Identifying the unmet supportive care needs of individuals affected by testicular cancer: a systematic review

PURPOSE

To critically appraise studies to identify experiences of unmet supportive care needs of individuals affected by testicular cancer.

METHODS

A registered priori systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. CINAHL, PsycINFO, and MEDLINE were searched for quantitative, qualitative, and mixed methods studies using a wide range of search terms. All articles were double screened according to a pre-determined eligibility criterion. Reference lists of the final included studies were checked for further eligible studies. The review process was managed using Covidence systematic review software. Data from the studies were extracted, methodological quality appraisal conducted, and a narrative synthesis conducted.

RESULTS

Of the 72 papers identified, 36 studies were included. In descending order of frequency of need, psychological needs were identified in 26/36, physical needs 18/36, interpersonal/intimacy needs 19/36, health system/information needs 11/36, cognitive needs 9/36, social needs 7/36, and of equal frequencies counts of 4/36 for family, practical, and patient-clinician information needs. Only one study explored spiritual needs and no daily living needs were identified.

CONCLUSIONS

The experience of needs varied in terms of frequency and distress which were commonly influenced by the age of the individual across the cancer care continuum persisting after 1-year post-treatment.

IMPLICATIONS FOR CANCER SURVIVORS

When caring for individuals affected by testicular cancer, clinicians are encouraged to take a holistic lens to cancer care, particularly to explore issue or concerns that young men affected by testicular cancer might be embarrassed or reticent to discuss.

Improved adherence to hip fracture standards reduces mortality after hip fractures

BACKGROUND

Hip fractures are increasing in incidence due to increasing life expectancy. Mortality continues to improve but it is important to explore which factors are responsible for driving improvements.

METHODS

A cohort of hip fracture patients predating SARS-CoV-2 was examined to determine the predictors of adherence to the six Irish Hip Fracture Standards (IHFS) and the impact of adherence on short (30 day) and long term (1 year) mortality. Our primary aim was assess the impact of a single HFS and cumulative number of HFS on mortality after hip fracture. Our secondary aim was to determine the impact of the HFS which are intrinsically linked to specialist Geriatric care.

RESULTS

Across 962 patients, over 5 years, the factors which were associated with adherence to HFS were female gender, increasing ASA grade and being nursed on an orthopaedic ward. Patients with increasing ASA were more likely to have met HFS 4-6 (Geriatrician review HFS4, bone health HFS5 & specialist falls assessment HFS6), less likely to have surgery within 48 h are more likely to develop a pressure ulcer. If the patient was not nursed on an orthopaedic ward all HFS were less likely to be met. At 30 days HFS 4-6 were associated with a statistically significant odds ratio (OR) of being alive, while at one year HFS 1 (admitted to an orthopaedic ward within 4 h), 5 and 6 were associated with a statistically significant OR of being alive. As increasing numbers of hip fracture standards were met patients were more likely to be alive at 30 days and one year.

CONCLUSION

This study has identified that improved adherence to hip fracture standards are associated with improved mortality at 30 days and one year.

190 CONNECTED HEALTH SUSTAINING HOME STAY IN DEMENTIA (CHESS): FACTORS ASSOCIATED WITH THE BURDEN EXPERIENCED BY CAREGIVERS OF PEOPLE WITH DEMENTIA

Background

To date, little research has been carried out exploring the burden experienced by informal caregivers of People with Dementia (PwD). We explored factors that influence the burden experienced by caregivers of PwD over 12 months.

Methods

Fifty-two PwD and their informal caregivers were recruited by convenience sampling to the “CHESS” Study. Data were collected at five time points over 12 months between April 2017 and November 2019. Mixed model analyses were used to investigate associations of caregiver burden (measured by the Zarit-Burden Interview; ZBI) with factors in four domains: 1) Psychological Well-Being (PWB; measures of anxiety, depression, and caregiver distress); 2) Social Capital and Resources (SCR; incorporating access to community-based health services, transportation needs, education level, occupation and living situation of the PwD, and employment status of the caregiver); 3) Physical Fitness and Health (PFH; including the Quantitative Timed Up and Go (QTUG), baseline grip strength, indices of frailty, sensory acuity); and Managing Everyday life with Dementia (MED; incorporating measures of cognition, behavioural disturbances, functional ability, and indices of dependence of PwD.

Results

Across all domains, caregiver burden significantly increased over time (p<0.001) and less burden was experienced by caregivers of older PwD (p<0.05). In PWB, higher caregiver depression levels predicted higher levels of caregiver burden (p=0.033). In the SCR domain, caregivers of PwD who were independent in their transport needs experienced lower levels of burden (p=0.002). No other factors within the PFH or MED domains reached significance in predicting caregiver burden.

Conclusion

This longitudinal analysis elucidates potential predictors of caregiver burden and highlights the need for future research to be carried out in this area. In particular, psychological well-being in caregivers was shown to significantly impact on the experience of burden. Interventions to alleviate caregiver burden should be tailored to include support for psychological well-being.

313 STREAMLINING A ZOLEDRONIC ACID SERVICE TO A LEVEL TWO HOSPITAL

Background

Approximately, 350-400 patients are admitted to a level 4 hospital for hip-fractures yearly (2019). According to the Irish Hip Fracture Database (2020) the average age for a hip-fracture is 81 years old. Patients post-hip fractures are commenced on Zoledronic acid; a bisphosphonate which is given intravenously 10 days post-surgery and then annually in year two and three. Zoledronic acid is a first line choice of bisphosphonate for the ≥65 population with a fragility fracture.

Methods

274 patients were transferred from the level 4 Hospital waiting list to a level 2 hospital waiting list to streamline the service. Meetings occurred to establish a pathway for the transition of services. A rapid improvement of the level 2 Day Hospital (DH) was commenced. Essential resources, training and information leaflets were developed in order to begin the service. A policy review, procedure guidelines and referral pathway were implemented. An excel database of patient information was transferred between organisations. The 274 patients were triaged by the DH. Pre-assessment phone calls were conducted determining if patients were still eligible for Zoledronic acid.

Results

Of the 274 referrals; 24 had died; 30 refused; 37 were on other bone treatments and another 7 patients haven’t made creatinine clearance, leaving 176. All 176 patients were allocated an appointment for 2022. Of the 176 patients; currently 57 patients have received their Zoledronic acid infusion in the DH. 69 of these referrals had an indicative date for their next Zoledronic acid infusion for dates after April 2022. There are 50 patients yet to receive their treatment which is overdue.

Conclusion

With the prospect of service demands increasing due to Irelands aging population inevitably placing extra pressures on infusion suites in a level 4 hospital. The level 2 hospital has effectively managed to focus on tackling the backlog, streamlining referrals to the bone health service and thus reducing the risk of subsequent hip fractures.

192 CONNECTED HEALTH SUSTAINING HOME STAY IN DEMENTIA (CHESS): 12-MONTH TRAJECTORY OF QUALITY OF LIFE IN PEOPLE WITH DEMENTIA

Background

Research is needed to examine how Quality of Life (QoL) changes as dementia progresses. We explored QoL trajectories over a 12-month period and examined factors that influence QoL in People with Dementia (PwD).

Methods

Fifty-two PwD and their informal caregivers participated in the “CHESS” Study. Data were collected at five time points over 12 months between April 2017 and November 2019. Mixed-model analyses were used to investigate associations of self-rated QoL and caregiver-rated QoL (measured by the DEMQoL and DEMQoL Proxy, respectively) with factors in four domains: 1) Psychological Well-Being (PWB; measures of anxiety and depression); 2) Social Capital and Resources (SCR; incorporating access to community-based health services, education level, occupation and living situation of the PwD, employment status of the caregiver); 3) Physical Fitness and Health (PFH; including the Quantitative Timed Up and Go (QTUG), baseline grip strength, indices of frailty, sensory acuity); and Managing Everyday life with Dementia (MED; incorporating measures of cognition, behavioural disturbances, functional ability, indices of dependence of PwD).

Results

Across all domains, caregivers’ ratings of QoL for PwD decreased over time (p=0.012). In PWB, greater levels of depression (p=0.007) and anxiety in the PwD (p<0.001) predicted lower self-rated QoL, and higher caregiver anxiety levels predicted lower caregiver-rated QoL (p=0.012). In PFH, having a caregiver administer medication (p=0.03) was associated with higher self-rated QoL. Interestingly, caregiver-rated QoL was higher for PwD who took longer to return to sitting during the QTUG (p=0.043). In MED, being independently mobile (p=0.012) predicted higher self-rated QoL. No other factors within the SCR domain reached significance in predicting QoL.

Conclusion

This longitudinal analysis elucidates potential predictors of QoL in PwD. Psychological well-being in PwD and their caregivers was shown to significantly impact on QoL, and so, these factors should be routinely included in future research studies and clinical assessments.

194 CONNECTED HEALTH SUSTAINING HOME STAY IN DEMENTIA (CHESS): SMART HEALTH TECHNOLOGY ACCEPTABILITY BY INFORMAL CAREGIVERS OF PEOPLE WITH DEMENTIA

Background

The prevalence of dementia is increasing worldwide, and innovative strategies are required to meet increasing demands on health services. The Connected HEalth Sustaining home Stay in Dementia (CHESS) Study aimed to provide support to People with Dementia (PwD) and their caregivers in their homes. We aimed to quantitatively assess the acceptance of smart connected health technology by caregivers of PwD through use of standardised questionnaires.

Methods

Fifty-two PwD and their informal caregivers were recruited by convenience sampling to the intervention arm of the CHESS Study. An additional 25 dyads acted as control participants. Questionnaire data were collected following completion of the CHESS study from 27 informal caregivers from the CHESS Technology group and 16 informal caregivers from the Control group. Measures of health technology acceptability included the System Usability Scale (SUS), the eHealth Literacy Scale (eHEALS), the Technology Readiness Index 2.0 (TRI), and the Unified Theory of Acceptance and Use of Technology Scale (UTAUT). Univariate analyses of variance were used to explore differences between groups.

Results

Internal consistency (Cronbach’s alpha) was high for all measures (range 0.68 – 0.96). The SUS score for the technology group was high (M=70.07, SD=17.69), indicating that the CHESS technology had a high level of usability. All participants had a high level of eHealth literacy (M=33.61, SD=10.51). Both groups performed similarly on the TRI and UTAUT, however the control group indicated greater discomfort with health technology and felt less secure in providing their personal information electronically to healthcare professionals than the technology group.

Conclusion

Caregivers across the technology and control groups had high levels of eHealth literacy and found health technology to be generally acceptable. The CHESS technology in particular was rated as highly usable on the SUS by those who used it. These findings offer support for a Connected Health model of care.

15 FRAILTY AND ADVERSE OUTCOMES IN HIP FRACTURE PATIENTS

Background

Frailty is highly prevalent in older hip fracture patients, conferring greater risk of poorer outcomes including increased Length of Stay (LOS), Nursing Home (NH) placement and mortality

Methods

This prospective observational study took place in a large university hospital with a daily trauma list and an established orthogeriatric service. We compared 3 different screening tools; Rockwood Clinical Frailty Scale (CFS), Zuckerman’s Functional Recovery Score (FRS) and New Mobility Score (NMS) and their ability to predict outcomes in hip fracture patients. Participants included all hip fracture patients (>/= 60 years old) admitted to the orthopaedic ward from 2016-2018. Scores were assigned by an ortho-geriatrician and were analysed at admission and at 1 year.

Results

Increasing frailty scores were associated with increased mortality, LOS and NH admission rates. Those with a CFS of 4-6 had an increased risk of mortality compared to those with a CFS of 1-3 (OR:3.81, CI 2.15-6.76). Those with a CFS of 7-9 demonstrated increased risk of mortality compared to those without frailty (OR: 8.75, CI 4.58-16.72). Patients with mild-moderate frailty (CFS 4-6) were 5 times more likely to require NH at 1-year (OR 5.09, CI 3.03-8.56) and those with severe frailty (CFS 7-9) were 7 times more likely to be in a NH at 1-year (OR 7.03, CI 3.82-12.94). The moderate frailty group had an inpatient stay 16 days longer than the non-frail group and the severe frailty group, 26 days longer than the non-frail group. Results were similar for FRS and NMS and when adjusted for age. Comparing the discrimination of the different measures for predicting survival, analysis of receiver operating characteristic curves revealed - 0.73 (CFS), 0.72 (NMS) 0.74 (FRS). Interestingly, the mortality rate for men was 32% compared to 21% for females (OR: 1.75 p=0.005).

Conclusion

Assessing frailty with a standardised protocol could reliably estimate the risk of adverse outcomes in hip fracture patients.

193 CONNECTED HEALTH SUSTAINING HOME STAY IN DEMENTIA (CHESS): HEALTH-RELATED QUALITY OF LIFE IN CAREGIVERS OF PEOPLE WITH DEMENTIA

Background

Caregivers of People with Dementia (PwD) can experience high levels of distress, which can negatively affect their physical and psychological well-being. We explored factors that influence Health-Related Quality of Life (HRQoL) of caregivers of PwD over 12 months.

Methods

Fifty-two PwD and their informal caregivers were recruited by convenience sampling to the “CHESS” Study. Data were collected at five time points over 12 months between April 2017 and November 2019. Mixed model analyses were used to investigate associations of caregiver HRQoL (measured by the EuroQol Visual Analogue Scale; EQVAS) with factors in four domains: 1) Psychological Well-Being (PWB; measures of anxiety, depression, and caregiver distress); 2) Social Capital and Resources (SCR; incorporating access to community-based health services, transportation needs, education level, occupation and living situation of the PwD, and employment status of the caregiver); 3) Physical Fitness and Health (PFH; including the Quantitative Timed Up and Go (QTUG), baseline grip strength, indices of frailty, sensory acuity); and Managing Everyday life with Dementia (MED; incorporating measures of cognition, behavioural disturbances, functional ability, and indices of dependence of PwD.

Results

In the PWB domain, greater levels of caregiver depression (p<0.001) and a greater change over time in caregiver distress related to PwD behavioural disturbances (p=0.008) predicted lower caregiver HRQoL. In the PFH domain, HRQoL was lower for caregivers of PwD who were frail (p=0.04) and had severe comorbidities (p=0.037). None of the factors within the SCR or MED domains reached significance.

Conclusion

This longitudinal analysis elucidates potential predictors of HRQoL in caregivers of PwD. In particular, caregiver depression and distress related to behavioural disturbances in PwD were shown to significantly impact on HRQoL ratings. Caregiver interventions should be tailored to include support for psychological well-being.

Clozapine prescribing during follow-up of a first-episode psychosis cohort

Introduction

Of those with schizophrenia, one third develop treatment-resistant illness. Nearly 60% of these benefit from clozapine- the only antipsychotic medication licensed in this group.

Objectives

As treatment-resistant illness developed in the follow-up of a first-episode psychosis (FEP) cohort, clozapine was prescribed. This study retrospectively compared the clozapine prescribing patterns, within this cohort, to National Institute for Health and Care Excellence (NICE) guidelines. In addition, impact on hospitalisation, physical health monitoring and augmentation strategies employed following clozapine initiation were examined. Factors delaying initiation of clozapine treatment or contributing to its discontinuation were also explored.

Methods

The study included 339 individuals resident within an Irish community mental health team catchment area, referred with FEP from 1 January 2005 to 31 August 2016. Data were extracted from electronic medical records.

Results

Within the cohort, clozapine was prescribed to 32 individuals (9.4%). The mean number of adequate trials of antipsychotic prior to starting clozapine was 2.74 (SD 1.13; range 1–5). The mean time to clozapine trial was 2.1 years (SD 1.95; range 0.17–6.25). Following initiation of clozapine, mean hospital admissions per year fell from 2.3 to 0.3 (p=0.00). Mean inpatient days pre- and post-clozapine also decreased (147 vs. 53; p=0.00). In all, 18 patients ceased use of clozapine, 5 temporarily and 13 permanently.

Conclusions

Patients are being prescribed clozapine earlier than previously demonstrated. However, delayed treatment remains common, and many patients discontinue clozapine. Further research is necessary to describe and address factors which contribute to its discontinuation.

Disclosure

No significant relationships.

REDUCE-IT: outcomes by baseline statin type

Background

REDUCE-IT (Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial) randomized 8,179 statin-treated patients with elevated triglycerides and increased cardiovascular (CV) risk to either icosapent ethyl (IPE), a pure, stable prescription form of eicosapentaenoic acid, 4g/day or placebo. IPE significantly reduced time to first occurrence of the primary composite endpoint of major adverse CV events (CV death, nonfatal myocardial infarction [MI], nonfatal stroke, coronary revascularization, or hospitalization for unstable angina) (HR 0.75, CI 0.68–0.83) and key secondary endpoint events (composite of CV death, nonfatal MI, or nonfatal stroke) (HR 0.74, CI 0.65–0.83) versus placebo (all p<0.0001). A modest reduction in placebo-corrected LDL-C was observed (−6.6%; p<0.0001). The mechanisms for the CV benefit of icosapent ethyl are not fully understood.

Purpose

Explore the impact of statin type and lipophilic/lipophobic category on outcomes, and on LDL-C, to further consider the possible relevance of LDL-C pathways to the observed CV benefit of icosapent ethyl.

Methods

Primary and key secondary endpoint analyses and LDL-C changes from baseline were explored by individual statin type (atorvastatin, simvastatin, rosuvastatin, or pravastatin) at baseline, and then by categorizing these statins into lipophilic (i.e., hydrophobic: atorvastatin, simvastatin) and lipophobic (i.e., hydrophilic: rosuvastatin, pravastatin) statin groups; 96.1% of patients fell within these individual statin groups.

Results

CV outcomes were similar across statin types (interaction p=0.61) and lipophilic/lipophobic categories (interaction p=0.51) (Figure). Statin type and category had a similar lack of meaningful impact on the modest placebo-corrected median LDL-C changes from baseline to one year, which ranged from −5.8 to −8.4% (all p≤0.0003).

Conclusion

No meaningful treatment differences in the primary or key secondary endpoints across statin type or lipophilic/lipophobic category were observed. A similar lack of treatment difference was observed in LDL-C changes from baseline to one year. Therefore, the LDL-C changes and CV risk reduction in REDUCE-IT appear independent of the type of concomitant statin therapy. These data provide clinicians with additional insight regarding concomitant statin therapy considerations when prescribing icosapent ethyl and suggest there are important mechanisms of action for the substantial CV risk reduction observed with icosapent ethyl that are distinct from the LDL receptor pathway.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): The study was funded by Amarin Pharma, Inc.

REDUCE-IT: accumulation of data across prespecified interim analyses to final results

Background

REDUCE-IT (Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial), an event-driven trial, randomized 8,179 statin-treated patients with elevated triglycerides (TGs) and increased cardiovascular (CV) risk to icosapent ethyl (IPE); pure, stable prescription eicosapentaenoic acid, 4g/day or placebo. 1,612 primary endpoint events (CV death, nonfatal myocardial infarction [MI], nonfatal stroke, coronary revascularization, or hospitalization for unstable angina) projected 90% power to detect 15% relative risk reduction (5% 2-sided alpha). The key secondary composite endpoint was CV death, nonfatal MI, or nonfatal stroke. An independent data and safety monitoring committee (DMC) performed prespecified interim analyses (IAs) at ∼60% (IA1 31 May 2016 data cutoff; 2.9 y median primary endpoint follow-up) and ∼80% (IA2 01 May 2017; 3.7 y) of events; final analysis included 1,606 events (06 Sep 2018; 4.9 y median study follow-up).

Purpose

Explore REDUCE-IT efficacy and safety across prespecified IAs for insight into progression of robustness and consistency of conclusions.

Methods

The interim statistical analysis plan guided study continuation decisions by a prespecified decision-making process, including assessment of safety, treatment arm performance, primary composite endpoint formal analyses, and informal robustness analyses, with no futility or efficacy stopping requirements. Prior to DMC IA study continuation decisions, the need for a mature dataset to support the robustness of final efficacy and safety findings was discussed. Sponsor, Steering Committee, and Clinical Endpoint Committee were blinded throughout.

Results

Primary and key secondary endpoints achieved statistical significance at IA1 and IA2 that persisted at final analyses (p-value below final adjusted 2-sided alpha of 0.0437); hazard ratios also remained consistent and similar robustness was observed across individual endpoint components; clarity of findings across endpoints and subgroups improved with more events. Stopping for overwhelming efficacy was discussed at each IA; prior to IA study continuation recommendations, the DMC considered historical examples of failed CV outcome studies for TG-lowering and mixed omega-3 therapies, reflected on the potential for overestimating final demonstrated benefit using incomplete data, and weighed societal impacts of fuller datasets relative to patient therapy access.

Conclusions

Consistent, potent efficacy emerged early and persisted across the two prespecified interim and final analyses. The mature dataset demonstrated highly statistically significant reductions in the primary (25%; p=0.00000001) and key secondary (26%; p=0.0000006) endpoints and allowed robust analyses to support overall efficacy and safety conclusions. Allowing the REDUCE-IT dataset to fully mature provided clinicians with robust, consistent, and reliable data upon which to base clinical decisions for IPE in CV risk reduction.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): The study was funded by Amarin Pharma, Inc.

REDUCE-IT: total ischemic events reduced across the full range of baseline LDL cholesterol and other key subgroups

Background

REDUCE-IT (Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial), a study of 8,179 randomized statin-treated patients with elevated triglycerides (TG) and increased cardiovascular (CV) risk followed for a median of 4.9 years, demonstrated robust results. Icosapent ethyl (IPE), a pure and stable prescription form of eicosapentaenoic acid, 4g/day reduced both time-to-first and total primary endpoint ischemic events (CV death, nonfatal myocardial infarction [MI], nonfatal stroke, coronary revascularization, or hospitalization for unstable angina) by 25% (HR 0.75; 95% CI 0.68–0.83; p<0.0001) and 30% (rate ratio 0.70; 95% CI 0.62–0.78; p<0.0001), respectively. Similar substantial reductions in first and total key secondary endpoint ischemic events (composite of CV death, nonfatal MI, or nonfatal stroke) were also observed. Demographic and baseline disease characteristics were generally balanced across treatment groups. Time-to-first event analyses showed robust and generally consistent benefit across subgroups. Previous total event analyses by baseline TG demonstrated large, consistent, statistically significant reductions across tertiles, suggesting the CV benefit of IPE is tied primarily to non-TG factors.

Purpose

Further explore the extent to which IPE reduced total primary and key secondary events across prespecified baseline demographic, disease, treatment, and lipid/lipoprotein/inflammatory biomarker subgroups.

Methods

Total events across subgroups were assessed with the prespecified negative binomial regression method. Main outcomes were total (first and subsequent) primary and key secondary composite endpoint events.

Results

Median baseline LDL-C levels in ascending tertiles were 58, 76, and 96 mg/dL; there were large, significant relative reductions in total primary endpoint events with IPE across tertiles (35%, 28%, and 27%, respectively; interaction p=0.62), with parallel substantial absolute risk reductions. Similar, significant relative reductions of 33%, 28%, and 24% in total key secondary endpoint events were observed, along with substantial absolute risk reductions. Total events analyses of prespecified subgroups also demonstrated robust and generally consistent findings for the primary and key secondary composite endpoints.

Conclusion

REDUCE-IT demonstrated substantial reductions in first and total primary and key secondary endpoint ischemic events, with robust and generally consistent results across baseline TG and LDL-C levels, as well as other prespecified baseline biomarker, demographic, disease, and treatment subgroups. These analyses provide useful insights for clinicians considering the range of patients who may benefit from IPE therapy and suggest that mechanisms beyond the lipid/lipoprotein/inflammatory pathways tested, including mechanisms beyond the LDL receptor pathways, may contribute to the observed substantial reductions in total ischemic burden with IPE therapy.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): The study was funded by Amarin Pharma, Inc.

Detection of Rickettsia spp. and Bartonella spp. in Ctenocephalides felis fleas from free-ranging crab-eating foxes (Cerdocyon thous)

Fleas are insects with a worldwide distribution that have been implicated in the transmission of several pathogens. The present study aimed to investigate the presence of Rickettsia spp. (Rickettsiales: Rickettsiaceae) and Bartonella spp. (Rhizobiales: Bartonellaceae) in fleas from free-ranging crab-eating foxes Cerdocyon thous (Linnaeus, 1766) (Carnivora: Canidae) from Rio Grande do Sul, southern Brazil. Fleas were collected manually from animals and used for the molecular detection of Rickettsia spp. and Bartonella spp. Twenty-nine C. thous were sampled in six municipalities. Four foxes were parasitized by 10 fleas, all of which were identified as Ctenocephalides felis (Bouché, 1935) (Siphonaptera: Pulicidae). DNA from Rickettsia felis Bouyer et al., 2001 and Rickettsia asembonensis Maina et al., 2016 were found in three and eight fleas, respectively. In four fleas, DNA of Bartonella sp. was identified. Phylogenetic analysis grouped Bartonella sp. together with other genotypes previously reported in C. felis worldwide. The scenario described in the present study highlights a Neotropical canid parasitized by the invasive cosmopolitan cat flea, which in turn, is carrying potentially invasive vector-borne microorganisms. These findings suggest that C. felis is adapted to wild hosts in wilderness areas in southern Brazil, hypothetically exposing the Neotropical fauna to unknown ecological and health disturbances.

Periapical infection may affect birth outcomes via systemic inflammation

OBJECTIVES

Maternal dental periapical infections are associated with preterm birth and intrauterine growth restriction. This study investigates whether the association is mediated through bacterial spread from periapical lesions to placenta (direct pathway) or systemic inflammatory reaction (indirect pathway).

MATERIALS AND METHODS

We compared birth outcomes in Malawian mothers with and without periapical infection. As markers of a direct pathway, we identified placental bacteria using a 16S rDNA approach and assessed histological evidence of inflammation in the placenta and amniotic membranes. We measured C-reactive protein, alpha-1-acid glycoprotein, and salivary cortisol as markers of an indirect pathway. We used regression models to associate the predictor variables with duration of pregnancy and newborn size.

RESULTS

Of 1,024 women, 23.5% had periapical infection. There was no association of periapical infection with either bacterial DNA or histological inflammation in placenta or membranes. Periapical infection was associated with C-reactive protein, alpha-1-acid glycoprotein, and cortisol concentrations in a dose-dependent manner at 36 weeks. Addition of alpha-1-acid glycoprotein or cortisol concentration into regression models attenuated the association between periapical infection and pregnancy outcomes.

CONCLUSION

There was no evidence of direct spread of periapical bacteria to the placenta. Periapical infections and adverse pregnancy outcomes are in part mediated through systemic inflammation.

Stifle joint luxation in the dog and cat: The use of temporary intraoperative transarticular pinning to facilitate joint reconstruction

Multiple ligament injuries of the canine and feline stifle joint which result in luxation are uncommon. Two cats and one dog, that had sustained such a joint injury were surgically treated. A rupture of the cranial and caudal cruciate ligaments, and at least one collateral ligament was observed in all of the three animals. Prosthetic reconstruction was used, as previously described, in combination with a novel technique of intraoperative placement of a temporary trans-articular pin (TTP) to maintain intra-operative anatomical reduction. TTP placement facilitated maintenance of joint alignment during surgical reconstruction and aided appropriate tensioning of the prosthetic sutures, preventing collapse of femorotibial joint compartments. The TTP was removed prior to closure of the joint allowing immediate post-operative joint mobilisation. Based on assessment by their owners, all the animals made a complete recovery. TTP was considered a relatively simple and effective adjunctive aid for surgical treatment of traumatic luxation of the stifle joint.

Use of Oncept melanoma vaccine in 69 canine oral malignant melanomas in the UK

OBJECTIVES

Oral malignant melanomas carry a poor-to-guarded prognosis because of their local invasiveness and high metastatic propensity. The Oncept melanoma vaccine is licensed to treat dogs with stage II or III locally-controlled oral malignant melanoma and this retrospective study aimed to assess survival of affected dogs treated with the vaccine in the UK.

MATERIAL AND METHODS

Medical records of dogs with histopathologically-confirmed oral malignant melanoma that received the vaccine as part of their treatment were evaluated. Survival analyses for potential prognostic factors were performed.

RESULTS

Sixty-nine dogs were included; 56 dogs, staged I to III, and with previous locoregional therapy, had a median survival time of 455 days (95% CI: 324 to 586 days). Based on Kaplan-Meier survival analysis with associated log-rank testing, no significant prognostic factors were identified for this population. Of the 13 patients with macroscopic disease treated with vaccine alone or in combination therapy, eight showed clinical response. Three patients with stage IV oral malignant melanoma survived 171, 178 and 288 days from diagnosis.

CLINICAL SIGNIFICANCE

Patients treated with the melanoma vaccine in our study had survival times similar to their counterparts receiving the vaccine in the USA. There were observed responses in patients with macroscopic disease and so the vaccine could be considered as palliative treatment in dogs with stage IV disease.

Crenosoma vulpis infection in a four-month old puppy

Here we report the case of a diagnostic and treatment challenge in a four-month old dog from England, presented with one-month history of unproductive cough. Antigen blood test for Angiostrongylus vasorum infection was negative. Thoracic radiographs revealed a generalised bronchointerstitial pattern and bronchoscopy showed moving nematodes in the mucus of the bronchial wall. Additionally, Baermann technique revealed a high burden of larvae per gram of faeces. Morphological and molecular analyses confirmed that they were first stage larvae of Crenosoma vulpis. The infection was firstly treated with a spot-on solution containing 10% imidacloprid + 2.5% moxidectin, but the dog was still positive after 13 days. Therefore, a seven-day course of fenbendazole was prescribed. This represents one of the youngest dogs ever reported naturally infected by C. vulpis. The scant number of reported cases of crenosomosis has led practitioners to consider it as a rare parasitic disease in dogs, delaying a correct and targeted on-time diagnosis. Further studies are needed to perceive the real prevalence of this lungworm and to understand if it is a rare parasite or just rarely diagnosed.

Atopic diseases and inflammation of the brain in the pathogenesis of autism spectrum disorders

Autism spectrum disorders (ASDs) affect as many as 1 in 45 children and are characterized by deficits in sociability and communication, as well as stereotypic movements. Many children also show severe anxiety. The lack of distinct pathogenesis and reliable biomarkers hampers the development of effective treatments. As a result, most children with ASD are prescribed psychopharmacologic agents that do not address the core symptoms of ASD. Autoantibodies against brain epitopes in mothers of children with ASD and many such children strongly correlate with allergic symptoms and indicate an aberrant immune response, as well as disruption of the blood-brain barrier (BBB). Recent epidemiological studies have shown a strong statistical correlation between risk for ASD and either maternal or infantile atopic diseases, such as asthma, eczema, food allergies and food intolerance, all of which involve activation of mast cells (MCs). These unique tissue immune cells are located perivascularly in all tissues, including the thalamus and hypothalamus, which regulate emotions. MC-derived inflammatory and vasoactive mediators increase BBB permeability. Expression of the inflammatory molecules interleukin (IL-1β), IL-6, 1 L-17 and tumor necrosis factor (TNF) is increased in the brain, cerebrospinal fluid and serum of some patients with ASD, while NF-kB is activated in brain samples and stimulated peripheral blood immune cells of other patients; however, these molecules are not specific. Instead the peptide neurotensin is uniquely elevated in the serum of children with ASD, as is corticotropin-releasing hormone, secreted from the hypothalamus under stress. Both peptides trigger MC to release IL-6 and TNF, which in turn, stimulate microglia proliferation and activation, leading to disruption of neuronal connectivity. MC-derived IL-6 and TGFβ induce maturation of Th17 cells and MCs also secrete IL-17, which is increased in ASD. Serum IL-6 and TNF may define an ASD subgroup that benefits most from treatment with the natural flavonoid luteolin. Atopic diseases may create a phenotype susceptible to ASD and formulations targeting focal inflammation of the brain could have great promise in the treatment of ASD.

Abstract P6-12-03: Delays in diagnosis and treatment of breast cancer patients: A safety-net population profile

Background: Timely detection and treatment of breast cancer patients is important in survival and recurrence. Given disparities in breast cancer outcomes based on socioeconomic status, we examined the time to diagnosis and treatment in a safety net hospital.

Methods: We conducted a retrospective review of all breast cancer patients identified by cancer registry records from 7/1/2010 to 6/30/2012 (n=124). We excluded patients with primary stage IV (n=8) and those with recurrent breast cancer within 5 years of primary diagnosis (n=4). We determined intervals between presentation to diagnosis, diagnosis to first treatment, last surgery to chemotherapy start, and last surgery to radiation start. We used logistic regression to calculate unadjusted odds of receiving timely treatment (< median time) versus more delayed treatment (≥ median time) as a function of age, language, ethnicity, insurance, Charlson co-morbidity index, cancer stage, method of first presentation (screening mammography vs. care provider), symptoms at presentation, and type of surgical treatment.

Results: Of 112 patients, the median age was 59. 42.9% were Hispanic, 29.5% were White, and 24.1% were African American. Clinical stage distribution was 20.0% stage 0, 31.8% stage I, 40.9% stage II, and 8% stage III. 83.9% of patients had surgery, of which 51.1% had breast conservation. The median time from presentation to diagnosis, time from diagnosis to first treatment, and time from surgery to chemotherapy start, fell within recommended intervals (Table 1). The time from last surgery to radiation start was greater than recommended intervals. Variables with significantly increased odds of taking longer than the median time include: stage, method of presentation, language, Charlson index, surgical treatment, ethnicity, symptoms at presentation (Table 2).

Conclusion: Acceptable diagnosis and treatment intervals were obtained for disadvantaged patients, except for time to radiation therapy. Room for improvement exists: focused interventions to facilitate access to radiation therapy, aid providers in accessing imaging more quickly, aid non-English speaking and Hispanic patients could lead to improved breast cancer care.

Table 1. Intervals of CareMeasure: Time From...Median (days)25th, 75th % (days)Recommended Intervals (days)Presentation to Diagnosis197, 4360Diagnosis to 1st Treatment3730, 4821-60Presentation to 1st Treatment6247, 83n/aLast Surgery to Chemo Start4831, 5928-90Last Surgery to Radiation Start*6853,7942-56* for patients needing surgery and radiation only

Table 2. Un-adjusted Odds Ratio of Taking Longer than Median TimeIntervalVariableReferenceO.R.p-valuePresentation to DiagnosisStage II or IIIStage 0 or I2.880.008 Method of Presentation: Care ProviderMethod of Presentation: Screening Mammogram4.270.0004Diagnosis to First TreatmentAge< 55Age ≥ 552.180.070 English-speakingNon-English speaking0.220.005 Charlson Index ≥ 3Charlson Index <30.420.040 Symptomatic PresentationAsymptomatic Presentation2.830.040 Breast ConservationMastectomy2.840.020Presentation to First TreatmentHispanicNon-Hispanic2.650.022 Charlson Index ≥ 3Charlson Index <30.520.120 Method of Presentation: Care ProviderMethod of Presentation: Screening Mammogram3.160.008

Citation Format: Jaiswal KR, Furniss A, Doyle R, Gayou N, Bayliss EA. Delays in diagnosis and treatment of breast cancer patients: A safety-net population profile. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-12-03.

The Porphyromonas gingivalis hemagglutinins HagB and HagC are major mediators of adhesion and biofilm formation

Porphyromonas gingivalis is a bacterium associated with chronic periodontitis that possesses a family of genes encoding hemagglutinins required for heme acquisition. In this study we generated ΔhagB and ΔhagC mutants in strain W83 and demonstrate that both hagB and hagC are required for adherence to oral epithelial cells. Unexpectedly, a double ΔhagB/ΔhagC mutant had less severe adherence defects than either of the single mutants, but was found to exhibit increased expression of the gingipain-encoding genes rgpA and kgp, suggesting that a ΔhagB/ΔhagC mutant is only viable in populations of cells that exhibit increased expression of genes involved in heme acquisition. Disruption of hagB in the fimbriated strain ATCC33277 demonstrated that HagB is also required for stable attachment of fimbriated bacteria to oral epithelial cells. Mutants of hagC were also found to form defective single and multi-species biofilms that had reduced biomass relative to biofilms formed by the wild-type strain. This study highlights the hitherto unappreciated importance of these genes in oral colonization and biofilm formation.

PA3 Using the lived experience of volunteers to enhance the care of dying patients and their families

BACKGROUND

In the UK, the majority of people die in hospital.(1) Community presence is considered to be a significant component to achieving a "good death",(2,3) however many patients die with no/few visitors, spending their last weeks of life isolated or alone.

AIM

To establish a Volunteer Service and offer: A presence to dying patients. A connexion to the community outside the Hospital. Support to families, unable to visit or emotionally exhausted from their bedside vigil.

METHODS

The Service was piloted on 6 wards (October 2012-March 2013) within a large NHS Trust, in the North of England. This was followed by a comprehensive evaluation, according to MRC guidance.

RESULTS

Analysis of the service evaluation indicated that the service was extremely beneficial, meeting its aims in providing an emotional support and spiritual presence to dying patients, and their families.

CONCLUSION

The Service provides a model of best practice that could be replicated in other Trusts and within other care settings. There are plans to further develop and expand service provision across the Trust.

REFERENCES

National End of Life Care Intelligence Network. What we know now. 2013. http://www.endoflifecare-intelligence.org.uk/resources/publications/what_we_know_now_2013 Department of Health. End of Life Care Strategy. 2008. https://www.gov.uk/government/publications/end-of-life-care-strategy-promoting-high-quality-care-for-adults-at-the-end-of-their-life Kellehear A. The end of death in late modernity, an emerging public health challenge. Crit Public Health 2007;17(1):71-79.

A double-edged sword: review of the interplay between physical health and mental health

It is widely acknowledged that there is interplay between physical and mental health, with causality in both directions. A common theme across countries is the uncertainty surrounding who should act as gatekeeper for physical health matters in psychiatry. Much of the metabolic monitoring is carried out by psychiatrists who often feel ill equipped to treat medical problems such as abnormal cholesterol or disturbances of glucose metabolism. However many patients do not attend primary care on a regular basis and may not be likely to follow through on referral to primary care. This review aims to examine the interplay between co-morbid physical and mental health conditions, identify the physical health conditions particularly associated with severe affective and psychotic illness and briefly discuss interventions and recommendations in this area. As people with severe mental illness die 10-20 years younger than their peers, with much of this premature mortality due to cardiovascular disease, this topic is emerging as one of great importance amongst clinicians and policymakers internationally.

A case of malignancy-associated cryoglobulinemia

We present a case of type 1 cryoglobulinemia with an underlying hematological malignancy. Unusually, the entire unifying diagnosis was made on the basis of the renal biopsy. Initially, serum cryoglobulin was not identified; repeat samples were positive. It is important to note that there is a significant false-negative rate with laboratory testing for cryoglobulin, due, at least in part, to the specific conditions required for collection and processing. With that in mind, in all cases with strong clinical or histological evidence of cryoglobulin but negative testing, carefully repeated samples should be sent.

Relationship between cancer and psychology: an updated history

The mechanism and formation of cancer have always been topics of interest for scientists, even for doctors in ancient times. Nowadays a great role for cancer is played by psychological stress which promotes relevant changes in neuronal activity and gene regulations across the different brain areas. It has been reported by many authors that stress can have an important role in the immune system and may be relevant in the formation of cancer. Our observations, in accordance with other research studies, confirm the importance of the influence of depression, linked to neuroendocrine stress, on the enhancement of cancer pathogenesis by inhibiting anti-tumor immune responses. In this article we review the past and present history of the relationship between cancer and psychology.

Longer-term risk of Mycobacterium bovis in Irish cattle following an inconclusive diagnosis to the single intradermal comparative tuberculin test

In Ireland, new bovine tuberculosis (bTB) cases are detected using both field and abattoir surveillance. During field surveillance, an animal may be deemed a 'standard inconclusive reactor' (SIR) to the single intradermal comparative tuberculin test (SICTT) if the bovine response is >2mm, and from 1 to 4mm greater than the avian response. Little is known about the future infection risk posed by SIR animals that pass a subsequent retest, so-called 'transient SIR' (TIR) animals. The objective of this study was to critically evaluate the future bTB status of TIR animals, by examining the future risk of bTB diagnosis over the 4 years following initial SIR diagnosis and clearance at the subsequent retest. The study included all TIRs that were identified as SIRs in 2005 in otherwise free herds at tests with no other reactors at that test and that were clear at the subsequent retest. The analysis was restricted to cows that were neither sold, other than direct to slaughter, nor exported from the herd during the follow up period (to the end of 2009). Five control cows were randomly selected from each study herd. A parametric survival model with shared frailties, to account for clustering within herds, was developed to model time from passing a retest to future bTB diagnosis. The final parametric survival model contained the variables: TIR status in 2005, inconclusive status during the follow-up period, location, herd restricted during the study, time since last restriction within the herd and age. The time ratio for the TIR status variable was significant (p<0.001) indicating that on average the time to diagnosis with bTB for TIRs was 78% shorter compared to the non-TIRs. The frailty term was significant (p<0.001) indicating that animals within some herds were more likely to become reactors compared to other herds. These results have important implications for national policy and future management of TIR animals. Further, private veterinary practitioners and their clients should be aware of the increased risk associated with TIRs.

Psychological stress and vitamins

Conditions of stress and anxiety have complex interactions with insufficient vitamin intake and malnutrition. This study, based on literature research in Medline, analyzes the inter-relationship between vitamins and stress. This report concerns a number of vitamins that have been receiving much attention in earlier reviews of the literature, for their potential to protect against stress-related events, and focus is placed upon recent findings.

Use of a biodegradable self-expanding stent in the management of a benign oesophageal stricture in a cat

An 11-year-old domestic shorthair cat presented with a six-week history of regurgitation following a dental procedure. Endoscopy identified a single oesophageal stricture in the cervical oesophagus. Stricture reformation occurred following endoscopic balloon catheter dilation on two occasions. Following a third balloon dilation a biodegradable polydioxanone self-expanding stent was placed across the stricture site. Following the implantation the cat was able to eat soft canned food orally without regurgitation. Fluoroscopic examination performed four months after placement indicated that the stent was no longer present and the cervical oesophagus was able to pass boluses of canned food with no signs of obstruction.

Autism and immunity: revisited study

Autism spectrum disorder is of interest neurochemically because it represents a relatively homogeneous disorder with regard to disease development, abnormal cognitive development and intellectual development disturbance. A consistent finding in autistic children is a high number of mast cells and a high level of serotonin which is also found at elevated concentrations in the urine of autistic patients. In addition, a dysfunction of clinical conditions, such as gastrointestinal and immunological symptoms, is frequently noted in autistic children, however, IgE does not appear to be prevalent in these children but probably an increase of cytokines/chemokines produced by mast cells at an early age may play an important role. Therefore an immune hypothesis, involving also autoimmunity, is one possible pathogenetic mechanism in autism. In conclusion, mast cell activation could contribute to immune and neuroinflammatory abnormalities that are evident in patients with autism spectrum disorders.

Biology of neurotensin: revisited study

The tridecapeptide neurotensin (NT) acts in the mammalian brain as a primary neurotransmitter or neuromodulator of classical neurotransmitters. Morphological and functional in vitro and in vivo studies have demonstrated the existence of close interactions between NT and dopamine both in limbic and in striatal brain regions. Additionally, biochemical and neurochemical evidence indicates that in these brain regions NT also plays a crucial role in the regulation of the aminoacidergic signalling. Immune cells, such as lymphocytes, macrophages and mast cells are reported to be activated by neuropeptides, such as neurotensin; this activation leads to cytokine and immunoglobulin production. In addition, neurotensin increases calcium level and the production of nitric oxide. Therefore neurotensin is deeply involved in immunity and inflammation but its real function still remains to be elucidated.

Quality of life in non-allergic rhinitis depends on the predominant inflammatory cell type

Three main types of inflammatory Non-Allergic Rhinitis (NAR) have been defined: NAR infiltrated by eosinophils (NARES), by mast cells (NARMA), and by neutrophils (NARNE). In the absence of studies that investigated the Quality of Life (QoL) in NAR, the present work is aimed at evaluating the Quality of Life of patients with NARES, NARMA, and NARNE. One hundred thirty one (131) NAR patients were prospectively and consecutively evaluated: 54 patients with NARES, 38 with NARMA, and 39 with NARNE. Their history, nasal infiltration and rhinomanometry were characterized, and Quality of Life (using 2 instruments) was evaluated, and associated to clinical and histological features. Quality of Life was significantly different in the 3 groups (p less than 0.001); NARES patients had the worst Quality of Life. Nasal resistances were significantly higher in the NARES group. Significant associations were shown in NARES patients between Quality of Life and nasal function. This study provides the first evidence that Quality of Life is impaired in NAR as well as in allergic rhinitis. Furthermore, Quality of Life impairment differs among the various forms of NAR, and there is a correlation with the cellular infiltrating type.

Multilocus sequence typing of Campylobacter jejuni isolates from New South Wales, Australia

AIMS

Multilocus sequence typing (MLST) was used to examine the diversity and population structure of Campylobacter jejuni isolates associated with sporadic cases of gastroenteritis in Australia, and to compare these isolates with those from elsewhere.

METHODS AND RESULTS

A total of 153 Camp. jejuni isolates were genotyped. Forty sequence types (STs) were found, 19 of which were previously undescribed and 21 identified in other countries. The 19 newly described STs accounted for 43% of isolates, 16 of which were assigned to known clonal complexes. Eighty-eight percent of isolates were assigned to a total of 15 clonal complexes. Of these, four clonal complexes accounted for 60% of isolates. Three STs accounted for nearly 40% of all isolates and appeared to be endemic, while 21 STs were represented by more than one isolate. Seven infections were acquired during international travel, and the associated isolates all had different STs, three of which were exclusive to the travel-acquired cases. Comparison of serotypes among isolates from clonal complexes revealed further diversity. Eight serotypes were identified among isolates from more than one clonal complex, while isolates from six clonal complexes displayed serotypes not previously associated with those clonal complexes.

CONCLUSIONS

Multilocus sequence typing is a useful tool for the discrimination of subtypes and examination of the population structure of Camp. jejuni associated with sporadic infections.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study highlights the genotypic diversity of Camp. jejuni in Australia, demonstrating that STs causing disease have both a global and a local distribution evident from the typing of domestically and internationally acquired Camp. jejuni isolates.

Study of the pharmacokinetic interaction between simvastatin and prescription omega-3-acid ethyl esters

The coadministration of prescription omega-3-acid ethyl esters (P-OM3) with a statin may present a treatment option for patients with mixed hyperlipidemia. This open-label, randomized, 2-way crossover, drug-drug interaction study evaluated the impact of P-OM3 capsules on plasma simvastatin pharmacokinetics in 24 healthy volunteers. Under fasted conditions, 80 mg simvastatin was administered with or without 4 g P-OM3 for two 14-day periods. After 14 days of dosing to achieve steady state, no significant differences were found in either the extent (AUC(tau)) or rate (Cmax) of exposure to simvastatin or its major beta-hydroxy metabolite after coadministration of P-OM3 with simvastatin compared with administration of simvastatin alone. At steady state, the coadministration of P-OM3 capsules did not appear to affect the pharmacokinetics of simvastatin tablets. The combination of P-OM3 capsules and simvastatin appeared to be well tolerated.

Psychometric comparison of students in medicine and other faculties: social factors and psychologic symptoms

Few studies have investigated personality and psychopathological profiles associated to the choice of university education. Our study examined students from four faculties of Turin University, in Turin, Italy (Medicine, Engineering, Education, Law), comparing sociodemographic features, personality characteristics and psychiatric symptoms. A heterogeneous group of 1,323 students were assessed using a semistructured interview, the Personality Diagnostic Questionnaire-Revised (PDQ-R), and the Symptoms Checklist 90 (SCL-90). Statistical analysis included four logistic regression models, each fitted for one faculty, considering the other three as a control group. Associations were found in Medical and Engineering students concerning type of high school, school final score, and father?s socioeducational level. Factors associated with students of Law and Education included socioeducational characteristics, but stronger correlations were seen with PDQ-R personality scales and SCL-90 symptom clusters. In conclusion, four different profiles were identified. Medicine was not significantly related to personality and psychiatric factors. Engineering was related to male gender, choice of technical high school and father?s social level. Law was related to female gender and narcissistic personality profile. These data may be useful for counseling activities addressed to high school and university students.

Circulating levels of beta2-glycoprotein I in thrombotic disorders and in inflammation

Beta2-glycoprotein I (beta2GPI) is a plasma protein suspected to have a role in inhibition of thrombosis. This suspicion is reinforced by the observation that beta2GPI is the major target for autoantibodies in the antiphospholipid syndrome. However, little is known about its circulating levels in common thrombotic diseases or inflammation. We measured beta2GPI levels in 344 healthy controls, 58 normal pregnancies, 102 patients with non-haemorrhagic stroke, 121 patients with acute coronary syndrome and 200 patients with elevated C-reactive protein (CRP). In healthy individuals, we found a strong positive correlation between age and beta2GPI concentration (r = 0.274, P < 0.001) and that beta2GPI levels fall significantly after the eighth week of pregnancy (P = 0.002). We also found significantly reduced levels of beta2GPI in patients with stroke and in elderly patients with myocardial syndrome (P = 0.013 and 0.043). However, in neither group did beta2GPI levels change in the following six months, suggesting that the reduced levels were not a transient post-event phenomenon. In patients with inflammation, beta2GPI levels showed a significant negative correlation with CRP (r = -0.284, P < 0.001) and positively correlated with albumin and transferrin (r = 0.372 and 0.453, respectively with P < 0.001 for both). Furthermore, the largest reduction in beta2GPI levels occurred in patients with the highest CRP values (P < 0.001).

Adrenoceptor blockade alters plasma gelatinase activity in patients with heart failure and MMP-9 promoter activity in a human cell line (ECV304)

This study assessed the effects of short-term adrenoceptor blockade on plasma matrix metalloproteinase (MMP) activity in patients with heart failure, and the ability of adrenoceptor stimulation to modulate matrix metalloproteinase-9 (MMP-9) promoter activity in vitro. Patients with heart failure received standard therapy or standard therapy plus carvedilol. Plasma MMP activity was determined by zymography and tissue inhibitor (TIMP-1) expression was measured by immunoblotting. MMP-9 promoter activity was assessed in transfected ECV304 cells following exposure to isoprenaline or phenylephrine in the absence or presence of either propranolol or prazosin. In patients with heart failure, carvedilol attenuated the increase in proMMP-9 activity observed at 4 and 12 weeks in non-beta-blocker-treated patients (44.0 +/- 4.9 AU versus 60.8 +/- 6.7 AU; P < 0.05). Although TIMP-1 expression was unaltered, the MMP-9:TIMP-1 ratio was lower in those receiving carvedilol at 4 and 12 weeks (0.54 +/- 0.07 versus 1.04 +/- 0.17; P < 0.05). Isoprenaline transiently increased MMP-9 promoter activity after 4 h exposure (80.6 +/- 14.8-fold; P < 0.001) before returning to baseline. The response to isoprenaline was prevented by propranolol (P < 0.01). Phenylephrine caused a biphasic increase in MMP-9 promoter activity, with the greatest increase occurring at 24 h (23 +/- 3.7-fold) compared to baseline. This response was unaffected by co-incubation with prazosin. In conclusion, treatment with a mixed alpha1/beta-adrenoceptor antagonist attenuates MMP activity and tips the degradative balance to a less degradative phenotype in heart failure patients. Furthermore, adrenoceptor stimulation increases MMP-9 promoter activity, which is inhibited by beta- but not alpha-adrenoceptor blockade. Therefore, mixed adrenoceptor blockade may reduce remodeling in heart failure as a direct consequence of a beta-adrenoceptor-mediated reduction in MMP-9 transcription.

Magnetic resonance imaging in the diagnosis and surgical management of sacral osteochondrosis in a mastiff dog

The clinical, radiographic, magnetic resonance imaging (MRI), surgical and pathological findings related to an osteochondral lesion of the sacrum in a mastiff dog are described. The dog showed chronic signs of pain in its pelvic limbs. Radiography revealed a triangular mineralised opacity at the craniodorsal aspect of the sacrum consistent with sacral osteochondrosis. A T2-weighted spin-echo MRI revealed dorsal and lateral compression of the cauda equina. The osteochondral fragment was removed via a dorsal laminectomy, and the clinical signs resolved. Histological abnormalities in the fragment were consistent with a diagnosis of osteochondrosis.

Re-examining comorbidity of Obsessive Compulsive and Attention-Deficit Hyperactivity Disorder using an empirically derived taxonomy

BACKGROUND

Using an empirically derived instrument to reduce the assessor bias inherent in structured diagnostic interviews, we sought to re-examine and validate the putative comorbidity between Obsessive Compulsive Disorder (OCD) and Attention-Deficit/Hyperactivity Disorder (ADHD) in children and adolescents.

METHOD

We examined the correlation between Child Behavior Checklist (CBCL) syndrome, competence, and composite scores in children with: 1) OCD plus ADHD (OCD + ADHD), N = 47; 2) OCD without comorbid ADHD (OCD), N = 33; 3) ADHD without comorbid OCD (ADHD) N = 43; and 4) comparison controls recruited from general pediatric clinics,N = 32.

RESULTS

CBCL findings in our ADHD children were similar to previous findings reported in ADHD youth, irrespective of the presence or absence of comorbid OCD. Comorbid youth generally had additive scores on the CBCL scales, reflecting the independent contribution of symptomatic and functional impairment from each disorder.

CONCLUSION

These findings suggest that when ADHD-like symptoms are seen in OCD youth, they reflect a true comorbid state of OCD plus ADHD. The CBCL may provide a rapid assessment tool to identify comorbid ADHD in OCD youth.

Low serum cholesteryl ester-docosahexaenoic acid levels in Alzheimer's disease: a case-control study

Low n-3 polyunsaturated fatty acid (PUFA) status may be associated with neuro-degenerative disorders, in particular Alzheimer's disease, which has been associated with poor dietary fish or n-3 PUFA intake, and low docosahexaenoic acid (DHA) status. The present case-control study used an established biomarker of n-3 PUFA intake (serum cholesteryl ester-fatty acid composition) to determine n-3 PUFA status in patients with Alzheimer's disease, who were free-living in the community. All cases fulfilled the National Institute of Neurological and Communicative Disorders and Stroke and Alzheimer's Disease and Related Disorders Association criteria for Alzheimer's disease. Detailed neuropsychological testing and neuroimaging established the diagnosis in all cases. The subjects (119 females and twenty-nine males) aged 76.5 (SD 6.6) years had a clinical dementia rating (CDR) of 1 (SD 0.62) and a mini mental state examination (MMSE) score of 19.5 (SD 4.8). The control subjects (thirty-six females and nine males) aged 70 (SD 6.0) years were not cognitively impaired (defined as MMSE score <24): they had a mean MMSE score of 28.9 (SD 1.1). Serum cholesteryl ester-eicosapentaenoic acid and DHA levels were significantly lower (P<0.05 and P<0.001 respectively) in all MMSE score quartiles of patients with Alzheimer's disease compared with control values. Serum cholesteryl ester-DHA levels were progressively reduced with severity of clinical dementia. DHA levels did not differ in patients with Alzheimer's disease across age quartiles: all were consistently lower than in control subjects. Step-wise multiple regression analysis showed that cholesteryl ester-DHA and total saturated fatty acid levels were the important determinants of MMSE score and CDR. It remains to be determined whether low DHA status in Alzheimer's disease is a casual factor in the pathogenesis and progression of Alzheimer's disease.