Relationship of Sleep Health and Endoscopic Disease Activity in Inflammatory Bowel Disease: Endoscopic Disease Activity and Sleep

Among adults with inflammatory bowel disease (IBD), self-reported sleep disturbances are associated with active symptoms, but the association between sleep measures and endoscopic disease activity is unknown. This study aimed to (1) compare sleep-wake behaviors among IBD patients based on endoscopic and clinical disease activity and (2) describe associations between actigraphy, self-reported sleep measures, and symptoms of fatigue, anxiety, and depression. Participants wore a wrist actigraph for 10 consecutive days and completed self-reported sleep questionnaires (Pittsburgh Sleep Quality Index [PSQI] and Patient-Reported Outcome Measures System [PROMIS] Sleep Disturbance and Sleep Interference questionnaires). Clinical and endoscopic disease activity were assessed. Based on actigraphic recordings ( n = 26), average total nighttime sleep was 437 minutes and sleep efficiency was 84%. Objective sleep measures did not differ based on endoscopic or clinical disease activity. Individuals with active clinical disease had higher PROMIS Sleep Disturbance (57.3 vs. 49.7, d = 1.28) and PROMIS Sleep-Related Impairment (58.1 vs. 52.8, d = 0.51) compared with those with inactive clinical disease. Self-reported sleep was significantly associated with anxiety, depression, and fatigue. Further research is needed to better characterize the relationship between sleep and endoscopic disease activity, and determine underlying mechanisms related to poor sleep in the IBD population.

Virtual Reality Meditation for Fatigue in Persons With Rheumatoid Arthritis: Mixed Methods Pilot Study

BACKGROUND

Effective symptom management is crucial to enhancing the quality of life for individuals with chronic diseases. Health care has changed markedly over the past decade as immersive, stand-alone, and wearable technologies including virtual reality have become available. One chronic pain population that could benefit from such an intervention is individuals with rheumatoid arthritis (RA). Recent pharmacologic advances in the management of RA have led to a decrease in inflammatory symptoms (eg, chronic pain) or even disease remission, yet up to 70% of patients with RA still suffer from fatigue. While VR-delivered behavior, meditation, and biofeedback programs show promise for pain and anxiety management, there is little information on the use of virtual reality meditation (VRM) for fatigue management among individuals with RA.

OBJECTIVE

This study aims to (1) examine the feasibility of implementing a study protocol that uses VRM, (2) determine the acceptability of using VRM for fatigue management in an outpatient population, and (3) identify barriers and contextual factors that might impact VRM use for fatigue management in outpatients with RA.

METHODS

We used a convergent, mixed methods design and enrolled adults aged 18 years or older with a clinical diagnosis of RA. Patient-Reported Outcome Measure Information System (PROMIS) measures of fatigue, depression, anxiety, pain behavior, and physical function were assessed alongside the brief mood introspection scale at baseline and weekly for 4 weeks. VRM use across the 4-week study period was automatically stored on headsets and later extracted for analysis. Semistructured interview questions focused on feedback regarding the participant's experience with RA, previous experience of fatigue, strategies participants use for fatigue management, and the participant's experience using VRM and recommendations for future use.

RESULTS

A total of 13 participants completed this study. Most participants completed all study surveys and measures (11/13, 84% and 13/13, 100%, respectively) and were active participants in interviews at the beginning and end of the program. Participants used VRM an average of 8.9 (SD 8.5) times over the course of the 4-week program. Most participants enjoyed VRM, found it relaxing, or recommended its use (12/13, 92%), but 8 (62%) noted barriers and conceptual factors that impacted VRM use. On average, participants saw decreases in PROMIS fatigue (-6.4, SD 5.1), depression (-5.6, SD 5.7), anxiety (-4.5, SD 6), and pain behavior (-3.9, SD 5.3), and improvements in PROMIS physical function (1.5, SD 2.7) and Brief Mood Introspection Scale mood (5.3, SD 6.7) over the course of this 4-week study.

CONCLUSIONS

While this study's implementation was feasible, VRM's acceptability as an adjunctive modality for symptom management in RA is contingent on effectively overcoming barriers to use and thoughtfully addressing the contextual factors of those with RA to ensure successful intervention deployment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04804462; https://classic.clinicaltrials.gov/ct2/show/NCT04804462.

Complex differences in infection rates between ethnic groups in Scotland: a retrospective, national census-linked cohort study of 1.65 million cases

BACKGROUND

Ethnicity can influence susceptibility to infection, as COVID-19 has shown. Few countries have systematically investigated ethnic variations in infection.

METHODS

We linked the Scotland 2001 Census, including ethnic group, to national databases of hospitalizations/deaths and serological diagnoses of bloodborne viruses for 2001-2013. We calculated age-adjusted rate ratios (RRs) in 12 ethnic groups for all infections combined, 15 infection categories, and human immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C (HCV) viruses.

RESULTS

We analysed over 1.65 million infection-related hospitalisations/deaths. Compared with White Scottish, RRs for all infections combined were 0.8 or lower for Other White British, Other White and Chinese males and females, and 1.2-1.4 for Pakistani and African males and females. Adjustment for socioeconomic status or birthplace had little effect. RRs for specific infection categories followed similar patterns with striking exceptions. For HIV, RRs were 136 in African females and 14 in males; for HBV, 125 in Chinese females and 59 in males, 55 in African females and 24 in males; and for HCV, 2.3-3.1 in Pakistanis and Africans.

CONCLUSIONS

Ethnic differences were found in overall rates and many infection categories, suggesting multiple causative pathways. We recommend census linkage as a powerful method for studying the disproportionate impact of COVID-19.

The challenge of using routinely collected data to compare hospital admission rates by ethnic group: a demonstration project in Scotland

BACKGROUND

Recording patients' ethnic group supports efforts to achieve equity in health care provision. Before the Equality Act (2010), recording ethnic group at hospital admission was poor in Scotland but has improved subsequently. We describe the first analysis of the utility of such data nationally for monitoring ethnic variation.

METHODS

We analysed all in-patient or day case hospital admissions in 2013. We imputed missing data using the most recent ethnic group recorded for a patient from 2009 to 2015. For episodes lacking an ethnic code, we attributed known ethnic codes proportionately. Using the 2011 Census population, we calculated rates and rate ratios for all-cause admissions and ischaemic heart diseases (IHDs) directly standardized for age.

RESULTS

Imputation reduced missing ethnic group codes from 24 to 15% and proportionate redistribution to zero. While some rates for both all-cause and IHD admissions appeared plausible, unexpectedly low or high rates were observed for several ethnic groups particularly amongst White groups and newly coded groups.

CONCLUSIONS

Completeness of ethnicity recoding on hospital admission records has improved markedly since 2010. However the validity of admission rates based on these data is variable across ethnic groups and further improvements are required to support monitoring of inequality.

Factors Associated with the Development of Persistent Pain after mTBI

BACKGROUND

Persistent pain after mild traumatic brain injury (mTBI) is widely experienced, yet little is known about who is at risk for experiencing persistent pain after their injury.

AIMS

The purpose of this study was to 1) determine if there are factors associated with later experiencing persistent pain after mTBI and 2) examine if there are symptom patterns associated with the experience of persistent pain.

DESIGN

Secondary analysis was conducted using de-identified data from an NIH-funded longitudinal study.SettingsParticipants were enrolled in the emergency department.

PARTICIPANTS

Participants were aged 21 to 92 and all had experienced mTBI.

METHODS

We examined baseline characteristics, symptoms, and injury related variables associated with the endorsement of persistent pain among those with mTBI (N = 183) from baseline to 6 months post-injury. In order to identify a persistent pain phenotype, exploratory factor analysis was used to determine which symptoms co-occur with persistent pain.

RESULTS

Persistent pain was found in 78% of those with mTBI. Those with lower overall health status at day 7 and at 1-month following injury had greater odds of developing persistent pain. Those with higher levels of general health status and physical function health status at day 7 and 1 month, and those with higher levels of overall health related status at 1 month had significantly lesser odds of persistent pain at 6 months. Factor analysis revealed that persistent pain and co-occurring symptoms (anxiety, depression, dizziness, nausea and vomiting, sleep disturbance, poor memory, poor concentration, longer to think and light sensitivity) loaded on one factor, indicating that these symptoms are associated.

CONCLUSIONS

Those at increased risk for persistent pain should be screened beginning early in the recovery trajectory to reduce their risk of developing persistent pain. Identification of a phenotype offers potential for recognition of symptoms that cluster with persistent pain, improving the ability to treat patients more holistically, and develop interventions to support recovery from injury.

Pain and Symptoms after Mild Traumatic Brain Injury: Should Technology Play a Role in Self-Management?

BACKGROUND

Those with mild traumatic brain injury (mTBI) often experience pain and symptoms long after their initial injury. A gap in current knowledge is how persons would prefer to monitor and manage these symptoms following mTBI.

AIMS

The purpose of this study was to explore self-management strategies to inform design of an informatics tool to support self-management of pain and symptoms following mTBI.

DESIGN

A qualitative descriptive approach using semi-structured interviews of participants was used.

SETTINGS

Participants were interviewed by phone.

PARTICIPANTS

Seven female participants with recent mTBI completed interviews.

METHODS

A descriptive approach was utilized to determine what the tool should address, and which features should be included in a future tool. Themes were identified using a Qualitative Description analysis approach, which is based in naturalistic inquiry.

RESULTS

Participants described difficulty coping with symptoms, limited access to or knowledge of treatments and trial and error with compensatory strategies. These challenges often led to difficulty keeping up with work, school and other commitments. All participants indicated that they were interested in a tool that addresses pain, memory and concentration. The main features that participants wanted were pain and symptom tracking as well as suggestions based on tracking information.

CONCLUSIONS

Patients are interested in using technology to help with self-management of their pain and symptoms following mTBI. Tools that help patients with self-management should integrate into health systems and provide ways to effectively interact with providers during the most vulnerable phases of recovery.

Ethnic variations in falls and road traffic injuries resulting in hospitalisation or death in Scotland: the Scottish Health and Ethnicity Linkage Study

Objectives

To investigate ethnic differences in falls and road traffic injuries (RTIs) in Scotland.

Study design

A retrospective cohort of 4.62 million people, linking the Scottish Census 2001, with self-reported ethnicity, to hospitalisation and death records for 2001–2013.

Methods

We selected cases with International Classification of Diseases–10 diagnostic codes for falls and RTIs. Using Poisson regression, age-adjusted risk ratios (RRs, multiplied by 100 as percentages) and 95% confidence intervals (CIs) were calculated by sex for 10 ethnic groups with the White Scottish as reference. We further adjusted for country of birth and socio-economic status (SES).

Results

During about 49 million person-years, there were 275,995 hospitalisations or deaths from fall-related injuries and 43,875 from RTIs. Compared with the White Scottish, RRs for falls were higher in most White and Mixed groups, e.g., White Irish males (RR: 131; 95% CI: 122–140) and Mixed females (126; 112–143), but lower in Pakistani males (72; 64–81) and females (72; 63–82) and African females (79; 63–99). For RTIs, RRs were higher in other White British males (161; 147–176) and females (156; 138–176) and other White males (119; 104–137) and females (143; 121–169) and lower in Pakistani females (74; 57–98). The ethnic variations differed by road user type, with few cases among non-White motorcyclists and non-White female cyclists. The RRs were minimally altered by adjustment for country of birth or SES.

Conclusion

We found important ethnic variations in injuries owing to falls and RTIs, with generally lower risks in non-White groups. Culturally related differences in behaviour offer the most plausible explanation, including variations in alcohol use. The findings do not point to the need for new interventions in Scotland at present. However, as the ethnic mix of each country is unique, other countries could benefit from similar data linkage-based research.

•

Ethnic inequalities in injuries are demonstrated in Scotland based on a large sample size and a fine ethnic granularity.

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White minority ethnic groups had the highest risks of fall-related injuries in Scotland.

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Fall-related injuries were the least likely in the Pakistani population.

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Ethnic differences in road traffic injuries varied by the type of road user.

•

Ethnic differences in injuries were not explained by socio-economic status or country of birth.

Daycase trauma list: a safe and cost-effective service delivery

INTRODUCTION

Daycase trauma surgery is an evolving and a novel approach. The aim of our study was to report our experience of daycase trauma surgery with a focus on safety, patient experience, complications and limitations.

MATERIAL AND METHODS

Patients scheduled and operated on a daycase trauma list from January 2013 to December 2016 were included in the study. Age, sex, case mix, readmissions within 48 hours, complications, patient satisfaction, reasons for overnight stay and cost effectiveness were evaluated.

RESULTS

A total of 229 procedures were carried out. The mean age of the patients was 44.3 years (range 16-85 years) . There were 128 men and 101 women, 178 upper-limb and 51 lower-limb cases. Only 2.6% of the patients had stayed overnight for pain control, physiotherapy and neurological observations; 94.5% of the patients were satisfied. The mean visual analogue scale score for satisfaction was 8.7. There were no admissions within 48 hours of discharge and one complication with failure of ankle fixation. The estimated cost saving was £65,562.

CONCLUSION

We conclude that a daycase trauma service is safe, cost effective, and yields high patient satisfaction. It reduces the burden on hospital beds and a wide range of upper- and lower-limb cases can be performed as daycase trauma surgery with adequate planning and teamwork.

The prognostic impact of consensus molecular subtypes (CMS) and its predictive effects for bevacizumab benefit in metastatic colorectal cancer: molecular analysis of the AGITG MAX clinical trial

BACKGROUND

The consensus molecular subtypes (CMS) is a transcriptome-based classification of colorectal cancer (CRC) initially described in early-stage cohorts, but the associations of CMS with treatment outcomes in the metastatic setting are yet to be established. This study aimed to evaluate the prognostic impact of CMS classification and its predictive effects for bevacizumab benefit in metastatic CRC by correlative analysis of the AGITG MAX trial.

PATIENTS AND METHODS

The MAX trial previously reported improved progression-free survival (PFS) for the addition of bevacizumab (B) to chemotherapy [capecitabine (C)±mitomycin (M)]. Archival primary tumours from 237 patients (50% of trial population) underwent gene expression profiling and classification into CMS groups. CMS groups were correlated to PFS and overall survival (OS). The interaction of CMS with treatment was assessed by proportional hazards model.

RESULTS

The distribution of CMS in MAX were CMS1 18%, CMS2 47%, CMS3 12%, CMS4 23%. CMS1 was the predominant subtype in right-sided primary tumours, while CMS2 was the predominant subtype in left-sided. CMS was prognostic of OS (P = 0.008), with CMS2 associated with the best outcome and CMS1 the worst. CMS remained an independent prognostic factor in a multivariate analysis. There was a significant interaction between CMS and treatment (P-interaction = 0.03), for PFS, with hazard ratios (95% CI) for CB+CBM versus C arms in CMS1, 2, 3 and 4: 0.83 (0.43-1.62), 0.50 (0.33-0.76), 0.31 (0.13-0.75) and 1.24 (0.68-2.25), respectively.

CONCLUSIONS

This exploratory study found that CMS stratified OS outcomes in metastatic CRC regardless of first-line treatment, with prognostic effects of CMS groups distinct from those previously reported in early-stage cohorts. In CMS associations with treatment, CMS2 and possibly CMS3 tumours may preferentially benefit from the addition of bevacizumab to first-line capecitabine-based chemotherapy, compared with other CMS groups. Validation of these findings in additional cohorts is warranted.

CLINICAL TRIAL NUMBER

This is a molecular sub-study of MAX clinical trial (NCT00294359).

Differences in all-cause hospitalisation by ethnic group: a data linkage cohort study of 4.62 million people in Scotland, 2001-2013

OBJECTIVES

Immigration into Europe has raised contrasting concerns about increased pressure on health services and equitable provision of health care to immigrants or ethnic minorities. Our objective was to find out if there were important differences in hospital use between the main ethnic groups in Scotland.

STUDY DESIGN

A census-based data linkage cohort study.

METHODS

We anonymously linked Scotland's Census 2001 records for 4.62 million people, including their ethnic group, to National Health Service general hospitalisation records for 2001-2013. We used Poisson regression to calculate hospitalisation rate ratios (RRs) in 14 ethnic groups, presented as percentages of the White Scottish reference group (RR = 100), for males and females separately. We adjusted for age and socio-economic status and compared those born in the United Kingdom or the Republic of Ireland (UK/RoI) with elsewhere. We calculated mean lengths of hospital stay.

RESULTS

9.79 million hospital admissions were analysed. Compared with the White Scottish, unadjusted RRs for both males and females in most groups were about 50-90, e.g. Chinese males 49 (95% confidence interval [CI] = 45-53) and Indian females 76 (95% CI 71-81). The exceptions were White Irish, males 120 (95% CI 117-124) and females 115 (95% CI 112-119) and Caribbean females, 103 (95% CI 85-126). Adjusting for age increased the RRs for most groups towards or above the reference. Socio-economic status had little effect. In many groups, those born outside the UK/RoI had lower admission rates. Unadjusted mean lengths of stay were substantially lower in most ethnic minorities.

CONCLUSIONS

Use of hospital beds in Scotland by most ethnic minorities was lower than by the White Scottish majority, largely explained by their younger average age. Other countries should use similar methods to assess their own experience.

The role of intramedullary fixation in ankle fractures - A systematic review

BACKGROUND

Ankle fractures are one of the most commonly occurring fractures in the elderly population. The overall incidence has been reported to be up to 184 fractures per 100,000 persons per year, of which 20-30% occur in the elderly. Medical co-morbidities, osteoporosis, suboptimal skin quality and poor toleration of non-weight bearing status all contribute to difficulties in managing these injuries in this population. Intramedullary implants are advantageous as they utilise smaller incisions, minimise soft tissue disruption and may allow early weight bearing. This systematic review aims to analyse the use of both fibula nails and talo-tibial-calcaneal (TTC) implants in the management of fragility ankle fractures.

METHODS

We conducted a systematic review of the literature using the online databases Medline and EMBASE on 26th December 2015. Only studies assessing ankle fractures that were treated with either an intramedullary fibula nail or TTC implant were included. Studies must have reported complications, patient mobility status or a functional outcome measure. Studies were excluded if the intramedullary device utilised was an adjunct to plate fixation or where a variety of surgical treatments were included in the study. The included studies were appraised with respect to a validated quality assessment scale.

RESULTS

Our search strategy produced 350 studies although only 17 studies met inclusion criteria; ten assessed a fibula nail and seven assessed a standard hindfoot nail, a TTC implant. 15 studies were case series, the overall quality of the studies was low and only one randomised controlled trial was reviewed. The mean Olerud and Molander Ankle Score for fibula nail studies ranged from 58 to 97 and the complication rate from 0 to 22%. Two comparative studies reported a statistically significant increase in complication rate with plate fixation but similar functional outcomes. Studies assessing TTC implants reported a mean Olerud and Molander Ankle Score of 50-62 and complication rate from 18 to 22.6%.

CONCLUSION

The studies reviewed suggest that fibula nails may be capable of producing similar functional outcomes with lower rates of complications to plate fixation. TTC implants produce lower functional outcomes but this may be acceptable in a subgroup of patients at high risk or with reduced pre-injury mobility. However, the low quality of evidence reviewed, the variation in patients included, implant used and outcome scores measured restricts the ability to draw definitive conclusions. Further comparative studies are required to explore the role of these implants further.

Mathematical Modeling to Predict the Responses to Poorly Soluble Particles in Rat Lungs

Rat inhalation experiments with titanium dioxide (TiO2) and barium sulfate (BaSO4), at concentrations calculated to produce similar volumetric lung burden for both dusts, showed overload with TIO2 but not for BaSO4 "Overload," occurring in rats exposed to "low-toxicity" dusts at high concentrations, is characterized by a rapid deterioration in clearance and onset of inflammation. Impairment of alveolar macrophage (AM) mediated clearance, dust translocation to the lymph nodes, and neutrophil (PMN) recruitment for both dusts were better predicted by the lung burden expressed as surface area rather than mass or volume. A mathematical model describing the translocation (in terms of particulate mass) of inhaled particles in various physiologically based pulmonary compartments was used to calculate pulmonary clearance when effective and also when impairment by overload leads to increased dust translocation to the lymph nodes. Our objectives were: (I) to modify this model to include the influence of particle surface area on clearance and interstitialization; (2) to extend the model to describe the PMN recruitment; and (3) to use the model to estimate the highest exposure level such that overload would be avoided in a chronic inhalation experiment with rats. In extrapolating down to no-overload concentrations, due account was taken of the observed interanimal variation (assuming this variation was mainly due to differences in inhaled dose). For TiO2 and BaSO4, with the given size distributions, the predicted concentrations at which 95% of the animals were expected to avoid overload were 3 mg m(-3) and 7.5 mg m(-3), respectively. The general quantitative relationships on the role of particle surface area and on the estimation of the no-overload level have important implications for setting standards for poorly soluble particles.

Comparing levels of social capital in three northern post-industrial UK cities

OBJECTIVES

A high level of 'excess' mortality (i.e. that seemingly not explained by deprivation) has been shown for Scotland compared to England & Wales and, in particular, for its largest city, Glasgow, compared to the similarly deprived postindustrial English cities of Liverpool and Manchester. The excess has been observed across all social classes, but, for premature mortality, has been shown to be highest in comparison of those of lowest socio-economic status (SES). Many theories have been proposed to explain this phenomenon. One such suggestion relates to potential differences in social capital between the cities, given the previously evidenced links between social capital and mortality. The aim of this study was to ascertain whether any aspects of social capital differed between the cities and whether, therefore, this might be a plausible explanation for some of the excess mortality observed in Glasgow.

STUDY DESIGN

Cross-sectional study.

METHODS

A representative survey of Glasgow, Liverpool and Manchester was undertaken in 2011. Social capital was measured using an expanded version of the Office for National Statistics (ONS) core 'Social Capital Harmonised Question Set'. Differences between the cities in five sets of social capital topics (views about the local area, civic participation, social networks and support, social participation, and reciprocity and trust) were explored by means of a series of multivariate regression models, while controlling for differences in the characteristics (age, gender, SES, ethnicity etc.) of the samples.

RESULTS

Some, but not all, aspects of social capital were lower among the Glasgow sample compared to those in Liverpool and Manchester. A number of these differences were greatest among those of higher, rather than lower, SES. Levels of social participation, trust and (some measures of) reciprocity were lower in Glasgow, particularly in comparison with Liverpool. However, assessment of any potential impact of these differences is limited by the cross-sectional nature of the data.

CONCLUSIONS

The analyses suggest it is at least possible that differences in some aspects of social capital could play some part in explaining Glasgow's excess mortality, especially among particular sections of its population (e.g. those of higher SES). However, in the absence of more detailed longitudinal data, this remains speculative.

Three-dimensional segmentation of three-dimensional ultrasound carotid atherosclerosis using sparse field level sets

PURPOSE

Three-dimensional ultrasound (3DUS) vessel wall volume (VWV) provides a 3D measurement of carotid artery wall remodeling and atherosclerotic plaque and is sensitive to temporal changes of carotid plaque burden. Unfortunately, although 3DUS VWV provides many advantages compared to measurements of arterial wall thickening or plaque alone, it is still not widely used in research or clinical practice because of the inordinate amount of time required to train observers and to generate 3DUS VWV measurements. In this regard, semiautomated methods for segmentation of the carotid media-adventitia boundary (MAB) and the lumen-intima boundary (LIB) would greatly improve the time to train observers and for them to generate 3DUS VWV measurements with high reproducibility.

METHODS

The authors describe a 3D algorithm based on a modified sparse field level set method for segmenting the MAB and LIB of the common carotid artery (CCA) from 3DUS images. To the authors' knowledge, the proposed algorithm is the first direct 3D segmentation method, which has been validated for segmenting both the carotid MAB and the LIB from 3DUS images for the purpose of computing VWV. Initialization of the algorithm requires the observer to choose anchor points on each boundary on a set of transverse slices with a user-specified interslice distance (ISD), in which larger ISD requires fewer user interactions than smaller ISD. To address the challenges of the MAB and LIB segmentations from 3DUS images, the authors integrated regional- and boundary-based image statistics, expert initializations, and anatomically motivated boundary separation into the segmentation. The MAB is segmented by incorporating local region-based image information, image gradients, and the anchor points provided by the observer. Moreover, a local smoothness term is utilized to maintain the smooth surface of the MAB. The LIB is segmented by constraining its evolution using the already segmented surface of the MAB, in addition to the global region-based information and the anchor points. The algorithm-generated surfaces were sliced and evaluated with respect to manual segmentations on a slice-by-slice basis using 21 3DUS images.

RESULTS

The authors used ISD of 1, 2, 3, 4, and 10 mm for algorithm initialization to generate segmentation results. The algorithm-generated accuracy and intraobserver variability results are comparable to the previous methods, but with fewer user interactions. For example, for the ISD of 3 mm, the algorithm yielded an average Dice coefficient of 94.4% ± 2.2% and 90.6% ± 5.0% for the MAB and LIB and the coefficient of variation of 6.8% for computing the VWV of the CCA, while requiring only 1.72 min (vs 8.3 min for manual segmentation) for a 3DUS image.

CONCLUSIONS

The proposed 3D semiautomated segmentation algorithm yielded high-accuracy and high-repeatability, while reducing the expert interaction required for initializing the algorithm than the previous 2D methods.

The future of breast cancer research and practice in Asia, Latin America, and the Middle East/North Africa: a qualitative horizon scanning analysis

Abstract #5095

Objective: To conduct a horizon-scanning analysis to identify future needs, challenges and trends relating to breast cancer research and practices globally with special emphasis on emerging and understudied regions.
 Methods: Following the design and pilot of the survey instrument, data was derived from key informant interviews with 221 thought leaders in breast cancer in Asia (n=97), Latin America (n=46), Middle East/North Africa (n=39) and Australia and Canada (n=39). Thought leaders were identified using a combination of purposive and snowballing sampling and included oncologists, surgeons, other breast cancer specialists, advocacy leaders and policy makers. Transcripts and field notes were then coded and compared, and a taxonomy of 20 issues was developed. The propensity of these themes were then analyzed and compared across the four regions.
 Results: In Asia the most prevalent issues were i) building capacity for clinical research, ii) more nurses for patient care/education, iii) keeping up to date with new information and iv) increased targeted/personalized treatment. In Latin America key themes were the need to i) increase targeted/personalized treatment, ii) address disparities among the underserved, iii) high cost to third party payers, iv) increase capacity for clinical research and v) control out of pocket costs for patients. In the Middle East/North Africa key themes were the need for i) building capacity for clinical research, ii) more nurses for patient care/education, iii) increased public education on screening and iv) increased capacity for early detection. In Australia and Canada issues were i) keeping up to date with new information, ii) weighing the cost effectiveness of new treatments, iii) the need for increased data sharing and iv) improving communication between stakeholders.
 Discussion: While a number of respondents expressed observations relating to country specific etiology of disease (such as women presenting at younger ages and with more aggressive tumors) the lack of national registries and local clinical/genetic research make it hard to confirm these anecdotes scientifically. Finally, increased focus on the development of effective advocacy and policy leadership are needed in these regions to draw attention and resources towards issues of community empowerment, survivorship and quality of life which were neglected by all but a handful of respondents.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5095.

A frame-shift mutation of PMS2 is a widespread cause of Lynch syndrome

BACKGROUND

When compared to the other mismatch repair genes involved in Lynch syndrome, the identification of mutations within PMS2 has been limited (<2% of all identified mutations), yet the immunohistochemical analysis of tumour samples indicates that approximately 5% of Lynch syndrome cases are caused by PMS2. This disparity is primarily due to complications in the study of this gene caused by interference from pseudogene sequences.

METHODS

Using a recently developed method for detecting PMS2 specific mutations, we have screened 99 patients who are likely candidates for PMS2 mutations based on immunohistochemical analysis.

RESULTS

We have identified a frequently occurring frame-shift mutation (c.736_741del6ins11) in 12 ostensibly unrelated Lynch syndrome patients (20% of patients we have identified with a deleterious mutation in PMS2, n = 61). These individuals all display the rare allele (population frequency <0.05) at a single nucleotide polymorphism (SNP) in exon 11, and have been shown to possess a short common haplotype, allowing us to calculate that the mutation arose around 1625 years ago (65 generations; 95% confidence interval 22 to 120).

CONCLUSION

Ancestral analysis indicates that this mutation is enriched in individuals with British and Swedish ancestry. We estimate that there are >10 000 carriers of this mutation in the USA alone. The identification of both the mutation and the common haplotype in one Swedish control sample (n = 225), along with evidence that Lynch syndrome associated cancers are rarer than expected in the probands' families, would suggest that this is a prevalent mutation with reduced penetrance.

To suspend or not to suspend: a randomised single blind trial of simple trapeziectomy versus trapeziectomy and flexor carpi radialis suspension

The thumb carpometacarpal joint is the second most common site of osteoarthritis in humans. There are numerous operations for the condition but, perhaps, the commonest is trapeziectomy, sometimes supplemented by a suspension procedure, most commonly using part of the flexor carpi radialis tendon. In order to determine whether there is an advantage to a suspension procedure, or not, 65 patients with Eaton and Glickel Grade III or IV arthritis of the carpometacarpal joint of their thumbs were randomised into either undergoing trapeziectomy alone (with no wiring) or a trapeziectomy with flexor carpi radialis suspension. Patient satisfaction from both operations was similar. There was increased range of movement in the trapeziectomy alone group, but there was no difference in grip or pinch strength. Measurement of the gap on X-ray left by the trapeziectomy was less when trapeziectomy alone was performed.

Extensive DNA methylation in normal colorectal mucosa in hyperplastic polyposis

BACKGROUND

Hyperplastic polyposis of the colorectum is a precancerous condition that has been linked with DNA methylation. The polyps in this condition have been distinguished from typical small hyperplastic polyps and renamed sessile serrated adenomas. Sessile serrated adenomas also occur sporadically and appear to be indistinguishable from their counterparts in hyperplastic polyposis.

AIMS AND METHODS

The existence of distinguishing molecular features was explored in a series of serrated polyps and matched normal mucosa from patients with and without hyperplastic polyposis by assessing mutation of BRAF, DNA methylation in 14 markers (MINTs 1, 2 and 31, p16, MGMT, MLH1, RASSF1, RASSF2, NORE1 (RASSF5), RKIP, MST1, DAPK, FAS, and CHFR), and immunoexpression of MLH1.

RESULTS

There was more extensive methylation in sessile serrated adenomas from subjects with hyperplastic polyposis (p<0.0001). A more clearcut difference in patients with hyperplastic polyposis was the finding of extensive DNA methylation in normal mucosa from the proximal colon.

CONCLUSIONS

A genetic predisposition may underlie at least some forms of hyperplastic polyposis in which the earliest manifestation may be hypermethylation of multiple gene promoters in normal colorectal mucosa. Additionally, some of the heterogeneity within hyperplastic polyposis may be explained by different propensities for MLH1 inactivation within polyps.

Advanced colorectal polyps with the molecular and morphological features of serrated polyps and adenomas: concept of a 'fusion' pathway to colorectal cancer

AIM

To establish and explain the pattern of molecular signatures across colorectal polyps.

METHODS AND RESULTS

Thirty-two sessile serrated adenomas (SSA), 10 mixed polyps (MP), 15 traditional serrated adenomas (SA), 49 hyperplastic polyps (HP) and 84 adenomas were assessed for mutation of KRAS and BRAF and aberrant expression of p53. The findings were correlated with loss of expression of O-6-methylguanine DNA methyltransferase (MGMT). KRAS mutation occurred more frequently (26.5%) than BRAF mutation (4.8%) in adenomas (P < 0.001) and particularly in adenomas with villous architecture (50%). Loss of expression of MGMT correlated with KRAS mutation in small tubular adenomas (P < 0.04). BRAF mutation was frequent in HPs (67%) and SSAs (81%), while KRAS mutation was infrequent (4% and 3%, respectively). Of MPs and SAs, 72% had either BRAF or KRAS mutation. Aberrant expression of p53 was uncommon overall, but occurred more frequently in MPs and SAs (12%) than adenomas (1%) (P < 0.04) and there was concordant loss of expression of MGMT.

CONCLUSIONS

Molecular alterations that are characteristic of the serrated pathway and adenoma-carcinoma sequence can co-occur in a minority of advanced colorectal polyps that then show morphological features of both pathways. These lesions account for only 2% of colorectal polyps, but may be relatively aggressive.

Why is mortality higher in Scotland than in England and Wales? Decreasing influence of socioeconomic deprivation between 1981 and 2001 supports the existence of a 'Scottish Effect'

OBJECTIVES

To determine the degree to which changing patterns of deprivation in Scotland and the rest of Great Britain between 1981 and 2001 explain Scotland's higher mortality rates over that period.

DESIGN

Cross-sectional analyses using population and mortality data from around the 1981, 1991 and 2001 censuses.

SETTING

Great Britain (GB).

PARTICIPANTS

Populations of Great Britain enumerated in the 1981, 1991 and 2001 censuses.

MAIN OUTCOME MEASURES

Carstairs deprivation scores derived for wards (England and Wales) and postcode sectors (Scotland). Mortality rates adjusted for age, sex and deprivation decile.

RESULTS

Between 1981 and 2001 Scotland became less deprived relative to the rest of Great Britain. Age and sex standardized all-cause mortality rates decreased by approximately 25% across Great Britain, including Scotland but mortality rates were on average 12% higher in Scotland in 1981 rising to 15% higher in 2001. While over 60% of the excess mortality in 1981 could be explained by differences in deprivation profile, less than half the excess could be explained in 1991 and 2001. After adjusting for age, sex and deprivation, excess mortality in Scotland rose from 4.7% (95% CI: 3.9% to 5.4%) in 1981 to 7.9% (95% CI: 7.2% to 8.7%) in 1991 and 8.2% (95% CI: 7.4% to 9.0%) in 2001. All deprivation deciles showed excess indicating that populations in Scotland living in areas of comparable deprivation to populations in the rest of Great Britain always had higher mortality rates. By 2001 the largest excesses were found in the most deprived areas in Scotland with a 17% higher mortality rate in the most deprived decile compared to similarly deprived areas in England and Wales. Excess mortality in Scotland has increased most among males aged <65 years.

CONCLUSIONS

Scotland's relative mortality disadvantage compared to the rest of Great Britain, after allowing for deprivation, is worsening. By 1991 measures of deprivation no longer explained most of the excess mortality in Scotland and the unexplained excess has persisted during the 1990s. More research is required to understand what is causing this 'Scottish effect'.