Unveiling Disparities: Exploring Differential Attainment in Postgraduate Training Within Clinical Oncology

AIMS

Differential attainment (DA) in post graduate medical training is a recognised challenge and refers to unexplained variation across groups when split by several protected characteristics. The Royal College of Radiology is committed to fostering diversity, inclusivity, and equality with the goal of narrowing existing gaps and improving training outcomes.

MATERIALS AND METHODS

This was a mixed methods study aiming to understand the causes of DA with view to helping the RCR develop strategies to address this. A cross-sectional survey was completed by 140 clinical oncology trainees in September 2022. Trainees and trainers (17 and 6 respectively) from across England, Scotland, Wales and Northern Ireland, took part in focus group and interviews from August to December 2022. Quantitative and qualitative data merged and interpreted.

RESULT

Results showed international medical graduates and trainees from ethnic minority backgrounds were more likely to encounter challenges. The qualitative findings were used to identify three themes through which these problems could be framed. The trainee as a "space invader," the hidden curriculum of clinical oncology training and the process of navigating and tacking the training journey.

CONCLUSION

Differential attainment is the product of a complex interplay between the trainee, trainer, and the training environment. Therefore, interventions must be tailored to different people and contexts. At a national level, the RCR can adopt general policies to promote this such as mentorship programmes, protected time for supervision and cultural competency training. Efficacy of proposed interventions for trial and their impact on DA should be evaluated to drive evidence-based changes.

Integration of Raman spectra with transcriptome data in glioblastoma multiforme defines tumour subtypes and predicts patient outcome

Raman spectroscopy is an imaging technique that has been applied to assess molecular compositions of living cells to characterize cell types and states. However, owing to the diverse molecular species in cells and challenges of assigning peaks to specific molecules, it has not been clear how to interpret cellular Raman spectra. Here, we provide firm evidence that cellular Raman spectra (RS) and transcriptomic profiles of glioblastoma can be computationally connected and thus interpreted. We find that the dimensions of high-dimensional RS and transcriptomes can be reduced and connected linearly through a shared low-dimensional subspace. Accordingly, we were able to predict global gene expression profiles by applying the calculated transformation matrix to Raman spectra and vice versa. From these analyses, we extract a minimal gene expression signature associated with specific RS profiles and predictive of disease outcome.

Mortality in residential care services for people with disabilities in Ireland

Background

All-cause mortality is higher in people with disability than in people without disability. There is a need for descriptive epidemiological studies of deaths in people with disability to inform the development of public health interventions. All deaths in residential disability services in Ireland are notified to the Chief Inspector in the Health Information and Quality Authority (HIQA). These include notification of unexpected and expected deaths. The herein aim was to describe total, unexpected and expected deaths, and identify leading causes of death in residential disability services in Ireland.

Methods

Data on deaths in residential disability services in 2019 and 2020 were extracted from the Database of Statutory Notifications from Social Care in Ireland. The number of total deaths was calculated along with the percent and number of unexpected and expected deaths. The primary cause of death notified by services was coded using ICD-11 chapter headings.

Results

During 2019 and 2020, on average 9,115 people resided in residential disability services. Of these, 395 died, of which 45% (n = 178) were notified as unexpected. The leading causes of unexpected deaths were respiratory system diseases (35%, n = 62) and circulatory system diseases (18%, n = 32). The leading causes of expected death were respiratory system diseases (41%, n = 89) and cancers (31%, n = 67).

Conclusions

Almost half of deaths in residential disability services were notified as unexpected. Respiratory disease was the leading cause of both expected and unexpected death in people with disability residing in residential services in Ireland; three-fold the general Irish population (10.7%). Public health interventions aimed at reducing respiratory disease may reduce deaths in this group.

Key messages

In 2019 and 2020, nearly half of deaths of people with a disability residing in residential services were notified as unexpected. Death from respiratory diseases was substantially higher in people with disability living in residential services in Ireland than in the general population and warrants public health intervention.

The prevalence of potential drug-drug interactions in adults with intellectual disability

BACKGROUND

There is a high use of medications in adults with intellectual disability (ID). One implication of taking multiple medications is the potential for drug-drug interactions (DDIs). However, despite this being well highlighted in the mainstream literature, little is known about the incidence or associations of DDIs in the ID population.

METHODS

This study describes the prevalence, patterns and associations of potential DDIs in a total administrative sample of adults with ID known to services in Jersey. Demographic, health-related and medication data were collected from 217 adults known to ID services. Data were collected using a face-to-face survey. The Anatomical Therapeutic Chemical classification system was used to categorise medications, and Stockley's Drug Interaction Checker was used to classify potential DDIs. Drug-drug pairings were considered to be of clinical significance if they were to be 'avoided, adjusted, monitored or required further information'.

RESULTS

Potential DDIs of clinical significance were common. Exposure to potential DDIs of clinical significance was associated with being female, taking more than five medications (polypharmacy), living in residential care and having more health conditions. A simple regression was used to understand the effect of number of prescribed medications on potential DDIs of clinical significance. Every prescribed drug led to a 0.87 (95% confidence interval: 0.72-1.00) increase in having a potential DDI of clinical significance.

CONCLUSION

Adults with ID who live in residential care, who are female, exposed to polypharmacy and have more health conditions may be more likely to have potential DDIs of clinical significance. Urgent consideration needs to be given to the potential of DDIs in this population given their exposure to high levels of medication.

Polypharmacy and psychotropic polypharmacy in adults with intellectual disability: a cross-sectional total population study

BACKGROUND

Adults with intellectual disability (ID) are prescribed high levels of medication, with polypharmacy and psychotropic polypharmacy common. However, reported rates vary between studies, and there has been an over-reliance on obtaining data from convenience samples. The objective of this study was to determine the prevalence of medication use and polypharmacy in a population-level sample of adults with IDs. Factors associated with polypharmacy and psychotropic polypharmacy are explored.

METHODS

We used a total population sample of 217 adults with IDs known to services in Jersey (sampling frame n = 285). The Anatomical Therapeutic Chemical classification system was used to categorise medications that participants were currently taking on a regular basis. We examined associations of polypharmacy and psychotropic polypharmacy with socio-economic status, health and demographic variables using univariate and multivariate analyses.

RESULTS

A total of 83.4% of participants were prescribed medication, with high doses common. Of the participants, 38.2% were exposed to polypharmacy while 23% of participants were exposed to psychotropic polypharmacy. After controlling for demographic, health and socio-economic characteristics, polypharmacy was significantly associated with older age, increased severity of ID, living in a residential setting and having increased comorbidities. Psychotropic polypharmacy was associated with being male, being aged 50+ years and having had a psychiatric diagnosis over the life course. Being prescribed psychotropic drugs above the defined daily dose was not associated with having had a psychiatric diagnosis over the life course, suggesting the possibility of 'off label' prescribing.

CONCLUSIONS

Our results indicate that medication use, in high doses, alongside polypharmacy and psychotropic polypharmacy are highly prevalent in adults with ID. The exposure to multiple medications increases the risk of developing adverse drug events, drug-drug interactions and medication-related problems. Future population-level, prospective cohort studies should examine the prevalence of polypharmacy and psychotropic polypharmacy using standardised definitions and consider the potential impact of adverse drug events, drug-drug interactions and medication-related problems in this population.

Containing a measles outbreak in Minnesota, 2017: methods and challenges

AIMS

We report on a measles outbreak largely occurring in Minnesota's under-vaccinated Somali community in the spring of 2017. The outbreak was already into its third generation when the first two cases were confirmed, and rapid public health actions were needed. The aim of our response was to quickly end transmission and contain the outbreak.

METHODS

The state public health department performed laboratory testing on suspect cases and activated an Incident Command staffed by subject matter experts that was operational within 2 h of case confirmation. Epidemiologic interviews identified exposures in settings where risk of transmission was high, that is, healthcare, childcare, and school settings. Vaccination status of exposed persons was assessed, and postexposure prophylaxis (PEP) was offered, if applicable. Exposed persons who did not receive PEP were excluded from childcare centers or schools for 21 days. An accelerated statewide measles, mumps, and rubella (MMR) recommendation was made for Somali Minnesota children and children in affected outbreak counties. Partnerships with the Somali Minnesota community were deepened, building off outreach work done with the community since 2008.

RESULTS

Public health identified 75 measles cases from 30 March to 25 August 2017: 43% were female, 81% Somali Minnesotan, 91% unvaccinated, and 28% hospitalized. The median age of cases was 2 years (range: 3 months-57 years). Most transmission (78%) occurred in childcare centers and households. A secondary attack rate of 91% was calculated for unvaccinated household contacts. Over 51,000 doses of MMR were administered during the outbreak above expected baseline. At least 8490 individuals were exposed to measles; 155 individuals received PEP; and over 500 persons were excluded from childcare and school. State and key public health partners spent an estimated $2.3 million on response.

CONCLUSION

This outbreak demonstrates the necessity of immediate, targeted disease control actions and strong public health, healthcare, and community partnerships to end a measles outbreak.

A novel discharge pathway for patients with advanced cancer requiring home parenteral nutrition

BACKGROUND

The use of home parenteral nutrition (HPN) for palliative indications is increasing internationally and is the leading indication in some countries. Discharge on HPN can be complex in metabolically unstable patients and requires intestinal failure expertise.

METHODS

Between 2012 and 2018, we performed a retrospective analysis aiming to assess the impact of a novel remote discharge pathway for palliative HPN patients. This was evaluated using a quality improvement approach.

RESULTS

One hundred and twenty-five patients with active malignancy [mean (range) age 58 (25-80) years] were referred to the intestinal failure unit (IFU) for remote discharge. Of 82 patients were discharged from the oncology Centre on HPN using the pathway. The remaining 43 patients either declined HPN or the Oncology team felt that the patient became too unwell for HPN or died prior to discharge. There was an increase in patients referred for remote discharge from 13 in 2012 to 43 in 2017. The mean number of days between receipt of referral by the IFU to discharge on HPN from the oncology centre reduced from 29.4 days to 10.1 days. Following remote discharge, the mean number of days on HPN was 215.9 days. Catheter-related blood stream infection rates in this cohort were very low at 0.169 per 1000 catheter days.

CONCLUSIONS

This is the first study to demonstrate the remote safe, effective and rapid discharge of patients requiring palliative HPN between two hospital sites. This allows patients with a short prognosis more time in their desired location.

Transcription of the NKG2D ligand MICA is suppressed by the IRE1/XBP1 pathway of the unfolded protein response through the regulation of E2F1

The unfolded protein response (UPR) is an adaptive signaling pathway activated in response to endoplasmic reticulum (ER) stress. The effectors of the UPR are potent transcription activators; however, some genes are suppressed by ER stress at the mRNA level. The mechanisms underlying UPR-mediated gene suppression are less known. Exploration of the effect of UPR on NK cells ligand expression found that the transcription of NK group 2 member D (NKG2D) ligand major histocompatibility complex class I polypeptide-related sequence A/B (MICA/B) is suppressed by the inositol-requiring enzyme 1 (IRE1)/X-box binding protein 1 (XBP1) pathway of the UPR. Deletion of IRE1 or XBP1 was sufficient to promote mRNA and surface levels of MICA. Accordingly, NKG2D played a greater role in the killing of IRE1/XBP1 knockout target cells. Analysis of effectors downstream to XBP1s identified E2F transcription factor 1 (E2F1) as linking UPR and MICA transcription. The inverse correlation between XBP1 and E2F1 or MICA expression was corroborated in RNA-Seq analysis of 470 primary melanoma tumors. While mechanisms that connect XBP1 to E2F1 are not fully understood, we implicate a few microRNA molecules that are modulated by ER stress and possess dual suppression of E2F1 and MICA. Because of the importance of E2F1 and MICA in cancer progression and recognition, these observations could be exploited for cancer therapy by manipulating the UPR in tumor cells.-Obiedat, A., Seidel, E., Mahameed, M., Berhani, O., Tsukerman, P., Voutetakis, K., Chatziioannou, A., McMahon, M., Avril, T., Chevet, E., Mandelboim, O., Tirosh, B. Transcription of the NKG2D ligand MICA is suppressed by the IRE1/XBP1 pathway of the unfolded protein response through the regulation of E2F1.

Dual IRE1 RNase functions dictate glioblastoma development

Proteostasis imbalance is emerging as a major hallmark of cancer, driving tumor aggressiveness. Evidence suggests that the endoplasmic reticulum (ER), a major site for protein folding and quality control, plays a critical role in cancer development. This concept is valid in glioblastoma multiform (GBM), the most lethal primary brain cancer with no effective treatment. We previously demonstrated that the ER stress sensor IRE1α (referred to as IRE1) contributes to GBM progression, through XBP1 mRNA splicing and regulated IRE1-dependent decay (RIDD) of RNA Here, we first demonstrated IRE1 signaling significance to human GBM and defined specific IRE1-dependent gene expression signatures that were confronted to human GBM transcriptomes. This approach allowed us to demonstrate the antagonistic roles of XBP1 mRNA splicing and RIDD on tumor outcomes, mainly through selective remodeling of the tumor stroma. This study provides the first demonstration of a dual role of IRE1 downstream signaling in cancer and opens a new therapeutic window to abrogate tumor progression.

Regulation of the unfolded protein response by noncoding RNA

Cells are exposed to various intrinsic and extrinsic stresses in both physiological and pathological conditions. To adapt to those conditions, cells have evolved various mechanisms to cope with the disturbances in protein demand, largely through the unfolded protein response (UPR) in the endoplasmic reticulum (ER), but also through the integrated stress response (ISR). Both responses initiate downstream signaling to transcription factors that, in turn, trigger adaptive programs and/or in the case of prolonged stress, cell death mechanisms. Recently, noncoding RNAs, including microRNA and long noncoding RNA, have emerged as key players in the stress responses. These noncoding RNAs act as both regulators and effectors of the UPR and fine-tune the output of the stress signaling pathways. Although much is known about the UPR and the cross talk that exists between pathways, the contribution of small noncoding RNA has not been fully assessed. Herein we bring together and review the current known functions of noncoding RNA in regulating adaptive pathways in both physiological and pathophysiological conditions, illustrating how they operate within the known UPR functions and contribute to diverse cellular outcomes.

Prevalence of psychotropic medication use and association with challenging behaviour in adults with an intellectual disability. A total population study

BACKGROUND

There is a high prevalence of psychotropic medication use in adults with Intellectual Disabilities (ID), often in the absence of psychiatric disorder, also associated with challenging behaviour. Previous research has focused on specific sample frames or data from primary care providers. There is also a lack of consistency in the definition of challenging behaviour used.

METHODS

We adopted a total population sampling method. Medication data on 265 adults with ID were classified according to the Anatomical Therapeutic Chemical classification system. The Behaviour Problems Inventory - short form classified challenging behaviours. We examined the association between challenging behaviour and the use of psychotropic medication, and whether any association would still be present after accounting for socio-demographic and clinical characteristics.

RESULTS

70.57% of adults with ID were prescribed at least one class of any medication (mean per person =2.62; range 0-14). Psychotropic medications were used by 37.73% of participants with antipsychotics the commonest type used by 21.89% of individuals. Polypharmacy and high dosages were common. Generalised Linear Models indicated significant associations between psychotropic medication and the presence of a psychiatric diagnosis, challenging behaviour, older age and type of residence. Male gender was additionally associated with antipsychotic medication.

CONCLUSIONS

The use of a total population sample identified via multiple routes is less likely to overestimate prevalence rates of medication use. Current challenging behaviour was a predictor of medication use after controlling for other variables. Data indicate that there may be differences in prescribing patterns associated with different topographies of challenging behaviours.

Inflammation and the pathogenesis of atherosclerosis in systemic lupus erythematosus

Atherosclerosis is a complicated inflammatory process characterized by the interactions of numerous different moieties including lipids, enzymes, endothelial cells, cytokines, chemokines, leukocytes, adhesion molecules, complement and antibodies. As in the pathogenesis of many lupus disease processes, the increased risk of atherosclerosis seen in systemic lupus erythematosus (SLE) is likely due to the complex interplay of many of these inflammatory mediators. Expanding our understanding of the pathogenesis of atherosclerosis in SLE is critical if we are to improve the quality of care and reduce mortality in this vulnerable population.

Anticholinergic burden in schizophrenia and ability to benefit from psychosocial treatment programmes: a 3-year prospective cohort study

BACKGROUND

Many medications administered to patients with schizophrenia possess anticholinergic properties. When aggregated, pharmacological treatments may result in a considerable anticholinergic burden. The extent to which anticholinergic burden has a deleterious effect on cognition and impairs ability to participate in and benefit from psychosocial treatments is unknown.

METHOD

Seventy patients were followed for approximately 3 years. The MATRICS consensus cognitive battery (MCCB) was administered at baseline. Anticholinergic burden was measured with the Anticholinergic Cognitive Burden (ACB) scale. Ability to benefit from psychosocial programmes was measured using the DUNDRUM-3 Programme Completion Scale (D-3) at baseline and follow-up. Psychiatric symptoms were measured using the PANSS. Total antipsychotic dose was measured using chlorpromazine equivalents. Functioning was measured using the Social and Occupational Functioning Assessment Scale (SOFAS).

RESULTS

Mediation analysis found that the influence of anticholinergic burden on ability to participate and benefit from psychosocial programmes was completely mediated by the MCCB. For every 1-unit increase on the ACB scale, change scores for DUNDRUM-3 decreased by -0.27 points. This relationship appears specific to anticholinergic burden and not total antipsychotic dose. Moreover, mediation appears to be specific to cognition and not psychopathology. Baseline functioning also acted as mediator but only when MCCB was not controlled for.

CONCLUSIONS

Anticholinergic burden has a significant impact on patients' ability to participate in and benefit from psychosocial treatment programmes. Physicians need to be mindful of the cumulative effect that medications can have on patient cognition, functional capacity and ability to benefit from psychosocial treatments.

The changing pattern of wheelchair provision

The last 20 years has seen a substantial increase in the number of wheelchair users: in 1973, Fenwick estimated that 137 000 wheelchairs were on loan in England and Wales; in 1990, Kettle and Rowley estimated that 500 000 chairs were on ioan from the Disablement Services Authority.

In a survey of requests for new wheelchairs over two separate one-month periods, it was found that 310 requests resulted in the supply of 302 wheelchairs. Females received 66.6% of the chairs. The ages of the recipients ranged from three to 98 years old (average 71). Patients aged 60 and over received 79.8% of all chairs supplied. Attendant-propelled chairs accounted for 75.2% of chairs supplied, and 19.2% were self-propelled. The leading diagnostic groups for provision were: arthritis (21.5%); cerebrovascular disease (19.2%); chronic obstructive airways disease/asthma (16.5%); and ischaemic heart disease/congestive cardiac failure (13.6%)

When compared with the earlier two national surveys there have been changes in the age of wheelchair users, the diagnoses necessitating the use of a wheelchair, and the type of wheelchair used. These changes are inter-related and are likely to be driven by an increasingly elderly population.

Abstract P1-01-10: Pleomorphic lobular carcinoma in situ (PLCIS)-presentation, associated lesions and outcome

Pleomorphic lobular carcinoma in situ (PLCIS) is an uncommon lesion characterised by dyscohesive lobular cells showing high grade nuclei. It is commonly associated with comedo necrosis and luminal calcifications and hence diagnosed on mammographic screening. Data on the presentation, focality, associated lesions, optimal treatment and outcome of PLCIS is patchy.

Methods

Cases diagnosed as PLCIS between 2005 and 2015 were identified from the imaging and pathology databases of two UK large breast screening units. Cases diagnosed on diagnostic core biopsy/VAB or surgical excisions were included. Comprehensive data was collected on age, mode of presentation (screening vs symptomatic), imaging (mammography, ultrasound and MRI), surgical management, histological features on core biopsy and excision including type, grade and immunohistochemical profile of associated ductal carcinoma in situ (DCIS) and invasive carcinoma.

Results

86 cases with the diagnosis of PLCIS (confirmed by review and e-cadherin negativity) were identified. The mean patient age at diagnosis was 61.04 years, range: 39-84 years. 32 cases were treated with wide local excision with/without axillary procedure.

A total of 38 patients were screen detected & 36 cases were diagnosed in the symptomatic setting. Others presented as incidental calcifications on family history screening, incidental histological findings in breast reductions and risk reducing mastectomy.

On mammography, 6 patients presented with an asymmetrical density, with or without calcifications, 25 with calcifications, 44 as a mass and 2 as stromal deformity. No mammographic abnormality was found in 9 cases. PLCIS was multifocal in 19.7% of cases, diffuse in 9.9%, focal in 69% and multi-centric in 1.4% on imaging.

Histologically, PLCIS was the most advanced lesion on core biopsy without associated DCIS or invasive disease (pure PLCIS) in 23 patients. Of these, surgical excision revealed an invasive carcinoma in 7 cases (upgrade rate =30.4%). Six more patients presented as DCIS and PLCIS on core biopsy; three of whom (50%) had invasive disease on excision.

Classical LCIS was associated with PLCIS in 27/86 cases (31.3%). The most common type of associated invasive carcinoma on surgical excision was invasive classical lobular carcinoma (ILC, 40 cases), followed by invasive pleomorphic lobular carcinoma (IPLC, 27 cases). Ductal no special type carcinoma, solid papillary and tubulo-lobular carcinoma were also identified.

The size of PLCIS on excision ranged from 1-80mm. DCIS was associated in 26.7% of cases. The majority of invasive cancers were of grade 2 (53.5%) and 3 (19%). The tumors were ER positive (53 cases), PR positive (43 cases) and HER2 negative (52 cases).

Conclusion

PLCIS is an uncommon in situ carcinoma presenting via mammographic and also in the symptomatic setting. Unlike classical LCIS, PLCIS is a disease of postmenopausal women. It is multifocal in approximately one fifth of the cases.

PLCIS is commonly associated with classical LCIS and both ILC and IPLC. When identified in core biopsy, the upgrade rate in this series was 30.4% which increased to 50% if the lesion co-existed with DCIS. The associated cancers are often ER positive, HER2 negative. These findings support managing those lesions surgically as per DCIS.

Citation Format: Shaaban AM, Smith S, Bradley S, McMahon M, Sharma N. Pleomorphic lobular carcinoma in situ (PLCIS)-presentation, associated lesions and outcome. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-01-10.

Reversal of loop ileostomy under an Enhanced Recovery Programme - Is the stapled anastomosis technique still better than the handsewn technique?

INTRODUCTION

Recent literature suggests that stapled anastomotic (SA) technique for the reversal of loop ileostomy (LI) may be beneficial in terms of early recovery and reduced incidence of small bowel obstruction when compared to the handsewn anastomosis (HA). Enhanced Recovery Programme (ERP) after colorectal procedures has demonstrated a reduction in some aspects of surgical morbidity. The aim of this study was to investigate the outcomes of patients undergoing reversal of LI within an ERP programme and compare the HA to the SA in relation to clinical outcomes.

MATERIAL AND METHODS

All adult patients undergoing elective reversal of loop ileostomy between January 2008 and December 2012 without any additional procedures, were included in our study. Adherence to ERP modules and 30 day postoperative complications were assessed via retrospective review of patient case notes.

RESULTS

One hundred and eight patients had an ileostomy reversal; 61 in the SA and 47 in the HA group. There were no demographic differences between the two groups. ERP module compliance was satisfactory (>80%) in 11 of the 14 modules with no difference in individual module compliance between the two groups. The operating times were found to be comparable (p = 0.35). Overall mortality (p = 0.44), anastomotic leak rates (p = 1.00), intra-abdominal collections (p = 0.65), small bowel obstruction (p = 1.00), reoperation rates (p = 0.65), ileus (p = 0.14) and other significant complications (Clavien-Dindo > 2) (p = 0.08) were similar between the two groups. A significantly longer total length of hospital stay (TLOS) was found in the SA group (median 3 Vs 4 days, p = 0.009).

CONCLUSION

Reversal of LI under an ERP appears to potentially neutralise the suggested SA benefits in terms of postoperative complications without any additional negative implications. Other non-operative factors may have a potential effect on outcomes such as the TLOS.

Rituximab: an emerging treatment for recurrent diffuse alveolar hemorrhage in systemic lupus erythematosus

Diffuse alveolar hemorrhage (DAH) is a rare manifestation of systemic lupus erythematosus (SLE) and is associated with high mortality rates. Treatment typically consists of aggressive immunosuppression with pulse-dose steroids, cyclophosphamide, and plasma exchange therapy. Mortality rates remain high despite use of multiple medical therapies. We present a case of recurrent DAH in a 52-year-old female with SLE after a deceased donor renal transplant who was successfully treated with rituximab. Our report highlights the pathophysiologic importance of B-cell-mediated immunosuppression in SLE-associated DAH and suggests that rituximab may represent a viable alternative to cyclophosphamide in the treatment of this disease. We also review eight other reported cases of rituximab use in SLE-associated DAH.

Effects of preplasma scale length and laser intensity on the divergence of laser-generated hot electrons

We report on a numerical study of the effects of preplasma scale length and laser intensity on the hot-electron (≥1 MeV) divergence angle using full-scale 2D3V (two dimensional in space, three dimensional in velocity) simulations including a self-consistent laser-plasma interaction and photoionization using the particle-in-cell code LSP. Our simulations show that the fast-electron divergence angle increases approximately linearly with the preplasma scale length for a fixed laser intensity. On the other hand, for a fixed preplasma scale length, the laser intensity has little effect on the divergence angle in the range between 10(18) and 10(21) W/cm(2). These findings have important implications for the interpretation of experimental results.

Nrf2 is controlled by two distinct β-TrCP recognition motifs in its Neh6 domain, one of which can be modulated by GSK-3 activity

Identification of regulatable mechanisms by which transcription factor NF-E2 p45-related factor 2 (Nrf2) is repressed will allow strategies to be designed that counter drug resistance associated with its up-regulation in tumours that harbour somatic mutations in Kelch-like ECH-associated protein-1 (Keap1), a gene that encodes a joint adaptor and substrate receptor for the Cul3-Rbx1/Roc1 ubiquitin ligase. We now show that mouse Nrf2 contains two binding sites for β-transducin repeat-containing protein (β-TrCP), which acts as a substrate receptor for the Skp1-Cul1-Rbx1/Roc1 ubiquitin ligase complex. Deletion of either binding site in Nrf2 decreased β-TrCP-mediated ubiquitylation of the transcription factor. The ability of one of the two β-TrCP-binding sites to serve as a degron could be both increased and decreased by manipulation of glycogen synthase kinase-3 (GSK-3) activity. Biotinylated-peptide pull-down assays identified DSGIS³³⁸ and DSAPGS³⁷⁸ as the two β-TrCP-binding motifs in Nrf2. Significantly, our pull-down assays indicated that β-TrCP binds a phosphorylated version of DSGIS more tightly than its non-phosphorylated counterpart, whereas this was not the case for DSAPGS. These data suggest that DSGIS, but not DSAPGS, contains a functional GSK-3 phosphorylation site. Activation of GSK-3 in Keap1-null mouse embryonic fibroblasts (MEFs), or in human lung A549 cells that contain mutant Keap1, by inhibition of the phosphoinositide 3-kinase (PI3K) – protein kinase B (PKB)/Akt pathway markedly reduced endogenous Nrf2 protein and decreased to 10-50% of normal the levels of mRNA for prototypic Nrf2-regulated enzymes, including the glutamate-cysteine ligase catalytic and modifier subunits, glutathione S-transferases Alpha-1 and Mu-1, heme oxygenase-1 and NAD(P)H:quinone oxidoreductase-1. Pre-treatment of Keap1^−/− MEFs or A549 cells with the LY294002 PI3K inhibitor or the MK-2206 PKB/Akt inhibitor increased their sensitivity to acrolein, chlorambucil and cisplatin between 1.9-fold and 3.1-fold, and this was substantially attenuated by simultaneous pre-treatment with the GSK-3 inhibitor CT99021.

Time dependence of fast electron beam divergence in ultraintense laser-plasma interactions

We report on the measurement and computer simulation of the divergence of fast electrons generated in an ultraintense laser-plasma interaction (LPI) and the subsequent propagation in a nonrefluxing target. We show that, at Iλ(2) of 10(20) Wcm(-2)μm(2), the time-integrated electron beam full divergence angle is (60±5)°. However, our time-resolved 2D particle-in-cell simulations show the initial beam divergence to be much smaller (≤30°). Our simulations show the divergence to monotonically increase with time, reaching a final value of (68±7)° after the passage of the laser pulse, consistent with the experimental time-integrated measurements. By revealing the time-dependent nature of the LPI, we find that a substantial fraction of the laser energy (~7%) is transported up to 100 μm with a divergence of 32°.

Active mobilisation following single cross grasp four-strand flexor tenorrhaphy (Adelaide repair)

This paper presents our initial experience using a single cross grasp, four-strand repair with an active mobilization regimen in a general trauma hospital setting. Variably experienced members of the trauma service of a large general hospital used a four-strand single cross grasp tenorrhaphy technique for acute repair of 73 zone one and two flexor digitorum profundus tendon lacerations in 53 patients. Postoperatively, all patients commenced an active mobilization program within 12 hours of the surgical repair. With a minimum 3 months post-repair follow-up of 89% of the repaired flexor digitorum profundus tendons, 71% of fingers achieved a good or excellent outcome. There were three (4.6%) flexor digitorum profundus ruptures post surgery. A four-strand single cross grasp repair using 3-0 braided polyester suture and active post-repair mobilization can achieve satisfactory outcomes in the general trauma service setting; however, patient compliance remains a problem.