Benefit of respiratory gating in the Danish Breast Cancer Group partial breast irradiation trial

BACKGROUND AND PURPOSE

Partial breast irradiation (PBI)has beenthe Danish Breast Cancer Group(DBCG) standard for selected breast cancer patients since 2016 based onearlyresults from the DBCG PBI trial.During trial accrual, respiratory-gated radiotherapy was introduced in Denmark. This study aims to investigate the effect of respiratory-gating on mean heart dose (MHD).

PATIENTS AND METHODS

From 2009 to 2016 the DBCG PBI trial included 230 patientswith left-sided breast cancer receiving external beam PBI, 40 Gy/15 fractions/3 weeks.Localization of the tumor bed on the planning CT scan, the use of respiratory-gating, coverage of the clinical target volume (CTV), and doses to organs at risk were collected.

RESULTS

Respiratory-gating was used in 123 patients (53 %). In 176 patients (77 %) the tumor bed was in the upper and in 54 patients (23 %) in the lower breast quadrants. The median MHD was 0.37 Gy (interquartile range 0.26-0.57 Gy), 0.33 Gy (0.23-0.49 Gy) for respiratory-gating, and 0.49 Gy (0.31-0.70 Gy) for free breathing, p < 0.0001. MHD was < 1 Gy in 206 patients (90 %) and < 2 Gy in 221 patients (96 %). Respiratory-gating led to significantly lower MHD for upper-located, but not for lower-located tumor beds, however, all MHD were low irrespective of respiratory-gating. Respiratory-gating did not improve CTV coverage or lower lung doses.

CONCLUSIONS

PBI ensured a low MHD for most patients. Adding respiratory-gating further reduced MHD for upper-located but not for lower-located tumor beds but did not influence target coverage or lung doses. Respiratory-gating is no longer DBCG standard for left-sided PBI.

Caesarean section rate reduced by a redesigned birthing room. Results of a quality improvement intervention at a hospital in Democratic Republic of Congo

OBJECTIVE

To evaluate the influence of a new birthing room at a tertiary hospital in eastern Democratic Republic of Congo (DRC), on the caesarean section (CS) rate in women classified as Robson group 1, i.e., nulliparous women at term with spontaneous onset of labour of one foetus in cephalic presentation.

METHOD

As part of quality improvement interventions, a new birthing room designed to promote person-centredness was constructed at the labour ward at Panzi General Referral Hospital in DRC. In a quasi-experimental study on women classified as Robson 1, a comparison was performed between the group being cared for in the new birthing room and the group being cared for in the general birthing room. The main outcome measure was CS rate.

RESULTS

In the new person-centred birthing room, the CS rate was 17.1 % versus 28.4 % in women cared for in the general birthing room (p-value 0.001). There was also a higher presence of accompanying persons (p-value < 0.0001) and less use of synthetic oxytocin for the augmentation of labour (p-value 0.024). No difference in fear and childbirth experience was identified between women in the two rooms.

CONCLUSION

The results demonstrate that it is possible, in a low-income country as the Democratic Republic of Congo, to reduce the CS rate in women classified as Robson 1 by adapting the birthing environment to be more person-centred, without compromising other obstetric and neonatal outcomes.

Patient-reported lower limb edema after primary radiotherapy for prostate cancer

BACKGROUND

Secondary lymphedema is a known side effect to radiotherapy (RT), but limited information regarding prevalence and risk factors for lower limb edema (LLE) after curative radiotherapy in patients with prostate cancer (PCa) is available. This study provides a descriptive analysis of patient-reported LLE with analysis of risk factors in a cohort of patients with PCa treated with curative RT.

MATERIAL AND METHODS

A total of 302 patients with PCa with prospective registration of patient-reported LLE (EORTC QLQ-PR25 (Question 46)) were included. Analysis of LLE was done with the calculation of prevalence rates and Kaplan-Meier statistics. Risk factors for LLE were analyzed multivariate with Cox regression analysis.

RESULTS

At a median follow-up of 15 (3-51) months, the overall crude incidence of patients reporting 'quite a bit' or 'a lot' of LLE was 49 (16.2%) and 21 (7.0%), respectively. The baseline prevalence rate of 'quite a bit' and 'a lot' of LLE was 5.0% and 0.8%, respectively. During follow-up the prevalence rate for 'quite a bit' or 'a lot' of LLE increased significantly and remained constant from 6 months where 11.5% (±1.7%) reported 'quite a bit' and 2.9% (±0.5%) reported 'very much' LLE (p < 0.001), respectively.Significant risk factors (p < 0.10) for LLE in univariate analysis included lymph node irradiation (HR:2.325), baseline Body Mass Index (BMI) (HR:1.100), Charlson Comorbidity Index (HR:1.227), Androgen Deprivation Therapy (HR:2,979), and Performance Status (HR:0.594). Only high BMI (HR:1.091) remained significant in multivariate analysis with a three-fold increase in LLE in patients with BMI ≥ 30 compared to normal weight patients.

CONCLUSION

Severe patient-reported LLE after curative RT for PCa is rare. Significantly more patients with a high BMI report 'quite a bit' or 'very much' LLE compared to patients with a normal BMI. Obese PCa patients could be offered a rehabilitation program for early detection and management of LLE.

Pyruvate dehydrogenase kinase regulates vascular inflammation in atherosclerosis and increases cardiovascular risk

AIMS

Recent studies have revealed a close connection between cellular metabolism and the chronic inflammatory process of atherosclerosis. While the link between systemic metabolism and atherosclerosis is well established, the implications of altered metabolism in the artery wall are less understood. Pyruvate dehydrogenase kinase (PDK)-dependent inhibition of pyruvate dehydrogenase (PDH) has been identified as a major metabolic step regulating inflammation. Whether the PDK/PDH axis plays a role in vascular inflammation and atherosclerotic cardiovascular disease remains unclear.

METHODS AND RESULTS

Gene profiling of human atherosclerotic plaques revealed a strong correlation between PDK1 and PDK4 transcript levels and the expression of pro-inflammatory and destabilizing genes. Remarkably, the PDK1 and PDK4 expression correlated with a more vulnerable plaque phenotype, and PDK1 expression was found to predict future major adverse cardiovascular events. Using the small-molecule PDK inhibitor dichloroacetate (DCA) that restores arterial PDH activity, we demonstrated that the PDK/PDH axis is a major immunometabolic pathway, regulating immune cell polarization, plaque development, and fibrous cap formation in Apoe-/- mice. Surprisingly, we discovered that DCA regulates succinate release and mitigates its GPR91-dependent signals promoting NLRP3 inflammasome activation and IL-1β secretion by macrophages in the plaque.

CONCLUSIONS

We have demonstrated for the first time that the PDK/PDH axis is associated with vascular inflammation in humans and particularly that the PDK1 isozyme is associated with more severe disease and could predict secondary cardiovascular events. Moreover, we demonstrate that targeting the PDK/PDH axis with DCA skews the immune system, inhibits vascular inflammation and atherogenesis, and promotes plaque stability features in Apoe-/- mice. These results point toward a promising treatment to combat atherosclerosis.

Possibilities and challenges for landscape observatories

The twentieth century saw rapid environmental degradation due to changes that contributed to increased net GHG emissions, loss of natural ecosystems, and declining biodiversity. Deterioration of unprotected landscapes during swift industrialization, urbanization, increasing monocultures in agriculture, expansion of commercial production significantly contributed to these negative consequences. However, a cultural shift occurred during the last two decades in favour of landscape conservation. In response to widespread landscape degradation and loss of ecosystem services, the Council of Europe saw the need to protect, manage, and develop the landscapes, and thus signed the European Landscape Convention (ELC) in 2000. This was the world's first international agreement that described all aspects of landscape management in detail. The European Landscape Convention fully meets the challenges through its goal of correcting a lack of understanding of landscapes as a unique system embracing natural, economic, and social features throughout Europe. It goes beyond simply protecting landscapes and addresses landscape management and development, as well as raising public and government awareness of the importance of paying attention to all types of landscapes, whether exceptional or spoiled. Landscape observatories, multifunctional platforms and knowledge centres for researchers, technicians, administrators, and citizens, are one of the Council of Europe's instruments for implementing the European Landscape Convention (ELC). They can be established on a variety of scales and can serve as a vital link between administrations, civil society, researchers, and the economic sector. This article discusses the emergence of landscape observatories and the role they can play as decision support instruments in promoting sustainable landscape development through a regenerative approach. Additionally, the paper discusses the implementation of ELC in Västra Götaland in Sweden through the establishment of Landscape Observatory Västra Götaland, and its impacts and challenges associated with landscape development. Furthermore, we propose a comprehensive and holistic, to any landscape type adaptable landscape observatory concept, based on multifunctionality of these institutions, emphasizing their decision support roles, social and economic importance.

Partial Breast Irradiation Versus Whole Breast Irradiation for Early Breast Cancer Patients in a Randomized Phase III Trial: The Danish Breast Cancer Group Partial Breast Irradiation Trial

PURPOSE

On the basis of low risk of local recurrence in elderly patients with breast cancer after conservative surgery followed by whole breast irradiation (WBI), the Danish Breast Cancer Group initiated the noninferiority external-beam partial breast irradiation (PBI) trial (ClinicalTrials.gov identifier: NCT00892814). We hypothesized that PBI was noninferior to WBI regarding breast induration.

METHODS

Patients operated with breast conservation for relatively low-risk breast cancer were randomly assigned to WBI versus PBI, and all had 40 Gy/15 fractions. The primary end point was 3-year grade 2-3 breast induration.

RESULTS

In total, 865 evaluable patients (434 WBI and 431 PBI) were enrolled between 2009 and 2016. Median follow-up was 5.0 years (morbidity) and 7.6 years (locoregional recurrence). The 3-year rate of induration was 9.7% for WBI and 5.1% for PBI (P = .014). Large breast size was significantly associated with induration with a 3-year incidence of 13% (WBI) and 6% (PBI) for large-breasted patients versus 6% (WBI) and 5% (PBI) for small-breasted patients. PBI showed no increased risk of dyspigmentation, telangiectasia, edema, or pain, and patient satisfaction was high. Letrozole and smoking did not increase the risk of radiation-associated morbidity. Sixteen patients had a locoregional recurrence (six WBI and 10 PBI; P = .28), 20 patients had a contralateral breast cancer, and eight patients had distant failure (five WBI and three PBI). A nonbreast second cancer was detected in 73 patients (8.4%), and there was no difference between groups.

CONCLUSION

External-beam PBI for patients with low-risk breast cancer was noninferior to WBI in terms of breast induration. Large breast size was a risk factor for radiation-associated induration. Few recurrences were detected and unrelated to PBI.

Internal Mammary Node Irradiation in Patients With Node-Positive Early Breast Cancer: Fifteen-Year Results From the Danish Breast Cancer Group Internal Mammary Node Study

PURPOSE

The Danish Breast Cancer Group Internal Mammary Node study demonstrated improved 8-year overall survival (OS) with internal mammary node irradiation (IMNI) in patients with node-positive early breast cancer. Here, we present long-term results from the Danish Breast Cancer Group Internal Mammary Node study cohort.

PATIENTS AND METHODS

This nationwide, prospective cohort study allocated patients with node-positive early breast cancer to adjuvant radiotherapy with or without IMNI depending on cancer laterality. Patients with right-sided cancer received IMNI. Patients with left-sided cancer were treated without IMNI because of risk of radiation-induced heart disease. Other treatment was independent of laterality. The primary study end point was OS. Secondary end points were distant recurrence and breast cancer mortality. Analyses were by intention to treat.

RESULTS

During 2003-2007, 3,089 women were allocated to IMNI (right-sided, n = 1,491) or no IMNI (left-sided, n = 1,598). With a median follow-up of 14.8 years, 589 patients with and 701 patients without IMNI had died. The corresponding 15-year OS rates were 60.1% and 55.4%. The adjusted hazard ratio (HR) for death was 0.86 (95% CI, 0.77 to 0.96; P = .007) in favor of IMNI. The 15-year risk of developing distant recurrence was 35.6% (523 recurrences) and 38.6% (602 recurrences) with vs. without IMNI (adjusted HR, 0.88 [95% CI, 0.79 to 0.99; P = .04]). The 15-year breast cancer mortality with IMNI was 31.7% (467 deaths) compared with 33.9% (537 deaths) without IMNI (adjusted HR, 0.88 [95% CI, 0.78 to 1.00; P = .05]). The distribution of other deaths was similar across groups.

CONCLUSION

In patients with node-positive early breast cancer treated with IMNI or without IMNI depending on breast cancer laterality, IMNI reduced the risk of distant recurrence and death from breast cancer, thereby improving long-term survival.

A combined experimental and computational framework to evaluate the behavior of therapeutic cells for peripheral nerve regeneration

Recent studies have explored the potential of tissue‐mimetic scaffolds in encouraging nerve regeneration. One of the major determinants of the regenerative success of cellular nerve repair constructs (NRCs) is the local microenvironment, particularly native low oxygen conditions which can affect implanted cell survival and functional performance. In vivo, cells reside in a range of environmental conditions due to the spatial gradients of nutrient concentrations that are established. Here we evaluate in vitro the differences in cellular behavior that such conditions induce, including key biological features such as oxygen metabolism, glucose consumption, cell death, and vascular endothelial growth factor secretion. Experimental measurements are used to devise and parameterize a mathematical model that describes the behavior of the cells. The proposed model effectively describes the interactions between cells and their microenvironment and could in the future be extended, allowing researchers to compare the behavior of different therapeutic cells. Such a combinatorial approach could be used to accelerate the clinical translation of NRCs by identifying which critical design features should be optimized when fabricating engineered nerve repair conduits.

Emergence of Avian coronavirus Escape Mutants Under Suboptimal Antibody Titers

To perform a quasispecies assessment of the effect of vaccine combinations and antibody titers on the emergence of Avian coronavirus (AvCoV) escape mutants, 5-week-old males from a commercial chicken breeder lineage were vaccinated intramuscularly with one dose of a monovalent (genotype GI-1) or a bivalent (genotypes GI-1 and GI-11 (n = 40 birds/group) AvCoV vaccine. Seven birds were kept as controls. Six weeks later, pools of sera of each group were prepared and incubated at virus neutralization doses of 10 and 10^–1 with the Beaudette strain (GI-1) of AvCoV in VERO cells. Rescued viruses were then submitted to genome-wide deep sequencing for subconsensus variant detection. After treatment with serum from birds vaccinated with the bivalent vaccine at a titer of 10^–1, an F307I variant was detected in the spike glycoprotein that mapped to an important neutralizing region, which indicated an escape mutant derived from natural selection. Further variants were detected in nonstructural proteins and non-coding regions that are not targets of neutralizing antibodies and might be indicators of genetic drift. These results indicate that the evolution of AvCoV escape mutants after vaccination depends on the type of vaccine strain and the antibody titer and must be assessed based on quasispecies rather than consensus dominant sequences only because quasispecies may be otherwise undetected.

3-Hydroxyanthralinic acid metabolism controls the hepatic SREBP/lipoprotein axis, inhibits inflammasome activation in macrophages, and decreases atherosclerosis in Ldlr-/- mice

Aims

Atherosclerosis is a chronic inflammatory disease involving immunological and metabolic processes. Metabolism of tryptophan (Trp) via the kynurenine pathway has shown immunomodulatory properties and the ability to modulate atherosclerosis. We identified 3-hydroxyanthranilic acid (3-HAA) as a key metabolite of Trp modulating vascular inflammation and lipid metabolism. The molecular mechanisms driven by 3-HAA in atherosclerosis have not been completely elucidated. In this study, we investigated whether two major signalling pathways, activation of SREBPs and inflammasome, are associated with the 3-HAA-dependent regulation of lipoprotein synthesis and inflammation in the atherogenesis process. Moreover, we examined whether inhibition of endogenous 3-HAA degradation affects hyperlipidaemia and plaque formation.

Methods and results

In vitro, we showed that 3-HAA reduces SREBP-2 expression and nuclear translocation and apolipoprotein B secretion in HepG2 cell cultures, and inhibits inflammasome activation and IL-1β production by macrophages. Using Ldlr^−/− mice, we showed that inhibition of 3-HAA 3,4-dioxygenase (HAAO), which increases the endogenous levels of 3-HAA, decreases plasma lipids and atherosclerosis. Notably, HAAO inhibition led to decreased hepatic SREBP-2 mRNA levels and lipid accumulation, and improved liver pathology scores.

Conclusions

We show that the activity of SREBP-2 and the inflammasome can be regulated by 3-HAA metabolism. Moreover, our study highlights that targeting HAAO is a promising strategy to prevent and treat hypercholesterolaemia and atherosclerosis.

Disruption of GPR35 Signaling in Bone Marrow-Derived Cells Does Not Influence Vascular Inflammation and Atherosclerosis in Hyperlipidemic Mice

G-protein-coupled receptor-35 (GPR35) has been identified as a receptor for the tryptophan metabolite kynurenic acid (KynA) and suggested to modulate macrophage polarization in metabolic tissues. Whether GPR35 can influence vascular inflammation and atherosclerosis has however never been tested. Lethally irradiated LdlrKO mice were randomized to receive GPR35KO or wild type (WT) bone marrow transplants and fed a high cholesterol diet for eight weeks to develop atherosclerosis. GPR35KO and WT chimeric mice presented no difference in the size of atherosclerotic lesions in the aortic arch (2.37 ± 0.58% vs. 1.95 ± 0.46%, respectively) or in the aortic roots (14.77 ± 3.33% vs. 11.57 ± 2.49%, respectively). In line with these data, no changes in the percentage of VCAM-1+, IA^b + cells, and CD3+ T cells, as well as alpha smooth muscle cell actin expression, was observed between groups. Interestingly, the GPR35KO group presented a small but significant increase in CD68+ macrophage infiltration in the plaque. However, in vitro culture experiments using bone marrow-derived macrophages from both groups indicated that GPR35 plays no role in modulating the secretion of major inflammatory cytokines. Our study indicates that GPR35 expression does not play a direct role in macrophage activation, vascular inflammation, and the development of atherosclerosis.

Dose constraints for whole breast radiation therapy based on the quality assessment of treatment plans in the randomised Danish breast cancer group (DBCG) HYPO trial

Purpose

Quality assessment of the treatment plans in the Danish Breast Cancer Group (DBCG) HYPO trial was carried out based on prospectively reported dosimetric parameters and evidence-based dose constraints for whole breast radiation therapy were derived.

Materials and methods

From 2009 to 2014, 1882 patients (pts) were randomised between 50 Gy/25fractions (fr) versus 40 Gy/15fr. Doses to CTVp_breast (V_95%, V_107%-V_110%, D_max, and in addition for 40 Gy plans V_105%-V_107%), ipsilateral lung (V_20Gy/V_17Gy), heart (V_20Gy/V_17Gy, V_40Gy/V_35Gy), and left anterior descending coronary artery (LADCA) (D_max) and use of respiratory gated technique were prospectively reported to the DBCG database. After end of accrual, these dosimetric parameters from all plans in the trial were compared to the pre-specified treatment constraints.

Results

In total, 1854 pts from eight radiation therapy (RT) centres in three countries were treated. No statistically significant differences were found between the results for 40 Gy and 50 Gy plans, except for CTVp_breast hot-spot volume (V_107%-V_110%). Of the 40 Gy pts, 90% with CTVp_breast > 600 mL and 95% with CTVp_breast ≤ 600 mL had a CTVp_breast hot-spot volume (V_105%-V_107%) <2%. In 95% of the 50 Gy plans, the CTVp_breast absolute hot-spot volume (V_107%-V_110%) was <0.5 mL and 1.7 mL for CTVp_breast ≤ 600 mL and > 600 mL, respectively. Compliance was >99% for both heart and lung constraints. Largest deviation from protocol constraints was found for the volume of CTVp_breast covered with 95% of the prescription dose or more (V_95%). The CTV dose coverage (V_95%) was >94.3% in 95% of the right-sided pts, whereas the figures for 95% of the left-sided pts treated with and without respiratory gating were 93.2% and 88.8%, respectively.

Conclusion

A high degree of compliance with protocol dose constraints was found for treatment plans in the DBCG HYPO trial. New constraints for dose to organs at risk and high-dose volumes in the breast are suggested for breast-only RT planning.

Evidence that a deviation in the kynurenine pathway aggravates atherosclerotic disease in humans

BACKGROUND

The metabolism of tryptophan (Trp) along the kynurenine pathway has been shown to carry strong immunoregulatory properties. Several experimental studies indicate that this pathway is a major regulator of vascular inflammation and influences atherogenesis. Knowledge of the role of this pathway in human atherosclerosis remains incomplete.

OBJECTIVES

In this study, we performed a multiplatform analysis of tissue samples, in vitro and in vivo functional assays to elucidate the potential role of the kynurenine pathway in human atherosclerosis.

METHODS AND RESULTS

Comparison of transcriptomic data from carotid plaques and control arteries revealed an upregulation of enzymes within the quinolinic branch of the kynurenine pathway in the disease state, whilst the branch leading to the formation of kynurenic acid (KynA) was downregulated. Further analyses indicated that local inflammatory responses are closely tied to the deviation of the kynurenine pathway in the vascular wall. Analysis of cerebrovascular symptomatic and asymptomatic carotid stenosis data showed that the downregulation of KynA branch enzymes and reduced KynA production were associated with an increased probability of patients to undergo surgery due to an unstable disease. In vitro, we showed that KynA-mediated signalling through aryl hydrocarbon receptor (AhR) is a major regulator of human macrophage activation. Using a mouse model of peritoneal inflammation, we showed that KynA inhibits leukocyte recruitment.

CONCLUSIONS

We have found that a deviation in the kynurenine pathway is associated with an increased probability of developing symptomatic unstable atherosclerotic disease. Our study suggests that KynA-mediated signalling through AhR is an important mechanism involved in the regulation of vascular inflammation.

Role of in Situ Natural Organic Matter in Mobilizing As during Microbial Reduction of FeIII-Mineral-Bearing Aquifer Sediments from Hanoi (Vietnam)

Natural organic matter (NOM) can contribute to arsenic (As) mobilization as an electron donor for microbially-mediated reductive dissolution of As-bearing Fe(III) (oxyhydr)oxides. However, to investigate this process, instead of using NOM, most laboratory studies used simple fatty acids or sugars, often at relatively high concentrations. To investigate the role of relevant C sources, we therefore extracted in situ NOM from the upper aquitard (clayey silt) and lower sandy aquifer sediments in Van Phuc (Hanoi area, Vietnam), characterized its composition, and used 100-day microcosm experiments to determine the effect of in situ OM on Fe(III) mineral reduction, As mobilization, and microbial community composition. We found that OM extracted from the clayey silt (OMC) aquitard resembles young, not fully degraded plant-related material, while OM from the sandy sediments (OMS) is more bioavailable and related to microbial biomass. Although all microcosms were amended with the same amount of C (12 mg C/L), the extent of Fe(III) reduction after 100 days was the highest with acetate/lactate (43 ± 3.5% of total Fe present in the sediments) followed by OMS (28 ± 0.3%) and OMC (19 ± 0.8%). Initial Fe(III) reduction rates were also higher with acetate/lactate (0.53 mg Fe(II) in 6 days) than with OMS and OMC (0.18 and 0.08 mg Fe(II) in 6 days, respectively). Although initially more dissolved As was detected in the acetate/lactate setups, after 100 days, higher concentrations of As (8.3 ± 0.3 and 8.8 ± 0.8 μg As/L) were reached in OMC and OMS, respectively, compared to acetate/lactate-amended setups (6.3 ± 0.7 μg As/L). 16S rRNA amplicon sequence analyses revealed that acetate/lactate mainly enriched Geobacter, while in situ OM supported growth and activity of a more diverse microbial community. Our results suggest that although the in situ NOM is less efficient in stimulating microbial Fe(III) reduction than highly bioavailable acetate/lactate, it ultimately has the potential to mobilize the same amount or even more As.

Year-round distribution, activity patterns and habitat use of a poorly studied pelagic seabird, the fluttering shearwater Puffinus gavia

We present the first study to examine the year-round distribution, activity patterns, and habitat use of one of New Zealand’s most common seabirds, the fluttering shearwater (Puffinus gavia). Seven adults from Burgess Island, in the Hauraki Gulf, and one individual from Long Island, in the Marlborough Sounds, were successfully tracked with combined light-saltwater immersion loggers for one to three years. Our tracking data confirms that fluttering shearwaters employ different overwintering dispersal strategies, where three out of eight individuals, for at least one of the three years when they were being tracked, crossed the Tasman Sea to forage over coastal waters along eastern Tasmania and southeastern Australia. Resident birds stayed confined to waters of northern and central New Zealand year-round. Although birds frequently foraged over pelagic shelf waters, the majority of tracking locations were found over shallow waters close to the coast. All birds foraged predominantly in daylight and frequently visited the colony at night throughout the year. We found no significant inter-seasonal differences in the activity patterns, or between migratory and resident individuals. Although further studies of inter-colony variation in different age groups will be necessary, this study presents novel insights into year-round distribution, activity patterns and habitat use of the fluttering shearwater, which provide valuable baseline information for conservation as well as for further ecological studies.

Offensive waste valorisation in the UK: Assessment of the potentials for absorbent hygiene product (AHP) recycling

Offensive human waste refers to non-hazardous waste that contains body fluids from non-infectious humans, comprised of post-consumer Absorbent Hygiene Products (AHPs), swabs, dressings, bedding, gloves, and other materials. While this waste category requires more stringent handling, storage and disposal measures than general waste, its non-hazardous nature suggests that there are opportunities for waste valorisation. An inventory of 200 offensive human waste bags collected from various healthcare institutions in South-Eastern England show that about 76% of the waste is comprised of AHPs, most of which are adult incontinence pads and child nappies. Mixed plastics comprised of predominantly HDPE represent 9% of the waste. To evaluate the potentials for offensive human waste valorisation, small-scale separation tests involving artificially-soiled nappies and associated mixed plastic packaging wastes have been performed. Findings suggest that about 50% of the total superabsorbent polymer is recoverable from fluff pulp fractions, recoveries of which are unaffected by the presence of ionic species typically present in human waste. On the other hand, recovery of mixed plastic packaging is more challenging. Overall, however, findings suggest that viable AHP recycling is possible if recyclate materials are targeted towards non-food related markets outlets such as the construction and land remediation sectors.

The Mobile Surgical Outreach Model for women with genital fistula in the Democratic Republic of Congo

Aims: To describe the PH Mobile Surgical Outreach (MSO) model of care delivery for women with GF and to present data highlighting the program’s scope and clinical impact in 2011-2017. Methods: PH created the MSO program to deliver health services to women with genital fistula (GF) living in remote areas in DRC. The MSO model facilitates reintegration through community education about GF, leveraging local staff in all aspects of care. Outreach trips are organized annually/bi-annually per site, depending on case volume and funding. Site selection is a two-step process: (1) identification of accessible, strategically located hospitals; (2) initial site visit and readiness assessment. This paper presents 2011-2017 MSO activities, including geographic scope, patient and provider outcomes. Results: The MSO team has worked with 43 clinic sites across 12 provinces. Since 2011, they have conducted 77 site visits and provided surgical care for 2,017 women. Table1 summarizes surgeries conducted annually by province, 2011-2017.Table 2 provides a clinical snapshot of 2017 case mix. Conclusions: The MSO model demonstrates feasibility and indicates program successes for capacity-building in skilled medico-surgical care and enhancing community awareness of GF. Training serves to improve local provider skills, strengthens health workforce and offers scalable, sustainable solutions to prevention and treatment.

Breast cancer patients report reduced sensitivity and pain using a barrier film during radiotherapy - A Danish intra-patient randomized multicentre study

BACKGROUND AND PURPOSE

Radiodermatitis is a well-known toxicity of radiotherapy and barrier film has been shown to reduce the severity of radiodermatitis. We have validated prior findings in a Danish cohort, using a similar barrier film and patient reported outcomes.

MATERIALS AND METHODS

101 Danish breast cancer patients were included at three radiotherapy centres. Based on randomization either the lateral or medial part of their chest was covered by Mepitel film; making the patients their own control. The primary endpoint was patient reported symptoms and experience. A secondary endpoint was radiotherapy staff evaluation of dermatitis.

RESULTS

Within the skin area covered by film, the patients reported a statistical significant lower level of pain (p < .001), itching (p = 0.005), burning sensation (p = 0.005) as well as edema (p = 0.017) and reduced sensitivity (p < .001). Most patients (76%) would have preferred film on the entire treatment area (p < 0.001) and Mepitel Film as a standard treatment option (84%) (p < 0.001). Patients treated after mastectomy had a significantly lower severity of radiation-induced dermatitis with film at the end of RT compared to standard care (p = 0.005). However, in the blinded staff evaluation, no significant differences were found at follow-up.

CONCLUSIONS

Patients reported reduced symptoms from the skin with Mepitel Film and the majority would have preferred film as a standard offer to cover their entire treatment area. Especially women treated after mastectomy had a significantly lower level of radiodermatitis and preferred the film over standard care.

Neurofilament light interaction with GluN1 modulates neurotransmission and schizophrenia-associated behaviors

Neurofilament (NFL) proteins have recently been found to play unique roles in synapses. NFL is known to interact with the GluN1 subunit of N-methyl-D-aspartic acid (NMDAR) and be reduced in schizophrenia though functional consequences are unknown. Here we investigated whether the interaction of NFL with GluN1 modulates synaptic transmission and schizophrenia-associated behaviors. The interaction of NFL with GluN1 was assessed by means of molecular, pharmacological, electrophysiological, magnetic resonance spectroscopy (MRS), and schizophrenia-associated behavior analyses. NFL deficits cause an NMDAR hypofunction phenotype including abnormal hippocampal function, as seen in schizophrenia. NFL-/- deletion in mice reduces dendritic spines and GluN1 protein levels, elevates ubiquitin-dependent turnover of GluN1 and hippocampal glutamate measured by MRS, and depresses hippocampal long-term potentiation. NMDAR-related behaviors are also impaired, including pup retrieval, spatial and social memory, prepulse inhibition, night-time activity, and response to NMDAR antagonist, whereas motor deficits are minimal. Importantly, partially lowering NFL in NFL+/- mice to levels seen regionally in schizophrenia, induced similar but milder NMDAR-related synaptic and behavioral deficits. Our findings support an emerging view that central nervous system neurofilament subunits including NFL in the present report, serve distinctive, critical roles in synapses relevant to neuropsychiatric diseases.

Novel Multiomics Profiling of Human Carotid Atherosclerotic Plaques and Plasma Reveals Biliverdin Reductase B as a Marker of Intraplaque Hemorrhage

Clinical tools to identify individuals with unstable atherosclerotic lesions are required to improve prevention of myocardial infarction and ischemic stroke. Here, a systems-based analysis of atherosclerotic plaques and plasma from patients undergoing carotid endarterectomy for stroke prevention was used to identify molecular signatures with a causal relationship to disease. Local plasma collected in the lesion proximity following clamping prior to arteriotomy was profiled together with matched peripheral plasma. This translational workflow identified biliverdin reductase B as a novel marker of intraplaque hemorrhage and unstable carotid atherosclerosis, which should be investigated as a potential predictive biomarker for cardiovascular events in larger cohorts.

Applying the phenotype approach for rosacea to practice and research

BACKGROUND

Rosacea diagnosis and classification have evolved since the 2002 National Rosacea Society expert panel subtype approach. Several working groups are now aligned to a more patient-centric phenotype approach, based on an individual's presenting signs and symptoms. However, subtyping is still commonplace across the field and an integrated strategy is required to ensure widespread progression to the phenotype approach.

OBJECTIVES

To provide practical recommendations that facilitate adoption of a phenotype approach across the rosacea field.

METHODS

A review of the literature and consolidation of rosacea expert experience.

RESULTS

We identify challenges to implementing a phenotype approach in rosacea and offer practical recommendations to overcome them across clinical practice, interventional research, epidemiological research and basic science.

CONCLUSIONS

These practical recommendations are intended to indicate the next steps in the progression from subtyping to a phenotype approach in rosacea, with the goals of improving our understanding of the disease, facilitating treatment developments and ultimately improving care for patients with rosacea.

Disruption of microbial community composition and identification of plant growth promoting microorganisms after exposure of soil to rapeseed-derived glucosinolates

Land plants are engaged in intricate communities with soil bacteria and fungi indispensable for plant survival and growth. The plant-microbial interactions are largely governed by specific metabolites. We employed a combination of lipid-fingerprinting, enzyme activity assays, high-throughput DNA sequencing and isolation of cultivable microorganisms to uncover the dynamics of the bacterial and fungal community structures in the soil after exposure to isothiocyanates (ITC) obtained from rapeseed glucosinolates. Rapeseed-derived ITCs, including the cyclic, stable goitrin, are secondary metabolites with strong allelopathic affects against other plants, fungi and nematodes, and in addition can represent a health risk for human and animals. However, the effects of ITC application on the different bacterial and fungal organisms in soil are not known in detail. ITCs diminished the diversity of bacteria and fungi. After exposure, only few bacterial taxa of the Gammaproteobacteria, Bacteriodetes and Acidobacteria proliferated while Trichosporon (Zygomycota) dominated the fungal soil community. Many surviving microorganisms in ITC-treated soil where previously shown to harbor plant growth promoting properties. Cultivable fungi and bacteria were isolated from treated soils. A large number of cultivable microbial strains was capable of mobilizing soluble phosphate from insoluble calcium phosphate, and their application to Arabidopsis plants resulted in increased biomass production, thus revealing growth promoting activities. Therefore, inclusion of rapeseed-derived glucosinolates during biofumigation causes losses of microbiota, but also results in enrichment with ITC-tolerant plant microorganisms, a number of which show growth promoting activities, suggesting that Brassicaceae plants can shape soil microbiota community structure favoring bacteria and fungi beneficial for Brassica plants.

Variability in the time to initiation of CPR in continuously monitored pediatric ICUs

AIM

To study the influence of patient characteristics and unit ergonomics and human factors on the time to initiation of CPR.

METHODS

A single center study of children, 0 to 21 years old, admitted to an ICU who experienced cardiopulmonary arrest (CPA) requiring >1 min of chest compressions. Time of CPA was determined by analysis of continuous ECG, plethysmography, arterial blood pressure, and end-tidal CO₂ (EtCO₂) waveforms. Initiation of CPR was identified by the onset of cyclic artifact in the ECG waveform. Patient characteristics and unit ergonomics and human factors were examined including CPA cause, identification on the High-Risk Checklist (HRC), existing monitoring, ICU type, time of day, nursing shift change, and outcome.

RESULTS

The median time from CPA to initiation of CPR was 50.5 s (IQR 26.5 to 127.5) in 36 CPAs. Forty-seven percent of patients experienced time from CPA to initiation of CPR of >1 min. There was no difference in CPA cause, ICU type, time of day, or nursing shift change.

CONCLUSION

Nearly half of pediatric patients who experienced CPA in an ICU setting did not meet AHA guidelines for early initiation of CPR. This is an opportunity to study the recognition phase of CPA using continuous monitoring data with the aim of improving the understanding of and factors contributing to delays in initiation of CPR.

Medical Work and the ComputerBased Patient Record: A Sociological Perspective

The computer-based patient record (CPR) is a tool likely to have great impact on the practice of medicine in the years to come. Yet, clinical settings with a fully integrated CPR are hard to find. This paper takes a sociological look at the attempts to construe and introduce CPRs. It is argued that part of the current trouble in getting these tools to work lies in the model of medical work that is inscribed in many (attempted) CPRs. A more sociological perspective on medical work should be able to offer points of departure for the construction of systems wh ich might fit the needs of health care workers better. Based on participatory observation, the paper outlines what it is medical work comes down to from a sociological perspective, and how the medical record figures in this work. Finally, some consequences this depiction has for current discussions on and (proposed) implementations of CPRs are described.

The Search for Synergy: Interrelating Medical Work and Patient Care Information Systems

Objectives: This article aims to search for the way patient care information systems can be most fruitfully put to work in health care.

Methods: Given the calls for improved health care quality, there is a need for IT’s coordination capacities in health care. Yet IT’s track record in this area is less than many expected. Moreover, many argue that the nature of health care work sets natural limits to the possibilities of IT to revolutionize this work. Starting with an analysis of the paper record, this article explores the way IT and professional work can be interrelated synergistically.

Results: Two principles are discussed: 1) The key to a fruitful operation of IT in health care work lies in the unraveling of the care process, and the redistribution of tasks between professionals and the IT application. 2) Professionals should be given the skills and resources to adapt the IT application’s demands to the needs of their work practices.

Conclusion: IT can bring true process support to health care when taking the two principles discussed here into account.

ICT in Health Care: Sociotechnical Approaches

The importance of the social sciences for medical informatics is increasingly recognized. As ICT requires interaction with people and thereby inevitably affects them, understanding ICT requires a focus on the interrelation between technology and its social environment. Socio-technical approaches increase our understanding of how ICT applications are developed, introduced and become a part of social practices. Sociotechnical approaches share several starting points: 1) they see health care work as a social, ‘real life’ phenomenon, which may seem ‘messy’ at first, but which is guided by a practical rationality that can only be overlooked at a high price (i.e. failed systems). 2) They see technological innovation as a social process, in which organizations are deeply affected. 3) Through in-depth, formative evaluation, they can help improve system design and implementation.

Integrating Quantitative and Qualitative Methods in Patient Care Information System Evaluation

Objective: The aim of this paper is twofold. First, we describe two important dimensions of patient care information systems (PCIS) evaluation: the domain of evaluation and the different phases of the PCIS implementation. Second, we claim that, though Randomized Controlled Trials (RCTs) are often still seen as the standard approach, this type of design hardly generates relevant information for the organizational decision maker.

Method: Interpretive study of evaluation literature. Results and Conclusions: The field of evaluation is scattered and the types of questions that can be asked and methods that can be used seem infinite and badly demarcated. Different stakeholders, moreover, often have different priorities in evaluating ICT. The most important reason for the lack of relevance of RCTs is that they are ill suited for investigating why and how a PCIS is being used, or not, and what the (often unplanned) effects and consequences are. Subsequently, our aim is to contribute to the discussion about the viability of qualitative versus quantitative methods in PCIS evaluation, by arguing for a specific integration of quantitative and qualitative research methods. The joint utilization of these methods, we claim, yields the richest results.

Same Systems, Different Outcomes

Objectives: To compare the outcome of the implementation of computerized physician order entry (CPOE) systems in two Dutch hospitals.

Methods: Qualitative research methods, including interviews in both hospitals, observations of system in use, observations of staff meetings and document analysis were used to understand the implementation of CPOE. The transcribed texts and implementation documents were analyzed for relevant concepts.

The transcripts and field notes were analyzed using a heuristic success and failure model with medical work as the primary focus.

Results: Occasions that determined the outcome of the implementation were classified according to factors that may influence the success or failure of implementing systems.

Conclusions: The themes and patterns that emerged from the data helped validate the concept of medical work as the primary focus of our analysis model; in addition the concept of a support base necessary to accept changes in medical work that result from introducing CPOE may help to understand the different implementation outcomes.

Person-centred, web-based support in pregnancy and early motherhood for women with Type 1 diabetes mellitus: a randomized controlled trial

AIMS

To report results from and explore use of a multicentre, parallel-group, unblinded, randomized controlled trial testing the effectiveness in terms of well-being and diabetes management of a person-centred, web-based support programme for women with Type 1 diabetes, in pregnancy and postpartum.

METHODS

Between 2011 and 2014, 174 pregnant women with Type 1 diabetes were randomly allocated (1:1) to web-based support and standard care (intervention group, n=83), or standard care (control group, n=91). The web-based support consisted of evidence-based information; a self-care diary for monitoring of daily activities; and peer support in a discussion forum. The primary outcomes (mean difference, measured at 6 months after childbirth) were well-being and diabetes management.

RESULTS

No differences were found with regard to the primary outcome measure scores for general well-being [1.04 (95% CI -1.28 to 3.37); P=0.68] and self-efficacy of diabetes management [0.08 (95% CI -0.12 to 0.28); P= 0.75], after adjustment for baseline differences in the insulin administration method, nor with regard to the secondary outcome measures.

CONCLUSIONS

At 6 months after childbirth, the web-based support plus standard care was not superior to standard care in terms of general well-being or self-efficacy of diabetes management. This might be explained by the low number of participants who had a high activity level. Few simultaneously active participants in the web-based programme and stressors in motherhood and diabetes postpartum were the main barriers to its use. Further intervention studies that offer web-based support are needed, with lessons learned from the present study. (Clinicaltrials.gov identification number: NCT015665824).

Intra-organizational Communication in Healthcare

Objectives: Intra-organizational communication is mostly interpersonal. Synchronous interruptive communication is recognized as aprimary source of inefficiency anderror in healthcare, and there is much potential for information and communication technology (ICT) to improve such communication. As recently suggested, however, due to communication failures ICT can also compound medical errors. In this paper we analyze factors that restrict the role of ICT in improving interpersonal healthcare communication and suggest solutions. Methods: We critically analyzed the literature from a selection of diverse scientific disciplines. These were related to interpersonal communication, tothe role and place of standardization and computerization in its improvement, and to reducing medical errors.

Results: Four possible scenarios were defined on how ICT can serve healthcare communication. Two differing conceptual frameworks about communication in health-care were discussed. Considering “information space” as apart of “communication space ” allows the recognition and control of the source of the semantic gaps in conventional standardization and an enhancement of the role of ICT in improving intra-organizational communication. Moreover, cognitive, social, and organizational dimensions of complexity in interpersonal communication can be managed. Three approaches to control the variability in those dimensions and to promote therole of ICT in intra-organizational communication were discussed.

Conclusion: A multi-dimensional approach is required to promote the role of ICT in intra-organizational communication in healthcare. Parallel to conventional standardization, atleast three dimensions need to be addressed: controlling the effect of the social context, developing standard information processing skills, and most importantly, controlling variations in care practices’ performance.

DBCG hypo trial validation of radiotherapy parameters from a national data bank versus manual reporting

INTRODUCTION

The current study evaluates the data quality achievable using a national data bank for reporting radiotherapy parameters relative to the classical manual reporting method of selected parameters.

METHODS

The data comparison is based on 1522 Danish patients of the DBCG hypo trial with data stored in the Danish national radiotherapy data bank. In line with standard DBCG trial practice selected parameters were also reported manually to the DBCG database. Categorical variables are compared using contingency tables, and comparison of continuous parameters is presented in scatter plots.

RESULTS

For categorical variables 25 differences between the data bank and manual values were located. Of these 23 were related to mistakes in the manual reported value whilst the remaining two were a wrong classification in the data bank. The wrong classification in the data bank was related to lack of dose information, since the two patients had been treated with an electron boost based on a manual calculation, thus data was not exported to the data bank, and this was not detected prior to comparison with the manual data. For a few database fields in the manual data an ambiguity of the parameter definition of the specific field is seen in the data. This was not the case for the data bank, which extract all data consistently.

CONCLUSIONS

In terms of data quality the data bank is superior to manually reported values. However, there is a need to allocate resources for checking the validity of the available data as well as ensuring that all relevant data is present. The data bank contains more detailed information, and thus facilitates research related to the actual dose distribution in the patients.