Success of Liquid Tumor Biopsy in Men with Metastatic Prostate Cancer According to Self-Identified Race

PURPOSE/OBJECTIVE(S)

Liquid biopsy using cell-free DNA (cfDNA) is increasingly used to identify somatic prostate cancer (PrCa) alterations when tissue biopsy of a metastatic lesion is infeasible or impractical. High-risk somatic alterations identified by cfDNA have been recently shown to predict the benefit of metastasis-directed therapy with stereotactic body radiation therapy in PrCa. However, given the older age of PrCa patients, liquid biopsy is often contaminated with alterations related to clonal hematopoiesis of indeterminate potential (CHIP), generating uncertainty in the clinical utility of the results. Given the higher incidence and aggressiveness of metastatic PrCa in Black men, we sought to determine if the success of cfDNA testing varied by race in a large and diverse cohort of United States Veterans with metastatic PrCa, hypothesizing that race would not influence the success of cfDNA testing.

MATERIALS/METHODS

Veterans with metastatic PrCa underwent next-generation sequencing of cfDNA biopsy specimens through the VA National Precision Oncology Program from February 2019 to November 2022. Successful identification of PrCa with cfDNA testing was defined as the identification of an alteration in one or more PrCa-related related genes in the gene panel tested (AR, CDK12, SPOP, MED12, CCND1, BRAF, AKT1, TMPRSS2, ERG, ETV1, and ETV4). Univariate logistic regression was employed to explore the association between patient self-identified race, as well as other patient and disease-specific factors at the time of cfDNA biopsy, with the likelihood of yielding a successful cfDNA biopsy result.

RESULTS

A total of 2066 cfDNA tests from 1985 Veterans were related to a diagnosis of PrCa, passed quality control measures, and were linkable to patient-level demographics. Median age at testing was 74, median PSA at testing was 22.7, median PSA doubling time (PSADT) was 3.6 months, and median Gleason score was 8. 57% of Veterans self-identified as White, 33% as Black, and 10% as Other. Eight hundred fourteen (39%) tests were deemed successful by finding a PrCa related gene alteration. Among successful tests, the most frequently encountered alterations were AR alterations in 60.4% White men and 33.9% Black men (p = 0.72), followed by TMPRSS2 alterations in 70.3% White men and 22.0% Black men (p<0.001). Despite a lower rate of PrCa-specific alterations in Black men, on univariate analysis, Veteran self-identified race was not associated with successful cfDNA testing (OR 0.95, 95% CI 0.78-1.14, p = 0.6), whereas PSA in quintiles 2-4, PSADT <12 months, and unit increase in Gleason score were associated with successful cfDNA testing (p<0.01 for all).

CONCLUSION

Successful cfDNA biopsy in metastatic PrCa is associated with PSA and PSADT, but not related to patient self-identified race. In appropriate clinical scenarios, patients who self-identify as Black or White are equally likely to have PrCa-specific alterations detected on cfDNA testing when evaluating metastatic PrCa patients for local and systemic therapies.

Comparing the accuracy of lay diagnosis of childhood malaria and pneumonia with that of the revised IMCI guidelines in Nigeria

BACKGROUND

Improving caregivers' recognition of childhood malaria and pneumonia is crucial to early treatment and improving outcomes. The objective of this study was to assess the accuracy and reliability of caregivers' recognition of malaria and pneumonia (lay diagnosis) as compared to the revised IMCI guidelines.

METHODS

A cross-sectional study design was used to recruit 903 children aged 2-59 months who were assessed for malaria and pneumonia by health workers at five primary healthcare centres in Benin City, Nigeria. Accuracy of lay diagnosis as compared to the revised IMCI guidelines was assessed using sensitivity, specificity, positive and negative predictive values and area under the receiver operating characteristic curve (AUROC) values.

RESULTS

The accuracy of caregivers' ability to recognise malaria (AUROC: 0.60; 95% CI: 0.57-0.64) and pneumonia (AUROC: 0.54; 95% CI: 0.50-0.58) was, respectively, moderate and poor as compared to the IMCI guidelines. Caregivers were better able to identify children without than those with malaria and pneumonia. Agreement between caregivers and the IMCI guidelines for malaria and pneumonia diagnosis was poor (k = 0.14, 95% CI: 0.09-0.19; P = 0.0001).

CONCLUSION

Caregivers' ability to recognise these childhood diseases as compared to the IMCI guidelines was poor overall, which was partly due to the approach used to ascertain lay diagnosis.

429 Preoperative Risk Assessment In Elective Colorectal Patients

Introduction

Cardiopulmonary Exercise Testing (CPET) and the Colorectal Physiology and Operative Severity Score (CR-POSSUM) are increasingly used in colorectal surgical practice to risk-stratify patients preoperatively and for planning level 2 HDU or ITU admission. This study aims to generate a simple, objective pre-operative risk assessment model to complement clinical judgement, and to determine objectively for whom CPET is necessary in colorectal pre-assessment.

Method

A retrospective cohort study was conducted. Demographic and perioperative data were gathered, and CR-POSSUM score was determined retrospectively. Mortality at 12 months was considered the primary outcome with readmissions up to 12 months as secondary outcomes. Statistical analysis used Binary Logistic Regression, and odds ratios were reported with confidence intervals. A new combined pre-operative risk assessment model with the most significant individual predictors was constructed.

Results

Some 167 elective patients were included in the final analysis. Half of patients had planned HDU admissions. The all-cause mortality at 90 days was 3.5% and at 12 months was 11%. Readmission rate at 30 days was 10%, with a further 11.3% at 90 days postoperatively. The ASA, Physiology Score and Operative Severity Scores correlated with mortality rates (p &lt; 0.05). Current diagnostic performance using CPET vs. the combined model identified 48% and 35% ‘high risk’ patients with 83.3% and 56.5% vs 94.4% and 76.1% sensitivity and specificity, respectively. The model draws its predictive power mainly from the CR-POSSUM.

Conclusions

Current practice at the study centre produces outcomes above the national average. The process can be improved whilst focusing resources further using the combined model.

Learning to implement Smart Healthy Age-Friendly Environments

To develop trainings on the implementation of smart healthy age-friendly environments for people who aim to support, for example, their parents, their neighbours or local community, there are precautionary measures that have to be taken into account: the role of the facilitator (volunteer or self-employed), the level of skills, the needs of the end-users, training content and methodologies together with the sustainability of the learning. This article examines these aspects, based on desk research and expert interviews in the Smart Healthy Age-Friendly Environments (SHAFE) fields.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Controlled population-based comparative study of USA and international adult [55-74] neurological deaths 1989-2014

Objectives

A population‐based controlled study to determine whether adult (55‐74 years) neurological disease deaths are continuing to rise and are there significant differences between America and the twenty developed countries 1989‐91 and 2012‐14.

Method

Total Neurological Deaths (TND) rates contrasted against control Cancer and Circulatory Disease Deaths (CDD) extrapolated from WHO data. Confidence intervals compare USA and the other countries over the period. The Over‐75's TND and population increases are examined as a context for the 55‐74 outcomes.

Results

Male neurological deaths rose >10% in eleven countries, the other countries average rose 20% the USA 43% over the period. Female neurological deaths rose >10% in ten counties, averaging 14%, the USA up 68%. USA male and female neurological deaths increased significantly more than twelve and seventeen countries, respectively. USA over‐75s population increased by 49%, other countries 56%. Other countries TND up 187% the USA rose fourfold. Male and female cancer and CDD fell in every country averaging 26% and 21%, respectively, and 64% and 67% for CDD. Male neurological rates rose significantly more than Cancer and CCD in every country; Female neurological deaths rose significantly more than cancer in 17 countries and every country for CDD. There was no significant correlation between increases in neurological deaths and decreases in control mortalities.

Conclusions

There are substantial increases in neurological deaths in most countries, significantly so in America. Rises in the 55‐74 and over‐75's rates are not primarily due to demographic changes and are a matter of concern warranting further investigation.

The portrayal of infant feeding in British women's magazines: a qualitative and quantitative content analysis

Background

Exclusive breastfeeding is the best start an infant can receive. However, in many high-income countries breastfeeding rates are low and this may be a reflection of social norms which in turn may be influenced by the media. This study therefore explored the portrayal of infant feeding in women's general interest magazines.

Methods

The five top selling women's weekly magazines in Britain and Ireland for 2013 over a 4-month period were included. A quantitative and qualitative content analysis was conducted for both written and visual content.

Results

In 58 magazines, there were 90 references to infant feeding with an average of 1.5 (range: 0-5) per magazine. Breastfeeding and formula feeding references were present in equal number and both were predominantly portrayed positively. There was only 1 visual representation of breast feeding compared with 11 of bottle feeding. Potential drivers for breastfeeding included its role in post-pregnancy weight loss and celebrity endorsement while family routine, the role of males in the house and concerns about adverse health effects were identified as barriers to breastfeeding.

Conclusion

An improvement in visual representations of breast feeding and factual information in women's weekly magazines may be helpful in re-defining social norms regarding infant feeding. Keywords: food and nutrition, health promotion, public health.

The cost-effectiveness of patient-controlled analgesia vs. standard care in patients presenting to the Emergency Department in pain, who are subsequently admitted to hospital

The clinical effectiveness of patient-controlled analgesia has been demonstrated in a variety of settings. However, patient-controlled analgesia is rarely utilised in the Emergency Department. The aim of this study was to compare the cost-effectiveness of patient-controlled analgesia vs. standard care in participants admitted to hospital from the Emergency Department with pain due to traumatic injury or non-traumatic abdominal pain. Pain scores were measured hourly for 12 h using a visual analogue scale. Cost-effectiveness was measured as the additional cost per hour in moderate to severe pain avoided by using patient-controlled analgesia rather than standard care (the incremental cost-effectiveness ratio). Sampling variation was estimated using bootstrap methods and the effects of parameter uncertainty explored in a sensitivity analysis. The cost per hour in moderate or severe pain averted was estimated as £24.77 (€29.05, US$30.80) (bootstrap estimated 95%CI £8.72 to £89.17) for participants suffering pain from traumatic injuries and £15.17 (€17.79, US$18.86) (bootstrap estimate 95%CI £9.03 to £46.00) for participants with non-traumatic abdominal pain. Overall costs were higher with patient-controlled analgesia than standard care in both groups: pain from traumatic injuries incurred an additional £18.58 (€21.79 US$23.10) (95%CI £15.81 to £21.35) per 12 h; and non-traumatic abdominal pain an additional £20.18 (€23.67 US$25.09) (95%CI £19.45 to £20.84) per 12 h.

Abstract P6-05-08: Integrating whole exome sequencing data with RNAseq and quantitative proteomics to better inform clinical treatment decisions in patients with metastatic triple negative breast cancer

Background: The use of next-generation sequencing has significantly advanced personalized medicine for patients (pts) with breast cancer. Despite this technological advancement, there remains the challenge of understanding how and if tumor heterogeneity can confound molecular analysis and treatment decisions. It has been shown that the expression of ER, PR, and HER2 can vary widely within different areas of the same tumor and between matched primary and metastatic lesions. The "Intensive Trial of OMics in Cancer"-001 (ITOMIC-001; NCT01957514) enrolls pts with metastatic TNBC who are platinum-naive and scheduled to receive cisplatin. Multiple biopsies of up to 7 metastatic sites are performed prior to cisplatin and repeated upon completion of cisplatin and following subsequent therapies. A subset of specimens is chosen for DNA sequencing, RNA sequencing, and quantitative proteomics. We explored the discordance of genomic and proteomic alterations for intrapatient and temporal heterogeneity in pts with TNBC, and the potential benefit of panomic analysis to better inform treatment decisions.

Methods: Between 7 and 107 tumor samples/biopsy specimens were obtained from each pt from 1-23 different time points. Blood samples were collected for matched tumor-normal genomic analysis. DNA sequencing data were processed using Contraster; RNASeq data confirmed the presence of gene mutations and was used to identify mutational and transcript abundance. PARADIGM was used to determine associations between gene mutations and signaling pathways. Selected reaction monitoring-mass spectrometry (SRM-MS) was used for proteomics analysis.

Results: Almost all pts had loss of TP53 (common in TNBC), and 5 pts had germline BRCA1/2 events, some exhibiting a signature of mutations corresponding to a mismatch repair defect in ≥1 pt. FGFR1/2/3 mutations/amplifications occurred in 5 pts. Three of 12 pts (25%) achieved partial responses after receiving treatments (post cisplatin) based on the molecular profile of their tumor: 1 pt with two FGFR2 activating mutations treated with ponatinib, 1 with a germline BRCA2 mutation treated with veliparib, and 1 with highly expressed Gpnmb treated with an antibody drug conjugate against Gpnmb. Tumor samples showed increased mutational and rearrangement burdens over time but shared mutational characteristics that were unique to each pt. Through the shared alterations across time points for 3 pts, it was possible to reconstruct the clonal history and heterogeneity of the tumors as various therapeutic approaches were attempted.

Conclusions: Here we show in TNBC, intrapatient and temporal heterogeneity that may lead to a lack of response to identified targeted therapies. Tumor samples taken over time from the same pt become enriched for more complex genomic structures post therapy but share mutational characteristics, indicating the presence of recurrent tumor populations. This study enabled us to reconstruct the clonal history and heterogeneity of tumors across space (metastatic vs primary at t=0) and time, illustrating the need for comprehensive molecular analysis and combination/multi-targeted therapeutics for optimal treatment in TNBC.

Citation Format: Soon-Shiong P, Rabizadeh S, Benz S, Cecchi F, Hembrough T, Mahen E, Burton K, Song C, Senecal F, Schmechel S, Pritchard C, Dorschner M, Blau S, Blau A. Integrating whole exome sequencing data with RNAseq and quantitative proteomics to better inform clinical treatment decisions in patients with metastatic triple negative breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-05-08.

Study protocol for a double blind, randomised, placebo-controlled trial of continuous subpectoral local anaesthetic infusion for pain and shoulder function following mastectomy: SUB-pectoral Local anaesthetic Infusion following MastEctomy (SUBLIME) study

INTRODUCTION

Over 16 000 mastectomies are performed in England and Wales annually. Acute postoperative pain and nausea are common. The most frequently occurring long-term complications are chronic pain (up to 50%) and reduced shoulder function (reported at 35%). Regional techniques that improve acute postoperative pain relief may reduce the incidence of these complications. This study assesses the effectiveness of a 24-hour continuous local anaesthetic in the subpectoral plane in improving postoperative pain and quality of life in patients undergoing mastectomy.

METHODS AND ANALYSIS

This is a randomised, double blind, placebo-controlled, two-centre, parallel group trial in women undergoing mastectomy with or without axillary involvement. One hundred and sixty participants will be randomised in a 1:1 ratio to receive either 0.25% levobupivacaine or 0.9% saline by subpectoral infusion postoperatively for 24 h. All participants will be provided with an intravenous morphine patient-controlled analgesia (PCA) system. Participants will be followed-up for 24 h in hospital and at approximately 14 days and 6 months postoperatively. Joint primary outcome measures are total morphine consumption and total pain score (captured via patient-recorded visual analogue scale (VAS) 4 hourly) during the first 24 h postoperatively. Primary statistical analysis of total pain is based on the area under the curve of pain versus time graph. Secondary outcomes include PCA attempts in first 24 h; VAS pain scores and shoulder function by goniometry at 24 h, 14 days (approximately) and 6 months; Verbal Rating Scale pain scores in first 24 h; Brief Pain Inventory and Oxford Shoulder Score at 6 months; duration of hospital stay; incidence of postoperative nausea and vomiting; cost-effectiveness.

ETHICS AND DISSEMINATION

The study is approved by the South West England Research Ethics Committee (12/SW/0149).

RESULTS

will be published in a peer-reviewed journal and presented at local, national and international scientific meetings.

TRIAL REGISTRATION

ISRCTN46621916. EudraCT 2011-005775-16.

Case study of controlled recirculation at a Wyoming trona mine

Controlled recirculation has been used in the metal/nonmetal mining industry for energy savings when heating and cooling air, in undersea mining and for increasing airflow to mining areas. For safe and effective use of controlled district recirculation, adequate airflow to dilute contaminants must exist prior to implementation, ventilation circuit parameters must be accurately quantified, ventilation network modeling must be up to date, emergency planning scenarios must be performed and effective monitoring and control systems must be installed and used. Safety and health issues that must be considered and may be improved through the use of controlled district recirculation include blasting fumes, dust, diesel emissions, radon and contaminants from mine fires. Controlled recirculation methods are expected to become more widely used as mines reach greater working depths, requiring that these health and safety issues be well understood. The U.S. National Institute for Occupational Safety and Health (NIOSH) conducted two controlled recirculation tests over three days at a Wyoming trona mine, utilizing an inline booster fan to improve airflow to a remote and difficult-to-ventilate development section. Test results were used to determine the effect that recirculation had on air qualities and quantities measured in that section and in other adjacent areas. Pre-test conditions, including ventilation quantities and pressures, were modeled using VnetPC. During each test, ventilation quantities and pressures were measured, as well as levels of total dust. Sulfur hexafluoride (SF ₆ ) tracer gas was used to simulate a mine contaminant to monitor recirculation wave cycles. Results showed good correlation between the model results and measured values for airflows, pressure differentials, tracer gas arrival times, mine gasses and dust levels.

Macroalgae decrease growth and alter microbial community structure of the reef-building coral, Porites astreoides

With the continued and unprecedented decline of coral reefs worldwide, evaluating the factors that contribute to coral demise is of critical importance. As coral cover declines, macroalgae are becoming more common on tropical reefs. Interactions between these macroalgae and corals may alter the coral microbiome, which is thought to play an important role in colony health and survival. Together, such changes in benthic macroalgae and in the coral microbiome may result in a feedback mechanism that contributes to additional coral cover loss. To determine if macroalgae alter the coral microbiome, we conducted a field-based experiment in which the coral Porites astreoides was placed in competition with five species of macroalgae. Macroalgal contact increased variance in the coral-associated microbial community, and two algal species significantly altered microbial community composition. All macroalgae caused the disappearance of a γ-proteobacterium previously hypothesized to be an important mutualist of P. astreoides. Macroalgal contact also triggered: 1) increases or 2) decreases in microbial taxa already present in corals, 3) establishment of new taxa to the coral microbiome, and 4) vectoring and growth of microbial taxa from the macroalgae to the coral. Furthermore, macroalgal competition decreased coral growth rates by an average of 36.8%. Overall, this study found that competition between corals and certain species of macroalgae leads to an altered coral microbiome, providing a potential mechanism by which macroalgae-coral interactions reduce coral health and lead to coral loss on impacted reefs.

The longitudinal profile of bilirubin and ferritin in the cerebrospinal fluid following a subarachnoid hemorrhage: diagnostic implications

BACKGROUND

Cerebrospinal fluid (CSF) spectrophotometry for bilirubin is a highly sensitive test in the diagnostic work up of a suspected subarachnoid hemorrhage (SAH).

CASES

We report two cases suffering from an aneurysmal SAH in which extraventricular drainage for acute hydrocephalus was required. Longitudinal analyses of the CSF samples demonstrated that CSF bilirubin was detectable in all cases during the first week, becoming undetectable in one case in the second week. Importantly, CSF ferritin levels rose substantially (>1,000 ng/ml) after 6 days, peaking around 3,000 ng/ml after 2 weeks (normal upper reference range 12 ng/ml). In both cases blood was visible on the initial CT brain scan, disappearing on a later scan.

CONCLUSION

CSF ferritin levels may be an important additional laboratory test in the diagnostic work-up of patients with a suspected SAH. CSF ferritin levels may prove particularly helpful in cases with late presentation if the CT brain scan is normal and CSF bilirubin level is undetectable.

International evidence of who kill children? child protection-psychiatric interface

This study will be controversial as it highlights the continuing link of violent deaths of children and psychiatric disorder and the forgotten/ hidden psychiatric-criminological child protection interface.

We challenge the Child Protection assumption that there is a continuum of neglect into abuse that, at the extremes, leads to the death of a child. The avoidance of such tragedies has become the benchmark of the effectiveness of child protection, reflected in the high profile situations in every Western country.

This has led to a practice culture of fearing the ‘worst case scenario’ with inevitable defensive bureaucratisation, hence the importance of answering the question’who kill children’?

Based upon an analysis of the latest WHO mortality statistics in the 20 Western Countries, we juxtapose All forms of children’s (0–14) mortality against indices of relative poverty i.e. Income Inequalities, and answer the core question from a decade cohort of people who actually killed children,

We show that whilst child neglect is related to poverty, statistically poverty is Not related to child-abuse-related-deaths (CARD).

It will be shown that men with previous convictions for violence pose physical risk to children, followed by psychotic parents. Consequently, assailants’ problems are essentially ‘psychological/ criminological’, rather than socio-economic though poverty always compounds vulnerable situations.

A more accurate risk assessment would enable psychiatric and child protection practitioners to differentiate the neglect and poverty interface from CARD, enabling each discipline to offer an optimal practice intervention earlier and more effectively.

The 6-month safety and efficacy of abatacept in patients with rheumatoid arthritis who underwent a washout after anti-tumour necrosis factor therapy or were directly switched to abatacept: the ARRIVE trial

OBJECTIVE

To assess the safety, tolerability and efficacy of abatacept in patients with rheumatoid arthritis (RA) who had failed anti-tumour necrosis factor (TNF) therapy and were switched to abatacept directly or after completing washout.

METHODS

In this international, 6-month, open-label trial, patients had active RA, an inadequate response to anti-TNF therapy for 3 months or longer and a disease activity score in 28 joints (DAS28 (C-reactive protein; CRP) of 5.1 or greater. "Washout" patients discontinued anti-TNF therapy 2 months or longer pre-screening; "direct-switch" patients began abatacept ( approximately 10 mg/kg) at their next scheduled anti-TNF therapy dose.

RESULTS

1046 patients were treated (449 washout, 597 direct-switch; baseline characteristics were similar between groups). At 6 months, adverse events (AE; 78.0% vs 79.2%), serious AE (11.1% vs 9.9%) and discontinuations due to AE (3.8% vs 4.0%) and serious AE (2.0% vs 1.3%) were comparable in washout versus direct-switch patients. There were no opportunistic infections. At 6 months, in washout versus direct-switch patients, similar clinically meaningful improvements were seen in DAS28 (CRP) (> or =1.2 unit improvement, 59.5% vs 53.6%, respectively; low disease activity state, 22.5% vs 22.3%; DAS28-defined remission, 12.0% vs 13.7%), physical function (health assessment questionnaire disability index > or =0.22 improvement; 46.3% vs 47.1%) and health-related quality of life (mean change in short-form 36 scores: physical component summary, 5.5 vs 6.1; mental component summary, 4.8 vs 5.4).

CONCLUSION

Abatacept demonstrated acceptable safety and tolerability and clinically meaningful efficacy over 6 months in patients with inadequate response to anti-TNF therapy. Results were comparable with or without a washout, supporting direct switching from anti-TNF therapy to abatacept as an option in clinical practice.

TRIAL REGISTRATION NUMBER

NCT00124982.

Chemotherapy in the community: what do patients want?

The aim of this study was to compare the outcomes of chemotherapy delivered at a cancer centre with chemotherapy given at a community hospital. The services were compared in terms of safety, preference for location, satisfaction and resource use. Patients were randomly allocated to two groups. One group received their first two cycles of chemotherapy at a community hospital; the other group received theirs at the cancer centre. The patients then crossed over to receive their next two cycles of chemotherapy at outreach or the cancer centre and then chose where they wanted to receive the remaining two cycles of their chemotherapy. Data were collected about patient preference, anxiety and depression, satisfaction and chemotherapy-related toxicity. Forty-two patients were randomized to the study: 38, 31 and 28 patients completed cycles two, four and final chemotherapies respectively. Thirty-one patients reached the end of the crossover period, of which 30 chose the outreach location for the remainder of their chemotherapy treatments. There was strong evidence that patients were more satisfied with outreach location for ease of access and also the environment. Recommendation from this study was that a permanent outreach chemotherapy service to community hospitals be established.

Changes in cancer incidence and mortality in England and Wales and a comparison of cancer deaths in the major developed countries by age and sex 1979-2002 in context of GDP expenditure on health

Background:

The successful treatment of cancer is a major health and political issue for England and Wales and the major developed countries (MDCs). All malignancy deaths by age and sex are analysed to determine how successful the MDCs were in reducing cancer mortality between the end points of 1979–81 and 2000–2, and whether there was any association between each nations ‘gross domestic product expenditure on health’ (GDPEH) and the reduction in their cancer deaths.

Method:

Incidence of cancer in England and Wales was examined for 1979–80 to 2003–4 to highlight the extent of the problem. The cancer mortality rates for England and Wales were compared with each MDC by age and sex, using ‘WHO all malignancies mortality rates’ for the periods of 1979–81 and 2000–2, and tests of significance were made. The GDPEH for each MDC was examined for 1980–2002, and Spearman rank-order correlations calculated to explore any association between declining cancer deaths and the GDPEH of each MDC.

Results:

Conclusions:

The rising incidence in cancer-related deaths poses a problem for every MDC, and the poorer women’s results should be a matter of concern for most MDCs. The reduction in cancer deaths reflects well on frontline services, and the significant association between reduced cancer mortality and increased GDPEH is encouraging, but still a challenge for governments, especially if the incidence continues to rise.

Amine-reactive isobaric tagging reagents: requirements for absolute quantification of proteins and peptides

Amine-reactive isobaric tagging reagents such as iTRAQ (isobaric tags for relative and absolute quantitation) have recently become increasing popular for relative protein quantification, cell expression profiling, and biomarker discovery. This is due mainly to the possibility of simultaneously identifying and quantifying multiple samples. The principles of iTRAQ may also be applied to absolute protein quantification with the use of synthetic peptides as standards. The prerequisites that must be fulfilled to perform absolute quantification of proteins by iTRAQ have been investigated and are described here. Three samples of somatropin were quantified using iTRAQ and synthetic peptides as standards, corresponding to a portion of the protein sequence. The results were compared with those obtained by quantification of the same protein solutions using double exact matching isotope dilution mass spectrometry (IDMS). To obtain reliable results, the appropriate standard peptides needed to be selected carefully and enzymatic digestion needed to be optimized to ensure complete release of the peptides from the protein. The kinetics and efficiency of the iTRAQ derivatization reaction of the standard peptides and digested proteins with isobaric tagging reagents were studied using a mixture of seven synthetic peptides and their corresponding labeled peptides. The implications of incomplete derivatization are also presented.

Reporting of skin cancer risks in the house-building industry: alternative approaches to the analysis of categorical data

BACKGROUND

Increasing incidence of skin cancer is of concern to public health. Working predominantly outside, construction workers are at increased risk of sunburn and certain forms of skin cancer. The objective of this paper was to explore these concerns via use of alternative approaches to categorical data analysis by considering the relationship between the size of house-building companies, use of risk assessments and the system for reporting sunburn.

METHODS

The survey population was speculative house-building companies. A self-administered questionnaire was sent to health and safety advisors in house-building companies. Questions related to the number of house units built, inclusion of adverse weather in the risk assessment, and the presence or absence of a system for reporting sunburn were analysed. Alternative approaches to conventional chi(2) tests were used in order to investigate a multiway data structure. A loglinear model was employed using Statistical Package for Social Sciences to explain data in three-way tables.

RESULTS

The questionnaire achieved a response rate of 31% (n=94). A significant association identified in a two-way study of the mechanisms of reporting sunburn also appeared at the sublevels introduced by the inclusion of a third method of categorization. Finally, correspondence analysis was used to present a graphical insight into the study.

CONCLUSIONS

In the two-way analysis, the size of house-building company had a significant impact on the presence of a system for reporting sunburn, although this was not translated into the three-way analysis. The establishment of systems within risk assessments to incorporate exposure of construction workers to ultraviolet radiation, and reporting of incidents of sunburn, is essential if this public health issue is to be addressed.

Gene expression profiling in a mouse model for African trypanosomiasis

This study aimed to provide the foundation for an integrative approach to the identification of the mechanisms underlying the response to infection with Trypanosoma congolense, and to identify pathways that have previously been overlooked. We undertook a large-scale gene expression analysis study comparing susceptible A/J and more tolerant C57BL/6 mice. In an initial time course experiment, we monitored the development of parasitaemia and anaemia in every individual. Based on the kinetics of disease progression, we extracted total RNA from liver at days 0, 4, 7, 10 and 17 post infection and performed a microarray analysis. We identified 64 genes that were differentially expressed in the two strains in non-infected animals, of which nine genes remained largely unaffected by the disease. Gene expression profiling at stages of low, peak, clearance and recurrence of parasitaemia suggest that susceptibility is associated with high expression of genes coding for chemokines (e.g. Ccl24, Ccl27 and Cxcl13), complement components (C1q and C3) and interferon receptor alpha (Ifnar1). Additionally, susceptible A/J mice expressed higher levels of some potassium channel genes. In contrast, messenger RNA levels of a few immune response, metabolism and protease genes (e.g. Prss7 and Mmp13) were higher in the tolerant C57BL/6 strain as compared to A/J.

Quality of life, morbidity, and mortality after low trauma hip fracture in men

BACKGROUND

Osteoporotic hip fractures have been extensively studied in women, but they have been relatively ignored in men.

OBJECTIVE

To study the mortality, morbidity, and impact on health related quality of life of male hip fractures.

METHODS

100 consecutive men aged 50 years and over, with incident low trauma hip fracture, admitted to Royal Cornwall Hospital, UK during 1995-97, were studied. 100 controls were recruited from a nearby general practice. Mortality and morbidity, including health status assessed using the SF-36, were evaluated over a 2 year follow up period.

RESULTS

Survival after 2 years was 37% in fracture cases compared with 88% in controls (log rank test 62.6, df = 1, p = 0.0001). In the first year 45 patients died but only one control. By 2 years 58 patients but only 8 controls had died. Patients with hip fracture died from various causes, the most common being bronchopneumonia (21 cases), heart failure (9 cases), and ischaemic heart disease (8 cases). Factors associated with increased mortality after hip fracture included older age, residence before fracture in a nursing or residential home, presence of comorbid diseases, and poor functional activity before fracture. Patients with fracture were often disabled with poor quality of life. By 24 months 7 patients could not walk, 12 required residential accommodation, and the mean SF-36 physical summary score was 1.7SD below the normal standards.

CONCLUSIONS

Low trauma hip fracture in men is associated with a significant increase in mortality and morbidity. Impaired function before fracture is a key determinant of mortality after fracture.

Methods employed by genitourinary medicine clinics in the United Kingdom to diagnose bacterial vaginosis

OBJECTIVE

To determine the methods used by genitourinary medicine (GUM) clinics in the United Kingdom for the diagnosis of bacterial vaginosis (BV).

METHODS

A questionnaire survey of UK GUM clinics was conducted.

RESULTS

148/221 (67%) clinics returned a questionnaire. 96/148 (64.9%) clinics reported using Amsel's criteria to diagnose BV but only 29 (30.5%) of these used all four of the composite criteria. 139/148 (93.9%) clinics used the appearance of a Gram stained vaginal smear as an aid in BV diagnosis, although a variety of scoring methods was employed. In the majority of clinics, 92/148 (62.2%), one staff discipline provided the microscopy service, in 50 (33.8%) clinics two staff disciplines provided microscopy services. The bulk of microscopy services within UK GUM clinics is provided by nurses.

CONCLUSIONS

Most UK GUM clinics utilise the appearance of a Gram stained vaginal smear for the diagnosis of BV although there is little consensus at present about the type of scoring method employed. Adaptation of a uniform scoring method would have enormous benefits, including consistency and reproducibility of results and the development of quality assurance schemes for BV diagnosis on a national basis. There are important issues to be addressed regarding the initial training and ongoing support for nurses providing microscopy services within UK GUM clinics.

Two-year prospective study of psychosocial outcomes and a cost-analysis of 'treatment-as-usual' versus an 'enhanced' (specialist liaison nurse) service for aneurysmal sub arachnoid haemorrhage (ASAH) patients and families

An 18-month retrospective study of 'treatment-as-usual' of aneurysmal subarachnoid haemorrhage (ASAH, n = 142) used as control to compare prospective study (n = 184) of an 'enhanced' ('Specialist Liaison Nurse'-SLN) service to reduce psychosocial trauma. Consultant notes, Glasgow Coma Scores and 'High Risk' bleeds scores provided clinical data. A standardized patient/carer designed questionnaire provided psychosocial data, plus a cost-analysis. The cohorts were good clinical and social matches. Sixty-five per cent of patients had 'high risk' bleeds, and 81% were Grade 1 and 2 on the GCS, 54% aged less than 55 years, 83% belonged to social classes 1-3 and 32% had school-aged children. Satisfaction with SLN inpatient and discharge care increased significantly, with reduced psychosocial trauma. The SLN produced net 'savings' of pounds sterling 155,000 p.a., from reduced time-off work, medical time and re-admissions. Prospectively, pounds sterling 1.6 + million annual 'savings' were identified on 80% of employed patients returning to work. Long-term dysfunctional stress is not inevitable for most ASAH patients as a SLN is clinically and fiscally cost-effective.

Psycho-socio-economic outcomes in acoustic neuroma patients and their carers related to tumour size

The objective was to explore psycho-socio-economic outcomes of a 2-year cohort of patients having surgery for an acoustic neuroma, and carers and their relationship to tumour size after surgery. The Wessex Patient Carer Questionnaire was designed in conjunction with Patients and Carers, to determine psycho-socio-economic outcomes. The results were juxtaposed against clinical profiles. The House-Brackman (HB) scale was used to assess facial function at 6 and 12 months after operation. The cohort contained 102 patients. There were 87% effective responders. Half were aged below 54 years and 30% had school-aged children. The majority (93%) of patients were operated via the translabyrinthine approach. Patients with large tumours, i.e. greater than 3 cm (28%), had most post-treatment physical problems, including hearing and balance difficulties, and 42% reported difficulty eating in public. Thirty-four per cent felt 'stressed' and 18%'depressed'. After 6 months, facial function was recorded as HB scale 5/6 in 21% of patients but by 1 year only 8% of patients were HB 5/6. Patients and carers were generally very satisfied with their in-patient neurosurgical care, but significantly dissatisfied with post-discharge care - particularly the shortcoming of the community services. The majority of families felt 'unsupported' and only 20% of patients had confidence in their General Practitioner's knowledge. Families faced severe socio-economic disruption and patients"time-off-work' was estimated to cost pound 954,000. Carers carried considerable post-discharge psychological burdens and costs to the public purse were calculated to be pound 52,000.

Changing patterns of adult (45–74 years) neurological deaths in the major Western world countries 1979–1997

OBJECTIVES

To compare changes in 'adult' (45-74 years) 'all-cause deaths' (ACDs) with all neurological death categories by age and gender in the 10 major Western countries between the 1970s (1979-1981) and the 1990s (1995-1997).

METHOD

World Health Organization standardized mortality data for age and gender (1979/97) were used to examine changes in adult mortality rates per million based upon ICD-9 categories for ACDs, 'neurological deaths' and the special neurological categories of 'other neurological deaths' (ONDs) and 'mental disorder deaths' (MDDs), which include the dementias. Ratios of ratios were calculated to demonstrate how each individual country's pattern changed over the period by age and gender, resolving the problem of cross-national comparisons. Rates of change across the endpoints and between age groups (45-54, 55-64, 65-74 and 75+ years) were examined using analysis of variance, stepwise regression analysis and cross-tabulation analyses.

RESULTS

Meningitis deaths fell substantially, but there was little change in multiple sclerosis or epilepsy deaths. OND rates for the 1990s increased compared with the 1970s rates for males and female, in actual terms and relative to ACDs for almost all countries. Many of the relative rates of increase were substantially higher than 20%. There were significant statistical differences with respect to relative rates of ONDs between the 1970s and the 1990s data, even when the 75+ years age group was excluded. Significant differences were also found between age groups, but only in the 1990s data. MDD rates showed similar trends. Analyses of actual rates of increase in these causes of death showed that males outnumber females in all ages below 74 years. The extent of this difference remained constant across the endpoints. However, in those aged 75 years and over, females outnumbered males at both endpoints, but this disparity widened significantly in the 1990s data.

CONCLUSIONS

The 1990s data indicate substantial increases compared with the 1970s data for ONDs (especially amongst 65-74 year olds), and rises in MDDs in 55-64 year olds in five countries, including England and Wales and Germany, and in 65-74 year olds in most countries, suggesting earlier onsets of the underlying conditions. Further country-specific research is required to explain the emerging morbidity and mortality.

Tumour necrosis factor alpha inhibitor treatment for sarcoidosis refractory to conventional treatments: a report of five patients

OBJECTIVE

To study the effectiveness of tumour necrosis factor alpha (TNFalpha) inhibitor treatment for sarcoidosis refractory to conventional treatments.

METHODS

Five patients (two men, three women) were treated with infliximab. All patients received a loading dose of 3 mg/kg at 0, 2, and 6 weeks and then maintenance infusions every 4-8 weeks. Patients had their dose increased or the dosing interval reduced when the disease relapsed. These patients had active disease despite treatment with corticosteroids and other immunomodulatory agents. All patients had a negative tuberculin skin test.

RESULTS

Sarcoidosis in all patients improved significantly without any serious adverse reactions.

CONCLUSION

This study suggests that TNFalpha is effective in patients for whom conventional treatment fails.

Molecular phenotyping of the mouse ky mutant reveals UCP1 upregulation at the neuromuscular junctions of dystrophic soleus muscle

The ky mutant mouse displays a muscular dystrophy that affects almost exclusively slow type muscles in which persistent muscle regeneration, neuromuscular junction instability and an absence of the hypertrophic response are prominent features. In order to gain insights into the pathogenesis of this muscular dystrophy we have undertaken RNA profiling of the extensor digitorum longus, a fast unaffected muscle, and the highly pathological soleus slow muscle, followed by further expression studies to validate the results. In dystrophic soleus, there is a coordinated change in the expression level of genes encoding energy transducing mitochondrial proteins and an increase in the expression of stretch response genes. Upregulation of uncoupling proteins 1 and 2 is a unique molecular signature of the ky muscular dystrophy and was further characterised at the protein level. Our results show a spatial and temporal association between disorganisation of acetylcholine receptor clusters and upregulation of uncoupling protein 1. There is also evidence of a breakdown of neuromuscular junction muscle-specific kinase-dependent signalling in adult mutant soleus. Sarcolemma-associated proteins implicated in muscular dystrophies revealed no differences on microarrays and were confirmed as normally distributed by immunofluorescence. Altogether, the data presented suggest that the ky muscular dystrophy develops by a distinctive pathogenic mechanism.