Multimorbidity patterns in older persons and their association with self-reported quality of life and limitations in activities of daily living

BACKGROUND

As populations age, multimorbidity (the presence of two or more chronic morbidities) is increasingly more common. These evolving demographics demand further research into the identification of morbidity patterns in different settings as well as the longitudinal effects of these patterns.

METHODS

Prospectively collected data on 12,755 older persons aged 65+ years were derived from The Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS-MDS, www.topics-mds.eu). Latent class analyses were performed to identify unobserved relationship patterns between morbidities in older persons. Using linear mixed models, the average difference in health-related quality of life (EQ-5D) and general quality of life scores (Cantril's Self Anchoring Ladder) as well as limitations in Activities of Daily Living and Instrumental Activities of Daily Living (ADL/IADL) were examined over a 12-month period.

RESULTS

Five multimorbidity patterns were identified: sensory (n = 3882), cardio-metabolic (n = 2627), mental health (n = 920), osteo-articular (n = 4486), and system decline (n = 840). Relative to older persons in the sensory group, multimorbidity patterns did not have a strong effect on health-related quality of life, general quality of life or ADL/IADLs over a one-year period.

CONCLUSIONS

The observed multimorbidity patterns are similar to others based on different methodologies and study populations. When examining the effect of such patterns on quality of life, the EQ-5D and Cantril's Ladder may be insufficient outcome measures. Further investigations into the prognostic value of morbidity patterns would be of benefit.

Predicting hospital admissions from individual patient data (IPD): an applied example to explore key elements driving external validity

OBJECTIVE

To explore factors that potentially impact external validation performance while developing and validating a prognostic model for hospital admissions (HAs) in complex older general practice patients.

STUDY DESIGN AND SETTING

Using individual participant data from four cluster-randomised trials conducted in the Netherlands and Germany, we used logistic regression to develop a prognostic model to predict all-cause HAs within a 6-month follow-up period. A stratified intercept was used to account for heterogeneity in baseline risk between the studies. The model was validated both internally and by using internal-external cross-validation (IECV).

RESULTS

Prior HAs, physical components of the health-related quality of life comorbidity index, and medication-related variables were used in the final model. While achieving moderate discriminatory performance, internal bootstrap validation revealed a pronounced risk of overfitting. The results of the IECV, in which calibration was highly variable even after accounting for between-study heterogeneity, agreed with this finding. Heterogeneity was equally reflected in differing baseline risk, predictor effects and absolute risk predictions.

CONCLUSIONS

Predictor effect heterogeneity and differing baseline risk can explain the limited external performance of HA prediction models. With such drivers known, model adjustments in external validation settings (eg, intercept recalibration, complete updating) can be applied more purposefully.

TRIAL REGISTRATION NUMBER

PROSPERO id: CRD42018088129.

End-of-life care preferences of older patients with multimorbidity: protocol of a mixed-methods systematic review

INTRODUCTION

End-of-life care is an essential task performed by most healthcare providers and often involves decision-making about how and where patients want to receive care. To provide decision support to healthcare professionals and patients in this difficult situation, we will systematically review a knowledge cluster of the end-of-life care preferences of older patients with multimorbidity that we previously identified using an evidence map.

METHODS AND ANALYSIS

We will systematically search for studies reporting end-of-life care preferences of older patients (mean age ≥60) with multimorbidity (≥2 chronic conditions) in MEDLINE, CINAHL, PsycINFO, Social Sciences Citation Index, Social Sciences Citation Index Expanded, PSYNDEX and The Cochrane Library from inception to September 2019. We will include all primary studies that use quantitative, qualitative and mixed methodologies, irrespective of publication date and language.Two independent reviewers will assess eligibility, extract data and describe evidence in terms of study/population characteristics, preference assessment method and end-of-life care elements that matter to patients (eg, life-sustaining treatments). Risk of bias/applicability of results will be independently assessed by two reviewers using the Mixed-Methods Appraisal Tool. Using a convergent integrated approach on qualitative/quantitative studies, we will synthesise information narratively and, wherever possible, quantitatively.

ETHICS AND DISSEMINATION

Due to the nature of the proposed systematic review, ethics approval is not required. Results from our research will be disseminated at relevant (inter-)national conferences and via publication in peer-reviewed journals. Synthesising evidence on end-of-life care preferences of older patients with multimorbidity will improve shared decision-making and satisfaction in this final period of life.

PROSPERO REGISTRATION NUMBER

CRD42020151862.

Health-related preferences of older patients with multimorbidity: an evidence map

OBJECTIVES

To systematically identify knowledge clusters and research gaps in the health-related preferences of older patients with multimorbidity by mapping current evidence.

DESIGN

Evidence map (systematic review variant).

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, PSYNDEX, CINAHL and Science Citation Index/Social Science Citation Index/-Expanded from inception to April 2018.

STUDY SELECTION

Studies reporting primary research on health-related preferences of older patients (mean age ≥60 years) with multimorbidity (≥2 chronic/acute conditions).

DATA EXTRACTION

Two independent reviewers assessed studies for eligibility, extracted data and clustered the studies using MAXQDA-18 content analysis software.

RESULTS

The 152 included studies (62% from North America, 28% from Europe) comprised 57 093 patients overall (range 9-9105). All used an observational design except for one interventional study: 63 (41%) were qualitative (59 cross-sectional, 4 longitudinal), 85 (57%) quantitative (63 cross-sectional, 22 longitudinal) and 3 (2%) used mixed methods. The setting was specialised care in 85 (56%) and primary care in 54 (36%) studies. We identified seven clusters of studies on preferences: end-of-life care (n=51, 34%), self-management (n=34, 22%), treatment (n=32, 21%), involvement in shared decision making (n=25, 17%), health outcome prioritisation/goal setting (n=19, 13%), healthcare service (n=12, 8%) and screening/diagnostic testing (n=1, 1%). Terminology (eg, preferences, views and perspectives) and concepts (eg, trade-offs, decision regret, goal setting) used to describe health-related preferences varied substantially between studies.

CONCLUSION

Our study provides the first evidence map on the preferences of older patients with multimorbidity. Included studies were mostly conducted in developed countries and covered a broad range of issues. Evidence on patient preferences concerning decision-making on screening and diagnostic testing was scarce. Differences in employed terminology, decision-making components and concepts, as well as the sparsity of intervention studies, are challenges for future research into evidence-based decision support seeking to elicit the preferences of older patients with multimorbidity and help them construct preferences.

TRIAL REGISTRATION NUMBER

Open Science Framework (OSF): DOI 10.17605/OSF.IO/MCRWQ.

Health-related preferences of older patients with multimorbidity: the protocol for an evidence map

INTRODUCTION

Interaction of conditions and treatments, complicated care needs and substantial treatment burden make patient-physician encounters involving multimorbid older patients highly complex. To optimally integrate patients' preferences, define and prioritise realistic treatment goals and individualise care, a patient-centred approach is recommended. However, the preferences of older patients, who are especially vulnerable and frequently multimorbid, have not been systematically investigated with regard to their health status. The purpose of this evidence map is to explore current research addressing health-related preferences of older patients with multimorbidity, and to identify the knowledge clusters and research gaps.

METHODS AND ANALYSIS

To identify relevant research, we will conduct searches in the electronic databases MEDLINE, EMBASE, PsycINFO, PSYNDEX, CINAHL, Social Science Citation Index, Social Science Citation Index Expanded and the Cochrane library from their inception. We will check reference lists of relevant articles and carry out cited reference research (forward citation tracking). Two independent reviewers will screen titles and abstracts, check full texts for eligibility and extract the data. Any disagreement will be resolved and consensus reached with the help of a third reviewer. We will include both qualitative and quantitative studies, and address preferences from the patients' perspectives in a multimorbid population of 60 years or older. There will be no restrictions on the publication language. Data extraction tables will present study and patient characteristics, aim of study, methods used to identify preferences and outcomes (ie, type of preferences). We will summarise the data using tables and figures (ie, bubble plot) to present the research landscape and to describe clusters and gaps.

ETHICS AND DISSEMINATION

Due to the nature of the proposed evidence map, ethics approval will not be required. Results from our research will be disseminated by means of specifically prepared materials for patients, at relevant (inter)national conferences and via publication in peer-reviewed journals.

Genomic analysis of a novel nontoxigenic Corynebacterium diphtheriae strain isolated from a cancer patient

The genome of a novel nontoxigenic Corynebacterium diphtheriae, strain 5015, isolated from a patient with adenoid cystic carcinoma was sequenced and compared with 117 publically available genomes. This strain is phylogenetically distinct and lacks virulence genes encoding the toxin, BigA and Sdr-like adhesins. Strain 5015 possesses spaD-type and spaH-type pilus gene clusters with a loss of some gene functions, and 31 unique genes that need molecular characterization to understand their potential role in virulence characteristics.

Circulating serum miR-223-3p and miR-16-5p as possible biomarkers of early rheumatoid arthritis

Small non-coding RNAs have emerged as possible biomarkers for various diseases including autoimmune diseases. A number of studies have demonstrated that the expression of specific microRNAs (miRNAs) is dysregulated in rheumatoid arthritis (RA). So far, all studies on miRNAs in RA patients have been performed using either microarray or reverse transcription-quantitative polymerase chain reaction (RT-qPCR) analyses. Compared to RT-qPCR and microarray analyses, next-generation sequencing (NGS) allows the genome-wide analysis of small RNAs and the differentiation between miRNAs that differ by a single nucleotide. The application of NGS to the analysis of small RNAs circulating in sera of RA patients has not been reported. This study provides a global overview of the circulating small RNAs in the sera of RA patients and healthy subjects and identifies differences between these groups using NGS. Several classes of small RNAs, including hY RNA-derived fragments, tRNA-derived fragments and miRNAs, were determined. Differentially expressed individual small RNAs were verified by RT-qPCR. The levels of two miRNAs, miR-223-3p and miR-16-5p, were significantly lower in the sera from early RA patients than in those from established RA patients and healthy controls. In contrast, the serum level of miR-16-5p was higher in patients with established RA than in healthy control samples. These miRNAs may not only serve as biomarkers, but may also shed more light on the pathophysiology of RA.

DREAMeR: Drug use Reconsidered in the Elderly using goal Attainment scales during Medication Review; study protocol of a randomised controlled trial

Background

Clinical medication reviews (CMR) are increasingly performed in older patients with polypharmacy. Studies have shown positive effects of CMR on process- and intermediate outcomes, like drug-related problems (DRPs). Little effect has been shown on clinical outcomes, like hospital admissions or health-related quality of life (HR-QoL). In particular, HR-QoL is related to the individual health-related goals and complaints of patients. The aim of this study is to investigate the effects of a CMR focused on personal goals on HR-QoL and health-related complaints in older patients with polypharmacy.

Methods

A randomised controlled trial will be performed in 35 Dutch community pharmacies aiming to include 630 patients aged 70 years and older using seven or more chronic drugs. Patients will be randomly assigned to control or intervention group by block-randomisation per pharmacy. Patients in the intervention group receive a CMR focused on patients’ preferences, personal goals and health-related complaints. With every goal a goal attainment scale (GAS) will be proposed. Primary outcome measures are HR-QoL, measured with the EQ-5D-5L and EQ-VAS and the number of health-related complaints per patient measured with a written questionnaire, during a follow-up period of six months. Secondary outcomes are healthcare utilisation, number and type of drug changes, number and type of health-related goals, scores on GAS and number and type of DRPs and interventions.

Discussion

This study is expected to add evidence on the effects of a CMR on HR-QoL and health-related complaints in older patients with polypharmacy. New in this study is the use of personal goals measured with GAS and health-related complaints as patient-related outcome measures.

Trial registration

Netherlands Trial Register; NTR5713.

A review of bioinformatics platforms for comparative genomics. Recent developments of the EDGAR 2.0 platform and its utility for taxonomic and phylogenetic studies

The rapid development of next generation sequencing technology has greatly increased the amount of available microbial genomes. As a result of this development, there is a rising demand for fast and automated approaches in analyzing these genomes in a comparative way. Whole genome sequencing also bears a huge potential for obtaining a higher resolution in phylogenetic and taxonomic classification. During the last decade, several software tools and platforms have been developed in the field of comparative genomics. In this manuscript, we review the most commonly used platforms and approaches for ortholog group analyses with a focus on their potential for phylogenetic and taxonomic research. Furthermore, we describe the latest improvements of the EDGAR platform for comparative genome analyses and present recent examples of its application for the phylogenomic analysis of different taxa. Finally, we illustrate the role of the EDGAR platform as part of the BiGi Center for Microbial Bioinformatics within the German network on Bioinformatics Infrastructure (de.NBI).

Deciphering the virulence factors of the opportunistic pathogen Mycobacterium colombiense

Mycobacterium avium complex (MAC) contains clinically important nontuberculous mycobacteria worldwide and is the second largest medical complex in the Mycobacterium genus after the Mycobacterium tuberculosis complex. MAC comprises several species that are closely phylogenetically related but diverse regarding their host preference, course of disease, virulence and immune response. In this study we provided immunologic and virulence-related insights into the M. colombiense genome as a model of an opportunistic pathogen in the MAC. By using bioinformatic tools we found that M. colombiense has deletions in the genes involved in p-HBA/PDIM/PGL, PLC, SL-1 and HspX production, and loss of the ESX-1 locus. This information not only sheds light on our understanding the virulence mechanisms used by opportunistic MAC pathogens but also has great potential for the designing of species-specific diagnostic tools.

Screening vs. non-screening detected colorectal cancer: Differences in pre-therapeutic work up and treatment

Objectives To compare preoperative staging, multidisciplinary team-assessment, and treatment in patients with screening detected and non-screening detected colorectal cancer. Methods Data on patient and tumour characteristics, staging, multidisciplinary team-assessment and treatment in patients with screening and non-screening detected colorectal cancer from 2008 to 2012 were collected from the Stockholm-Gotland screening register and the Swedish Colorectal Cancer Registry. Results The screening group had a higher proportion of stage I disease (41 vs. 15%; p < 0.001), a more complete staging of primary tumour and metastases and were more frequently multidisciplinary team-assessed than the non-screening group ( p < 0.001). In both groups, patients with endoscopically resected cancers were less completely staged and multidisciplinary team-assessed than patients with surgically resected cancers ( p < 0.001). No statistically significant differences were observed between the screening and non-screening groups in the use of neoadjuvant treatment in rectal cancer (68 vs.76%), surgical treatment with local excision techniques in stage I rectal cancer (6 vs. 9%) or adjuvant chemotherapy in stages II and III disease (46 vs. 52%). Emergency interventions for colorectal cancer occurred in 4% of screening participants vs. 11% of non-compliers. Conclusions Screening detected cancer patients were staged and multidisciplinary team assessed more extensively than patients with non-screening detected cancers. Staging and multidisciplinary team assessment prior to endoscopic resection was less complete compared with surgical resection. Extensive surgical and (neo)adjuvant treatment was given in stage I disease. Participation in screening reduced the risk of emergency surgery for colorectal cancer.

Phenotypic, molecular characterization, antimicrobial susceptibility and draft genome sequence of Corynebacterium argentoratense strains isolated from clinical samples

During a 12-year period we isolated five Corynebacterium argentoratense strains identified by phenotypic methods, including the use of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF) and 16S rRNA gene sequencing. In addition, antimicrobial susceptibility was determined, and genome sequencing for the detection of antibiotic resistance genes was performed. The organisms were isolated from blood and throat cultures and could be identified by all methods used. All strains were resistant to cotrimoxazole, and resistance to β-lactams was partly present. Two strains were resistant to erythromycin and clindamycin. The draft genome sequences of theses isolates revealed the presence of the erm(X) resistance gene that is embedded in the genetic structure of the transposable element Tn5423. Although rarely reported as a human pathogen, C. argentoratense can be involved in bacteraemia and probably in other infections. Our results also show that horizontal transfer of genes responsible for antibiotic resistance is occurring in this species.

Effectiveness and cost-effectiveness of a proactive, goal-oriented, integrated care model in general practice for older people. A cluster randomised controlled trial: Integrated Systematic Care for older People--the ISCOPE study

Background: older people often experience complex problems. Because of multiple problems, care for older people in general practice needs to shift from a ‘problem-based, disease-oriented’ care aiming at improvement of outcomes per disease to a ‘goal-oriented care’, aiming at improvement of functioning and personal quality of life, integrating all healthcare providers. Feasibility and cost-effectiveness of this proactive and integrated way of working are not yet established.

Design: cluster randomised trial.

Participants: all persons aged ≥75 in 59 general practices (30 intervention, 29 control), with a combination of problems, as identified with a structured postal questionnaire with 21 questions on four health domains.

Intervention: for participants with problems on ≥3 domains, general practitioners (GPs) made an integrated care plan using a functional geriatric approach. Control practices: care as usual.

Outcome measures: (i) quality of life (QoL), (ii) activities of daily living, (iii) satisfaction with delivered health care and (iv) cost-effectiveness of the intervention at 1-year follow-up.

Trial registration: Netherlands trial register, NTR1946.

Results: of the 11,476 registered eligible older persons, 7,285 (63%) participated in the screening. One thousand nine hundred and twenty-one (26%) had problems on ≥3 health domains. For 225 randomly chosen persons, a care plan was made. No beneficial effects were found on QoL, patients' functioning or healthcare use/costs. GPs experienced better overview of the care and stability, e.g. less unexpected demands, in the care.

Conclusions: GPs prefer proactive integrated care. ‘Horizontal’ care using care plans for older people with complex problems can be a valuable tool in general practice. However, no direct beneficial effect was found for older persons.

Results of collagen plug occlusion of anal fistula: a multicentre study of 126 patients

AIM

The Biodesign(®) anal fistula plug was introduced as a means of obliterating the fistula tract and promoting healing through biocompatibility. The results demonstrated unexplained variations from good to bad. This report analysed the results of a retrospective multicentre study.

METHOD

All plug procedures performed in four Stockholm hospitals between June 2006 and June 2010 were identified and studied using a common protocol. The outcome after the first plug-insertion procedure was assessed by chart review performed a minimum of 8 months after plug insertion. Cox proportional-hazards models were used to assess the associations of various factors with fistula healing.

RESULTS

One-hundred and twenty-six patients (mean age 47 years) were deemed suitable for the plug procedure. Eighty-five per cent of fistulae were cryptoglandular, 64% of patients were male and a mean of 2.9 previous fistulae procedures had been performed. All patients, except four, had an indwelling seton at the time of the plug procedure, which was performed in accordance with previously established principles of day surgery. After a median of 13 months, 30 (24%) fistulae had closed with no discomfort or secretion reported. The outcome in the four hospitals varied from 13% to 33% with similar numbers of patients in each hospital. A success rate of 12% was observed for patients with anterior fistula compared with 32% for those with posterior tracks [hazard ratio (HR) for successful healing = 2.98; 95% CI: 1.01-8.78) and 41% for those with a lateral internal opening (HR = 3.76; 95% CI: 1.03-13.75). Age, sex and number of previous procedures were not associated with healing.

CONCLUSION

Four independent patient groups showed low success rates after the first plug-insertion procedure. Anterior fistulae were much less likely to heal compared with fistulae in other locations.

Prevalence, determinants and patterns of multimorbidity in primary care: a systematic review of observational studies

INTRODUCTION

Multimorbidity is a major concern in primary care. Nevertheless, evidence of prevalence and patterns of multimorbidity, and their determinants, are scarce. The aim of this study is to systematically review studies of the prevalence, patterns and determinants of multimorbidity in primary care.

METHODS

Systematic review of literature published between 1961 and 2013 and indexed in Ovid (CINAHL, PsychINFO, Medline and Embase) and Web of Knowledge. Studies were selected according to eligibility criteria of addressing prevalence, determinants, and patterns of multimorbidity and using a pretested proforma in primary care. The quality and risk of bias were assessed using STROBE criteria. Two researchers assessed the eligibility of studies for inclusion (Kappa= 0.86).

RESULTS

We identified 39 eligible publications describing studies that included a total of 70,057,611 patients in 12 countries. The number of health conditions analysed per study ranged from 5 to 335, with multimorbidity prevalence ranging from 12.9% to 95.1%. All studies observed a significant positive association between multimorbidity and age (odds ratio [OR], 1.26 to 227.46), and lower socioeconomic status (OR, 1.20 to 1.91). Positive associations with female gender and mental disorders were also observed. The most frequent patterns of multimorbidity included osteoarthritis together with cardiovascular and/or metabolic conditions.

CONCLUSIONS

Well-established determinants of multimorbidity include age, lower socioeconomic status and gender. The most prevalent conditions shape the patterns of multimorbidity. However, the limitations of the current evidence base means that further and better designed studies are needed to inform policy, research and clinical practice, with the goal of improving health-related quality of life for patients with multimorbidity. Standardization of the definition and assessment of multimorbidity is essential in order to better understand this phenomenon, and is a necessary immediate step.

In silico prediction of conserved vaccine targets in Streptococcus agalactiae strains isolated from fish, cattle, and human samples

Streptococcus agalactiae (Lancefield group B; group B streptococci) is a major pathogen that causes meningoencephalitis in fish, mastitis in cows, and neonatal sepsis and meningitis in humans. The available prophylactic measures for conserving human and animal health are not totally effective and have limitations. Effective vaccines against the different serotypes or genotypes of pathogenic strains from the various hosts would be useful. We used an in silico strategy to identify conserved vaccine candidates in 15 genomes of group B streptococci strains isolated from human, bovine, and fish samples. The degree of conservation, subcellular localization, and immunogenic potential of S. agalactiae proteins were investigated. We identified 36 antigenic proteins that were conserved in all 15 genomes. Among these proteins, 5 and 23 were shared only by human or fish strains, respectively. These potential vaccine targets may help develop effective vaccines that will help prevent S. agalactiae infection.

European guidelines for quality assurance in colorectal cancer screening and diagnosis: overview and introduction to the full supplement publication

Population-based screening for early detection and treatment of colorectal cancer (CRC) and precursor lesions, using evidence-based methods, can be effective in populations with a significant burden of the disease provided the services are of high quality. Multidisciplinary, evidence-based guidelines for quality assurance in CRC screening and diagnosis have been developed by experts in a project co-financed by the European Union. The 450-page guidelines were published in book format by the European Commission in 2010.  They include 10 chapters and over 250 recommendations, individually graded according to the strength of the recommendation and the supporting evidence. Adoption of the recommendations can improve and maintain the quality and effectiveness of an entire screening process, including identification and invitation of the target population, diagnosis and management of the disease and appropriate surveillance in people with detected lesions. To make the principles, recommendations and standards in the guidelines known to a wider professional and scientific community and to facilitate their use in the scientific literature, the original content is presented in journal format in an open-access Supplement of Endoscopy. The editors have prepared the present overview to inform readers of the comprehensive scope and content of the guidelines.

[An inpatient version of mentalisation-based treatment for patients with cluster A personality disorders]

BACKGROUND

Despite the severity of their disorder, only a few patients suffering from cluster A personality problems are admitted to mental health care facilities for appropriate treatment. A review of the international literature on the treatment of cluster A patients does not reveal any description of non-pharmaceutical treatment for this group of patients, nor does it mention any research into the effectiveness of treatment for the group.

AIM

To describe the development of a step-down inpatient treatment model for patients suffering from severe cluster A problems.

METHOD

We reviewed the sparse research and the limited reports of clinical experience.

RESULTS

The arguments supporting a step-down inpatient version of mentalisation-based treatment and its application in clinical practice are discussed.

CONCLUSION

A step-down inpatient treatment model has been developed and will be tested in research.

Endoanal ultrasonography may distinguish Crohn's anal fistulae from cryptoglandular fistulae in patients with Crohn's disease: a cross-sectional study

BACKGROUND

The aim of the study was a cross-sectional investigation into the types of anal fistulae in patients with Crohn's disease using 3-dimensional endoanal ultrasonography.

METHODS

The study population consisted of 45 patients with established Crohn's disease referred in a 2-year period for treatment of anal fistula. The fistulae were classified according to the presence of three criteria: 1. bifurcation or secondary extension; 2. cross-sectional width ≥ 3 mm; and 3. content of hyperechoic secretions.

RESULTS

The fistulae of 24 patients (53%) satisfied two or three criteria and were classified as true Crohn's fistulae, while the fistulae of 21 patients satisfied one or none of the criteria and were the cryptoglandular type. The fistulae in the two or three criteria group had been in existence for 8.4 years on average and those in the cryptoglandular group for 4.5 years on average (P = 0.283). The corresponding numbers of previous operations for fistula were 5.7 (range 0-32) and 1.5 (range 0-6), respectively (P = 0.0211). The presence of colitis or proctitis was similar across the groups, but the perianal Crohn's disease activity index was higher with a Crohn's type of fistula (P = 0.0097). Also, a larger proportion had been treated with anti-TNF-monoclonal antibody (0.0169).

CONCLUSIONS

Endoanal ultrasonography was capable of discerning two subgroups of fistula in Crohn's patients. These groups were clinically different indicating that the prospect of surgical cure is also different.

Injury profile of musicians in the Bloemfontein-based Free State symphony orchestra: a short report

Similar  to  professional  athletes,  musicians  are  required  to perform optimally.  Few  studies  have  been  conducted  to  clarify  the  nature of injuries associated with musicians. This study aimed to determine the types of injuries and their prevalence amongst the musicians of the Free State Symphony orchestra (FSSo), contributing factors, the musicians’ response to injury, and their perception of physiotherapy. Forty-five members of the FSSO participated in this descriptive study. Analysis of data included frequencies and percentages for categorical data and percentiles for continuous data. Thirty-eight (84.4%) participants reported injuries related to playing their instruments. Insufficient resting  periods  during playing  sessions  (70.3%),  continuing  to  play  while experiencing symptoms (63.2%) and performing the same movement repetitively (64.9%) were identified as the perceived risk factors in the development of symptoms.  Seventeen  (44.7%)  participants  indicated that they  did  nothing  to relieve their symptoms, while 34.2% sought physiotherapy treatment, 31.6% took medication to alleviate their symptoms and 31.6% reduced their playing hours. Majority of participants (75%) felt that their symptoms could be relieved by physiotherapy. Injuries amongst musicians result from a combination of factors such as posture, repetitive movements and fatigue. Possible physiotherapeutic intervention identified included educating musicians on the advantages of early management of injuries in extending their professional careers.

Sensitivity to Taxane Chemotherapy for Metastatic Breast Cancer in BRCA1 and BRCA2 Mutation Carriers Compared to Sporadic Breast Cancer Patients

Purpose: Data of in vitro and small retrospective studies suggest that breast cancer (BC) (cells) without functional BRCA1 or BRCA2 protein have an increased sensitivity to chemotherapeutic agents causing double strand DNA breaks, while sensitivity to spindle poisons, such as paclitaxel and docetaxel, has been found to be decreased. Clinical data on the latter, however, are very scarce. In this study, we assessed the sensitivity to taxane chemotherapy for metastatic BRCA1/2-associated compared with sporadic breast cancer.Methods: From the family cancer clinic database, we retrieved 36 BRCA1 and 13 BRCA2-associated BC patients treated with taxane chemotherapy for metastatic disease before October 1, 2008, and with available data on follow-up and response assessment. Objective response (OR), and progression-free survival (PFS) after start of taxane chemotherapy were compared with those of 62 sporadic patients with comparable age at diagnosis and year of detection of metastatic BC. A t-test or chi-square test was used to test for differences in characteristics and response types, and Kaplan-Meier survival analysis to calculate PFS.Results: Taxane chemotherapy consisted of docetaxel (n= 76) or paclitaxel (n=21), while 10 (9%) patients received a taxane/trastuzumab regimen. It was given as first-line palliative therapy in 9 BRCA1, 1 BRCA2 and 22 sporadic patients; but mainly as second/third line treatment (BRCA1 n=27, BRCA2 n=12, sporadic patients n=40, respectively). As compared to sporadic patients, BRCA1-associated patients had a significantly lower OR rate (ORR) overall (22% vs 46%, p&lt;0.001) and to 2nd/3rd line taxane treatment (19% vs 46%, p&lt;0.001). Median PFS was shorter in BRCA1 patients (2.0 vs 4.1 mo, p=0.08), with a trend for significance for 2nd/3rd line therapy (1.6 vs 3.9 mo, p=0.05). Also, compared to BRCA2 patients, the ORR in BRCA1 patients was significantly lower, overall as well as to 2nd/3d line therapy (both p=0.003). In BRCA2 mutation carriers compared to sporadic patients, the ORR was higher (75% vs 48%, p=0.28) and PFS longer (6.4 vs 4.1 mo, p=0.33). After exclusion of the patients receiving a taxane/trastuzumab schedule, similar data were observed.Conclusion: Objective response rate to taxane chemotherapy for metastatic disease is lower in BRCA1-associated BC in comparison with sporadic as well as BRCA2-associated BC, resulting in a shorter PFS. If confirmed, these data may have substantial clinical relevance.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2098.

Association between the CHEK2*1100delC germ line mutation and estrogen receptor status

Already published data were further analyzed regarding the association between the CHEK2*1100delC germ line mutation and estrogen receptor (ER) status in patients with breast cancer. The CHEK2*1100delC mutation was more prevalent among the patients with a positive ER status (4.2% versus 1.0%). An ER-negative status was beside CHEK2*1100delC mutation and independently associated with an earlier of age onset of breast cancer. There was a trend that an ER-negative status, beside the presence of a CHEK2*1100delC mutation, was associated with a worse disease-free survival. There might be an association between ER status and a CHEK2*1100delC mutation. More studies with larger number of patients are needed to further investigate the relation between CHEK2*1100delC and ER status.

A comparative study of embryonic development of Japanese quail selected for different patterns of postnatal growth

Patterns of early embryonic development have traditionally been viewed as invariant within vertebrate taxa. It has been argued that the specific differences which are found arise during the later stages of development. These differences may be a result of allometry, heterochrony or changes in relative growth rates. To test whether early embryonic development is indeed invariant, or whether selection of adult characteristics can alter embryonic growth, we compared embryonic development in birds selected for different patterns of postnatal growth. Using quail lines selected for high and low body mass, we compared somite formation, and muscle and feather development. We obtained data that showed changes in the rate of myotome formation in the brachial somites which contribute to muscle formation in the limbs and thorax. We think these observations are connected with intraspecific changes in adult morphology, ie., breast muscle size. Our findings suggest that selection for late ontogenetic/adult stages affects early embryonic development.

Analysis of local recurrence after breast conservative treatment for invasive breast cancer: a single institution cohort

In a group of 900 patients treated for carcinoma of the breast, we evaluated patient-, tumour- and treatment-related parameters, predicting the success or failure of conservative treatment for invasive breast cancer. Thirty-one patients developed local recurrences which were detected within 0.1-12.1 years after treatment of the primary tumour (with a median of 6.2 years), providing a risk of 2% at 5 years and 9% at 10 years. The locally recurrent tumours and their original primary tumours of 28 patients could be retrieved from the pathology laboratory archives. These 28 tumours of the recurrence group (RG) were matched with tumours without local recurrence, the non-recurrence group, for age at time of diagnosis, duration of follow-up and T- and N-stage. The tumours were studied for type and grade of invasive tumour including the in situ component and involvement of surgical margins. In addition, the expression of cell-cycle proteins, p53, Ki-67 (MIB-1) and BCL-1, as well as HER-2/ neu oncoprotein, estrogen and progesterone receptor were investigated. We found a mean age at diagnosis for the RG of 50 years, and the mean age at time of diagnosis for the whole group of 900 patients was 56 years (p=0.003). Thirty-nine percent of the RG had a positive surgical margin, which was the case for only 18% in the control group (p=0.09). The presence of the in situ component was also correlated with increased local recurrence (p=0.022). Furthermore, local recurrence was also associated with a significantly increased occurrence of distant metastases (p=0.001). We conclude that breast conservative treatment is safe with a low local recurrence rate.

Tumour characteristics and prognosis of breast cancer patients carrying the germline CHEK2*1100delC variant

BACKGROUND

The germline CHEK2*1100delC variant has been associated with breast cancer in multiple case families where involvement of BRCA1 and BRCA2 has been excluded.

METHODS

We have investigated the tumour characteristics and prognosis of carriers of this germline variant by means of a prospective cohort study in an unselected cohort of 1084 consecutive patients with primary breast cancer. Data were collected for 34 patients with a germline CHEK2*1100delC mutation and for 102 patients without this mutation, stratified by age and date of diagnosis of the first primary breast cancer (within 1 year).

RESULTS

Carriers developed steroid receptor positive tumours (oestrogen receptor (ER): 91%; progesterone receptor (PR): 81%) more frequently than non-carriers (ER: 69%; PR: 53%; p = 0.04). Mutation carriers more frequently had a female first or second degree relative with breast cancer (p = 0.03), or had any first or second degree relative with breast or ovarian cancer (p = 0.04). Patients with the CHEK2 variant had a more unfavourable prognosis regarding the occurrence of contralateral breast cancer (relative risk (RR) = 5.74; 95% confidence interval (CI) 1.67 to 19.65), distant metastasis-free survival (RR = 2.81; 95% CI 1.20 to 6.58), and disease-free survival (RR = 3.86; 95% CI 1.91 to 7.78). As yet, no difference with respect to overall survival has been found at a median follow up of 3.8 years.

CONCLUSION

We conclude that carrying the CHEK2*1100delC mutation is an adverse prognostic indicator for breast cancer. If independently confirmed by others, intensive surveillance, and possibly preventive measures, should be considered for newly diagnosed breast cancer cases carrying the CHEK2*1100delC variant.

Aerococcus urinae: polyphasic characterization of the species

A polyphasic characterization of Aerococcus urinae is presented. In this study the intraspecies relationships between 26 strains of varying geographical origin were examined by phenotypic tests, ribotyping and multilocus enzyme electrophoresis. The results demonstrated two main phenotypic patterns that could be distinguished in tests for hydrolysis of aesculin, and acid production from amygdalin and salicin. Strains were either negative (n=19) or positive (n=6) in these tests. One strain had a deviating pattern. Heterogeneity within the 19 pattern I strains was demonstrated especially by phenotypic tests (acid production from ribose, mannitol, sorbitol, sucrose and D-arabitol) and by multilocus enzyme electrophoresis. However, DNA sequence analysis of the 16S rRNA (n=7) and gyrB genes (n=3) from strains representing the two main patterns showed no variation in sequences among strains. Comparison of A. urinae and representatives of related taxa by 16S rDNA sequence analysis showed that the taxon is related to, but distinct from, other Aerococcus spp.

Intracellular persistence of Escherichia coli in urinary bladders from mecillinam-treated mice

OBJECTIVES

It has been suggested recently that intracellular bacteria surviving antibiotic treatment might serve as a reservoir for recurrent infection. The purpose of this study was to directly examine the location of Escherichia coli bacteria in the mouse bladder after treatment with mecillinam.

METHODS

The bladders were studied by use of colony counts, in situ hybridization and electron microscopy.

RESULTS

The bacterial counts in the bladder remained approximately 10(3-4) cfu/bladder even after mecillinam treatment had finished, and re-growth in the urine was observed. In the bladder epithelium from treated mice, bacteria cells were occasionally seen, presumably representing intracellularly located bacteria.

CONCLUSIONS

This is the first in vivo study indicating that during mecillinam treatment E. coli cells can penetrate the mouse bladder epithelium and persist.

Colorectal cancer screening with flexible sigmoidoscopy—participants' experiences and technical feasibility

AIM

To evaluate tolerability and technical feasibility of colorectal cancer screening with flexible sigmoidoscopy.

METHODS

One thousand men and women aged 59-61 years, randomly selected from the population register of Uppsala, Sweden, were invited by mail. After random allocation, half of them were called up by a nurse (group 1), while the other half were asked to call themselves (group 2) to book a sigmoidoscopy. After the examination, the participants anonymously answered a questionnaire about their subjective experiences. Endoscopists and their assisting nurse filled out structured forms documenting various technical aspects including an estimation of the subjects' discomfort.

RESULTS

Four hundred and sixty-nine subjects participated. Mean intubation depth was 59 cm (range 28-60) and mean duration 5.8 min (range 2-23). On average, participants reported low degrees of discomfort and feeling of exposure, but 19 and 27% rated pain and distension, respectively, on the upper half of a visual analogue scale (VAS). Most subjects found the duration acceptable. Patient discomfort, as appraised by the endoscopists, was lower in men than in women, positively linked to duration of the procedure, but inversely associated with intubation distance. However, the overall differences between strata of participants were small. Among self-reported variables, group 1 and 2 differed significantly only with regard to 'other discomfort'. All but six subjects would accept a repeat examination. Failures, resulting in incomplete examinations, occurred in 14 subjects.

CONCLUSIONS

Flexible sigmoidoscopy is generally well tolerated and technically feasible in screening for colorectal cancer. A more personalised invitation did not have any important effects on the subjective experience.

Possible consequences of applying guidelines to healthy women with a family history of breast cancer

Possible effects of consistently applying published guidelines on healthy women with breast cancer in their family history were analysed. We investigated 1060 unrelated breast cancer patients and calculated the numbers of first-degree relatives that would be referred to a familial cancer clinic if the guidelines were consistently applied. A first-degree relative was considered a candidate for referral if she was female, without breast cancer at the moment of the interview, alive and over the age of 24. The criteria for referral were based on one Dutch and two British guidelines. According to the Dutch guideline, for one affected woman with breast cancer, 0.25 (95% CI 0.22-0.28) healthy first-degree female relatives should be offered a consultation at a familial cancer clinic (FCC). Application of the British guidelines would lead to a similar number of referrals. Of all healthy first-degree female relatives, who should be referred to an FCC, 34-37% had an index case among their family who was already known at a genetic department. If current guidelines are consistently applied, a sharp increase in referrals to FCCs may be expected. These guidelines, however, are arbitrary and only limited data are available on the efficacy of this surveillance for high-risk healthy women.

Compliance and findings in a Swedish population screened for colorectal cancer with sigmoidoscopy

AIM

The aim of this study was to evaluate the patterns of compliance and the frequency of adenomas and neoplasms in a Swedish population.

METHODS

In 1996, 2000 men and women born in 1935 or 1936 were selected at random from the population registers of Uppsala and Malmö/Lund. All subjects were invited by mail to participate. In a randomised study design, subjects were either called up by a nurse to schedule the appointment for sigmoidoscopy or instructed to call themselves. At sigmoidoscopy subjects with a cancer, an adenoma (neoplastic polyp) or more than three hyperplastic polyps were scheduled for a complete colonoscopy.

RESULTS

Thirty-nine percent (770/1988) of all the invited subjects had a sigmoidoscopy. The participation differed between the two centres, 47% at the Uppsala centre and 30% at the Malmö/Lund centre (P<0.01). There was no statistically significant difference between the two different invitation groups. In all, 98 subjects (13%) were planned for colonoscopy. Thirty-one (35%) of the subjects having a colonoscopy were women and 57 (65%) were men. Fifty-five true adenomas were found in 46 subjects. All together, six subjects had proximal adenomas. Five adenocarcinomas were diagnosed, all within the reach of the sigmoidoscope.

CONCLUSIONS

The compliance was lower and the adenomas were fewer than expected. To increase compliance it is necessary with rigorously controlled invitation routines.

The influence of pre-operative radiotherapy on the expression of p53 and adhesion molecules: correlation with treatment results in patients with squamous cell carcinoma or adenocarcinoma

E-cadherin and the catenins are responsible for inter-cellular adhesion in epithelial tissues. E-cadherin and/or catenin expression is often altered in malignancies, leading to increased invasiveness and metastatic activity of tumour cells. Intact adhesion molecules reduce the risk on distant metastases. This is confirmed by studies mostly performed on surgical series, correlating e-cadherin expression in tumours with prognosis and treatment outcome. It has become more apparent that anti-cancer treatment by itself can also affect the expression of adhesion molecules. We therefore suggest that the prognostic value of e-cadherin expression may depend on the treatment modality and the sequence of therapies administered for malignant tumours. We used paraffin embedded specimens from patients with rectal tumours and patients with laryngeal tumours treated by short course radiotherapy before definitive surgery. Expression of p53, e-cadherin, and beta-catenin was determined in pre-radiotherapy biopsies and in the surgical specimens. Material was available from 37 patients. We found no correlation between the expression of p53, e-cadherin or beta-catenin and pre-treatment parameters. Mutated p53 in pre-radiation biopsy correlated with increased occurrence of distant metastases and there was an unexpected trend for abnormal e-cadherin expression to correlate with reduced metastases. The prognostic value of p53 no longer existed after examination of the surgical specimens (post-radiotherapy). There was a trend for e-cadherin to reverse from abnormal to normal expression in laryngeal squamous cell carcinomas after radiotherapy, in 5/7 cases it was accompanied with p53 conversion from positive to negative expression. Based on this study it is suggested that the predictive value of the e-cadherin expression for the occurrence of distant metastases in tumours treated by radiotherapy before surgery may be different from that found in tumours treated by surgery only. This may be related to the influence of radiotherapy on e-cadherin expression, especially in squamous cell carcinomas. Alteration in p53 expression was of predictive value only in pre-treatment biopsies and the beta-catenin status did not correlate with treatment outcome in this series.

Efficacy of desmopressin combined with alarm therapy for monosymptomatic nocturnal enuresis

PURPOSE

We evaluated the combination of alarm and desmopressin versus alarm monotherapy for the treatment of nocturnal enuresis.

MATERIALS AND METHODS

A double-blind, placebo controlled study of alarm therapy combined with desmopressin for children with nocturnal enuresis is described. Of 93 patients 47 were randomized to receive alarm therapy and 40 microg. intranasal desmopressin for 3 weeks followed by 20 microg. desmopressin for 3 weeks (group 1) and 46 received alarm therapy and placebo (group 2). After 6 weeks on alarm therapy and medication or placebo, both groups received an additional 3 weeks of alarm monotherapy. A specialized nurse practitioner advised patients and families of the treatment to be given at home and in the outpatient department. Bed-wetting frequency was evaluated before during and 2 weeks and 6 months after treatment.

RESULTS

A significantly greater reduction in the number of wet nights was observed after the first 3 weeks of treatment in group 1. However, after long-term followup no significant differences in bed-wetting frequency were noted.

CONCLUSIONS

There is a temporary, positive effect on enuresis using desmopressin combined with alarm therapy. However, both treatment modalities have a low long-term success rate of 36% to 37%.

Error-related brain potentials are differentially related to awareness of response errors: evidence from an antisaccade task

The error negativity (Ne/ERN) and error positivity (Pe) are two components of the event-related brain potential (ERP) that are associated with action monitoring and error detection. To investigate the relation between error processing and conscious self-monitoring of behavior, the present experiment examined whether an Ne and Pe are observed after response errors of which participants are unaware. Ne and Pe measures, behavioral accuracy, and trial-to-trial subjective accuracy judgments were obtained from participants performing an antisaccade task, which elicits many unperceived, incorrect reflex-like saccades. Consistent with previous research, subjectively unperceived saccade errors were almost always immediately corrected, and were associated with faster correction times and smaller saccade sizes than perceived errors. Importantly, irrespective of whether the participant was aware of the error or not, erroneous saccades were followed by a sizable Ne. In contrast, the Pe was much more pronounced for perceived than for unperceived errors. Unperceived errors were characterized by the absence of posterror slowing. These and other results are consistent with the view that the Ne and Pe reflect the activity of two separate error monitoring processes, of which only the later process, reflected by the Pe, is associated with conscious error recognition and remedial action.

Modulating the distribution of fluxes among respiration and fermentation by overexpression of HAP4 in Saccharomyces cerevisiae

The tendency of Saccharomyces cerevisiae to favor alcoholic fermentation over respiration is a complication in aerobic, biomass-directed applications of this yeast. Overproduction of Hap4p, a positive transcriptional regulator of genes involved in respiratory metabolism, has been reported to positively affect the balance between respiration and fermentation in aerobic glucose-grown batch cultures. In this study, the effects of HAP4 overexpression have been quantified in the prototrophic S. cerevisiae strain CEN.PK 113-7D under a variety of growth conditions. In aerobic glucose-limited chemostat cultures, overexpression of HAP4 increased the specific growth rate at which aerobic fermentation set in by about 10% relative to the isogenic wild-type. Upon relief of glucose-limited conditions, the HAP4-overexpressing strain produced slightly less ethanol than the wild-type strain. The effect of Hap4p overproduction was most drastic in aerobic, glucose-grown chemostat cultures in which ammonium was limiting. In such cultures, the biomass yield on glucose was double that of the wild-type.

Carbon source-dependent transcriptional regulation of the QCR8 gene in Kluyveromyces lactis. Identification fo cis-acting regions and trans-acting factors in the KlQCR8 upstream region

The QCR8 gene of the yeast K1uyveromyces lactis is transcriptionally regulated by the carbon source in the growth medium. Deletion analysis of the KlQCR8 promoter shows that an element located between -144 bp and -113 bp specifically controls induction of QCR8 gene expression on non-fermentable carbon sources. Specific and differential protein-binding to the activating sequence was observed with extracts from glucose- and ethanol/glycerol-grown cells. Induction of the reporter gene and protein-binding was dependent on the presence of a functional KlCAT8 gene, suggesting that, in K. lactis, K1Cat8p acts in the transcriptional regulation of respiratory function. The activating element contains no other known regulatory sites but two elements required for RNA holoenzyme functioning, raising the intriguing possibility of carbon source-dependent regulation by a subunit of the RNA polymerase holoenzyme in K. lactis.

Reduced intracellular survival of Helicobacter pylori vacA mutants in comparison with their wild-types indicates the role of VacA in pathogenesis

The vacuolating cytotoxin VacA of Helicobacter pylori plays an important but yet unknown role in pathogenesis. We studied the impact of the vacuolating cytotoxin on H. pylori invasion of and survival within AGS cells (human gastric cell line derived from an antral adenocarcinoma). Isogenic vacA and cagA mutants were constructed in a wild-type clinical isolate H. pylori, AF4. An H. pylori VacA-deficient mutant, AF4(vacA::kan), was cultured in significantly lower numbers from AGS cells after 24 h incubation with gentamicin added to the culture medium than were the type I wild-type strain AF4 (P<0.03) and an isogenic cagA mutant (P<0.01). Complementation of the AF4 vacA mutant with broth culture supernatant from wild-type AF4 improved the intracellular survival of the vacA mutant. We conclude that H. pylori's vacuolating cytotoxin improves the intracellular survival of H. pylori within AGS cells, suggesting the role of the vacuolating cytotoxin in H. pylori pathogenesis.

Different patterns of Helicobacter pylori adherence to gastric mucosa cells in children and adults. An ultrastructural study

BACKGROUND

Infection with Helicobacter pylori in childhood may be the initiation of a lifelong coexistence between microorganisms and epithelial cells resulting in chronic inflammation. The adhesion pattern of H. pylori found in antral biopsies from a group of H. pylori-infected children with recurrent abdominal pain was compared with a group of H. pylori-infected adults suffering from dyspepsia, in an attempt to reveal differences in the type of adhesion.

METHODS

The histology of antrum biopsies and the ultrastructure of adherent H. pylori in biopsies from 26 children (median age, 10.1 years) were compared with organisms in biopsies from 19 adults (median age, 54.4 years).

RESULTS

More than 1000 adherent H. pylori were studied and divided into four types of adhesion: 1) contact to microvilli; 2) connection to the plasma membrane via filamentous material; 3) adhesive pedestal formation; and 4) abutting or making a depression in the plasma membrane. Contact to microvilli was significantly higher (69% versus 39%; P = 0.002) in children compared with adults and comprised two-thirds of all adherent organisms in children. The more intimate adhesion types as abutting or adhesive pedestals dominated in adults.

CONCLUSIONS

These results indicate a change in contact types between H. pylori and gastric epithelial cells in adults compared with children and this may be a natural development in the lifelong infection of humans.

P53 and radiotherapy for oesophageal carcinoma: A comparison between 4 different antibodies

Wild-type p53 protein plays an important role in the cellular response to ionising radiation and other DNA damaging agents and is mutated in many human tumours. Immunohistochemistry is a rapid method to detect elevated protein levels. The p53 status in a group of patients treated by radiotherapy exclusively for oesophagus carcinoma was examined and correlated with pre-treatment parameters and treatment outcome with regard to overall survival, local recurrence-free survival and distant metastases-free survival. Four different antibodies were used to evaluate their predictive power to detect p53 expression. Immunostaining for p53 protein with 4 different antibodies was performed on paraffin-embedded specimens from 69 patients with adenocarcinoma and squamous cell carcinoma of the oesophagus. All patients were treated with radiotherapy exclusively, consisting of external irradiation combined with intraluminal brachytherapy. Detection of p53 using the antibody (DO7) was significantly correlated with overall survival and distant metastases-free survival. For local recurrence-free survival no statistical significance was reached. The use of the other 3 antibodies all showed the same trend with regard to distant metastases, however statistical significance was not reached. The use of multiple antibodies did not increase the predictive value of DO7. Both for survival and metastases-free survival the use of DO7 alone was sufficient as a significant prognostic factor. We conclude that in this series, only the use of DO7 was correlated with prognosis in oesophagus carcinoma treated by radiotherapy only and that addition of 3 antibodies did not improve the predictive power.