Editorial: Muscles at the expense of liver injury. Is it worth it?

This article is linked to Nash et al paper. To view this article, visit https://doi.org/10.1111/apt.17906

Frequent Friers: Outcomes in Patients Who Receive Multiple Courses of Lung SBRT

PURPOSE/OBJECTIVE(S)

Stereotactic body radiation therapy (SBRT) is a definitive therapy for early-stage non-small cell lung cancer and solitary pulmonary metastases with high tolerability and excellent survival rates. With longer survival and patients developing subsequent primaries or oligometastatic disease, patients are receiving multiple repeat lung SBRT courses. This study aims to assess safety and efficacy of high-frequency SBRT (HF-SBRT) to the lung, defined as >3 courses.

MATERIALS/METHODS

A retrospective review was performed of patients who received >3 courses of lung SBRT. Logistic regression was performed to identify predictors of radiation pneumonitis (RP) and worsening pulmonary function (WPF). Local control (LC) and overall survival (OS) were evaluated using the Kaplan-Meier method.

RESULTS

Ninety-four courses of HF-SBRT to the lung were identified among 28 patients. 78% of patients received 3 SBRT courses, 12% received 4 courses, and 7.1% received >5 courses. Median follow-up was 4.4 years. Median age at time of treatment was 73 years-old; 58% males; 42% had an underlying pulmonary comorbidity; 39% prior lung surgery; 52% history of cardiac disease; 52% prior tobacco use; median ECOG 0. Median SBRT dose was 48 Gy. Median interval between courses was 5.6 months. Zero patients experienced greater than grade 2 acute CTCAE v5 toxicity. 7.2% (7) of patients developed RP at median time of 2.6 months [IQR: 1.4,7.4]; grade 1: 3 patients, grade 2: 1 patient, grade 3: 2 patients. Of patients who developed RP, 42% (3) went on to receive further SBRT without experiencing significant adverse events (AEs). History of pulmonary disease, prior lung surgery, and history of tobacco use strongly correlated with WPF but not RP (WPF p-values: <0.001, 0.003, <0.001, respectively). History of cardiac disease did not correlate with WPF or RP. Receiving bilateral lung SBRT treatment (vs unilateral) trended towards correlation with WPF (p = 0.06) and RP (p = 0.08). Time between SBRT courses did not significantly differ for those who developed RP (p = 0.62) or WPF (p = 0.42). No individual or plan sum dosimetric constraint (GTV, PTV, unilateral lung V5, lung V10, lung V20, unilateral mean lung dose, or total lung V20) significantly differed in those who experienced RP. WPF correlated with the plan sum unilateral lung V10 (p = 0.05). LC at 1-year was 100%, 1 local failure occurred at 13 months; 2-year OS was 91.7%, median OS 5.4 years.

CONCLUSION

Overall, HF-SBRT was well tolerated. Development of RP did not correlate with a specific individual or plan sum dosimetric parameter, with patients receiving subsequent courses of SBRT without increased AEs. WPF increasingly occurred with subsequent SBRT courses and correlated with unilateral plan sum V10. This study suggests that in appropriately selected patients, SBRT after RP can still be provided as definitive care, while further studies should validate this and focus attention on mitigating long-term WPF in patients who receive HF-SBRT.

Mortality Risk Related to Heatwaves in Dezful City, Southwest of Iran

BACKGROUND

We aimed to evaluate the impact of heatwaves on daily deaths due to non-accidental, cardiovascular and respiratory causes in the city of Dezful in Iran from 2013 to 2019.

METHOD

We collected daily ambient temperature and mortality and defined 2 types of heatwaves by combining daily temperature ⩾90th in each month of the study period or since 30 years with duration ⩾2 and 3 days. We used a distributed lag non-linear model to study the association between each type of heatwave definition, and deaths due to non-accidental, cardiovascular and respiratory causes with lags up to 13 days.

RESULTS

There was no discernible correlation in this area, despite the fact that heatwaves raised the risk of death from cardiovascular causes and lowered the risk from respiratory causes. On the other hand, the risk of total non-accidental mortality on days with the heatwaves is significantly higher than normal days. In main effects, the heatwaves have a significant relationship with the risk of total non-accidental mortality (in the first heatwave definition, Cumulative Excess Risk (CER) in lag_0-2 was 10.4 and in second heatwave definition, CER values in lag_{0, 0-2, and 0-6} were 12.4, 29.2, and 38.8 respectively). Also, in added effects, heatwaves have a significant relationship with the risk of total non-accidental mortality (in the first heatwave definition, CER in lag_{0 and 0-2} were 1.79 and 4.11 and in the second heatwave definition, CER values in lag_{0, 0-2, and 0-6} were 7.76, 18.35 and 24.87 respectively). In addition, heatwaves appeared to contribute to a cumulative excess risk of non-accidental death among the male group as well as the older adults.

CONCLUSION

However, the results showed that heatwaves could have detrimental effects on health, even in populations accustomed to the extreme heat. Therefore, early warning systems which monitor heatwaves should provide the necessary warnings to the population, especially the most vulnerable groups.

Aromatic L-amino acid decarboxylase deficiency: a systematic review

Aim: To gain greater knowledge regarding the natural history of aromatic L-amino acid decarboxylase (AADC) deficiency, a genetic disorder that causes severe deficits in motor and cognitive development. Materials & methods: A systematic literature review was performed of all case reports and clinical studies published through December 2019 of patients with AADC deficiency. The data were summarized descriptively. Results: The search identified 94 publications that described 237 unique patients. Mean (standard deviation) age at diagnosis was 3.2 (±5.7) years and 16 deaths were reported. Most patients (57%) received the standard of care therapies, which showed limited efficacy in this patient population. Conclusion: AADC deficiency is a devastating disease and prospectively defined natural history studies are warranted to further understand this disease.

Effect of Dust Storms on Non-Accidental, Cardiovascular, and Respiratory Mortality: A Case of Dezful City in Iran

BACKGROUND

Despite the fact that Iran has been exposed to severe dust storms during the past 2 decades, few studies have investigated the health effects of these events in Iran. This study was conducted to assess the association between dust storms and daily non-accidental, cardiovascular, and respiratory mortality in Dezful City (Khuzestan Province, Iran) during 2014 to 2019.

METHODS

In this study, mortality, meteorological, and climatological data were obtained from the Dezful University of Medical Sciences, Iranian Meteorological Organization, and Department of Environment in Khuzestan Province, respectively. Days of dust storm were identified based on the daily concentration threshold of particulate matter with an aerodynamic diameter of less than 10 μm (PM10) according to Hoffmanns҆ definition, and then an ecological time-series was used to estimate the short-term effects of dust storms on daily mortality. Statistical analysis was performed using a distributed lag linear model (DLM) and a distributed lag non-linear model (DLNM) packages by R software and the study results were reported as excess mortality.

RESULTS

During the study period, 15 223 deaths were recorded, and 139 dust storms occurred in Dezful city. In addition, there was statistically significant excess risk of mortality due to dust storms in Dezful City (mortality in the group under 15 years of age, lag4: 34.17% and 15-64 years of age groups, lag5: 32.19%, lag6: 3.28%), also dust storms had statistically significant effects on respiratory mortality (lag6: 5.49%).

CONCLUSION

The findings of the current study indicate that dust storms increase the risk of mortality with some lags. An evidence-based early warning system may be able to aware the people of the health effects of dust storms.

Antibody responses after first and second Covid-19 vaccination in patients with chronic lymphocytic leukaemia

B-cell chronic lymphocytic leukaemia (CLL) is associated with immunosuppression and patients are at increased clinical risk following SARS-CoV-2 infection. Covid-19 vaccines offer the potential for protection against severe infection but relatively little is known regarding the profile of the antibody response following first or second vaccination. We studied spike-specific antibody responses following first and/or second Covid-19 vaccination in 299 patients with CLL compared with healthy donors. 286 patients underwent extended interval (10-12 week) vaccination. 154 patients received the BNT162b2 mRNA vaccine and 145 patients received ChAdOx1. Blood samples were taken either by venepuncture or as dried blood spots on filter paper. Spike-specific antibody responses were detectable in 34% of patients with CLL after one vaccine (n = 267) compared to 94% in healthy donors with antibody titres 104-fold lower in the patient group. Antibody responses increased to 75% after second vaccine (n = 55), compared to 100% in healthy donors, although titres remained lower. Multivariate analysis showed that current treatment with BTK inhibitors or IgA deficiency were independently associated with failure to generate an antibody response after the second vaccine. This work supports the need for optimisation of vaccination strategy in patients with CLL including the potential utility of booster vaccines.

Global Health Impacts of Dust Storms: A Systematic Review

BACKGROUND

Dust storms and their impacts on health are becoming a major public health issue. The current study examines the health impacts of dust storms around the world to provide an overview of this issue.

METHOD

In this systematic review, 140 relevant and authoritative English articles on the impacts of dust storms on health (up to September 2019) were identified and extracted from 28 968 articles using valid keywords from various databases (PubMed, WOS, EMBASE, and Scopus) and multiple screening steps. Selected papers were then qualitatively examined and evaluated. Evaluation results were summarized using an Extraction Table.

RESULTS

The results of the study are divided into two parts: short and long-term impacts of dust storms. Short-term impacts include mortality, visitation, emergency medical dispatch, hospitalization, increased symptoms, and decreased pulmonary function. Long-term impacts include pregnancy, cognitive difficulties, and birth problems. Additionally, this study shows that dust storms have devastating impacts on health, affecting cardiovascular and respiratory health in particular.

CONCLUSION

The findings of this study show that dust storms have significant public health impacts. More attention should be paid to these natural hazards to prepare for, respond to, and mitigate these hazardous events to reduce their negative health impacts.Registration: PROSPERO registration number CRD42018093325.

How decision-making about euthanasia for animals is taught to Australasian veterinary students

This study set out to explore how euthanasia decision-making for animals was taught to students in eight Australasian veterinary schools. A questionnaire-style interview guide was used by a representative at each university to interview educators. Educators were interviewed about their teaching of euthanasia decision-making for four categories of animals: livestock, equine, companion and avian/wildlife. Using thematic analysis, the terms provided by participants to describe how (mode of teaching) and what (specific content) they taught to students were categorised. Information about content was categorised into human-centred factors that influence decision-making, and animal-based indicators used to directly inform decision-making. All eight representatives reported some teaching relevant to euthanasia decision-making at their university for livestock, companion animal and avian/wildlife. One representative reported no such teaching for equid animals at their university. Observation of a euthanasia case was rarely reported as a teaching method. Five universities reported multiple modes of teaching relevant information, while two universities made use of modalities that could be described as opportunistic teaching (e.g., 'Discussion of clinical cases'). Factors taught at most universities included financial considerations, and that it is the owner's decision to make, while animal-based indicators taught included QoL/animal welfare, prognosis and behaviour change. Overall, most universities used a variety of methods to cover relevant material, usually including lectures and several other approaches for all animal types. However, because two universities relied on presentation of clinical cases, not all students at these veterinary schools will be exposed to make, or assist in making, euthanasia decisions.

How management of grief associated with ending the life of an animal is taught to Australasian veterinary students

OBJECTIVE

Veterinarians have an important role in supporting and understanding their clients' grief. Veterinary schools have a duty to teach students how best to manage grief - both that of the students/future veterinarians and the clients. This study explores how grief management, associated with ending the life of an animal, was taught to students in eight Australasian veterinary schools.

METHODS

A questionnaire-style interview guide was used by a representative at each university to conduct structured interviews with educators in a snowball sampling approach. Educators were interviewed about the teaching of grief management for four categories of animals: livestock, equine, companion and avian/wildlife. The terms used by participants to describe what they taught were grouped into common themes. Teaching was defined by individual participants and included structured and unstructured approaches. The stage in the degree (preclinical or clinical years) that grief management was taught in the veterinary curriculum and by whom (e.g. clinicians or psychologists) is also described.

RESULTS

Grief management was taught more in preclinical than clinical years. However, due to how grief was characterised, much of this teaching was general 'nonspecific' teaching that included all categories of animals. Client grief was taught more generically, whereas, grief of veterinarians was taught using specific examples given by clinicians.

CONCLUSION

A more robust end-of-life (EoL) management curriculum that includes all aspects of grief management is likely to increase job satisfaction, client happiness and professional satisfaction.

A-75 Predicting neurocognitive impairment using the Green’s Medical Symptom Validity Test dementia profile formula

Objective

The Green’s Medical Symptom Validity Test (MSVT) is a measure of performance validity and has a formula to help distinguish genuine cognitive impairment from suboptimal engagement. The current study used the MSVT “dementia profile” formula to discriminate patients with no neurocognitive disorder (no NCD), mild neurocognitive disorder (mild NCD), and major neurocognitive disorder (major NCD).

Method

198 patients who were seen for comprehensive outpatient neuropsychological testing and passed all MSVT validity measures were included in the study. Specifically, participants included 103 persons with no NCD, 62 diagnosed with a mild NCD, and 33 with major NCD, who were collectively 58% male, with a mean age of 52-years-old (SD = 16.1) and mean education of 14.5 years (SD = 2.5).

Results

The difference score between easy and hard MSVT subtests predicted group assignment (r = .57, p < .001) and effectively differentiated the three groups (p < .001). Mean difference scores of both groups with diagnosed NCD exceeded recommended criteria suggestive of genuine cognitive impairment, with the differences score of major NCD being greater (p < .01) than the mild NCD. Group differences remained significant (p < .001) after adjusting for the effects of age and education. When the NCD groups were compared to the no diagnosis group, ROC curve analysis produced an AUC of .84, with a sensitivity of .72 and specificity of .83.

Conclusions

Findings from this study validate the established difference score between easy and hard subtests of the MSVT, and suggest that the difference score on a valid MSVT profile yields diagnostically relevant information pertaining to the level of an individual’s neurocognitive impairment.

Strategies for engaging with future radiation protection professionals: a public outreach case study

It is evident that there is a nuclear skills shortage within the UK, and logically it can be assumed that the shortfall extends to the radiation protection arena. Plans for nuclear new-build and the decommissioning of existing nuclear sites will require many more people with radiological knowledge and practical competencies. This converts to a nuclear industry requirement in the order of 1000 new recruits per year over at least the next ten years, mainly as new apprentices and graduates. At the same time, the strong demand for persons with radiation protection know-how in the non-nuclear and health care sectors is unlikely to diminish. The task of filling this skills gap is a significant one and it will require a determined effort from many UK stakeholders. The Society for Radiological Protection (SRP) has adopted a strategy in recent years to help address this skills gap. The aim is to engage the interest of secondary school students in the science of radiation and inspire them to follow a career in radiation protection. This paper presents the reasoning behind this strategy and, in an 'outreach case study', describes the establishment of the annual SRP Schools Event. This event is becoming an important addition to the national efforts aimed at increasing the numbers of skilled UK radiation protection professionals over the forthcoming decades.

Distinct phenotype of hepatotoxicity associated with illicit use of anabolic androgenic steroids

BACKGROUND

We have observed an increase in hepatotoxicity (DILI) reporting related to the use of anabolic androgenic steroids (AAS) for bodybuilding.

AIM

To characterise phenotype presentation, outcome and severity of AAS DILI.

METHODS

Data on 25 cases of AAS DILI reported to the Spanish (20) and Latin-American (5) DILI Registries were collated and compared with previously published cases.

RESULTS

AAS DILI increased from representing less than 1% of the total cases in the Spanish DILI Registry in the period 2001-2009 to 8% in 2010-2013. Young men (mean age 32 years), requiring hospitalisation, hepatocellular injury and jaundice were predominating features among the AAS cases. AAS DILI caused significantly higher bilirubin values independent of type of damage when compared to other drug classes (P = 0.001). Furthermore, the cholestatic AAS cases presented significantly higher mean peak bilirubin (P = 0.029) and serum creatinine values (P = 0.0002), compared to the hepatocellular cases. In a logistic regression model, the interaction between peak bilirubin values and cholestatic damage was associated with the development of AAS-induced acute kidney impairment (AKI) [OR 1.26 (95% CI: 1.035-1.526); P = 0.021], with 21.5 ×ULN being the best bilirubin cut-off point for predicting AKI risk (AUCROC 0.92). No fatalities occurred.

CONCLUSIONS

Illicit recreational AAS use is a growing cause of reported DILI that can lead to severe hepatic and renal injury. AAS DILI is associated with a distinct phenotype, characterised by considerable bilirubin elevations independent of type of damage. Although hepatocellular injury predominates, acute kidney injury develops in cholestatic cases with pronounced jaundice.

KRAS mutations in non-small-cell lung cancer and colorectal cancer: implications for EGFR-targeted therapies

BACKGROUND

KRAS mutations are associated with diverse biologic functions as well as prognostic and predictive impact in non-small cell-lung cancer (NSCLC) and colorectal cancer (CRC). In CRC, benefit from monoclonal antibody therapies targeting EGFR is generally limited to patients whose tumors have wild-type (WT) KRAS, whereas data suggest that this association is not present for NSCLC. We hypothesized that the unique tobacco-related carcinogenesis of NSCLC results in a divergence of KRAS MT genotype compared with CRC, contributing to differences in outcomes from EGFR-targeted therapies.

MATERIAL AND METHODS

Tumor from 2603 patients (838 CRC and 1765 NSCLC) was analyzed for KRAS mutations. DNA was extracted from microdissected formalin-fixed-paraffin-embedded specimens (FFPE) and 7 different base substitutions in codons 12 and 13 of KRAS were determined.

RESULTS

KRAS mutation genotype differed significantly between NSCLC and CRC in frequency (25% vs. 39%; p<0.001), smoking-associated G>T transversions (73% versus 27%; p<0.001), and ratio of transversions to transitions (3.5 vs. 0.79; p<0.001). In NSCLC GLY12Cys mutations, resulting from a codon 12 GGT>TGT substitution, were observed in 44% compared to 10% for CRC. In contrast, codon 12 or 13 GLY>ASP substitutions (resulting in a G>A transition) were more frequent in CRC (42%) compared with NSCLC (21%).

CONCLUSION

In this large dataset, KRAS mutation patterns are quantitatively and qualitatively distinct between NSCLC and CRC, reflecting in part differences in tobacco-related carcinogenesis. In light of differences in predictive value for EGFR-directed monoclonal antibody therapy and prognosis for specific KRAS mutations between NSCLC and CRC, these data provide an underlying biologic rationale.

Assessing and Communicating Risk with Communities Living on Contaminated Land

The U.K. government has emphasized redeveloping derelict land for housing. As a result, tools for assessing brownfield sites are well developed. However, there are many potentially contaminated sites on which people live, often not to the people's knowledge. For these situations, statutory guidance for risk communication is underdeveloped and, in certain situations, inadequate. This paper illustrates limitations of current methods using a heavily populated site where levels of specific contaminants exceed statutory limits. The authors describe how residents were involved in the site assessment process and how the process may be improved, and propose a framework to incorporate risk communication into the contaminated-land use strategy.

Women's Experience at the Time of Menopause: Accounting for Biological, Cultural and Psychological Embodiment

In understanding health and illness, it has long been apparent that psychological and social aspects are as important as the biological explanations of the biomedical model. Recent studies of women's experience of menopause have demonstrated the psychological and social constructions of women's bodies, but have neglected to include individual embodiment and the notion of a social world that is inescapably embodied. This paper presents arguments for the consideration of an integrated approach to embodiment and, drawing upon recent theorizing, a conceptual framework that is able to take into account the integration of psyche, biology, and culture. The accounts of 80 New Zealand women, aged between 45 and 60, are analysed, using categories labelled, 'visceral', 'experiential', 'normative' and 'pragmatic', to provide a description of women's embodied and culturally embedded experience of menopause. The incorporation of these analytic categories, and the usefulness of the application of the model in contemporary applied work, is discussed.