Oncology distress screening within predominately Black Veterans: Outcomes on supportive care utilization, hospitalizations, and mortality

BACKGROUND

We evaluated whether patients' initial screening symptoms were related to subsequent utilization of supportive care services and hospitalizations, and whether patient-level demographics, symptoms, hospitalizations, and supportive care service utilization were associated with mortality in primarily low-income, older, Black Veterans with cancer.

METHODS

This quality improvement project created collaborative clinics to conduct cancer distress screenings and refer to supportive care services at an urban, VA medical center. All patients completed a distress screen with follow-up screening every 3 months. Supportive care utilization, hospitalization rates, and mortality were abstracted through medical records. Poisson regression models and cox proportional hazard models were utilized.

RESULTS

Five hundred and eighty five screened patients were older (m = 72), mostly Black 70% (n = 412), and had advanced cancer 54%. Fifty-eight percent (n = 340) were screened only once with 81% (n = 470) receiving ≥1 supportive care service and 51.5% (n = 297) being hospitalized ≥1 time 18 months following initial screen. Symptom severity was significantly related to number of hospitalizations. Low mood was significantly related to higher supportive services (p < 0.001), but not hospitalizations (p ≥ 0.52). Pain, fatigue, physical function, nutrition, and physical symptoms were significantly associated with more supportive services and hospitalizations (p < 0.01). Twenty percent (n = 168) died; Veterans who were Black, had lower stage cancers, better physical health, and utilized less supportive care services had lower odds of mortality (p ≤ 0.01).

CONCLUSION

Individuals with elevated distress needs and those reporting lower physical function utilized more supportive care services and had higher hospitalization rates. Lower physical function, greater supportive care use, higher stage cancer, and being non-Black were associated with higher odds of death.

Comprehensive and Equitable Care for Vulnerable Veterans With Integrated Palliative, Psychology, and Oncology Care

Objective

Veterans who live with cancer need comprehensive care. The National Comprehensive Cancer Network and the American College of Surgeons Commission on Cancer guidelines recommend evaluating distress and providing appropriate follow-up to all patients with cancer.

Methods

We created patient-centered, collaborative clinics to screen for and address cancer-related distress. Medical oncologists received education about available supportive services and instructions on how to make referrals. Participants completed the Coleman Supportive Oncology Collaborative screening questions.

Results

Patients in this outpatient US Department of Veterans Affairs medical oncology clinic were primarily older, African American men. Most veterans screened positive for ≥ 1 type of cancer-related distress. Patients screened for high levels of distress received in-person clinical follow-up for further evaluation and to make immediate referrals to supportive care services.

Conclusions

We evaluated patients' needs, made referrals as needed, and helped bring care directly into the oncology clinic. Using a screening tool for cancer-related distress and managing distress with integrated psychosocial providers could improve care coordination and enhance patient-centered supportive oncology care, especially for high-risk patients. A full-time social worker was integrated into the medical oncology clinics based on our program's success.

Preoperative diagnosis of intraductal papillary neoplasm of the bile duct with endoscopic ultrasound

Intraductal papillary mucinous neoplasm of the bile duct is a rare tumour only recently classified as a distinct pathological entity. These neoplasms, rarely encountered in clinical practice in the UK, are now considered to be important precursors for the development of cholangiocarcinoma. We present a histologically confirmed case of intraductal papillary neoplasm of the bile duct in a male patient and discuss the main radiographic manifestations of this rare condition across multiple imaging modalities, with an emphasis on the imaging features of endoscopic ultrasonography and its role in establishing the diagnosis.

Meeting the guidelines: Implementing a distress screening intervention for veterans with cancer

BACKGROUND

Guidelines recommend systematic evaluation of distress screening and referral for cancer patients. Implementation remains a notable gap for cancer centers serving disadvantaged communities. We present the implementation of a distress screening program within a Veterans Affairs hospital oncology clinic, serving a majority African American (AA) male population of low socioeconomic status (SES).

METHODS

The Coleman Foundation funded this program supporting a palliative care physician and psychologist to implement screening in a phased approach as follows: (1) Organizing key stakeholders, (2) educating clinical staff, (3) delivering distress screening, (4) generating documentation, and (5) implementing clinical action and referral pathways. We utilized validated measures in the "Patient Screening Questions for Supportive Care" screening tool.

RESULTS

This program was unsuccessful in screening all veterans with cancer; however, we were able to implement 3 years of longitudinal screening. In distress screens from the initial program period (n = 253), patients were primarily males (95.6%) of older age (m = 70, standard deviation = 9.45), AA (76.4%), with various cancers of advanced disease (69%). Males reported moderate psychosocial distress and elevated financial needs. For males with elevated psychosocial distress (n = 63, PHQ-4 ≥3), 36% were previously connected with psychosocial services. Following screening, engagement increased as the majority (77%) established psychosocial care.

CONCLUSIONS

This screening program had mixed success. Centralized program staff and available supportive care referrals were critical for program implementation. Screening may have increased engagement in social work/mental health services for males of low SES. Screening programs should be tailored to the needs of underserved communities with accessible housing/food subsidies.

0475 Reducing Dysfunctional Sleep-Related Cognitions Improves Nighttime Sleep and Daytime Consequences in Older Adults with Insomnia

Introduction

The long-term impact of addressing sleep-related cognitions, which is an important component of cognitive behavioral therapy for insomnia (CBTI), has not been established, particularly in older adults. We examined whether specific changes in sleep-related cognitions predicted long-term changes in sleep and other outcomes following CBTI in older adults.

Methods

We analyzed data from a randomized controlled trial testing CBTI in older veterans with insomnia (N=159, mean age 72 years). Sleep-related cognitions were assessed with the Dysfunctional Beliefs and Attitudes about Sleep scale (DBAS, subscales: Consequences, Worry/Helplessness, Sleep Expectations, Medication). Outcome measures included the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), sleep diary variables, Flinders Fatigue Scale (FFS), and Short Form-12 health-related quality of life (QOL). Analyses completed slope of change in DBAS subscales (baseline to post-treatment: T1) between CBTI and control with respect to slope of change in sleep and other outcomes from post-treatment to 6-months (T2).

Results

Compared to controls, the CBTI group had significantly stronger associations between improvement (T1) in DBAS-Consequences and subsequent (T2) improvement in PSQI (difference in slopes [DIS]=0.9, 95%CI=[.29, 1.43], p=0.004), ISI (DIS=1.1, 95%CI=[.18, 2.0], p=0.019), ESS (DIS=0.6, 95%CI=[.10, 1.18], p=0.020), and FFS (DIS=1.9, 95%CI=[.76, 3.09], p=0.001). The CBTI group also had significantly stronger associations between improvement in DBAS-Worry/Helplessness and subsequent improvements in PSQI, ISI, and FFS; improvement in DBAS-Medication and PSQI and ISI; and improvement in DBAS-Sleep Expectations and improved FFS. Slopes were not different between groups for sleep diary variables or QOL.

Conclusion

Significant improvements in sleep-related cognitions with CBTI across DBAS subscales in older adults predicted improvement in several outcomes of nighttime sleep and daytime consequences. These findings suggest the importance of addressing dysfunctional sleep-related cognitions for sustained improvement with CBTI in older adults

Support

The study was supported by VA Health Services, Research and Development (Alessi, IIR 08-295), National Institute on Aging (K23AG055668, Song), National Heart, Lung, and Blood Institute (K24HL 143055, Martin) of the National Institutes of Health and VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center.

0581 Characteristics of US Women Veterans with Sleep Apnea: Results of a National Survey of VA Healthcare Users

Introduction

Sleep apnea (SA) is the most commonly diagnosed sleep disorder among patients in the US Veterans Administration (VA). The dramatic rise in women receiving VA care makes it essential to understand the presentation and treatment of SA in women Veterans. We performed a nationwide survey about sleep among US women Veterans and compared characteristics of respondents with and without a self-reported history of SA diagnosis and treatment.

Methods

A survey was mailed to a random sample of 4000 women VA healthcare users. The survey included demographics, Insomnia Severity Index (ISI), Patient Health Questionnaire-4 (PHQ-4 depression/anxiety), Primary Care-Post-Traumatic Stress Disorder (PC-PTSD), RLS symptom presence, SA symptoms (snore loudly, observed breathing pauses), diagnosis of SA, and use of PAP therapy (APAP, BPAP, CPAP). We compared women with and without SA, and (among those with SA) women who did and did not use PAP, using Chi-square and t-tests.

Results

1,498 completed surveys were returned (mean age 51.6 years, range 18-105 years, 62% non-Hispanic White). 200 respondents (13.4%) reported diagnosed SA. Women with SA were older (p&lt;.001), likely to be employed (p=.013), more likely to snore loudly (p&lt;.001) and to have breathing pauses while asleep (p&lt;.001). They also had higher ISI (p&lt;.001), were more like to report RLS (p&lt;.001) nightmares (p=.027), and had higher PHQ-4 (p&lt;.001) and PC-PTSD (p&lt;.001) scores. Among women with SA, 130 (65%) used PAP. Loud snorers (p&lt;.001) and those with observed breathing pauses were more likely to use PAP (p&lt;.001).

Conclusion

One in 7 women who receive VA care report diagnosed SA. Women with SA had more mental health symptoms and comorbid sleep problems. Most reported using PAP therapy, although the amount of use is unknown. Those with SA symptoms were more likely to use PAP. Future work is needed to understand barriers to diagnosis and treatment of SA among women Veterans.

Support

Funding: VA Quality Enhancement Research Initiative RRP12-189 (Martin); NIH/NHLBI K24 HL143055 (Martin).

0537 Cognitive Functioning Before and After Insomnia Treatment in Women Veterans

Introduction

Women are at higher risk for cognitive impairment and dementia compared to men. Identifying potentially treatable risk factors such as insomnia is an important clinical goal. In a trial comparing two behavioral treatments for insomnia in women veterans, we hypothesized that 1) worse baseline insomnia severity would be associated with poorer cognitive function, and 2) improvement in insomnia severity with treatment would be associated with improvement in cognitive functioning.

Methods

347 women veterans with insomnia disorder [mean age 48.3 (12.9) years] completed baseline testing. Of these, 149 women were randomized to receive cognitive behavioral therapy for insomnia (CBT-I) or acceptance and commitment (ACT) based insomnia treatment (both treatments included sleep restriction, stimulus control, and sleep hygiene). Insomnia Severity Index (ISI) was assessed at baseline, post-treatment, and 3-month follow-up. Cognitive functioning was measured with Symbol Digit Coding (SDC) and Trail Making Test A and B (TMTA and TMTB). Pearson correlations were used to examine associations between insomnia severity and cognitive functioning at baseline and changes in both insomnia severity and cognitive functioning from before to after treatment.

Results

At baseline (N=347), mean ISI was 14.1 (5.3). Worse baseline ISI was associated with worse baseline cognitive functioning on TMTA (r=-.15, p&lt;.01) and SDC (r=-.12, p&lt;.05). In the randomized sample (N=149), ISI scores improved at post-treatment (mean ISI change= -9.0; p&lt;.001) and 3-month follow-up (mean change= -8.0; p&lt;.001) relative to baseline. Improvement in ISI from baseline to post-treatment was significantly associated with improvement in SDC from baseline to post-treatment (r=-.18, p&lt;.05), but not improvement in TMTA and TMTB. Change in ISI was not significantly related to change in cognitive tasks from baseline to 3-month follow-up.

Conclusion

More severe insomnia is associated with worse cognitive functioning in women veterans. The magnitude of improvement in insomnia symptoms may be associated with improvement in cognition.

Support

NIH/NIA K23AG049955 (PI: Dzierzewski); VA/HSR&D IIR-HX002300 (PI: Martin), NIH/NHLBI K24HL143055 (PI: Martin).

0644 An Educational and Behavioral Intervention Failed to Improve PAP Use Among Veterans With Spinal Cord Injuries and Diseases: Results of a Randomized Controlled Trial

Introduction

Sleep disordered breathing (SDB) is common among individuals with spinal cord injuries or diseases (SCI/D), many of whom are military Veterans, and physical limitations make use of positive airway pressure (PAP) therapy challenging. This study sought to test the effects of an educational and behavioral intervention to improve PAP adherence among Veterans with SCI/D over the first 3 months of use.

Methods

63 Veterans (mean age=60.7(10.2) years; 92% male) with SCI/D (33 SCI, 30 SCD; 25 cervical involvement; 38 thoracic and below) and SDB (23 with AHI 5-15; 40 with AHI&#8805;15) who received PAP treatment (CPAP or BPAP) were randomly assigned to receive a comprehensive 3-month intervention (INT) or an equal attention control (EAC). INT and EAC both included 1 face-to-face session (week 1) and 5 additional telephone sessions (weeks 2, 3, 4, 8 and 12). Main outcome measures were PAP use over the first 3 months: nights of use, nights of use &#8805;4 hours, and mean hours of use per night. Repeated measures ANCOVA models were used to test the differences between INT and EAC over the first 3 months of treatment.

Results

Number of nights with &#8805;4 hours of use in months 1-3 was 9, 7, and 6 nights in the INT and 8, 5 and 4 nights in the EAC (p’s&#8805;.37), respectively. There were no significant differences between INT and EAC for number of nights with any use (p’s&#8805;.24), or mean hours of use per night (p’s&#8805;.30). All 3 PAP use variables declined over time in both groups.

Conclusion

Sustained use of PAP therapy was difficult to achieve among those with SCI/D, and a 6-session behavioral intervention did not lead to significant improvements in use. Even when relatively high levels of initial use are achieved, this is difficult to sustain over time. Future studies should explore whether SCI/D patients experience significant symptom relief with PAP, and if so, whether home-based interventions or more intensive face-to-face PAP adherence programs will be effective.

Support

VA Rehabilitation Research and Development Service, Merit Review (1RX002116; PI: Badr); NIH/NHLBI K24 HL143055 (Martin).

0467 Benefits of CBT-I for Women Veterans with and without PTSD

Introduction

A quarter of women Veterans (WVs) receiving VA healthcare meet diagnostic criteria for both insomnia disorder and posttraumatic stress disorder (PTSD). Cognitive Behavioral Therapy for Insomnia (CBT-I) is effective at improving sleep among individuals with comorbid psychiatric conditions; however, no studies have examined the impact of CBT-I in women with insomnia plus PTSD. The current analyses examined changes in sleep symptoms, quality of life (QoL), and mental health symptoms from pre- to post-CBT-I in WVs with and without PTSD.

Methods

This was a secondary analysis of 75 WVs with insomnia (32 with probable PTSD), who received CBT-I within a behavioral sleep intervention study (NCT02076165). Measures completed at baseline, posttreatment, and 3-month follow-up included: insomnia severity (Insomnia Severity Index, ISI), sleep quality (Pittsburgh Sleep Quality Index, PSQI), PTSD symptoms (PTSD Checklist-5, PCL-5; probable PTSD=total score ≥33), depressive symptoms (Patient Health Qestionnaire-9, PHQ-9), and mental and physical quality of life (Short Form Health Survey, SF-12). One sample T-tests examined changes in ISI, PSQI, PHQ-9, PCL-5, and SF-12 from baseline to posttreatment and baseline to follow-up. Two samples T-tests compared change scores in ISI, PSQI, PHQ-9, and SF-12 between participants with and without PTSD.

Results

There were significant improvements in ISI (p≤.001), PSQI (p≤.001), PHQ-9 (p≤.001), PCL-5 (p=.001), and SF-12 mental (p≤.001) and physical (p=.03) from baseline to posttreatment and 3-month follow-up (p≤.001-.01). There were no significant change score differences between WVs with and without PTSD from baseline to posttreatment (p=.06-.98) or 3-month follow-up (p=.09-.93).

Conclusion

CBT-I appears to be an effective treatment to improve insomnia symptoms among WVs with and without PTSD, and may reduce psychiatric symptoms as well. These findings suggest WVs with comorbid insomnia and PTSD benefit from CBT-I. The appropriate sequencing of CBT-I and PTSD treatments remains potentially important, but unstudied.

Support

VA/HSR&D IIR-HX002300; NIH/NHLBI K24HL14305; VA Office of Academic Affiliations through the Advanced Fellowship Programs in HSR&D and Women’s Health

0131 Decreased Habitual Sleep Efficiency is Associated with Increased Insulin Resistance in Healthy Adult Men

Introduction

Partial sleep deprivation is associated with increased insulin resistance (IR), a metabolic disease risk marker. Little is known about habitual sleep patterns and IR in the absence of acute sleep restriction. We anticipated greater change in habitual sleep over one month would be associated with increased IR.

Methods

24 males (age=33.6±6.4 years; BMI=25.7±2.5kg/m2) completed baseline (T1) and follow-up (T2; ≥4 weeks post-T1) study procedures: actigraphy (one week) followed by polysomnography (PSG; one 10h sleep opportunity) and a next morning oral glucose tolerance test (OGTT; homeostatic model assessment insulin resistance [HOMA-IR], β-cell function [HOMA-β], and Matsuda Index). Weekly average actigraphy total sleep time (aTST; 291-511min) and sleep efficiency (aSE; 72–93%) were computed at T1 and T2, as well as across the 1, 2, and 3 days prior to PSG/OGTT. Pearson and Spearman correlations assessed the change (T1-T2) in actigraphy (aSEΔ, aTSTΔ, PSGΔ) or PSG sleep (PSG-TSTΔ, PSG-SEΔ, sleep stages) versus change in metabolic risk (HOMA-IRΔ, HOMA-βΔ, MatsudaΔ).

Results

There were significant correlations between HOMA-IRΔ and aSEΔ [r(22)=-0.42, p=0.01; rs=-0.45, p=0.03], PSG TSTΔ [r(22)=0.50, p=0.012; rs=0.41, p=.045], and PSG-SEΔ [r(22)=0.49, p=0.015; rs=0.43, p=.037]. No significant associations emerged between change in metabolic risk versus aTSTΔ one week prior to PSG/OGTT, aSEΔ or aTSTΔ across 1–3 days prior to PSG/OGTT, or PSG sleep stages.

Conclusion

Within-subject T1-T2 decrease in habitual sleep quality, but not TST, was associated with increased IR. T1-T2 PSG TST and SE were associated with following day IR. At home sleep 1–3 days beforehand were not correlated with IR. Although preceding night sleep quality and TST are associated with IR, habitual sleep quality, rather than TST, may be a more important determinant of metabolic risk in community dwelling middle-aged men.

Support

This work was supported by NIH/NHLBI R01HL124211, NIH/NHLBI K24HL138632, NIH National Center for Advancing Translational Sciences (NCATS) UCLA CTSI Grant UL1TR001881 (PI: Liu); and NIH/NHLBI K24HL143055 (PI: Martin). Dr. Kelly is supported by the VA Office of Academic Affiliations through the Advanced Fellowship Programs in Geriatrics.

0597 Precision of Sleep-Disordered Breathing Event Classification Using Simulated Home Sleep Apnea Testing in Patients with Spinal Cord Injury, or Disease

Introduction

Sleep-disordered breathing (SDB) is highly prevalent among patients with spinal cord injury or disease (SCI/D). In-laboratory polysomnography (PSG) is difficult for these patients due to functional limitations and the physical construction of most sleep laboratories. Our objective was to evaluate the concordance between simulated HSAT and PSG in identifying SDB severity and subtypes of respiratory events in this patient population.

Methods

Within a larger study, 33 Veterans with SCI/D completed one night of in-laboratory PSG. Limited-channel HSAT was simulated by extracting 5 channels from PSG signals to include nasal pressure, thermistor, thoracic and abdominal belts, and oxygen saturation.

Results

Mean age of patients was 59.8 ± 10.9 years; 87.9% were male, and the average BMI was 28.1 ± 6.3. The mean Apnea-Hypopnea Index (AHI) from PSG was 35.5 ± 22.7. The mean Respiratory Event Index (REI) based on simulated HSAT was 22.5 ± 18.6. Thirty-one patients (93.9%) had SDB defined as AHI ≥5/hour. Simulated limited-channel HSAT accurately identified 32 out of 33 patients (96.96%). When SDB was further classified into mild (AHI 5-15 events/hr), moderate (AHI 15-30 events/hr), and severe (AHI&gt;30/hr), simulated HSAT consistently underestimated the severity of underlying SDB. Spearman correlation between estimating AHI (PSG-HSAT) and subtypes of respiratory events was primarily accounted for by the difference in the number of hypopneas (r=0.72, -0.021 and -0.001 for hypopneas, obstructive and central apneas, respectively).

Conclusion

Our findings support the diagnostic utility of HSAT in SCI/D patients with SDB; however, HSAT underestimation of SDB may lead to difficulties in optimizing therapy. The misclassification of SDB severity is mainly driven by the number of hypopneas. Classification of hypopneas as obstrcutive or central may shed further light on the nature of this difference. Further research on the usability of HSAT devices in this patient population is needed.

Support

VA Rehabilitation Research and Development Service (RX002116; PI Badr and RX002885; PI Sankari) and NIH/NHLBI (K24HL143055; PI: Martin)

The Common Sense of Counseling Psychology: Introducing the Common-Sense Model of Self-Regulation

The goal of therapy is typically to improve clients' self-management of their problems, not only during the course of therapy but also after therapy ends. Although it seems obvious that therapists are interested in improving client's self-management, the psychotherapy literature has little to say on the topic. This article introduces Leventhal's Common-Sense Model of Self-Regulation, a theoretical model of the self-management of health, and applies the model to the therapeutic process. The Common-Sense Model proposes that people develop illness representations of health threats and these illness representations guide self-management. The model has primarily been used to understand how people self-manage physical health problems, we propose it may also be useful to understand self-management of mental health problems. The Common-Sense Model's strengths-based perspective is a natural fit for the work of counseling psychologists. In particular, the model has important practical implications for addressing how clients understand mental health problems over the course of treatment and self-manage these problems during and after treatment.

A red tide of Alexandrium fundyense in the Gulf of Maine

In early July 2009, an unusually high concentration of the toxic dinoflagellate Alexandrium fundyense occurred in the western Gulf of Maine, causing surface waters to appear reddish brown to the human eye. The discolored water appeared to be the southern terminus of a large-scale event that caused shellfish toxicity along the entire coast of Maine to the Canadian border. Rapid-response shipboard sampling efforts together with satellite data suggest the water discoloration in the western Gulf of Maine was a highly ephemeral feature of less than two weeks in duration. Flow cytometric analysis of surface samples from the red water indicated the population was undergoing sexual reproduction. Cyst fluxes downstream of the discolored water were the highest ever measured in the Gulf of Maine, and a large deposit of new cysts was observed that fall. Although the mechanisms causing this event remain unknown, its timing coincided with an anomalous period of downwelling-favorable winds that could have played a role in aggregating upward-swimming cells. Regardless of the underlying causes, this event highlights the importance of short-term episodic phenomena on regional population dynamics of A. fundyense.

Abstract P5-07-05: Insulin-like growth factor binding protein-3 is a key component of the breast cancer cell response to DNA-damaging therapy

Introduction. Breast cancer cells frequently develop resistance to DNA-damaging therapies, such as radiation and the cytotoxic drugs doxorubicin and etoposide, and activation of the epidermal growth factor receptor (EGFR) may play an important role in this process. However many estrogen receptor (ER)-negative breast tumors respond poorly to DNA-damaging drugs even when combined with an EGFR inhibitor. EGFR can modulate the repair of DNA double strand breaks (DSB) by non-homologous end-joining (NHEJ), by forming protein complexes that include the catalytic subunit of DNA-dependent protein kinase (DNA-PKcs). In previous studies we have shown that the growth-regulatory protein, insulin-like growth factor binding protein-3 (IGFBP-3), can translocate to the nucleus, is a substrate for DNA-PKcs, and can transactivate EGFR. The aim of this study was to delineate the role of IGFBP-3 in the response of breast cancer cells to DSB-inducing chemotherapeutic agents.

Results. In the triple-negative breast cancer cell lines MDA-MB-468 and Hs578T, which express IGFBP-3 highly, nuclear localization of EGFR and IGFBP-3, and of their complex as measured by coimmunoprecipitation (coIP), was enhanced by exposure to etoposide or doxorubicin, peaking 2 h after etoposide treatment. This effect was blocked by the EGFR kinase inhibitor gefitinib. Concomitantly, the co-location of EGFR-IGFBP-3 complexes with lipid rafts, visualized by proximity ligation assay (PLA) and confocal microscopy, decreased in response to drug treatment, consistent with the loss of this complex from the plasma membrane. Similar to the nuclear DNA-PKcs-EGFR complex, the nuclear DNA-PKcs-IGFBP-3 complex (seen by both coIP and PLA) was greatest 4 h after treatment. DNA-PKcs activation at serine-2056, required for the repair of DNA DSB and stimulated by etoposide treatment, was decreased by IGFBP-3 downregulation using two separate siRNAs, and this treatment also attenuated the enhanced DNA-PKcs-EGFR complexes seen in response to etoposide. Collectively these data suggest that IGFBP-3 has an obligatory role in the DNA repair response to DNA-damaging therapy through its interactions with EGFR and DNA-PKcs.

Conclusion. IGFBP-3 co-translocation to the nucleus of breast cancer cells and its complex formation with DNA-PKcs and EGFR in response to DNA damage demonstrate its previously unrecognized involvement in the regulation of DNA DSB repair by NHEJ. These novel findings suggests the possibility of a therapeutic approach for sensitizing ER-negative breast cancers to chemo- or radiotherapy by targeting the DNA repair function of IGFBP-3. Supported by the Australian Research Council.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-07-05.

Physiology and Endocrinology Symposium: Nutritional aspects of developing replacement heifers

Studies in numerous species provide evidence that diet during development can mediate physiological changes necessary for puberty. In cattle, several studies have reported inverse correlations between postweaning growth rate and age at puberty and heifer pregnancy rates. Thus, postweaning growth rate was determined to be an important factor affecting age of puberty, which in turn influences pregnancy rates. This and other research conducted during the late 1960s through the early 1980s indicated puberty occurs at a genetically predetermined size, and only when heifers reach their target BW can increased pregnancy rates be obtained. Guidelines were established indicating replacement heifers should achieve 60 to 65% of their expected mature BW by breeding. Traditional approaches for postweaning development of replacement heifers used during the last several decades have primarily focused on feeding heifers to achieve or exceed an appropriate target BW and thereby maximize heifer pregnancy rates. Intensive heifer development systems may maximize pregnancy rates, but not necessarily optimize profit or sustainability. Since inception of target BW guidelines, subsequent research demonstrated that the growth pattern heifers experience before achieving a critical target BW could be varied. Altering rate and timing of BW gain can result in compensatory growth periods, providing an opportunity to decrease feed costs. Recent research has demonstrated that feeding replacement heifers to traditional target BW increased development costs without improving reproduction or subsequent calf production relative to development systems in which heifers were developed to lighter target BW ranging from 50 to 57% of mature BW.

Nogo-A knockdown inhibits hypoxia/reoxygenation-induced activation of mitochondrial-dependent apoptosis in cardiomyocytes

Programmed cell death of cardiomyocytes following myocardial ischemia increases biomechanical stress on the remaining myocardium, leading to myocardial dysfunction that may result in congestive heart failure or sudden death. Nogo-A is well characterized as a potent inhibitor of axonal regeneration and plasticity in the central nervous system, however, the role of Nogo-A in non-nervous tissues is essentially unknown. In this study, Nogo-A expression was shown to be significantly increased in cardiac tissue from patients with dilated cardiomyopathy and from patients who have experienced an ischemic event. Nogo-A expression was clearly associated with cardiomyocytes in culture and was localized predominantly in the endoplasmic reticulum. In agreement with the findings from human tissue, Nogo-A expression was significantly increased in cultured neonatal rat cardiomyocytes subjected to hypoxia/reoxygenation. Knockdown of Nogo-A in cardiomyocytes markedly attenuated hypoxia/reoxygenation-induced apoptosis, as indicated by the significant reduction of DNA fragmentation, phosphatidylserine translocation, and caspase-3 cleavage, by a mechanism involving the preservation of mitochondrial membrane potential, the inhibition of ROS accumulation, and the improvement of intracellular calcium regulation. Together, these data demonstrate that knockdown of Nogo-A may serve as a novel therapeutic strategy to prevent the loss of cardiomyocytes following ischemic/hypoxic injury.

Surgeon opinion on new technologies in orthopaedic surgery

Technological advances such as computer navigation systems and robotics, including support systems for minimally invasive surgery, have the potential to revolutionise how orthopaedic surgery is carried out. However uptake has so far been limited. Increased awareness of user requirements in adoption decision-making will be useful. In this regard, the opinion of the individual surgeon regarding his or her willingness to engage in a novel technology has rarely been garnished. This paper analyses the opinions of orthopaedic consultants from the UK and USA about technological advances in hip and knee arthroplasty, factors contributing to successful short-term and long-term surgical outcome, and patient preferences. The survey, using a web-based questionnaire, was carried out in 2006-2007 and followed up in 2010. The results of this research give a greater insight into why surgical technologies that have the potential to improve patient outcome are not more speedily adopted in the health service.

Dendritic spine alterations in neocortical pyramidal neurons following postnatal neuronal Nogo-A knockdown

The myelin-associated protein Nogo-A is a well-known inhibitor of axonal regeneration and compensatory plasticity, yet functions of neuronal Nogo-A are not as clear. The present study examined the effects of decreased levels of neuronal Nogo-A on dendritic spines of developing neocortical neurons. Decreased Nogo-A levels in these neurons resulted in lowered spine density and an increase in filopodial type protrusions. These results suggest a role for neuronal Nogo-A in maintaining a spine phenotype in neocortical pyramidal cells.

Femtosecond spectroscopy of electron transfer in the reaction center of the photosynthetic bacterium Rhodopseudomonas sphaeroides R-26: Direct electron transfer from the dimeric bacteriochlorophyll primary donor to the bacteriopheophytin acceptor with a time constant of 2.8 +/- 0.2 psec

The primary light-induced charge separation in reaction centers from Rhodopseudomonas sphaeroides R-26 has been investigated after excitation with laser pulses of 150 fsec duration within the longwave absorption band of the primary donor at 850 nm. An excited state of the primary donor, characterized by a broad absorption spectrum extending over the whole spectral range investigated (545-1240 nm), appeared within 100 fsec and gave rise to stimulated emission in the 870- to 1000-nm region with a 2.8-psec lifetime. The photooxidation of the primary donor, as measured at 1240 nm, and the photoreduction of the bacteriopheophytin acceptor, monitored at 545 nm and 675 nm, have been found to proceed simultaneously with a time constant of 2.8 +/- 0.2 psec. Kinetics of absorbance changes at other probe wavelengths gave no indication that an accessory bacteriochlorophyll is involved as a transient electron acceptor.

Femtosecond spectroscopy of excitation energy transfer and initial charge separation in the reaction center of the photosynthetic bacterium Rhodopseudomonas viridis

Reaction centers from the photosynthetic bacterium Rhodopseudomonas viridis have been excited within the near-infrared absorption bands of the dimeric primary donor (P), of the "accessory" bacteriochlorophylls (B), and of the bacteriopheophytins (H) by using laser pulses of 150-fsec duration. The transfer of excitation energy between H, B, and P occurs in slightly less than 100 fsec and leads to the ultrafast formation of an excited state of P. This state is characterized by a broad absorption spectrum and exhibits stimulated emission. It decays in 2.8 +/- 0.2 psec with the simultaneous oxidation of the primary donor and reduction of the bacteriopheophytin acceptor, which have been monitored at 545, 675, 815, 830, and 1310 nm. Although a transient bleaching relaxing in 400 +/- 100 fsec is specifically observed upon excitation and observation in the 830-nm absorption band, we have found no indication that an accessory bacteriochlorophyll is involved as a resolvable intermediary acceptor in the primary electron transfer process.

Effect of dietary crude protein source on hormone and follicle characteristics in beef heifers

Ground, raw soybeans (SB), or dried distillers grain plus solubles (DDGS) were utilized in heifer development diets to determine the effect of dietary fat and protein source on hormone and follicle characteristics and ADG. The experiment was conducted over 2 yr with 100 June-born heifers (199 +/- 2 kg initial BW, n = 50 per yr). The experimental periods were 157 and 207 d in yr 1 and 2, respectively. Heifers were provided a dietary supplement (DM basis) of 1.23 kg of SB and 0.40 kg of corn or 1.65 kg of DDGS between weaning and breeding. Estrus was synchronized with 2 injections of PGF(2alpha) 14 d apart. Dominant follicles were measured and aspirated via transvaginal ultrasonography 60 h after the second PGF(2alpha) injection. Heifers were exposed to bulls beginning 14 d after aspiration for 45 d. Heifer ADG was greater (P = 0.02) for DDGS heifers in yr 1, but was similar (P = 0.47) in yr 2. However, there was no difference (P = 0.35) in final BW in either year. There was no difference (P >or= 0.67) in follicle size, follicle hormone concentrations, or pregnancy rate (88%) between yr 1 and 2. Serum estrogen at 48 or 60 h after PGF(2alpha) injection were similar (P >or= 0.91); however, LH at 60 h in yr 2 tended to be greater (P = 0.07) for DDGS heifers. The percentage of heifers experiencing an LH surge 48 and 60 h after PGF(2alpha) injection was not affected (P >/= 0.40) by treatment. Calf production was not affected (P >or= 0.20) by developmental diet. In summary, DDGS and SB have similar effects on hormone and follicle characteristics at the inclusion rates used in these studies.

Lower predation risk for migratory birds at high latitudes

Quantifying the costs and benefits of migration distance is critical to understanding the evolution of long-distance migration. In migratory birds, life history theory predicts that the potential survival costs of migrating longer distances should be balanced by benefits to lifetime reproductive success, yet quantification of these reproductive benefits in a controlled manner along a large geographical gradient is challenging. We measured a controlled effect of predation risk along a 3350-kilometer south-north gradient in the Arctic and found that nest predation risk declined more than twofold along the latitudinal gradient. These results provide evidence that birds migrating farther north may acquire reproductive benefits in the form of lower nest predation risk.

Mechanisms, chemical structures and drug metabolism

From the studies that have been done by many laboratories over the last 2 decades, it is now clear that the toxicities produced by many drugs are due to their reactive metabolites. It is though that, in many cases, reactive metabolites cause toxicity by binding covalently to tissue proteins. However, until recently it was difficult to identify these protein targets. Due to the development of an immunochemical approach, this problem has been overcome, as is illustrated here by studies that have been conducted on the metabolic basis of the idiosyncratic hepatitis caused by the inhalation anaesthetic halothane. The major problem to solve in the future will be to determine how protein adduct formation leads to toxicity. It is possible that protein adduct formation may alter an important cellular function or may lead to immunopathology, as is thought to occur in the case of halothane hepatitis. If an allergic reaction is suspected, purified protein targets of reactive metabolites can serve as antigens for identifying sensitized individuals. This information can be used to prevent not only an allergic reaction to the drug, but possible cross-reactions to other drugs that are structurally related. Another important application of these studies is the design of safer alternative drugs that will not produce structurally similar toxic reactive metabolites.

Winter grazing system and supplementation during late gestation influence performance of beef cows and steer progeny

A 2 x 2 factorial study evaluated effects of cow wintering system and last trimester CP supplementation on performance of beef cows and steer progeny over a 3-yr period. Pregnant composite cows (Red Angus x Simmental) grazed winter range (WR; n = 4/yr) or corn residue (CR; n = 4/yr) during winter and within grazing treatment received 0.45 kg/d (DM) 28% CP cubes (PS; n = 4/yr) or no supplement (NS; n = 4/yr). Offspring steer calves entered the feedlot 14 d postweaning and were slaughtered 222 d later. Precalving BW was greater (P = 0.02) for PS than NS cows grazing WR, whereas precalving BCS was greater (P < 0.001) for cows grazing CR compared with WR. Calf birth BW was greater (P = 0.02) for CR than WR and tended to be greater (P = 0.11) for PS than NS cows. Prebreeding BW and BCS were greater (P <or= 0.001) for CR than WR cows and PS than NS (P = 0.006) cows. At weaning, CR cows were heavier (P < 0.001) than WR cows but had similar BCS (P = 0.74). Cow weaning BW and BCS were not affected (P > 0.32) by PS. Calf weaning BW was less (P = 0.01) for calves from NS cows grazing WR compared with all other treatments. Pregnancy rate was unaffected by treatment (P > 0.39). Steer ADG, 12th-rib fat, yield grade, and LM area (P > 0.10) were similar among all treatments. However, final BW and HCW (P = 0.02) were greater for steers from PS-WR than NS-WR cows. Compared with steers from NS cows, steers from PS cows had greater marbling scores (P = 0.004) and a greater (P = 0.04) proportion graded USDA Choice or greater. Protein supplementation of dams increased the value of calves at weaning (P = 0.03) and of steers at slaughter regardless of winter grazing treatment (P = 0.005). Calf birth and weaning BW were increased by grazing CR during the winter. Calf weaning BW was increased by PS of the dam if the dam grazed WR. Compared with steers from NS cows, steer progeny from PS cows had a greater quality grade with no (P = 0.26) effect on yield grade. These data support a late gestation dam nutrition effect on calf production via fetal programming.

Crystallization and preliminary diffraction analysis of a DsbA homologue from Wolbachia pipientis

alpha-DsbA1 is one of two DsbA homologues encoded by the Gram-negative alpha-proteobacterium Wolbachia pipientis, an endosymbiont that can behave as a reproductive parasite in insects and as a mutualist in medically important filarial nematodes. The alpha-DsbA1 protein is thought to be important for the folding and secretion of Wolbachia proteins involved in the induction of reproductive distortions. Crystals of native and SeMet alpha-DsbA1 were grown by vapour diffusion and belong to the monoclinic space group C2, with unit-cell parameters a = 71.4, b = 49.5, c = 69.3 A, beta = 107.0 degrees and one molecule in the asymmetric unit (44% solvent content). X-ray data were recorded from native crystals to a resolution of 2.01 A using a copper anode and data from SeMet alpha-DsbA1 crystals were recorded to 2.45 A resolution using a chromium anode.

Effect of prebreeding body weight or progestin exposure before breeding on beef heifer performance through the second breeding season

Two experiments evaluated prebreeding target BW or progestin exposure for heifers developed lighter than traditional recommendations. Experiment 1 evaluated the effects of the system on heifer performance through subsequent calving and rebreeding over 3 yr. Heifers (229 kg) were assigned randomly to be developed to 55% of mature BW (299 kg) before a 45-d breeding season (intensive, INT; n = 119) or 50% of mature BW (272 kg) before a 60-d breeding season (relaxed, RLX; n = 142). Prebreeding and pregnancy diagnosis BW were greater (P <or= 0.006) for INT than RLX heifers. Overall pregnancy rate did not differ (88.4%; P = 0.51), but RLX heifers had later calving dates (7 d; P < 0.001) and lighter calf weaning weights (194 +/- 4 vs. 199 +/- 4 kg; P < 0.07) compared with INT heifers. Calf birth weight, calving difficulty, second-calf conception rates, and 2-yr-old retention rate did not differ (P > 0.15) between systems. Cost per pregnant 2-yr-old cow was less for the RLX than the INT heifer development system. Of heifers that failed to become pregnant, a greater proportion (P = 0.07) of heifers in the RLX than in the INT system were prepubertal when the breeding season began. Therefore, a second 2-yr experiment evaluated melengestrol acetate (MGA, 0.5 mg/d) as a means of hastening puberty in heifers developed to 50% of mature BW. Heifers were assigned randomly to the control (n = 103) or MGA (n = 81) treatment for 14 d and were placed with bulls 13 d later for 45 d. Prebreeding and pregnancy diagnosis BW were similar (280 and 380 kg, respectively; P > 0.10) for heifers in the control and MGA treatments. The proportion of heifers pubertal before breeding (74%), pregnancy rate (90%), calving date, calf weaning weight, and second breeding season pregnancy rate (92%) were similar (P > 0.10) between treatments. Developing heifers to 50 or 55% of mature BW resulted in similar overall pregnancy rates, and supplementing the diets of heifers developed to 50% of mature BW with MGA before breeding did not improve reproductive performance.

Expression and crystallization of DsbA from Staphylococcus aureus

Bacterial Dsb proteins catalyse the in vivo formation of disulfide bonds, a critical step in the stability and activity of many proteins. Most studies on Dsb proteins have focused on Gram-negative bacteria and thus the process of oxidative folding in Gram-positive bacteria is poorly understood. To help elucidate this process in Gram-positive bacteria, DsbA from Staphylococcus aureus (SaDsbA) has been focused on. Here, the expression, purification, crystallization and preliminary diffraction analysis of SaDsbA are reported. SaDsbA crystals diffract to a resolution limit of 2.1 A and belong to the hexagonal space group P6(5) or P6(1), with unit-cell parameters a = b = 72.1, c = 92.1 A and one molecule in the asymmetric unit (64% solvent content).

Towards time-resolved diffraction studies with glycogen phosphorylase

Laue diffraction with high intensity, broad-spectrum synchrotron radiation sources allows three-dimensional data sets on protein crystals to be recorded in seconds or milliseconds and opens the way for time-resolved studies on dynamic events in crystals. This chapter briefly reviews the field and describes progress towards time-resolved studies with glycogen phosphorylase. Methods for the synchronization of the start of reaction with the start of data collection have been developed for the phosphorolytic reaction of glycogen phosphorylase. The compound 3,5-dinitrophenylphosphate is photolabile, yielding Pi and the by-product, 3,5-dinitrophenol, which is non-reactive with the enzyme. Spectroscopic studies show that the compound has good quantum yield and that photolysis is rapid (greater than 1000 s-1). Release of the dinitrophenylate anion, following a pulse of light from a xenon flash lamp, has been monitored with a diode array spectrophotometer specially adapted for measurements on crystals. In a laboratory X-ray experiment with crystals of glycogen phosphorylase b, release of Pi and formation of the enzyme-product complex have been demonstrated. The way is now open for Laue diffraction studies on the catalytic reaction in the crystal.

Utilization of dried distillers grains for developing beef heifers1,2,3

A 2-yr study was conducted at 2 locations to determine if supplementing beef heifers with dried distillers grains (DDG) as an energy source affected growth or reproduction. Spring-born crossbred heifers (n = 316) were blocked by age or sire and age and assigned randomly to DDG or control (dried corn gluten feed, whole corn germ, urea) supplement. Heifers received prairie hay in amounts sufficient for ad libitum intake and 0.59% of BW DDG or 0.78% of BW control supplement (DM basis). Supplements were formulated to be isocaloric, but protein degradability differed. Supplemental undegradable intake protein intake from DDG averaged 267 g/animal daily and reached 318 g/animal daily; control supplemental undegradable intake protein intake averaged 90 g/animal daily and peaked at 107 g/animal daily. Initial pubertal status was determined by 2 blood samples collected 10 d apart, and monthly BW were collected from November through January; then biweekly BW and blood samples were collected from February until May yearly. Heifers were synchronized with 2 injections of PGF2alpha 14 d apart; estrus was detected and heifers were artificially inseminated for 5 d and placed with bulls 10 d later. Conception and pregnancy rates were determined via transrectal ultrasonography. Initial age, BW, and BCS did not differ (P > 0.92) for control and DDG heifers. Final BW, ADG, and final BCS also were not affected (P > 0.31) by supplementation. Estimated age and BW at puberty did not differ (P > 0.23) between treatments, and the proportions of pubertal heifers did not differ at the initiation of the experiment (P > 0.82), at the beginning of the 14-d sampling intervals, or before synchronization. Estrus synchronization rate (75.9%), time of estrus, and overall pregnancy rate (89.5%) were not affected (P > 0.14) by treatment. However, a greater proportion (P = 0.008) of DDG than control heifers conceived to AI (75.0 vs. 52.9%), resulting in greater (P = 0.07) AI pregnancy rates for DDG heifers (57.0 vs. 40.1%). Body weight or BCS at pregnancy diagnosis did not differ (P > 0.52) between DDG and control heifers. Supplementing beef heifers with DDG during development did not affect age at puberty but improved AI conception and pregnancy rates compared with an isocaloric control supplement.

Effects of dam nutrition on growth and reproductive performance of heifer calves1

A 3-yr study was conducted with heifers (n = 170) whose dams were used in a 2 x 2 factorial arrangement of treatments to determine the effects of late gestation (LG) or early lactation (EL) dam nutrition on subsequent heifer growth and reproduction. In LG, cows received 0.45 kg/d of a 42% CP supplement (PS) or no supplement (NS) while grazing dormant Sandhills range. During EL, cows from each late gestational treatment were fed cool-season grass hay or grazed sub-irrigated meadow. Cows were managed as a single herd for the remainder of the year. Birth date and birth weight of heifer calves were not affected (P > 0.10) by dam nutrition. Meadow grazing and PS increased (P = 0.02; P = 0.07) heifer 205-d BW vs. feeding hay and NS, respectively. Weight at prebreeding and pregnancy diagnosis were greater (P < 0.04) for heifers from PS dams but were unaffected by EL nutrition (P > 0.10). There was no effect (P > 0.10) of LG or EL dam nutrition on age at puberty or the percentage of heifers cycling before breeding. There was no difference (P > 0.10) in pregnancy rates due to EL treatment. Pregnancy rates were greater (P = 0.05) for heifers from PS dams, and a greater proportion (P = 0.005) of heifers from PS dams calved in the first 21 d of the heifers' first calving season. Nutrition of the dams did not influence (P < 0.10) heifers' average calving date, calving difficulty, and calf birth weight during the initial calving season. Weight at the beginning of the second breeding season was greater (P = 0.005) for heifers from PS dams but was not affected by maternal nutrition during EL (P > 0.10). Dam nutrition did not affect (P > 0.10) heifer ADG or G:F ratio. Heifers from PS dams had greater DMI (P = 0.09) and residual feed intake (P = 0.07) than heifers from NS cows if their dams were fed hay during EL but not if their dams grazed meadows. Heifers born to PS cows were heavier at weaning, prebreeding, first pregnancy diagnosis, and before their second breeding season. Heifers from cows that grazed meadows during EL were heavier at weaning but not postweaning. Despite similar ages at puberty and similar proportions of heifers cycling before the breeding season, a greater proportion of heifers from PS dams calved in the first 21 d of the heifers' first calving season, and pregnancy rates were greater compared with heifers from NS dams. Collectively, these results provide evidence of a fetal programming effect on heifer postweaning BW and fertility.

Asynchronous administration of xenon and hypothermia significantly reduces brain infarction in the neonatal rat

BACKGROUND

Neonatal asphyxia causes long-term neurological and behavioural impairment in the developing brain. Concurrent administration of xenon and hypothermia synergistically reduces long-term damage in a rat model of neonatal asphyxia. This study sought to investigate whether asynchronous administration of xenon and hypothermia is capable of combining synergistically to provide neuroprotection.

METHODS

Seven-day-old rats were subjected to right common carotid artery occlusion followed by 90 min hypoxia with 8% oxygen. After a 1 h recovery period, rats received asynchronous administration of mild hypothermia (35 degrees C) and xenon (20%) with a 1 or 5 h gap between interventions, xenon (20%) alone, or mild hypothermia (35 degrees C) alone. Infarct volume in the brain was measured 4 days after injury.

RESULTS

Administration of hypothermia or xenon alone, 1 and 6 h after the hypoxic ischaemic insult, respectively, provided no neuroprotection. Asynchronous administration of xenon and hypothermia at a 1 h interval produced a significant reduction in infarct volume [93 (7) vs 74 (8); P < 0.05]. Reduction in infarct volume was also present when hypothermia and xenon were asynchronously administered with an intervening gap of 5 h [97 (5) vs 83 (3); P < 0.05].

CONCLUSIONS

This finding provides a rationale for investigating the combined use of hypothermia and xenon in a progressive manner for the management of neonatal asphyxia. Thus, hypothermia can be administrated at the site of delivery and xenon can be administered later.

Effects of supplementation of whole corn germ on reproductive performance, calf performance, and leptin concentration in primiparous and mature beef cows

A 2-yr study using primiparous and multiparous, spring-calving, crossbred beef cows was conducted to evaluate the effects of supplemental whole corn germ on reproductive performance, calf performance, and serum leptin concentrations. Each year, cows were blocked by age and BCS and assigned randomly to one of three treatments: PRE (n = 115) cows received 1.14 kg/d (DM basis) of whole corn germ for approximately 45 d before calving; POST (n = 109) cows were fed 1.14 kg/d of whole corn germ for approximately 45 d after calving; and control cows (n = 118) were fed similar energy and protein from dry-rolled corn (1.82 kg of DM/d) for 45 d before and after calving. Additionally, PRE cows were grouped with controls after calving, and POST cows were grouped with control cows before calving, so that corn germ-supplemented cows received the control supplement in the alternate feeding period. Cow BW (538 +/- 13 kg) and BCS (5.4 +/- 0.13) did not differ among treatments at any time during the experiment. Calf birth weight (39 +/- 2 kg), weaning weight (225 +/- 7 kg), and age-adjusted weaning weight (234 +/- 8 kg) did not differ because of dam supplementation regimen. Treatment did not affect the proportion of cows exhibiting ovarian luteal activity before the start of the breeding season (67%) or pregnancy rate (91%). The interval from exposure to bulls until subsequent calving did not differ (P = 0.16) among PRE (298 +/- 2.3 d), POST (303 +/- 2.6 d), and control (304 +/- 2.3 d) cows. Leptin concentrations did not differ among treatments and were 2.15 +/- 0.75, 1.88 +/- 0.76, and 1.91 +/- 0.75 ng/mL for control, POST, and PRE cows, respectively. Age and week relative to calving influenced leptin concentration. Primiparous cows had similar leptin concentrations to 3-yr-old and mature cows for wk -7 and -6 relative to calving, but lower (P < 0.10) concentrations than mature cows for wk -5, and lower (P < 0.05) concentrations than either 3-yr-old or mature cows for wk -4 to +7 relative to calving. Serum leptin was correlated with BCS (P < 0.0001; r = 0.35) at initiation of the feeding period and was correlated with BCS (P = 0.02; r = 0.12) and weight (P < 0.01; r = 0.14) at the completion of the supplement period, but it was not correlated with initial BW or interim BCS. Calving interval was not correlated (P > 0.12) with weekly measures of serum leptin concentration. Supplementing beef cows with whole corn germ had no effect on cow performance, calf performance, or serum leptin concentrations of cows.

Systematic review and evaluation of methods of assessing urinary incontinence

OBJECTIVES

To identify and synthesise studies of diagnostic processes of urinary incontinence and to construct an economic model to examine the cost-effectiveness of simple, commonly used primary care tests.

DATA SOURCES

The electronic databases MEDLINE (1966--2002), CINAHL (1982--2002) and EMBASE (1980--2002).

REVIEW METHODS

Studies were selected and assessed using the Quality Assessment of Diagnostic Studies (QUADAS) tool. Studies that reported the results of applying the same diagnostic procedure using the same threshold value (cut-off) were pooled using a random effects meta-analysis model to produce pooled estimates of sensitivity, specificity and diagnostic odds ratio together with 95% confidence intervals.

RESULTS

In total, 6009 papers were identified from the literature search, of which 129 were deemed relevant for inclusion in the review, and these papers compared two or more diagnostic techniques. The gold-standard diagnostic test for urinary incontinence with which each reference test was compared was multichannel urodynamics. In general, reporting in the primary studies was poor; there was a lack of literature in the key clinical areas and minimal literature dealing with diagnosis in men. Only a limited number of studies could be combined or synthesised, providing the following results when compared with multichannel urodynamics. A clinical history for diagnosing urodynamic stress incontinence (USI) in women was found to have a sensitivity of 0.92 and specificity of 0.56 and for detrusor overactivity (DO) a sensitivity of 0.61 and specificity of 0.87. For validated scales, question 3 of the Urogenital Distress Inventory was found to have a sensitivity of 0.88 and specificity of 0.60. Seven studies compared a pad test with multichannel urodynamics; however, four different pad tests were studied and therefore it was difficult to draw any conclusions about diagnostic accuracy. Of the four studies comparing urinary diary with multichannel urodynamics, only one presented data in a format that allowed sensitivity and specificity to be calculated. Their reported values of 0.88 and 0.83 suggest that a urinary diary may be effective in the diagnosis of DO in women. Examination of the incremental cost-effectiveness of three primary care tests used in addition to history found that the diary had the lowest cost-effectiveness ratio of between pound 35 and pound 77 per extra unit of effectiveness (or case diagnosed). Imaging by ultrasound to determine leakage was found to be effective in the diagnosis of USI in women, with a sensitivity of 0.94 and specificity of 0.83.

CONCLUSIONS

This is the first systematic review of methods for diagnosing urinary incontinence. As reporting of the primary studies was poor, clinical interpretation was often difficult because few studies could be synthesised and conclusions made. The report found that a large proportion of women with USI can be correctly diagnosed in primary care from clinical history alone. On the basis of diagnosis the diary appears to be the most cost-effective of the three primary care tests (diary, pad test and validated scales) used in addition to clinical history. Ultrasound imaging may offer a valuable alternative to urodynamic investigation. The clinical stress test is effective in the diagnosis of USI. Adaptation of such a test so that it could be performed in primary care with a naturally filled bladder may prove clinically useful. If a patient is to undergo an invasive urodynamic procedure, multichannel urodynamics is likely to give the most accurate result in a secondary care setting. There is a dearth of literature on the diagnosis of urinary incontinence in men, with no studies meeting the study criteria for data extraction in the diagnosis of bladder outlet obstruction. There is a need for large-scale, high-quality primary studies evaluating the use of a number of diagnostic methods in a primary care setting to be undertaken so that the results of this systematic review can be verified or not. Such studies should include not only an assessment of clinical effectiveness, in this case diagnostic accuracy, but also an assessment of costs and quality of life/satisfaction to inform future health policy decisions. Studies carried out should be reported to a better standard. The recommendations of the Standards for Reporting Diagnostic Accuracy (STARD) initiative should be followed to ensure the accuracy and completeness of reporting design and results.

[Consequences for children involved in a road traffic accident: one year of observation and follow-up in the Rhone county]

Children aged 6 to 11 who have been injured in a traffic accident were observed over a one year period, in parallel with a control group of children. More than one-third of the injured children had been hospitalized (for periods ranging anywhere between 1 and 47 days). One year later, one injured child out of ten was still suffering from pain, and/or still being treated for injuries resulting from the accident. Many other factors were linked to the initial overall level of severity of the injuries, contrary to that of pain, such as the rate and duration of hospitalization, the duration of care provided, the number of medical consultations, and absenteeism from school. Children who had been injured in a road traffic accident were found to be more anxious and nervous, in general, as well as having a high prevalence of sleeping disorders in comparison to the children in the control group.

Systematic review and meta-analysis of methods of diagnostic assessment for urinary incontinence

AIMS

To evaluate the performance of all tests proposed for the diagnosis of urinary incontinence.

METHODS

A systematic review and meta-analyses of the published literature of methods for diagnostic assessment of urinary incontinence.

RESULTS

One hundred twenty-one papers were included in the full review [Martin et al., 2006]. The quality of reporting in the primary studies was poor which reduced the number of studies that could be included in the data analysis. The literature suggests that women with urodynamic stress incontinence (USI) can be correctly identified in primary care from clinical history alone with a sensitivity of 0.92 (95% C.I.: 0.91-0.93) and specificity of 0.56 (0.53-0.60). A clinical history for the diagnosis of detrusor overactivity (DO) was found to be 0.61 (0.57-0.65) sensitive and 0.87 (0.85-0.89) specific. Within secondary care imaging of leakage by ultrasound was found to be effective in the diagnosis of USI in women with a sensitivity of 0.89 (0.84-0.93) and specificity of 0.82 (0.73-0.89).

CONCLUSIONS

Clinical interpretation of the results of the review is difficult because few studies could be synthesized and conclusions made. The published evidence suggests that a large proportion of women with USI can be correctly identified in primary care from history alone. Ultrasound offers a useful diagnostic tool which could be used prior to, and possibly instead of, multi-channel urodynamics in some circumstances. If a patient is to undergo urodynamic testing, multi-channel urodynamics is likely to give the most accurate result. Further primary studies adhering to STARD guidelines are required on commonly used tests.

Modelling the hierarchical structure of road crash data--application to severity analysis

Road crashes have an unquestionably hierarchical crash-car-occupant structure. Multilevel models are used with correlated data, but their application to crash data can be difficult. The number of sub-clusters per cluster is small, with less than two cars per crash and less than two occupants per car, whereas the number of clusters can be high, with several hundred/thousand crashes. Application of the Monte-Carlo method on observed and simulated French road crash data between 1996 and 2000 allows comparing estimations produced by multilevel logistic models (MLM), Generalized Estimating Equation models (GEE) and logistic models (LM). On the strength of a bias study, MLM is the most efficient model while both GEE and LM underestimate parameters and confidence intervals. MLM is used as a marginal model and not as a random-effect model, i.e. only fixed effects are taken into account. Random effects allow adjusting risks on the hierarchical structure, conferring an interpretative advantage to MLM over GEE. Nevertheless, great care is needed for data coding and quite a high number of crashes are necessary in order to avoid problems and errors with estimates and estimate processes. On balance, MLM must be used when the number of vehicles per crash or the number of occupants per vehicle is high, when the LM results are questionable because they are not in line with the literature or finally when the p-values associated to risk measures are close to 5%. In other cases, LM remains a practical analytical tool for modelling crash data.

Links between phytoplankton and bacterial community dynamics in a coastal marine environment

Bacteria and phytoplankton dynamics are thought to be closely linked in coastal marine environments, with correlations frequently observed between bacterial and phytoplankton biomass. In contrast, little is known about how these communities interact with each other at the species composition level. The purpose of the current study was to analyze bacterial community dynamics in a productive, coastal ecosystem and to determine whether they were related to phytoplankton community dynamics. Near-surface seawater samples were collected in February, May, July, and September 2000 from several stations in the Bay of Fundy. Savin et al. (M.C. Savin et al., Microb Ecol 48: 51-65) analyzed the phytoplankton community in simultaneously collected samples. The attached and free-living bacterial communities were collected by successive filtration onto 5 microm and 0.22 microm pore-size filters, respectively. DNA was extracted from filters and bacterial 16S rRNA gene fragments were amplified and analyzed by denaturing gradient gel electrophoresis (DGGE). DGGE revealed that diversity and temporal variability were lower in the free-living than the attached bacterial community. Both attached and free-living communities were dominated by members of the Roseobacter and Cytophaga groups. Correspondence analysis (CA) ordination diagrams showed similar patterns for the phytoplankton and attached bacterial communities, indicating that shifts in the species composition of these communities were linked. Similarly, canonical CA revealed that the diversity, abundance, and percentage of diatoms in the phytoplankton community accounted for a significant amount of the variability in the attached bacterial community composition. In contrast, ordination analyses did not reveal an association between free-living bacteria and phytoplankton. These results suggest that there are specific interactions between phytoplankton and the bacteria attached to them, and that these interactions influence the composition of both communities.

Hypokalaemia in ibuprofen and codeine phosphate abuse

Ibuprofen abuse may be more prevalent than generally considered. Although normally benign, serious complications have been documented. We report an unusual presentation of hypokalaemia and its associated symptoms as a result of Nurofen Plus (200 mg ibuprofen + 12.8 mg codeine phosphate) abuse. Ibuprofen is generally not included in a standard toxicology screen, but should be considered as a rare cause of hypokalaemia.