Impact of Prior COVID-19 Infections on Cardiac Rehabilitation Completion Rates and Outcomes

PURPOSE

This is a retrospective cohort study designed to evaluate the impact of having a prior COVID-19 infection on cardiac rehabilitation (CR) completion rates and outcomes.

METHODS

Participants enrolled into the CR program from June 1, 2020, to March 30, 2022. They completed both physical and mental health assessments prior to enrollment and upon completion of the program. The cohort was divided into (-) COVID and (+) COVID based on whether they self-reported a prior COVID-19 infection. Outcome measures included General Anxiety Disorder-7, Patient Health Questionnaire-9, Mental Composite Score (Short Form Health Survey-36), Physical Composite Score (Short Form Health Survey-36), and exercise capacity (reported in METs). Program completion rates and outcome measures were compared between (-) COVID and (+) COVID cohorts.

RESULTS

A total of 806 participants were enrolled in the study. Program completion rates were 58.7% in the (-) COVID group and 67.2% in the (+) COVID group ( P = .072). African Americans ( P = .017), diabetics ( P = .017), and current smokers ( P = .003) were less likely to complete the program. Both (-) COVID and (+) COVID groups showed significant improvement in all outcome measures after completing the CR program. However, there was no difference in outcomes between groups.

CONCLUSIONS

Having a prior COVID-19 infection did not negatively impact the mental and physical health benefits obtained by completing the CR program, regardless of the American Association of Cardiovascular and Pulmonary Rehabilitation risk category.

An evolutionary continuum from nucleated dwarf galaxies to star clusters

Systematic studies1-4 have revealed hundreds of ultra-compact dwarf galaxies (UCDs5) in the nearby Universe. With half-light radii rh of approximately 10-100 parsecs and stellar masses M* ≈ 106-108 solar masses, UCDs are among the densest known stellar systems6. Although similar in appearance to massive globular clusters7, the detection of extended stellar envelopes4,8,9, complex star formation histories10, elevated mass-to-light ratio11,12 and supermassive black holes13-16 suggest that some UCDs are remnant nuclear star clusters17 of tidally stripped dwarf galaxies18,19, or even ancient compact galaxies20. However, only a few objects have been found in the transient stage of tidal stripping21,22, and this assumed evolutionary path19 has never been fully traced by observations. Here we show that 106 galaxies in the Virgo cluster have morphologies that are intermediate between normal, nucleated dwarf galaxies and single-component UCDs, revealing a continuum that fully maps this morphological transition and fills the 'size gap' between star clusters and galaxies. Their spatial distribution and redder colour are also consistent with stripped satellite galaxies on their first few pericentric passages around massive galaxies23. The 'ultra-diffuse' tidal features around several of these galaxies directly show how UCDs are forming through tidal stripping and that this evolutionary path can include an early phase as a nucleated ultra-diffuse galaxy24,25. These UCDs represent substantial visible fossil remnants of ancient dwarf galaxies in galaxy clusters, and more low-mass remnants probably remain to be found.

Factors Affecting Adherence, Intake, and Perceived Palatability of Oral Nutritional Supplements: A Literature Review

Oral nutritional supplements (ONS) are a clinically effective and relatively inexpensive way to supplement the diet of patients with, or at risk of, undernutrition. Good adherence is a primary determinant of the effectiveness of ONS. However adherence can be problematic for those with the greatest clinical need, such as undernourished older adults. This review aimed to appraise the available literature for the factors (contextual, personal and product related) affecting patient adherence and perceived palatability of ONS, identify areas requiring improvement and uncover gaps in the evidence to guide the focus of future research. Contextual factors identified were healthcare staff and the timing of administration. Personal factors included sensory changes and motivation which alter experience of and desire to consume ONS. The product's sensory characteristics determined palatability and intake, but undesirable attributes, such as off-flavours, can stem from nutritional ingredients. The contribution made by aroma to older adults' experience of ONS was a comparatively under-researched area. Further research should address this evidence gap to optimise the flavour, aroma profile and palatability for undernourished older consumers, thereby optimising intake. A combined multidisciplinary effort involving strategic expansion of research, industry development and clinical practice should simultaneously address the factors identified, to provide the best approach to improve adherence.

Systemic Barriers and Potential Concerns from Reporting Serious Adverse Drug Reactions

About 1-10% of all serious adverse drug reactions (sADRs) are reported to the Food and Drug Administration (FDA) ( Moore T, Bennett C. Underreporting of Hemorrhagic and Thrombotic Complications of Pharmaceuticals to the U.S. Food and Drug Administration: Empirical Findings for Warfarin, Clopidogrel, Ticlopidine, and Thalidomide from the Southern Network on Adverse Reactions (SONAR). Semin Thromb Hemost. 2012;38(08):905-907. https://doi.org/10.1055/s-0032-1328890 ). Prevailing opinion suggests that low reporting rates reflect time constraints.

The relation between stimulated salivary flow and the temporal consumption experience of a liquid oral nutritional supplement

Use of oral nutritional supplements (ONS) in undernourished patients has proven clinical benefits, but this can be hampered by low adherence due to poor experience of palatability. Many patients, particularly older patients, experience hyposalivation which can cause taste changes and reduce the enjoyment of foods. The aim of this study was to investigate differences in the temporal consumption experience (comprising sensory perception, in-mouth aroma release and subjective appetite) of a clinically relevant portion of ONS, for groups differing in saliva flow rates (SFR). The SFR (mL/min) of thirty healthy individuals was measured on three occasions. This data was used to categorise individuals into three groups using quartile analysis: low flow (LF) (0.3–0.6 mL/min, n = 5), medium flow (MF) (0.7–1.2 mL/min, n = 16) and high flow (HF) (1.3–1.8 mL/min, n = 9). Over the consumption of eight 15 mL sips of ONS, individuals rated their sensory perception and subjective appetite perception using line scales. Additionally, in-mouth aroma release was measured for each sip, using atmospheric pressure chemical ionisation (APCI). Compared with the MF and HF group, the LF group reported a significantly greater increase of mouth-drying over increased sips (p = 0.02). The LF group also experienced significantly higher aftertaste perception (p < 0.001), and more intense in-mouth aroma release (p = 0.015), compared with the HF group. These findings occurred concurrently with relatively lower hunger sensations in the LF and MF group. Many patients who are prescribed ONS likely experience reduced salivary flow rates. The unique sensory experiences of these individuals should be considered in order to optimise palatability and nutritional intake.

•

A full portion of ONS was evaluated by three groups differing in saliva flow rates.

•

A sensory profiling method captured perceptual differences over repeated sips.

•

Mouth-drying built up most significantly for the low saliva flow group.

•

Intensity of aftertaste and aroma release was highest in the low saliva flow group.

•

Sensorial intensity of ONS may be associated with greater feelings of satiation.

Synergism of 4HPR and SAHA increases anti-tumor actions in glioblastoma cells

Glioblastoma is the most malignant and prevalent brain tumor in adults. It can grow and spread quickly causing harm to the brain health. One of the major challenges in treatment of glioblastoma is drug resistance. Use of synergistic combination of two drugs with different anti-tumor effects is nowadays highly considered in the development of effective therapeutic strategies for many malignancies. In the present study, we showed synergistic therapeutic efficacies of two chemical compounds, N-(4-hydroxyphenyl) retinamide (4HPR) and suberoylanilide hydroxamic acid (SAHA), for significant reduction in cell viability of rat C6 and human T98G glioblastoma cells. These compounds (4HPR and SAHA) were used alone or in synergistic combination for evaluating their various anti-tumor effects. The results showed that combination of 4HPR and SAHA significantly induced morphological and molecular features of astrocytic differentiation in C6 and T98G glioblastoma cells. Combination of 4HPR and SAHA proved to be an important therapeutic strategy for inhibiting cell growth and inducing differentiation in glioblastoma cells. Furthermore, combination of the two drugs showed more efficacies than either dug alone in reducing in vitro cell invasion (transwell assay), cell migration (wound healing assay), and angiogenesis (tube formation assay) due to down regulation of the molecules involved in these processes. The ultimate of goal of using this combination of drugs was induction of apoptosis. The results showed that these drugs in synergistic combination contributed highly to increases in morphological and molecular features of apoptotic death in the tumor cells. The results from molecular studies indicated that cell death occurred via activation of the extrinsic and intrinsic pathways of apoptosis in both C6 and T98G cells. The drugs in combination also contributed to dramatic inhibition of histone deacetylase 1, an important epigenetic player in promoting growth in glioblastoma cells. This novel combination of drugs should also be considered as a promising therapeutic strategy for the treatment of glioblastoma in vivo.

Improving oncology biosimilar launches in the EU, the USA, and Japan: an updated Policy Review from the Southern Network on Adverse Reactions

The EU, the USA, and Japan account for the majority of biological pharmacotherapy use worldwide. Biosimilar regulatory approval pathways were authorised in the EU (2006), in Japan (2009), and in the USA (2015), to facilitate approval of biological drugs that are highly similar to reference products and to encourage market competition. Between 2007 and 2020, 33 biosimilars for oncology were approved by the European Medicines Agency (EMA), 16 by the US Food and Drug Administration (FDA), and ten by the Japan Pharmaceuticals and Medical Devices Agency (PMDA). Some of these approved applications were initially rejected because of manufacturing concerns (four of 36 [11%] with the EMA, seven of 16 [44%] with the FDA, none of ten for the PMDA). Median times from initial regulatory submission before approval of oncology biosimilars were 1·5 years (EMA), 1·3 years (FDA), and 0·9 years (PMDA). Pharmacists can substitute biosimilars for reference biologics in some EU countries, but not in the USA or Japan. US regulation prohibits substitution, unless the biosimilar has been approved as interchangeable, a designation not yet achieved for any biosimilar in the USA. Japan does not permit biosimilar substitution, as prescribers must include the product name on each prescription and that specific product must be given to the patient. Policy Reviews published in 2014 and 2016 in The Lancet Oncology focused on premarket and postmarket policies for oncology biosimilars before most of these drugs received regulatory approval. In this Policy Review from the Southern Network on Adverse Reactions, we identify factors preventing the effective launch of oncology biosimilars. Introduction to the market has been more challenging with therapeutic than for supportive care oncology biosimilars. Addressing region-specific competition barriers and educational needs would improve the regulatory approval process and market launches for these biologics, therefore expanding patient access to these products in the EU, the USA, and Japan.

Consequences to patients, clinicians, and manufacturers when very serious adverse drug reactions are identified (1997-2019): A qualitative analysis from the Southern Network on Adverse Reactions (SONAR)

BACKGROUND

Adverse drug/device reactions (ADRs) can result in severe patient harm. We define very serious ADRs as being associated with severe toxicity, as measured on the Common Toxicity Criteria Adverse Events (CTCAE)) scale, following use of drugs or devices with large sales, large financial settlements, and large numbers of injured persons. We report on impacts on patients, clinicians, and manufacturers following very serious ADR reporting.

METHODS

We reviewed clinician identified very serious ADRs published between 1997 and 2019. Drugs and devices associated with reports of very serious ADRs were identified. Included drugs or devices had market removal discussed at Food and Drug Advisory (FDA) Advisory Committee meetings, were published by clinicians, had sales > $1 billion, were associated with CTCAE Grade 4 or 5 toxicity effects, and had either >$1 billion in settlements or >1,000 injured patients. Data sources included journals, Congressional transcripts, and news reports. We reviewed data on: 1) timing of ADR reports, Boxed warnings, and product withdrawals, and 2) patient, clinician, and manufacturer impacts. Binomial analysis was used to compare sales pre- and post-FDA Advisory Committee meetings.

FINDINGS

Twenty very serious ADRs involved fifteen drugs and one device. Legal settlements totaled $38.4 billion for 753,900 injured persons. Eleven of 18 clinicians (61%) reported harms, including verbal threats from manufacturer (five) and loss of a faculty position (one). Annual sales decreased 94% from $29.1 billion pre-FDA meeting to $4.9 billion afterwards (p<0.0018). Manufacturers of four drugs paid $1.7 billion total in criminal fines for failing to inform the FDA and physicians about very serious ADRs. Following FDA approval, the median time to ADR reporting was 7.5 years (Interquartile range 3,13 years). Twelve drugs received Box warnings and one drug received a warning (median, 7.5 years following ADR reporting (IQR 5,11 years). Six drugs and 1 device were withdrawn from marketing (median, 5 years after ADR reporting (IQR 4,6 years)).

INTERPRETATION

Because very serious ADRs impacts are so large, policy makers should consider developing independently funded pharmacovigilance centers of excellence to assist with clinician investigations.

FUNDING

This work received support from the National Cancer Institute (1R01 CA102713 (CLB), https://www.nih.gov/about-nih/what-we-do/nih-almanac/national-cancer-institute-nci; and two Pilot Project grants from the American Cancer Society's Institutional Grant Award to the University of South Carolina (IRG-13-043-01) https://www.cancer.org/ (SH; BS).

Do gastroenterologists have medical inertia towards coeliac disease? A UK multicentre secondary care study

OBJECTIVE

This study aimed to assess if there is secondary care medical inertia towards coeliac disease (CD).

DESIGN

Group (1): Time from primary care presentation to diagnostic endoscopy was quantified in 151 adult patients with a positive endomysial antibody test and compared with 92 adult patients with histologically proven inflammatory bowel disease (IBD). Group (2): Across four hospitals, duodenal biopsy reports for suspected CD were reviewed (n=1423). Group (3): Clinical complexity was compared between known CD (n=102) and IBD (n=99) patients at their respective follow-up clinic appointments. Group (4): 50 gastroenterologists were questioned about their perspective on CD and IBD.

RESULTS

Group (1): Suspected coeliac patients waited significantly longer for diagnostic endoscopy following referral (48.5 (28-89) days) than suspected patients with IBD (34.5 (18-70) days; p=0.003). Group (2): 1423 patients underwent diagnostic endoscopy for possible CD, with only 40.0% meeting guidelines to take four biopsies. Increased diagnosis of CD occurred if guidelines were followed (10.1% vs 4.6% p<0.0001). 12.4% of newly diagnosed CD patients had at least one non-diagnostic gastroscopy in the 5 years prior to diagnosis. Group (4): 32.0% of gastroenterologists failed to identify that CD has greater prevalence in adults than IBD. Moreover, 36.0% of gastroenterologists felt that doctors were not required for the management of CD.

CONCLUSION

Prolonged waiting times for endoscopy and inadequacies in biopsy technique were demonstrated suggesting medical inertia towards CD. However, this has to be balanced against rationalising care accordingly. A Coeliac UK National Patient Charter may standardise care across the UK.

Diagnosis at gut point: rapid identification of pneumoperitoneum via point-of-care ultrasound

Undifferentiated abdominal pain is a common presentation often requiring immediate medical or surgical intervention. Providing an accurate diagnosis involves a detailed patient history and thorough physical exam. Point of care ultrasound is gaining acceptance as a rapid diagnostic tool that can be used to accurately detect life-threatening conditions while potentially avoiding unnecessary radiation exposure and facilitating rapid treatment. Detection of pneumoperitoneum with point-of-care ultrasound is a simple procedure that relies heavily on the experience of the investigating practitioner. Standard technique involves placing a high-frequency linear-array transducer in the right upper quadrant, where abdominal free air is most likely to accumulate. Detection of the ‘gut point’, which is the transition of abdominal wall sliding to lack thereof in a single image, is the pathognomonic finding of pneumoperitoneum. If visualization is difficult, moving the patient to the left lateral decubitus position or using the scissors technique can provide additional image views. This representative case report and review highlights the use of abdominal POCUS for the diagnosis of pneumoperitoneum. Ultrasound should continue to be explored by clinicians to narrow the differential diagnosis of acute abdominal pain.

An alternative methodology to determine 210Pb activity soil profiles

Unsupported ²¹⁰Pb (Pb_exc) is generated in air and is subsequently deposited on soil surface. The Pb_exc can be used for sediment dating, soil erosion/sedimentation and air mass studies. In many cases, ²¹⁰Pb activity determination (gamma ray 46.5 keV) cannot be performed due to the lack of efficiency calibration curve, especially when radioactive patron source is not available. This work presents an alternative methodology to obtain the ²¹⁰Pb activity values, based on the activity definition and the attenuation coefficient determinations and assuming that soil samples coming from depth higher than 25 cm only contain ²¹⁰Pb generated in the soil (Pb_exc free, i.e., for those soil layers the ²¹⁰Pb activity is equal to the ²²⁶Ra activity, at secular equilibrium). The proposed methodology was evaluated using soils from La Plata region, Argentina. The same soil samples were also analyzed in a second laboratory by the conventional methodology. The obtained results indicated that the proposed procedure can be used as a good alternative in cases where a calibration sample is not available.

Caveat Medicus: Clinician experiences in publishing reports of serious oncology-associated adverse drug reactions

Oncology-associated adverse drug/device reactions can be fatal. Some clinicians who treat single patients with severe oncology-associated toxicities have researched case series and published this information. We investigated motivations and experiences of select individuals leading such efforts. Clinicians treating individual patients who developed oncology-associated serious adverse drug events were asked to participate. Inclusion criteria included having index patient information, reporting case series, and being collaborative with investigators from two National Institutes of Health funded pharmacovigilance networks. Thirty-minute interviews addressed investigational motivation, feedback from pharmaceutical manufacturers, FDA personnel, and academic leadership, and recommendations for improving pharmacovigilance. Responses were analyzed using constant comparative methods of qualitative analysis. Overall, 18 clinicians met inclusion criteria and 14 interviewees are included. Primary motivations were scientific curiosity, expressed by six clinicians. A less common theme was public health related (three clinicians). Six clinicians received feedback characterized as supportive from academic leaders, while four clinicians received feedback characterized as negative. Three clinicians reported that following the case series publication they were invited to speak at academic institutions worldwide. Responses from pharmaceutical manufacturers were characterized as negative by 12 clinicians. One clinician’s wife called the post-reporting time the “Maalox month,” while another clinician reported that the manufacturer collaboratively offered to identify additional cases of the toxicity. Responses from FDA employees were characterized as collaborative for two clinicians, neutral for five clinicians, unresponsive for negative by six clinicians. Three clinicians endorsed developing improved reporting mechanisms for individual physicians, while 11 clinicians endorsed safety activities that should be undertaken by persons other than a motivated clinician who personally treats a patient with a severe adverse drug/device reaction. Our study provides some of the first reports of clinician motivations and experiences with reporting serious or potentially fatal oncology-associated adverse drug or device reactions. Overall, it appears that negative feedback from pharmaceutical manufacturers and mixed feedback from the academic community and/or the FDA were reported. Big data, registries, Data Safety Monitoring Boards, and pharmacogenetic studies may facilitate improved pharmacovigilance efforts for oncology-associated adverse drug reactions. These initiatives overcome concerns related to complacency, indifference, ignorance, and system-level problems as barriers to documenting and reporting adverse drug events- barriers that have been previously reported for clinician reporting of serious adverse drug reactions.

Economic impact of traumatic spinal cord injuries in the United States

Individuals having sustained traumatic spinal cord injury (TSCI) in the United States are living longer as compared to historical trends, thanks to an ever-evolving understanding of the nature of this injury. Despite this, multiple barriers to care for TSCI patients remain including variations in government-issued veteran insurance, privatized insurance, and among uninsured individuals. The United States alone experiences 12,000 new TSCI cases every year, many of these are found to occur in a growing proportion of elderly individuals. It is crucial to understand both the short-term direct costs as wells as the long-term rehabilitation costs required by these TSCI patients. The lifetime financial burden for those having sustained a TSCI can be immense for patients, insurance companies, and hospital systems alike. Among those with TSCI, re-hospitalization rates are high, leading to increased healthcare resource utilization within this specific patient population. Costs can quickly balloon into hundreds of thousands of dollars and cause a profound financial burden for these patients. This review article seeks to communicate an understanding of the current financial landscape surrounding TSCI patients. The authors will also examine the costs of acute emergency room surgical care such as American spinal injury association grade, hospital length of stay, as well as the timing delay between injury and surgical decompression. Long-term costs associated with TSCI such as rehabilitation, care of secondary comorbidities, and post-injury employment prospects will be examined as well. These costs will be framed from the patient’s perspective as well as from both the hospital and insurance company’s perspectives. It is hoped a complete understanding as to what makes TSCI such a medically and financially burdensome injury will allow for improved healthcare resource utilization in this population.

An in vitro developmental neurotoxicity screening assay for retinoic acid-induced neuronal differentiation using the human NT2/D1 cell line

Traditional approaches (e.g., neurobehavior, neuropathology) can detect alterations in apical endpoints indicative of developmental neurotoxicity (DNT). However, there is an increasing desire to understand mode-of-action (MOA) for DNT effects; thus, this short communication describes initial work on a neuronal differentiation assay. Basically, our laboratory used the human NT2/D1 cell line to develop an assay to evaluate toxicants for effects on all-trans retinoic acid (RA)-induced neuronal differentiation. Based on literature reports, we selected a neuronal protein, neuronal class III β-tubulin (β3-tubulin), as a marker of differentiation. For this assay, cultured RA-treated NT2 cells were trypsinized to individual cells, methanol fixed, and labeled with a β3-tubulin specific monoclonal antibody (TUJ1). Characterization studies using 100,000 cells/sample showed that NT2 cells had appreciable expression of β3-tubulin starting around day 7 of the differentiation process with a peak expression noted around day 12. Methylmercury, 22(R)-hydroxycholesterol, N-(4-hydroxyphenol)retinamide (4HPR), and 9-cis retinoic acid were selected as initial test compounds. Of these, only 9-cis RA, which is known to affect the RA pathway, was positive for specific impacts on differentiation. These results demonstrate the feasibility of using a flow cytometry method targeting specific cellular biomarkers for evaluating effects on neuronal differentiation. Additional assays are needed to detect compounds targeting other (non-RA) neuronal differentiation pathways. Ultimately, a battery of in vitro assays would be needed to evaluate the potential MOAs involved in altered neuronal differentiation.

Preferred Terms and Icons for Labels on Electrosurgical Units: Survey of VA Nurses

Electrosurgical units (ESUs) developed by different manufacturers use varying terminology and icons to label the same components, which can result in confusion among users and the potential for erroneous ESU configuration. The objective of the current study was to identify nurse-preferred terms and icons for labeling ESU components. A total of 165 operating room (OR) nurses from Veterans Health Administration facilities across the United States were surveyed regarding terms and icons found on 25 ESU models. The results showed that 81% of OR nurses preferred ESUs that included both a term and an icon for labeling each component. In addition, greater consensus existed among OR nurses regarding preferred terms, rather than preferred icons, for representing each component. These findings on OR nurses' preferred terms and icons can be leveraged to improve ESU labeling practices and inform the development of a standardized, user-centered set of labels for ESU components.

Targeting autophagy for combating chemoresistance and radioresistance in glioblastoma

Autophagy is an evolutionarily conserved catabolic process that plays an essential role in maintaining cellular homeostasis by degrading unneeded cell components. When exposed to hostile environments, such as hypoxia or nutrient starvation, cells hyperactivate autophagy in an effort to maintain their longevity. In densely packed solid tumors, such as glioblastoma, autophagy has been found to run rampant due to a lack of oxygen and nutrients. In recent years, targeting autophagy as a way to strengthen current glioblastoma treatment has shown promising results. However, that protective autophagy inhibition or autophagy overactivation is more beneficial, is still being debated. Protective autophagy inhibition would lower a cell's previously activated defense mechanism, thereby increasing its sensitivity to treatment. Autophagy overactivation would cause cell death through lysosomal overactivation, thus introducing another cell death pathway in addition to apoptosis. Both methods have been proven effective in the treatment of solid tumors. This systematic review article highlights scenarios where both autophagy inhibition and activation have proven effective in combating chemoresistance and radioresistance in glioblastoma, and how autophagy may be best utilized for glioblastoma therapy in clinical settings.

Fabrication of fillable microparticles and other complex 3D microstructures

Three-dimensional (3D) microstructures created by microfabrication and additive manufacturing have demonstrated value across a number of fields, ranging from biomedicine to microelectronics. However, the techniques used to create these devices each have their own characteristic set of advantages and limitations with regards to resolution, material compatibility, and geometrical constraints that determine the types ofmicrostructures that can be formed.We describe a microfabrication method, termed StampEd Assembly of polymer Layers (SEAL), and create injectable pulsatile drug-delivery microparticles, pH sensors, and 3D microfluidic devices that we could not produce using traditional 3D printing. SEAL allows us to generate microstructures with complex geometry at high resolution, produce fully enclosed internal cavities containing a solid or liquid, and use potentially any thermoplastic material without processing additives.

Assessing Use Errors Related to the Interface Design of Electrosurgical Units

Medical device use errors, such as instrument connection errors made with electrosurgical units (ESUs), can lead to adverse events. Current device acquisition processes at health care facilities do not typically include a proactive evaluation of use-error risk before device purchase. We conducted an evaluation to identify ESU user interface design features that can help prevent or mitigate instrument connection errors during clinical care. Thirty-six current ESU users participated in the evaluation. We used a randomized crossover design in which each participant used two ESU models in a simulated OR scenario. We compared participants' instrument connection accuracy, efficiency, and subjective feedback regarding the user interface design across the two ESU models. Overall, we found that the ESU model that incorporated more user interface design principles resulted in better performance and increased acceptance from users. Based on the results, we designed a decision-support tool to assess the risk of instrument connection errors before ESU purchase.

Evaluation of an in-vehicle monitoring system (IVMS) to reduce risky driving behaviors in commercial drivers: Comparison of in-cab warning lights and supervisory coaching with videos of driving behavior

PROBLEM

Roadway incidents are the leading cause of work-related death in the United States.

METHODS

The objective of this research was to evaluate whether two types of feedback from a commercially available in-vehicle monitoring system (IVMS) would reduce the incidence of risky driving behaviors in drivers from two companies. IVMS were installed in 315 vehicles representing the industries of local truck transportation and oil and gas support operations, and data were collected over an approximate two-year period in intervention and control groups. In one period, intervention group drivers were given feedback from in-cab warning lights from an IVMS that indicated occurrence of harsh vehicle maneuvers. In another period, intervention group drivers viewed video recordings of their risky driving behaviors with supervisors, and were coached by supervisors on safe driving practices.

RESULTS

Risky driving behaviors declined significantly more during the period with coaching plus instant feedback with lights in comparison to the period with lights-only feedback (ORadj=0.61 95% CI 0.43-0.86; Holm-adjusted p=0.035) and the control group (ORadj=0.52 95% CI 0.33-0.82; Holm-adjusted p=0.032). Lights-only feedback was not found to be significantly different than the control group's decline from baseline (ORadj=0.86 95% CI 0.51-1.43; Holm-adjusted p>0.05).

CONCLUSIONS

The largest decline in the rate of risky driving behaviors occurred when feedback included both supervisory coaching and lights.

PRACTICAL APPLICATIONS

Supervisory coaching is an effective form of feedback to improve driving habits in the workplace. The potential advantages and limitations of this IVMS-based intervention program are discussed.

Investigating anthelmintic efficacy against gastrointestinal nematodes in cattle by considering appropriate probability distributions for faecal egg count data

The Faecal Egg Count Reduction Test (FECRT) is the most widely used field-based method for estimating anthelmintic efficacy and as an indicator of the presence of anthelmintic resistant nematodes in cattle, despite never having been validated against the gold standard of controlled slaughter studies. The objectives of this study were to assess the normality of cattle faecal egg count (FEC) data and their transformed versions, since confidence intervals used to aid the interpretation of the FECRT, are derived from data assumed to be normally distributed, and violation of this assumption could potentially lead to the misclassification of anthelmintic efficacy. Further, probability distributions and associated parameters were evaluated to determine those most appropriate for representing cattle FEC data, which could be used to estimate percentage reductions and confidence limits. FEC data were analysed from 2175 cattle on 52 farms using a McMaster method at two different diagnostic sensitivities (30 and 15 eggs per gram (epg)) and a sensitive centrifugal flotation technique (SCFT) with a sensitivity of 1 epg. FEC data obtained from all egg count methods were found to be non-normal even upon transformation; therefore, it would be recommended that confidence or credible intervals be generated using either a Bootstrapping or Bayesian approach, respectively, since analyses using these frameworks do not necessarily require the assumption of normality. FEC data obtained using the SCFT method were best represented by distributions associated with the negative binomial and hence arithmetic means could be used in FECRT calculations.

Where FEC data were obtained with less sensitive counting techniques (i.e. McMaster 30 or 15 epg), zero-inflated distributions and their associated central tendency were the most appropriate and would be recommended to use, i.e. the arithmetic group mean divided by the proportion of non-zero counts present; otherwise apparent anthelmintic efficacy could be misrepresented.

•

Efficacy can be misrepresented if inappropriate central tendencies are used in calculations.

•

Sensitivity of counting technique used influences the distributions of best representation.

•

Confidence intervals assuming normality of data would not be recommended to use with FEC data.

Experimental analysis of using examples and non-examples in safety training

INTRODUCTION

The effects of training content consisting of examples and/or non-examples was studied on the acquisition of safety-related skills.

METHOD

Participants (N=160) were randomly assigned to first receive computer-based training on office ergonomics that included either no examples of safe or at-risk postures, safe examples only, at-risk examples only, or both safe and at-risk examples. Participants then attempted to classify as safe or at-risk various postures depicted in short video clips and demonstrate with their own posture the range of safe postures.

RESULTS

Groups that were trained with both safe and at-risk examples showed greater classification accuracy and less error in their demonstration of safe postures. Training with only safe or at-risk examples resulted in a moderate amount of error and a consistent underestimation of risk.

CONCLUSION

Training content consisting of both examples and non-examples improved acquisition of safety-related skills.

PRACTICAL APPLICATIONS

The strategic selection of training content may improve identification of risks and safe work practices.

Approximate total Fe content determined by Mössbauer spectrometry: Application to determine the correlation between gamma-ray-emitter activities and total content of Fe phases in soils of the Province of Buenos Aires, Argentina

Pearson correlation coefficients between ⁴⁰K, ²²⁶Ra and ²³²Th activities and the total Fe phase fractions yielded by Mössbauer spectroscopy have been calculated for soils of the Province of Buenos Aires, Argentina. Total fractions of Fe phases have been obtained from the relative fractions reported in previous works weighted by the Fe soil content and the recoilless-fraction of each Fe phase. An approximate method based on the relationship between the Mössbauer spectral absorption area (obtained from the ⁵⁷Fe Mössbauer data) and the total Fe concentration (determined by colorimetric methods, after microwave assisted acid digestion of soil samples) has been used for the first time to determine the Fe concentration in soils with an accuracy of 15%. Protocol to extend the method for unknown samples is also discussed. The determined new coefficients differ from those reported previously. A significant and positive correlation between the total fraction of Fe²⁺ and the ⁴⁰K activity values has been obtained. This result validates the hypothesis put forward in a previous work, i.e., that illite captures the ⁴⁰K existing in the soil. In addition, with the new approximation, the Pearson correlation coefficients for the other natural radionuclides give values that indicate that the methodology reported here is appropriate to study the correlations between the activity values with the total fractions of Fe phases.

Enhanced MAPK signaling drives ETS1-mediated induction of miR-29b leading to downregulation of TET1 and changes in epigenetic modifications in a subset of lung SCC

Non-small-cell lung cancer is the leading cause of cancer death worldwide and is comprised of several histological subtypes, the two most common being adenocarcinoma (AC) and squamous cell carcinoma (SCC). Targeted therapies have successfully improved response rates in patients with AC tumors. However, the majority of SCC tumors lack specific targetable mutations, making development of new treatment paradigms for this disease challenging. In the present study, we used iterative non-negative matrix factorization, an unbiased clustering method, on mRNA expression data from the cancer genome atlas (TCGA) and a panel of 24 SCC cell lines to classify three disease segments within SCC. Analysis of gene set enrichment and drug sensitivity identified an immune-evasion subtype that showed increased sensitivity to nuclear factor-κB and mitogen-activated protein kinase (MAPK) inhibition, a replication-stress associated subtype that showed increased sensitivity to ataxia telangiectasia inhibition, and a neuroendocrine-associated subtype that showed increased sensitivity to phosphoinositide 3-kinase and fibroblast growth factor receptor inhibition. Additionally, each of these subtypes exhibited a unique microRNA expression profile. Focusing on the immune-evasion subtype, bioinformatic analysis of microRNA promoters revealed enrichment for binding sites for the MAPK-driven ETS1 transcription factor. Indeed, we found that knockdown of ETS1 led to upregulation of eight microRNAs and downregulation of miR-29b in the immune-evasion subtype. Mechanistically, we found that miR-29b targets the DNA-demethylating enzyme, TET1, for downregulation resulting in decreased 5-hmC epigenetic modifications. Moreover, inhibition of MAPK signaling by gefitinib led to decreased ETS1 and miR-29b expression with a corresponding increase in TET1 expression and increase in 5-hmC. Collectively, our work identifies three subtypes of lung SCC that differ in drug sensitivity and shows a novel mechanism of miR-29b regulation by MAPK-driven ETS1 expression which leads to downstream changes in TET1-mediated epigenetic modifications.

Comparative efficacy of diclazuril (Vecoxan®) and toltrazuril (Baycox bovis®) against natural infections of Eimeria bovis and Eimeria zuernii in French calves

A blinded, randomized, controlled, multi-centric field study was conducted on French dairy farms (n = 9) to evaluate the long term efficacy of metaphylactic, single oral treatments with either 1 mg/kg body weight (BW) of diclazuril (Vecoxan®), or 15 mg/kg BW of toltrazuril (Baycox®) against natural infections with Eimeria zuernii and/or Eimeria bovis, compared to untreated control animals. A total of 199 calves from nine commercial farms aged between 21 and 55 days old at the start of study were included and randomly allocated to one of three groups. Calves on all farms were observed for a period of 78 days post treatment, using both parasitological (oocyst excretion), and clinical parameters (faecal score and body weight). The assessment of efficacy was based on both control of oocyst excretion, and on the average daily weight gains throughout the study. During the whole study period, the mean number of days with diarrhoea (≥ 2) was similar (0.7 days) between treated groups. Excretion in the untreated group peaked at 21 days after treatment. In both the diclazuril and toltrazuril-treated groups, mean oocyst excretion decreased dramatically in the five days following treatment. Thereafter, particularly towards the end of the study period, oocyst counts and percentage levels of E. zuernii were highest in the toltrazuril-treated group. In pooled data from all trial sites, the average daily weight gain was significantly (p = 0.01) higher (+ 0.057 kg/day) in the diclazuril group when compared to the toltrazuril group, and the average body weight gain of the diclazuril treated group was 4.4 kg higher than the toltrazuril group. On eight of the nine trial sites, the average daily gain was greater in the diclazuril group than in the toltrazuril group. This study demonstrates that, over an extended observation period of 78 days, metaphylactic treatment with both diclazuril and toltrazuril reduces the impact of coccidiosis, but greater performance benefits based on average daily weight gains, were achieved following the use of diclazuril.

Interval sampling methods and measurement error: a computer simulation

A simulation study was conducted to provide a more thorough account of measurement error associated with interval sampling methods. A computer program simulated the application of momentary time sampling, partial-interval recording, and whole-interval recording methods on target events randomly distributed across an observation period. The simulation yielded measures of error for multiple combinations of observation period, interval duration, event duration, and cumulative event duration. The simulations were conducted up to 100 times to yield measures of error variability. Although the present simulation confirmed some previously reported characteristics of interval sampling methods, it also revealed many new findings that pertain to each method's inherent strengths and weaknesses. The analysis and resulting error tables can help guide the selection of the most appropriate sampling method for observation-based behavioral assessments.

Bilothorax as a rare sign of intra-abdominal bile leak in a patient without peritonitis

We present the case of a 60-year-old patient who developed a right-sided bilothorax following para-aortic lymph node sampling. Bilothorax is a very rare condition, with most of the reported cases resulting from direct flow of bile from the biliary system to the pleural space through a fistula or other defect in the diaphragm. In this case, there was no obvious communication found between peritoneal and pleural spaces. Our patient proceeded to an exploratory laparotomy following this finding in the absence of peritonitis. Bilothorax should be considered in patients who develop a progressive pleural effusion following upper gastrointestinal surgery, particularly if it involves manipulation of the biliary system.

Discounting the value of safety: effects of perceived risk and effort

INTRODUCTION

Although falls from heights remain the most prevalent cause of fatalities in the construction industry, factors impacting safety-related choices associated with work at heights are not completely understood. Better tools are needed to identify and study the factors influencing safety-related choices and decision making.

METHOD

Using a computer-based task within a behavioral economics paradigm, college students were presented a choice between two hypothetical scenarios that differed in working height and effort associated with retrieving and donning a safety harness. Participants were instructed to choose the scenario in which they were more likely to wear the safety harness. Based on choice patterns, switch points were identified, indicating when the perceived risk in both scenarios was equivalent.

RESULTS

Switch points were a systematic function of working height and effort, and the quantified relation between perceived risk and effort was described well by a hyperbolic equation.

CONCLUSION

Choice patterns revealed that the perceived risk of working at heights decreased as the effort to retrieve and don a safety harness increased.

IMPACT ON INDUSTRY

Results contribute to the development of computer-based procedure for assessing risk discounting within a behavioral economics framework. Such a procedure can be used as a research tool to study factors that influence safety-related decision making with a goal of informing more effective prevention and intervention strategies.

Role of carcinoembryonic antigen as a marker for colorectal liver metastases

Carcinoembryonic antigen (CEA), a marker for colorectal adenocarcinoma, can monitor disease progression and treatment response. This study aims to determine the accuracy of CEA in the detection and resectability of colorectal liver metastases. Patients with primary colorectal cancer were divided into three groups: resectable hepatic metastases (group 1), unresectable metastases (group 2), and disease-free cases (group 3). The CEA concentration was recorded pre- and post-hepatectomy in group 1 and on radiological confirmation of disease state in the other groups. It was expressed as median (95% confidence interval [CI]), with predictors of concentration determined. Group 1 (n=141) had pre-operative CEA of 8.9 (4.6-13.1), with 38.1% of patients being normal. Maximum tumour diameter correlated with CEA level (r=0.41, P<0.0001). Post-hepatectomy CEA was 2.3 (1.9-2.7; P<0.0001), with 81.1% of patients being normal. Group 2 (n=158) had CEA of 20.6 (9.4-31.9). Group 3 (n=361) had CEA of 2.0 (1.8-2.2). Sensitivity of CEA pre- and post-hepatectomy was 61.2% and 69.3%, respectively, while specificity was 79.8% for both groups. Concentration was elevated in hepatic colorectal metastases but is not a marker of resectability. A CEA reduction post-resection indicates that it may be used as an indicator of treatment response, while CEA is increased by tumour burden and lesion size.

Timing of the introduction of complementary feeding and risk of childhood obesity: a systematic review

The World Health Organisation recommends exclusive breastfeeding until 6 months of age and continued breastfeeding until 2 years of age or beyond. Appropriate complementary foods should be introduced in a timely fashion, beginning when the infant is 6 months old. In developing countries, early or inappropriate complementary feeding may lead to malnutrition and poor growth, but in countries such as the United Kingdom and United States of America, where obesity is a greater public health concern than malnutrition, the relationship to growth is unclear. We conducted a systematic review of the literature that investigated the relationship between the timing of the introduction of complementary feeding and overweight or obesity during childhood. Electronic databases were searched from inception until 30 September 2012 using specified keywords. Following the application of strict inclusion/exclusion criteria, 23 studies were identified and reviewed by two independent reviewers. Data were extracted and aspects of quality were assessed using an adapted Newcastle-Ottawa scale. Twenty-one of the studies considered the relationship between the time at which complementary foods were introduced and childhood body mass index (BMI), of which five found that introducing complementary foods at <3 months (two studies), 4 months (2 studies) or 20 weeks (one study) was associated with a higher BMI in childhood. Seven of the studies considered the association between complementary feeding and body composition but only one study reported an increase in the percentage of body fat among children given complementary foods before 15 weeks of age. We conclude that there is no clear association between the timing of the introduction of complementary foods and childhood overweight or obesity, but some evidence suggests that very early introduction (at or before 4 months), rather than at 4-6 months or >6 months, may increase the risk of childhood overweight.

Inventories and concentration profiles of 137Cs in undisturbed soils in the northeast of Buenos Aires Province, Argentina

Inventories and vertical distribution of (137)Cs were determined in La Plata region undisturbed soils, Argentina. A mean inventory value of 891 ± 220 Bq/m(2) was established, which is compatible with the values expected from atmospheric weapon tests fallout. The study was complemented with pH, organic carbon fraction, texture and mineralogical soil analyses. Putting together Southern Hemisphere (137)Cs inventory data, it is possible to correlate these data with the mean annual precipitations. The large differences in (137)Cs concentration profiles were attributed to soil properties, especially the clay content and the pH values. A convection-dispersion model with irreversible retention was used to fit the activity concentration profiles. The obtained effective diffusion coefficient and effective convection velocity parameters values were in the range from 0.2 cm(2)/y to 0.4 cm(2)/y and from 0.23 cm/y to 0.43 cm/y, respectively. These data are in agreement with values reported in literature. In general, with the growth of clay content in the soil, there was an increase in the transfer rate from free to bound state. Finally, the highest transfer rate from free to bound state was obtained for soil pH value equal to 8.

Hepatic cytokine response can be modulated using the Kupffer cell blocker gadolinium chloride in obstructive jaundice

INTRODUCTION

Depletion of Kupffer cells by gadolinium chloride (GdCl(3)) reduces the systemic response during sepsis. The study aim was to investigate the effect of this depletion on hepatic proinflammatory cytokine response to portal endotoxaemia.

METHODS

Sixteen Wistar rats were randomised to receive either saline IV (n = 8) or GdCl(3) (10 mg/kg IV, n = 8) six days after bile duct ligation (BDL). 24 h later the animals were perfused for 2 h, using isolated hepatic perfusion. Aliquots of effluent perfusate were collected at 20-min intervals for cytokine analysis. Sections of liver were sampled and the hepatic Kupffer cell number of each group was measured using ED1 immunohistochemistry.

RESULTS

Pre-treatment with GdCl(3) resulted in significantly reduced serum bilirubin concentrations but significantly elevated serum ALP and AST levels compared to the control group. It was also associated with a significant reduction in Kupffer cell numbers and a corresponding significant reduction in hepatic TNFα and IL-6 production in response to portal endotoxaemia.

CONCLUSIONS

Pre-treatment with GdCl(3) in jaundiced animals reduced Kupffer cell numbers, attenuated liver enzyme abnormalities and reduced TNFα and IL-6 in response to portal endotoxaemia. Hepatic Kupffer cells, therefore, play a significant role in the development of an exaggerated inflammatory response in obstructive jaundice.

Anthelmintic resistance in sheep flocks in Ontario, Canada

Gastrointestinal nematodes (GIN) are a significant constraint to pasture-based sheep production worldwide. Anthelmintic resistance (AR) has been reported in most sheep-raising areas in the world, yet little is known about the AR status in Canada. This study was conducted to determine the frequency of AR in GIN in sheep flocks in Ontario, Canada. Forty-seven sheep flocks were enrolled in the study, and their level of parasitism was monitored monthly throughout a grazing season by analyzing owner-acquired fecal samples from 15 grazing lambs per flock. When the mean GIN fecal egg count (FEC) reached a threshold of 200 eggs per gram (epg), oral ivermectin was supplied to producers to check ivermectin efficacy; the reduction in mean FEC 14 days after ivermectin treatment was calculated. 'Drench failure' was defined as a reduction in mean FEC of <95%. In those flocks with apparent drench failure, researchers performed a Fecal Egg Count Reduction Test (FECRT), dividing sheep into 4 treatment groups (n=10-15): control (i.e. untreated), ivermectin, and, if sufficient numbers of animals - fenbendazole and levamisole. AR was defined as a reduction in mean FEC <95% and a lower 95% confidence interval <90%. Larval cultures were performed on pooled post-treatment FECRT samples. Larval Development Assays (LDAs) to detect the presence of resistance to thiabendazole and levamisole were performed prior to the ivermectin drench check on pooled owner-acquired fecal samples that reached the 200 epg threshold. Approximately 89% (42/47) of the farms reached the FEC threshold of 200 epg; 93% (39/42) of these farms performed an ivermectin drench check, and 88% (34/39) of these farms had drench failure. The FECRT was performed on 29 of the 34 farms. Resistance to ivermectin, fenbendazole and levamisole was demonstrated on 97% (28/29), 95% (19/20) and 6% (1/17) of the farms tested, respectively, with considerable variability in resistance levels among farms. Haemonchus sp. was the most commonly cultured parasite from post-treatment fecal samples. LDA results for 21 farms were available; of these, 14% (3/21) and 62% (13/21) had low and high levels of thiabendazole resistance, respectively, while none of the farms exhibited resistance to levamisole. Amongst these tested farms, resistance to both ivermectin and benzimidazoles was very common. These findings strongly suggest that AR, particularly in Haemonchus sp., is a serious problem in these sheep flocks. Thus, marked changes in GIN management need to be instituted immediately to mitigate a worsening situation.

Degradation of myofibrils from rabbit, chicken and beef by cathepsin l and lysosomal lysates

The degradation of rabbit, chicken and beef myofibrils by cathepsin L or lysosomal lysates was studied by SDS-polyacrylamide-gel electrophoresis and electron microscopy (EM). Similar degradation patterns were observed for each myofibrillar preparation incubated with cathepsin L, except that myosin heavy chain and tropomyosin of beef were more susceptible than those of rabbit and chicken. Otherwise, troponin T, troponin in I and C-protein were rapidly degraded with slower degradation of titin, nebulin, myosin heavy chain, α-actinin, α-tropomyosin, actin and myosin light chains, LC1 and LC2. However, the component of 30 000 Mr was found to be further degraded to smaller peptides. Degradation at pH 5·5 (approximate post-mortem limit value) was faster than at pH 6·0 but slower than at pH 5·0. A number of new protein bands were identified (130 000, 120 000, 90 000, 85 000, 80 000, 31 000 and 30 000 Mr). The degradation patterns of rabbit myofibrils by rabbit muscle lysosomal lysates were similar to that of myofibrils incubated with purified cathepsin L except for the retention of the 30 000 Mr component and reduced degradation of actin, due presumably to the reduced amount or stability of cathepsin L in the crude enzyme preparations. Electron micrographs revealed that myofibrillar degradation by cathepsin L occurred preferentially at the Z-lines leading to removal of the Z-line proteins and fracturing of the myofibrils at these sites. Catheptic damage was seen to be most rapid in chicken myofibrils and least rapid in beef myofibrils consistent with the more rapid conditioning process in chicken.

Modelling post-mortem tenderisation-II: Enzyme changes during storage of electrically stimulated and non-stimulated beef

Levels of calpains I and II, cathepsins B and L and β-glucuronidase were determined in extracts of electrically stimulated and control beef M. Pectoralis profundus stored at temperatures between 0 and 30°C and varied to avoid muscle shortening. The level of lysosomal enzymes remained essentially unchanged throughout storage. The levels of calpain II were largely unaffected by the early treatments and decreased slightly throughout ageing. The level of calpain I, in both stimulated and control meats, was unaffected by temperature prior to the attainment of about pH 6·2 and thereafter the loss was accelerated at higher temperatures. In the extreme case studied, that of stimulated meat held at 15°C, 73% of the activity was lost in the first 24 h. After ageing, the level was about 11% of the initial when stored at 1°C and 25% when stored at 15°C. The exponential decay constants for the decrease in the levels of calpain I were 0·01 h(-1) at 1°C and 0·06 h(-1) at 15°C, and were the same as those for the previously determined rate of tenderisation. This suggested that the rate of proteolysis by calpain I was linked to the rate of tenderisation.

Sleep disruption as a correlate to cognitive and adaptive behavior problems in autism spectrum disorders

Sleep problems associated with autism spectrum disorders (ASD) have been well documented, but less is known about the effects of sleep problems on day-time cognitive and adaptive performance in this population. Children diagnosed with autism or pervasive developmental disorder-not otherwise specified (PDD-NOS) (N = 335) from 1 to 10 years of age (M = 5.5 years) were evaluated for the relationships of Behavioral Evaluation of Disorders of Sleep (BEDS; Schreck, 1998) scores to measures of intelligence and adaptive behavior. Results suggested that children who slept fewer hours per night had lower overall intelligence, verbal skills, overall adaptive functioning, daily living skills, socialization skills, and motor development. Children who slept fewer hours at night with waking during the night had more communication problems. Breathing related sleep problems and fewer hours of sleep related most often to problems with perceptual tasks. The results indicate that quality of sleep--especially sleep duration--may be related to problems with day-time cognitive and adaptive functioning in children with autism and PDD-NOS. However, future research must be conducted to further understand these relationships.

Assessment of natural radioactivity levels and their relationship with soil characteristics in undisturbed soils of the northeast of Buenos Aires province, Argentina

Surface and depth profile concentrations (down to 50 cm) of ²³²Th chain, ²²⁶Ra, and ⁴⁰K radionuclides were determined in undisturbed coastal and inland soils of La Plata city region, Argentina, through their gamma-ray activity using a high-purity Ge detector spectrometer. These results were compared with superficial activities determined in soils from the surroundings of the Centro Atómico Ezeiza (Ezeiza Atomic Center) located in Ezeiza, Buenos Aires Province, Argentina. The hyperfine and magnetic Fe phase's properties of soil profiles were characterized by Mössbauer spectroscopy, magnetic hysteresis loops and AC magnetic susceptibility. No dependence of the activity of the ²³²Th natural chain on depth was found, whereas variations for ²²⁶Ra and ⁴⁰K activities were observed. Positive correlations, determined by the Pearson correlation coefficients, were established between ⁴⁰K, ²²⁶Ra and ²³²Th activity concentrations for the whole set of soil samples. The annual external equivalent dose for adults was similar for La Plata and Ezeiza regions, with average values of 0.08 ± 0.01 mSv and 0.06 ± 0.02 mSv, respectively. The thermal dependence of the AC magnetic susceptibility revealed the existence of magnetite and hematite. The Mössbauer spectra of all soils were made up of signals associated with α-Fe₂O₃, a paramagnetic relaxation component, and Fe³⁺ and Fe²⁺ doublets. In addition, the spectra of inland soils revealed the presence of Fe₃O₄. A negative correlation was found between the activity concentrations and the α-Fe₂O₃ and Fe₃O₄ relative fractions, whereas a positive correlation was found between the Fe³⁺ relative fraction and the ⁴⁰K activity.

Towards a standardised surveillance for Trichinella in the European Union

Each year, more than 167 million pigs in the European Union (EU) are tested for Trichinella spp. under the current meat hygiene regulations. This imposes large economic costs on countries, yet the vast majority of these pigs test negative and the public health risk in many countries is therefore considered very low. This work reviewed the current Trichinella status across the EU as well as the national level of monitoring and reporting. It also reviewed which animal species were affected by Trichinella and in which species it should be surveyed. This information was used to design a cost-effective surveillance programme that enables a standardised monitoring approach within the EU. The proposed surveillance programme relies on identifying sub-populations of animals with a distinct risk. Low-risk pigs are finisher pigs that originate from so-called controlled housing. All other pigs are considered high-risk pigs. Controlled housing is identified by the application of a specific list of management and husbandry practices. We suggest that member states (MS) be categorised into three classes based on the confidence that Trichinella can be considered absent, in the specified sub-population of pigs above a specified design prevalence which we set to 1 per million pigs. A simple and transparent method is proposed to estimate this confidence, based on the sensitivity of the surveillance system, taking into account the sensitivity of testing and the design prevalence. The probability of detecting a positive case, if present, must be high (>95 or >99%) to ensure that there is a low or negligible risk of transmission to humans through the food chain. In MS where the probability of a positive pig is demonstrated to be negligible, testing of fattening pigs from a sub-population consisting of pigs from controlled housing can be considered unnecessary. Furthermore, reduced testing of finishers from the sub-population consisting of pigs from non-controlled housing might even be considered, if conducted in conjunction with a proportionate sampling scheme and a risk-based wildlife surveillance programme where applicable. The proposed surveillance programme specifies the required number of samples to be taken and found negative, in a MS. A MS with no data or positive findings will initially be allocated to class 1, in which all pigs should be tested. When a MS is able to demonstrate a 95% or 99% confidence that Trichinella is absent, the MS will be allocated to class 2 or 3, in which the testing requirement is lower than in class 1.

Abstract P2-09-24: Relationship of Capecitabine Response to Thymidine Phosphorylase Expression and Overall Survival in Advanced Breast Cancer

Background: Capecitabine is an oral fluoropyrimidine carbamate that is metabolised to FU through three enzymatic steps. Thymidine phosphorylase (TP) is involved in the final step of the conversion from 5'-deoxy-5-fluorouridine (5'-DFUR) to 5-FU. TP is highly expressed in cancer cells compared to normal tissue. By exploiting this difference in TP activity, capecitabine is activated and preferentially converted into 5-FU within tumours. Besides this, TP is identical to platelet-derived endothelial cell growth factor (PD-ECGF), a known angiogenic factor. While TP expression is predictive of benefit from capecitabine in colorectal cancer (CRC), initial studies in advanced breast cancer (ABC) examining the predictive value of TP and related enzymes have produced mixed results. Furthermore, whether response to capecitabine is associated with any overall survival (OS) benefit has not been studied. Materials and Methods: This retrospective study analysed 92 ABC patients who received at least one cycle of capecitabine for locally advanced or metastatic disease with intention to treat. Best responses to capecitabine (assessed clinically or by imaging) whilst patients were on capecitabine were included for analysis. TP expression was analysed by immunohistochemistry in primary excised samples. Composite TP scoring (including cytoplasm and stroma) was used to define TP status. Chi-squared tests were carried out to find associations between TP and clinical factors. Kaplan Meier survival curves were produced for relapse free survival and OS. The logrank statistic was calculated to test independence of the survival curves by category.

Results: On multivariate analysis, when the TP composite factor was added to a Cox regression model for OS using age, ER, grade, nodal status and size, it appeared to act as an independent prognostic factor for OS after first primary (hazard ratio: 0.45, p=0.01). Overall, responses included partial response (PR) in 38% and stable disease (SD) for 3 months or longer in 25% patients. There was no statistically significant correlation for capecitabine response and TP status. Also there was no significant difference in time to first relapse or from first relapse to start of capecitabine stratified by response, showing that response was not intrinsically related to better prognosis or slower growing cancers. However, there was a significantly prolonged OS equivalent for both SD and PR to capecitabine (logrank, p=0.02).

Discussion: Most studies in ABC have not found high TP expression alone to predict better response to capecitabine. The results of our study, the largest to date, confirm these findings. A combined approach studying plasma levels of 5'-DFUR along with intra-tumoral TP should be investigated further. Interestingly, the finding of high TP as an independent prognostic factor could be due to deprivation of thymidine needed for proliferation, but this also needs further investigation. By analysing the long term course of breast cancer based on ultimate pattern of response, this study suggests a substantial benefit of capecitabine even though second or third line. It also suggests that if patients achieve SD therapy should continue.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-09-24.

Estimation and external validation of a new prognostic model for predicting recurrence-free survival for early breast cancer patients in the UK

Background:

We aimed to estimate and externally validate a new UK-specific prognostic model for predicting the long-term risk of a first recurrent event (local recurrence, metastatic recurrence, or second primary breast cancer) in women diagnosed with early breast cancer.

Methods:

Using data on the prognostic characteristics and outcomes of 1844 women treated for early breast cancer at the Churchill Hospital in Oxford, parametric regression-based survival analysis was used to estimate a prognostic model for recurrence-free survival. The model, which incorporated established prognostic factors, was externally validated using independent data. Its performance was compared with that of the Nottingham Prognostic Index (NPI) and Adjuvant! Online.

Results:

The number of positive axillary lymph nodes, tumour grade, tumour size and patient age were strong predictors of recurrence. Oestrogen receptor (ER) positivity was shown to afford a moderate protective effect. The model was able to separate patients into distinct prognostic groups, and predicted well at the patient level, mean Brier Accuracy Score=0.17 (s.e.=0.004) and overall C=0.745 (95% CI, 0.717–0.773). Its performance diminished only slightly when applied to a second independent data set. When compared with the NPI, the model was able to better discriminate between women with excellent and good prognoses, and it did not overestimate 10-year recurrence-free survival to the extent observed for Adjuvant! Online.

Conclusion:

The model estimated here predicts well at both the individual patient and group levels, and appears transportable to patients treated at other UK hospitals. Its parametric form permits long-term extrapolation giving it an advantage over other prognostic tools currently in use. A simple point scoring system and reference table allow 5-, 10-, and 15-year predictions from the model to be quickly and easily estimated. The model is also available to download as an interactive computer program.

The nature of the compensatory response to low thyroid hormone in the developing brain

Thyroid hormone is essential for normal brain development, although the degree to which the developing brain is sensitive to small perturbations in serum thyroxin is not clear. An important concept related to this is that the developing brain possesses potent mechanisms to compensate for low serum thyroid hormone, and this concept is routinely employed in discussions concerning clinical treatments or public health. However, experimental studies have not directly tested whether (or the degree to which) putative compensatory mechanisms can ameliorate the consequences of small reductions in serum thyroxin (T(4)). To formally test this concept, we employed a model of graded T(4) reductions using doses of propylthiouracil (PTU) that were 200- to 67-fold lower than the dose traditionally used to produce hypothyroidism in rats. PTU produced a stepwise decrease in serum total T(4), and a stepwise increase in serum thyroid-stimulating hormone (TSH), in type 2 deiodinase mRNA expression and enzyme activity in the brain, and in the expression of the mRNA encoding the tri-iodothyronine (T(3)) transporter MCT8 in the postnatal day (P) 15 cortex. However, the mRNA encoding RC3/neurogranin, a direct target of T(3) action, exhibited a strong negative linear correlation with serum total T(4) despite these adaptive responses. In addition, single-cell analysis of RC3 mRNA levels in cortical neurones demonstrated that the co-expression of MCT8 did not alter the relationship between RC3 mRNA and serum T(4). These findings do not support the currently envisioned concept of the developing brain being capable of compensating for low T(4).