Longitudinal ultrasound imaging and network modeling in rats reveal sex-dependent suppression of liver regeneration after resection in alcoholic liver disease

Liver resection is an important surgical technique in the treatment of cancers and transplantation. We used ultrasound imaging to study the dynamics of liver regeneration following two-thirds partial hepatectomy (PHx) in male and female rats fed via Lieber-deCarli liquid diet protocol of ethanol or isocaloric control or chow for 5–7 weeks. Ethanol-fed male rats did not recover liver volume to the pre-surgery levels over the course of 2 weeks after surgery. By contrast, ethanol-fed female rats as well as controls of both sexes showed normal volume recovery. Contrary to expectations, transient increases in both portal and hepatic artery blood flow rates were seen in most animals, with ethanol-fed males showing higher peak portal flow than any other experimental group. A computational model of liver regeneration was used to evaluate the contribution of physiological stimuli and estimate the animal-specific parameter intervals. The results implicate lower metabolic load, over a wide range of cell death sensitivity, in matching the model simulations to experimental data of ethanol-fed male rats. However, in the ethanol-fed female rats and controls of both sexes, metabolic load was higher and in combination with cell death sensitivity matched the observed volume recovery dynamics. We conclude that adaptation to chronic ethanol intake has a sex-dependent impact on liver volume recovery following liver resection, likely mediated by differences in the physiological stimuli or cell death responses that govern the regeneration process. Immunohistochemical analysis of pre- and post-resection liver tissue validated the results of computational modeling by associating lack of sensitivity to cell death with lower rates of cell death in ethanol-fed male rats. Our results illustrate the potential for non-invasive ultrasound imaging to assess liver volume recovery towards supporting development of clinically relevant computational models of liver regeneration.

Adapting and pilot testing an HIV and intersectional stigma reducing intervention for Dominican Republic healthcare contexts: Protocol for translational research

Background

This protocol details the adaptation and pilot testing of the Finding Respect and Ending Stigma around HIV (FRESH) intervention in Dominican Republic. FRESH is a healthcare setting stigma-reduction intervention designed to reduce stigmas affecting people living with HIV (PLHIV), focusing on HIV and intersectional stigmas experienced by sexual and gender minority (SGM) people living with HIV. After the successful adaptation of the FRESH intervention, it will be pilot-tested through the conduct of a pilot stepped wedge cluster randomized controlled trial.

Methods

Three aims are included in this study; Aim 1 includes exploratory qualitative assessment, specifically the conduct four focus groups with men who have sex with men (MSM) living with HIV (n = 24-32) and in-depth interviews with transgender women living with HIV to explore their experiences with stigma in clinics (n = 9-12). In-depth interviews will also be held with HIV healthcare workers to elucidate their perceptions and behaviors towards their SGM clients (n = 9-12). In Aim 2, informed by Aim 1 data, we will use the sequential phases of the ADAPT-ITT framework to iteratively adapt the FRESH intervention for the Dominican Republic. In Aim 3, the adapted intervention will be pilot-tested via a cluster stepped wedge randomized controlled trial to assess feasibility and acceptability of the intervention and study protocols.

Conclusions

If this pilot trial is successful, next steps will include testing the adapted intervention across Dominican Republic or in similar Spanish-speaking Caribbean nations in a larger trial to assess effectiveness in reducing stigma in clinical settings towards PLHIV.

Esophagectomy for End-Stage Achalasia

Esophagectomy for achalasia is reserved for patients with end-stage disease for whom prior treatment has failed. Esophagectomy can be performed safely through a variety of techniques. Conduit options include stomach, colon, and small intestine. There are many potential complications following esophagectomy. Outcomes of esophagectomy for achalasia are good when performed in experienced surgical centers.

Parenteral NSAIDs for acute treatment of migraine: Adherence to the IHS guidelines for controlled trials

Background:

Parenteral non-steroidal anti-inflammatory drugs (NSAIDs) are important alternatives to oral NSAIDs, especially in patients with severe migraine who have emesis or gastroparesis. With increasing research on using parenteral NSAIDs for acute migraine, it is critical to examine the quality of these studies. Our goal was to assess the adherence of these trials to the International Headache Society (IHS) controlled trial guidelines for acute treatment of migraine.

Methods:

We queried PubMed for clinical trials investigating parenteral NSAIDs for acute treatment of migraine in adult patients. We developed a 14-point scoring system based on the essential components of the IHS guidelines. To date, four versions of the IHS’s Guidelines for controlled trials of acute treatment of migraine attacks have been published. Each trial was evaluated with the appropriate edition of the guidelines.

Results:

We identified 216 studies and assessed 27 eligible clinical trials. The mean score was 6.7 ± 2.1 (2–11). Most trials followed the IHS migraine diagnosis criteria (85.2%), but only six (22.2%) selected patients based on the recommended headache frequency. Most trials were randomized (88.8%), but fewer were double-blinded (74.1%) or placebo-controlled (11.1%). Almost every trial clearly explained the pain scale (96.3%), and three-quarters (77.8%) assessed headache-associated symptoms. However, no trial utilized the recommended primary endpoint: pain-freedom at 2-hours.

Conclusions:

Most clinical trials on parenteral NSAIDs for acute migraine did not fully adhere to the IHS recommendations. Future studies should pay special attention to the IHS guideline to improve the quality of clinical trials for the acute treatment of migraine.

HIV knowledge among cisgender female sex workers of Haitian descent working at the border of Haiti and Dominican Republic

In this brief report, we aim to assess levels of HIV mis-information among cisgender Haitian female sex workers engaged in sex work at the Haiti and Dominican Republic border. We conducted bivariate analyses on the 2014 Border Study on Sex Workers comparing responses from female sex workers on the Haiti side of the border to those from their peers on the Dominican Republic side (N = 212). Prevention of HIV acquisition by correct and consistent condom use with each sex act was correctly endorsed by 90.5% of female sex workers in Haiti but only 57.0% of their peers in Dominican Republic (χ2 = 32.28, p < 0.001); 84.1% of respondents in Haiti correctly identified that HIV can be transmitted through a single unprotected sexual act, compared to 52.3% in Dominican Republic (χ2 = 25.2, p < 0.001). Significantly higher percentages of female sex workers in Dominican Republic correctly responded that HIV can be transmitted in pregnancy, compared to respondents in Haiti (96.5 vs. 71.4%; χ2 = 21.42, p < 0.001). Higher percentages of respondents in Dominican Republic correctly answered that HIV can be transmitted through needle sharing, relative to respondents in Haiti (100.0 vs. 89.7%; χ2 = 9.45, p < 0.01). Respondents in Dominican Republic more accurately rejected the possibility of transmission through food or through mosquito bites, compared to respondents in Haiti (95.4 vs. 81.8%, χ2 = 8.51, p < 0.01; 97.7 vs. 86.5%, χ2 = 7.81, p < 0.01, respectively). Findings indicate that if HIV knowledge is examined aggregating responses to individual questions, then elements of misinformation may remain unaddressed. For example, we found significant differences in correct answers ranging from 16.7 to 100.0%.

Left hand necrosis as the initial presentation of disseminated mucormycosis: A case report and literature review

Cutaneous mucormycosis typically occurs as a primary infection following traumatic inoculation or as a secondary disseminated disease in immunocompromised patients with hematologic malignancy or organ transplantation. We describe an unusual case of a poorly controlled type 1 diabetic patient presenting with wet gangrene of the hand due to angioinvasive dissemination from a primary pulmonary infection, with additional suspected foci of cardiac and central nervous system involvement. Despite combined medical and surgical treatment, the patient ultimately died due to complications of her infection. This case and the associated literature review of secondary cutaneous mucormycosis highlight that invasive fungal infections can present peripherally, and identifying the primary source is important in order to promptly pursue aggressive combined medical and surgical treatment for this highly fatal disease.

Assessing Human Immunodeficiency Virus (HIV) Prevention Through Knowledge and Condom Use Among Female Sex Workers at the Border of Haiti and Dominican Republic

Geographic border studies are relatively scare, but have the potential to inform bilateral health policies that affect the well-being of female sex workers (FSWs) who work at these borders as well as those individuals who solicit their services, both groups being at high risk for human immunodeficiency virus (HIV). We applied bivariate and multivariate techniques to examine FSWs' HIV knowledge and condom use across three partner types, at the Haiti Dominican Republic border, using data from the Study on Sex Workers (n = 241, 2014). Condom use was significantly lower among FSWs on the Haitian side of the border compared to the Dominican side, yet levels of HIV knowledge were similar; specifically, 81% of respondents on the Dominican side reported using condoms every time they had sex with a client, compared to 38% of peers in Haiti (p < 0.001). After introducing controls, FSWs in Haiti continued to have lower odds of using condoms with clients (p < 0.001), noncommercial partners (p < 0.001), and regular partners (p < 0.05) compared to peers in the Dominican Republic. This unique border study highlights disparities in FSWs' condom use regardless of HIV knowledge. The lack of consistent condom use by FSWs in Haiti has the potential to exacerbate the HIV epidemic at the border and impact both nations' HIV incidence rates.

Female Sex Workers' Experiences of Violence and Substance Use on the Haitian, Dominican Republic Border

Background

Female sex workers (FSW) are socially and economically marginalized, and this vulnerability can be exacerbated when they hold the intersectional identity of also being an immigrant, such as in the case of Haitian FSWs in the Dominican Republic.

Objective

Considering that half of migratory young women and girls relocating across the Latin American and Caribbean region do so without their families, increasing the likelihood of experiencing abuses, our primary objective was to test the hypothesis that Haitian FSWs in the Dominican Republic have higher odds of being physically abused by sexual partners compared to Haitian FSWs in Haiti.

Methods

We conducted bivariate analyses and multivariate analyses on 2014 Hispaniola Sex Workers Study (N = 232).

Findings

Approximately 80% of Haitian FSWs in the Dominican Republic reported experiencing violence by a regular partner (80.3%), compared with 60.0% of Haitian FSWs in Haiti (χ2 = 11.34, p < 0.001). Controlling for socio-demographics, substance use, childhood abuse, and sexual behaviors, Haitian FSWs in Haiti maintained lower odds of experiencing violence by a regular partner (OR:0.37, p < 0.01) and higher odds of experiencing violence from a coworker (OR:6.38, p < 0.001) compared to FSWs in the Dominican Republic. Using sex to avoid arrest is associated with higher odds of experiencing violence by a client and violence by a coworker (OR:2.18, p < 0.05; OR:3.74, p < 0.001; respectively). Accepting payment in the form of drugs/alcohol is associated with higher odds of experiencing physical violence by a regular partner but lower odds of experiencing violence by a client (OR:3.99, p < 0.05; OR:0.43, p < 0.05; respectively).

Conclusions

Assuming health is a human right, then practitioners and scholars must actively collaborate to fortify vulnerable populations against injurious structural and sociocultural forces examining the intersectionality and compound effects of multiple stigmatized identities, in this study being an FSW and an immigrant, that moderate the potential positive effects of public health interventions.

Lemierre's syndrome treated operatively

Lemierre's syndrome (LS) is a pharyngeal infection complicated by infectious jugular vein thrombosis and septic emboli. Most commonly caused by Fusobacterium necrophorum, it may result in metastatic infection, especially when antibiotic treatment is delayed. Patients with LS are often healthy adults between 16 and 30 years who present with prolonged symptoms of pharyngitis, lateral neck pain, and fever. Other symptoms may include shortness of breath, tachycardia, and hypotension. When administered promptly, antibiotics can act as an effective treatment. However, complications may arise that require additional intervention. Herein, we report a case of LS in a young adult, complicated by severe pleural effusions that required surgical decortication.

Separation of hemodynamic signals from GCaMP fluorescence measured with wide-field imaging

Wide-field calcium imaging is often used to measure brain dynamics in behaving mice. With a large field of view and a high sampling rate, wide-field imaging can monitor activity from several distant cortical areas simultaneously, revealing cortical interactions. Interpretation of wide-field images is complicated, however, by the absorption of light by hemoglobin, which can substantially affect the measured fluorescence. One approach to separating hemodynamics and calcium signals is to use multiwavelength backscatter recordings to measure light absorption by hemoglobin. Following this approach, we develop a spatially detailed regression-based method to estimate hemodynamics. This Spatial Model is based on a linear form of the Beer–Lambert relationship but is fit at every pixel in the image and does not rely on the estimation of physical parameters. In awake mice of three transgenic lines, the Spatial Model offers improved separation of hemodynamics and changes in GCaMP fluorescence. The improvement is pronounced near blood vessels and, in contrast with the Beer–Lambert equations, can remove vascular artifacts along the sagittal midline and in general permits more accurate fluorescence-based determination of neuronal activity across the cortex.

NEW & NOTEWORTHY This paper addresses a well-known and strong source of contamination in wide-field calcium-imaging data: hemodynamics. To guide researchers toward the best method to separate calcium signals from hemodynamics, we compare the performance of several methods in three commonly used mouse lines and present a novel regression model that outperforms the other techniques we consider.

Abstract P4-12-10: Evaluation of quality, cost, and value in clinical stage IA breast cancer

Background: There is increasing emphasis in providing high-value care. Value can be interpreted as a ratio of quality of care delivered and the cost to provide that care. We set out to evaluate the value of our care by defining a set of quality metrics (points) for each patient, then evaluating our cost to the payors to the deliver this care.

Methods: Patients with clinical Stage IA breast cancer managed completely at our Cancer Center between 1/1/2014 and 12/31/2014 were identified from cancer registry. An IRB-approved retrospective review of clinical charts and financial data was performed. Based on The Advisory Board Company metrics, a set of 18 quality measures was developed. These included process measures (time to initial biopsy, rate of needle biopsy, time to pathology reports, ER/PR and HER2 assessment, pathology synoptic report generation, time to surgery or neoadjuvant chemotherapy), treatment measures (performance of sentinel node biopsy, administration of chemotherapy for ER- or HER2+ disease, administration of radiation for lumpectomy or pN2/pN3 disease after mastectomy, administration of endocrine therapy for ER+ disease), and complication measures (flap complication after reconstruction, chemotherapy ER visits and inpatient admissions). Depending on the treatment pathway, patients were eligible for a different number of quality points. A patient received a quality point if they were eligible for the measure and met it. Financial review identified actual technical revenue received by the hospital, and apportioned it accordingly to the various revenue centers. Revenue was included for 365 days after the date of first contact, and was used as a proxy for cost to the payors. All patients were included regardless of type of insurance or free-care.

Results: There were 110 patients treated. All patients (100%) underwent surgery (lumpectomy 69%; mastectomy 5%, mastectomy with reconstruction 26%). Chemotherapy was delivered in 20% of patients (neoadjuvant 13%; adjuvant 7%). Radiation therapy was delivered in 57% of patients. Most common treatment pathways were lumpectomy with radiation (46%), mastectomy with reconstruction alone (18%), and lumpectomy alone (14%). Number of potential quality points depended on care pathway, and ranged from 6 to 15 per patient. There were 939 quality points achieved out of possible 1104 (85%) in the entire cohort. Quality ratios per patient varied from 55% to 100%. Lowest quality measure was time-to-surgery &lt;=30 days at 75%. Overall revenue (cost to payors) was $6.2 million for the cohort. Medicare was 35% of patients. Average cost of care per patient was $56.5K (range $0 to $385K). The cost per point of quality was $6,443 (range $0 to $45.4K). Highest cost per quality point was in a commercial insurance patient treated with neoadjuvant TCHP, followed by bilateral mastectomy with DIEP reconstruction and radiation.

Conclusions: We have established a model to assess the value of breast cancer care provided as cost of care delivered per quality point achieved. To improve our value proposition to the payors, and ultimately to our patients, we plan to focus on improving our compliance with the quality measures, monitor care pathway utilization, and identify opportunities to lower the cost of care.

Citation Format: Dvorak T, Rostorfer R, Smith J, Coltey D, Waters J, Mamounas E. Evaluation of quality, cost, and value in clinical stage IA breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-12-10.

Transgender female sex workers' HIV knowledge, experienced stigma, and condom use in the Dominican Republic

INTRODUCTION

Not only do transgender female sex workers have some of the highest rates of sexually transmitted infections (STI), human immunodeficiency virus (HIV), and experienced stigma, they also have higher likelihood of early sexual debut and some of the lowest levels of educational attainment compared to other stigmatized populations. Some of the most common interventions designed to reduce transmission of HIV and STIs seek to educate high-risk groups on sexual health and encourage condom use across all partner types; however, reaching stigmatized populations, particularly those in resource-limited settings, is particularly challenging. Considering the importance of condom use in stopping the spread of HIV, the aim of this study was two-fold; first to characterize this hard-to-reach population of transgender female sex workers in the Dominican Republic, and second, to assess associations between their HIV knowledge, experienced stigma, and condom use across three partner types.

METHODS

We analyzed self-reported data from the Questionnaire for Transgender Sex Workers (N = 78). Respondents were interviewed at their workplaces. Univariate and bivariate analyses were employed. Fisher Chi-square tests assessed differences in HIV knowledge and experienced stigma by condom use across partner types.

RESULTS

HIV knowledge was alarmingly low, condom use varied across partner type, and the respondents in our sample had high levels of experienced stigma. Average age of first sexual experience was 13.12 years with a youngest age reported of 7. Dominican Republic statutory rape laws indicate 18 years is the age of consent; thus, many of these transgender women's first sexual encounters would be considered forcible (rape) and constitute a prosecutable crime. On average, respondents reported 8.45 sexual partners in the prior month, with a maximum of 49 partners. Approximately two thirds of respondents used a condom the last time they had sex with a regular partner. This was considerably lower than condom use reported with coercive partners (92.96%) and clients (91.78%). Bivariate analyses revealed two trends: experienced stigma was associated with lower rates of condom use, and lower HIV knowledge was associated with lower rates of condom use. The former provides additional evidence that experienced stigma may become internalized, affecting individual-level behaviors-lowering self-confidence and resilience-making it more difficult to negotiate condom use due to lack of self-efficacy and desire to show trust in one's partner. The latter supports public health research that suggests gaps in HIV knowledge persist and are pronounced in highly stigmatized populations.

DISCUSSION

The vulnerabilities experienced by transgender persons, particularly in environments that vehemently adhere to conservative ideologies related to sex and gender, are significant and harm this population. These vulnerabilities could potentially be addressed through critically examining of impact of policies that indirectly promote or allow victimization of transgender citizens and subsequently diminish the effectiveness of public health and educational interventions. By taking action through the revocation of such laws, the Dominican Republic has the opportunity to improve overall population health, to protect some of its most stigmatized citizens, and to become the flag bearer of enhanced human rights in the Caribbean and Latin America.

Protein turnover measurement using selected reaction monitoring-mass spectrometry (SRM-MS)

Protein turnover represents an important mechanism in the functioning of cells, with deregulated synthesis and degradation of proteins implicated in many diseased states. Therefore, proteomics strategies to measure turnover rates with high confidence are of vital importance to understanding many biological processes. In this study, the more widely used approach of non-targeted precursor ion signal intensity (MS1) quantification is compared with selected reaction monitoring (SRM), a data acquisition strategy that records data for specific peptides, to determine if improved quantitative data would be obtained using a targeted quantification approach. Using mouse liver as a model system, turnover measurement of four tricarboxylic acid cycle proteins was performed using both MS1 and SRM quantification strategies. SRM outperformed MS1 in terms of sensitivity and selectivity of measurement, allowing more confident determination of protein turnover rates. SRM data are acquired using cheaper and more widely available tandem quadrupole mass spectrometers, making the approach accessible to a larger number of researchers than MS1 quantification, which is best performed on high mass resolution instruments. SRM acquisition is ideally suited to focused studies where the turnover of tens of proteins is measured, making it applicable in determining the dynamics of proteins complexes and complete metabolic pathways.This article is part of the themed issue 'Quantitative mass spectrometry'.

Association between violence exposure and condom non-use among transgender sex workers in the Dominican Republic: the mediating role of trust

Transgender women are a high-risk population, and transgender female sex workers are one of the most vulnerable populations globally. Transgender female sex workers have high rates of sexually transmitted infections, HIV, and exposure to violence compared to cisgender sex workers; these negative exposures are associated with an increase in HIV risk behaviors. Thus, the aim of this study is to examine the relationship between exposure to violence and condom non-use in transgender female sex workers residing in the Dominican Republic. We hypothesize that mediation exists wherein the effects of violence on condom non-use are mediated by distrust. Facilitated interview data ( N = 78) were used. Primary outcome was condom non-use with coercive partner. Four logistic regression models and a mediation analysis were employed. Respondents' mean age was 23.0 years (SD = 4.8) with an average level education attainment of 10.1 years (SD = 2.6); 35% reported experiencing violence; 17% believed that a person who asks a partner to use a condom does not trust that partner. Exploratory mediation analyses yielded a significant indirect effect of experience with violence on condom non-use through distrust (b = 0.64, SE = 0.33, p = .05). Results suggest that distrust mediates the association between experienced violence and condom use with coercive partners. It was concluded that developing interventions on increasing resilience and perceived self-worth, plus provision of screening for violence and referral services may reduce maladaptive attributions and cognitions about condom use. Furthermore, by implementing policies that protect vulnerable populations, and subsequently enforcing them, the Dominican Republic has the opportunity to improve overall population health and protect their most disadvantaged citizens.

Superconductivity in Potassium-Doped Metallic Polymorphs of MoS2

Superconducting layered transition metal dichalcogenides (TMDs) stand out among other superconductors due to the tunable nature of the superconducting transition, coexistence with other collective electronic excitations (charge density waves), and strong intrinsic spin-orbit coupling. Molybdenum disulfide (MoS2) is the most studied representative of this family of materials, especially since the recent demonstration of the possibility to tune its critical temperature, Tc, by electric-field doping. However, just one of its polymorphs, band-insulator 2H-MoS2, has so far been explored for its potential to host superconductivity. We have investigated the possibility to induce superconductivity in metallic polytypes, 1T- and 1T'-MoS2, by potassium (K) intercalation. We demonstrate that at doping levels significantly higher than that required to induce superconductivity in 2H-MoS2, both 1T and 1T' phases become superconducting with Tc = 2.8 and 4.6 K, respectively. Unusually, K intercalation in this case is responsible both for the structural and superconducting phase transitions. By adding new members to the family of superconducting TMDs, our findings open the way to further manipulate and enhance the electronic properties of these technologically important materials.

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.

Impermeable barrier films and protective coatings based on reduced graphene oxide

Flexible barrier films preventing permeation of gases and moistures are important for many industries ranging from food to medical and from chemical to electronic. From this perspective, graphene has recently attracted particular interest because its defect-free monolayers are impermeable to all atoms and molecules. However, it has been proved to be challenging to develop large-area defectless graphene films suitable for industrial use. Here we report barrier properties of multilayer graphitic films made by gentle chemical reduction of graphene oxide laminates with hydroiodic and ascorbic acids. They are found to be highly impermeable to all gases, liquids and aggressive chemicals including, for example, hydrofluoric acid. The exceptional barrier properties are attributed to a high degree of graphitization of the laminates and little structural damage during reduction. This work indicates a close prospect of graphene-based flexible and inert barriers and protective coatings, which can be of interest for numerous applications.

Bevacizumab with peri-operative epirubicin, cisplatin and capecitabine (ECX) in localised gastro-oesophageal adenocarcinoma: a safety report

BACKGROUND

Peri-operative chemotherapy and surgery is a standard treatment of localised oesophagogastric adenocarcinoma; however, the outcomes remain poor.

PATIENTS AND METHODS

ST03 is a multicentre, randomised, phase II/III study comparing peri-operative ECX with or without bevacizumab (ECX-B). The primary outcome measure of phase II (n = 200) was safety, specifically gastrointestinal (GI) perforation rates and cardiotoxicity.

RESULTS

Two hundred patients were randomised between October 2007 and April 2010. Ninety-one/101 (90%) ECX and 86/99 (87%) ECX-B patients completed pre-operative chemotherapy; 7 ECX and 9 ECX-B patients stopped due to toxicity. Gastrointestinal perforations (3 ECX, 1 ECX-B), cardiac events (1 ECX, 4 ECX-B) and venous thromboembolic events (VTEs, 8 ECX, 7 ECX-B) were uncommon. Arterial thromboembolic events (ATEs, myocardial infarction (MI) or cerebrovascular accident) were more frequent with ECX-B (5 versus 1 with ECX). Delayed wound healing, anastomotic leaks and GI bleeding rates were similar. More asymptomatic left ventricular ejection fraction (LVEF) falls (≥15% and/or to <50%) occurred with ECX-B (21.2% versus 11.1% with ECX). Clinically significant falls (≥10% to below lower limit of normal, LLN) occurred in (15.3%) and (8.9%) respectively, with no associated cardiac failure (median 22 months follow-up).

CONCLUSIONS

Addition of bevacizumab to peri-operative ECX chemotherapy is feasible with acceptable toxicity and no negative impact on surgical outcomes.

Gemcitabine versus gemcitabine plus dalteparin thromboprophylaxis in pancreatic cancer

BACKGROUND

Annualised figures show an up to 7-fold higher incidence of vascular thromboembolism (VTE) in patients with advanced pancreatic cancer (APC) compared to other common malignancies. Concurrent VTE has been shown to confer a worse overall prognosis in APC.

METHODS

One hundred and twenty three APC patients were randomised to receive either gemcitabine 1000 mg/m(2) or the same with weight-adjusted dalteparin (WAD) for 12 weeks. Primary end-point was the reduction of all-type VTE during the study period. NCT00462852, ISRCTN: 76464767.

FINDINGS

The incidence of all-type VTE during the WAD treatment period (<100 days from randomisation) was reduced from 23% to 3.4% (p = 0.002), with a risk ratio (RR)of 0.145, 95% confidence interval (CI) (0.035-0.612) and an 85% risk reduction. All-type VTE throughout the whole follow-up period was reduced from 28% to 12% (p = 0.039), RR = 0.419, 95% CI (0.187-0.935) and a 58% risk reduction. Lethal VTE <100 days was seen only in the control arm, 8.3% compared to 0% (p = 0.057), RR = 0.092, 95% CI (0.005-1.635).

INTERPRETATION

Weight adjusted dalteparin used as primary prophylaxis for 12 weeks is safe and produces a highly significant reduction of all-type VTE during the prophylaxis period. The benefit is maintained after dalteparin withdrawal although decreases with time.

Evidence-based practice guidelines for plasma transfusion

BACKGROUND

There is little systematically derived evidence-based guidance to inform plasma transfusion decisions. To address this issue, the AABB commissioned the development of clinical practice guidelines to help direct appropriate transfusion of plasma.

STUDY DESIGN AND METHODS

A systematic review (SR) and meta-analysis of randomized and observational studies was performed to quantify known benefits and harms of plasma transfusion in common clinical scenarios (see accompanying article). A multidisciplinary guidelines panel then used the SR and the GRADE methodology to develop evidence-based plasma transfusion guidelines as well as identify areas for future investigation.

RESULTS

Based on evidence ranging primarily from moderate to very low in quality, the panel developed the following guidelines: 1) The panel suggested that plasma be transfused to patients requiring massive transfusion. However, 2) the panel could not recommend for or against transfusion of plasma at a plasma : red blood cell ratio of 1:3 or more during massive transfusion, 3) nor could the panel recommend for or against transfusion of plasma to patients undergoing surgery in the absence of massive transfusion. 4) The panel suggested that plasma be transfused in patients with warfarin therapy-related intracranial hemorrhage, 5) but could not recommend for or against transfusion of plasma to reverse warfarin anticoagulation in patients without intracranial hemorrhage. 6) The panel suggested against plasma transfusion for other selected groups of patients.

CONCLUSION

We have systematically developed evidence-based guidance to inform plasma transfusion decisions in common clinical scenarios. Data from additional randomized studies will be required to establish more comprehensive and definitive guidelines for plasma transfusion.

Cryptic differences in dispersal lead to differential sensitivity to habitat fragmentation in two bumblebee species

Habitat loss has led to fragmentation of populations of many invertebrates, but social hymenopterans may be particularly sensitive to habitat fragmentation due to their low effective population sizes. The impacts of fragmentation depend strongly on dispersal abilities, but these are difficult to quantify. Here, we quantify and compare dispersal abilities of two bumblebee species, Bombus muscorum and Bombus jonellus, in a model island system. We use microsatellites to investigate population genetic structuring, dispersal and spatial patterns in genetic diversity. Populations of both species showed significant structuring, and isolation by distance, but this was markedly greater in B. muscorum (theta = 0.13) than in B. jonellus (theta = 0.034). This difference could reflect a higher effective population size in B. jonellus compared to B. muscorum, but this is not consistent with the observed abundance of the two species. We argue that it is more likely that B. jonellus has a higher propensity to disperse than B. muscorum. This will influence their relative susceptibility to habitat fragmentation and may in part explain differential declines of mainland populations of these and other bumblebee species.

Malignancy and leg ulceration in a community-based leg ulcer clinic in New Zealand

The high prevalence of non-melanoma skin cancers in this patient population highlights the need for early, accurate diagnosis. This can be achieved by biopsying atypical ulcers early and all chronic ulcers within three months of starting treatment.

Ligand influence on the formation of P/Se semiconductor materials from metal-organic complexes

The complexes [Ni{(SeP(i)Pr(2))(2)N}(2)] (2), [Ni(Se(2)P(i)Pr(2))(2)] (), and [Co(Se(2)P(i)Pr(2))(2)] (4) were synthesised and the X-ray single crystal structures of (1) and (2) were determined. Thin films of nickel selenide, cobalt selenide and cobalt phosphide have been deposited by the chemical vapour deposition method using imidodiselenophosphinato-nickel(ii) (1), -cobalt(ii) [Co{(SeP(i)Pr(2))(2)N}(2)] (3), diselenophosphinato-nickel(ii) (2), -cobalt(ii) (4) and diselenocarbamato-nickel(ii) [Ni(Se(2)CNEt(2))(2)] (5), and -cobalt(iii) [Co(Se(2)CNEt(2))(3)] (6) precursors.