The differentiating effect of COVID-19-associated stress on the morbidity of blood donors with symptoms of hidradenitis suppurativa, hyperhidrosis, or psoriasis

PURPOSE

The burden of different skin diseases may vary leading individuals to have different sensitivity to stress. Therefore, we compared the health-related quality of life (HRQoL) and stress before and during the universal stress from the severe acute respiratory syndrome coronavirus-2-pandemic in individuals with and without hyperhidrosis, hidradenitis suppurativa, or psoriasis.

METHODS

The study cohort was the Danish Blood Donor Study. Overall, 12,798 participants completed a baseline questionnaire before the pandemic, in 2018-2019, and a follow-up questionnaire during the pandemic, in 2020. Regression determined the association between the skin diseases and outcomes. Outcomes were the physical and mental component summary (MCS, PCS, respectively), which assess the mental and physical HRQoL, and the perceived stress scale, which assesses stress in the past four weeks.

RESULTS

Overall, 1168 (9.1%) participants had hyperhidrosis, 363 (2.8%) had hidradenitis suppurativa, and 402 (3.1%) had psoriasis. At follow-up, the participants with hyperhidrosis had worse MCS (coefficient -0.59 [95% confidence interval (CI) -1.05, -0.13]) and higher odds of moderate-to-severe stress (odds ratio 1.37 [95% CI 1.13, 1.65]) and the participants with hidradenitis suppurativa worse PCS (coefficient -0.74 [95% CI -1.21, -0.27]) than the control groups. The associations were independent of baseline HRQoL, stress, the Connor-Davidson Resilience scale, and other covariables. Psoriasis was not associated with the outcomes.

CONCLUSION

Individuals with hyperhidrosis or hidradenitis suppurativa experienced worse mental or physical well-being and individuals with hyperhidrosis also had higher stress during the pandemic compared to healthy individuals. This suggests that individuals with these skin diseases are particularly susceptible to external stress.

A study protocol outlining the development and evaluation of a training program for frontline managers on leading well-being and the psychosocial work environment in Danish hospital settings - a cluster randomized waitlist controlled trial

BACKGROUND

Hospital staff are often exposed to stressful psychosocial working conditions and report high levels of stress and burnout, which may negatively impact the safety of employees and patients. Managers hold unique knowledge of workplace conditions and needs of employees, but leadership interventions to improve the well-being of managers and employees in hospital settings are scarce. This study evaluates the effects of a leadership intervention based on a health-oriented leadership approach on the well-being and psychosocial work environment aspects of managers and employees.

METHODS/DESIGN

The study is designed as a randomized, waitlist-controlled trial with two groups (intervention and waitlist control group) and measurements at baseline, 6- and 12-month follow-up. We aim to include 200 frontline managers in Danish hospital settings and their approximately 5,000 employees. The leadership training comprises five full day modules and four smaller group-training sessions over a period of 5 months. The main aim is to improve stress, burnout, self-care, and perceived level of staff-care among managers and employees. Sickness absence will also be assessed at both manager and employee level. In addition, several psychosocial factors will be assessed at the employee level. A quantitative and qualitative process evaluation will also be conducted.

DISCUSSION

Action towards supporting the mental health of hospital employees is important to maintain a strong healthcare system. There is increasing recognition that best practice in workplace mental health requires an integrated approach that prevents harm and promotes positive mental health. There is also increasing understanding of the key role managers' play in maintaining well-being within the workplace, however they often report a lack of knowledge and skills to promote employee mental health. The current leadership training program has been developed for frontline managers working in a hospital setting. The aim is to increase managers' application of strategies to facilitate a healthy psychosocial work environment to benefit well-being and mental health among staff and managers themselves.

TRIAL REGISTRATION

The study was retrospectively registered on November 21, 2022 in Clinical Trial.gov with identifier: NCT05623371.

From analytic to synthetic-organizational pluralisms: A pluralistic enactive psychiatry

INTRODUCTION

Reliance on sole reductionism, whether explanatory, methodological or ontological, is difficult to support in clinical psychiatry. Rather, psychiatry is challenged by a plurality of approaches. There exist multiple legitimate ways of understanding human functionality and disorder, i.e., different systems of representation, different tools, different methodologies and objectives. Pluralistic frameworks have been presented through which the multiplicity of approaches in psychiatry can be understood. In parallel of these frameworks, an enactive approach for psychiatry has been proposed. In this paper, we consider the relationships between the different kinds of pluralistic frameworks and this enactive approach for psychiatry.

METHODS

We compare the enactive approach in psychiatry with wider analytical forms of pluralism.

RESULTS

On one side, the enactive framework anchored both in cognitive sciences, theory of dynamic systems, systems biology, and phenomenology, has recently been proposed as an answer to the challenge of an integrative psychiatry. On the other side, two forms of explanatory pluralisms can be described: a non-integrative pluralism and an integrative pluralism. The first is tolerant, it examines the coexistence of different potentially incompatible or untranslatable systems in the scientific or clinical landscape. The second is integrative and proposes to bring together the different levels of understanding and systems of representations. We propose that enactivism is inherently a form of integrative pluralism, but it is at the same time a component of the general framework of explanatory pluralism, composed of a set of so-called analytical approaches.

CONCLUSIONS

A significant number of mental health professionals are already accepting the variety of clinical and scientific approaches. In this way, a rigorous understanding of the theoretical positioning of psychiatric actors seems necessary to promote quality clinical practice. The study of entanglements between an analytical pluralism and a synthetic-organizational enactivist pluralism could prove fruitful.

Incidence and remission rates of self-reported hidradenitis suppurativa - A prospective cohort study conducted in Danish blood donors

BACKGROUND

A large discrepancy between physician-diagnosed and self-reported Hidradenitis suppurativa (HS) exists. Knowledge regarding incidence and remission rates of self-reported HS is missing, but may help bridge the gap in understanding between these two phenotypes.

OBJECTIVES

To determine the incidence and remission rates of self-reported HS, and to what degree these are affected by sex, smoking and BMI.

METHODS

A prospective cohort of 23 930 Danish blood donors. Information on self-reported HS, symptom-localisation, sex, age, BMI and smoking status was collected at baseline and study termination. Self-reported HS fulfilled clinical obligatory diagnostic criteria. Cox proportional hazards regression analyses were conducted for both incidence and remission rates providing a hazard ratio (HR) of risk for each variable in the regression.

RESULTS

Incidence rate of self-reported HS was 10.8/1000 person-years (95% confidence interval (CI): 9.9-11.7), decreasing as a function of numbers of areas affected. Female BMI points above 25 (HR = 1.11, 95% CI: 1.09-1.13), male BMI points above 25 (HR = 1.07, 95% CI: 1.04-1.11), active smoking (HR = 1.72, 95% CI: 1.15-2.57), male sex (HR = 0.55, 95% CI: 0.45-0.67) and years of age above 25 (HR = 0.97, 95% CI: 0.96-0.97) were all statistically associated with the development of self-reported HS. Remission rate of self-reported HS was 256.7/1000 person-years (95% CI: 223.9-292.6), decreasing as a function of numbers of affected areas. Symptoms in ≥3 areas (HR = 0.54, 95% CI: 0.34-0.85), active smoking (HR = 0.49, 95% CI: 0.32-0.76) and female weight loss (every percentage drop in BMI: HR = 1.07, 95% CI: 1.05-1.11) all significantly affected the remission rate.

CONCLUSIONS

Both incidence and remission rates of self-reported HS are high, indicating that many with self-reported HS are unlikely to be diagnosed, as they to a higher degree experience mild transient HS symptoms.

Survival in 31 670 patients with thin melanomas: a Swedish population-based study

BACKGROUND

The incidence of cutaneous malignant melanoma (CMM) continues to increase in most countries worldwide and the majority are diagnosed with thin tumours (≤ 1 mm).

OBJECTIVES

The aim of the present study was to investigate the melanoma-specific survival (MSS) as well as conditional MSS (CMSS) in patients with thin CMM in Sweden.

PATIENTS AND METHODS

Clinical and histological parameters were obtained from the Swedish Melanoma Registry for patients diagnosed with thin CMM between 1990 and 2017. Patients were followed until the end of 2017. MSS as well as CMSS for different thickness groups were calculated using the Kaplan-Meier method and Cox regression analyses were used to calculate for survival differences between thickness groups.

RESULTS

There were 31 670 patients included for final analyses. The overall 10- and 20-year MSS for thin CMMs was 97% [95% confidence interval (CI) 97-97] and 95% (95% CI 95-96), respectively. From 0·7 mm and above, MSS decreased significantly with increasing thickness level. All thickness groups had an increased survival over time. The lowest CMSS was confirmed for men with 1·0 mm in thickness but their 10-year CMSS increased steadily over time. Women had overall better MSS as well as CMSS than men. However, the relation between MSS and CMSS was similar for both sexes.

CONCLUSIONS

MSS was confirmed as excellent for patients with thin CMMs in Sweden. Although we could show a decreased MSS for patients with 0·7 mm thickness and above, the long-term survival and, in addition, a very favourable CMSS for those patients do not support more extended follow-up programmes than the current recommendations in Sweden.

Surgical treatment of basal cell carcinoma: a case series on factors influencing the risk of an incomplete primary excision

BACKGROUND

Basal cell carcinoma (BCC) is the most common skin cancer form, and one first-line treatment is surgical excision. Complete excision is vital to minimize risk of recurrence. Studies on occurrence of incomplete excisions have given diverse results and seldom include large populations from a dermatological setting.

OBJECTIVES

The rate of positive surgical margins in primary surgery of BCC at a tertiary dermatology clinic is studied. Factors associated with an incomplete primary excision are analysed.

METHODS

Patients scheduled for standard excision, without perioperative margin control, of BCC during the years 2008-2015 were prospectively enrolled in the study. Tumour-specific factors, including histopathologic subtype, as well as postoperative outcome were registered. Incomplete excisions were analysed in relation to patient- and tumour-related factors.

RESULTS

In total, 4.6% of 3911 BCC tumours were incompletely excised. The rate of incomplete excisions was higher for facial tumours and among tumours with an aggressive histological subtype. Morpheiform BCC on the nose or ear had the highest rate of an incomplete excision, 61.5% and 50%, respectively.

CONCLUSIONS

Most BCCs, irrespective of subtype, were completely excised during the primary excision. Tumour sites nose and ears were associated with the highest rate of positive primary surgical margins, especially for infiltrative or morpheiform BCCs. Surgery with perioperative examination of margins is strongly recommended for these tumours.

Phenomena complexes as targets of explanation in psychopathology: The relational analysis of phenomena approach

In this article, we briefly overview some current approaches to identifying targets of explanation in psychopathology. We suggest that DSM syndromes and symptom network models are too large to facilitate explanatory progress, while approaches couched in the Research Domain Criteria (RDoC) are too tightly focused, thereby overlooking the self-maintaining structures and processes that constitute mental disorders. We then present the Relational Analysis of Phenomena (RAP) as a complementary method. The RAP is a metamethodological explanatory framework that prescribes the repeated targeting of “phenomena complexes” (PCs). PCs are small systems of clinical phenomena and their relations. We describe a process by which PCs are targeted, richly described, and then explained. The RAP’s explanatory focus is on the relationships between clinical phenomena, which should help to reveal the constitutional structure of mental disorders. This framework is designed to be useful for theoreticians, research teams planning multidisciplinary investigatory projects, and clinicians reflecting on their explanatory methods.

Diagnostic accuracy of urinary intestinal fatty acid binding protein in detecting colorectal anastomotic leakage

BACKGROUND

Anastomotic leakage (AL) remains a severe complication following colorectal surgery, having a negative impact on both short- and long-term outcomes. Since timely detection could enable early intervention, there is a need for the development of novel and accurate, preferably, non-invasive markers. The aim of this study was to investigate whether urinary intestinal fatty acid binding protein (I-FABP) could serve as such a marker.

METHODS

This prospective multicenter cross-sectional phase two diagnostic study was conducted at four centers in the Netherlands between March 2015 and November 2016. Urine samples of 15 patients with confirmed colorectal AL and 19 patients without colorectal AL on postoperative day 3 were included. Urinary I-FABP levels were determined using enzyme-linked immunosorbent assays and adjusted for urinary creatinine to compensate for renal dysfunction.

RESULTS

Urinary I-FABP levels were significantly elevated in patients with confirmed AL compared to patients without AL on postoperative day 3 (median: 2.570 ng/ml vs 0.809 ng/ml, p = 0.006). The area under the receiver operating characteristics curve (AUROC) was 0.775, yielding a sensitivity of 80% and specificity of 74% at the optimal cutoff point (> 1.589 ng/ml). This difference remained significant after calculation of I-FABP/creatinine ratios (median: 0.564 ng/µmol vs. 0.158 ng/µmol, p = 0.040), with an AUROC of 0.709, sensitivity of 60% and specificity of 90% at the optimal cutoff point (> 0.469 ng/µmol).

CONCLUSIONS

Levels of urinary I-FABP and urinary I-FABP/creatinine were significantly elevated in patients with confirmed AL following colorectal surgery, suggesting their potential as a non-invasive biomarker for colorectal anastomotic leakage.

Urinary volatile organic compound markers and colorectal anastomotic leakage

AIM

Inflammatory markers such as serum C-reactive protein (CRP) are used as routine markers to detect anastomotic leakage following colorectal surgery. However, CRP is characterized by a relatively low predictive value, emphasizing the need for the development of novel diagnostic approaches. Volatile organic compounds (VOCs) are gaseous metabolic products deriving from all conceivable bodily excrements and reflect (alterations in) the patient's physical status. Therefore, VOCs are increasingly considered as potential non-invasive diagnostic biomarkers. The aim of this study was to assess the diagnostic accuracy of urinary VOCs for colorectal anastomotic leakage.

METHODS

In this explorative multicentre study, urinary VOC profiles of 22 patients with confirmed anastomotic leakage and 27 uneventful control patients following colorectal surgery were analysed by field asymmetric ion mobility spectrometry (FAIMS).

RESULTS

Urinary VOCs of patients with anastomotic leakage could be distinguished from those of control patients with high accuracy: area under the receiver operating characteristics curve 0.91 (95% CI 0.81-1.00, P < 0.001), sensitivity 86% and specificity 93%. Serum CRP was significantly increased in patients with a confirmed anastomotic leak but with lower diagnostic accuracy compared to VOC analysis (area under the receiver operating characteristics curve 0.82, 95% CI 0.68-0.95, P < 0.001). Combining VOCs and CRP did not result in a significant improvement of the diagnostic performance compared to VOCs alone.

CONCLUSION

Analysis by FAIMS allowed for discrimination between urinary VOC profiles of patients with a confirmed anastomotic leak and control patients following colorectal surgery. A superior accuracy compared to CRP and apparently high specificity was observed, underlining the potential as a non-invasive biomarker for the detection of colorectal anastomotic leakage.

Characteristics of 252 patients with bronchopulmonary neuroendocrine tumours treated at the Copenhagen NET Centre of Excellence

BACKGROUND

Bronchopulmonary neuroendocrine tumours are divided into typical carcinoid (TC), atypical carcinoid (AC), large cell neuroendocrine carcinoma (LCNEC), and small cell lung cancer (SCLC).

AIM

To thoroughly describe a cohort of 252 patients with TC, AC and LCNEC (SCLC excluded).

MATERIAL AND METHODS

Collection of data from 252 patients referred to and treated at Rigshospitalet 2008-2016. Data was collected from electronic patient files and our prospective NET database. Statistics were performed in SPSS.

RESULTS

162 (64%) had TC, 29 (12%) had AC and 61 (24%) had LCNEC. Median age at diagnosis was 69 years (range: 19-89) with no difference between genders. Thoraco-abdominal CT was performed in all patients at diagnosis. FDG-PET/CT was performed in 207 (82%) at diagnosis and was positive in 95% of the entire cohort, with no difference between tumour types. Synaptophysin was positive in 98%, chromogranin A in 92% and CD56 in 97%. Mean Ki67 index was 5% in TC, 16% in AC and 69% in LCNEC (p < 0.001). Metastatic disease was found in 4% of TC, 27% of AC and 58% of LCNEC at time of initial diagnosis (p < 0.001). In total 179 patients (71%) underwent surgical resection; TC: 87%, AC: 72% and LCNEC: 28% (p < 0.001). Of the resected patients, 11 (6%) had recurrence. Five-year survival rate was 88% for TC, 63% for AC and 20% for LCNEC.

CONCLUSION

In this comprehensive study of a cohort of 252 patients, one of the largest until date, with TC, AC and LCNEC, the gender distribution showed female predominance with 68%. FDG-PET/CT was positive in 95% of the patients independent of tumour type, which confirms that FDG-PET/CT should be a part of the preoperative work-up for TC, AC and LCNEC. Tumour type was the single most potent independent prognostic factor.

Towards a new conceptual framework for psychopathology: Embodiment, enactivism, and embedment

Psychopathology classification is at a conceptual crossroads. It is becoming increasingly accepted that the flaws of the DSM relate to its struggles to pick out “real” entities as opposed to clusters of symptoms. The Research Domain Criteria (RDoC) was formulated in response to this failure, and attempts to address the concerns confronting the DSM by shifting to a causal and continuous model of psychopathology. Noting key criticisms of neurocentricism and problems with conceptual validity leveled at the RDoC, we argue that they stem from its grounding in the metaphysical position of eliminative materialism, or at least material-reductionism. We propose that 3e cognition (viewing the mind as embodied, embedded, and enactive) offers a superior alternative to eliminative materialism. A 3e-informed framework of mental disorder is sketched out and its advantages as a basis for classifying and conceptualizing mental disorders are considered.

An Experimental Obliterating Thromboangiitis Limited to the Posterior Part of the Body*

After a brief outline of the principles involved in the production of thrombo- hemorrhagic phenomena (THP) with special organotropic localizations, an experimental technique is described which permits the production of acrocyanosis and thrombohemorrhagic lesions largely limited to the posterior part of the body.

This phenomenon can be consistently produced by certain combinations of THP elicitors, anaphylactoid agents and noradrenaline (NA). The most effective combination among those tested is thorium dextrin (Th-Din) plus tannic acid plus NA.

Several drugs can decisively influence the course of this reaction. Most notable among these are Neo-Antergan (an antihistaminic) which sensitizes for the production of the aboral THP, while heparin (presumably through its anticoagulant effect) and Dibenamine (presumably through its antiadrenergic action) offer virtually complete protection.

When only Th-Din plus tannic acid is given, there develops an intense but reversible cyanosis in the hind paws and tail; additional treatment with NA induces obliterating thromboangiitis with hemorrhages and gangrene. None of these changes are produced by Th-Din, tannic acid or NA alone. Evidently, here, we are dealing with pluricausal experimental diseases whose possible relationship to Raynaud’s disease, thromboangiitis obliterans and anaphylactoid purpura is briefly discussed.

Fast and stable gratings inscription in POFs made of different materials with pulsed 248 nm KrF laser

This paper presents fiber Bragg grating (FBG) inscription with a pulsed 248 nm UV KrF laser in polymer optical fibers (POFs) made of different polymers, namely polymethyl methacrylate (PMMA), cyclic-olefin polymer and co-polymer, and Polycarbonate. The inscribed gratings and the corresponding inscription parameters are compared with grating inscribed in POFs made of the aforementioned materials but with the hitherto most used laser for inscription, which is a continuous wave 325 nm UV HeCd laser. Results show a reduction of the inscription time of at least 16 times. The maximum time reduction is more than 130 times. In addition, a reflectivity and a bandwidth close to or higher than the ones with the 325 nm laser were obtained. The polymer optical fiber Bragg gratings (POFBGs) inscribed with the 248 nm laser setup present high stability with small variations in their central wavelength, bandwidth, and reflectivity after 40 days.

[A woman with acute abdominal pain after a gastric bypass]

A 35-year-old woman with a history of gastric bypass presented with acute abdominal pain, nausea and an urge to move. She showed normal vital signs. We found abdominal guarding and elevated ASAT, ALAT and LDH. A CT scan showed the whirl sign, caused by a mesenteric herniation through the Roux-en-Y gastric bypass.

Screening for late-onset Pompe disease in western Denmark

OBJECTIVE

Late-onset Pompe disease (LOPD) is a rare autosomal recessively inherited metabolic myopathy caused by reduced activity of the lysosomal enzyme alpha-glucosidase. In a previous screening study at two large neuromuscular university clinics in Denmark, three patients with LOPD were identified out of 103 patients screened. No systematic screening has been performed at the other neurological departments in the western part of Denmark. Thus, patients with a diagnosis of unspecified myopathy were screened for LOPD.

MATERIALS AND METHODS

At seven neurological departments in the western part of Denmark, medical records were evaluated for all patients registered with myopathy diagnosis codes (ICD 10 codes: G 71.0-71.9 and G 72.0-72.9) during the period January 1, 2002, to December 31, 2012. If no specific diagnosis has been reached, patients were invited for screening. Dried blood spot (DBS) test was used to analyze the activity of the enzyme alpha-glucosidase.

RESULT

A total of 654 patients were identified. From the medical records, information was obtained concerning symptoms, family history, electromyography, muscle biopsy results and creatine kinase levels. Eighty-seven patients (13.3%) (males 61%) at a mean age of 53.3 years (SD 16.5) fulfilled the criteria for screening. A DBS test was performed in 47 (54%) patients. In all patients, the enzyme activity was within reference values.

CONCLUSION

None of the screened patients had a reduced activity of the enzyme alpha-glucosidase. Although the cohort studied was small, our findings do not suggest that LOPD is underdiagnosed in patients with unspecified myopathy in western Denmark.

Avoidance of sun exposure as a risk factor for major causes of death: a competing risk analysis of the Melanoma in Southern Sweden cohort

OBJECTIVE

Women with active sunlight exposure habits experience a lower mortality rate than women who avoid sun exposure; however, they are at an increased risk of skin cancer. We aimed to explore the differences in main causes of death according to sun exposure.

METHODS

We assessed the differences in sun exposure as a risk factor for all-cause mortality in a competing risk scenario for 29 518 Swedish women in a prospective 20-year follow-up of the Melanoma in Southern Sweden (MISS) cohort. Women were recruited from 1990 to 1992 (aged 25-64 years at the start of the study). We obtained detailed information at baseline on sun exposure habits and potential confounders. The data were analysed using modern survival statistics.

RESULTS

Women with active sun exposure habits were mainly at a lower risk of cardiovascular disease (CVD) and noncancer/non-CVD death as compared to those who avoided sun exposure. As a result of their increased survival, the relative contribution of cancer death increased in these women. Nonsmokers who avoided sun exposure had a life expectancy similar to smokers in the highest sun exposure group, indicating that avoidance of sun exposure is a risk factor for death of a similar magnitude as smoking. Compared to the highest sun exposure group, life expectancy of avoiders of sun exposure was reduced by 0.6-2.1 years.

CONCLUSION

The longer life expectancy amongst women with active sun exposure habits was related to a decrease in CVD and noncancer/non-CVD mortality, causing the relative contribution of death due to cancer to increase.

Preoperative prediction of histopathological outcome in basal cell carcinoma: flat surface and multiple small erosions predict superficial basal cell carcinoma in lighter skin types

BACKGROUND

Prediction of the histopathological subtype of basal cell carcinoma (BCC) is important for tailoring optimal treatment, especially in patients with suspected superficial BCC (sBCC).

OBJECTIVES

To assess the accuracy of the preoperative prediction of subtypes of BCC in clinical practice, to evaluate whether dermoscopic examination enhances accuracy and to find dermoscopic criteria for discriminating sBCC from other subtypes.

MATERIALS AND METHODS

The main presurgical diagnosis was compared with the histopathological, postoperative diagnosis of routinely excised skin tumours in a predominantly fair-skinned patient cohort of northern Europe during a study period of 3 years (2011-13). The study period was split in two: during period 1, dermoscopy was optional (850 cases with a pre- or postoperative diagnosis of BCC), while during period 2 (after an educational dermoscopic update) dermoscopy was mandatory (651 cases). A classification tree based on clinical and dermoscopic features for prediction of sBCC was applied.

RESULTS

For a total of 3544 excised skin tumours, the sensitivity for the diagnosis of BCC (any subtype) was 93·3%, specificity 91·8%, and the positive predictive value (PPV) 89·0%. The diagnostic accuracy as well as the PPV and the positive likelihood ratio for sBCC were significantly higher when dermoscopy was mandatory. A flat surface and multiple small erosions predicted sBCC.

CONCLUSIONS

The study shows a high accuracy for an overall diagnosis of BCC and increased accuracy in prediction of sBCC for the period when dermoscopy was applied in all cases. The most discriminating findings for sBCC, based on clinical and dermoscopic features in this fair-skinned population, were a flat surface and multiple small erosions.

Prognostic instrument for survival outcome in melanoma patients: based on data from the population-based Swedish Melanoma Register

BACKGROUND

Several major analyses have identified a consistent set of independent risk factors for cutaneous malignant melanoma (CMM). A few prognostic models have been presented but some are based on a limited number of patients and others are based on selected groups of patients referred to major institutions. No nationwide population-based prognostic instrument for survival of CMM has been presented. The Swedish Melanoma Register (SMR) database covers 99% of CMM diagnosed in Sweden and includes today >50,000 cases.

OBJECTIVES

To create a prognostic instrument based on SMR data to give highly reliable risk profiles for patients diagnosed with localised CMM.

METHODS

Clinicopathological data were linked to the cause of death registry for calculation of CMM-specific survival. A generalised gamma method was used to derive 1, 5 and 10year probabilities of death for each combination of patient and tumour data: age, sex, tumour site, tumour thickness, tumour ulceration, Clark's level of invasion and when applicable also outcome of sentinel node biopsy (SNB).

RESULTS

Tumour thickness had the highest prognostic impact, explaining 77% of the model. Women had 30% lower risk of death because of CMM than men. Presence of ulceration nearly doubled the risk. If the patient had a positive SNB status the risk of death due to CMM increased three times versus a negative SNB status.

CONCLUSION

This unique population-based prognostic model for primary CMM shows better survival than the American Joint Commission on Cancer prognostic model widely used. The reason is probably that the referral bias is eliminated in a population-based cohort.

Time-dependent variation of fiber Bragg grating reflectivity in PMMA-based polymer optical fibers

In this Letter, we investigate the effects of viscoelasticity on both the strength and resonance wavelength of two fiber Bragg gratings (FBGs) inscribed in microstructured polymer optical fiber (mPOF) made of undoped PMMA. Both FBGs were inscribed under a strain of 1% in order to increase the material photosensitivity. After the inscription, the strain was released, and the FBGs spectra were monitored. We initially observed a decrease of the reflection down to zero after which it began to increase. After that, strain tests were carried out to confirm the results, and finally the gratings were monitored for a further 120 days, with a stable reflection response being observed beyond 50 days.

113 PRELIMINARY CHARACTERIZATION OF OXYTOCINASE IN EQUINE SERUM

Oxytocinase/insulin regulated aminopeptidase (IRAP) or leucyl-cystinyl aminopeptidase (LNPEP) is an enzyme that is involved in the regulation of hormones such as oxytocin, vasopressin, and angiotensin in both humans and sheep. Historically, very low levels of this aminopeptidase were reported in monthly samples obtained from cycling and pregnant mares using an enzymatic colourimetric method. The regulation of oxytocin in horses is of interest because of its central role in uterine clearance, luteal maintenance, parturition, passage of fetal membranes, maternal foal bonding, and milk let-down. A preliminary study was performed with the objective of re-examining the level of serum oxytocinase in nonpregnant control (n = 3 mares sampled every other day; EOD of the oestrous cycle), and n = 5 mares sampled Day 12 to 15; oxytocin-treated (n = 2 mares sampled Day 12 to 15), and early pregnant mares (n = 6 mares sampled EOD), using more sensitive ELISA methodology. Mares were examined daily in oestrus until ovulation (Day 0) and from Days 10 to 21, using transrectal ultrasonography of the reproductive tract. Palpable changes in uterine and cervical tone, ultrasound measurement of dominant follicles, oedema scores (0 to 4 with 4 being maximal oedema), and changes in luteal echotexture and size were recorded. Pregnant mares were bred using AI (>200 million motile and normal sperm) from a proven stallion while in oestrus until ovulation, beginning when the dominant follicle was >35 mm. Oxytocin-treated mares were administered 60 IU IM oxytocin SID from Day 7 to 14. Blood was collected to obtain serum. Changes in serum oxytocinase levels were measured using a commercially available ELISA kit for Horse LNPEP according to the manufacturer's instructions (MyBioSource, San Diego, CA, USA) and validated for use in our laboratory using serial dilutions of pooled serum with an intra-assay and inter-assay CV <15%. The lowest standard of the assay was 31.2 ng mL–1. Preliminary results of this pilot study demonstrated in control cycles median serum oxytocinase levels below the lowest standard (2.0 to 30.1 ng mL–1). Oxytocin-treated mares had median serum oxytocinase levels from 39 to 61 ng mL–1 on Days 12 to 15. Early pregnant mares had detectable levels from Day 8 to 21 (medians ranging from 40 to 89 ng mL–1). We concluded that serum oxytocinase levels were below the lowest standard in diestrus, and were low but detectable in oxytocin-treated mares. The highest oxytocinase levels were measured during early pregnancy. Further studies of serum oxytocinase in a larger population of mares, along with studies of tissue mRNA levels of oxytocinase, are required to better understand the regulation of oxytocin in horses. Research was supported by the Natural Sciences and Engineering Research Council of Canada (Ottawa, ON, Canada) and the Equine Health Research Fund (University of Saskatchewan, SK, Canada).

Anaesthetic management during open and percutaneous irreversible electroporation

BACKGROUND

Irreversible electroporation (IRE) is a novel tumour ablation technique involving repetitive application of electrical energy around a tumour. The use of pulsed electrical gradients carries a risk of cardiac arrhythmias, severe muscle contractions, and seizures. We aimed to identify IRE-related risks and the appropriate precautions for anaesthetic management.

METHODS

All patients who were treated with IRE were prospectively included. Exclusion criteria were arrhythmias, congestive heart failure, active coronary artery disease, and epilepsy. All procedures were performed under general anaesthesia with complete muscle relaxation during ECG-synchronized pulsing. Adverse events, cardiovascular effects, blood samples, cerebral activity, and post-procedural pain were analysed.

RESULTS

Twenty-eight patients underwent 30 IRE sessions for tumours in the liver, pancreas, kidney, and lesser pelvis. No major adverse events occurred during IRE. Median systolic and diastolic blood pressure increased by 44 mm Hg (range -7 to 108 mm Hg) and 19 mm Hg (range 1-50 mm Hg), respectively. Two transient minor cardiac arrhythmias without haemodynamic consequences were observed. Muscle contractions were mild and IRE caused no reactive brain activity on a simplified EEG. Pain in the first 24 h after percutaneous IRE was generally mild, but higher pain scores were reported after pancreatic treatment (mean VAS score 3; range 0-9).

CONCLUSIONS

Side-effects during IRE on tumours in the liver, pancreas, kidney, and lesser pelvis seem mild and manageable when current recommendations for anaesthesia management, including deep muscle relaxation and ECG synchronized pulsing, are followed. Electrical pulses do not seem to cause reactive cerebral activity and evidence for pre-existing atrial fibrillation as an absolute contra-indication for IRE is questionable.

The clinical significance of BRAF and NRAS mutations in a clinic-based metastatic melanoma cohort

BACKGROUND

BRAF and NRAS mutations are frequently found in melanoma tumours, and recently developed BRAF-targeted therapies demonstrate significant clinical benefit.

OBJECTIVES

We sought to investigate the clinical significance of BRAF and NRAS mutations in a clinic-based metastatic melanoma cohort.

METHODS

In total, 237 tumours, mostly metastatic lesions, from 203 patients were screened for mutations in exon 15 of BRAF and exon 2 of NRAS using Sanger sequencing. BRAF and NRAS mutation status was analysed in relation to clinical and histopathological characteristics, and outcome.

RESULTS

Mutation in BRAF and NRAS was present in 43% (88% V600E, 10% V600K) and 30% (48% Q61K, 40% Q61R) of metastatic melanomas, respectively. We found consistent BRAF and NRAS mutation status in all but one of 27 patients with multiple metastases. BRAF mutation was associated with younger age at primary diagnosis (P = 0.02). Among patients with distant metastatic melanoma, patients with BRAF-mutant tumours without BRAF inhibitor treatment had inferior survival compared with patients with BRAF inhibitor treatment [hazard ratio (HR) 2.35, 95% confidence interval (CI) 1.10-5.01, P = 0.03]. We also observed a trend towards better prognosis for patients with wild-type and NRAS-mutant tumours compared with BRAF V600E-mutant tumours (HR 0.64, 95% CI 0.39-1.04, P = 0.07; and HR 0.76, 95% CI 0.48-1.21, P = 0.25, respectively).

CONCLUSIONS

We were able to confirm the effect of BRAF inhibitor treatment in a single clinical institution. The results suggest further that BRAF mutation is a weak prognostic factor but a strong predictive factor and that BRAF-mutant melanoma might constitute one or more distinct subtypes of the disease with certain aetiology and clinical outcome.

Avoidance of sun exposure is a risk factor for all-cause mortality: results from the Melanoma in Southern Sweden cohort

BACKGROUND

Sunlight exposure and fair skin are major determinants of human vitamin D production, but they are also risk factors for cutaneous malignant melanoma (MM). There is epidemiological evidence that all-cause mortality is related to low vitamin D levels.

METHODS

We assessed the avoidance of sun exposure as a risk factor for all-cause mortality for 29 518 Swedish women in a prospective 20-year follow-up of the Melanoma in Southern Sweden (MISS) cohort. Women were recruited from 1990 to 1992 and were aged 25 to 64 years at the start of the study. We obtained detailed information at baseline on their sun exposure habits and potential confounders. Multivariable flexible parametric survival analysis was applied to the data.

RESULTS

There were 2545 deaths amongst the 29 518 women who responded to the initial questionnaire. We found that all-cause mortality was inversely related to sun exposure habits. The mortality rate amongst avoiders of sun exposure was approximately twofold higher compared with the highest sun exposure group, resulting in excess mortality with a population attributable risk of 3%.

CONCLUSION

The results of this study provide observational evidence that avoiding sun exposure is a risk factor for all-cause mortality. Following sun exposure advice that is very restrictive in countries with low solar intensity might in fact be harmful to women's health.

Photosensitivity mechanism of undoped poly(methyl methacrylate) under UV radiation at 325 nm and its spatial resolution limit

In this Letter, we provide evidence suggesting that the main photosensitive mechanism of an undoped poly(methyl methacrylate)-based microstructured optical fiber under UV radiation at 325 nm is a competitive process of both photodegradation and polymerization. We found experimentally that increasing strain during photo-inscription leads to an increased photosensitivity, which is evidence of photodegradation. Likewise, refractive index change in the fiber was measured to be positive, which provides evidence for further polymerization of the material. Finally, we relate the data obtained to the spatial recording resolution of the samples.