Trends in incidence and average waiting time for arthroplasty from 1998-2021: an observational study of 282,367 patients from the Scottish arthroplasty project

BACKGROUND

Current waiting times for arthroplasty are reported as being the worst on record. This is a combination of increasing demand, the COVID-19 pandemic and longer standing shortage of capacity. The Scottish Arthroplasty Project (SAP) is a National Audit that analyses all joint replacements undertaken in the Scottish NHS and Independent Sector. The aim of this study was to investigate the long-term trend in provision and waiting time for lower limb joint replacement surgery.

METHODS

All total hip replacements (THR) and total knee replacements (TKR) undertaken in NHS Scotland from 1998 to 2021 were identified. Waiting times data were analysed each year to determine the minimum, maximum, median, mean and standard deviation.

RESULTS

In 1998, there were 4,224 THR and 2,898 TKR with mean (range, SD) waiting time of 159.5 days (1-1,685, 119.8) and 182.9 days (1-1,946, 130.1). The minimum waiting times were both in 2013 for 7,612 THR - 78.8 days (0-539, 46) and 7,146 TKR - 79.1 days (0-489, 43.7). The maximum waiting times recorded were in 2021 with 4,070 THR waiting 283.7 days (0-945, 215) and 3,153 TKR waiting 316.8 days (4-1,064, 217).

CONCLUSIONS

This is the first robust large-scale national dataset showing trends in incidence and waiting time for THR and TKR over two decades. There was an expansion of activity with a reduction in waiting time, which peaked in 2013, followed by an increase in waiting time with a plateau and modest decline in the number of procedures.

'Unable to have a proper conversation over the phone about my concerns': a multimethods evaluation of the impact of COVID-19 on routine childhood vaccination services in London, UK

OBJECTIVES

Investigating the completion rate of 12-month vaccinations and parental perspectives on vaccine services during COVID-19.

STUDY-DESIGN

Service evaluation including parental questionnaire.

METHODS

Uptake of 12-month vaccinations in three London general practices during three periods: pre-COVID (1/3/2018-28/2/2019, n = 826), during COVID (1/3/2019-28/2/2020, n = 775) and post-COVID first wave (1/8/2020-31/1/2021, n = 419). Questionnaire of parents whose children were registered at the practices (1/4/2019-1/22/2021, n = 1350).

RESULTS

Comparing pre-COVID and both COVID cohorts, the completion rates of 12-month vaccines were lower. Haemophilus influenzae type B/meningococcal group C (Hib/MenC) vaccination uptake was 5.6% lower (89.0% vs 83.4%, P=<0.001), meningococcal group B (MenB) booster uptake was 4.4% lower (87.3% vs 82.9%, P = 0.006), pneumococcal conjugate vaccine (PCV) booster uptake was 6% lower (88.0% vs 82.0%, P < 0.001) and measles, mumps and rubella (MMR) vaccine uptake was 5.2% lower (89.1% vs 83.9%, P = 0.003). Black/Black-British ethnicity children had increased odds of missing their 12-month vaccinations compared to White ethnicity children (adjusted odds ratio 0.43 [95% confidence interval 0.24-0.79, P = 0.005; 0.36 [0.20-0.65], P < 0.001; 0.48 [0.27-0.87], P = 0.01; 0.40 [0.22-0.73], P = 0.002; for Hib/MenC, MenB booster, PCV booster and MMR. Comparing pre-COVID and COVID periods, vaccinations coded as not booked increased for MMR (10%), MenB (7%) and PCV booster (8%). Parents reported changes to vaccination services during COVID-19, including difficulties booking and attending appointments and lack of vaccination reminders.

CONCLUSION

A sustained decrease in 12-month childhood vaccination uptake disproportionally affected Black/Black British ethnicity infants during the first wave of the pandemic. Vaccination reminders and availability of healthcare professionals to discuss parental vaccine queries are vital to maintaining uptake.

Vibration Controlled Transient Elastography to Evaluate Steatosis in Candidate Living Donors for Liver Transplantation

BACKGROUND

The ability of vibration controlled transient elastography (VCTE) to reliably exclude significant steatosis in living donor candidates could obviate the need for invasive liver biopsies, expedite the donor approval process, and reduce recipient wait time. We therefore aimed to determine whether VCTE controlled attenuation parameter (CAP) could be used to detect steatosis in potential living donors.

METHODS

Living donor candidates who presented for evaluation between 2016 and 2019 underwent standard donor workup, VCTE, and liver biopsy if indicated. CAP scores were compared with MRI-Fat Fraction and, when available, histologic fat fraction from liver biopsy. Receiver operating characteristic curves were used to identify cutoffs with appropriate sensitivity and specificity for screening. Statistical analysis was conducted using R (version 3.6.0).

RESULTS

Seventy-nine candidate living donors presented during the study period, of whom 71 were included in the final analysis and of whom 20 underwent liver biopsy. There was a positive correlation between MRI-Fat Fraction and CAP scores with an observed Spearman correlation coefficient of 0.424 ( P < 0.01). A CAP score of 271.5 dB/m or less was determined to have 89.8% sensitivity and 75% specificity for detecting <5% steatosis on MRI. The correlation between CAP and steatosis of available histologic samples had a Pearson correlation coefficient of 0.603 ( P = 0.005). A CAP cutoff of 276.0 dB/m demonstrated 66.7% sensitivity and 85.7% specificity for detecting <15% histopathologic steatosis and positive and negative predictive values of 71.5% and 82.7%, respectively.

CONCLUSIONS

VCTE can be integrated into living donor evaluation to accurately screen for hepatic steatosis.

The role of outpatient needle arthroscopy in the diagnosis and management of musculoskeletal complaints: A systematic review of the Arthrex NanoScope

BACKGROUND

The aim was to review the literature regarding needle arthroscopy using the Arthrex NanoScope system and evaluate: (1) the diagnostic indications, utility, and efficacy compared to conventional methods, and (2) the therapeutic indications, safety, and reported outcomes.

METHODS

Searches of three databases (MEDLINE, Embase and PubMed) were conducted in November 2021 using MeSH terms: 'needle arthroscopy', 'human', 'in office arthroscopy', 'needle arthroscope', 'nanoscopic', 'surgery', 'nanoscope' and 'percutaneous arthroscopy'. The included studies were catalogued, quality-assessed using Methodological Index for Non-Randomised Studies (MINORS), and analysed using the Cochrane data collection templates for randomised control trials (RCT) and non-randomised control trials (non-RCT). The majority of studies were non-numerical and were examined using qualitative analysis.

RESULTS

The search yielded 314 studies, 22 of which were included for analysis. MINORS assessment was applicable to four studies. Mean MINORS was 10.7/16 with the most frequent limitations being lack of unbiased endpoint or sample size calculation. The level of evidence ranged from level IV-V. Diagnostic and therapeutic indications were described in relation to the: knee (n = 10); shoulder (n = 6); foot/ankle (n = 3); elbow (n = 2), and miscellaneous (n = 1).

CONCLUSIONS

Needle arthroscopy can augment the diagnostic process in patients presenting with musculoskeletal complaints, and may provide benefits in terms of diagnostic accuracy, cost efficiency, timeliness of investigation, and a visually impactful patient-centred consultation. Therapeutic interventions are reported by a small number of pioneer groups who report some benefits over conventional arthroscopy. The available literature remains small and of low quality, and more evidence is needed with regards to patient selection, efficacy, safety, and cost.

LEVEL OF EVIDENCE

Level V (based on the weakest study included in the Systematic Review).

Abstract 60: An emerging paradigm of Cxcl12 & Cxcr4 involvement in breast cancer metastasis

The Cxcl12/Cxcr4 signaling axis has been shown to promote metastasis in multiple mouse models of breast carcinoma, and has been linked to breast cancer cell seeding, homing, survival, and proliferation at future metastatic sites. The precise mechanism by which Cxcr4+ breast cancer cells escape the primary tumors (which also highly express Cxcl12), remains poorly understood. By using a novel multichannel immunofluorescence (mIF) based methodology for quantifying chemotactic gradients in fixed tissue, we here demonstrate that Cxcl12 gradients in mouse primary breast tumors are concentrically expressed around sites of cancer cell intravasation known as Tumor Microenvironment of Metastasis (TMEM) doorways. Via distance analysis algorithms, we additionally demonstrate that TMEM doorway-mediated Cxcl12 gradients associate with Cxcr4+ breast cancer cells migrating towards the underlying TMEM doorways. Consistent with this observation, pharmacological inhibition of the Cxcl12/Cxcr4 pathway significantly abrogates the translocation of Cxcr4+ cancer cells to TMEM doorways, suppressing TMEM doorway-mediated metastatic dissemination. However, targeted elimination of the Cxcr4 gene specifically from breast cancer cells, paradoxically results in a suboptimal response, thus suggesting the existence of a bypass or compensatory mechanism. Previously, it was shown that Cxcr4+ tumor-associated macrophages (TAMs) support the invasive and migratory properties of tumor cells that utilize TMEM doorways. We thus hypothesized that, absent Cxcr4 expression in tumor cells, accompanying Cxcr4+ TAMs may still “read” TMEM-generated Cxcl12 chemotactic gradients. Indeed, clodronate-mediated TAM depletion results in the significant suppression of Cxcr4+ cancer cell translocation to TMEM doorways and their subsequent dissemination to the peripheral circulation and future metastatic sites. Finally, we used a variety of stromal and immune cell lineage markers to identify the precise source of TMEM doorway-generated Cxcl12 gradients in mouse primary breast cancers. Despite the fact that blood vessels (irrespective of presence of TMEM doorways) were primarily lined by Pdgfrb+ stromal cells with basal Cxcl12 expression, TMEM-generated Cxcl12 gradients were specifically linked to a subset of Cxcl12+Iba1+ perivascular TAMs. Pharmacological inhibition of Pdgfrb depletes Pdgfrb+Cxcl12+ stromal cells, but does not significantly affect Cxcl12/Cxcr4- mediated translocation of Cxcr4+ tumor cells to TMEM doorways. Overall, our data support a new paradigm implicating the Cxcl12/Cxcr4 axis during the early stages of the metastatic cascade, and point to a new avenue for rationalized antimetastatic treatments for breast cancer.

Citation Format: Dimitra P. Anastasiadou, Luis R. Sanchez, Camille L. Duran, Joseph Burt, Xiaoming Chen, Yu Lin, Robert Eddy, Allison S. Harney, David Entenberg, John S. Condeelis, Maja H. Oktay, George S. Karagiannis. An emerging paradigm of Cxcl12 & Cxcr4 involvement in breast cancer metastasis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 60.

Moving orthopaedic procedures out of the operating theatre:Outpatient needle arthroscopy can reduce cost & waste, and increase inpatient capacity compared to conventional knee arthroscopy

BACKGROUND

Needle arthroscopy (NA) is an emerging technique that could streamline pathways, facilitate timely care, and reduce service burden. The primary aim was to assess the practical and economic viability of an outpatient NA service. Secondary aims were to assess the relative costs and benefits compared to a conventional arthroscopy (CA) service.

METHODS

This service feasibility study was conducted between 2021-2022 in a high-volume national treatment centre. A NA pathway was established for patients with chronic soft tissue pathology or early degenerative knee disease. The pathway was evaluated in terms of: i) cost; ii) efficiency, and iii) waste production, and an assessment was conducted of the patient-related and service-related effects.

RESULTS

The cost of the NA pathway was £1555.20 per patient, compared to £2,351.53 for CA. Time to management was 45 days for NA versus 180 days for CA. The NA pathway involved two hospital attendances, whereas CA required a minimum of three. NA cases produced 1.4 kg of non-recyclable waste compared to 5.0 kg produced by CA. For every two cases managed by NA instead of CA, capacity for one additional obligate-inpatient procedure was created.

CONCLUSIONS

The NA pathway offers a technically and economically viable approach for the management of refractory knee symptoms in the context of chronic soft tissue or early degenerative disease. NA placed less demand on hospital resources, produced two-thirds less non-recyclable waste, and is amenable to a one-stop clinic approach. Clinical studies focused on objective and patient-reported outcome measures are required to assess clinical efficacy.

Survey of ants (Hymenoptera, Formicidae) in the city of Providence (Rhode Island, United States) and a new northern-most record for Brachyponera chinensis (Emery, 1895)

We surveyed ants in Providence, Rhode Island, from 2015 to 2019. Methods including repeated pitfall trap sampling and manual searching were used to collect ants at Providence College and a rapid biological assess-ment was conducted at Roger Williams Park. A total of 36 species were identified based on morphology, including the first observations of a colony of Needle Ants (Brachyponera chinensis Emery, 1895) in New England. Twenty-six species identified were new county records and seven species were new state records, representing a substantial update to the list of known ant species in Rhode Island, currently totaling 41 species in Providence and 69 spe-cies from six subfamilies across the state. These results are comparable with similarly scaled surveys conducted at parks and cities across the world, and they also offer a reminder that while urbanization can be associated with reductions in habitat availability for some fauna, cities can be accessible and ecologically important locations for exploring myrmecological biodiversity.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Abstract 3124: An emerging paradigm of Cxcl12/Cxcr4 involvement in breast cancer metastasis

The Cxcl12/Cxcr4 signaling axis has been shown to promote metastasis in multiple mouse models of breast carcinoma and to be associated with increased metastatic risk in humans. Indeed, prior studies have specifically linked Cxcl12/Cxcr4 to breast cancer cell seeding, homing, survival and proliferation at future metastatic sites, due to the aberrant Cxcl12 expression in these sites (e.g. lung, liver and bone marrow). Interestingly however, the precise mechanism via which Cxcr4+ breast cancer cells escape the primary tumors in the first place (which also highly express Cxcl12), remains poorly understood. By using a novel methodology for quantifying chemotactic gradients using fixed tissue multichannel immunofluorescence (mIF), here, we demonstrate in mouse primary breast tumors that Cxcl12 gradients are concentrically expressed around cancer cell intravasation sites, known as Tumor Microenvironment of Metastasis (TMEM) doorways. Via distance analysis algorithms using mIF, we also demonstrate that TMEM-mediated Cxcl12 gradients contextually associate with Cxcr4+ breast cancer cells migrating towards the underlying TMEM doorways. As such, pharmacological inhibition of the Cxcl12/Cxcr4 pathway significantly abrogates the translocation of Cxcr4+ cancer cells to TMEM doorways, suppressing TMEM-mediated metastatic dissemination. However, targeted elimination of the Cxcr4+ gene specifically from breast cancer cells, paradoxically results in a suboptimal response, thus suggesting the existence of a bypass or compensatory mechanism. Previously, it was shown that Cxcr4+ tumor-associated macrophages (TAMs) support the invasive and migratory properties of tumor cells utilizing TMEM doorways. We thus theorized that, in the absence of Cxcr4 expression in tumor cells, the accompanying Cxcr4+ TAMs may still “read” TMEM-generated Cxcl12 chemotactic gradients. Indeed, clodronate-mediated TAM depletion results in the significant suppression of Cxcr4+ cancer cell translocation to TMEM doorways and their subsequent dissemination to the peripheral circulation and future metastatic sites. Finally, we used a variety of stromal and immune cell lineage markers to identify the precise source of TMEM-generated Cxcl12 gradients in mouse primary breast cancers. Despite that blood vessels (irrespective of presence of TMEM doorways) were primarily lined by Pdgfrb+ stromal cells with basal Cxcl12 expression, TMEM-generated Cxcl12 gradients were specifically linked to a subset of Cxcl12+Iba1+ perivascular TAMs. Pharmacological inhibition of Pdgfrb depletes Pdgfrb+Cxcl12+ stromal cells, but does not significantly affect Cxcl12/Cxcr4- mediated translocation of Cxcr4+ tumor cells to TMEM doorways. Overall, our data support a new paradigm for the implication of the Cxcl12/Cxcr4 axis during the early stages of the metastatic cascade, and propose a new avenue for rationalized antimetastatic treatments for breast cancer.

Citation Format: Maria K. Lagou, Luis G. Rivera, Camille E. Duran, Joseph Burt, Xiaoming Chen, Yu Lin, Robert Eddy, Allison S. Harney, David Entenberg, John S. Condeelis, Maja H. Oktay, George S. Karagiannis. An emerging paradigm of Cxcl12/Cxcr4 involvement in breast cancer metastasis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3124.

An Emerging and Previously Unrecognized Paradigm of Cxcl12/Cxcr4 Pathway Implication in Breast Cancer Metastasis

The Cxcl12/Cxcr4 signaling axis promotes metastasis in mouse models of breast carcinoma and is linked with increased metastatic risk in humans. Prior studies have linked Cxcl12/Cxcr4 to breast cancer cell homing and survival at metastatic sites. However, the precise mechanism via which Cxcr4+ breast cancer cells escape primary tumors, which also express Cxcl12, is poorly understood. By using a novel imaging method for visualizing chemokine gradients, we show that Cxcl12 is concentrically expressed around cancer cell intravasation doorways, known as Tumor Microenvironment of Metastasis (TMEM). Using distance analysis algorithms, we also show that TMEM-mediated Cxcl12 gradients contextually associate with Cxcr4+ breast cancer cells migrating towards TMEM doorways. As such, pharmacological inhibition of the Cxcl12/Cxcr4 axis significantly abrogates translocation of Cxcr4+ cancer cells to TMEM doorways, thus suppressing metastatic dissemination. However, the targeted elimination of Cxcr4 from breast cancer cells paradoxically results in a suboptimal response compared to pharmacologic inhibition, implying the existence of a compensatory mechanism. Using clodronate-mediated macrophage depletion, we demonstrate that, in the absence of Cxcr4 expression in tumor cells, accompanying Cxcr4+ macrophages may still “read” TMEM-generated Cxcl12 chemotactic gradients. Indeed, Pdgfrb+ stromal cells may express low levels of Cxcl12, but TMEM-generated Cxcl12 gradients are primarily linked to a subset of Iba1+ perivascular tumor-associated macrophages. Overall, our data reveal a new paradigm for the implication of Cxcl12/Cxcr4 in early stages of metastasis and propose an avenue for rationalized antimetastatic treatments.

Supported by Recruitment Funds RECR 3A3218

Training in the use of intrapartum electronic fetal monitoring with cardiotocography: systematic review and meta‐analysis

Background

Sub‐optimal classification, interpretation and response to intrapartum electronic fetal monitoring using cardiotocography are known problems. Training is often recommended as a solution, but there is lack of clarity about the effects of training and which type of training works best.

Objectives

Systematic review of the effects of training healthcare professionals in intrapartum cardiotocography (PROSPERO protocol: CRD42017064525).

Search strategy

CENTRAL, Cochrane Library, MEDLINE, EMBASE, PsycINFO, British Nursing Database, CINAHL, ERIC, Scopus, Web of Science, ProQuest, grey literature and ongoing clinical trials were searched.

Selection criteria

Primary studies that reported impact of training healthcare professionals in intrapartum cardiotocography. Title/abstract, full‐text screening and quality assessment were conducted in duplicate.

Data collection and analysis

Data were synthesised both narratively and using meta‐analysis. Risk of bias and overall quality were assessed with the Mixed Methods Appraisal Tool and GRADE.

Main results

Sixty‐four studies were included. Overall, training and reporting were heterogeneous, the outcomes evaluated varied widely and study quality was low. Five randomised controlled trials reported that training improved knowledge of maternity professionals compared with no training, but evidence was of low quality. Evidence for the impact of cardiotocography training on neonatal and maternal outcomes was limited, showed inconsistent effects, and was of low overall quality. Evidence for the optimal content and method of delivery of training was very limited.

Conclusions

Given the scale of harm and litigation claims associated with electronic fetal monitoring, the evidence‐base for training requires improvement. It should address intervention design, evaluation of clinical outcomes and system‐wide contexts of sub‐optimal practice.

Tweetable abstract

Training in fetal monitoring: systematic review finds little evidence of impact on neonatal outcomes.

Training in fetal monitoring: systematic review finds little evidence of impact on neonatal outcomes.

P2649Do these data apply to me? Examining the applicability of trials assessing strategies for optimal management of blood pressure to older patients in UK primary care

Background

There is debate as to what extent older patients (≥80 years) should be treated for high blood pressure. Existing trials show that blood pressure lowering in this population is effective at preventing stroke and heart failure but also results in an increased risk of adverse events. However, it has been suggested that these studies enrolled healthier patients, who are less representative of the general population and more likely to benefit from treatment.

Purpose

This study aimed to compare the characteristics of patients eligible for three blood pressure management trials and assess the likelihood of eligibility for each trial based on common characteristics of older patients.

Methods

Cross-sectional study of data extracted from the medical records of 15,376 patients aged ≥80 years, registered to 24 general practices in the south of England. Anonymised patient data relating to the eligibility criteria for two previous medication intensification trials (HYVET, SPRINT) and one medication reduction trial (OPTiMISE) were extracted. Patients eligible for each trial were defined according to criteria specified in each trial protocol. Descriptive statistics were used to define the characteristics of each trial population. A logistic regression model was constructed to estimate predictors of eligibility for each trial, with practice included as a random effect.

Results

Approximately 268 (1.7%), 5,290 (34.4%) and 3,940 (25.6%) patients were eligible for HYVET, SPRINT and OPTiMISE trials respectively. There was little overlap in eligibility for each trial (1.0% were eligible for HYVET and SPRINT; 0% were eligible for HYVET and OPTiMISE; 10.2% were eligible for SPRINT and OPTiMISE). Patients eligible for OPTiMISE were comparable to the general population in terms of frailty (eFI 0.12 [OPTiMISE] vs 0.11 [general population]), but had more morbidities (4 vs 3) and cardiovascular medications prescribed (4 vs 2). Patients in HYVET and SPRINT were less frail, multi-morbid and prescribed less cardiovascular medications. Overall, increasing frailty and a history of cardiovascular disease reduced the likelihood of being eligible for any trial.

Conclusions

Patients eligible for OPTiMISE appear to best represent the population aged ≥80 years attending UK primary care. Increasing frailty and/or multi-morbidity reduce the likelihood of eligibility for all three blood pressure trials. Caution should be exercised when applying the results from randomised controlled trials to management of blood pressure in frail and multi-morbid patients.

Acknowledgement/Funding

This study was funded by the National Institute for Health Research (NIHR) SPCR and Oxford CLAHRC

Abstract P2-05-01: Chemotherapy-induced metastasis: Mechanisms and translational opportunities

1 Department of Anatomy and Structural Biology, Albert Einstein College of Medicine, NY, USA

2 Integrated Imaging Program, Albert Einstein College of Medicine, NY, USA

3 Gruss-Lipper Biophotonics Center, Albert Einstein College of Medicine, NY, USA

4 Department of Pathology, Albert Einstein College of Medicine, NY, USA

Background: Chemotherapy has become essential in the care of patients with advanced breast cancer. However, as we have previously discovered, chemotherapy may induce pro-metastatic changes in the breast cancer microenvironment by promoting the assembly and function of cancer cell intravasation sites called tumor microenvironment of metastasis (TMEM), and by increasing the proportion of the highly-invasive MenaINV-HI tumor cells that utilize TMEM sites for hematogenous dissemination. Consequently, chemotherapy-treated animals demonstrate increased numbers of circulating-tumor cells and micrometastases. Since the formation of metastases depends on both the presence of functional doorways for dissemination (TMEM) and cancer cells capable of using these doorways (MenaINV-HI tumor cells), we investigated the cellular and molecular contexts required for chemotherapy-mediated induction of TMEM function and MenaINV expression. Since TMEM function depends on Tie2 expressing macrophages and MenaINV expression is inducible by cancer cell -macrophage contact, we focused on inhibiting Tie2 receptors and chemotherapy-induced macrophage influx to inhibit chemotherapy-induced metastasis.

Materials and Methods: We used spontaneous models of mouse breast carcinoma (MMTV-PyMT) and patient-derived xenografts treated with chemotherapy with or without co-treatment with either Tie2 inhibitor (rebastinib), inhibitors of Cxcr4+ macrophage chemotaxis (Cxcl12 inhibitors) or macrophage depletion agents (clodronate). Pro-metastatic endpoints were measured by intravital imaging, multichannel immunofluorescence and standard metastasis dissemination assays.

Results: We demonstrated, using multiple methods of macrophage suppression, that chemotherapy-mediated induction of MenaINV-HI tumor cells depends on the presence of macrophages. In particular, depletion of either the entire macrophage lineage using clodronate liposomes or the use of specific inhibitors of the Cxcl12/Cxcr4 chemotactic pathway, resulted in a significant suppression of the MenaINV-hi cancer cell subpopulation in all mammary tumors examined. Moreover, inhibition of Tie2 by rebastinib blocked TMEM function and decreased the number of circulating tumor cells and metastatic foci, despite the chemotherapy-mediated induction of MenaINV-HI tumor cells.

Conclusions: Our data indicate that both the MenaINV-HI disseminating cancer cell population and the TMEM doorways are necessary but not individually sufficient for metastasis. As such, suppression of either the MenaINV-HI population or TMEM function can suppress chemotherapy-induced metastasis, thus providing a target to improve clinical care and eliminate non-beneficial effects of chemotherapy.

Citation Format: Rivera Sanchez LG, Karagiannis GS, Wang Y, Sharma VP, Burt J, Entenberg D, Oktay M, Condeelis JS. Chemotherapy-induced metastasis: Mechanisms and translational opportunities [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-05-01.

Abstract 913: MENAINV expression identifies a de novo chemotherapy-induced prometastatic subpopulation in breast cancer

Neoadjuvant chemotherapy (NAC) is used for treatment of localized breast cancer to decrease tumor size and improve surgical outcome. However, Karagiannis et al. (2017) has uncovered a previously unrecognized side-effect, which involves the induction of pro-metastatic changes in the primary breast cancer microenvironment, in response to NAC treatment. In particular, NAC promotes the assembly of structures that serve as doorways for intravasation of tumor cells called tumor microenvironment of metastasis (TMEM), and increases the proportion of the highly invasive and migratory MenaINV-hi/Mena11alo (MenaCalc+) tumor cells, which utilize the TMEM sites for hematogenous dissemination (Karagiannis et al., 2017). MenaINV expression in particular is associated with decreased sensitivity of cancer cells to receptor tyrosine-kinase (RTK) and tyrosine-kinase (TK) inhibitors and with dramatically increased TMEM-dependent intravasation. The mechanism behind these pro-metastatic changes was not known until recently. Here, we report that NAC induces an influx of macrophages in the tumors, resulting in increased contact between macrophages and tumor cells leading to MenaINV expression in the cancer cells, and MenaINV- and TMEM-dependent tumor cell intravasation. Multichannel IF imaging and distance analysis algorithms demonstrate that MENAINV-hi cells have a higher probability of being in direct cell contact with infiltrating macrophages in chemotherapy-treated tumors. Specific depletion of the macrophage lineage in transgenic MMTV-PyMT mice developing spontaneous breast carcinoma and patient-derived xenografts results in a significant suppression of the prometastatic MenaINV-hi cancer cell subpopulation. Moreover, chemotherapy-induced MenaINV expression in tumor cells is not seen in such macrophage-depleted mice, indicating that macrophage influx is both necessary and sufficient for the generation of the de novo prometastatic tumor cell subpopulation. These data provide an explanation as to why mice and patients with breast cancer do not always respond with a decrease in circulating tumor cells (CTCs), or even respond with a slight increase, following cytotoxic NAC treatment. Our work has uncovered a previously unrecognized mechanism behind pro-metastatic changes in response to cytotoxic chemotherapy and the markers that predict these changes (TMEM, MenaCalc and MenaINV).

Reference: Karagiannis GS, et al. Neoadjuvant chemotherapy induces breast cancer metastasis through aTMEM-mediated mechanism. Sci Transl Med, 2017; 9 aeen0026.

Citation Format: George S. Karagiannis, Luis Rivera Sanchez, Yarong Wang, Ved P. Sharma, Joseph Burt, Sara Brizio, David Entenberg, Maja H. Oktay, John S. Condeelis. MENAINV expression identifies a de novo chemotherapy-induced prometastatic subpopulation in breast cancer [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 913.

Perceptions of self-rated health among stroke survivors: a qualitative study in the United Kingdom

Background

Self-rated health predicts health outcomes independently of levels of disability or mood. Little is known about what influences the subjective health experience of stroke survivors. Our aim was to investigate stroke survivors’ perceptions of self-rated health, with the intention of informing the design of interventions that may improve their subjective health experience.

Methods

We conducted semi-structured interviews with a purposive sample of 28 stroke survivors recruited from a stroke unit and follow-up outpatient clinic, 4–6 months after stroke, to explore what factors are perceived to be part of self-rated health in the early stages of recovery. Qualitative data were analysed using a thematic analysis approach to identify underlying themes.

Results

Participants’ accounts show that stroke survivors’ perceptions of self-rated health are multifactorial, comprising physical, psychological and social components. Views on future recovery after stroke play a role in present health experience and are shaped by psychosocial resources that are influenced by past experiences of ill-health, dispositional outlook such as degree of optimism, a sense of control and views on ageing.

Conclusions

Severity of physical limitations alone does not influence perceptions of self-rated health among stroke survivors. Self-rated health in stroke survivors is a multidimensional construct shaped by changes in health status occurring after the stroke, individual characteristics and social context. Understanding the factors stroke survivors themselves associate with better health will inform the development of effective approaches to improve rehabilitation and recovery after stroke.

Abstract B030: Neoadjuvant chemotherapy promotes macrophage-induced MenaINV-dependent pro-metastatic changes in breast tumors

Neoadjuvant chemotherapy (NAC) is used for treatment of localized breast cancer to decrease tumor size and improve surgical outcome. However, our recent study has uncovered a previously unrecognized side effect of NAC, which involves the induction of pro-metastatic changes in the primary breast cancer microenvironment. In particular, NAC promotes the assembly of structures that serve as doorways for intravasation of tumor cells called tumor microenvironment of metastasis (TMEM), and increases the proportion of the highly invasive and migratory MenaINV-hi/Mena11alo (MenaCalc+) tumor cells, which utilize the TMEM sites for hematogenous dissemination (1). MenaINV expression in particular is associated with decreased sensitivity of cancer cells to receptor tyrosine-kinase (RTK) and tyrosine-kinase (TK) inhibitors and with dramatically increased TMEM-dependent intravasation. The mechanism behind these pro-metastatic changes was not known. Here we report that NAC induces increased levels of Tie2Hi macrophages in the tumors, resulting in increased contact between macrophages and tumor cells leading to MenaINV expression in the cancer cells, and MenaINV-dependent TMEM assembly and tumor cell intravasation. Furthermore, we demonstrate that the Tie2 switch control inhibitor rebastinib sufficiently suppresses Tie2 signaling in macrophages, thereby inhibiting increased levels of Tie2Hi macrophages in the tumor, resulting in decreased MenaINV expression in the cancer cells and decreased TMEM-associated tumor cell intravasation. Our work has uncovered a previously unrecognized mechanism behind pro-metastatic changes in response to cytotoxic chemotherapy, the markers that predict these changes (TMEM, MenaCalc and MenaINV), and shows that this mechanism could be addressed by combining chemotherapy with rebastinib. Reference: 1. Karagiannis GS, et al. Neoadjuvant chemotherapy induces breast cancer metastasis through a TMEM-mediated mechanism. Sci Transl Med 2017;9:aeen0026.

Citation Format: George S. Karagiannis, Ved P. Sharma, Sara Brizio, Joseph Burt, Yarong Wang, David Entenberg, Bryan Smith, Daniel Flynn, Maja H. Oktay, John Condeelis. Neoadjuvant chemotherapy promotes macrophage-induced MenaINV-dependent pro-metastatic changes in breast tumors [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2017 Oct 26-30; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Ther 2018;17(1 Suppl):Abstract nr B030.

The Patient Assessment of Chronic Illness Care produces measurements along a single dimension: results from a Mokken analysis

Background

As the worldwide prevalence of chronic illness increases so too does the demand for novel treatments to improve chronic illness care. Quantifying improvement in chronic illness care from the patient perspective relies on the use of validated patient-reported outcome measures. In this analysis we examine the psychometric and scaling properties of the Patient Assessment of Chronic Illness Care (PACIC) questionnaire for use in the United Kingdom by applying scale data to the non-parametric Mokken double monotonicity model.

Methods

Data from 1849 patients with long-term conditions in the UK who completed the 20-item PACIC were analysed using Mokken analysis. A three-stage analysis examined the questionnaire’s scalability, monotonicity and item ordering. An automated item selection procedure was used to assess the factor structure of the scale. Analysis was conducted in an ‘evaluation’ dataset (n = 956) and results were confirmed using an independent ‘validation’ (n = 890) dataset.

Results

Automated item selection procedures suggested that the 20 items represented a single underlying trait representing “patient assessment of chronic illness care”: this contrasts with the multiple domains originally proposed. Six items violated invariant item ordering and were removed. The final 13-item scale had no further issues in either the evaluation or validation samples, including excellent scalability (Ho = .50) and reliability (Rho = .88).

Conclusions

Following some modification, the 13-items of the PACIC were successfully fitted to the non-parametric Mokken model. These items have psychometrically robust and produce a single ordinal summary score. This score will be useful for clinicians or researchers to assess the quality of chronic illness care from the patient's perspective.

Care plans and care planning in long-term conditions: a conceptual model

The prevalence and impact of long-term conditions continues to rise. Care planning for people with long-term conditions has been a policy priority for chronic disease management in a number of health-care systems. However, patients and providers appear unclear about the formulation and implementation of care planning. Further work in this area is therefore required to inform the development, implementation and evaluation of future care planning initiatives. We distinguish between 'care planning' (the process by which health-care professionals and patients discuss, agree and review an action plan to achieve the goals or behaviour change of most relevance and concern to the patient) and a 'care plan' (a written document recording the outcome of a care planning process). We propose a typology of care planning and care plans with three core dimensions: perspective (patient or professional), scope (a focus on goals or on behaviours) and networks (confined to the professional-patient dyad or extending to the entire care network). In addition, we draw on psychological models of mediation and moderation to outline potential mechanisms through which care planning and care plans may lead to improved outcomes for both patients and the wider health-care system. The proposed typology of care planning and care plans offered here, along with the model of the process by which care planning may influence outcomes, provide a useful framework for future policy developments and evaluations. Empirical work is required to explore the degree to which current care planning approaches and care plans can be described according to these dimensions, and the factors that determine which types of patients and professionals use which type of care plans.

Corals from the Persian/Arabian Gulf as models for thermotolerant reef-builders: prevalence of clade C3 Symbiodinium, host fluorescence and ex situ temperature tolerance

Corals in the Arabian/Persian Gulf endure summer temperatures of up to 36°C, making them ideal subjects to study the mechanisms underlying thermal tolerance. Unexpectedly, we found the "generalist" Symbiodinium clade C3 to be the prevalent symbiont among seven coral species from Abu Dhabi (UAE) waters. Moreover, C3 represented the only dominant symbiont type in Porites spp. from this region. The "thermotolerant" symbionts D1a and C15 were not encountered, indicating that the association with these symbionts cannot be the sole reason for the heat tolerance of Gulf corals. The association of Porites lobata with specific symbiont types (C3 vs. C15) in samples from habitats with very different temperature regimes (Abu Dhabi vs. Fiji) remained unaffected by laboratory culture. During temperature stress experiments specimens from both locations strongly downregulated green fluorescent protein (GFP)-like pigments. However, the Abu Dhabi samples were less prone to bleaching and showed lower mortality.

A comparison of once versus twice per week training on leg press strength in women

AIM

The purpose of this study was to compare strength differences between 2 groups of untrained women, who performed a single set of the leg press exercise once or twice per week.

METHODS

Twenty-one women were divided randomly into 2 groups: Group 1 (n=10) performed a single set of the leg press exercise once per week, while Group 2 (n=11) performed a single set of the leg press exercise twice per week for a period of 8 weeks. Throughout the duration of the study, an amount of resistance was utilized that allowed for a single set of 6 to 10 repetitions to muscular failure. At the conclusion of the study, subjects were tested for their 6-RM strength. A 2x2 ANOVA was used to compare strength differences. The a level was set at 0.05 in order for differences to be considered significant.

RESULTS

The 2x2 ANOVA demonstrated that strength increases were significant between tests (P=0.0001), but not significant between groups (P=0.757).

CONCLUSIONS

These results indicate that performing a single set of the leg press once or twice per week results in statistically similar strength gains in untrained women.

Assessing the impact of nutrient enrichment in estuaries: susceptibility to eutrophication

The main aim of this study was to develop a generic tool for assessing risks and impacts of nutrient enrichment in estuaries. A simple model was developed to predict the magnitude of primary production by phytoplankton in different estuaries from nutrient input (total available nitrogen and/or phosphorus) and to determine likely trophic status. In the model, primary production is strongly influenced by water residence times and relative light regimes. The model indicates that estuaries with low and moderate light levels are the least likely to show a biological response to nutrient inputs. Estuaries with a good light regime are likely to be sensitive to nutrient enrichment, and to show similar responses, mediated only by site-specific geomorphological features. Nixon's scale was used to describe the relative trophic status of estuaries, and to set nutrient and chlorophyll thresholds for assessing trophic status. Estuaries identified as being eutrophic may not show any signs of eutrophication. Additional attributes need to be considered to assess negative impacts. Here, likely detriment to the oxygen regime was considered, but is most applicable to areas of restricted exchange. Factors which limit phytoplankton growth under high nutrient conditions (water residence times and/or light availability) may favour the growth of other primary producers, such as macrophytes, which may have a negative impact on other biological communities. The assessment tool was developed for estuaries in England and Wales, based on a simple 3-category typology determined by geomorphology and relative light levels. Nixon's scale needs to be validated for estuaries in England and Wales, once more data are available on light levels and primary production.

Four year follow up of fatigue in a geographically defined primary biliary cirrhosis patient cohort

BACKGROUND AND AIMS

Fatigue is the commonest symptom described by patients in most populations with the autoimmune liver disease primary biliary cirrhosis (PBC), and appears to be unrelated to liver disease severity. At present, it is unclear how the fatigue experienced by patients (only characterised to date in cross sectional studies) evolves over time. In this study, we set out to address how fatigue had changed over four years of follow up in a geographically defined cohort of PBC patients who participated in an earlier cross sectional study of fatigue impact.

METHODS

Participants in the original 2000 study who were still alive in 2004 were asked to complete the same fatigue assessment tool (fatigue impact score, FIS). In those who had died between 2000 and 2004, medical notes, death certificates, and primary care records were reviewed.

RESULTS

A total of 108 of the original cohort of 136 patients were alive at the time of the follow up study, 99 of whom (92%) participated in the follow up study. With the exception of four patients who underwent transplantation between 2000 and 2004, all of whom showed significant improvement in fatigue severity as assessed by FIS, fatigue severity was unchanged over four years of follow up. Among the 28 patients who died during the follow up period, survival was significantly lower in patients who were fatigued at the 2000 baseline (FIS above the median for the whole PBC population (40/160); log rank test, p = 0.006 v non-fatigued patients at baseline). Increased fatigue severity was independently associated with decreased survival on multivariate analysis. Fatigued PBC subjects were significantly more likely to have suffered a cardiac death than non-fatigued patients.

CONCLUSIONS

The fatigue phenotype appears to be highly stable in PBC. The presence of fatigue in PBC is independently associated with a significantly increased risk of death in general, and cardiac death in particular. Factors underpinning fatigue in PBC, and the mechanisms whereby fatigue is associated with increased mortality, warrant further study.

A comparison of multifaceted versus Clostridium difficile-focused VRE surveillance strategies in a low-prevalence setting

We compared our current screening strategy for vancomycin-resistant Enterococcus (VRE) with a focused strategy that screens all stool samples sent for Clostridium difficile toxin assay but limits rectal swab screening to wards with new VRE cases detected via C. difficile samples. The proposed strategy detects 72.7% of new VRE cases, with substantial cost savings.

Analyzing the quality of ophthalmic nursing research

The purpose of this project was to describe, classify, and analyze ophthalmic nursing research published between 1975 and 1996. Sixty-six quantitative research articles were reviewed. This mainly descriptive body of research covered such topics as assessment/screening, self-care, and risk factors. The research articles were generally rated as superior or average, with many of the average being at the low end of the scale. Twenty-eight percent of the research was not applicable to nursing practice, and 42% had low or no theoretical relevance to nursing. This review will help to establish a research agenda in the area of ophthalmic nursing.

Efficacy of Psychoeducational Group Therapy in reducing symptoms of posttraumatic stress disorder among multiply traumatized women

OBJECTIVE

The role of group therapy in treatment of posttraumatic stress disorder (PTSD) has been traditionally restricted to issues of self-esteem and interpersonal relationships, rather than primary symptoms of the disorder. In this study, the authors examined the effectiveness of a 16-week trauma-focused, cognitive-behavioral group therapy, named Interactive Psychoeducational Group Therapy, in reducing primary symptoms of PTSD in five groups (N=29) of multiply traumatized women diagnosed with chronic PTSD.

METHOD

The authors made assessments at baseline, at 1-month intervals during treatment, at termination, and at 6-month follow-up by using self-report and structured interview measures of PTSD and psychiatric symptoms. The absence of a control group limits the conclusions drawn from the study.

RESULTS

At termination, subjects showed significant reductions in all three clusters of PTSD symptoms (i.e., reexperiencing, avoidance, and hyperarousal) and in depressive symptoms; they showed near-significant reductions in general psychiatric and dissociative symptoms, at termination. These improvements were sustained at 6-month follow-up.

CONCLUSIONS

The role of group therapy in PTSD treatment should not be prematurely restricted to addressing self-esteem and interpersonal dimensions only. The use of structured, cognitive-behavioral elements within the group format may allow for more targeted treatment of core symptoms of the disorder.

Spreading and retention of vaginal formulations in post-menopausal women as assessed by gamma scintigraphy

PURPOSE

In this paper we report on the first scintigraphic evaluation of vaginal dosage forms in post-menopausal women. To date, almost nothing is known about the in vivo performance of pharmaceutical formulations in the human vagina, which is a major deficiency in the rational design of drug delivery systems for both existing and new indications.

METHODS

The vaginal spreading and clearance of a radiolabelled pessary formulation and Replens (polycarbophil) gel, was assessed in six healthy, post-menopausal female volunteers over a six hour period using the technique of gamma scintigraphy.

RESULTS

In five out of the six subjects studied, clearance of the two formulations exhibited very little intra-subject variation. However, there was considerable inter-subject variability in clearance; in Subject 5 circa 80% of the products were retained whilst in Subject 2 less than 2% was present at the end of the six hour imaging period. Importantly, there was no evidence to suggest that either of the formulations dispersed material beyond the cervix, into the uterus, in any of the subjects studied.

CONCLUSIONS

The lack of significant retention of these products in most of the volunteers has obvious implications for the delivery of therapeutic agents. This study shows that gamma scintigraphy is an invaluable technique with which to assess novel formulations aimed at optimising retention in the vagina for topical or systemic drug delivery.

More pain, more tender points: is fibromyalgia just one end of a continuous spectrum?

OBJECTIVES

To investigate the hypothesis that fibromyalgia represents one end of a spectrum in which there is a more general association between musculoskeletal pain and tender points.

METHODS

The subjects studied were 177 individuals selected from a population based screening survey for musculoskeletal pain. All subjects completed a pain mannikin and were examined for the presence of tender points at the nine American College of Rheumatology bilateral sites.

RESULTS

There were moderately strong associations (odds ratios range 1.3-3.1) between the reported presence of pain in a body segment and the presence of a tender point within that segment. Further, there was evidence of a trend of increasing number of tender points with increasing number of painful segments. The reporting of non-specific pain, aching, or stiffness, was also associated with high tender point counts.

CONCLUSION

This study illustrates that the association between tender points and pain is not restricted to the clinically defined subgroup with chronic widespread pain. Given that widespread pain and tender points have previously been linked with distress, this might reflect lesser degrees, or earlier phases of the somatisation of distress.

Health symptoms and the work environment in four nonproblem United States office buildings

OBJECTIVES

The objective of this study was to quantify health symptom reports in four "nonproblem" buildings and to assess the relationship between symptoms and air quality measures, workstation characteristics, and psychosocial aspects of the workplace.

METHODS

Environmental sampling was conducted in four office buildings occupied by employees working for the state of Washington in March of 1992. A questionnaire was concurrently administered to building occupants.

RESULTS

While measured contaminant levels were low, symptoms were frequent. Fifty-five percent of the 646 respondents reported recent symptoms which affected the eyes, nose, or throat and improved when away from work. Symptoms were not associated with measured contaminant levels, but, rather, with perceptions about air movement, dryness, odors, and noise. Psychosocial factors were less strongly associated with symptoms.

CONCLUSIONS

Even in nonproblem buildings, symptom reports can be frequent and may represent overall satisfaction with the work environment. In response to symptoms ascribed to air quality problems, it may be appropriate to address employee perceptions regarding the work environment in addition to evaluating environmental characteristics relating to chemicals, biological contamination, air movement, temperature, and humidity.

Occupational lead poisoning: can it be eliminated?

The continued occurrence of occupational lead poisoning and overexposure in the United States represents a serious challenge to the occupational health community. We outline a proposed action strategy which integrates case-based surveillance, hazard surveillance, increased requirements for biological monitoring, and targeted educational activities, with a goal of eliminating occupational lead poisoning. The system provides a simple mechanism for monitoring compliance in lead-using employers, in order to identify employers for enforcement action. Lead poisoning should be viewed as an eradicable condition; successfully solving the persistent lead overexposure problem can serve as a model for approaching other occupational diseases.

Consistency of morning stiffness: an analysis of diary data

This study aimed to determine the within-individual daily variation in morning stiffness (MS) of RA patients, and to validate the routine clinically derived duration of MS against that recorded prospectively by patients. Forty-nine RA patients, who during a detailed clinical interview reported experiencing MS that week were studied. They were asked to prospectively record, using a diary, daily information on the duration of their MS. The times both of waking and of getting up were noted, as well as the times to first improvement, maximum improvement and complete disappearance of MS, providing six possible estimates of MS duration, three of which, using waking as starting points, could be compared with the interview. The daily variation of MS was assessed by the within-patient range. The median duration of the diary scores was then compared with the MS estimates recorded at the interview. There was a large intra-individual variation in duration of MS, whichever of the six definitions were used. Half of the patients recorded ranges of MS scores of 3 h or more within the same week. There was also marked variation between the median diary derived duration and that ascertained by interview. This variation was at its smallest when the duration of MS was calculated as time until maximum improvement. The routine recording of the 'typical' duration of MS seems to have little clinical value in the face of the large within-patient variation. Of the possible choices for estimating duration, the time from waking to maximum improvement appeared to be the best indicator of the average duration of MS in RA patients.

Laser ablation of the prostate in patients with benign prostatic hypertrophy

Seventeen patients with bladder neck obstruction due to benign prostatic hypertrophy have been treated with the Neodymium: YAG laser. We review our experience since the first patient was treated in September 1990. Using a prototype deflecting gold alloy tip on a quartz laser fibre (Lateralase TM), we ablated obstructing prostatic adenoma and constricting bladder neck tissue. Experience with this technique has enabled a patient population to be defined in whom laser therapy for prostatic obstruction may be effective. The treatment is relatively simple, speedy and attended by virtually no blood loss. Laser ablation therapy may offer some advantages over conventional transurethral resection of the prostate (TURP) in a selected subgroup of patients. The advent of new delivery systems may make laser ablation therapy a practical alternative to TURP.

Household size and the cost of nutritionally equivalent diets

Economy of scale factors were developed in 1975 and have since been utilized as household size adjustment factors in estimating household costs of US Department of Agriculture (USDA) food plans. As such, these adjustment factors have a direct impact on the Food Stamp Program coupon allotments. In the present study, the stability of these factors over time was assessed, and the impact of diet quality measures in determining the adjustment factors was investigated. The reported household scale factors, estimated using regression analyses and the Nationwide Food Consumption Survey, Survey of Food Consumption in Low-Income Households, 1977-78, varied somewhat from former estimates and were found to be highly dependent on the diet quality measures incorporated in the analysis. Incorporation of several diet quality variables as well as partition specific means are recommended for determining household size adjustment factors to be used in estimating household costs of USDA food plans.

Laser microsurgery in cell and developmental biology

New applications of laser microbeam irradiation to cell and developmental biology include a new instrument with a tunable wavelength (217- to 800-nanometer) laser microbeam and a wide range of energies and exposure durations (down to 25 X 10(-12) second). Laser microbeams can be used for microirradiation of selected nucleolar genetic regions and for laser microdissection of mitotic and cytoplasmic organelles. They are also used to disrupt the developing neurosensory appendages of the cricket and the imaginal discs of Drosophila.

5-hydroxytryptamine depletion with para-chlorophenylalanine: effects on eating, drinking, irritability, muricide, and copulation

Forty-four male rats were tested for eating, drinking, irritability, and copulation before and after intraperitonial para-chlorophenylalanine (PCPA) or control injections. Eleven of these rats were tested for muricide before and after PCPA injections (Group 1), while 18 others were tested only after PCPA injections (Groups 2). Group 1 rats received four 350 mg/kg PCPA injections spaced 6 days apart and showed hyperdipsia, weight loss, and a 24% increase in muricide. Group 2 rats received five daily 100 mg/kg PCPA injections repeated 11 days later and showed hyperdipsia and weight loss; in addition, 78% of them killed mice. Neither group showed significant changes in copulation. At the end of the experiment, t6 rats from Group 2 that were irritable and killed mice were injected intraperitonially with 5-hydroxytryptophan (80 mg/kg). Five of these rats lost their irritability and four stopped killing. The various behavioral changes were not corrleated significantly either with each other or with the degree of 5-hydroxytryptamine depletion. This tentatively suggests that PCPA may produce its effects on behavior by other means in addition to 5-hydroxytryptamine depletion.

Nasolacrimal duct anomaly in calves

Supernumerary openings of the nasolacrimal drainage apparatus were found in 13 Brown Swiss calves. The cause of the anomaly was not determined but was assumed to be similar to that in man.