Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Conversion of leftover ice cream into bakery product for food sustainability

Food sustainability has become so important nowadays not only in order to ensure all raw materials are converted into food for consumption, but also to recycle leftover food for gastronomy. The innovative product created from leftover or unfinished food is a good alternative to throwing away food by-products. In this study, the unutilized ice cream post -selling or post-production process was reformulated with other ingredients to produce bakery products such as cake. Four different cake formulations were used which consisted of melted leftover ice cream, instant cake mix and eggs. The physical qualities of the samples were investigated, and sensory evaluation was also conducted. Cake made conventionally from instant cake mix without the addition of the leftover ice cream was used as a control sample in this study. Cake produced from melted ice cream using three eggs (sample A) had the highest moisture content among all samples which was 39.09%. The control sample had the highest specific volume (2.99 cm3 /g) which indicated a high amount of air remained in the structure after baking. All samples showed a positive symmetry index which indicated good expansion except for cake produced from melted ice cream with no egg (sample D). Cake produced from melted ice cream with no egg (sample D) had the lowest firmness as compared to other cake samples. Cake produced using melted ice cream which contained two eggs (Sample B) had the highest value of springiness which was 0.94 mm. A plot of chewiness as a function of firmness with an R 2 value of 0.9887 confirms the positive correlation between firmness and chewiness. From the sensory evaluation conducted, the cake produced from melted ice cream using three eggs (sample A) scored the highest mark for colour, aroma, sweetness, taste and overall acceptability among the formulated cakes. The results suggested that using melted ice cream as the base ingredient for cake making would tremendously help in solving food waste created by the by-product of the ice cream business and turn it into profit.

Pityriasis rubra pilaris-like eruption following administration of the BNT163b2 (Pfizer-BioNTech) mRNA COVID-19 vaccine

We describe a case of a pityriasis rubra pilaris (PRP)-like eruption occurring following administration of the Pfizer-Biontech mRNA COVID-19 vaccine, with worsening of the condition following the second dose. To our knowledge, this is the first reported case of a PRP-like eruption as a cutaneous adverse event of the Pfizer-Biontech mRNA COVID-19 vaccine.

Immunohistochemical expression of PCNA, STRO-1 and CD 44 in the healing of experimentally induced periapical lesions in rats

OBJECTIVE

The aim of the study was to determine the expression of cell proliferating marker, anti-proliferating cell nuclear antigen (anti-PCNA) and mesenchymal stem cell (MSC) markers (anti-STRO-1 and anti-CD44) in periapical periodontitis and their role in the healing of periapical lesion in periapical periodontitis.

MATERIALS AND METHODS

Ninety Sprague-Dawley male rats (100 g) were divided into 3 groups: Experimental group I (EG I: n = 30), experimental group II (EG II: n=30) and control group (CG: n = 30). Periapical lesions were experimentally developed by leaving the dental pulp of maxillary first molars mesial root open to oral environment for 4 weeks. Conventional root canal treatment was performed in EG II. Maxillary first molars along with alveolar bone were resected and fixed. The processed samples were stained with routine hematoxylin and eosin (H&E), and evaluated immunohistochemically using antibodies against anti-PCNA, anti-STRO-1, and anti-CD44 polyclonal antibodies. Data were analyzed using Chi-square test and a p-value of <0.05 was considered significant.

RESULTS

Immunostaining of anti-PCNA showed 30%, 70% and 53.3% positive staining in CG, EG I, and EG II, respectively (p<0.001). Moreover, the CD44 staining was 20% in CG in contrast to 63.6% in EG I and 43.3 in EG II. STRO-1 staining in CG was 10%, 50% in the EG I and 36.6% in the EG II (p<0.001).

CONCLUSIONS

Periapical inflammatory tissues expressed significant proliferative cell marker PCNA and mesenchymal stem cell markers STRO-1, and CD44. These findings further reaffirm the promising role of mesenchymal stem cells in the healing of periapical periodontitis.

Illusion of coronary artery chronic total occlusion-associated ventricular arrhythmia: results from a multi-centre study

Background/Introduction

Coronary artery chronic total occlusion (CTO) is frequently encountered in patients with established coronary artery disease (CAD) with a reported incidence of more than thirty percent in this population (1). A previous large single-centre study established CTO as an independent risk factor for occurrence of ventricular arrhythmia in patients with ICD and ischemic heart disease (2). The significance of CTO in all-comers has not been investigated. In this large retrospective data, it was analysed that there is no significant difference in ventricular arrhythmia occurrence in patients with CTO versus those with CAD and no CTO.

Purpose

The purpose of this study is to examine the association between CTO and ventricular arrhythmia in patients with CAD using a pooled de-identified database.

Methods

This retrospective observational study used IBM Explorys, which is a pooled de-identified multi-institutional database of more than 60 million unique patients in the United States. A search was done to identify patients with CTO and those with CAD with the exclusion of CTO diagnosis. The data were analysed for ventricular tachycardia (VT) and/or ventricular fibrillation (VF) occurrence. The data were stratified by presence of systolic HF to identify possible effect modification. Statistical analysis was performed by calculating odds ratios (OR) with associated confidence intervals.

Results

Among the 190 patients with the diagnosis of CTO, 11.8% had VT/VF. Of the 2,796,600 patients with CAD and no CTO, 6.9% had VT/VF. The diagnosis of CTO was associated with an increased risk for VT/VF with OR 1.7143 (1.0786, 2.7247), p&lt;0.05. Upon stratification by presence or absence of systolic HF, there was no statistically significant difference in occurrence of VT/VF in the two strata. In the systolic HF group, the OR was 1.4331 (0.6708, 3.0619), p=0.47; the no systolic HF group had OR 0.9717 (0.5123, 1.843), p=0.92. In patients with CAD, the diagnosis of systolic HF was associated with an increased risk of CTO with OR 2.5616 (1.7268, 3.7999), p&lt;0.05.

Conclusion

Stratification by presence or absence of systolic HF yielded inconsistent and statistically insignificant odds ratios compared to the all-comers group, suggesting effect modification by HF with no statistically significant association between CTO and VT/VF. These findings from this large multicentre retrospective data suggest that CTO itself is not an independent risk factor for ventricular arrhythmia in patients with CAD. Limitations of this study include that it is a retrospective pooled analysis without individualised data on ejection fraction and the inability to distinguish if the CTO was infarct-related. Further prospective studies are needed to evaluate the significance of CTO in patients with CAD as it pertains to ventricular arrhythmia.

Funding Acknowledgement

Type of funding sources: None.

1600 Assessing Necessity and Cost-Effectiveness of Routine Pre-Thyroidectomy Group and Save Tests

Aim

To determine the necessity and cost effectiveness of routine blood group and save tests (G&S) before thyroidectomy

Background

Sub-total or total thyroidectomy is the mainstay of treatment for several thyroid disorders. The incidence of post-thyroidectomy haemorrhage has been reported between 0.36% and 4.3% in the literature. Many patients undergo routine G&S testing in anticipation of a peri-operative haemorrhage requiring blood transfusion.

Method

Retrospective review identified 276 patients undergoing an elective total or sub-total thyroidectomy at a London University Teaching Hospital between February 2018 and August 2020. Electronic medical and transfusion department records were audited to identify patients who had pre-operative G&S tests, pre-operatively reserved blood products and peri-operative transfusions.

Results

261 (94.6%) patients had a valid pre-operative group and save test. 17 (6.16%) patients had a total of 61 units of blood products ordered pre-operatively. Only 2 patients required transfusion.

Conclusions

The blood transfusion rate for elective thyroidectomies at this centre was 0.72%. Routine G&S tests cost the trust thousands of pounds and create unnecessary burden on healthcare providers’ time and hospital resources. We propose that routine pre-operative G&S tests are unnecessary for elective thyroidectomies.

1384 Managing Peri-Orbital and Orbital Cellulitis: A New Multi-Specialty Care Pathway

Aim

1) To review current practice in the diagnosis and management of peri-orbital and orbital cellulitis in children at a London University Teaching Hospital. 2) To design and implement a streamlined, multi-specialty care pathway to improve the quality of care.

Background

Clinical differentiation between peri-orbital cellulitis and orbital cellulitis is often difficult, especially in young children. Early recognition and aggressive, multi-specialty treatment are required in order to prevent any vision and life-threatening sequelae.

Method

A retrospective case note analysis was performed for all paediatric patients with suspected peri-orbital or orbital cellulitis over a nineteen-month period. Extensive literature review was undertaken to ascertain current best practice in diagnosis and management. A streamlined, multi-specialty care pathway was developed, ratified by specialist departments, and introduced to optimise safety and quality of care.

Results

The results correlate with trends found in recent literature. 94.3% of patients had a blood culture taken with only 9.1% being positive. There were inadequate eye (37.1%) and endonasal (17.1%) cultures. Wide variation was noted in the criteria for imaging and in the antibiotic regimen used. 25.7% of patients received any nasal treatment. Suboptimal specialist review was identified in both orbital (60%) and peri-orbital (50.0%) cellulitis.

Conclusions

The new care pathway clearly informs investigation and empiric treatment based on initial risk stratification. The paediatric team is now the main, named care provider responsible for coordinating specialist input.

925 Is Routine Bloods Group and Save Required for Emergency Appendicectomy?

Introduction

Appendicectomy is commonly a safe and low bleeding risk procedure. However, some hospital guidelines stipulate a requirement for routine pre-operative blood group and save (G&S).We aim to determine if pre-operative G&S is required for appendicectomies by looking at the number of tests vs transfusion conducted.The cost of G&S is £4.14 per sample in our trust.

Method

A retrospective review was conducted over a 3-month period. Patient data and demographics were identified using the hospital coding, theatre records and transfusion departments.

Results

118 consecutive appendicectomies were identified. Of which, 99 laparoscopic vs 19 open (13 started open vs 6 converted to open) operations were performed. No patients required a blood transfusion during their admission. There was a total of 219 G&S conducted. Cross matching tests for these procedures cost a total of £906. We estimate a cost projection of £3624 for G&S tests over a year and £18120 over 3 years.

Conclusions

Bleeding complications requiring transfusion following appendicectomies are very uncommon. In our unit, 0% of patients identified required a transfusion during their admission. We suggest stopping routine pre-operative G&S for these patients would be clinically safe and would lead to financial savings and reduce pre-operative waiting time.

902 Too Hot to Handle? Acute Cholecystitis (‘Hot Gallbladder’) Management and Compliance with NICE Guidelines in A District General Hospital

Introduction

Current NICE guidelines recommend that patients with acute cholecystitis should be offered laparoscopic cholecystectomy within 1 week of diagnosis. However, the recommendation is often not met within our trust. We aim to investigate our compliance with these guidelines while outlining the complications and cost effects associated with delayed operation.

Method

A retrospective study identifying emergency patients presenting with image proven uncomplicated acute cholecystitis was performed. Hospital coding and finance departments were used to obtain this information.

Results

166 patients were identified within a 3-month period. Of which, 85 patients were diagnosed with acute uncomplicated cholecystitis and fulfilled the inclusion criteria. On average, patients waited 108 days for their cholecystectomies (range 14-281). No patients received a cholecystectomy within 1 week of diagnosis. 33 patients re-presented to hospital at least once and the total number of repeated admissions was 51. The average length of stay during readmissions was 6 days (range 1-27). The total cost incurred for those readmissions was £117,118.

Conclusion

Endogenous indole-3-acetamide levels contribute to the crosstalk between auxin and abscisic acid, and trigger plant stress responses in Arabidopsis

The evolutionary success of plants relies to a large extent on their extraordinary ability to adapt to changes in their environment. These adaptations require that plants balance their growth with their stress responses. Plant hormones are crucial mediators orchestrating the underlying adaptive processes. However, whether and how the growth-related hormone auxin and the stress-related hormones jasmonic acid, salicylic acid, and abscisic acid (ABA) are coordinated remains largely elusive. Here, we analyse the physiological role of AMIDASE 1 (AMI1) in Arabidopsis plant growth and its possible connection to plant adaptations to abiotic stresses. AMI1 contributes to cellular auxin homeostasis by catalysing the conversion of indole-acetamide into the major plant auxin indole-3-acetic acid. Functional impairment of AMI1 increases the plant's stress status rendering mutant plants more susceptible to abiotic stresses. Transcriptomic analysis of ami1 mutants disclosed the reprogramming of a considerable number of stress-related genes, including jasmonic acid and ABA biosynthesis genes. The ami1 mutants exhibit only moderately repressed growth but an enhanced ABA accumulation, which suggests a role for AMI1 in the crosstalk between auxin and ABA. Altogether, our results suggest that AMI1 is involved in coordinating the trade-off between plant growth and stress responses, balancing auxin and ABA homeostasis.

A population-based study of pulmonary monitoring and toxicity for patients with testicular cancer treated with bleomycin

Background

Bleomycin is commonly used to treat advanced testicular cancer and can be associated with severe pulmonary toxicity. The primary objective of the present study was to describe the use of pulmonary function tests (pfts) and chest imaging before, during, and after treatment with bleomycin.

Methods

To identify all incident cases of testicular cancer treated with bleomycin-based chemotherapy in the Canadian province of Ontario during 2005-2010, the Ontario Cancer Registry was linked with chemotherapy treatment records. Health administrative databases were used to describe use of pfts, chest imaging, and physician visits for respiratory complaints.

Results

Of 394 patients treated with orchiectomy and chemotherapy who received at least 1 dose of bleomycin, 93% had complete chemotherapy records available. In the 4 weeks before, during, and within 2 years after finishing bleomycin-based chemotherapy, pfts were performed in 17%, 17%, and 29% of patients respectively. Chest imaging was performed in 68%, 62%, and 98% of patients in the same time periods. In the 2 years after bleomycin-based chemotherapy, 23% of treated patients had a physician visit for respiratory symptoms. That rate was substantially higher for men with greater exposure to bleomycin: 40% (24 of 60) for 10-12 doses bleomycin compared with 21% (53 of 250) for 7-9 doses and with 14% (8 of 58) for 1-6 doses (p = 0.002).

Conclusions

Quality improvement initiatives are needed to increase baseline rates of chest imaging within 4 weeks of starting chemotherapy for testicular cancer; to understand why such a high proportion of men have chest imaging during bleomycin-based chemotherapy; and to mitigate the excess pulmonary toxicity seen with increasing exposure to bleomycin.

Prognostic utility of cardiopulmonary exercise testing indices in arrhythmogenic right ventricular cardiomyopathy

Introduction

Cardiopulmonary exercise testing (CPET) has an established role in the clinical evaluation of exercise intolerance and in the risk stratification of patients with heart failure. There is limited data assessing its prognostic utility in the evaluation of patients with Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC). The predisposition of patients with ARVC for ventricular arrhythmias and sudden cardiac death has led to recommendations for exercise restrictions and limits our understanding of how the impairment in oxygen extraction and cardiac output impact disease progression and outcomes in these patients.

Purpose

We examined the association between CPET indices and event free survival (time to mortality or cardiac transplantation) in patients with Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC).

Methods

Patients with definite ARVC based on 2010 task force criteria and genetically positive were enrolled into our institutional ARVC registry. 43 patients underwent CPET and have been included in our analyses. Indications for testing included: Evaluation of exercise-induced palpitations/arrhythmias or syncope (37%), pharmacotherapy optimization (28%), heart failure evaluation (19%), and ARVC management decisions (16%). CPET data (peak oxygen consumption (pVO2), respiratory exchange ratio (RER), and ventilatory efficiency (VE/VCO2) were assessed in patients at time of initial evaluation. Median follow-up time was 4.9 years (IQR 9 years).

Results

126 patients were studied (age 43.7+ 15 yrs; 41% women; LVEF 57+ 11%; 15% with LVEF &lt;50%) and 43 underwent CPET evaluation. 41 patients (95%) performed at near maximal effort (RER &gt;1) and no fatal events were reported during testing. During the follow up period, the outcome (death or cardiac transplantation) occurred in 31 patients. On Kaplan Meier analysis, pVO2 ≤14 mL/kg/min was associated with worse outcomes (unadjusted p&lt;0.001). Peak oxygen consumption (pVO2) ≤14 mL/kg/min and ventilatory efficiency (VE/VCO2) &gt;34 were associated with shorter event free survival (HR 5.58, p=0.002 and HR 5.56 p=0.005, respectively). After adjusting for age, sex, and right ventricular function, the association between peak oxygen consumption (pVO2) and event free survival remained significant (p=0.02).

Conclusions

In patients with ARVC, peak oxygen consumption (pVO2) was a prognostic indicator of worse outcomes. Our findings suggest a potential role for pVO2 in disease surveillance and early assessment for advanced heart failure therapies.

Figure 1. KM plot pVO2 & event free survival

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Mayo Clinic

Venous Thromboembolism During Chemotherapy for Testicular Cancer: A Population-Based Study

AIMS

Venous thromboembolism (VTE) is a potential complication among germ cell tumour patients. We evaluated the incidence rate, timing and factors associated with VTE among patients with germ cell cancer in routine practice.

MATERIALS AND METHODS

The Ontario Cancer Registry was linked to electronic records of treatment to identify all cases of testicular cancer treated in Ontario during 2000-2010. Administrative databases were used to identify VTE in the 3 months before and 5 years after orchiectomy. We explored patient-, disease- and treatment-related factors associated with VTE among all patients as well as those with detailed chemotherapy records available.

RESULTS

During 2000-2010, 2650 patients underwent orchiectomy for testicular cancer; among this cohort, 920 (33%) received chemotherapy. The VTE rate was 8% (69/920) among patients treated with chemotherapy and 0.6% (11/1730) among those without chemotherapy. Among the patients treated with chemotherapy who had VTE, 13% (9/69) occurred in the month before starting chemotherapy, 62% (42/69) in the first 3 months after starting and 25% thereafter. For patients who received three and four cycles, VTE rates were 8% (21/258) and 16% (19/121), respectively. In adjusted analyses, the only factor independently associated with VTE was increasing number of cycles (odds ratio 3.91 for four cycles, odds ratio 1.63 for three cycles (P = 0.022) compared with one to two cycles).

CONCLUSION

This population-based study confirms findings from institutional case series regarding the high rate of VTE among patients with germ cell tumours treated with chemotherapy. Future studies should evaluate the extent to which VTE prophylactic strategies might mitigate this risk.

Generalisability of Common Oncology Clinical Trial Eligibility Criteria in the Real World

AIMS

Strict oncology clinical trial eligibility criteria can contribute to low accrual and result in poorly generalisable study findings. Using common eligibility criteria, we sought to (i) determine how many patients would be eligible versus ineligible and (ii) describe real-world patterns of treatments and outcomes between those considered trial eligible and ineligible.

MATERIALS AND METHODS

The Alberta Cancer Registry was used to assemble a population-based cohort of patients diagnosed with 11 common malignancies between 2004 and 2015. We considered age >75 years, anaemia, comorbid conditions (heart disease, uncontrolled diabetes, kidney disease, liver disease) and history of a prior malignancy or immunosuppression to be exclusion criteria. Logistic regression was used to characterise the likelihood of receiving treatment. Cox regression models were constructed to determine cancer-specific and overall survival.

RESULTS

We identified 125 316 cancer patients, of whom 53% were men; the median age was 66 (interquartile range 48-84) years. Approximately 38% of patients were considered trial ineligible. The most common reasons for ineligibility were advanced age (24%) and heart disease (16%). In this ineligible group, 12, 47 and 19% still underwent chemotherapy, surgery and radiotherapy, respectively. Compared with ineligible patients, eligible patients were more likely to undergo chemotherapy (odds ratio 1.98, 95% confidence interval 1.89-2.07, P < 0.0001), surgery (odds ratio 1.39, 95% confidence interval 1.32-1.46, P < 0.0001) and radiotherapy (odds ratio 1.46, 95% confidence interval 1.4-1.52, P < 0.0001). Compared with ineligible patients who did not receive treatment, those considered ineligible but who still received treatment experienced improved cancer-specific survival (hazard ratio 0.75, 95% confidence interval 0.74-0.77, P < 0.0001) and overall survival (hazard ratio 0.89, 95% confidence interval 0.87-0.90, P < 0.0001).

CONCLUSIONS

A significant proportion of real-world patients are unable to participate in clinical trials due to stringent exclusion criteria, but many still receive treatment in routine practice. The eligibility criteria of oncology clinical trials should be broadened.

Toward improved goals-of-care documentation in advanced cancer: report on the development of a quality improvement initiative

Background

Documentation of advance care planning for patients with terminal cancer is known to be poor. Here, we describe a quality improvement initiative.

Methods

Patients receiving palliative chemotherapy for metastatic lung, pancreatic, colorectal, and breast cancer during 2010-2015 at the Cancer Centre of Southeastern Ontario were identified from electronic pharmacy records. Clinical notes were reviewed to identify documentation of care plans in the event of acute deterioration. After establishing baseline practice, we sought to improve documentation of goals of care and referral rates to palliative care. Using quality improvement methodology, we developed a guideline, a standardized documentation system, and a process to facilitate early referral to palliative care.

Results

During 2010-2015, 456 patients were included in the baseline cohort: 63% with lung cancer, 16% with colorectal cancer, 13% with pancreatic cancer, and 7% with breast cancer. Care goals in the event of an acute illness were documented by medical oncologists in 6% of cases (26 of 456). Of the 456 patients, 47% (n = 214) were seen by palliative care; care goals were documented by palliative care in 48% of the patients seen (103 of 214). With those baseline data in hand, a local practice guideline and process was developed to facilitate the identification of patients for whom advance care planning and early palliative care referral should be considered. A system was also established so that goals-of-care documentation will be supported with a written framework and broadly accessible in the electronic medical record.

Conclusions

Low rates of documentation of advance care planning and referral to palliative care persist and have stimulated a local quality improvement initiative.

The predictive effect of primary tumour location in the treatment of metastatic colorectal cancer: a Canadian consensus statement

In recently published data, the predictive value of primary tumour location for the treatment of metastatic colorectal cancer with available biologic therapies has been explored. Recognizing the potential effect of those data on clinical practice, we convened a meeting of Canadian experts who treat metastatic colorectal cancer to develop a set of national, evidence-based treatment guidelines based on primary tumour location. This report summarizes the relevant evidence and presents the consensus recommendations of those experts.

Uptake and Effectiveness of FOLFIRINOX for Advanced Pancreatic Cancer: a Population-based Study

AIMS

Although FOLFIRINOX is a standard treatment option for advanced pancreas cancer, there are few data describing utilisation and effectiveness in routine clinical practice. Here we report practice patterns and outcomes in the general population of Ontario, Canada.

MATERIALS AND METHODS

Using the Ontario Cancer Registry and New Drug Funding Program, we identified all patients with pancreas cancer treated with palliative intent gemcitabine or FOLFIRINOX in Ontario during 2006-2014. FOLFIRINOX became available in Ontario's single-payer health system in November 2011. Gemcitabine cases were classified as pre-FOLFIRINOX era (2006-2010) or post-FOLFIRINOX era (2011-2014). Cases treated with perioperative chemotherapy were excluded. Comparisons of proportions between study groups were made using the chi-square test. Overall survival was measured from the date of chemotherapy initiation.

RESULTS

During 2006-2014, 3826 patients in Ontario were treated with gemcitabine (n = 3042) or FOLFIRINOX (n = 784) chemotherapy for advanced pancreas cancer. Uptake of FOLFIRINOX increased from 41% (206/505) of treated cases in 2012 to 56% (274/486) of treated cases in 2014. The median overall survival of patients treated with gemcitabine was 5.0 months in 2006-2010 and 4.8 months in 2011-2014. The median overall survival of FOLFIRINOX patients treated in 2011-2014 was 8.2 months.

CONCLUSION

The use of FOLFIRINOX in the general population has increased since 2011. Survival outcomes show a substantial efficacy-effectiveness gap between the pivotal Prodige 4/ACCORD 11 clinical trial and routine practice.

Chemotherapy for resected colorectal cancer pulmonary metastases: Utilization and outcomes in routine clinical practice

BACKGROUND

The role of chemotherapy in the setting of resected colorectal cancer pulmonary metastases (CRCPM) is not well defined. Here we describe utilization of peri-operative chemotherapy and outcomes among patients with resected CRCPM in the general population.

METHODS

All cases of CRCPM who underwent resection from 2002 to 2009 were identified using the Ontario Cancer Registry (OCR). Electronic treatment records identified peri-operative chemotherapy delivered within 16 weeks before or after pulmonary metastasectomy (PM). Modified Poisson regression was used to evaluate factors associated with chemotherapy delivery. Cox proportional models were used to explore the association between post-operative chemotherapy and cancer-specific (CSS) and overall survival (OS).

RESULTS

The study population included 420 patients. Thirty-six percent of patients (151/420) received peri-operative chemotherapy. Among these patients, 75% (113/151) received post-operative chemotherapy. Factors that were independently associated with use of post-operative chemotherapy included higher socioeconomic status (SES) and no prior adjuvant chemotherapy (p < 0.01). In adjusted analyses post-operative chemotherapy was not associated with improved CSS (HR 0.99, 95% CI 0.67-1.47) or OS (HR 0.93 95% CI 0.66-1.31). In exploratory analyses, among those patients who did not receive previous adjuvant therapy for the primary colorectal cancer, post-operative chemotherapy following lung metastasectomy was associated with HR 0.50 (95% CI 0.27-0.95) for OS and HR 0.59 (95% CI 0.27-1.27) for CSS.

CONCLUSION

One third of patients with resected CRCPM in routine practice receive peri-operative chemotherapy. A randomized controlled trial is warranted to evaluate whether chemotherapy following resection of CRCPM is associated with improved survival.

Multimodality Treatment Outcome of Hepatoblastoma in a Resource Limited Country

Our objective is to review the records of management of hepatoblastoma (HB) at the Paediatric Haematology and Oncology (PHO) department in the Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from January 2004 to December 2012. This is a retrospective study of clinical, radiological and pathological data of hepatoblastoma patients treated at our institution. Thirteen patients were treated for HB between 2004 and 2012. The records of clinical presentations, chemotherapy tolerance and response, surgical procedure undertaken, and complications were analyzed. Median age of the study population was 12 months (3-60 months) and male: female was 3.3:1. Nine patients were treated with neoadjuvant chemotherapy consists of cisplatin and adriamycin. Primary surgery was done in four patients. Extent of hepatic resection in the operated patients varied. Mixed type was the predominant histopathological diagnosis. Adjuvant chemotherapy was well tolerated with no morbidity or mortality. Five-year event-free survival (EFS) and overall survival (OS) of all the 13 patients is 76.9%. All the nine patients who could complete multimodality treatment are alive with no evidence of disease or complications with median follow-up of 63 months (46-122 months). Treatment of HB with multidisciplinary approach was well tolerated. OS and EFS of patients were comparable with published studies.

Arabidopsis RabF1 (ARA6) Is Involved in Salt Stress and Dark-Induced Senescence (DIS)

Arabidopsis small GTPase RabF1 (ARA6) functions in endosomal vesicle transport and may play a crucial role in recycling and degradation of molecules, thus involved in stress responses. Here we have reported that complementary overexpression lines RabF1^OE (overexpression), GTPase mutants RabF1^Q93L (constitutively active) and RabF1^S47N (dominant negative) lines show longer root growth than wild-type, rabF1 knockout and N-myristoylation deletion (Δ1−29, N-terminus) complementary overexpression mutant plants under salt induced stress, which indicates that N-myristoylation of RabF1 is indispensable for salt tolerance. Moreover, RabF1 is highly expressed during senescence and RabF1^OE lines were more tolerant of dark-induced senescence (DIS) than wild-type and rabF1.

Cancer care in South India: perspectives from visiting Canadian oncologists

Cancer is recognized as an increasing threat to public health in low- and middle-income countries (lMICS).[...]

Evaluation of Iron Store by Serum Ferritin in Healthy Blood Donors of Bangladesh

Iron stores in the body exist primarily in the form of ferritin. Small amounts of ferritin secreted into the plasma and plasma ferritin is positively correlated with the size of the total body iron stores. The present study conducted to determine the iron status using the serum ferritin level among healthy Bangladeshi blood donors. The present cross sectional study was conducted in the Department of Transfusion Medicine, Dhaka Medical College, Dhaka, Bangladesh from July 2011 to June 2012. Blood donor signed informed consent and has satisfactory pre-donation health assessment and satisfactory post-donation blood test results were included in the study. Full blood counts were performed within 4 hours of collection using an automated haematology analyzer. Serum ferritin was measured using a validated enzyme immunoassay. Data were analyzed using SPSS version 16 (SPPS Incorporation, Chicago, IL, USA). P value <0.05 was considered as statistically significant. Total 100 blood donors were included in the study, among them 88 were male and 12 were female. Mean±SD of the age of the respondents was 26.8±5.9 years with a range of 19 to 45 years. Mean±SD of heamoglobin level (gm/dl) and total count of Red Blood Cell (million/cmm) were 14.1±1.4 and 5.1±0.4 respectively. Mean±SD of serum ferritin level (ng/ml) was 96.4±69.0ng/ml with a range of 4.1ng/ml to 298.7ng/ml. Among the respondents 9.0% had depleted iron store, 7.0 reduced iron store and 84.0% had normal iron store. Among the respondents 5.0% had iron deficiency anaemia in term of serum ferritin level. Statistically significant difference of serum ferritin level observed between male and female and donors with and without history of previous blood donation. Among the healthy blood donors of Bangladesh abnormal serum ferritin is highly prevalent among blood donors specially among female. Monitoring of iron stores by serum ferritin seems justified in order to identify those with depleted iron stores who will benefit from iron supplementation.

Relationship between Serum Iron Profile and Blood Groups among the Voluntary Blood Donors of Bangladesh

Blood donation results in a substantial iron loss and subsequent mobilization from body stores. Chronic iron deficiency is a well-recognized complication of regular blood donation. The present study conducted to compare the level of serum ferritin, serum iron, total iron binding capacity (TIBC) and percentage transferrin saturation in different ABO and Rhesus type blood groups among the voluntary blood donors of Bangladesh. The present prospective study included 100 healthy voluntary donors attending at Department of Blood Transfusion, Dhaka Medical College, Dhaka between the periods of July 2013 to Jun 2014. From each donor 10mL venous blood sample was taken and divided into heparinized and non-heparinized tubes for determination of hemoglobin (Hb), hematocrit (Hct), serum iron (SI), total iron binding capacity (TIBC) and serum ferritin by standard laboratory methods. Percentage of transferrin saturation (TS) calculated from serum iron and TIBC. Data were analyzed with SPSS (version 16) software and comparisons between groups were made using student's t-test and one way ANOVA. In the present study mean±SD of age of the respondents was 27.2±6.5 years with a range of 18 to 49 years and 81.0% were male and 19.0% were female. Among the donors 18.0% had blood group A, 35.0% had blood group B, 14.0% had blood group AB and 33.0% had blood group O. Among the donors 91.0% had rhesus positive and 9.0% had rhesus negative. Donors with blood group O had lowest haemoglobin, serum iron and transferring saturation levels. Donors with blood group A had highest TIBC level. Donors with blood group B had lowest serum ferritin level. An independent samples 't' test showed statistically significant difference in serum ferritin and percentage transferrin saturation between blood group AB and blood group O and in percentage transferrin saturation between blood group B and blood group O. One way ANOVA showed that there is no significant difference in haemoglobin, serum iron, serum ferritin and percentage transferring saturation in different ABO and Rh blood grouping categories. Blood donors with blood group O had lowest haemoglobin, serum iron and transferring saturation levels and donors with blood group A had highest TIBC level. Blood donors with blood group B had lowest serum ferritin level. The understanding of the different blood groups ability to retain iron in their system can give an insight into their ability to handle the disease iron deficiency anaemia.

An insight into the functional role of thioredoxin reductase, a selenoprotein, in maintaining normal native microbiota in the Gulf Coast tick (Amblyomma maculatum)

Tick selenoproteins have been associated with antioxidant activity in ticks. Thioredoxin reductase (TrxR), also a selenoprotein, belongs to the pyridine nucleotide-disulphide oxidoreductase family of proteins and is an important antioxidant. Molecular interactions between native microbiota and tick hosts have barely been investigated to date. In this study, we determined the functional role of TrxR in tick feeding and in maintenance of the native microbial community. TrxR transcript levels remained high and microbial load was reduced throughout tick attachment to the vertebrate host. RNA interference (RNAi) showed that depletion of TrxR activity did not interfere with tick haematophagy or phenotype but did reduce the viability of the microbiome within the tick tissues, presumably by perturbing redox homeostasis. The transcriptional activity of various antioxidant genes remained unaffected whereas the antioxidant genes Manganese superoxide dismutase (MnSOD), copper/zinc superoxide dismutase (Cu/Zn SOD) and selenoprotein M (SelM) were significantly down-regulated in salivary glands of the ticks subjected to RNAi. The perturbed TrxR enzymatic activity in the knocked-down tick tissues negatively affected the bacterial load as well. Furthermore, we observed the altered bacterial profiles in TrxR-silenced tick tissues. Taken together, these results indicate an essential functional role for TrxR in maintaining the bacterial community associated with ticks.

Transcriptional activation of antioxidants may compensate for selenoprotein deficiencies in Amblyomma maculatum (Acari: Ixodidae) injected with selK- or selM-dsRNA

The Gulf-Coast tick, Amblyomma maculatum, possesses an elaborate set of selenoproteins, which prevent the deleterious effects from oxidative stress that would otherwise occur during feeding. In the current work, we examined the role of selenoprotein K (SelK) and selenoprotein M (SelM) in feeding A. maculatum by bioinformatics, transcriptional gene expression, RNA interference and antioxidant assays. The transcriptional expression of SelK did not vary significantly in salivary glands or midguts throughout the bloodmeal. However, there was a 58-fold increase in transcript levels of SelM in tick midguts. Ticks injected with selK-dsRNA or selM-dsRNA did not reveal any observable differences in egg viability but oviposition was reduced. Surprisingly, salivary antioxidant activity was higher in selenoprotein knockouts compared with controls, which is probably the result of compensatory transcriptional expression of genes involved in combating reactive oxygen species. In fact, quantitative real-time PCR data suggest that the transcriptional expression of catalase increased in ticks injected with selM-double-stranded RNA. Additionally, the transcriptional expression of selN decreased ∼90% in both SelK/SelM knockdowns. These data indicate that SelK and SelM are salivary antioxidants but are not essential for tick survival or reproduction and are compensated by other antioxidant systems.

A novel chloroplast localized Rab GTPase protein CPRabA5e is involved in stress, development, thylakoid biogenesis and vesicle transport in Arabidopsis

A novel Rab GTPase protein in Arabidopsis thaliana, CPRabA5e (CP = chloroplast localized) is located in chloroplasts and has a role in transport. Transient expression of CPRabA5e:EGFP fusion protein in tobacco (Nicotiana tabacum) leaves, and immunoblotting using Arabidopsis showed localization of CPRabA5e in chloroplasts (stroma and thylakoids). Ypt31/32 in the yeast Saccharomyces cerevisiae are involved in regulating vesicle transport, and CPRabA5e a close homolog of Ypt31/32, restores the growth of the ypt31Δ ypt32(ts) mutant at 37 °C in yeast complementation. Knockout mutants of CPRabA5e displayed delayed seed germination and growth arrest during oxidative stress. Ultrastructural studies revealed that after preincubation at 4 °C mutant chloroplasts contained larger plastoglobules, lower grana, and more vesicles close to the envelopes compared to wild type, and vesicle formation being enhanced under oxidative stress. This indicated altered thylakoid development and organization of the mutants. A yeast-two-hybrid screen with CPRabA5e as bait revealed 13 interacting partner proteins, mainly located in thylakoids and plastoglobules. These proteins are known or predicted to be involved in development, stress responses, and photosynthesis related processes, consistent with the stress phenotypes observed. The results observed suggest a role of CPRabA5e in transport to and from thylakoids, similar to cytosolic Rab proteins involved in vesicle transport.

Gene expression pattern for putative chloroplast localized COPII related proteins with emphasis on Rab related proteins

Vesicle transport occurs in the cytosol through COPI, COPII and a clathrin coated vesicle system for transport of lipids and proteins to different subcellular compartments. All three systems consist of several different protein components to maintain a functional transport. In chloroplasts photosynthesis takes place in thylakoids. Thylakoids contain a large amount of lipids and proteins but none of these components are produced there. Transport of lipids occurs from the envelope membrane where they are produced and through the aqueous stroma before being directed to the thylakoids. Nuclear encoded proteins use distinct pathways for entering thylakoids after import into chloroplasts. Transport of lipids through stroma requires either lipid transfer proteins, association between the envelope and the thylakoid membrane, or a vesicle transport system similar to the cytosolic one. No evidence exists for lipid transfer proteins in chloroplasts, nor for a consistent association between the envelope and the thylakoid membrane. However, vesicle transport has support from e.g., biochemical and genetics data as well as transelectron microscopy data. Moreover, a recent bioinformatics study revealed putatively COPII related proteins to be chloroplast localized in Arabidopsis and thus function in vesicle transport in chloroplasts. Here we present gene expression profiles of these putatively COPII related chloroplast localized proteins using Genevestigator (https://www.genevestigator.com/gv/) with special emphasis on Rab related proteins since they represent several stage of vesicle transport e.g., uncoating, tethering and fusion.