Dietary intervention in gestational diabetes: a qualitative study of the acceptability and feasibility of a novel whole-diet intervention in healthcare professionals

Gestational diabetes is treated with medical nutrition therapy, delivered by healthcare professionals; however, the optimal diet for affected women is unknown. Randomised controlled trials, such as the DiGest (Dietary Intervention in Gestational Diabetes) trial, will address this knowledge gap, but the acceptability of whole-diet interventions in pregnancy is unclear. Whole-diet approaches reduce bias but require high levels of participant commitment and long intervention periods to generate meaningful clinical outcomes. We aimed to assess healthcare professionals' views on the acceptability of the DiGest dietbox intervention for women with gestational diabetes and to identify any barriers to adherence which could be addressed to support good recruitment and retention to the DiGest trial. Female healthcare professionals (n 16) were randomly allocated to receive a DiGest dietbox containing 1200 or 2000 kcal/d including at least one weeks' food. A semi-structured interview was conducted to explore participants' experience of the intervention. Interviews were audio-recorded, transcribed verbatim and analysed thematically using NVivo software. Based on the findings of qualitative interviews, modifications were made to the dietboxes. Participants found the dietboxes convenient and enjoyed the variety and taste of the meals. Factors which facilitated adherence included participants having a good understanding of study aims and sufficient organisational skills to facilitate weekly meal planning in advance. Barriers to adherence included peer pressure during social occasions and feelings of deprivation or hunger (affecting both standard and reduced calorie groups). Healthcare professionals considered random allocation to a whole-diet replacement intervention to be acceptable and feasible in a clinical environment and offered benefits to participants including convenience.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Understanding the relationship between oral health and psychosis: qualitative analysis

BACKGROUND

Individuals with psychosis have poor oral health compared with the general population. The interaction between oral health and psychosis is likely to be complex and have important ramifications for improving dental and mental health outcomes. However, this relationship is poorly understood and rarely studied using qualitative methods.

AIMS

To explore patient perspectives on the relationship between oral health and psychosis.

METHOD

The authors recruited 19 people with experiences of psychosis from community mental health teams, early intervention in psychosis services, and rehabilitation units. Participants completed a qualitative interview. Transcripts were analysed with reflexive thematic analysis.

RESULTS

The analysis resulted in three themes: theme 1, psychosis creates barriers to good oral health, including a detachment from reality, the threat of unusual experiences and increased use of substances; theme 2, the effects of poor oral health in psychosis, with ramifications for self-identify and social relationships; and theme 3, systems for psychosis influence oral health, with central roles for formal and informal support networks.

CONCLUSIONS

Psychosis was perceived to affect adherence to oral health self-care behaviours and overall oral health. Poor oral health negatively affected self-identity and social relationships. Clinical implications include a systemic approach to provide early intervention and prevention of the sequelae of dental disease, which lead to tooth loss and impaired oral function and aesthetics, which in turn affect mental health. Participants felt that mental health services play an important role in supporting people with oral health.

Evidence of Antineutrinos from Distant Reactors Using Pure Water at SNO

The SNO+ Collaboration reports the first evidence of reactor antineutrinos in a Cherenkov detector. The nearest nuclear reactors are located 240 km away in Ontario, Canada. This analysis uses events with energies lower than in any previous analysis with a large water Cherenkov detector. Two analytical methods are used to distinguish reactor antineutrinos from background events in 190 days of data and yield consistent evidence for antineutrinos with a combined significance of 3.5σ.

The barriers and facilitators to research in practice: the experiences of a medicines optimisation team within a clinical commissioning group

Introduction

Research active healthcare organisations and staff have been shown to significantly improve performance and patient outcomes1. Undertaking research is a core element of the pharmacist role, however many pharmacists report not having the skills, knowledge and/or resources to take part2. There are many opportunities for the delivery of transformational research within primary care, however pharmacy team engagement is lacking.

Aim

To explore the barriers and facilitators to research engagement within a Clinical Commissioning Group (CCG) Medicines Optimisation team.

Methods

Twelve focus groups, guided by a semi-structured topic guide, were held over MS Teams between October 2021 and February 2022. 37 participants (pharmacists, pharmacy technicians and administrative support roles) attended and discussed topics relating to their experiences of engaging with research, as well as what helped or hindered them. Detailed notes were taken and analysed using Thematic Analysis. Following this inductive analysis, which aimed to capture all themes arising from the data, the Consolidated Framework for Implementation Research (CFIR)3 was applied. This helped to categorise the barriers and facilitators into domains which influence to what extent research is undertaken. The analysis was validated by the CCG team. This study was deemed to be service evaluation and therefore no ethical approval was needed.

Results

Three core themes emerged: People, Place and Practicalities. Individuals felt they had limited knowledge and capabilities in the field of research, despite having an internal motivation to engage in research activity. The perception of research was often linked in peoples’ thoughts to academia or secondary care/ acute Trusts or lab-based, and therefore not really something they would engage with in their current role. A lack of research culture, leadership and visibility of projects were all thought to hinder the team. A clear need for training and education in research (what it is, how it can be done, and available tools) was expressed, as well as appropriate resource allocation. Mapping to the CFIR illustrated that most barriers fell within the inner setting (i.e. the organisation itself) and with the process of conducting research, such as limited time, lack of encouragement from champions and poor feedback from projects. Enablers were also identified which included advice offered by external organisations, dissemination about work conducted in other primary care organisations and beliefs about the benefits of being research active.

Discussion/Conclusion

Participants perceived there to be many more barriers to research engagement than enablers, and these ranged from challenges with the individual projects, the process of conducting research within the organisation, things about the person themselves, their organisation or the wider setting of primary care. Areas for improvement were identified, mainly through increased training, visibility of projects and interested people, development of champions and role models, and stronger links with academia. This study was conducted with only one CCG and therefore further work needs to explore the experience within other integrated care boards and across secondary and community practice.

References

1. Hanney, S., Boaz, A., Soper, B. and Jones, T. Engagement in research: an innovative three-stage review of the benefits for health-care performance. Health Services and Delivery Research, 2013;1(8). ISSN (print) 2050-4349

2. Crilly P, Patel N, Ogunrinde A, Berko D, Kayyali R. Community Pharmacists’ Involvement in Research in the United Kingdom. Pharmacy. 2017;5(3):48. https://doi.org/10.3390/pharmacy5030048

3. Damschroder, L.J., Aron, D.C., Keith, R.E. et al. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Sci 2009;4:50. https://doi.org/10.1186/1748-5908-4-50

Community-Based Malaria Testing Reduces Polypharmacy in a Population-Based Survey of Febrile Illness in Western Kenya

Objective: The objective was to describe the relationship between the location of care, the malaria test result, and the type of medicine consumed for the fever, and to determine whether community-based access to malaria testing reduced polypharmacy.

Methods: This is a secondary analysis of a cluster-randomized trial of an intervention designed to increase diagnostic testing and targeting of Artemesinin Combined Therapies (ACTs). Data collected at baseline, 12, and 18 months were analyzed to determine the impact of diagnostic testing on drug consumption patterns among febrile individuals.

Results: Of the 5,756 participants analyzed, 60.1% were female, 42% were aged 5–17 years, and 58.1% sought care for fever in a retail outlet. Consumption of both ACT and antibiotics was 22.1% (n = 443/2008) at baseline. At endline, dual consumption had declined to 16.6%. There was reduced antibiotic consumption among those testing positive for malaria (39.5%–26.5%) and those testing negative (63.4%–55.1%), accompanied by a substantial decline in ACT use among malaria-negative participants.

Conclusion: Diagnostic testing for malaria reduces dual consumption of ACTs and antibiotics, especially among those testing outside the formal healthcare sector.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

UK Research and Innovation and National Institute for Health Research.

Does Higher Intraoperative Fraction of Inspired Oxygen Improve Complication Rates Following Implant-Based Breast Reconstruction?

Background

The surgical literature debates about whether an average intraoperative fractional inspired level of oxygen (FiO₂) greater than 80% confers lower postsurgical complication rates. Although some evidence demonstrates minimal or no difference in short-term mortality or surgical site infections, few studies suggest negative long-term outcomes.

Objectives

To the best of our knowledge, this is the first study examining the relationship between intraoperative FiO₂ levels and postoperative outcomes in the setting of immediate prepectoral implant-based breast reconstruction.

Methods

The authors retrospectively reviewed the complication profiles of 309 patients who underwent prepectoral 2-stage breast reconstruction following mastectomy between 2018 and 2021 at a single institution. Two cohorts were created based on whether intraoperative FiO₂ was greater than 80% or less than or equal to 80%. Complication rates between the cohorts were analyzed using Chi-squared test, Fisher's exact test, and multivariable logistic regressions. Variables examined included demographic information; smoking history; preexisting comorbidities; history of chemotherapy, radiation, or axillary lymph node dissection; and perioperative information.

Results

Chi-squared and multivariable regression analysis demonstrated no significant difference between cohorts in complication rates other than reoperation. Reoperation rates were significantly increased in the FiO₂ greater than 80% cohort (P = 0.018). Multivariable logistic regression also demonstrated that the use of acellular dermal matrix was significantly associated with increased postoperative complications (odds ratio 11.985; P = 0.034).

Conclusions

Complication rates did not statistically differ in patients with varying intraoperative FiO₂ levels outside of reoperation rates. In the setting of implant-based prepectoral breast reconstruction, hyperoxygenation likely does not lead to improved postsurgical outcomes.

Level of Evidence 3

Oral health self-care behaviours in serious mental illness: A systematic review and meta-analysis

AIM

To understand the relationship between serious mental illness and oral health self-care behaviours using meta-analytic methods and a narrative synthesis of available literature.

METHOD

The review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines [PROSPERO reference: CRD42020176779]. Search terms pertaining to serious mental illness and oral health were entered into EMBASE, PsycINFO, Medline and CINAHL. Eligible studies included a sample of people with a serious mental illness and a quantitative measure of an oral health self-care behaviour (eg dental visits, toothbrushing). The Effective Public Health Practice Project tool was utilised to appraise the quality of the literature. Studies in the meta-analysis contained a non-clinical or general population comparator sample.

RESULTS

People with a serious mental illness were significantly less likely to visit the dentist (OR 0.46, 95% CI 0.32-0.065, p > 0.001) or brush their teeth (OR 0.19, 95% CI 0.08-0.42, p < 0.001) when compared to non-clinical comparator samples. Few studies explored other oral health self-care behaviours (eg flossing and mouth washing), but uptake was generally low in people with a serious mental illness. The study quality of included studies was variable.

CONCLUSIONS

The research showed a reduced uptake of oral health self-care behaviours in people with a serious mental illness. Suboptimal oral health can negatively impact on physical, social and psychological functioning. Further research is needed to understand the reasons for low rates of oral health self-care behaviours in this population.

Community Science for Coastal Acidification Monitoring and Research

Ocean and coastal acidification (OCA) present a unique set of sustainability challenges at the human-ecological interface. Extensive biogeochemical monitoring that can assess local acidification conditions, distinguish multiple drivers of changing carbonate chemistry, and ultimately inform local and regional response strategies is necessary for successful adaptation to OCA. However, the sampling frequency and cost-prohibitive scientific equipment needed to monitor OCA are barriers to implementing the widespread monitoring of dynamic coastal conditions. Here, we demonstrate through a case study that existing community-based water monitoring initiatives can help address these challenges and contribute to OCA science. We document how iterative, sequential outreach, workshop-based training, and coordinated monitoring activities through the Northeast Coastal Acidification Network (a) assessed the capacity of northeastern United States community science programs and (b) engaged community science programs productively with OCA monitoring efforts. Our results (along with the companion manuscript) indicate that community science programs are capable of collecting robust scientific information pertinent to OCA and are positioned to monitor in locations that would critically expand the coverage of current OCA research. Furthermore, engaging community stakeholders in OCA science and outreach enabled a platform for dialogue about OCA among other interrelated environmental concerns and fostered a series of co-benefits relating to public participation in resource and risk management. Activities in support of community science monitoring have an impact not only by increasing local understanding of OCA but also by promoting public education and community participation in potential adaptation measures.

Synoptic assessment of coastal total alkalinity through community science

Comprehensive sampling of the carbonate system in estuaries and coastal waters can be difficult and expensive because of the complex and heterogeneous nature of near-shore environments. We show that sample collection by community science programs is a viable strategy for expanding estuarine carbonate system monitoring and prioritizing regions for more targeted assessment. 'Shell Day' was a single-day regional water monitoring event coordinating coastal carbonate chemistry observations by 59 community science programs and seven research institutions in the northeastern United States, in which 410 total alkalinity (TA) samples from 86 stations were collected. Field replicates collected at both low and high tides had a mean standard deviation between replicates of 3.6 ± 0.3 μmol kg^-1 (σ _mean ± SE, n = 145) or 0.20 ± 0.02%. This level of precision demonstrates that with adequate protocols for sample collection, handling, storage, and analysis, community science programs are able to collect TA samples leading to high-quality analyses and data. Despite correlations between salinity, temperature, and TA observed at multiple spatial scales, empirical predictions of TA had relatively high root mean square error >48 μmol kg^-1. Additionally, ten stations displayed tidal variability in TA that was not likely driven by low TA freshwater inputs. As such, TA cannot be predicted accurately from salinity using a single relationship across the northeastern US region, though predictions may be viable at more localized scales where consistent freshwater and seawater endmembers can be defined. There was a high degree of geographic heterogeneity in both mean and tidal variability in TA, and this single-day snapshot sampling identified three patterns driving variation in TA, with certain locations exhibiting increased risk of acidification. The success of Shell Day implies that similar community science based events could be conducted in other regions to not only expand understanding of the coastal carbonate system, but also provide a way to inventory monitoring assets, build partnerships with stakeholders, and expand education and outreach to a broader constituency.

Synoptic assessment of coastal total alkalinity through community science

Comprehensive sampling of the carbonate system in estuaries and coastal waters can be difficult and expensive because of the complex and heterogeneous nature of near-shore environments. We show that sample collection by community science programs is a viable strategy for expanding estuarine carbonate system monitoring and prioritizing regions for more targeted assessment. 'Shell Day' was a single-day regional water monitoring event coordinating coastal carbonate chemistry observations by 59 community science programs and seven research institutions in the northeastern United States, in which 410 total alkalinity (TA) samples from 86 stations were collected. Field replicates collected at both low and high tides had a mean standard deviation between replicates of 3.6 ± 0.3 μmol kg-1 (σ mean ± SE, n = 145) or 0.20 ± 0.02%. This level of precision demonstrates that with adequate protocols for sample collection, handling, storage, and analysis, community science programs are able to collect TA samples leading to high-quality analyses and data. Despite correlations between salinity, temperature, and TA observed at multiple spatial scales, empirical predictions of TA had relatively high root mean square error >48 μmol kg-1. Additionally, ten stations displayed tidal variability in TA that was not likely driven by low TA freshwater inputs. As such, TA cannot be predicted accurately from salinity using a single relationship across the northeastern US region, though predictions may be viable at more localized scales where consistent freshwater and seawater endmembers can be defined. There was a high degree of geographic heterogeneity in both mean and tidal variability in TA, and this single-day snapshot sampling identified three patterns driving variation in TA, with certain locations exhibiting increased risk of acidification. The success of Shell Day implies that similar community science based events could be conducted in other regions to not only expand understanding of the coastal carbonate system, but also provide a way to inventory monitoring assets, build partnerships with stakeholders, and expand education and outreach to a broader constituency.

Association of maternal depression and home adversities with infant hypothalamic-pituitary-adrenal (HPA) axis biomarkers in rural Pakistan

BACKGROUND

Each year, almost 35% of children are exposed to maternal depression and more grow up in persistent poverty, increasing the risk for stress-related disease and other socio-developmental deficits later in life. These impacts are likely related to chronic stress via the hypothalamic-pituitary-adrenal (HPA) axis. However, there is little evidence relating early windows of child HPA axis activity to multiple exposures.

METHODS

We investigated chronic measures of hair-derived HPA axis hormones (cortisol and dehydroepiandrosterone (DHEA)) in 104 one-year old infants from rural Pakistan and longitudinal measures of maternal depression, intimate partner violence (IPV), socio-economic status (SES), and the home environment.

RESULTS

Estimates from adjusted linear mixed effects models did not reveal consistent significant associations between infant cortisol and maternal depression or home adversities. By contrast, infants exposed to maternal depression during pregnancy had lower DHEA levels (ß= -0.18 95% confidence interval [CI]: -0.34, -0.02) as did those whose mothers experienced multiple types of IPV (ß=-4.14 95% CI: -7.42, -0.79) within one year postpartum. Higher SES had a significant positive association with infant DHEA levels (ß= 0.77 95% CI: 0.08, 1.47). Depression severity and chronicity at one year postpartum had near significant associations with infant DHEA. Measures of home environment had no observable impacts on infant HPA axis activity.

LIMITATIONS

Limitations include the modest sample size and aggregation of hair samples for analysis.

CONCLUSION

Results point to possible early HPA axis dysregulation driven by changes in DHEA activity, but not cortisol at one year of age. Findings contribute to growing research examining intergenerational transmissions of maternal depression, IPV, and household environment on infant stress-response systems.

Dynamics of Cadmium Acclimation in Daphnia pulex: Linking Fitness Costs, Cross-Tolerance, and Hyper-Induction of Metallothionein

Acclimation increases tolerance to stress in individuals but is assumed to contribute fitness costs when the stressor is absent, though data supporting this widely held claim are sparse. Therefore, using clonal (i.e., genetically identical) cultures of Daphnia pulex, we isolated the contributions of acclimation to the regulation of the metal response gene, metallothionein 1 (MT1), and defined the reproductive benefits and costs of cadmium (Cd)-acclimation. Daphnia pulex were exposed for 50 parthenogenetic generations to environmentally realistic levels (1 μg Cd/L), and tolerance to Cd and other metals assessed during this period via standard toxicity tests. These tests revealed (1) increased tolerance to Cd compared to genetically identical nonacclimated cultures, (2) fitness costs in Cd-acclimated Daphnia when Cd was removed, and (3) cross-tolerance of Cd-acclimated Daphnia to zinc and silver, but not arsenic, thereby defining a functional role for metallothionein. Indeed, Cd-acclimated clones had significantly higher expression of MT1 mRNA than nonacclimated clones, when Cd exposed. Both the enhanced induction of MT1 and tolerant phenotype were rapidly lost when Cd was removed (1-2 generations), which is further evidence of acclimation costs. These findings provide evidence for the widely held view that acclimation is costly and are important for investigating evolutionary principles of genetic assimilation and the survival mechanisms of natural populations that face changing environments.

Quantum Spin Dynamics in Fock Space Following Quenches: Caustics and Vortices

Caustics occur widely in dynamics and take on shapes classified by catastrophe theory. At finite wavelengths they produce interference patterns containing networks of vortices (phase singularities). Here we investigate caustics in quantized fields, focusing on the collective dynamics of quantum spins. We show that, following a quench, caustics are generated in the Fock space amplitudes specifying the many-body configuration and which are accessible in experiments with cold atoms, ions, or photons. The granularity of quantum fields removes all singularities, including phase singularities, converting point vortices into nonlocal vortices that annihilate in pairs as the quantization scale is increased. Furthermore, the continuous scaling laws of wave catastrophes are replaced by discrete versions. Such "quantum catastrophes" are expected to be universal dynamical features of quantized fields.

Design of N-Benzoxaborole Benzofuran GSK8175-Optimization of Human Pharmacokinetics Inspired by Metabolites of a Failed Clinical HCV Inhibitor

We previously described the discovery of GSK5852 (1), a non-nucleoside polymerase (NS5B) inhibitor of hepatitis C virus (HCV), in which an N-benzyl boronic acid was essential for potent antiviral activity. Unfortunately, facile benzylic oxidation resulted in a short plasma half-life (5 h) in human volunteers, and a backup program was initiated to remove metabolic liabilities associated with 1. Herein, we describe second-generation NS5B inhibitors including GSK8175 (49), a sulfonamide-N-benzoxaborole analog with low in vivo clearance across preclinical species and broad-spectrum activity against HCV replicons. An X-ray structure of NS5B protein cocrystallized with 49 revealed unique protein-inhibitor interactions mediated by an extensive network of ordered water molecules and the first evidence of boronate complex formation within the binding pocket. In clinical studies, 49 displayed a 60–63 h half-life and a robust decrease in viral RNA levels in HCV-infected patients, thereby validating our hypothesis that reducing benzylic oxidation would improve human pharmacokinetics and lower efficacious doses relative to 1.

Abstract 2153: Development of a novel MEK mutation driven drug resistant melanoma model by CRISPR/Cas9 technology

Melanoma remains the most lethal form of skin cancer exhibiting high mortality rates due to a high likelihood of developing metastases and acquiring drug resistance. Approximately 40-50% of melanomas contain oncogenic BRAF mutations of which 75-90% harbor the BRAFV600E mutation. This mutation constitutively activates the mitogen-activating protein kinase (MAPK) signaling pathway leading to uncontrolled cell growth and oncogenesis. Recent combination therapies of BRAF and MEK specific inhibitors have shown improved progression-free patient response in phase II clinical trials. However, in the majority of patients, acquired resistance to MAPK pathway inhibitor therapies develops after approximately 12 months of treatment. Preclinical studies have suggested that MEK1 mutations confer resistance to BRAF and MEK inhibitors. In this study, we used the CRISPR genome editing technology to generate a drug resistant MEK1Q56P knock-in mutation within the A375 melanoma cell line which naturally harbors the BRAFV600E mutation. We validated this new isogenic cell model using both molecular and biofunctional approaches. Method and results: Single guide RNAs (sgRNAs) were designed and built into Cas9 plasmids to bind and cut desired regions in the MEK1 target region. The melanoma cell line A375 was co-transfected with single guide-containing Cas9 plasmids and donor plasmids. Single cells were cloned and expanded for subsequent screening of the desired gene mutation events. The introduction of the MEK1Q56P mutation in the cells was then confirmed via Sanger sequencing and NGS at the genetic level. Validation of the mutation in mRNA transcripts was carried out by RT-PCR followed by sequencing. The cell line maintains permanent and genetically stable resistance characteristics during cell culture expansion without the use of selective pressure. Drug responses to BRAF and MEK1 specific inhibitors and non-specific chemotherapy drugs were compared between the A375 MEK1Q56P isogenic cell line and the parental cell line in 2D and 3D culture environments. Results demonstrated that the isogenic MEK1Q56P cell line showed significant and specific resistance to BRAF inhibitors in comparison to the parental A375 line. Using gene editing we have targeted an endogenous loci within a melanoma cell line creating a novel in-vitro model to aid in basic and translational melanoma research as well as drug screening efforts. This new approach to cell line development provides direct in vitro bio-functional evidence of a drug resistant gene driving tumor cells survival under targeted anti-cancer treatments. Furthermore, this A375 MEK1Q56P isogenic cell line represents a new type of drug resistance model that contains a defined genetic resistance mechanism. This model provides an invaluable tool for developing next generation therapeutics that can overcome drug resistance in melanoma.

Citation Format: Lysa-Anne Volpe, Metewo Selase Enuameh, Luping Chen, Elizabeth Turner, John Foulke, Fang Tian. Development of a novel MEK mutation driven drug resistant melanoma model by CRISPR/Cas9 technology [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2153.

Abstract 5021: Assessment of RAS-RAF-MAPK pathway perturbations and PD-L1 expression in an Isogenic 3D tissue-culture model of drug-resistant melanoma

Development of the next generation of anti-cancer drugs, biologics, and immunotherapies is currently hampered by extremely poor success rates of seemingly promising experimental therapies in human clinical trials. This poor success rate is partially due to a lack of biologically relevant cancer model systems. The 2D culture system, while relatively inexpensive and easy to use, may not always be adequately representative of the tumor microenvironment. Conversely, the use of animal models is costly and time consuming. The 3D culture system is able to represent biologically relevant complexities such as cell-cell communication, differential proliferation rates, and compound penetration. Combining 3D culture with CRISPR/Cas9 genome editing technologies can generate powerful cell-based model systems with both physiological relevance and well-controlled genetic and drug-susceptibility profiles. These new models will enable the investigation of specific molecular mechanisms, biofunctional outcomes of newly identified genetic alternations, and targeted therapeutic drug responses within a more biologically intricate context. In this study, we use CRISPR/Cas9 to generate isogenic drug-resistant melanoma models that can be used as either 2D or 3D cancer models, as well as for studies of the acquired drug resistance. Two different models were generated starting with the BRAF-inhibitor sensitive A375 melanoma cell line. We introduced either the NRASQ61K or the KRASG13D point mutations, both of which are known to confer BRAF inhibitor resistance and are commonly encountered in BRAF-resistant tumor samples. We then assessed the susceptibility of these new isogenic lines to BRAF inhibitors in both 2D and 3D model systems. We also determined the specific effect of these point mutations on the RAS-RAF-MAPK signaling pathway, a key component of cell-cycle escape and tumor proliferation. Furthermore, we assessed the impact of these mutations on the expression of Programmed Death-Ligand 1 (PD-L1), which recent advances in cancer immunology have directly linked to cancer immune evasion and poor clinical outcomes. Our results show that A375 melanoma isogenic cells carrying KRASG13D have dramatically increased EGFR expression levels, while isogenic cells carrying NRASQ61K have constant activation of the MEK-ERK pathway. We also found a significant increase in PD-L1 expression in KRASG13D, but not in NRASQ61K A375 cells, indicating that expression of PD-L1 is directly linked to KRAS mutation or the downstream effects thereof, rather than to a general increase in RAS-RAF-MAPK signaling. These results have direct implications for cancer immune checkpoint molecule studies, and highlight the utility of these isogenic melanoma models in both 2D and 3D applications in research and development of novel anti-cancer drugs and combination therapies.

Citation Format: Elizabeth Turner, Luping Chen, Johnathan Haag, Alexei Miagkov, Lysa-Anne Volpe, Metewo Selase Enuameh, Robert Newman, Fang Tian. Assessment of RAS-RAF-MAPK pathway perturbations and PD-L1 expression in an Isogenic 3D tissue-culture model of drug-resistant melanoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5021.

Abstract 2012: The generation of a NSCLC EMT reporter cell line for metastatic lung cancer drug discovery and development

Cancer metastasis continues to be the leading cause of mortality in cancer patients around the world. One of the prominent biological processes implicated in cancer metastasis is epithelial-to-mesenchymal transition (EMT). EMT has also been shown to have roles in many aspects of cancer initiation and progression, including tumorigenesis and drug resistance. Despite the accumulation of a large body of data on the association of EMT with cancer, to date, EMT has not been an active target for therapeutic development partly due to the lack of appropriate in vitro models. Utilizing some of the basic biology of EMT, we have created a novel advanced in vitro model for use in both basic research and discovery of new anti-EMT drugs.

In lung cancer, vimentin (VIM) intermediate filament (IF) proteins are associated with EMT, and the metastatic spread of cancer. Vimentin expression is generally upregulated when epithelial cells transition to the mesenchymal phenotype. We capitalized on this biological phenomenon, using CRISPR/Cas9 gene editing to generate a VIM RFP (red fluorescent protein) reporter cell line in the A549 non-small cell lung cancer (NSCLC) cell line; one of the most widely used and recognized lung cancer cell lines. The A549 VIM RFP cell line harbors a C-terminal red fluorescent protein (RFP) tag on the vimentin gene which enables end-point or real-time tracking of the EMT status as cells transition from epithelial to mesenchymal phenotype under defined conditions. The EMT reporter cell line was verified at the nucleic acid (genomic and mRNA) and protein levels as well as in cell-based assays. Bio-functional evaluation of the A549 VIM RFP cell line shows sensitivity to metastatic NSCLC drugs PP1 (SRC inhibitor) and A83-01 (ALK5 inhibitor). These results provide the foundation for the use of this cell line in high throughput screening (HTS) applications including the identification of new anti-EMT drugs for metastatic NSCLC. Furthermore, the A549 Vim RFP reporter cell line is also a convenient and sensitive model for basic science research on the mechanisms of metastasis.

Citation Format: Metewo S. Enuameh, Sangeeta Kumari, Chauzhong Zou, John Foulke, Elizabeth Turner, Weiguo Shu, Robert Newman. The generation of a NSCLC EMT reporter cell line for metastatic lung cancer drug discovery and development [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2012.

Abstract 4948: Characterization of hTERT-immortalized prostate-derived stromal and epithelial cells: An authentic in vitro model for tumor microenvironment studies

Tumor development begins with mutational changes to the genetic makeup of a cell, but its progression is not solely determined by the mutated cell, but also by the tumor’s microenvironment. Prostate cancer, a leading cancer diagnosed in men, has been shown to be highly influenced by its surrounding stroma, particularly fibroblasts. It has been demonstrated that cancer-associated prostate fibroblast (CAFs) differ from normal-associated prostate fibroblast (NAFs). However, human prostate cancer model systems have focused largely on prostate cancer epithelial cells. Currently, a need exists for a more physiologically relevant human cell model system to study prostate cancer progression within the context of its tumor microenvironment. In this study, we characterized three prostate-derived cells: prostate cancer-associated fibroblast (CAFs), prostate normal-associated fibroblast (NAFs) and prostate cancer epithelial (PrE) cells; all three lines were immortalized by hTERT (human telomerase reverse transcriptase) alone, and have been continuously passaged for more than 40 PDL in our hands. Our data shows that the hTERT immortalized CAFs proliferate faster than the NAFs; in addition, both CAFs and NAFs express fibroblast markers such as TE7 and alpha smooth muscle actin (α-SMA), while neither cell line expresses epithelial marker such as CK14. Both CAFs and NAFs also express elevated levels of α-SMA upon TGF-β stimulation. All three prostate-derived cells express the prostate specific marker AR, and show similar markers staining after long time passaging. Importantly, conditioned media collected from CAFs promotes tumor cell growth better than NAF conditioned media. In conclusion, CAFs, NAFs, and immortalized prostate cancer epithelium may provide a very valuable model system for the study of prostate cancer cell progression and tumor microenvironment studies.

Citation Format: Luis G. Rodriguez, Russell E. McDaniel, Xiangshan Zhao, Elizabeth Turner, Christopher Annesi, Chaozhong Zou. Characterization of hTERT-immortalized prostate-derived stromal and epithelial cells: An authentic in vitro model for tumor microenvironment studies [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 4948. doi:10.1158/1538-7445.AM2017-4948

Dissecting Torsin/cofactor function at the nuclear envelope: a genetic study

Torsins are essential, disease-relevant ATPases, but their function is unknown. Monitoring of nuclear envelope morphology after deletion of multiple Torsins or their cofactors reveals a robust inner nuclear membrane–blebbing phenotype in HeLa cells. Nucleoporins and ubiquitin are defining molecular components of these omega-shaped blebs.

The human genome encodes four Torsin ATPases, the functions of which are poorly understood. In this study, we use CRISPR/Cas9 engineering to delete all four Torsin ATPases individually and in combination. Using nuclear envelope (NE) blebbing as a phenotypic measure, we establish a direct correlation between the number of inactivated Torsin alleles and the occurrence of omega-shaped herniations within the lumen of the NE. A similar, although not identical, redundancy is observed for LAP1 and LULL1, which serve as regulatory cofactors for a subset of Torsin ATPases. Unexpectedly, deletion of Tor2A in a TorA/B/3A-deficient background results in a stark increase of bleb formation, even though Tor2A does not respond to LAP1/LULL1 stimulation. The robustness of the observed phenotype in Torsin-deficient cells enables a structural analysis via electron microscopy tomography and a compositional analysis via immunogold labeling. Ubiquitin and nucleoporins were identified as distinctively localizing components of the omega-shaped bleb structure. These findings suggest a functional link between the Torsin/cofactor system and NE/nuclear pore complex biogenesis or homeostasis and establish a Torsin-deficient cell line as a valuable experimental platform with which to decipher Torsin function.

Learning and practicing police craft

Purpose

The authors consider current policy debates in the UK about the professionalisation of the police to respond to changing patterns of crime and, specifically, the suggestion that officers be educated to degree level. Drawing on the ethnographic evidence, the purpose of this paper is to focus attention on how officers learn, and continue to develop the applied, that is the craft aspects of the work of uniformed constables.

Design/methodology/approach

The authors draw on a long-term ethnographic project observing officers during the course of their duties. The focus is on the use of discretion and of particular powers. But in the course of the research, the authors also observe the way officers behave and the way they talk about their job.

Findings

The authors suggest that, while there may be a role for degree qualifications, attention needs to be paid to the practices the authors observe, practices that have long been the core craft skills of uniformed officers.

Originality/value

The authors suggest that, despite the emergence of cybercrime and other new forms of crime/threat, the evidence suggests that much has not. Not least, crime is not the only focus of police work.

Impact of a Multidisciplinary Bundle on Time to Antibiotic Administration in Septic SICU Patients

PURPOSE

The goal of this study was to investigate barriers to timely antibiotic administration in septic surgical intensive care unit (SICU) patients and examine the impact of a multidisciplinary bundle on the time from prescription to antibiotic administration.

METHODS

This was a pre- and postintervention study that consisted of 3 phases: (1) preintervention phase, retrospective evaluation of data, (2) intervention implementation, and (3) a postintervention phase. A nurse survey was conducted to identify barriers to rapid antibiotic administration during phase 1. Based on this survey, multidisciplinary interventions included adding antibiotics to the automatic dispensing cabinet, educating monthly staff, and providing an antibiotic dosing table to all prescribers, which is attached to the computer workstations. Our multidisciplinary team consisted of the ICU medical directors, nurse managers, nurses, a critical care fellow, and ICU pharmacists.

RESULTS

The percentage of antibiotics that were received within 60 minutes was 26.3% in the pregroup versus 84.0% in the postgroup ( P < .001). The mean total prescriber to patient time was 110 minutes in the pregroup versus 58.4 minutes in the postgroup ( P < .001).

CONCLUSION

We achieved a higher rate of timely antibiotic administration among septic SICU patients by implementing process changes based on barriers identified by the nurses.

The Lamin B receptor is essential for cholesterol synthesis and perturbed by disease-causing mutations

Lamin B receptor (LBR) is a polytopic membrane protein residing in the inner nuclear membrane in association with the nuclear lamina. We demonstrate that human LBR is essential for cholesterol synthesis. LBR mutant derivatives implicated in Greenberg skeletal dysplasia or Pelger-Huët anomaly fail to rescue the cholesterol auxotrophy of a LBR-deficient human cell line, consistent with a loss-of-function mechanism for these congenital disorders. These disease-causing variants fall into two classes: point mutations in the sterol reductase domain perturb enzymatic activity by reducing the affinity for the essential cofactor NADPH, while LBR truncations render the mutant protein metabolically unstable, leading to its rapid degradation at the inner nuclear membrane. Thus, metabolically unstable LBR variants may serve as long-sought-after model substrates enabling previously impossible investigations of poorly understood protein turnover mechanisms at the inner nuclear membrane of higher eukaryotes.

Thermal variation and factors influencing vertical migration behavior in Daphnia populations

The antipredator behavior diel vertical migration (DVM), common in aquatic keystone species Daphnia, involves daily migration from warmer surface waters before dawn to cooler deeper waters after dusk. Plasticity in Daphnia DVM behavior optimizes fitness via trade-offs between growth, reproduction, and predator avoidance. Migration behavior is affected by co-varying biotic and abiotic factors, including light, predator cues, and anthropogenic stressors making it difficult to determine each factor's individual contribution to the variation in this behavior. This study aims to better understand this ecologically significant behavior in Daphnia by: (1) determining how Daphnia pulicaria thermal preferences vary within and among natural populations; (2) distinguishing the role of temperature verses depth in Daphnia vertical migration; and (3) defining how two anthropogenic stressors (copper and nickel) impact Daphnia migratory behavior. Simulated natural lake stratification were constructed in 8L (0.5m tall, 14.5cm wide) water columns to monitor under controlled laboratory conditions the individual effects of temperature gradients, depth, and metal stressors on Daphnia vertical migration. Three major findings are reported. First, while no difference in thermal preference was found among the four populations studied, within lake populations variability among isolates was high. Second, decoupling temperature and depth revealed that depth was a better predictor of Daphnia migratory patterns over temperature. Third, exposure to environmentally relevant concentrations of copper or nickel inhibited classic DVM behavior. These findings revealed the high variability in thermal preference found within Daphnia populations, elucidated the individual roles that depth and temperature have on migratory behavior, and showed how copper and nickel can interfere with the natural response of Daphnia to fish predator cues. Thus contributing to the body of knowledge necessary to predict how natural populations of Daphnia will be affected by climate related changes in lake temperatures and increased presence of anthropogenic stressors.

Pentoxifylline as adjunct therapy to long-term clinical management of a right-to-left patent ductus arteriosus

Management of a right-to-left ("reversed") patent ductus arteriosus (PDA) focuses on control of clinical signs associated with hyperviscosity due to erythrocytosis. Pentoxifylline therapy is presented as an adjunct to routine phlebotomies for the long-term clinical management of reversed PDA in a 10-year-old Chihuahua.

Ultrasound-Guided Cannulation: Time to Bring Subclavian Central Lines Back

Despite multiple advantages, subclavian vein (SCV) cannulation via the traditional landmark approach has become less used in comparison to ultrasound (US) guided internal jugular catheterization due to a higher rate of mechanical complications. A growing body of evidence indicates that SCV catheterization with real-time US guidance can be accomplished safely and efficiently. While several cannulation approaches with real-time US guidance have been described, available literature suggests that the infraclavicular, longitudinal “in-plane” technique may be preferred. This approach allows for direct visualization of needle advancement, which reduces risk of complications and improves successful placement. Infraclavicular SCV cannulation requires simultaneous use of US during needle advancement, but for an inexperienced operator, it is more easily learned compared to the traditional landmark approach. In this article, we review the evidence supporting the use of US guidance for SCV catheterization and discuss technical aspects of the procedure itself.

A cluster-randomized controlled trial to assess the effectiveness of using 15% DEET topical repellent with long-lasting insecticidal nets (LLINs) compared to a placebo lotion on malaria transmission

BACKGROUND

Long-lasting insecticidal nets (LLINs) have limited effect on malaria transmitted outside of sleeping hours. Topical repellents have demonstrated reduction in the incidence of malaria transmitted in the early evening. This study assessed whether 15% DEET topical repellent used in combination with LLINs can prevent greater malaria transmission than placebo and LLINs, in rural Tanzania.

METHODS

A cluster-randomized, placebo-controlled trial was conducted between July 2009 and August 2010 in a rural Tanzanian village. Sample size calculation determined that 10 clusters of 47 households with five people/household were needed to observe a 24% treatment effect at the two-tailed 5% significance level, with 90% power, assuming a baseline malaria incidence of one case/person/year. Ten clusters each were randomly assigned to repellent and control groups by lottery. A total of 4,426 individuals older than six months were enrolled. All households in the village were provided with an LLIN per sleeping space. Repellent and placebo lotion was replaced monthly. The main outcome was rapid diagnostic test (RDT)-confirmed malaria measured by passive case detection (PCD). Incidence rate ratios were estimated from a Poisson model, with adjustment for potential confounders, determined a priori. According-to-protocol approach was used for all primary analyses.

RESULTS

The placebo group comprised 1972.3 person-years with 68.29 (95% C.I 37.05-99.53) malaria cases/1,000 person-years. The repellent group comprised 1,952.8 person-years with 60.45 (95% C.I 48.30-72.60) cases/1,000 person-years, demonstrating a non-significant 11.44% reduction in malaria incidence rate in this group, (Wilcoxon rank sum z=0.529, p=0.596). Principal components analysis (PCA) of the socio-economic status (SES) of the two groups demonstrated that the control group had a higher SES (Pearson's chi square=13.38, p=0.004).

CONCLUSIONS

Lack of an intervention effect was likely a result of lack of statistical power, poor capture of malaria events or bias caused by imbalance in the SES of the two groups. Low malaria transmission during the study period could have masked the intervention effect and a larger study size was needed to increase discriminatory power. Alternatively, topical repellents may have no impact on malaria transmission in this scenario. Design and implementation of repellent intervention studies is discussed.

TRIAL REGISTRATION

The trial was registered ISRCTN92202008--http://www.controlled-trials.com/ISRCTN92202008.

The helping network approach: Community promotion of mental health

The Galt Helping Network Project was a two-year program to augment mental health and community services in a rural California community through the use of natural or informal resources. The experiment made use of a preventive intervention model which identified important needs of local youth and families, board and care residents, the entire community for recreation and for mental health services, and the Mexican American Community for recognition and participation. It brought a number of volunteers into the provision of direct services and created a number of institutional forms by which continued services and enlarged voluntary participation in community affairs are continuing beyond the official end of the project. This article concludes that the Galt Helping Network Model can provide a major contribution to mental health maintenance and community involvement through the recognition of natural helpers and the involvement of the community in an active form of problem solving. Through these methods a community with limited fiscal resources can take a major step toward providing a caring and helping environment for its members.

Utilizing left ventricular outflow tract velocity changes to predict fluid responsiveness in septic patients: a case report

Toxin-mediated vasodilation in the sepsis syndrome can lead to end-organ dysfunction and shock. Assessing for fluid responsiveness and preload optimization with intravenous fluids is a central tenet in the management of sepsis. Aggressive fluid administration can lead to pulmonary edema and heart failure, whereas premature inotropic or vasopressor support can worsen organ perfusion. Inferior vena cava ultrasonography is commonly used to assess for fluid responsiveness but has multiple limitations.

Is it safe and efficacious for women with lymphedema secondary to breast cancer to lift heavy weights during exercise: a randomised controlled trial

PURPOSE

Resistance exercise has great potential to aid in the management of breast cancer-related lymphedema (BCRL); however, little is known regarding optimal exercise prescription. The pervasive view is that resistance exercise with heavy loads may be contraindicated, disregarding the dose-response relationship that exists between the load utilised in resistance exercise and the magnitude of structural and functional improvements. No previous research has examined various resistance exercise prescriptions for the management of BCRL. This study compared the effects of high load and low load resistance exercise on the extent of swelling, severity of symptoms, physical function and quality of life in women with BCRL.

METHODS

Sixty-two women with a clinical diagnosis of BCRL (>5 % inter-limb discrepancy) were randomly assigned to a high-load resistance exercise (n = 22), low-load resistance exercise (n = 21) or usual care (n = 19) group. Participants in the experimental groups completed a 3-month moderate- to high-intensity resistance exercise program in which the load of the exercises was manipulated from 10-6 repetition maximum (75-85 % of one repetition maximum [1RM]) for the high-load group or from 20-15 repetition maximum (55-65 % 1RM) for the low-load group. Outcome measures included the extent of swelling in the affected arm, symptom severity, physical function and quality of life.

RESULTS

There were no differences between groups in the extent of affected arm swelling or severity of symptoms. The change in muscle strength, muscle endurance and quality of life-physical functioning was significantly greater in both high-load and low-load groups compared with the control group (p < 0.040). Change in quality of life-physical function was significantly associated with the change in symptom severity and muscle strength. No lymphedema exacerbations or other adverse events occurred during this trial.

CONCLUSION

Women with BCRL can safely lift heavy weights during upper body resistance exercise without fear of lymphedema exacerbation or increased symptom severity.

IMPLICATIONS FOR CANCER SURVIVORS

Women with breast cancer-related lymphedema can be informed that appropriately prescribed and supervised upper body resistance exercise is safe and can aid in the management of lymphedema through improvements in physical function and quality of life.

Comparative field evaluation of combinations of long-lasting insecticide treated nets and indoor residual spraying, relative to either method alone, for malaria prevention in an area where the main vector is Anopheles arabiensis

Background

Long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) are commonly used together in the same households to improve malaria control despite inconsistent evidence on whether such combinations actually offer better protection than nets alone or IRS alone.

Methods

Comparative tests were conducted using experimental huts fitted with LLINs, untreated nets, IRS plus untreated nets, or combinations of LLINs and IRS, in an area where Anopheles arabiensis is the predominant malaria vector species. Three LLIN types, Olyset®, PermaNet 2.0® and Icon Life® nets and three IRS treatments, pirimiphos-methyl, DDT, and lambda cyhalothrin, were used singly or in combinations. We compared, number of mosquitoes entering huts, proportion and number killed, proportions prevented from blood-feeding, time when mosquitoes exited the huts, and proportions caught exiting. The tests were done for four months in dry season and another six months in wet season, each time using new intact nets.

Results

All the net types, used with or without IRS, prevented >99% of indoor mosquito bites. Adding PermaNet 2.0® and Icon Life®, but not Olyset® nets into huts with any IRS increased mortality of malaria vectors relative to IRS alone. However, of all IRS treatments, only pirimiphos-methyl significantly increased vector mortality relative to LLINs alone, though this increase was modest. Overall, median mortality of An. arabiensis caught in huts with any of the treatments did not exceed 29%. No treatment reduced entry of the vectors into huts, except for marginal reductions due to PermaNet 2.0® nets and DDT. More than 95% of all mosquitoes were caught in exit traps rather than inside huts.

Conclusions

Where the main malaria vector is An. arabiensis, adding IRS into houses with intact pyrethroid LLINs does not enhance house-hold level protection except where the IRS employs non-pyrethroid insecticides such as pirimiphos-methyl, which can confer modest enhancements. In contrast, adding intact bednets onto IRS enhances protection by preventing mosquito blood-feeding (even if the nets are non-insecticidal) and by slightly increasing mosquito mortality (in case of LLINs). The primary mode of action of intact LLINs against An. arabiensis is clearly bite prevention rather than insecticidal activity. Therefore, where resources are limited, priority should be to ensure that everyone at risk consistently uses LLINs and that the nets are regularly replaced before being excessively torn. Measures that maximize bite prevention (e.g. proper net sizes to effectively cover sleeping spaces, stronger net fibres that resist tears and burns and net use practices that preserve net longevity), should be emphasized.