Objective comparison of a sit to stand test to the walk test for the identification of unilateral lameness caused by cranial cruciate ligament disease in dogs

OBJECTIVE

The purpose of this study was to evaluate a sit to stand test with the walk test for the identification of unilateral cranial cruciate ligament rupture in dogs.

MATERIALS AND METHODS

Peak vertical force and vertical impulse were measured on a pressure-sensitive walkway, during a sit to stand test and walk test, and in 10 dogs with unilateral cranial cruciate ligament rupture and 18 non-lame dogs. Data collected were used to calculate symmetry indices (SI) of ipsilateral and contralateral hindlimbs (HL), diagonal limb pairs (DLP) and ipsilateral limb pairs (ILP).

RESULTS

The symmetry indices of peak vertical force of HL during the walk test and sit to stand test were 100% and 90% sensitive for discriminating lame and non-lame dogs respectively. The symmetry indices of vertical impulse of HLs during the walk test and sit to stand test were 100% and 50% sensitive for discriminating lame and non-lame dogs respectively. Analysis of ipsilateral and diagonal limb pairs did not improve the discrimination in either test. The time taken to collect data from the sit to stand test data was shorter than for the walk test.

CLINICAL SIGNIFICANCE

Whilst the sit to stand test required a shorter time for collection of data than the walk test, it did not accurately identify all dogs with lameness associated with CCLR, and thus has relatively limited clinical utility in its tested form.

Microbiome and Neurotrauma: Emerging Innovations

The gut-brain axis plays an important role in bidirectional communication that exists and can be altered by injury. Neurotrauma provides acute alteration in the GI tract and alters autonomic function. In this focused review, we highlight what is known about GI disruption following neurotrauma. We then delve into how this affects recovery. Areas of innovation and emerging pre-clinical results are addressed. Finally, we address the link between neurotrauma induced GI dysfunction and progression to neurodegenerative disease states.

SP9.1.4 Performance and Cost-Effectiveness of a Virtual Consultation Clinic for 2-Week-Wait Colorectal Cancer Referrals – A Response to the Covid-19 Pandemic

Aims

Measure performance and cost effectiveness of a Virtual Consultation (VC) clinic, compared to face-to-face (FF) clinic, for 2-week-wait (2WW) colorectal cancer (CRC) referrals, which did not meet the criteria for nurse-led Telephone Assessment Service.

Methods

2WW CRC referrals were triaged by a colorectal surgeon to either a doctor-led VC or FF clinic. Demographics, referral indications, and primary outcome measures (time to clinic/results; investigation type; cancer detection rate) were compared pre-pandemic (November 2019–January 2020) and during the pandemic (May–June 2021).

Results

158 (pre-pandemic) and 160 (pandemic) consecutive patients were analysed, with no difference in age (74 vs. 75 years, p=0.936). During the pandemic, patients were referred with an increased number of positive FIT tests (29 vs. 13%, p<0.001), were more likely to have computerised tomography (65 vs. 45%, p=0.003), had a longer time from referral to clinic assessment (10 vs. 8 days, p=0.002), but were informed of results more promptly (59 vs. 138 days, p<0.001) than pre-pandemic patients. During the pandemic patients were assessed earlier via VC than FF clinics (9 vs. 11 days, p=0.049). There were no significant differences in cancer detection rate pre or during the pandemic (12 vs. 8%, p=0.187), or between VC and FF clinic during the pandemic (6 vs. 12%, p=0.294). Cost effective analysis showed £15,000 per annum saving with doctor-led VC clinic.

Conclusion

Virtual consultation for 2WW CRC referrals may improve efficiency without compromising the cancer detection rate, as well as reducing risk of Covid-19 transmission and being more cost effective.

662 ENHANCING CARE BY IMPROVING DISCHARGE SUMMARIES

Introduction

Within the Geriatric Medicine department at the Lister Hospital, Stevenage, the timeliness and quality of discharge summaries had become a source of complaints. Both primary care practitioners and families reported documentation was inadequate or incorrect. This project aimed to improve the quality of these discharge summaries in accordance with standards generated from previous audit data. Through improving communication it was clear that patient care could be enhanced.

Methods

Each month 15 discharge summaries were selected at random for review. Alongside patient notes these summaries were appraised in regards to standard discharge summary requirements: timeliness of delivery; adequate description of admission; and documentation of the follow up plan. They were also appraised on documentation of specific requirements for older aged adults including cognitive status, mobility status, discharge destination, need for home help, Rockwood Frailty score and resuscitation and escalation plans. Interventions including informal communication with junior doctors, circulation of a ‘Top Tips’ sheet, generation of an information poster and dissemination of information at local teaching sessions, took place, and were assessed, over regular PDSA cycles.

Results

showed a clear, sustained improvement in the quality of the discharge summaries. At the end of data collection, 100% of discharge summaries contained an adequate description of admission and an appropriate follow up plan. There was also significant improvement in documentation of specific requirements. Where documentation was initially very limited, following interventions, most discharge summaries contained details pertaining to discharge destination, need for home support, mobility status and resuscitation and escalation plans.

Conclusion

The relatively simple interventions have been found to have a sustained improvement in the quality of discharge summaries from the Geriatric Medicine Department at Lister Hospital, Stevenage. Whilst more work needs to be done it is hoped that this will already have enhanced patient care.

Phylogenetics and comparative plastome genomics of two of the largest genera of angiosperms, Piper and Peperomia (Piperaceae)

Biological radiations provide unique opportunities to understand the evolution of biodiversity. One such radiation is the pepper plant family Piperaceae, an early-diverging and mega-diverse lineage that could serve as a model to study the diversification of angiosperms. However, traditional genetic markers lack sufficient variation for such studies, and testing hypotheses on poorly resolved phylogenetic frameworks becomes challenging. Limited genomic data is available for Piperaceae, which contains two of the largest genera of angiosperms, Piper (>2100 species) and Peperomia (>1300 species). To address this gap, we used genome skimming to assemble and annotate whole plastomes (152-161kbp) and >5kbp nuclear ribosomal DNA region from representatives of Piper and Peperomia. We conducted phylogenetic and comparative genomic analyses to study plastome evolution and investigate the role of hybridization in this group. Plastome phylogenetic trees were well resolved and highly supported, with a hard incongruence observed between plastome and nuclear phylogenetic trees suggesting hybridization in Piper. While all plastomes of Piper and Peperomia had the same gene content and order, there were informative structural differences between them. First, ycf1 was more variable and longer in Piper than Peperomia, extending well into the small single copy region by thousands of base pairs. We also discovered previously unknown structural variation in 14 out of 25 Piper taxa, tandem duplication of the trnH-GUG gene resulting in an expanded large single copy region. Other early-diverging angiosperms have a duplicated trnH-GUG, but the specific rearrangement we found is unique to Piper and serves to refine knowledge of relationships among early-diverging angiosperms. Our study demonstrates that genome skimming is an efficient approach to produce plastome assemblies for comparative genomics and robust phylogenies of species-rich plant genera.

A Standardized Approach to Cesarean Surgical Technique and Its Effect on Operative Time and Surgical Morbidity

OBJECTIVE

To evaluate the impact of a standardized surgical technique for primary cesarean deliveries (CDs) on operative time and surgical morbidity.

MATERIALS AND METHODS

Two-year retrospective chart review of primary CD performed around the implementation of a standardized CD surgical technique. The primary outcome was total operative time (TOT). Secondary outcomes included incision-to-delivery time (ITDT), surgical site infection, blood loss, and maternal and fetal injuries.

RESULTS

When comparing pre- versus postimplementation surgical times, there was no significant difference in TOT (76.5 vs. 75.9 minutes, respectively; p = 0.42) or ITDT (9.8 vs. 8.8 minutes, respectively; p = 0.06) when the entire cohort was analyzed. Subgroup analysis of CD performed early versus late in an academic year among the pre- and postimplementation groups showed no significant difference in TOT (79.3 early vs. 73.8 minutes late; p = 0.10) or ITDT (10.8 early vs. 8.8 minutes late; p = 0.06) within the preimplementation group. In the postimplementation group, however, there was significant decrease in TOT (80.5 early vs. 71.3 minutes late; p = 0.02) and ITDT (10.6 early vs. 6.8 minutes late; p < 0.01). Secondary outcomes were similar for both groups.

CONCLUSION

A standardized surgical technique combined with surgical experience can decrease TOT and ITDT in primary CD without increasing maternal morbidity.

Proteinase-activated receptor-2 blockade inhibits changes seen in a chronic murine asthma model

BACKGROUND

Proteinase-Activated Receptor-2 (PAR₂ ) is a G protein-coupled receptor activated by serine proteinases. We have shown that PAR₂ activation in the airways is involved in the development of allergic inflammation and airway hyperresponsiveness (AHR) in acute murine models. We hypothesized that functional inhibition of PAR₂ prevents allergic inflammation, AHR and airway remodeling in chronic allergic airway inflammation models.

MATERIAL AND METHODS

We developed and used a 12 week model of cockroach extract (CE)-mediated AHR, airway inflammation and remodeling in BALB/c mice.

RESULTS

Mice sensitized and challenged with CE for 12 weeks exhibit AHR, increased numbers of eosinophils in bronchoalveolar lavage (BAL) and increased collagen content in the lung tissue compared to saline controls. Administration of an anti-PAR₂ antibody, SAM-11, after the initial development of airway inflammation significantly inhibited all these parameters.

CONCLUSIONS

Our data demonstrate that PAR₂ signaling plays a key role in CE-induced AHR and airway inflammation/remodeling in long term models of allergic airway inflammation. Targeting PAR₂ activation may be a successful therapeutic strategy for allergic asthma.

The Emergence of Earliest Angiosperms may be Earlier than Fossil Evidence Indicates

Gaps between molecular ages and fossils undermine the validity of time-calibrated molecular phylogenies. An example of the time gap surrounds the age of angiosperm's origin. We calculate molecular ages of the earliest flowering plant lineages using 22 fossil calibrations (101 genera, 40 families). Our results reveal the origin of angiosperms at the late Permian, ~275 million years ago. Different prior probability curves of molecular age calculations on dense calibration point distributions had little effect on overall age estimates compared to the effects of altered calibration points. The same is true for reasonable root age constraints. We conclude that our age estimates based on multiple datasets, priors, and calibration points are robust and the true ages are likely between our extremes. Our results, when integrated with the ecophysiological evolution of early angiosperms, imply that the ecology of the earliest angiosperms is critical to understand the pre-Cretaceous evolution of flowering plants.

Guidelines on the management of atrial fibrillation in the emergency department: a critical appraisal

Several guidelines often exist on the same topic, sometimes offering divergent recommendations. For the clinician, it can be difficult to understand the reasons for this divergence and how to select the right recommendations. The aim of this study is to compare different guidelines on the management of atrial fibrillation (AF), and provide practical and affordable advice on its management in the acute setting. A PubMed search was performed in May 2014 to identify the three most recent and cited published guidelines on AF. During the 1-week school of the European School of Internal Medicine, the attending residents were divided in five working groups. The three selected guidelines were compared with five specific questions. The guidelines identified were: the European Society of Cardiology guidelines on AF, the Canadian guidelines on emergency department management of AF, and the American Heart Association guidelines on AF. Twenty-one relevant sub-questions were identified. For five of these, there was no agreement between guidelines; for three, there was partial agreement; for three data were not available (issue not covered by one of the guidelines), while for ten, there was complete agreement. Evidence on the management of AF in the acute setting is largely based on expert opinion rather than clinical trials. While there is broad agreement on the management of the haemodynamically unstable patient and the use of drugs for rate-control strategy, there is less agreement on drug therapy for rhythm control and no agreement on several other topics.

Population-based study demonstrating an increase in colorectal cancer in young patients

BACKGROUND

New Zealand has among the highest rates of colorectal cancer in the world and is an unscreened population. The aim of this study was to determine the trends in incidence and tumour location in the New Zealand population before the introduction of national colorectal cancer screening.

METHODS

Data were obtained from the national cancer registry and linked to population data from 1995 to 2012. Incidence rates for colorectal cancer by sex, age (less than 50 years, 50-79 years, 80 years or more) and location (proximal colon, distal colon and rectum) were assessed by linear regression.

RESULTS

Among patients aged under 50 years, the incidence of distal colonic cancer in men increased by 14 per cent per decade (incidence rate ratio (IRR 1·14), 95 per cent c.i. 1·00 to 1·30; P = 0·042); the incidence of rectal cancer in men increased by 18 per cent (IRR 1·18, 1·06 to 1·32; P = 0·002) and that in women by 13 per cent (IRR 1·13, 1·02 to 1·26; P = 0·023). In those aged 50-79 years, there was a reduction in incidence per decade of proximal, distal and rectal cancers in both sexes. In the group aged 80 years and over, proximal cancer incidence per decade increased by 19 per cent in women (IRR 1·19, 1·13 to 1·26; P < 0·001) and by 25 per cent in men (IRR 1·25, 1·18 to 1·32; P < 0·001); among women, the incidence of distal colonic cancer decreased by 8 per cent (IRR 0·92, 0·86 to 0·98); P = 0·012), as did that of rectal cancer (IRR 0·92, 0·86 to 0·97; P = 0·005).

CONCLUSION

The increasing incidence of rectal cancer among younger patients needs to be considered when implementing screening strategies.

Functional inhibition of PAR2 alleviates allergen-induced airway hyperresponsiveness and inflammation

BACKGROUND

Proteinase-activated receptor 2 (PAR2 ) is a G protein-coupled receptor activated by trypsin-like serine proteinases. PAR2 activation has been associated with inflammation including allergic airway inflammation. We have also shown that PAR2 activation in the airways leads to allergic sensitization. The exact contribution of PAR2 in the development of eosinophilic inflammation and airway hyperresponsiveness (AHR) in sensitized individuals is not clear.

OBJECTIVE

To investigate whether functional inhibition of PAR2 during allergen challenge of allergic mice would inhibit allergen-induced AHR and inflammation in mouse models of asthma.

METHODS

Mice were sensitized and challenged with ovalbumin (OVA) or cockroach extract (CE). To investigate the role of PAR2 in the development of AHR and airway inflammation, we administered blocking anti-PAR2 antibodies, or a cell permeable peptide inhibitor of PAR2 signalling, pepducin, i.n. before allergen challenges and then assessed AHR and airway inflammation.

RESULTS

Administration of anti-PAR2 antibodies significantly inhibited OVA- and CE-induced AHR and airway inflammation. In particular, two anti-PAR2 antibodies, the monoclonal SAM-11 and polyclonal B5, inhibited AHR, airway eosinophilia, the increase of cytokines in the lung tissue and antigen-specific T cell proliferation, but had no effect on antigen-specific IgG and IgE levels. Pepducin was also effective in inhibiting AHR and airway inflammation in an OVA model of allergic airway inflammation.

CONCLUSIONS AND CLINICAL RELEVANCE

Functional blockade of PAR2 in the airways during allergen challenge improves allergen-induced AHR and inflammation in mice. Therefore, topical PAR2 blockade in the airways, through anti-PAR2 antibodies or molecules that interrupt PAR2 signalling, has the potential to be used as a therapeutic option in allergic asthma.

Developing Treatments for Stimulant Abuse: A Brief Overview

The abuse of stimulants such as cocaine, amphetamine, and methamphetamine is a huge problem in many parts of the world. Abuse of these drugs does not ruin just the user's life, but also adversely affects those around them. Despite many years of research, there are no approved medications for stimulant dependence, and treatment is focused on psychotherapy and abstinence. Over the last 10 to 20 years, there have been some major changes in approach to medication development for stimulant dependence. These include assessing ligands for non-dopaminergic sites, atypical dopamine transporter ligands, blocking long-term potentiation and / or memory reconsolidation, vaccines against the stimulant, and molecular approaches including pharmacogenomics and gene silencing. Also included in this overview are non-drug treatments such as deep brain stimulation and psychosurgery. This overview highlights recent preclinical and clinical studies of treatment development for stimulant dependence.

Abstract 562: Impaired Transcriptional Regulation of Nrf2 and Antioxidant Signaling in Vascular Tissue of Aging Mice

Background: Chronic oxidative stress and dysregulation of vascular system are tightly linked to cardiac structure-function anomalies. We hypothesized that nuclear erythroid-2 like factor-2 (Nrf2), a redox-sensitive transcriptional regulator, distinctly regulate antioxidant transcription in aortic vessels on aging versus high intensity exercise stress (HIES).

Methods: Age and sex matched wild-type (WT) and Nrf2 -/- mice at young (3 months) and old (>20 months) ages were used in this study. Effect of loss of function for Nrf2 on transcription and translation of targets involve in antioxidant signaling was studied in response to HIES on aging.

Results: Under basal setting, Nrf2 abrogation resulted in moderate downregulation of a subset of antioxidant gene expression ( G6pd, catalase, Gclc, Gclm, Gstα, Gstμ, and Nqo1 ) in aortic vessel in relation to age-matched wild-type (WT) mice. Interestingly, some of the antioxidant genes ( G6pd, Sod1, Sod2, Ho1, Gclc, Gclm, Gstα and Gstμ ) were significantly downregulated in old-WT when compared to young-WT mice, suggesting age-associated impairment of Nrf2-dependent antioxidant signaling. On the other hand, the expression of certain antioxidant genes ( Gclm, Catalase, Gsr, Nqo1, Gpx1 and Gstμ ) were similar in HIES-subjected WT and Nrf2 -/- mice in relation to sedentary controls at old age. These observations suggest that the response to HIES is blunted on aging due to either impairment or ablation of Nrf2 in WT versus knockout mice. In addition, we observed a significant increase in mRNA levels of Keap1, G6pd, Sod1 and Sod2 in aorta of Nrf2 -/- mice when compared to its WT counterparts. These results indicate that either abrogation (in Nrf2 -/- mice) or age-associated decline (in old WT mice) of Nrf2 describes a distinctive molecular phenotype related to transcriptional regulation of redox signaling on aging.

Conclusion: Thus, our findings direct that dysregulation and/or absence of Nrf2 could impair the physiological adaptive events of aortic vessel to intense exercise stress tending to pathologic vascular remodeling and may therefore result in cardiovascular complications.

Biofilm formation in total hip arthroplasty: prevention and treatment

This review assesses the current knowledge on treatments, pathogenesis and the prevention of infections associated with orthopaedic implants, with a focus on total hip arthroplasty.

A feasibility study of behavioural activation for depressive symptoms in adults with intellectual disabilities

BACKGROUND

Important work has been carried out adapting cognitive behavioural therapy for people with intellectual disabilities. However, there is a lack of alternative psychological therapies available for people with intellectual disabilities and emotional difficulties. Behavioural activation for depression is less reliant on verbal communication and focuses on increasing purposeful activity and reducing avoidance.

METHOD

This feasibility study involved the development and piloting of an adapted manual of behavioural activation for people with intellectual disabilities. The intervention consisted of 10-12 sessions and a key adaptation was that the therapist worked with the clients alongside a significant other in their life, either a paid carer or family member. Baseline, post-intervention (3 months after entering the study) and 6-month quantitative follow-up data were obtained. Primary outcome data were gathered, concerning depressive symptoms, participants' levels of activity and general well-being.

RESULTS

Twenty-three adults with intellectual disabilities with symptoms of depression were recruited from specialist health services. In terms of acceptability, the behavioural activation intervention was well received and only two individuals dropped out, with a further two lost to follow-up. The main measures of depression appeared to be sensitive to change. Pre- to post-intervention data showed a significant reduction in self-report of depressive symptoms with a strong effect size (r = 0.78), that was maintained at follow-up (r = 0.86). Positive change was also obtained for informant reports of depressive symptoms from pre- to post-intervention, with a strong effect size (r = 0.7). Once again, this positive change was maintained at follow-up (r = 0.72).

CONCLUSIONS

The study suggested that behavioural activation may be a feasible and worthwhile approach to tackling depression in people with intellectual disabilities. However, a randomised controlled trial would be required to establish its effectiveness, with more sensitive measurement of change in activity.

Lenses and Lessons: Using three different research perspectives in early childhood education research

In contemporary Western research, collaboration is held in high esteem. This developing practice is chal¬lenging particularly for researchers who follow varying theoretical approaches. However although a challeng¬ing endeavour, when viewing the one data set with different lenses, there are various lessons that can be shared. A key aspect of this paper is involved researchers' different analytical perspectives in one data set to learn more about each other's research insights, rather than become instant expert in other's approaches. The interview data reported in this paper originates from a larger study researching parents' experience of using early child¬hood education and care (ECEC) in Australia. Here we analyse and report on two shared interview excerpts and use three different research lenses for analysis; phenomenographic study, conversational analysis and cul¬tural-historical theory. The finding of this paper demonstrates that applying different lenses provide different interpretations, including strengths, limitations and opportunities. In this paper we argue that collaborative research practices enhance our understanding of varying research approaches and the scope, quality, transla¬tion of research and the researchers' capacity are enhanced.

The practice of internal medicine in Europe: organisation, clinical conditions and procedures

BACKGROUND

Current information on the role of internists in the European countries is scarce. This report describes the results of a survey of the practice of internists in Europe.

METHODS

Two online questionnaire-based surveys were carried out by the European Board of Internal Medicine, one on the practice of internists and the other on postgraduate training in internal medicine. The national internal medicine societies of all 30 member countries of the European Federation of Internal Medicine were invited to participate. The responses were reviewed by internal medicine trainees from the respective countries and summaries of the data were sent to the national societies for approval. Descriptive analysis of the data on the practice of internists was carried out.

RESULTS

Twenty-seven countries (90%) completed the questionnaire and approved their datasets. In 8 European countries, most internists practised internal medicine alone and in 7 countries at least half of physicians practised internal medicine together with a subspecialty. Internal medicine was considered a hospital-based specialty in most countries. The majority of selected presenting problems and diagnoses were rated as commonly encountered in all countries. More variability between countries was observed in the performance of diagnostic and therapeutic procedures.

CONCLUSION

Many similarities exist in the practice of internal medicine between the European countries, while some differences are present that likely reflect the variable impact of subspecialisation. The results of the survey should prove valuable for the definition of specific competencies and development of a common curriculum for internal medicine at the European level.

Postgraduate education in internal medicine in Europe

BACKGROUND

Limited information exists on the framework and content of postgraduate education in internal medicine in Europe. This report describes the results of a survey of postgraduate training in internal medicine in the European countries.

METHODS

Two online questionnaire-based surveys were carried out by the European Board of Internal Medicine, one on the practice of internists and the other on postgraduate training in internal medicine. The national internal medicine societies of all 30 member countries of the European Federation of Internal Medicine were invited to participate. The responses were reviewed by internal medicine residents from the respective countries and summaries of the data were sent to the national societies for approval. Descriptive analysis of the data on postgraduate training in internal medicine was performed.

RESULTS

Twenty-seven countries (90%) completed the questionnaire and approved their datasets. The length of training ranged from four to six years and was commonly five years. The majority of countries offered training in internal medicine and a subspecialty. A common trunk of internal medicine was frequently a component of subspecialty training programmes. Hospital inpatient service was the predominant setting used for training. A final certifying examination was in place in 14 countries.

CONCLUSION

Although some similarities exists, there appear to be significant differences in the organisation, content and governance of postgraduate training in internal medicine between the European countries. Our findings will prove invaluable for harmonisation of training and qualification in internal medicine in Europe.

Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis

BACKGROUND

Gallstones are present in about 10% to 15% of the adult western population. Between 1% and 4% of these adults become symptomatic in a year (the majority due to biliary colic but a significant proportion due to acute cholecystitis). Laparoscopic cholecystectomy for acute cholecystitis is mainly performed after the acute cholecystitis episode settles because of the fear of higher morbidity and of need for conversion from laparoscopic to open cholecystectomy. However, delaying surgery exposes the people to gallstone-related complications.

OBJECTIVES

The aim of this systematic review was to compare early laparoscopic cholecystectomy (less than seven days of clinical presentation with acute cholecystitis) versus delayed laparoscopic cholecystectomy (more than six weeks after index admission with acute cholecystitis) with regards to benefits and harms.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and World Health Organization International Clinical Trials Registry Platform until July 2012.

SELECTION CRITERIA

We included all randomised clinical trials comparing early versus delayed laparoscopic cholecystectomy in participants with acute cholecystitis.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We identified seven trials that met the inclusion criteria. Out of these, six trials provided data for the meta-analyses. A total of 488 participants with acute cholecystitis and fit to undergo laparoscopic cholecystectomy were randomised to early laparoscopic cholecystectomy (ELC) (244 people) and delayed laparoscopic cholecystectomy (DLC) (244 people) in the six trials. Blinding was not performed in any of the trials and so all the trials were at high risk of bias. Other than blinding, three of the six trials were at low risk of bias in the other domains such as sequence generation, allocation concealment, incomplete outcome data, and selective outcome reporting. The proportion of females ranged between 43.3% and 80% in the trials that provided this information. The average age of participants ranged between 40 years and 60 years. There was no mortality in any of the participants in five trials that reported mortality. There was no significant difference in the proportion of people who developed bile duct injury in the two groups (ELC 1/219 (adjusted proportion 0.4%) versus DLC 2/219 (0.9%); Peto OR 0.49; 95% CI 0.05 to 4.72 (5 trials)). There was no significant difference between the two groups (ELC 14/219 (adjusted proportion 6.5%) versus DLC 11/219 (5.0%); RR 1.29; 95% CI 0.61 to 2.72 (5 trials)) in terms of other serious complications. None of the trials reported quality of life from the time of randomisation. There was no significant difference between the two groups in the proportion of people who required conversion to open cholecystectomy (ELC 49/244 (adjusted proportion 19.7%) versus DLC 54/244 (22.1%); RR 0.89; 95% CI 0.63 to 1.25 (6 trials)). The total hospital stay was shorter in the early group than the delayed group by four days (MD -4.12 days; 95% CI -5.22 to -3.03 (4 trials; 373 people)). There was no significant difference in the operating time between the two groups (MD -1.22 minutes; 95% CI -3.07 to 0.64 (6 trials; 488 people)). Only one trial reported return to work. The people belonging to the ELC group returned to work earlier than the DLC group (MD -11.00 days; 95% CI -19.61 to -2.39 (1 trial; 36 people)). Four trials did not report any gallstone-related morbidity during the waiting period. One trial reported five gallstone-related morbidities (cholangitis: two; biliary colic not requiring urgent operation: one; acute cholecystitis not requiring urgent operation: two). There were no reports of pancreatitis during the waiting time. Gallstone-related morbidity was not reported in the remaining trials. Forty (18.3%) of the people belonging to the delayed group had either non-resolution of symptoms or recurrence of symptoms before their planned operation and had to undergo emergency laparoscopic cholecystectomy in five trials. The proportion with conversion to open cholecystectomy was 45% (18/40) in this group of people.

AUTHORS' CONCLUSIONS

We found no significant difference between early and late laparoscopic cholecystectomy on our primary outcomes. However, trials with high risk of bias indicate that early laparoscopic cholecystectomy during acute cholecystitis seems safe and may shorten the total hospital stay. The majority of the important outcomes occurred rarely, and hence the confidence intervals are wide. It is unlikely that future randomised clinical trials will be powered to measure differences in bile duct injury and other serious complications since this might involve performing a trial of more than 50,000 people, but several smaller randomised trials may answer the questions through meta-analyses.

A phase I/II study of decitabine in combination with panitumumab in patients with wild-type (wt) KRAS metastatic colorectal cancer

PURPOSE

KRAS mutations are predictive of lack of response to monoclonal antibodies (mAb) against EGFR in metastatic colorectal cancer (mCRC). Most wild-type KRAS patients, however, are also resistant. Retrospective data suggest that EGFR silencing play a role in resistance to therapy. We conducted a study to evaluate the safety and efficacy of decitabine (a hypomethylating agent) in combination with panitumumab (mAb against EGFR) in mCRC patients.

EXPERIMENTAL DESIGN

20 patients with wild-type KRAS mCRC were included in this phase I/II study. Patients were treated with decitabine at 45 mg/m(2) IV over 2 h on day 1 and 15 and panitumumab 6 mg/kg IV over 1 h on day 8 and 22 every 28 days. Blood samples were collected at baseline, day 8, 15 and 22. Quantitative polymerase chain reaction was used to measure promoter-specific methylation in peripheral-blood cells (PBMCs).

RESULTS

The most common adverse events were grade 1-2 (rash and hypomagnesemia); 3 (16 %) patients had grade III-IV neutropenia including one patient with neutropenic fever. Two of 20 patients (10 %) had a partial response. Both had previously received cetuximab. Ten patients had stable disease (3 of them longer than 16 weeks). Decreased methylation of the MAGE promoter was not evidenced in PBMCs.

CONCLUSIONS

The combination of decitabine and panitumumab was well tolerated and showed activity in wild-type KRAS mCRC patients previously treated with cetuximab. Target modulation in surrogate tissues was not achieved and tumor biopsies were not available. Future studies evaluating hypomethylating agents in combination with EGFR mAb in patients with mCRC are warranted.

Abstract P6-07-24: Prognostic Tools in Early Breast Cancer: Predicting benefit of adjuvant chemotherapy

Introduction: Adjuvant chemotherapy (CT) in early breast cancer reduces the risk of mortality. However, absolute reductions in mortality can be small. For patient with low risk disease, prognostic tools such as ‘Adjuvant! Online’ and ‘Predict’ can be used to estimate the benefit of adjuvant chemotherapy. We compare the survival gains estimated using ‘Adjuvant! Online’ and ‘Predict’ in routine clinical practice, assessing the characteristics of patients in which ‘Adjuvant! Online’ and ‘Predict’ disagree.

Methods: In a retrospective study using the hospital electronic database, the clinical and pathological details of all patients with early breast cancer referred for adjuvant therapy at the Northern Ireland Cancer Centre in a 3 month period in 2011 were collected and were entered in to ‘Adjuvant! Online’ and ‘Predict’ to assess percentage benefit (absolute reduction in mortality at 10 years) from CT. We categorised patients into three prognostic groups: those where risk from CT outweighs benefit (&lt;2% predicted benefit), marginal benefit (2 to 5%) and significant benefit from CT (&gt;5%) We excluded patients with metastatic disease at presentation, DCIS, a second primary breast cancer or receiving neo-adjuvant treatment.

Results: Of the 250 patients identified, 61 (24.4%) fell in to different prognostic groups depending on whether ‘Adjuvant! Online’ or ‘Predict’ was used to calculate benefit from CT. In those in whom there was disagreement, ‘Adjuvant! Online’ suggested marginal or significant benefit in 75.4% of patients, compared to 55.7% using ‘Predict’. Nine patients had “major” comorbidities, which is weighted only in ‘Adjuvant! Online’, and were excluded in subsequent analysis. Of those without major comorbidities, ‘Adjuvant! Online’ offered at least 2% benefit in 85% of cases, and ‘Predict’ in only 58.3%. The majority (93.3%) of cases were ER positive, and node negative (85.0%). This difference was notable in women aged 65 or less, with 86.2% with &gt;2% benefit using ‘Adjuvant! Online’, compared to 55.1% using ‘Predict’. ‘Adjuvant! Online’ estimates of benefit were on average 3.7% higher for this age group. HER2 status had little impact, with similar recommendations using either ‘Adjuvant! Online’ or ‘Predict’.

Conclusions: This study highlights lack of concordance between two available online prognostic tools, notably in ER positive, node negative patients. For patients with a marginal benefit from adjuvant chemotherapy, care must be used when making adjuvant treatment decisions as other prognostic tools may be of help in this group of patients.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-07-24.

The single nucleotide polymorphism CRTh2 rs533116 is associated with allergic asthma and increased expression of CRTh2

BACKGROUND

CRTh2 (chemoattractant-receptor homologous molecule expressed on Th2 cells) is expressed by Th2 cells and other cells involved in allergic inflammation. Single nucleotide polymorphisms (SNPs) in CRTh2 (rs11571288, rs545659, rs634681) have been associated with various phenotypes of allergy in ethnically distinct populations. Here, we assessed the association between CRTh2 rs533116 and allergic asthma, expression of CRTh2 and Th2 cytokine production.

METHODS

CRTh2 rs533116 was genotyped in an ethnically diverse population (n = 1282). The proportion of cells expressing CRTh2 was determined in peripheral blood from subjects with allergic airways disease and controls as well as with in vitro differentiated Th2 cells. Receptor function was assessed by stimulating Th2 cells with the CRTh2-specific agonist 13,14-dihydro-15-keto-PGD(2) (DK-PGD(2) ) and measuring IL-4 and IL-13 by intracellular staining and ELISA.

RESULTS

CRTh2 rs533116 was associated with allergic asthma in White people (2.67 [1.09-6.55], P < 0.05), and expression of CRTh2 was higher in subjects with allergic airways disease compared to controls (P < 0.05). Among allergic individuals, the AA genotype was significantly associated with more eosinophils and higher expression of CRTh2 by both CD4(+) T cells and eosinophils (P < 0.05). In vitro, the AA genotype was associated with a higher proportion of CRTh2(+) cells during Th2 differentiation as well as more IL-4 and IL-13 expression following DK-PGD(2) stimulation (P < 0.05).

CONCLUSIONS

These findings show an association between CRTh2 rs533116 and allergic asthma and suggest this may be mediated by elevated expression of CRTh2, leading to higher numbers of circulating eosinophils and Th2 cytokine production.

The role of natural history collections in documenting species declines

Efforts to document the decline of extant populations require a historical record of previous occurrences. Natural history museums contain such information for most regions of the world, at least at a coarse spatial scale. Museum collections have been successfully used to analyse declines in a wide range of plants and animals, at spatial scales ranging from single localities to large biotic and political regions. Natural history museum collections, when properly analysed, can be an invaluable tool in documenting changes in biodiversity during the past century.

Allopregnanolone protects against dopamine-induced striatal damage after in vitro ischaemia via interaction at GABA A receptors

Sex steroid hormones, such as progesterone, have been shown to display neuroprotective properties after various models of central nervous system injury, including cerebral ischaemia, although the mechanism(s) of action remain largely undetermined. Allopregnanolone, an active progesterone metabolite, may explain some of the protective actions of progesterone. We utilised an in vitro model of ischaemia to evaluate the neuroprotective potential of allopregnanolone and examine its interaction at the GABA(A) receptor, which is hypothesised to be its main neuroprotective mechanism. In adult male mouse coronal caudate slices exposed to oxygen glucose deprivation (OGD), we measured aspects of OGD-induced dopamine release, which is neurotoxic during ischaemia, using fast cyclic voltammetry and also assessed tissue viability. The GABA(A) agonist, muscimol, displayed a neuroprotective profile in terms of delaying the OGD-evoked dopamine efflux (P < 0.05) and reducing the amount of dopamine released after OGD (P < 0.05). Allopregnanolone, at a concentration of 10(-6)  m, also displayed a neuroprotective profile because it significantly reduced the amount of dopamine efflux (P < 0.05) and reduced the loss of viable tissue after OGD compared to slices exposed to vehicle during OGD (P < 0.05). However, the effect of 10(-6)  m allopregnanolone on dopamine efflux was prevented in the presence of bicuculline, a competitive GABA(A) receptor antagonist. These results describe the use of an in vitro model of ischaemia with respect to determining that allopregnanolone is neuroprotective during the acute phase of ischaemia, and also demonstrate that such actions are dependent, at least in part, upon interaction at the GABA(A) receptor.

Effectiveness of the Pasos Adelante chronic disease prevention and control program in a US-Mexico border community, 2005-2008

INTRODUCTION

Pasos Adelante is a lifestyle intervention program facilitated by community health workers (promotores) targeting chronic disease prevention and control in Mexican Americans. Initial studies of Pasos Adelante indicated significant improvements in self-reported nutrition and physical activity. This study examined whether Pasos Adelante participants living in a US border community showed improvements in selected physiological measures after participating in the program and whether changes were maintained at 3-month follow-up.

METHODS

The program took place in 12-week sessions from January 2005 to May 2008 and included walking groups and education targeting nutrition and physical activity. Questionnaires, anthropometric measures, and laboratory tests were conducted at baseline (n = 305), conclusion of program (n = 254), and 3-month follow-up (n = 221).

RESULTS

Participants demonstrated decreases in body mass index (P = .04), waist and hip circumference (P < .001), diastolic and systolic blood pressure (P < .001), and total cholesterol (P = .008) from baseline to program conclusion. No values worsened significantly between program conclusion and follow-up, except systolic blood pressure. Glucose levels improved between conclusion and follow-up (P = .01).

CONCLUSION

These results support the initial findings of improvements in participants' self-reported physical activity and nutrition patterns through changes in objective measures. This evidence-based program demonstrates the potential for a promotores-facilitated chronic disease prevention and control program to improve physical health and targets both primary and secondary prevention in Hispanic communities and organizations.

Altered vitamin E status in Niemann-Pick type C disease

Vitamin E (α-tocopherol) is the major lipid-soluble antioxidant in many species. Niemann-Pick type C (NPC) disease is a lysosomal storage disorder caused by mutations in the NPC1 or NPC2 gene, which regulates lipid transport through the endocytic pathway. NPC disease is characterized by massive intracellular accumulation of unesterified cholesterol and other lipids in lysosomal vesicles. We examined the roles that NPC1/2 proteins play in the intracellular trafficking of tocopherol. Reduction of NPC1 or NPC2 expression or function in cultured cells caused a marked lysosomal accumulation of vitamin E in cultured cells. In vivo, tocopherol significantly accumulated in murine Npc1-null and Npc2-null livers, Npc2-null cerebella, and Npc1-null cerebral cortices. Plasma tocopherol levels were within the normal range in Npc1-null and Npc2-null mice, and in plasma samples from human NPC patients. The binding affinity of tocopherol to the purified sterol-binding domain of NPC1 and to purified NPC2 was significantly weaker than that of cholesterol (measurements kindly performed by R. Infante, University of Texas Southwestern Medical Center, Dallas, TX). Taken together, our observations indicate that functionality of NPC1/2 proteins is necessary for proper bioavailability of vitamin E and that the NPC pathology might involve tissue-specific perturbations of vitamin E status.