = 42), KRAS mutated ctDNA was detected in 62% (23/37) pre-operative and 37% (13/35) post-operative cases. At a median follow-up of 38.4 months, ctDNA detection in the pre-operative setting was associated with inferior recurrence-free survival (RFS) [hazard ratio (HR) 4.1; P = 0.002)] and OS (HR 4.1; P = 0.015). Detectable ctDNA following curative intent resection was associated with inferior RFS (HR 5.4; P < 0.0001) and OS (HR 4.0; P = 0.003). Recurrence occurred in 13/13 (100%) patients with detectable ctDNA post-operatively, including in seven that received gemcitabine-based adjuvant chemotherapy.

CONCLUSION

ctDNA studies in localized pancreatic cancer are challenging, with a substantial number of patients not able to undergo resection, not having sufficient tumor tissue for analysis or not completing per protocol sample collection. ctDNA analysis, pre- and/or post-surgery, is a promising prognostic marker. Studies of ctDNA guided therapy are justified, including of treatment intensification strategies for patients with detectable ctDNA post-operatively who appear at very high risk of recurrence despite gemcitabine-based adjuvant therapy.

A Predictive Model for Diabetic Foot Ulcer Outcome: The Wound Healing Index

Objective: To develop a healing index for patients with diabetic foot ulcers (DFUs) for use in clinical practice, research analysis, and clinical trials.

Approach: U.S. Wound Registry data were examined retrospectively and assigned a clear outcome (healed, amputated, etc.). Significant variables were identified with bivariate analyses. A multivariable logistic regression model was created based on significant factors (p < 0.05) and tested on a hold-out sample of data. Out of 13,266 DFUs from the original dataset, 6,440 were eligible for analysis. The logistic regression model included 5,239 ulcers, of which 3,462 healed (66.1%). The 10% validation sample utilized 555 ulcers, of which 377 healed (67.9%).

Results: Variables that significantly predicted healing were as follows: wound age (duration in days), wound size, number of concurrent wounds of any etiology, evidence of bioburden/infection, patient age, Wagner grade, being nonambulatory, renal dialysis, renal transplant, peripheral vascular disease, and patient hospitalization for any reason.

Innovation: We present a validated stratification system, previously described as the Wound Healing Index (WHI), which predicts healing likelihood of patients with DFUs, incorporating patient- and wound-specific variables.

Conclusion: The DFU WHI is a comprehensive and user-friendly validated predictive model for DFU healing. It can risk stratify patients enrolled in clinical research trials, stratify patient data for quality reporting and benchmarking activities, and identify patients most likely to require costly therapy to heal.

A 4-arm randomized controlled pilot trial of innovative solutions for jugular central venous access device securement in 221 cardiac surgical patients

PURPOSE

To improve jugular central venous access device (CVAD) securement, prevent CVAD failure (composite: dislodgement, occlusion, breakage, local or bloodstream infection), and assess subsequent trial feasibility.

MATERIALS AND METHODS

Study design was a 4-arm, parallel, randomized, controlled, nonblinded, pilot trial. Patients received CVAD securement with (i) suture+bordered polyurethane (suture + BPU; control), (ii) suture+absorbent dressing (suture + AD), (iii) sutureless securement device+simple polyurethane (SSD+SPU), or (iv) tissue adhesive+simple polyurethane (TA+SPU). Midtrial, due to safety, the TA+SPU intervention was replaced with a suture + TA+SPU group.

RESULTS

A total of 221 patients were randomized with 2 postrandomization exclusions. Central venous access device failure was as follows: suture + BPU controls, 2 (4%) of 55 (0.52/1000 hours); suture + AD, 1 (2%) of 56 (0.26/1000 hours, P=.560); SSD+SPU, 4 (7%) of 55 (1.04/1000 hours, P=.417); TA+SPU, 4 (17%) of 23 (2.53/1000 hours, P=.049); and suture + TA+SPU, 0 (0%) of 30 (P=.263; intention-to-treat, log-rank tests). Central venous access device failure was predicted (P<.05) by baseline poor/fair skin integrity (hazard ratio, 9.8; 95% confidence interval, 1.2-79.9) or impaired mental state at CVAD removal (hazard ratio, 14.2; 95% confidence interval, 3.0-68.4).

CONCLUSIONS

Jugular CVAD securement is challenging in postcardiac surgical patients who are coagulopathic and mobilized early. TA+SPU was ineffective for CVAD securement and is not recommended. Suture + TA+SPU appeared promising, with zero CVAD failure observed. Future trials should resolve uncertainty about the comparative effect of suture + TA+SPU, suture + AD, and SSD+SPU vs suture + BPU.

When a LIC came to town: the impact of longitudinal integrated clerkships on a rural community of healthcare practice

INTRODUCTION

Two small rural towns in Australia, where medical practitioners provide primary care to the population, including emergency, anaesthetic and obstetric services, were early adopters of an innovative year-long integrated clerkship (clinical placement) designed to foster medical student skill attainment and a commitment to underserved rural communities. Primary care vocational trainees had previously trained in the region. Engaging with the university to participate in the clerkship initiative for undergraduate medical education offered the local healthcare service an opportunity to really integrate education with service. This study sought perspectives from a multidisciplinary group of stakeholders on the impact of the longitudinal integrated clerkship (LIC) on the healthcare community.

METHOD

Three analysts independently analysed the transcripts arising from semi-structured interviews with a range of health care clinicians and managers (N=23). Themes were identified using inductive content analysis methodology.

RESULTS

Four major themes emerged from the perspectives of a multi-professional group of participants from both towns: transforming a community of practice, realising the potential of the health service, investment in rural return, and sustainability.

CONCLUSIONS

There was significant clinical exposure, skill and teaching capacity in these previously unrecognised rural placements but realising the potential of the health service needs careful management to sustain this resource. Early engagement and initial enthusiasm have produced many positive outcomes for the healthcare community, but this alone is not sufficient to sustain an increasing role for rural primary care in medical education. The study identified issues that need addressing for sustainability, namely validation, time and costs. Strategies to address these are key to continuation of LICs in small rural communities.

Hydrodynamic evaluation of aortic cardiopulmonary bypass cannulae using particle image velocimetry

The high velocity jet from aortic arterial cannulae used during cardiopulmonary bypass potentially causes a "sandblasting" injury to the aorta, increasing the possibility of embolisation of atheromatous plaque. We investigated a range of commonly available dispersion and non-dispersion cannulae, using particle image velocimetry. The maximum velocity of the exit jet was assessed 20 and 40 mm from the cannula tip at flow rates of 3 and 5 L/min. The dispersion cannulae had lower maximum velocities compared to the non-dispersion cannulae. Dispersion cannulae had fan-shaped exit profiles and maximum velocities ranged from 0.63 to 1.52 m/s when measured at 20 mm and 5 L/min. Non-dispersion cannulae had maximum velocities ranging from 1.52 to 3.06 m/s at 20 mm and 5 L/min, with corresponding narrow velocity profiles. This study highlights the importance of understanding the hydrodynamic performance of these cannulae as it may help in selecting the most appropriate cannula to minimize the risk of thromboembolic events or aortic injury.

Abstract P4-19-02: Early experience of patient donation and researcher use of tissues donated to a national breast cancer tissue bank

The need for a specialist breast cancer biobank was recognised through a Gap Analysis conducted by the UK charity, Breast Cancer Campaign (Thompson AM et al., Breast Cancer Res 2008: 10(2); R26). As a result The Breast Cancer Campaign Tissue Bank (www.breastcancertissuebank.org) was launched in 2010 as a coalition of 4 centres of excellence for breast cancer research in the UK. Breast cancer patients presenting to these centres are offered the opportunity to donate surplus tissue and bloods to The Breast Cancer Campaign Tissue Bank. Researchers can apply for these samples by completing a simple on line application form. Here we describe our early experience of patient donation to The Breast Cancer Campaign Tissue Bank and outline the sample requests received from researchers to date. Most of the first year of operation (2010) was spent developing SOPs and ensuring collection protocols were robust, with some limited prospective collection. The collection was pump-primed from existing resources. By 2011 all sites were operational and working to the same standards. Over a 2 year period (Jan 2011 - Dec 2012), over 90% of suitable patients (1803) consented to tissue donation. From these we derived 3951 frozen tissue aliquots, 1517 formalin-fixed paraffin-embedded cases and 2012 blood derivatives (serum, plasma and whole blood). Asian patients were less likely to consent while younger patients tended not to donate blood, but were happy to donate tissue. All male patients consented to tissue and blood donation. At Dec 2012, the total numbers of sample aliquots derived from these donated tissue and blood samples was 22, 127. This includes frozen and formalin-fixed paraffin-embedded tissues, serum, plasma and whole blood. At present, application for tissue samples is restricted to the UK and Ireland but we aim to open to international applications in the near future. All applications are reviewed by an international Tissue Access Committee which includes appropriate clinical and scientific expertise plus representation by patient advocates. At 1st June 2013, seventeen applications had been received, of which 14 were approved. Three applications were rejected, made on the basis that the applicants were not making the best use of the donated material. Thus far, tissues have been dispatched to 9 researchers with 5 in preparation. These include 465 formalin-fixed paraffin-embedded cases and 158 frozen samples, all provided with a basic minimum dataset. Early experience of patient consent was encouraging with patients overall very enthusiastic and willing to donate to our biobanking programme. More research is needed to help understand the barriers in preventing ethnic minorities to donate and the reluctance in some young people to donate blood samples. Interest by the breast cancer research community in accessing samples is steadily rising as the resource becomes more widely known and increased website traffic is translating into applications for tissues. This has been an ambitious multidisciplinary endeavour but we are building a valuable resource to service the needs of the breast cancer research community with the goal of helping translate laboratory results into clinical benefit.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-19-02.

Electronic Health Records, Registries, and Quality Measures: What? Why? How?

The transition from volume-based healthcare to value-based care is advancing via the reporting of quality measures, initially as a part of "pay for performance" within Medicare's Physician Quality Reporting System (PQRS) initiative. However, "value-based purchasing" requirements within the Affordable Care Act will increase the percentage of reimbursement linked to the reporting of quality measures. Currently, only five PQRS measures are relevant to wound care, and the venous ulcer care measure will be retired this year. PQRS measures in wound care can only be reported via claims or qualified patient registries, and no wound care measures are endorsed by the National Quality Forum (NQF). The recent Health Informational Technology for Economic and Clinical Health (HITECH) Act promoting the adoption of electronic health records (EHRs) requires quality reporting by clinicians wishing to access EHR adoption money. These clinicians will be able to comply with the next stage of "meaningful use" of EHRs, beginning in 2015, by submitting data to a qualified registry, and registry submission may eventually be required by Medicare for reimbursement of some wound care products and procedures. Other specialties are using registries to track adverse events, measure compliance with practice guidelines, and for comparative effectiveness data. Evidence-based measures should be developed as electronic measures that can be submitted directly from the clinicians' EHR. New wound care measures should undergo testing for NQF endorsement. The not-for-profit U.S. Wound Registry is a qualified patient registry that is available for PQRS reporting, measure testing, and future registry submission requirements. The lack of tested wound care quality measures threatens the entire wound care industry, as quality-based reimbursement is not limited to physician payment. Quality measures are an increasingly important part of many Medicare payment systems, including those for acute care hospitals, hospital-based outpatient wound care departments, and accountable care organizations.

Examining the relationship between physician and facility level-of-service coding in outpatient wound centers: results of a multicenter study 

The evaluation and management (E/M) services for the physician and the hospital-based outpatient center ("facility") are calculated using different federal regulations. In addition, patients visiting outpatient wound care centers require different levels of care from the physician than the facility. The purpose of this study was to analyze and compare physician and facility E/M level-of-service coding using the electronic wound registry records from three geographically diverse, hospital-based outpatient wound centers. De-identified data on 9,985 patient visit level-of-service codes were prospectively collected using an electronic health record (EHR) system that internally and automatically audits the chart and calculates the physician and the facility E/M level of service based on the documentation present in the chart. Correlations were calculated using Kendall's tau b/Goodman-Kruskal gamma statistics. Correlations were weak between facility and physician E/M level-of-service codes, varying from 0.084 to 0.179 for follow-up and from 0.066 to 0.354 for initial visits. Although facility E/M levels of service followed a normal distribution, physician E/M visits were heavily skewed toward higher levels of care (3 to 5). These findings confirm that, especially during the initial visit, patients presenting at outpatient wound centers require different levels of care from the physician than from the facility. The finding that initial physician level of service coding was higher than facility E/M levels of service for both initial and follow-up visits is not unexpected, considering the high number of comorbidities in many wound patients and the general risk of their presenting problems.

Prolactin acts on the hypothalamic-pituitary axis to modulate follicle-stimulating hormone gene expression in the female brushtail possum (Trichosurus vulpecula)

Brushtail possums exhibit a distinct preovulatory pattern of prolactin (Prl) secretion suggesting that Prl is involved in normal reproductive function. In some mammals, Prl is essential for corpus luteum (CL) function and/or modulation of steroidal effects on hypothalamic-pituitary activity. The aim of this study was to test the effects of biologically active recombinant possum Prl (recPosPrl) on both pituitary gland and CL function in possums. To confirm biological activity, administration of recPosPrl-N2C1 (10 μg) resulted in an 18-fold stimulation (P<0.05) of progesterone (P(4)) production by possum granulosa cells in vitro. Based on these findings, minipumps containing either recPosPrl-N2C1 (n=10) or saline (n=8) were inserted into lactating female possums. The expression levels of pituitary-derived PRL, LHB, FSHB and GNRHR and CL-derived LHR mRNA were quantified. Following a resumption of reproductive activity, no differences in ovulation incidence or plasma Prl concentrations were observed. Plasma Prl levels were less variable (P<0.001) in Prl-treated possums, confirming a self-regulatory role for Prl in this species. There was a marked down-regulation (P<0.001) of FSHB mRNA at the mid-luteal stage in Prl-treated possums, whereas mean PRL, LHB, GNRHR and LHR mRNA expression levels were not different between experimental groups. Plasma P(4) concentrations were not different (P=0.05) in Prl-treated possums, although tended to be higher in the peri-ovulatory and early-luteal phase. We conclude in the brushtail possum that Prl is self-regulated via a short-feedback loop common to all mammals studied and is able to modulate FSHB expression probably at the level of the hypothalamus and/or pituitary gland.

Type 2 diabetes does not worsen prognosis in hepatocellular carcinoma

INTRODUCTION

Type 2 diabetes (T2DM) is associated with liver inflammation and carcinogenesis. The prevalence of T2DM among patients with liver cirrhosis and hepatocellular carcinoma is increasing. However, the effect of T2DM on the natural history of hepatocellular carcinoma is not known.

AIM

To examine the effect of T2DM on hepatocellular carcinoma (HCC) survival in treated and untreated disease.

METHODS

Retrospective analysis was performed on HCC cases diagnosed during 2000-2005, and prospectively during 2006-August 2007. Demographics, HCC staging, response to treatment, and survival were collected. A comparison was made between patients with T2DM and without T2DM.

RESULTS

One hundred and thirty-five patients were recruited in total; 58 (43%) had T2DM. Seventy (37 diabetic) patients were treated with percutaneous radiological therapies, with 168 treatments given. Treatment was determined by AASLD guidelines and patient tolerance, there was no randomisation. There was no significant difference in survival between diabetic and nondiabetic patients. There was a nonsignificant trend towards greater survival in diabetic patients (overall median survival diabetics 21 mths vs nondiabetics 5 mths, P=0.355).

CONCLUSIONS

T2DM does not negatively impact on the natural history of treated or untreated HCC.

A retrospective data analysis of antimicrobial dressing usage in 3,084 patients

Knowledge about practice patterns and optimal usage criteria for topical antimicrobial dressings is limited. A retrospective data analysis was conducted to evaluate: 1) the length of time these dressings are applied in a typical episode of wound care, 2) the number of episodes of antimicrobial dressing use, and 3) whether antimicrobial dressings are applied in consideration of signs and symptoms of infection. Wound care registry data from a level-4 electronic medical record were analyzed, providing information on 3,084 patients older than 17 years seen from July 2003 through December 2008 in 26 hospital-based, outpatient wound centers in 14 states. The 5,541 recorded wounds ranged in size from 0.3 to 225 cm2. One antimicrobial dressing use episode was recorded for 71% of wounds (4.7% had four or more). Mean treatment episode length was 32.5 days (median 21 days). Clinicians used these dressings for a longer period of time if patients had multiple comorbidities (P = .0001), a refractory wound (P <.00001), or were prescribed oral antibiotics (P <.0002); first dressing use was more common in wounds with signs and symptoms of infection (P <.00001). During an average of 16 (median 10) visits and a follow-up time of 269 days, 61.4% of wounds healed (range 42.2% for flaps or grafts to 67.9% for surgical wounds of all 5,541 wounds). Antimicrobial dressing use for 2 to 4 weeks was associated with a higher proportion of healed wounds, but in wounds that healed, longer dressing use was associated with a longer healing time. The practice pattern observed suggests that antimicrobial dressing usage generally is based on patient and wound assessment variables but prospective studies are needed to develop optimal guidelines of care.

The safety of negative pressure wound therapy using vacuum-assisted closure in diabetic foot ulcers treated in the outpatient setting

The purpose of this project was to evaluate the safety of negative pressure wound therapy using the vacuum-assisted closure (V.A.C.) Therapy System (KCI, San Antonio, TX) in diabetic foot ulcers (DFUs) among wound centre outpatients. We defined events that could represent complications or adverse events (AEs) as a result of treatment with the V.A.C., including symptoms of infection, pain, bleeding and periwound skin breakdown. The frequency of these AEs among V.A.C. patients with DFUs was compared with those among similar non V.A.C. patients. This project prospectively queried data collected during routine clinical care from 16 outpatient wound centres using the Intellicure electronic medical record system. The electronic records were de-identified according to HIPAA requirements and pooled to create a data repository dedicated to research (the Intellicure Research Consortium). Analysis was performed on 1331 DFUs representing 16,438 outpatient visits. A total of 1299 non V.A.C. and 72 V.A.C. DFUs were available for analysis. There was either no statistical difference between the AEs of V.A.C. versus non V.A.C. patients or the V.A.C. exerted a protective effect. We conclude that the V.A.C. is safe in outpatient use.

Diagnosis of solid pancreatic masses by endoscopic ultrasound-guided fine-needle aspiration

BACKGROUND

Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) is increasingly being used in the staging algorithm for pancreatic carcinoma. This allows for a tissue diagnosis, which was previously difficult to obtain. The aim of this study is to assess the utility of EUS-FNA in establishing the diagnosis of solid pancreatic mass lesions in an Australian population.

METHODS

A retrospective review of the EUS databases of St Vincent's Hospital Melbourne and Western Hospital, Melbourne from November 2002 to May 2006 was undertaken. The focus was on patients with a solid pancreatic mass who underwent EUS-FNA. Surgical pathology or long-term follow up was used to identify false-positive or false-negative results.

RESULTS

EUS was undertaken to investigate a solid pancreatic or distal common bile duct mass lesion in 155 patients. Seventy-two of these underwent EUS-guided FNA. Mean age was 68 years. A positive tissue diagnosis of malignancy could be made in 55 (76%). Nine (13%) had benign histology, with 8 (11%) having inadequate tissue obtained from FNA. A later tissue diagnosis of carcinoma was made in eight of those with either benign or inadequate histology, although in all cases there were EUS features diagnostic of malignancy, with FNA limited by technical difficulties. The overall utility of EUS-FNA showed a sensitivity of 87%, specificity 100%, positive predictive value 100%, negative predictive value 52% and overall accuracy 89%.

CONCLUSION

EUS-FNA gives a high return for histological diagnosis of solid pancreatic mass lesions and should be part of the standard management algorithm for pancreatic carcinoma.

Diagnosis of solid pancreatic masses by endoscopic ultrasound-guided fine-needle aspiration

BACKGROUND

Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) is increasingly being used in the staging algorithm for pancreatic carcinoma. This allows for a tissue diagnosis, which was previously difficult to obtain. The aim of this study is to assess the utility of EUS-FNA in establishing the diagnosis of solid pancreatic mass lesions in an Australian population.

METHODS

A retrospective review of the EUS databases of St Vincent's Hospital Melbourne and Western Hospital, Melbourne from November 2002 to May 2006 was undertaken. The focus was on patients with a solid pancreatic mass who underwent EUS-FNA. Surgical pathology or long-term follow up was used to identify false-positive or false-negative results.

RESULTS

EUS was undertaken to investigate a solid pancreatic or distal common bile duct mass lesion in 155 patients. Seventy-two of these underwent EUS-guided FNA. Mean age was 68 years. A positive tissue diagnosis of malignancy could be made in 55 (76%). Nine (13%) had benign histology, with 8 (11%) having inadequate tissue obtained from FNA. A later tissue diagnosis of carcinoma was made in eight of those with either benign or inadequate histology, although in all cases there were EUS features diagnostic of malignancy, with FNA limited by technical difficulties. The overall utility of EUS-FNA showed a sensitivity of 87%, specificity 100%, positive predictive value 100%, negative predictive value 52% and overall accuracy 89%.

CONCLUSION

EUS-FNA gives a high return for histological diagnosis of solid pancreatic mass lesions and should be part of the standard management algorithm for pancreatic carcinoma.

Limitations of Daily Living Activities in Patients With Venous Stasis Ulcers Undergoing Compression Bandaging: Problems With the Concept of Self-bandaging

Venous stasis ulcers (VSUs) represent both an enormous cost to the healthcare system and significant quality-of-life issue to patients. While certain high-technology products have shown promise, compression bandaging continues to be the gold standard of care. Recently, some regional Medicare carriers suggested that patients with VSUs should be able to perform self-bandaging in an effort to avoid reimbursing caregivers to provide this service. Using a database of 7251 patients from 29 wound care facilities maintained as part of an agreement under the Intellicure Research Consortium for users of Intellicure Inc's (The Woodlands, Tex) wound care software; activity of daily living (ADL) data was extracted for all patients with a VSU in whom this was collected (547 patients) to examine such an impact. Analysis showed that 55% of these patients required assistance with ADLs-the majority had issues with dressing and toileting. It is unlikely that patients who require assistance with dressing and toileting will be able to achieve adequate positioning to perform self-bandaging. Since it is possible that even patients who do not require assistance with ADLs might be unable to perform self-bandaging, the authors consider these results a conservative estimation. These results indicate that a significant number of patients are not capable of self-bandaging, thus placing their prognosis and quality-of-life at risk if they are unable to pay for the necessary professional services or do not have family members who are capable of bandaging.

Hepatic stellate cells on poly(DL-lactic acid) surfaces control the formation of 3D hepatocyte co-culture aggregates in vitro

Evidence for the functional superiority of cells cultured as 3D aggregates or on 3D scaffolds over conventional 2D monolayer cultures has created interest in material and cell based methods that influence the formation and structure of multicellular aggregates in vitro. We have created a co-culture of primary rat hepatocytes and hepatic stellate cells on a poly(DL-lactic acid) surface, a poor substrate for rat hepatocyte adhesion, to study the dynamics of multicellular spheroid formation and the resultant cell arrangement. The poly(DL-lactic acid) surface allows dynamic and rapid interaction of hepatocytes and stellate cells to form co-culture spheroids in a complex multistage process (shown by time lapse microscopy). This spheroid morphology supports enhanced cell viability relative to a mono-culture mono-layer system (measured by lactate dehydrogenase leakage). The distribution of the aggregating cell type in the final structure is related to the mechanics of formation i.e. mainly central and peripheral. This study provides a unique and generically applicable insight into the dynamics of multicellular spheroid formation where aggregation is induced by one cell type and imposed on another. This has implications for 3D cell culture models and a wide number of currently used stromal co-culture systems.

Comparison of multidimensional flow cytometry with standard morphology for evaluation of early marrow response in pediatric acute lymphoblastic leukemia

PURPOSE

We compared multidimensional flow cytometry (MDF) with morphology in evaluating early marrow response to induction chemotherapy in pediatric ALL.

METHODS

Chemotherapy response was determined by standard morphology or by MDF assessed by residual leukemic cell percentage remaining in the marrow on days 7, 14, and 28 of induction. Bone marrow response was classified as M3 (>25% leukemic blasts) or M1/M2 (< or = 25% leukemic blasts). Multidimensional flow cytometry evaluation was compared with that of standard morphology. Available day-7 and day-14 marrow slides were also reevaluated by a single pathologist without patients' clinical information.

RESULTS

Of 46 day-7 specimens, eight (17%) had discordant MDF and morphologic results (P < 0.001), including six classified as M3 by morphology but were M1/M2 by MDF, and two were classified as M3 by MDF but were M1/M2 by morphology. Of 24 day-14 bone marrow specimens, five (20.5%) were discordant (P < 0.001), including two classified as M3 by morphology but were M1/M2 by MDF, and three were classified as M3 by MDF but were M1/M2 by morphology. Reevaluation of the blinded day-7 and day-14 marrow slides yielded discordance between repeated pathology readings of 11% (P < 0.001) and 6% (P = 0.04), respectively.

CONCLUSION

Our data show significant discordance between the morphologic and MDF evaluation of early marrow response. Early response to therapy is a significant prognostic indicator in pediatric acute lymphoblastic leukemia and is used to alter subsequent treatment; thus, precise assessment of response is important. A larger comparison of MDF with morphology for the evaluation of early response, including correlation with clinical outcome, is warranted.

Differences in repair responses between immature and mature cartilage

Cartilage has a poor reparative capacity although it is unclear as to what extent this may be dependent on age or maturation. In the current study, the cellular responses of chondrocytes to experimental wounding in vitro using embryonic, immature, and mature cartilage have been compared. In all cases, the response was consistent (a combination of cell death that included apoptosis and proliferation). The speed of response varied in terms of cell death with embryonic cartilage showing the most rapid response and mature cartilage showing the slowest response. Intrinsic repair as assessed by the ability to heal the lesion was not detected in any of the culture systems used. It was concluded that the poor repair potential of cartilage is not maturation dependent in the systems studied.

NK cells recover early and mediate cytotoxicity via perforin/granzyme and Fas/FasL pathways in umbilical cord blood recipients

Umbilical cord blood (UCB) is now widely accepted as a source of stem cells in patients with malignant hematologic and genetic disorders. We have recently reported that in a series of 30 pediatric UCB transplant recipients comparable outcome to that anticipated with other unrelated stem cell sources. In our series, however, the probability of GVHD for grade III-IV was 9% and no UCB recipient developed chronic GVHD. The reason for the low incidence of GVHD after UCB transplantation is not fully understood. Because functional NK cells are among the first population of lymphocytes to be detected in UCB transplant recipients, 2 months post-transplant on average, we wanted to establish whether NK cells could be implicated in reducing the risk of GVHD. Here, we confirm that early NK cells detected in UCB transplant recipients activate the granzyme/perforin lytic pathway and, in addition, they can mediate Fas/Fas ligand (FasL) activity, a finding not previously reported. Both pathways develop simultaneously and are detectable months before the other lymphocytes, notably CD8 are fully functional. Our contention, therefore, is that the low GVHD observed in UCB recipients may be partially due to early NK cells.

Histology-specific expression of a DNA repair protein in pediatric rhabdomyosarcomas

PURPOSE

DNA repair enzymes have a critical role in cellular maintenance and survival. The enzyme apurinic/apyrimidinic endonuclease/redox factor 1 (APE/ref1), a key protein in the base excision repair pathway, displays both repair and redox control. We examined the role of APE/ref1 in pediatric embryonal and alveolar rhabdomyosarcomas (ARMS).

MATERIALS AND METHODS

Using an immunohistochemical method, fixed tissue from 31 newly diagnosed pediatric rhabdomyosarcomas were evaluated for expression of APE/ref1. Tissue was obtained from Indiana University and the Cooperative Human Tissue Network.

RESULTS

We demonstrated high levels of expression within the localized and metastatic embryonal rhabdomyosarcomas. This contrasted with both localized and metastatic ARMS, which had low levels of APE/ref1 expression. This histology-specific difference proved to be significant (P = 0.003). Furthermore, the expression within all tumors examined was localized to the nucleus and did not differ between localized and metastatic tumors.

CONCLUSIONS

We propose several hypotheses to explain this histology-specific expression of APE/ref1 in pediatric rhabdomyosarcomas. Because the majority of ARMS expressed either the PAX3/FKHR or PAX7/FKHR fusion transcript, the low level of expression may be related to the redox activity of APE/ref1. The low levels may also be related to the bioreductive activity of APE/ref 1.

T-cell recovery following marrow transplant: experience with delayed lymphocyte infusions to accelerate immune recovery or treat infectious problems

All forms of hematopoietic stem-cell transplantation are complicated by delayed immune reconstitution, which results in an increased risk of infectious complications and relapse of disease. Donor lymphocyte infusions have been used in an attempt to enhance immune recovery and for the prevention and treatment of specific infections following transplantation. While there is little data to support the use of donor lymphocytes for the enhancement of general immune function post-transplant, unselected and virus-specific donor T cells may have efficacy for the prophylaxis and treatment of infections and disease caused by Epstein-Barr virus (EBV) and cytomegalovirus (CMV). While donor lymphocyte infusions may cause significant morbidity and mortality, they are a novel and potentially powerful approach for the treatment of frequently fatal post-transplant infectious complications.