Primary care usage at the end of life: a retrospective cohort study of cancer patients using linked primary and hospital care data

PURPOSE

Health service use is most intensive in the final year of a person's life, with 80% of this expenditure occurring in hospital. Close involvement of primary care services has been promoted to enhance quality end-of-life care that is appropriate to the needs of patients. However, the relationship between primary care involvement and patients' use of hospital care is not well described. This study aims to examine primary care use in the last year of life for cancer patients and its relationship to hospital usage.

METHODS

Retrospective cohort study in Victoria, Australia, using linked routine care data from primary care, hospital and death certificates. Patients were included who died related to cancer between 2008 and 2017.

RESULTS

A total of 758 patients were included, of whom 88% (n = 667) visited primary care during the last 6 months (median 9.1 consultations). In the last month of life, 45% of patients were prescribed opioids, and 3% had imaging requested. Patients who received home visits (13%) or anticipatory medications (15%) had less than half the median bed days in the last 3 months (4 vs 9 days, p < 0.001, 5 vs 10 days, p = 0.001) and 1 month of life (0 vs 2 days, p = 0.002, 0 vs 3 days, p < 0.001), and reduced emergency department presentations (32% vs 46%, p = 0.006, 31% vs 47% p < 0.001) in the final month.

CONCLUSION

This study identifies two important primary care processes-home visits and anticipatory medication-associated with reduced hospital usage and intervention at the end of life.

Silver Diammine Fluoride Usage in General Dentistry Offices in Louisiana

Purpose: To evaluate the current knowledge and usage of silver diammine fluoride (SDF) by general dentists in Louisiana and to identify primary barriers to the imple- mentation of SDF. Methods: A 16-item survey was emailed to 1719 Louisiana Dental Association members to identify factors influencing general dentists' usage of SDF. Results: Eighty-two surveys were completed with a response rate of 4.8 percent, with 69 identified as general dentists. Over half of the respondents were male (53.6%) and their practice experience ranged from less than one year to 48 years. The majority were solo owners (43.5%) while 7.3 percent had jobs in the corporate setting. Most agreed/strongly agreed that their knowledge of SDF was from either dental journals or online resources, while fewer stated they were taught about SDF (25%) or used SDF (8%) in dental school. The majority knew the advantages and off-label usage of SDF. However, only 40 percent recognized that SDF was officially approved for tooth hypersensitivity only. The most reported perceived barrier to SDF implementation was not learning about SDF in dental school (36%). Conclusion: There is a lack of understanding of SDF usage among Louisiana general dentists. The main reason for not incorporating SDF into their practice is the lack of training in their dental education.

The virulence of Dichelobacter nodosus, measured by the elastase test, is an important predictor for virulent footrot diagnosis in New South Wales sheep flocks

Ovine footrot is a contagious bacterial disease that causes foot lesions, and depending on the virulence of the causative strains, may lead to severe underrunning of the hoof and lameness. Virulent footrot can be identified, treated and controlled more effectively than less virulent benign forms. The in vitro elastase test for virulence of the causative bacteria, Dichelobacter nodosus, has been used to support clinical diagnosis. However, not all laboratory-designated virulent D. nodosus strains cause clinical signs of virulent footrot. This study evaluated retrospectively how well the elastase test supported clinical footrot diagnosis in 150 sheep flocks examined for suspect footrot in New South Wales between August 2020 and December 2021. Flocks were included if measures of clinical disease, environmental conditions and the virulence of D. nodosus isolates were available. Variation in the elastase activity result between D. nodosus isolated from the same flock made bacterial virulence hard to interpret, but calculating the mean elastase rate for all isolates from the same flock made correlations between bacterial virulence and flock footrot diagnosis possible. Simplifying bacterial virulence into whether there were any elastase-positive D. nodosus isolates before 12 days increased the predictive value of elastase results for virulent diagnosis, compared with using the first day that any isolate was elastase positive or the percentage of elastase-positive isolates by 12 days, but not all clinically virulent flocks had isolates with elastase activity before 12 days. Logistic regression models were fitted to identify the minimum number of predictors for virulent footrot diagnosis, with models suggesting that virulent footrot diagnosis was best predicted by adding the elastase test result and environmental conditions to the prevalence of severe foot lesions (score 4 and 5). However, performing the same analysis with different breeds, ages of sheep and seasons might highlight other factors important in the diagnosis of virulent footrot.

Systemic acidemia impairs cardiac function in critically Ill patients

BACKGROUND

Acidemia, is associated with reduced cardiac function in animals, but no studies showing an effect of acidemia on cardiac function in humans are reported. In the present study, we examined the effect of acidemia on cardiac function assessed with transpulmonary thermodilution technique with integrated pulse contour analysis (Pulse Contour Cardiac Output, PiCCO™) in a large cohort of critically ill patients.

METHODS

This was a prospective multicenter observational cross-sectional study of 297 patients from 6 intensive care units in London, England selected from all patients admitted consecutively between May 2018 and March 2019. Measurements of lowest plasma pH and concurrent assessment of cardiac function were obtained.

FINDINGS

There was a significant difference between two pH categories (pH ≤ 7.28 vs. pH > 7.28) for the following variables of cardiac function: SVI (difference in means 32.7; 95% CI: 21 to 45 mL/m2; p < 0.001); GEF (18; 95% CI: 11 to 26%; p < 0.001), dPmax (-331; 95% CI: -510 to -153 mmHg/s; p = 0.001), CFI (0.7; 95% CI: 0.2 to 1.3 1/min; p = 0.01) and CPI (0.09; 95% CI: 0.03 to 0.15 W/m2; p < 0.001). However, there was no significant difference in CI (0.13; 95% CI: -0.20 to 0.47 L/min/m2; p = 0.12) between the pH categories. Also, a significant relationship was found between the quantitative pH and the following variables: SVI (132; 95% CI: 77 to 188 mL/m2; p < 0.001), GEF (74.7; 95% CI: 37.1 to 112.4%; p < 0.001), dPmax (-1587; 95% CI: -2361 to -815 mmHg/s; p < 0.001), CFI (3.5; 95% CI: 0.9 to 6.1 /min; p = 0.009), CPI (0.62; 95% CI: 0.36 to 0.88 W/m2; p < 0.001) and CI (regression coefficient 1.96; 95% CI:0.45 to 3.47 L/min/m2; p = 0.01).

INTERPRETATION

Acidemia is associated with impaired cardiac function in seriously ill patients hospitalized in the intensive care unit supporting the potential value of early diagnosis and improvement of arterial pH in these patients.

FUNDING

The study was partially supported by unrestricted funds from the UCLA School of Medicine.

Innovative Follow-up Strategies for Endometrial Cancer

Increasing recognition of the heterogeneous nature of endometrial cancer, the excellent prognosis of low-risk cases and improvements in risk stratification offer opportunities for innovative, personalised follow-up strategies. This review article outlines the evidence base for alternative follow-up strategies in the different risk categories of endometrial cancer, cancer survivorship programmes and considers future directions in endometrial cancer follow-up, including emerging new techniques, such as the liquid biopsy, and opportunities for combining molecular and clinicopathological features to personalise endometrial cancer follow-up.

Children are safe in schools: a review of the Irish experience of reopening schools during the COVID-19 pandemic

Objectives

Schools in the Republic of Ireland reopened to students and staff in late August 2020. We sought to determine the test positivity rate of close contacts of cases of coronavirus disease 2019 (COVID-19) in schools during the first half-term of the 2020/2021 academic year.

Methods

National-level data from the schools' testing pathway were interrogated to determine the positivity rate of close contacts of cases of COVID-19 in Irish primary, postprimary and special schools during the first half-term of 2020/2021 academic year. The positivity rates among adult and child close contacts were compared and the proportion of national cases of COVID-19 who were aged 4–18 years during the observation period was calculated to assess whether this proportion increased after schools reopened.

Results

Of all, 15,533 adult and child close contacts were tested for COVID-19 through the schools' testing pathway during the first half-term of the 2020/2021 academic year. Three hundred and ninety-nine close contacts tested positive, indicating a positivity rate of 2.6% (95% confidence interval: 2.3–2.8%). The positivity rates of child and adult close contacts were similarly low (2.6% vs 2.7%, P = 0.7). The proportion of all national cases of COVID-19 who were aged 4–18 years did not increase during the first half-term of the 2020/2021 school year.

Conclusions

The low positivity rate of close contacts of cases of COVID-19 in schools indicate that transmission of COVID-19 in Irish schools during the first half-term of the 2020/2021 academic year was low. These findings support policies to keep schools open during the pandemic.

Subdural extravasation of crystalloids and blood products through a scalp peripheral intravenous catheter into the subdural space of a neonate on veno-arterial extracorporeal membrane oxygenation

We describe a rare and devastating complication of a malpositioned scalp peripheral intravenous catheter (PIV) that resulted in subdural extravasation of infused fluids and midline shift in a critically ill neonate who required extracorporeal membrane oxygenation (ECMO). Recognition of increased intracranial pressure was hindered by the hemodynamic changes of being on ECMO and only identified by routine surveillance ultrasonography. Awareness of this complication may lead providers to seek alternate sites for vascular access in such patients, and encourage closer monitoring for this complication when an alternate site is unavailable.

Background prevalence of subclinical Shiga toxin-producing Escherichia coli in children attending childcare facilities in the Irish Midlands

BACKGROUND

Exclusion of asymptomatic shedders of Shiga toxin-producing Escherichia coli (STEC) from childcare facilities (CCFs) is a recognized measure to minimize risk of secondary transmission. This is predicated on factors including an assumption of low background prevalence of STEC amongst CCF attendees. There is a paucity of scientific evidence regarding the true prevalence of STEC in paediatric populations. The study aimed to develop and test a methodology to estimate background prevalence of STEC amongst CCF attendees at regional level in Ireland.

METHODS

Computerized Infectious Disease Reporting data were used to compile a list of outbreaks of STEC occurring in CCFs in the Irish Midlands since the introduction of polymerase chain reaction (PCR)-based testing. Laboratory data were used to determine background prevalence of STEC in screened children in each outbreak individually and across all outbreaks.

RESULTS

A pooled summary prevalence estimate of 2.9% (95% confidence interval 1.4-5.5%) was determined for the entire screened cohort across all outbreaks. Sensitivity analysis supported the validity of the estimate.

CONCLUSIONS

The relatively high prevalence estimate of 2.9% suggests that a public health risk assessment approach to return of prolonged asymptomatic shedders to the CCF may be appropriate in peak STEC season in the Midlands.

[Strawberry and raspberry anaphylaxis]

Strawberry IgE-mediated hypersensitivity is often reported rarely confirmed. Only a few cases are described in medical literature, unlike other fruits of the rosacea family. Strawberry is rich in histamine. It can cause histamine release syndrome, especially when eaten in large quantities. However IgE-mediated hypersensitivity exists. We reported the case of a 9-year-old boy with a history of strawberry and raspberry anaphylaxis.

Abstract 1060: Establishment of a panel of prostate patient derived xenograft (PDX) models and evaluation of anti-androgen therapy

BACKGROUND: Prostate cancer is one of the most common cancer worldwide with limited treatment options and very poor prognosis. Surgery, chemo therapy such as docetaxel (Taxotere®) and targeted therapies such as abiraterone (Zytiga®) and enzalutamide (Xtandi®) are the options available for prostate cancer patients but they all have their limitations. The development of new prostate cancer therapy has been slow due to the lack or preclinical models that adequately represent the spectrum of benign, latent, aggressive, and metastatic forms of the human disease. PDX have been reported to be more clinically relevant that cell lines but the generation of prostate PDX models has always been challenging. Here we report the establishment and validation of a panel of prostate PDX models and their utilization in preclinical studies which will help prostate cancer research.

MATERIAL & METHODS: Primary prostate cancer samples from patients undergoing radical prostatectomy in the UK were collected with ethical consent. These samples were then inoculated subcutaneously in Rag2-/-gC-/- mice (Jackson Laboratory) to generate PDX models. Subcutaneous tumor growth was evaluated and monitored by electronic callipers. Successfully established PDX tissue were collected for RNA sequencing and immunohistochemistry (IHC) for key prostate markers. PDX were also tested for sensitivity to docetaxel (Taxotere®), abiraterone and enzalutamide in vivo in mice bearing subcutaneous tumours. Tumours were samples pre and post dosing as well as blood samples collected.

RESULTS: A panel of prostate PDX models have been established and expanded. Two models were established using tumour tissue from patients diagnosed with castrate resistant prostate cancer (CRPC) and two models were from patients who showed hormone sensitivity. Histologically the structure of the original patient sample was retained in the PDX models. These models also showed high KLK3 (PSA) expression levels by RNA sequencing and IHC staining as well as androgen receptor expression. One of the CRPC models showed a TMPRSS-ETS fusion, response to docetaxel (p&lt;0.0001, Two way ANOVA) in vivo and poor response to abiraterone and enzalutamide, whereas the second CRPC model showed no response to any of the agents tested.

CONCLUSIONS: We have established and characterised a panel of prostate PDX models which provide unique and clinically relevant models for preclinical drug evaluation for prostate cancer.

Citation Format: Jason Davis, Anthony Oakden, Jane Wrigley, Chira Roberts, W Qian, Bin Fan, A Collins, Davy Ouyang, Jie Cai, Rajendra Kumari, Yinfei Yin. Establishment of a panel of prostate patient derived xenograft (PDX) models and evaluation of anti-androgen therapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 1060.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

The Triangular Sign, a Useful Diagnostic Marker for Biliary Atresia: A Case Series of Three Irish Infants

Background The triangular cord (TC) sign is the appearance of a triangular shaped echogenic density visualised immediately cranial to the portal vein bifurcation on ultrasonographic examination. Several studies have reported that this ultrasonographic sign is a reliable and helpful marker in identifying Biliary Atresia (BA). Aims To report the identification of the TC sign in three infants with BA in the Rotunda Hospital, Dublin. Methods A retrospective chart review was performed to evaluate the clinical presentation and imaging of the three patients with positive TC sign and BA. Discussion Timely, accurate diagnosis of BA is essential to minimise morbidity and optimise patient outcome. The TC is a valuable ultrasonographic sign to aid early diagnosis of BA.

Cancer Incidence and Mortality due to Excess Body Weight in Ireland: An Analysis of 10-year data

Excess body weight (EBW) increases the risk of specific cancers. The prevalence of EBW has risen significantly in Ireland over recent decades. To highlight the impact on cancer, and to inform future policies, we calculated the proportion of cancers in Ireland that were attributable to EBW using the Population Attributable Fraction (PAF). This fraction was then applied to Irish incidence and mortality data for specific cancers from 2003-2012 to estimate the number of new cancers and cancer deaths attributable to EBW. We found that each year in Ireland, approximately 800 new cancers and 300 cancer deaths are attributable to EBW. The greatest attributable risk of cancer was seen for the upper digestive tract and endometrium, whilst breast and colorectal have the greatest numbers of attributable cancers. EBW is a major cause of cancer, responsible for 4.5% of all cancers in Ireland. Public awareness of this significant preventable risk must improve.

Sex Differences in Stipulated Preferences in Personal Advertisements

A study was conducted on the content of personal advertisements using data from 259 placements in a national English newspaper. Univariate statistical tests and a multivariate classification analysis confirmed the previous findings in American studies of women seeking financial resources and men offering financial resources and seeking physical attributes. In contrast to previous studies, women are not significantly more likely to describe physical attributes than are men. Univariate statistical tests suggest a new finding of lesser offers of commitment by men.

Commercial chicken breeds exhibit highly divergent patterns of linkage disequilibrium

The analysis of linkage disequilibrium (LD) underpins the development of effective genotyping technologies, trait mapping and understanding of biological mechanisms such as those driving recombination and the impact of selection. We apply the Malécot-Morton model of LD to create additive LD maps that describe the high-resolution LD landscape of commercial chickens. We investigated LD in chickens (Gallus gallus) at the highest resolution to date for broiler, white egg and brown egg layer commercial lines. There is minimal concordance between breeds of fine-scale LD patterns (correlation coefficient <0.21), and even between discrete broiler lines. Regions of LD breakdown, which may align with recombination hot spots, are enriched near CpG islands and transcription start sites (P<2.2 × 10^-16), consistent with recent evidence described in finches, but concordance in hot spot locations between commercial breeds is only marginally greater than random. As in other birds, functional elements in the chicken genome are associated with recombination but, unlike evidence from other bird species, the LD landscape is not stable in the populations studied. The development of optimal genotyping panels for genome-led selection programmes will depend on careful analysis of the LD structure of each line of interest. Further study is required to fully elucidate the mechanisms underlying highly divergent LD patterns found in commercial chickens.

Longitudinal copy number, whole exome and targeted deep sequencing of 'good risk' IGHV-mutated CLL patients with progressive disease

The biological features of IGHV-M chronic lymphocytic leukemia responsible for disease progression are still poorly understood. We undertook a longitudinal study close to diagnosis, pre-treatment and post relapse in 13 patients presenting with cMBL or Stage A disease and good-risk biomarkers (IGHV-M genes, no del(17p) or del(11q) and low CD38 expression) who nevertheless developed progressive disease, of whom 10 have required therapy. Using cytogenetics, fluorescence in situ hybridisation, genome-wide DNA methylation and copy number analysis together with whole exome, targeted deep- and Sanger sequencing at diagnosis, we identified mutations in established chronic lymphocytic leukemia driver genes in nine patients (69%), non-coding mutations (PAX5 enhancer region) in three patients and genomic complexity in two patients. Branching evolutionary trajectories predominated (n=9/13), revealing intra-tumoural epi- and genetic heterogeneity and sub-clonal competition before therapy. Of the patients subsequently requiring treatment, two had sub-clonal TP53 mutations that would not be detected by standard methodologies, three qualified for the very-low-risk category defined by integrated mutational and cytogenetic analysis and yet had established or putative driver mutations and one patient developed progressive, therapy-refractory disease associated with the emergence of an IGHV-U clone. These data suggest that extended genomic and immunogenetic screening may have clinical utility in patients with apparent good-risk disease.

Making literature reviews more reliable through application of lessons from systematic reviews

Review articles can provide valuable summaries of the ever-increasing volume of primary research in conservation biology. Where findings may influence important resource-allocation decisions in policy or practice, there is a need for a high degree of reliability when reviewing evidence. However, traditional literature reviews are susceptible to a number of biases during the identification, selection, and synthesis of included studies (e.g., publication bias, selection bias, and vote counting). Systematic reviews, pioneered in medicine and translated into conservation in 2006, address these issues through a strict methodology that aims to maximize transparency, objectivity, and repeatability. Systematic reviews will always be the gold standard for reliable synthesis of evidence. However, traditional literature reviews remain popular and will continue to be valuable where systematic reviews are not feasible. Where traditional reviews are used, lessons can be taken from systematic reviews and applied to traditional reviews in order to increase their reliability. Certain key aspects of systematic review methods that can be used in a context-specific manner in traditional reviews include focusing on mitigating bias; increasing transparency, consistency, and objectivity, and critically appraising the evidence and avoiding vote counting. In situations where conducting a full systematic review is not feasible, the proposed approach to reviewing evidence in a more systematic way can substantially improve the reliability of review findings, providing a time- and resource-efficient means of maximizing the value of traditional reviews. These methods are aimed particularly at those conducting literature reviews where systematic review is not feasible, for example, for graduate students, single reviewers, or small organizations.

Congenital Arteriovenous Malformation of the Forearm and Hand

We report the case of an asymptomatic arteriovenous malformation (AVM), extending from the forearm into the palm, in an 11-year-old boy. A debulking procedure was performed meticulously dissecting the lesion from the involved structures. The post-operative course was uncomplicated and no evidence of recurrence was noted at eighteen months follow-up. Extensive AVMs involving structures vital for hand function may be asymptomatic. Clinical follow-up is paramount, due to the inherent risk of recurrence.

Large-scale discovery of novel genetic causes of developmental disorders

Despite three decades of successful, predominantly phenotype-driven discovery of the genetic causes of monogenic disorders, up to half of children with severe developmental disorders of probable genetic origin remain without a genetic diagnosis. Particularly challenging are those disorders rare enough to have eluded recognition as a discrete clinical entity, those with highly variable clinical manifestations, and those that are difficult to distinguish from other, very similar, disorders. Here we demonstrate the power of using an unbiased genotype-driven approach to identify subsets of patients with similar disorders. By studying 1,133 children with severe, undiagnosed developmental disorders, and their parents, using a combination of exome sequencing and array-based detection of chromosomal rearrangements, we discovered 12 novel genes associated with developmental disorders. These newly implicated genes increase by 10% (from 28% to 31%) the proportion of children that could be diagnosed. Clustering of missense mutations in six of these newly implicated genes suggests that normal development is being perturbed by an activating or dominant-negative mechanism. Our findings demonstrate the value of adopting a comprehensive strategy, both genome-wide and nationwide, to elucidate the underlying causes of rare genetic disorders.