A tool to identify potential primary care presentations in the hospital emergency department

Background

Access to primary care has an impact on health outcomes and is a significant public health issue. Limited access to primary care has seen non-urgent presentations to hospital emergency departments continue to rise globally. A lack of a universal workable definition of what a primary care presentation is has impeded national and international estimations of the true burden. Our aim was to develop a standardised code frame to identify potential primary care patients in the emergency department to allow accurate data estimations to be made, and help inform future interventions.

Methods

An audit of medical records was conducted in two major hospitals in Sydney, Australia. A code frame was developed, tested and applied retrospectively to five years of data.

Results

Of 601,168 presentations to the emergency department, 171,906 (29%) were deemed to be potential primary care presentations. The code frame had a sensitivity of 99.9% and a specificity of 49.0%.

Conclusions

This standardised code frame enables accurate retrospective local and national data estimations of the impact of primary care presentations in the emergency department, which was previously not available. The code frame could be used prospectively to evaluate interventions such as diverting patients to primary care settings, and to identify populations for specifically targeted interventions. The conservative nature of the code frame ensures that only those that can safely receive care in a primary care setting are identified as potential primary care.

Key messages

This robust tool will enable more accurate data estimations of primary care appropriate presentations in the emergency department, which can assist planning and policy efforts. It can be easily adapted to incorporate triage codes in international settings and provides a useful tool for comparing international trends.

The logistical management of tertiary urethral disease in the United Kingdom: Implications from an online audit of male reconstructive urethral surgery

Objective:

To determine those patient groupings, based on volume and risk, whose optimal urethral reconstructive management might be provided by a reorganisation of UK reconstructive surgeons.

Methods:

Between 2010 and 2017, ~689 men/year were enrolled onto an online audit platform collecting data about urethral reconstruction in the UK; this accrual was compared against hospital episode statistics (HES). The available workforce, and where this was based, was collected. Individual and institutional incumbent patient volumes, pathology, surgical complexity and outcomes from treatment were collated to stratify volume/risk groups.

Results:

More than 90% of all HES-recorded data were accrued, being provided by 50 surgeons at 39 operative sites. Most reconstructive surgery was provided at 10 centres performing >20 procedures/year. More than 50% of all interventions were of a high-volume low-risk type. Of activity, 32.3% was intermediate volume or moderate risk, and 12.5% of men presented for lower-volume or higher-risk procedures.

Conclusion:

Correlation of detailed volume/outcome data allows the definition of patient populations presenting for urethral reconstruction. Stratification of each group’s management, to optimise the surgical outcome, may be applied to a hierarchical service delivery model based on the complexity of the patient’s presenting urethral pathology.

Level of evidence:

Level IV

Abstract P6-18-10: A phase 1b/2 study of ribociclib plus trastuzumab for the treatment of advanced, treatment-refractory HER2-positive breast cancer

Introduction:

Despite the success of anti-HER2 therapy, acquired resistance usually develops in the metastatic setting. CDK4/6 pathway activity has been identified as a mediator of this resistance, and in preclinical studies the combination of CDK4/6 and HER2 blockade can be more effective than either therapy alone. We conducted a single-arm phase 1b/2 study of the CDK4/6 inhibitor ribociclib given with trastuzumab or T-DM1 to subjects with advanced, treatment-refractory HER2-positive breast cancer. The results of the trastuzumab cohort are presented below. The primary objective was to determine the clinical benefit rate (CBR) at 24 weeks, and secondary endpoints included objective response rate (ORR), progression-free survival (PFS), and adverse events.

Methods: Individuals with locally advanced or metastatic, measurable HER2-positive breast cancer were eligible. All subjects must have previously received trastuzumab, pertuzumab, and T-DM1 as (neo)adjuvant or metastatic therapy. There was no limit on the number of prior lines of treatment. Patients with previous CDK4/6 inhibitor exposure, QTcF > 450msec on EKG, or without stable brain metastases were excluded. An initial safety run-in phase (with dose-limiting toxicity (DLT) monitoring) included six subjects who received trastuzumab (8mg/kg loading then 6mg/kg IV three-weekly) and ribociclib 400mg PO daily on a continuous schedule (cycle length 21 days). The study had a two-stage design. The first stage required 20 patients, at least 6 of whom must have demonstrated clinical benefit (CR+PR+ SD>24 weeks) in order to recruit 15 more patients to the second stage. All patients with accessible disease underwent metastatic tumor biopsies at baseline and C2D1.

Results: 13 patients were enrolled (6 in the safety run-in and 7 in the expansion cohort). One patient was found to have HER2-negative disease and did not receive treatment. Patient characteristics are shown in Table 1 No DLTs were observed during the safety run-in phase, and ribociclib was thus used at 400mg po daily for the expansion cohort. Grade 3/4 toxicities were observed in 5 patients (41.7%) and included neutropenia (n=2), and fatigue, pain, and muscle weakness (all n=1). No patient demonstrated QTc prolongation >480 msec, or grade 3/4 LFTs. 1/12 patients ((8.3%); 95% CI 0.2%-38.5%) achieved stable disease>24 weeks; no objective responses were observed, and median PFS was 41.5 days. The trastuzumab portion of study was closed early due to limited clinical activity observed (the T-DM1 with ribociclib cohort remains open).

Table 1Age (median, range)50.5 (42 - 71)Number of prior lines of systemic therapy for metastatic disease (median, range)5.5 (0-14)Number with Hormone receptor-positive disease (%)8 (67 %)Number of metastatic sites (median, range)2.5 (2 - 5)

Conclusions: The combination of trastuzumab and ribociclib (400mg daily continuous schedule) is safe, with no new safety signals observed. The limited activity seen in this heavily pretreated population suggests that future efforts to incorporate CDK4/6 inhibition should be limited to a less extensively treat population.

Citation Format: Goel S, Spring L, Rees R, Andrews C, Tahara RK, Mayer EL, Bardia A, Winer EP, Tolaney SM. A phase 1b/2 study of ribociclib plus trastuzumab for the treatment of advanced, treatment-refractory HER2-positive breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-10.

Assessing the toxic effects of DMSO on cord blood to determine exposure time limits and the optimum concentration for cryopreservation

BACKGROUND AND OBJECTIVES

Advantages of using cord blood (CB) over other sources of haematopoietic progenitor cells, such as bone marrow, include the ability to cryopreserve and bank the samples until requested for a transplant. Cryopreservation requires the addition of a cryoprotectant to prevent the formation of intracellular ice during freezing. Dimethyl sulphoxide (DMSO) is commonly used at a concentration of 10% (v/v); however, there is evidence to suggest this chemical is toxic to cells as well as to patients after infusion.

MATERIALS AND METHODS

The toxic effects of DMSO were assessed through cell viability and in vitro functional assays in fresh and post-thaw CB samples before determining the maximum exposure time and optimal concentration for cryopreservation.

RESULTS

A dose-dependent toxicity of DMSO was observed in fresh samples with 40% removing all viable and functional haematopoietic progenitor cells (HPC). In fresh and post-thaw analysis, minimal toxic effect was observed when cryopreservation was delayed for up to 1 h after 10% DMSO addition. After thawing, DMSO washout was superior to dilution or unmanipulated when maintained for long periods (advantage observed 1 h after thawing). Finally, the optimum concentration for cryopreserving CB was found to be 7.5 to 10% with detrimental effects observed outside of this range.

CONCLUSION

These results support the use of 7.5-10% as the optimal DMSO concentration and the maximum exposure time should be limited to <1 h prior to freezing and 30 min post-thaw.

Susceptibility of cat fleas (Siphonaptera: Pulicidae) to fipronil and imidacloprid using adult and larval bioassays

The monitoring of the susceptibility offleas to insecticides has typically been conducted by exposing adults on treated surfaces. Other methods such as topical applications of insecticides to adults and larval bioassays on treated rearing media have been developed. Unfortunately, baseline responses of susceptible strains of cat flea, Ctenocephalides felis (Bouchè), except for imidacloprid, have not been determined for all on-animal therapies and new classes of chemistry now being used. However, the relationship between adult and larval bioassays of fleas has not been previously investigated. The adult and larval bioassays of fipronil and imidacloprid were compared for both field-collected isolates and laboratory strains. Adult topical bioassays of fipronil and imidacloprid to laboratory strains and field-collected isolates demonstrated that LD50s of fipronil and imidacloprid ranged from 0.11 to 0.40 nanograms per flea and 0.02 to 0.18 nanograms per flea, respectively. Resistance ratios for fipronil and imidacloprid ranged from 0.11 to 2.21. Based on the larval bioassay published for imidacloprid, a larval bioassay was established for fipronil and reported in this article. The ranges of the LC50s of fipronil and imidacloprid in the larval rearing media were 0.07-0.16 and 0.11-0.21 ppm, respectively. Resistance ratios for adult and larval bioassays ranged from 0.11 to 2.2 and 0.58 to 1.75, respectively. Both adult and larval bioassays provided similar patterns for fipronil and imidacloprid. Although the adult bioassays permitted a more precise dosage applied, the larval bioassays allowed for testing isolates without the need to maintain on synthetic or natural hosts.

Abstract P6-07-09: Identification of Trophinin associated protein (TROAP) as a novel biological marker in breast cancer (BC): Co-expression of TROAP and TOPO2A predicts response of anthracycline based chemotherapy (ATC-CT)

Introduction: Recently, TOPO2A alteration was found to be a predictor for ATC-CT and by using neural network and pathways analysis of gene expression array data, TROAP gene was revealed as a major hub in TOPO2A pathway and strongly related to genes that are involved in mitotic cell cycle regulation. In addition, we found that TROAP gene was among top 10 ranked genes out of 48,000 of transcripts, that accurately predicted worse clinical outcome, and differentiated between low and high grade based on a 10-fold external cross-validation analysis with an average classification accuracy of &gt;99.999%. TROAP protein is essential for centrosome integrity and proper bipolar organisation of spindle assembly during mitosis and plays essential role in cell proliferation.

In the current study the molecular and clinicopathological functions of TROAP expression and its effect on management of breast cancer have been investigated.

Methods: The co-expression of TROAP and TOPO2A protein was evaluated by using dual immunoflurescent in BC cell lines. In addition both TROAP and TOP2A protein expressions were immunohistochemically (IHC) assessed in 40 normal breast tissues and a well characterised series of 1650 primary BC and were correlated to clinicopathological and other biomarkers. IHC staining was performed using Anti-TROAP rabbit polyclonal (HPA044102; Sigma).

The association between TROAP and response to chemotherapy was investigated in 350 ER negative BC treated with adjuvant ATC-CT and 260 locally advanced BC treated with neoadjuvant ATC-CT. In addition the clinical outcome of TROAP expression was evaluated in a series of 180 ER− high risk BC patients who did not received any CT.

Results: No expression of TROAP protein was observed in normal breast tissue while, 25% of BC showed TROAP protein overexpression. By using dual immunoflurescent in BC cell lines, The MCF7 cells showed strong cytoplasmic TROAP staining with no TOPO2A expression, while The T47D cells did not express TROAP but expressed TOPO2A. SKBr3, MDA468 and MDA231 cell lines showed co-expression of TROAP and TOPO2A. TROAP overexpression was significantly associated with aggressive clinico-pathological features including; high grade, high mitotic rate, absence of hormonal receptors, overexpression of HER2, TOP2A and EGFR (p &lt; 0.001), Triple negative phenotype (p &lt; 0.001), basal-like BC (p &lt; 0.001), p53 mutation (p &lt; 0.001) and inactive p16 (p &lt; 0.001). With regard to outcome, receiving anthracycline chemotherapy had a positive impact on high risk ER− BC patients with TROAP protein over-expression as TROAP protein overexpression showed 50% less risk of recurrence compared to TROAP negative expression; p &lt; 0.0001. Moreover, in locally advanced BC who received anthracycline-based neoadjuvant chemotherapy, 31/81 (39%) of BC with co-expression of TROAP+/TOPO2A+ achieved pCR while none of those with absence of both TROAP−/TOPO2A− (0/51) had achieved pCR (p &lt; 0.00001).

Conclusion: TROAP is an important novel gene implicated in the survival of BC cells and its protein expression is a predictor for Anthracycline CT. TROAP may provide new avenues for the discovery of new predictive marker to guide therapeutic intervention.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-07-09.

Regulation of matrix metalloproteinases - their role in tumor invasion and metastasis

In order for tumor cells to colonise secondary organs and tissues it is necessary for them to be able to complete all the essential steps of the metastatic cascade. We discuss here some of the important aspects of this process, highlighting those events likely to be important in the control of tumor cell invasion. The expression of matrix metalloproteinases (MMP) capable of degrading tissue matrix or basement membranes, constitutes an important feature of tumor cell escape from the primary neoplasm and entry into/ colonisation of the secondary body site. In particular, the balance between MMP and protease inhibitor expression will determine the invasive capacity of a cancer cell. The molecular control of gene expression, together with the molecules important in regulating the production of proteinases and their inhibitors is complex, and the important facets of these pathways are discussed. Cytokines, particularly tumor necrosis factor-alpha (TNF-alpha), interleukin-1 (IL-1) and transforming growth factor-beta (TGF-beta), play a crucial role in modulating MMP-2 and MMP-9 expression, and these, together with other regulatory cytokines constitute an important mechanism whereby the tumor cells can increase their invasive potential through the secretion of proteases.

Canine vector-borne disease pathogens in dogs from south-east Queensland and north-east Northern Territory

OBJECTIVES

To determine the prevalence of canine vector-borne diseases (CVBD: Babesia spp., Anaplasma spp., Ehrlichia spp., haemotropic mycoplasmas and Hepatozoon) in Australian dogs; namely, dogs from pounds in south-east Queensland and an indigenous Aboriginal community in the north-east of the Northern Territory.

DESIGN AND PROCEDURE

Blood samples were collected from 100 pound dogs and 130 Aboriginal community dogs and screened for the CVBD pathogens using polymerase chain reaction (PCR). All positive PCR products were sequenced for species confirmation.

RESULTS

In total, 3 pound dogs and 64 Aboriginal community dogs were infected with at least one CVBD pathogen. Overall, B. vogeli was detected in 13 dogs, A. platys in 49, M. haemocanis in 23, Candidatus Mycoplasma haematoparvum in 3 and C. M. haemobos in 1 dog. Co-infections were detected in 22 Aboriginal community dogs.

CONCLUSIONS

This study found B. vogeli, A. platys and haemotropic mycoplasma infections to be common in dogs in subtropical and tropical areas of Australia. This study also reports for the first time the prevalence and genetic characterisation of haemotropic mycoplasmas in dogs in Australia.

Immunogenicity of MHC Class I Peptides Derived from Leishmania mexicana Gp63 in HLA-A2.1 Transgenic (HHDII) and BALB/C Mouse Models

BACKGROUND

Leishmania is an intracellular parasite infecting humans and many wild and domestic animals. Recent studies have suggested an important role for cytotoxic T cells against Leishmania. Peptide-based vaccines targeting short sequences derived from known immunogenic proteins have been shown to elicit cellular immune responses against disparate pathogens.

METHODS

We predicted four HLA-A2 peptides derived from L. mexican/major gp63 and tested these in HHD II mice, as well as four peptides for mouse MHC class I from the same proteins tested in BALB/ mice.

RESULTS

The results revealed immunogenicity for three of the four peptides predicted for HLA-A2. Immunisation with these peptides, along with IFA, induced CTL responses detected by standard 4-hour cytotoxicity assay and significantly upregulated the production of IFN-γ. When HHDII mice were injected IM with L. mexicana gp63 cDNA and splenocytes were restimulated with blasts loaded with the immunogenic peptides, two of the peptides were able to induce significant level of IFN-γ detected by ELISA. None of the peptides predicted for Balb/c mouse MHC class I elicited CTL activity or significantly upregulated the IFN-γ.

CONCLUSION

The results may help in developing a peptide-based vaccine, which can be applied alone or in combination with drugs against Leishmania.

Leishmania mexicana Gp63 cDNA Using Gene Gun Induced Higher Immunity to L. mexicana Infection Compared to Soluble Leishmania Antigen in BALB/C

BACKGROUND

Leishmaniasis is a worldwide disease prevalent in tropical and sub tropical countries. Many attempts have been made and different strategies have been approached to develop a potent vaccine against Leishmania. DNA immunisation is a method, which is shown to be effective in Leishmania vaccination. Leishmania Soluble Antigen (SLA) has also recently been used Leishmania vaccination.

METHODS

The immunity generated by SLA and L. mexicana gp63 cDNA was compared in groups of 6 mice, which were statistically analysed by student t- test with the P-value of 0.05. SLA was administered by two different methods; intramuscular injection and injection of dendritic cells (DCs) loaded with SLA. L. mexicana gp63 cDNA was administered by the gene gun.

RESULTS

Immunisation of BALB/c mice with L. mexicana gp63 resulted in high levels of Th1-type immune response and cytotoxic T lymphocytes (CTL) activity, which were accompanied with protection induced by the immunisation against L. mexicana infection. In contrast, administration of SLA, produced a mixed Th1/Th2-type immune responses as well as a high level of CTL activity but did not protect mice from the infection.

CONCLUSION

The results indicate higher protection by DNA immunisation using L. mexicana gp63 cDNA compared to SLA, which is accompanied by a high level of Th1 immune response. However, the CTL activity does not necessarily correlate with the protection induced by the vaccine. Also, gene gun immunisation is a potential approach in Leishmania vaccination. These findings would be helpful in opening new windows in Leishmania vaccine research.

Penile reconstruction for a case of genital lymphoedema secondary to proteus syndrome

To our knowledge penile lymphoedema secondary to Proteus syndrome has not previously been reported. Hence we report a case of a 16-year-old male who was referred with features of right hemi-hypertrophy and severe lymphoedema affecting his scrotum and penis. He had previously undergone scrotal reduction surgery at the age of 13, but had since developed worsening penile oedema. His main concern was that of cosmetic appearance prior to sexual debut, and he also complained of erectile dysfunction. An MRI confirmed gross oedema of the penile skin, but normal underlying cavernosal structure, and no other anatomical abnormality. Under general anaesthesia, the entire diseased penile skin was excised. Two full thickness skin grafts were harvested from the axillae, and grafted onto the dorsal and ventral penile shaft respectively. A compressive dressing and urinary catheter was applied for 7 days. Follow-up at 4 months confirmed complete graft take with minimal scarring, and the patient was very satisfied with the cosmetic outcome. He had also noticed a recovery in erectile activity, and feels psychologically and physically more prepared for sexual relations.

High-throughput ultra-high-performance liquid chromatography/tandem mass spectrometry quantitation of insulin-like growth factor-I and leucine-rich alpha-2-glycoprotein in serum as biomarkers of recombinant human growth hormone administration

Insulin-like growth factor-I (IGF-I) is a known biomarker of recombinant human growth hormone (rhGH) abuse, and is also used clinically to confirm acromegaly. The protein leucine-rich alpha-2-glycoprotein (LRG) was recently identified as a putative biomarker of rhGH administration. The combination of an ACN depletion method and a 5-min ultra-high-performance liquid chromatography/tandem mass spectrometry (uHPLC/MS/MS)-based selected reaction monitoring (SRM) assay detected both IGF-I and LRG at endogenous concentrations. Four eight-point standard addition curves of IGF-I (16-2000 ng/mL) demonstrated good linearity (r(2) = 0.9991 and coefficients of variance (CVs) <13%). Serum samples from two rhGH administrations were extracted and their uHPLC/MS/MS-derived IGF-I concentrations correlated well against immunochemistry-derived values. Combining IGF-I and LRG data improved the separation of treated and placebo states compared with IGF-I alone, further strengthening the hypothesis that LRG is a biomarker of rhGH administration. Artificial neural networks (ANNs) analysis of the LRG and IGF-I data demonstrated an improved model over that developed using IGF-I alone, with a predictive accuracy of 97%, specificity of 96% and sensitivity of 100%. Receiver operator characteristic (ROC) analysis gave an AUC value of 0.98. This study demonstrates the first large scale and high throughput uHPLC/MS/MS-based quantitation of a medium abundance protein (IGF-I) in human serum. Furthermore, the data we have presented for the quantitative analysis of IGF-I suggest that, in this case, monitoring a single SRM transition to a trypsin peptide surrogate is a valid approach to protein quantitation by LC/MS/MS.

Animal-type melanoma: a clinical and histopathological study of 22 cases from a single institution

Background Animal-type melanoma is a rare distinct melanoma subtype, characterized by proliferation of heavily pigmented epithelioid and spindled melanocytes that resembles the heavily pigmented melanomas seen in grey horses. While animal-type melanoma is generally considered to be more indolent than conventional melanoma, only a limited number of cases have been reported and, as such, the clinical characteristics of animal-type melanoma are incompletely understood. Objectives To characterize the clinical and histopathological features of animal-type melanoma, and determine any features that may predict outcome. Patients/Methods Data was extracted from a prospectively collected melanoma database (1994-2008), and a retrospective pathology database (1991-2008) for all patients with a diagnosis of both equivocal (8) and unequivocal (14) malignant animal-type melanoma. We reviewed the clinical and histopathological features, including the sentinel lymph node biopsy (SLNB) status. Results A total of 22 patients were identified, with a median age of 35 years. The median Breslow depth was 2.22 mm. A SLNB was performed in 17 patients, eight (47%) were positive. Younger age was associated with: (i) animal-type melanoma with features equivocal for malignancy (median age of 7 vs. 48 years, P = 0.01), and (ii) a negative SLNB (median age 12 vs. 53 years, P = 0.03). Four patients with unequivocal animal-type melanoma developed recurrent metastatic disease, with one patient death. No patient with an equivocal animal-type melanoma or negative SLNB developed recurrent disease; however, this did not reach statistical significance (P = 0.13 and P = 0.09, respectively). Conclusions Animal-type melanoma has a propensity for regional lymphatic metastasis and is rarely capable of disseminated metastatic disease and death. Animal-type melanoma appears to exhibit a spectrum of biological behaviour, with young patient age associated with more indolent disease.

Serum biomarker profiling in cancer studies: a question of standardisation?

Companion animals are exposed to similar environmental conditions and carcinogens as humans. In some animal cancers, there also appears to be the same genetic changes associated as in humans. However, little work has been carried out in cancer biomarker identification in animals. The recent dramatic advances in molecular medicine, genomics, proteomics and translational research will allow biomarker identification, which may provide the best strategies for veterinarians and clinicians to combat disease by early diagnosis and administration of effective treatments. Proteomics may have important applications in cancer diagnosis, prognosis and predictive clinical outcome that could directly change clinical practice by affecting critical elemen-ts of care and management. This review summarizes the advances in proteomics that has propelled us to this exciting age of clinical proteomics, and highlights the future work that is required for this to become a reality. In this review, we will discuss the available proteomic technologies and their limitations, and highlight the key areas of research and how they have been used to discover cancer biomarkers. The principles described here are equally applicable to human and animal disease, but implementation of 'omic' technologies requires stringent guidelines for collection of clinical material, the application of analytical techniques and interpretation of the data.

Young people and mental health: novel methods for systematic review of research on barriers and facilitators

This paper describes how barriers to, and facilitators of, good mental health amongst young people (11-21 years) were elucidated from a systematic review of studies of young people's views and how these barriers and facilitators were compared with effectiveness studies to identify effective and appropriate interventions, promising interventions needing further evaluation and the need for further intervention. All studies were published before 2000. No clear pattern for effectiveness emerged in terms of mental health promotion focus, the type of intervention, intervention provider or young people. Well-evaluated interventions neither always target what we know young people themselves see as important barriers to their mental health (for instance, loss of friends and family, violence and bullying) nor always build on what they see as key facilitators, particularly their preferred coping strategies. In particular, while young people see material and physical resources as major influences on their mental health, few evaluated interventions targeted these. Rigorously evaluated interventions more often addressed priorities not raised by young people themselves and populations at low risk for mental health problems. These innovative review methods can inform intervention development and evaluation in a new way based on the strengths and needs identified by the target population.

Characterization of biomarkers in polycystic ovary syndrome (PCOS) using multiple distinct proteomic platforms

A variety of prefractionation methods (including a novel reversed-phase solid-phase-extraction (RP-SPE) combined with SDS-PAGE and proteomic based approaches (e.g., 2-dimensional gel electrophoresis (2DE) and MALDI-TOF mass spectrometry combined with Artificial Neural Network (ANN) bioinformatic tools) were used to investigate the protein/peptide signatures in patients with Polycystic Ovary Syndrome (PCOS). Four potential PCOS biomarkers were identified (complement C4alpha3c and C4gamma and haptoglobin alpha and beta chains).

Assessment of generalisability in trials of health interventions: suggested framework and systematic review

Most evaluations of new treatments use highly selected populations, making it difficult to decide whether they would work elsewhere. Systematic evaluation and reporting of applicability is required

Young people and healthy eating: a systematic review of research on barriers and facilitators

A systematic review was conducted to examine the barriers to, and facilitators of, healthy eating among young people (11-16 years). The review focused on the wider determinants of health, examining community- and society-level interventions. Seven outcome evaluations and eight studies of young people's views were included. The effectiveness of the interventions was mixed, with improvements in knowledge and increases in healthy eating but differences according to gender. Barriers to healthy eating included poor school meal provision and ease of access to, relative cheapness of and personal taste preferences for fast food. Facilitators included support from family, wider availability of healthy foods, desire to look after one's appearance and will-power. Friends and teachers were generally not a common source of information. Some of the barriers and facilitators identified by young people had been addressed by soundly evaluated effective interventions, but significant gaps were identified where no evaluated interventions appear to have been published (e.g. better labelling of food products), or where there were no methodologically sound evaluations. Rigorous evaluation is required particularly to assess the effectiveness of increasing the availability of affordable healthy food in the public and private spaces occupied by young people.

Surveillance in patients with sarcoma of the extremities

AIM

To evaluate the efficiency of our follow-up regime for patients with sarcoma of the extremities.

METHODS

We have reviewed our follow-up policy in 480 patients with non-metastatic bone or soft tissue sarcomas and with more than 5 years of follow-up.

RESULTS

We detected 24% of the soft tissue sarcoma recurrences and 38% of the bone tumour recurrences. We detected 67% of the pulmonary metastases before they became symptomatic. Only 11% of those patients who developed metastases were cured, as were only 26% of those who developed local recurrence.

CONCLUSIONS

This study shows that our surveillance programme detects most metastases, but only about one third of the local recurrences.

Involving consumers in research and development agenda setting for the NHS: developing an evidence-based approach

OBJECTIVES

To look at the processes and outcomes of identification and prioritisation in both national and regional R&D programmes in health and elsewhere, drawing on experiences of success and failure. Also to identify the barriers to, and facilitators of, meaningful participation by consumers in research identification and prioritisation.

DATA SOURCES

Electronic databases and interviews with UK consumers and research programme managers.

REVIEW METHODS

A framework was devised for examining the diverse ways of involving consumers in research. It identified key distinguishing features as: the types of consumers involved; whether consumers or researchers initiated the involvement; the degree of consumer involvement (consultation, collaboration or consumer control); forums for communication (e.g. committees, surveys, focus groups); methods for decision-making; and the practicalities for implementation. Context (institutional, geographical and historical setting) and underpinning theories were considered as important variables for analysing examples of consumer involvement. This innovative framework was then applied to the review data from reports selected for inclusion and interviews.

RESULTS

The study found 286 documents explicitly mentioning consumer involvement in identifying or prioritising research topics. Of these, 91 were general discussions, some of which included a theoretical analysis or a critique of research agendas from a consumer perspective, 160 reported specific efforts to include consumers in identifying or prioritising research topics and a further 51 reported consumers identifying or prioritising research topics in the course of other work. Detailed reports of 87 specific examples were identified. Most of this literature was descriptive reports by researchers who were key actors in involving consumers. A few reports were written by consumer participants. Fewer still were by independent researchers. Our conclusions are therefore not based on rigorous research, but implications for policy are drawn from individual reports and comparative analyses.

CONCLUSIONS

Productive methods for involving consumers require appropriate skills, resources and time to develop and follow appropriate working practices. The more that consumers are involved in determining how this is to be done, the more research programmes will learn from consumers and about how to work with them. Further success might be expected if research programmes embarking on collaborations approach well-networked consumers and provide them with information, resources and support to empower them in key roles for consulting their peers and prioritising topics. To be worthwhile, consultations should engage consumer groups directly and repeatedly in facilitated debate; when discussing health services research, more resources and time are required if consumers are drawn from groups whose main focus of interest is not health. These barriers can largely be overcome with good leadership, purposeful outreach to consumers, investing time and effort in good communication, training and support and thereby building good working relationships and building on experience. Organised consumer groups capable of identifying research priorities also need to find ways of introducing their ideas into research programmes. Further research is suggested to develop and evaluate different training methods, information and education and other support for consumers and those wishing to involve them; to address the barriers to consumers' ideas influencing research agendas; and to carry out prospective comparative studies of different methods for involving consumers. Research about collective decision-making would also be further advanced by addressing the processes and outcomes of consensus development that involves consumers.

Internal fixation after intra-articular fracture of the distal ulna

We describe a patient who sustained a displaced isolated intra-articular fracture of the distal ulna, causing limitation of rotation of the forearm. The extent of displacement of the fracture which was not evident on plain radiographs was revealed by CT. The fracture was reduced and internally fixed using a standard technique applicable to the fixation of fractures of the radial head. Full movement was restored. An isolated injury to the distal ulna is rare and requires careful clinical and radiological assessment.

Current management of torus fractures of the distal radius

The use of a forearm cast for paediatric buckle fractures of the distal radius is widespread practice. These fractures do not displace and follow-up in fracture clinic is only for cast removal. This may mean missed school for the child, or work for parents. Modern materials allow a robust lightweight backslab to be used for protection of these stable, though painful, injuries. Unlike a plaster of Paris backslab, Prelude (Smith and Nephew) is removed by unwrapping the outer bandage. Parents can do this at home. We prospectively studied 41 consecutive children aged 12 years or less with buckle fractures of the distal radius, presenting to our fracture clinic. After the diagnosis of isolated buckle fracture was confirmed, a Prelude backslab was applied. Parents were given a full explanation and written instructions, which were also sent to the GP. Telephone follow-up was carried out at 3-4 weeks. Forty out of forty-one parents expressed satisfaction with both the treatment and the instructions. The parents of one patient misunderstood the instructions, represented to fracture clinic and were dissatisfied for this reason.With modern casting materials and adequate instructions in fracture clinic, further follow-up of patients with buckle fractures is unnecessary. Resource savings can be made in this way with no compromise to patient care and increased patient/parent satisfaction.

Modelling mutagenicity using properties calculated by computational chemistry

The recent advances in combinatorial chemistry and high throughput screening technologies have led to an explosion in the numbers of possible therapeutic candidates being produced at the early stages of drug discovery. This rapid increase in the number of chemicals to be classified results in a greater need for alternative methods for the prediction of toxicity. Most QSAR models for mutagenicity have been constructed for congeneric series. The prediction requirements of the pharmaceutical industry, however, cover quite diverse chemical structures. This paper reports a study of mutagenicity data for a diverse set of 90 compounds. Good discriminant models have been built for this data set using properties calculated by the techniques of computational chemistry. Jack-knifed (leave one out) predictions for these models are of the order of 85%.

Renal effects of recombinant prolactin in anaesthetized rats

OBJECTIVE

To re-examine the controversial possibility that prolactin exerts renal effects, using recombinant mouse prolactin (rmP), in the presence and absence of circulating vasopressin.

DESIGN

In experiment 1, the renal effects of rmP were examined in anaesthetized Brattleboro rats with hereditary hypothalamic diabetes insipidus (BDI) lacking circulating vasopressin and normal animals of the parent Long Evans (LE) strain. In experiment 2, salt and water excretion were studied in fluid-loaded normal Sprague-Dawley (SD) rats, some of which received rmP.

METHODS

In experiment 1, BDI and LE rats maintained in fluid balance were infused i.v. with each of three concentrations of rmP (10, 20 and 40 microg/ml per h) or maintained on 150 mmol/l NaCl vehicle (controls). In experiment 2, the SD rats were infused with 75 mmol/l NaCl in order to induce a state of diuresis comparable to that of BDI rats, some of them then receiving the rmP i.v.

RESULTS

A profound rmP-induced dose-dependent decrease in urine excretion (P<0.005) and a lesser decrease in sodium excretion in the BDI rats was in marked contrast with the small but significant increase in urine excretion in the LE rats compared with controls (P<0.025). The rmP-infused fluid-loaded SD rats also demonstrated a significant (P<0.05) dose-related antidiuresis compared with the control animals, in addition to a decrease in sodium excretion.

CONCLUSIONS

These results show that prolactin has a profound antidiuretic effect in the absence of circulating vasopressin. In contrast, when vasopressin is present in the circulation rmP has a small, but opposite, diuretic effect. Thus the use of a recombinant prolactin has provided evidence for renal effects of this hormone which are modified in the presence of the circulating neurohypophysial hormone vasopressin.

The prevalence of complementary and alternative medicine use among the general population: a systematic review of the literature

OBJECTIVE

To conduct a systematic review of published research investigating the prevalence of complementary and alternative medicine (CAM) use in the general population.

DESIGN

A protocol was developed for a systematic review of survey literature identified using two bibliographic databases and citation tracking. The protocol specified criteria for: 1) database searches; 2) selection of studies for review; and 3) description of methodological and substantive aspects of the studies.

RESULTS

Twelve studies were reviewed. These estimated the prevalence of CAM use in Australia, Canada, Finland, Israel, the UK, and the USA. The most rigorous studies, conducted in Australia and the USA, showed that a high proportion of the population was using CAM. There was evidence from the USA that CAM use increased significantly among the general population during the 1990s.

CONCLUSION

CAM is used by substantial proportions of the general population of a number of countries, but differences in study design and methodological limitations make it difficult to compare prevalence estimates both within and between countries.

Disabled infectious single-cycle herpes simplex virus as an oncolytic vector for immunotherapy of colorectal cancer

New modalities of treatment for colorectal cancer are required to support and improve those currently available. One such approach is immunotherapy by transfer of immunostimulatory genes to tumor cells. Here, we report the use of a herpes simplex virus (HSV) vector that is capable of a single round of infection (disabled infectious single-cycle [DISC]-HSV) as a gene transfer vehicle for colorectal cancer. This vector has potential advantages over other vectors for cancer immunotherapy in that it lyses infected tumor cells. Infection with DISC-HSV inhibited tumor cell growth both in vitro and in vivo. In addition, DISC-HSV-mediated cell killing occurs by both apoptotic and necrotic mechanisms. A range of colorectal tumor cell lines could be rapidly transduced with DISC-HSV/lacZ (14-90% in 4 hr). Both tumor prevention and tumor therapy protocols showed clear antitumor effects with DISC-HSV/mGM-CSF. In the prophylactic approach, an infected/irradiated whole cell vaccine protected up to 80% of mice from rechallenge. In addition, intratumoral injection of established tumors with DISC-HSV/GM-CSF caused rejection in 40% of mice and generated some protection from subsequent rechallenge. In both cases, however, it is clear that a dominant therapeutic effect of the DISC-HSV vector derives from its oncolytic properties, irrespective of the transduced gene. As a prelude to taking these studies forward to human clinical trials, we demonstrate that tumor cells could be successfully grown from freshly obtained human colorectal cancer resections (within 1 week of surgery), were transduced with DISC-HSV/hGM-CSF, and secreted the cytokine. This study provides the preclinical basis for trials of immunotherapy of colorectal cancer using DISC-HSV.

Acupuncture for migraine and headache in primary care: a protocol for a pragmatic, randomized trial

This paper presents the protocol for a randomized trial of acupuncture for migraine and headache.

SUBJECTS

Four hundred patients with migraine or headache will be recruited from GP practices.

INCLUSION CRITERIA

Eighteen to 65 years old, contractable by telephone, onset at least 1 year prior at age less than 50, two headaches per month in the previous 6 months, adequate data completion and headache severity during pre-randomization baseline.

EXCLUSION CRITERIA

Pregnancy or malignancy, cluster headache, serious pathological aetiology, cranial neuralgia, acupuncture treatment in the past year.

DESIGN

Following a 4-week baseline, patients will be allocated to acupuncture or control by minimized randomization. Up to 12 acupuncture treatments will be provided by advanced members of the Acupuncture Association of Chartered Physiotherapists. The type of acupuncture given will be recorded. STUDY MEASURES: Outcome will be assessed by headache diary, medication diary and SF36 at 3 months and 1 year. Resource use and days off sick will be assessed by quarterly questionnaire. Adverse events will be monitored by self-report. The primary outcome measure will be the change in mean daily headache score between baseline and the 1 year follow-up. An economic evaluation will also be undertaken.