The effects of prehospital TXA on mortality and neurologic outcomes in patients with traumatic intracranial hemorrhage: a subgroup analysis from the prehospital TXA for TBI trial

BACKGROUND

In the Prehospital Tranexamic Acid (TXA) for TBI Trial, TXA administered within two hours of injury in the out-of-hospital setting did not reduce mortality in all patients with moderate/severe traumatic brain injury (TBI). We examined the association between TXA dosing arms, neurologic outcome, and mortality in patients with intracranial hemorrhage (ICH) on computed tomography (CT).

METHODS

This was a secondary analysis of the Prehospital Tranexamic Acid for TBI Trial (ClinicalTrials.gov [NCT01990768]) that randomized adults with moderate/severe TBI (Glasgow Coma Scale<13) and systolic blood pressure > =90 mmHg within two hours of injury to a 2-gram out-of-hospital TXA bolus followed by an in-hospital saline infusion, a 1-gram out-of-hospital TXA bolus/1-gram in-hospital TXA infusion, or an out-of-hospital saline bolus/in-hospital saline infusion (placebo). This analysis included the subgroup with ICH on initial CT. Primary outcomes included 28-day mortality, 6-month Glasgow Outcome Scale-Extended (GOSE) < = 4, and 6-month Disability Rating Scale (DRS). Outcomes were modeled using linear regression with robust standard errors.

RESULTS

The primary trial included 966 patients. Among 541 participants with ICH, 28-day mortality was lower in the 2-gram TXA bolus group (17%) compared to the other two groups (1-gram bolus/1-gram infusion 26%, placebo 27%). The estimated adjusted difference between the 2-gram bolus and placebo groups was -8·5 percentage points (95% CI, -15.9 to -1.0) and between the 2-gram bolus and 1-gram bolus/1-gram infusion groups was -10.2 percentage points (95% CI, -17.6 to -2.9). DRS at 6 months was lower in the 2-gram TXA bolus group than the 1-gram bolus/1-gram infusion (estimated difference -2.1 [95% CI, -4.2 to -0.02]) and placebo groups (-2.2 [95% CI, -4.3, -0.2]). Six-month GOSE did not differ among groups.

CONCLUSIONS

A 2-gram out-of-hospital TXA bolus in patients with moderate/severe TBI and ICH resulted in lower 28-day mortality and lower 6-month DRS than placebo and standard TXA dosing.

LEVEL OF EVIDENCE

Therapeutic/Care Management, Level II.

1174 THE ROLE OF HIP FRACTURE IN TRAJECTORIES OF DEPRESSIVE SYMPTOMS AMONG OLDER ADULTS: ANALYSIS FROM THE ENGLISH LONGITUDINAL STUDY

Introduction

Older adults experience ‘Late life depression’. Hip fractures may negatively influence trajectories of depressive symptoms in older adults. This study aimed to determine trajectories of depressive symptoms among older adults in England, overall and for those after hip fracture, and identify characteristics defining trajectory membership.

Methods

Analysis of adults aged 60 years or more (n=7,050), including a hip fracture subgroup (n = 384), from the English Longitudinal Study of Ageing. Latent class growth mixture modelling was completed. Depressive symptom prevalence was estimated at baseline. Chi-squared tests were completed to compare baseline characteristics across trajectories.

Results

Three trajectory groups were identified overall and for those with hip fracture: no-, mild-, and moderate-severe- symptoms. The moderate-severe group comprised 13.7% and 7% of participants for overall and hip fracture populations respectively. Overall, the proportion of participants with depressive symptoms were 0.4%, 12.4% and 65.4% for no-, mild-, and moderate-severe- symptom groups, respectively. For the hip fracture subgroup, these proportions were 0.7%, 28.8%, and 85.2%. Depressive symptoms were stable over time, with a weak trend towards increasing severity for the moderate-severe group. Individuals with moderate-severe trajectories were older, more likely to be female, live alone and had worse health outcomes (p &lt; 0.001).

Conclusions

Older adults, and those after hip fracture, follow one of three trajectories of depressive symptoms which are broadly stable over time. The prevalence of depressive symptoms was lower for those with hip fracture however, when present, the symptoms were more severe than the overall population. Results suggest a role of factors including age, gender, and marital status in depressive symptoms trajectories.

O12: IHC ANALYSIS OF RESIDUAL DISEASE POST NEOADJUVANT TRASTUZUMAB FOR EARLY STAGE BREAST CANCER REVEALS ER/HER2 CROSSTALK THROUGH INCREASED ER SIGNALLING

Introduction

Therapeutic pressure functionally affects oncogenes and related signalling pathways through dynamic alterations in transcriptional and epigenetic alterations. Altered receptor status occurs throughout tumour progression and may be influenced by adjuvant and neoadjuvant therapies. Recurrent transcriptional remodelling events have been described in the progression of primary breast cancer to metastasis, including increased tyrosine kinase signalling, specifically Her2, and loss of ESR1 gene expression. We hypothesise that in the setting of tyrosine kinase inhibition, an increase in estrogen receptor (ER) signalling is observed.

Method

A database of patients recruited to ICORG trial 07/09 was queried to identify patients with histologically confirmed, Her2-overexpressing or Her2 amplified, nonmetastatic, invasive breast cancer who received neoadjuvant trastuzumab, alone or in combination with neoadjuvant systemic chemotherapy. Clinicopathological characteristics recorded include age at diagnosis, clinical stage, receptor status and percentage positivity, and pathological complete response.

Result

A total of 55 patients identified on ICORG trial 09/07 received neoadjuvant trastuzumab. Of these, 27 achieved a complete pathological response (49%; n=27/55). In those with residual disease, a gain in mean ER staining percentage positivity was observed in the residual disease compared to diagnostic biopsy staining (59.22 vs 45.11; p=0.03). A corresponding loss in Her2 percentage staining positivity was also observed (p=0.006).

Conclusion

An inverse correlation was observed between loss of Her2 positivity and percentage gain in ER staining in patients with residual disease following treatment with neoadjuvant trastuzumab. Further study is needed to elucidate the regulatory mechanism of ER/Her2 crosstalk, which may be epigenetically regulated through DNA methylation.

Take-home message

ER/Her2 crosstalk can be demonstrated clinically in IHC analysis of patients with residual disease post neoadjuvant trastuzumab. Tyrosine kinase inhibition in the form of neoadjuvant trastuzumab results in loss of Her2 signalling and corresponding gain in ER signalling.

Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury

IMPORTANCE

Traumatic brain injury (TBI) is the leading cause of death and disability due to trauma. Early administration of tranexamic acid may benefit patients with TBI.

OBJECTIVE

To determine whether tranexamic acid treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, double-blinded, randomized clinical trial at 20 trauma centers and 39 emergency medical services agencies in the US and Canada from May 2015 to November 2017. Eligible participants (N = 1280) included out-of-hospital patients with TBI aged 15 years or older with Glasgow Coma Scale score of 12 or less and systolic blood pressure of 90 mm Hg or higher.

INTERVENTIONS

Three interventions were evaluated, with treatment initiated within 2 hours of TBI: out-of-hospital tranexamic acid (1 g) bolus and in-hospital tranexamic acid (1 g) 8-hour infusion (bolus maintenance group; n = 312), out-of-hospital tranexamic acid (2 g) bolus and in-hospital placebo 8-hour infusion (bolus only group; n = 345), and out-of-hospital placebo bolus and in-hospital placebo 8-hour infusion (placebo group; n = 309).

MAIN OUTCOMES AND MEASURES

The primary outcome was favorable neurologic function at 6 months (Glasgow Outcome Scale-Extended score >4 [moderate disability or good recovery]) in the combined tranexamic acid group vs the placebo group. Asymmetric significance thresholds were set at 0.1 for benefit and 0.025 for harm. There were 18 secondary end points, of which 5 are reported in this article: 28-day mortality, 6-month Disability Rating Scale score (range, 0 [no disability] to 30 [death]), progression of intracranial hemorrhage, incidence of seizures, and incidence of thromboembolic events.

RESULTS

Among 1063 participants, a study drug was not administered to 96 randomized participants and 1 participant was excluded, resulting in 966 participants in the analysis population (mean age, 42 years; 255 [74%] male participants; mean Glasgow Coma Scale score, 8). Of these participants, 819 (84.8%) were available for primary outcome analysis at 6-month follow-up. The primary outcome occurred in 65% of patients in the tranexamic acid groups vs 62% in the placebo group (difference, 3.5%; [90% 1-sided confidence limit for benefit, -0.9%]; P = .16; [97.5% 1-sided confidence limit for harm, 10.2%]; P = .84). There was no statistically significant difference in 28-day mortality between the tranexamic acid groups vs the placebo group (14% vs 17%; difference, -2.9% [95% CI, -7.9% to 2.1%]; P = .26), 6-month Disability Rating Scale score (6.8 vs 7.6; difference, -0.9 [95% CI, -2.5 to 0.7]; P = .29), or progression of intracranial hemorrhage (16% vs 20%; difference, -5.4% [95% CI, -12.8% to 2.1%]; P = .16).

CONCLUSIONS AND RELEVANCE

Among patients with moderate to severe TBI, out-of-hospital tranexamic acid administration within 2 hours of injury compared with placebo did not significantly improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale-Extended.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01990768.

Post-discharge outcomes after resuscitation from out-of-hospital cardiac arrest: A ROC PRIMED substudy

IMPORTANCE

Assessment of morbidity is an important component of evaluating interventions for patients with out-of-hospital cardiac arrest (OHCA).

OBJECTIVE

We evaluated among survivors of OHCA cognition, functional status, health-related quality of life and depression as functions of patient and emergency medical services (EMS) factors.

DESIGN

Prospective cohort sub-study of a randomized trial.

SETTING

The parent trial studied two comparisons in persons with non-traumatic OHCA treated by EMS personnel participating in the Resuscitation Outcomes Consortium.

PARTICIPANTS

Consenting survivors to discharge.

MAIN OUTCOME MEASURES

Telephone assessments up to 6 months after discharge included neurologic function (modified Rankin score, MRS), cognitive impairment (Adult Lifestyle and Function Mini Mental Status Examination, ALFI-MMSE), health-related quality of life (Health Utilities Index Mark 3, HUI3) and depression (Telephone Geriatric Depression Scale, T-GDS).

RESULTS

Of 15,794 patients enrolled in the parent trial, 729 (56% of survivors) consented. About 644 respondents (88% of consented) completed ≥ 1 assessment. Likelihood of assessment was associated with baseline characteristics and study site. Most respondents had MRS ≤ 3 (82.7%), no cognitive impairment (82.7% ALFI-MMSE ≥ 17), no severe impairment in health (71.6%, HUI3 ≥ 0.7) and no depression (90.1% T-GDS≤10). Outcomes did not differ by trial intervention or time from hospital discharge.

CONCLUSIONS AND RELEVANCE

The majority of patients in this large cohort who survived cardiac arrest and were interviewed had no, mild or moderate health impairment. Concern about poor quality of life is not a valid reason to abandon efforts to improve an EMS system's response to cardiac arrest.

Revisiting the "Golden Hour": An Evaluation of Out-of-Hospital Time in Shock and Traumatic Brain Injury

STUDY OBJECTIVE

We evaluate patients with shock and traumatic brain injury who were previously enrolled in an out-of-hospital clinical trial to test the association between out-of-hospital time and outcome.

METHODS

This was a secondary analysis of patients with shock and traumatic brain injury who were aged 15 years or older and enrolled in a Resuscitation Outcomes Consortium out-of-hospital clinical trial by 81 emergency medical services agencies transporting to 46 Level I and II trauma centers in 11 sites (May 2006 through May 2009). Inclusion criteria were systolic blood pressure less than or equal to 70 mm Hg or systolic blood pressure 71 to 90 mm Hg with pulse rate greater than or equal to 108 beats/min (shock cohort) and Glasgow Coma Scale score less than or equal to 8 (traumatic brain injury cohort); patients meeting both criteria were placed in the shock cohort. Primary outcomes were 28-day mortality (shock cohort) and 6-month Glasgow Outcome Scale-Extended score less than or equal to 4 (traumatic brain injury cohort).

RESULTS

There were 778 patients in the shock cohort (26% 28-day mortality) and 1,239 patients in the traumatic brain injury cohort (53% 6-month Glasgow Outcome Scale-Extended score ≤4). Out-of-hospital time greater than 60 minutes was not associated with worse outcomes after accounting for important confounders in the shock cohort (adjusted odds ratio [aOR] 1.42; 95% confidence interval [CI] 0.77 to 2.62) or traumatic brain injury cohort (aOR 0.77; 95% CI 0.51 to 1.15). However, shock patients requiring early critical hospital resources and arriving after 60 minutes had higher 28-day mortality (aOR 2.37; 95% CI 1.05 to 5.37); this finding was not observed among a similar traumatic brain injury subgroup.

CONCLUSION

Among out-of-hospital trauma patients meeting physiologic criteria for shock and traumatic brain injury, there was no association between time and outcome. However, the subgroup of shock patients requiring early critical resources and arriving after 60 minutes had higher mortality.

Addressing the challenges of obtaining functional outcomes in traumatic brain injury research: missing data patterns, timing of follow-up, and three prognostic models

Traumatic brain injury (TBI) is common and debilitating. Randomized trials of interventions for TBI ideally assess effectiveness by using long-term functional neurological outcomes, but such outcomes are difficult to obtain and costly. If there is little change between functional status at hospital discharge versus 6 months, then shorter-term outcomes may be adequate for use in future clinical trials. Using data from a previously published multi-center, randomized, placebo-controlled TBI clinical trial, we evaluated patterns of missing outcome data, changes in functional status between hospital discharge and 6 months, and three prognostic models to predict long-term functional outcome from covariates available at hospital discharge (functional measures, demographics, and injury characteristics). The Resuscitation Outcomes Consortium Hypertonic Saline trial enrolled 1282 TBI patients, obtaining the primary outcome of 6-month Glasgow Outcome Score Extended (GOSE) for 85% of patients, but missing the primary outcome for the remaining 15%. Patients with missing outcomes had less-severe injuries, higher neurological function at discharge (GOSE), and shorter hospital stays than patients whose GOSE was obtained. Of 1066 (83%) patients whose GOSE was obtained both at hospital discharge and at 6-months, 71% of patients had the same dichotomized functional status (severe disability/death vs. moderate/no disability) after 6 months as at discharge, 28% had an improved functional status, and 1% had worsened. Performance was excellent (C-statistic between 0.88 and 0.91) for all three prognostic models and calibration adequate for two models (p values, 0.22 and 0.85). Our results suggest that multiple imputation of the standard 6-month GOSE may be reasonable in TBI research when the primary outcome cannot be obtained through other means.

Sirolimus and mycophenolate mofetil as GVHD prophylaxis in myeloablative, matched-related donor hematopoietic cell transplantation

We investigated sirolimus and mycophenolate mofetil (MMF) as graft-versus-host disease (GVHD) prophylaxis in patients with advanced hematologic malignancies receiving myeloablative hematopoietic cell transplantation (HCT) from HLA-identical sibling donors. Based on pre-study stopping rules, the trial was closed to accrual after enrollment of 11 adult patients. Seven of the 11 patients received busulfan-containing preparative regimens. Sirolimus was discontinued in 3 patients due to toxicity-related events of severe sinusoidal obstructive syndrome, portal vein thrombosis, altered mental status and in 1 patient due to risk of poor wound healing. Six of the 11 patients developed grade II-IV acute GVHD (AGVHD) a median of 15.5 days post-HCT. Two of 3 patients with grade IV AGVHD had sirolimus discontinued by 9 days post-HCT. All patients responded to AGVHD therapy without GVHD-related deaths. There were 2 nonrelapse- and 2 relapse-related deaths. At a median follow-up of 38 months (2–47 months), 7 of 11 patients were alive without disease. MMF and sirolimus GVHD prophylaxis did not reduce the risk of acute GVHD, however, there were no GVHD-related deaths. The severe toxicities in the patients receiving the busulfan-containing preparative regimens limited the continued use of sirolimus and MMF for the prevention of AGVHD.

Rapid effects of phytoestrogens on human colonic smooth muscle are mediated by oestrogen receptor beta

Epidemiological studies have correlated consumption of dietary phytoestrogens with beneficial effects on colon, breast and prostate cancers. Genomic and non-genomic mechanisms are responsible for anti-carcinogenic effects but, until now, the effect on human colon was assumed to be passive and remote. No direct effect on human colonic smooth muscle has previously been described. Institutional research board approval was granted. Histologically normal colon was obtained from the proximal resection margin of colorectal carcinoma specimens. Circular smooth muscle strips were microdissected and suspended under 1g of tension in organ baths containing oxygenated Krebs solution at 37 degrees C. After an equilibration period, tissues were exposed to diarylpropionitrile (DPN) (ER beta agonist) and 1,3,5-tris(4-hydroxyphenyl)-4-propyl-1H-pyrazole (PPT) (ER alpha agonist) or to the synthetic phytoestrogen compounds genistein (n=8), daidzein (n=8), fisetin (n=8) and quercetin (n=8) in the presence or absence of fulvestrant (oestrogen receptor antagonist). Mechanism of action was investigated by inhibition of downstream pathways. The cholinergic agonist carbachol was used to induce contractile activity. Tension was recorded isometrically. Phytoestrogens inhibit carbachol-induced colonic contractility. In keeping with a non-genomic, rapid onset direct action, the effect was within minutes, reversible and similar to previously described actions of 17 beta oestradiol. No effect was seen in the presence of fulvestrant indicating receptor modulation. While the DPN exerted inhibitory effects, PPT did not. The effect appears to be reliant on a p38/mitogen activated protein kinase mediated induction of nitric oxide production in colonic smooth muscle. The present data set provides the first description of a direct effect of genistein, daidzein, fisetin and quercetin on human colonic smooth muscle. The presence of ER in colonic smooth muscle has been functionally proven and the beta isoform appears to play a predominant role in exerting non-genomic effects.

Personalized therapy for metastatic colorectal cancer: A closer possibility?

4131

Background: Colorectal cancer (CRC) is the second leading cause of cancer related death in the Western world, and survival rate is closely associated with the development of metastases. Personalized targeted therapies promise to have a dramatic impact on the treatment of cancer over the next decade. The molecular fingerprint of a patient’s tumor is the basis for specific targeted therapy. Most often, we are not measuring what we are treating. If we choose therapy based on the primary tumor, but we are treating the metastasis, we are likely giving the wrong therapy if the two microenvironments are not equivalent. In this study we employed reverse phase protein microarrays (RPPA) to compare the protein kinases signal pathway derangements in the primary CRC and in its synchronous liver metastasis. Methods: Pure cell populations of 34 cases of patient-matched CRC and hepatic metastases (collected at the same surgical time) were isolated through laser capture microdissection and then lysed. The lysed cells were evaluated using RPPA technology that allowed us to analyze the activation status of 80 different kinases. Data analysis was performed using commercially available software. Results: Of the 80 kinases only 20 endpoints were significantly (p< 0.05) altered between the two populations. These endpoints were contained within just a few signaling pathways, including the PI3K-AKT prosurvival pathway and the c-kit/PDGFr/c-abl growth factor pathway. We noted a significant increase in phosphorylation of AKT along with a decrease in phosphorylation of PTEN in the liver metastasis compared to the matched primary tumors. This is in keeping with what is known about AKT since phosphorylation of PTEN serves to destabilize the protein, which serves as a natural upstream suppressor of AKT kinase. Conclusions: Specific cell signaling pathways, such as the PI3K-AKT and the c-kit/PDGFr/c-abl growth factor signaling pathway, are significantly altered and activated in hepatic metastasis compared to the primary colorectal site. Since the data reveals elevation in kinase activity increases on a pathway-wide level, a rational hypothesis can be developed whereby combinations of drugs such as an AKT- mTOR inhibitor and/or Gleevec may be an effective and novel therapeutic strategy for the treatment of metastatic CRC.

No significant financial relationships to disclose.

Watershed nitrogen and mercury geochemical fluxes integrate landscape factors in long-term research watersheds at Acadia National Park, Maine, USA

This paper is an overview of this special issue devoted to watershed research in Acadia National Park (Acadia NP). The papers address components of an integrated research program on two upland watersheds at Acadia NP, USA (44 degrees 20' N latitude; 68 degrees 15' E longitude). These watersheds were instrumented in 1998 to provide a long-term foundation for regional ecological and watershed research. The research was initiated as part of EPA/NPS PRIMENet (Park Research and Intensive Monitoring of Ecosystems Network), a system of UV-monitoring stations and long-term watershed research sites located in US national parks. The initial goals at Acadia NP were to address research questions about mercury, acid rain, and nitrogen saturation developed from prior research. The project design was based on natural differences in forests and soils induced by an intense wildfire in one watershed in 1947. There is no evidence of fire in the reference watershed for several hundred years. We are testing hypotheses about controls on surface water chemistry, and bioavailability of contaminants in the contrasting watersheds. The unburned 47-ha Hadlock Brook watershed is 70% spruce-fir mature conifer forest. In contrast, burned 32-ha Cadillac Brook watershed, 4 km northeast of the Hadlock watershed, is 20% regenerating mixed northern hardwoods and 60% shrub/rocky balds. Differences in atmospheric deposition are controlled primarily by forest stand composition and age. The watersheds are gauged and have water chemistry stations at 122 m (Cadillac) and 137 m (Hadlock); watershed maximum elevations are 468 and 380 m, respectively. The stream water chemistry patterns reflect, in part, the legacy of the intense fire, which, in turn, controls differences in forest vegetation and soil characteristics. These factors result in higher nitrogen and mercury flux from the unburned watershed, reflecting differences in atmospheric deposition, contrasting ecosystem pools of nitrogen and mercury, and inferred differences in internal cycling and bioavailabilty.

Production of myeloid dendritic cells (DC) pulsed with tumor-specific idiotype protein for vaccination of patients with multiple myeloma

BACKGROUND

Immunotherapy of cancer with DC vaccines has produced encouraging results in clinical trials. Antigen (Ag)-pulsed DC have elicited CD4+ and CD8+ T-cell immunity and tumor regression in humans. However, there is no standard method of DC production. The DC phenotype, number and Ag-loading process used in these studies have varied, making comparisons between trials difficult.

METHODS

In the present report a reproducible method was developed for the production of a DC-based vaccine. Monocytes were enriched by adhesion from healthy donor apheresis products and cultured with growth factors for maturation into DC. The cells were loaded with the tumor Ag idiotype proteins from patients with multiple myeloma. DC culture and Ag loading were performed in an automated and closed system. The DC product was characterized for phenotype by flow cytometry and for function in Ag uptake and Ag presentation.

RESULTS

These monocyte-derived DC expressed high levels of costimulatory molecules (CD80/86). Ag-pulsed DC functioned to induce allogeneic proliferative lymphocyte responses and Ag-specific cytotoxic T lymphocyte (CTL) responses. The DC viability, phenotype and function were well preserved following prolonged frozen storage. Aliquots from the product of a single DC preparation could be used for sequential vaccinations without batch to batch variability.

DISCUSSION

Ag-pulsed DC can be reproducibly generated for clinical use. These standardized methods are now being employed for a clinical trial to evaluate idiotype-pulsed DC vaccine therapy following non-myeloablative transplant for the treatment of multiple myeloma.

Alterations in molecular networks of metastatic colorectal carcinoma reveal organ-specific signatures: Implications for targeted therapy of metastatic disease

3532

Background: Proteomic analysis of aberrant protein kinase activity is poised to provide crucial knowledge that could drive molecular-targeted therapeutics and personalized medicine. Many cancers are detected at late stages when metastasis has already occurred. Knowledge about the molecular derangements in the metastatic lesion is crucial for the rational selection of therapeutics. Very little is known about the signaling networks in the metastatic microenvironment. We employed reverse phase protein microarrays coupled to laser capture microdissection for a multiplexed phosphoproteomic fingerprint of colorectal metastatic disease to begin to understand the molecular functional changes that occur upon metastasis. Methods: 68 frozen cases of patient-matched colorectal cancer and hepatic metastasis, 15 cases of pulmonary metastasis, and 27 cases of hepatic metastasis of other primary cancers including breast, melanoma, pancreatic, ovarian, and stomach cancers (all taken at the same time at surgery), were subjected to laser capture microdissection. Procured tumor epithelia (20,000 cells per sample), were lysed and subjected to reverse phase protein microarray analysis. Using this technique, we measured the phosphorylation state of 75 kinase substrates. Molecular network analysis was performed using commercially available software. Results: Our results indicate that, unlike analysis of gene microarray data, we observe a significant difference between the molecular networks of activated kinase substrates within the metastatic lesion compared to the patient-matched primary tumor. In fact, despite overall patient-specific heterogeneity of the portraits, organ specific signatures that were independent of the primary origin of the tumor were identified. Conculsions: Effective treatment in the new era of personalized targeted therapeutics will require the ability to understand the functional activation of cellular signaling pathways since these are the drug targets themselves. Our results indicate that treatment of metastatic disease, and patient stratification for matching with the appropriate therapy may be organ-specific and not predicated upon the primary site of the disease.

No significant financial relationships to disclose.

Positional differences in fitness and anthropometric characteristics in Australian football

To evaluate the utility of fitness assessment and trends in drafting of players in the Australian Football League, we analysed height, mass, skinfolds, 20-m sprint, vertical jump, agility run and endurance assessed in the 495 players attending the annual national draft camps between 1999 and 2004. Effects of player position and assessment year were expressed as standardised mean differences (Cohen effect sizes) and interpreted qualitatively. Effect of birth month on chance of being drafted, which may be important in team sports, was also analysed. Compared with midfield players, ruckmen, tall forwards and tall defenders were decisively taller (effect-size range 1.33-1.95, large) and heavier (1.30-1.63, large), but had poorer sprint speed (0.23-0.57, small), aerobic ability (0.66-1.18, moderate) and agility (0.64-1.11, moderate). The only substantial changes in fitness scores over the 5-year period were an increase in height (0.76, moderate) and an increase in 20-m sprint time (0.39, small). A majority (65%) of players attending the camps were born in the first half of a given year, but their chance of being drafted (70%) was similar to that of players born in the second half (64%). We conclude that fitness assessment is useful for differentiating between player positions and identifying some annual trends in recruitment in Australian football, and that players with a second half birth month have been disadvantaged with lower representation at the national draft camp.

Workload and short-term outcome of babies weighing 2,500 grams or more at birth admitted to the paediatric unit of the Rotunda Hospital

BACKGROUND

Audit is important in ensuring adequate use of resources and maintaining optimum standards of care. Most of the emphasis in neonatal audit is focused on very low birth weight infants. However, term and near-term infants account for a significant proportion of the workload in neonatal units and warrant regular audit. In addition, audit of these infants may be useful as a marker of the organisation of the perinatal service.

METHODS

A retrospective audit was performed of all infants with birth weights greater than or equal to 2,500 grams admitted to the neonatal department in the first week of life over a two-year period, examining mode of delivery, level of care, duration of stay, diagnosis and short-term outcome.

RESULTS

Eight hundred and seventy infants were admitted greater than or equal to 2,500 grams birth weight, 54% of all neonatal admissions, during the study period. Six hundred and eighty seven of these infants were admitted in the first week of life and were included in the study; this was 5.8% of infants born with a birth weight 2500 grams or more. Infants born by caesarean section were twice as likely to require admission (9.8%) compared with infants born by vaginal delivery (4.5%). The median length of stay was 3 days (3 hours to 45 days). One hundred and six (15.4%) infants required level 1 or level 2 care. One hundred and eleven infants received normal care, only. Most of these infants were admitted for maternal or social reasons. Other common reasons for admission were jaundice, respiratory disease, neonatal abstinence syndrome and congenital abnormality. Forty-one infants required transfer to another hospital, most commonly for surgical or cardiac conditions. Six infants died after admission. However, only one normally formed infant delivered in our hospital died prior to discharge or transfer. One infant was born at home and four infants who had a lethal congenital abnormality are known to have died following transfer.

CONCLUSION

Term and near-term infants account for a significant proportion of neonatal admissions and deserve regular audit. Many admissions are potentially avoidable. Survival for infants weighing 2,500 grams or greater is excellent. Only one normally formed infant died following admission during the study period. The number of "social" admissions of "well" infants highlighted by this study reflects poorly on the services available for well infant whose mothers are unable to care for them for whatever reason. We recommend regular audit of these infants in order to ensure efficient use of neonatal resources and to ensure optimum levels of neonatal intensive care.

Tryptophan hydroxylase 2 (TPH2) gene variants associated with ADHD

Genetic and pharmacological studies have emphasised the role of serotonin 5-hydroxytryptamine (5-HT) as a possible etiologic factor in the development of attention-deficit hyperactivity disorder (ADHD). Tryptophan hydroxylase (TPH) is a rate-limiting enzyme in the biosynthesis of serotonin from tryptophan. Originally, the TPH gene was thought to be widely expressed, but a second form of TPH, TPH2, was recently identified and the TPH2 gene was found to be solely expressed in the brain. We examined eight single nucleotide polymorphisms (SNP) in the TPH2 gene for association with ADHD in 179 Irish nuclear families. Transmission disequilibrium test analysis revealed significant association between the T allele of marker rs1843809 with the disorder (chi2=12.2, P=0.0006, OR=2.36). Stratifying data by the sex of the transmitting parent showed that this association was enhanced when paternal transmission was considered (OR=3.7). In addition, several haplotypes (all including the associated marker) were associated with ADHD. These preliminary findings suggest that TPH2 is a susceptibility locus for ADHD. Further confirmation, preferably from different ethnic groups, is required to firmly implicate TPH2 in the pathophysiology of ADHD.

Fitness testing and career progression in AFL football

Relationships between fitness testing and career progression in the Australian Football League (AFL) are under-explored. This study investigated relationships between anthropometric and fitness tests conducted at the annual AFL National Draft Camp and subsequent career progression of players. A total of 283 players was tested over three consecutive camps (1999-2001). The anthropometric and fitness measures were: height, mass, sum of skinfolds, 20-m sprint test, vertical jump (standing and bilateral running), agility run and a multi-stage incremental shuttle run. The five outcome variables were: drafted (yes/no), AFL debut (yes/no), number of AFL games played to the end of 2003, and subjective ratings of career potential and career value (5-point scale). Of 205 players (72%) subsequently drafted, 166 (59%) eventually made their AFL debut. Players drafted to AFL clubs were faster over 5 m, 10 m and 20 m, ran further in the shuttle run and ran marginally faster in the agility test than players not drafted. Multi-regression analysis showed small to moderate correlations (r = 0.27-0.31) between the designated outcome variables and selected fitness tests: 20-m sprint time (faster), agility run test (faster), and running vertical jump (higher absolute height and smaller difference between left and ride sides). Regression analysis for the standing vertical jump relative to standing reach height showed a counterintuitive negative correlation with positive outcomes, possibly reflecting non-compliance with testing procedures by the less successful athletes. We conclude that the 20-m sprint, jump, agility and shuttle run tests have a small but important association with career progression of AFL footballers.

Oral vitamin C reduces the injury to skeletal muscle caused by compartment syndrome

Compartment syndrome is a unique form of ischaemia of skeletal muscle which occurs despite patency of the large vessels. Decompression allows the influx of activated leucocytes which cause further injury. Vitamin C is a powerful antioxidant which concentrates preferentially in leucocytes and attenuates reperfusion-induced muscle injury. We have evaluated the use of pretreatment with oral vitamin C in the prevention of injury caused by compartment syndrome in a rat cremasteric muscle model. Acute and delayed effects of pretreatment with vitamin C were assessed at one and 24 hours after decompression of compartment syndrome. Muscle function was assessed electrophysiologically. Vascular, cellular and tissue inflammation was assessed by staining of intercellular adhesion molecule-1 (ICAM-1) and by determination of the activity of myeloperoxidase (MPO) in neutrophils and tissue oedema. Compartment syndrome impaired skeletal muscle function and increased the expression of ICAM-1, activity of MPO and muscle weight increased significantly. Pretreatment with vitamin C preserved muscle function and reduced the expression of ICAM-1, infiltration of the neutrophils and oedema.

Non-invasive mapping of connections between human thalamus and cortex using diffusion imaging

Evidence concerning anatomical connectivities in the human brain is sparse and based largely on limited post-mortem observations. Diffusion tensor imaging has previously been used to define large white-matter tracts in the living human brain, but this technique has had limited success in tracing pathways into gray matter. Here we identified specific connections between human thalamus and cortex using a novel probabilistic tractography algorithm with diffusion imaging data. Classification of thalamic gray matter based on cortical connectivity patterns revealed distinct subregions whose locations correspond to nuclei described previously in histological studies. The connections that we found between thalamus and cortex were similar to those reported for non-human primates and were reproducible between individuals. Our results provide the first quantitative demonstration of reliable inference of anatomical connectivity between human gray matter structures using diffusion data and the first connectivity-based segmentation of gray matter.

Late onset Alzheimer's disease and apolipoprotein association in the Irish population: relative risk and attributable fraction

BACKGROUND

Familial and sporadic late onset Alzheimer's disease (LOAD) shows a consistent genetic association with APOE epsilon4.

AIMS

To examine the role of APOE in the AD Irish population.

METHODS

One hundred and ten Irish LOAD patients and 217 ethnically-matched controls were genotyped for APOE marker as described by Crook et al. Chi square test was used to compare allelic and genotypic frequencies between patients and controls samples. Attributable fractions were calculated as described by Levin.

RESULTS

A highly significant association between AD and APOE epsilon4 was observed (chi2=37.9, p=0.0000000, RR=2.18). Further, the influence of APOEepsilon4 seems to follow a dose-dependent manner whereby individuals with the genotype APOEepsilon4/4 have a higher relative risk than those heterozygous for the epsilon4 allele (RR=4.03 and 1.76 respectively). The relative risk and the attributable fraction calculated for APOE epsilon4 are consistent with those reported for other European populations. This places the influence of this locus on AD development in the Irish population between those of the Spanish and New York white populations.

CONCLUSION

These findings provide further evidence for the importance of APOE in the development of AD.

Teenagers' perceptions of personal safety and the role of the emergency health care provider

STUDY OBJECTIVE

We designed this study to determine the experiences, attitudes, and beliefs of teenagers regarding violence in their lives and to gain an understanding of the perceived role of the emergency health care professional.

METHODS

A qualitative study involving 10-person focus groups was conducted in 4 cities representing urban/low socioeconomic and suburban/high socioeconomic areas. Participants were 14 or 15 years of age and were recruited from local community centers. Moderators were matched by sex to the teenagers, and groups were segmented by race and sex. A semistructured guide was developed to help facilitate the discussion. All groups were audiotaped and videotaped, and the tapes were reviewed by the investigators for reoccurring themes.

RESULTS

A total of 140 adolescents (14 groups of 10) participated; one half were male. Urban teenagers expressed concerns about gangs, rape, and homicide; suburban teenagers were concerned about parental pressure and suicide. The teenagers expressed distrust of teachers, police officers, and doctors and felt safest with their parents. The emergency department was viewed as a confusing and frightening place, and participants believed that the role of the ED staff was to treat the patient's medical problem and not inquire or counsel about violence.

CONCLUSION

All of the teenagers, regardless of socioeconomic status, were concerned about violence in their lives. All of the teenagers believed that the emergency department is not the place for patients to be counseled about safety and violence prevention. A better understanding of the problem of violence from the point of view of the teenager is important in refining an effective role for the emergency health care provider in adolescent violent injury prevention.

Expression of a novel antigen, EEM-1, in the mouse embryo and embryonic stem cell-derived embryoid bodies

A novel monoclonal antibody designated EEM-1 is described. EEM-1 recognizes an intracellular protein with an apparent molecular weight of >250 kDa. Expression of the EEM-1 antigen is largely confined to extra-embryonic membranes, but some expression does occur in the embryo. In the embryonic day 6 (E6) and E7 embryo it is expressed in visceral and parietal endoderm; later derivatives of these structures in the yolk sac are negative. The outer layer of the amnion also stains. Within the embryo proper, antigen is expressed in limited regions of the gut, kidney, and pancreas. EEM-1 is also expressed in embryonic stem (ES) cells differentiating in vitro. Undifferentiated ES cells do not express the antigen. Embryoid bodies (EBs) derived from ES cells have patches of EEM-1-positive cells on their surface at 2 days in culture. Older EBs have increasing numbers of positive cells which are confined to the surface. A special class of EBs, termed "cystic EBs," are covered by a cell layer which strongly express EEM-1 antigen. The EEM-1 antibody will be useful for investigating the development of extra-embryonic membranes and their counterparts in the ES cell in vitro model.

Adapting the gang model: peer mentoring for violence prevention

OBJECTIVES

This study assessed the effectiveness of an inner-city peer-mentoring program in modifying the attitudes and behaviors involving violence of preadolescent mentees.

METHODS

In a case-matched cohort study involving 7- to 13-year-old children, 50 children enrolled in peer mentoring (case subjects) were compared with 75 control subjects. Case subjects were involved before enrollment in the community program in which the intervention occurred; control subjects lived in the same housing project and were matched with case subjects on age, sex, and census tract. A total of 19 community adolescents mentored the case subjects by designing and presenting violence prevention lessons. Two reliable self-report scales, Determining our Viewpoints of Violent Events and Normative Beliefs About Aggression Scale, were used to measure attitudinal change. Teachers completed the Revised Behavior Problem Checklist to assess changes in behavior.

RESULTS

At baseline, the survey scores of the case and control subjects were not different. After the intervention period, the case scores indicated less support for violence than the control scores. Case behavior scores did not change, but control behavior scores worsened.

CONCLUSIONS

The data suggest that peer mentoring for younger children may be an important component of efforts to reduce youth violence. A larger multisite trial is warranted.

A comparative study on the efficacy of CD8-positive cells in enhancing allogeneic bone marrow engraftment: cell sorting vs microbead selection

We have used a superparamagnetic microbead selection system to positively select a murine bone marrow CD8+ cell population. The functional ability of these cells to enhance allogeneic bone marrow engraftment was compared with that of fluorescence activated cell sorter purified CD8+ cells. The CD8+ cell population prepared by the microbead selection procedure was as effective as cell sorter purified CD8+ cells in enhancing T cell-depleted allogeneic bone marrow engraftment in lethally irradiated mice. Phenotypic characterization of these cells shows that most of these CD8+ cells express CD3 and the T cell antigen receptor complex.

Thrombopoietin is synthesized by bone marrow stromal cells

We have previously characterized stromal progenitor cells contained in fetal bone marrow by fluorescence-activated cell sorting (FACS) using the differential expression of CD34, CD38, and HLA-DR, and found that a small number were contained within the CD34(+) cell fraction. In the present study, the frequency of stromal progenitors in both the CD34+ and CD34- subpopulations from samples of fetal and adult bone marrow was approximately one in 5,000 of the mononuclear cell fraction. Using multiparameter single-cell sorting, one in 20 fetal bone marrow cells with the CD34+, CD38-, HLA-DR-, CDw90+ phenotype were clonogenic stromal progenitors, whereas greater than one in five single cells with the CD34-, CD38-, HLA-DR-, CDw90+ phenotype formed stromal cultures. We found that cultures initiated by hematopoietic and stromal progenitors contained within the CD34+ fraction of bone marrow cells formed mixed hematopoietic/stromal cell cultures that maintained the viability of the hematopoietic progenitor cells for 3 weeks in the absence of added hematopoietic cytokines. We characterized some of the hematopoietic cytokines synthesized by stromal cultures derived from either CD34+ or CD34- bone marrow cells using reverse transcriptase-polymerase chain reaction (RT-PCR) amplification of interleukin-3 (IL-3), stem cell factor (SCF), CD34, Flt3/Flk2 ligand (FL), and thrombopoietin (TPO) mRNA sequences. We found ubiquitous expression of TPO mRNA in greater than 90% of stromal cultures initiated by either CD34+ or CD34- cells, and variable expression of SCF, FL, and CD34 mRNA. In particular, SCF and CD34 mRNA were detected only in stromal cultures initiated by CD34+ bone marrow cells, although the differences between CD34+ and CD34- stromal cells were not statistically significant. IL-3 mRNA was not found in any stromal cultures. An enzyme-linked immunosorbent assay (ELISA) of soluble SCF and TPO present in culture supernatants demonstrated that biologically significant amounts of protein were secreted by some cultured stromal cells: eight of 16 samples of conditioned media from stromal cultures initiated by fetal and adult bone marrow contained more than 32 pg/mL SCF (in the linear range of the ELISA), with a median value of 32 pg/mL (range, 9 to 230), while 13 of 24 samples of conditioned media had more than 16 pg/mL TPO (in the linear range of the ELISA), with a median of 37 pg/mL (range, 16 to 106). Our data indicate that stromal cultures initiated by single bone marrow cells can make FL, SCF, and TPO. Local production of early-acting cytokines and TPO by stromal cells may be relevant to the regulation of hematopoietic stem cell self-renewal and megakaryocytopoiesis in the bone marrow microenvironment.

Children's exposure to violence in an urban setting

OBJECTIVE

To assess the exposure to violence of a representative sample of children living in an inner-city public housing development.

DESIGN

Self-report survey.

SETTING

Chicago public housing development that covers 4 census tracts; population, 95% African American, 75% below the poverty level.

PARTICIPANTS

One hundred forty-six African American youth, aged 7 through 13 years, completed the survey; 53% were male, mean and median ages, 11 years. Seventy-two children (case subjects) are involved in a community-based health and recreation program. They completed the survey prior to participating in a peer-mentoring violence prevention curriculum. The other 74 children (control subjects) were recruited by a community member going door to door. Control subjects were matched to case subjects for age, sex, and census tract.

RESULTS

The case and control subjects were similar in their exposure to violence and so were grouped for analysis. Of the 146 children, 42% had seen someone shot and 37% had seen someone stabbed; 21% lived with someone who had been shot and 16% lived with someone who had been stabbed. Forty-seven percent of the girls and 55% of the boys had witnessed violence (P > .25). Almost all subjects (90%) felt safe at home. Two thirds (65%) of the children were not afraid to play outside, but almost half (43%) worried about getting hurt at school.

CONCLUSIONS

These data, which describe a representative sample of children from an inner-city housing project, confirm the results from older clinic- and school-based convenience samples. In this low-income community, children are frequently exposed to deadly violence. In contrast with other reports, girls here are not spared.

Case report: mesenteric lymphangiomatous cyst

Mesenteric lymphangiomas are rare benign tumours of lymphatic vessels. We present the case of a mesenteric lymphangioma in a 14 year old boy.

Dexamethasone in bronchiolitis: a randomised controlled trial

BACKGROUND

Although corticosteroids are commonly prescribed in the treatment of bronchiolitis, there is no evidence on the efficacy of these drugs in this disorder. We designed a randomised, double-blind, prospective study to assess the efficacy of dexamethasone in infants with bronchiolitis who require hospital management.

METHODS

Infants younger than 12 months who had been admitted to hospital for an initial episode of wheezing, were randomly allocated intramuscular dexamethasone (1 mg/kg daily) or placebo, every 24 h for three doses. We excluded infants who were younger than 4 weeks, who required admission to the intensive care unit, or who had a history of congenital heart disease, mechanical ventilation, or supplemental oxygen use. We assessed infants on admission and every 12 h thereafter--vital signs were taken, severity of accessory muscle use and wheezing were measured by a clinical severity score, and pulse oximetry in room air was done. Our primary endpoints were the time to resolution of symptoms--defined as the number of assessments needed to reach oxygen saturation of more than 95% while receiving no supplemental oxygen, an accessory muscle score of 0, a wheeze score of 0 or 1, and resumption of normal feeding--and duration of oxygen therapy. Follow-up assessments were made 10-14 days after discharge by telephone. We used a proportional-hazards model for our survival analysis.

FINDINGS

197 infants presented with bronchiolitis that required inpatient management. 75 were not enrolled (31 no consent, 28 no approach made, 16 transferred elsewhere). Of the 122 enrolled, four were excluded (clinical deterioration, diagnosis of cystic fibrosis, previous intubation, did not receive all study treatment). There were no differences between the dexamethasone (n = 65) and placebo-treated infants in demographic factors, exposure to tobacco smoke, duration of illness, presence of respiratory syncytial virus (RSV) antigen, respiratory rate, or severity score. More dexamethasone-treated patients had an initial oxygen saturation of 95% or less (51 [79%] dexamethasone vs 31 [59%] placebo, p = 0.02). There were no differences in duration of oxygen therapy (p = 0.74) or time to resolution of symptoms (p = 0.22). Stratification for presence of RSV antigen or family history of atopy did not affect the results.

INTERPRETATION

Our findings do not support the use of dexamethasone in the treatment of bronchiolitis in infants.

Anti-tumor necrosis factor modulates anti-CD3-triggered T cell cytokine gene expression in vivo

De novo expression of TNF, IFN gamma, IL-3, IL-4, and IL-6 genes was initiated rapidly by treatment of mice with anti-CD3. A specific feature of this reaction was that TNF was derived exclusively from T cells. TNF was produced both as a mature soluble trimeric protein and as a 26-kD anti-TNF-reactive protein compatible with membrane-anchored TNF. Pretreatment with anti-TNF did not affect anti-CD3-triggered TNF mRNA expression in T cells. In contrast, in vivo and in vitro anti-TNF treatment upregulated anti-CD3-induced IFN gamma mRNA expression and inhibited IL-4 mRNA expression. These latter effects were not dependent on TNF neutralization: pretreatment with soluble recombinant 55-kD TNF receptor (TBPI) as an alternative TNF-neutralizing agent did not modify the anti-CD3-induced cytokine profile. These results suggest that a direct interaction between anti-TNF and T cell membrane-anchored TNF could account for the observed modulation of cytokine gene expression. The increased expression of INF gamma mRNA observed in anti-TNF-treated animals correlated with a decrease in IL-3 and IL-6 mRNA expression. Conversely, IFN gamma blockade by a neutralizing anti-IFN gamma mAb led to a substantial increase in both IL-3 and IL-6 gene expression induced by anti-CD3. Taken together, these results strongly argue for the existence, in the anti-CD3-induced cytokine cascade, of IFN gamma-dependent regulation of IL-3 production, which in turn modulates IL-6 production.

Routine use of lamotrigine, a new anti-epileptic medication, and the value of measuring its blood levels

Lamotrigine (LTG) has recently been approved for marketing in Australia as add-on therapy in resistant partial seizure disorders. Early reports cited a therapeutic blood level for LTG of 1-3 mg/L (4-12 mumol/L). Aspects of routine patient care with LTG, devoid of the restrictions of trial protocols, are discussed. Forty-five patients commenced therapy but 15 discontinued LTG. Of the remaining 30 patients, 9 became seizure free, 3 from the de novo trial in focal epilepsy and 6 with generalised epilepsy. Global evaluation of patients showed mild to moderate improvement for those with focal epilepsy and moderate to marked improvement for those with generalised epilepsy. Blood levels of LTG did not provide clinically useful information.