Racial and Socioeconomic Disparities in Laminoplasty Versus Laminectomy With Fusion in Patients With Cervical Spondylosis

STUDY DESIGN

A retrospective cohort study using prospectively collected data.

OBJECTIVE

The aim of this study was to investigate preoperative differences in racial and socioeconomic factors in patients undergoing laminoplasty (LP) versus laminectomy and fusion (LF) for degenerative cervical myelopathy (DCM).

SUMMARY OF BACKGROUND DATA

DCM is prevalent in the United States, requiring surgical intervention to prevent neurological degeneration. While LF is utilized more frequently, LP is an emerging alternative. Previous studies have demonstrated similar neurological outcomes for both procedures. However, treatment selection is primarily at the discretion of the surgeon and may be influenced by social determinants of health that impact surgical outcomes.

MATERIALS AND METHODS

The Quality Outcome Database (QOD), a national spine registry, was queried for adult patients who underwent either LP or LF for the management of DCM. Covariates associated with socioeconomic status, pain and disability, and demographic and medical history were collected. Multivariate logistic regression was performed to assess patient factors associated with undergoing LP versus LF.

RESULTS

Of 1673 DCM patients, 157 (9.4%) underwent LP and 1516 (90.6%) underwent LF. A significantly greater proportion of LP patients had private insurance (P<0.001), a greater than high school level education (P<0.001), were employed (P<0.001), and underwent primary surgery (P<0.001). LP patients reported significantly lower baseline neck/arm pain and Neck Disability Index (P<0.001). In the multivariate regression model, lower baseline neck pain [odds ratio (OR)=0.915, P=0.001], identifying as non-Caucasian (OR=2.082, P<0.032), being employed (OR=1.592, P=0.023), and having a greater than high school level education (OR=1.845, P<0.001) were associated with undergoing LP rather than LF.

CONCLUSIONS

In DCM patients undergoing surgery, factors associated with patients undergoing LP versus LF included lower baseline neck pain, non-Caucasian race, higher education, and employment. While symptomatology may influence the decision to choose LP over LF, there may also be socioeconomic factors at play. The trend of more educated and employed patients undergoing LP warrants further investigation.

The Combined Influence of Sleep Disturbance and Depression on 12-month Outcomes after Lumbar Spine Surgery

STUDY DESIGN

Retrospective analysis of prospectively collected data.

OBJECTIVE

To examine the combined influence of preoperative sleep disturbance and depression on 12-month patient-reported outcomes after lumbar spine surgery (LSS).

SUMMARY OF BACKGROUND DATA

Psychological and behavioral factors are considered major risk factors of poor outcome after LSS. However, there is a need to explore the combined effects of preoperative factors such as sleep disturbance and depression. Understanding the influence of sleep disturbance and depression can inform evidence-based preoperative assessment and shared-decision making of preoperative and postoperative treatment.

METHODS

Data from 700 patients undergoing LSS were analyzed. Preoperative sleep disturbance and depression were assessed with PROMIS subscales. Established thresholds defined patients with moderate/severe symptoms. Outcomes for disability (Oswestry Disability Index) and back and leg pain (Numeric Rating Scales) were assessed preoperatively and at 12 months. Separate multivariable linear regressions examined the influence of each factor on 12-month outcomes with and without accounting for the other, and in combination as a 4-level variable: 1) moderate/severe sleep disturbance alone, 2) moderate/severe depression alone, 3) both moderate/severe sleep disturbance and depression, 4) no moderate/severe sleep disturbance or depression.

RESULTS

Preoperative sleep disturbance and depression were associated with 12-month disability and pain (P<0.05). After accounting for depression, preoperative sleep disturbance remained associated with disability, while preoperative depression adjusting for sleep disturbance remained associated with all outcomes (P<0.05). Patients reporting both moderate/severe sleep disturbance and moderate/severe depression had 12.6 points higher disability and 1.5 points higher back and leg pain compared to patients without moderate/severe sleep disturbance or depression.

CONCLUSION

The combination of sleep disturbance and depression impacts postoperative outcomes considerably. The high-risk group of patients with moderate/severe sleep disturbance and depression could benefit from targeted treatment strategies.

Impact of Unplanned Readmission on Patient-Reported Outcomes After Cervical Spine Surgery: A National Study of 13 355 Patients

BACKGROUND AND OBJECTIVES

Although risk factors for unplanned readmission after cervical spine surgery have been widely reported, less is known about how readmission itself affects patient-reported outcome measures (PROMs). Using the Quality Outcomes Database registry of patients undergoing elective cervical spine surgery, we sought to (1) determine the impact of unplanned readmission on PROMs and (2) compare the effect of specific readmission reasons on PROMs.

METHODS

An observational study was performed using a multi-institution, retrospective registry for patients undergoing cervical spine surgery. The occurrence of 90-day unplanned readmission classified into medical, surgical, pain only, and no readmissions was the exposure variable. Outcome variables included 12-month PROMs of Neck Disability Index (NDI), Numeric Rating Scale (NRS)-neck/arm pain, EuroQol-5D (EQ-5D), and patient dissatisfaction. Multivariable models predicting each PROM were built using readmission reasons controlling for demographics, clinical characteristics, and preoperative PROMs.

RESULTS

Data from 13 355 patients undergoing elective cervical spine surgery (82% anterior approach and 18% posterior approach) were analyzed. Unplanned readmission within 90 days of surgery occurred in 3.8% patients, including medical (1.6%), surgical (1.8%), and pain (0.3%). Besides medical reasons, wound infection/dehiscence was the most common reason for unplanned readmission for the total cohort (0.5%), dysphagia in the anterior approach (0.6%), and wound infection/dehiscence in the posterior approach (1.5%). Based on multivariable regression, surgical readmission was significantly associated with worse 12-month NDI, NRS-neck pain, NRS-arm pain, EQ-5D, and higher odds of dissatisfaction. Pain readmissions were associated with worse 12-month NDI and NRS-neck pain scores, and worse dissatisfaction. For specific readmission reasons, pain, surgical site infection/wound dehiscence, hematoma/seroma, revision surgery, deep vein thrombosis, and pulmonary embolism were significantly associated with worsened 12-month PROMs.

CONCLUSION

In patients undergoing elective cervical spine surgery, 90-day unplanned surgical and pain readmissions were associated with worse 12-month PROMs compared with patients with medical readmissions and no readmissions.

Impact of Racial/Ethnic Disparities on Patient Reported Outcomes Following Cervical Spine Surgery: QOD Analysis

STUDY DESIGN

Retrospective analysis of data from the cervical module of a national spine registry, the Quality Outcomes Database (QOD).

OBJECTIVE

To examine the association of race and ethnicity with patient-reported outcome measures (PROMs) at 1 year after cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Evidence suggests that Black individuals are 39% to 44% more likely to have postoperative complications and prolonged length of stay after cervical spine surgery compared to Whites. The long-term recovery assessed with PROMs after cervical spine surgery among Black, Hispanic and other non-Hispanic groups (i.e., Asian) remains unclear.

METHODS

PROMs were used to assess disability (NDI) and neck/arm pain preoperatively and 1-year postoperative. Primary outcomes were disability and pain, and not being satisfied from pre-operative to 12-months after surgery. Multivariable logistic and proportional odds regression analyses were used to determine the association of racial/ethnic groups (Hispanic, non-Hispanic White (NHW), non-Hispanic Black (NHB), and non-Hispanic Asian (NHA)) with outcomes after covariate adjustment and to compute the odds of each racial/ethnic group achieving MCID 1-year postoperatively.

RESULTS

Of the 14,429 participants, all had significant reductions in pain and disability, and 87% were satisfied at 1-year follow-up. Hispanic and NHB patients had higher odds of not being satisfied (40% and 80%) and having worse pain outcomes (30% to 70%) compared to NHW. NHB had 50% higher odds of worse disability scores compared to NHW. NHA reported similar disability and neck pain outcomes compared to NHW.

CONCLUSIONS

Hispanic and non-Hispanic Black patients had worse patient-reported outcomes 1-year after cervical spine surgery compared to non-Hispanic White individuals, even after adjusting for potential confounders, yet there was no difference in disability and neck pain outcomes reported for non-Hispanic Asian patients. This study highlights the need to address inherent racial/ethnic disparities in recovery trajectories following cervical spine surgery.

LEVEL OF EVIDENCE

3.

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.

The Relationships Between Grit, Burnout, and Demographic Characteristics in Medical Students

Grit, a positive psychological trait comprised of perseverance and passion, has been correlated with physician burnout but has not been extensively studied among medical students. Identification of the relationship between grit and burnout as well as between burnout and other demographics could help to identify students at risk of burnout, while informing educational strategies to increase grit in the medical occupation. For this cross-sectional study, an online, email-based survey including demographic questions, the Maslach Burnout Inventory-Human Services (Medical Personnel) Survey, and the Short Grit Scale was distributed to an entire student body of allopathic medical students via a schoolwide listserv in 2019. The response rate was 39.6% (177/444). Negative correlations were displayed between grit and emotional exhaustion, depersonalization, and overall burnout. Positive correlation was demonstrated between grit and personal accomplishment. Male participants had higher depersonalization than female participants and fourth year medical students had higher depersonalization than other years of training. Fourth year medical students had higher personal accomplishment than other years of training and married students had higher personal accomplishment than those who had never been married. These findings are important not only for potential identification of students at risk of burnout, but also for development of strategies to bolster grit and mitigate distressing experiences in the medical occupation. Future studies are necessary to gauge how this relationship may evolve throughout a medical career.

The Ideal Threshold of Hemoglobin A1C in Diabetic Patients Undergoing Elective Lumbar Decompression Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate the association of Hemoglobin A1C (HbA1c) with surgical site infection (SSI) and patient-reported outcomes (PROs), and to identify optimal HbA1c thresholds to minimize the risk of SSI and maximize PROs.

SUMMARY OF BACKGROUND DATA

Diabetes mellitus has been associated with worsened outcomes following spine surgery. HbA1c, a surrogate of glycemic control, is an important assessment tool in diabetic patients.

METHODS

A single-center, retrospective cohort study using prospectively collected data was undertaken. Diabetic patients undergoing elective lumbar decompression surgery between October 2010 and May 2021 were included. HbA1c, demographics, comorbidities, and perioperative data were collected. Primary outcomes included: 1) SSI, and 2) PROs, including the Numeric Rating Scale (NRS)-back/leg pain and Oswestry Disability Index (ODI). Secondary outcomes included: complications, readmissions, and reoperations within 90-days postoperatively. The minimum clinically important difference (MCID) was set at a 30% improvement from baseline PROs.

RESULTS

Of 1819 patients who underwent lumbar decompression surgery, 368 patients had diabetes mellitus, and 177 had a documented preoperative HbA1c value. Of patients with available HbA1c values, the mean age was 62.5±12.3, the mean HbA1c value was 7.2±1.5%, and SSI occurred in 3 (1.7%) patients only, which prevented further analysis of SSI and HbA1c. A significant association was seen with a higher HbA1c and failure to achieve NRS-Back pain MCID30 [Odds ratio(OR)=0.53, 95% confidence interval(CI) 0.42-0.78; P =0.001] and ODI MCID30 (OR=0.58, 95%CI 0.44-0.77; P =0.001), but not NRS-Leg pain MCID30 (OR=1.29, 95%CI 0.86-1.93; P =0.208). ROC-curve analysis and Youden's index revealed an HbA1c threshold of 7.8 for NRS-Back pain MCID30 (AUC=0.65, P <0.001) and 7.5 for ODI MCID30 (AUC=0.65, P =0.001).

CONCLUSIONS

In diabetic patients undergoing elective lumbar decompression surgery, HbA1c levels above 7.8 and 7.5 were associated with less improvement of NRS-Back and ODI scores at 12-months postoperatively, respectively. To optimize PROs, We recommend a preoperative HbA1c of 7.5 or below for diabetic patients undergoing elective lumbar decompression surgery.

Coordination and Pilot Implementation of a Standardized Data Collection for Touching Hands

PURPOSE

Touching Hands is an American Society for Surgery of the Hand program that provides hand surgeries to the world's underserved communities. The purpose of this study was to develop and implement a systematic data collection method for Touching Hands to assess patient outcomes, volunteer impact, alleviated disease burden, and cost-effectiveness.

METHODS

Research electronic data capture (REDCap) was used as the secure software platform to facilitate data collection. The Quick Disabilities of the Arm, Shoulder and Hand questionnaire was used to assess pre-and postoperative patient-reported outcomes. The Maslach Burnout Inventory-Human Services (Medical Personnel) survey was administered to volunteers before and after the mission to measure impact on volunteers. Case information was collected to calculate disability-adjusted life years and cost-effectiveness.

RESULTS

The data collection system was implemented in some capacity in 4 domestic and 3 international mission sites during 2020 and 2021.

CONCLUSIONS

Substantial limitations exist for the implementation of a systematic data collection framework for Touching Hands and warrant further modification and optimization.

CLINICAL RELEVANCE

A REDCap database can be used for standardized and centralized patient and volunteer data collection for Touching Hands missions.

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.

Optimal hemoglobin A1C target in diabetics undergoing elective cervical spine surgery

BACKGROUND CONTEXT

Diabetes mellitus (DM) is a well-established risk factor for suboptimal outcomes following cervical spine surgery. Hemoglobin A1C (HbA1c), a surrogate for long-term glycemic control, is a valuable assessment tool in diabetic patients.

PURPOSE

In patients undergoing elective cervical spine surgery, we sought to identify optimal HbA1c levels to: (1) maximize 1-year postoperative patient-reported outcomes (PROs), and (2) predict the occurrence of medical and surgical complications.

STUDY DESIGN/SETTING

A retrospective cohort study using prospectively collected data was performed in a single academic center.

PATIENT SAMPLE

Diabetic patients undergoing elective anterior cervical fusion and posterior cervical laminectomy and fusion (PCLF) between October 2010-March 2021 were included.

OUTCOME MEASURES

Primary outcomes included Numeric Rating Scale (NRS)-Neck pain, NRS-Arm pain, and Neck Disability Index (NDI). Secondary outcomes included surgical site infection (SSI), complications, readmissions, and reoperations within 90-days postoperatively.

METHODS

HbA1c, demographic, comorbidity, and perioperative variables were gathered in diabetic patients only. PROs were analyzed as continuous variables and minimum clinically difference (MCID) was set at 30% improvement from baseline.

RESULTS

Of 1992 registry patients undergoing cervical surgery, 408 diabetic patients underwent cervical fusion surgery. Anterior: A total of 259 diabetic patients underwent anterior cervical fusion, 141 of which had an available HbA1c level within one year prior to surgery. Mean age was 55.8±10.1, and mean HbA1c value was 7.2±1.4. HbA1c levels above 6.1 were associated with failure to achieve MCID for NDI (AUC=0.77, 95%CI 0.70-0.84, p<.001), and HbA1c levels above 6.8 may be associated with increased odds of reoperation (AUC=0.61, 95%CI 0.52-0.69, p=.078). Posterior: A total of 149 diabetic patients underwent PCLF, 65 of which had an available HbA1c level within 1 year. Mean age was 63.6±9.2, and mean HbA1c value was 7.2±1.5. Despite a low AUC for NRS-Arm pain and readmission, HbA1c levels above 6.8 may be associated with failure to achieve MCID for NRS-Arm pain (AUC=0.61, 95%CI 0.49-0.73, p=.094), and HbA1c levels above 7.6 may be associated with higher readmission rate (AUC=0.63, 95%CI 0.50-0.75, p=.185).

CONCLUSIONS

In a cohort of diabetic patients undergoing elective cervical spine surgery, HbA1c levels above 6.1 were associated with decreased odds of achieving MCID for NDI in anterior cervical fusion surgery. Though only moderate associations were seen for the select outcomes of reoperation (6.8), readmission (7.6), and MCID for NRS-Arm pain (6.8), preoperative optimization of HbA1c using these levels as benchmarks should be considered to reduce the risk of complications and maximize PROs for patients undergoing elective cervical spine surgery.

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.

Is Grit Associated with Burnout and Well-being in Orthopaedic Resident and Faculty Physicians? A Multi-institution Longitudinal Study Across Training Levels

BACKGROUND

Grit has been defined as "perseverance and passion for long-term goals" and is characterized by maintaining focus and motivation toward a challenging ambition despite setbacks. There are limited data on the impact of grit on burnout and psychologic well-being in orthopaedic surgery, as well as on which factors may be associated with these variables.

QUESTIONS/PURPOSES

(1) Is grit inversely correlated with burnout in orthopaedic resident and faculty physicians? (2) Is grit positively correlated with psychologic well-being in orthopaedic resident and faculty physicians? (3) Which demographic characteristics are associated with grit in orthopaedic resident and faculty physicians? (4) Which demographic characteristics are associated with burnout and psychologic well-being in orthopaedic resident and faculty physicians?

METHODS

This study was an institutional review board-approved interim analysis from the first year of a 5-year longitudinal study of grit, burnout, and psychologic well-being in order to assess baseline relationships between these variables before analyzing how they may change over time. Orthopaedic residents, fellows, and faculty from 14 academic medical centers were enrolled, and 30% (335 of 1129) responded. We analyzed for the potential of response bias and found no important differences between sites in low versus high response rates, nor between early and late responders. Participants completed an email-based survey consisting of the Duckworth Short Grit Scale, Maslach Burnout Inventory-Human Services (Medical Personnel) Survey, and Dupuy Psychological Well-being Index. The Short Grit Scale has been validated with regard to internal consistency, consensual and predictive validity, and test-retest stability. The Psychological Well-being Index has similarly been validated with regard to reliability, test-retest stability, and internal consistency, and the Maslach Burnout Inventory has been validated with regard to internal consistency, reliability, test-retest stability, and convergent validity. The survey also obtained basic demographic information such as survey participants' age, gender, race, ethnicity, marital status, current year of training or year in practice (as applicable), and region of practice. The studied population consisted of 166 faculty, 150 residents, and 19 fellows. Beyond the expected age differences between sub-populations, the fellow population had a higher proportion of women than the faculty and resident populations did. Pearson correlations and standardized β coefficients were used to assess the relationships of grit, burnout, psychologic well-being, and continuous participant characteristics.

RESULTS

We found moderate, negative relationships between grit and emotional exhaustion (r = -0.30; 95% CI -0.38 to -0.21; p < 0.001), depersonalization (r = -0.34; 95% CI -0.44 to -0.23; p < 0.001), and the overall burnout score (r = -0.39; 95% CI -0.48 to -0.31; p < 0.001). The results also showed a positive correlation between grit and personal accomplishment (r = 0.39; 95% CI 0.29 to 0.48; p < 0.001). We also found a moderate, positive relationship between grit and psychologic well-being (r = 0.39; 95% CI 0.30 to 0.49; p < 0.001). Orthopaedic surgeons with 21 years or more of practice had higher grit scores than physicians with 10 to 20 years of practice. Orthopaedic surgeons in practice for 21 years or more also had lower burnout scores than those in practice for 10 to 20 years. Married physicians had higher psychologic well-being than unmarried physicians did.

CONCLUSION

Among orthopaedic residents, fellows, and faculty, grit is inversely related to burnout, with lower scores for emotional exhaustion and depersonalization and higher scores for personal accomplishment as grit increases.

CLINICAL RELEVANCE

The results suggest that grit could be targeted as an intervention for reducing burnout and promoting psychologic well-being among orthopaedic surgeons. Other research has suggested that grit is influenced by internal characteristics, life experiences, and the external environment, suggesting that there is potential to increase one's grit. Residency programs and faculty development initiatives might consider measuring grit to assess for the risk of burnout, as well as offering curricula or training to promote this psychologic characteristic.

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.

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.

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.

Laboratory evaluation of citronella, picaridin, and deet repellents against Psorophora ciliata and Psorophora howardii

Commercial formulations of 3 repellents: OFF Active (active ingredient [AI] 15% N,N-diethyl-meta-toluamide [deet]), OFF Family Care (AI 5% picaridin), and CVS Pharmacy Fresh Insect Repellent (AI 10% citronella, 2% lauryl sulfate, and 0.2% potassium sorbate) were evaluated to determine the mean protection time provided against the large floodwater mosquitoes, Psorophora ciliata and Ps. howardii. Each of these products contained different active ingredients and displayed different protection times, but repellency was in accordance with each product's label reapplication times/repellency durations. The CVS Pharmacy Fresh Insect Repellent provided the least protection (2 h and 26 min), followed by OFF Family Care (3 h and 46 min). OFF Active afforded the longest protection (5 h and 41 min), which was significantly higher than the other treatments (P < 0.001).

Body size, blood feeding activity, and fecundity of Psorophora howardii, Psorophora ciliata, and Psorophora ferox (Diptera: Culicidae)

Field-collected female Psorophora howardii (Coquillett), Psorophora ciliate (F.), and Psorophora ferox (Humboltd) mosquitoes were tested in laboratory conditions to measure body size, blood engorgement duration, bloodmeal size, fecundity, and egg morphology. Mean bloodmeal size was significantly different among the three species of mosquitoes, whereas there was no difference in blood engorgement duration. Mean body weights and wing lengths of Ps. howardii and Ps. ciliata were significantly greater than Ps.ferox. Seven days after bloodmeals, oviposition rates for Ps. howardii, Ps. ciliata, and Ps.ferox were 18.8, 56.2, and 0%, respectively. The mean number of total eggs produced per female for the three species was 59, 81, and 73, respectively. Mean egg lengths of Ps. howardii and Ps. ciliata were significantly greater than Ps.ferox, and egg diameters for each of the three species were significantly different from one another. Length per diameter ratios of Ps. howardii and Ps. ciliata were significantly smaller than Ps. ferox. Bloodmeal size was positively related to body weight, but not related to blood engorgement duration, and the total egg number was positively related to bloodmeal size.

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.