Improving the efficiency of integrated cancer screening delivery across multiple cancers: case studies from Idaho, Rhode Island, and Nebraska

BACKGROUND

Three current and former awardees of the Centers for Disease Control and Prevention's Colorectal Cancer Control Program launched integrated cancer screening strategies to better coordinate multiple cancer screenings (e.g., breast, cervical, colorectal). By integrating the strategies, efficiencies of administration and provision of screenings can be increased and costs can be reduced. This paper shares findings from these strategies and describes their effects.

METHODS

The Idaho Department of Health and Welfare developed a Baseline Assessment Checklist for six health systems to assess the current state of policies regarding cancer screening. We analyzed the checklist and reported the percentage of checklist components completed. In Rhode Island, we collaborated with a nurse-patient navigator, who promoted cancer screening, to collect details on patient navigation activities and program costs. We then described the program and reported total costs and cost per activity. In Nebraska, we described the experience of the state in administering an integrated contracts payment model across colorectal, breast, and cervical cancer screening and reported cost per person screened. Across all awardees, we interviewed key stakeholders.

RESULTS

In Idaho, results from the checklist offered guidance on areas for enhancement before integrated cancer screening strategies, but identified challenges, including lack of capacity, limited staff availability, and staff turnover. In Rhode Island, 76.1% of 1023 patient navigation activities were for colorectal cancer screening only, with a much smaller proportion devoted to breast and cervical cancer screening. Although the patient navigator found the discussions around multiple cancer screening efficient, patients were not always willing to discuss all cancer screenings. Nebraska changed its payment system from fee-for-service to fixed cost subawards with its local health departments, which integrated cancer screening funding. Screening uptake improved for breast and cervical cancer but was mixed for colorectal cancer screening.

CONCLUSIONS

The results from the case studies show that there are barriers and facilitators to integrating approaches to increasing cancer screening among primary care facilities. However, more research could further elucidate the viability and practicality of integrated cancer screening programs.

Time from breast cancer diagnosis to treatment among Idaho's National Breast and Cervical Cancer Early Detection Program population, 2011-2017

PURPOSE

Idaho's Women's Health Check (WHC) Program provides breast and cervical cancer screening to under- and uninsured women via funding from the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Because WHC serves populations with less access to health care, this study evaluated time from breast cancer diagnosis to treatment for women enrolled in the WHC program and linked to Cancer Data Registry of Idaho (CDRI) case data (WHC-linked) and the remainder of female Idaho resident breast cases.

METHODS

Among Idaho residents aged 50-64 years diagnosed during 2011-2017 with ductal carcinoma in situ or invasive breast cancer, we assessed differences in the median time from definitive diagnosis to treatment initiation overall and by demographic and tumor characteristics, and differences in the distribution of demographic and tumor-related variables between 231 WHC-linked and 3,040 non-linked breast cancer cases.

RESULTS

WHC-linked cases were significantly less likely to be non-Hispanic white, and more likely to live in poorer census tracts, be diagnosed at a later stage, and be treated with mastectomy. Most WHC-linked (92%) and non-linked women (94%) began treatment within 60 days of diagnosis; no differences in time to treatment were observed.

CONCLUSION

Disparities in the interval from definitive diagnosis to breast cancer treatment initiation were not observed for women enrolled in the WHC program relative to other Idaho women.

Preparations for a European R&D roadmap for an inertial fusion demo reactor

A European consortium of 15 laboratories across nine nations have worked together under the EUROFusion Enabling Research grants for the past decade with three principle objectives. These are: (a) investigating obstacles to ignition on megaJoule-class laser facilities; (b) investigating novel alternative approaches to ignition, including basic studies for fast ignition (both electron and ion-driven), auxiliary heating, shock ignition, etc.; and (c) developing technologies that will be required in the future for a fusion reactor. A brief overview of these activities, presented here, along with new calculations relates the concept of auxiliary heating of inertial fusion targets, and provides possible future directions of research and development for the updated European Roadmap that is due at the end of 2020. This article is part of a discussion meeting issue 'Prospects for high gain inertial fusion energy (part 2)'.

Whole-beam self-focusing in fusion-relevant plasma

Fast ignition inertial confinement fusion requires the production of a low-density channel in plasma with density scale-lengths of several hundred microns. The channel assists in the propagation of an ultra-intense laser pulse used to generate fast electrons which form a hot spot on the side of pre-compressed fusion fuel. We present a systematic characterization of an expanding laser-produced plasma using optical interferometry, benchmarked against three-dimensional hydrodynamic simulations. Magnetic fields associated with channel formation are probed using proton radiography, and compared to magnetic field structures generated in full-scale particle-in-cell simulations. We present observations of long-lived, straight channels produced by the Habara-Kodama-Tanaka whole-beam self-focusing mechanism, overcoming a critical barrier on the path to realizing fast ignition. This article is part of a discussion meeting issue 'Prospects for high gain inertial fusion energy (part 2)'.

Surveillance for Lyme disease in Canada, 2009 to 2012

OBJECTIVES

To summarize the first four years of national surveillance for Lyme disease in Canada from 2009 to 2012 and to conduct a preliminary comparison of presenting clinical manifestations in Canada and the United States.

METHODS

The numbers and incidence of reported cases by province, month, year, age and sex were calculated. Logistic regression was used to examine trends over time. Acquisition locations were mapped and presenting clinical manifestations reported for jurisdictions where data was available. Variations by province, year, age and sex as well as presenting clinical symptoms were explored by logistic regression. An initial comparative analysis was made of presenting symptoms in Canada and the United States.

RESULTS

The numbers of reported cases rose significantly from 144 in 2009 to 338 in 2012 (coefficient = 0.34, standard error = 0.07, P <0.05), mostly due to an increased incidence of infections acquired in Canada. More cases were classified as 'confirmed' (71.5%) than 'probable' (28.5%). Most cases occurred in locations where vector tick populations were known to be present. More men than women were affected (53.4% versus 46.6%), incidence was highest in adults aged 55 to 74 years and in children aged five to 14 years. Most cases (95%) were acquired from April to November. Of cases acquired in endemic areas, 39.7% presented with manifestations of early Lyme disease, while 60.3% had manifestations of disseminated Lyme disease. There were significant differences among age groups, sexes and provinces in the frequencies of reported clinical manifestations. The proportion of cases acquired in endemic areas presenting with early Lyme disease was lower than that reported in the US.

CONCLUSION

Lyme disease incidence is increasing in Canada. Most cases are acquired where vector tick populations are spreading and this varies geographically within and among provinces. There is also variation in the frequency of age, season and presenting manifestations. The lower proportion of cases presenting with early Lyme disease in Canada compared with the US suggests lower awareness of early Lyme disease in Canada, but this requires further study.

Hospital mortality under surgical care

INTRODUCTION

The 'hospital standardised mortality ratio' (HSMR) has been used in England since 1999 to measure NHS hospital performance. Large variations in reported HSMR between English hospitals have recently led to heavy criticism of their use as a surrogate measure of hospital performance. This paper aims to review the mortality data for a consultant general surgeon contributed by his NHS trust over a 3-year period as part of the trust's HSMR calculation and evaluate the accuracy of coding the diagnoses and covariates for case mix adjustment.

SUBJECTS AND METHODS

The Dr Foster Intelligence database was interrogated to extract the NHS trust's HSMR benchmark data on inpatient mortality for the surgeon from 1 April 2006 to 31 March 2009 and compared to the hospital notes.

RESULTS

30 patients were identified of whom 12 had no evidence of being managed by the surgeon. This represents a potential 40% inaccuracy rate in designating consultant responsibility. The remaining 18 patients could be separated into 'operative' (11 patients) and 'non-operative' (7 patients) groups. Only 27% in the operative group and 43% of the non-operative mortality group respectively had a Charlson co-morbidity index recorded despite 94% of the cases having significant co-morbidities

CONCLUSIONS

Highlighting crude and inaccurate clinician-specific mortality data when only 1-5% of deaths under surgical care may be associated with avoidable adverse events seems potentially irresponsible.

The effects of paclitaxel (PTX) and 2-methoxyestradiol (2-ME2) on tumor oxygenation and HIF-1α in breast cancer

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Background: Radiation activates HIF-1a via a free radical mediated mechanism associated with reoxygenation. This response could be inhibited, resulting in reduced tumor vascularity and proliferation. Preclinical breast cancer models and a Phase Ib clinical trial (CT) were employed to look at the effects of chemo with or without an oral HIF-1a inhibitor, 2-ME2 (EntreMed) on tumor oxygenation and HIF-1a. Methods: Preclinical models of chemo effects on HIF-1a/oxygenation used 4T1 tumors and either doxorubicin (DOX) or cyclophosphamide (CTX). In addition, MDA-MB-231 tumors were treated with 2-ME2 (5days), and HIF-1a/MVD was assessed. In the CT, up to 15 pts with metastatic breast cancer, and biopsiable (>2 cm) non-bone sites were eligible. Tx was: D 1: PTX, 90 mg/m2; D 8: PTX, 90 mg/m2 with 2-ME2 (cohorts of 1,000/1,250/1,500 mg, qid). PTX was given 3 out of 4 wks. Bxs were done at enrollment, D8 (post-PTX), and D22 (post-PTX/2-ME2). Tumors were examined for changes in HIF-1a and CA9 levels, MVD, and genomic signatures of hypoxia. Plasma was obtained for osteoponin, PAI-1, and VEGF. Results: DOX and CTX both led to increases in HIF-1a, oxygenation, vascularity, and proliferation 4–10 days post treatment in the 4T1 model, while 2-ME2 reduced HIF-1a and MVD post treatment (5 d) in the MDA-MB-231 model. The CT opened in 6–2006, 9 pts have consented and 8 pts have undergone sequential biopsies and accrual continues. No DLT have been seen. Biopsy sites include chest wall, liver, and LN. Sufficient tissue/RNA/plasma has been obtained and the planned analyses will be presented. Conclusions: HIF-1a and tumor oxygenation appear to be modulated as a response to chemotherapy. The combination of PTX and 2-ME2 is clinically active, well-tolerated, and could serve as one of the first approaches to target HIF-1a in order to optimize therapy. Supported by Komen Grant BCTR0504044.

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Evaluation of a silicone occlusive dressing after laser skin resurfacing

BACKGROUND

Closed dressings are thought to promote postoperative wound healing after laser skin resurfacing; however, quantitative data are lacking.

OBJECTIVE

To compare postoperative healing after combination carbon dioxide and erbium:YAG full-face laser skin resurfacing in patients who were treated with a silicone occlusive dressing (Silon-TSR; Bio Med Sciences, Inc, Bethlehem, Pa) vs open-wound care consisting of soaks and ointment application.

DESIGN

Thirty-five patients with closed dressings compared retrospectively with 35 control subjects with open-wound care. In a prospective evaluation, 27 patients with closed dressings were then compared with 27 historical controls matched by age, sex, skin type, and treatment technique. Erythema, crusting, swelling, pain, pruritus, purpura, long-term complications, and dressing comfort were evaluated.

SETTING

Referral-based academic practice.

RESULTS

Prospectively, closed-dressing and open-wound care groups differed significantly in maximum erythema severity (1.8 vs 2.0 on a scale of 0-3; P =.03), noticeable erythema duration (15.4 vs 31.1 days; P =.04), and time until complete erythema resolution (41.8 vs 96.1 days; P =.02). Swelling resolution was more rapid in the dressing group (12.1 vs 29.5 days; P =.02). Crusting was limited to uncovered areas in the dressing group, and crusting duration was shorter (5.0 vs 9.1 days; P<.001). Pain was more likely to be reported prospectively, but severity was mild, in the closed-dressing group. Other short- and long-term complications did not differ significantly. Subjective patient attitudes toward the dressing were positive.

CONCLUSIONS

Occlusive silicone dressing application decreases immediate postoperative morbidity with significantly reduced severity and duration of erythema and decreased duration of swelling and crusting. Long-term results and complication rates remain unchanged.

Synopsis of laser assisted hair removal systems

Conventional treatment options for hypertrichosis and hirsutism are tedious and time consuming. Laser hair removal offers an efficient way to permanently reduce excessive hair growth. Hair is damaged using the principle of selective photothermolysis with wavelengths of light well absorbed by follicular melanin and pulse durations that selectively thermally damage the target without damaging surrounding tissue. Patients with dark hair and light skin are ideal candidates. Multiple treatments (3 to 6) performed every 6-8 weeks are necessary to achieve a permanent reduction of hair growth. As the field develops, a better sense of the effectiveness of laser hair removal will evolve and reasonable expectations will be determined.

The activity of a blood type B specific exoglycosidase from Glycine max

Soluble antigens, enzyme-linked immunosorbent assays (ELISA), and cell suspension assays were used to study the blood group B activity of Glycine max (soybean) alpha-D-galactosidase. The enzyme readily hydrolyzed the terminal alpha-D-galactosyl of the B antigen under a variety of conditions, converting it to H antigen. Conversion of the B antigen to H antigen produces blood type O which is universally transfusable. These preliminary studies are important in determining optimal conditions for enzymatic conversion of blood type B to O erythrocytes if efficient large-scale production of enzymatically converted, universally transfusable red blood cells is to be achieved.

New Chromenols From a Southern Australian Tunicate, Aplidium solidum

Two new chromenols, namely (R)-2-methyl-2-(4-methylpenta-1,3-dienyl)-2H-chromen-6-ol (7) and 1-[(R)-6-hydroxy-2-methyl-2H-chromen-2-yl]-4-methylpentan-2-one (8), have been isolated from a southern Australian tunicate, Aplidium solidum. The structures of (7) and (8) were assigned by spectroscopic analysis, and the absolute stereochemistry of (7) by chemical degradation.

A New Sesterterpene Tetronic Acid From an Australian Marine Sponge, Psammocinia sp

A new sesterterpene tetronic acid (5) exhibiting antimicrobial activity has been isolated from an Australian marine sponge, Psammocinia sp., and its structure secured by detailed spectroscopic analysis. The tetronic acid (5) possesses almost identical spectroscopic characteristics to, and is a structural isomer of, the known marine natural product (6) previously reported from an Australian sponge.

Lamellarins Q and R: New Aromatic Metabolites From an Australian Marine Sponge, Dendrilla cactos

A specimen of Dendrilla cactos collected off the coast of New South Wales, Australia, has yielded two new alkaloids, lamellarins Q (19) and R (20), the structures of which were secured by spectroscopic analysis and by chemical derivatization.

Deantigenation of human type B erythrocytes with Glycine max alpha-D-galactosidase

Conversion of erythrocyte membrane B antigen to H antigen produces blood type O which is universally transfusable. If efficient large-scale production of enzymatically converted red blood cells is to be achieved, then optimal conditions for deantigenation must be determined. Cell suspension assays were used to study the blood group B activity of Glycine max (soybean) alpha-D-galactosidase on native human erythrocytes. The enzyme readily hydrolyzed the terminal alpha-D-galactosyl residue of the B antigen, converting it to H antigen. Optimal conditions for the enzymatic conversion of red cells with the Glycine enzyme are described. Normal cell morphology and function were maintained under optimal conditions.

Vaginal birth after lower segment caesarean section

One delivery in eight in the UK is by caesarean section. Women who have had a previous caesarean section may approach a midwife in subsequent pregnancies because they want more control over their labour. Vaginal birth after caesarean section (VBAC) is a safe option for women with a lower segment scar. Factors associated with a favourable outcome include spontaneous labour and freedom of movement during labour. Factors hindering successful outcome include reduced mobility, use of oxytocin, and time limits set on progress of labour.

Introducing quality management in the community: the VON experience

How does a national, non-profit, community health organization introduce and implement quality management (QM) throughout its branches? This article traces VON's move from a traditional quality assurance model to a systematic QM approach, focused on customers and on outcomes. Implementing Quality Management in a three-tiered organization (national, provincial and local levels), with boards and staff, is not an easy challenge but is feasible. Effective and creative strategic planning is a necessity. Educational strategies and ideas for implementation are included.

An ELISA for blood group specific exoglycosidases

An enzyme-linked immunosorbent assay (ELISA) for studying erythrocyte A, B and H epitope specific exoglycosidases is described. Human blood type B erythrocyte membranes and Coffea canephora alpha-D-galactosidase were used as a model. Membrane coated microtiter wells were incubated with exoglycosidase, probed with IgM monoclonal antibody, and then with anti-murine mu chain specific alkaline phosphatase conjugate. The assay is useful for studying exoglycosidase modification of the A, B and H epitopes on human erythrocyte membranes as well as in screening prokaryotic and eukaryotic extracts for blood group active enzymes. Furthermore, this technique has the advantage of simplicity, sensitivity, and objectivity of data interpretation.

Glucose-6-phosphate dehydrogenase from Saccharomyces cerevisiae: characterization of a reactive lysine residue labeled with acetylsalicylic acid

Glucose-6-phosphate dehydrogenase from Saccharomyces cerevisiae (bakers' yeast) reacts with acetylsalicylic acid, and this is accompanied by inactivation and modification of essentially one lysine residue per subunit. The amino acid sequence of an 11-residue tryptic peptide containing the reactive lysine residue of the yeast enzyme is given and establishes the existence of different subgroups of glucose-6-phosphate dehydrogenases. Thus, the labeled yeast structure has few similarities to the known structure around the reactive lysine residue of the enzyme from Leuconostoc mesenteroides, although it has extensive similarities with a structure in the human enzyme. It is further shown that amino acid sequences around reactive lysine residues of dehydrogenases in general vary, even though similarities occur around reactive lysine residues in 6-phosphogluconate, glutamate, and glyceraldehyde-3-phosphate dehydrogenases.

Glucose-6-phosphate dehydrogenase. A transferred nuclear Overhauser enhancement study of NADP+ conformations in enzyme-coenzyme binary complexes

The conformation of NADP+ in glucose-6-phosphate-dehydrogenase--NADP+ binary complexes has been investigated using proton-proton transferred nuclear Overhauser enhancement measurements to determine interproton distance ratios between bound NADP+ protons. The enzymes from Saccharomyces cerevisiae (brewer's yeast and baker's yeast) and Hansenula jadinii (Candida utilis, Torula utilis) form binary complexes with NADP+ in which the glycosidic bond of the adenine moiety is in the anti conformation whereas that of the nicotinamide moiety exists as a syn (69-70%)/anti (30-40%) mixture. The enzymes have similar subunit sizes (Mr approximately 58 000) and it is shown that they bind NADP+ in essentially similar conformations. Inactivation of the baker's yeast enzyme with acetylsalicylic acid caused little if any alteration in the conformation of bound NADP+, and the presence of NADP+ during inactivation afforded very little protection to the enzyme. Inactivation rates were, however, lower in the presence of glucose 6-phosphate. It is concluded that the epsilon-amino group of the lysine residue that is acetylated during the inactivation reaction with acetylsalicylic acid is not necessary for binary complex formation between the enzyme and NADP+, but that it is situated in a part of the molecule affected by formation of the enzyme--glucose-6-phosphate complex. The implication of the findings for the catalytic process, and related evolutionary aspects, are discussed briefly.