Examining spatial variation for immunisation coverage in pregnant women: A nationwide and geospatial retrospective cohort study in Aotearoa New Zealand

BACKGROUND

Maternal influenza and pertussis immunisation is crucial for protecting mothers during pregnancy and their babies in the first weeks of life against severe disease. We examined geospatial variation in maternal immunisation coverage among pregnant women in Aotearoa New Zealand and its health equity implications.

METHOD

We constructed a retrospective cohort including all pregnant women who delivered between 01 January 2013 and 31 December 2020 using administrative health datasets. Our outcomes were receipt of influenza or pertussis vaccine in any one of three relevant national databases (e.g. National Immunisation Register, Proclaims, or Pharmaceutical collection) during the eligible pregnancy.

RESULTS

Data from our retrospective cohort study show significant regional variation in maternal immunisation coverage for both influenza and pertussis from 2013 to 2020. Maximal coverage was around 50% in the best performing regions, which means that half of the women who were pregnant (183,737 women) were not protected. In addition, we found significant spatio-temporal variation and clustering of immunisation coverage. Our findings are interactively available to explore here: https://geohealthlab.shinyapps.io/hapumama/ CONCLUSION: Our study is one of the first to examine spatial variation in maternal vaccination coverage in pregnant women at a national level over space and time. This provides powerful tools to measure the impact of interventions to improve coverage at national and regional levels, with specific reference to inequities between ethnic groups, likely applicable to similar settings internationally.

1235 A Multi-Site Review of Second Hip Fractures Across 6 Dublin Teaching Hospitals

Introduction

Hip fractures are a common presentation to Irish hospitals with 3,701 hip fractures recorded by 16 hospitals in the Irish Hip Fracture Database (IHFD) in 2019. Second hip fractures (HF2) make up a significant proportion of hip fractures and represent an opportunity to prevent subsequent fragility fracture.

Method

Hip fracture datasheets from 2019 in six Dublin hospitals were analysed.

Results

1,284 hip fractures in total were recorded in 2019 in these six hospitals. 112 of these were second hip fractures (8.72%). 24.1% of patients had a HF2 in year 1 post their first hip fracture (HF1). 14.3% of patients had a HF2 in Year 2, 8% in Year 3, 8.9% in Year 4 and 6.3% in Year 5. 17.9% of patients had an HF2 at an unknown time in relation to their HF1. 57.6% of all patients with any hip fracture were started on bone protection medications (BPMs) during their admission. 18.9% continued a pre-admission prescription. 7% of all patients were previously assessed and determined not to require BPM. 6.9% of patients were awaiting outpatient department (OPD) assessment for bone protection. 8.6% had no assessment for bone protection conducted. Of all patients with an HF2, 48.2% were started on BPMs on admission with their HF2. 33% continued BPMs started pre-admission.

Discussion

In 2019, approximately 1 in 10 hip fractures were second hip fractures. Evidence suggests that fracture liaison services represent a viable, economic means of preventing second hip fractures to improve patient outcomes and reduce healthcare expenditure.

Anaesthesia for Electroconvulsive Therapy: A Comparison of Sevoflurane with Propofol

This study was a prospective audit of patients receiving either intravenous induction of anaesthesia with propofol 2 mg/kg or inhalational induction using 8% sevoflurane for patients undergoing electroconvulsive therapy (ECT). All patients received inhaled 50% nitrous oxide. The anaesthetic agent was determined by psychiatrist preference. Each psychiatrist nominated only one induction technique for all his or her patients. Seventy treatments were studied in each group. Induction time was longer in the sevoflurane group. The time from commencing induction to loss of verbal contact was [mean (SD)] 64 (29.9) seconds for sevoflurane and 36 (33.6) seconds for propofol (P=0.001). Time to loss of eyelash reflex was 82 (32.6)s for sevoflurane and 44 (17.9)s for propofol (P<0.001). The duration of seizure activity was longer in sevoflurane patients, 35 (17.8)s, compared with 20 (9.8)s in the propofol group (P< 0.001). Discharge times were similar. Minor adverse effects occurred in three patients, all in the sevoflurane group (one bradycardia and two episodes of post-procedural nausea). There were no major adverse events in either group. Propofol and sevoflurane both appear to be suitable agents for induction of anaesthesia for ECT.

Effects of a Si-doped InGaN Underlayer on the Optical Properties of InGaN/GaN Quantum Well Structures with Different Numbers of Quantum Wells

In this paper we report on the optical properties of a series of InGaN polar quantum well structures where the number of wells was 1, 3, 5, 7, 10 and 15 and which were grown with the inclusion of an InGaN Si-doped underlayer. When the number of quantum wells is low then the room temperature internal quantum efficiency can be dominated by thermionic emission from the wells. This can occur because the radiative recombination rate in InGaN polar quantum wells can be low due to the built-in electric field across the quantum well which allows the thermionic emission process to compete effectively at room temperature limiting the internal quantum efficiency. In the structures that we discuss here, the radiative recombination rate is increased due to the effects of the Si-doped underlayer which reduces the electric field across the quantum wells. This results in the effect of thermionic emission being largely eliminated to such an extent that the internal quantum efficiency at room temperature is independent of the number of quantum wells.

Resonant photoluminescence studies of carrier localisation in c-plane InGaN/GaN quantum well structures

In this paper we report on changes in the form of the low temperature (12 K) photoluminescence spectra of an InGaN/GaN quantum well structure as a function of excitation photon energy. As the photon energy is progressively reduced we observe at a critical energy a change in the form of the spectra from one which is determined by the occupation of the complete distribution of hole localisation centres to one which is determined by the resonant excitation of specific localisation sites. This change is governed by an effective mobility edge whereby the photo-excited holes remain localised at their initial energy and are prevented from scattering to other localisation sites. This assignment is confirmed by the results of atomistic tight binding calculations which show that the wave function overlap of the lowest lying localised holes with other hole states is low compared with the overlap of higher lying hole states with other higher lying hole states.

Origin of enhancement in Raman scattering from Ag-dressed carbon-nanotube antennas: experiment and modelling

The D- and G-band Raman signals from random arrays of vertically aligned, multi-walled carbon nanotubes are significantly enhanced (up to ∼14×) while the signal from the underlying Si substrate is simultaneously attenuated (up to ∼6×) when the nanotubes are dressed, either capped or coated, with Ag. These Ag-induced counter-changes originate with the difference in geometry of the nanotubes and planar Si substrate and contrast in the Ag depositions on the substrate (essentially thin film) and the nanotube (nano-particulate). The surface integral equation technique is used to perform detailed modelling of the electromagnetic response of the system in a computationally efficient manner. Within the modelling the overall antenna response of the Ag-dressed nanotubes is shown to underpin the main contribution to enhancement of the nanotube Raman signal with hot-spots between the Ag nanoparticles making a subsidiary contribution on account of their relatively weak penetration into the nanotube walls. Although additional hot-spot activity likely accounts for a shortfall in modelling relative to experiment it is nonetheless the case that the significant antenna-driven enhancement stands in marked contrast to the hot-spot dominated enhancement of the Raman spectra from molecules adsorbed on the same Ag-dressed structures. The Ag-dressing procedure for amplifying the nanotube Raman output not only allows for ready characterisation of individual nanotubes, but also evidences a small peak at ∼1150 cm^-1 (not visible for the bare, undressed nanotube) which is suggested to be due to the presence of trans-polyacetylene in the structures.

Developing a national colorectal educational agenda: a survey of the Association of Coloproctology of Great Britain and Ireland

AIM

In order to develop its education agenda, the Association of Coloproctology of Great Britain and Ireland (ACPGBI) sought the opinion of its members on current coloproctology training needs. The aims of this study were to canvass multidisciplinary needs and explore the perceived gaps and barriers to meeting them.

METHOD

A learner-needs analysis was performed between July 2015 and October 2016. A bespoke electronic survey was sent to 1453 colorectal healthcare professionals [ACPGBI membership (1173), colorectal nurse specialists and allied health professionals (NAHPs) (261) and regional chapter-leads (19)] seeking their needs, experiences and barriers to training across the coloproctology disciplines.

RESULTS

In all, 390 responses were received [26.8% overall; 180 consultants/trainees (15%); 196 NAHPs (75%); 14 (74%) chapter-leads]. Lack of funding and difficulties in obtaining study leave were the most frequently reported barriers to course and conference attendance. Transanal total mesorectal excision and laparoscopic training were the top educational needs for consultants and trainees respectively. 79% of NAHP respondents reported education gaps on a broad range of clinical and non-clinical topics. NAHPs lacked information on relevant training opportunities and 27% felt available courses were insufficient to meet their educational needs. Wide heterogeneity in ACPGBI chapter composition and activity was reported. All groups felt the ACPGBI should increase the number of courses offered with coloproctology knowledge updates commonly requested.

CONCLUSION

A series of training needs across the coloproctology disciplines have been identified. These will underpin the development of the educational agenda for the ACPGBI.

Novel routes to electromagnetic enhancement and its characterisation in surface- and tip-enhanced Raman scattering

Quantitative understanding of the electromagnetic component in enhanced Raman spectroscopy is often difficult to achieve on account of the complex substrate structures utilised. We therefore turn to two structurally simple systems amenable to detailed modelling. The first is tip-enhanced Raman scattering under electron scanning tunnelling microscopy control (STM-TERS) where, appealing to understanding developed in the context of photon emission from STM, it is argued that the localised surface plasmon modes driving the Raman enhancement exist in the visible and near-infrared regime only by virtue of significant modification to the optical properties of the tip and sample metals (gold here). This is due to the strong dc field-induced (∼10⁹ V m^-1) non-linear corrections to the dielectric function of gold via the third order susceptibility term in the polarisation. Also, sub-5 nm spatial resolution is shown in the modelling. Secondly, we suggest a novel deployment of hybrid plasmonic waveguide modes in surface enhanced Raman scattering (HPWG-SERS). This delivers strong confinement of electromagnetic energy in a ∼10 nm oxide 'gap' between a high-index dielectric material of nanoscale width (a GaAs nanorod and a 100 nm Si slab are considered here) and a metal, yielding a monotonic variation in the Raman enhancement factor as a function of wavelength with no long-wavelength cut-off, both features that contrast with STM-TERS.

A study of the optical and polarisation properties of InGaN/GaN multiple quantum wells grown on a-plane and m-plane GaN substrates

We report on a comparative study of the low temperature emission and polarisation properties of InGaN/GaN quantum wells grown on nonpolar ([Formula: see text]) a-plane and ([Formula: see text]) m-plane free-standing bulk GaN substrates where the In content varied from 0.14 to 0.28 in the m-plane series and 0.08 to 0.21 for the a-plane series. The low temperature photoluminescence spectra from both sets of samples are broad with full width at half maximum height increasing from 81 to 330 meV as the In fraction increases. Photoluminescence excitation spectroscopy indicates that the recombination mainly involves strongly localised carriers. At 10 K the degree of linear polarisation of the a-plane samples is much smaller than of the m-plane counterparts and also varies across the spectrum. From polarisation-resolved photoluminescence excitation spectroscopy we measured the energy splitting between the lowest valence sub-bands to lie in the range of 23-54 meV for the a- and m-plane samples in which we could observe distinct exciton features. Thus the thermal occupation of a higher valence sub-band cannot be responsible for the reduction of the degree of linear polarisation at 10 K. Time-resolved spectroscopy indicates that in a-plane samples there is an extra emission component which is at least partly responsible for the reduction in the degree of linear polarisation.

Component-resolved analysis of IgA, IgE, and IgG4 during egg OIT identifies markers associated with sustained unresponsiveness

BACKGROUND

In a previously reported CoFAR study, 55 subjects with egg allergy underwent randomized, placebo-controlled egg oral immunotherapy (eOIT). Active treatment induced desensitization in most and sustained unresponsiveness (SU) in a smaller subset. We hypothesized that component-resolved analysis of IgE, IgG4, IgA, IgA1, and IgA2 may identify potential biomarkers of SU in OIT subjects.

METHODS

Longitudinal samples for 51 egg-allergic subjects (37 active and 14 placebo) were available. Egg white (EW)-, ovalbumin (OVA)-, and ovomucoid (OVM)-specific levels of IgA, IgA1, and IgA2 were quantified by ELISA. IgE and IgG4 to these antigens were quantified using ImmunoCAP^® . Clinical responders achieved SU to egg; all others were considered nonresponders. Between-group comparisons were made among active and placebo, as well as responders and nonresponders.

RESULTS

No placebo subjects achieved responder status. Through month 48, among the 37 active subjects, baseline IgE-OVM was lower in responders (median 3.97 kU/l, n = 19) than in nonresponders (10.9 kU/l, n = 18, P = 0.010). Logistic regression analysis revealed that lower baseline IgE-EW (P = 0.038), IgE-OVM (P = 0.032), and a higher IgG4/IgE-OVM ratio (P = 0.013) were associated with clinical response. Relative increases in IgG4-EW, IgA-EW, and IgA2-EW were observed in responders (P = 0.024, 0.024, and 0.029, respectively). IgG4/IgE, IgA/IgE, and IgA2/IgE ratios for EW and IgA/IgE ratio for OVA were found to be significantly elevated among responders (P = 0.004, 0.009, 0.028, and 0.008, respectively).

CONCLUSIONS

Increased IgG4-EW, IgA-EW, and IgA2-EW during eOIT are associated with clinical response to eOIT. Lower pretreatment IgE-EW and IgE-OVM are also associated with SU. Future studies are needed to evaluate and validate these potential biomarkers.

Second international standard for endotoxin: calibration in an international collaborative study

On behalf of the World Health Organization, 26 scientists in 13 countries calibrated a candidate international standard for endotoxin and compared it with the Pharmacopoeial standards of the US, Europe and Japan. The study showed that the candidate standard is suitable to serve as the second international standard for endotoxin for all applications, with an assigned unitage of 10,000 international units (IU)/vial, with 1 IU = 1 EU (FDA/USP endotoxin unit). This value maintains continuity of unitage with EC5 (the primary calibrant for the first international standard), EC6 (the current FDA/USP standard), the Japanese Pharmacopoeia Standard and commercial preparations of Limulus lysate. This value is also consistent with calibration of the candidate standard in terms of the European Pharmacopoeia Standard, BRP-2. The establishment of this international standard for endotoxin will permit the global harmonisation of unitage for standards of endotoxin.

Neuroendocrine Carcinoma of the Cervix: Review of a Series of Cases and Correlation With Outcome

Introduction Neuroendocrine carcinoma (NEC) of the cervix is associated with a poor prognosis despite multimodal treatment. The correct diagnosis of this tumor type is imperative to provide clinicians and patients with prognostic information and ensure that appropriate treatment is provided. Methods A clinicopathological study was undertaken on all cervical tumors registered as NEC with the West Midlands Cancer Intelligence Unit between January 1, 1998 and December 31, 2009. Of the 45 cases diagnosed during the study period, the tumor samples of 41 cases were traced, anonymized, and then independently reviewed by 2 gynecological pathologists. Results The review confirmed 31/41 (78%) cases to be NEC, which overall, represented 1.3% of all the cervical cancers registered in the West Midlands over the period of the study. In the correct histological context, synaptophysin was the most sensitive and specific positive immunohistochemical marker of NEC differentiation. The cases that on review were confirmed as NEC had a significantly worse outcome than the non-NEC cases: median survival for NEC cases was 33.3 months versus 315.0 months for the non-NEC cases, P = .013. Conclusions Histological review of a series of NECs has shown significantly reduced survival in those patients with confirmed NEC in comparison with those patients where a diagnosis of NEC was not confirmed. We propose morphological and immunohistochemical criteria for the diagnosis of cervical NEC; and discourage unqualified use of the term "small cell carcinoma" as this does not accurately convey the diagnosis of SCNEC. We urge pathologists to use the 2014 World Health Organization classification when reporting these tumors.

IFPA meeting 2015 workshop report I: placental mitochondrial function, transport systems and epigenetics

Workshops are an important part of the IFPA annual meeting as they allow for discussion of specialized topics. At IFPA meeting 2015 there were twelve themed workshops, three of which are summarized in this report. These workshops covered areas of placental regulation and nutrient handling: 1) placental epigenetics; 2) placental mitochondrial function; 3) placental transport systems.

Post operative complications in a dedicated elective orthopaedic hospital: transfers requiring specialist critical care support

We aim to report our experience with out of hospital transfers for postoperative complications in a stand-alone elective orthopaedic hospital. We aim to describe the cohort of patients transferred, the rate of transfer and assess the risk factors for transfer. Patients were identified who were transferred out of the hospital to another acute hospital for management of non-routine medical problems. Patient data was collected relating to age, BMI, ASA, type of surgery, nature of the complication, timing and the outcome of transfer. In 2012, 2,853 inpatient surgical procedures were carried out, 51 patients (1.8%) developed a postoperative complication that required out of hospital transfer. Mean age of patients transferred was 67 (12-86) years, mean age of the overall case mix 58 years (0-96) (p = 0.01). 37.7% of the overall case mix of surgeries was made up of primary hip and knee arthroplasty procedures, these patients made up 63.7% of patients transferred out (p = 0.001). Mean BMI recorded was 31.7 (22-48) compared to the mean BMI of the total arthroplasty case mix of 28.8 (20-44) (p = 0.02). 59% of all patients at our institution were ASA category II or III. 76% of patients transferred were ASA category II or III (p = 0.005). We can conclude that patients requiring transfer are typically older. Arthroplasty patients are more likely to require transfer than patients undergoing other orthopaedic procedures. Among the arthroplasty cohort transferred patients will typically have a higher BMI than average. Patients with ASA category II or III make up nearly three quarters of those patients transferred. The mean age of patients transferred is typically older by 9 years.

Neoadjuvant chemotherapy and primary-first approach for rectal cancer with synchronous liver metastases

AIM

Up to a quarter of patients with rectal cancer have synchronous liver metastases at the time of diagnosis. This is a predictor of poor outcome. There are no standardized guidelines for treatment. We reviewed the outcomes of our patients with synchronous rectal liver metastases treated with a curative intent by neoadjuvant chemotherapy with or without chemoradiotherapy followed by resection of the primary tumour and then liver metastases.

METHOD

Between 2004 and 2012, patients who presented with rectal cancer and synchronous liver metastasis were treated with curative intent with peri-operative systemic chemotherapy as the first line of treatment. Responders to chemotherapy underwent resection of the primary tumour with or without preoperative chemoradiotherapy followed by hepatic resection.

RESULTS

Fifty-three rectal cancer patients with 152 synchronous liver lesions were identified. After a median follow-up of 29.6 months, the median survival was 41.4 months. Overall survival was 59.0% at 3 years and 39.0% at 5 years.

CONCLUSION

Rectal resection before hepatic resection combined with neoadjuvant chemotherapy is associated with promising clinical outcome. It allows downstaging of liver lesions and removal of the primary tumour before the progression of further micrometastases. Furthermore, patients who do not respond to chemotherapy can be identified and may avoid major surgical intervention.

Is uterine serous carcinoma a part of hereditary breast cancer syndrome?

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Background: Whilst the association between breast cancer and uterine serous carcinoma (USC) is attributed to tamoxifen treatment, few studies have reported that this increased risk is independent of tamoxifen. Methods: To further investigate the relationship between breast cancer and USC, we retrospectively studied 216 patients from 5 hospital trusts in Birmingham, UK who were diagnosed with USC between 1993 and 2012. We collected personal history of cancer in these cases before or after USC diagnosis. In addition FIGO staging, clinical and survival data were collected from our local cancer registry and patients’ clinical records. Results: In this case series, 56 patients (25.9%) had personal history of at least one cancer before and 18 patients (8.3%) had history of at least one cancer after the diagnosis of USC. Within the group of patients with the history of cancer before the USC, 38 patients (68%, 17.5% of all cases) had personal history of breast cancer prior to the development of USC, higher than the UK expected age standardised relative incidence of breast cancer (350 in 100,000, CRUK 2006-2008). Although 27/38 cases (71%) had endocrine treatment for their primary breast cancer, 11/38 patients (29%) did not have any tamoxifen treatment due to hormone receptor negative breast cancer. Additionally the median age of breast cancer diagnosis for the hormone receptor negative group was significantly lower than those patients who had hormonal treatment for their breast cancer (56 vs. 64 years, p :0.036) compatible with the younger age at diagnosis expected of the familial (BRCA mutated) or triple negative breast cancer. Of 18 patients with a second cancer after diagnosis of USC, 6 patients (33%) were diagnosed with breast/ovarian cancer. This group also had no treatment with tamoxifen. Conclusions: Lack of exposure to tamoxifen and younger age at diagnosis in this subgroup suggest that other factors such as a common underlying genetic predisposition may be responsible for the development of both malignancies. We propose that at least a subgroup of USC may be a part of hereditary breast cancer syndrome. This may have implications in prevention (prophylactic hysterectomy) or trials of targeted treatments (PARP inhibitors) for a subgroup of USC patients.

Feasibility and acceptability of gentamicin in the Uniject prefilled injection system for community-based treatment of possible neonatal sepsis: the experience of female community health volunteers in Nepal

OBJECTIVE

Explore feasibility and acceptability of gentamicin in the Uniject prefilled injection system, in combination with oral cotrimoxazole-p and an appropriate newborn weighing scale, for treatment of possible neonatal sepsis when administered in the community by female community health volunteers.

STUDY DESIGN

In a community-based program in Nepal, 45 volunteers recorded 422 live births. Among these, 82 infants were identified as having possible severe bacterial infection. In all, 67 of these infants were treated with gentamicin in Uniject and 15 were referred to the health facility. Mixed methods were used to collect data about Uniject performance, acceptability and safety.

RESULT

Volunteers successfully treated 67 infants with gentamicin in Uniject. Gentamicin in Uniject performed well and was acceptable.

CONCLUSION

Gentamicin in Uniject, in combination with cotrimoxazole-p and an appropriate newborn weighing scale, is a feasible and acceptable option for treatment of possible neonatal sepsis in the community by female community health volunteers.

Multipotent human breast stem cell line MCF1OAT

Human breast epithelial MCF10AT cells injected with Matrigel into the subcutis of nude/beige mice form simple ducts which, with time, resemble human proliferative breast disease and sporadically progress to carcinoma. Basement membrane was visualized with a silver stain and myoepithelial cells detected by their reactivity with antibody against smooth muscle actin. The ducts formed in situ are bilayered, composed of both myoepithelial and luminal epithelial layers circumscribed by a distinct basement membrane. The human origins of both luminal and myoepithelial layers were confirmed with fluorescent in situ hybridization with a probe for human chromosome 9. Electron microscopic studies reveal actin bundles and the formation of hemidesmosomes bordering the basement membrane, consistent with myoepithelium, as well as the formation of desmosomes between luminal and myoepithelial cells.

Indigenous Health: ACTION on Prevention - 50th annual Australian Society for Medical Research National Scientific Conference

The 50th annual National Scientific Conference of the Australian Society for Medical Research was held in Cairns, Queensland, 13-16 November 2011. The theme, 'Indigenous Health: ACTION on Prevention' highlighted the direct action being undertaken by health and medical researchers, as well as allied health professionals, to improve long-term health outcomes for Indigenous Australians.

Exploration and innovation in addressing maternal, infant and neonatal mortality

The Government of Nepal has been remarkably progressive in introducing innovative community-based maternal newborn and child health interventions in an effort to address the major causes of maternal and child mortality in the country. This article describes the introduction of innovative interventions, including a review of the landmark research that precipitated the discussion and provided evidence of practical feasibility, the acceptance of the intervention concept and validity, the approval process and the introduction and results from the pilot interventions. These interventions, which include the use of misoprostol to prevent post partum haemorrhage during homebirths, Morang Innovative Neonatal Intervention, gentamicin in Uniject and for the management of neonatal sepsis and newborn vitamin A supplementation, are in various stages and demonstrate the responsiveness of the Government to new approaches that address the major causes of maternal and child mortality.

High sensitivity (1 ppm) hydrogen detection using an unconventional Pd/n-InP Schottky device

Hydrogen is detected using a Pd/n-InP Schottky diode in which the elongated, very thin Pd electrode is of greater resistance than the underlying semiconductor substrate. Four-probe measurements of the device resistance, as a function of hydrogen concentration, are made by contacting only the Pd electrode, with a sensitivity of 1 ppm being achieved. On hydrogen exposure the device resistance drops from an initial high value, characteristic of the Pd electrode alone, to a lower value due to a hydrogen-induced lowering of the Schottky barrier that opens up the InP substrate as a parallel current carrying channel.

Verbal autopsy to ascertain causes of neonatal deaths in a community setting: A study from Morang, Nepal

Introduction: Clinical registration of the cause of death is available for less than one-third of the global newborn deaths, but the need for good quality data on causes of death for public health planning has renewed the interest in the Verbal Autopsy (VA). We aimed to determine the cause of neonatal deaths by VA in Morang district of Nepal. Methods: Caretakers of the deceased were interviewed using a semi-structured VA questionnaire by female community health volunteers. The cause of death was assigned by two senior pediatricians independently and disagreements in ascertaining the proximate cause of death were resolved by consensus. Results: The proximate causes of deaths were infections (41 %), birth asphyxia (37.2 %), prematurity (11.5 %), and low birth weight related causes (6.9 %). There was no signifi cant statistical difference in deaths due to infection seen in non-institutional deliveries (43.5 %) than institutional deliveries (34.6 %). More than half of the deaths (58.5 %) occurred within the fi rst three days of life where the predominant cause of death was birth asphyxia (60.7 %). Conclusions: Analysis of verbal autopsies demonstrates that the major causes of death still are infections and birth asphyxia. The timing of deaths suggests that neonatal interventions should be aimed at the fi rst week of life. There is no comparative advantage between institutional deliveries at below district level institutions and non-institutional deliveries to prevent neonatal infection. Thus, further study on the quality of care at institutes below the district level should be conducted. Disparities still occur in deaths, with most deaths in Morang occurring in non-institutional deliveries and in disadvantaged groups. Keywords: neonatal deaths, Nepal, newborn, verbal autopsy.

Combined antenna and localized plasmon resonance in Raman scattering from random arrays of silver-coated, vertically aligned multiwalled carbon nanotubes

The electric field enhancement associated with detailed structure within novel optical antenna nanostructures is modeled using the surface integral equation technique in the context of surface-enhanced Raman scattering (SERS). The antennae comprise random arrays of vertically aligned, multiwalled carbon nanotubes dressed with highly granular Ag. Different types of "hot-spot" underpinning the SERS are identified, but contrasting characteristics are revealed. Those at the outer edges of the Ag grains are antenna driven with field enhancement amplified in antenna antinodes while intergrain hotspots are largely independent of antenna activity. Hot-spots between the tops of antennae leaning towards each other also appear to benefit from antenna amplification.

Verbal autopsy to ascertain causes of neonatal deaths in a community setting: a study from Morang, Nepal

INTRODUCTION

Clinical registration of the cause of death is available for less than one-third of the global newborn deaths, but the need for good quality data on causes of death for public health planning has renewed the interest in the Verbal Autopsy (VA). We aimed to determine the cause of neonatal deaths by VA in Morang district of Nepal.

METHODS

Caretakers of the deceased were interviewed using a semi-structured VA questionnaire by female community health volunteers. The cause of death was assigned by two senior pediatricians independently and disagreements in ascertaining the proximate cause of death were resolved by consensus.

RESULTS

The proximate causes of deaths were infections (41%), birth asphyxia (37.2%), prematurity (11.5%), and low birth weight related causes (6.9%). There was no significant statistical difference in deaths due to infection seen in non-institutional deliveries (43.5%) than institutional deliveries (34.6%). More than half of the deaths (58.5%) occurred within the first three days of life where the predominant cause of death was birth asphyxia (60.7%).

CONCLUSIONS

Analysis of verbal autopsies demonstrates that the major causes of death still are infections and birth asphyxia. The timing of deaths suggests that neonatal interventions should be aimed at the first week of life. There is no comparative advantage between institutional deliveries at below district level institutions and non-institutional deliveries to prevent neonatal infection. Thus, further study on the quality of care at institutes below the district level should be conducted. Disparities still occur in deaths, with most deaths in Morang occurring in non-institutional deliveries and in disadvantaged groups.

Impact of laparoscopic right hemicolectomy for colon cancer

INTRODUCTION

This study specifically examined right colonic cancer resection, a common operation for colorectal surgeons starting laparoscopic resection, to assess the impact of commencing laparoscopy.

PATIENTS AND METHODS

A total of 56 patients undergoing open (n = 34) and attempted laparoscopic (n = 22) elective right hemicolectomy for colorectal cancer between November 2003 and March 2007 were compared. Postoperative stay was the primary outcome. Secondary outcomes included analgesic requirements, bowel recovery, morbidity and mortality. Frequency of laparoscopic versus open surgery over time was also examined.

RESULTS

Resections attempted laparoscopically increased from 9.1% to 75% in the first and last quarters of the study period, respectively (P = 0.0002). Uptake of 'enhanced recovery' was mainly in the laparoscopic group. Conversion was required in two of 22 patients. Attempted laparoscopic cases had a shorter median postoperative stay (6 vs 10 days; P < 0.0001), duration of parenteral or epidural analgesia (48 vs 72 h; P < 0.0001) and time to first bowel action (3 vs 4 days; P = 0.001) compared with open cases. Demography, tumour characteristics, morbidity and mortality were comparable between groups. Multivariate analysis identified decreased age, attempted laparoscopic surgery, use of enhanced recovery and absence of complications as independently shortening postoperative stay.

CONCLUSIONS

Advantages of laparoscopic surgery and enhanced recovery, even early in a surgeon's experience, suggest this is the preferred mode for elective right colon cancer resection.

The biology and prognostic value of lymphatic vessel density (LD) and lymphatic invasion (LI) in regression in melanoma

9017

Background: Regression in melanoma is characterized by increased vascularity, lymphocytic infiltrate and fibroplasia in the papillary dermis, accompanied by the absence (complete regression, CoR) or presence (partial regression, PaR) of melanoma cells in the epidermis. The prognostic value of regression is controversial. We noticed that LD and LI were increased in the areas of regression (AR) or areas with brisk lymphocytic infiltration (AB). Our goal was to clarify the prognostic value of regression in melanoma. Methods: Dual immunohistochemical staining was done using antibodies to podoplanin (lymphatic vessels) and S100 (melanoma cells) on paraffin tissues from 321 patients with vertical growth phase (VGP) primary melanomas who had 10 years or more of follow-up. LD in AR (both CoR and PaR) was compared with that of normal dermis adjacent and distant, as well as LD in the AB. LI in these areas was also scored. Unadjusted and adjusted hazard rates were obtained from univariate and multivariate Cox models for time to melanoma-specific death using established melanoma prognostic factors. Results: 116 patients (36%) had regression: 75 CoR (23%) and 41 PaR (13%). LD significantly decreased stepwise from CoR (mean ± se, 23.7 ± 2.7) to PaR (15.5 ± 1.1), adjacent normal dermis (7.3 ± 0.28) and distant normal dermis (5.4±0.31) and it was significantly elevated in the AB (18.5±0.78). Melanomas with CoR had the highest percentage of LI in both AR and AB. In addition, the percentage of LI in AB was highest for men and for those with VGP tumor infiltrating lymphocytes (TILs). Both high LD in AR and more LI in AB were associated with poor prognosis (p=0.004 and p=0.002, respectively). Six factors were significant in the final multivariate model: LI in AB (HR=2.3), LD in AR (HR=1.04), thickness (HR=1.44), axial (HR=7.7), ulceration (HR=2.5) and no VGP TILs (HR=2.8). Conclusions: AR and AB were associated with increased LD and higher incidence of LI in primary melanomas. LD and LI in AR or AB are independent prognostic factors. Our data suggest that the effects of regression on prognosis are mediated at least in part through lymphangiogenesis and LI.

No significant financial relationships to disclose.

The prognostic significance of lymphatic invasion in primary melanoma

9050

Background: Lymphatic invasion (LI) is an under-observed phenomenon in primary malignancies that can be better detected by immunostaining and that may associate with prognosis. In this study we sought to test the hypothesis that LI was associated with melanoma-specific survival (MSS) and was an independent prognostic factor. Methods: This study included 277 patients with stage I/II melanomas in vertical growth phase (VGP) who had at least 10 years of follow up. The log-rank test was used to test the study hypothesis - 72 melanoma-specific deaths were needed for 80% power to detect an odds ratio of 2.1. Paraffin sections were stained with antibodies to podoplanin (lymphatic vessels) and S-100 (melanoma cells) to identify LI. Univariate and multivariate Cox models were used to evaluate the prognostic significance of LI. An independent cohort of 106 similar patients was used for validation of the 10-year MSS rates. Results: LI was observed in 44.5% (95% CI: 38.6% - 50.4%) of the melanomas and its presence was significantly associated with thickness, mitotic rate, gender, age, and ulceration (U). The Kaplan-Meier survival curves for those with and without LI were significantly different (log-rank test p=0.022). The final multivariate model for time to MSD identified 4 independent prognostic factors: thickness (HR=1.5, p<0.001), U (HR=2.2 p=0.013), site (HR=3.9, p<0.001) and LI (HR=1.9, p=0.015). These factors were used to define a prognostic tree with 5 risk groups defined by melanomas that were thin (≤1.0mm) with no LI or U; thin with LI but no U; 1–3mm with no U; 1–3mm with U; and >3mm. Respectively, MSS rates were 100%, 88.6%, 77%, 48% and 42%. In the validation set, observed 10-year MSS rates in each risk group were not significantly different from those predicted from the survival curves for the tree-based risk groups. Conclusions: LI is an independent prognostic factor for MSS. Among patients with thin melanomas without U the 10-year MSS was lower for those patients with LI (89%, 95% CI=78% - 99%; n=41) compared to those without (100%, n=78). LI is an important prognostic factor that needs further validation in a population of patients from the sentinel node biopsy era.

No significant financial relationships to disclose.

A randomised study comparing the effects of anastrozole (A), letrozole (L), exemestane (E) and tamoxifen (T) on coagulation

Abstract #1132

Background:&#x2028; Aromatase inhibitors (AIs) reduce circulating oestrogens and so should have either no or a positive effect on coagulation . This study compares the effects of the non-steroidal aromatase inhibitors, A and L and the steroidal inactivator, E on coagulation.&#x2028; Patients and Methods:&#x2028; This was an open, randomized pharmacodynamic study. Plasma coagulation factors were measured in 120 postmenopausal women with invasive ER +ve breast cancer. As part of their adjuvant hormone therapy, patients were randomized to receive upfront therapy with either:&#x2028; 16 weeks of A, 16 weeks of L or 16 weeks of E.&#x2028; Fasting blood samples were collected at entry and after 12 and 16 weeks of each drug. AI patients were then switched to T and further samples measured after 8 months on T.&#x2028; Plasminogen activator inhibitor (PAI) antigen, von Willebrand's Factor (vWF) antigen, antithrombin III (AT111), protein C, protein S total, protein S free, activated protein C, resistance (APCR), factor VIII and fibrinogen were measured.&#x2028; Results:&#x2028; Results expressed as % change from baseline.&#x2028; E vs A vs L&#x2028; Protein C. E caused a significant fall compared to A and L (-15.75 (-21.48, -10.02) vs -3.80 (-10.77, 3.16) vs -3.63 (-10.50, 3.25)) respectively. p = 0.008.&#x2028; ATIII. E caused a significant fall from baseline (-8.55 (-13.33, -3.79))&#x2028; Protein S Free. E + A caused a significant increase from baseline (E 6.90 (1.98, 11.82), A 7.36 (1.37, 13.34).&#x2028; Steroidal vs non-steroidal:&#x2028; Protein C. A significantly greater fall was seen with E than A+L (-15.75 (-21.45, -10.05) vs -3.71 (-8.58, 1.15)) p = 0.002.&#x2028; vWF A+L caused a significant increase from baseline (6.52 (0.66, 12.38) but this was not statistically different to E 5.02 (-1.88, 11.91)).&#x2028; ATIII A significant decrease from baseline was seen with A + L, -4.54 (-8.64, -0.43) but no difference from E 8.55 (13.31, -3.70) p=0.21.&#x2028; Protein S Free There was a significant increase from baseline in both groups (A+L: 5.70 (1.47, 9.92), E: 6.90 (1.98, 11.81), but no difference between the groups p=0.72.&#x2028; T effect:&#x2028; AT111 and protein C levels fell significantly on T whereas protein S free increased on T. Prior A, E or L had no significant impact on post-tamoxifen results.&#x2028; Conclusions:&#x2028; No significant differences in any coagulation factors were seen between A and L&#x2028; E caused a significant fall in protein C and ATIII.&#x2028; The non-steroidal AIs caused a significant increase in vWF.&#x2028; T caused a significant fall in protein C and ATIII and a significant increase in protein S free.&#x2028; No AI significantly influenced post-tamoxifen results.&#x2028; These drugs have significant effects on coagulation which helps to explain their clinical effects on thrombotic and thromboembolic disease.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1132.

From research to national expansion: 20 years' experience of community-based management of childhood pneumonia in Nepal

PROBLEM

Pneumonia is a leading cause of mortality of children aged under five in Nepal. Research conducted by John Snow Inc. in the 1980s determined that pneumonia case management by community-based workers decreased under-five mortality by 28%.

APPROACH

Female community health volunteers were selected as the national cadre to manage childhood pneumonia at community level using oral antibiotics. A technical working group composed of government officials, local experts and donor partners embarked on a process to develop a strategy to pilot the approach and expand it nationally.

LOCAL SETTING

High under-five mortality rates, low access to peripheral health facilities and severe constraints in human resources led Nepal's Ministry of Health to test this innovative approach.

RELEVANT CHANGES

Community-based management of pneumonia doubled the total number of cases treated compared with districts with facility-based treatment only. Over half of the cases were treated by the female community health volunteers. The programme was phased in over 14 years and now 69% of Nepal's under-five population has access to pneumonia treatment.

LESSONS LEARNED

Community-based management of pneumonia provides a medium-term solution to address a leading cause of child mortality while the efforts continue to strengthen and extend the reach of facility-based care. Trained community health workers can significantly increase the number of pneumonia cases receiving correct case management in resource-constrained settings, with appropriate health systems' support for logistics, supervision and monitoring. Community-based management of pneumonia can be scaled up and provides an effective approach to reducing child deaths in countries faced with insufficient human resources for health.

Orthogonal ligation: a three piece assembly of a PNA-peptide-PNA conjugate

A PNA-peptide-PNA conjugate was assembled from three fragments using a combination of native chemical ligation and an orthogonal, auxiliary-mediated ligation.

Optical transmission through single subwavelength apertures using prism coupled input of laser light of annular intensity profile

Light transmission through a single subwavelength aperture in a silver film is examined with a novel input configuration comprising an annular laser beam of variable diameter that is prism-coupled to the back face of the silver. Transmission peaks driven by excitation of the back-face surface plasmon mode or by the aperture resonance itself are separately observed. For both cases, comparison of films with and without a front-face, circular, grating implies significantly more efficient coupling from the aperture fields to the front-face surface plasmon than directly to free radiation.