Emotional and informational social support from health visitors and breastfeeding outcomes in the UK

BACKGROUND

Shorter breastfeeding duration is associated with detrimental consequences for infant health/development and maternal health. Previous studies suggest social support is essential in maintaining breast/chest-feeding and helping to improve general infant feeding experiences. Public health bodies therefore work to support breastfeeding in the UK, yet UK breastfeeding rates continue to be one of the lowest globally. With this, a better understanding of the effectiveness and quality of infant feeding support is required. In the UK, health visitors (community public health nurses specialising in working with families with a child aged 0-5 years) have been positioned as one of the key providers of breast/chest-feeding support. Research evidence suggests that both inadequate informational support and poor/negative emotional support can lead to poor breastfeeding experiences and early breastfeeding cessation. Thus, this study tests the hypothesis that emotional support from health visitors moderates the relationship between informational support and breastfeeding duration/infant feeding experience among UK mothers.

METHODS

We ran cox and binary logistic regression models on data from 565 UK mothers, collected as part of a 2017-2018 retrospective online survey on social support and infant feeding.

RESULTS

Informational support, compared to emotional support, was a less important predictor of both breastfeeding duration and experience. Supportive emotional support with unhelpful or absent informational support was associated with the lowest hazard of breastfeeding cessation before 3 months. Results for breastfeeding experience followed similar trends, where positive experience was associated with supportive emotional and unhelpful informational support. Negative experiences were less consistent; however, a higher probability of negative experience was found when both types of support were reported as unsupportive.

CONCLUSIONS

Our findings point to the importance of health visitors providing emotional support to bolster the continuation of breastfeeding and encourage a positive subjective experience of infant feeding. The emphasis of emotional support in our results encourages increased allocation of resources and training opportunities to ensure health visitors are able to provide enhanced emotional support. Lowering health visitors caseloads to allow for personalised care is just one actionable example that may improve breastfeeding outcomes in the UK.

1277 A Closed-Loop Audit of the use of qFIT in Symptomatic “Two Week Wait” referrals in Somerset Foundation Trust

Introduction

Quantitative faecal immunochemical test (qFIT) is recommended as the replacement test for faecal occult blood testing by NICE. We audited qFIT use in two week-wait (2WW) referrals in Somerset Foundation Trust (SFT) following its introduction in 2019.

Method

Following qFIT being made available to general practitioners, all 2WW referrals received before (July 2019) and after (December 2019) the introduction of the new 2WW referral form were reviewed. Electronic patient records were analysed to determine investigations performed and if a diagnosis of cancer was made.

Results

July 2019: 288 2WW referrals with 74 patients eligible for qFIT – only 7 of these underwent qFIT; total of 93 qFIT performed by GPs with 11 positive tests. December 2019: 222 2WW referrals with 18 patients eligible for qFIT – all of whom underwent qFIT; total of 155 qFIT performed by GPs with 18 positive (and 137 negative) tests. 1 patient with a positive qFIT was found to have colorectal malignancy (qFIT = 267 g/dL, investigation showed benign TVA). An increase in qFIT was observed over time, coinciding with a reduction in 2WW referrals, including reduction in patients who were qFIT eligible. The 2WW service identified 11 (3.8%) cases of colorectal cancer in July 2019 compared to 12 (5.4%) cases in December 2019, showing an increased pickup rate.

Conclusions

High proportions of 2WW referrals undergo investigation. The results of this audit highlight the utility of qFIT in screening 2WW referrals and reducing burden on the service, particularly where access to investigations is severely restricted due to coronavirus.

70 Availability of Personal Protective Equipment in NHS Hospitals During COVID-19: A National Survey

Introduction

The continuous supply of personal protective equipment (PPE) in the National Health Service (NHS) is paramount in order to sustain a safe level of staffing and to reduce transmission of COVID-19 to patients, public and staff.

Method

A 16-question survey was created to assess the availability and personal thoughts of healthcare professionals regarding PPE supply in England. The survey was distributed via social media (Facebook © and Twitter ©) to all UK COVID-19 healthcare professional groups, with responses collected over 3 weeks in March 2020 during the beginning of the pandemic.

Results

A total of 121 responses from physicians in 35 different hospitals were collected (105 inpatient wards, 16 from intensive care units). In inpatient wards, eye and face protection were unavailable to 19.1% of respondents. Masks were available to 97.7% of respondents and gloves in all respondents (100%). Body protection was available primarily as a plastic apron (83.8%). All of respondents working in intensive care had access to full-body PPE, except FFP3 respirator masks (available in 87.5%). PPE is ‘Always’ available for 29.8% of all respondents, and ‘Never’ or ‘Almost Never’ in 11.6%. There was a statistically significant difference between London and non-London responders that ‘Always’ had PPE available (43.9% versus 19.0%, p = 0.003).

Conclusions

This is the first survey to evaluate PPE supply in England during the COVID-19 pandemic. Our survey demonstrated an overall lack of PPE volume supply in the UK, with preferential distribution in London. Eye and full body protection are in most lack of supply.

Adapting Rapid Diagnostic Tests to Detect Historical Dengue Virus Infections

The only licensed dengue vaccine, Dengvaxia®, increases risk of severe dengue when given to individuals without prior dengue virus (DENV) infection but is protective against future disease in those with prior DENV immunity. The World Health Organization has recommended using rapid diagnostic tests (RDT) to determine history of prior DENV infection and suitability for vaccination. Dengue experts recommend that these assays be highly specific (≥98%) to avoid erroneously vaccinating individuals without prior DENV infection, as well as be sensitive enough (≥95%) to detect individuals with a single prior DENV infection. We evaluated one existing and two newly developed anti-flavivirus RDTs using samples collected >6 months post-infection from individuals in non-endemic and DENV and ZIKV endemic areas. We first evaluated the IgG component of the SD BIOLINE Dengue IgG/IgM RDT, which was developed to assist in confirming acute/recent DENV infections (n=93 samples). When evaluated following the manufacturer's instructions, the SD BIOLINE Dengue RDT had 100% specificity for both non-endemic and endemic samples but low sensitivity for detecting DENV seropositivity (0% non-endemic, 41% endemic). Sensitivity increased (53% non-endemic, 98% endemic) when tests were allowed to run beyond manufacturer recommendations (0.5 up to 3 hours), but specificity decreased in endemic samples (36%). When tests were evaluated using a quantitative reader, optimal specificity could be achieved (≥98%) while still retaining sensitivity at earlier timepoints in non-endemic (44-88%) and endemic samples (31-55%). We next evaluated novel dengue and Zika RDTs developed by Excivion to detect prior DENV or ZIKV infections and reduce cross-flavivirus reactivity (n=207 samples). When evaluated visually, the Excivion Dengue RDT had sensitivity and specificity values of 79%, but when evaluated with a quantitative reader, optimal specificity could be achieved (≥98%) while still maintaining moderate sensitivity (48-75%). The Excivion Zika RDT had high specificity (>98%) and sensitivity (>93%) when evaluated quantitatively, suggesting it may be used alongside dengue RDTs to minimize misclassification due to cross-reactivity. Our findings demonstrate the potential of RDTs to be used for dengue pre-vaccination screening to reduce vaccine-induced priming for severe dengue and show how assay design adaptations as well quantitative evaluation can further improve RDTs for this purpose.

Conditional approval of cancer drugs in Canada: accountability and impact on public funding

Background

We examined how conditional market approval of cancer pharmaceuticals by Health Canada (hc) affects public funding recommendations by the pan-Canadian Oncology Review (pcodr). We were also interested to see how often hc conditions are enforced.

Methods

Health Canada and pcodr databases for 2010-2017 were analyzed for patterns in hc conditional authorization and post-authorization reviews of cancer drugs and for correlation with pcodr reimbursement recommendations.

Results

Between 2010 and 2017, pcodr reviewed 105 unique drug-indication pairings; 21% (n = 22) had conditional hc authorization. In all cases, conditional authorization was given on the basis of preliminary data in a surrogate endpoint and was contingent on further data showing benefit in more robust outcome measures (for example, overall survival). Of those 22 drugs, 36% did not have updated data, 36% had updated data that met hc conditions, and 27% had data that met some, but not all, conditions. During the period considered, hc never revoked conditional authorization for failure to meet conditions. None of the 22 drugs was given an unconditional positive recommendation for public reimbursement by pcodr. A conditional recommendation was given to 11 of the drugs (50%), and reimbursement was not recommended for 6 drugs (27%) because of insufficient evidence.

Conclusions

One fifth of the cancer drugs reviewed for public reimbursement in Canada were conditionally authorized by hc based on preliminary data. Conditional authorization was associated with a recommendation against public funding by pcodr. No drugs had their conditional market authorization revoked for failure to meet conditions, suggesting that a more robust hc reappraisal framework is needed.

Doping control study of AICAR in post-race urine and plasma samples from horses

Acadesine, 5-aminoimidazole-4-carboxamide-1-β-D-ribofuranoside, commonly known as AICAR, is a naturally occurring adenosine monophosphate-activated protein kinase (AMPK) activator in many mammals, including humans and horses. AICAR has attracted considerable attention recently in the field of doping control because of a study showing the enhancement of endurance performance in unexercised or untrained mice, resulting in the term 'exercise pill'. Its use has been classified as gene doping by the World Anti-Doping Agency (WADA), and since it is endogenous, it may only be possible to control deliberate administration of AICAR to racehorses after establishment of an appropriate threshold. Herein we report our studies of AICAR in post-race equine urine and plasma samples including statistical studies of AICAR concentrations determined from 1,470 urine samples collected from thoroughbreds and standardbreds and analyzed in Australia, France, and Hong Kong. Quantification methods in equine urine and plasma using liquid chromatography-mass spectrometry were developed by the laboratories in each country. An exchange of spiked urine and plasma samples between the three countries was conducted, confirming no significant differences in the methods. However, the concentration of AICAR in plasma was found to increase upon haemolysis of whole blood samples, impeding the establishment of a suitable threshold in equine plasma. A possible urine screening cut-off at 600 ng/mL for the control of AICAR in racehorses could be considered for adoption. Application of the proposed screening cut-off to urine samples collected after intravenous administration of a small dose (2 g) of AICAR to a mare yielded a short detection time of approximately 4.5 h. Copyright © 2017 John Wiley & Sons, Ltd.

Clinician participation in CADTH's pan-Canadian Oncology Drug Review: contribution and impact on cancer drug funding recommendations

In any given week, media headlines publicize the benefits of a new “breakthrough” cancer drug, with patients and clinicians subsequently advocating for its use. [...]

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Improving postoperative pain management in subpectoral tissue expander implant reconstruction of the breast using an elastomeric pump

INTRODUCTION

Postoperative pain after breast surgery is one of the major factors contributing to delay in mobilisation and prolonged hospital stay. A retrospective analysis was performed of patients undergoing skin sparing mastectomy and insertion of a subpectoral implant. The aim was to determine whether the use of an elastomeric local anaesthetic pump improved pain control and length of stay.

METHODS

Twenty-five consecutive patients undergoing the above procedure were sited with an elastomeric local anaesthetic infusion pump intraoperatively, in addition to standard regular and pro re nata analgesia. The control group comprised 25 patients undergoing the same procedure in the same year who received standard analgesia alone. Visual analogue scale scores were recorded for the duration of inpatient stay, as was any further analgesic requirement.

RESULTS

The median age was 51 years (range: 26-75 years) in the intervention group and 50 years (range: 28-70 years) in the control group. The mean visual analogue scale score was 0.28 (standard deviation [SD]: 0.61) at 24 hours for the intervention group and 1.84 (SD: 0.37) for the control group (p<0.0001). The mean length of stay was 1.8 days (SD: 0.71 days) for the intervention group and 2.28 days (SD: 0.94 days) for the control group (p=0.15). There were no complications involving catheter placement, leakage or toxicity relating to use of the local anaesthetic.

CONCLUSIONS

There was significantly reduced pain with the use of the local anaesthetic infusion pump. The elastomeric pump is a step towards enhanced patient recovery after breast surgery in the case of skin sparing mastectomy and subpectoral tissue expander reconstruction.

Selective Use of (18)F-Fluorodeoxyglucose-Positron Emission Tomography and Computed Tomography in the Management of Metastatic Disease from Colorectal Cancer: Results from a regional centre

OBJECTIVES

Computed tomography (CT) scans are routinely used for primary staging and disease surveillance in patients with colorectal cancer. However, these scans have limited sensitivity in some organs and can only detect lesions with morphological changes, whereas (18)F-fluorodeoxyglucose-positron emission tomography ((18)F-FDG-PET) scans are able to detect areas of metabolic change before morphological changes appear. The aim of this study was to evaluate the impact of (18)F-FDG-PET/CT scans over conventional imaging during preoperative work-ups or follow-ups in a selected group of patients.

METHODS

This retrospective cohort study, which took place between July 2009 and May 2011, assessed 1,043 patient records from the South East Scotland Cancer Network colorectal cancer database. A total of 102 patients who underwent (18)F-FDG-PET/CT scans in addition to conventional imaging were included in the study. These patients had potentially resectable metastases, equivocal findings on CT scans and elevated carcinoembryonic antigen levels with negative conventional imaging.

RESULTS

Of the 102 patients included in the study, 22 underwent a preoperative (18)F-FDG-PET/CT scan and 80 underwent a follow-up 18F-FDG-PET/CT scan. In the preoperative scan group, the (18)F-FDG-PET/CT scan had a major impact on 16 patients (72.75%) and no impact on six patients (27.25%). In the follow-up scan group, the (18)F-FDG-PET/CT scan had a major impact on 51 (63.75%), a minor impact on four (5%), no impact on 22 (27.5%) and a negative impact on three (3.75%) patients.

CONCLUSION

The results of this study demonstrated that (18)F-FDG-PET/CT scans have a considerable effect on disease management when undertaken among indicated colorectal cancer patients.

HOSPEX in the antipodes

The Australian Army recently adopted the British concept of hospital exercise (HOSPEX) as a means of evaluating the capabilities of its deployable NATO Role 2E hospital, the 2nd General Health Battalion. The Australian approach to HOSPEX differs from the original UK model. This article describes the reasons why the Australian Army needed to adopt the HOSPEX concept, how it was adapted to suit local circumstances and how the concept may evolve to meet the needs of the wider Australian Defence Force and our allies.

Electrical stimulation for drug-resistant epilepsy: an evidence-based analysis

OBJECTIVE

The objective of this analysis was to evaluate the effectiveness of deep brain stimulation (DBS) and vagus nerve stimulation (VNS) for the treatment of drug-resistant epilepsy in adults and children.

DATA SOURCES

A literature search was performed using MEDLINE, EMBASE, the Cochrane Library, and the Centre for Reviews and Dissemination database, for studies published from January 2007 until December 2012.

REVIEW METHODS

Systematic reviews, meta-analyses, randomized controlled trials (RCTs), and observational studies (in the absence of RCTs) of adults or children were included. DBS studies were included if they specified that the anterior nucleus of thalamus was the area of the brain stimulated. Outcomes of interest were seizure frequency, health resource utilization, and safety. A cost analysis was also performed.

RESULTS

The search identified 6 studies that assessed changes in seizure frequency after electrical stimulation: 1 RCT on DBS in adults, 4 RCTs on VNS in adults, and 1 RCT on VNS in children. The studies of DBS and VNS in adults found significantly improved rates of seizure frequency, but the study of VNS in children did not find a significant difference in seizure frequency between the high and low stimulation groups. Significant reductions in hospitalizations and emergency department visits were found for adults and children who received VNS. No studies addressed the use of health resources for patients undergoing DBS. Five studies reported on adverse events, which ranged from serious to transient for both procedures in adults and were mostly transient in the 1 study of VNS in children.

LIMITATIONS

We found no evidence on DBS in children or on health care use related to DBS. The measurement of seizure frequency is self-reported and is therefore subject to bias and issues of compliance.

CONCLUSIONS

Based on evidence of low to moderate quality, both DBS and VNS seemed to reduce seizure frequency in adults. In children, VNS did not appear to be as effective at reducing seizure frequency, but children had significantly fewer hospitalizations and ED visits after VNS implantation. Despite the considerable risks associated with these invasive procedures, long-term adverse events appear to be limited.

PLAIN LANGUAGE SUMMARY

Electrical stimulation of specific areas of the brain is a procedure used to control epileptic seizures when more conventional treatments are not working. Most adults and children with epilepsy are able to control their seizures with medication, but for some patients, drugs are not effective and surgery to remove the part of the brain where the seizures start is not an appropriate option. This study looked at the research available on the effectiveness, safety, and cost of two types of electrical stimulation devices currently licensed for treatment of epilepsy for adults and children in Canada: vagus nerve stimulation (VNS) and deep brain stimulation (DBS). Both approaches appear to be effective at reducing the frequency of seizures in adults. However, the evidence on DBS is limited to a single study with adults; we found no studies of DBS with children. Studies on VNS showed that both adults and children had fewer hospitalizations and emergency department visits after the procedure. Both procedures carry serious risks, but several longer-term studies have found that adverse events appear to be limited. The cost of VNS, including the process of assessing whether or not patients are good candidates for the procedure, is estimated to be about $40,000 per person (and higher for DBS because the device is more expensive and the operating time is longer). Of the 70,000 people in Ontario with epilepsy, about 1,400 (300 children and 1,110 adults) may be candidates for VNS to reduce their seizures.

Abstract P1-14-13: Increased Pathologic Complete Response Rate and Reduced Tumour RNA Levels Upon Treatment of Locally Advanced Breast Cancer with Neoadjuvant Concurrent Chemotherapy and Radiation

Introduction: Patients with locally advanced breast cancer (LABC) have a 5-year survival rate of 50% using standard treatment that includes neo-adjuvant chemotherapy, surgery and adjuvant radiation. Given this poor prognosis, we proposed use of an adjuvant regimen in the neoadjuvant setting, involving radiation with docetaxel for radiosensitization. Pathological complete response (pCR) at surgery (the best surrogate for overall survival) was the primary end-point of this single-arm prospective Phase II trial. Given that dose-dependent reductions in tumour RNA integrity mid-treatment were correlated with post-treatment pCRs in similar patients in the NCIC-CTG-MA.22 clinical trial (Breast Cancer Research and Treatment 119:347–56), we also assessed whether changes in tumour RNA integrity and concentration could be observed following this regimen.

Methodology: Thirty-two patients with stage III non-metastatic LABC were enrolled at a single institution from 2009–2011. They were treated with neoadjuvant 5-Fluoro-uracil, Epirubicin, and Cyclophosphamide (FEC) q3 weekly for 4 cycles followed by weekly Docetaxel (35 mg/m2) concurrently with regional radiation (45 Gy with 16 Gy boost in 25 & 5 fractions) for the first 6 of 9 weeks (D/R). Serial 14 gauge tumour core biopsies were taken from the patients pre-, mid- and post-treatment and 1 mm3 samples used to assess RNA quantity and quality using an Agilent 2100 Bioanalyzer. This was followed by a modified radical mastectomy.

Results: Treatment-related toxicities included grade 3 resolving pneumonitis (6 patients), grade 3 dermatitis (6 patients) and one treatment-related death. The pCR rate was 23%–about twice the provincial rate for LABC. At a mean 21 months follow-up, the relapse-free survival was 100% in the pCR cohort and 65% among partial responders (PRs). While biopsies were not normalized for mass, little difference in RNA concentration was observed between pre-treatment and post-FEC tumour biopsies (means of 50 ± 15 nanograms/microliter and 50 ± 12 nanograms/microliter, respectively). In contrast, the mean tumour RNA concentration was reduced to 10 ± 2.1 nanograms/microliter post-D/R. While the post-treatment biopsies often yielded insufficient RNA for assignment of tumour RNA integrity (RIN) values, treatment response appeared to be associated with low tumour RNA integrity, since patients with disease progression or stable disease had higher RIN values than patients exhibiting PRs or pCRs.

Conclusions: This is the first study to use a full chemotherapy regimen with radiation in the neo-adjuvant setting for LABC. Although not without toxicity, the regimen appeared to significantly improve the pCR rate for this high-risk group, resulting in a much-improved outcome even at short-term follow-up. In addition, the FEC→D/R regimen produced reductions in tumour RNA concentration, and treatment response appeared to be associated with reduced RNA integrity.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-14-13.

The open abdomen and temporary abdominal closure systems--historical evolution and systematic review

AIM

Several techniques for temporary abdominal closure have been developed. We systematically review the literature on temporary abdominal closure to ascertain whether the method can be tailored to the indication.

METHOD

Medline, Embase, the Cochrane Central Register of Controlled Trials and relevant meeting abstracts until December 2009 were searched using the following headings: open abdomen, laparostomy, VAC (vacuum assisted closure), TNP (topical negative pressure), fascial closure, temporary abdominal closure, fascial dehiscence and deep wound dehiscence. The data were analysed by closure technique and aetiology. The primary end-points included delayed fascial closure and in-hospital mortality. The secondary end-points were intra-abdominal complications.

RESULTS

The search identified 106 papers for inclusion. The techniques described were VAC (38 series), mesh/sheet (30 series), packing (15 series), Wittmann patch (eight series), Bogotá bag (six series), dynamic retention sutures (three series), zipper (15 series), skin only and locking device (one series each). The highest facial closure rates were seen with the Wittmann patch (78%), dynamic retention sutures (71%) and VAC (61%).

CONCLUSION

Temporary abdominal closure has evolved from simple packing to VAC based systems. In the absence of sepsis Wittmann patch and VAC offered the best outcome. In its presence VAC had the highest delayed primary closure and the lowest mortality rates. However, due to data heterogeneity only limited conclusions can be drawn from this analysis.

Management of single brain metastasis: a practice guideline

QUESTIONS

Should patients with confirmed single brain metastasis undergo surgical resection? Should patients with single brain metastasis undergoing surgical resection receive adjuvant whole-brain radiation therapy (wbrt)? What is the role of stereotactic radiosurgery (srs) in the management of patients with single brain metastasis?

PERSPECTIVES

Approximately 15%-30% of patients with cancer will develop cerebral metastases over the course of their disease. Patients identified as having single brain metastasis generally undergo more aggressive treatment than do those with multiple metastases; however, in the province of Ontario, management of patients with single brain metastasis varies. Given that conflicting evidence has been reported, the Neuro-oncology Disease Site Group (dsg) of the Cancer Care Ontario Program in Evidence-based Care felt that a systematic review of the evidence and a practice guideline were warranted.

OUTCOMES

Outcomes of interest were survival, local control of disease, quality of life, and adverse effects.

METHODOLOGY

The medline, cancerlit, embase, and Cochrane Library databases and abstracts published in the proceedings of the annual meetings of the American Society of Clinical Oncology (1997-2005) and American Society for Therapeutic Radiology and Oncology (1998-2004) were systematically searched for relevant evidence. The review included fully published reports or abstracts of randomized controlled trials (rcts), nonrandomized prospective studies, and retrospective studies. The present systematic review and practice guideline has been reviewed and approved by the Neuro-oncology dsg, which comprises medical and radiation oncologists, surgeons, neurologists, a nurse, and a patient representative. External review by Ontario practitioners was obtained through an electronic survey. Final approval of the guideline report was obtained from the Report Approval Panel and the Neuro-oncology dsg.

RESULTS

QUALITY OF EVIDENCE

The literature search found three rcts that compared surgical resection plus wbrt with wbrt alone. In addition, a Cochrane review, including a meta-analysis of published data from those three rcts, was obtained. One rct compared surgical resection plus wbrt with surgical resection alone. One rct compared wbrt plus srs with wbrt alone. Evidence comparing srs with surgical resection or examining srs with or without wbrt was limited to prospective case series and retrospective studies.

BENEFITS

Two of three rcts reported a significant survival benefit for patients who underwent surgical resection as compared with those who received wbrt alone. Pooled results of the three rcts indicated no significant difference in survival or likelihood of dying from neurologic causes; however, significant heterogeneity was detected between the trials. The rct that compared surgical resection plus wbrt with surgical resection alone reported no significant difference in overall survival or length of functional independence; however, tumour recurrence at the site of the metastasis and anywhere in the brain was less frequent in patients who received wbrt as compared with patients in the observation group. In addition, patients who received wbrt were less likely to die from neurologic causes. Results of the rct that compared wbrt plus srs with wbrt alone indicated a significant improvement in median survival in patients who received srs. No quality evidence compares the efficacy of srs with surgical resection or examines the question of whether patients who receive srs should also receive wbrt.

HARMS

Pooled results of the three rcts that examined surgical resection indicated no significant difference in adverse effects between groups. Postoperative complications included respiratory problems, intracerebral hemorrhage, and infection. One rct reported no significant difference in adverse effects between patients who received wbrt plus srs and those who received wbrt alone.

PRACTICE GUIDELINE

TARGET POPULATION

The recommendations that follow apply to adults with confirmed cancer and a single brain metastasis. This practice guideline does not apply to patients with metastatic lymphoma, small-cell lung cancer, germ-cell tumour, leukemia, or sarcoma.

RECOMMENDATIONS

Surgical excision should be considered for patients with good performance status, minimal or no evidence of extracranial disease, and a surgically accessible single brain metastasis amenable to complete excision. Because treatment in cases of single brain metastasis is considered palliative, invasive local treatments must be individualized. Patients with lesions requiring emergency decompression because of intracranial hypertension were excluded from the rcts, but should be considered candidates for surgery. To reduce the risk of tumour recurrence for patients who have undergone resection of a single brain metastasis, postoperative wbrt should be considered. The optimal dose and fractionation schedule for wbrt is 3000 cGy in 10 fractions or 2000 cGy in 5 fractions. As an alternative to surgical resection, wbrt followed by srs boost should be considered for patients with single brain metastasis. The evidence is insufficient to recommend srs alone as a single-modality therapy.

QUALIFYING STATEMENTS

No high-quality data are available regarding the choice of surgery versus radiosurgery for single brain metastasis. In general, the size and location of the metastasis determine the optimal approach. The standard wbrt regimen for management of patients with single brain metastasis in the United States is 3000 cGy in 10 fractions, and this treatment is usually the standard arm in randomized studies of radiation in patients with brain metastases. Based solely on evidence, the understanding that no reason exists to choose 3000 cGy in 10 fractions over 2000 cGy in 5 fractions is correct; however, fraction size is believed to be important, and therefore 300 cGy daily (3000/10) is believed to be associated with fewer long-term neurocognitive effects than 400 cGy daily (2000/5) in the occasional long-term survivor. For that reason, many radiation oncologists in Ontario prefer 3000 cGy in 10 fractions. No data exist to either support or refute that preference; therefore, finding a resolution to this issue is not currently possible. The Neuro-oncology dsg will update the recommendations as new evidence becomes available.

Gliadel wafers in the treatment of malignant glioma: a systematic review

Question

What is the safety and efficacy of interstitial chemotherapy with carmustine-loaded polymers (Gliadel wafers: MGI Pharma, Bloomington, MN, U.S.A.) in the treatment of newly diagnosed or recurrent malignant glioma (that is, glioblastoma multiforme, anaplastic astrocytoma, anaplastic oligoastrocytoma, and anaplastic oligodendroglioma)?

Perspectives

Malignant glioma is the most common type of primary brain tumour in adults. In general, efficacy of systemic therapy in this patient population has been disappointing, and novel treatment approaches are needed. Because several randomized controlled trials (rcts) investigating the safety and efficacy of Gliadel are available, the Neuro-oncology Disease Site Group of Cancer Care Ontario’s Program in Evidence-Based Care decided that a systematic review of the evidence was necessary.

Outcomes

The outcomes of interest for this review were overall survival, adverse events, and quality of life.

Methodology

Systematic searches of the medline, embase, and Cochrane Library databases were conducted for relevant evidence. Fully-published reports of rcts comparing treatment with Gliadel wafers to placebo or alternative treatment were selected for inclusion. Prospective cohort studies were also included.

Results

Two rcts that compared Gliadel to placebo in patients with newly diagnosed malignant glioma were obtained. Both rcts reported a significant survival benefit for patients who received Gliadel as compared with patients in the control group. One rct and one prospective cohort study were obtained that examined the role of Gliadel in patients with recurrent malignant glioma. The rct demonstrated a significant survival benefit for Gliadel only after adjustment for prognostic factors, and the prospective cohort study reported no survival benefit for Gliadel as compared with a historical control group. All three rcts reported similar rates of adverse events in the treatment and control groups. The most frequently reported adverse events were convulsions, confusion, brain edema, infection, hemiparesis, aphasia, and visual field defects.

Conclusions

Gliadel is an option for selected patients with newly diagnosed malignant glioma where a near gross total resection is possible. No evidence is available comparing Gliadel with systemic therapy, and a decision to combine Gliadel with systemic therapy should be made for patients individually. The patient population that would benefit from Gliadel (age, histology, and performance status) is unclear; further investigation is needed. Gliadel is also an option for patients with surgically resectable recurrent malignant glioma.

Genetic modification of a baculovirus vector for increased expression in insect cells

Generating large amounts of recombinant protein in transgenic animals is often challenging and has a number of drawbacks compared to cell culture systems. The baculovirus expression vector system (BEVS) uses virus-infected insect cells to produce recombinant proteins to high levels, and these are usually processed in a similar way to the native protein. Interestingly, since the development of the BEVS, the virus most often used (Autographa californica multi-nucleopolyhedovirus; AcMNPV) has been little altered genetically from its wild-type parental virus. In this study, we modified the AcMNPV genome in an attempt to improve recombinant protein yield, by deleting genes that are non-essential in cell culture. We deleted the p26, p10 and p74 genes from the virus genome, replacing them with an antibiotic selection cassette, allowing us to isolate recombinants. We screened and identified recombinant viruses by restriction enzyme analysis, PCR and Western blot. Cell viability analysis showed that the deletions did not improve the viability of infected cells, compared to non-deletion viruses. However, expression studies showed that recombinant protein levels for the deletion viruses were significantly higher than the expression levels of non-deletion viruses. These results confirm that there is still great potential for improving the BEVS, further increasing recombinant protein expression yields and stability in insect cells.

The Use of Prophylactic Anticonvulsants in Patients with Brain Tumours—A Systematic Review

Questions: Should patients with newly diagnosed brain tumours receive prophylactic anticonvulsants to reduce seizure risk? What is the best practice for patients with brain tumours who are taking anticonvulsant medications but who have never had a seizure? Perspectives: Patients with primary or metastatic brain tumours who have never had a seizure still have a 20% risk of experiencing a seizure over the course of their disease. Because considerable practice variation exists in regard to the management of patients with brain tumours who have never had a seizure, and because conflicting evidence has been reported, the Neuro-oncology Disease Site Group (DSG) of Cancer Care Ontario’s Program in Evidence-based Care felt that a systematic review of the evidence was warranted. Outcomes: Outcomes of interest were incidence of seizures and adverse effects of prophylactic anticonvulsant therapy. Methodology: The MEDLINE and Cochrane Library databases were systematically searched for relevant evidence. The review included fully published reports or abstracts of randomized controlled trials (RCTs), systematic reviews, meta-analyses, and practice guidelines. The present systematic review was reviewed and approved by the Neuro-oncology DSG, which comprises medical and radiation oncologists, surgeons, neurologists, a nurse, and a patient representative. Results: Quality of Evidence: The literature search located one evidence-based practice guideline, one systematic review, and five RCTs that addressed prophylactic anticonvulsants for patients with brain tumours. Evidence for the best management of seizure-naïve patients who are already taking anticonvulsants was limited to one retrospective study and exploratory analyses within several RCTs. Benefits and Harms: Pooled results of the five RCTs suggest that the incidence of seizures in patients who receive prophylactic anticonvulsants is not significantly different from that in patients who do not receive anticonvulsants (relative risk: 1.04; 95% confidence interval: 0.70 to 1.54; p = 0.84). This analysis accords with results from a published meta-analysis. Evidence is insufficient to determine whether patients who are currently taking anticonvulsants but who have never had a seizure should taper the anticonvulsants. Patients who received anticonvulsants reported adverse effects, including rash, nausea, and hypotension, but whether these effects are a result of the anticonvulsants or of other treatments could not be determined. Conclusions: Based on the available evidence, the routine use of postoperative anticonvulsants is not recommended in seizure-naïve patients with newly diagnosed primary or secondary brain tumours, especially in light of a significant risk of serious adverse effects and problematic drug interactions. Because data are insufficient to recommend whether anticonvulsants should be tapered in patients who are already taking anticonvulsants but who have never had a seizure, treatment must be individualized.

The effect of sodium chloride on the dissolution of calcium silicate hydrate gels

The use of cement based materials will be widespread in the long-term management of radioactive materials in the United Kingdom. One of the applications could be the Nirex reference vault backfill (NRVB) as an engineered barrier within a deep geological repository. NRVB confers alkaline conditions, which would provide a robust chemical barrier through the control of the solubility of some key radionuclides, enhanced sorption and minimised corrosion of steel containers. An understanding of the dissolution of C-S-H gels in cement under the appropriate conditions (e.g., saline groundwaters) is necessary to demonstrate the expected evolution of the chemistry over time and to provide sufficient cement to buffer the porewater conditions for the required time. A programme of experimental work has been undertaken to investigate C-S-H gel dissolution behaviour in sodium chloride solutions and the effect of calcium/silicon ratio (C/S), temperature and cation type on this behaviour. Reductions in calcium concentration and pH values were observed with samples equilibrated at 45 degrees C compared to those prepared at 25 degrees C. The effect of salt cation type on salt-concentration dependence of the dissolution of C-S-H gels was investigated by the addition of lithium or potassium chloride in place of sodium chloride for gels with a C/S of 1.0 and 1.8. With a C/S of 1.0, similar increases in dissolved calcium concentration with increasing ionic strength were recorded for the different salts. However, at a C/S of 1.8, anomalously high calcium concentrations were observed in the presence of lithium.

The telomere-binding protein Taz1p as a target for modification by a SUMO-1 homologue in fission yeast

In fission yeast (Schizosaccharomyces pombe) the homologue of the mammalian SUMO-1 ubiquitin-like modifier is encoded by the pmt3 gene. A two-hybrid screen using the telomere-binding protein Taz1p as bait identified Pmt3p as an interacting factor. In vitro experiments using purified components of the fission yeast Pmt3p modification system demonstrated that Taz1p could be modified directly by Pmt3p. The amino acid sequence of Taz1p contains a close match to the consensus modification site for SUMO-1, and a PEST sequence similar to those found in established SUMO-1 targets. Although previous experiments have identified an increase in telomere length as one consequence of the pmt3--genotype, we could not detect Pmt3p modification of Taz1p in protein extracts made from exponentially growing haploid cells or any effect of Pmt3p on the localization of GFP-Taz1p at discrete foci in the haploid cell nucleus.

Development of a foundation degree in health and social care

Health care in the UK is at present experiencing a shortfall of qualified health-care professionals. One initiative that has been proposed is to provide foundation degrees, which meet the needs of employers in a range of health and welfare settings and prepares students to support clients in maximizing their independence within a programme of care.

This article describes the development of the foundation degree in health and social care at the University of Central Lancashire, UK. A two-stage consultative exercise with practitioners was undertaken in the form of focus groups. These were multidisciplinary and grouped according to practice area. This form of consultation has enabled clinicians to feel valued for their skills and opinions and has ensured a curriculum that is relevant and current to the needs of practice.

Therapeutic impact of abdominopelvic computed tomography in patients with acute abdominal symptoms

PURPOSE

To determine the diagnostic and therapeutic impact of abdominopelvic computed tomography (CT) in patients with acute abdominopelvic pain.

MATERIAL AND METHODS

Referring clinicians completed pre-CT and post-CT questionnaires for 50 patients in whom CT had been requested because of acute abdominopelvic pain. Clinicians recorded their leading diagnosis, confidence in this, and intended management. Following CT, clinicians again recorded these responses in the light of CT findings. Responses pre-CT and post-CT were compared in order to determine diagnostic and therapeutic impact.

RESULTS

Diagnostic confidence rose significantly following CT (mean score 6.8 pre-CT versus 8.3 post-CT; P<0.0001). Intended management changed because of CT findings in 29 (58%) patients: 14 (28%) subjects whose intended management was surgical were treated medically and an additional 2 were transferred to gynecological care; 4 patients whose intended management was medical were treated surgically; 2 patients whose intended management was medical were treated by percutaneous drainage; a patient whose intended management was percutaneous drainage was treated by surgery. Of 6 patients with uncertain management pre-CT, 2 were treated surgically and 4 medically. The leading diagnosis also changed as a consequence of CT in 7 (33%) of 21 patients in whom intended management did not alter.

CONCLUSION

CT in patients with acute abdominopelvic pain has considerable diagnostic and therapeutic impact, altering management in 58% of patients studied. The major effect is to avert intended laparotomy.

The therapeutic impact of abdominal ultrasound in patients with acute abdominal symptoms

AIM

The technical performance of abdominal ultrasound in the investigation of acute abdominal pain has been thoroughly investigated but its therapeutic effects are less well understood. We aimed to determine the therapeutic effect of abdominal ultrasound in the investigation of acute abdominal pain.

MATERIAL AND METHODS

A pre- and post-intervention observational study design was used to determine the diagnostic and therapeutic effects of abdominal ultrasound for acute abdominal pain. Referring clinicians completed a pre-ultrasound questionnaire that detailed their leading diagnosis, confidence in this and intended management in 100 consecutive adult patients. Following ultrasound a second questionnaire was completed. This again detailed the leading diagnosis, confidence in this and their intended management. Clinicians quantified the management contribution of ultrasound both for the individual case in question and in their clinical experience generally.

RESULTS

The leading diagnosis was either confirmed or rejected in 72 patients and a new diagnosis provided where no prior differential diagnosis existed in 10. Diagnostic confidence increased significantly following ultrasound (mean score 6.5 pre-ultrasound vs 7.6 post-ultrasound, P < 0.001). Intended management changed following ultrasound in 22 patients; 15 intended laparotomies were halted and a further seven patients underwent surgery where this was not originally intended. Ultrasound was rated either 'very' or 'moderately' helpful in 87% of patients, with 99% of clinicians finding it either 'very' or 'moderately' helpful generally.

CONCLUSION

Abdominal ultrasound has considerable diagnostic and therapeutic effect in the setting of acute abdominal pain.

The N-terminal and C-terminal domains of RAP1 are dispensable for chromatin opening and GCN4-mediated HIS4 activation in budding yeast

Repressor activator protein 1 (RAP1) assists GCN4-mediated HIS4 activation by overcoming some repressive aspect of chromatin structure to facilitate GCN4 binding. RAP1 also participates in other nuclear processes, and discrete domains of RAP1 have been shown to have specific properties including DNA binding, DNA bending, transcriptional activation, and silencing and telomere functions. To investigate whether specific domains of RAP1 are required to "open" chromatin and help GCN4 to activate the HIS4 gene, we examined the abilities of different truncated RAP1 proteins to perturb positioned nucleosomes via a nucleosomal RAP1 site in a yeast episome in vivo, and we tested HIS4 activation in yeast strains harboring truncated RAP1 mutants. We found that neither the DNA bending domain nor the putative activation domain of RAP1 is required for its ability to perturb the chromatin structure of a plasmid containing a RAP1 site. Similarly, neither the putative activation domain nor the N-terminal DNA-bending domain was required for GCN4-mediated activation of HIS4. We also used a rap1(ts) mutant to show that continuous occupancy of the HIS4 promoter by RAP1 is required for GCN4-mediated gene activation.

Pharmacological differences between the human and rat vanilloid receptor 1 (VR1)

Vanilloid receptors (VR1) were cloned from human and rat dorsal root ganglion libraries and expressed in Xenopus oocytes or Chinese Hamster Ovary (CHO) cells. Both rat and human VR1 formed ligand gated channels that were activated by capsaicin with similar EC(50) values. Capsaicin had a lower potency on both channels, when measured electrophysiologically in oocytes compared to CHO cells (oocytes: rat=1.90+/-0.20 microM; human=1.90+/-0.30 microM: CHO cells: rat=0.20+/-0.06 microM; human=0.19+/-0.08 microM). In CHO cell lines co-expressing either rat or human VR1 and the calcium sensitive, luminescent protein, aequorin, the EC(50) values for capsaicin-induced responses were similar in both cell lines (rat=0.35+/-0.06 microM, human=0.53+/-0.03 microM). The threshold for activation by acidic solutions was lower for human VR1 channels than that for rat VR1 (EC(50) pH 5.49+/-0.04 and pH 5.78+/-0.09, respectively). The threshold for heat activation was identical (42 degrees C) for rat and human VR1. PPAHV was an agonist at rat VR1 (EC(50) between 3 and 10 microM) but was virtually inactive at the human VR1 (EC(50)>10 microM). Capsazepine and ruthenium red were both more potent at blocking the capsaicin response of human VR1 than rat VR1. Capsazepine blocked the human but not the rat VR1 response to low pH. Capsazepine was also more effective at inhibiting the noxious heat response of human than of rat VR1.