The feasibility and acceptability of mobile application-based assessment of suicidality using self-report components of a novel tool, the Suicide Ideation and Behavior Assessment Tool (SIBAT)

The aim of this study was to assess the validity of a mobile application-based self-report questionnaire in the assessment of suicidality. We developed a program for the administration of self-report components of the Suicide Ideation and Behavior Assessment Tool (SIBAT). We invited university students and trainees enrolled in a study of addictions to complete this component of the SIBAT using the program on their mobile devices or personal computer. 196 participants completed all required modules of the SIBAT, with 97 using their mobile device and 99 using their personal computer. Rates of completed questionnaires between the two groups were compared, as were the responses to the items and the total scores. There was a significant difference between proportions of scale completion in both groups, with a greater number of participants who used a personal computer to complete the scale not responding to all questions compared to participants who used a mobile device to complete the scale. Data collected via mobile device showed good concurrent validity with data collected via personal computer. A trend toward greater disclosure of suicidality was observed in the mobile device group however, replication of these findings using larger sample sizes is needed.

Internal consistency and concurrent validity of self-report components of a new instrument for the assessment of suicidality, the Suicide Ideation and Behavior Assessment Tool (SIBAT)

This study aimed to assess the internal consistency of self-report components of the Suicide Ideation and Behavior Assessment Tool (SIBAT) and validate it with relevant elements of the Mini International Neuropsychiatric Interview (MINI). The SIBAT is a newly developed instrument for the evaluation of suicidality. In this study, we invited university students and trainees participating in a study of addictions to complete the self-report component of the SIBAT as an add-on study. We evaluated the internal consistency of the self-report component of the SIBAT and validated it against the suicidality component of the MINI. Data were analysed using both complete case analysis and multiple imputation. SIBAT data were collected for 394 participants, 314 of whom had also completed the MINI. The internal consistency of modules 2, 3, and 5 of the SIBAT was high. Each item from module 5 had a statistically significant association with the corresponding item from the MINI. The sum of scores from modules 2 and 3 had a moderate correlation with the assessment of suicide risk determined by the MINI, and a strong correlation with the total score of SIBAT module 5. The completion median time of modules 2, 3 and 5 was 14.3 min.

Masculinity's association with the interpersonal theory of suicide among military personnel

OBJECTIVE

Given that the majority of those who die by suicide are male, masculine traits have been examined as a potential link to the development of capability for suicide. However, research has not examined if such traits influence suicidal desire (i.e., thwarted belongingness, perceived burdensomeness). This study examined the influence of stereotypically masculine traits of stoicism, sensation seeking, physical aggression, verbal aggression, and self-reliance on all three components of the Interpersonal Theory of Suicide within a sample of male and female service members.

METHODS

A total of 953 service members were recruited as part of a larger study.

RESULTS

Sensation seeking and stoicism were positively associated with capability for suicide. With regard to suicidal desire, self-reliance and verbal aggression were positively associated with both perceived burdensomeness and thwarted belongingness. Stoicism was positively associated with thwarted belongingness.

CONCLUSIONS

Findings suggest that different masculine traits are associated with the three components of the Interpersonal Theory of Suicide in various ways. Stoicism may be an especially important masculine trait that influences a component of suicidal desire and capability for suicide.

Lasofoxifene as a potential treatment for therapy-resistant ER-positive metastatic breast cancer

Background

Endocrine therapy remains the mainstay of treatment for estrogen receptor-positive (ER+) breast cancer. Constitutively active mutations in the ligand binding domain of ERα render tumors resistant to endocrine agents. Breast cancers with the two most common ERα mutations, Y537S and D538G, have low sensitivity to fulvestrant inhibition, a typical second-line endocrine therapy. Lasofoxifene is a selective estrogen receptor modulator with benefits on bone health and breast cancer prevention potential. This study investigated the anti-tumor activity of lasofoxifene in breast cancer xenografts expressing Y537S and D538G ERα mutants. The combination of lasofoxifene with palbociclib, a CDK4/6 inhibitor, was also evaluated.

Methods

Luciferase-GFP tagged MCF7 cells bearing wild-type, Y537S, or D538G ERα were injected into the mammary ducts of NSG mice (MIND model), which were subsequently treated with lasofoxifene or fulvestrant as single agents or in combination with palbociclib. Tumor growth and metastasis were monitored with in vivo and ex vivo luminescence imaging, terminal tumor weight measurements, and histological analysis.

Results

As a monotherapy, lasofoxifene was more effective than fulvestrant at inhibiting primary tumor growth and reducing metastases. Adding palbociclib improved the effectiveness of both lasofoxifene and fulvestrant for tumor suppression and metastasis prevention at four distal sites (lung, liver, bone, and brain), with the combination of lasofoxifene/palbociclib being generally more potent than that of fulvestrant/palbociclib. X-ray crystallography of the ERα ligand binding domain (LBD) shows that lasofoxifene stabilizes an antagonist conformation of both wild-type and Y537S LBD. The ability of lasofoxifene to promote an antagonist conformation of Y537S, combined with its long half-life and bioavailability, likely contributes to the observed potent inhibition of primary tumor growth and metastasis of MCF7 Y537S cells.

Conclusions

We report for the first time the anti-tumor activity of lasofoxifene in mouse models of endocrine therapy-resistant breast cancer. The results demonstrate the potential of using lasofoxifene as an effective therapy for women with advanced or metastatic ER+ breast cancers expressing the most common constitutively active ERα mutations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13058-021-01431-w.

A Smartphone App to Manage Cirrhotic Ascites Among Outpatients: Feasibility Study

BACKGROUND

Ascites is a common, painful, and serious complication of cirrhosis. Body weight is a reliable proxy for ascites volume; therefore, daily weight monitoring is recommended to optimize ascites management.

OBJECTIVE

This study aims to evaluate the feasibility of a smartphone app in facilitating outpatient ascites management.

METHODS

In this feasibility study, patients with cirrhotic ascites requiring active management were identified in both inpatient and outpatient settings. Patients were provided with a Bluetooth-connected scale, which transmitted weight data to a smartphone app and then via the internet to an electronic medical record (EMR). Weights were monitored every weekday. In the event of a weight change of ≥5 lbs in 1 week, patients were called and administered a short symptom questionnaire, and providers received an email alert. The primary outcomes of this study were the percentage of enrolled days during which weight data were successfully transmitted to an EMR and the percentage of weight alerts that prompted responses by the provider.

RESULTS

In this study, 25 patients were enrolled: 12 (48%) were male, and the mean age was 58 (SD 13; range 35-81) years. A total of 18 (72%) inpatients were enrolled. Weight data were successfully transmitted to an EMR during 71.2% (697/979) of the study enrollment days, with technology issues reported on 16.5% (162/979) of the days. Of a total of 79 weight change alerts fired, 41 (52%) were triggered by weight loss and 38 (48%) were by weight gain. Providers responded in some fashion to 66 (84%) of the weight alerts and intervened in response to 45 (57%) of the alerts, for example, by contacting the patient, scheduling clinic or paracentesis appointments, modifying the diuretic dose, or requesting a laboratory workup. Providers responded equally to weight increase and decrease alerts (P=.87). The staff called patients a mean of 3.7 (SD 3.5) times per patient, and the number of phone calls correlated with technology issues (r=0.60; P=.002). A total of 60% (15/25) of the patients chose to extend their participation beyond 30 days. A total of 17 patient readmissions occurred during the study period, with only 4 (24%) related to ascites.

CONCLUSIONS

We demonstrated the feasibility of a smartphone app to facilitate the management of ascites and reported excellent rates of patient and provider engagement. This innovation could enable early therapeutic intervention, thereby decreasing the burden of morbidity and mortality among patients with cirrhosis.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Attitudes towards digital health tools for outpatient cirrhosis management in patients with decompensated cirrhosis

Background

Technology represents a promising tool to improve healthcare delivery for patients with cirrhosis. We sought to assess utilisation of technology and preferred features of a digital health management tool, in patients with an early readmission for decompensated cirrhosis.

Methods

We conducted a cross-sectional study of patients readmitted within 90 days for decompensated cirrhosis. A semistructured interview obtained quantitative and qualitative data through open-ended questions.

Results

Of the 50 participants, mean age was 57.6 years and mean (range) model for end stage liver disease was 22.7 (10–46). Thirty-eight (76%) patients own a Smartphone and 62% have regular access to a computer with internet. Thirty-nine (78%) patients would consider using a Smartphone application to manage their cirrhosis. Forty-six (92%) patients report having a principal caregiver, of which 80% own a Smartphone. Patients were interested in a Smartphone application that could communicate with their physician (85%), send medication notifications to the patient (65%) and caregiver (64%), transmit diagnostic results and appointment reminders (82%), educate about liver disease (79%), regularly transmit weight data to the doctor (85% with ascites) and play a game to detect cognitive decline (67% with encephalopathy). Common themes from qualitative data include a desire to learn about liver disease and communicate with providers via digital tools.

Conclusion

Among patients with cirrhosis with an early readmission for decompensation, most have Smartphones and would be willing to use a Smartphone to manage their disease. Future digital health management tools should be tailored to the use patterns and preferences of the patients with cirrhosis and their caregivers.

Pulse- and field-resolved THz-diagnostics at 4 t h generation lightsources

Multi-color pump-probe techniques utilizing modern accelerator-based 4th generation light sources such as X-ray free electron lasers or superradiant THz facilities have become important science drivers over the past 10 years. In this type of experiments the precise knowledge of the properties of the involved accelerator-based light pulses crucially determines the achievable sensitivity and temporal resolution. In this work we demonstrate and discuss the powerful role pulse- and field-resolved- detection of superradiant THz pulses can play for improving the precision of THz pump - femtosecond laser probe experiments at superradiant THz facilities in particular and at 4th generation light sources in general. The developed diagnostic scheme provides real-time information on the properties of individual pulses from multiple accelerator based THz sources and opens a robust way for sub femtosecond timing. Correlations between amplitude and phase of the pulses emitted from different superradiant THz sources furthermore provide insides into the properties of the driving electron bunches and is of general interest for the ultra-fast diagnostics at 4th generation light sources.

SUN-006 Lasofoxifene Achieves Potent Anti-Tumor Activity in Hormone-Resistant Breast Tumors by Maintaining High Affinity Binding for Y537S ERα

Activating somatic mutations to the ligand binding domain (LBD) of ESR1 (the gene for estrogen receptor alpha) may arise after prolonged hormone treatments. Y537S and D538G are the most prevalent mutations, accounting for 16% and 32% of cases respectively. Both mutations resist tamoxifen by favoring the receptor’s active state in the absence of hormone to reduce the selective estrogen receptor modulator’s binding affinity. Fulvestrant, a selective estrogen receptor degrader, is the only clinically approved molecule that can fully ablate Y537S estrogen receptor alpha (ERα) transcriptional activity, but does so at decreased potency due to a reduced ligand binding affinity. Interestingly, lasofoxifene, a selective estrogen receptor modulator, possesses significant anti-tumor activity in preclinical models of luminal breast cancers harboring WT, Y537S, and D538G ERα. Comprehensive structural and biochemical studies were undertaken to determine the molecular basis for lasofoxifene potency towards Y537S ERα. X-ray crystal structures of lasofoxifene in complex with WT and Y537S ERα LBD show that the molecule adopts an identical conformation within the hormone binding pocket. While, a competitive ligand binding assay shows that lasofoxifene possesses the same affinity towards WT and Y537S ERα LBD in vitro, compared to 5-10 fold decrease compared to other SERMs and SERDs. Collectively, these data suggest that lasofoxifene achieves improved anti-tumor activity by retaining its high affinity binding for the Y537S ERα somatic mutant.

Clinical relevance of non-tuberculous mycobacteria isolated from respiratory specimens: seven year experience in a UK hospital

The frequency of isolation of non-tuberculous mycobacteria (NTM) species from respiratory specimens is increasing, however the clinical relevance of such identifications vary by mycobacterial species and geographical location. A retrospective study of 853 NTM isolates from respiratory samples from 386 patients over seven years was performed. Clinical records and radiographic information were examined. Clinical significance was assessed by American Thoracic Society diagnostic criteria. 25% of all patients with respiratory isolates met criteria for non-tuberculous mycobacterial pulmonary disease (NTM-PD). Significant symptoms were weight loss, fever, night sweats, productive cough and haemoptysis. HIV co-infection was a significant risk factor for disease. Cavities, nodules and tree-in-bud were significant radiographic findings. Mycobacterium avium complex (MAC) were the dominant species isolated from this patient cohort. Mycobacterium abscessus (M. abscessus) was the species most likely to cause clinically significant disease and be sputum smear positive, thus warranting particular attention.

On-chip THz spectrometer for bunch compression fingerprinting at fourth-generation light sources

The layout of an integrated millimetre-scale on-chip THz spectrometer is presented and its peformance demonstrated. The device is based on eight Schottky-diode detectors which are combined with narrowband THz antennas, thereby enabling the simultaneous detection of eight frequencies in the THz range on one chip. The size of the active detector area matches the focal spot size of superradiant THz radiation utilized in bunch compression monitors of modern linear electron accelerators. The 3 dB bandwidth of the on-chip Schottky-diode detectors is less than 10% of the center frequency and allows pulse-resolved detection at up to 5 GHz repetition rates. The performance of a first prototype device is demonstrated at a repetition rate of 100 kHz at the quasi-cw SRF linear accelerator ELBE operated with electron bunch charges between a few pC and 100 pC.

Towards femtosecond-level intrinsic laser synchronization at fourth generation light sources

In this Letter, the proof of principle for a scheme providing intrinsic femtosecond-level synchronization between an external laser system and fourth generation light sources is presented. The scheme is applicable at any accelerator-based light source that is based on the generation of coherent radiation from ultrashort electron bunches such as superradiant terahertz (THz) facilities or X-FELs. It makes use of a superradiant THz pulse generated by the accelerator as an intrinsically synchronized gate signal for electro-optical slicing. We demonstrate that the scheme enables a reduction of the timing instability by more than 2 orders of magnitude. This demonstration experiment thereby proves that intrinsically synchronized time-resolved experiments utilizing laser and accelerator-based radiation pulses on few tens of femtosecond (fs) to few fs timescales are feasible.

Determination of Plasma Concentration Reference Ranges for Risperidone and Paliperidone

Schizophrenia is a common disease managed by a range of interventions, with the primary treatment being antipsychotic medications (APS). Inadequate response, lack of adherence, and/or adverse events often prevent optimal therapeutic effects or therapeutic efficiency. Monitoring APS plasma concentrations can be used together with a full clinical evaluation to help improve patient care or offer better treatment options for the patient. To enable interpretation of individual risperidone and paliperidone plasma concentrations, we developed "reference ranges," which consider the expected variability in plasma concentrations between subjects across the population, rather than representing a "therapeutic range" that relates to efficacy and/or safety outcomes. The reference ranges were derived from population pharmacokinetic models, which varied based upon administration route, dose, and time after dose. Good agreement between the proposed reference ranges and external data was obtained through graphical and numerical evaluations, indicating they could be reliably used in clinical practice.

Analysis of Affordance, Time, and Adaptation in the Assessment of Industrial Control System Cybersecurity Risk

Industrial control systems increasingly use standard communication protocols and are increasingly connected to public networks-creating substantial cybersecurity risks, especially when used in critical infrastructures such as electricity and water distribution systems. Methods of assessing risk in such systems have recognized for some time the way in which the strategies of potential adversaries and risk managers interact in defining the risk to which such systems are exposed. But it is also important to consider the adaptations of the systems' operators and other legitimate users to risk controls, adaptations that often appear to undermine these controls, or shift the risk from one part of a system to another. Unlike the case with adversarial risk analysis, the adaptations of system users are typically orthogonal to the objective of minimizing or maximizing risk in the system. We argue that this need to analyze potential adaptations to risk controls is true for risk problems more generally, and we develop a framework for incorporating such adaptations into an assessment process. The method is based on the principle of affordances, and we show how this can be incorporated in an iterative procedure based on raising the minimum period of risk materialization above some threshold. We apply the method in a case study of a small European utility provider and discuss the observations arising from this.

Optimizing Antipsychotic Patient Management Using Population Pharmacokinetic Models and Point-of-Care Testing

Schizophrenia is a common disease, characterized by progressive functional decline exacerbated by psychotic relapses that often result from a lack of full adherence to antipsychotic (APS) medication. Although atypical APS medications do not have clear therapeutic windows, as generally required for therapeutic drug monitoring (TDM), measuring APS plasma levels in the context of a population expected range at the point‐of‐care (POC) may provide valuable clinical insights for differentiating lack of efficacy from a lack of adherence to medication.

Challenging hierarchy in healthcare teams - ways to flatten gradients to improve teamwork and patient care

In healthcare, mistakes that are potentially harmful or fatal to patients are often the result of poor communication between members of a team. This is particularly important in high-risk areas such as operating theatres or during any intervention, and the ability to challenge colleagues who are in authority when something does not seem right or is clearly wrong, is crucial. Colleagues in oral and maxillofacial surgery recognised the importance of this as early as 2004, and it is now well known that failure or reluctance to challenge others who might be wrong can severely compromise a patient's safety. The Royal College of Surgeons of Edinburgh runs popular regular courses (Non-technical Skills for Surgeons, NOTSS) that teach how to ensure safety through good communication and teamwork. In this paper we introduce the concept of hierarchical challenge, and discuss models and approaches to address situations when problems arise within a team.

Probing ultra-fast processes with high dynamic range at 4th-generation light sources: Arrival time and intensity binning at unprecedented repetition rates

Understanding dynamics on ultrafast timescales enables unique and new insights into important processes in the materials and life sciences. In this respect, the fundamental pump-probe approach based on ultra-short photon pulses aims at the creation of stroboscopic movies. Performing such experiments at one of the many recently established accelerator-based 4th-generation light sources such as free-electron lasers or superradiant THz sources allows an enormous widening of the accessible parameter space for the excitation and/or probing light pulses. Compared to table-top devices, critical issues of this type of experiment are fluctuations of the timing between the accelerator and external laser systems and intensity instabilities of the accelerator-based photon sources. Existing solutions have so far been only demonstrated at low repetition rates and/or achieved a limited dynamic range in comparison to table-top experiments, while the 4th generation of accelerator-based light sources is based on superconducting radio-frequency technology, which enables operation at MHz or even GHz repetition rates. In this article, we present the successful demonstration of ultra-fast accelerator-laser pump-probe experiments performed at an unprecedentedly high repetition rate in the few-hundred-kHz regime and with a currently achievable optimal time resolution of 13 fs (rms). Our scheme, based on the pulse-resolved detection of multiple beam parameters relevant for the experiment, allows us to achieve an excellent sensitivity in real-world ultra-fast experiments, as demonstrated for the example of THz-field-driven coherent spin precession.

A regional EUS service using a collaborative network

Endoscopic ultrasound (EUS) is increasingly used in the management of hepatobiliary lesions, allowing staging and tissue acquisition. It is operator-dependent, and fine needle aspiration (FNA) of solid lesions provides an auditable standard; high-volume centres have shown excellent results for solid pancreatic lesion FNA with sensitivities of 92%-97%. The British Society of Gastroenterology guidelines stress that clinical quality should determine service provision, with geographical accessibility a secondary consideration. We set up the Wessex EUS network, working from a single hepatobiliary (HPB) pancreatic multidisciplinary team, with EUS provided in four local centres providing agreed standards and audit. Pancreatic solid lesion FNA results showed a pooled sensitivity of 94%, comparable with high-volume single centres. This demonstrates a network with good clinical governance is a plausible solution to providing a specialist service such as EUS and may be a roadmap that other specialist services under pressure could follow.

Information technology in nurse education: a multimedia approach to teaching biological sciences

The School of Health Science at the University of Wales Swansea offers programmes for nurses and other healthcare professionals ranging from pre-registration nursing to post-doctoral studies. Biological science is an important component of the pre-registration programme, the delivery of which has proved to be problematic. Research conducted by the school has identified that a more innovative approach to teaching and learning this subject is required.

There is a growing body of evidence that Multimedia Learning (MML) can enhance the quality of education, supporting or replacing the traditional didactic lecture and providing the student with information and standards of presentation that have never before been available. With this in mind, and responding to the research findings, the school has made a substantial investment in multimedia technology. We have now embarked on a programme to produce and deliver a biological science module for nursing students. If the evaluation of the programme demonstrates sustainable improvements in learning and offers enhanced quality in the delivery of programmes, it is the intention to extrapolate the biological science project to other curriculum subjects.

An update on the latest evidence for managing the clinically negative neck (cN0) in oral squamous cell carcinoma

The single most important prognostic indicator for survival in oral squamous cell carcinoma (OSCC) is the presence of lymph node metastases in the neck. While the treatment of the clinically node positive (cN+) neck is well established, the management of the clinically negative neck (cN0) is controversial. Various strategies have been advocated including close observation including regular ultrasound imaging, elective neck dissection and sentinel lymph node biopsy. Neck dissection surgery is not without potential morbidity with shoulder dysfunction being the main complication. A number of factors are associated with increased risk of neck node metastasis including primary tumour thickness and peri-neural invasion. A recent prospective randomised trial has found survival benefit following neck dissection even in patients with a cN0 neck at presentation. We discuss the latest evidence for managing the cN0 in OSCC and include our own experience on the role of neck dissection in certain cases.

Sentinel lymph node biopsy for head and neck mucosal cancers - an update on the current evidence

Regional metastases are a prominent feature of mucosal-associated head and neck squamous cell carcinomas and are an important prognostic factor. Sentinel lymph node biopsy (SLNB) is one modality that has potential to add to the accuracy of neck staging, although it is currently not used as widely in the head and neck as it is in other areas such as breast cancer. We review the efficacy of SLNB in head and neck mucosal squamous cell carcinomas and provide an overview of current practice and include details of technical advances.

Estrogen receptor alpha somatic mutations Y537S and D538G confer breast cancer endocrine resistance by stabilizing the activating function-2 binding conformation

Somatic mutations in the estrogen receptor alpha (ERα) gene (ESR1), especially Y537S and D538G, have been linked to acquired resistance to endocrine therapies. Cell-based studies demonstrated that these mutants confer ERα constitutive activity and antiestrogen resistance and suggest that ligand-binding domain dysfunction leads to endocrine therapy resistance. Here, we integrate biophysical and structural biology data to reveal how these mutations lead to a constitutively active and antiestrogen-resistant ERα. We show that these mutant ERs recruit coactivator in the absence of hormone while their affinities for estrogen agonist (estradiol) and antagonist (4-hydroxytamoxifen) are reduced. Further, they confer antiestrogen resistance by altering the conformational dynamics of the loop connecting Helix 11 and Helix 12 in the ligand-binding domain of ERα, which leads to a stabilized agonist state and an altered antagonist state that resists inhibition.

Around one in every eight women will be diagnosed with breast cancer in their lifetime. Hormone-based therapies – also referred to antiestrogen drugs – target a protein called estrogen receptor alpha and are effective treatments for the majority of these cancers. Unfortunately, about half of patients will develop recurrent breast cancers even though the cancer continues to produce the target of the drugs.

The estrogen receptor alpha drives breast cancer in a number of ways, many of which require the receptor to be activated by binding to the hormone estrogen. When estrogen binds it causes the receptor to change shape to expose a surface where other proteins called coactivators can bind. Once a coactivator is bound, the estrogen receptor is active and signals the cancer cell to grow, divide, invade local tissues, and spread to new sites in the body.

Antiestrogen drugs competitively block the binding of estrogen to the receptor and cause the receptor to take on a different shape that inhibits the binding of the coactivator. However, recent studies identified mutations at specific sites in the gene that encodes estrogen receptor alpha in a large subset of patients with breast cancers that have spread. These mutations make the receptor resistant to antiestrogen drugs, and two mutations (called Y537S and D538G) account for approximately 70% of cases. However, it was not clear how these mutations altered the activity of estrogen receptor alpha at the molecular level.

Fanning, Mayne, Dharmarajan et al. now show these two most common mutations allow estrogen receptor alpha to bind to the coactivator in the absence of hormone. This unfortunately also reduces the effectiveness of one of the mostly widely administered antiestrogen therapies – a drug called tamoxifen. However, Fanning, Mayne, Dharmarajan et al. also show that the newer and more potent antiestrogens that are currently under examination in clinical trials should be highly effective at treating the cancers with the mutated versions of estrogen receptor alpha.

Applying the knowledge gained from these new findings toward the development of new antiestrogens could help reverse the impact of these common mutations. If successful, these new drugs will provide life-saving treatments for many breast cancer patients.

Optical nanoscopy of transient states in condensed matter

Recently, the fundamental and nanoscale understanding of complex phenomena in materials research and the life sciences, witnessed considerable progress. However, elucidating the underlying mechanisms, governed by entangled degrees of freedom such as lattice, spin, orbit, and charge for solids or conformation, electric potentials, and ligands for proteins, has remained challenging. Techniques that allow for distinguishing between different contributions to these processes are hence urgently required. In this paper we demonstrate the application of scattering-type scanning near-field optical microscopy (s-SNOM) as a novel type of nano-probe for tracking transient states of matter. We introduce a sideband-demodulation technique that allows for probing exclusively the stimuli-induced change of near-field optical properties. We exemplify this development by inspecting the decay of an electron-hole plasma generated in SiGe thin films through near-infrared laser pulses. Our approach can universally be applied to optically track ultrafast/-slow processes over the whole spectral range from UV to THz frequencies.

Preoperative neutrophil:lymphocyte and platelet:lymphocyte ratios predict endometrial cancer survival

BACKGROUND

Variations in systemic inflammatory response biomarker levels have been associated with adverse clinical outcome in various malignancies. This study determined the prognostic significance of preoperative neutrophil:lymphocyte (NLR), platelet:lymphocyte (PLR) and monocyte:lymphocyte (MLR) ratios in endometrial cancer.

METHODS

Clinicopathological and 5-year follow-up data were obtained for a retrospective series of surgically treated endometrial cancer patients (n=605). Prognostic significance was determined for overall (OS) and cancer-specific survival (CSS) using Cox proportional hazards models and Kaplan-Meier analysis. Receiver-operator characteristic and log-rank functions were used to optimise cut-offs. NLR, PLR and MLR associations with clinicopathological variables were determined using non-parametric tests.

RESULTS

Applying cut-offs of ⩾2.4 (NLR), ⩾240 (PLR) and ⩾0.19 (MLR), NLR and PLR (but not MLR) had independent prognostic significance. Combining NLR and PLR scores stratified patients into low (NLR-low and PLR-low), intermediate (NLR-high or PLR-high) and high risk (NLR-high and PLR-high) groups: multivariable hazard ratio (HR) 2.51; P<0.001 (OS); HR 2.26; P<0.01 (CSS) for high vs low risk patients. Increased NLR and PLR were most strongly associated with advanced stage (P<0.001), whereas increased MLR was strongly associated with older age (P<0.001).

CONCLUSION

Both NLR and PLR are independent prognostic indicators for endometrial cancer, which can be combined to provide additional patient stratification.

Division of the spinal accessory nerve in the anterior triangle: a prospective clinical study

The anatomical relation between the spinal accessory nerve and internal jugular vein is well documented, but other variants of the nerve, including the contributions of the cervical plexus to supply motor fibres to the trapezius, are less well known. We have previously described an anatomical variant in which the spinal accessory nerve divided before entering the sternocleidomastoid, and the inferior trunk passed directly under it to supply the trapezius. We now present a prospective study of 133 neck dissections (excluding radical dissections) in which a meticulous search was made for the variant in the anterior triangle of the neck during operation. We found it in 3 necks (2%). One of the 3 patients had a bilateral neck dissection but it was found on one side only, and in 2 cases it communicated with the cervical plexus. In all 3, stimulation of the inferior division resulted in contraction of the trapezius while the upper division was found to supply the sternocleidomastoid only. The finding of this variant, which was more common than first thought, highlights the need for meticulous dissection of the nerve before it enters the sternocleidomastoid to ensure that, when present, the inferior branch is preserved to minimise potential postoperative shoulder dysfunction. Further research including a cadaveric study is needed to understand this important variant more fully.

Malignant cutaneous adnexal tumours of the head and neck: an update on management

Adnexal tumours form a heterogeneous group of relatively rare neoplasms. Many of them have a poor prognosis and treatment can sometimes be difficult and controversial. We summarise the latest publications relating to malignant cutaneous adnexal tumours of the head and neck, and give an update on their management. We discuss Merkel cell carcinoma and other rare malignant adnexal tumours including dermatofibrosarcoma protuberans and atypical fibroxanthoma.

Maternal request for caesarean section: audit of a care pathway

This report is based on an audit of the delivery outcome of a specific care pathway for women who had made a maternal request for caesarean section (MRCS). The study took place in a UK inner city National Health Service maternity unit with 6,000 births per year. All 31 multiparous and 16 nulliparous women on the pathway were included. All of the former group had delivered vaginally, all reported having experienced their previous birth as traumatic, and all subsequently delivered vaginally. Of the 16 nulliparous women, six delivered by planned caesarean section; four delivered vaginally; four had an instrumental delivery and two had an emergency caesarean section. A designated multidisciplinary care pathway that incorporates education and support may have the potential to help more women to achieve a normal delivery. More research is needed to assess its potential for reducing unnecessary caesarean deliveries and for improving user experience.