Telerheumatology: an idea whose time has come

Australia is a vast country with one-third of the population living outside capital cities. Providing specialist rheumatologist services to regional, rural and remote Australians has generally required expensive and time-consuming travel for the patient and/or specialist. As a result, access to specialist care for remote Australians is poor. Rheumatoid arthritis is a common disease, but like many rheumatic diseases, it is complex to treat. Time-dependent joint damage and disability occur unless best evidence care is implemented. The relatively poor access to rheumatologist care allotted to nonmetropolitan Australians therefore represents a significant cause of potentially preventable disability in Australia. Telehealth has the potential to improve access to specialist rheumatologists for patients with rheumatoid arthritis and other rheumatic diseases, thereby decreasing the burden of disability caused by these diseases. Advances in videoconferencing technology, the national broadband rollout and recent Federal government financial incentives have led to a heightened interest in exploring the use of this technology in Australian rheumatology practice. This review summarises the current evidence base, outlines telehealth's strengths and weaknesses in managing rheumatic disease, and discusses the technological, medicolegal and financial aspects of this model of care. A mixed model offering both face-to-face and virtual consultations appears to be the best option, as it can overcome the barriers to accessing care posed by distance while also mitigating the risks of virtual consultation.

Nutrient and light limitation of periphyton in the River Thames: implications for catchment management

Soluble reactive phosphorus (SRP) concentrations in the River Thames, south east England, have significantly decreased from an annual maximum of 2100 μg l(-1) in 1997 to 344 in 2010, primarily due to the introduction of phosphorus (P) removal at sewage treatment works within the catchment. However, despite this improvement in water quality, phytoplankton biomass in the River Thames has greatly increased in recent years, with peak chlorophyll concentrations increasing from 87 μg l(-1) in the period 1997 to 2002, to 328 μg l(-1) in 2009. A series of within-river flume mesocosm experiments were performed to determine the effect of changing nutrient concentrations and light levels on periphyton biomass accrual. Nutrient enrichment experiments showed that phosphorus, nitrogen and silicon were not limiting or co-limiting periphyton growth in the Thames at the time of the experiment (August-September 2010). Decreasing ambient SRP concentration from 225 μg l(-1) to 173 μg l(-1) had no effect on periphyton biomass accrual rate or diatom assemblage. Phosphorus limitation became apparent at 83 μg SRP l(-1), at which point a 25% reduction in periphyton biomass was observed. Diatom assemblage significantly changed when the SRP concentration was reduced to 30 μg l(-1). Such stringent phosphorus targets are costly and difficult to achieve for the River Thames, due to the high population density and intensive agriculture within the Thames basin. Reducing light levels by shading reduced the periphyton accrual rate by 50%. Providing shading along the River Thames by planting riparian tree cover could be an effective measure to reduce the risk of excessive algal growth. If the ecology of the Thames is to reach the WFD's "good ecological status", then both SRP concentration reductions (probably to below 100 μg l(-1)) and increased shading will be required.

Anterior thigh compartment syndrome after prone positioning for lumbosacral fixation

We report a case of a patient who developed anterior thigh compartment syndrome after being positioned prone for instrumented lumbar spine surgery. Although rare, clinicians should be aware that compartment syndrome is a possible complication of spinal surgery.

TS and ERCC-1 mRNA expressions and clinical outcome in patients with metastatic colon cancer in CONFIRM-1 and -2 clinical trials

To validate established cutoff levels of thymidylate synthase (TS) and excision repair cross-complementing (ERCC-1) intratumoral mRNA expressions in tumor samples from metastatic colorectal cancer (mCRC) patients treated with PTK787/ZK222584 (PTK/ZK). From 122 samples of patients with mCRC enrolled in CONFIRM-1 (Colorectal Oral Novel Therapy for the Inhibition of Angiogenesis and Retarding of Metastases) or CONFIRM-2, mRNA was isolated of microdissected formalin-fixed paraffin-embedded samples and quantitated using TaqMan-based technology. Existing TS and ERCC-1 cutoff levels were tested for their prognostic value in first-line and second-line therapy. TS expression was associated with overall survival (OS) in first-line, but not second-line therapy. ERCC-1 was associated with OS in patients treated with first-line and second-line FOLFOX4. In first-line FOLFOX4, combination of high TS and/or high ERCC-1 was associated with shorter OS. A correlation was observed between ERCC-1 expression and benefit from PTK/ZK+FOLFOX4 treatment. TS and ERCC-1 expression is associated with clinical outcome in mCRC. Baseline TS and ERCC-1 levels may allow the selection of patients who benefit from FOLFOX4 chemotherapy.

Abstract P3-10-24: Fibroblast Growth Factor Receptor 1 Amplification and Overexpression in Breast Cancer Tissue Microarrays Using Chromogenic In Situ Hybridization and Immunohistochemistry

Fibroblast growth factor receptors 1 (FGFR1) belongs to a subfamily of receptor tyrosine kinases (RTKs), which are involved in proliferation and apoptosis. FGFR1 amplification and mRNA overexpression occurs in ∼10% of breast cancers and has been associated with poor outcome. However, studies assessing FGFR1 amplification and protein overexpression in a large collection of breast tumors are lacking. In this prospective, we examined a series of primary breast cancers samples derived from the BCIRG trials assembled into 15 tissue microarrays. FGFR1 gene amplification was studied using chromogenic in situ hybridization (CISH) and evaluated with respect to association with level of protein expression and clinicopathological parameters. FGFR1 gene amplification was significantly associated with high protein levels as determined by immunohistochemistry (P<0.0001, 3294 pts with available matched CISH and IHC records). Overall, the incidence of FGFR1 amplification found was 9.7% (160 out of 1646 pts. with available clinicopathological records) without a statistically significant difference between Her2- (78 out 720 pts., 11%) and Her2+ (82 out of 926 pts., 9%) cancers. In both cohorts, the hormone receptor-positive (ER+/PR+) cancers showed statistically significant higher levels of FGFR1 amplification compared to hormone receptor-negative tumors. In the analysis of the association of FGFR1 and the presence of PIK3CA mutations, the incidence of FGFR1 amplificationwas greatly reduced in mutant vs. wt PI3KCA tumors. In these cohorts, a clear relationship between FGFR1 amplification status and clinical outcome was not detected. Data from this large study confirms recently reported incidences of FGFR1 amplification in breast cancer and shows for the first time an association between FGFR1 gene amplification and protein overexpression. Moreover, the lower incidence of FGFR1 amplification in PIK3CA mutated cancers suggests that these are largely exclusive molecular events that could benefit from different targeted therapies.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-10-24.

Chiari malformation in female monozygotic twins

We describe the cases of female monozygotic twins who presented almost synchronously with symptomatic Chiari malformation type I. Both were successfully treated with foramen magnum decompression. We analyse these findings in the context of previously reported cases and discuss the genetic implications.

Extended mapping and exploration of the vanadium dioxide stress-temperature phase diagram

Single-crystal micro- and nanomaterials often exhibit higher yield strength than their bulk counterparts. This enhancement is widely recognized in structural materials but is rarely exploited to probe fundamental physics of electronic materials. Vanadium dioxide exhibits coupled electronic and structural phase transitions that involve different structures existing at different strain states. Full understanding of the driving mechanism of these coupled transitions necessitates concurrent structural and electrical measurements over a wide phase space. Taking advantages of the superior mechanical property of micro/nanocrystals of VO(2), we map and explore its stress-temperature phase diagram over a phase space that is more than an order of magnitude broader than previously attained. New structural and electronic aspects were observed crossing phase boundaries at high-strain states. Our work shows that the actively tuning strain in micro/nanoscale electronic materials provides an effective route to investigate their fundamental properties beyond what can be accessed in their bulk counterpart.

Correlation of rheumatology subspecialty choice and identifiable strong motivations, including intellectual interest

OBJECTIVE

To describe motivations correlating with subspecialty choices, particularly rheumatology.

METHODS

A total of 179 respondents answered queries about various aspects affecting specialty and subspecialty choice with ordinal ratings of importance. Likert scale response data were analyzed to determine independent predictors of being a rheumatology fellow. Multivariate logistic regression analyses were used to develop models predicting rheumatology fellowship. Factor analysis methods to condense the individual responses into fewer underlying variables or factors were employed.

RESULTS

While every group ranked intellectual interest as more important than all other responses, its score in the rheumatology fellow group was significantly higher than that in the medical student group. A model using 4 composite variables based on prior literature did not fit well. Exploratory factor analysis identified 5 underlying motivations, which were designated as time, money, external constraints, practice content, and academics. All motivations except money were statistically significant, with the rheumatology fellow group attributing greater importance than medical students to time, practice content, and academics, and lesser importance than medical students to external constraints.

CONCLUSION

Values and motivations leading toward rheumatology subspecialty choice can be traced to identifiable factors. Intellectual interest appears to be split between 2 distinct significant variables: practice content and academics. Time or controllable lifestyle, external constraints, practice content, and academic issues appear to be important influences on the choice of rheumatology fellowship. Such variables appear to reflect underlying values and motivations.

PI3 Kinase Pathway Analysis in Tissue Microarrays Using Laser Capture Microdissection and Immunohistochemistry

Background. During the performance of the BCIRG trials primary patient tumor samples were obtained from paraffin blocks and assembled into 15 tissue microarrays, including 3000 samples from trial 005 (adjuvant taxol in Her2- node positive patients), 2200 in 006 (adjuvant herceptin in Her2+ high risk patients) and 300 in 007 (addition of platinum in Her2+ first line therapy). This array set was prepared prospectively, in anticipation of molecular epidemiologic studies of a variety of targets in relation to outcome. In order to address the potentially important role of the PIK3CA pathway in modulating outcome in different clinical situations we assessed components of the PIK3CA pathway by various methods.Methods. We analysed the expression of PTEN, Cyclin D1, p53 and Stathmin by immunohistochemistry using standard methods. All markers were scored by histoscore. Phospho S6 240 and phospho Akt 473 were assessed simultaneously by quantum dot immunofluorescence using automated image capture and segmentation. PIK3CA mutations were evaluated using SnaPshot analysis of laser captured TMA spots in a subset of approximately 2000 samples.Results. In the samples analyzed PIK3CA mutation had an incidence of 23%, with 9% being mutations in exon 9 and 13% in exon 20, with 0.5% being mutant in both exons. Initial analysis of the results prior to outcome analysis indicated that Stathmin expression, while being a robust marker with good dynamic range, did not appear to correlate with PTEN loss by IHC or with PIK3CA mutation.Conclusions. PIK3CA mutational analysis is feasible from TMA cores and gives mutation incidences similar to the published literature for archival material. Relationships of markers with outcome will be presented.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4043.