Socio-economic disparities in access to assisted reproductive technologies in Australia

Women from disadvantaged socio-economic groups access assisted reproductive technology treatment less than women from more advantaged groups. However, women from disadvantaged groups tend to start families younger, making them less likely to suffer from age-related subfertility and potentially have less need for fertility treatment. Whether socio-economic disparities in access to assisted reproductive technology treatment persist after controlling for the need for treatment, has not been previously explored. This population based study demonstrates that socio-economic disparities in access to assisted reproductive technology treatment persist after adjusting for several confounding factors, including age at first birth (used as a measure of delayed childbearing, hence a proxy for need for fertility treatment), geographic remoteness and Australian jurisdiction. Assisted reproductive technology access progressively decreased as socio-economic quintiles became more disadvantaged, with a 15.8% decrease in access in the most disadvantaged quintile compared with the most advantaged quintile after controlling for confounding factors. The adjusted rate of access to assisted reproductive technology treatment also decreased by 12.3% for women living in regional and remote areas compared with those in major cities. These findings indicate that financial and sociocultural barriers to assisted reproductive technology treatment remain in disadvantaged groups after adjusting for need.

Superiority of Deformable Image Co-registration in the Integration of Diagnostic Positron Emission Tomography-Computed Tomography to the Radiotherapy Treatment Planning Pathway for Oesophageal Carcinoma

AIMS

To investigate the use of image co-registration in incorporating diagnostic positron emission tomography-computed tomography (PET-CT) directly into the radiotherapy treatment planning pathway, and to describe the pattern of local recurrence relative to the PET-avid volume.

MATERIALS AND METHODS

Fourteen patients were retrospectively identified, six of whom had local recurrence. The accuracy of deformable image registration (DIR) and rigid registration of the diagnostic PET-CT and recurrence CT, to the planning CT, were quantitatively assessed by comparing co-registration of oesophagus, trachea and aorta contours. DIR was used to examine the correlation between PET-avid volumes, dosimetry and site of recurrence.

RESULTS

Positional metrics including the dice similarity coefficient (DSC) and conformity index (CI), showed DIR to be superior to rigid registration in the co-registration of diagnostic and recurrence imaging to the planning CT. For diagnostic PET-CT, DIR was superior to rigid registration in the transfer of oesophagus (DSC=0.75 versus 0.65, P<0.009 and CI=0.59 versus 0.48, P<0.003), trachea (DSC=0.88 versus 0.65, P<0.004 and CI=0.78 versus 0.51, P<0.0001) and aorta structures (DSC=0.93 versus 0.86, P<0.006 and CI=0.86 versus 0.76, P<0.006). For recurrence imaging, DIR was superior to rigid registration in the transfer of trachea (DSC=0.91 versus 0.66, P<0.03 and CI=0.83 versus 0.51, P<0.02) and oesophagus structures (DSC=0.74 versus 0.51, P<0.004 and CI=0.61 versus 0.37, P<0.006) with a non-significant trend for the aorta (DSC=0.91 versus 0.75, P<0.08 and CI=0.83 versus 0.63, P<0.06) structure. A mean inclusivity index of 0.93 (range 0.79-1) showed that the relapse volume was within the planning target volume (PTVPET-CT); all relapses occurred within the high dose region.

CONCLUSION

DIR is superior to rigid registration in the co-registration of PET-CT and recurrence CT to the planning CT, and can be considered in the direct integration of PET-CT to the treatment planning process. Local recurrences occur within the PTVPET-CT, suggesting that this is a suitable target for dose-escalation strategies.

Abstract P4-04-13: Comparison of tumor and stroma CD73 expression with TLR9 and survival in breast cancer

CD73 is a 5' ectonuclease that catalyzes the conversion of cyclic AMP into the highly immunosuppressive adenosine in extracellular space. In addition to the cells of the immune system, CD73 is highly expressed in various cancer cell lines and clinical cancer tissues. Toll like receptor-9 (TLR9) is a cellular DNA-receptor that is highly expressed in breast cancer. Both CD73 and TLR9 expression have recently been associated with TNBC prognosis but the mechanisms how these proteins possibly contribute to TNBC pathophysiology remains poorly understood. TLR9 and CD73 expression has been shown to be mutually regulated in various cell types. Whether this is the case in cancer is unknown. The aim of this study was to investigate the mutual role of TLR9 and CD73 in breast cancer (BC). Specifically our hypothesis was that TLR9 and CD73 expression correlate in TNBC. We compared immunohistological tumor TLR9 and CD73 expression scores using a previously characterized breast cancer (BC) cohort (n=184) with follow-up time of &gt; 10 years. We did not discover a connection between TLR9 and CD73 expression in tumor cells in BC. There was a trend for increased survival among patients that had high tumor cell CD73 expression, as compared with the lower tumor cell CD73 expression groups. There was a trend for a better survival among TNBC patients that had lower stromal CD73 expression, as compared with those TNBC patients that had higher stromal CD73 expression. No such difference was detected among patients with non-TNBC tumors. Our results suggest that stromal vs. tumor cell CD73 expression have opposite effects on survival in TNBC, but there is no connection between CD73 and TLR9 expression. Our conclusions are limited by low sample numbers.

Citation Format: Selander K, Mella M, Kauppila J, Karihtala P, Jukkola-Vuorinen A, Auvinen P, Soini Y, Kauppila S, Haapasaari K-M, Harris K, Vuopala K. Comparison of tumor and stroma CD73 expression with TLR9 and survival in breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-04-13.

The clinical symptom profile of early radiographic knee arthritis: a pain and function comparison with advanced disease

PURPOSE

Early knee OA is a significant problem that can be disabling. The purpose of this study was to understand the symptomatic profile of patients with early knee OA when compared to those with end-stage knee OA.

METHODS

A cross-sectional case control study design was used to compare those with early structural change to those with advanced structural change. In total, 100 consecutive patients with early radiographic knee OA presenting to the knee service outpatient clinic from December 2010 to August 2011 were prospectively identified on the basis of their radiographic changes. All met the symptomatic and radiological diagnostic criteria of early knee OA as defined by Luyten et al. They were compared with 200 knees with full thickness anteromedial knee OA and 200 knees with full thickness tricompartmental knee OA for their demographic, pain and functional profile.

RESULTS

Patients with early knee OA were younger than those with full thickness disease. However, 78% of individual patients with early radiographic OA had pain and function scores equal to individual patients presenting for UKA, whilst 74% of individual patients with early radiographic OA had pain and function scores that are equal to or worse than individual patients presenting for TKA.

CONCLUSIONS

Patients with early radiographic knee OA demonstrate considerable overlap in the severity of their symptoms with those demonstrating end-stage structural changes within the knee. Patients with early structural changes of arthritis should not be assumed by clinicians to have mild disease. In many cases, their symptoms are as bad as those with end-stage structural changes. This work will help clinicians to identify and categorise those with early arthritis and thereby assist in guiding appropriate treatments.

Socioeconomic influence on orofacial cleft patient care

Background

Cleft lip and palate is the most common craniofacial birth defect in the UK. Orofacial clefts have functional and aesthetic implications requiring intensive multi-disciplinary follow-up to optimise development. Failure to attend follow-up is likely to have a negative impact on patient outcomes. The aim of this retrospective audit is to establish if socioeconomic status influences attendance, DNA and cancellation rates in cleft patients.

Methods and results

A retrospective audit of 74 orofacial cleft patients born and operated on at the Royal Hospital for Sick Children Glasgow between 2006 and 2007. There was higher rate of DNA in more deprived social groups−21% (SIMD 1) against 10% (SIMD 5). A higher rate of DNA in cleft lip and palate patients was noted. This group of patients showed a marked difference in attendance between SIMD 1 (38%) and SIMD 5 (78%).

Conclusion

More deprived areas have a higher outpatient DNA rate for cleft patients resulting in suboptimal follow-up. Ultimately, causation of poorer outcomes in this group is likely to be multi-factorial but the financial implication of travelling to multiple clinics should be considered and it may be that resource reallocation is the answer to address the current inequality of health care provision.

Term and preterm labour are associated with distinct microbial community structures in placental membranes which are independent of mode of delivery

Infection is considered a possible trigger for preterm labour, supported by evidence showing the presence of bacteria in the placenta and placental membranes from preterm births. In this study, 16S rDNA pyrosequencing was used to identify bacteria in placental membranes. Caesarean sections and vaginal deliveries at term were found to harbour common genera. Mycoplasma hominis, Aerococcus christensenii, Gardnerella vaginalis and Fusobacterium nucleatum were either only present in preterm membranes or in greater abundance than at term. These data support previous studies that used either targeted qPCR or broad-range 16S rDNA PCR and cloning but not a recent microbiome analysis of placental tissue using high-throughput sequencing.

Influenza at the animal–human interface: a review of the literature for virological evidence of human infection with swine or avian influenza viruses other than A(H5N1)

Factors that trigger human infection with animal influenza virus progressing into a pandemic are poorly understood. Within a project developing an evidence-based risk assessment framework for influenza viruses in animals, we conducted a review of the literature for evidence of human infection with animal influenza viruses by diagnostic methods used. The review covering Medline, Embase, SciSearch and CabAbstracts yielded 6,955 articles, of which we retained 89; for influenza A(H5N1) and A(H7N9), the official case counts of the World Health Organization were used. An additional 30 studies were included by scanning the reference lists. Here, we present the findings for confirmed infections with virological evidence. We found reports of 1,419 naturally infected human cases, of which 648 were associated with avian influenza virus (AIV) A(H5N1), 375 with other AIV subtypes, and 396 with swine influenza virus (SIV). Human cases naturally infected with AIV spanned haemagglutinin subtypes H5, H6, H7, H9 and H10. SIV cases were associated with endemic SIV of H1 and H3 subtype descending from North American and Eurasian SIV lineages and various reassortants thereof. Direct exposure to birds or swine was the most likely source of infection for the cases with available information on exposure.

Development of a patient-reported outcome measure of activity and participation (the OKS-APQ) to supplement the Oxford knee score

The primary aim of this study was to develop a patient-reported Activity & Participation Questionnaire (the OKS-APQ) to supplement the Oxford knee score, in order to assess higher levels of activity and participation. The generation of items for the questionnaire involved interviews with 26 patients. Psychometric analysis (exploratory and confirmatory factor analysis and Rasch analysis) guided the reduction of items and the generation of a scale within a prospective study of 122 relatively young patients (mean age 61.5 years (42 to 71)) prior to knee replacement. A total of 99, completed pre-operative and six month post-operative assessments (new items, OKS, Short-Form 36 and American Knee Society Score).

The eight-item OKS-APQ scale is unidimensional, reliable (Cronbach’s alpha 0.85; intraclass correlation coefficient (ICC) 0.79; or 0.92 when one outlier was excluded), valid (r >  0.5 with related scales) and responsive (effect size 4.16).

We recommend that it is used with the OKS with adults of all ages when further detail regarding the levels of activity and participation of a patient is required.

Cite this article: Bone Joint J 2014;96-B:332–8.

Potential impact of new oral anticoagulants on the management of atrial fibrillation-related stroke in primary care

AIM

Anticoagulant prophylaxis with vitamin K antagonists (such as warfarin) is effective in reducing the risk of stroke in patients with atrial fibrillation (AF). New oral anticoagulants have emerged as potential alternatives to traditional oral agents. The purpose of this review was to summarise the effectiveness and safety of rivaroxaban, dabigatran and apixaban in stroke prevention in patients with AF in phase III trials, evaluate their cost-effectiveness and consider the implications for primary care.

METHODOLOGY

A literature search was performed between 2007 and 2012, selecting all phase III trials (ROCKET AF, RE-LY and ARISTOTLE) of new oral anticoagulants and relevant cost-benefit studies.

RESULTS

Evidence shows that all three agents are at least as effective as warfarin in the prevention of stroke and systemic emboli, with similar safety profiles. Cost-benefit studies of rivaroxaban and dabigatran further confirm their potential use as alternatives to warfarin in clinical practice. These observations may allow stratification of the general practice AF population, to help prioritise which patients may benefit from receiving a new oral anticoagulant.

CONCLUSION

The clinical and economic benefits of the new oral anticoagulants, along with appropriate risk stratification, may enable a higher number of patients with AF to receive effective and convenient prophylaxis for stroke prevention.