ALLIANCE A022104/NRG-GI010: The Janus Rectal Cancer Trial: a randomized phase II/III trial testing the efficacy of triplet versus doublet chemotherapy regarding clinical complete response and disease-free survival in patients with locally advanced rectal cancer

Background

Recent data have demonstrated that in locally advanced rectal cancer (LARC), a total neoadjuvant therapy (TNT) approach improves compliance with chemotherapy and increases rates of tumor response compared to neoadjuvant chemoradiation (CRT) alone. They further indicate that the optimal sequencing of TNT involves consolidation (rather than induction) chemotherapy to optimize complete response rates. Data, largely from retrospective studies, have also shown that patients with clinical complete response (cCR) after neoadjuvant therapy may be managed safely with the watch and wait approach (WW) instead of preemptive total mesorectal resection (TME). However, the optimal consolidation chemotherapy regimen to achieve cCR has not been established, and a randomized clinical trial has not robustly evaluated cCR as a primary endpoint. Collaborating with a multidisciplinary oncology team and patient groups, we designed this NCI-sponsored study of chemotherapy intensification to address these issues and to drive up cCR rates, to provide opportunity for organ preservation, improve quality of life for patients and improve survival outcomes.

Methods

In this NCI-sponsored multi-group randomized, seamless phase II/III trial (1:1), up to 760 patients with LARC, T4N0, any T with node positive disease (any T, N+) or T3N0 requiring abdominoperineal resection or coloanal anastomosis and distal margin within 12 cm of anal verge will be enrolled. Stratification factors include tumor stage (T4 vs T1-3), nodal stage (N+ vs N0) and distance from anal verge (0-4; 4-8; 8-12 cm). Patients will be randomized to receive neoadjuvant long course chemoradiation (LCRT) followed by consolidation doublet (mFOLFOX6 or CAPOX) or triplet chemotherapy (mFOLFIRINOX) for 3-4 months. LCRT in both arms involves 4500 cGy in 25 fractions over 5 weeks + 900 cGy boost in 5 fractions with a fluoropyrimidine (capecitabine preferred). Patients will undergo assessment 8-12 (+/- 4) weeks post-TNT completion. The primary endpoint for the phase II portion will compare cCR between treatment arms. A total number of 296 evaluable patients (148 per arm) will provide statistical power of 90.5% to detect an 17% increase in cCR rate, at a one-sided alpha=0.048. The primary endpoint for the phase III portion will compare disease-free survival (DFS) between treatment arms. A total of 285 DFS events will provide 85% power to detect an effect size of hazard ratio 0.70 at a one-sided alpha of 0.025, requiring enrollment of 760 patients (380 per arm). Secondary objectives include time-to event outcomes (overall survival, organ preservation time and time to distant metastasis) and adverse effects. Biospecimens including archival tumor tissue, plasma and buffy coat in EDTA tubes, and serial rectal MRIs will be collected for exploratory correlative research. This study, activated in late 2022, is open across the NCTN and has a current accrual of 312. Support: U10CA180821, U10CA180882, U24 CA196171; https://acknowledgments.alliancefound.org .

Discussion

Building off of data from modern day rectal cancer trials and patient input from national advocacy groups, we have designed the current trial studying chemotherapy intensification via a consolidation chemotherapy approach with the intent to enhance cCR and DFS rates, increase organ preservation rates, and improve quality of life for patients with rectal cancer.

Trial Registration

Clinicaltrials.gov ID: NCT05610163 ; Support includes U10CA180868 (NRG) and U10CA180888 (SWOG).

Functional immune boosters; the herb or its dead microbiome? Antigenic TLR4 agonist MAMPs found in 65 medicinal roots and algae's

Background

Humans have been consuming medicinal plants (as herbs/ spices) to combat illness for centuries while ascribing beneficial effects predominantly to the plant/phytochemical constituents, without recognizing the power of obligatory resident microorganism' communities (MOCs) (live/dead bacteria, fungus, yeast, molds etc.) which remain after industrial microbial reduction methods. Very little is known about the taxonomic identity of residual antigenic microbial associated molecular patterns (MAMPs) debris in our botanical over the counter (OTC) products, which if present would be recognized as foreign (non-self) antigenic matter by host pattern recognition receptors (PRRs) provoking a host immune response; this the basis of vaccine adjuvants. As of today, only few research groups have removed the herbal MAMP biomass from herbs, all suggesting that immune activation may not be from the plant but rather its microbial biomass; a hypothesis we corroborate.

Purpose

The purpose of this work was to conduct a high through put screening (HTPS) of over 2500 natural plants, OTC botanical supplements and phytochemicals to elucidate those with pro-inflammatory; toll like receptor 4 (TLR4) activating properties in macrophages.

Study Design

The HTPS was conducted on RAW 264.7 cells vs. lipopolysaccharide (LPS) E. coli 0111:B4, testing iNOS / nitric oxide production ( NO 2 - ) as a perimeter endpoint. The data show not a single drug/chemical/ phytochemical and approximately 98 % of botanicals to be immune idle (not effective) with only 65 pro-inflammatory (hits) in a potency range of LPS. Method validation studies eliminated the possibility of false artifact or contamination, and results were cross verified through multiple vendors/ manufacturers/lot numbers by botanical species. Lead botanicals were evaluated for plant concentration of LPS, 1,3:1,6-β-glucan, 1,3:1,4-β-D-glucan and α-glucans; where the former paralleled strength in vitro. LPS was then removed from plants using high-capacity endotoxin poly lysine columns, where bioactivity of LPS null "plant" extracts were lost. The stability of E.Coli 0111:B4 in an acid stomach mimetic model was confirmed. Last, we conducted a reverse culture on aerobic plate counts (APCs) from select hits, with subsequent isolation of gram-negative bacteria (MacConkey agar). Cultures were 1) heat destroyed (retested/ confirming bioactivity) and 2) subject to taxonomical identification by genetic sequencing 18S, ITS1, 5.8 s, ITS2 28S, and 16S.

Conclusion

The data show significant gram negative MAMP biomass dominance in A) roots (e.g. echinacea, yucca, burdock, stinging nettle, sarsaparilla, hydrangea, poke, madder, calamus, rhaponticum, pleurisy, aconite etc.) and B) oceanic plants / algae's (e.g. bladderwrack, chlorella, spirulina, kelp, and "OTC Seamoss-blends" (irish moss, bladderwrack, burdock root etc), as well as other random herbs (eg. corn silk, cleavers, watercress, cardamom seed, tribulus, duckweed, puffball, hordeum and pollen). The results show a dominance of gram negative microbes (e.g. Klebsilla aerogenes, Pantoae agglomerans, Cronobacter sakazakii), fungus (Glomeracaea, Ascomycota, Irpex lacteus, Aureobasidium pullulans, Fibroporia albicans, Chlorociboria clavula, Aspergillus_sp JUC-2), with black walnut hull, echinacea and burdock root also containing gram positive microbial strains (Fontibacillus, Paenibacillus, Enterococcus gallinarum, Bromate-reducing bacterium B6 and various strains of Clostridium).

Conclusion

This work brings attention to the existence of a functional immune bioactive herbal microbiome, independent from the plant. There is need to further this avenue of research, which should be carried out with consideration as to both positive or negative consequences arising from daily consumption of botanicals highly laden with bioactive MAMPS.

Optimal vaccine subsidies for endemic diseases

In Goodkin-Gold et al. (2021), we analyzed optimal subsidies for a vaccine against an epidemic outbreak like Covid-19. This companion paper alters the underlying epidemiological model to suit endemic diseases requiring continuous vaccination of new cohorts-also suiting an epidemic like Covid-19 if, following Gans (2020), one assumes peaks are leveled by social distancing. We obtain qualitatively similar results: across market structures ranging from perfect competition to monopoly, the subsidy needed to induce first-best vaccination coverage on the private market is highest for moderately infectious diseases, which invite the most free riding; extremely infectious diseases drive more consumers to become vaccinated, attenuating externalities. Stylized calibrations to HIV, among other diseases, suggest that first-best subsidies can be exorbitantly high when suppliers have market power, rationalizing alternative policies observed in practice such as bulk purchases negotiated by the government on behalf of the consumers.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

British Journal of Surgery Society.

1184 Operation Note – Are We Documenting Accessibility to The Larynx

Introduction

Diagnostic laryngeal procedures are often done under general anaesthesia to aid in assessment and management of laryngeal lesions. Obtaining tissue samples for histology is an extremely important tool used to aid in further surgical planning. Documentation of accessibility to the larynx is paramount to patient care and future surgical planning. We aimed to highlight operative notes for those undergoing diagnostic procedures and assess whether sufficient detail is documented. The Royal College of Surgeons recommends that all operative notes must be comprehensive and “all problems/complications” must be documented for good practice.

Method

We carried out a 3-month retrospective data collection on patients who have undergone diagnostic laryngeal procedures at the Royal Glamorgan Hospital. We included microlaryngoscopies, panendoscopies and laser-specific procedures. We accessed the theatre booking system and retrieved the operation notes.

Results

During the 3-month period, 33 procedures were undertaken. 52% of the operative notes did not document level of accessibility. 48% of the operative notes included the level of accessibility, highlighting keywords such as “good access”, “difficult access” and “difficult access but possible for laser therapy”.

Conclusions

Documentation of intra-operative findings can aid further surgical management and help prepare the surgeon and theatre staff. It is especially important in patients who have vocal cord lesions that might benefit from laser therapy. We recommend documenting the intubation grade (Malampati Score) and accessibility to the larynx.

Place-Based Drivers of Mortality: Evidence from Migration

We estimate the effect of current location on elderly mortality by analyzing outcomes of movers in the Medicare population. We control for movers' origin locations as well as a rich vector of pre-move health measures. We also develop a novel strategy to adjust for remaining unobservables, using the correlation of residual mortality with movers' origins to gauge the importance of omitted variables. We estimate substantial effects of current location. Moving from a 10th to a 90th percentile location would increase life expectancy at age 65 by 1.1 years, and equalizing location effects would reduce cross-sectional variation in life expectancy by 15 percent. Places with favorable life expectancy effects tend to have higher quality and quantity of health care, less extreme climates, lower crime rates, and higher socioeconomic status.

Private and Public Investments in Biomedical Research

Recent policy attention has focused on proposals to reduce prices for drugs that have received public funding. From an implementation perspective, such policies rely on public disclosure of government support for research. In this paper, we highlight two conceptual problems with past attempts to measure these public disclosures and construct a new dataset that corrects for these problems. Our corrected measures suggest that underreporting of public research support is less of an issue than previously thought.

A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales

Introduction

There is a paucity of knowledge and understanding of medical error in opioid substitution treatment programmes.

Objectives

To characterise patient safety incidents involving opioid-substitution treatment with methadone or buprenorphine in community-based care to identify the sources and nature of harm, describe and interpret themes and use this qualitative analysis to identify priorities to focus future improvement work.

Methods

We undertook a mixed-methods study examining incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care submitted between 2005 and 2015 from the National Reporting and Learning System, a repository of incident reports from England and Wales. We analysed each report using four frameworks to identify incident type, contributory factors, incident outcome and severity of harm. Analysis involved detailed data coding and iterative generation of data summaries using descriptive statistical and thematic analysis.

Results

2,284 reports were identified. We found that most risks of harm came from failure in one of four processes of care delivery: prescribing opiate-substitution (n=151); supervised dispensing errors (n=248); non-supervised dispensing errors (n=318); and monitoring and communication activities (n=1544). Most incidents resulting in harm involved supervised or non-supervised dispensing (n=91/127, 72%). Staff- (e.g. mistakes, not following protocols) and organisation-related (e.g. poor working conditions or poor continuity of care between services) contributory factors were present for over half of incidents.

Conclusions

We have identified four processes of care delivery and associated contributory factors, which represent potential target areas for healthcare systems worldwide to develop interventions to improve the safe delivery of opioid substitution treatment.

Screening and Selection: The Case of Mammograms

We analyze selection into screening in the context of recommendations that breast cancer screening start at age 40. Combining medical claims with a clinical oncology model, we document that compliers with the recommendation are less likely to have cancer than younger women who select into screening or women who never screen. We show this selection is quantitatively important: shifting the recommendation from age 40 to 45 results in three times as many deaths if compliers were randomly selected than under the estimated patterns of selection. The results highlight the importance of considering characteristics of compliers when making and designing recommendations.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Multi-centre retrospective study of the long-term outcome following suspected traumatic elbow luxation in 32 cats

OBJECTIVES

To describe reduction techniques and clinical outcome in a series of traumatic elbow luxations in cats.

MATERIALS AND METHODS

Retrospective review of unilateral elbow luxations treated at five specialist referral centres. Data included signalment, aetiology, concurrent injuries, luxation direction, time to reduction, primary reduction technique, surgical procedure and complications. Cases were excluded if reduction technique was unknown. Telephone owner questionnaire follow-up was completed using a Feline Musculoskeletal Pain Index.

RESULTS

Thirty-two cats were included. Lateral luxations were most common (n = 21). Time (hours) until attempted initial closed reduction was <24 (n = 12), 24-48 (n = 13), >48 (n = 3) or unrecorded (n = 4). Luxation was treated by closed reduction alone (n = 7) or by surgery (n = 25); 14 of 25 cases underwent primary surgical reduction and 11 of 25 were secondary procedures following failure of closed reduction. Transcondylar bone tunnels and circumferential suture (n = 19) was the most commonly used surgical technique. Catastrophic (n = 1), major (n = 11) and minor complications (n = 5) were recorded; reluxation occurred more frequently after closed reduction (n = 8) than after open reduction with fixation (n = 0). Feline Musculoskeletal Pain Index data were available for 12 cats; outcome was good-excellent in all 12, with a median function score of 64.5/68 (range: 55-68) and a median pain score of 0/15 (range: 0-5). Outcome was not associated with reduction technique.

CLINICAL SIGNIFICANCE

Elbow reluxation occurred in 61% of cats following primary closed reduction but did not occur in any open reduction cases. Reluxation rate increased with duration from injury. Most cats had good-excellent owner-assessed outcome, regardless of reduction technique.

High-Sensitivity Dry Rehydratable Film Method for Enumeration of Coliforms in Dairy Products: Collaborative Study

A dry-film coliform count plate that is inoculated with 5 mL sample was compared with the Violet Red Bile Agar plate method in a collaborative study by 18 laboratories. Products analyzed were 2% milk, chocolate milk, cream, vanilla ice cream, cottage cheese, and cheese. Collaborators tested blind duplicate uninoculated samples and samples inoculated at low, medium, and high level. Significantly (P&lt; 0.05) higher numbers of coliforms were recovered by the dry-film method from 2% milk samples at the 3 inoculum levels, the chocolate milk at the low- and high-inoculum levels, and the cream at the high-inoculum level. Significantly higher counts were obtained by the agar method for cottage cheese samples at the low-inoculum level. The repeatability standard deviation for the dry-film method was significantly higher for the high-inoculum level chocolate milk sample and the medium-inoculum level cottage cheese. The same statistic was significantly higher for the agar method at all 3 inoculum levels in the 2% milk and the medium-inoculum level cream. The high-sensitivity dry rehydratable film method for enumeration of coliforms in dairy products has been adopted first action by AOAC INTERNATIONAL.

Targeted PEG-poly(glutamic acid) complexes for inhalation protein delivery to the lung

Pulmonary delivery is increasingly seen as an attractive, non-invasive route for the delivery of forthcoming protein therapeutics. In this context, here we describe protein complexes with a new 'complexing excipient' - vitamin B₁₂-targeted poly(ethylene glycol)-block-poly(glutamic acid) copolymers. These form complexes in sub-200nm size with a model protein, suitable for cellular targeting and intracellular delivery. Initially we confirmed expression of vitamin B₁₂-internalization receptor (CD320) by Calu-3 cells of the in vitro lung epithelial model used, and demonstrated enhanced B₁₂ receptor-mediated cellular internalization of B₁₂-targeted complexes, relative to non-targeted counterparts or protein alone. To develop an inhalation formulation, the protein complexes were spray dried adopting a standard protocol into powders with aerodynamic diameter within the suitable range for lower airway deposition. The cellular internalization of targeted complexes from dry powders applied directly to Calu-3 model was found to be 2-3 fold higher compared to non-targeted complexes. The copolymer complexes show no complement activation, and in vivo lung tolerance studies demonstrated that repeated administration of formulated dry powders over a 3 week period in healthy BALB/c mice induced no significant toxicity or indications of lung inflammation, as assessed by cell population count and quantification of IL-1β, IL-6, and TNF-α pro-inflammatory markers. Importantly, the in vivo data appear to suggest that B₁₂-targeted polymer complexes administered as dry powder enhance lung retention of their protein payload, relative to protein alone and non-targeted counterparts. Taken together, our data illustrate the potential developability of novel B₁₂-targeted poly(ethylene glycol)-poly(glutamic acid) copolymers as excipients suitable to be formulated into a dry powder product for the inhalation delivery of proteins, with no significant lung toxicity, and with enhanced protein retention at their in vivo target tissue.

P5000Wnt/b-catenin signalling drives angiotensin II induced cardiac fibrosis via WISP-1

Background

Myocardial infarction (MI) and hypertension lead to myocardial injury, which induces negative remodelling and cardiac fibrosis. Cardiac fibrosis, which involves inflammatory cell infiltration and myofibroblast activation, causes worldwide mortality and morbidity. In response to MI or hypertension induced by prolonged angiotensin II (AngII) exposure, activated myofibroblasts produce extracellular matrix proteins. However, if unchecked, excessive collagen deposition occurs leading to myocardial stiffening, heart failure and arrhythmias.

Purpose

The underlying mechanisms leading to pathological collagen deposition are not fully elucidated. There is debate regarding the involvement of the Wnt signalling pathway and its product Wnt Inducible Signalling pathway protein-1 (WISP-1) in cardiac fibrosis. Therefore, this project aimed to investigate the interaction of AngII and the Wnt/β-catenin signalling pathway in cardiac fibrosis.

Methods

The effect of AngII (100nM) on collagen levels in human cardiac fibroblasts was investigated in vitro (data expressed as fold change from control ± SEM). In vivo experiments (n=6–8) determined the involvement of the Wnt/b-catenin pathway, specifically WISP-1, in response to AngII infusion (500ng/kg/min) for 4 weeks (Apolipoprotein E−/−/WISP-1+/+ vs. ApolipoproteinE−/−/WISP-1−/− mice on a high-fat diet, data expressed as mean positive pixel % ± SEM).

Results

AngII significantly increased collagen type 1 protein levels produced by human cardiac fibroblasts (2.94±0.75 vs 1±0, p<0.05). Inhibition of Wnt/b-catenin signalling with 25nM iCRT14 significantly suppressed AngII-induced collagen levels (0.46±0.07 vs. 1±0, p<0.05). As expected, AngII infusion significantly induced hypertension in all mice. Immunohistochemistry demonstrated type 1 collagen was markedly higher in AngII mice than control mice (1.07±0.27 vs. 0.29±0.06, p<0.05). However, in the absence of WISP-1, AngII did not enhance collagen type 1 levels. Further immunohistochemical analysis of murine hearts demonstrated that AngII infusion caused significant alterations in the Wnt/β-catenin signalling markers AXIN-2 (35±3.9 vs. 10.7±2.6 p<0.05) and PPAR-d (92±1.4 vs. 17.3±4.3 p<0.05). This effect was reduced by WISP-1 deletion. Furthermore, AngII-infusion disrupted N-cadherin junctions (0.55±0.08 vs. 0.29±0.02 p<0.05) suggesting modulation of cell-to-cell contacts and enhanced β-catenin signalling.

Conclusion

This study indicates that AngII enhances cardiac fibrosis via modulation of the Wnt signalling pathway, in part via WISP-1. Further delineation of this interaction may lead to the use of Wnt/β-catenin or WISP-1 inhibitors to suppress myocardial injury induced cardiac fibrosis in post-MI or hypertensive patients.

Acknowledgement/Funding

Elizabeth Blackwell Institute, British Heart Foundation

WHO PROFITS FROM PATENTS? RENT-SHARING AT INNOVATIVE FIRMS

This article analyzes how patent-induced shocks to labor productivity propagate into worker compensation using a new linkage of U.S. patent applications to U.S. business and worker tax records. We infer the causal effects of patent allowances by comparing firms whose patent applications were initially allowed to those whose patent applications were initially rejected. To identify patents that are ex ante valuable, we extrapolate the excess stock return estimates of Kogan et al. (2017) to the full set of accepted and rejected patent applications based on predetermined firm and patent application characteristics. An initial allowance of an ex ante valuable patent generates substantial increases in firm productivity and worker compensation. By contrast, initial allowances of lower ex ante value patents yield no detectable effects on firm outcomes. Patent allowances lead firms to increase employment, but entry wages and workforce composition are insensitive to patent decisions. On average, workers capture roughly 30 cents of every dollar of patent-induced surplus in higher earnings. This share is roughly twice as high among workers present since the year of application. These earnings effects are concentrated among men and workers in the top half of the earnings distribution and are paired with corresponding improvements in worker retention among these groups. We interpret these earnings responses as reflecting the capture of economic rents by senior workers, who are most costly for innovative firms to replace.

Acupuncture during pregnancy and the perinatal period: Women's attitudes, beliefs and practices

BACKGROUND

Acupuncture during pregnancy and the perinatal period aims to increase normal birth and enhance a woman's birth experience by decreasing intervention and adverse birth outcomes. Acupuncture in Australian maternity services has not been well accepted, and there is limited research evidence as to whether women are supportive of acupuncture treatment.

OBJECTIVE

The aims of this study were to understand childbearing aged women's attitudes, beliefs and practices to using acupuncture during pregnancy and the perinatal period, and possible acceptance of a midwife providing acupuncture treatments.

DESIGN

A descriptive/explorative quantitative methodology was used to gather data from childbearing aged women using an online survey. Statistical analysis was used for quantitative data and content analysis for the free-text responses. Recruitment of respondents took place in 2017 via Facebook birth and parenting groups and pages.

FINDINGS

Of 304 respondents, 68% (n = 206) had used acupuncture, and of these, 68% (n = 140) used acupuncture for concerns during pregnancy and the perinatal period. The majority of respondents indicated they would consider acupuncture during pregnancy and the perinatal period (89%) and 62% indicated they would have a midwife provide a treatment. The free-text responses provided mostly positive comments on the outcomes and satisfaction of acupuncture treatments (84% n = 199).

CONCLUSION

The majority of respondents would consider acupuncture during pregnancy and the perinatal period, were positive to trying acupuncture for various concerns, and were positive towards a midwife providing treatments. These findings raise awareness of women's desire for the choice of an acupuncture treatment during pregnancy and the perinatal period.

The More We Die, The More We Sell? A Simple Test of the Home-Market Effect

The home-market effect, first hypothesized by Linder (1961) and later formalized by Krugman (1980), is the idea that countries with larger demand for some products at home tend to have larger sales of the same products abroad. In this article, we develop a simple test of the home-market effect using detailed drug sales data from the global pharmaceutical industry. The core of our empirical strategy is the observation that a country's exogenous demographic composition can be used as a predictor of the diseases that its inhabitants are most likely to die from and, in turn, the drugs they are most likely to demand. We find that the correlation between predicted home demand and sales abroad is positive and greater than the correlation between predicted home demand and purchases from abroad. In short, countries tend to be net sellers of the drugs they demand the most, as predicted by Linder (1961) and Krugman (1980).

Toward a more scientific science

Climb atop shoulders and wait for funerals. That, suggested Newton and then Planck, is how science advances (more or less). We've come far since then, but many notions about how people and practices, policies, and resources influence the course of science are still more rooted in traditions and intuitions than in evidence. We can and must do better, lest we resign ourselves to “intuition-based policy” when making decisions and investments aimed at driving scientific progress. Science invited experts to highlight key aspects of the scientific enterprise that are steadily yielding to empirical investigation—and to explain how Newton and Planck got it right (and Einstein got it wrong). — Brad Wible

Carotid artery ligation induced intimal thickening and proliferation is unaffected by ageing

Following interventions to treat atherosclerosis, such as coronary artery bypass graft surgery, restenosis occurs in approximately 40% of patients. Identification of proteins regulating intimal thickening could represent targets to prevent restenosis. Our group previously demonstrated that in a murine model of vascular occlusion, Wnt4 protein expression and β-catenin signalling was upregulated which promoted vascular smooth muscle cell (VSMC) proliferation and intimal thickening. In this study, the effect of age on VSMC proliferation, intimal hyperplasia and Wnt4 expression was investigated. In vitro proliferation of VSMCs isolated from young (2 month) or old (18-20 month) C57BL6/J mice was assessed by immunocytochemistry for EdU incorporation. As previously reported, 400 ng/mL recombinant Wnt4 protein increased proliferation of VSMCs from young mice. However, this response was absent in VSMCs from old mice. As our group previously reported reduced intimal hyperplasia in Wnt4+/- mice compared to wildtype controls, we hypothesised that impaired Wnt4 signalling with age may result in reduced neointimal formation. To investigate this, carotid artery ligation was performed in young and old mice and neointimal area was assessed 21 days later. Surprisingly, neointimal area and percentage lumen occlusion were not significantly affected by age. Furthermore, neointimal cell density and proliferation were also unchanged. These data suggest that although Wnt4-mediated proliferation was impaired with age in primary VSMCs, carotid artery ligation induced neointimal formation and proliferation were unchanged in old mice. These results imply that Wnt4-mediated proliferation is unaffected by age in vivo, suggesting that therapeutic Wnt4 inhibition could inhibit restenosis in patients of all ages.

Drug-induced keratin 9 interaction with Hsp70 in bladder cancer cells

A pull-down experiment (co-immunoprecipitation) was performed on a T24 human bladder cancer cell lysate treated with the Hsp inhibitor VER155008 using an Hsp70 antibody attached to Dynabeads. Keratin 9, a cytoskeleton intermediate filament protein, was identified by LC MS/MS analysis. This novel finding was confirmed by Western blotting, RT-PCR, and immunocytochemistry. Other members of the keratin family of proteins have been shown to be involved in cancer progression, most recently identified to be associated with cell invasion and metastasis. The specific role of keratin 9 expression in these cells is yet to be determined.

Para-atrial non-acute mediastinal hematoma after left atrial maze procedure mimicking tumor in a patient with treated melanoma

INTRODUCTION

The Cox Maze III procedure is considered the gold standard open surgical procedure for management of atrial fibrillation. This article outlines a unique case of a para-atrial mediastinal hematoma following a bilateral thoracoscopic left atrial Maze procedure mimicking malignancy.

REPORT

A 60-year-old male, with past history of melanoma, underwent bilateral thoracoscopic left atrial mini maze procedure with radiofrequency energy and exclusion of the left atrial appendage. Seven months later, a chest computed tomography (CT) scan was performed to evaluate for pulmonary embolism. The CT scan unexpectedly showed an ill-defined, heterogeneous para-atrial mass immediately superior to the left atrium concerning for tumor and mediastinal adenopathy. The mass was moderately hypermetabolic on subsequent 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) scan. A follow-up PET/CT three months later demonstrated near-complete resolution of the para-atrial mass with minimal residual hematoma.

CONCLUSION

Non-acute mediastinal hematoma following a maze procedure can potentially be confused with a tumor mass and/or lymphadenopathy on CT and FDG PET/CT. With knowledge of the potential for false-positive FDG uptake in a hematoma, the lesion was monitored, and unnecessary biopsy was avoided.

Training experience in drug and alcohol liaison work

We describe our training experience as members of a drug and alcohol liaison service within a major general teaching hospital. This type of liaison work offers valuable experience in the joint management of patients with well established substance misuse problems and also provides the opportunity for early recognition and preventative interventions.

Shared decision making and patient decision aids in dermatology

Shared decision making combines individual patient interests and values with clinical best evidence under the guiding principle of patient autonomy. Patient decision aids can support shared decision making and facilitate decisions that have multiple options with varying outcomes for which patients may attribute different values. Given the variable psychosocial impact of skin disease on individuals and relative uncertainty regarding best treatments and their adherence in many dermatological conditions, informed shared decision making, supported by patient decision aids, should constitute a central component of dermatological care.

Is American Health Care Uniquely Inefficient? Evidence from Prescription Drugs

Alan Garber and Jonathan Skinner (2008) famously conjectured that the US health care system was “uniquely inefficient” relative to other countries. We test this idea using cross-country data on prescription drug sales newly linked with an arguably objective measure of relative therapeutic benefits, or drug quality. Specifically, we investigate how higher and lower quality drugs diffuse in the US relative to Australia, Canada, Switzerland, and the UK. Our tabulations suggest that lower quality drugs diffuse more in the US relative to high quality drugs compared to each of our four comparison countries--consistent with Garber and Skinner's conjecture.

SOURCES OF GEOGRAPHIC VARIATION IN HEALTH CARE: EVIDENCE FROM PATIENT MIGRATION

We study the drivers of geographic variation in US health care utilization, using an empirical strategy that exploits migration of Medicare patients to separate the role of demand and supply factors. Our approach allows us to account for demand differences driven by both observable and unobservable patient characteristics. Within our sample of over-65 Medicare beneficiaries, we find that 40-50 percent of geographic variation in utilization is attributable to demand-side factors, including health and preferences, with the remainder due to place-specific supply factors. JEL: H51, I1, I11.

Mid-term outcome of total elbow replacement for rheumatoid arthritis

PURPOSE

To review the outcome of total elbow replacement (TER) in 21 patients after a mean of 64 months.

METHODS

Records of 12 women and 9 men aged 32 to 78 (mean, 59.1) years who underwent 22 TERs for rheumatoid arthritis by a single surgeon were reviewed. Functional outcome was assessed using the disability of the arm, shoulder and hand (DASH) questionnaire. The range of movement and Kaplan- Meier survival curve was determined. Adequacy of cementation was assessed on immediate postoperative radiographs. Aseptic loosening was assessed on radiographs using the Mayo clinic scoring system.

RESULTS

After a mean follow-up of 64 (range, 10-145) months, the mean DASH score improved from 72.3 to 46.8, mean flexion improved from 96.9º to 128.1º, and mean extension lag from 37.3º to 24.0º. The 5-year survival rate with symptomatic aseptic loosening as the end point was 100%, and the revision rate for all reasons was 69%. Cement mantle was adequate in 17, marginal in 4 (most lacked cement around the prosthesis tip), and inadequate in one who was clinically asymptomatic. At the latest follow-up, 4 patients had a type-1 radiolucent line and one had a type-2 radiolucent line of both components; all remained clinically asymptomatic. Two patients developed transient radial nerve neuropraxia. One patient underwent revision for peri-operative fracture. One patient underwent a 2-stage revision for deep infection. One patient underwent revision for bilateral periprosthetic fracture. One patient underwent revision for symptomatic aseptic loosening. No patient had elbow dislocation.

CONCLUSION

TER is a viable option for pain relief and functional improvement in patients with rheumatoid arthritis.

Mitochondrial phosphoenolpyruvate carboxykinase (PEPCK-M) and serine biosynthetic pathway genes are co-ordinately increased during anabolic agent-induced skeletal muscle growth

We aimed to identify novel molecular mechanisms for muscle growth during administration of anabolic agents. Growing pigs (Duroc/(Landrace/Large-White)) were administered Ractopamine (a beta-adrenergic agonist; BA; 20 ppm in feed) or Reporcin (recombinant growth hormone; GH; 10 mg/48 hours injected) and compared to a control cohort (feed only; no injections) over a 27-day time course (1, 3, 7, 13 or 27-days). Longissimus Dorsi muscle gene expression was analyzed using Agilent porcine transcriptome microarrays and clusters of genes displaying similar expression profiles were identified using a modified maSigPro clustering algorithm. Anabolic agents increased carcass (p = 0.002) and muscle weights (Vastus Lateralis: p < 0.001; Semitendinosus: p = 0.075). Skeletal muscle mRNA expression of serine/one-carbon/glycine biosynthesis pathway genes (Phgdh, Psat1 and Psph) and the gluconeogenic enzyme, phosphoenolpyruvate carboxykinase-M (Pck2/PEPCK-M), increased during treatment with BA, and to a lesser extent GH (p < 0.001, treatment x time interaction). Treatment with BA, but not GH, caused a 2-fold increase in phosphoglycerate dehydrogenase (PHGDH) protein expression at days 3 (p < 0.05) and 7 (p < 0.01), and a 2-fold increase in PEPCK-M protein expression at day 7 (p < 0.01). BA treated pigs exhibit a profound increase in expression of PHGDH and PEPCK-M in skeletal muscle, implicating a role for biosynthetic metabolic pathways in muscle growth.