Patient satisfaction with a pilot chronic pain management programme in Cape Town, South Africa

Background: The goals of a chronic pain management clinic includeincreasing patient knowledge about pain, developing pain management skillsand increasing patients’ confidence in their pain management abilities.A  Chronic Pain Management Programme (CPMP) based on evidence basedguidelines was developed at a chronic pain management clinic to facilitatepatient discharge to a primary healthcare level. Aim: The aim of this study was to explore patient satisfaction with, acceptability of and the perceived success which could be due to the CPMP developed at the Chronic Pain Management Clinic of Groote Schuur Hospital,Cape Town.Methods: Patients (n=14) were referred to the pilot study from the Chronic Pain Management Clinic. A s a pilot, four courses were run over a period ofone year. In order to reach the research aim, an eleven-question, structuredopen-ended interview was conducted with all participants. Results: Fourteen patients enrolled in the CPMP. Responses were favourable with participants emphasising the roleof increased knowledge about pain, the role of exercise and of stress management techniques. Participants also recog-nised a positive change in behaviours and attitudes following participation in the CPMP.Conclusions: Findings suggest that participants found the format of the course acceptable as regards course content,structure and delivery. Participant responses suggest that the course was acceptable and perceived as useful. However,future courses would benefit from refresher courses or structured support groups.

Observation of self-generated flows in tokamak plasmas with lower-hybrid-driven current

In Alcator C-Mod discharges lower hybrid waves have been shown to induce a countercurrent change in toroidal rotation of up to 60 km/s in the central region of the plasma (r/a approximately <0.4). This modification of the toroidal rotation profile develops on a time scale comparable to the current redistribution time (approximately 100 ms) but longer than the energy and momentum confinement times (approximately 20 ms). A comparison of the co- and countercurrent injected waves indicates that current drive (as opposed to heating) is responsible for the rotation profile modifications. Furthermore, the changes in central rotation velocity induced by lower hybrid current drive (LHCD) are well correlated with changes in normalized internal inductance. The application of LHCD has been shown to generate sheared rotation profiles and a negative increment in the radial electric field profile consistent with a fast electron pinch.

Local impact of the English arm of the UK Bowel Cancer Screening Pilot study

Background

The English arm of the UK Bowel Cancer Screening Pilot study recently concluded its third round. The primary aim was to assess the impact of faecal occult blood test (FOBT) screening on the detection of symptomatic (non-screen-detected) cancers within the target age group (50–69 years). The secondary aim was to assess differences between screened and non-screened cohorts in Dukes' classification at diagnosis.

Methods

This population-based study utilized retrospective analysis of existing validated colorectal cancer (CRC) data over 5 years (April 2000 to March 2005), encompassing rounds one and two of screening.

Results

There was a 23 per cent (P = 0·011) reduction in the diagnosis of over the 5 years. Presentations with symptomatic cancer reduced by 49 per cent (P = 0·049), with a proportionate (2·6-fold) rise in the detection of screened (asymptomatic) malignancy. Cancers were diagnosed at an earlier stage in the screened population, with significantly more Dukes' A tumours than in the non-screen-detected cohort (P &lt; 0·001) and an estimated odds ratio of 0·27 (95 per cent confidence interval 0·08 to 0·91) (P = 0·035) for Dukes' ‘D’ cancers.

Conclusion

FOBT screening resulted in a significant reduction in the number of symptomatic cancers detected within the target age group. Tumours detected by screening were diagnosed at an earlier pathological stage.

The UK colorectal cancer screening pilot: results of the second round of screening in England

An evaluation of the second round of faecal occult blood (FOB) screening in the English site of the UK Colorectal Cancer Screening Pilot (comprising the Bowel Cancer Screening Pilot based in Rugby, general practices in four Primary Care Trusts, and their associated hospitals) was carried out. A total of 127 746 men and women aged 50–69 and registered in participating general practices were invited to participate. In all, 15.9% were new invitees not included in the previous round. A total of 52.1% of invitees returned a screening kit. Uptake varied with gender, age, and level of deprivation; was lower than in the first round (51.9 vs 58.5% P<0.0001), but was high (81.1%) in those who had participated in the first round with a negative result. Test positivity was 1.77%, significantly higher than in the first round, and the detection rate of neoplasia similar (5.67 per 1000), resulting in a lower positive predictive value. The sensitivity of FOBt in the first round was estimated as 57.7–64.4%. There was a significant impact on workload, particularly on endoscopy services. The cancer detection rate (0.94 per 1000) was lower than in the first round. Effort will be required to minimise inequalities in uptake, and to ensure adequate capacity of endoscopy services.

Detection and evolution of resistance to the pyrethroid cypermethrin in Helicoverpa zea (Lepidoptera: Noctuidae) populations in Texas

The bollworm, Helicoverpa zea (Boddie), is a key pest of cotton in Texas. Bollworm populations are widely controlled with pyrethroid insecticides in cotton and exposed to pyrethroids in other major crops such as grain sorghum, corn, and soybeans. A statewide program that evaluated cypermethrin resistance in male bollworm populations using an adult vial test was conducted from 2003 to 2006 in the major cotton production regions of Texas. Estimated parameters from the most susceptible field population currently available (Burleson County, September 2005) were used to calculate resistance ratios and their statistical significance. Populations from several counties had statistically significant (P < or = 0.05) resistance ratios for the LC(50), indicating that bollworm-resistant populations are widespread in Texas. The highest resistance ratios for the LC(50) were observed for populations in Burleson County in 2000 and 2003, Nueces County in 2004, and Williamson and Uvalde Counties in 2005. These findings explain the observed pyrethroid control failures in various counties in Texas. Based on the assumption that resistance is caused by a single gene, the Hardy-Weinberg equilibrium formula was used for estimation of frequencies for the putative resistant allele (q) using 3 and 10 microg/vial as discriminatory dosages for susceptible and heterozygote resistant insects, respectively. The influence of migration on local levels of resistance was estimated by analysis of wind trajectories, which partially clarifies the rapid evolution of resistance to cypermethrin in bollworm populations. This approach could be used in evaluating resistance evolution in other migratory pests.

TGF-beta in intestinal lymphoid organs contributes to the death of armed effector CD8 T cells and is associated with the absence of virus containment in rhesus macaques infected with the simian immunodeficiency virus

SIV-infected macaques exhibit distinct rates of progression to AIDS and despite significant increases in CD8+ T cells, immune cells fail to control and eradicate SIV in vivo. Here, we investigated the interplay between viral reservoir sites, CD8+ T-cell activation/death and outcome. Our data provide strong evidence that mesenteric (Mes) lymph nodes represent major reservoirs not only for SIV-infected macaques progressing more rapidly toward AIDS but also in controllers. We demonstrate that macaques progressing faster display greater expression of TGF-beta and Indoleamine 2,3 dioxygenase in particular in intestinal tissues associated with a phosphorylation of the p53 protein on serine 15 in CD8+ T cells from Mes lymph nodes. These factors may act as a negative regulator of CD8+ T-cell function by inducing a Bax/Bak/Puma-dependent death pathway of effector/memory CD8+ T cells. Greater T-cell death and viral dissemination was associated with a low level of TIA-1+ expressing cells. Finally, we provide evidence that abrogation of TGF-beta in vitro enhances T-cell proliferation and reduces CD8+ T-cell death. Our data identify a mechanism of T-cell exhaustion in intestinal lymphoid organs and define a potentially effective immunological strategy for the modulation of progression to AIDS.

Angiogenesis index (AI) as a predictor of tumor burden in lymph nodes in colon cancer (Cca) patients (pts) undergoing sentinel lymph node (SLN) mapping (M)

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Background: Lymph Node (LN) status is the most important prognostic factor in colon cancer (Cca). Angiogenesis Index (AI) has been studied as a prognostic marker in various solid tumors with conflicting results. Hence, a retrospective analysis was done to evaluate the role of AI as a prognostic marker in Cca. Methods: Pts with Cca who underwent SLNM to determine LN status were included. A portion of tumor was sent for tumor marker analysis including p53, Thrombospondin-1 and CD31 by IHC. AI was derived for each specimen by summing the biomarker specific score for the three tumor markers. AI of -ve 6 was taken as cut off for significance based on previous studies on solid tumors. Metastatic foci in SLNs and non-SLNs were measured in greatest diameter by ocular micrometer; and were added for each pt to estimate overall tumor burden in SLNs and non-SLNs. Results: A total of 111 consecutive pts with Cca were included in the study. SLNM was successful in 100% pts. Pts with distant metastasis (mets) (n=18), Tis (n=1) and skip mets (n=9) were excluded from final analysis. Out of the remaining 83 pts, an AI of -6 or less was found in 22 pts (26.5%) while 61 pts (73.5%) had AI of more than (>) -6. Of the 61 pts with AI > -6, 37.7% pts were SLN +ve while 62.3% pts were SLN -ve (p=0.05)( Table 1A ). Of the 22 pts with AI less than or -6, 45.5% pts were SLN +ve and 54.5% pts were SLN -ve (p=0.65). Size of the metastatic tumor burden in lymph nodes was available in 69.7% of SLN +ve pts. Total average tumor burden for pts with AI > -6 (n=15) was 2.04cm as compared to 1.48cm in pts with AI of -6 or less (n=8)(p=0.66). Average SLN met size was 0.73cm in pts with AI > -6 and 0.63cm in pts with AI of -6 or less (p=0.66)( Table 1B ). Conclusions: AI did not correlate with nodal positivity or tumor burden in LNs in pts with Cca. LN status remains the most important prognostic marker in Cca. Further larger trials are required to determine the role of AI as a prognostic marker in Cca.

[Table: see text] [Table: see text]

No significant financial relationships to disclose.

Correlation between immunohistochemical biomarker expression and in vitro drug response factors in stage III-IV ovarian cancer

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Background: The reliability of molecular biomarkers as predictors of treatment outcome remains unclear and, in relation to drug resistance even less is known. Immunohistochemical (IHC) expression of biomarkers and in vitro drug resistance (IVDR) relative to clinical outcome were evaluated in patients with stage III-IV epithelial ovarian cancer (OC) who received combination carboplatin (CAR) plus paclitaxel (TAX) chemotherapy. Methods: We correlated clinical outcome with histopathology and biomarker expression of MIB-1, p53, BCL2, EGFR, ER and PR in 98 OC patients with tumors tested for IVDR by extreme drug resistance (EDR) assay. IVDR was determined following exposures to single agents CAR, cisplatin (CP), TAX, taxotere (TXT), gemcitabine (GCB), topotecan (TP), liposomil doxorubicin, and cytoxan (CT). Percentage cell growth inhibition (PCI) for each drug was compared with PCI from untreated control cultures. Results: Tumors with prior chemotherapy (n=29) were more resistant to CAR (unpaired t-test, p=0.046), and CT (p=0.038), and more sensitive to liposomil doxorubicin (p=0.009), compared to treatment naive tumors (n=53). For 65 tumors, there was a positive relationship between MIB-1 vs p53 (r=0.419; p=0.001), and between ER vs PR (r=0.339; p=0.011). Correlation between biomarkers and drug response showed a significantly inverse relationship between MIB-1 vs liposomil doxorubicin, p53 vs liposomil doxorubicin, EGFR vs CAR, CP, GCB and TAX; and between ER vs TXT and CT, and PR vs CT and TP. With a 53% (33/61) response rate to CAR+TAX, time to progression (TTP) for responders (R) with EGFR+ tumors was longer (median TTP 15.6 mo); and shorter for R with EGFR- tumors (p=0.008). For R and non-R, BCL2+ tumors had longer overall survival (OS) (median OS 23.3 mo; p=0.006). No other significant correlations were seen. Conclusion: Prior chemotherapy increased IVDR to CAR and CT, and increased sensitivity to liposomil doxorubicin. Increased expression of proliferation biomarkers, particularly EGFR, correlated with resistance to several chemotherapeutic agents. EGFR expression in responders was associated with longer TTP. The significance of in vitro correlates of prognostic biomarker expression and IVDR for predicting chemoresistance warrants prospective studies to assess its value in clinical settings.

[Table: see text]

The Bali bombings and the evolving mental health response to disaster in Australia: lessons from Darwin

The Bali bombing in 2002 initiated a new phase of trauma response for public health services in Australia, and the Royal Darwin Hospital in particular. The mental health response to the initial disaster was limited to a debriefing of Royal Darwin Hospital staff some time after the disaster. Following this initial episode, a number of important developments occurred within the Royal Darwin Hospital and nationally to further develop mental health resources. A mental health consultation liaison nursing position was established within the hospital. The Director of Mental Health for the Northern Territory, along with the Director of Psychiatry, was involved with an evolving national mental health response to mass trauma through the National Planning Group of Mental Health Response to Trauma. The improved recognition of mental health in disaster response, along with increased recognition and confidence in the consultation liaison nursing staff, considerably improved the mental health services available to patients and Royal Darwin Hospital staff following the second Bali blast in October 2005.

Physiotherapy students’ assessment of psychosocial yellow flags in low back pain

Background: Low Back Pain (LBP) makes up a large proportion of referrals to physiotherapy worldwide. Thus training in its effective assessment and management is essential. With psychosocial yellow flags having been recognised as the strongest predictors of chronicity in LBP, guidelines on the management of LBP emphasise the importance of assessing and managing yellow flags. Aim: The aim of this research was to explore whether physiotherapy students were able to assess risk of chronicity based on the presence of yellow flags in descriptions of people with LBP.Method: A postal semi-structured questionnaire based on clinicalvignettes was sent to all the Level 3 physiotherapy students studying at Queen Margaret University College, Edinburgh.Results: The survey was responded to by 15 of the students (35%). The respondents overestimated risk of chronic LBP from the vignettes. Evaluation of risk for chronicity was based on few yellow flags i.e. the strongest predictors of chronicity were not effectively interpreted resulting in incorrect determination of risk for chronic LBP. All respondents included at least one risk factor not supported by the evidence. Conclusions: Physiotherapy students in this study did not appear to respond appropriately to the presence ofyellow flags in the presented vignettes.

Molecular modeling studies of the binding characteristics of phosphates to sevelamer hydrochloride--assessing a novel technique to reduce phosphates contamination

Recent advances in the use of polymeric materials for the remediation of phosphate from aqueous systems, including biological environments, have prompted the use of computational techniques to determine which methods are feasible to model such complex systems and to model the mechanism of binding action. In particular, Sevelamer Hydrochloride (Renagel®) is used as our model polymer. A relatively simple system is constructed with a dimer of Sevelamer Hydrochloride and four phosphate ions used for capture. This work reports on molecular dynamics and Monte Carlo simulations used to determine average structure, and points of intermolecular interaction, and calculate changes in volume after the successful capture of phosphate in our model. Our resulting volume changes are of the order of 20–25%, in comparison to experimental swelling measurements on similar systems, which have an average swelling of 50–60% in aqueous media.

61. GP PERSPECTIVES ON PARTNER NOTIFICATION FOR CHLAMYDIA

As part of a larger, combined qualitative-quantitative study of partner notification, 40 semi-structured in-depth telephone interviews were conducted with General Practitioners (GPs), from Victoria, ACT and Queensland, who had diagnosed at least one case of chlamydia in the last year. Rural doctors and those who had experience working with Aboriginal patients were over-sampled to ensure their views were represented in the study. The interviews explored GPs' current practices with regard to partner notification for chlamydia, barriers they perceived to partner notification for chlamydia in the general practice setting and what resources/incentives they felt would improve partner notification for chlamydia. The GPs in our study primarily ask the index patient to carry out partner notification themselves. It was relatively rare for GPs to have experience of notifying partners on the patient's behalf. Half of the GPs report that they only encourage notification of the patient's current/immediate past partners. There was considerable confusion amongst the GPs interviewed as to the role of government partner notification officers. Many thought that support from a government agency would allow partner notification to occur more effectively. Some were under the impression that this process is automatically activated when they 'notify' that they have diagnosed someone with chlamydia. Some of the main barriers perceived include confusion about issues of privacy and confidentiality with regard to partner notification and the sense that there is a lack of clarity as to what is expected of them in terms of partner notification for chlamydia. Most GPs feel that access to decision support tools and clear guidelines would be helpful. Financial incentives for doing partner notification were seen as particularly important to fund allied health workers' time rather than to pay GPs themselves e.g. for practice nurses and Aboriginal health workers. GPs were enthusiastic about computer based resources to aid in partner notification

56. TAKE THE SEX OUT OF STI SCREENING! VIEWS OF GPS AND YOUNG WOMEN ON IMPLEMENTING CHLAMYDIA SCREENING IN AUSTRALIA

In-depth face to face interviews were carried out with a randomly selected sample of 20 General Practitioners (GPs) and 24 young women from across Victoria. We aimed to determine the attitudes of GPs and young women to chlamydia screening, what systems and education would be required to support chlamydia screening in general practice in Australia and in particular to explore how young women feel about being asked to test for chlamydia when they attend a GP for any reason. Both GPs and young women accept age-based screening for chlamydia and screening during a sexual health related consultation in general practice. Both feel that a large scale public education program, encompassing the high prevalence of chlamydial infection in young people in Australia, the asymptomatic nature of infection and the potential consequences if untreated, will be essential in ensuring the success of a chlamydia screening program in Australia. For the women, trust in their GP, was a major factor in the acceptability of chlamydia screening. They also felt chlamydia screening should be offered to all young women rather than targeted at 'high risk' women based on sexual history and they particularly emphasised the importance of normalising chlamydia screening. Women were clear that they did not want to be asked to provide a sexual history as part of being asked to have a chlamydia test. This finding has not been widely published in the literature and is worthy of comment. There is considerable evidence suggesting that GPs also regard sexual history taking as a barrier to STI testing in general practice. Chlamydia is an STI and notification and treatment of sexual partners is important. Understanding these concepts promotes young women's acceptance of chlamydia screening. However, is a detailed sexual history really an important precursor to a chlamydia test? Our study suggests maybe not.

P53 as a predictor of tumor burden in lymph nodes (LN) in colon cancer (Cca) patients (pts) undergoing sentinel lymph node (SLN) mapping (M)

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Background: p53 and LN status(S) are important prognostic markers in Cca. Our study was done to evaluate whether p53 S could predict tumor burden in LNs in Cca undergoing SLNM. Methods: Pts with Cca underwent SLNM to determine the LN S. A portion of tumor was used for detection of p53 S by IHC.p53 Histo Score (HS) was defined as (Intensity of stain in cells from 0–4 +1) × (% cells staining). HS of 180 was taken as cut off for significance based on previous studies on solid tumors. Metastatic foci in SLNs and nonSLNs were measured in greatest diameter by ocular micrometer. For overall tumor burden in SLNs and nonSLNs,all metastatic foci were added for each pt. Results: SLNM was successful in 100% of the 117 consecutive pts with Cca. Pts with distant metastasis (mets) (18) and skip mets (9) were excluded. Of the remaining 90 pts,39% were SLN positive (+ve) and 61% were SLN negative (-ve). HS of ≤ 180 was found in 66% and HS >180 was found in 34% of the pts. In 55 SLN -ve pts 76% had HS ≤ 180 while 24% had HS >180. In 35 SLN +ve pts, 49% had HS of ≤ 180 and 51% had HS >180. ( Table ) Of SLN +ve pts, size of metastatic tumor in LNs was available in 86% of pts. Average (av.) non SLN met size was 0.95 cms in pts with HS ≤ 180 and 3.4 cms in pts with HS > 180. Av. SLN met size was 0.63 cms in pts with HS ≤ 180 and 0.9 cms in pts with HS>180 ( Table ). No statistical significance was found among T stage of pts with HS >180 vs ≤ 180. Conclusion: Pts with p53 HS >180 showed significantly greater tumor burden in both SLNs and non SLNs as compared to pts with HS ≤ 180. Also probability of having SLN -ve disease is higher in pts with HS ≤ 180 as compared to pts with HS >180 in Cca. Thus,even in SLN -ve pts, high HS may indicate a worse prognosis. Hence,a high p53 HS might predict pts with Cca having higher tumor burden in LNs and thus identify an aggressive subgroup of pts.

[Table: see text]

No significant financial relationships to disclose.

Intratumoral oxygenation of invasive squamous cell carcimoma of the vulva is not correlated with regional lymph node metastasis

INTRODUCTION

Tumour hypoxia has been found to be associated with tumour aggressiveness. Our primary aim was to explore the relationship between pretreatment tumour oxygenation in primary vulvar carcinoma and nodal status. Our secondary objective was to assess if there was a relationship between the clinical and biological variables.

METHODS

20 women with ISCC of the vulva were assessed with pretreatment primary tumour oxygenation with an Eppendorf pO2 probe. Patients underwent standard surgical management. Pathological assessment of the primary and nodal tissues was then performed. Primary tumour specimens were also stained for microvessel density and carbonic anhydrase IX. The relationship between smoking, preoperative Hgb, tumour CAIX expression, MVD, and Eppendorf pO2 measurements vs nodal metastasis and between these clinical and biological variables was assessed.

RESULTS

Seven patients had positive lymph nodes, 13 had negative nodes. While neither current smoking status, tumour size, tumour oxygen measurements, MVD and CAIX expression correlated with metastatic nodal disease, a low preoperative Hgb correlated with pathological nodal status (p < 0.027).

CONCLUSIONS

Although this analysis failed to demonstrate a strong correlation between various measures of tumour oxygenation with nodal metastasis, it may be due to the small number of patients. Only preoperative anaemia is correlated with nodal metastasis in early ISCC of the vulva.

Fracture of the radial donor site after composite free flap harvest: a ten-year review

The options for donor sites as a source of tissue for free vascularised osteocutaneous flaps are numerous, however, the radial forearm still has an important role. This series reports the largest published record of radial donor site fracture following the harvesting of osteocutaneous radial forearm free flaps used for reconstruction after ablative surgery for malignant disease. The relevant literature is reviewed. A retrospective review of cases treated using these flaps from 1991-2000 (inclusive) is carried out. Factors involved in the aetiology of fractures are discussed. Thirteen fractures are identified from seventy one osteocutaneous flaps (18%). A statistically significant majority of fractures occur in females. Limiting the percentage of radius diameter harvested is important and beveling of the osteotomy cuts may be advantageous in minimising weakening. Prophylactic plating of the donor site, particularly in the female patient, should be actively considered. The earlier the fracture occurs in the post-operative period, the more likely the need for operative intervention.

Modelling potential impacts of bottom trawl fisheries on soft sediment biogeochemistry in the North Sea

Bottom trawling causes physical disturbance to sediments particularly in shelf areas. The disturbance due to trawling is most significant in deeper areas with softer sediments where levels of natural disturbance due to wave and tidal action are low. In heavily fished areas, trawls may impact the same area of seabed more than four times per year. A single pass of a beam trawl, the heaviest gear routinely used in shelf sea fisheries, can kill 5-65% of the resident fauna and mix the top few cm of sediment. We expect that sediment community function, carbon mineralisation and biogeochemical fluxes will be strongly affected by trawling activity because the physical effects of trawling are equivalent to those of an extreme bioturbator, and yet, unlike bioturbating macrofauna, trawling does not directly contribute to community metabolism. We used an existing box-model of a generalised soft sediment system to examine the effects of trawling disturbance on carbon mineralisation and chemical concentrations. We contrasted the effects of a natural scenario, where bioturbation is a function of macrobenthos biomass, with an anthropogenic impact scenario where physical disturbance results from trawling rather than the action of bioturbating macrofauna. Simulation results suggest that the effects of low levels of trawling disturbance will be similar to those of natural bioturbators but that high levels of trawling disturbance prevent the modelled system from reaching equilibrium due to large carbon fluxes between oxic and anoxic carbon compartments. The presence of macrobenthos in the natural disturbance scenario allowed sediment chemical storage and fluxes to reach equilibrium. This is because the macrobenthos are important carbon consumers in the system whose presence reduces the magnitude of available carbon fluxes. In soft sediment systems, where the level physical disturbance due to waves and tides is low, model results suggest that intensive trawling disturbance could cause large fluctuations in benthic chemical fluxes and storage.