Are scrubs the new white coat? An exploration of MPharm students’ experiences of wearing scrubs

Introduction

Many healthcare professionals and students wear uniforms while working in clinical environments which help develop professional identity, however, there is limited data regarding uniforms for pharmacy professionals in the UK.1 Historically, pharmacists and some pharmacy students wore white coats which increased professionalism, yet they are not practical with clinical roles.2 In September 2021, one UK School of Pharmacy introduced scrubs as a uniform for MPharm students for work-based learning (WBL) at several NHS hospital trusts.

Aim

To explore the experiences of MPharm students wearing scrubs during WBL.

Methods

MPharm students in years 2-4 (n=311) were invited to participate in a 5-item anonymous online questionnaire which consisted of open-ended and closed-ended questions to explore perceptions of wearing scrubs. Years 3 and 4 were asked additional questions to compare wearing scrubs with their prior WBL where they had to dress ‘’professionally’’. The data underwent descriptive and content analysis. This project received institutional ethical approval (17759-2021).

Results

75 responses from years 2-4 were analysed (17%, 52%, and 31% respectively across the year groups, 24% overall response rate). Students were predominantly female (85%; n=64) and White British (52%; n=39). When asked how happy they were to wear scrubs on a Likert scale from ‘5-extremely happy’ to ‘1- not at all’, 92% (n=69) indicated they were extremely or moderately happy to wear scrubs (median=5; IQR 1). The accompanying free-text responses showed reoccurring groups of positive comments concerning: professionalism (21%), acceptance (24%), and identity (26%). Students viewed themselves as having a “shared identity, sense of professionalism and purpose and maturity” [P40]. More negative comments pertained to the sizing (13%), changing facilities (6%) and being mistaken for other professionals (9%). 44% (n=27) of year 3 and 4 students perceived a change in patients’ attitudes since wearing scrubs with 20% (n=13) citing patients as appearing more comfortable: ‘’Patients take us much more seriously - they see us as healthcare professionals rather than just students. I think it gives us greater confidence in ourselves.’’[P11]. Additionally, 39% (n=24) perceived a change in treatment from staff, with 10% of these students sharing that staff were more open to them being on the wards. ‘’we are taken more seriously by staff… there are no questions about why we are on the ward’’[P22].

Discussion/Conclusion

The introduction of scrubs had a positive impact on student experience and contributed to a sense of belonging to the profession and within the ward environment. There were practical issues around sizing and changing facilities which should be considered at a local level but with mindfulness so as not to discriminate against individuals. Further data should be sought exploring the patient perspective and from students at other institutions. It should be noted that three NHS Trusts hosted placements and so there is some transferability. Scrubs are an appropriate and well-liked uniform for pharmacy students. Introducing scrubs across other Schools of Pharmacy could increase the professionalism, confidence, and socialisation of MPharm students whilst also creating a shared identity between pharmacy students, like that of the historic white coat.

References

1. Timmons S, East L. Uniforms, status and professional boundaries in hospital. Sociol Health Illn. 2011;33(7):1035-1049.

2. Briceland LL, Brewer JM, Dominelli A. The Impact of Pharmacy Student Participation in the White Coat Ceremony on Professionalization. Am J Pharm Educ. 2020;84(3):7689.

The utility of the Sydney Melancholia Prototype Index (SMPI) for predicting response to electroconvulsive therapy in depression: A CARE Network study

An enhanced understanding of clinical predictors of positive ECT outcome could assist with the decision to prescribe ECT for select patients. Reliable predictors of ECT response such as psychotic symptoms and age have been identified, however, studies of melancholia and ECT response have been inconsistent. The Sydney Melancholia Prototype Index (SMPI) is a clinical measure designed to differentiate melancholic and non-melancholic depression. This study aimed to investigate whether melancholic depression (as measured by the clinician rated version of the SMPI) predicted a better response to ECT than non-melancholic depression. The study included data collated from four participating sites in the Clinical Alliance for ECT and Related treatments (CARE) network. The primary outcome was response (>50% improvement) on the Montgomery Asberg Depression Rating Scale (MADRS) and the secondary outcome was raw change in MADRS score. Of the 329 depressed patients included in the study, 81% had melancholic features and 76% met criteria for clinical response. SMPI defined melancholia was associated with older age, higher pre-treatment mood scores and presence of psychosis. Melancholia as defined by the SMPI, however, did not significantly predict either clinical response or overall mood improvement with ECT in multivariate analyses. Instead, older age, greater pre-treatment depression severity and the use of bifrontal compared to right unilateral ultrabrief ECT were significant predictors of mood improvement. Path analysis showed that higher pre-treatment mood score and older age were independently associated with mood improvement with ECT.

The utility of the brief ECT cognitive screen (BECS) for early prediction of cognitive adverse effects from ECT: A CARE network study

Although highly effective, electroconvulsive therapy (ECT) often produces cognitive side effects which can be a barrier for patients. Monitoring cognitive side effects during the acute course is therefore recommended to identify patients at increased risk for adverse outcomes. The Brief ECT Cognitive Screen (BECS) is a brief instrument designed to measure emerging cognitive side effects from ECT. The aim of this study was to examine the clinical utility of the BECS for predicting adverse cognitive outcomes in real world clinic settings. The study included data collated from four participating sites in the Clinical Alliance for ECT and Related treatments (CARE) network. The BECS was administered at pre ECT and post 3 or 4 ECT. The primary outcome was a ≥4 point decrease on the Montreal Cognitive Assessment (MoCA) from pretreatment to post ECT. Logistic multiple regression analyses examined the BECS and other relevant clinical and demographic and treatment factors as predictors. The final analysis included 623 patients with diverse indications for ECT including 53.6% with major depression and 33.7% with schizophrenia or schizoaffective disorder. A higher total score on the BECS significantly predicted decline in Total Scores on the MoCA [B = 0.25 (0.08), p = 0.003], though not decline in MoCA Delayed Recall scores (p > 0.1). Other significant predictors included higher pretreatment MoCA Total Scores and female gender for verbal anterograde memory decline. This study confirmed that the BECS has clinical utility for identifying patients with both reduced and increased risk for adverse cognitive outcomes from ECT.

Dysregulation of prostaglandins, leukotrienes and lipoxin A4 in bronchiectasis

Introduction

Bronchiectasis is characterised by excessive neutrophilic inflammation. Lipid mediators such as prostaglandins and leukotrienes have crucial roles in the inflammatory response. Further characterisation of these lipids and understanding the interplay of anti-inflammatory and proinflammatory lipid mediators could lead to the development of novel anti-inflammatory therapies for bronchiectasis.

Aim

The aim of our study was to characterise the lipids obtained from serum and airways in patients with bronchiectasis in the stable state.

Methods

Six healthy volunteers, 10 patients with mild bronchiectasis, 15 with moderate bronchiectasis and 9 with severe bronchiectasis were recruited. All participants had 60 mL of blood taken and underwent a bronchoscopy while in the stable state. Lipidomics was done on serum and bronchoalveolar lavage fluid (BALF).

Results

In the stable state, in serum there were significantly higher levels of prostaglandin E₂ (PGE₂), 15-hydroxyeicosatetranoic acid (15-HETE) and leukotriene B₄ (LTB₄) in patients with moderate–severe disease compared with healthy volunteers. There was a significantly lower level of lipoxin A₄ (LXA₄) in severe bronchiectasis.

In BALF, there were significantly higher levels of PGE₂, 5-HETE, 15-HETE, 9-hydroxyoctadecadienoic acid and LTB₄ in moderate–severe patients compared with healthy volunteers.

In the stable state, there was a negative correlation of PGE₂ and LTB₄ with % predicted forced expiratory volume in 1 s and a positive correlation with antibiotic courses.

LXA₄ improved blood and airway neutrophil phagocytosis and bacterial killing in patients with bronchiectasis. Additionally LXA₄ reduced neutrophil activation and degranulation.

Conclusion

There is a dysregulation of lipid mediators in bronchiectasis with excess proinflammatory lipids. LXA₄ improves the function of reprogrammed neutrophils. The therapeutic efficacy of LXA₄ in bronchiectasis warrants further studies.

A99 OPTIMIZING COLONOSCOPY PROCEDURES AND REDUCING PATIENT ANXIETY THROUGH RECENTLY DEVELOPED ONLINE INFORMATION RESOURCES

Background

Invasive medical procedures such as colonoscopies are known to cause psychological distress and anxiety. Patient anxiety leads to reduce patient compliance for colonoscopy and increased adverse effects. Patient education prior to colonoscopy has previously been shown to have positive effects on outcomes and experience. Based on patient and provider input, we have developed easy to read written materials and easy to follow video materials, which other patients have rated highly. These, along with other materials, are embedded on Mycolonoscopy.ca. Mycolonoscopy.ca is a website that provides online information access for patients regarding preparation and peri-procedural expectations. Information about accessing the website is provided with appointment materials (which includes information about split-dose versus one day bowel preparation, giving patients the option between the two) mailed to all patients undergoing outpatient colonoscopy in Winnipeg.

Aims

(1) To evaluate the current use of mycolonoscopy.ca among patients undergoing colonoscopy (2) To determine whether there is an association between visitation to the website and patient outcomes such as reduction in procedural anxiety, bowel preparation tolerance/compliance, and bowel preparation score.

Methods

A paper-based survey was given out to patients at their colonoscopy appointments. Univariate and multivariate logistic regression analyses was performed to determine the factors associated with website visitation and association with procedural anxiety, bowel preparation compliance and bowel preparation scores.

Results

A total of 593 participants were given the surveys, of which 506 were completed. 17.4% of participants had visited the website prior to their colonoscopy. Visitors to mycolonoscopy.ca and those that had heard of the website were more likely to consume a split-dose bowel preparation (63.9% and 68.2% respectively) compared with non-visitors (52.5%) (p=0.0062). Individuals who consumed split-dose bowel preparation had a median Boston bowel preparation score of 9, compared with a score of 7 for individuals who used other forms of preparation (p<0.0001). 31.3% of website visitors were very or extremely worried about their colonoscopy compared with 17.9% of non-visitors. 76.6% of individuals agreed or strongly agreed that visiting the website helped them prepare for their colonoscopy and 69.7% who visited the website agreed or strongly agreed that it helped to reduce their stress/anxiety for the procedure as well.

Conclusions

Our study suggests that use of an informative online platform such as mycolonoscopy.ca can help to improve patient education prior to colonoscopy, reduce anxiety and stress surrounding the procedure, and improve bowel preparation compliance and bowel cleansing score.

Funding Agencies

CAG

An evaluation of the bacteriostatic effect of platelet-rich plasma

Chronic wounds are a considerable health burden with high morbidity and poor rates of healing. Colonisation of chronic wounds by bacteria can be a significant factor in their poor healing rate. These bacteria can develop antibiotic resistance over time and can lead to wound infections, systemic illness, and occasionally amputation. When a large number of micro-organisms colonise wounds, they can lead to biofilm formation, which are self-perpetuating colonies of bacteria closed within an extracellular matrix, which are poorly penetrated by antibiotics. Platelet-rich plasma (PRP) is an autologous blood product rich in growth factors and cytokines that are involved in an inflammatory response. PRP can be injected or applied to a wound as a topical gel, and there is some interest regarding its antimicrobial properties and whether this can improve wound healing. This study aimed to evaluate the in vitro bacteriostatic effect of PRP. PRP was collected from healthy volunteers and processed into two preparations: activated PRP-activated with calcium chloride and ethanol; inactivated PRP. The activity of each preparation against Staphylococcus aureus and Staphylococcus epidermis was evaluated against a control by three experiments: bacterial kill assay to assess planktonic bacterial growth; plate colony assay to assess bacterial colony growth; and colony biofilm assay to assess biofilm growth. Compared with control, both preparations of PRP significantly inhibited growth of planktonic S aureus and S epidermis. Activated PRP reduced planktonic bacterial concentration more than inactivated PRP in both bacteria. Both PRP preparations significantly reduced bacterial colony counts for both bacteria when compared with control; however, there was no difference between the two. There was no difference found between biofilm growth in either PRP against control or against the other preparation. This study demonstrates that PRP does have an inhibitory effect on the growth of common wound pathogens. Activation may be an important factor in increasing the antimicrobial effect of PRP. However, we did not find evidence of an effect against more complex bacterial colonies.

A multicentre, clinical evaluation of a hydro-responsive wound dressing: the Glasgow experience

OBJECTIVE

Our aim was to assess the effectiveness of hydro-responsive wound dressing (HRWD) in debridement and wound bed preparation of a variety of acute and chronic wounds that presented with devitalised tissue needing removal so that healing may proceed.

METHOD

This was a non-comparative evaluation of acute and chronic wounds that required debridement as part of their normal treatment regimen. Clinicians recorded wound changes including a subjective assessment level of devitalised tissue and wound bed preparation, presence of pain, wound status (e.g., wound size) and periwound skin condition. Data was also collected from clinicians and patients to provide information on clinical performance of the dressing.

RESULTS

We recruited 100 patients with a variety of wound types into the study. Over 90% of the clinicians reported removal of devitalised tissue to enable a healing response in both chronic and acute wounds. Specifically, over the course of the evaluation period, levels of devitalised tissue (necrosis and slough) reduced from 85.5% to 26.3%, and this was accompanied by an increase in wound bed granulation from 12.0% to 33.7%. Correspondingly, there was a 40% reduction in wound area, hence a clinically relevant healing response was seen upon treatment with HRWD. It is also noteworthy that this patient population included a significant proportion of chronic wounds (51.4%) that showed no signs of wound progression within <4 weeks before study inclusion. Of these chronic wounds, 93% demonstrated wound progression upon treatment with HRWD. Despite reported pain levels being low pre- and post-dressing change, overall wound pain improved (reduced) in 48% of patients. Periwound skin condition showed a tendency towards improvement, and the fluid management capabilities of the HRWD was reported as good to excellent in the majority of cases. Wound infections were reduced by at least 60% over the evaluation period. A simple cost-effective analysis demonstrated significant savings using HRWD (£6.33) over current standard practice regimens of a four-step debridement process (£8.05), larval therapy (£306.39) and mechanical pad debridement (£11.46).

CONCLUSION

HRWD was well tolerated and was demonstrated to be an efficient debridement tool providing rapid, effective and pain free debridement in a variety of wound types.

Spatial Characterization of Soybean Yield and Quality (Amino Acids, Oil, and Protein) for United States

Continued economic relevancy of soybean is a function of seed quality. The objectives of this study were to: (i) assess the spatial association between soybean yield and quality across major US soybean producing regions, (ii) investigate the relationship between protein, oil, and yield with amino acids (AAs) composition, and (iii) study interrelationship among essential AAs in soybean seed. Data from soybean testing programs conducted across 14 US states from 2012 to 2016 period (n = 35,101 data points) were analyzed. Results indicate that for each Mg ha-1 yield increase, protein yield increased by 0.35 Mg protein ha-1 and oil yield improved by 0.20 Mg oil ha-1. Essential AA concentrations exhibit a spatial autocorrelation and there was a negative relationship between concentration of AA, protein, and oil, with latitude. There was a positive interrelationship with different degree of strength among all AAs, and the correlation between Isoleucine and Valine was the strongest (r = 0.93) followed by the correlation among Arginine, Leucine, Lysine, and Threonine (0.71 < r < 0.88). We concluded that the variability in genotype (G) x management (M) x environment (E) across latitudes influencing yield also affected soybean quality; AA, protein, and oil content in a similar manner.

Practical Application of Computer-Assisted Decision-Making in an Antenatal Clinic — A Feasibility Study

A feasibility study is described involving the use of a computer program in an antenatal clinic whose decisions were based on the observed policies of the group of obstetricians running that clinic. In 200 test cases the programme successfully detected all »at risk« cases at the first visit. Abnormalities appearing at later visits were all detected and appropriate investigations ordered by the programme. The programme ordered rather more investigations than the obstetrician and this difference has been investigated, in some detail with reference to the full blood count, glucose tolerance test and the ultrasonogram.

Since all of the basic data in the proposed clinic would be collected by the clerical staff or midwives, a comparison was made between two midwives and an obstetrician in estimating fundal height. The small number of discrepancies found was not regarded as serious from the viewpoint of the proposed clinic.

This preliminary study suggests that the technique described might play a useful part in some areas of ante-natal care by relieving the obstetricians of much of the workload associated with routine cases and enabling the midwife to play a larger role in ante-natal care.

The use of femoral stems with exchangeable necks in primary total hip arthroplasty increases the rate of revision

Aims

Femoral stems with exchangeable (modular) necks were introduced to offer surgeons an increased choice when determining the version, offset and length of the femoral neck during total hip arthroplasty (THA). It was hoped that this would improve outcomes and reduce complications, particularly dislocation. In 2010, the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) first reported an increased rate of revision after primary THA using femoral stems with an exchangeable neck. The aim of this study was to provide a more comprehensive up-to-date analysis of primary THA using femoral stems with exchangeable and fixed necks.

Materials and Methods

The data included all primary THA procedures performed for osteoarthritis (OA), reported to the AOANJRR between 01 September 1999 and 31 December 2014. There were 9289 femoral stems with an exchangeable neck and 253 165 femoral stems with a fixed neck. The characteristics of the patients and prostheses including the bearing surface and stem/neck metal combinations were examined using Cox proportional hazard ratios (HRs) and Kaplan-Meier estimates of survivorship.

Results

It was found that prostheses with an exchangeable neck had a higher rate of revision and this was evident regardless of the bearing surface or the size of the femoral head. Exchangeable neck prostheses with a titanium stem and a cobalt-chromium neck had a significantly higher rate of revision compared with titanium stem/titanium neck combinations (HR 1.83, 95% confidence interval 1.49 to 2.23, p < 0.001). Revisions were higher for these combinations compared with femoral stems with a fixed neck.

Conclusion

There appears to be little evidence to support the continued use of prostheses with an exchangeable neck in primary THA undertaken for OA. Cite this article: Bone Joint J 2017;99-B:766–73.

Recovery, responsiveness and interpretability of patient-reported outcome measures after surgery for Dupuytren's disease

This prospective cohort study investigated the responsiveness and interpretability of the Disabilities of the Arm, Shoulder and Hand (DASH) and Unité Rhumatologique des Affections de la Main (URAM) outcome measures for assessing recovery after fasciectomy and dermofasciectomy for Dupuytren's disease. DASH outcome scores at 1 year were significantly better than at 6 weeks, suggesting that recovery is not complete by 6 weeks. Of the 101 patients recruited to the DASH cohort, 71 completed preoperative, 6 week and 1 year postoperative DASH scores; 68 of them completed preoperative and 1 year postoperative DASH scores and an external anchor question. In the URAM cohort, 30/44 completed the preoperative and the 1 year postoperative URAM scores and the anchor question. The DASH score exhibited moderate responsiveness but poor interpretability on receiver operating characteristic curve analysis, such that a minimal important change could not be estimated. The URAM score showed acceptable responsiveness, and an MIC of 10.5 on receiver operating characteristic analysis.

LEVEL OF EVIDENCE

II.

Functional outcome and complications following surgery for Dupuytren's disease: a multi-centre cross-sectional study

Variables associated with recurrent Dupuytren's disease, or a 'diathesis', have been investigated, but those associated with functional outcome and complications are less well studied. Outcomes 1 or 5 years after an aponeurotomy, fasciectomy or dermofasciectomy were assessed by patient interview and examination at five UK centres. A total of 432 procedures were studied. The reoperation rate did not differ at 1 year ( p = 0.396, Chi-square test with Monte Carlo simulation), but was higher after aponeurotomy in the 5-year group (30%, versus 6% after fasciectomy and 0% after dermofasciectomy, p = 0.003, Chi square test with Monte Carlo simulation). Loss of function (DASH>15) did not differ between procedures at 5 years, even when reoperation and other variables were controlled. Diabetes, female gender and previous ipsilateral surgery were associated with poorer function in logistic regression analysis. The variables associated with poor function after treatments differ from diathesis variables. Aponeurotomy had lower complication rates than fasciectomy and dermofasciectomy. This may counterbalance the former's higher recurrence rate and explain why aponeurotomy demonstrated similar long-term functional outcome compared with excisional surgery in this study.

LEVEL OF EVIDENCE

III.

Optimal radiologic position of an umbilical venous catheter tip as determined by echocardiography in very low birth weight newborns

OBJECTIVE

To compare chest X-ray with echocardiogram (ECHO) in the localization of an umbilical venous catheter (UVC) tip in very low birth weight infants (VLBW). Secondary objectives determined the association between techniques for tip placement by the vertebral body level on X-ray, as well as the length of the thoracic inferior vena cava-right atrial (TIVC-RA) junction by ECHO.

STUDY DESIGN

Prospective, sequentially enrolled, masked, single regional perinatal center study. Shortly after birth, one or more anterior-posterior X-rays were ordered by the clinical team to verify that the UVC tip was fixed in the central right atrium (cRA) or at the TIVC-RA junction. An echocardiogram was performed as soon as possible after the last X-ray and UVC tip location was interpreted by a pediatric cardiologist. The pediatric radiologist and cardiologist were masked with regard to each other's reading.

RESULTS

The newborns (n = 51) were 27 (±3) weeks by gestational age with birth weights of 1029 (±288) grams (mean±SD). The radiologist read 50 UVC tips (98%) in the cRA or TIVC-RA junction and 1 (2%) in the LA. The cardiologist read 22 (43%) in the cRA or TIVC-RA, 21 (41%) in the LA and 8 (16%) tips could not be located in the heart. When the UVC tip was interpreted by X-ray as located in the TIVC-RA junction 8/29 (28%) were in the LA by echocardiogram. There was no agreement between vertebral level and tip position in the TIVC-RA junction, RA or LA. The TIVC-RA junction measured 6±1 mm and correlated with birth weight r = 0.54 (p < 0.001).

CONCLUSION

In VLBW newborns, placement of the UVC tip into the cRA or TIVC-RA junction by X-ray does not avoid misplacement in the left atrium as demonstrated by echocardiography. For VLBW infants, it is suggested that echocardiography may be helpful in verifying that the original placement or migration of the UVC tip into the LA has not occurred.

Novel pH sensing semiconductor for point-of-care detection of HIV-1 viremia

The timely detection of viremia in HIV-infected patients receiving antiviral treatment is key to ensuring effective therapy and preventing the emergence of drug resistance. In high HIV burden settings, the cost and complexity of diagnostics limit their availability. We have developed a novel complementary metal-oxide semiconductor (CMOS) chip based, pH-mediated, point-of-care HIV-1 viral load monitoring assay that simultaneously amplifies and detects HIV-1 RNA. A novel low-buffer HIV-1 pH-LAMP (loop-mediated isothermal amplification) assay was optimised and incorporated into a pH sensitive CMOS chip. Screening of 991 clinical samples (164 on the chip) yielded a sensitivity of 95% (in vitro) and 88.8% (on-chip) at >1000 RNA copies/reaction across a broad spectrum of HIV-1 viral clades. Median time to detection was 20.8 minutes in samples with >1000 copies RNA. The sensitivity, specificity and reproducibility are close to that required to produce a point-of-care device which would be of benefit in resource poor regions, and could be performed on an USB stick or similar low power device.

Validity of the Disabilities of the Arm, Shoulder and Hand patient-reported outcome measure (DASH) and the Quickdash when used in Dupuytren's disease

This study investigated aspects of the validity and reliability of the 30-item Disabilities of the Arm, Shoulder and Hand patient-reported outcome measure (DASH) and its relationship with the shorter 11-item QuickDASH in patients with Dupuytren's disease.Seven hundred and fifty-nine DASH questionnaires were studied, covering pre- and postoperative patients undergoing different treatments for Dupuytren's disease. Items related to pain rose early after treatment before returning to baseline, suggesting that studying pain is relevant during postoperative recovery. Across all 759 sets of responses, the QuickDASH agreed closely with the DASH. In exploratory factor analysis, the DASH was not unidimensional, questioning the validity of the DASH summary score in Dupuytren's disease.Further validation of existing PROMs for use in Dupuytren's disease is needed. These data suggest that pain is a relevant symptom to study during postoperative recovery following treatment for Dupuytren's disease.

LEVEL OF EVIDENCE

III.

Benefit of Treating Hepatocellular Carcinoma Recurrence after Liver Transplantation and Analysis of Prognostic Factors for Survival in a Large Euro-American Series

PURPOSE

To identify prognostic factors after hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT).

METHODS

We retrospectively reviewed the combined experience at Toronto General Hospital and Hospital Vall d'Hebron managing HCC recurrence after LT (n = 121) between 2000 and 2012. We analyzed prognostic factors by uni- and multi-variate analysis. Median follow-up from LT was 29.5 (range 2-129.4) months. Median follow-up from HCC recurrence was 12.2 (range 0.1-112.5) months.

RESULTS

At recurrence, 31.4 % were treated with curative-intent treatments (surgery or ablation), 42.1 % received palliative treatment, and 26.4 % received best supportive care. The 1-, 3-, and 5-year survivals, respectively, after HCC recurrence were 75, 60, and 31 %, vs. 60, 19, and 12 %, vs. 52, 4, and 5 % (p < 0.001). By multivariate analysis, not being amenable to a curative-intent treatment [hazard ratio (HR) 4.7, 95 % confidence interval (CI) 2.7-8.3, p < 0.001], α-fetoprotein of ≥100 ng/mL at the time of HCC recurrence (HR 2.1, 95 % CI 1.3-2.3, p = 0.002) and early recurrence (<12 months) after LT (HR 1.6, 95 % CI 1.1-2.5, p = 0.03) were found to be poor prognosis factors. A prognostic score was devised on the basis of these three independent variables. Patients were divided into three groups, as follows: good prognosis, 0 points (n = 22); moderate prognosis, 1 or 2 points (n = 84); and poor prognosis, 3 points (n = 15). The 1-, 3-, and 5-year actuarial survival for each group was 91, 50, and 50 %, vs. 52, 7, and 2 %, vs. 13, 0, and 0 %, respectively (p < 0.001).

CONCLUSIONS

Patients with HCC recurrence after transplant amenable to curative-intent treatments can experience significant long-term survival (~50 % at 5 years), so aggressive management should be offered. Poor prognosis factors after recurrence are not being amenable to a curative-intent treatment, α-fetoprotein of ≥100 ng/mL, and early (<1 year) recurrence after LT.

Abstract P3-06-28: Use of the MiCK drug-induced apoptosis assay improves clinical outcomes in recurrent breast cancer (BRCA)

Background: The microculture kinetic (MiCK) assay (Correct Chemo™) correlates with outcomes in acute myelocytic leukemia and ovarian cancer (Cancer Research, in press). A prior trial suggested that its use in breast cancer could improve clinical outcomes (Cancer, in press). This study was designed to correlate MiCK assay results with clinical outcomes in recurrent or metastatic BRCA.

Methods: 30 patients with recurrent or metastatic breast cancer in 4 different institutions were evaluated. Each patient (pt) had a BRCA biopsy sent to a central laboratory, tumor cells were purified to over 90% homogeneity, and were then cultured with individual drugs or drug combinations. The induction of apoptosis was measured every five minutes continuously for 48 hours. The amount of apoptosis was expressed in kinetic units (KU), and results were sent to the attending oncologist within 72 hours of submission. Physicians were free to choose any treatment plan for the pts, and were free to add hormonal therapy or biotherapy. Clinical results were evaluated by oncologists using clinical criteria and the results of the MiCK assay were correlated with outcomes of complete (CR) or partial (PR) response, time-to-relapse (TTR), and overall survival (OS).

Results: Median age was 57 years, and number of lines of prior therapy was a median of 2 (range 1–8). Median ECOG performance status was 1. The total number of drugs tested in the assay was a median of 12 (range 3–31). The MiCK assay was used to help select therapy in 22 pts (73%). There was change between drugs originally planned before MiCK assay and drugs used after MiCK in 15 pts (50%). The best therapy from the MiCK assay was used for treatment in 16 pts (53%). In five pts (17%), a single drug was used in place of a combination. Generic drugs were used in place of proprietary drugs in nine pts (30%). Hormonal therapy was added to drugs selected based on the MiCK assay in seven pts (23%), and bio-therapy drugs were added to chemotherapy drugs in eight pts (27%). If the MiCK results were used to help select therapy, eight pts had a CR or PR (27%), compared to 0 pts with CR or PR if MiCK was not used (p = 0.04). If the MiCK assay was used to determine therapy, 17 pts (59%) had a CR, PR or stable disease compared to only 2 pts (6.9%) in whom the MiCK assay was not used (p &lt; 0.01). The TTR was significantly longer if the MiCK assay was used to select chemotherapy, 7.4 months, compared to only 2.2 months if the MiCK assay was not used (p &lt; 0.01). There was a trend toward longer survival if the MiCK assay was used, 16.8 months, compared to 13.1 months if the MiCK assay was not used, but the difference was not statistically significant (p = 0.3). If the best chemotherapy from the MiCK assay was used, there were trends for increased TTR (7.3 vs 3.9 mo if best not used p = 0.13) and increased rate of CR or PR or stable (54% vs 17% p = 0.11).

Conclusions: Use of the MiCK assay to determine chemotherapy was associated with a higher response rate and a longer time to relapse in pts with recurrent or metastatic BRCA. It is possible that OS is also improved, but longer follow up is needed. There was a trend for improved outcomes if the best chemotherapy based on the MiCK assay was used.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-06-28.

The European renal genome project: an integrated approach towards understanding the genetics of kidney development and disease

Rapid progress in genome research creates a wealth of information on the functional annotation of mammalian genome sequences. However, as we accumulate large amounts of scientific information we are facing problems of how to integrate and relate the data produced by various genomic approaches. Here, we propose the novel concept of an organ atlas where diverse data from expression maps to histological findings to mutant phenotypes can be queried, compared and visualized in the context of a three-dimensional reconstruction of the organ. We will seek proof of concept for the organ atlas by elucidating genetic pathways involved in development and pathophysiology of the kidney. Such a kidney atlas may provide a paradigm for a new systems-biology approach in functional genome research aimed at understanding the genetic bases of organ development, physiology and disease.

Ontologies for the description of mouse phenotypes

Ontologies are becoming increasingly important for the efficient storage, retrieval and mining of biological data. The description of phenotypes using ontologies is a particularly complex problem. We outline a schema that can be used to describe phenotypes by combining orthologous axiomatic ontologies. We also describe tools for storing, browsing and searching such complex ontologies. Central to this approach is that assays (protocols for measuring phenotypic characters) describe what has been measured as well as how this was done, allowing assays to link individual organisms to ontologies describing phenotypes. We have evaluated this approach by automatically annotating data on 600 000 mutant mice phenotypes using the SHIRPA protocol. We believe this approach will enable the flexible, extensible and detailed description of phenotypes from any organism.

Non-respiratory functions of the lung in the perinatal period

Beginning with the hypothesis that interference with the metabolic function of the lung could lead to perinatal respiratory disease, we explored the role of one of these functions, angiotensin-converting enzyme activity, in the control of the fetal and newborn circulation. Converting enzyme regulates the concentration of two peptides, bradykinin and angiotensin, important in adapting the fetus to extrauterine life. Initial studies demonstrated decreasing amounts of converting enzyme activity and a parallel decrease in vascular surface with decreasing gestational age. Because we had demonstrated that there is little converting enzyme activity at the low PO2 values of the fetus we examined the fetal-placental unit and found that the placenta is the predominant site of converting enzyme activity in utero and this activity is modulated by maternal PO2. We also found that such pathophysiological accompaniments of premature birth as chilling and acidosis can stimulate the kallikrein-kinin system into overactivity. Because the kallikrein-kinin and renin-angiotensin systems are so closely interrelated with other vasoactive substances, an imbalance in production and degradation is likely to produce some of the pathophysiology seen with premature birth, including systemic hypotension, coagulopathy and oedema.

Human TLR-7-, -8-, and -9-mediated induction of IFN-alpha/beta and -lambda Is IRAK-4 dependent and redundant for protective immunity to viruses

Five TLRs are thought to play an important role in antiviral immunity, sensing viral products and inducing IFN-alpha/beta and -lambda. Surprisingly, patients with a defect of IRAK-4, a critical kinase downstream from TLRs, are resistant to common viruses. We show here that IFN-alpha/beta and -lambda induction via TLR-7, TLR-8, and TLR-9 was abolished in IRAK-4-deficient blood cells. In contrast, IFN-alpha/beta and -lambda were induced normally by TLR-3 and TLR-4 agonists. Moreover, IFN-beta and -lambda were normally induced by TLR-3 agonists and viruses in IRAK-4-deficient fibroblasts. We further show that IFN-alpha/beta and -lambda production in response to 9 of 11 viruses tested was normal or weakly affected in IRAK-4-deficient blood cells. Thus, IRAK-4-deficient patients may control viral infections by TLR-3- and TLR-4-dependent and/or TLR-independent production of IFNs. The TLR-7-, TLR-8-, and TLR-9-dependent induction of IFN-alpha/beta and -lambda is strictly IRAK-4 dependent and paradoxically redundant for protective immunity to most viruses in humans.

Issues and options for the safe destruction and disposal of used injection materials

It has long been known that the re-use of syringes can cause the spread of infections such as HIV and hepatitis. The production of disposable syringes was undertaken as a solution to the infection problem. In developing countries, however, there has been an unwanted result: the re-use and recycling of disposable syringes. One response has been "auto-disable" syringes that lock the plug and piston in place after a single use. These types of approaches, however, have resulted in greatly increased volumes of used injection materials. This is a particular problem in developing countries where contaminated medical wastes find their way into municipal garbage where people are known to scavenge and recycle. This poses obvious health risks, both in terms of direct exposure and environmental contamination. This study of issues and options for the safe destruction and disposal of used injection materials was undertaken using document analysis was to bring together and summarise approaches to the inter-related issues of "syringe re-use" and "clinical waste disposal". The authors suggest that holistic approaches to syringe use and clinical waste disposal need to be utilized in addressing the situation outlined. The focus is on technology and procedures that may be adaptable to rural areas in developing countries.

Building mouse phenotype ontologies

The structured description of mutant phenotypes presents a major conceptual and practical problem. A general model for generating mouse phenotype ontologies that involves combing a variety of different ontologies to better link and describe phenotypes is presented. This model is based on the Phenotype and Trait Ontology schema proposal and incorporates practical limitations and designing solutions in an attempt to model a testbed for the first phenotype ontology constructed in this manner, namely the mouse behavior phenotype ontology. We propose the application of such a model could provide curators with a powerful mechanism of annotation, mining and knowledge representation as well as achieving some level of free text disassociation.

Corn Silage Management: Effects of Hybrid, Maturity, Chop Length, and Mechanical Processing on Rate and Extent of Digestion

Five experiments were conducted to evaluate the effects of hybrid, chop length, maturity, and mechanical processing of corn silage on dry matter and nutrient disappearance in the rumen. Corn silage that had not been dried or ground was incubated in macro in situ bags (30 x 35 cm) for 8, 16, 24,48, and 96 h. Experiments la and 2 evaluated the effects of maturity and mechanical processing for two corn silage hybrids harvested at two theoretical lengths-of-cut. Experiments 3 through 5 evaluated the effects of chop length and mechanical processing for two corn silage hybrids harvested at two-thirds milkline. The hybrid with low neutral fiber (NDF) concentrations had greater dry matter and starch disappearance than the hybrid with high NDF concentrations. The effect of chop length on nutrient disappearance was variable across experiments 3 through 5. Processing improved dry matter disappearance in experiments la, 2 (two-thirds milkline and blackline), 3, 4, and 5 at the majority of ruminal incubation timepoints. Starch disappearance was greater for unprocessed corn silage in experiment la (hard dough and two-thirds milkline) and was greater for processed corn silage in experiments 2 and 5. However, there was no consistent trend in starch disappearance between processed and unprocessed corn silage in experiments 3 and 4. This can be partially explained by the high disappearance of starch (experiment 3, > or = 98% and experiment 4, > or = 94%) by 24 h of ruminal incubation. Minimal differences were detected in NDF disappearance between processed and unprocessed corn silage across maturities. In experiments 2 and 5, crude protein disappearance was improved due to processing at some incubation timepoints. Rate of dry matter, starch (one-third milkline and two-thirds milkline), and NDF disappearance tended to increase when corn silage was mechanically processed in experiment 2. Dry matter, starch, and crude protein disappearance tended to be greater for corn silage harvested at the early maturity (one-third milkline) in experiment 2 compared with advanced maturities (two-thirds milkline and blackline). Disappearance of NDF was greater at early maturities compared with advanced maturities in experiments 1a and 2. Rate of dry matter (hybrid 3845), starch, and NDF (hybrid 3845) disappearance tended to decrease as maturity advanced from one-third milkline to blackline in experiment 2. These results suggest that the macro in situ method can be used to evaluate nutrient disappearance in the rumen.

Factors affecting application of milk allantoin as an estimator of microbial protein flow to the duodenum under commercial conditions

Three experiments were conducted to determine the effect of diet change, milk sampling technique, and bovine somatotropin (bST) on allantoin output in milk and the use of allantoin as a practical, noninvasive method for estimating microbial protein flow in dairy cattle. In experiment 1, four lactating Holstein cows were used in a 2 x 2 Latin square design with two treatments (ratio of forage to concentrate) and two periods. In experiment 2, six Holstein cows were used in a completely randomized design, and milk was collected by 1) a strip sample collected immediately before milking, 2) a strip sample collected 3 min from start of milking, and 3) a composite sample taken with an autosampler. In experiment three, 10 cows were used in a randomized block design to determine the effect of bST on milk allantoin. Milk samples were taken daily for 21 d, 7 d before, and 14 d after bST administration. In experiment 1, allantoin output (mmol/d) was significantly greater for cows fed the higher ratio of concentrate to forage, and there was a significant change in the amount of allantoin in milk 12 h (first subsequent milking) after a diet change. There was no difference in milk yield or dry matter intake between treatments. In experiment 2, no difference was detected in milk allantoin concentration among the three sampling methods. In experiment 3, milk yield, allantoin concentration, and total allantoin output was significantly increased after bST administration even though dry matter intake (DMI) remained unchanged. During the first 14 d following bST administration, estimates of microbial protein production derived from milk allantoin may be inaccurate due to increased milk production without an increase in DMI.