1q amplification and PHF19 expressing high-risk cells are associated with relapsed/refractory multiple myeloma

Multiple Myeloma is an incurable plasma cell malignancy with a poor survival rate that is usually treated with immunomodulatory drugs (iMiDs) and proteosome inhibitors (PIs). The malignant plasma cells quickly become resistant to these agents causing relapse and uncontrolled growth of resistant clones. From whole genome sequencing (WGS) and RNA sequencing (RNA-seq) studies, different high-risk translocation, copy number, mutational, and transcriptional markers can be identified. One of these markers, PHF19, epigenetically regulates cell cycle and other processes and is already studied using RNA-seq. In this study, we generate a large (325,025 cells and 49 patients) single cell multi-omic dataset and jointly quantify ATAC- and RNA-seq for each cell and matched genomic profiles for each patient. We identify an association between one plasma cell subtype with myeloma progression that we call relapsed/refractory plasma cells (RRPCs). These cells are associated with chromosome 1q alterations, TP53 mutations, and higher expression of PHF19. We also identify downstream regulation of cell cycle inhibitors in these cells, possible regulation by the transcription factor (TF) PBX1 on chromosome 1q, and determine that PHF19 may be acting primarily through this subset of cells.

Measurement of the major ignored burden of multiple myeloma, pernicious anaemia and of other haematological conditions on partners and family members: A cross-sectional study

BACKGROUND

Having a haematological condition can adversely affect the quality of life (QoL) of family members/partners of patients. It is important to measure this often ignored burden in order to implement appropriate supportive interventions.

OBJECTIVE

To measure current impact of haematological conditions on the QoL of family members/partners of patients, using the Family Reported Outcome Measure-16 (FROM-16).

METHODS

A cross-sectional study, recruited online through patient support groups, involved UK family members/partners of people with haematological conditions completing the FROM-16.

RESULTS

183 family members/partners (mean age = 60.5 years, SD = 13.2; females = 62.8%) of patients (mean age = 64.1, SD = 12.8; females = 46.4%) with 12 haematological conditions completed the FROM-16. The FROM-16 mean total score was 14.0 (SD = 7.2), meaning 'a moderate effect on QoL'. The mean FROM-16 scores of family members of people with multiple myeloma (mean = 15.8, SD = 6.3, n = 99) and other haematological malignancies (mean = 13.9, SD = 7.8, n = 29) were higher than of people with pernicious anaemia (mean = 10.7, SD = 7.5, n = 47) and other non-malignant conditions (mean = 11, SD = 7.4, n = 56, p < .01). Over one third (36.1%, n = 183) of family members experienced a 'very large effect' (FROM-16 score>16) on their quality of life.

CONCLUSIONS

Haematological conditions, in particular those of malignant type, impact the QoL of family members/partners of patients. Healthcare professionals can now, using FROM-16, identify those most affected and should consider how to provide appropriate holistic support within routine practice.

Responsiveness and minimal important change of the Family Reported Outcome Measure (FROM-16)

BACKGROUND

The FROM-16 is a generic family quality of life (QoL) instrument that measures the QoL impact of patients' disease on their family members/partners. The study aimed to assess the responsiveness of FROM-16 to change and determine Minimal Important Change (MIC).

METHODS

Responsiveness and MIC for FROM-16 were assessed prospectively with patients and their family members recruited from outpatient departments of the University Hospital Wales and University Hospital Llandough, Cardiff, United Kingdom. Patients completed the EQ-5D-3L and a global severity question (GSQ) online at baseline and at 3-month follow-up. Family members completed FROM-16 at baseline and a Global Rating of Change (GRC) in addition to FROM-16 at follow-up. Responsiveness was assessed using the distribution-based (effect size-ES, standardized response mean -SRM) and anchor-based (area under the receiver operating characteristics curve ROC-AUC) approaches and by testing hypotheses on expected correlation strength between FROM-16 change score and patient assessment tools (GSQ and EQ-5D). Cohen's criteria were used for assessing ES. The AUC ≥ 0.7 was considered a good measure of responsiveness. MIC was calculated using anchor-based (ROC analysis and adjusted predictive modelling) and distribution methods based on standard deviation (SD) and standard error of the measurement (SEM).

RESULTS

Eighty-three patients with 15 different health conditions and their relatives completed baseline and follow-up questionnaires and were included in the responsiveness analysis. The mean FROM-16 change over 3 months = 1.43 (SD = 4.98). The mean patient EQ-5D change over 3 months = -0.059 (SD = 0.14). The responsiveness analysis showed that the FROM-16 was responsive to change (ES = 0.2, SRM = 0.3; p < 0.01). The ES and SRM of FROM-16 change score ranged from small (ES = 0.2; SRM = 0.3) for the distribution-based method to large (ES = 0.8, SRM = 0.85) for anchor-based methods. The AUC value was above 0.7, indicating good responsiveness. There was a significant positive correlation between the FROM-16 change scores and the patient's disease severity change scores (p < 0.001). The MIC analysis was based on data from 100 family members of 100 patients. The MIC value of 4 was suggested for FROM-16.

CONCLUSIONS

The results of this study confirm the longitudinal validity of FROM-16 which refers to the degree to which an instrument is able to measure change in the construct to be measured. The results yield a MIC value of 4 for FROM-16. These psychometric attributes of the FROM-16 instrument are useful in both clinical research as well as clinical practice.

Medical students' perspectives on and understanding of anesthesiology: a Canadian cross-sectional survey

PURPOSE

In Canada, three out of 17 medical schools do not mandate an anesthesia rotation in their clerkship curriculum. Understanding the effects of a mandatory anesthesiology rotation is important in determining its value to the specialty and guiding decision-making for medical educators. We sought to determine whether a mandatory anesthesia rotation affected students' understanding of anesthesiology, as well as their perspectives on anesthesia.

METHODS

We conducted an anonymous cross-sectional survey of Canadian medical students graduating in 2021. Our survey consisted of 46 questions related to student's perspectives of anesthesiology, understanding of anesthesia, their interest in the specialty, and participant's demographics. This included 16 Likert-scale questions, 19 quiz-style questions, four free-text response questions, and seven demographics questions. The survey was hosted by SurveyMonkey® (SurveyMonkey Inc., San Mateo, CA, USA) and distributed to the participants by each individual institution.

RESULTS

We collected a total of 331 responses across 13 different Canadian medical schools, representing a 17.3% response rate of students surveyed and 11.7% of all graduating medical Canadian students in 2021. A mandatory rotation in anesthesiology was associated with a more positive perspective (P = 0.01) but not understanding (P = 0.07) of the specialty. A mandatory rotation was not related to students' application to anesthesiology at a statistically significant level (P = 0.06).

CONCLUSIONS

The results of this national survey study show the benefits of including a mandatory clerkship rotation in anesthesiology, namely on increasing positive perceptions of the specialty, while also revealing avenues for future research and insights on how to further optimize a mandatory anesthesiology rotation in clerkship.

Overall Survival in Patients With Multiple Myeloma in the U.S.: A Systematic Literature Review of Racial Disparities

Multiple myeloma (MM) accounts for 10% of hematologic cancers in the U.S.; however, incidence and mortality occur disproportionately between racial groups in real-world settings. Our study's objective was to systematically characterize the disparities in overall survival (OS) among Black and White patients with MM in the US using real-world evidence studies. A systematic literature review was undertaken by searching Embase and MEDLINE for observational studies conducted in the US, published between January 1, 2015 and October 25, 2021, and reporting OS for Black and White patients with MM. Records were reviewed by 2 independent researchers. OS data were extracted as hazard ratios (HR), median survival, or %, with methods of adjustment, as reported. Evidence quality was assessed by data source, population, and variables for which HRs for risk of death were adjusted. We included 33 US studies comprising 410,086 patients (21.5% Black; 78.5% White) with MM. Receipt of treatment varied; however, most studies reported that patients either underwent stem cell transplant and/or received systemic therapy. HRs from 9 studies were considered "high quality" by comparing nationally representative, generalizable cohorts and adjusting for key prognostic, treatment, and/or socioeconomic factors. After adjustment, these data suggested that Black patients exhibit similar or superior survival outcomes compared with their White counterparts. When data are adjusted for important confounders, Black patients exhibit better or equal survival to White patients, indicating that similarities in patient populations and equal access to treatment can bridge the disparity in patient outcomes between races.

Identifying 1q amplification and PHF19 expressing high-risk cells associated with relapsed/refractory multiple myeloma

Multiple Myeloma is an incurable plasma cell malignancy with a poor survival rate that is usually treated with immunomodulatory drugs (iMiDs) and proteosome inhibitors (PIs). The malignant plasma cells quickly become resistant to these agents causing relapse and uncontrolled growth of resistant clones. From whole genome sequencing (WGS) and RNA sequencing (RNA-seq) studies, different high-risk translocation, copy number, mutational, and transcriptional markers have been identified. One of these markers, PHF19, epigenetically regulates cell cycle and other processes and has already been studied using RNA-seq. In this study a massive (325,025 cells and 49 patients) single cell multiomic dataset was generated with jointly quantified ATAC- and RNA-seq for each cell and matched genomic profiles for each patient. We identified an association between one plasma cell subtype with myeloma progression that we have called relapsed/refractory plasma cells (RRPCs). These cells are associated with 1q alterations, TP53 mutations, and higher expression of PHF19. We also identified downstream regulation of cell cycle inhibitors in these cells, possible regulation of the transcription factor (TF) PBX1 on 1q, and determined that PHF19 may be acting primarily through this subset of cells.

Uncovering inclusivity gaps in design pedagogy through the digital design marginalization framework

Designers play a key role in the design of inclusive and socially conscious interfaces. Thus, it is imperative for designers to be thoughtful of the ethical and social implications of design. However, gaps in the foundational training that designers receive (e.g., as university students) can negatively impact their ability to consider the social implications of their design practice. This can result in consequences such as digital marginalization, which, as defined by the Digital Design Marginalization (DDM) framework, is the “pushing away”, whether intentional or not, of a defined group of users from a digital or online service or system, where the exclusion has additional, indirect, and long-lasting social consequences on that particular user group. Designers can contribute, even unintentionally, to digital marginalization through their design practices and the design choices they make. We argue that our role as educators includes ensuring not only that our design pedagogy is inclusive, but that the designers we train now are prepared to conduct their future design practice in a manner that is inclusive to all users. As such, we propose to use the Digital Design Marginalization as a lens to guide a reflection-based approach to identify gaps in our pedagogy that may lead to designers becoming ill-equipped to identify how their designs may lead to digital marginalization. Through seven case studies from our own teaching practice, we demonstrate the use of the DDM framework to guide marginalization-focused introspective reflections of curricula. These reflections through the DDM lens revealed gaps in our pedagogy with respect to providing future designers with training that enables them to consider the broader societal and individual implications of the design choices they will make in future practice. Based on our experience using the DDM framework, we then discuss in greater depth how reflection of social consequences of design pedagogy can be operationalized within institutions to reduce educational gaps that may be associated with design-mediated digital marginalization. Finally, we comment on avenues for further development of pedagogical reflection using DDM.

Treatment patterns and outcomes according to cytogenetic risk stratification in patients with multiple myeloma: a real-world analysis

A clearer understanding of the prognostic implications of t(11;14) in multiple myeloma (MM) is needed to inform current and future therapeutic options. We utilized real-world data from a US database to examine treatment patterns and outcomes in patients by t(11;14) status compared with high- and standard-risk subgroups across different lines of therapy (LoT). This retrospective, observational cohort study used de-identified patient-level information from adults with MM and first-line treatment initiation between January 2011 and January 2020, followed until February 2020. The high-risk cohort comprised patients with high-risk genetic abnormalities per mSMART criteria (including those with co-occurring t(11;14)). Among 6138 eligible patients, 6137, 3160, and 1654 received first-, second-, and third-line treatments, respectively. Of 645 patients who had t(11;14), 69.1% had t(11;14) alone, while 30.9% had co-occurring high-risk abnormalities. Altogether, 1624 and 2544 patients were classified as high- and standard-risk, respectively. In the absence of biomarker-driven therapy, treatment patterns remain similar across LoT in high-risk, t(11;14)+, and standard-risk subgroups. Across all LoT, patient outcomes in the high-risk subgroup were less favorable than those in the t(11;14)+ and standard-risk subgroups. Thus, there is an opportunity for novel therapeutics targeted to t(11;14) and other defined subgroups to personalize MM therapy and optimize patient outcomes.

P14.24 Estimating survival outcomes in elderly (70+ years) patients with primary glioblastoma

BACKGROUND

Elderly patients with glioblastoma are perceived to face a poor prognosis, with perceptions around older age and a relative lack of randomized data raising a concern about their undertreatment. The EANO guidelines recommend &gt;70-year-old patients with good performance status to undergo maximal safe resection followed by hypofractionated (40 Gy in 15 fractions, i.e. RT40/15) radiotherapy with or without concurrent and adjuvant Temozolomide (TMZ), depending on MGMT promoter methylation. This study evaluated the relative survival impact of biological, histological, surgical and oncological factors and aimed to devise a scoring system to estimate the survival of elderly glioblastoma patients, with an aim to more accurately guide treatment in this cohort.

METHODS

The records of 169 elderly (≥70 years) patients with a new diagnosis of IDH-wild type glioblastoma were retrospectively examined for gender, age, WHO performance status (PS), comorbidities, MGMT methylation, surgical intervention and chemoradiation regime. The adjusted survival impact of these factors was determined using Cox proportional hazards model and used to devise a two-stage scoring system to estimate survival of patients at the stage of surgical (Elderly Glioblastoma Surgical Score, EGSS) and oncological management (Elderly Glioblastoma Oncological Score, EGOS).

RESULTS

The overall median survival (MS) of the cohort was 28.8 weeks. Subtotal resection (MS=27.7 weeks, 95%CI 24.1–31.6 weeks, HR=0.58) and gross-total resection (MS=77.8 weeks, 95%CI 67.0–88.6 weeks, HR=0.36) were associated with significant overall survival benefit compared to biopsy alone (MS=18.2 weeks, 95%CI 15.7–20.7 weeks, HR=5.23), p&lt;0.05. Hypofractionated radiation with Temozolomide (RT40/15+TMZ, MS=60.9 weeks, 95%CI 49.9–71.8 weeks, HR=0.13) was non-inferior to the Stupp protocol (RT60/30+TMZ, MS=50.6 weeks, 95%CI 32.4–66.7 weeks, HR=0.11), p=0.72. Negative prognosticators included age above 75 years, biopsy alone and no chemoradiotherapy. Subgroup analysis revealed that MGMT unmethylated 70–75 year old patients who received the Stupp protocol had significantly improved overall survival (MS=57.6 weeks, 95%CI 27.7–88.1 weeks) compared to standard of care RT40/15 alone (MS=29.7 weeks, 95%CI 7.1–51.6 weeks), p=0.002. EGSS and EGOS scores estimated survival with 65% and 73% accuracy, respectively.

CONCLUSION

When appropriate and safe, a subgroup of elderly glioblastoma patients may benefit from more aggressive surgical and oncological management. The proposed EGSS and EGOS scores takes into account important prognostic factors to help guide which patients should receive such treatment.

Intraoperative pyloric botulinum toxin injection during Ivor-Lewis gastroesophagectomy to prevent delayed gastric emptying

Delayed gastric emptying (DGE) is a common morbidity that affects 10%-50% of Ivor-Lewis gastroesophagectomy (ILGO) patients. DGE management is variable with no gold standard prevention or treatment. We conducted a study to assess the effectiveness of intraoperative pyloric botulinum toxin injection in preventing DGE. All patients undergoing an ILGO for curative intent, semi-mechanical anastomosis, and enhanced recovery between 1st December 2011 and 30th June 2017 were included. Patients with pyloroplasties were excluded and botulinum toxin was routinely given from the 2nd April 2016. We compared botulinum toxin injection (BOTOX) against no intervention (NONE) for patient demographics, adjuvant therapy, surgical approach, DGE incidence, length of stay (LOS), and complications. Additionally, we compared pneumonia risk, anastomotic leak rate, and LOS in DGE versus non-DGE patients. DGE was defined using nasogastric tube input/output differences and chest X-ray appearance according to an algorithm adopted in our unit, which were retrospectively applied. There were 228 patients: 65 (28.5%) received botulinum toxin and 163 (71.5%) received no intervention. One hundred twenty-four (54.4%) operations were performed laparoscopically, of which 11 (4.8%) were converted to open procedures, and 104 (45.6%) were open operations. DGE incidence was 11 (16.9%) in BOTOX and 29 (17.8%) in NONE, P = 0.13. Medical management was required in 14 of 228 (6.1%) cases: 3 (4.6%) in BOTOX and 11 (4.8%) in NONE. Pyloric dilatation was required in 26 of 228 (11.4%): 8 of 65 (12.3%) in the BOTOX and 18 of 163 (11.0%) in NONE. There were no significant differences between groups and requirement for intervention, P = 0.881. Overall median LOS was 10 (6.0-75.0) days: 9 (7.0-75.0) in BOTOX and 10 (6.0-70.0) in NONE, P = 0.516. In non-DGE versus DGE patients, median LOS was 9 (6-57) versus 14 (7-75) days (P < 0.0001), pneumonia incidence of 27.7% versus 30.0% (P = 0.478), and anastomotic leak rate of 2.1% versus 10.0% (P = 0.014). Overall leak rate was 3.5%. Overall complication rate was 67.1%, including minor/mild complications. There were 43 of 65 (66.2%) in BOTOX and 110 of 163 (67.5%) in NONE, P = 0.482. In-hospital mortality was 1 (0.44%), 30-day mortality was 2 (0.88%), 90-day mortality was 5 (2.2%), and there were no 30-day readmissions. Intraoperative pyloric botulinum toxin injections were ineffective in preventing DGE (BOTOX vs. NONE: 16.9% vs. 17.8%) or reducing postoperative complications. DGE was relatively common (17.5%) with 11.4% of patients requiring postoperative balloon dilatation. DGE also resulted in prolonged LOS (increase from 9 to 14 days) and significant increase in leak rate from 2.1% to 10.0%. A better understanding of DGE will guide assessment, investigation, and management of the condition.

Laparoscopic common bile duct exploration; a preferential pathway for elderly patients

Background

Laparoscopic common bile duct exploration (LCBDE) has emerged as a recommended alternative to endoscopic retrograde cholangiopancreatography (ERCP) for the management of choledocholithiasis. However, its use in the elderly has been limited, and evidence of its safety and efficacy in these patients is yet to be established. This study describes our experience of LCBDE in elderly patients, analysing the safety and efficacy of this technique in comparison to younger patients.

Methods

All patients undergoing laparoscopic cholecystectomy (LC) with LCBDE for choledocholithiasis in our unit between January 2015 and January 2017 were included. Data pertaining to patient demographics, comorbidities, investigations, operative technique and outcomes were analysed. Patients were divided into 2 groups based on age (Group A:<65 years vs Group B: >/ = 65 years) for comparative analysis.

Results

124 patients (Group A: 65, Group B: 59) were included. Group B were more co-morbid and had a higher ASA grade than Group A. However, there was no significant difference between groups in rates of conversion to open or complications, including bile leak (3.1% vs 5.1%, p = 0.67), retained stone (4.6% vs 1.7%, p = 0.62), or complications according to Clavien-Dindo classification (p = 0.78). Re-intervention rates were also similar between groups (7.7% vs 3.4%, p = 0.44 and 3.1% vs 3.4%, p = 1.0 respectively), as was length of stay.

Conclusion

Despite higher frequency of comorbidities and ASA grade, LCBDE in elderly patients is safe and effective, and has similar outcomes to younger patients. Therefore elderly patients with choledocholithiasis should be offered LCBDE as an alternative to ERCP.

Abstract P1-13-08: Extended adjuvant neratinib/fulvestrant blocks ER/HER2 crosstalk and maintains complete responses of ER+/HER2+ tumors following treatment with chemotherapy and anti-HER2 therapy

Background: Neratinib is a potent, irreversible pan-HER tyrosine kinase inhibitor. The phase III trial ExteNET showed improved disease-free survival in patients (pts) with HER2+ breast cancer treated with neratinib vs placebo after trastuzumab-based adjuvant therapy. The benefit from neratinib appeared to be greater in pts with ER+ tumors. Thus, we sought to elucidate mechanisms that may explain the benefit from extended adjuvant therapy with neratinib in pts with ER+/HER2+ breast cancer using a human-in-mouse model that simulates the clinical outcomes seen in ExteNET.

Results: Mice with established ER+/HER2 amplified MDA-361 tumors were treated with trastuzumab (tz) + paclitaxel (pac) for 4 weeks, and then randomized to fulvestrant (fulv) ± neratinib for 4 weeks. All MDA-361 tumors exhibited a prompt and marked reduction in volume after tz/pac treatment; 10 mice achieved a complete response (CR) before receiving 'extended adjuvant' therapy with fulv (n=5) or neratinib/fulv (n=5). A CR was maintained with neratinib/fulv following tz/pac. However, mice treated with fulv alone, relapsed rapidly (p&lt;0.05 at week 8) despite of a complete downregulation of tumor ER levels. In a second experiment, nude mice with established MDA-361 xenografts were treated with pertuzumab/tz/pac for 4 weeks. Following a CR, mice were randomized to neratinib/fulv vs. fulv. Again, mice treated with neratinib/fulv maintained a CR, while mice in the fulv alone arm exhibited tumor progressions within a week. In three ER+/HER2+ cell lines (MDA-361, BT474 and UACC893) but not in ER+/HER– MCF7 cells, treatment with neratinib induced ER reporter transcriptional activity whereas treatment with fulv resulted in an increase in HER2 phosphorylation, suggesting compensatory crosstalk between the ER and HER2 pathways. To further understand the molecular basis of this crosstalk, MDA-361 tumor-bearing mice were treated with either fulv, neratinib or the combination for 7 days, after which tumors were harvested and analyzed using a Nanostring breast cancer ER panel consisting of 196 ER-regulated genes. Compared to vehicle or fulv-treated tumors, tumors treated with neratinib alone and neratinib/fulv showed marked downregulation of cyclin D1 mRNA expression. Similarly, in MDA-361, BT474 and UACC893 cells but not in MCF7 cells, only neratinib/fulv downregulated cyclin D1, P-AKT and P-ERK. Finally, treatment with neratinib/fulv but not fulv alone reduced cyclin D1 transcriptional reporter activity and cyclin D1 protein levels, and induced cell cycle arrest, suggesting double blockade is required to overcome compensatory crosstalk between ER and amplified HER2.

Conclusions: Neratinib/fulv but not fulv alone maintained complete responses of ER+/HER+ tumors following treatment with tz/pac or pertuzumab/tz/pac, reminiscent of the results in ExteNET. Neratinib treatment promoted ER transcriptional activity whereas ER downregulation with fulv was associated with increased HER2 signaling. In ER+/HER2+ breast cancer cells and tumors, neratinib/fulv synergistically inhibited growth, cyclin D1 expression, and AKT and MAPK activation, thus providing a plausible mechanism to explain the results in the ExteNET trial.

Citation Format: Sudhan DR, Schwarz LJ, Guerrero-Zotano AL, Nixon M, Formisano L, Croessmann S, Gonzalez Ericsson PI, Sanders ME, Balko JM, Avogadri-Connors F, Cutler RE, Lalani AS, Bryce R, Auerbach A, Arteaga CL. Extended adjuvant neratinib/fulvestrant blocks ER/HER2 crosstalk and maintains complete responses of ER+/HER2+ tumors following treatment with chemotherapy and anti-HER2 therapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-13-08.

An atypical case of medial radial head dislocation

Radial head dislocations are common in children who fall onto outstretched hands. We present a case of medial radial head dislocation without a concomitant ulna fracture in a 14-year-old girl and the long-term sequelae of the injury.

Organising medication discontinuation: a qualitative study exploring the views of general practitioners toward discontinuing statins

BACKGROUND

Discontinuing medications is a complex decision making process and an important medical practice. It is a tool in reducing polypharmacy, reducing health system expenditure and improving patient quality of life. Few studies have looked at how general practitioners (GPs) discontinue a medication, in agreement with the patients, from a professional perspective. Three research questions were examined in this study: when does medication discontinuation occur in general practice, how is discontinuing medication handled in the GP's practice and how do GPs make decisions about discontinuing medication?

METHODS

Twenty four GPs were interviewed using a maximum variation sample strategy. Participant observations were done in three general practices, for one day each, totalling approximately 30 consultations.

RESULTS

The results show that different discontinuation cues (related to the type of consultation, medical records and the patient) create situations of dissonance that can lead to the GP considering the option of discontinuation. We also show that there is a lot of ambiguity in situations of discontinuing and that some GPs trialled discontinuing as means of generating more information that could be used to deal with the ambiguity.

CONCLUSIONS

We conclude that the practice of discontinuation should be conceptualised as a continually evaluative process and one that requires sustained reflection through a culture of systematically scheduled check-ups, routinely eliciting the patient's experience of taking drugs and trialling discontinuation. Some policy recommendations are offered including supporting GPs with lists or handbooks that directly address discontinuation and by developing more person centred clinical guidelines that discuss discontinuation more explicitly.

Coupled lasers: phase versus chaos synchronization

The synchronization of chaotic lasers and the optical phase synchronization of light originating in multiple coupled lasers have both been extensively studied. However, the interplay between these two phenomena, especially at the network level, is unexplored. Here, we experimentally compare these phenomena by controlling the heterogeneity of the coupling delay times of two lasers. While chaotic lasers exhibit deterioration in synchronization as the time delay heterogeneity increases, phase synchronization is found to be independent of heterogeneity. The experimental results are found to be in agreement with numerical simulations for semiconductor lasers.

Efficient method for controlling the spatial coherence of a laser

An efficient method to tune the spatial coherence of a degenerate laser over a broad range with minimum variation in the total output power is presented. It is based on varying the diameter of a spatial filter inside the laser cavity. The number of lasing modes supported by the degenerate laser can be controlled from 1 to 320,000, with less than a 50% change in the total output power. We show that a degenerate laser designed for low spatial coherence can be used as an illumination source for speckle-free microscopy that is nine orders of magnitude brighter than conventional thermal light.

Phase locking of lasers with self-stabilized minimal coupling

A novel configuration for phase locking two ring lasers with self-stabilized minimal exchange of power between them is presented. We show experimentally that losses introduced between the lasers are self compensated in order to maintain minimal power exchange between them. The experimental results are in good agreement with numerical results.

5α-reduced glucocorticoids exhibit dissociated anti-inflammatory and metabolic effects

BACKGROUND AND PURPOSE

Dissociating anti-inflammatory efficacy from the metabolic side effects of glucocorticoids is an attractive therapeutic goal. 5α-Tetrahydro-corticosterone (5αTHB), produced from corticosterone by 5α-reductases, activates glucocorticoid receptors. This study compares the effects of 5αTHB on inflammation and metabolism in vitro and in vivo.

METHODS

Suppression of cytokine release by 5αTHB and corticosterone were studied following LPS activation of mouse bone marrow derived macrophages. In vivo the efficacy of these steroids to dysregulate metabolic homeostasis and modulate immune suppression and the responses to thioglycollate-induced peritonitis in C57BL/6 mice were studied following acute injection (1.5-15 mg) and chronic infusion (50 µg·day(-1) , 14 days).

RESULTS

In macrophages, 5αTHB increased secretion of IL-10 similarly to corticosterone (180%, 340%; data are % vehicle, treated with 5αTHB and corticosterone, respectively) and suppressed LPS-induced secretion of TNF-α (21.9%, 74.2%) and IL-6 (16.4%, 69.4%). In mice with thioglycollate-induced peritonitis, both 5αTHB and corticosterone reduced the numbers of neutrophils (58.6%, 49.9%) and inflammatory monocytes (69.5%, 96.4%), and also suppressed MCP-1 (48.7%, 80.9%) and IL-6 (53.5%, 86.7%) in peritoneal exudate. In mice chronically infused with 5αTHB and corticosterone LPS-induced production of TNF-α from whole blood was suppressed to the same degree (63.2%, 37.2%). However, in contrast to corticosterone, 5αTHB did not induce body weight loss, increase blood pressure or induce hyperinsulinaemia.

CONCLUSIONS

5αTHB has anti-inflammatory effects in vitro and in vivo. At doses with equivalent anti-inflammatory efficacy to corticosterone, 5αTHB did not induce metabolic toxicity and thus may be a prototype for a safer anti-inflammatory drug.

Enhanced coherence of weakly coupled lasers

We present the phase-locking and coherence properties between two weakly coupled lasers. We show how the degree of coherence between the two lasers can be enhanced by nearly 1 order of magnitude after taking into account the effects of coupling on both their phases as well as their amplitudes. Specifically, correlations between synchronized spikes in the amplitude dynamics and the phase dynamics of the lasers allow for an interference pattern with a fringe visibility of 90%, even when the coupling strength is far below the critical value and they are not phase locked.

Genetic parameters of milking frequency and milk production traits in Canadian Holsteins milked by an automated milking system

Twice-a-day milking is currently the most frequently used milking schedule in Canadian dairy cattle. However, with an automated milking system (AMS), dairy cows can be milked more frequently. The objective of this study was to estimate genetic parameters for milking frequency and for production traits of cows milked within an AMS. Data were 141,927 daily records of 953 primiparous Holstein cows from 14 farms in Ontario and Quebec. Most cows visited the AMS 2 (46%) or 3 (37%) times a day. A 2-trait [daily (24-h) milking frequency and daily (24-h) milk yield] random regression daily animal model and a multiple-trait (milk, fat, protein yields, somatic cell score, and milking frequency) random regression test-day animal model were used for the estimation of (co)variance components. Both models included fixed effect of herd x test-date, fixed regressions on days in milk (DIM) nested within age at calving by season of calving, and random regressions for additive genetic and permanent environmental effects. Both fixed and random regressions were fitted with fourth-order Legendre polynomials on DIM. The number of cows in the multiple-trait test-day model was smaller compared with the daily animal model. Heritabilities from the daily model for daily (24-h) milking frequency and daily (24-h) milk yield ranged between 0.02 and 0.08 and 0.14 and 0.20, respectively. Genetic correlations between daily (24-h) milk yield and daily (24-h) milking frequency were largest at the end of lactation (0.80) and smallest in mid-lactation (0.27). Heritabilities from the test-day model for test-day milking frequency, milk, fat and protein yield, and somatic cell score were 0.14, 0.26, 0.20, 0.21, and 0.20, respectively. The genetic correlation was positive between test-day milking frequency and official test-day milk, fat, and protein yields, and negative between official test-day somatic cell score and test-day milking frequency.

Incidence of MRSA surgical-site infection in MRSA carriers in an orthopaedic trauma unit

We examined the incidence of infection with methicillin-resistant Staphylococcus aureus (MRSA) in patients admitted to the Leicester Royal Infirmary Trauma Unit between January 2004 and June 2006. The influence of MRSA status at the time of their admission was examined, together with age, gender and diagnosis, using multi-variant analysis. Of 2473 patients, 79 (3.2%) were MRSA carriers at the time of admission and 2394 (96.8%) were MRSA-negative. Those carrying MRSA at the time of admission were more likely to develop surgical site infection with MRSA (7 of 79 patients, 8.8%) than non-MRSA carriers (54 of 2394 patients, 2.2%, p < 0.001). Further analysis showed that hip fracture and increasing age were also risk factors with a linear increase in relative risk of 1.8% per year.

MRSA carriage at admission, age and the pathology are all associated with an increased rate of developing MRSA wound infection. Identification of such risk factors at admission helps to target health-care resources, such the use of glycopeptide antibiotics at induction and the ‘building-in’ of increased vigilance for wound infection pre-operatively.

Phase locking of lasers with intracavity polarization elements

New configurations for phase locking several laser beams with intracavity polarization elements are presented. With this configuration we demonstrated efficient phase lock of up to 24 ND:YAG laser beams with only two polarization beam displacers.

Does bone quality predict loosening of cemented total hip replacements?

We matched 78 patients with a loose cemented Charnley Elite Plus total hip replacement (THR) by age, gender, race, prosthesis and time from surgery with 49 patients with a well-fixed stable hip replacement, to determine if poor bone quality predisposes to loosening. Clinical, radiological, biomechanical and bone mineral density indicators of bone quality were assessed.

Patients with loose replacements had more pain, were more likely to have presented with atrophic arthritis and to have a history of fragility fracture, narrower femoral cortices and lower peri-prosthetic or lumbar spine bone mineral density (all t-test, p < 0.01). They also tended to be smokers (chi-squared test, p = 0.08). Vitamin-D deficiency was common, but not significantly different between the two groups (t-test, p = 0.31)

In this series of cemented hip replacements performed between 1994 and 1998, aseptic loosening was associated with poor bone quality. Patients with a THR should be screened for osteoporosis and have regular radiological surveillance.

Methicillin-resistant Staphylococcus aureus on orthopaedic wards: incidence, spread, mortality, cost and control

We examined the rates of infection and colonisation by methicillin-resistant Staphylococcus aureus (MRSA) between January 2003 and May 2004 in order to assess the impact of the introduction of an MRSA policy in October 2003, which required all admissions to be screened. Emergency admissions were treated prophylactically and elective beds ring-fenced. A total of 5,594 admissions were cross-referenced with 22,810 microbiology results. The morbidity, mortality and cost of managing MRSA-carrying patients, with a proximal fracture of the femur were compared, in relation to age, gender, American Society of Anaesthesiologists grade and residential status, with a group of matched controls who were MRSA-negative. In 2004, we screened 1795 of 1,796 elective admissions and MRSA was found in 23 (1.3%). We also screened 1,122 of 1,447 trauma admissions and 43 (3.8%) were carrying MRSA. All ten ward transfers were screened and four (40%) were carriers (all p < 0.001). The incidence of MRSA in trauma patients increased by 2.6% per week of inpatient stay (r = 0.97, p < 0.001). MRSA developed in 2.9% of trauma and 0.2% of elective patients during that admission (p < 0.001). The implementation of the MRSA policy reduced the incidence of MRSA infection by 56% in trauma patients (1.57% in 2003 (17 of 1,084) to 0.69% in 2004 (10 of 1,447), p = 0.035). Infection with MRSA in elective patients was reduced by 70% (0.56% in 2003 (7 of 1,257) to 0.17% in 2004 (3 of 1,806), p = 0.06). The cost of preventing one MRSA infection was 3,200 pounds. Although colonisation by MRSA did not affect the mortality rate, infection by MRSA more than doubled it. Patients with proximal fractures of the femur infected with MRSA remained in hospital for 50 extra days, had 19 more days of vancomycin treatment and 26 more days of vacuum-assisted closure therapy than the matched controls. These additional costs equated to 13,972 pounds per patient. From this experience we have been able to describe the epidemiology of MRSA, assess the impact of infection-control measures on MRSA infection rates and determine the morbidity, mortality and economic cost of MRSA carriage on trauma and elective orthopaedic wards.

Primary endoluminal stenting of transplant renal artery stenosis from cadaver and non-heart-beating donor kidneys

This study evaluated the efficacy of primary endovascular stenting in cases of transplant renal artery stenosis (TRAS) from cadaver and non-heart-beating donor kidneys. Patients with TRAS (n = 13) from a single-centre transplant population (n = 476) were treated by primary percutaneous angioplasty and endovascular stenting. The short-term efficacy of this intervention is demonstrated in terms of serum creatinine, glomerular filtration rate (GFR) biochemical, anti-hypertensive medications and mean arterial blood pressure control. Stenting for TRAS was performed in male (n = 10) and female (n = 3) recipients. The median age at transplantation was 55 yr (range 10-67 yr). Stenting occurred at a median duration of 410 d post-transplantation (range 84-5799 d). Mean serum creatinine (pre, 247 micromol/L; post, 214 micromol/L; p = 0.002), GFR (pre, 82.6 mL/min; post, 100.9 mL/min; p < 0.001), arterial blood pressure (pre, 104 mmHg; post, 97 mmHg; p = 0.036) and the number of anti-hypertensive medications required (pre, 3.4; post, 3.0; p = 0.002) showed significant improvement after post-endovascular therapy. There were no serious complications encountered. Primary endovascular stenting of TRAS produces a significant improvement in biochemical parameters of renal graft function and in blood pressure stability, with the benefit of low patient morbidity and single arterial puncture. Primary endoluminal stenting of TRAS is a safe and effective procedure for the treatment of TRAS.

Green fluorescent protein as a novel indicator of antimicrobial susceptibility in Aureobasidium pullulans

Presently there is no method available that allows noninvasive and real-time monitoring of fungal susceptibility to antimicrobial compounds. The green fluorescent protein (GFP) of the jellyfish Aequoria victoria was tested as a potential reporter molecule for this purpose. Aureobasidium pullulans was transformed to express cytosolic GFP using the vector pTEFEGFP (A. J. Vanden Wymelenberg, D. Cullen, R. N. Spear, B. Schoenike, and J. H. Andrews, BioTechniques 23:686-690, 1997). The transformed strain Ap1 gfp showed bright fluorescence that was amenable to quantification using fluorescence spectrophotometry. Fluorescence levels in Ap1 gfp blastospore suspensions were directly proportional to the number of viable cells determined by CFU plate counts (r(2) > 0.99). The relationship between cell viability and GFP fluorescence was investigated by adding a range of concentrations of each of the biocides sodium hypochlorite and 2-n-octylisothiozolin-3-one (OIT) to suspensions of Ap1 gfp blastospores (pH 5 buffer). These biocides each caused a rapid (< 25-min) loss of fluorescence of greater than 90% when used at concentrations of 150 microg of available chlorine ml(-1) and 500 microg ml(-1), respectively. Further, loss of GFP fluorescence from A. pullulans cells was highly correlated with a decrease in the number of viable cells (r(2) > 0.92). Losses of GFP fluorescence and cell viability were highly dependent on external pH; maximum losses of fluorescence and viability occurred at pH 4, while reduction of GFP fluorescence was absent at pH 8.0 and was associated with a lower reduction in viability. When A. pullulans was attached to the surface of plasticized poly(vinylchloride) containing 500 ppm of OIT, fluorescence decreased more slowly than in cell suspensions, with > 95% loss of fluorescence after 27 h. This technique should have broad applications in testing the susceptibility of A. pullulans and other fungal species to antimicrobial compounds.

Fungal colonization and biodeterioration of plasticized polyvinyl chloride

Significant substratum damage can occur when plasticized PVC (pPVC) is colonized by microorganisms. We investigated microbial colonization of pPVC in an in situ, longitudinal study. Pieces of pPVC containing the plasticizers dioctyl phthalate and dioctyl adipate (DOA) were exposed to the atmosphere for up to 2 years. Fungal and bacterial populations were quantified, and colonizing fungi were identified by rRNA gene sequencing and morphological characteristics. Aureobasidium pullulans was the principal colonizing fungus, establishing itself on the pPVC between 25 and 40 weeks of exposure. A group of yeasts and yeast-like fungi, including Rhodotorula aurantiaca and Kluyveromyces spp., established themselves on the pPVC much later (after 80 weeks of exposure). Numerically, these organisms dominated A. pullulans after 95 weeks, with a mean viable count +/- standard error of 1,000 +/- 200 yeast CFU cm(-2), compared to 390 +/- 50 A. pullulans CFU cm(-2). No bacterial colonization was observed. We also used in vitro tests to characterize the deteriogenic properties of fungi isolated from the pPVC. All strains of A. pullulans tested could grow with the intact pPVC formulation as the sole source of carbon, degrade the plasticizer DOA, produce extracellular esterase, and cause weight loss of the substratum during growth in vitro. In contrast, several yeast isolates could not grow on pPVC or degrade DOA. These results suggest that microbial succession may occur during the colonization of pPVC and that A. pullulans is critical to the establishment of a microbial community on pPVC.

Plasticizers increase adhesion of the deteriogenic fungus Aureobasidium pullulans to polyvinyl chloride

Initial adhesion of fungi to plasticized polyvinyl chloride (pPVC) may determine subsequent colonization and biodeterioration processes. The deteriogenic fungus Aureobasidium pullulans was used to investigate the physicochemical nature of adhesion to both unplasticized PVC (uPVC) and pPVC containing the plasticizers dioctyl phthalate (DOP) and dioctyl adipate (DOA). A quantitative adhesion assay using image analysis identified fundamental differences in the mechanism of adhesion of A. pullulans blastospores to these substrata. Adhesion to pPVC was greater than that to uPVC by a maximum of 280% after a 4-h incubation with 10(8) blastospores ml(-1). That plasticizers enhance adhesion to PVC was confirmed by incorporating a dispersion of both DOA and DOP into the blastospore suspension. Adhesion to uPVC was increased by up to 308% in the presence of the dispersed plasticizers. Hydrophobic interactions were found to dominate adhesion to uPVC because (i) a strong positive correlation was observed between substratum hydrophobicity (measured by using a dynamic contact angle analyzer) and adhesion to a range of unplasticized polymers including uPVC, and (ii) neither the pH nor the electrolyte concentration of the suspension buffer, both of which influence electrostatic interactions, affected adhesion to uPVC. In contrast, adhesion to pPVC is principally controlled by electrostatic interactions. Enhanced adhesion to pPVC occurred despite a relative reduction of 13 degrees in the water contact angle of pPVC compared to that of uPVC. Furthermore, adhesion to pPVC was strongly dependent on both the pH and electrolyte concentration of the suspension medium, reaching maximum levels at pH 8 and with an electrolyte concentration of 10 mM NaCl. Plasticization with DOP and DOA therefore increases adhesion of A. pullulans blastospores to pPVC through an interaction mediated by electrostatic forces.

An investigation of laser scanning techniques for quantifying changes in facial soft-tissue volume

This paper describes a laser scanning technique to measure accurately changes in facial volume. Three potential sources of error were identified: the registration algorithm, the inherent accuracy of the scanner, and the natural minute-to-minute variability of the human face. In experiments performed to discover the relative magnitude and significance of each source of error, the performance of the registration algorithm was found to be limited by the accuracy of the data, being 1.6 cc, on average, measured over the entire face of a plaster model. Scan-to-scan variability in the shape of the human face was measured at 3.3 cc on average. We conclude that laser scanning is a simple, non-invasive, accurate, and reproducible means of assessing changes in facial volume.

Expanding the nursing repertoire: the effect of massage on post-operative pain

An equivalent groups design with a treatment group of 19 patients and a control group of 20 patients was used to investigate the impact of massage therapy on patients' perceptions of post-operative pain. Data were analysed using analysis of covariance repeated measures (within subjects) design. Controlling for age, the results indicated that massage produced a significant reduction in patients' perceptions of pain over a 24 hour period. A linear positive relationship emerged between patients' age and the duration of the massage. The study indicates that further investigation of the potential for massage to reduce pain is warranted.

Effect of treatment of hyperthyroidism on renal function in cats

OBJECTIVE

To determine whether increases in BUN and serum creatinine (SCr) concentrations, which have been reported to develop after surgical bilateral thyroidectomy in hyperthyroid cats, also develop after treatment of hyperthyroidism with radioactive iodine and methimazole.

DESIGN

Prospective, clinical trial.

ANIMALS

58 hyperthyroid cats.

PROCEDURE

Urine specific gravity, SCr, BUN, and serum thyroxine (T4) concentrations were determined before and 30 and 90 days after treatment of hyperthyroidism with radioactive iodine, methimazole, or surgical bilateral thyroidectomy.

RESULTS

Mean SCr and BUN concentrations determined 30 and 90 days after treatment were significantly higher than those measured before treatment. Mean SCr, BUN, and T4 concentrations were not different among groups before treatment or 30 and 90 days after treatment.

CLINICAL IMPLICATIONS

Reduction of serum T4 concentrations after treatment of hyperthyroidism may result in azotemia in older cats with chronic renal disease. Treating azotemic hyperthyroid cats with methimazole until it can be determined whether correction of the hyperthyroid state will exacerbate the azotemia may be prudent.

A prospective study of isolation of Moraxella catarrhalis in a hospital during the winter months

Sputum samples submitted to the microbiology laboratory from general medical and respiratory wards were monitored for Moraxella catarrhalis on a prospective basis. All isolates were typed by restriction endonuclease typing. Nosocomial spread was found both by the clustering of cases and typing of isolates. Sampling of the environment of some cases was performed. Seven out of 37 samples revealed environmental contamination. Sampling for persistence of the organism in the environment was positive on one occasion out of 13. Evaluation of acquisition of M. catarrhalis in relation to length of stay showed that the average length of stay of a case with M. catarrhalis was considerably longer than average patient stay without M. catarrhalis. Four patients had two isolates available for typing. The type of M. catarrhalis was different on the second occasion to that on the first. Nosocomial spread of M. catarrhalis in the setting of general medical and respiratory wards was found to occur in the winter months.

A case of pseudoanaphylactic reaction to intramuscular procaine penicillin G (Hoigne's syndrome)

A personal record of a pseudoanaphylactic reaction to procaine penicillin G is presented, together with a brief discussion of the topic. Since procaine penicillin is widely used in Papua New Guinea the reaction may be more common than is generally realized. The reaction is not a true anaphylaxis and is probably caused by the procaine component after inadvertent intravenous injection of the drug.

Anxiety and unrealistic optimism

Substantial evidence suggest that people tend to be unrealistically optimistic that positive events will happen to them and that negative events will not. However, recent research indicates that under certain conditions they may be unrealistically pessimistic. Variations in the levels of optimism and pessimism experienced towards events are generally given cognitive explanations. A relation between optimism and pessimism and anxiety, a variable related to emotion as well as cognition, was investigated in the present study. An inverse correlation was found between how anxious female students in England felt about certain negative events and how unrealistically optimistic they were about the occurrence of those events. It was concluded that the degree of anxiety experienced toward a negative event may affect the level of unrealistic optimism or pessimism toward it.