Impact of COVID-19 on cancer incidence, presentation, diagnosis, treatment and survival in Northern Ireland

The COVID-19 pandemic had a major impact on cancer patients and services but has been difficult to quantify. We examined how the entire cancer pathway-from incidence, presentation, diagnosis, stage, treatment and survival-was affected in Northern Ireland during April-December 2020 compared to equivalent 2018-2019 periods using retrospective, observational cancer registry data from the Northern Ireland Cancer Registry (NICR). There were 6748 cancer cases in April-December 2020 and an average 7724 patients in April-December 2018-2019. Incident cases decreased by 13% (almost 1000). Significant differences were found across age cohorts and deprivation quintiles, with reductions greatest for younger people (<55 years; 19% decrease) and less deprived (22% decrease). A higher proportion had emergency admission (16%-to-20%) with lower proportions diagnosed pathologically (85%-to-83%). There was a significant stage shift, with lower proportions of early stage (29%-to-25%) and higher late-stage (21%-to-23%). Lower proportions received surgery (41%-to-38%) and radiotherapy (24%-to-22%) with a higher proportion not receiving treatment (29%-to-33%). One-year observed-survival decreased from 73.7% to 69.8% and 1-year net-survival decreased from 76.1% to 72.9%, with differences driven by five tumours; Lung (40.3%-to-35.0%), Head-and-Neck (77.4%-to-68.4%), Oesophageal (53.5%-to-42.3%), Lymphoma (81.1%-to-75.2%) and Uterine cancer (87.4%-to-80.4%). Our study reveals profound adverse impact of COVID-19 on the entire cancer patient pathway, with 13% fewer cases, greater emergency admissions and significant stage-shift from early to more advanced-stage disease. There was major treatment impact with lower rates of surgery and radiotherapy and higher proportions receiving no treatment. There were significant reductions in 1-year survival. Our study will support service recovery and protect cancer services in future pandemics or disruptions.

Whole-population trends in pathology-confirmed cancer incidence in Northern Ireland, Scotland and Wales during the SARS-CoV-2 pandemic: A retrospective observational study

INTRODUCTION

The COVID-19 epidemic interrupted normal cancer diagnosis procedures. Population-based cancer registries report incidence at least 18 months after it happens. Our goal was to make more timely estimates by using pathologically confirmed cancers (PDC) as a proxy for incidence. We compared the 2020 and 2021 PDC with the 2019 pre-pandemic baseline in Scotland, Wales, and Northern Ireland (NI).

METHODS

Numbers of female breast (ICD-10 C50), lung (C33-34), colorectal (C18-20), gynaecological (C51-58), prostate (C61), head and neck (C00-C14, C30-32), upper gastro-intestinal (C15-16), urological (C64-68), malignant melanoma (C43), and non-melanoma skin (NMSC) (C44) cancers were counted. Multiple pairwise comparisons generated incidence rate ratios (IRR).

RESULTS

Data were accessible within 5 months of the pathological diagnosis date. Between 2019 and 2020, the number of pathologically confirmed malignancies (excluding NMSC) decreased by 7315 (14.1 %). Scotland experienced early monthly declines of up to 64 % (colorectal cancers, April 2020 versus April 2019). Wales experienced the greatest overall change in 2020, but Northern Ireland experienced the quickest recovery. The pandemic's effects varied by cancer type, with no significant change in lung cancer diagnoses in Wales in 2020 (IRR 0.97 (95 % CI 0.90-1.05)), followed by an increase in 2021 (IRR 1.11 (1.03-1.20).

CONCLUSION

PDC are useful in reporting cancer incidence quicker than cancer registrations. Temporal and geographical differences between participating countries mirrored differences in responses to the COVID-19 pandemic, indicating face validity and the potential for quick cancer diagnosis assessment. To verify their sensitivity and specificity against the gold standard of cancer registrations, however, additional research is required.

Towards a data transfer agreement for the South African research community: The empowerment approach

The idea of a data transfer agreement (DTA) template for the South African (SA) research community is receiving increasing attention. While developing such a DTA template is certainly a worthwhile project, questions regarding the project's practical execution should be addressed, including how to best operationalise the envisioned DTA template, and the content of the envisioned DTA template. It is proposed that an empowerment approach be followed in operationalising the envisioned DTA template, which is contrasted with the regulatory approach followed with the material transfer agreement that the Minister of Health promulgated in 2018. While the regulatory approach would entail government making the use of the envisioned DTA template compulsory regardless of the quality of such a template, the empowerment approach, by contrast, entails a focus on developing a high-quality, professionally drafted DTA template for the SA research community and making the use thereof a matter of own choice. Regarding the content of the envisioned DTA template, four hot-button content provisions are analysed, and it is argued that SA research institutions and researchers should be empowered to: (i) have clarity and legal certainty regarding their ownership of data, where relevant; (ii) be able to commercialise their research findings without unnecessary contractual constraints; (iii) avoid falling into the trap of unlawful benefit sharing with research participants; and (iv) be aware that their legal role as responsible parties, where relevant, cannot be contracted out via a DTA.

T-Cell Infiltration and Clonality May Identify Distinct Survival Groups in Colorectal Cancer: Development and Validation of a Prognostic Model Based on The Cancer Genome Atlas (TCGA) and Clinical Proteomic Tumor Analysis Consortium (CPTAC)

Predicting the survival outcomes of patients with colorectal cancer (CRC) remains challenging. We investigated the prognostic significance of the transcriptome and tumour-infiltrating lymphocyte T-cell receptor (TIL/Tc-TCR) repertoire and analysed TIL/Tc-TCR sequences of The Cancer Genome Atlas (TCGA) and the Clinical Proteomic Tumor Analysis Consortium (CPTAC) CRC cohorts. Using a multivariate Cox regression, we tested whether TIL/Tc-TCR repertoire, patient and tumour characteristics (stage, sidedness, total non-synonymous mutations, microsatellite instability (MSI) and transcriptional signatures) correlated with patient overall survival (OS) and designed a prognostic nomogram. A multivariate analysis (C-index = 0.75) showed that only patient age, disease stage, TIL/Tc degree of infiltration and clonality were independent prognostic factors for OS. The cut-offs for patients’ allocation to TIL/Tc abundance subgroups were determined using a strategy of maximally selected rank statistics with the OptimalCutpoints R package. These were “high”, “low” and “very high” (90 th percentile) TIL/Tc infiltration-stratified OS (median not reached, 67 and 44.3 months; p < 0.001); the results were validated in the CPTAC cohort. TIL/Tc clonality was prognostic (median OS in “high” vs. “low” clonality not reached and 67.3 months; p = 0.041) and independent of TIL/Tc infiltration. Whilst tumour sidedness was not prognostic, the “very highly” infiltrated tumours were prevalent among right-sided CRCs (p = 0.039) and showed distinct immunological features, with lower Th1 signature (p = 0.004), higher PD-L1 expression (p < 0.001) and likely enrichment in highly suppressory IL1R1+ Tregs (FoxP3 and IL1R1 overexpression, p < 0.001). TIL/Tc abundance and clonality are independent prognosticators in CRC and, combined with clinical variables, refine risk stratification. We identified a subset of CRCs with “very high” TIL/Tc infiltration, poor prognosis and distinct genetic and immunologic features, which may benefit from alternative therapeutic approaches. These results need validation in prospective patient cohorts.

Artificial intelligence in healthcare: Proposals for policy development in South Africa

Despite the tremendous promise offered by artificial intelligence (AI) for healthcare in South Africa, existing policy frameworks are inadequate for encouraging innovation in this field. Practical, concrete and solution-driven policy recommendations are needed to encourage the creation and use of AI systems. This article considers five distinct problematic issues which call for policy development: (i) outdated legislation; (ii) data and algorithmic bias; (iii) the impact on the healthcare workforce; (iv) the imposition of liability dilemma; and (v) a lack of innovation and development of AI systems for healthcare in South Africa. The adoption of a national policy framework that addresses these issues directly is imperative to ensure the uptake of AI development and deployment for healthcare in a safe, responsible and regulated manner.

P-OGC38 The Impact of the COVID-19 Pandemic on Barrett’s Oesophagus and Oesophago-gastric Cancer

Background

The COVID-19 pandemic has placed an inexorable strain on endoscopy services worldwide, affecting the diagnosis of oesophago-gastric (OG) cancer and Barrett’s oesophagus (BO). As coronavirus infection rates rose many professional bodies advised that all endoscopy, except emergency and essential procedures be stopped immediately. We sought to quantify the decline in OG cancer and BO diagnoses following implementation of British Society of Gastroenterology (BSG) guidance related to COVID-19 and the psychosocial effects on BO patients.

Methods

We examined OG cancer and BO diagnoses in Northern Ireland from March-September 2020 and compared them with the three-year average number of patients  during the same time period (corresponding to weeks 10-37) between 2017-2019 by utilising Northern Ireland Cancer Registry (NICR) data. The psychosocial impact of COVID-19 was assessed using an online survey, which included validated WHOQOL-BREF and EQ-5D-5L quality of life measures, and was completed by 24 BO patients from April-May 2020.

Results

Between March and September 2020 in Northern Ireland, the proportion of OG cancer and BO diagnoses declined by 26.6% and 59.3%, respectively, compared to expected levels. In April, BO diagnoses fell by 95.5% but by September, whilst OG cancer rates had returned to baseline, BO cases remained supressed by approximately 20%. We estimate that these declines in diagnosis represent 53 ‘missed’ OG cancer and 236 ‘missed’ BO diagnoses. In the online survey sample, BO patients reported consistently lower quality of life scores than population norms, and highlighted a number of concerns with regard to their health and care.

Conclusions

The COVID-19 pandemic has resulted in an abrupt decline in OG cancer and BO diagnoses and has profoundly impacted the wellbeing of BO patients. Our study represents the first report of the impact of COVID-19 on the diagnosis of BO.  Strategies to mitigate the ongoing effects of the pandemic are urgently required to preserve the ability to rapidly detect and diagnose cancer and pre-malignant conditions.

Abstract S02-03: The impact of the COVID-19 pandemic on Barrett’s esophagus and esophago-gastric cancer

Objective The COVID-19 pandemic has placed an inexorable strain on endoscopy services worldwide, affecting the diagnosis of esophago-gastric (EG) cancer and Barrett’s esophagus (BE). As coronavirus infection rates rose many professional bodies advised that all endoscopy, except emergency and essential procedures, be stopped immediately. We sought to quantify the decline in EG cancer and BE diagnoses following implementation of British Society of Gastroenterology (BSG) guidance related to COVID-19 and the psychosocial effects on BE patients. Methods We examined EG cancer and BE diagnoses in Northern Ireland from March-September 2020 and compared them with the three-year average number of patients during the same time period between 2017-2019 by utilizing Northern Ireland Cancer Registry (NICR) data. The psychosocial impact of COVID-19 was assessed using an online survey, which included validated WHOQOL-BREF and EQ-5D-5L quality of life measures, and was completed by 24 BE patients from April-May 2020. Results During the first six months of the pandemic the proportion of EG cancer and BE diagnoses declined by 26.6% and 59.3%, respectively, compared to expected levels. In April, BE diagnoses fell by 95.5% but by September, whilst EG cancer rates had returned to baseline, BE cases remained suppressed by approximately 20%. We estimate that these declines in diagnosis represent 53 ‘missed’ EG cancer and 236 ‘missed’ BE diagnoses. In the online survey sample, BE patients reported consistently lower quality of life scores than population norms, and highlighted a number of concerns with regard to their health and care. Conclusion The COVID-19 pandemic has resulted in an abrupt decline in EG cancer and BE diagnoses and has profoundly impacted the wellbeing of BE patients. Our study represents the first report of the impact of COVID-19 on the diagnosis of BE. Strategies to mitigate the ongoing effects of the pandemic are urgently required to preserve the ability to rapidly detect and diagnose cancer and pre-malignant conditions.

Citation Format: Richard C. Turkington, Anita Lavery, David Donnelly, Anna T. Gavin, Damian T. McManus, Victoria Cairnduff, Charlene M. McShane, Brian T. Johnston, Lesley A. Anderson, Helen G. Coleman. The impact of the COVID-19 pandemic on Barrett’s esophagus and esophago-gastric cancer [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2021 Feb 3-5. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(6_Suppl):Abstract nr S02-03.

An Assessment of the Performance of the PLUS+ Tool in Supporting the Evaluation of Water Framework Directive Compliance in Scottish Standing Waters

Phosphorus is one of the main causes of waterbodies in Scotland being at less than good ecological status (GES) in terms of the water framework directive (WFD). In Scotland, there are more than 8000 standing waters, defined as lakes and reservoirs that have a surface area of more than 1 hectare. Only about 330 of these are monitored routinely to assess compliance with the WFD. The export coefficient tool PLUS+ (phosphorus land use and slope) has been developed to estimate total phosphorus (TP) concentrations in the unmonitored sites; modelled values are then compared to WFD target concentrations for high, good, moderate, poor, and bad status to assess compliance. These type-specific or site-specific targets are set by the regulatory authority and form part of a suite of physical, chemical, and ecological targets that are used to assess GES, all of which must be met. During development, the PLUS+ tool was applied to 323 monitored catchments and 7471 unmonitored catchments. The efficacy of the tool was assessed against TP concentrations observed in 2014 and found to perform well in the rural catchments. 51% of standing waters had the same modelled and observed WFD class (i.e., High, Good, Moderate, Poor, Bad), and a further 40% of standing waters had a modelled WFD class that was within one class of observed water quality. The tool performed less well in catchments with larger inputs of TP from urban sources (e.g., sewage). The greatest deviations between measured and modelled classes were explained by the shortage of information on wastewater treatment works, fish farms, migratory birds, levels of uncertainty in TP measurements, and the amount of in-lake re-cycling of P. The limitations of the tool are assessed using data from six well documented case study sites and recommendations for improving the model performance are proposed.

Migratory convergence facilitates cultural transmission of humpback whale song

Cultural transmission of behaviour is important in a wide variety of vertebrate taxa from birds to humans. Vocal traditions and vocal learning provide a strong foundation for studying culture and its transmission in both humans and cetaceans. Male humpback whales (Megaptera novaeangliae) perform complex, culturally transmitted song displays that can change both evolutionarily (through accumulations of small changes) or revolutionarily (where a population rapidly adopts a novel song). The degree of coordination and conformity underlying song revolutions makes their study of particular interest. Acoustic contact on migratory routes may provide a mechanism for cultural revolutions of song, yet these areas of contact remain uncertain. Here, we compared songs recorded from the Kermadec Islands, a recently discovered migratory stopover, to multiple South Pacific wintering grounds. Similarities in song themes from the Kermadec Islands and multiple wintering locations (from New Caledonia across to the Cook Islands) suggest a location allowing cultural transmission of song eastward across the South Pacific, active song learning (hybrid songs) and the potential for cultural convergence after acoustic isolation at the wintering grounds. As with the correlations in humans between genes, communication and migration, the migration patterns of humpback whales are written into their songs.

The potential for modelling peatland habitat condition in Scotland using long-term MODIS data

Globally, peatlands provide an important sink of carbon in their near natural state but potentially act as a source of gaseous and dissolved carbon emission if not in good condition. There is a pressing need to remotely identify peatland sites requiring improvement and to monitor progress following restoration. A medium resolution model was developed based on a training dataset of peatland habitat condition and environmental covariates, such as morphological features, against information derived from the Moderate Resolution Imaging Spectroradiometer (MODIS), covering Scotland (UK). The initial, unrestricted, model provided the probability of a site being in favourable condition. Receiver operator characteristics (ROC) curves for restricted training data, limited to those located on a peat soil map, resulted in an accuracy of 0.915. The kappa statistic was 0.8151, suggesting good model fit. The derived map of predicted peatland condition at the suggested 0.56 threshold was corroborated by data from other sources, including known restoration sites, areas under known non-peatland land cover and previous vegetation survey data mapped onto inferred condition categories. The resulting locations of the areas of peatland modelled to be in favourable ecological condition were largely confined to the North and West of the country, which not only coincides with prior land use intensity but with published predictions of future retraction of the bioclimatic space for peatlands. The model is limited by a lack of spatially appropriate ground observations, and a lack of verification of peat depth at training site locations, hence future efforts to remotely assess peatland condition will require more appropriate ground-based monitoring. If appropriate ground-based observations could be collected, using remote sensing could be considered a cost-efficient means to provide data on changes in peatland habitat condition.

Collapse in the scrum

CLINICAL INTRODUCTION

A 17-year-old male patient was brought by ambulance to the ED following a witnessed collapse while playing rugby. He denied any significant trauma, chest pain or breathlessness, and was alert and uncomplaining on arrival, with normal observations and a normal physical exam. Witnesses described a loss of consciousness, with a period of respiratory arrest requiring rescue breaths at the scene. Paramedics reported frequent ventricular extrasystoles on their arrival.The patient had no medical history and was on no medication, although admitted to 'fainting' some 3 weeks previously, again while playing rugby. A paternal uncle had died suddenly at the age of 45.His initial ECG is shown in figure 1.emermed;35/12/764/F1F1F1Figure 1Initial ECG.

QUESTION

What is the most likely diagnosis?Pulmonary embolism (PE)Hypertrophic obstructive cardiomyopathy (HOCM)Arrhythmogenic right ventricular cardiomyopathy (ARVC)Right ventricular outflow tract tachycardia (RVOT).

Life after prostate cancer diagnosis: One step beyond

40

Background: Prostate cancer (PCa) outcome studies are frequently restricted to specific disease stage or treatments. Interpretation may be restricted through lack of population control data & selection bias. We report a whole population evaluation of health-related quality of life (HRQL) following diagnosis of PCa compared to a general population (GenPop) cohort. Methods: Cross-sectional postal survey of all men diagnosed with PCa in the UK 18-42 months earlier. Measures of generic HRQL (EQ-5D) and PCa specific outcomes (EPIC-26 & interventions for erectile dysfunction), as defined in ICHOM minimum dataset, were utilized. Comparable GenPop data was collected from men never diagnosed with PCa in Northern Ireland. Results: 35,823 PCa survivors responded (60.8% response rate), median age 71, and 2,995 from the GenPop (30%). Overall HRQL was slightly lower in the PCa men than the GenPop, this difference was significant only in stage 4 disease. Men with PCa were less likely to report problems in individual EQ5D domains than men in the GenPop (62.0% vs. 68.8%). Both populations were most likely to report pain/discomfort, this was lower in PCa men than the GenPop (42.1% vs. 60.8%). Problems increased with age in all domains, with the exception of anxiety/depression. Men generally reported good function on EPIC-26; however PCa survivors reported poorer sexual function (78.9% vs 48%) except in the oldest. Medications/devices/services to aid or improve erections were offered to 45.4%, 26.0% & 16.9% respectively (and considered helpful by 14.7%, 7.5% & 3.2%). Men with PCa reported more problems with urinary leakage (13.1% vs. 7.1%), particularly after surgery. Hormonal symptoms were linked with receiving Androgen Deprivation Therapy and, to a lesser extent, external beam radiation. Conclusions: 18-42 months following diagnosis of PCa significant sexual and urinary morbidity is experienced relative to the GenPop. Specialist support for sexual dysfunction is not always offered. With the exception of men with stage 4 disease, overall HRQL is only mildly reduced. Funding The Life After Prostate Cancer Diagnosis study was funded by the Movember Foundation, in partnership with Prostate Cancer UK, as part of the Prostate Cancer Outcomes programme, grant number BO26/MO.

Using simulation to iteratively test and re-design a cognitive aid for use in the management of severe local anaesthetic toxicity

Introduction

Cognitive aids, such as a guideline for the management of severe local anaesthetic (LA) toxicity, are tools designed to help users complete a task. Human factors experts recommend the use of simulation to iteratively test and re-design these tools. The purpose of this study was to apply human factors engineering principles to the testing and iterative re-design of three existing cognitive aids used for the management of severe LA toxicity and to use these data to develop a ‘new’ cognitive aid.

Methods

Twenty anaesthetist–anaesthetic assistant pairs were randomised into four groups. Each of the first three groups received one of three different existing cognitive aids during a standardised simulated LA toxicity crisis. Postsimulation semistructured interviews were conducted to identify features beneficial and detrimental to the format and usability of the aid. Synthesis of the interview data with established checklist design recommendations resulted in a prototype aid, which was subjected to further testing and re-design by the fourth group (five more pairs) under the same conditions thus creating the final iteration of the new aid.

Results

Features of the new aid included a single-stream flowchart structure, single-sided, large-font design with colour contrast, simplified instructions and no need for calculations. This simplified tool contains only the information users reported as essential for the immediate crisis management.

Conclusions

Utilisation of formative usability testing and simulation-based user-centred design resulted in a visually very different cognitive aid and reinforces the importance of designing aids in the context in which they are to be used. Simplified tools may be more appropriate for use in emergencies but more detailed guidelines may be necessary for training, education and development of local standard operating procedures. Iterative simulation-based testing and re-design is likely to be of assistance when developing aids for other crises, and to eliminate design failure as a confounder when investigating the relationship between use of cognitive aids and performance.

Abstract 871: [18F]BMS-986192 as a novel PET imaging agent for assessment of PD-L1 expression in vivo

Objectives Inhibition of the Programmed Death Ligand-1 (PD-L1)/PD-1 interaction allows for potent anti-tumor activity and antibodies that disrupt this interaction have been approved for the treatment of multiple cancer types. PD-L1 expression has been investigated clinically as a potential biomarker to predict response to anti-PD-1/PD-L1 therapy. BMS-986192, an Adnectin with high affinity and specificity for human PD-L1, was selected in vitro from a complex library. Here we report the discovery and first preclinical evaluation of [18F]BMS-986192 as a PET imaging agent to detect PD-L1 expression in vivo.

Methods [18F]BMS-986192 was radiolabeled via copper-free click chemistry and assessed for its ability to detect PD-L1 expression. Tracer binding to human L2987 (PD-L1+) and HT-29 (PD-L1-) xenografts as well as human non-small cell lung cancer (NSCLC) tissue samples was assessed by autoradiography (ARG). Tracer binding was compared to PD-L1 expression assessed independently with anti-PD-L1 immunohistochemistry (IHC). In vivo performance of the tracer was also assessed by PET imaging in mice bearing bilateral L2987 and HT-29 xenografts, and tracer biodistribution was further assayed in these animals ex vivo by gamma counter. Finally, initial in vivo biodistribution and radiation dosimetry was measured by PET in cynomolgus monkey.

Results ARG studies showed increased [18F]BMS-986192 total binding to PD-L1(+) L2987 xenograft compared to PD-L1(-) HT-29 xenograft tissue. Radiotracer binding was higher in all tested human NSCLC tissue samples compared to xenografts. Dose-dependent blockade was seen in all PD-L1(+) tissues co-incubated with cold BMS-986192, and binding was unaffected by co-incubation with cold non-PD-L1 binding control. Visual comparison of tracer binding aligns closely with PD-L1 IHC both spatially as well as in intensity. Preferential accumulation of [18F]BMS-986192 was noted in PD-L1(+) L2987 compared to PD-L1(-) HT-29 xenografts in tumor-bearing mice. PET studies in cynomolgus monkeys confirmed binding to PD-L1(+) tissue (e.g. spleen) with minimal nonspecific background signal exclusive of primary clearance organs. Radiation dosimetry of [18F]BMS-986192 indicates an estimated single administration dose limit of 6.2 mCi for an average human subject.

Conclusions ARG, PET studies, and ex vivo measurements in rodent and cynomolgus monkey demonstrated sensitive and specific [18F]BMS-986192 binding to PD-L1. Low background signal in cynomolgus monkey in the context of endogenous PD-L1 expression further supports the potential of this tracer for sensitive detection of PD-L1(+) lesions in vivo. Radiation dosimetry suggests that [18F]BMS-986192 can be safely administered in human trials, with estimated absorbed radiation doses well within safe parameters for human administration. [18F]BMS-986192 has potential as a sensitive PD-L1 imaging agent for same-day imaging in patients.

Citation Format: Ralph A. Smith, David Donnelly, Paul E. Morin, Dasa Lipovsek, Jochem Gokemeijer, Daniel Cohen, Joonyoung Kim, Adrienne Pena, Olufemi Adelakun, Xi-Tao Wang, Patrick Chow, Samuel J. Bonacorsi, Wendy Hayes. [18F]BMS-986192 as a novel PET imaging agent for assessment of PD-L1 expression in vivo [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 871. doi:10.1158/1538-7445.AM2017-871

Effect of investigation intensity and treatment differences on prostate cancer survivor's physical symptoms, psychological well-being and health-related quality of life: a two country cross-sectional study

AIM

To investigate effects on men's health and well-being of higher prostate cancer (PCa) investigation and treatment levels in similar populations.

PARTICIPANTS

PCa survivors in Ireland where the Republic of Ireland (RoI) has a 50% higher PCa incidence than Northern Ireland (NI).

METHOD

A cross-sectional postal questionnaire was sent to PCa survivors 2-18 years post-treatment, seeking information about current physical effects of treatment, health-related quality of life (HRQoL; EORTC QLQ-C30; EQ-5D-5L) and psychological well-being (21 question version of the Depression, Anxiety and Stress Scale, DASS-21). Outcomes in RoI and NI survivors were compared, stratifying into 'late disease' (stage III/IV and any Gleason grade (GG) at diagnosis) and 'early disease' (stage I/II and GG 2-7). Responses were weighted by age, jurisdiction and time since diagnosis. Between-country differences were investigated using multivariate logistic and linear regression.

RESULTS

3348 men responded (RoI n=2567; NI n=781; reflecting population sizes, response rate 54%). RoI responders were younger; less often had comorbidities (45% vs 38%); were more likely to present asymptomatically (66%; 41%) or with early disease (56%; 35%); and less often currently used androgen deprivation therapy (ADT; 2%; 28%). Current prevalence of incontinence (16%) and impotence (56% early disease, 67% late disease) did not differ between RoI and NI. In early disease, only current bowel problems (RoI 12%; NI 21%) differed significantly in multivariate analysis. In late disease, NI men reported significantly higher levels of gynaecomastia (23% vs 9%) and hot flashes(41% vs 19%), but when ADT users were analysed separately, differences disappeared. For HRQoL, in multivariate analysis, only pain (early disease: RoI 11.1, NI 19.4) and financial difficulties (late disease: RoI 10.4, NI 7.9) differed significantly between countries. There were no significant between-country differences in DASS-21 or index ED-5D-5L score.

CONCLUSIONS

Treatment side effects were commonly reported and increased PCa detection in RoI has left more men with these side effects. We recommended that men be offered a PSA test only after informed discussion.

Atypical residency of short-beaked common dolphins (Delphinus delphis) to a shallow, urbanized embayment in south-eastern Australia

Short-beaked common dolphins (Delphinus delphis) are typically considered highly mobile, offshore delphinids. This study assessed the residency of a small community of short-beaked common dolphins in the shallow, urbanized Port Phillip Bay, south-eastern Australia. The ability to identify common dolphins by their dorsal fin markings and coloration using photo-identification was also investigated. Systematic and non-systematic boat surveys were undertaken between 2007 and 2014. Results showed that 13 adult common dolphins and their offspring inhabit Port Phillip Bay, of which 10 adults exhibit residency to the bay. The majority of these adults are reproductively active females, suggesting that female philopatry may occur in the community. Systematic surveys conducted between 2012 and 2014 revealed that the dolphins were found in a median water depth of 16 m and median distance of 2.2 km from the coast. The shallow, urbanized habitat of this resident common dolphin community is atypical for this species. As a result, these common dolphins face threats usually associated with inshore bottlenose dolphin communities. We suggest that the Port Phillip Bay common dolphin community is considered and managed separate to those outside the embayment and offshore to ensure the community's long-term viability and residency in the bay.

Large-scale discovery of novel genetic causes of developmental disorders

Despite three decades of successful, predominantly phenotype-driven discovery of the genetic causes of monogenic disorders, up to half of children with severe developmental disorders of probable genetic origin remain without a genetic diagnosis. Particularly challenging are those disorders rare enough to have eluded recognition as a discrete clinical entity, those with highly variable clinical manifestations, and those that are difficult to distinguish from other, very similar, disorders. Here we demonstrate the power of using an unbiased genotype-driven approach to identify subsets of patients with similar disorders. By studying 1,133 children with severe, undiagnosed developmental disorders, and their parents, using a combination of exome sequencing and array-based detection of chromosomal rearrangements, we discovered 12 novel genes associated with developmental disorders. These newly implicated genes increase by 10% (from 28% to 31%) the proportion of children that could be diagnosed. Clustering of missense mutations in six of these newly implicated genes suggests that normal development is being perturbed by an activating or dominant-negative mechanism. Our findings demonstrate the value of adopting a comprehensive strategy, both genome-wide and nationwide, to elucidate the underlying causes of rare genetic disorders.

Risk of several cancers is higher in urban areas after adjusting for socioeconomic status. Results from a two-country population-based study of 18 common cancers

Some studies suggest that there are urban-rural variations in cancer incidence but whether these simply reflect urban-rural socioeconomic variation is unclear. We investigated whether there were urban-rural variations in the incidence of 18 cancers, after adjusting for socioeconomic status. Cancers diagnosed between 1995 and 2007 were extracted from the population-based National Cancer Registry Ireland and Northern Ireland Cancer Registry and categorised by urban-rural status, based on population density of area of residence at diagnosis (rural <1 person per hectare, intermediate 1-15 people per hectare, urban >15 people per hectare). Relative risks (RR) were calculated by negative binomial regression, adjusting for age, country and three area-based markers of socioeconomic status. Risks were significantly higher in both sexes in urban than rural residents with head and neck (males RR urban vs. rural = 1.53, 95 % CI 1.42-1.64; females RR = 1.29, 95 % CI 1.15-1.45), esophageal (males 1.21, 1.11-1.31; females 1.21, 1.08-1.35), stomach (males 1.36, 1.27-1.46; females 1.19, 1.08-1.30), colorectal (males 1.14, 1.09-1.18; females 1.04, 1.00-1.09), lung (males 1.54, 1.47-1.61; females 1.74, 1.65-1.84), non-melanoma skin (males 1.13, 1.10-1.17; females 1.23, 1.19-1.27) and bladder (males 1.30, 1.21-1.39; females 1.31, 1.17-1.46) cancers. Risks of breast, cervical, kidney and brain cancer were significantly higher in females in urban areas. Prostate cancer risk was higher in rural areas (0.94, 0.90-0.97). Other cancers showed no significant urban-rural differences. After adjusting for socioeconomic variation, urban-rural differences were evident for 12 of 18 cancers. Variations in healthcare utilization and known risk factors likely explain some of the observed associations. Explanations for others are unclear and, in the interests of equity, warrant further investigation.

Pharmacophore model of the quercetin binding site of the SIRT6 protein

SIRT6 is a histone deacetylase that has been proposed as a potential therapeutic target for metabolic disorders and the prevention of age-associated diseases. We have previously reported on the identification of quercetin and vitexin as SIRT6 inhibitors, and studied structurally related flavonoids including luteolin, kaempferol, apigenin and naringenin. It was determined that the SIRT6 protein remained active after immobilization and that a single frontal displacement could correctly predict the functional activity of the immobilized enzyme. The previous study generated a preliminary pharmacophore for the quercetin binding site on SIRT6, containing 3 hydrogen bond donors and one hydrogen bond acceptor. In this study, we have generated a refined pharmacophore with an additional twelve quercetin analogs. The resulting model had a positive linear behavior between the experimental elution time verses the fit values obtained from the model with a correlation coefficient of 0.8456.

Rectourethral fistula secondary to a bowel management system

A 67-year-old Caucasian male was admitted under the vascular team with critical lower limb ischaemia. Bypass surgery was performed and he was admitted to the intensive care unit post-operatively. The patient experienced a turbulent post-operative recovery complicated by pneumonia, poor respiratory wean and faecal incontinence. A bowel management system was inserted but after 18 days it was reported faecal matter was bypassing his catheter. A CT scan demonstrated an area of necrosis where the bowel management system had been sited which formed a rectourethral fistula. Bowel management systems are frequently used in intensive care unit settings where a high proportion of patients suffer from faecal incontinence. If used correctly they can reduce skin contamination, infection and maintain patient hygiene. However, appropriate assessment and investigations should be addressed before inserting such devices. This case report highlights serious adverse effects of these devices and describes the first documented case of these devices causing a rectourethral fistula.

Trends in skin cancer knowledge, sun protection practices and behaviours in the Northern Ireland population

BACKGROUND

Sun exposure increases risk of skin cancer, especially melanoma, incidence of which continues to rise. Reported skin cancer knowledge and trends in sun care behaviours are documented in a UK region where there has been 20 years of sun-related health promotion campaigns.

METHODS

In 2000, 2004 and 2008, a 'care in the sun' module was included in the Northern Ireland (NI) Omnibus survey. Randomly selected subjects were asked to complete a sun-related questionnaire and proportions of respondents analysed by demographic and socio-economic factors, with differences tested using z-tests and the chi-squared test.

RESULTS

Around 3623 persons responded. Skin cancer knowledge was high (97%). Sun avoidance decreased with time and was lowest among younger age groups and males. Sunscreen use was high (70%), unchanged over 8 years, and more likely among younger age groups, females, those in paid employment, and those with tertiary level education. Use of sunscreen with minimum Sun Protection Factor (SPF) 15 (a campaign message) increased from 45% to 70% (P < 0.01). Skin self-examination was infrequent (8%), less common among those aged ≥65 years, males and those with only primary or secondary level education.

CONCLUSIONS

Messages on sunscreen use have penetrated the population well, but lower use among the unemployed suggests cost as an issue. Lack of sun avoidance in young people, especially men, poses a risk for further skin cancer increases. Low levels of reported skin self-examination in older people, men and those with lower educational attainment identify areas for further action.

The major determinant of exendin-4/glucagon-like peptide 1 differential affinity at the rat glucagon-like peptide 1 receptor N-terminal domain is a hydrogen bond from SER-32 of exendin-4

BACKGROUND AND PURPOSE

Exendin-4 (exenatide, Ex4) is a high-affinity peptide agonist at the glucagon-like peptide-1 receptor (GLP-1R), which has been approved as a treatment for type 2 diabetes. Part of the drug/hormone binding site was described in the crystal structures of both GLP-1 and Ex4 bound to the isolated N-terminal domain (NTD) of GLP-1R. However, these structures do not account for the large difference in affinity between GLP-1 and Ex4 at this isolated domain, or for the published role of the C-terminal extension of Ex4. Our aim was to clarify the pharmacology of GLP-1R in the context of these new structural data.

EXPERIMENTAL APPROACH

The affinities of GLP-1, Ex4 and various analogues were measured at human and rat GLP-1R (hGLP-1R and rGLP-1R, respectively) and various receptor variants. Molecular dynamics coupled with in silico mutagenesis were used to model and interpret the data.

KEY RESULTS

The membrane-tethered NTD of hGLP-1R displayed similar affinity for GLP-1 and Ex4 in sharp contrast to previous studies using the soluble isolated domain. The selectivity at rGLP-1R for Ex4(9-39) over Ex4(9-30) was due to Ser-32 in the ligand. While this selectivity was not observed at hGLP-1R, it was regained when Glu-68 of hGLP-1R was mutated to Asp.

CONCLUSIONS AND IMPLICATIONS

GLP-1 and Ex4 bind to the NTD of hGLP-1R with similar affinity. A hydrogen bond between Ser32 of Ex4 and Asp-68 of rGLP-1R, which is not formed with Glu-68 of hGLP-1R, is responsible for the improved affinity of Ex4 at the rat receptor.

Second primary cancers in patients with skin cancer: a population-based study in Northern Ireland

Among all 14,500 incident cases of basal cell carcinoma (BCC), 6405 squamous cell carcinomas (SCC) and 1839 melanomas reported to the Northern Ireland Cancer Registry between 1993 and 2002, compared with the general population, risk of new primaries after BCC or SCC was increased by 9 and 57%, respectively. The subsequent risk of cancer, overall, was more than double after melanoma.

Peptide binding at the GLP-1 receptor

The receptor for GLP-1 [glucagon-like peptide-1-(7-36)-amide] is a member of the 'Family B' of GPCRs (G-protein-coupled receptors) comprising an extracellular N-terminal domain containing six conserved cysteine residues (the N-domain) and a core domain (or J-domain) comprising the seven transmembrane helices and interconnecting loop regions. According to the two-domain model for peptide binding, the N-domain is primarily responsible for providing most of the peptide binding energy, whereas the core domain is responsible for binding the N-terminal region of the peptide agonists and transmitting the signal to the intracellular G-protein. Two interesting differences between the binding properties of two GLP-1 receptor agonists, GLP-1 and EX-4 (exendin-4), can be observed. First, while GLP-1 requires its full length to maintain high affinity, the eight N-terminal residues of EX-4 can be removed with little reduction in affinity. Secondly, EX-4 (but not GLP-1) can bind to the fully isolated N-domain of the receptor with an affinity matching that of the full-length receptor. In order to better understand these differences, we have studied the interaction between combinations of full-length or truncated ligands with full-length or truncated receptors.

Skin cancer trends in Northern Ireland and consequences for provision of dermatology services

BACKGROUND

The incidence of skin cancer, both melanoma and nonmelanoma skin cancer (NMSC), is rising throughout the world. The evaluation of trends in skin cancer will allow better planning of the future development of skin cancer services.

OBJECTIVES

Using data collected from the Northern Ireland Cancer Registry (NICR), the incidence of the three major cutaneous cancers, basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and malignant melanoma (MM), was determined and the workload associated with their management assessed.

METHODS

The records of patients with a first diagnosis of BCC, SCC or MM occurring between 1993 and 2002 were retrieved from the NICR database. The annual age- and sex-adjusted incidence rates of all three skin cancers were computed per 100 000 person-years by direct standardization according to the European Standard Population. Trends in incidence were estimated by calculating the estimated annual percentage change using Microsoft Excel. For patients registered with the NICR as having BCC, SCC or MM, the number of pathological reports where malignant samples had been examined was counted and then summed to provide the number of specimens examined each year between 1993 and 2004.

RESULTS

For all three cancers the age-specific rates for both males and females increased with age, except for MM in men aged 75 years and over, where the rates were seen to decrease. Over the 12-year period there was a 62% increase in the overall number of skin cancer samples processed by local pathology laboratories and a 20% increase in the number of patients. These data highlight the fact that many patients will have more than one skin cancer, which reinforces the benefit in collecting data for both patient and sample numbers in order to obtain a true reflection of the workload. The data have also shown that more affluent men and women have higher rates of BCC and MM than their less affluent counterparts.

CONCLUSIONS

In view of the data presented it is clear that management of NMSC and MM will impose significant demands on services in the years ahead. This will impact on the entire multidisciplinary team. Future planning, in terms of manpower and resources, will prove essential if we are to remain in a position to manage our patients with these malignant tumours appropriately.

Neuroprotective potential of ceftriaxone in in vitro models of stroke

Astrocytic glutamate transporters are considered an important target for neuroprotective therapies as the function of these transporters is abnormal in stroke and other neurological disorders associated with excitotoxicity. Recently, Rothstein et al., [Rothstein JD, Patel S, Regan MR, Haenggeli C, Huang YH, Bergles DE, Jin L, Dykes Hoberg M, Vidensky S, Chung DS, Toan SV, Bruijn LI, Su ZZ, Gupta P, Fisher PB (2005) Beta-lactam antibiotics offer neuroprotection by increasing glutamate transporter expression. Nature 433:73-77] reported that beta-lactam antibiotics (including ceftriaxone, which easily crosses the blood-brain barrier) increase glutamate transporter 1 (GLT-1) expression and reduce cell death resulting from oxygen-glucose deprivation (OGD) in dissociated embryonic cortical cultures. To determine whether a similar neuroprotective mechanism operates in more mature neurons, which show a different pattern of response to ischemia than primary cultures, we exposed acute hippocampal slices obtained from rats treated with ceftriaxone for 5 days (200 mg/kg; i.p.) to OGD. Whole-cell patch clamp recording of glutamate-induced N-methyl-d-aspartate (NMDA) currents from CA1 pyramidal neurons showed a larger potentiation of these currents after application of 15 microM dl-threo-beta-benzyloxyaspartic acid (TBOA; a potent blocker of glutamate transporters) in ceftriaxone-injected animals than in untreated animals, indicating increased glutamate transporter activity. Western blot analysis did not reveal GLT-1 upregulation in the hippocampus. Delay to OGD-induced hypoxic spreading depression (HSD) recorded in slices obtained from ceftriaxone-treated rats was longer (6.3+/-0.2 vs. 5.2+/-0.2 min; P<0.001) than that in the control group, demonstrating a neuroprotective action of the antibiotic in this model. The effect of ceftriaxone was also tested in organotypic hippocampal slices obtained from P7-9 rats (>14 days in vitro). OGD or glutamate (3.5-5.0 mM) damaged CA1 pyramidal neurons as assessed by propidium iodide (PI) fluorescence. Similar damage was observed after pre-treatment with ceftriaxone (10-200 microM; 5 days) and ceftriaxone exposure did not result in GLT-1 upregulation as assayed by Western blot. Treatment of slice cultures with dibutyryl cAMP (100-250 microM; 5 days) increased GLT-1 expression but did not reduce cell damage induced by OGD or glutamate. Thus we confirm the neuroprotective effect of antibiotic exposure on OGD-induced injury, but suggest that this action is related to independent modulation of transporter activity rather than to the level of GLT-1 protein expression. In addition, our results indicate that the protective effects of beta-lactam antibiotics are highly dependent on the experimental model.

Nod factor enhances calcium uptake by soybean

Inoculation with rhizobia or application of Nod factors (lipo-chitooligosaccharides, LCOs) causes transient increases in cytosolic calcium concentration in root hairs of legume plants. We conducted experiments to evaluate whether application of LCO and inoculation with rhizobia improved (45)CaCl(2) uptake into soybean (Glycine max [L.] Merr.) leaves. Roots of soybean seedlings with one developing trifoliolate were immersed in Murashige and Skoog (MS) basal liquid medium containing treatment solutions and (45)CaCl(2), and the plants were incubated under continuous light. After 24 h, leaf samples were taken, and their radioactivity levels were determined. Addition of NodBj-V (C18:1 MeFuc) at a concentration of 10(-7) M increased (45)Ca(2+) uptake. Inoculation with genistein-induced Bradyrhizobium japonicum strain 532C and USDA3 also increased (45)Ca(2+) uptake; whereas, inoculation with strain Bj-168, a nodC-mutant incapable of producing LCO, did not. Rhizobia that do not normally nodulate soybean, i.e. Rhizobium leguminosarum, and Sinorhizobium meliloti did not affect calcium uptake, nor did the tetramer or pentamer of chitosan, or lumichrome. Surprisingly, Rhizobium sp. NGR234, which can nodulate some types of soybean, although without effective N(2)-fixation, also did not affect calcium uptake. This work suggests that the rhizobial symbiosis, in addition to its known role in provision of nitrogen fixation, also improves early calcium uptake into soybean plants.

Indoor air modification interventions for prolonged non-specific cough in children

BACKGROUND

Non-specific cough has been defined as non-productive cough in the absence of identifiable respiratory disease or known aetiology and is common in childhood. These children are treated with a variety of therapies, including non-pharmacological treatments. There is a wide variety and a growing market for these non-pharmacological treatments that include air-modification modalities.

OBJECTIVES

To determine the efficacy of air-modification modalities, (ionisers, vaporisers, humidifiers, air filters, regular vacuuming), in treating children with non-specific cough.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, OLDMEDLINE and EMBASE databases were searched by the Cochrane Airways Group. The latest searches were performed in November 2005.

SELECTION CRITERIA

All randomised controlled trials comparing air-modification modalities with a placebo treatment, for any duration.

DATA COLLECTION AND ANALYSIS

Results of searches were reviewed against pre-determined criteria for inclusion. Five papers were considered for inclusion but no eligible trials were identified and thus no data was available for analysis.

MAIN RESULTS

No randomised controlled trials that examined the efficacy of air-modification modalities in the management of prolonged, non-specific cough in children were found.

AUTHORS' CONCLUSIONS

Based on the evidence currently available, a recommendation can not be given for air-modification interventions in the treatment of prolonged, non-specific cough in children.

A pilot study of oral L-arginine in cystic fibrosis

Exhaled nitric oxide has previously been found to be low in cystic fibrosis. The aim of this study was to determine whether exhaled nitric oxide levels would increase in response to oral L-arginine supplementation administered daily for 4 weeks. Exhaled and nasal nitric oxide was measured weekly. Plasma L-arginine levels increased in response to supplementation but this was not reflected in an increase in eNO levels.