Women's cardiovascular health - the cardio-oncologic jigsaw

Improvements in cancer care have led to an exponential increase in cancer survival. This is particularly the case for breast cancer, where 5-year survival in Australia exceeds 90%. Cardiovascular disease (CVD) has emerged as one of the competing causes of morbidity and mortality among cancer survivors, both as a complication of cancer therapies and because the risk factors for cancer are shared with those for CVD. In this review we cover the key aspects of cardiovascular care for women throughout their cancer journey: the need for baseline cardiovascular risk assessment and management, a crucial component of the cardiovascular care; the importance of long-term surveillance for ongoing maintenance of cardiovascular health; and strong evidence for the beneficial effects of physical exercise to improve both cancer and cardiovascular outcomes. There is general disparity in cardiovascular outcomes for women, which is further exacerbated when both CVD and cancer co-exist. Collaboration between oncology and cardiac services, with an emergence of the whole field of cardio-oncology, allows for expedited investigation and treatment for these patients. This collaboration as well as a holistic approach to patient care and key role of patients' general practitioners are essential to ensure long-term health of people living with, during and beyond cancer.

Appraisal of Systemic Treatment Strategies in Early HER2-Positive Breast Cancer-A Literature Review

BACKGROUND

The overexpression of the human epidermal growth factor receptor 2 (HER2+) accounts for 15-20% of all breast cancer phenotypes. Even after the completion of the standard combination of chemotherapy and trastuzumab, relapse events occur in approximately 15% of cases. The neoadjuvant approach has multiple benefits that include the potential to downgrade staging and convert previously unresectable tumors to operable tumors. In addition, achieving a pathologic complete response (pCR) following preoperative systemic treatment is prognostic of enhanced survival outcomes. Thus, optimal evaluation among the suitable strategies is crucial in deciding which patients should be selected for the neoadjuvant approach.

METHODS

A literature search was conducted in the Embase, Medline, and Cochrane electronic libraries.

CONCLUSION

The evaluation of tumor and LN staging and, hence, stratifying BC recurrence risk are decisive factors in guiding clinicians to optimize treatment decisions between the neoadjuvant versus adjuvant approaches. For each individual case, it is important to consider the most likely postsurgical outcome, since, if the patient does not obtain pCR following neoadjuvant treatment, they are eligible for adjuvant T-DM1 in the case of residual disease. This review of HER2-positive female BC outlines suitable neoadjuvant and adjuvant systemic treatment strategies for guiding clinical decision making around the selection of an appropriate therapy.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Preoperative serum artemin (ARTN) as a predictive biomarker of recurrence following curative resection for hepatocellular carcinoma (HCC)

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Background: Tumor-induced generation of splenic erythroblast- like cells (Ter-cells) has been shown to promote tumor progression. These Ter-cells produce the glial-line derived neurotropic factor, ARTN. We investigated the association of pre-operative serum ARTN and the risk of recurrence in HCC patients (pts) undergoing curative resection. Methods: Blood samples were collected prior to surgery as part of an institutional molecular epidemiologic study. Serum ARTN concentration was measured using an enzyme-linked immunosorbent assay (ELISA). Demographics, pathological variables known to be associated with outcomes and clinical outcomes were collected. Uni- and multi-variate analysis were conducted. The optimal cutpoint method was used to define high and low ARTN concentrations. Cox models (hazard ratios, HR) were used to compare progression-free (PFS, primary endpoint), and overall survival (OS) of pts with high vs low serum ARTN. Results: Pre-operative blood samples were available for 58 pts. Median age was 63 years (range: 25-85 years); 74% were male and 50% were Asian. Etiology of liver disease was hepatitis B (43%) and hepatitis C (22%); 43% of tumors were ≤5cm, and vascular invasion was seen in 62%. A baseline alpha-fetoprotein (AFP) of > 100 mcg/L was observed in 36% pts. Median follow-up was 18.9 months. Median ARTN concentration was 0.322 ng/mL. The optimal ARTN concentration cut-off was 0.206 ng/mL. Median PFS for pts with high ( > 0.206 ng/mL) vs low (≤0.206 ng/mL) ARTN was 15.7 vs 55 months (p = 0.04) respectively. Three year PFS was 34% vs 55%, and three year OS 54% vs 91% for high vs low groups. Univariate analysis found that high ARTN concentration (HR 2.44, p = 0.05) and multifocal tumors were associated with a worse PFS. In a multivariate analysis adjusted for AFP > 100mcg/L, vascular invasion, hepatitis status and multifocal tumors, high ARTN remained a negative prognostic factor for PFS, aHR 3.32 (95% CI: 1.22-9.05, p = 0.02). Conclusions: A high pre-surgery serum ARTN is associated with earlier recurrence in HCC pts undergoing curative resection. ARTN should be further studied in HCC to determine its value as a prognostic marker.

In their own words: investigating the preparedness of final year dental students in the UK for independent general dental practice

Introduction

There is relatively little data on the preparedness of UK dental graduates for independent general dental practice. Two recent studies have indicated that graduates appear well prepared, but although quantifying the level of preparedness, they provide limited understanding of the underlying factors contributing to preparedness. This study aims to more deeply understand the contributing factors leading to assertions of graduate preparedness using focus groups of final year dental students, and semi-structured interviews of senior faculty members.

Materials and methods

Three UK dental schools were visited in order to conduct both study elements. Focus groups and semi-structured interviews were audio recorded and fully transcribed. Thematic analysis of the transcripts resulted in the production of a thematic matrix.

Results

The major categories of the thematic matrix were classified as extrinsic; including the role of educators and features of the course, and intrinsic; relating to fear of the unknown, the development of adult learning abilities and less easily identifiable attributes in the development of competence, which became known as 'bricks and mortar'.

Discussion

Students felt that the most important factor affecting their preparation was clinical exposure. Outreach placements were felt to be particularly useful, the simulation of general dental practice being highly valued by final year students. The interaction with educators was also felt to be a key influence on preparedness, with the involvement of general practitioners in dental school teaching felt to be helpful, perhaps giving students an extended exposure to general practice.

Conclusion

It is hoped that the rich data derived from this study may allow an invaluable insight into factors contributing to preparedness of new dental graduates, which may then be considered in the light of any proposed changes in the curricula or syllabi.

Bifidobacteria and its rice fermented products on diet induced obese mice: analysis of physical status, serum profile and gene expressions

Obesity is highly correlated with the dysbiosis of intestinal microbiota, and bifidobacteria are one of the soft targets of this metabolic syndrome. The aim of this study is to evaluate the efficacy of Bifidobacterium sp. MKK4 and rice-based fermented foods on physical, haematological, gut microbiota and lypogenic-lypolytic marker genes in diet-induced obese mice. Adult male mice (21±0.7 g) were randomly divided into four groups (n=10) according to the type of diet: normal diet (ND), high fat diet (HFD), HFD supplemented with Bifidobacterium sp. MKK4 and HFD supplemented with MKK4 associated rice-fermented food. 8 weeks of bacterial therapy in the obese mice resulted in significant reduction of body and organ weights, improved serum levels of glucose, triglyceride and cholesterol, the histological structure of the liver (steatosis), and re-establishment of gut Lactobacillus, Bifidobacterium and Bacteroides species. The bacterial therapy led to up-regulation of lipolytic transcription factors, such as peroxisome proliferator-activated receptor (PPAR)-α, PPAR-δ, and their regulated gene products in fatty acid metabolism and glucose uptake, such as acyl-CoA oxidase, carnitine palmitoyl-transferase-1, uncoupling protein-3 and glucose transporter-4. Concomitantly, both adipocytogenesis and fatty acid synthesis were arrested as reflected by the down-regulation of sterol regulatory element binding protein-1c, acetyl-CoA carboxylase, fatty acid synthase and tumour necrosis factor alpha genes. The effectiveness of the fermented product was more profound than the single bacterium. These data provide experimental support with regard to the use of Bifidobacterium sp. MKK4 as a natural therapeutic agent to control obesity.

Audit on Prescribing Practice of Depot Antipsychotic Injections in the Adult Community Mental Health Service

Introduction

There are a number of good standard practices available for prescribing long acting antipsychotics. Adherence to these guidelines will minimise any harm to the service users.

Aims

To compare depot antipsychotic prescribing practice with good standard practice guidelines of BNF, Trust and Maudsley guidelines.

Objectives

To compare practice with standards in the areas of:

– licensed indication;

– dose/frequency range;

– avoiding poly-pharmacy;

– regular review of clinical and side effects.

Methods

Case notes of a randomly selected sample of 30 patients from the depot clinic at the City East Adult Community Mental Health Team Leicester, UK were retrospectively investigated. The data collected was analysed and the results were produced. Compliance with the best practice guidelines was calculated and recommendations made based on the findings.

Results

One hundred percent compliance was noticed in licensed indications and dose/frequency within BNF range. However, 14% patients received poly-pharmacotherapy, 86% had regular outpatient review, but only 46% had review of side effects.

Conclusions

Better quality of documentations by the clinicians, improvised technology to elicit automatic review reminders, introduction of checklist for clinics to include review of all clinically important information, wider dissemination of the findings of this investigation, and re-auditing practice to explore impact of this investigation was recommended.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Use of a positional therapy device significantly improves nocturnal gastroesophageal reflux symptoms

The aim of this study was to measure the efficacy of a positional therapy device (PTD) at reducing proton pump inhibitor (PPI) refractory nocturnal GERD symptoms. Among patients with GERD, nocturnal symptoms are very common. A recent study demonstrated a decrease in nocturnal acid exposure and reflux episodes in healthy volunteers who slept using a PTD. This is a single-center prospective trial involving patients on anti-secretory medications with continued nocturnal heartburn and regurgitation. Patients completed the Nocturnal GERD Symptom Severity and Impact Questionnaire (N-GSSIQ) and GERD health-related quality of life questionnaire (GERD-HRQL) at enrollment. Patients were instructed to sleep on the PTD for at least 6 hours a night during the two week study period; subjects continued their baseline anti-secretory medication dose. After 2 weeks, the questionnaires were repeated. A total of 27 patients (16 females and 11 males; age 57.8 ± 15.1) were recruited. After 2 weeks of PTD use, N-GSSIQ scores significantly improved from baseline, with a mean total score improvement of 39.5 (mean 57.7 [pre] vs. 18.2 [post], P < 0.001). Significant improvement from baseline was also observed for the GERD-HRQL questionnaire (29.8 vs. 16.7, P < 0.001). No adverse events were reported. At 3 months after the trial period, 91% of the subjects continued to use the PTD on a nightly basis. Use of the PTD significantly decreased nocturnal GERD symptoms and improved GERD-HRQL. The PTD was well tolerated during the study period and for 3 months after enrollment.

An Exploratory Statistical Analysis of the effect of Demographic risk factors on uterine Cervical squamous Intraepithelial Lesion

Pap Smear test (Pap test), a cytological screening test of the cervical squamous intraepithelial lesion (SIL) is a widely accepted screening technique for uterine cervical cancer (UCC). UCC is a major canter burden for Indian women. In this article, we present an in-depth exploratory analysis on various statistical relationships between the Pap test and a set of demographic risk factors, such as Age, Age at consummation of marriage [ACM], parity [PAR] etc. The data had been collected from the Calcutta Medical College Hospital (CMCH) on 308 subjects. Major statistical findings in this article include a possible Age dependent association between PAR and the SIL-status. It seems that a high value of parity at a relatively young age is an important risk factor for developing SIL in future. This finding may be useful in relating to overall female helath issues in developing and underdeveloped country-senario.

AMS (2000) Subject Classification: Primary 62-07, 62Pl0, 92C60, Secondary 92C50, 62F03, 62F10.

C60 fullerene localization and membrane interactions in RAW 264.7 immortalized mouse macrophages

There continues to be a significant increase in the number and complexity of hydrophobic nanomaterials that are engineered for a variety of commercial purposes making human exposure a significant health concern. This study uses a combination of biophysical, biochemical and computational methods to probe potential mechanisms for uptake of C60 nanoparticles into various compartments of living immune cells. Cultures of RAW 264.7 immortalized murine macrophage were used as a canonical model of immune-competent cells that are likely to provide the first line of defense following inhalation. Modes of entry studied were endocytosis/pinocytosis and passive permeation of cellular membranes. The evidence suggests marginal uptake of C60 clusters is achieved through endocytosis/pinocytosis, and that passive diffusion into membranes provides a significant source of biologically-available nanomaterial. Computational modeling of both a single molecule and a small cluster of fullerenes predicts that low concentrations of fullerenes enter the membrane individually and produce limited perturbation; however, at higher concentrations the clusters in the membrane causes deformation of the membrane. These findings are bolstered by nuclear magnetic resonance (NMR) of model membranes that reveal deformation of the cell membrane upon exposure to high concentrations of fullerenes. The atomistic and NMR models fail to explain escape of the particle out of biological membranes, but are limited to idealized systems that do not completely recapitulate the complexity of cell membranes. The surprising contribution of passive modes of cellular entry provides new avenues for toxicological research that go beyond the pharmacological inhibition of bulk transport systems such as pinocytosis.

Legal Aspects in Obstetric Anesthesia

Obstetric anesthesia is a particularly high-risk sub-specialty of anesthesia and may lead to serious morbidities and even mortality. Good doctor-patient relation from the time of admission till discharge is the most important factor to avert future litigations. Any procedure done or planned should be clearly documented. Documentation should start with a valid consent in the patient’s own language, and have all three components of voluntariness, capacity and knowledge. A ‘Surgical Safety’ checklist is particularly helpful in documentation and decreasing errors. Safety of the mother (and her child) is paramount. Both regional as well as general anesthesia, either inadvertently or if not administered properly may be associated with morbidities like headache, pain and emotional distress. However, deaths do occur and general anesthesia is associated with care should be routine practice and inculcated by everyone involved in patient care.

Ocular bartonellosis in transplant recipients: two case reports and review of the literature

Cat scratch disease is caused by Bartonella henselae and usually manifests as localized lymphadenopathy and fever in immunocompetent patients. Immunocompromised patients are at risk for developing disseminated disease affecting the liver, spleen, eyes, central nervous system, and other organs. Bartonellosis is infrequently reported in solid organ transplant recipients, and published case reports usually discuss disseminated infection. Localized ocular disease with B. henselae, while well documented in immunocompetent hosts, is uncommon in immunocompromised patients. Herein, we present 2 cases of ocular bartonellosis in renal transplant patients, 1 with disseminated infection, and 1 without.

Identifying CpG sites associated with eczema via random forest screening of epigenome-scale DNA methylation

BACKGROUND

The prevalence of eczema is increasing in industrialized nations. Limited evidence has shown the association of DNA methylation (DNA-M) with eczema. We explored this association at the epigenome-scale to better understand the role of DNA-M. Data from the first generation (F1) of the Isle of Wight (IoW) birth cohort participants and the second generation (F2) were examined in our study. Epigenome-scale DNA methylation of F1 at age 18 years and F2 in cord blood was measured using the Illumina Infinium HumanMethylation450 Beadchip. A total of 307,357 cytosine-phosphate-guanine sites (CpGs) in the F1 generation were screened via recursive random forest (RF) for their potential association with eczema at age 18. Functional enrichment and pathway analysis of resulting genes were carried out using DAVID gene functional classification tool. Log-linear models were performed in F1 to corroborate the identified CpGs. Findings in F1 were further replicated in F2.

RESULTS

The recursive RF yielded 140 CpGs, 88 of which showed statistically significant associations with eczema at age 18, corroborated by log-linear models after controlling for false discovery rate (FDR) of 0.05. These CpGs were enriched among many biological pathways, including pathways related to creating transcriptional variety and pathways mechanistically linked to eczema such as cadherins, cell adhesion, gap junctions, tight junctions, melanogenesis, and apoptosis. In the F2 generation, about half of the 83 CpGs identified in F1 showed the same direction of association with eczema risk as in F1, of which two CpGs were significantly associated with eczema risk, cg04850479 of the PROZ gene (risk ratio (RR) = 15.1 in F1, 95 % confidence interval (CI) 1.71, 79.5; RR = 6.82 in F2, 95 % CI 1.52, 30.62) and cg01427769 of the NEU1 gene (RR = 0.13 in F1, 95 % CI 0.03, 0.46; RR = 0.09 in F2, 95 % CI 0.03, 0.36).

CONCLUSIONS

Via epigenome-scaled analyses using recursive RF followed by log-linear models, we identified 88 CpGs associated with eczema in F1, of which 41 were replicated in F2. Several identified CpGs are located within genes in biological pathways relating to skin barrier integrity, which is central to the pathogenesis of eczema. Novel genes associated with eczema risk were identified (e.g., the PROZ and NEU1 genes).