A retrospective review of the short Synacthen test in Queensland hospitals

BACKGROUND

The short Synacthen test (SST) is widely used to investigate adrenal insufficiency, but it can be time-consuming, costly and labour-intensive to perform and is not without risk of adverse events.

AIM

To review SST requesting patterns and practices across public hospitals in Queensland.

METHODS

The electronic medical records of patients who underwent a SST with Pathology Queensland between January 2020 and December 2020 were reviewed to collect data regarding the indication for the test, the requesting speciality, SST results and any adverse events.

RESULTS

Six hundred and fifty-two SSTs were identified, of which 363 individual patients were included in the analysis. The majority of the tests (n = 198, 54.5%) were performed in the inpatient setting. Endocrinology most commonly ordered SSTs (n = 188, 51.8%). The suspected aetiology of adrenal insufficiency was unclear in a large proportion of requests (n = 167, 46.0%). Static testing of morning cortisol prior to SST was performed in only 249 (68.6%) patients. Of 140 inpatients data, 17.9% (n = 25) showed a robust static cortisol of ≥400 nmol/L and were treated as having normal adrenal function, suggesting SST was unnecessary in these patients. Twenty-two (6.1%) patients had a documented adverse event occurring during or after the SST.

CONCLUSIONS

There was wide variability in requesting patterns and practices for SSTs across Queensland. More than one in six SSTs could have been avoided if a static morning cortisol had been performed prior. Clinician education and the adoption of a structured referral form may improve testing practices.

Queensland Inpatient Diabetes Survey (QuIDS): patient experience survey evaluation

BACKGROUND

Measurement of inpatient experience can allow for treatment tailored to patient preferences and needs. The patient experience of diabetes care has not been explored in Queensland hospitals.

AIMS

To investigate the experiences of patients with diabetes when hospitalised using the Queensland Inpatient Diabetes Survey (QuIDS).

METHODS

In 2019 and 2021, patient experience surveys were collected as part of the statewide QuIDS, a cross-sectional study assessing the quality of inpatient care received by people with diabetes in Queensland, Australia. Patient responses were categorised and frequencies reported as percentages. Free text comments were analysed using thematic analysis methods. Pooled descriptive data were presented.

RESULTS

Responses were collected from 27 hospitals in 2019 (n = 526, 52.4% of all patients with diabetes) and 35 hospitals in 2021 (n = 709, 55.5%). Overall, patients were satisfied with their inpatient diabetes care. Areas for improvement identified by surveyed patients include the choice and timing of meals, staff knowledge about diabetes and increased diabetes self-management. Access to a specialist diabetes team was also identified as being potentially underutilised. Patient comments fell into four major themes: communication, food choices, patient autonomy and education.

CONCLUSION

Many patients reported positive inpatient experiences; however, patients also expressed dissatisfaction with their inpatient diabetes care. Our data provide unique insight and an opportunity to improve standards of care and service provision for inpatients with diabetes.

Educational pathways of childhood cancer survivors-a parental cohort

PURPOSE

Using the International Standard Classification of Education (ISCED), we examined the educational and vocational pathways of two comparable, parental cohorts: childhood cancer survivors (CCS) and their siblings. Both cohorts had previously entered parenthood. The aim of the study was to elucidate whether childhood cancer and treatment affect the educational pathways chosen by parents who are former patients.

METHODS

We analysed data that was collected from childhood cancer survivors and their siblings regarding their offspring's health within the FeCt Multicentre Offspring Study (conducted 2013-2016). We evaluated and compared the professional pathways of (i) all participating survivors and all participating siblings and those of (ii) survivors and their biological siblings.

RESULTS

Overall information on parental gender, age, and education were available from 1077 survivors and 246 siblings (group (i)). The majority of participants were female with a mean age of 35.2 (survivor) and 37.9 (sibling) years at time of survey. For subgroup (ii), analysis information was available on 191 survivors and 210 siblings. Fathers achieved university degrees significantly more often than mothers (p = 0.003 (i), p < 0.001 (ii)). The distribution of professional education was not significantly different between cancer survivors and siblings in either cohort (i) or (ii).

CONCLUSIONS

Regarding our research on the educational and vocational trajectory of CCS, patients can be reassured that family planning and vocational education are well compatible. Inequalities regarding gender-specific educational pathways remain to be addressed.

IMPLICATIONS FOR CANCER SURVIVORS

CCS should monitor their fertility status regularly and, if necessary, cryopreserve germ cells or tissue in order to optimize their family planning. Educational opportunities should be pursued as desired and with confidence. Local as well as European aftercare programs can assist with family planning and education.

P-100 Quality of semen and testicular tissue samples collected before and after cancer treatment. Results from our 15 year monocentric experience at Charité-Universitätsmedizin Berlin

Study question

To examine the influence of patient- and cancer treatment-related factors on the quality of semen and testicular tissue samples collected 2004-2019 in our centre.

Summary answer

Semen quality was reduced before cancer treatment in patients with a testicular or haematological malignancy and following any gonadotoxic-risk treatment when compared to no-risk treatment.

What is known already

Young men with cancer are at increased risk of fertility impairment. Therefore, cryopreservation of semen or testicular tissue is recommended. Usually, these steps are taken before cancer treatment. However, in some cases it may be necessary to undergo fertility protection following gonadotoxic treatment. The cancer diagnosis itself may have a negative impact on semen quality. Fertility impairment may occur especially following treatment with alkylating agents, radiotherapy to the pelvis/testes and high dose treatment as used in stem cell transplantation regimen. Risk groups have been defined according to the gonadotoxicity of cancer treatment in previous guidelines.

Study design, size, duration

In our centre, patients have been cryopreserving semen and/or testicular tissue samples for more than 15 years now. We conducted a retrospective cohort study between 01/2020 and 09/2021 in the subgroup of 506 cancer patients that had collected samples in our department between 03/2004 and 05/2019 and for whom cancer treatment data was available. In total, we included information on 601 samples (semen and testicular tissue) from these patients.

Participants/materials, setting, methods

Cancer treatment data and results from semen/testicular tissue analyses were collected from medical records. Cancer diagnoses were classified as brain, testicular or solid tumors in other locations or haematological malignancies. Samples were categorized as collected before or after the start of a gonadotoxic treatment (high/medium/low/no, defined according to existing guidelines). Descriptive analyses and multiple linear and logistic regression were conducted to determine influencing factors on the quality of cryopreservation in adolescent and adult cancer patients.

Main results and the role of chance

Over the period of 15 years, we observed an overall increase in sperm concentration and progressive motility in adolescent cancer samples, whereas concentrations remained stable during this period in adult samples. However, before cancer treatment, semen quality was already reduced in both adolescent (median sperm concentration 8x106/ml, IQR:6-116.8) and adult testicular cancer patients (median sperm concentration 18x106/ml, IQR:7-45) as well as in adolescents with a haematological malignancy (median sperm concentration: 10x106/ml, IQR:2.93±51.53; mean vitality: 55.19%, SD ± 22.85%; median progressive motility: 20%, IQR:7-50). Almost half (17/45, 38.7%) of adolescent and 18.5% (70/380) of adult samples showed oligoasthenoteratozoospermia prior to cancer treatment. Before start of treatment, adolescents who collected testicular tissue opted to cryopreserve their samples despite azoospermia to a higher rate than adults (50% vs. 20%). Not only high-risk gonadotoxic treatment, but also moderate- and low-risk treatment resulted in significant reduction of semen quality compared to cancer patients who did not receive a gonadotoxic treatment. When compared to patient samples collected before cancer treatment, sperm concentration and progressive motility significantly decreased in samples following high risk treatment in 60-70% of patients. Number of samples diagnosed with azoospermia was significantly higher in samples collected following high-risk treatment compared to samples collected before treatment.

Limitations, reasons for caution

We analysed retrospective data from our hospital records. We could not oversee how many cancer patients were treated during this time-period and who might have been eligible for cryopreservation. We were able to compare samples from before and after treatment only in a subgroup of patients.

Wider implications of the findings

Surveillance of fertility parameters, including regular spermiograms, following cancer treatment should be standard follow-up care to detect impairment, especially in men who have not cryopreserved samples previously. Even after moderate/low-risk gonadotoxic treatment, semen quality may be reduced. Simultaneously, these patients might be less likely to cryopreserve and therefore require attention.

Trial registration number

not applicable

P-461 “15 years of cryopreservation of semen and testicular tissue samples and outcomes of fertility treatments – a single centre experience at Charité-Universitätsmedizin Berlin”

Study question

To explore practices of cryopreservation among male cancer patients and describe outcomes of fertility treatments with samples collected before and after cancer treatment.

Summary answer

Only 9.1% of cancer patients used their samples for fertility treatment (ART). Patients underwent ART mostly within the first two years and following high-risk treatment.

What is known already

Fertility preservation has become an important issue, due to the potential gonadotoxicity of oncological therapies. Most cancer patients who undergo gonadotoxic treatment desire to have children. Yet, cancer patients may suffer impaired spermatogenesis in more than a third to over two thirds of cases following standard or high dose cancer treatments, respectively. Identifying risk factors of infertility is therefore fundamental for individual and risk adapted patient counseling. Current guidelines recommend fertility preservation, especially cryopreservation of sperm/testicular tissue, in cancer patients who require gonadotoxic treatment. Rates of utilisation of cryopreserved samples for fertility treatment are low (often &lt;10%).

Study design, size, duration

In our retrospective study, we collected data from 506 cancer patients who cryopreserved semen/testicular tissue samples between 2004 and 2019 in our centre and for who oncological treatment data was available. Additionally, former patients who had used their previously cryopreserved samples were asked for informed consent to collect information on fertility treatment from the respective fertility centre in which they were treated.

Participants/materials, setting, methods

We collected oncologic and cryopreservation data from medical records, and fertility treatment data from external clinics. Patients were stratified according to age at diagnosis (&lt;18 or ≥ 18 years old), diagnosis (brain, testicular or solid tumors in other locations or hematologic malignancy) and time-point of cryopreservation (before or after gonadotoxic treatment). We assessed the following fertility outcomes: fertilisation, pregnancy, miscarriage and live birth rate as well as perinatal outcomes (gestational age, weight and height at delivery).

Main results and the role of chance

The majority of the 506 cancer patients (including 10.5% adolescents) had suffered from a testicular or hematological malignancy. The number of patients that underwent cryopreservation annually in our centre had increased over time. On average, patients collected one sample (1.2±0.4, range:1-3). The majority of samples were collected before oncologic treatment (460/600, 76.7%) and were semen samples (554/601, 92.2%). The rate of cryopreserved tissue was higher in adolescents compared to adults. At the time-point of our study, only 46 patients (9.1%) had used their samples (15,2% tissue samples) for fertility treatment after a median of 18 months following cryopreservation (IQR:7.25±27.5). We received fertility cycle information on 21 patients. Eleven couples (55.0%) had only required one cycle to achieve a pregnancy (range:1-3 cycles, n = 38). Between 70-80% of couples, depending on the cancer diagnosis, achieved at least one pregnancy. Out of 16 patients who had successfully achieved a pregnancy, thirteen succeeded using cryopreserved sperm, one patient required to change from fresh to cryopreserved sperm in the third cycle and two patients used fresh sperm. Rate of pregnancy per e mbryo transfer (ET) was 51.4% (19/37), including eleven singletons, three twin pairs, four miscarriages (in two patients) and one pregnancy with unknown outcome.

Limitations, reasons for caution

Bias might be caused by the restrospective study design and the fact that recommendations for clinical practice have changed over time. We could not collect information on patients who would have been eligible but did not perform cryopreservation, whose partners conceived spontaneously or who used tissue samples for ART.

Wider implications of the findings

This study supports sperm and tissue cryopreservation as effective methods for fertility preservation. The rate of ART utilisation is still low, however results from ART cycles are reassuring, also when cryopreserved semen samples are used. Upcoming high-risk treatment is a predictor for ART utilisation, whereas follow-up time is not.

Trial registration number

Our study was approved by the ethics committee of Charité-Universitätsmedizin Berlin (EA4/158/19).

Post-Traumatic Heterotopic Ossification With Incidental Hyperparathyroidism

Background: Heterotopic ossification (HO) is a rare disease characterised by abnormal bone growth in non-osseous tissues, causing pain, immobility and impaired quality of life. Although still being elucidated, the underlying pathophysiology may relate to local macrophage-driven inflammation in response to trauma¹.

Case: A 35-year-old man involved in a motor vehicle accident (MVA) fractured over twenty bones (multiple vertebrae, ribs and complex open book pelvic fracture with shattered left acetabulum) with extensive soft tissue injuries requiring multiple surgeries. Past medical history included a renal calculus three years earlier. His serum corrected calcium on admission was elevated at 2.87mmol/L (2.10-2.60mmol/L). Peri-operative fluid over-resuscitation necessitated boluses of intravenous furosemide, and serum calcium transiently normalised before rapidly incrementing and peaking at 3.04 mmol/L. Serum parathyroid hormone post-operatively was inappropriately high at 9.4pmol/L (1.0–7.0pmol/L) and 25-hydroxyvitamin D low at 24nmol/L (50-150nmol/L). Oral vitamin D replacement was commenced and he received intravenous pamidronate (3x60mg infusions) which briefly restored normocalcaemia. Neck ultrasound and sestamibi scintigraphy demonstrated a left parathyroid adenoma, and he underwent parathyroidectomy. Histology revealed a single parathyroid adenoma. He has been normocalcaemic since surgery. Despite excellent overall recovery, mobility at the left hip remained restricted in all planes of movement. He could not perform simple activities such as putting on his shoe. Plain radiographs showed HO lateral to the left acetabulum, femoral head and neck, with bony bridging to the left ilium on computed tomography. Bone turnover markers (BTMs) measured eleven months post-MVA (and pamidronate) were elevated, with CTX of 750ng/L (100-600ng/L) and P1NP of 207ug/L (15-80ug/L). BTMs gradually reduced over time, plateauing two years post-MVA (CTX 480ng/L and P1NP 103ug/L). Surgery with pre-operative radiotherapy to remove the left hip HO is now planned.

Discussion: This man had multiple recognised risk factors for HO, including male sex, trauma followed by immobilisation and pelvic fracture. His hyperparathyroidism may have predisposed HO development through excess calcium-phosphate product promoting soft tissue calcification. Bisphosphonates may also increase the risk². Elevated BTMs have been demonstrated in the early phase of HO; further research may elucidate whether BTMs can guide timing of surgical intervention relative to the pathophysiological processes driving HO.

References:

1 Meyers C et al. Heterotopic Ossification: A Comprehensive Review. JBMR Plus 2019, 3: e10172

2 Genêt F et al. Neurological heterotopic ossification following spinal cord injury is triggered by macrophage-mediated inflammation in muscle 2015. J Pathol. 236(2):229–40

An efficient algorithm for extracting the magnitude of the measurement error for fractional dynamics

Modern live-imaging fluorescent microscopy techniques following the stochastic motion of labeled tracer particles, i.e. single particle tracking (SPT) experiments, have uncovered significant deviations from the laws of Brownian motion in a variety of biological systems. Accurately characterizing the anomalous diffusion for SPT experiments has become a central issue in biophysics. However, measurement errors raise difficulty in the analysis of single trajectories. In this paper, we introduce a novel surface calibration method based on a fractionally integrated moving average (FIMA) process as an effective tool for extracting both the magnitude of the measurement error and the anomalous exponent for autocorrelated processes of various origins. This method is developed using a toy model - fractional Brownian motion disturbed by independent Gaussian white noise - and is illustrated on both simulated and experimental biological data. We also compare this new method with the mean-squared displacement (MSD) technique, extended to capture the measurement noise in the toy model, which shows inferior results. The introduced procedure is expected to allow for more accurate analysis of fractional anomalous diffusion trajectories with measurement errors across different experimental fields and without the need for any calibration measurements.

Health-Related Behaviour Among Children of Childhood Cancer Survivors in Germany

Purpose: Childhood cancer survivors fear that previous therapy could not only impair their own but also their children's health. We examined whether health-related behaviour in children of childhood cancer survivors differs from the general population. Methods: Our first nationwide survey wave (2013-2014) surveyed offspring health in 396 German childhood cancer survivors known to have a child of their own. Answers about health behaviour were analysed using descriptive statistics. Data were collected for 418 offspring and 394 could be integrated for matched-pair analyses with data from the German general population (KIGGS, n=17 641). Results: Teeth-cleaning routine, body-mass-index or subjective body image evaluation by parents were no different from children in the general population. Parents who included a cancer survivor smoked less in the presence of their children (p=0.01). During pregnancy, mothers in cancer survivor parent pairs abstained from drinking alcohol more often (p=0.01) and smoked less (p=0.05). While the calculated effect sizes (Phi) were generally low (0.135-0.247), children from cancer survivors played less outdoors than peers did (p=0.01). Boys participated in sports outside a club more often (p=0.05) and watched less TV on weekdays (p=0.01) and girls spent more time on the computer during weekdays than peers did (p=0.01). Conclusions: This study provides the first data for health-related behaviour in cancer survivors' offspring and sheds light on differences to parenting in the general population. Multivariate analyses in a larger study population are needed to relate these differences to fear issues in cancer survivors.

Nationwide Survey on the Health of Offspring from Former Childhood Cancer Patients in Germany

BACKGROUND

Increased risk for infertility from cancer treatment and fear of health impairment in their offspring may prevent survivors of childhood cancer from having own children. Even though most studies report no increased risk for malformations, in our German fertility study 2008 a higher occurrence of cleft lip and palate was found in offspring of former patients.

METHODS

Since 2010 we assess offspring's health in a survey-based multicenter study, comparing diseases, well-being, healthcare utilization and health-related behavior between offspring from survivors, siblings or the general population. Within a first nationwide survey wave survivors who were known to have at least one child by previous fertility studies, received a questionnaire supported by the German Childhood Cancer Registry. Questionnaires were based on the KiGGS study on children's health in the German general population conducted by the Robert-Koch Institute (n=17,641).

RESULTS

Questionnaires on 418 children were answered by 65% (254/393) of survivors contacted to participate in the first nationwide offspring study wave. Participants were more likely to be female (p<0.01), to have achieved higher educational levels (p<0.05) and to be a survivor of a soft tissue tumor (p<0.05). Former patients expressed moderate to high anxiety for the occurrence of cancer in 74% and feared other diseases in their children in 20%.

CONCLUSION

Offspring health is a topic of major relevance to former patients. Our offspring study is currently being extended to ~1500 offspring of childhood cancer survivors in Europe.

Conversion of sugar beet leaf polysaccharides into single cell protein

Conversion of low-cost sugar beet leaves into valuable yeast biomass was described.

Ketanserin, an antagonist of 5-HT2A receptor of serotonin, inhibits testosterone secretion by rat Leydig cells in vitro

The effect of ketanserin, an antagonist of 5-HT2A receptor of serotonin, added to the culture medium, on basal and LH-stimulated testosterone secretion was studied in primary cultures of adolescent rat Leydig cells. Ketanserin decreased the basal secretion of testosterone but showed an insignificant influence on the LH-stimulated process. It can be concluded that ketanserin may affect the testosterone-secreting cells by an indirect action at the vascular level as well as directly at the level of Leydig cells, at least in adolescent rats, leading to down-regulation of the basal testosterone secretion.