A Comparison of Outcomes among Hospital Survivors with and without Severe Comorbidity Admitted to the Intensive Care Unit

Little is known about the experiences of patients with severe comorbidity discharged from Intensive Care Units (ICUs). This project aimed to determine the effects of an ICU stay for patients with severe comorbidity by comparing 1) quality of life (QOL), 2) the symptom profile of hospital survivors and 3) health service use after hospital discharge for patients admitted to ICU with and without severe comorbidity. A case-control study was used. Patients with severe comorbidity were matched to a contemporaneous cohort of ICU patients by age and severity of illness. Assessment tools were the Medical Outcome Study 36-item short-form and European Organisation for Research and Treatment of Cancer QLQ-C15-PAL questionnaires for QOL and the Symptom Assessment Scale for symptom distress. A proportional odds assumption was performed using an ordinal regression model. The difference in QOL outcome was the dependent variable for each pair. Health service use after discharge from ICU was monitored with patient diaries. Patients aged 18+ years admitted to an ICU in a metropolitan teaching hospital between 2011 and 2012 were included. We recruited 30 cases and 30 controls. QOL improved over the six months after hospital discharge for patients with and without severe comorbidity ( P <0.01) within the groups but there was no difference found between the groups ( P >0.3). There was no difference in symptoms or health service use between patients with and without severe comorbidity. ICU admission for people with severe comorbidity can be appropriate to stabilise the patient's condition and is likely to be followed by some overall improvement over the six months after hospital discharge.

The performance of BRCA1 immunohistochemistry for detecting germline, somatic, and epigenetic BRCA1 loss in high-grade serous ovarian cancer

BACKGROUND

BRCA1 expression can be lost by a variety of mechanisms including germline or somatic mutation and promotor hypermethylation. Given the potential importance of BRCA1 loss as a predictive and prognostic biomarker in high-grade serous ovarian cancer, we sought to evaluate the utility of BRCA1 immunohistochemistry (IHC) in screening for BRCA1 loss by germline, somatic, and epigenetic mechanisms.

PATIENTS AND METHODS

Patients with advanced high-grade serous ovarian cancer who had previously undergone germline BRCA1 testing were identified. Samples from each tumor were stained for BRCA1 and reviewed independently by two pathologists blinded to BRCA status. Tumors with abnormal BRCA1 IHC and wild-type germline testing underwent further evaluation for somatic BRCA1 mutations and promoter hypermethylation. McNemar's test was used to determine the association of BRCA1 IHC with germline BRCA1 mutations and BRCA1 loss through any mechanism. Kaplan-Meier methods were used to estimate overall survival (OS), and the log-rank test was used to assess differences between groups.

RESULTS

Inter-rater reliability between the two pathologists on BRCA IHC interpretation was very good (kappa coefficient 0.865, P = 0.16; McNemar's test). BRCA1 IHC was abnormal in 36% (48/135) of cases. When compared with germline BRCA1 status, BRCA1 IHC had a high negative predictive value (95.4%) but a low positive predictive value (PPV, 52.1%). When accounting for promoter hypermethylation and somatic mutations as alternative methods of BRCA1 loss, the PPV rose to 87.5%. Five-year OS rate was 49.6% [95% confidence interval (CI) 26.3% to 69.3%] for patients with germline BRCA1 mutations, 50.4% (95% CI 27.5% to 69.5%) for germline wild-type BRCA1 and abnormal IHC, and 52.1% (95% CI 38.4% to 64.2%) for germline wild-type BRCA1 and normal IHC (P = 0.92).

CONCLUSIONS

BRCA1 IHC interpretation was a highly reproducible and accurate modality for detecting germline, somatic, or epigenetic mechanisms of BRCA1 loss. These results support further development of BRCA1 IHC as a potential biomarker for BRCA1 loss in high-grade serous ovarian cancer.

Prognostic nomogram for diffuse large B-cell lymphoma incorporating the International Prognostic Index with interim-positron emission tomography findings

BACKGROUND/AIMS

Results from interim-positron emission tomography (PET) studies in diffuse large B-cell lymphoma (DLBCL) patients are varied. We evaluated the prognostic value of interim-PET in our centre. To improve concordance, interim-PET was combined with the International Prognostic Index (IPI).

METHODS

We retrospectively reviewed 100 new consecutive DLBCL patients treated with immunochemotherapy from 2005 to 2010. Twenty-four patients did not receive interim-PET and were excluded. Interim-PET images were re-examined using a qualitative assessment technique. Progression-free survival (PFS) and overall survival (OS) were analysed by the Cox proportional hazards model and prognostic accuracy was assessed using Harrell's C statistics (C).

RESULTS

Eleven patients were positive, and 65 were negative at interim-PET. The 2-year OS and PFS were 70.8% and 60.0%, respectively, in the PET-negative group, 36.4% and 36.4% for the PET-positive group (log-rank P-value 0.0008 for PFS, 0.0001 for OS). The IPI and interim-PET were minimally correlated. On Cox regression analysis, both were significant indicators of PFS (P < 0.001 and P = 0.002 respectively). The prognostic accuracy for PFS of a negative PET result was limited (C = 0.63), as it was for IPI (C = 0.75), but with the two indicators combined, the predictive accuracy was improved (C = 0.81). A nomogram, predictive for relapse-free survival at 2 years, was constructed.

CONCLUSION

In DLBCL patients treated with immunochemotherapy, the IPI and interim-PET provide independent prognostic information. In combination, a more powerful predictive model may be created as a nomogram. This can be refined in prospective trials and may help clinical decision making.

Development of a consumer product ingredient database for chemical exposure screening and prioritization

Consumer products are a primary source of chemical exposures, yet little structured information is available on the chemical ingredients of these products and the concentrations at which ingredients are present. To address this data gap, we created a database of chemicals in consumer products using product Material Safety Data Sheets (MSDSs) publicly provided by a large retailer. The resulting database represents 1797 unique chemicals mapped to 8921 consumer products and a hierarchy of 353 consumer product "use categories" within a total of 15 top-level categories. We examine the utility of this database and discuss ways in which it will support (i) exposure screening and prioritization, (ii) generic or framework formulations for several indoor/consumer product exposure modeling initiatives, (iii) candidate chemical selection for monitoring near field exposure from proximal sources, and (iv) as activity tracers or ubiquitous exposure sources using "chemical space" map analyses. Chemicals present at high concentrations and across multiple consumer products and use categories that hold high exposure potential are identified. Our database is publicly available to serve regulators, retailers, manufacturers, and the public for predictive screening of chemicals in new and existing consumer products on the basis of exposure and risk.

Knowing prior methicillin-resistant Staphylococcus aureus (MRSA) infection or colonization status increases the empirical use of glycopeptides in MRSA bacteraemia and may decrease mortality

To compare the management and outcome of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia in patients known to be MRSA-colonized/infected (C-patients) with the management and outcome in those not known to be colonized/infected (NC-patients), we conducted a 10-year retrospective review of MRSA bacteraemia in an adult tertiary hospital. Clinical data were obtained by chart review, and mortality data from linked databases. Prior MRSA colonization/infection status was available to treating clinicians at the time of the bacteraemia as a 'Micro-Alert' tag on the patient's labels, in medical charts, and in electronic information systems. C-patients accounted for 35.4% of all MRSA bacteraemia episodes. C-patients were more likely to be indigenous, to be diabetic, or to have a history of previous S. aureus infection. Markers of illness severity (Simplified Acute Physiology Score (SAPS)-II, need for admission to the intensive-care unit, length of stay, and metastatic seeding) were similar in both groups. Empirical therapy included a glycopeptide in 49.3% of C-patients vs. 18.9% of NC-patients (p <0.01), and contained an antibiotic to which the MRSA isolate tested susceptible in vitro in 56.7% of C-patients vs. 45.1% of NC-patients (p 0.13). All-cause 7-day and 30-day mortality were 7.5% vs. 18.9% (p 0.04), and 22.4% vs. 31.1% (p 0.20), in the C-patient and NC-patient groups, respectively. Knowing MRSA colonization status was significantly associated with lower 30-day mortality in Cox regression analysis (p <0.01). These data suggest that mortality from MRSA bacteraemia is lower in C-patients, which may reflect the earlier use of glycopeptides. The low use of empirical glycopeptides in septic patients known to be previously MRSA-colonized/infected may represent a missed opportunity for infection control to positively impact on clinical management.

Diffusion measures indicate fight exposure-related damage to cerebral white matter in boxers and mixed martial arts fighters

BACKGROUND AND PURPOSE

Traumatic brain injury is common in fighting athletes such as boxers, given the frequency of blows to the head. Because DTI is sensitive to microstructural changes in white matter, this technique is often used to investigate white matter integrity in patients with traumatic brain injury. We hypothesized that previous fight exposure would predict DTI abnormalities in fighting athletes after controlling for individual variation.

MATERIALS AND METHODS

A total of 74 boxers and 81 mixed martial arts fighters were included in the analysis and scanned by use of DTI. Individual information and data on fight exposures, including number of fights and knockouts, were collected. A multiple hierarchical linear regression model was used in region-of-interest analysis to test the hypothesis that fight-related exposure could predict DTI values separately in boxers and mixed martial arts fighters. Age, weight, and years of education were controlled to ensure that these factors would not account for the hypothesized effects.

RESULTS

We found that the number of knockouts among boxers predicted increased longitudinal diffusivity and transversal diffusivity in white matter and subcortical gray matter regions, including corpus callosum, isthmus cingulate, pericalcarine, precuneus, and amygdala, leading to increased mean diffusivity and decreased fractional anisotropy in the corresponding regions. The mixed martial arts fighters had increased transversal diffusivity in the posterior cingulate. The number of fights did not predict any DTI measures in either group.

CONCLUSIONS

These findings suggest that the history of fight exposure in a fighter population can be used to predict microstructural brain damage.

Friction force microscopy: a simple technique for identifying graphene on rough substrates and mapping the orientation of graphene grains on copper

At a single atom thick, it is challenging to distinguish graphene from its substrate using conventional techniques. In this paper we show that friction force microscopy (FFM) is a simple and quick technique for identifying graphene on a range of samples, from growth substrates to rough insulators. We show that FFM is particularly effective for characterizing graphene grown on copper where it can correlate the graphene growth to the three-dimensional surface topography. Atomic lattice stick-slip friction is readily resolved and enables the crystallographic orientation of the graphene to be mapped nondestructively, reproducibly and at high resolution. We expect FFM to be similarly effective for studying graphene growth on other metal/locally crystalline substrates, including SiC, and for studying growth of other two-dimensional materials such as molybdenum disulfide and hexagonal boron nitride.

A simple scoring method using cardiometabolic risk measurements in pregnancy to determine 10-year risk of type 2 diabetes in women with gestational diabetes

Objective:

To examine if clustering of cardiometabolic risk factors in pregnancy predicts type 2 diabetes and cardiovascular disease (CVD) risk at 10 years in women with gestational diabetes mellitus (GDM).

Study design and subjects:

A prospective case–control study in 150 GDM and 72 overweight women with normal glucose tolerance (NGT) measured cardiometabolic risk factors (body mass index (BMI), systolic blood pressure (SBP), fasting glucose, insulin, and triglycerides and high-density lipoprotein (HDL) cholesterol) at 28 weeks gestation and 6 months and 10 years after pregnancy. Cluster analysis of cardiometabolic risk factors in pregnancy was used to stratify GDM as ‘high' and ‘low risk' for diabetes and CVD risk at 10 years. The data in pregnancy were used to determine a simple method for assessing risk of future diabetes.

Results:

BMI in the 150 GDM at study entry was similar to NGT, but 35% of GDM fell into a ‘high-risk cluster' with elevated BMI, SBP, glucose, insulin and triglycerides and lower HDL levels. At 10 years, type 2 diabetes was sixfold higher in ‘high-risk' GDM (odds ratio (OR)=6.75, confidence interval (CI)=2.0, 22.7, P=0.002) compared with ‘low-risk' GDM and was not reported in NGT. The ‘high-risk' cluster predicted type 2 diabetes better than BMI>30 (OR=2.13, CI=0.71, 6.4, P=0.179) or fasting glucose >5.5 mmol l^–1, (OR=4.56, CI=1.50, 13.85, P=0.007). We determined that GDM with any four of the cardiometabolic risk factors (BMI>30 kg m^–2, fasting glucose>5.0 mmol l^–1, insulin>7.8 mU l^–1, triglycerides >2.4 mmol l^–1, HDL<1.6 mmol l^–1 or SBP>105 mm Hg) in pregnancy would be in a ‘high-risk' cluster.

Conclusions:

A metabolic syndrome-like cluster in pregnant GDM identifies risk for type 2 diabetes providing an opportunity to focus on rigorous lifestyle interventions after delivery to reduce the burden of disease attributed to this condition.

Adaptive IMRT using a multiobjective evolutionary algorithm integrated with a diffusion-invasion model of glioblastoma

We demonstrate a patient-specific method of adaptive IMRT treatment for glioblastoma using a multiobjective evolutionary algorithm (MOEA). The MOEA generates spatially optimized dose distributions using an iterative dialogue between the MOEA and a mathematical model of tumor cell proliferation, diffusion and response. Dose distributions optimized on a weekly basis using biological metrics have the potential to substantially improve and individualize treatment outcomes. Optimized dose distributions were generated using three different decision criteria for the tumor and compared with plans utilizing standard dose of 1.8 Gy/fraction to the CTV (T2-visible MRI region plus a 2.5 cm margin). The sets of optimal dose distributions generated using the MOEA approach the Pareto Front (the set of IMRT plans that delineate optimal tradeoffs amongst the clinical goals of tumor control and normal tissue sparing). MOEA optimized doses demonstrated superior performance as judged by three biological metrics according to simulated results. The predicted number of reproductively viable cells 12 weeks after treatment was found to be the best target objective for use in the MOEA.

The impact of new national HIV testing guidelines at a district general hospital in an area of high HIV seroprevalence

The latest UK national human immunodeficiency virus (HIV) testing guidelines, released in September 2008, state that HIV testing should be offered to all patients with indicator conditions and considered in all general medical admissions in high-prevalence areas. We audited testing rates at Blackpool Victoria Hospital, a high-prevalence area, one year before and one year after the publication of the new guidelines. In the year after publication the rate of HIV testing in patients with indicator diseases was as follows: hepatitis B 6%, hepatitis C 28%, tuberculosis 9% and lymphoma 14%. The overall rate of HIV testing in acute medical admissions was 0.5%. Our results demonstrate that traditional methods of guideline dissemination did not lead to implementation. We are now assessing alternative methods such as marking all positive laboratory results for indicator diseases with the phrase 'HIV testing should be considered' and implementing universal opt-out screening in our Clinical Decisions Unit.

Indicator microbes correlate with pathogenic bacteria, yeasts and helminthes in sand at a subtropical recreational beach site

AIMS

Research into the relationship between pathogens, faecal indicator microbes and environmental factors in beach sand has been limited, yet vital to the understanding of the microbial relationship between sand and the water column and to the improvement of criteria for better human health protection at beaches. The objectives of this study were to evaluate the presence and distribution of pathogens in various zones of beach sand (subtidal, intertidal and supratidal) and to assess their relationship with environmental parameters and indicator microbes at a non-point source subtropical marine beach.

METHODS AND RESULTS

In this exploratory study in subtropical Miami (Florida, USA), beach sand samples were collected and analysed over the course of 6 days for several pathogens, microbial source tracking markers and indicator microbes. An inverse correlation between moisture content and most indicator microbes was found. Significant associations were identified between some indicator microbes and pathogens (such as nematode larvae and yeasts in the genus Candida), which are from classes of microbes that are rarely evaluated in the context of recreational beach use.

CONCLUSIONS

Results indicate that indicator microbes may predict the presence of some of the pathogens, in particular helminthes, yeasts and the bacterial pathogen Staphylococcus aureus including methicillin-resistant forms. Indicator microbes may thus be useful for monitoring beach sand and water quality at non-point source beaches.

SIGNIFICANCE AND IMPACT OF THE STUDY

The presence of both indicator microbes and pathogens in beach sand provides one possible explanation for human health effects reported at non-point sources beaches.

Impact of multidisciplinary team management in head and neck cancer patients

BACKGROUND

We analysed the outcomes of 726 cases of primary head and neck cancer patients managed between 1996 and 2008, including those managed in the multidisciplinary clinic or team setting (MDT) and those managed outside of an MDT by individual disciplines (non-MDT) in the same institution.

METHODS

Data were collected from the Hospital Based Cancer Registry and a database within the Head and Neck Cancer Clinic. Univariable comparisons and multivariable analyses were performed using a logistic regression model. Survival by staging was analysed. Comparisons of management and outcomes were made between MDT and non-MDT patients.

RESULTS

395 patients (54%) had been managed in the MDT vs 331 patients (46%) non-MDT. MDT patients were more likely to have advanced disease (likelihood ratio χ(2)=44.7, P<0.001). Stage IV MDT patients had significantly improved 5-year survival compared with non-MDT patients (hazard ratio=0.69, 95% CI=0.51-0.88, P=0.004) and more synchronous chemotherapy and radiotherapy (P=0.004), and the non-MDT group had more radiotherapy as a single modality (P=0.002).

CONCLUSIONS

The improved survival of MDT-managed stage IV patients probably represents both the selection of multimodality treatment and chemotherapeutic advances that these patients received in a multidisciplinary team setting by head and neck cancer specialists as opposed to cancer generalists in a non-MDT setting.

Informed consent in the context of pharmacogenomic research: ethical considerations

Although the scientific research surrounding pharmacogenomics (PGx) has been relatively plentiful, the ethical research concerning this discipline has developed rather conservatively. Following investigation of the ethical, legal and social issues (ELSI) of PGx research, as well as consulting with key stakeholders, we identified six outstanding ethical issues raised by the informed consent process in PGx research: (1) scope of consent; (2) consent to 'add-on' studies; (3) protection of personal information; (4) commercialization; (5) data sharing; and (6) potential risks stemming from population-based research. In discussing these six areas as well as offering specific considerations, this article offers a solid base from which future practical guidelines for informed consent in PGx research can be constructed. As such, this effort works toward filling the ELSI gap and provides ethical support to the numerous PGx projects undertaken by researchers every year.

Pack hike test finishing time for Australian firefighters: pass rates and correlates of performance

The pack hike test (PHT, 4.83 km hike wearing a 20.4-kg load) was devised to determine the job readiness of USA wildland firefighters. This study measured PHT performance in a sample of Australian firefighters who currently perform the PHT (career land management firefighters, LMFF) and those who do not (suburban/regional volunteer firefighters, VFF). The study also investigated the relationships between firefighters' PHT performance and their performance across a range of fitness tests for both groups. Twenty LMFF and eighteen age-, body mass-, and height-matched VFF attempted the PHT, and a series of muscular endurance, power, strength and cardiorespiratory fitness tests. Bivariate correlations between the participants' PHT finishing time and their performance in a suite of different fitness tests were determined using Pearson's product moment correlation coefficient. The mean PHT finishing time for LMFF (42.2 ± 2.8 min) was 9 ± 14% faster (p = 0.001) than for VFF (46.1 ± 3.6 min). The pass rate (the percentage of participants who completed the PHT in under 45 min) for LMFF (90%) was greater than that of VFF (39%, p = 0.001). For LMFF, VO(2peak) in L min(-1)(r = -0.66, p = 0.001) and the duration they could sustain a grip 'force' of 25 kg (r = -0.69, p = 0.001) were strongly correlated with PHT finishing time. For VFF, VO(2peak) in mL kg(-1) min(-1)(r = -0.75, p = 0.002) and the duration they could hold a 1.2-m bar attached to 45.5 kg in a 'hose spray position' (r = -0.69, p = 0.004) were strongly correlated with PHT finishing time. This study shows that PHT fitness-screening could severely limit the number of VFF eligible for duty, compromising workforce numbers and highlights the need for specific and valid firefighter fitness standards. The results also demonstrate the strong relationships between PHT performance and firefighters' cardiorespiratory fitness and local muscular endurance. Those preparing for the PHT should focus their training on these fitness components in the weeks and months prior to undertaking the PHT.