RADCAM-A radiation camera system combining foil bolometers, AXUV diodes, and filtered soft x-ray diodes

Measurements of radiated power are critical for characterizing and optimizing tokamak performance. The RADCAM system, comprising arrays of foil bolometers, Absolute eXtreme UltraViolet (AXUV), and filtered soft x-ray diodes, has been constructed to provide improved measurements of plasma radiation on "Tokamak a Configuration Variable" (TCV). An overview of the physical geometry, electronics, and design of the system is provided. The construction of the bolometer foils together with the improved sensitivity characteristics resulting from the inclusion of an anti-reflection carbon coating are presented. The large number of lines of sight in RADCAM are shown to significantly increase the spatial resolution over the legacy system. The system calibration procedure is detailed, and the mean system sensitivity is shown to vary by less than 5% over 1000 discharges. Additionally, the methodology for cross-calibration of the AXUV diodes with the bolometer foils is presented and applied to generate high temporal resolution measurements. The RADCAM radiation camera system is a compact, versatile system that is demonstrated to provide high resolution profiles of the radiated power in TCV.

Robust impurity detection and tracking for tokamaks

A robust impurity detection and tracking code, able to generate large sets of dust tracks from tokamak camera footage, is presented. This machine learning-based code is tested with cameras from the Joint European Torus, Doublet-III-D, and Magnum-PSI and is able to generate dust tracks with a 65-100% classification accuracy. Moreover, the number dust particles detected from a single camera shot can be up to the order of 1000. Several areas of improvement for the code are highlighted, such as generating more significant training data sets and accounting for selection biases. Although the code is tested with dust in single two-dimensional camera views, it could easily be applied to multiple-camera stereoscopic reconstruction or nondust impurities.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

The metabolic syndrome and cancer: Is the metabolic syndrome useful for predicting cancer risk above and beyond its individual components?

AIMS

The metabolic syndrome (MetS) is a risk factor for cancer. However, it is not known if the MetS confers a greater cancer risk than the sum of its individual components, which components drive the association, or if the MetS predicts future cancer risk.

MATERIALS AND METHODS

We linked 20,648 participants from the Australian and New Zealand Diabetes and Cancer Collaboration with complete data on the MetS to national cancer registries and used Cox proportional hazards models to estimate associations of the MetS, the number of positive MetS components, and each of the five MetS components separately with the risk for overall, colorectal, prostate and breast cancer. Hazard ratios (HR) and 95% confidence intervals (95%CI) are reported. We assessed predictive ability of the MetS using Harrell's c-statistic.

RESULTS

The MetS was inversely associated with prostate cancer (HR 0.85; 95% CI 0.72-0.99). We found no evidence of an association between the MetS overall, colorectal and breast cancers. For those with five positive MetS components the HR was 1.12 (1.02-1.48) and 2.07 (1.26-3.39) for overall, and colorectal cancer, respectively, compared with those with zero positive MetS components. Greater waist circumference (WC) (1.38; 1.13-1.70) and elevated blood pressure (1.29; 1.01-1.64) were associated with colorectal cancer. Elevated WC and triglycerides were (inversely) associated with prostate cancer. MetS models were only poor to moderate discriminators for all cancer outcomes.

CONCLUSIONS

We show that the MetS is (inversely) associated with prostate cancer, but is not associated with overall, colorectal or breast cancer. Although, persons with five positive components of the MetS are at a 1.2 and 2.1 increased risk for overall and colorectal cancer, respectively, and these associations appear to be driven, largely, by elevated WC and BP. We also demonstrate that the MetS is only a moderate discriminator of cancer risk.

The Presence of Borrelia miyamotoi, A Relapsing Fever Spirochaete, in Questing Ixodes ricinus in Belgium and in The Netherlands

Borrelia miyamotoi is a tick-borne bacterium that may cause relapsing fever in humans. As this pathogen has been discovered in Europe only recently, only little is known about its local impact on human health and its spatial distribution. In this study, we show the results of PCR screenings for B. miyamotoi in flagged Ixodes ricinus from Belgium and the Netherlands. B. miyamotoi was detected in nine of thirteen, and three of five locations from the Netherlands and Belgium, respectively. These outcomes indicate that B. miyamotoi is more spread than previously thought. The mean infection rate B. miyamotoi was 1.14% for Belgium and 3.84% for the Netherlands.

Foci report on indigenous Dermacentor reticulatus populations in Belgium and a preliminary study of associated babesiosis pathogens

The occurrence of autochthonous clinical cases of canine and equine babesiosis in Belgium during the last two decades suggests that the vector of the pathogens responsible for these diseases, Dermacentor reticulatus (Ixodida: Ixodidae), may be present in this country. Consequently, evidence for the presence of this tick species in different locations within Belgium was investigated. Four different locations were monitored by flagging in 2010; these included the locations at which D. reticulatus was previously found on a dog in 2009 and on two red deer in 2007. Two different species of tick were identified, Ixodes ricinus (Ixodida: Ixodidae) and D. reticulatus. A total of 282 D. reticulatus adult ticks (98 males, 184 females) were collected from the four sites. Ticks were found mainly from early March until the end of May and a peak in activity was apparent in March. A Babesia spp. (Piroplasmida: Babesiidae) genus-specific polymerase chain reaction test based on the amplification of a fragment of the 18S rRNA gene was used to investigate the potential presence of Babesia spp. All DNA extracts isolated from the total tick samples yielded negative results. Additional studies to accurately determine the distribution and vectorial capacity of this important tick species in Belgium are warranted.

A score for the prediction of cardiovascular events in the hypertensive aged

BACKGROUND

With few exceptions, tools used to estimate cardiovascular disease (CVD) risk in those without prior events are based mainly on data from middle-aged subjects. Given the ever increasing number of older people, many with hypertension, a risk score relevant to this group is warranted. Our aim was to develop a cardiovascular risk equation suitable for risk prediction in elderly, hypertensive populations.

METHODS

We utilized cardiovascular end point data from 4.1 years median follow-up in 5,426 hypertensive subjects without previous CVD from the Second Australian National Blood Pressure Study (ANBP2). Our risk model, based on Cox regression, was developed using 75% of subjects without evident CVD (n = 4,072), randomly selected and stratified by age and gender, and internally validated using the remaining 25%. The model was also externally validated against the Dubbo Study dataset.

RESULTS

The final model included sex, age, physical activity in the 2 weeks prior to entry into study, family history, use of anticoagulants, centrally acting antihypertensive agents or diabetes medication, and an interaction term for sex and diabetes medication. The C-statistic was 0.65 (0.62-0.67) for our predictive model on the model development dataset and 0.62 (0.57-0.67) on the internal validation dataset. The Dubbo Data C-statistic for CVD was 0.68 (95% CI 0.65-0.71).

CONCLUSIONS

All models performed similarly. Because of greater ease of implementation, we recommend that existing algorithms be extended into older age groups.

An analysis of discourses shaping mental health practitioners

A mental health practitioner (MHP) role was introduced to health services in southern England in 2003. The paper will discuss the initial phase within a longitudinal research study. A discursive approach will be adopted in order to understand how healthcare discourses constrain and provide possibilities for the emergence of a new worker role in mental health. The manner in which MHPs understand and talk about their work is socially constructed in interaction and constantly being modified by competing discourses. This paper will analyse three overarching health discourses, namely, the biomedical, person-centred and psychological discourses that have shaped MHP trainees. Discourses intersect to inform the role, where practices of nursing, psychology, medicine and occupational therapy are combined. Thus, the inclusion of physical, psychological and person-centred components of care serve as a multifaceted approach to care. This form of interprofessionalism leads MHPs one step closer in the advance towards an interdisciplinary discourse of holistic care.

New ways of working: how mental health practitioners perceive their training and role

This paper outlines advances in the mental health workforce by detailing the development, education and training of graduates from the social sciences in mental health practice. The mental health practitioner (MHP) programme is a partnership between higher education and the National Health Service to provide graduates with a new point of entry into the mental health workforce. The MHP is a new role in mental health i.e. in principle, trans-disciplinary, traversing psychology, nursing and occupational therapy. The role is informed by a bio-psychosocial philosophy of collaborative mental health care and therefore acts as a bridge between the different professions that constitute a multidisciplinary team on acute inpatient units and in the community. However, MHPs form part of the nursing team and work most closely with mental health nurses. They see their role as linked to, but other than, nursing. This paper will discuss the development of this programme and its philosophy of care, and will present outcome research on trainee perceptions and experiences of occupying the MHP role in mental health. It will present findings from the first stage of a longitudinal study (employing interviews and survey data) about trainee perceptions of their role and training before the programme commenced, 6 months into their training and at graduation.

The Emerging Risk Factors Collaboration: analysis of individual data on lipid, inflammatory and other markers in over 1.1 million participants in 104 prospective studies of cardiovascular diseases

Many long-term prospective studies have reported on associations of cardiovascular diseases with circulating lipid markers and/or inflammatory markers. Studies have not, however, generally been designed to provide reliable estimates under different circumstances and to correct for within-person variability. The Emerging Risk Factors Collaboration has established a central database on over 1.1 million participants from 104 prospective population-based studies, in which subsets have information on lipid and inflammatory markers, other characteristics, as well as major cardiovascular morbidity and cause-specific mortality. Information on repeat measurements on relevant characteristics has been collected in approximately 340,000 participants to enable estimation of and correction for within-person variability. Re-analysis of individual data will yield up to approximately 69,000 incident fatal or nonfatal first ever major cardiovascular outcomes recorded during about 11.7 million person years at risk. The primary analyses will involve age-specific regression models in people without known baseline cardiovascular disease in relation to fatal or nonfatal first ever coronary heart disease outcomes. This initiative will characterize more precisely and in greater detail than has previously been possible the shape and strength of the age- and sex-specific associations of several lipid and inflammatory markers with incident coronary heart disease outcomes (and, secondarily, with other incident cardiovascular outcomes) under a wide range of circumstances. It will, therefore, help to determine to what extent such associations are independent from possible confounding factors and to what extent such markers (separately and in combination) provide incremental predictive value.

Preliminary results of a multicenter phase II trial of vinflunine (with trastuzumab in HER2+ pts) as first-line treatment in metastatic breast cancer

1043

Background: Vinflunine (VFL) is a new and innovative microtubule inhibitor of the vinca alkaloid class that achieves high intracellular concentrations. By inhibition of tubulin polymerization, cell proliferation is arrested leading to apoptotic death. Demonstrating anti- angiogenic and vascular disrupting activities, VFL has demonstrated significant efficacy as 2nd line chemotherapy in MBC (M. Campone, BJC 2006). This trial was designed to evaluate the response rate and safety of VFL as 1st line therapy in MBC as well as its activity in combination with trastuzumab in HER2+ MBC pts. Methods: Eligibility: 0 prior regimens for MBC, > 6 mo from adjuvant therapy, RECIST measurable disease, ECOG PS 0–2, adequate organ function, < G2 neuropathy. Treatment: 320 mg/m2 IV over 20 minutes q3 weeks; 280 mg/m2 with trastuzumab 6 mg/kg q3 weeks in HER2+ pts. Response evaluations q9 weeks; treatment continued until progression or toxicity. A total of 96 pts will be enrolled, 48 pts per each of 2 cohorts, HER2- and HER2+. Results: 18 pts are enrolled, 13 pts evaluable for toxicity and 12 pts for response. 3 pts received VFL monotherapy and 10 pts were treated with VFL + trastuzumab. Median age: 59 years (43–78). ECOG PS 0: 9 pts, 1: 3 pts, 2: 1 pt. Prior adjuvant chemo: 7 pts (54%), with 5 prior anthracyclines and 6 prior taxanes. 2 pts received adjuvant hormonal therapy only. 4 pts presented with de novo stage IV HER2+ MBC. Metastatic disease sites: liver: 6 pts, lung: 7 pts, bone: 5 pts, lymph nodes: 6 pts. 46% had 3 or more sites of organ involvement. Median of 3 cycles (range:1 - 11) was delivered. 7 pts (58%, all HER2+) had a PR and 4 pts (33%) achieved SD. Only 1 pt progressed. Heme toxicity: G3/4 neutropenia: 2 pts (16%); no febrile neutropenia was noted. G3 non-heme toxicity consisted of N/V: 2 pts and myalgia, 2 pts. There were no G4 events. 4 pts were hospitalized (vomiting: 2, cerebro-vascular accident: 1, back pain: 1 pt). 92% of pts remain free of progression at 6 months. Median TTP has not been reached. Conclusions: Vinflunine is a promising new drug with a high level of activity as first line MBC therapy, especially in combination with trastuzumab. VFL is well tolerated in this patient population with a manageable toxicity profile. Accrual to this trial continues.

[Table: see text]

Biweekly neoadjuvant gemcitabine, epirubicin, and nano-particle albumin bound (nab) paclitaxel (GEA) with tumor SPARC analysis correlated with pathologic responses: Results of a multicenter phase II trial

11060

Background: The triplet combination of gemcitabine (G), anthracyclines and taxanes have demonstrated significant activity in the metastatic as well as neoadjuvant breast cancer setting with objective response rates of 90% and pathologic CRs of 20–25% with a variety of schedules. SPARC, a poor prognostic indicator, is a glycoprotein expressed in many solid tumors, including breast cancer, and is thought to mediate active tumor transport of nab paclitaxel resulting in high intratumoral concentrations. The present tumor analysis correlates SPARC expression with pathologic responses to neoadjuvant GEA. Methods: Patients with clinical T1c-T4d and/or N0–3, M0 (T1N0M0 excluded) breast cancer, chemo naive, ECOG PS 0–2, normal LVEF, adequate organ function were treated with neoadjuvant G 2000 mg/m2, epirubicin 50 mg/m2, nab paclitaxel (A)175 mg/m2 IV q14 x 6 cycles followed by surgery. Postoperative therapy: G 2000 mg/m2 and A 220 mg/m2 q14 x 4 cycles. Neulasta 6 mg sc D2 was given with all cycles although alternative granulocyte stimulating factors was permitted. Enrollment planned for 120 pts. Results: 72 pts are enrolled, 48 patients evaluable for toxicityand pathologic responses available for 35 pts. Median age: 48 years (29–73), ECOG PS 0 - 45 pts (96%), 1 - 3 (6%), median tumor size 4.5 cm, 79% ductal, 4% lobular, 13% inflammatory. 54% ER-/PR-, 81% HER2 negative. 21 (60%) were triple negative, basal subtype. Heme toxicity was minimal: G3/4 neutropenia: 4 (8%) pts, thrombocytopenia: 3 (6%) pts. There were no episodes of febrile neutropenia. Nonheme toxicity significant for G3/4 arthraglias: 5 (10%) pts & fatigue in 3 (6%) pts. 3 pts hospitalized (infection, PE, abd pain). 1 pt developed PD during neoadjuvant therapy; 5 pts did not complete post op chemo (pt compliance: 2, PD: 2, MD discretion: 1). pCR was noted in both breast and LNs in 7 pts (20%) and pPR in 26 (74%). Conclusions: Neoadjuvant dose dense GEA is feasible and extremely well tolerated. Significant activity with a pCR of 20% is evident with the basal subtype of breast cancer. SPARC tumor analysis correlations with observed pathologic responses will be presented and updated with the continuing accrual to this trial.

No significant financial relationships to disclose.

Importance of timing of PET scan after therapy in oncology

13014

Background: Growth factors are routine after systemic chemotherapy both as primary and secondary prophylaxis. Similarly PET scan is increasingly used for initial staging and follow-up of response. Timing of both is important since false positive results are noted due to high sensitivity of the test. Methods: Records of four patients with super positive PET scan with diffuse uptake in the axial skeleton were analyzed for the timing of administration of white cell growth factor before imaging and confirmation of bone finding with a follow- up bone scan to rule out mets. Results: Two patients were treated for stage IIIB/IV non-small cell lung cancer, one patient with breast cancer was receiving adjuvant treatment for stage IIIA breast cancer, and the last patient was treated for metastatic pancreatic cancer. All had negative scans for bone mets before the start of treatment. PET scan was done for staging in one patient and evaluation of abnormal CT scan in another, and follow-up of response in two patients. It was inadvertently obtained 10–14 days after the filgrastim/pefilgrastim administration. Based on the unusual uptake in bony skeleton, bone scan was ordered to rule out bone mets in all four patients. Since their bone scans were negative for metastatic disease they were continued on their treatment plan as scheduled. Conclusions: PET scan has been sparingly used until 1990’s due to high cost. Currently Medicare has approved it for wider indications. PET scan in general has high sensitivity and low specificity and false positive results are more common from metabolically active infection and inflammation. Granulocyte colony stimulating factor used with cancer treatments can increase the FDG uptake in PET scan. Diffuse increased uptake in bone marrow by PET scan can be seen in reactive marrow following growth factor therapy. Usually FDG uptake is modest with SUV of less than 3, uniform and diffuse if due to growth factor stimulation in contrast to greater intensity with SUV around 6 with non uniform distribution. Awareness of this pitfalls associated with PET scan allows image interpretation accurately. PET-CT fusion may increase the diagnostic specificity. However timing of the scan in relation to growth factor administration may also help to avoid the unnecessary anxiety and further follow up testing which adds to the health care costs.

No significant financial relationships to disclose.

Cost-effectiveness of referral for generic care or problem-solving treatment from community mental health nurses, compared with usual general practitioner care for common mental disorders: Randomised controlled trial

BACKGROUND

UK general practitioners (GPs) refer patients with common mental disorders to community mental health nurses.

AIMS

To determine the effectiveness and cost-effectiveness of this practice.

METHOD

Randomised trial with three arms: usual GP care, generic mental health nurse care, and care from nurses trained in problem-solving treatment; 98 GPs in 62 practices referred 247 adult patients with new episodes of anxiety, depression and life difficulties, to 37 nurses.

RESULTS

There were 212 (86%) and 190 (77%) patients followed up at 8 and 26 weeks respectively. No significant differences between groups were found in effectiveness at either point. Mean differences in Clinical Interview Schedule - Revised scores at 26 weeks compared with GP care were -1.4 (95% CI -5.5 to 2.8) for generic nurse care, and 1.1 (-2.9 to 5.1) for nurse problem-solving. Satisfaction was significantly higher in both nurse-treated groups. Mean extra costs per patient were 283 pound (95% CI154-411) for generic nurse care, and 315 pound (183-481) for nurse problem-solving treatment.

CONCLUSIONS

GPs should not refer unselected patients with common mental disorders to specialist nurses. Problem-solving should be reserved for patients who have not responded to initial GP care.

A phase II trial of biweekly pemetrexed (P) and gemcitabine (G) in the first-line treatment (tx) of patients (pts) with advanced non-small cell lung cancer (NSCLC)

17054

Background: P and G are active and well-tolerated non-platinum agents used in the tx of NSCLC. Previous trials have combined P and G in the first-line NSCLC setting using a 21D schedule. This trial examined the safety and activity of biweekly P/G. Methods: Theprimary endpoints of this single center community-based phase II study were toassess the safety and response rate (RR) of P/G in pts with previously untreated stage III (unresectable) or IV NSCLC. Tx included: P 500mg/m2 IV D1 and G 1500mg/m2 IV D1 Q 14D for 8–12 cycles. Pts also received folate and B12 prophylaxis. Pts were restagedafter 4 cycles. Eligibility included:measurable disease, ECOG PS 0–2, adequate organ function, informed consent, and no active brain metastases. Analysis was by intent to treat. Results: Thirty-five pts were enrolled between 5/05 and 8/05. The median follow-upis 6 months (3.5–7.5 months). Baseline characteristics include: medianage 65 years (41–85); male/female, 71%/29%; ECOG PS 0,1,2:17%/71%/12%; and histology, adenocarcinoma (34%), large cell (29%), squamous (11%), mixed or not specified (26%). The median number of cycles delivered was 8 (1–12). Grade (G)3/4 non-hematologic toxicity included:chest pain (6%), constipation (6%), fatigue (17%), hypercalcemia (6%), dyspnea (9%), and tachyarrhythmia (9%). G3/4 hematologic toxicity included: neutropenia(51%), anemia (8%), and thrombocytopenia (3%). G3/4 febrile neutropenia occurred in 14%. There were notx-related deaths. Response data are availablefor 35 pts. Complete/partial responses for all pts were observed in 0 pts/7pts, respectively, for an overall RR of 20% (95% CI 10%-36%, 1 pt unconfirmed by RECIST criteria). Fifty-four percentof pts had stable disease, and 14% had disease progression(4 pts were unevaluable.) Six-month progression-free survival (PFS) andoverall survival (OS) were 51% and 67%, respectively. Median PFS and OS have not been reached. Conclusions: Biweekly P/G is a safe and well-tolerated regimen with RRsimilar to other standard first-line regimens for the tx of pts with advanced NSCLC, and further study is warranted. Median and 1-year PFSand OS endpoints have not been reached in this trial.

[Table: see text]

Phase II pilot trial of imatinib mesylate with weekly docetaxel in metastatic breast cancer

10716

Background: Overexpression of platelet derived growth factor receptor (PDGFR) has been associated with breast cancer tumor progression and may serve as a potential target for therapy. Inhibition of PDGFR signaling in tumor stroma represents a novel strategy that has demonstrated enhanced chemotherapy antitumor effects, decreased tumor interstitial fluid pressure as well as increased tumor transcapillary transport. Imatinib mesylate (G) is a potent PDGFR tyrosine kinase antagonist. This phase II pilot study evaluates the feasibility, toxicity, and efficacy of imatinib administered with docetaxel as a strategy to enhance docetaxel’s chemotherapeutic effects in metastatic breast cancer (MBC). Methods: Eligibility requirements: 0–1 prior regimens for MBC, > 6 months from prior adjuvant taxanes, RECIST measurable disease, ECOG PS 0–2, adequate organ function, < G2 neuropathy. Treatment: docetaxel 30 mg/m2 IV weekly 3 of 4 weeks. Imatinib mesylate 600 mg po QD. Pts were evaluated for response every 8 weeks; treatment continued until progression or toxicity. Results: 7 pts have been enrolled to date. Median age is 61, all with ECOG PS 0. 5 pts received prior adjuvant therapy; 2 pts received prior taxanes. 43% received prior hormonal therapy. Only 1 pt was ER+/PR+. Hematologic toxicity was mild, consisting only of G3/4 anemia in 2 pts and G3 thrombocytopenia in 1. No febrile neutropenia was noted. Nonhematologic toxicity was characterized primarily by G3 GI toxicity: 4 pts diarrhea, 3 N, V, 1 anorexia, 1 abdominal pain. This was attributed to imatinib in all but 1 pt, in whom both drugs were implicated. 2 pts were removed from treatment and 3 pts required dose reductions, all due to GI toxicity consisting of N, V, and diarrhea. 3 pts experienced dose interruptions and 2 pts exhibited disease progression. Conclusion: These early preliminary results demonstrate imatinib mesylate, in combination with weekly docetaxel as a strategy to inhibit breast cancer PDGFR signaling, is feasible. GI toxicity with this combination was prominent and warrants dose modifications. Updated toxicity and efficacy data will be presented.

[Table: see text]

Phase II trial of gemcitabine and carboplatin, plus trastuzumab in HER2+ patients as first line therapy in metastatic breast cancer

10590

Background: Gemcitabine (G) and carboplatin (C) demonstrate significant preclinical synergy together as well as in combination with trastuzumab (H) in metastatic breast cancer (MBC) pts. This multicenter phase II trial evaluates the efficacy and safety of G + C with trastuzumab in HER2 + pts as 1st line therapy in MBC. Methods: Eligibility requirements: females > 18 with no prior regimens for MBC, ECOG 0–2, RECIST bidimensional disease, and adequate organ function. FISH HER2 + pts received H with GC. Treatment: G 1,000 mg/m2 D1& 8 with C AUC 5 D1 in the first 20 pts. Following a toxicity assessment revealing significant myelosuppression, C was administered in subsequent pts at AUC 4. 14 HER2+ pts received H 8 mg/kg loading dose followed by 6 mg/kg q21 days. Pts were evaluated for response after 9 weeks; treatment continued until progression or toxicity except in HER2+ pts who received up to 6 cycles GCH followed by single agent H. Results: Between 11/03 & 11/05, 45 pts have been treated: median age 55 for GC, 65 for GCH, ECOG 0/1 22/23. 19 pts were chemonaive. 26 pts received prior adjuvant chemotherapy: 20 pts adjuvant anthracyclines (A) & taxanes (T), 3 only prior A and 3 prior T. 73% had 2 or more metastatic sites of disease. 31 pts received GC & 14 pts received GCH. 18 of 41 evaluable pts (44%) had objective responses (PR 16, CR 2) with 17 pts (42%) exhibiting SD & 6 pts PD (15%). 91% of AT pretreated pts demonstrated SD or better. 9 remain on study. 6 went off study due to heme related toxicities and 9 due to MD discretion [4 max benefit, 3 XRT]. Median # of cycles was 5. Combined G3/4 hematologic toxicity was notable for 66% neutropenia (only 1 FN), 55% thrombocytopenia, and 32% anemia, predominately occurring at the carboplatin AUC 5 dose level. Transfusions of PRBCs and plts were administered in 14 and 8 pts respectively. Nonhematologic toxicity was minimal and remarkable for G3/4 fatigue in 20%. Conclusions: In FISH HER2+ pts, the addition of trastuzumab to GC yielded a 50% RR, with no evident cardiotoxicity. The combination of gemcitabine with carboplatin AUC 4 is active, albeit with moderate hematologic toxicity, warranting further exploration of alternate GC ± H schedules in breast cancer.

[Table: see text]

Ultrasonic treatment to improve anaerobic digestibility of dairy waste streams

The dairy-processing industry generates various types of organic wastes, which are utilised as stock feed, for anaerobic digestion, spread on land or alternatively land-filled at high costs. Owing to the generation of renewable energy, anaerobic digestion is an attractive option for many factories. To enhance the biological degradation process, a mechanical disintegration of various waste dairy streams was undertaken. While the successful application of ultrasonic treatment has been reported for various municipal waste streams, limited information was available for dairy industry applications. The results of this study showed that ultrasonic treatment can improve the digestibility of the more problematic dairy waste streams, such as sludges, by breaking down micro-organisms' cell walls and releasing soluble cell compounds. For more soluble streams, such as dairy factory effluent, an increased gas production was observed and attributed to the reduced particle size of the fat globules.

A trial of problem-solving by community mental health nurses for anxiety, depression and life difficulties among general practice patients. The CPN-GP study

OBJECTIVES

To compare the effectiveness of community mental health nurse (CMHN) problem-solving and generic CMHN care, against usual general practitioner (GP) care in reducing symptoms, alleviating problems, and improving social functioning and quality of life for people living in the community with common mental disorders; and to undertake a cost comparison of each CMHN treatment compared with usual GP care.

DESIGN

A pragmatic, randomised controlled trial with three arms: CMHN problem-solving, generic CMHN care and usual GP care.

SETTING

General practices in two southern English counties were included in the study. CMHNs were employed by local NHS trusts providing community mental health services.

PARTICIPANTS

Participants were GP patients aged 18--65 years with a new episode of anxiety, depression or reaction to life difficulties and had to score at least 3 points on the General Health Questionnaire-12 screening tool. Symptoms had to be present for a minimum of 4 weeks but no longer than 6 months.

INTERVENTIONS

Patients were randomised to one of three groups: (1) CMHN problem-solving treatment, (2) generic CMHN treatment, or (3) usual GP care. All three groups of patients remained free to consult their GPs throughout the course of the study, and could be prescribed psychotropic drug treatments.

MAIN OUTCOME MEASURES

Patients were assessed at baseline, and 8 weeks and 26 weeks after randomisation. The primary outcome measure was psychological symptoms measured on the Clinical Interview Schedule -- Revised. Other measures included social functioning, health-related quality of life, problem severity and satisfaction. The economic outcomes were evaluated with a cost--utility analysis.

RESULTS

Twenty-four CMHNs were trained to provide problem-solving under supervision, and another 29 were referred patients for generic support. In total, 247 patients were randomised to the three arms of the study, referred by 98 GPs in 62 practices. All three groups of patients were greatly improved by the 8-week follow-up. No significant differences were found between the groups at 8 weeks or 26 weeks in symptoms, social functioning or quality of life. Greater satisfaction with treatment was found in the CMHN groups. CMHN care represented a significant additional health service cost and there were no savings in sickness absence.

CONCLUSIONS

The study found that specialist mental health nurse support is no better than support from GPs for patients with anxiety, depression and reactions to life difficulties. The results suggest that healthcare providers could consider adopting policies of restricting referrals of unselected patients with common mental disorders to specialist CMHNs, although there may be other roles in primary care that CMHNs could play effectively. Further research should address the predictors of chronicity in common mental disorders and target extra treatment. More research is also needed into the effectiveness and cost-effectiveness of problem-solving treatment for other disorders, of facilitated self-help treatments for common mental disorders and of CMHN care for people with severe and enduring mental illnesses, as well as the prevention of mental disorders.

The financial cost of optimising blood pressure control

We have investigated the financial costs of attempts to optimise blood pressure control in patients referred to our blood pressure clinic. At first referral, the average blood pressure in the 262 patients studied were 167/97 mmHg and the monthly costs of the antihypertensive drugs was 23.44 pounds. After 1 year of clinic attendance, the blood pressure was reduced to 149/87 mmHg, and the average drug costs had risen to 30.68 pounds. For drug expenditure alone, the cost of reducing systolic blood pressure by 1 mmHg was 0.36p pounds (Euro 0.55, USD 0.55) and for diastolic blood pressure the cost-was 0.72p pounds (Euro 1.12, USD 1.13).

Assessment of control measures to achieve a food safety objective of less than 100 CFU of Listeria monocytogenes per gram at the point of consumption for fresh precut iceberg lettuce

The important new concept of the food safety objective (FSO) offers a strategy to translate public health risk into a definable goal such as a specified maximum frequency or concentration of a hazardous agent in a food at the time of consumption that is deemed to provide an appropriate level of health protection. For the foodborne pathogen Listeria monocytogenes, there is a proposed FSO of < 100 CFU/g in ready-to-eat (RTE) products at the time of consumption. Fresh precut iceberg lettuce is one of these RTE products. In this study, we worked with a commercial manufacturer to evaluate the effectiveness of two antimicrobial washing agents (sodium hypochlorite and a mixture of hydrogen peroxide and peroxyacetic acid) against L. monocytogenes under simulated fresh precut washing conditions and evaluated the growth potential of this pathogen on lettuce packaged in a gas-permeable film and stored at 4 or 8 degrees C for 14 days. We used the results of this experiment to demonstrate how the commercial manufacturer could meet the FSO for L. monocytogenes in fresh precut lettuce through the application of performance, process, and microbiological criteria.

Needs assessment and discharge: a Scottish perspective

Discharge from hospital remains a difficult area for health services and it is unclear how much impact policy directives have had on discharge outcomes. The recent National Service Framework for mental health has highlighted discharge as a key area with Standard Five indicating minimum requirements at discharge from hospital. In order to aid this process this paper discusses the findings of a needs assessment of patients following discharge from psychiatric inpatient care in Scotland. The needs and unmet needs as assessed by both patients and mental health community staff on the Camberwell Assessment of Need (CAN) are presented. The CAN seeks to identify needs in a range of domains addressing basic, health, social, functioning and service issues. The sample comprised 173 patients recently discharged from acute psychiatric units in eight health board areas of Scotland and 98 community staff identified as providing key support to 98 of the patient sample. The findings indicate that the needs of patients discharged from hospital are complex and that the targeting of mental health services according to diagnostic criteria may not be the best way of ensuring support reaches those in most need. The range of needs identified suggests that fully integrated multidisciplinary care is essential to meet needs at discharge. The period initially after hospital discharge is one of vulnerability and incorporating a needs assessment into the discharge planning could aid the care planning process required by the Framework.

Rheumatic manifestations of hyperlipidaemia

Familial hypercholesterolaemia is characterized by elevated serum cholesterol, tendon xanthomas, xanthelasmas, arcus corneae and premature atherosclerosis. Rheumatological manifestations include acute episodes of polyarthritis and tendinitis. Patients who are homozygous for familial hypercholesterolaemia have cardiovascular and rheumatological manifestations more frequently and at an earlier age than patients who are heterozygous.

The A1166C mutation in the angiotensin II type I receptor and hypertension in the elderly

1. Using a nested case-control study of 661 non-institutionalized elderly (> or = 60 years) residents of Dubbo, New South Wales, Australia, the aim of this study is to determine whether the A1166C polymorphism of the angiotensin II type I (AT1) receptor gene is associated with hypertension in the elderly. 2. Individuals were classified as isolated systolic hypertension (ISH, n = 146), systolic diastolic hypertension (SDH, n = 188), or normotensive, age- and sex-matched controls (n = 327). AA, CC and AC genotypes were determined using restriction fragment length polymorphism analysis of DNA generated by nested polymerase chain reaction. 3. A univariate analysis (chi 2) was complemented by a logistic regression analysis, facilitating adjustment for potential confounders. The unadjusted genotype and allele frequencies in ISH or SDH subjects did not differ significantly from the control subjects (chi 2 = 3.0, P = 0.55, 4 d.f.; chi 2 = 3.0, P = 0.23, 2 d.f., respectively). After adjustment for potential confounders neither genotype nor allele predicted ISH or SDH in this cohort. 4. From this study we conclude that the A1166C polymorphism of the AT1 receptor gene is not a marker for ISH nor for SDH in this large, elderly community sample.

A comparative study of the efficacy of simvastatin and gemfibrozil in combined hyperlipoproteinemia: prediction of response by baseline lipids, apo E genotype, lipoprotein(a) and insulin

Combined hyperlipoproteinemia (CHL) can be difficult to treat because of the heterogeneous nature of the lipoprotein abnormalities. We compared the relative efficacies of simvastatin and gemfibrozil and sought predictors of responsiveness in terms of the baseline lipids and other potential metabolic determinants (plasma insulin, Lp(a) and apo E genotype). Sixty-six subjects entered a cross-over, randomized trial involving 12 weeks on each drug. Efficacy was assessed after 6 and 12 weeks on each treatment. Simvastatin lowered total cholesterol 24%, triglycerides 12%, LDL cholesterol 33%, raised HDL cholesterol 13% and substantially reduced the cholesterol:triglyceride ratio in VLDL and IDL. Gemfibrozil lowered total cholesterol 5%, triglycerides 44%, raised HDL 26% and reduced VLDL and IDL lipids more than simvastatin did. LDL size increased with both treatments and HDL size increased with simvastatin. Responsiveness (25% fall in cholesterol or 40% fall in triglycerides) was shown by 31/61 subjects when taking simvastatin (cholesterol-lowering) and by 44/60 taking gemfibrozil (triglyceride-lowering). Responsiveness was greatest in those with apo E2 genotype with both drugs (P < 0.05). Unexpectedly, responders to simvastatin tended to have lower baseline total cholesterol but higher triglyceride levels than those whose cholesterol or triglyceride was lowered by gemfibrozil. Nevertheless, more hypercholesterolemic subjects responded to simvastatin and more hypertriglyceridemic subjects to gemfibrozil. Lp(a) (P = 0.04) and plasma insulin concentrations (P = 0.03) were negative predictors of percentage triglyceride-lowering with gemfibrozil. The difference between the two drugs in triglyceride-lowering lessened with rising insulin and falling HDL cholesterol. Thus, the responsiveness to the two major classes of lipid lowering drugs can be partly predicted from baseline lipids and related metabolic parameters.

Patterns and costs of post-acute care: a longitudinal study of people aged 60 and over in Dubbo

Declining length of stay of older people in hospital has caused concern about shifting of costs from acute to community care services. Because the two types of care are funded through different programs and from different jurisdictions, the coordination of acute and post-acute care has become the major issue. There is, however, little information available on patterns of use and costs of post-acute care either in Australia or elsewhere. In an existing longitudinal community study of older people in Dubbo, New South Wales, data on use of services by people aged 60 years and over for 12 months of hospitalisations was collected by linkage to the records of Home and Community Care providers. Only a quarter of older people received any type of Home and Community Care service in the 12 weeks after discharge and two-thirds of these received only one type of service. While less than 5 per cent received a service from an occupational therapist, physiotherapist or speech therapist, 78 per cent visited a general practitioner after discharge. The average cost of all Home and Community Care services received after hospital discharge was around $12.50 per week per person discharged. The predictors of higher costs of service use were: living alone, and the interactions of high levels of disability with owning a house. Results on service coordination, the identification of post-acute services, cost consequences of program funding, assessment and discharge planning are related to debates emerging from the Commonwealth Heads of Government.

Measurement properties of the Center for Epidemiological Studies Depression Scale: an Australian community study of aged persons

The measurement properties of the Center for Epidemiological Studies Depression Scale (CES-D) were examined in an Australian community study of aged persons in order to contribute to international validation of the measure. Confirmatory analysis of polychoric correlations was conducted using the generally weighted least squares method. The original four-factor solution proposed by Radloff was successfully replicated for Australians, showing similar underlying structures as for Americans, Canadians, and Japanese. Schmid-Leiman parameterization of the second order factor analysis showed that little information was lost in considering full-scale scores rather than the four subscales separately. The behavior of the CES-D in an Australian population aligns with existing North American research and thus confirms the exceptional functioning of the Well-Being scale in Japan. More work on the behavior of the CES-D in non-English speaking societies is needed to separate issues of wording and grammar from genuine cultural variations. The CES-D was confirmed as essentially unidimensional and robust to minor changes; therefore, it is recommended for use in cross-cultural studies of depression in elderly persons.

The continuum of care for older people

The introduction of casemix in hospitals has increased concerns about cost-shifting to community services. There has been little evidence with which to test claims about shifting balances in the continuum of care, in particular for major user groups like older people. These matters have come into greater prominence with the Council of Australian Governments Communique which agreed in April to radical reforms of health and community services. We used an existing longitudinal study of people aged 60 years and over in the community of Dubbo, New South Wales, to study hospital and aged care service use over 50 months. Fifty-five per cent of those studied were hospitalised but only 1.7 per cent were admitted to nursing homes over the period. In the 12 weeks after hospital discharge, 24 per cent received Home and Community Care services, while 78 per cent visited a general practitioner. All post-acute community services over 12 weeks after discharge cost an average of $150. In the light of this new evidence, current proposals for structural reform are critically discussed.

Low serum cholesterol is not associated with depression in the elderly: data from an Australian community study

BACKGROUND

Low serum cholesterol may contribute to depressive symptoms in the elderly.

AIMS

To test the relationship between depressive symptoms and low serum cholesterol in an elderly cohort.

METHODS

This was an examination of cross-sectional data in a community study of 1237 men and 1568 women aged 60+ years in Dubbo, NSW. Quintiles of serum cholesterol were defined for men and women. The Center for Epidemiological Studies Depression Scale was used as a continuous, dependent variable in multiple regression analyses.

RESULTS

Low serum cholesterol was not associated with depressive symptoms in older men or women. Health status, measured by poorer self-ratings, recent hospitalisation, higher disability levels and higher consumption of prescribed and self-prescribed drugs, predicted depressive symptoms. As well, the significance in the statistical model of financial difficulties, low self esteem, low feelings of self efficacy, the adequacy of practical help and emotional support, and recent widowhood, confirmed the importance of social origins of depressive symptoms.

Lipoprotein(a) is not associated with coronary heart disease in the elderly: cross-sectional data from the Dubbo study

Lipoprotein(a) (Lp(a)) may be an independent risk factor for cardiovascular disease. We have examined Lp(a) concentration in 1202 males and 1512 females, aged 60 years and older, who were participants in an ongoing prospective study of cardiovascular disease in the elderly. This report relates to cross-sectional data at study entry. Median Lp(a) concentration was significantly higher in females than in males (P < 0.001), but did not vary with age. Lp(a) concentration rank was significantly correlated with total (r = 0.16, P < 0.001) and LDL cholesterol (r = 0.19, P < 0.001), but this relationship disappeared after adjustment of LDL cholesterol for Lp(a) cholesterol content. Twenty-four percent of males and 17% of females had prevalent coronary heart disease (CHD) at study entry based on non-invasive criteria. Median Lp(a) concentration was slightly higher in those subjects with CHD, compared with those without CHD, but the difference was not statistically significant (P > 0.20). In a multiple logistic model, the following variables were independent predictors of CHD in this elderly population: age, hypertension (males only), family history of CHD, HDL cholesterol and triglycerides (females only), but not total cholesterol or Lp(a). These relationships were similar whether or not the model included Lp(a) concentration. The findings do require confirmation in the prospective study now in progress.

A rapid method for diagnosis of the Lebanese allele in the low-density lipoprotein receptor gene

The Lebanese allele in the low-density lipoprotein receptor gene is one of the alleles which results in the disease familial hypercholesterolemia. We describe a rapid method for detection of the Lebanese allele, using the polymerase chain reaction to amplify part of exon 13, intron 14 and all of exon 14. The amplified DNA is then digested with HinfI which distinguishes between the normal and Lebanese alleles. A previously unidentified HinfI site is described in the intron. HinfI fragments are separated using polyacrylamide gel electrophoresis, and visualized by ethidium bromide staining.

Reduced serum antibodies associated with social defeat in rats

Many studies have linked various physical stressors with changes in immune function. The present experiment examined the effect of a social stressor, defeat associated with territorial defense, on serum antibodies to a specific protein, keyhole limpet hemocyanin (KLH). Pairs of male rats formed colonies and experimental rats were intruders. Experimental animals were immunized with KLH prior to exposures to territorially defensive colonies. Control animals were placed into colonies but separated from residents by a Plexiglas barrier. Behavioral measures, including number of bites and total time spent in submissive postures, were taken for colony-intruder interactions. Serum antibody levels were determined from blood samples taken one, two, and three weeks following immunization. Experimental animals had significantly less serum antibodies to KLH than did controls. Within the experimental group, total time spent in submissive postures at week one was significantly correlated with serum antibody levels, such that animals spending the most time in submission had lower antibody levels. Total bites correlated only slightly with antibody levels. The correlation between submission and serum antibody levels increased when the bites factor was partialled out. A stressful social encounter may thus affect immune function in a manner independent of the influence of physical (nociceptive) stressors.

Suppression of specific antibody production by inescapable shock: stability under varying conditions

The effect of exposure to uncontrollable shock on the production of antibodies to a novel antigen, keyhole limpet hemocyanin (KLH), was studied in adult male Sprague-Dawley rats. Groups of rats were tested under one of four experimental conditions which included testing during either the light or dark portions of their light cycles and following either one or three daily exposures to tail shock. Control subjects were immunized with KLH in the absence of shock exposure during either the light or dark phases of their light cycle. A tertiary (memory) response was evoked 60 days following the initial immunization sequence in all animals in the absence of a shock exposure. Blood samples were obtained from the tip of the tail at the time of each immunization and at 1-week intervals for 3 weeks following immunizations. Specific IgG antibodies to KLH were determined by an enzyme-linked immunosorbent assay (ELISA). All animals exposed to shock showed reduced levels of IgG antibodies to KLH regardless of the experimental conditions of shock exposure. Antibody levels were highest among animals immunized during the dark phase of their cycle for both control and shocked animals. Antibody production to a novel antigen appears to be a robust and sensitive measure for studies of modulation of immunity by behavioral factors.