Outcome of elderly patients with diffuse large B-cell lymphoma treated with R-CHOP: results from the UK NCRI R-CHOP14v21 trial with combined analysis of molecular characteristics with the DSHNHL RICOVER-60 trial

BACKGROUND

There is an on-going debate whether 2- or 3-weekly administration of R-CHOP is the preferred first-line treatment for elderly patients with diffuse large B-cell lymphoma (DLBCL). The UK NCRI R-CHOP14v21 randomized phase 3 trial did not demonstrate a difference in outcomes between R-CHOP-14 and R-CHOP-21 in newly diagnosed DLBCL patients aged 19-88 years, but data on elderly patients have not been reported in detail so far. Here, we provide a subgroup analysis of patients ≥60 years treated on the R-CHOP14v21 trial with extended follow-up.

PATIENTS AND METHODS

Six hundred and four R-CHOP14v21 patients ≥60 years were included in this subgroup analysis, with a median follow-up of 77.7 months. To assess the impact of MYC rearrangements (MYC-R) and double-hit-lymphoma (DHL) on outcome in elderly patients, we performed a joint analysis of cases with available molecular data from the R-CHOP14v21 (N = 217) and RICOVER-60 (N = 204) trials.

RESULTS

Elderly DLBCL patients received high dose intensities with median total doses of ≥98% for all agents. Toxicities were similar in both arms with the exception of more grade ≥3 neutropenia (P < 0.0001) and fewer grade ≥3 thrombocytopenia (P = 0.05) in R-CHOP-21 versus R-CHOP-14. The elderly patient population had a favorable 5-year overall survival (OS) of 69% (95% CI: 65-73). We did not identify any subgroup of patients that showed differential response to either regimen. In multivariable analysis including individual factors of the IPI, gender, bulk, B2M and albumin levels, only age and B2M were of independent prognostic significance for OS. Molecular analyses demonstrated a significant impact of MYC-R (HR = 1.96; 95% CI: 1.22-3.16; P = 0.01) and DHL (HR = 2.21; 95% CI: 1.18-4.11; P = 0.01) on OS in the combined trial cohorts, independent of other prognostic factors.

CONCLUSIONS

Our data support equivalence of both R-CHOP application forms in elderly DLBCL patients. Elderly MYC-R and DHL patients have inferior prognosis and should be considered for alternative treatment approaches.

TRIAL NUMBERS

ISCRTN 16017947 (R-CHOP14v21); NCT00052936 (RICOVER-60).

Lessons learned implementing a province-wide smoking cessation initiative in Ontario’s cancer centres

Purpose A large body of evidence clearly shows that cancer patients experience significant health benefits with smoking cessation. Cancer Care Ontario, the provincial agency responsible for the quality of cancer services in Ontario, has undertaken a province-wide smoking cessation initiative. The strategies used, the results achieved, and the lessons learned are the subject of the present article.Methods Evidence related to the health benefits of smoking cessation in cancer patients was reviewed. A steering committee developed a vision statement for the initiative, created a framework for implementation, and made recommendations for the key elements of the initiative and for smoking cessation best practices.Results New ambulatory cancer patients are being screened for their smoking status in each of Ontario’s 14 regional cancer centres. Current or recent smokers are advised of the benefits of cessation and are directed to smoking cessation resources as appropriate. Performance metrics are captured and used to drive improvement through quarterly performance reviews and provincial rankings of the regional cancer centres.Conclusions Regional smoking cessation champions, commitment from Cancer Care Ontario senior leadership, a provincial secretariat, and guidance from smoking cessation experts have been important enablers of early success. Data capture has been difficult because of the variety of information systems in use and non-standardized administrative and clinical processes. Numerous challenges remain, including increasing physician engagement; obtaining funding for key program elements, including in-house resources to support smoking cessation; and overcoming financial barriers to access nicotine replacement therapy. Future efforts will focus on standardizing processes to the extent possible, while tailoring the approaches to the populations served and the resources available within the individual regional cancer programs.

Lessons learned implementing a province-wide smoking cessation initiative in Ontario's cancer centres

PURPOSE

A large body of evidence clearly shows that cancer patients experience significant health benefits with smoking cessation. Cancer Care Ontario, the provincial agency responsible for the quality of cancer services in Ontario, has undertaken a province-wide smoking cessation initiative. The strategies used, the results achieved, and the lessons learned are the subject of the present article.

METHODS

Evidence related to the health benefits of smoking cessation in cancer patients was reviewed. A steering committee developed a vision statement for the initiative, created a framework for implementation, and made recommendations for the key elements of the initiative and for smoking cessation best practices.

RESULTS

New ambulatory cancer patients are being screened for their smoking status in each of Ontario's 14 regional cancer centres. Current or recent smokers are advised of the benefits of cessation and are directed to smoking cessation resources as appropriate. Performance metrics are captured and used to drive improvement through quarterly performance reviews and provincial rankings of the regional cancer centres.

CONCLUSIONS

Regional smoking cessation champions, commitment from Cancer Care Ontario senior leadership, a provincial secretariat, and guidance from smoking cessation experts have been important enablers of early success. Data capture has been difficult because of the variety of information systems in use and non-standardized administrative and clinical processes. Numerous challenges remain, including increasing physician engagement; obtaining funding for key program elements, including in-house resources to support smoking cessation; and overcoming financial barriers to access nicotine replacement therapy. Future efforts will focus on standardizing processes to the extent possible, while tailoring the approaches to the populations served and the resources available within the individual regional cancer programs.

Vaccination to improve the persistence of CD19CAR gene-modified T cells in relapsed pediatric acute lymphoblastic leukemia

Trials with second generation CD19 chimeric antigen receptors (CAR) T-cells report unprecedented responses but are associated with risk of cytokine release syndrome (CRS). Instead, we studied the use of donor Epstein-Barr virus-specific T-cells (EBV CTL) transduced with a first generation CD19CAR, relying on the endogenous T-cell receptor for proliferation. We conducted a multi-center phase I/II study of donor CD19CAR transduced EBV CTL in pediatric acute lymphoblastic leukaemia (ALL). Patients were eligible pre-emptively if they developed molecular relapse (>5 × 10-4) post first stem cell transplant (SCT), or prophylactically post second SCT. An initial cohort showed poor expansion/persistence. We therefore investigated EBV-directed vaccination to enhance expansion/persistence. Eleven patients were treated. No CRS, neurotoxicity or graft versus host disease (GVHD) was observed. At 1 month, 5 patients were in CR (4 continuing, 1 de novo), 1 PR, 3 had stable disease and 3 no response. At a median follow-up of 12 months, 10 of 11 have relapsed, 2 are alive with disease and 1 alive in CR 3 years. Although CD19CAR CTL expansion was poor, persistence was enhanced by vaccination. Median persistence was 0 (range: 0-28) days without vaccination compared to 56 (range: 0-221) days with vaccination (P=0.06). This study demonstrates the feasibility of multi-center studies of CAR T cell therapy and the potential for enhancing persistence with vaccination.

Abstract P3-04-26: Establishment and characterization of ST941/C; an ESR1-mutant ER+ breast cancer cell line and xenograft from a patient with acquired resistance to endocrine therapy

Background: The estrogen receptor (ERα) plays an integral role in the progression of luminal type breast cancers and while targeted endocrine therapies provide effective initial treatment many patients develop acquired resistance to treatment even with continued ER receptor expression. Recently studies identified ER mutations as a possible mechanism for acquired resistance and several activating point mutations have been identified including Y537S (ESR1Y537S) resulting in hormone independent proliferation in preclinical studies. However, lack of validated ESR1-mutant cell lines has limited detailed mechanistic studies of these mutations in endocrine-resistant ER+ breast cancer. Previously we established and evaluated a patient derived xenograft (PDX) designated ST941 representing ESR1Y537S-mutated ER+ breast cancer (Wick et al, SABCS 2015). To better understand the role of ESR1-mutations in endocrine resistant breast cancer we established an immortalized cell line from ST941 designated ST941/C to use for in vitro mechanistic assays and correlative in vivo studies.

Methods: The ST941/C cell line was generated from harvested low-passage ST941 PDX tissue using published methods. Once established the line was characterized by immunohistochemistry and NGS and its tumorigenicity assessed. Drug sensitivity studies were carried out evaluating relevant endocrine and chemotherapy agents and results compared with in vivo drug studies. Timepoints for cell proliferation assays were Days 4, 7 and 10 following cell plating using standard MTS assay. Endpoints for in vivo studies were a mean group tumor volume of ~1 cm3 or sixty days following treatment initiation.

Results: Subcutaneous cell injection into athymic nude mice produced xenografts which grew in the absence of exogenous hormone. The ST941/C cell line and resulting xenograft retained immunohistologic and NGS characteristics of the parent model including receptor expression and ER mutation. Both the cell line and xenograft were insensitive to most endocrine therapies including tamoxifen, fulvestrant and aromatase inhibitors and reported correlative activity towards docetaxel and other chemotherapies.

Conclusion: We have established and evaluated an ESR1-mutant cell line designated ST941/C which is tumorigenic in nude mice and potentially useful for mechanistic and correlative in vivo studies to better understand acquired resistance in endocrine-treated ER+ breast cancer.

Citation Format: Wick MJ, Diaz A, Thomas M, Moriarty A, Quinn M, Guerra M, Zhu P, Smith P, Tolcher AW, Puyang X, Patnaik A, Korpal M, Rasco D, Papadopoulos KP. Establishment and characterization of ST941/C; an ESR1-mutant ER+ breast cancer cell line and xenograft from a patient with acquired resistance to endocrine therapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-04-26.

Newborn drug testing practices in Iowa birthing hospitals

OBJECTIVES

Federal law mandates states to have policies and procedures to identify newborns exposed to maternal substance use during pregnancy. National guidelines for newborn drug testing are lacking; therefore, procedures are variable and determined by state law and local practices. In Iowa, maternal substance use during pregnancy is considered child abuse and must be reported.The objective of this study was to identify newborn drug testing policies and procedures among birthing hospitals in Iowa.

METHODS

This was a cross sectional survey of all birthing hospitals in Iowa identified via the Statewide Perinatal Care Program. An electronic survey was sent to the representative at each affiliated hospital.

RESULTS

Sixty-nine of 76 hospitals completed the survey for a 90.8% response rate. Newborn drug testing is ordered in 97.1% of responding hospitals with most testing 25% or less of newborns annually. The majority utilized a risk assessment tool (89.6%), although many (62.7%) also allowed for provider discretion. No hospital performed universal testing of all newborns. 86.6% of hospitals reported all positive newborn drug test results including illicit and/or prescription drugs to child protective services. 35.0% of hospitals notified mothers of the report and 45.5% offered substance abuse services and/or treatment to the mothers.

CONCLUSIONS

Most Iowa birthing hospitals perform newborn drug testing and report all positive test results to child protective services. The majority use risk assessment tools. Maternal notification practices and referral for substance use disorder treatment are suboptimal and represent an area for future improvement.

Pegylated-asparaginase during induction therapy for adult acute lymphoblastic leukaemia: toxicity data from the UKALL14 trial

Safety and efficacy data on pegylated asparaginase (PEG-ASP) in adult acute lymphoblastic leukaemia (ALL) induction regimens are limited. The UK National Cancer Research Institute UKALL14 trial NCT01085617 prospectively evaluated the tolerability of 1000 IU/m2 PEG-ASP administered on days 4 and 18 as part of a five-drug induction regimen in adults aged 25-65 years with de novo ALL. Median age was 46.5 years. Sixteen of the 90 patients (median age 56 years) suffered treatment-related mortality during initial induction therapy. Eight of the 16 died of sepsis in combination with hepatotoxicity. Age and Philadelphia (Ph) status were independent variables predicting induction death >40 versus ⩽40 years, odds ratio (OR) 18.5 (2.02-169.0), P=0.01; Ph- versus Ph+ disease, OR 13.60 (3.52-52.36), P<0.001. Of the 74 patients who did not die, 37 (50.0%) experienced at least one grade 3/4 PEG-ASP-related adverse event, most commonly hepatotoxicity (36.5%, n=27). A single dose of PEG-ASP achieved trough therapeutic enzyme levels in 42/49 (86%) of the patients tested. Although PEG-ASP delivered prolonged asparaginase activity in adults, it was difficult to administer safely as part of the UKALL14 intensive multiagent regimen to those aged >40 years. It proved extremely toxic in patients with Ph+ ALL, possibly owing to interaction with imatinib.

Fabrication, characterisation and stability of oil-in-water emulsions stabilised by solid lipid particles: the role of particle characteristics and emulsion microstructure upon Pickering functionality

Emulsifier-mediated wettability of solid lipid particles promotes the Pickering functionality in oil-in-water emulsions.

Effect of expiratory positive airway pressure on tidal volume during non-invasive ventilation

During non-invasive ventilation (NIV), tidal volume ( V_t) will depend upon the difference between inspiratory and expiratory positive airway pressure (IPAP and EPAP, respectively), provided the respiratory muscles are relaxed and the lungs and chest wall therefore move along their passive pressure-volume curves. To test this hypothesis, we studied the effect of increasing EPAP during pressure-controlled modes of NIV in 30 long-term ventilator users (10 each with scoliosis, obesity hypoventilation or neuromuscular disorders). While maintaining the same IPAP, addition of 5 cmH₂O of EPAP reduced mean V_t by 167 ml; 10 cmH₂O reduced V_t by 367 ml. This pattern was seen in all three patient groups. EPAP has several potential advantages, for example maintaining upper airway patency, preventing basal atelectasis and facilitating triggering. EPAP does, however, appear to reduce V_t. Decreasing EPAP is an alternative to increasing IPAP if measurements of gas exchange during NIV indicate that ventilation is inadequate.

The synthesis and characterization of liquid crystalline oligoimides and polyimides

There are few examples of thermotropic polyimides reported in the literature. In the present article the authors report the synthesis and characterization of some novel oligoand poly-imides which exhibit mesogenic behaviour. The solution method of Yamazaki et al (Yamazaki N, Higashi F and Kawasaki J 1974 J. Polym. Sci., Polym. Chem. Ed. 12 2149) for the preparation of polyamides was successfully applied to the formation of imide compounds and oligomers. Liquid crystal phases were characterized by optical polarizing microscopy and by differential scanning calorimetry. Two anhydrides were employed which were considered to be suitable building blocks for preparing potentially mesogenic polyimides, namely biphenyl tetracarboxytic dianhydride and pyromellitic dianhydride. Low-molar-mass materials were first synthesized with monoanhydride units to endcap the chains. using nadic and maleic anhydrides. Nematic phases Awere observed in several nadic diimide compounds containing multicyclic cores and in some low-molar-mass diimides and polyimides which contained a biphenylene unit in conjunction with at least one other unsaturated ring When the nadlmldes were heated above 220 C cross-linking and decomposition occurred with loss of mesogenic properties. A fusible polyimide was synthesized containing a flexible chain which exhibited thermotropic behaviour below its decomposition temperature.

Impaired calcium mobilization in natural killer cells from chronic fatigue syndrome/myalgic encephalomyelitis patients is associated with transient receptor potential melastatin 3 ion channels

Transient receptor potential melastatin subfamily 3 (TRPM3) ion channels play a role in calcium (Ca²⁺) cell signalling. Reduced TRPM3 protein expression has been identified in chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) patients. However, the significance of TRPM3 and association with intracellular Ca²⁺ mobilization has yet to be determined. Fifteen CFS/ME patients (mean age 48·82 ± 9·83 years) and 25 healthy controls (mean age 39·2 ± 12·12 years) were examined. Isolated natural killer (NK) cells were labelled with fluorescent antibodies to determine TRPM3, CD107a and CD69 receptors on CD56^dimCD16⁺NK cells and CD56^brightCD16^dim/– NK cells. Ca²⁺ flux and NK cytotoxicity activity was measured under various stimulants, including pregnenolone sulphate (PregS), thapsigargin (TG), 2‐aminoethoxydiphenyl borate (2APB) and ionomycin. Unstimulated CD56^brightCD16^dim/– NK cells showed significantly reduced TRPM3 receptors in CFS/ME compared with healthy controls (HC). Ca²⁺ flux showed no significant difference between groups. Moreover, PregS‐stimulated CD56^brightCD16^dim/–NK cells showed a significant increase in Ca²⁺ flux in CFS/ME patients compared with HC. By comparison, unstimulated CD56^dimCD16⁺ NK cells showed no significant difference in both Ca²⁺ flux and TRPM3 expression. PregS‐stimulated CD56^dimCD16⁺ NK cells increased TRPM3 expression significantly in CFS/ME, but this was not associated with a significant increase in Ca²⁺ flux. Furthermore, TG‐stimulated CD56^dimCD16⁺ NK cells increased K562 cell lysis prior to PregS stimulation in CFS/ME patients compared with HC. Differential expression of TRPM3 and Ca²⁺ flux between NK cell subtypes may provide evidence for their role in the pathomechanism involving NK cell cytotoxicity activity in CFS/ME.

The effectiveness of gynaecology teaching associates in teaching pelvic examination to medical students: a randomised controlled trial

OBJECTIVES

To assess whether teaching female pelvic examinations using gynaecological teaching associates (GTAs); women who are trained to give instruction and feedback on gynaecological examination technique, improves the competence, confidence and communication skills of medical students compared to conventional teaching.

STUDY DESIGN

Randomised controlled trial.

SETTING

Ten University of Birmingham (UoB) affiliated teaching hospitals in the UK.

POPULATION

492 final year medical students.

METHODS

GTA teaching of gynaecological examination compared with conventional pelvic manikin based teaching at the start of a five week clinical placement in obstetrics and gynaecology (O&G).

MAIN OUTCOME MEASURES

Student's perception of their confidence was measured on a 10cm visual analogue scale (VAS). Domains of competence were measured by a senior clinical examiner using a standardised assessment tool which utilised 10cm VAS and by a GTA using a four point Likert scale. Assessors were blinded to the allocated teaching intervention.

RESULTS

407/492 (83%) students completed both the intervention and outcome assessment. Self-reported confidence was higher in students taught by GTAs compared with those taught on manikins (median score GTA 6.3; vs. conventional 5.8; p=0.03). Competence was also higher in those taught by GTAs when assessed by an examiner (median global score GTA 7.1 vs. conventional 6.0; p<0.001) and by a GTA (p<0.001).

CONCLUSIONS

GTA teaching of female pelvic examination at the start of undergraduate medical student O&G clinical placements improves their confidence and competence compared with conventional pelvic manikin based teaching. GTAs should be introduced into undergraduate medical curricula to teach pelvic examination.

Training Teachers in Human Sexuality: Effect on Attitude and Knowledge

The current study investigated the extent to which a 9-wk. course on human sexuality for teachers changed their knowledge and attitudes. Significant changes were found from the pre- to post-course assessment on both measures of knowledge. The only significant change in attitude scores, however, was on the Autoeroticism Attitude Scale. This pilot program encourages further exploration of the differences in methodological approaches and the long-term effects of training on specific attitudes and knowledge.

A pathway to clinician-led culture change in the operating theatre

Noise in the operating theatre environment has remained a persistent and unresolved problem (Szalma & Hancock 2011). The problem currently lacks an effective solution (Schafer et al 2012). In order to partially resolve this issue, the authors created a behavioural noise reduction tool called ‘Below Ten Thousand’. This study identifies a potential solution to the problem of behavioural noise in the operating theatre, and indicates further research must be undertaken to identify the full scale of benefits this technique can deliver to the team environment in the operating theatre.

Long-term non-invasive ventilation in muscular dystrophy

Long-term non-invasive ventilation (NIV) was introduced in the 1980s, initially mainly for patients with poliomyelitis, muscular dystrophy (MD) or scoliosis. The obesity-hypoventilation syndrome has since become the commonest reason for referral to most centres providing home-NIV. Patients with MD are numerically a much smaller part of the workload, but as their disease progresses the need for ventilatory support changes and they require regular comprehensive assessment of their condition. We have examined the trend in MD use of home-NIV in our unit over the last 25 years. The number of new referrals appears to be stabilizing at around 20-25 over a 5-year period, equivalent to approximately 0.5 per 100,000 of population per year. The mean age at commencement of home-NIV is now 37.5 years, with 5-year survival rates of 70-75%. Ten-year survival rates are just over 40%. The distance of usual place of residence from our unit is fairly stable, currently at a mean of 27 km. Excellent survival rates mean that patients with MD, while numerically small, are likely to remain an important part of the workload of centres providing home-NIV. Our data should prove useful in the planning of future services for this group of patients.

Novel identification and characterisation of Transient receptor potential melastatin 3 ion channels on Natural Killer cells and B lymphocytes: effects on cell signalling in Chronic fatigue syndrome/Myalgic encephalomyelitis patients

BACKGROUND

Transient receptor potential melastatin 3 (TRPM3) cation channels are ubiquitously expressed by multiple cells and have an important regulatory role in calcium-dependent cell signalling to help maintain cellular homeostasis. TRPM3 protein expression has yet to be determined on Natural Killer (NK) cells and B lymphocytes. Multiple single nucleotide polymorphisms have been reported in TRPM3 genes from isolated peripheral blood mononuclear cells, NK and B cells in Chronic fatigue syndrome/Myalgic encephalomyelitis (CFS/ME) patients and have been proposed to correlate with illness presentation. The object of the study was to assess TRPM3 surface expression on NK and B lymphocytes from healthy controls, followed by a comparative investigation examining TRPM3 surface expression, and cytoplasmic and mitochondrial calcium influx in CD19(+) B cells, CD56(bright) and CD56(dim) cell populations from CFS/ME patients.

RESULTS

TRPM3 cell surface expression was identified for NK and B lymphocytes in healthy controls (CD56(bright) TRPM3 35.72 % ± 7.37; CD56(dim) 5.74 % ± 2.00; B lymphocytes 2.05 % ± 0.19, respectively). There was a significant reduction of TRPM3 surface expression on CD19(+) B cells (1.56 ± 0.191) and CD56(bright) NK cells (17.37 % ± 5.34) in CFS/ME compared with healthy controls. Anti-CD21 and anti-IgM conjugated biotin was cross-linked with streptavidin,and subsequently treatment with thapsigargin. This showed a significant reduction in cytoplasmic calcium ion concentration in CD19(+) B lymphocytes. CD56(bright) NK cells also had a significant decrease in cytoplasmic calcium in the presence of 2-APB and thapsigargin in CFS/ME patients.

CONCLUSIONS

The results from this preliminary investigation identify, for the first time, TRPM3 surface expression on both NK and B lymphocytes in healthy controls. We also report for the first time, significant reduction in TRPM3 cell surface expression in NK and B lymphocytes, as well as decreased intracellular calcium within specific conditions in CFS/ME patients. This warrants further examination of these pathways to elucidate whether TRPM3 and impaired calcium mobilisation has a role in CFS/ME.

Prebiotic-supplemented partially hydrolysed cow's milk formula for the prevention of eczema in high-risk infants: a randomized controlled trial

Background

Prevention guidelines for infants at high risk of allergic disease recommend hydrolysed formula if formula is introduced before 6 months, but evidence is mixed. Adding specific oligosaccharides may improve outcomes.

Objective

To evaluate whether partially hydrolysed whey formula containing oligosaccharides (0.8 g/100 ml) (pHF‐OS) can prevent eczema in high‐risk infants [ISRCTN65195597].

Methods

We conducted a parallel‐group, multicentre, randomized double‐blind controlled trial of pHF‐OS vs standard cow's milk formula. Infants with a family history of allergic disease were randomized (stratified by centre/maternal allergy) to active (n = 432) or control (n = 431) formula until 6 months of age if formula was introduced before 18 weeks. Primary outcome was cumulative incidence of eczema by 12 months in infants randomized at 0–4 weeks (375 pHF‐OS, 383 control). Secondary outcomes were cumulative incidence of eczema by 12 or 18 months in all infants randomized, immune markers at 6 months and adverse events.

Results

Eczema occurred by 12 months in 84/293 (28.7%) infants allocated to pHF‐OS at 0‐4 weeks of age, vs 93/324 (28.7%) control (OR 0.98 95% CI 0.68, 1.40; P = 0.90), and 107/347 (30.8%) pHF‐OS vs 112/370 (30.3%) control in all infants randomized (OR 0.99 95% CI 0.71, 1.37; P = 0.94). pHF‐OS did not change most immune markers including total/specific IgE; however, pHF‐OS reduced cow's milk‐specific IgG1 (P < 0.0001) and increased regulatory T‐cell and plasmacytoid dendritic cell percentages. There was no group difference in adverse events.

Conclusion

pHF‐OS does not prevent eczema in the first year in high‐risk infants. The immunological changes found require confirmation in a separate cohort.

Normal Development and Measurements of the Occipital Condyle-C1 Interval in Children and Young Adults

BACKGROUND AND PURPOSE

Widening of the occipital condyle-C1 interval is the most specific and sensitive means of detecting atlanto-occipital dislocation. Recent studies attempting to define normal measurements of the condyle-C1 interval in children have varied substantially. This study was performed to test the null hypothesis that condyle-C1 interval morphology and joint measurements do not change as a function of age.

MATERIALS AND METHODS

Imaging review of subjects undergoing CT of the upper cervical spine for reasons unrelated to trauma or developmental abnormality was performed. Four equidistant measurements were obtained for each bilateral condyle-C1 interval on sagittal and coronal images. The cohort was divided into 7 age groups to calculate the mean, SD, and 95% CIs for the average condyle-C1 interval in both planes. The prevalence of a medial occipital condyle notch was calculated.

RESULTS

Two hundred forty-eight joints were measured in 124 subjects with an age range of 2 days to 22 years. The condyle-C1 interval varies substantially by age. Average coronal measurements are larger and more variable than sagittal measurements. The medial occipital condyle notch is most prevalent from 1 to 12 years and is uncommon in older adolescents and young adults.

CONCLUSIONS

The condyle-C1 interval increases during the first several years of life, is largest in the 2- to 4-year age range, and then decreases through late childhood and adolescence. A single threshold value to detect atlanto-occipital dissociation may not be sensitive and specific for all age groups. Application of this normative data to documented cases of atlanto-occipital injury is needed to determine clinical utility.

The risk of oesophageal adenocarcinoma in a prospectively recruited Barrett's oesophagus cohort

BACKGROUND

Varying rates of oesophageal adenocarcinoma (OAC) complicating Barrett's oesophagus (BO) have been reported. Recent studies and meta-analyses suggest a lower incidence, questioning the value of endoscopic surveillance.

AIM

We aimed to retrospectively examine the rate of OAC, risk factors and causes of death in a prospectively recruited BO cohort.

METHODS

Data from patients with BO from a cohort from 1982-2007 were studied. Patients were subdivided into surveyed, failed to attend surveillance and unfit for surveillance. Standardised mortality ratios (SMR) were calculated for common causes of death. Cox proportional hazards models were used to determine which factors were associated with progression to OAC.

RESULTS

In total, 671 BO patients (61% male) were studied; 37 (76% male) were diagnosed with OAC. OAC incidence was 0.47% per annum and stable across three decades (1982-1991 0.56%, 1992-2001 0.46%, 2002-2012 0.41% (p = 0.8)). All-cause mortality was increased for the whole cohort (SMR 163(95% CI 145-183)). Mortality from OAC appeared higher in patients who failed to attend surveillance (SMR 3216(95% CI 1543-5916)) compared with surveyed (SMR 1753(95% CI 933-2998)) and those unfit for surveillance due to co-morbidity (SMR 440(95% CI 143-1025)). Multivariable analysis identified low-grade dysplasia (HR 4.4(95% CI 1.56-12.43), p = 0.005) and length of BO (HR 1.2(95% (1.1-1.3)), p < 0.001)) as associated with OAC.

CONCLUSIONS

Progression to OAC appeared stable over three decades at 0.47% per annum. Patients with BO had a modest increase in all-cause mortality and a large increase in OAC mortality, particularly if fit for surveillance. Low-grade dysplasia and the length of the BO segment were associated with developing OAC.

Epidemiological cut-off values for Flavobacterium psychrophilum MIC data generated by a standard test protocol

Epidemiological cut-off values were developed for application to antibiotic susceptibility data for Flavobacterium psychrophilum generated by standard CLSI test protocols. The MIC values for ten antibiotic agents against Flavobacterium psychrophilum were determined in two laboratories. For five antibiotics, the data sets were of sufficient quality and quantity to allow the setting of valid epidemiological cut-off values. For these agents, the cut-off values, calculated by the application of the statistically based normalized resistance interpretation method, were ≤16 mg L(-1) for erythromycin, ≤2 mg L(-1) for florfenicol, ≤0.025 mg L(-1) for oxolinic acid (OXO), ≤0.125 mg L(-1) for oxytetracycline and ≤20 (1/19) mg L(-1) for trimethoprim/sulphamethoxazole. For ampicillin and amoxicillin, the majority of putative wild-type observations were 'off scale', and therefore, statistically valid cut-off values could not be calculated. For ormetoprim/sulphadimethoxine, the data were excessively diverse and a valid cut-off could not be determined. For flumequine, the putative wild-type data were extremely skewed, and for enrofloxacin, there was inadequate separation in the MIC values for putative wild-type and non-wild-type strains. It is argued that the adoption of OXO as a class representative for the quinolone group would be a valid method of determining susceptibilities to these agents.

Factors that affect fractured neck of femur outcome: Clinical commissioning groups influence length of stay and discharge destination

BACKGROUND

The average length of stay (LOS) following a hip fracture in hospitals around the UK has been approximately 20 days in recent years. This can vary between hospitals and there are numerous factors that can affect LOS. We had the impression that LOS varied by Clinical Commissioning Group (CCG) from which the patient originates. The aim of our study was to discover whether the concern was valid, and if so, what the reasons may be.

METHODS

We analysed hip fracture data collected at our Trust between September 2008 and December 2014. LOS was compared for each of three CCGs in our Trust's catchment areas, and those patients admitted from outlying CCGs. Sub-analysis was performed by patient age, ASA grade, abbreviated mental test score, procedure type and discharge destination to determine which factors influence LOS.

RESULTS

1847 patients were identified. After excluding deaths, missing data and extreme outliers, 1603 patients were included in the analysis. The median LOS varied from 14.9 to 23.4 days across CCGs. The major reason for this variation was discharge destination. CCGs associated with longer LOS had a significantly higher rate of discharge to the patient's own home, rather than institutional care. This was independent of patient age, mental status, ASA grade and promptness of surgery.

CONCLUSION

We have shown that CCGs vary in their performance to aid discharge. This directly influences a Trust's performance on the National Hip Fracture Database. Compared with other hospitals, our results show a poor outcome in terms of length of stay, but much better performance regarding home discharge. We recommend that more emphasis in future be placed on discharge destination than LOS.

Amphetamine and other pharmacological agents in human and animal studies of recovery from stroke

Neuromodulation with pharmacological agents, including drugs of abuse such as amphetamine, when paired with behavioral experience, has been shown to positively modify outcomes in animal models of stroke. A number of clinical studies have tested the efficacy of a variety of drugs to enhance recovery of language deficit post-stroke. The purpose of this paper is to: (1) present pertinent animal studies supporting the use of dextro-amphetamine sulfate (AMPH) to enhance recovery after experimental lesions with emphasis on the importance of learning dependent activity for lasting recovery; (2) briefly review neuropharmacological explorations in the treatment of aphasia; (3) present a pilot study in aphasia exploring a drug combination of AMPH and donepezil hydrochloride paired with behavioral treatment to facilitate recovery; and (4) conclude with comments regarding the role of adjunctive pharmacotherapy in the rehabilitation of aphasia, particularly AMPH.

Compulsivity and probabilistic reversal learning in OCD and cocaine addiction

Compulsive behavior is a core symptom of both obsessive compulsive disorder (OCD) and cocaine addiction (CA). Across both pathologies, one can identify a priori goal-directed actions (purportedly anxiolytic checking or washing in OCD and pleasure-seeking drug use in addiction) that turn into rigid, ritualized and repetitive behaviors over which the patient loose control. One possible psychopathological mechanism underlying compulsivity is behavioral inflexibility, namely a deficit in the aptitude to dynamically adapt to novel contexts and changing reward rules. The probabilistic reversal learning paradigm allows to objectively assess behavioral flexibility by challenging participants with a task where they have to learn through trials-and-errors which of two stimuli is the most-often rewarded one, while adjusting to sudden inconspicuous contingency reversals. We therefore hypothesized that both OCD and CA would be associated with impaired cognitive flexibility, as measured through perseverative response rate following contingency reversals in this task. Interestingly, impulsivity may also be assessed within this task via the tendency of participants to switch from one stimulus to the other following probabilistic errors. To investigate cognitive inflexibility in relation to CA and OCD respectively, we first compared the performance in a probabilistic reversal learning task of cocaine users, ex cocaine users (abstinent for 2 months or more), and controls, as well as that of participants from the general population whose obsessive-compulsive traits were assessed using the OCI-R, a well-validated self-questionnaire. Our task yielded results similar to those found in the literature: cocaine addicts changed their responses more often, and learned less effectively. Ex-cocaine addicts performed better than addicts but worse than controls, suggesting that addicts’ poor results may be in part explained by reversible cognitive consequences of addiction. Addicts with less cognitive impairments may also be less likely to relapse. Regarding the relationship of flexibility to subclinical OCD traits, we found no link between OCI-R score and perseveration, or between impulsiveness and excessive switching.

What happens to the mental health of UK service personnel after they return home from Afghanistan?

OBJECTIVE

Fear et al identified a small but significant increase in probable post-traumatic stress disorder (PTSD) in UK military personnel from around 3% in first year post deployment to around 6% by year 5. As yet it is not clear what factors are linked to the increase in probable PTSD, and therefore, serial measurement of poor mental health would be helpful.

METHOD

Rates of mental ill health among UK service personnel were compared upon deployment completion and at follow-up and identified factors associated with maladjustment.

RESULTS

Poor mental health symptomatology increased from baseline to follow-up, PTSD symptoms and related functional impairment increased significantly. Poor baseline mental health was predictive of transition and family relationship difficulties.

CONCLUSIONS

The results are discussed in relation to encouraging recognition and reporting of symptoms among personnel and their social networks.