A multicentre survey investigating the knowledge, behaviour, and attitudes of surgical healthcare professionals to frailty assessment in emergency surgery: DEFINE(surgery)

PURPOSE

Screening for frailty in people admitted with emergency surgical pathology can initiate timely referrals to enhanced perioperative services such as intensive care and geriatric medicine. However, there has been little research exploring surgical healthcare professionals' opinions to frailty assessment, or accuracy in identification. This study aimed to assess the knowledge, behaviour, and attitudes of healthcare professionals to frailty assessment in emergency surgical admissions.

METHODS

We designed a cross-sectional multicentre study developed by a multiprofessional team of surgeons, geriatricians, and supported by patients. A semi-structured survey examined attitudes and behaviours. Knowledge was assessed by comparing respondents' accuracy in scoring twenty-two surgical case vignettes using the Clinical Frailty Scale.

RESULTS

Eleven hospitals across England, Wales, and Scotland participated. Two hundred and eleven clinicians responded-20.4% junior doctors, 43.6% middle grade doctors, 24.2% senior doctors, 11.4% nurses and physician associates. Respondents strongly supported perioperative frailty assessment. Most were already assessing for frailty, although frequently not using a standardised tool. There was a strong call for more frailty education. Participants scored 2175 vignettes with 55.4% accurately meeting the gold standard; accuracy improved to 87.3% when categorised into "not frail/mildly frail/severely frail" and 94% when dichotomised to "not frail/frail".

CONCLUSION

Frailty assessment is well supported by healthcare professionals working in surgery. However, standardised tools are not routinely being used, and only half of respondents could accurately identify frailty. Better education around frailty assessment is needed for healthcare professionals working in surgery to improve perioperative pathway for people living with frailty.

Changes in motor activity level in individuals with frontotemporal dementia

Changes in motor activity are common in individuals with Frontotemporal dementia (FTD). Yet, it remains unclear why some individuals become motorically hyperactive, while others hypoactive even in early stages of the disease. This study aimed to examine the relationship between motor activity level and (1) FTD clinical subtype, and (2) cortical thickness and subcortical volumes. Eighty-two charts were retrospectively reviewed from patients meeting consensus criteria for one of the three main clinical subtypes of FTD: probable bvFTD, semantic variant Primary Progressive Aphasia (PPA), or non-fluent variant PPA. Participants were assigned to one of three groups: (1) hyperactive, (2) hypoactive, or (3) no record of change. Hyperactivity was prevalent among bvFTD (58.5%) and semantic PPA (68.8%) subtypes while hypoactivity was less common in both subtypes (29.3% and 18.8%, respectively). The majority of patients with non-fluent PPA showed no record of change in motor activity (66.7%). The analysis of cortical thickness and subcortical volumes did not identify significant associations with motor activity levels. In conclusion, increased motor activity is highly prevalent among individuals with FTD, especially bvFTD and svPPA subtypes. These findings may inform prognosis and prediction of changes in motor activity, and allow planning for appropriate environmental and behavioural interventions. Future studies with prospective, standardized longitudinal collection of information regarding the type and level of change in motor activity, including wearable measures of actigraphy, may help to further delineate the onset and progression of abnormal motor behaviours and determine neuroanatomic associations in FTD.

Integrating EM and Patch-seq data: Synaptic connectivity and target specificity of predicted Sst transcriptomic types

Neural circuit function is shaped both by the cell types that comprise the circuit and the connections between those cell types ¹ . Neural cell types have previously been defined by morphology ^{2, 3} , electrophysiology ^{4, 5} , transcriptomic expression ^6-8 , connectivity ^9-13 , or even a combination of such modalities ^14-16 . More recently, the Patch-seq technique has enabled the characterization of morphology (M), electrophysiology (E), and transcriptomic (T) properties from individual cells ^17-20 . Using this technique, these properties were integrated to define 28, inhibitory multimodal, MET-types in mouse primary visual cortex ²¹ . It is unknown how these MET-types connect within the broader cortical circuitry however. Here we show that we can predict the MET-type identity of inhibitory cells within a large-scale electron microscopy (EM) dataset and these MET-types have distinct ultrastructural features and synapse connectivity patterns. We found that EM Martinotti cells, a well defined morphological cell type ^{22, 23} known to be Somatostatin positive (Sst+) ^{24, 25} , were successfully predicted to belong to Sst+ MET-types. Each identified MET-type had distinct axon myelination patterns and synapsed onto specific excitatory targets. Our results demonstrate that morphological features can be used to link cell type identities across imaging modalities, which enables further comparison of connectivity in relation to transcriptomic or electrophysiological properties. Furthermore, our results show that MET-types have distinct connectivity patterns, supporting the use of MET-types and connectivity to meaningfully define cell types.

Factors associated with prevalent Mycobacterium tuberculosis infection and disease among adolescents and adults exposed to rifampin-resistant tuberculosis in the household

BACKGROUND

Understanding factors associated with prevalent Mycobacterium tuberculosis infection and prevalent TB disease in household contacts of patients with drug-resistant tuberculosis (TB) may be useful for TB program staff conducting contact investigations.

METHODS

Using data from a cross-sectional study that enrolled index participants with rifampin-resistant pulmonary TB and their household contacts (HHCs), we evaluated HHCs age ≥15 years for factors associated with two outcomes: Mycobacterium tuberculosis infection and TB disease. Among HHCs who were not already diagnosed with current active TB disease by the TB program, Mycobacterium tuberculosis infection was determined by interferon-gamma release assay (IGRA). TB disease was adjudicated centrally. We fitted logistic regression models using generalized estimating equations.

RESULTS

Seven hundred twelve HHCs age ≥15 years enrolled from 279 households in eight high-TB burden countries were a median age of 34 years, 63% female, 22% current smokers and 8% previous smokers, 8% HIV-positive, and 11% previously treated for TB. Of 686 with determinate IGRA results, 471 tested IGRA positive (prevalence 68.8% (95% Confidence Interval: 64.6%, 72.8%)). Multivariable modeling showed IGRA positivity was more common in HHCs aged 25-49 years; reporting prior TB treatment; reporting incarceration, substance use, and/or a period of daily alcohol use in the past 12 months; sharing a sleeping room or more evenings spent with the index participant; living with smokers; or living in a home of materials typical of low socioeconomic status. Forty-six (6.5% (95% Confidence Interval: 4.6%, 9.0%)) HHCs age ≥15 years had prevalent TB disease. Multivariable modeling showed higher prevalence of TB disease among HHCs aged ≥50 years; reporting current or previous smoking; reporting a period of daily alcohol use in the past 12 months; and reporting prior TB treatment.

CONCLUSION

We identified overlapping and distinct characteristics associated with Mycobacterium tuberculosis infection and TB disease that may be useful for those conducting household TB investigations.

Caregiver willingness to give TPT to children living with drug-resistant TB patients

BACKGROUND Pediatric household contacts (HHCs) of patients with multidrug-resistant TB (MDR-TB) are at high risk of infection and active disease. Evidence of caregiver willingness to give MDR-TB preventive therapy (TPT) to children is limited.METHODS This was a cross-sectional study of HHCs of patients with MDR-TB to assess caregiver willingness to give TPT to children aged <13 years.RESULTS Of 743 adult and adolescent HHCs, 299 reported caring for children aged <13 years of age. The median caregiver age was 35 years (IQR 27-48); 75% were women. Among caregivers, 89% were willing to give children MDR TPT. In unadjusted analyses, increased willingness was associated with TB-related knowledge (OR 5.1, 95% CI 2.3-11.3), belief that one can die of MDR-TB (OR 5.2, 95% CI 1.2-23.4), concern for MDR-TB transmission to child (OR 4.5, 95% CI 1.6-12.4), confidence in properly taking TPT (OR 4.5, 95% CI 1.6-12.6), comfort telling family about TPT (OR 5.5, 95% CI 2.1-14.3), and willingness to take TPT oneself (OR 35.1, 95% CI 11.0-112.8).CONCLUSIONS A high percentage of caregivers living with MDR- or rifampicin-resistant TB patients were willing to give children a hypothetical MDR TPT. These results provide important evidence for the potential uptake of effective MDR TPT when implemented.

Cost-effectiveness of Interventions for Chronic Fatigue Syndrome or Myalgic Encephalomyelitis: A Systematic Review of Economic Evaluations

INTRODUCTION

Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) has profound quality of life and economic consequences for individuals, their family, formal services and wider society. Little is known about which therapeutic interventions are more cost-effective.

OBJECTIVE

A systematic review was carried out to identify and critically appraise the evidence on the cost-effectiveness of CFS/ME interventions.

METHODS

The review protocol was prespecified (PROSPERO: CRD42018118731). Searches were carried out across two databases-MEDLINE (1946-2020) and EMBASE (1974-2020). Additional studies were identified by searching reference lists. Only peer-reviewed journal articles of full economic evaluations examining CFS/ME interventions were included. Trial- and/or model-based economic evaluations were eligible. Data extraction and screening were carried out independently by two reviewers. The methodological quality of the economic evaluation and trial were assessed using the Consensus Health Economic Criteria checklist (CHEC-list) and Risk of Bias-2 (RoB-2) tool, respectively. A narrative synthesis was used to summarise the economic evidence for interventions for adults and children in primary and secondary care settings.

RESULTS

Ten economic evaluations, all based on data derived from randomised controlled trials, met our eligibility criteria. Cognitive behavioural therapy (CBT) was evaluated across five studies, making it the most commonly evaluated intervention. There was evidence from three trials to support CBT as a cost-effective treatment option for adults; however, findings on CBT were not uniform, suggesting that cost-effectiveness may be context-specific. A wide array of other interventions were evaluated in adults, including limited evidence from two trials supporting the cost effectiveness of graded exercise therapy (GET). Just one study assessed intervention options for children. Our review highlighted the importance of informal care costs and productivity losses in the evaluation of CFS/ME interventions.

CONCLUSIONS

We identified a limited patchwork of evidence on the cost-effectiveness of interventions for CFS/ME. Evidence supports CBT as a cost-effective treatment option for adults; however, cost-effectiveness may depend on the duration and frequency of sessions. Limited evidence supports the cost effectiveness of GET. Key weaknesses in the literature included small sample sizes and short duration of follow-up. Further research is needed on pharmacological interventions and therapies for children.

Increased care at discharge from COVID-19: The association between pre-admission frailty and increased care needs after hospital discharge; a multicentre European observational cohort study

BACKGROUND

The COVID-19 pandemic has placed significant pressure on health and social care. Survivors of COVID-19 may be left with substantial functional deficits requiring ongoing care. We aimed to determine whether pre-admission frailty was associated with increased care needs at discharge for patients admitted to hospital with COVID-19.

METHODS

Patients were included if aged over 18 years old and admitted to hospital with COVID-19 between 27 February and 10 June 2020. The Clinical Frailty Scale (CFS) was used to assess pre-admission frailty status. Admission and discharge care levels were recorded. Data were analysed using a mixed-effects logistic regression adjusted for age, sex, smoking status, comorbidities, and admission CRP as a marker of severity of disease.

RESULTS

Thirteen hospitals included patients: 1671 patients were screened, and 840 were excluded including, 521 patients who died before discharge (31.1%). Of the 831 patients who were discharged, the median age was 71 years (IQR, 58-81 years) and 369 (44.4%) were women. The median length of hospital stay was 12 days (IQR 6-24). Using the CFS, 438 (47.0%) were living with frailty (≥ CFS 5), and 193 (23.2%) required an increase in the level of care provided. Multivariable analysis showed that frailty was associated with an increase in care needs compared to patients without frailty (CFS 1-3). The adjusted odds ratios (aOR) were as follows: CFS 4, 1.99 (0.97-4.11); CFS 5, 3.77 (1.94-7.32); CFS 6, 4.04 (2.09-7.82); CFS 7, 2.16 (1.12-4.20); and CFS 8, 3.19 (1.06-9.56).

CONCLUSIONS

Around a quarter of patients admitted with COVID-19 had increased care needs at discharge. Pre-admission frailty was strongly associated with the need for an increased level of care at discharge. Our results have implications for service planning and public health policy as well as a person's functional outcome, suggesting that frailty screening should be utilised for predictive modelling and early individualised discharge planning.

Nosocomial COVID-19 infection: examining the risk of mortality. The COPE-Nosocomial Study (COVID in Older PEople)

Background

Hospital admissions for non-coronavirus disease 2019 (COVID-19) pathology have decreased significantly. It is believed that this may be due to public anxiety about acquiring COVID-19 infection in hospital and the subsequent risk of mortality.

Aim

To identify patients who acquire COVID-19 in hospital (nosocomial COVID-19 infection (NC)) and their risk of mortality compared to those with community-acquired COVID-19 (CAC) infection.

Methods

The COPE-Nosocomial Study was an observational cohort study. The primary outcome was the time to all-cause mortality (estimated with an adjusted hazard ratio (aHR)), and secondary outcomes were day 7 mortality and the time-to-discharge. A mixed-effects multivariable Cox's proportional hazards model was used, adjusted for demographics and comorbidities.

Findings

The study included 1564 patients from 10 hospital sites throughout the UK, and one in Italy, and collected outcomes on patients admitted up to April 28^th, 2020. In all, 12.5% of COVID-19 infections were acquired in hospital; 425 (27.2%) patients with COVID died. The median survival time in NC patients was 14 days compared with 10 days in CAC patients. In the primary analysis, NC infection was associated with lower mortality rate (aHR: 0.71; 95% confidence interval (CI): 0.51–0.98). Secondary outcomes found no difference in day 7 mortality (adjusted odds ratio: 0.79; 95% CI: 0.47–1.31), but NC patients required longer time in hospital during convalescence (aHR: 0.49, 95% CI: 0.37–0.66).

Conclusion

The minority of COVID-19 cases were the result of NC transmission. No COVID-19 infection comes without risk, but patients with NC had a lower risk of mortality compared to CAC infection; however, caution should be taken when interpreting this finding.

A Child's Right to Play: Results from the Brain-Computer Interface Game Jam 2019 (Calgary Competition)

Children with severe neurological disabilities may be unable to communicate or interact with their environments, depriving them of their right to play. Brain-computer interfaces (BCI) offer a means for such children to control external devices using only their brain signals, thereby introducing new opportunities for interaction. We organized the first North American BCI Game Jam to incite the development of BCI-compatible games for children. Nine games were submitted by 30 participants across North America. Games were judged by researchers and disabled children currently using BCI. Preliminary results demonstrate variety in game criteria preferences amongst the children who judged the games. The BCI Game Jam demonstrated promising potential for the creation of enjoyable games to suit the individual needs and preferences of children with severe neurological disabilities.

Fourteen polymorphic microsatellite markers for the widespread Labrador tea (Rhododendron groenlandicum)

PREMISE

Microsatellite markers were developed for Labrador tea (Rhododendron groenlandicum, Ericaceae) to facilitate downstream genetic investigation of this species and the extremely closely related, circumboreal Rhododendron subsect. Ledum.

METHODS AND RESULTS

Forty-eight primer pairs were designed using Illumina data and screened for excellent amplification. Sixteen successful pairs were developed as microsatellite markers using fluorescently labeled amplification to generate chromatogram data. These data were evaluated for intrapopulation and interpopulation variability in three populations from Alaska and Maine, USA, and the Northwest Territories, Canada. Fourteen polymorphic markers genotyped reliably, each with one to eight alleles. Cluster analysis indicates that across the range, populations can be easily discriminated. Cross-amplification in other Rhododendron subsect. Ledum species shows broad application of the developed markers within this small, well-supported clade.

CONCLUSIONS

These microsatellite markers exhibit significant variability and will be useful in population genetics within R. groenlandicum and for investigation of species boundaries across Rhododendron subsect. Ledum.

Fifteen microsatellite markers for the Appalachian rockcap fern, Polypodium appalachianum (Polypodiaceae), and its relatives

PREMISE OF THE STUDY

Microsatellite markers were developed for Polypodium appalachianum (Polypodiaceae) to facilitate investigation of species boundaries between P. appalachianum and its putative hybrid, P. virginianum, and potentially among other members of the Miocene-age P. vulgare species complex.

METHODS AND RESULTS

Forty-eight primer pairs were designed from Illumina data and screened for successful amplification. Sixteen pairs were genotyped and evaluated for variability within and among three populations in North Carolina, Vermont, and New Hampshire. Twelve of these primer pairs were reliable and polymorphic, exhibiting one to 10 alleles per locus. Cross-species amplification experiments were conducted for P. virginianum and four additional close relatives from the P. vulgare complex in order to maximize information about likely utility within a phylogenetic context.

CONCLUSIONS

These microsatellite markers will be useful in population genetics and species boundaries studies of P. appalachianum and P. virginianum, and likely in other species within the P. vulgare complex.

How health-related quality of life assessment should be used in advanced colorectal cancer clinical trials

Traditionally, the efficacy of cancer treatment in patients with advance or metastatic disease in clinical studies has been studied using overall survival and more recently tumor-based end points such as progression-free survival, measurements of response to treatment. However, these seem not to be the relevant clinical end points in current situation if such end points were no validated as surrogate of overall survival to demonstrate the clinical efficacy. Appropriate, meaningful, primary patient-oriented and patient-reported end points that adequately measure the effects of new therapeutic interventions are then crucial for the advancement of clinical research in metastatic colorectal cancer to complement the results of tumor-based end points. Health-related quality of life (HRQoL) is effectively an evaluation of quality of life and its relationship with health over time. HRQoL includes the patient report at least of the way a disease or its treatment affects its physical, emotional and social well-being. Over the past few years, several phase III trials in a variety of solid cancers have assessed the incremental value of HRQoL in addition to the traditional end points of tumor response and survival results. HRQoL could provide not only complementary clinical data to the primary outcomes, but also more precise predictive and prognostic value. This end point is useful for both clinicians and patients in order to achieve the dogma of precision medicine. The present article examines the use of HRQoL in phase III metastatic colorectal cancer clinical trials, outlines the importance of HRQoL assessment methods, analysis, and results presentation. Moreover, it discusses the relevance of including HRQoL as a primary/co-primary end point to support the progression-free survival results and to assess efficacy of treatment in the advanced disease setting.

Ciclosporin compared with prednisolone therapy for patients with pyoderma gangrenosum: cost-effectiveness analysis of the STOP GAP trial

Background

Pyoderma gangrenosum (PG) is a painful, ulcerating skin disease with poor evidence for management. Prednisolone and ciclosporin are the most commonly used treatments, although not previously compared within a randomized controlled trial (RCT).

Objectives

To compare the cost‐effectiveness of ciclosporin and prednisolone‐initiated treatment for patients with PG.

Methods

Quality of life (QoL, EuroQoL five dimensions three level questionnaire, EQ‐5D‐3L) and resource data were collected as part of the STOP GAP trial: a multicentre, parallel‐group, observer‐blind RCT. Within‐trial analysis used bivariate regression of costs and quality‐adjusted life years (QALYs), with multiple imputation of missing data, informing a probabilistic assessment of incremental treatment cost‐effectiveness from a health service perspective.

Results

In the base case analysis, when compared with prednisolone, ciclosporin was cost‐effective due to a reduction in costs [net cost: −£1160; 95% confidence interval (CI) −2991 to 672] and improvement in QoL (net QALYs: 0·055; 95% CI 0·018–0·093). However, this finding appears driven by a minority of patients with large lesions (≥ 20 cm²) (net cost: −£5310; 95% CI −9729 to −891; net QALYs: 0·077; 95% CI 0·004–0·151). The incremental cost‐effectiveness of ciclosporin for the majority of patients with smaller lesions was £23 374/QALY, although the estimate is imprecise: the probability of being cost‐effective at a willingness‐to‐pay of £20 000/QALY was 43%.

Conclusions

Consistent with the clinical findings of the STOP GAP trial, patients with small lesions should receive treatment guided by the side‐effect profiles of the drugs and patient preference – neither strategy is clearly a preferred use of National Health Service resources. However, ciclosporin‐initiated treatment may be more cost‐effective for patients with large lesions.

What's already known about this topic?

Pyoderma gangrenosum is characterized by severe, painful skin ulcers.

Although prednisolone has been the main systemic treatment, ciclosporin has been used increasingly because of its perceived greater effectiveness and fewer side‐effects.

STOP GAP was a pragmatic randomized controlled trial comparing ciclosporin and prednisolone: clinical effectiveness was similar, but only 50% of ulcers had healed by 6 months on either drug and adverse events were common with both drugs.

What does this study add?

For patients with small lesions (< 20 cm²), neither treatment is clearly more cost‐effective than the other.

However, ciclosporin‐initiated treatment may be the more cost‐effective option in patients with large (≥ 20 cm²) lesions.

Decisions about treatment will continue to be informed primarily by patient preference, underlying comorbidities, and drug side‐effect profiles (e.g. serious infections with prednisolone, hypertension and renal dysfunction with ciclosporin).

Linked Comment: Bray. Br J Dermatol 2017; 177:1475–1476.

Plain language summary available online

A need to simplify informed consent documents in cancer clinical trials. A position paper of the ARCAD Group

Background

In respect of the principle of autonomy and the right of self-determination, obtaining an informed consent of potential participants before their inclusion in a study is a fundamental ethical obligation. The variations in national laws, regulations, and cultures contribute to complex informed consent documents for patients participating in clinical trials. Currently, only few ethics committees seem willing to address the complexity and the length of these documents and to request investigators and sponsors to revise them in a way to make them understandable for potential participants. The purpose of this work is to focus on the written information in the informed consent documentation for drug development clinical trials and suggests (i) to distinguish between necessary and not essential information, (ii) to define the optimal format allowing the best legibility of those documents.

Methods

The Aide et Recherche en Cancérologie Digestive (ARCAD) Group, an international scientific committee involving oncologists from all over the world, addressed these issues and developed and uniformly accepted a simplified informed consent documentation for future clinical research.

Results

A simplified form of informed consent with the leading part of 1200-1800 words containing all of the key information necessary to meet ethical and regulatory requirements and 'relevant supportive information appendix' of 2000-3000 words is provided.

Conclusions

This position paper, on the basis of the ARCAD Group experts discussions, proposes our informed consent model and the rationale for its content.

Rickettsia parkeri and "Candidatus Rickettsia andeanae" in Questing Amblyomma maculatum (Acari: Ixodidae) From Mississippi

Amblyomma maculatum Koch (Acari: Ixodidae), the primary vector for Rickettsia parkeri, may also be infected with a rickettsia of unknown pathogenicity, "Candidatus Rickettsia andeanae." Infection rates with these rickettsiae vary geographically, and coinfected ticks have been reported. In this study, infection rates of R. parkeri and "Ca. R. andeanae" were evaluated, and rickettsial DNA levels quantified, in 335 questing adult A. maculatum collected in 2013 (n = 95), 2014 (n = 139), and 2015 (n = 101) from Oktibbeha County, MS. Overall infection rates of R. parkeri and "Ca. R. andeanae" were 28.7% and 9.3%, respectively, with three additional A. maculatum (0.9%) coinfected. While R. parkeri-infected ticks were detected all three years (34.7% in 2013; 13.7% in 2014; 43.6% in 2015), "Ca. R. andeanae" was not detected in 2013, and was detected at rates of 10.8% in 2014, and 15.8% in 2015. Interestingly, rickettsial DNA levels in singly-infected ticks were significantly lower in "Ca. R. andeanae"-infected ticks compared to R. parkeri-infected ticks (P < 0.0001). Thus, both infection rates and rickettsial DNA levels were higher for R. parkeri than "Ca. R. andeanae." Infection rates of R. parkeri were also higher, and "Ca. R. andeanae" lower, here compared to A. maculatum reported previously in Kansas and Oklahoma. As we continue to monitor infection rates and levels, we anticipate that understanding temporal changes will improve our awareness of human risk for spotted fever rickettsioses. Further, these data may lead to additional studies to evaluate potential interactions among sympatric Rickettsia species in A. maculatum at the population level.

Mycobacterial Arthritis and Synovitis in Painted Reed Frogs (Hyperolius marmoratus)

Several species of atypical mycobacteria have been isolated from wild and captive amphibians. In captive anurans, cutaneous and visceral mycobacteriosis are common and can result in significant mortality, particularly when animals are immunocompromised. Mycobacterial arthritis and synovitis are reported rarely in amphibians. We describe 20 cases in painted reed frogs (Hyperolius marmoratus), which presented with cachexia, limb paresis or paralysis or 'spindly leg syndrome'. Histopathology revealed multifocal histiocytic to granulomatous synovitis affecting appendicular, rib or spinal intervertebral joints. Periarticular granulomata, granulomatous cellulitis and skeletal muscle atrophy, necrosis and degeneration were also present. In one case, granulomatous spinal osteomyelitis was recorded. Ziehl-Neelsen stains showed large numbers of acid-fast bacteria in macrophages and histiocytes. The mycobacterial isolates obtained from culture were identified as members of the Mycobacterium chelonae complex (either M. chelonae or Mycobacterium abscessus). This was confirmed by 5'-16S ribosomal ribonucleic acid (rRNA) sequencing. In 17 cases mycobacterial lesions were present only in the joints and skeleton, highlighting the importance of not ruling out mycobacterial infection on the basis of absence of cutaneous or visceral lesions.

Multiple inorganic toxic substances contaminating the groundwater of Myingyan Township, Myanmar: arsenic, manganese, fluoride, iron, and uranium

In South Asia, the technological and societal shift from drinking surface water to groundwater has resulted in a great reduction of acute diseases due to water borne pathogens. However, arsenic and other naturally occurring inorganic toxic substances present in groundwater in the region have been linked to a variety of chronic diseases, including cancers, heart disease, and neurological problems. Due to the highly specific symptoms of chronic arsenic poisoning, arsenic was the first inorganic toxic substance to be noticed at unsafe levels in the groundwater of West Bengal, India and Bangladesh. Subsequently, other inorganic toxic substances, including manganese, uranium, and fluoride have been found at unsafe levels in groundwater in South Asia. While numerous drinking water wells throughout Myanmar have been tested for arsenic, relatively little is known about the concentrations of other inorganic toxic substances in Myanmar groundwater. In this study, we analyzed samples from 18 drinking water wells (12 in Myingyan City and 6 in nearby Tha Pyay Thar Village) and 2 locations in the Ayeyarwaddy River for arsenic, boron, barium, beryllium, cadmium, cobalt, chromium, copper, fluoride, iron, mercury, manganese, molybdenum, nickel, lead, antimony, selenium, thallium, uranium, vanadium, and zinc. Concentrations of arsenic, manganese, fluoride, iron, or uranium exceeded health-based reference values in most wells. In addition, any given well usually contained more than one toxic substance at unsafe concentrations. While water testing and well sharing could reduce health risks, none of the wells sampled provide water that is entirely safe with respect to inorganic toxic substances. It is imperative that users of these wells, and users of other wells that have not been tested for multiple inorganic toxic substances throughout the region, be informed of the need for drinking water testing and the health consequences of drinking water contaminated with inorganic toxic substances.

Investigation of bone quality of the first and second sacral segments amongst trauma patients: concerns about iliosacral screw fixation

Background

Iliosacral screw fixation has become a common method for surgical stabilization of acute disruptions of the pelvic ring. Placement of iliosacral screws into the first sacral (S1) body is the preferred method of fixation, but size limitations and sacral dysmorphism may preclude S1 fixation. In these clinical situations, fixation into the second sacral (S2) body has been recommended. The objective of this study was to evaluate the bone quality of the S1 compared to S2 in the described “safe zone” of iliosacral screw fixation in trauma patients.

Materials and methods

The pelvic computed tomography scans of 25 consecutive trauma patients, ages 18–49, at a level 1 trauma center were prospectively analyzed. Hounsfield units, a standardized computed tomography attenuation coefficient, was utilized to measure regional cancellous bone mineral density of the S1 and S2. No change in the clinical protocol or treatment occurred as a consequence of inclusion in this study.

Results

A statically significant difference in bone quality was found when comparing the first and second sacral segment (p = 0.0001). Age, gender, or smoking status did not independently affect bone quality.

Conclusion

In relatively young, otherwise healthy trauma patients there is a statistically significant difference in the bone density of the first sacral segment compared to the second sacral segment. This study highlights the need for future biomechanical studies to investigate whether this difference is clinically relevant. Due to the relative osteopenia in the second sacral segment, which may impact the quality of fixation, we feel this technique should be used with caution.

Level of evidence

III

Variability in Accreditation Council for Graduate Medical Education Resident Case Log System practices among orthopaedic surgery residents

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) Resident Case Log System is designed to be a reflection of residents' operative volume and an objective measure of their surgical experience. All operative procedures and manipulations in the operating room, Emergency Department, and outpatient clinic are to be logged into the Resident Case Log System. Discrepancies in the log volumes between residents and residency programs often prompt scrutiny. However, it remains unclear if such disparities truly represent differences in operative experiences or if they are reflections of inconsistent logging practices. The purpose of this study was to investigate individual recording practices among orthopaedic surgery residents prior to August 1, 2011.

METHODS

Orthopaedic surgery residents received a questionnaire on case log practices that was distributed through the Council of Orthopaedic Residency Directors list server. Respondents were asked to respond anonymously about recording practices in different clinical settings as well as types of cases routinely logged. Hypothetical scenarios of common orthopaedic procedures were presented to investigate the differences in the Current Procedural Terminology codes utilized.

RESULTS

Two hundred and ninety-eight orthopaedic surgery residents completed the questionnaire; 37% were fifth-year residents, 22% were fourth-year residents, 18% were third-year residents, 15% were second-year residents, and 8% were first-year residents. Fifty-six percent of respondents reported routinely logging procedures performed in the Emergency Department or urgent care setting. Twenty-two percent of participants routinely logged procedures in the clinic or outpatient setting, 20% logged joint injections, and only 13% logged casts or splints applied in the office setting. There was substantial variability in the Current Procedural Terminology codes selected for the seven clinical scenarios.

CONCLUSIONS

There has been a lack of standardization in case-logging practices among orthopaedic surgery residents prior to August 1, 2011. ACGME case log data prior to this date may not be a reliable measure of residents' procedural experience.

Mental health training experiences among Haitian healthcare workers post-earthquake 2010

BACKGROUND

After the 2010 earthquake in Haiti, the large number of persons with major limb damage, amputations, shock, trauma, anxiety and depression placed a severe strain on mental health (MH) services.

PURPOSE

This qualitative study describes the impact and acceptability of a Mental Health Training Program (MHTP) implemented in the north of Haiti after the earthquake.

METHODS

A total of 113 healthcare workers (HCWs) participated in a training program designed to build local MH care capacity. The training curriculum draws on literature related to MH and the impact of the Haiti earthquake. Two focus groups were conducted with 16 HCWs; discussions centred on the personal and professional impact and acceptability of the training program.

DISCUSSION

Results demonstrated that the MHTP changed the HCWs' perceptions about MH issues and provided them with the knowledge and skills to respond to growing community MH needs. Acceptability of the MHTP was related to the content covered, to the delivery mode of the content and to the cultural appropriateness of the program.

CONCLUSIONS

Disasters of different types will continue to occur and to impact MH in communities around the world. MH training will allow nurses to quickly and effectively respond to disasters. A coordinated emergency plan that is subject to frequent review, rehearsal and evaluation is also essential.

Relationship among circulating tumor cells, CEA and overall survival in patients with metastatic colorectal cancer

BACKGROUND

We previously reported results of a prospective trial evaluating the significance of circulating tumor cells (CTCs) in patients with metastatic colorectal cancer (mCRC). This secondary analysis assessed the relationship of the CTC number with carcinoembryonic antigen (CEA) and overall survival.

PATIENTS AND METHODS

Patients with mCRC had CTCs measured at baseline and specific time points after the initiation of new therapy. Patients with a baseline CEA value ≥ 10 ng/ml and CEA measurements within ± 30 days of the CTC collection were included.

RESULTS

We included 217 patients with mCRC who had a CEA value of ≥ 10 ng/ml. Increased baseline CEA was associated with shorter survival (15.8 versus 20.7 months, P = 0.012). Among all patients with a baseline CEA value of ≥ 25 ng/ml, patients with low baseline CTCs (<3, n = 99) had longer survival than those with high CTCs (≥ 3, n = 58; 20.8 versus 11.7 months, P = 0.001). CTCs added prognostic information at the 3-5- and 6-12-week time points regardless of CEA. In a multivariate analysis, CTCs at baseline but not CEA independently predicted survival and both CTCs and CEA independently predicted survival at 6-12 weeks.

CONCLUSIONS

This study demonstrates that both CEA and CTCs contribute prognostic information for patients with mCRC.

A protective effect of Lactobacillus rhamnosus HN001 against eczema in the first 2 years of life persists to age 4 years

BACKGROUND

Using a double blind randomized placebo-controlled trial (Australian New Zealand Clinical Trials Registry: ACTRN12607000518460), we have shown that in a high risk birth cohort, maternal supplementation from 35 weeks gestation until 6 months if breastfeeding and infant supplementation until 2 years with Lactobacillus rhamnosus HN001 (HN001) (6 × 10(9) cfu/day) halved the cumulative prevalence of eczema by age 2 years. Bifidobacterium animalis subsp lactis HN019 (HN019) (9 × 10(9) cfu/day) had no effect.

OBJECTIVE

The aim of this study was to investigate the associations of HN001 and HN019 with allergic disease and atopic sensitization among these children at age 4 years, 2 years after stopping probiotic supplementation.

METHODS

The presence (UK Working Party's Diagnostic Criteria) and severity SCORing Atopic Dermatitis (SCORAD) of eczema and atopy (skin prick tests) and parent-reported symptoms of asthma and rhinoconjunctivitis were assessed using standard protocols and questions.

RESULTS

Four-hundred and seventy-four infants were eligible at birth of whom 425 (90%) participated in this follow-up. The cumulative prevalence of eczema by 4 years (Hazard ratio (HR) 0.57 (95% CI 0.39-0.83)) and prevalence of rhinoconjunctivitis at 4 years (Relative risk 0.38 (95% CI 0.18-0.83)) were significantly reduced in the children taking HN001; there were also nonsignificant reductions in the cumulative prevalence of SCORAD ≥ 10 (HR 0.74 (95% CI 0.52-1.05), wheeze (HR 0.79 (95% CI 0.59-1.07)) and atopic sensitization (HR = 0.72 (95% CI 0.48-1.06)). HN019 did not affect the prevalence of any outcome.

CONCLUSIONS AND CLINICAL RELEVANCE

This study showed that the protective effect of HN001 against eczema, when given for the first 2 years of life only, extended to at least 4 years of age. This, together with our findings for a protective effect against rhinoconjunctivitis, suggests that this probiotic might be an appropriate preventative intervention for high risk infants.

A protective effect of Lactobacillus rhamnosus HN001 against eczema in the first 2 years of life persists to age 4 years

BACKGROUND

Using a double blind randomized placebo-controlled trial (Australian New Zealand Clinical Trials Registry: ACTRN12607000518460), we have shown that in a high risk birth cohort, maternal supplementation from 35 weeks gestation until 6 months if breastfeeding and infant supplementation until 2 years with Lactobacillus rhamnosus HN001 (HN001) (6 × 10(9) cfu/day) halved the cumulative prevalence of eczema by age 2 years. Bifidobacterium animalis subsp lactis HN019 (HN019) (9 × 10(9) cfu/day) had no effect.

OBJECTIVE

The aim of this study was to investigate the associations of HN001 and HN019 with allergic disease and atopic sensitization among these children at age 4 years, 2 years after stopping probiotic supplementation.

METHODS

The presence (UK Working Party's Diagnostic Criteria) and severity SCORing Atopic Dermatitis (SCORAD) of eczema and atopy (skin prick tests) and parent-reported symptoms of asthma and rhinoconjunctivitis were assessed using standard protocols and questions.

RESULTS

Four-hundred and seventy-four infants were eligible at birth of whom 425 (90%) participated in this follow-up. The cumulative prevalence of eczema by 4 years (Hazard ratio (HR) 0.57 (95% CI 0.39-0.83)) and prevalence of rhinoconjunctivitis at 4 years (Relative risk 0.38 (95% CI 0.18-0.83)) were significantly reduced in the children taking HN001; there were also nonsignificant reductions in the cumulative prevalence of SCORAD ≥ 10 (HR 0.74 (95% CI 0.52-1.05), wheeze (HR 0.79 (95% CI 0.59-1.07)) and atopic sensitization (HR = 0.72 (95% CI 0.48-1.06)). HN019 did not affect the prevalence of any outcome.

CONCLUSIONS AND CLINICAL RELEVANCE

This study showed that the protective effect of HN001 against eczema, when given for the first 2 years of life only, extended to at least 4 years of age. This, together with our findings for a protective effect against rhinoconjunctivitis, suggests that this probiotic might be an appropriate preventative intervention for high risk infants.

P3-09-02: Intermittent Dietary Carbohydrate Restriction Enables Weight Loss and Reduces Breast Cancer Risk Biomarkers

Background: Energy restriction is a potential strategy for breast cancer prevention but is difficult to achieve and maintain. We found that intermittent energy restriction (2 days strict dieting week) is comparable to the standard approach of moderate daily restriction for weight loss and marginally better for improving insulin sensitivity, but no easier to follow1. In this follow on study we wished to test whether 2 novel intermittent low carbohydrate/low energy diets were feasible and easier to follow than a standard daily energy restriction. Design: Randomised comparison of 3 dietary types over 4 months in 115 overweight or obese (mean body mass index 31.0 [±5.3 SD] kg/m2) women at increased risk of breast cancer (lifetime risk &gt; 1 in 6).

Diets:

1. A restricted low carbohydrate diet (RLCD): 650 kcal and &lt;50g carbohydrate / day for 2 days per week

2. Ad lib low carbohydrate diet (ALCD): &lt;50g / day for 2 days per week with other food types (e.g. protein) ad lib

3. A standard daily restricted Mediterranean diet (DRMD): ∼ 1500kcal/day for 7 days per week

Methods: Weight, anthropometrics, blood markers for breast cancer; insulin resistance, oxidative stress markers, leptin, adiponectin, lipids, inflammatory markers IGF-1 were assessed at baseline, 1, 3 and 4 months.

Results: 88/114 completed the study (77%, drop outs 6 RLCD, 8 ALCD 12 DRMD). Last observation carried forward analyses show both intermittent low carbohydrate diets were superior to standard daily restriction for reducing weight and body fat: mean (95% confidence interval [CI]) change in body fat for RLCD was −4.3 (−5.6 to −3.0) kg, for ALCD −4.1 (−5.2 to −3.1) kg vs. −2.4 (−3.4 to −1.2) kg for DRMD (P value for difference between groups = 0.02). The intermittent groups had greater improvement in insulin resistance: mean (95% CI) change for RLCD was −22 (−35 to −11) %, ALCD −14 (−27 to −5%) % vs. −4 (−16 to 9) % for DRMD (P = 0.02). Other biomarkers are being assayed currently.

Conclusion: Greater weight loss, fewer drop outs and greater reductions in insulin resistance with the novel intermittent low carbohydrate diets indicate that these are alternative approaches for energy restriction for potentially reducing risk of breast cancer and other diseases.

Reference:

1Harvie MN, Pegington M, Mattson MP, Frystyk J, Dillon B, Evans G et al. The effects of intermittent or continuous energy restriction on weight loss and metabolic disease risk markers: a randomized trial in young overweight women. Int.J Obes (Lond) 35; 714–27, 2011. This study is funded by the Genesis Breast Cancer Prevention Appeal: www.genesisuk.org

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-09-02.

P5-14-12: Bayesian Belief Network Mortality Analysis of a Breast Cancer Registry Data Set

Introduction: Bayesian Belief Networks have been used in medicine to evaluate clinical data and develop predictive and prognostic models. As classification models, they allow us to represent pattern complexity beyond what can be accomplished with traditional Kaplan-Meier or regression models. We sought to evaluate the use of machine-learned Bayesian Belief Networks (ml-BBNs) to develop mortality models in breast cancer and to evaluate classification performance for this method.

Methods: A set of 2,300 breast bancer cases from a tumor registry at Thomas Jefferson University were used to train ml-BBNs. The registry set was broken into cohorts for modeling by follow-up times of 1 (n=2,202), 2 (n=2,183), 3 (n=2,157), and 5 (n=2,027) years. Each cohort was then used to train a ***m1-BBN and each model was evaluated for structure. Variables were recoded into categories: biomarkers (ER, PR, Ki67, HER2, p53) as positive or negative; grading, staging, and size were broken in categories; while race was recoded into Caucasian or African-American. Income and poverty level by census tract were also included. Models were evaluated for ability to classify mortality (yes/no) within the follow-up period using 10-fold cross-validation and Receiver Operating Characteristic curves.

Results: Area Under the Curve (AUC), Positive Predictive Value (PPV), and Negative Predictive Value (NPV) were calculated for each set of cohort training models and mean values and 95% confidence intervals were calculated for mortality (yes/no) within the follow-up period. AUCs (and CIs) for 1, 2, 3, and 5 years were: 0.81 (0.70 — 0.91), 0.74 (0.69 — 0.79), 0.81 (0.77 — 0.86), 0.77 (0.74 — 0.80). PPVs for 1, 2, 3, and 5 years were: 12.3% (7.5% — 17.1%), 18.8% (15.4% — 22.1%), 18.0% (15.1% — 20.9%), 28.2% (24.7% — 31.7%). NPVs for 1, 2, 3, and 5 years were: 99.2% (98.8% — 99.7%), 97.4% (96.9% — 97.8%), 96.4% (95.1% — 97.7%), 91.7% (89.1% — 94.3%). Predictors of mortality at 1 year were Tumor Stage, at 2 years were Estrogen Receptor and Tumor Stage, and at 3 and 5 years were Diagnosis Age, Tumor Stage, Estrogen Receptor status, and Ki-67 receptor status. Discussion / Conclusion: We were able to successfully train ***m1-BBNs to estimate mortality using breast cancer registry cohorts. Cross-validation showed the models to be robust. The structure of the models can inform us how different data elements contribute to the estimate of mortality. These models can be used to calculate individual probabilities for prognostic guidance given age, staging criteria, and biomarkers. Overall 5-year mortality in the study set is 15.2%, however we can derive subject-specific mortality estimates. For example, a 43-year old Stage 3, ER-Negative, Ki-67 Negative subject has a 19.9% probability of 5-year mortality, while the same subject with positive Ki-67 has a 37.8% probability of mortality. Meanwhile, the same probabilities for a 70 year old woman are 67.0% and 59.0%, respectively.