Family Recall of and Response to Germline Pathologic Variants Found on Paired Tumor-Germline Sequencing in Pediatric Oncology

PURPOSE

Paired tumor-germline sequencing can identify somatic variants for targeted therapy and germline pathogenic variants (GPVs) causative of hereditary cancer/tumor predisposition syndromes. It is unknown how patients/families in pediatric oncology use information about an identified GPV. We assessed recall of germline results and actions taken on the basis of findings.

METHODS

We completed phone surveys with patients (and/or their parent) with GPVs identified via a single academic medical center's paired tumor-germline sequencing study. Seven hundred forty pediatric (aged 0-25 years) oncology patients were enrolled in this sequencing study between May 2012 and August 2021. Ninety-six participants (13.0%) had at least one GPV identified and were therefore eligible for this survey. The parent/guardian (for patients younger than 18 years or deceased patients) or patients themselves (if 18 years or older) were contacted. Survey topics included germline result recall, experience with genetic counseling, changes to patient's cancer treatment/screening, sharing of results with family members, and lifestyle changes.

RESULTS

Fifty-three surveys (response rate, 55.2%) were completed between October 2021 and June 2022. Thirty-seven (69.8%) respondents correctly recalled the identified GPV. Discussing results with a genetic counselor (P = .0001), having a GPV related to the cancer/tumor diagnosis (P = .002), and non-Hispanic White race/ethnicity (P = .02) were associated with accurate recall. Twenty-five respondents (47.2%) reported a change in the child's cancer treatment and/or screening recommendations, 17 respondents (32.1%) made a lifestyle change on the basis of the results, and 44 respondents (83.0%) shared results with at least one family member.

CONCLUSION

While most respondents remembered that a GPV was identified in the patient, some did not recall having a GPV found, and others recalled germline findings incorrectly. Future work may determine patient/family preferences for timing/method of result return to optimize patient recall and use of germline results.

Psychosocial factors impacting barriers and motivators to cancer genetic testing

BACKGROUND

Only a small proportion of patients who qualify for clinical genetic testing for cancer susceptibility get testing. Many patient-level barriers contribute to low uptake. In this study, we examined self-reported patient barriers and motivators for cancer genetic testing.

METHODS

A survey comprised of both new and existing measures related to barriers and motivators to genetic testing was emailed to patients with a diagnosis of cancer at a large academic medical center. Patients who self-reported receiving a genetic test were included in these analyses (n = 376). Responses about emotions following testing as well as barriers and motivators prior to getting testing were examined. Group differences in barriers and motivators by patient demographic characteristics were examined.

RESULTS

Being assigned female at birth was associated with increased emotional, insurance, and family concerns as well as increased health benefits compared to patients assigned male at birth. Younger respondents had significantly higher emotional and family concerns compared to older respondents. Recently diagnosed respondents expressed fewer concerns about insurance implications and emotional concerns. Those with a BRCA-related cancer had higher scores on social and interpersonal concerns scale than those with other cancers. Participants with higher depression scores indicated increased emotional, social and interpersonal, and family concerns.

CONCLUSIONS

Self-reported depression emerged as the most consistent factor influencing report of barriers to genetic testing. By incorporating mental health resources into clinical practice, oncologists may better identify those patients who might need more assistance following through with a referral for genetic testing and the response afterwards.

The Michigan Genetic Hereditary Testing (MiGHT) study's innovative approaches to promote uptake of clinical genetic testing among cancer patients: a study protocol for a 3-arm randomized controlled trial

BACKGROUND

Although most cancers are sporadic, germline genetic variants are implicated in 5-10% of cancer cases. Clinical genetic testing identifies pathogenic germline genetic variants for hereditary cancers. The Michigan Genetic Hereditary Testing (MiGHT) study is a three-arm randomized clinical trial that aims to test the efficacy of two patient-level behavioral interventions on uptake of cancer genetic testing.

METHODS

The two interventions being tested are (1) a virtual genetics navigator and (2) motivational interviewing by genetic health coaches. Eligible participants are adults with a diagnosis of breast, prostate, endometrial, ovarian, colorectal, or pancreatic cancer who meet the National Comprehensive Cancer Network (NCCN) criteria for genetic testing. Participants are recruited through community oncology practices affiliated with the Michigan Oncology Quality Consortium (MOQC) and have used the Family Health History Tool (FHHT) to determine testing eligibility. The recruitment goal is 759 participants, who will be randomized to usual care or to either the virtual genetics navigator or the motivational interviewing intervention arms. The primary outcome will be the proportion of individuals who complete germline genetic testing within 6 months.

DISCUSSION

This study addresses patient-level factors which are associated with the uptake of genetic testing. The study will test two different intervention approaches, both of which can help address the shortage of genetic counselors and improve access to care.

TRIAL REGISTRATION

This study has been approved by the Institutional Review Board of the University of Michigan Medical School (HUM00192898) and registered in ClinicalTrials.gov (NCT05162846).

Motivational interviewing for genetic counseling: A unified framework for persuasive and equipoise conversations

Genetic counselors (GCs) have traditionally been trained to adopt a position of equipoise or clinical neutrality. They provide information, answer questions, address barriers, and engage in shared decision-making, but generally, they do not prescribe a genetic test. Historically, GCs have generally been trained not to persuade the ambivalent or resistant patient. More recently, however, there has been discussion regarding when a greater degree of persuasion or directionality may be appropriate within genetic counseling (GC) and what role MI may play in this process. The role for "persuasive GC" is based on the premise that some genetic tests provide actionable information that would clearly benefit patients and families by impacting treatment or surveillance. For other tests, the benefits are less clear as they do not directly impact patient care or the benefits may be more subjective in nature, driven by patient values or psychological needs. For the former, we propose that GCs may adopt a more persuasive clinical approach while for the latter, a more traditional equipoise stance may be more appropriate. We suggest that motivational interviewing (MI) could serve as a unifying counseling model that allows GCs to handle both persuasive and equipoise encounters. For clearly beneficial tests, while directional, the MI encounter can still be non-directive, autonomy-supportive, and patient-centered. MI can also be adapted for equipoise situations, for example, placing less emphasis on eliciting and strengthening change talk as that is more a behavior change strategy than a shared decision-making strategy. The core principles and strategies of MI, such as autonomy support, evocation, open questions, reflective listening, and affirmation would apply to both persuasive and equipoise encounters. Key issues that merit discussion include how best to train GCs both during their initial and post-graduate education.

Oncologist knowledge of cost of genetic testing

10591

Background: Genetic testing allows patients and their families to identify hereditary cancer syndromes. Financial barriers to genetic testing are a major concern for patients offered genetic risk assessment. The cost of germline genetic testing has decreased substantially over the last several years. It is not clear, however, that oncologists are knowledgeable about the cost of genetic testing. The purpose of this study was to investigate oncologists’ knowledge of genetic testing costs. Methods: We deployed a survey to all oncologists who are members of the Michigan Oncology Quality Consortium, a physician-led quality improvement collaborative whose members represent 95% of the oncologists in Michigan. The modified Dillman method was used to achieve the maximum response rate. Responses were collected from December 2020 through May 2021. The responses to the question, “If a patient were to ask you how much it would cost for them to have clinical genetic testing for hereditary cancer syndromes, what would you tell them?” were independently coded by three investigators into one of three categories – correct and helpful, correct and not helpful, or incorrect and not helpful. We investigated associations between the number of years in practice and how important was cost as a barrier to genetic risk assessment. Results: The response rate to the survey was 61.2% (194/317). Only 25% of respondents provided an answer that was deemed to be both correct and helpful to a patient, for example “approximately $250 if out of pocket.” Nearly 40% of respondents gave an answer that was correct but was non-specific and would not help a patient decide about pursuing genetic testing. This category included responses such as deferring to a genetic counselor or that cost varies based on insurance. About 28% gave an incorrect response, such as “several thousand dollars” or responded, “I don’t know.” No associations were found between cost response category, number of years in practice, or reported responses that financial barriers play a role in referral patterns. Conclusions: The majority of oncologists in our statewide sample do not have an accurate understanding of the cost of germline genetic testing. Lack of precise information about the costs of testing may lead patients to believe that genetic testing is either not important or not within reach. Furthermore, providing incorrect information can have a downstream effect and prevent patients and their families from pursuing genetic counseling. Improving oncologists’ knowledge about the cost of testing may decrease barriers to uptake of genetic risk assessment. [Table: see text]

Family history assessment to identify patients at risk for hereditary cancer syndromes in community oncology practices

e18735

Background: Identification of hereditary cancer syndromes can have implications for cancer treatment and prevention. However, only a fraction of cancer patients undergo germline genetic testing (GT). We employed a family health history tool (FHHT) to assist in identifying cancer patients eligible for GT in the outpatient oncology setting. Methods: Patients with cancer with a visit scheduled at one of two community-based oncology practices received email invitations to complete a web-based FHHT that elicits cancer type and age at diagnosis for 1st and 2nd degree relatives. NCCN guidelines were applied to identify individuals meeting clinical criteria for GT. We compared proportions of individuals eligible for GT by sex and cancer type using Fisher’s exact tests. Results: Of the 1292 cancer patients seen over a 4-month period, 276 (21.4%) completed the FHHT. Of those, 58% were female (N = 160) and breast cancer was the most common cancer diagnosis (N = 73, 26.4%), followed by prostate (N = 25, 9.1%) and colorectal cancer (CRC) (N = 15, 5.4%). 59 (21.3%) patients met criteria for GT, including 49.3% of those with breast cancer (N = 36), 66.7% of those with CRC (N = 10), 28% of those with prostate (N = 7), and 100% of those with pancreatic and ovarian cancers (N = 3 each). Breast cancer accounted for 61% of those meeting GT criteria, including personal history of breast cancer age < 50 (N = 17), and personal history of breast cancer with family history of ovarian cancer (N = 7). The proportion of CRC patients meeting GT criteria was higher than for breast cancer (66.7% vs 49.3%). Seven of 10 (70%) CRC patients meeting GT criteria would not have been identified without their accompanying family history. Overall, women were more likely than men to meet GT criteria (OR 1.8, 95% CI: 1.01 to 3.47, p = 0.045). Conclusions: Approximately 1 in 5 cancer patients who were invited to complete the FHHT met NCCN guidelines for GT. While a personal history of young breast cancer was the most common GT eligibility criterion, the proportion of patients eligible for GT was highest among CRC. Across all cancer types, family history increased the number of patient meeting GT criteria by 42.4%. Implementing a patient-facing family history tool can assist community oncologists in clinically appropriate identification of cancer patients who are eligible for GT. While 48% of patients who completed the FHHT met GT criteria, generalizability is limited due to small sample size.[Table: see text]

Effects of healthcare provider recommendation for genetic testing

10601

Background: This pilot study was conducted to elucidate the barriers and drivers for genetic testing by combining validated measures to inform the content of a clinical trial aimed at increasing uptake of clinically appropriate genetic testing amongst individuals with a personal history of cancer. Previous research shows that the rate of recommendation of genetic testing varies among Healthcare Providers (HCPs) despite national guidelines. Here we evaluate the rate and effect of HCP recommendation on the uptake of clinical cancer genetic testing. Methods: Data for these analyses were obtained from a cross-sectional survey completed by 794 adults (> 18 years) who were diagnosed with cancer in the past 10 years and were seen at an academic medical center within the past two years. Statistical analysis includes logistic regression and crosstabulation with SPSS and R statistical software. Results: Provider recommendation of genetic testing was found to be a very strong indicator of receiving genetic testing across all cancer types (OR = 146.4, p = <.001). HCPs more frequently recommended genetic testing to females (OR = 12.5, p = <.001), younger patients (OR = 1.05, p = <.001). While females are more likely to receive a recommendation, there were no significant differences on genetic testing uptake when a HCP recommended it for any gender. Conclusions: Without the recommendation of their provider, patients were significantly less likely to receive genetic testing that could affect their cancer treatment, surveillance, or family members. More aggressive patient health education is needed in cancer affected patients to decrease knowledge deficits and increase motivation for cancer genetic testing uptake. Education to providers regarding genetic testing recommendation guidelines could increase motivation to refer patients for genetic testing and counseling.

Integrating Medical Genetics Into Precision Oncology Practice in the Veterans Health Administration: The Time Is Now

PURPOSE

Increased access and utilization of tumor profiling of cancers in our veteran population uncovered a modest number of potentially pathogenic germline variants (PPGVs) that require genetics referral for follow-up evaluation and germline sequencing. Challenges identified specific to the veteran population include paucity of genetics providers, either at a veteran's VA facility or nearby non-VA facilities. We sought to investigate the number of veterans who would benefit from having such resources at both local and national levels.

METHODS

Annotated clinical reports of mutations identified by tumor-only profiling and medical records of veterans with solid tumors at the Veterans Administration Ann Arbor Healthcare System (VA AAHS) between 2015 and 2020 were reviewed. PPGVs were identified according to society recommendations (such as ESMO and American Board of Medical Genetics and Genomics), expert review, and/or previously published criteria. After the analysis of our local VA population, these same criteria were then applied to veterans in the National Precision Oncology Program (NPOP).

RESULTS

Two hundred eight veterans underwent tumor profiling at the VA AAHS over the defined time period. This included 20 different primary tumor sites with over half (n = 130) being advanced cancer at diagnosis. Of these, 18 veterans (8.5%) had mutations suggestive of a PPGV. Applying these criteria to the larger NPOP database (n = 20,014), a similar percentage (6%) of PPGVs were identified.

CONCLUSION

These results indicate a PPGV frequency (6%-9% of veterans) consistent with the prevalence of inherited cancer predisposition syndromes in the general population, underscoring the need for medical genetics as part of standard oncologic care for veterans. We explore current and future care delivery models to optimize incorporation of medical genetics and genetic counseling to best serve veterans needing such services.

Viral metagenomics reveals the presence of novel Zika virus variants in Aedes mosquitoes from Barbados

Background

The Zika virus (ZIKV) epidemic of 2015/2016 spread throughout numerous countries. It emerged in mainland Latin America and spread to neighboring islands, including the Caribbean island of Barbados. Recent studies have indicated that the virus must have already been circulating in local mosquito populations in Brazil for almost 2 years before it was identified by the World Health Organization in 2015. Metagenomic detection assays have the potential to detect emerging pathogens without prior knowledge of their genomic nucleic acid sequence. Yet their applicability as vector surveillance tools has been widely limited by the complexity of DNA populations from field-collected mosquito preparations. The aim of this study was to investigate local vector biology and characterize metagenomic arbovirus diversity in Aedes mosquitoes during the ongoing 2015/2016 ZIKV epidemic.

Methods

We performed a short-term vector screening study on the island of Barbados during the ongoing 2015/2016 ZIKV epidemic, where we sampled local Aedes mosquitoes. We reanalyzed mosquito viral microbiome data derived from standard Illumina MiSeq sequencing to detect arbovirus sequences. Additionally, we employed deep sequencing techniques (Illumina HiSeq) and designed a novel bait capture enrichment assay to increase sequencing efficiency for arbovirus sequences from complex DNA samples.

Results

We found that Aedes aegypti seemed to be the most likely vector of ZIKV, although it prevailed at a low density during the observed time period. The number of detected viruses increased with sequencing depth. Arbovirus sequence enrichment of metagenomic DNA preparations allowed the detection of arbovirus sequences of two different ZIKV genotypes, including a novel one. To our knowledge, this is the first report of the S3116W mutation in the NS5 gene region of ZIKV polyprotein.

Conclusions

The metagenomic arbovirus detection approach presented here may serve as a useful tool for the identification of epidemic-causing arboviruses with the additional benefit of enabling the collection of phylogenetic information on the source. Apart from detecting more than 88 viruses using this approach, we also found evidence of novel ZIKV variants circulating in the local mosquito population during the observed time period.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-021-04840-0.

Have we forgotten about heller’s? a case report of childhood disintegrative disorder

Introduction

We report on the case of a 15 year old young person with a known diagnosis of autism presenting with a rapid and acute regression in functional abilities, decline in expressive speech and bizarre posturing. The symptoms first started during lockdown (April 2020) with anxiety related to school work followed by urinary incontinence, insomnia, muttering to self and incongruent smiling. Initial medical investigations including MRI, lumbar puncture and 24hour EEG were inconclusive, so she was referred to Paediatric Liaison for assessment.

Objectives

We demonstrate the value of a child psychiatry liaison service being involved with young people in an acute medical hospital

Methods

This young person had a thorough psychiatric assessment.

Results

Through daily psychiatric assessment and reviews with the young person, her parent, social care, wider community team, school and Paediatric Inpatient ward in order to expand on the understanding of the young person and develop a case formulation. She was started on oral Olanzapine 2.5mg which was gradually increased to 10mg OD with minimal improvement.

Conclusions

Childhood Disintegrative Disorder (CDD or Heller’s Syndrome) is a rare pervasive disorder presenting as a loss of previously acquired skills after at least two years of normal development. Despite no longer being included in DSM-V, it is important for Psychiatrists to have a working knowledge of CDD and consider other differentials when assessing young people.

Disclosure

No significant relationships.

Complications of augmentation procedures for dental implants in private practice, Victoria, Australia

PURPOSE

This study audited complications associated with augmentation for dental implants, retrospectively over a 5-year period in a variety of private dental practices in Victoria (Australia).

METHODS

Complications were categorized as surgical or biological and compared to a group not requiring augmentation. Implant factors underwent univariate and multivariate analysis.

RESULTS

The study assessed 8486 implants with 26.9% undergoing augmentation. Augmentation had no effect on implant survival, however, a significant increase in complications for those implants requiring augmentation was found (P = <0.001). The hard tissue augmented group had significantly more cases of insufficient bone/dehiscences at implant placement (P < 0.001), and post-placement bone loss (P = 0.0014). These implants were grafted simultaneously (P < 0.05) with particulate autogenous bone and/or Bio-Oss (P < 0.05) with resorbable xenograft membrane (P < 0.001). There was significantly more bone loss in open sinus lifted cases than implants placed in native bone (1.90% v 0.30%; P = 0.009).

CONCLUSIONS

The study demonstrated no increase in graft complications that could be related to any specific augmentation technique, suggesting that routine grafting procedures used in private practice were safe and appropriate. Previously augmented sites were found to be more likely to require further augmentation at implant placement.

Glanzmann thrombasthenia in pregnancy: Optimising maternal and fetal outcomes

Glanzmann thrombasthenia is a rare autosomal recessive haemorrhagic disorder. The risks of miscarriage, antepartum and postpartum haemorrhage, and neonatal complications are all increased in individuals presenting with the disease in pregnancy. Some individuals may develop antibodies to platelet glycoproteins; the presence of these antibodies is a rare cause of neonatal alloimmune thrombocytopenia and potential intracranial haemorrhage. Multidisciplinary care is paramount for ensuring optimal fetal and maternal outcomes in such cases. We report a case of neonatal alloimmune thrombocytopenia secondary to maternal Glanzmann thrombasthenia in pregnancy.

Analysis of commonly reported medical conditions amongst patients receiving dental implant therapy in private practice

BACKGROUND

The population seeking implants in private practice is a demographically and medically unique group. Understanding their medical needs can improve treatment planning and service delivery specifically for this population.

METHODS

Privately practising dental clinicians from Victoria, Australia, participated in a five-year retrospective study. Data were collected from the medical histories of 4116 patients who met the inclusion criterion of at least one implant placed within the study period of 1 January 2005 to 31 December 2009. Descriptive statistics were used to describe patient demographics and commonly reported medical conditions.

RESULTS

The most common age group to receive implant therapy was between 51 and 60 years (30.4% of patients). The patient population reported a broad range of co-morbidities including psychiatric disorders (83 patients), cardiovascular disorders (253 patients), gastrointestinal disorders (224 patients) and respiratory disorders (502 patients). Smoking was less prevalent amongst the study population compared to the general population.

CONCLUSIONS

The population assessed in this study was a medically diverse group. Clinicians must be familiar with their target demographic and understand how the common co-morbidities amongst this patient group can influence clinical decision making and outcomes.

Successful combined liver/kidney transplantation from a donor with Pompe disease

Pompe disease results from inherited deficiency of the enzyme acid alpha-glucosidase resulting in lysosomal accumulation of glycogen primarily in skeletal muscle. Reported is the first case in which a donor with late onset Pompe disease (LOPD) was successfully used for deceased donor liver and kidney transplantation. This case demonstrates co-operative transplant surgery and genetic medicine evaluation and risk estimation for donors with inherited metabolic disorders some of which may be suitable for donation of selected organs for transplantation.

Third Åland islands conference on von Willebrand disease, 26-28 September 2012: meeting report

The first meeting of international specialists in the field of von Willebrand disease (VWD) was held in the Åland islands in 1998 where Erik von Willebrand had first observed a bleeding disorder in some members of a family from Föglö and a summary of the meeting was published in 1999. The second meeting was held in 2010 and a report of the meeting was published in 2012. Topics covered included progress in understanding of VWD over the last 50 years; multimers; classification of VWD; pharmacokinetics and laboratory assays; genetics; treating the paediatric patient; prophylaxis; geriatrics; gene therapy and treatment guidelines. This third meeting held over 3 days covered the structure and function of von Willebrand factor (VWF); type 1 VWD, the most common form of the disease; a lifespan of pharmacokinetics in VWD; detecting inhibitors in VWD patients; and special challenges in understanding and treating the female VWD patient.

Longitudinal study of Pelvicol pubovaginal slings using magnetic resonance imaging

The mechanism of urinary continence is complicated and is poorly understood. One current opinion is that there is an absence or weakness of the endopelvic fascial supports of the urethra. Pubovaginal slings are rapidly becoming the surgical procedure of choice in the management of urodynamic stress incontinence but their method of action is unclear. This study using magnetic resonance imaging shows how a pubovaginal sling can restore the normal anatomy and continence and adds to the global understanding of this condition.

Contamination from historic metal mines and the need for non-invasive remediation techniques: a case study from Southwest England

The UK is legally required by the EU Water Framework Directive (WFD) to improve the environmental quality of inland and coastal waters in the coming years. Historic metal mine sites are recognised as an important source of some of the elements on the WFD priority chemicals list. Despite their contamination potential, such sites are valued for their heritage and for other cultural and scientific reasons. Remediating historic mining areas to control the contamination of stream waters, whilst also preserving the integrity of the mine site, is a challenge but might be achieved by novel forms of remediation. In this study, we have carried out environmental monitoring at a historic, and culturally-sensitive, lead-silver mine site in southwest England and have undertaken a pilot experiment to investigate the potential for a novel, non-invasive remediation method at the site. Concentrations of Pb and Zn in mine spoil were clearly elevated with geometric mean concentrations of 6,888 and 710 microg g(-1), respectively. Mean concentrations of Pb in stream waters were between 21 and 54 microg l(-1), in exceedance of the WFD environmental quality standard (EQS) of 7.2 microg l(-1) (annual average). Mean Zn concentrations in water were between 30 and 97 microg l(-1), compared to the UK EQS of 66.5 microg l(-1) (average). Stream sediments within, and downstream from, the mining site were similarly elevated, indicating transport of mine waste particles into and within the stream. We undertook a simple trial to investigate the potential of hydroxyapatite, in the form of bonemeal, to passively remove the Pb and Zn, from the stream waters. After percolating through bonemeal in a leaching column, 96-99% of the dissolved Pb and Zn in stream water samples was removed.

Effect of AC II, an herbal formulation in cyclophosphamide-induced immunosuppression in BALB/c mice--Implication in HIV treatment

Effect of AC II, herbal drug formulation in reducing immunosuppression caused by administration of cyclophosphamide was studied. Mice were injected cyclophosphamide (CTX) 50 mg/kg b.wt. for 14 days with or without the drug and total WBC, bone marrow cellularity and alpha-esterase positive cells were determined. On day 15, total WBC count in cyclophosphamide treated mice was 1500 +/- 420 cells/mm3, while in AC II-treated mice it was 7658 +/- 376 cells/mm3. On day 16, administration of cyclophosphamide reduced bone marrow cellularity to 3.42 +/- 0.38 x 10(6) cells/femur from the normal value of 13.83 +/- 0.96 x 10(6) cells/femur. In AC II treated group bone marrow cellularity was increased to 8.05 +/- 0.7 x 10(6) cells/femur. The number of alpha-esterase positive cells was found to be reduced to 177 +/- 25 cells per 4000 cells in CTX treated groups. But in AC II-treated group the number of alpha-esterase positive cells were raised to 843 +/- 86 cells per 4000 cells, which was closer to that of normal (710 +/- 49 cells per 4000 cells). Results indicate the usefulness of AC II to combat immunosuppression induced by chemical and biological agents.

An audit of corneal abrasion management following the introduction of local guidelines in an accident and emergency department

BACKGROUND AND OBJECTIVES

Corneal abrasions are a common presentation to accident and emergency (A&E) departments. Patients can be treated and discharged by A&E staff without the need for an ophthalmologist's attention; complicated cases, however, should be recognised and referred. Inexperience and limited training in ophthalmology may lead to suboptimal patient care and inappropriate use of ophthalmology outpatient clinics. Issues of poor documentation may also arise. The purpose of this audit was to assess the effect of guidelines on the management of corneal abrasion by A&E staff.

METHODS

A retrospective case note audit was performed to assess current management of corneal abrasions. Guidelines for management of corneal abrasions were formulated following a literature search and collaboration between A&E and ophthalmology staff. A prospective case note audit was undertaken to assess management after introduction of the guidelines.

RESULTS

A total of 51 cases were audited before the introduction of the guidelines and 57 cases after. Following the introduction of the guidelines documentation of visual acuity increased to 93% and specific enquiry into contact lens wear rose from 35.3% to 71.9%. A&E staff stopped giving out local anaesthetic eye drops. The follow up profile also improved; appropriate patient discharges increased by 40% whereas inappropriate referrals to eye clinic dropped by 75%. More patients were given abrasion advice (a 101% increase).

CONCLUSIONS

A&E staff members are capable of managing corneal abrasions if they are given guidance and some training. This audit identified shortcomings in current management and showed that guidelines can significantly improve clinical practice.

Staffing: know your liability

Read this case of poor staffing judgment regarding outside agency employees and answer the questions, then check your answers at http://www.nursingmanagement.com.

Pharmacokinetics of levobupivacaine 0.25% following caudal administration in children under 2 years of age † †Declaration of interest. This work was funded by Chiroscience Limited, Cambridge, UK

BACKGROUND

Levobupivacaine, the S(-)enantiomer of racemic bupivacaine is less cardiotoxic than racemic bupivacaine and the R(+)enantiomer dexbupivacaine, while retaining similar local anaesthetic properties and potency to racemic bupivacaine. The pharmacokinetic profiles of the two bupivacaine enantiomers differs and that of racemic bupivacaine may be age dependent. We examined the pharmacokinetics of levobupivacaine after its single shot caudal epidural administration in children.

METHODS

An open-label phase 2 study was undertaken to examine the pharmacokinetics of levobupivacaine 0.25% 2 mg kg(-1) in 49 children aged less than 2 yr, after single shot caudal epidural administration. Plasma concentrations were determined at intervals up to 60 min after caudal injection.

RESULTS

Time to peak plasma concentration (T(max)) ranged between 5 and 60 min (median 30 min) and was reached later in children aged less than 3 months (P<0.005). Peak plasma concentration (C(max)) ranged between 0.41 and 2.12 micro g ml(-1) (median 0.80, mean (SD) 0.91 (0.40) micro g ml(-1)).

CONCLUSION

After the caudal epidural administration of levobupivacaine 2 mg kg(-1) in children less than 2 yr of age, C(max) was within the accepted safe range for racemic bupivacaine. T(max) varied and occurred later in some children, particularly those aged less than 3 months. Sampling in future pharmacokinetic studies in this age group should extend beyond 60 min.

Efficacy and safety of caudal injection of levobupivacaine, 0.25%, in children under 2 years of age undergoing inguinal hernia repair, circumcision or orchidopexy

BACKGROUND

Levobupivacaine is the S(-)-enantiomer of racemic bupivacaine. Evidence suggests that it is less cardiotoxic than racemic bupivacaine and the R(+)-enantiomer, dexbupivacaine, while retaining similar local anaesthetic properties and potency to racemic bupivacaine.

METHODS

This was an open study designed to assess the efficacy and safety of 0.25% levobupivacaine administered as a caudal injection at a dose of 2 mg.kg(-1) to 49 paediatric patients aged less than 2 years old undergoing circumcision (group 1), or hernia repair or orchidopexy (group 2).

RESULTS

Adequate analgesia (an increase of <20% in pulse or respiratory rate compared with baseline and an absence of gross movement on application of surgical stimulus) was achieved in 43/48 patients evaluable for efficacy (89.6%). All 22 patients in the circumcision group had adequate analgesia, and two of these patients did not require additional analgesia. The mean time to the use of additional analgesia was 7.3 h. Only one event (a mild rash) was considered possibly related to study medication.

CONCLUSIONS

Levobupivacaine is a promising new local anaesthetic agent for pain management in paediatric patients and appears to offer similar anaesthetic efficacy to racemic bupivacaine with a potentially improved tolerability profile.

COX-2 inhibitors and the cardiovascular system

Cyclooxygenase-2 selective inhibitors (coxibs) represent a new class of non steroidal anti-inflammatory drugs that exhibit preference for inhibition of cyclooxygenase-2 (COX-2), the COX isoform thought to account largely for prostanoid formation in inflammation. We review the divergent incidence of cardiovascular events derived from the two large clinical trials of coxibs, the Vioxx Gastrointestinal Outcomes Research Trial (VIGOR) and the Celecoxib Long-term Arthritis Safety Study (CLASS), in the context of current understanding of relevant clinical and basic pharmacology. The incidence of cardiovascular events was higher in patients receiving rofecoxib than in those receiving naproxen in VIGOR and did not differ between the groups in CLASS. By contrast, while the primary gastrointestinal (GI) endpoint comparison favored rofecoxib in VIGOR, no significant difference in the incidence of the primary GI endpoint was evident between celecoxib and two NSAID comparators not attained in CLASS. The cardiovascular results in VIGOR may have resulted from chance, a cardioprotective effect of naproxen, or suppression of prostacyclin but not thromboxane on rofecoxib. Differences in cardiovascular outcome between the two trials may also have resulted either from chance, or from aspects of the trial design (such as the use of aspirin by roughly one-fifth of the participants in CLASS), or from differences in the COX-2 selectivity or other pharmacology of the coxibs. Individuals who warrant low-dose aspirin for cardioprotection may have less likelihood of a GI event if they combine aspirin with rofecoxib, rather than a traditional NSAID. However, evidence addressing directly this hypothesis is currently unavailable. On the other hand, coxib consumption alone does not currently warrant initiation of a cardioprotective regimen, such as low-dose aspirin.

A safe standard of care for medication administration

Review caregivers' degree of responsibility and accountability when administering medication.

Cell toxicity caused by products of the p(L) operon of bacteriophage lambda

Induction of a lambda prophage causes the death of the host cell even in the absence of phage replication and lytic functions due to expression of functions from the lambda p(L) operon. We genetically modified the lambda prophage to determine which lambda p(L) operon functions were involved in cell killing. Viability assays and flow cytometry were used to monitor cell death and filamentation. The kil gene was shown to cause cell death and filamentation as described previously. Another killing activity was mapped within the p(L) operon to the gam gene. Inspection of the DNA sequence showed that there are two possible translation start points for both kil and gam. In both cases, the shorter of the two possible products could cause cell killing. The shorter products were also sufficient for the known filamentation and recombination activities of the respective Kil and Gam functions. The expression level of the p(L) operon is down-regulated by Cro repressor. In the absence of Cro, higher p(L) expression levels allow either Kil or Gam to be lethal or growth inhibitory, whereas at lowered expression in Cro-repressed conditions, only Kil is lethal. The filamentation function of Kil and recombination activity of Gam are unaffected at Cro-repressed levels of expression.

Proper equipment use makes or breaks care

Review the following case that addresses proper staff education regarding equipment usage and standards. Test your knowledge with the following questions, then check your answers at http://www.nursingmanagement.com.

An analysis of the factory model for chromosome replication and segregation in bacteria

Recent advances in microscopy have given us important clues as to the nature of chromosome segregation in bacteria. Most current observations favour the view that the process is co-replicational: DNA replication forks are anchored at the cell centre, and the newly replicated DNA is moved towards the cell poles. This scheme can account for orderly segregation even at high growth rates where multiple replication cycles overlap. We argue that there are five distinct activities directly involved in co-replicational segregation dynamics. These we refer to as Push, Direct, Condense, Hold and Clear. We attempt to assign one of these roles to each protein implicated in chromosome segregation. The proposed process is very different from mitosis in eukaryotic cells and perhaps more closely resembles the formation of separate sister chromatids during DNA replication.

Policies and procedures: friend or foe? Part 3

Review a case where policy and procedure violation resulted in patient death and hospital liability. Test your knowledge with the following questions, then check your answers at http://www.nursingmanagement.com.

Activation of the murine EP3 receptor for PGE2 inhibits cAMP production and promotes platelet aggregation

The importance of arachidonic acid metabolites (termed eicosanoids), particularly those derived from the COX-1 and COX-2 pathways (termed prostanoids), in platelet homeostasis has long been recognized. Thromboxane is a potent agonist, whereas prostacyclin is an inhibitor of platelet aggregation. In contrast, the effect of prostaglandin E2 (PGE2) on platelet aggregation varies significantly depending on its concentration. Low concentrations of PGE2 enhance platelet aggregation, whereas high PGE2 levels inhibit aggregation. The mechanism for this dual action of PGE2 is not clear. This study shows that among the four PGE2 receptors (EP1-EP4), activation of EP3 is sufficient to mediate the proaggregatory actions of low PGE2 concentration. In contrast, the prostacyclin receptor (IP) mediates the inhibitory effect of higher PGE2 concentrations. Furthermore, the relative activation of these two receptors, EP3 and IP, regulates the intracellular level of cAMP and in this way conditions the response of the platelet to aggregating agents. Consistent with these findings, loss of the EP3 receptor in a model of venous inflammation protects against formation of intravascular clots. Our results suggest that local production of PGE2 during an inflammatory process can modulate ensuing platelet responses.

Protein-protein interactions in the complex between the enhancer binding protein NIFA and the sensor NIFL from Azotobacter vinelandii

The enhancer binding protein NIFA and the sensor protein NIFL from Azotobacter vinelandii comprise an atypical two-component regulatory system in which signal transduction occurs via complex formation between the two proteins rather than by the phosphotransfer mechanism, which is characteristic of orthodox systems. The inhibitory activity of NIFL towards NIFA is stimulated by ADP binding to the C-terminal domain of NIFL, which bears significant homology to the histidine protein kinase transmitter domains. Adenosine nucleotides, particularly MgADP, also stimulate complex formation between NIFL and NIFA in vitro, allowing isolation of the complex by cochromatography. Using limited proteolysis of the purified proteins, we show here that changes in protease sensitivity of the Q linker regions of both NIFA and NIFL occurred when the complex was formed in the presence of MgADP. The N-terminal domain of NIFA adjacent to the Q linker was also protected by NIFL. Experiments with truncated versions of NIFA demonstrate that the central domain of NIFA is sufficient to cause protection of the Q linker of NIFL, although in this case, stable protein complexes are not detectable by cochromatography.

Policies and procedures: Friend or foe? Part 2

Review a case where policy and procedure breaches resulted in disaster. Test your knowledge with the following questions, then check your answers at http://www.nursingmanagement.com.

Policies and procedures: friend or foe? Part 1

Policy and procedure wording can make or break caregiving accountability. Test your knowledge with the following questions, then check your answers at http://www.nursingmanagement.com.