A realist approach to understanding alliancing within Local Government public health and social care service provision

BACKGROUND

Within the current context of continued austerity and post-pandemic recovery, it remains important that Local Government services address the increasing needs of residents as cost-effectively as possible. Alliancing, whereby services work collaboratively focusing on the 'whole-system', has gained popularity as a tool with the potential to support collaborative whole systems approaches. This synthesis aims to identify how alliancing can be successfully operationalised in the commissioning of public health, wider National Health Service (NHS) and social care-related services.

METHODS

A realist literature synthesis was undertaken in order to identify underlying generative mechanisms associated with alliancing, the contextual conditions surrounding the implementation and operationalisation of the alliancing approach mechanisms, and the outcomes produced as a result. An iterative approach was taken, using a recent systematic review of the effectiveness of Alliancing, online database searches, and grey literature searches.

RESULTS

Three mechanistic components were identified within the data as being core to the successful implementation of alliances in public health and social care-related services within Local Government: (i) Achieving a system-level approach; (ii) placing local populations at the heart of the system; and (iii) creating a cultural shift. Programme theories were postulated within these components.

CONCLUSIONS

The alliancing approach offers an opportunity to achieve system-level change with the potential to benefit local populations. The realist synthesis approach taken within this study has provided insights into the necessary contextual and mechanistic factors of the Alliancing approach, above and beyond effectiveness outcomes typically collected through more conventional evaluation methodologies.

An assessment of introducers used for airway management

Different introducers are available to assist with tracheal intubation. Subtle differences in the design of introducers can have a marked effect on safety and performance. The Difficult Airway Society's Airway Device Evaluation Project Team proposal states that devices should only be purchased for which there is at least a case-control study on patients assessing airway devices. However, resources are not currently available to carry out a case-control study on all introducers available on the market. This study comprised a laboratory and manikin-based investigation to identify introducers that could be suitable for clinical investigation. We included six different introducers in laboratory-based assessments (design characteristics) and manikin-based assessments involving the participation of 30 anaesthetists. Each anaesthetist attempted placement in the manikin's trachea with each of the six introducers in a random order. Outcomes included first-time insertion success rate; insertion success rate; number of attempts; time to placement; and distance placed. Each anaesthetist also completed a questionnaire. First-time insertion success rate depended significantly on the introducer used (p = 0.0016) and varied from 47% (Armstrong and P3) to 77% (Intersurgical and Frova). Median time to placement (including oesophageal placement) varied from 10 s (Eschmann and Frova) to 20 s (P3) (p = 0.0025). Median time to successful placement in the trachea varied from 9 s (Frova) to 22 s (Armstrong) (p = 0.037). We found that the Armstrong and P3 devices were not as acceptable as other introducers and, without significant improvements to their design and characteristics, the use of these devices in studies on patients is questionable. The study protocol is suitable for differentiating between different introducers and could be used as a basis for assessing other types of devices.

Electronic personal assessment questionnaire for vascular conditions (ePAQ-VAS): development and validity

Background

This paper describes the development and validation of an electronic personal assessment questionnaire for vascular conditions (ePAQ-VAS) that captures the symptomatology, quality of life and clinically relevant data of patients presenting to vascular services.

Methods

A two-stage survey was conducted in patients attending a tertiary vascular department. Patients completed the ePAQ-VAS remotely online, or on site using an electronic tablet. In the first stage of the survey, the responses were used to perform confirmatory factor analysis to assess the construct validity and remove redundant items. The internal reliability of disease-specific scales was investigated. In the second stage of the survey, the acceptability, known-group validity, test–retest reliability, and responsiveness of ePAQ-VAS was assessed.

Results

In total, 721 patients completed ePAQ-VAS. Their mean(s.d.) age was 63·5(15·7) years and 468 (64·9 per cent) were men. Some 553 patients (76·7 per cent) completed the questionnaire in clinic and the remainder completed the questionnaire online. The results of the confirmatory factor analysis confirmed the conceptual model for ePAQ-VAS structure and eliminated six items. Internal reliability was acceptable for all the scales (Cronbach's α greater than 0·7). The test–retest reliability measured by the intraclass correlation coefficient ranged from 0·65 to 0·99. The results showed that the instrument was responsive over time with the standardized response mean ranging from 0·69 to 1·60.

Conclusion

ePAQ-VAS is a holistic data-collection process that is relevant to vascular service users and has potential to contribute to patient-focused care and the collection of aggregate data for service evaluation. A demonstration version of the final version of ePAQ can be viewed at http://demo-questionnaire.epaq.co.uk/home/project?id=VASC_1.7&page=1.

P2866Automated ultrasound ablation parameters predict lesion depth in a perfused thigh model

Background

The accuracy and safety of lesions created during catheter ablation of cardiac tissue rely on the user's ability to predict the size of lesions that form under variable conditions during treatment. A user-directed robotic system was developed that uses Low-Intensity Collimated Ultrasound (LICU) for cardiac imaging and to produce linear lesions without tissue contact. Molecular absorption of mechanical energy induced in the tissue by LICU causes a temperature rise resulting in thermal tissue necrosis.

Purpose

By varying the speed of the LICU beam as it traces the desired lesion path, while considering the beam intensity, distance from catheter tip to tissue, and relative motion of the target tissue, we demonstrate the capability to deposit lesions of known depth according to a predictive model.

Methods

The LICU catheter was mounted in a servo-controlled, 3 axis stage suspended above a perfused porcine thigh that simulates the thermodynamic properties of the myocardium such as acoustic attenuation, thermal conduction, and specific heat capacity. Therapy was delivered along a linear path while varying the distance to tissue, speed of the beam, and motion of the catheter relative to the tissue in 3 dimensions. Programmed relative motion was representative of typical and extreme motion in humans. Pathological analysis after necropsy was used to quantify lesion depth which was then compared to lesion depth as predicted by a mathematical model from approx. 4–12 mm.

Results

Data from 66 samples were categorized according to typical and extreme motion at 4 different distances (3, 8, 9 and 13 mm). Measured vs predicted lesion depth was well correlated (R = 0.898) with 98.5% of the samples within ±2 mm.

Assessment of LICU lesion depth

Conclusion

Lesion depth using LICU is well controlled in an animal model for the range of distances and relative motion typically encountered in a human subject. The range of acoustic beam speeds and acoustic power density with LICU predictably produces lesions up to 12 mm deep. The LICU thermal model may be useful to create lesions of known depth thus ensuring transmurality of lesions while potentially avoiding unintended extra-cardiac injury.

ROBO2 is a stroma suppressor gene in the pancreas and acts via TGF-β signalling

Whereas genomic aberrations in the SLIT-ROBO pathway are frequent in pancreatic ductal adenocarcinoma (PDAC), their function in the pancreas is unclear. Here we report that in pancreatitis and PDAC mouse models, epithelial Robo2 expression is lost while Robo1 expression becomes most prominent in the stroma. Cell cultures of mice with loss of epithelial Robo2 (Pdx1Cre;Robo2F/F) show increased activation of Robo1+ myofibroblasts and induction of TGF-β and Wnt pathways. During pancreatitis, Pdx1Cre;Robo2F/F mice present enhanced myofibroblast activation, collagen crosslinking, T-cell infiltration and tumorigenic immune markers. The TGF-β inhibitor galunisertib suppresses these effects. In PDAC patients, ROBO2 expression is overall low while ROBO1 is variably expressed in epithelium and high in stroma. ROBO2low;ROBO1high patients present the poorest survival. In conclusion, Robo2 acts non-autonomously as a stroma suppressor gene by restraining myofibroblast activation and T-cell infiltration. ROBO1/2 expression in PDAC patients may guide therapy with TGF-β inhibitors or other stroma /immune modulating agents.

Systematic review assessing the measurement properties of patient-reported outcomes for venous leg ulcers

Background

A variety of instruments have been used to assess outcomes for patients with venous leg ulcers. This study sought to identify, evaluate and recommend the most appropriate patient‐reported outcome measures (PROMs) for English‐speaking patients with venous leg ulcers.

Methods

This systematic review used a two‐stage search approach. Electronic searches of major databases including MEDLINE were completed in October 2015, and then updated in July 2016. Additional studies were identified from citation checking. Study selection, data extraction and quality assessment were undertaken independently by at least two reviewers. Evaluation and summary of measurement properties of identified PROMs were done using standard and adapted study‐relevant criteria.

Results

Ten studies with data for four generic PROMS and six condition‐specific measures were identified. No generic PROM showed adequate content and criterion validity; however, the EuroQoL Five Dimensions (EQ‐5D™), Nottingham Health Profile (NHP) and 12‐item Short‐Form Health Survey (SF‐12®) had good acceptability. In general, the EQ‐5D™ showed poor responsiveness in patients with venous leg ulcers. Most condition‐specific PROMs demonstrated poor criterion and construct validity. Overall, there was some evidence of internal consistency for the Venous Leg Ulcer Quality of Life (VLU‐QoL) and the Sheffield Preference‐based Venous Ulcer questionnaire (SPVU‐5D). Test–retest reliability was satisfactory for the Venous Leg Ulcer Self‐Efficacy Tool (VeLUSET).

Conclusion

The NHP and VLU‐QoL questionnaire seemed the most suitable PROMs for use by clinicians. However, a valid condition‐specific PROM is still required.

Systematic review of patient-reported outcome measures in patients with varicose veins

Background

Varicose veins can affect quality of life. Patient-reported outcome measures (PROMs) provide a direct report from the patient about the impact of the disease without interpretation from clinicians or anyone else. The aim of this study was to examine the quality of the psychometric evidence for PROMs used in patients with varicose veins.

Methods

A systematic review was undertaken to identify studies that reported the psychometric properties of generic and disease-specific PROMs in patients with varicose veins. Literature searches were conducted in databases including MEDLINE, up to July 2016. The psychometric criteria used to assess these studies were adapted from published recommendations in accordance with US Food and Drug Administration guidance.

Results

Nine studies were included which reported on aspects of the development and/or validation of one generic (36-Item Short Form Health Survey, SF-36®) and three disease-specific (Aberdeen Varicose Vein Questionnaire, AVVQ; Varicose Veins Symptoms Questionnaire, VVSymQ®; Specific Quality-of-life and Outcome Response – Venous, SQOR-V) PROMs. The evidence from included studies provided data to support the construct validity, test–retest reliability and responsiveness of the AVVQ. However, its content validity, including weighting of the AVVQ questions, was biased and based on the opinion of clinicians, and the instrument had poor acceptability. VVSymQ® displayed good responsiveness and acceptability rates. SF-36® was considered to have satisfactory responsiveness and internal consistency.

Conclusion

There is a scarcity of psychometric evidence for PROMs used in patients with varicose veins. These data suggest that AVVQ and SF-36® are the most rigorously evaluated PROMs in patients with varicose veins.

Systematic review of carotid artery procedures and the volume-outcome relationship in Europe

BACKGROUND

Hospitals that conduct more procedures on the carotid arteries may achieve better outcomes. In the context of ongoing reconfiguration of UK vascular services, this systematic review was conducted to evaluate the relationship between the volume of carotid procedures and outcomes, including mortality and stroke.

METHODS

Searches of electronic databases identified studies that reported the effect of hospital or clinician volume on outcomes. Reference and citation searches were also performed. Inclusion was restricted to European populations on the basis that the model of healthcare delivery is similar across Europe, but differs from that in the USA and elsewhere. Analyses of hospital and clinician volume, and carotid endarterectomy (CEA) and carotid artery stenting (CAS) were conducted separately.

RESULTS

Eleven eligible studies were identified (233 411 participants), five from the UK, two from Sweden, one each from Germany, Finland and Italy, and a combined German, Austrian and Swiss population. All studies were observational. Two large studies (179 736 patients) suggested an inverse relationship between hospital volume and mortality (number needed to treat (NNT) as low as 165), and combined mortality and stroke (NNT as low as 93), following CEA. The evidence was less clear for CAS; multiple analyses in three studies did not identify convincing evidence of an association. Limited data are available on the relationship between clinician volume and outcome in CAS; in CEA, an inverse relationship was identified by two of three small studies.

CONCLUSION

The evidence from the largest and highest-quality studies included in this review support the centralization of CEA.

Inhibition of group 1 p21-activated kinases suppresses pancreatic stellate cell activation and increases survival of mice with pancreatic cancer

Pancreatic cancer remains one of the most lethal of all solid tumors. Pancreatic stellate cells (PSCs) are primarily responsible for the fibrosis that constitutes the stroma and p21-activated kinase 1 (PAK1) may have a role in signalling pathways involving PSCs. This study aimed to examine the role of PAK1 in PSCs and in the interaction of PSCs with pancreatic cancer cells. Human PSCs were isolated using the modified outgrowth method. The effect of inhibiting PAK1 with group 1 PAK inhibitor, FRAX597, on cell proliferation and apoptosis in vitro was measured by thymidine incorporation and annexin V assays, respectively. The effect of depleting host PAK1 on the survival of mice with pancreatic Pan02 cell tumors was evaluated using PAK1 knockout (KO) mice. PAK1 was expressed in isolated PSCs. FRAX597 reduced the activation of PSCs, inhibited PSC proliferation, and increased PSC apoptosis at least in partial by inhibiting PAK1 activity. The decreased expression and activity of PAK1 in PAK1 KO mice tumors was associated with an increased mouse survival. These results implicate PAK1 as a regulator of PSC activation, proliferation and apoptosis. Targeting stromal PAK1 could increase therapeutic response and survival of patients with pancreatic cancer.

MutY-Homolog (MYH) inhibition reduces pancreatic cancer cell growth and increases chemosensitivity

Patients with pancreatic ductal adenocarcinoma (PC) have a poor prognosis due to metastases and chemoresistance. PC is characterized by extensive fibrosis, which creates a hypoxic microenvironment, and leads to increased chemoresistance and intracellular oxidative stress. Thus, proteins that protect against oxidative stress are potential therapeutic targets for PC. A key protein that maintains genomic integrity against oxidative damage is MutY-Homolog (MYH). No prior studies have investigated the function of MYH in PC cells. Using siRNA, we showed that knockdown of MYH in PC cells 1) reduced PC cell proliferation and increased apoptosis; 2) further decreased PC cell growth in the presence of oxidative stress and chemotherapy agents (gemcitabine, paclitaxel and vincristine); 3) reduced PC cell metastatic potential; and 4) decreased PC tumor growth in a subcutaneous mouse model in vivo. The results from this study suggest MYH may be a novel therapeutic target for PC that could potentially improve patient outcome by reducing PC cell survival, increasing the efficacy of existing drugs and reducing metastatic spread.

Drug-resistant tuberculosis clinical trials: proposed core research definitions in adults

Drug-resistant tuberculosis (DR-TB) is a growing public health problem, and for the first time in decades, new drugs for the treatment of this disease have been developed. These new drugs have prompted strengthened efforts in DR-TB clinical trials research, and there are now multiple ongoing and planned DR-TB clinical trials. To facilitate comparability and maximise policy impact, a common set of core research definitions is needed, and this paper presents a core set of efficacy and safety definitions as well as other important considerations in DR-TB clinical trials work. To elaborate these definitions, a search of clinical trials registries, published manuscripts and conference proceedings was undertaken to identify groups conducting trials of new regimens for the treatment of DR-TB. Individuals from these groups developed the core set of definitions presented here. Further work is needed to validate and assess the utility of these definitions but they represent an important first step to ensure there is comparability in clinical trials on multidrug-resistant TB.

Control of IBMIR in neonatal porcine islet xenotransplantation in baboons

The instant blood-mediated inflammatory reaction (IBMIR) is a major obstacle to the engraftment of intraportal pig islet xenografts in primates. Higher expression of the galactose-α1,3-galactose (αGal) xenoantigen on neonatal islet cell clusters (NICC) than on adult pig islets may provoke a stronger reaction, but this has not been tested in the baboon model. Here, we report that WT pig NICC xenografts triggered profound IBMIR in baboons, with intravascular clotting and graft destruction occurring within hours, which was not prevented by anti-thrombin treatment. In contrast, IBMIR was minimal when recipients were immunosuppressed with a clinically relevant protocol and transplanted with NICC from αGal-deficient pigs transgenic for the human complement regulators CD55 and CD59. These genetically modified (GM) NICC were less susceptible to humoral injury in vitro than WT NICC, inducing significantly less complement activation and thrombin generation when incubated with baboon platelet-poor plasma. Recipients of GM NICC developed a variable anti-pig antibody response, and examination of the grafts 1 month after transplant revealed significant cell-mediated rejection, although scattered insulin-positive cells were still present. Our results indicate that IBMIR can be attenuated in this model, but long-term graft survival may require more effective immunosuppression or further donor genetic modification.

Towards a framework for analysis of eye-tracking studies in the three dimensional environment: a study of visual search by experienced readers of endoluminal CT colonography

OBJECTIVE

Eye tracking in three dimensions is novel, but established descriptors derived from two-dimensional (2D) studies are not transferable. We aimed to develop metrics suitable for statistical comparison of eye-tracking data obtained from readers of three-dimensional (3D) "virtual" medical imaging, using CT colonography (CTC) as a typical example.

METHODS

Ten experienced radiologists were eye tracked while observing eight 3D endoluminal CTC videos. Subsequently, we developed metrics that described their visual search patterns based on concepts derived from 2D gaze studies. Statistical methods were developed to allow analysis of the metrics.

RESULTS

Eye tracking was possible for all readers. Visual dwell on the moving region of interest (ROI) was defined as pursuit of the moving object across multiple frames. Using this concept of pursuit, five categories of metrics were defined that allowed characterization of reader gaze behaviour. These were time to first pursuit, identification and assessment time, pursuit duration, ROI size and pursuit frequency. Additional subcategories allowed us to further characterize visual search between readers in the test population.

CONCLUSION

We propose metrics for the characterization of visual search of 3D moving medical images. These metrics can be used to compare readers' visual search patterns and provide a reproducible framework for the analysis of gaze tracking in the 3D environment.

ADVANCES IN KNOWLEDGE

This article describes a novel set of metrics that can be used to describe gaze behaviour when eye tracking readers during interpretation of 3D medical images. These metrics build on those established for 2D eye tracking and are applicable to increasingly common 3D medical image displays.

Effective delivery of siRNA into cancer cells and tumors using well-defined biodegradable cationic star polymers

Cancer is one of the most common causes of death worldwide. Two types of cancer that have high mortality rates are pancreatic and lung cancer. Despite improvements in treatment strategies, resistance to chemotherapy and the presence of metastases are common. Therefore, novel therapies which target and silence genes involved in regulating these processes are required. Short-interfering RNA (siRNA) holds great promise as a therapeutic to silence disease-causing genes. However, siRNA requires a delivery vehicle to enter the cell to allow it to silence its target gene. Herein, we report on the design and synthesis of cationic star polymers as novel delivery vehicles for siRNA to silence genes in pancreatic and lung cancer cells. Dimethylaminoethyl methacrylate (DMAEMA) was polymerized via reversible addition-fragmentation transfer polymerization (RAFT) and then chain extended in the presence of both cross-linkers N,N-bis(acryloyl)cistamine and DMAEMA, yielding biodegradable well-defined star polymers. The star polymers were characterized by transmission electron microscopy, dynamic light scattering, ζ potential, and gel permeation chromatography. Importantly, the star polymers were able to self-assemble with siRNA and form small uniform nanoparticle complexes. Moreover, the ratios of star polymer required to complex siRNA were nontoxic in both pancreatic and lung cancer cells. Treatment with star polymer-siRNA complexes resulted in uptake of siRNA into both cell lines and a significant decrease in target gene mRNA and protein levels. In addition, delivery of clinically relevant amounts of siRNA complexed to the star polymer were able to silence target gene expression by 50% in an in vivo tumor setting. Collectively, these results provide the first evidence of well-defined small cationic star polymers to deliver active siRNA to both pancreatic and lung cancer cells and may be a valuable tool to inhibit key genes involved in promoting chemotherapy drug resistance and metastases.

Healthy Eating, Aerobic and Resistance Training in Youth (HEARTY): study rationale, design and methods

PURPOSE

The objective of the Healthy Eating Aerobic and Resistance Training in Youth (HEARTY) trial (ClinicalTrials.Gov # NCT00195858) was to examine the effects of resistance training, with and without aerobic training, on percent body fat in sedentary, post-pubertal overweight or obese adolescents aged 14-18 years. This paper describes the HEARTY study rationale, design and methods.

METHODS

After a 4-week supervised low-intensity exercise run-in period, 304 overweight or obese adolescents with a body mass index≥85th percentile for age and sex were randomized to 4 groups for 22 weeks (5 months): diet+aerobic exercise, diet+resistance exercise, diet+combined aerobic and resistance exercise, or a diet only waiting-list control. All participants received dietary counseling designed to promote healthy eating with a maximum daily energy deficit of -250 kcal.

OUTCOMES

The primary outcome is percent body fat measured by Magnetic Resonance Imaging. Secondary outcomes include changes in anthropometry, regional body composition, resting energy expenditure, cardiorespiratory fitness, musculoskeletal fitness, cardiometabolic risk markers, and psychological health.

SUMMARY

To our knowledge, HEARTY is the largest clinical trial examining effects of aerobic training, resistance training, and combined aerobic and resistance training on changes in adiposity and cardiometabolic risk markers in overweight and obese adolescents. The findings will have important clinical implications regarding the role that resistance training should play in the management of adolescent obesity and its co-morbidities.

Abstract LB-395: Hepatocyte growth factor: a potential therapeutic target in pancreatic cancer

Pancreatic stellate cells (PSCs, which produce the desmoplastic reaction of pancreatic cancer) interact with pancreatic cancer (PC) cells to potentiate PC progression. A candidate factor that may mediate this interaction is the hepatocyte growth factor (HGF). High serum HGF levels in PC patients correlate with poor outcome. However, there is limited knowledge about the role of HGF in PC. Aims: To i) determine whether human PSCs and PC cell lines express HGF; and

ii) assess the effects of HGF inhibition on PC progression in an orthotopic mouse model.

Methods:

i) HGF expression in PSCs and PC cells assessed by RT-PCR, immunoblotting/immunocytochemistry.

ii) Orthotopic model: AsPC-1 (a human PC cell line) ± human PSCs implanted into the pancreas mice. One week later, mice divided into groups (n=8 mice/group) and treated with: HGF antibody AMG102 [(Amgen Inc.), 300 or 600μg IP biweekly] or isotype IgG (600 μg IP biweekly). Seven weeks later, tumour size and metastasis assessed.

Results:

i) PSCs express HGF at both mRNA and protein levels. In contrast, PC cells (MiaPaCa2, Panc-1, AsPC-1) express negligible HGF mRNA.

ii) Orthotopic model: a) IgG treated AsPC-1+PSC mice showed larger tumours than mice injected with AsPC-1 alone (Table); b) 300 and 600μg AMG102 inhibited tumour growth in AsPC-1+PSC mice compared to the IgG treated group. However, AMG102 did not reduce tumour size in mice injected with AsPC-1 alone (Table). c) 600μg AMG102 inhibited metastasis (liver, diaphragm, mediastinum) in AsPC-1+PSC mice (p<0.05) compared to IgG treated mice.

Conclusions: We have shown for the first time that i)human PSCs synthesise HGF; ii)HGF inhibition reduces tumour growth and metastasis of tumours representative of human PC i.e., exhibiting both tumour elements and a stromal reaction, but not in the clinically non-representative cancers formed by PC cells alone.

Implication: Targeting the stromal reaction with relevant specific inhibitors may represent a novel therapeutic approach in PC.

An engineered solution to the maladministration of spinal injections

BACKGROUND

An overview is provided of the progress made in a Department of Health (DH) initiative to implement an engineered solution to the maladministration of spinal injections. In an effort to eliminate the possibility of misconnection errors at the spinal route, the DH is investigating the potential for dedicated spinal equipment that will be incompatible with standard Luer syringes, needles and associated devices.

METHOD

Background information on the problem of misconnection errors is provided and a systematic approach to their eradication is detailed. Research to date has entailed extensive bench-testing of prototype non-Luer connectors, a prospective hazard analysis of spinal procedures in haematology and anaesthesia and usability evaluation of prototype non-Luer devices in simulated environments.

RESULTS

The prospective hazard analysis identified two potential risks which will need to be managed as part of a successful implementation programme.

CONCLUSION

Usability testing of two prototype connection systems concluded that one design was inadequate, as the non-Luer element was provided as a separable adapter. The second connection system was modified following the first round of testing, and achieved improved satisfaction ratings from clinicians in round two. This system was selected to proceed to a pre-implementation evaluation and the research team are currently evaluating its acceptability in clinical use.

FC21-07 - Trends in health-related quality of life and health service use associated with comorbid diabetes and major depression in South Australia, 1998–2008

Purpose

To investigate trends in health-related quality of life and health service use associated with diabetes and/or major depression in South Australia from 1998 to 2008.

Methods

Data analyzed were from 9,059 persons aged ≥15 years who participated in representative surveys of the South Australian population in 1998, 2004 and 2008. Major depression was determined using the mood module of the Primary Care Evaluation of Mental Disorders (PRIME-MD). Diagnosed diabetes and health service use was determined by self-report. Health-related quality of life was assessed using the 36-item Short-Form Health Survey (SF-36) and the 15-item Assessment of Quality of Life (AQoL) instruments. Weighted age-standardized and multiple-adjusted means of dependent measures were computed.

Results

The prevalence of diabetes only, major depression only, and comorbid diabetes and major depression increased by 74%, 36% and 53% from 1998 to 2008. Mean health-related quality of life scores were 9% to 41% lower (worse), and health service use was 49% higher for persons with comorbid diabetes and major depression than for those with diabetes only (all P-values < 0.05), consistently over the 10-year period.

Conclusions

If past trends continue, our results suggest that the population health and economic burden of comorbid diabetes and major depression will grow similarly over the next decade or so. These trends have important implications for making health policy and resource allocation decisions.

Calving patterns in seasonal dairy herds

Two field studies examined the calving patterns of cows in seasonal dairy herds in the Waikato (Field Study 1) and South Taranaki regions (Field Study 2). The first study examined patterns for cows commencing their second or subsequent lactation in herds which had used an inseminating service during the previous season. The second study included first lactation heifers only in 15 herds where animals had been naturally mated, and in 15 herds in which they had been synchronised and then artificially inseminated at the synchronised oestrus. The parameters describing calving patterns were based on the date for each herd's planned start of calving (PSC), which was 282 days from the date on which breeding commenced in the preceding season. The average interval from PSC to mean calving date for the 35 herds in Field Study 1 was 22 days, with individual herds ranging from 15 to 30 days. In herds with heifers which had been naturally mated (Field Study 2), it was 17.6 days compared to 11.0 days for previously synchronised animals. Calculating the intervals from PSC to median calving date and separately for the last two quartiles more effectively described a herd's calving pattern. The duration for the last quartile of the calving pattern was influenced by the extent and timing of induced calving. In Field Study 1, 88.6% of the 35 herd owners induced premature parturition in at least one cow. In these herds, 11.3% of cows were treated and calved prematurely. Only 61.7% of heifers which had previously been naturally mated calved by 3 weeks after PSC. Their calving dates were not evenly distributed over this 3-week period, with 9.8% in the first week and 25.6% in the third week. The calving pattern for heifers which had been previously synchronised showed several distinct peaks. Calvings to the synchronised mating were completed 15 days after PSC, by which time 64.7% of animals had calved. By 3 weeks after PSC, 72.9% of these heifers had calved. The results showed that there was considerable variation in calving patterns in seasonal dairy herds. This variation would have been due to differences in conception pattern, and the way induced calving had been applied. The calving pattern in heifers which had been naturally mated was less concentrated than had been expected. Synchronisation can significantly concentrate the calving pattern of these first lactation animals. The parameters used to describe calving patterns may be less applicable in herds in which a high proportion of animals is induced to calve prematurely, or where a whole herd is synchronised. Nonetheless, they do serve as an illustrative example of the variation in calving patterns among herds.

Biofilm maturity studies indicate sharp debridement opens a time- dependent therapeutic window

OBJECTIVE

To investigate the hypothesis that newly formed wound biofilms (or bioburdens) are more susceptible to antimicrobial treatment.

METHOD

Four separate and distinct models were performed by four separate biofilm research laboratories to evaluate the resistance of biofilms to antimicrobial treatments over time. These included a drip-flow biofilm model along with a hydrodebridement study, a porcine skin punch biopsy ex vivo model, a mouse chronic wound model and clinical longitudinal debridement study.

RESULTS

All four models showed that, within the first 24 hours, the biofilm community was more susceptible to the selected antibiotics, and after maturing for up to 48 hours became increasingly tolerant. In each model, there was at least a 24-hour period in which the biofilms were more resistant to antibiotics. Each of the models utilised showed a significant decrease in the resistance of the biofilm/ burden to gentamicin for up to 24 hours with a confidence interval of at least 95%. The resistance increased in each of the models by 48 hours and reached original resistance levels by 72 hours.

CONCLUSION

These data suggest the principles of biofilm-based wound care, along with the use of serial debridement to continually remove mature biofilm, followed by biofilm wound management strategies, including topical antibiotics while the bioburden is still immature and more susceptible, are valid.

Electron cyclotron emission diagnostic for ITER

Electron temperature measurements and electron thermal transport inferences will be critical to the nonactive and deuterium phases of ITER operation and will take on added importance during the alpha heating phase. The diagnostic must meet stringent criteria on spatial coverage and spatial resolution during full field operation. During the early phases of operation, it must operate equally well at half field. The key to the diagnostic is the front end design. It consists of a quasioptical antenna and a pair of calibration sources. The radial resolution of the diagnostic is less than 0.06 m. The spatial coverage extends at least from the core to the separatrix with first harmonic O-mode being used for the core and second harmonic X-mode being used for the pedestal. The instrumentation used for the core measurement at full field can be used for detection at half field by changing the detected polarization. Intermediate fields are accessible. The electron cyclotron emission systems require in situ calibration, which is provided by a novel hot calibration source. The critical component for the hot calibration source, the emissive surface, has been successfully tested. A prototype hot calibration source has been designed, making use of extensive thermal and mechanical modeling.

A phase I pharmacokinetic trial of sonic hedgehog (SHH) antagonist GDC-0449 in pediatric patients with recurrent or refractory medulloblastoma: A Pediatric Brain Tumor Consortium study (PBTC 25)

CRA9501

Background:Aberrant signaling in SHH pathway is implicated in causing medulloblastoma in approximately 20% of children with this disease. GDC-0449 is an orally active agent that binds to the SMO receptor and prevents downstream signaling through GLI. Preclinical murine models predict efficacy of an SMO antagonist to treat tumors dependent on the SHH pathway. Adult studies have documented the efficacy of this compound against recurrent medulloblastoma and basal cell carcinoma. A phase I pharmacokinetic trial of GDC 0449 was conducted in children with recurrent or refractory medulloblastoma to select, based on safety and pharmacokinetics, one of two dosages to recommend for a pediatric phase II trial. We also used immunonistochemistry (IHC) and in situ hybridization (ISH) on paraffin-embedded tissue to determine which tumors belonged to the SHH subtype.

Methods: GDC 0449 was administered once daily for 28 days dose levels of (1) 85 mg/m2/dose and (2) 170 mg/m2/dose. A course was defined as 28 days in duration. PK analysis was performed during the first course and steady-state concentrations were obtained prior to each subsequent course (day 21). MRI scans of the knees were obtained at baseline and 3 mos to assess abnormalities in bone development.

Results: To date 11 eligible patients have been enrolled on the trial (10 males, median age 11.6 years (range 4.4–20.9). All patients were fully evaluable for toxicity. 1 DLT, grade 3 gamma-Glutamyl transpeptidase, occurred in a patient enrolled at 170 mg/m2/dose. There were no grade 4 toxicities. The median (range) steady-state day 21 concentration at 85 mg/m2 (n=5) is 10.15 μ M (9.10–18.99 μ M) and at 170 mg/m2 (n=2) is 14.50 μ M (14.43–14.57 μ M). The steady-state GDC-0449 clearance (n=7) is 0.86 (0.44 – 1.17 L/h/m2). At steady state (day 21), the ratio of GDC-0449 CSF to plasma is 1.3%, which is an estimate of the CSF penetration of GDC-0449.

Conclusions: GDC 0449 is well-tolerated in children with recurrent or refractory medulloblastoma. The phase I study estimating the recommended phase II dose of GDC 0449 is ongoing; final results including medulloblastoma subgroup data will be presented.

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Effects of aerobic exercise, resistance exercise or both, on patient-reported health status and well-being in type 2 diabetes mellitus: a randomised trial

AIMS/HYPOTHESIS

The Diabetes Aerobic and Resistance Exercise (DARE) study showed that aerobic and resistance exercise training each improved glycaemic control and that a combination of both was superior to either type alone in patients with type 2 diabetes mellitus. Here we report effects on patient-reported health status and well-being in the DARE Trial.

METHODS

We randomised 218 inactive participants with type 2 diabetes mellitus in parallel to 22 weeks of aerobic exercise (n = 51), resistance exercise (n = 58), combined aerobic and resistance exercise (n = 57) or no exercise (control; n = 52). Intervention allocation was managed by a central office. Outcomes included health status as assessed by the physical and mental component scores of the Medical Outcomes Trust Short-Form 36-item version (SF-36) and well-being as measured by the Well-Being Questionnaire 12-item version (WBQ-12); these were measured at the Ottawa Hospital.

RESULTS

Using a p value of 0.0125 for statistical significance due to multiple comparisons, mixed model analyses indicated that resistance exercise led to clinically but not statistically significant improvements in the SF-36 physical component score compared with aerobic exercise (Delta = 2.7 points; p = 0.048) and control (i.e. no exercise; Delta = 3.3 points; p = 0.015). For mental component scores, there were clinically important improvements favouring no (control) compared with resistance (Delta = 7.6 points; p < 0.001) and combined (Delta = 7.2 points; p < 0.001) exercise. No effects on WBQ-12 scores were noted. Overall, 59/218 (27%) of participants included in this analysis sustained an adverse event during the course of the study, including 16 participants in the combined exercise group, 19 participants in the resistance exercise group, 16 participants in the aerobic exercise group, and eight participants in the control group. All participants were included in the intent-to-treat analyses. The trial is now closed to follow-up.

CONCLUSIONS/INTERPRETATION

Resistance exercise was better than aerobic or no exercise for improving physical health status in these patients. No exercise was superior to resistance or combined exercise for improving mental health status. Well-being was unchanged by intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00195884

FUNDING

This study was funded by the Canadian Institutes of Health Research (grant MCT-44155) and the Canadian Diabetes Association (The Lillian Hollefriend Grant).

Alcohol, signaling, and ECM turnover

Alcohol is recognized as a direct hepatotoxin, but the precise molecular pathways that are important for the initiation and progression of alcohol-induced tissue injury are not completely understood. The current understanding of alcohol toxicity to organs suggests that alcohol initiates injury by generation of oxidative and nonoxidative ethanol metabolites and via translocation of gut-derived endotoxin. These processes lead to cellular injury and stimulation of the inflammatory responses mediated through a variety of molecules. With continuing alcohol abuse, the injury progresses through impairment of tissue regeneration and extracellular matrix (ECM) turnover, leading to fibrogenesis and cirrhosis. Several cell types are involved in this process, the predominant being stellate cells, macrophages, and parenchymal cells. In response to alcohol, growth factors and cytokines activate many signaling cascades that regulate fibrogenesis. This mini-review brings together research focusing on the underlying mechanisms of alcohol-mediated injury in a number of organs. It highlights the various processes and molecules that are likely involved in inflammation, immune modulation, susceptibility to infection, ECM turnover and fibrogenesis in the liver, pancreas, and lung triggered by alcohol abuse.

Impact of toll-like receptor 4 on the severity of acute pancreatitis and pancreatitis-associated lung injury in mice

BACKGROUND AND AIMS

Acute pancreatitis is an inflammatory disease involving acinar cell injury, and the rapid production and release of inflammatory cytokines, which play a dominant role in local pancreatic inflammation and systemic complications. Toll-like receptor 4 (TLR4) initiates a complex signalling pathway when it interacts with lipopolysaccharide (LPS), which ultimately results in a proinflammatory response. We hypothesised that TLR4 is important in the pathophysiology of acute pancreatitis, independently of LPS. Using two different models of acute pancreatitis, we investigated how genetic deletion of TLR4 or its co-receptor CD14 effects its progression and severity.

METHODS

We induced acute pancreatitis by administering either caerulein or L-arginine to wild-type, TLR4(-/-), and CD14(-/-) mice. Control mice received normal saline injections. The severity of acute pancreatitis was determined by measuring serum amylase activity, quantifying myeloperoxidase (MPO) activity in the pancreatic tissue, and histologically assessing acinar cell injury.

RESULTS

It was found that administering caerulein and L-arginine to wild-type mice resulted in acute pancreatitis (as assessed by hyperamylasaemia, oedema, increased pancreatic MPO activity, and pancreatic necrosis) and associated lung injury. The same treatment to TLR4(-/-) or CD14(-/-) mice resulted in significantly less severe acute pancreatitis, and reduced lung injury. We found no evidence of either bacteria or LPS in the blood or in pancreatic tissue.

CONCLUSIONS

The severity of acute pancreatitis is ameliorated in mice that lack either TLR4 or CD14 receptors. Furthermore, these results indicate that TLR4 plays a significant pro-inflammatory role independently of LPS in the progression of acute pancreatitis.

Nanoparticle-targeted delivery of nonanticoagulant heparin and doxorubicin in doxorubicin-resistant breast cancer

e11599

Background: In comparison to low molecular weight heparin (LMWH), non-anticoagulant heparin (NACH), originally developed in our laboratory, has minimal effects on hemostasis. Encapsulation of chemotherapeutic agents and NACH in biodegradable nanoparticles has tremendous potential in improving survival among the breast cancer patients. Furthermore, custom-made nanoparticles with a targeted moiety on the surface would enable us to increase the efficacy and decrease the adverse effects of doxorubicin. Methods: PLGA-PEG nanoparticles co-encapsulating NACH and doxorubicin were synthesized by double emulsion solvent evaporation method. The in vitro efficacy of these nanoparticles was examined in MCF-7 doxorubicin resistant (MCF-7R) cells using MTT cell viability assay. Confocal microscopy was used to examine the uptake of αvβ3 antibody conjugated nanoparticles in human dermal microvascular endothelial cells (HDMEC), which are known to over express αvβ3 integrins. Results: Size measurement by DLS revealed that these nanoparticles co-encapsulating doxorubicin and heparins to be 200–300 nm in size. Data from the MTT assays in MCF-7R cells showed synergy between NACH and doxorubicin when encapsulated in PLGA-PEG nanoparticles. Confocal imaging in HDMEC cells indicates that these nanoparticles have the potential to be used for site specific delivery to the tumor neovascularization. In vivo data in nude mice xenograft (MCF-7R) are shown in the table below (doses of doxorubicin and NACH injected subcutaneously were 0.625 mg/kg and 2.5 mg/kg body weight, respectively). Significant decrease in tumor weight was observed in the mice xenograft, when treated with αvβ3 conjugated nanoparticles co-encapsulating doxorubcin or to greater extent doxorubicin and NACH compares to its non encapsulated counterparts. Conclusions: These data indicated distinct improvement in the anti-tumor efficacy using αvβ3site directed delivery doxorubicin and NACH encapsulted in PLGA-PEG nanoparticles.

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No significant financial relationships to disclose.