Personalised exercise rehabilitation in cancer survivorship: the percs triage and referral system study protocol

BACKGROUND

To effectively embed exercise rehabilitation in cancer survivorship care, a co-ordinated system of acute and community exercise rehabilitation services, forming a stepped model of care, is recommended. Patients can be directed to the exercise rehabilitation service which best meets their needs through a system of assessment, triage and referral. Triage and referral systems are not yet widely applied in cancer survivorship practice and need to be evaluated in real-world contexts. The PERCS (Personalised Exercise Rehabilitation in Cancer Survivorship) study aims to evaluate the real-world application of an exercise rehabilitation triage and referral system in cancer survivors treated during the COVID-19 pandemic. Secondary aims are to evaluate change in physical and psychosocial outcomes, and to qualitatively evaluate the impact of the system and patient experiences, at three months after application of the triage and referral system.

METHODS

This study will assess the implementation of an exercise rehabilitation triage and referral system within the context of a physiotherapy-led cancer rehabilitation clinic for cancer survivors who received cancer treatment during the COVID-19 pandemic. The PERCS triage and referral system supports decision making in exercise rehabilitation referral by recommending one of three pathways: independent exercise; fitness professional referral; or health professional referral. Up to 100 adult cancer survivors treated during the COVID-19 pandemic who have completed treatment and have no signs of active disease will be recruited. We will assess participants' physical and psychosocial wellbeing and evaluate whether medical clearance for exercise is needed. Participants will then be triaged to a referral pathway and an exercise recommendation will be collaboratively decided. Reassessment will be after 12 weeks. Primary outcomes are implementation-related, guided by the RE-AIM framework. Secondary outcomes include physical function, psychosocial wellbeing and exercise levels. Qualitative analysis of semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR) will provide insights on implementation and system impact.

DISCUSSION

The PERCS study will investigate the real-world application of a cancer rehabilitation triage and referral system. This will provide proof of concept evidence for this triage approach and important insights on the implementation of a triage system in a specialist cancer centre.

TRIAL REGISTRATION

This study is registered on ClinicalTrials.gov, registration number: NCT05615285, date registered: 21st October 2022.

Effective maNagement of depression among patients witH cANCEr (ENHANCE): a protocol for a hybrid systematic review and network meta-analysis of randomised controlled trials of interventions for depressive symptoms

BACKGROUND

Depression is common among patients with cancer and is associated with lower treatment participation, lower satisfaction with care, poorer quality of life, greater symptom burden and higher healthcare costs. Various types of interventions (e.g. pharmacological, psychotherapy) are used for the treatment of depression. However, evidence for these among patients with cancer is limited. Furthermore, the relative effectiveness and acceptability of different approaches are unknown because a direct comparison between all available treatments has not been carried out. We will address this by conducting a network meta-analysis (NMA) of interventions for depression among people with cancer using a hybrid overview of reviews and systematic review methodology.

METHODS

We will search for and extract data from systematic reviews of randomised controlled trials (RCTs) of depression interventions for patients with cancer from inception, before performing a supplemental search for more recent RCTs. We will include RCTs comparing pharmacological, psychotherapy, exercise, combination therapy, collaborative care or complementary and alternative medicine interventions with pill placebo, no treatment, waitlist, treatment as usual or minimal treatment control groups, or directly in head-to-head trials, among adults who currently have cancer or have a history of any cancer and elevated depressive symptoms (scores above a cut-off on validated scales or meeting diagnostic criteria). Our primary outcomes will be change in depressive symptoms (standardised mean difference) and intervention acceptability (% who withdrew). Our secondary outcomes will be 6-month change in depressive symptoms, health-related quality of life, adverse events and mortality. We will independently screen for eligibility, extract data and assess risk of bias using the RoB 2 tool. We will use frequentist random-effects multivariate NMA in Stata, rankograms and surface under the cumulative ranking curves to synthesise evidence and obtain a ranking of intervention groups. We will explore heterogeneity and inconsistency using local and global measures and evaluate the credibility of results using the Confidence in NEtwork Meta-Analysis (CINeMA) framework.

DISCUSSION

Our findings will provide the best available evidence for managing depression among patients with cancer. Such information will help to inform clinical guidelines, evidence-based treatment decisions and future research by identifying gaps in the current literature.

SYSTEMATIC REVIEW REGISTRATION

Submitted to PROSPERO (record number: 290145), awaiting registration.

Volatility of Springtime ambient organic aerosol derived with thermodenuder aerosol mass spectrometry in Seoul, Korea

The volatilities of ambient organic aerosol (OA) components are important to forecasting OA formation with models. However, providing the OA volatility distribution inputs for models is challenging, and models often rely on measurements from chamber experiments. We measured the volatility of submicron ambient OA in Seoul during May/June of 2019 by connecting a thermodenuder to an Aerodyne Time-of-Flight Aerosol Mass Spectrometer (AMS). We calculated a volatility basis set (VBS) of the organic aerosol with a thermodenuder mass transfer model and data from the thermodenuder set to various temperatures (30-200 °C). We found a large discrepancy between the measured ambient VBS and a reference VBS used in air quality models, with the ambient organics being less volatile. The results suggest that a modeling study that tries to account for this discrepancy may be needed to identify the impact it has on modeling outcomes. Chamber experiments aiming to determine VBSs for specific chemical systems should address limitations caused by wall losses and incomplete modeling parameters.

Persistent Influence of Wildfire Emissions in the Western United States and Characteristics of Aged Biomass Burning Organic Aerosols under Clean Air Conditions

Wildfire-influenced air masses under regional background conditions were characterized at the Mt. Bachelor Observatory (∼2800 m a.s.l.) in summer 2019 to provide a better understanding of the aging of biomass burning organic aerosols (BBOAs) and their impacts on the remote troposphere in the western United States. Submicron aerosol (PM₁) concentrations were low (average ± 1σ = 2.2 ± 1.9 μg sm^-3), but oxidized BBOAs (average O/C = 0.84) were constantly detected throughout the study. The BBOA correlated well with black carbon, furfural, and acetonitrile and comprised above 50% of PM₁ during plume events when the peak PM₁ concentration reached 18.0 μg sm^-3. Wildfire plumes with estimated transport times varying from ∼10 h to >10 days were identified. The plumes showed ΔOA/ΔCO values ranging from 0.038 to 0.122 ppb ppb^-1 with a significant negative relation to plume age, indicating BBOA loss relative to CO during long-range transport. Additionally, increases of average O/C and aerosol sizes were seen in more aged plumes. The mass-based size mode was approximately 700 nm (D_va) in the most oxidized plume that likely originated in Siberia, suggesting aqueous-phase processing during transport. This work highlights the widespread impacts that wildfire emissions have on aerosol concentration and properties, and thus climate, in the western United States.

Female Reproductive Health Disturbance Experienced During the COVID-19 Pandemic Correlates With Mental Health Disturbance and Sleep Quality

The COVID-19 pandemic has adversely affected population mental health. Periods of psychological distress can induce menstrual dysfunction. We previously demonstrated a significant disruption in women's reproductive health during the first 6 months of the pandemic. The present study investigates longer-term reproductive and mental health disturbances. A cross-sectional online survey was completed by 1335 women of reproductive age in April 2021. It included validated standardized measures of depression (PHQ-9), anxiety (GAD-7) and sleep quality (PSQI). 581 (56%) of women reported an overall change in their menstrual cycle since the beginning of the pandemic. There was no change in median cycle length [28 days (28-30)] or days of menses [5 (4-5)], but there was a wider variability in minimum (p<0.0001) and maximum (p<0.0001) cycle length. There was a significant increase in heavy menstrual bleeding, painful periods and missed periods compared to pre-pandemic (all p<0.0001). 64% of women reported worsening pre-menstrual symptoms. Rates of severe depression, anxiety and poor sleep were more than double those from large scale representative community samples. Poor sleep quality was an independent predictor of overall change in menstrual cycle (OR=1.11, 95%CI 1.05-1.18), and missed periods (OR=1.11, 95%CI 1.03-1.19) during the pandemic. Increased anxiety was independently associated with a change from non-painful to painful periods (OR=1.06, 95%CI 1.01-1.11) and worsening of pre-menstrual symptoms (OR=1.06, 95%CI 1.01-1.07) during the pandemic. The COVID-19 pandemic continues to bear a significant impact on female reproductive health. Increased levels of psychological distress and poor sleep are associated with menstrual cycle disruption.

Characteristics and sources of water-soluble organic aerosol in a heavily polluted environment in Northern China

Water-soluble organic aerosol (WSOA) in fine particles (PM_2.5) collected during wintertime in a polluted city (Handan) in Northern China was characterized using a High-Resolution Time-of-Flight Aerosol Mass Spectrometer (AMS). Through comparing with real-time measurements from a collocated Aerosol Chemical Speciation Monitor (ACSM), we determined that WSOA on average accounts for 29% of total organic aerosol (OA) mass and correlates tightly with secondary organic aerosol (SOA; Pearson's r = 0.95). The mass spectra of WSOA closely resemble those of ambient SOA, but also show obvious influences from coal combustion and biomass burning. Positive matrix factorization (PMF) analysis of the WSOA mass spectra resolved a water-soluble coal combustion OA (WS-CCOA; O/C = 0.17), a water-soluble biomass burning OA (WS-BBOA; O/C = 0.32), and a water-soluble oxygenated OA (WS-OOA; O/C = 0.89), which account for 10.3%, 29.3% and 60.4% of the total WSOA mass, respectively. The water-solubility of the OA factors was estimated by comparing the offline AMS analysis results with the ambient ACSM measurements. OOA has the highest water-solubility of 49%, consistent with increased hygroscopicity of oxidized organics induced by atmospheric aging processes. In contrast, CCOA is the least water soluble, containing 17% WS-CCOA. The distinct characteristics of WSOA from different sources extend our knowledge of the complex aerosol chemistry in the polluted atmosphere of Northern China and the water-solubility analysis may help us to understand better aerosol hygroscopicity and its effects on radiative forcing in this region.

Prevalence of Insomnia in an Oncology Patient Population: An Irish Tertiary Referral Center Experience

BACKGROUND

The NCCN Guidelines for Survivorship recommend dedicated sleep assessment. Reported insomnia prevalence in the general Irish population is 6% to 15%. Reported insomnia prevalence internationally among new/recently diagnosed patients with cancer varies from 30.9% to 54.3%. Insomnia prevalence has not been previously quantified in an Irish oncology cohort.

METHODS

A 40-item questionnaire was prospectively administered to ambulatory patients with cancer aged ≥18 years. Prespecified criteria to define insomnia syndrome combined those of the International Classification of Sleep Disorders, version 1, and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The Hospital Anxiety and Depression Scale-Depression/Anxiety (HADS-D/A) was used to screen for potential confounding variables.

RESULTS

The response rate to the questionnaire was 87% (294/337). The predominant respondent age group was 55 to 64 years (26%; 77/294), 70.7% were female (208/294), and the most common cancer subtypes were breast (37.4%), colorectal (12.9%), and lung (12.2%). A total of 62% (183/294) of patients reported sleep disturbance after diagnosis, 63% (115/183) reported moderate/severe distress related to this disturbance, and 37% (61/183) reported a significant impact on physical function. Although 33% (98/294) met insomnia syndrome criteria, only 34% (33/98) of these patients had a preexisting history of sleep disturbance. Female sex, age <65 years, cancer subtype, alcohol consumption, and HADS-D/A ≥11 were associated with statistically significant higher odds ratios (OR) of insomnia syndrome. Multivariate analysis identified breast cancer (OR, 3.17; P=.01), age <65 years (OR, 1.8; P=.03), and alcohol consumption (OR, 2.3; P=.005) as independent predictors of insomnia syndrome.

CONCLUSIONS

Insomnia syndrome prevalence in this cohort is comparable to that reported previously and supports dedicated sleep assessment. This study identifies potentially modifiable risk factors for insomnia and demonstrates additional utility of the HADS score in identifying patients at risk.

The factors associated with distress a minimum of six months after BRCA1/2 confirmation: A systematic review

PROBLEM IDENTIFICATION

Many BRCA1/2 carriers experience an increase in distress after diagnosis; however, there is a need to review the longer term psychological implications of genetic confirmation and the factors associated with persistent distress.

LITERATURE SEARCH

This article systematically reviewed the literature in line with PRISMA guidelines on distress a minimum of six months after BRCA1/2 confirmation focusing on prevalence rates and factors associated with distress.

DATA EVALUATION AND SYNTHESIS

Fifteen studies were identified for inclusion and a narrative synthesis was conducted. Distress was associated with a range of demographic, clinical and psychological factors. A consistent finding was that although most carriers experience a reduction in distress 6-12 months after BRCA1/2 confirmation, those who experience persistent distress are more likely to have had higher distress levels at time of genetic testing. Risk reducing surgery may also play a role in reducing distress.

CONCLUSION

The review highlights the importance of psychological assessment and the use of specific distress measures. Given the considerable challenges in synthesizing the data there is a need for further prospective studies of high methodological quality.

Self-concept and health anxiety relate to psychological outcomes for BRCA1/2 carriers

OBJECTIVE

Leventhal's common sense model of self-regulation highlights how specific beliefs about illness influence psychological outcomes. Little is known on how such beliefs relate to BRCA1/2 adjustment. Furthermore, beliefs about one's self-concept may be relevant to genetic conditions and may relate to psychological wellbeing.

METHODS

One-hundred and eighteen female BRCA1/2 carriers from an Irish University Hospital completed questionnaires for this cross-sectional study. Outcomes measured were state anxiety and physical and mental health-related quality of life (HRQOL). Explanatory variables included sociodemographics, health anxiety, illness perceptions, coping and self-concept. Hierarchical multiple regression analyses were conducted.

RESULTS

Then, 44% of participants had clinically significant state anxiety and 12% had clinically significant health anxiety. Vulnerability, stigma, mastery and health anxiety explained 42% of the variance in state anxiety. Previous mental health difficulty, vulnerability, stigma, mastery and health anxiety explained 40% of the variance in mental HRQOL. Dysfunctional coping strategies were strongly related to the physical functioning aspect of quality of life.

CONCLUSION

BRCA-specific beliefs related to self and health anxiety are important factors to consider in the adjustment to BRCA1/2 confirmation.

The Influence of Attitudes to Acupuncture on the Outcome of Treatment

The aim of this randomised controlled trial was to investigate the possible influence of attitudes towards and knowledge of acupuncture on treatment outcome. A total of 41 pain patients acted as the subjects in the study and 25 of them completed a semi-structured interview prior to treatment. This included the Shod Form McGill Pain Questionnaire, questions regarding the source of patients’ information on acupuncture, their preparation for treatment and a knowledge and attitude questionnaire. The remaining 16 subjects received only the Short Form McGill Pain Questionnaire. All subjects again completed the pain questionnaire approximately one week following their last acupuncture session. Discussing attitudes and views prior to treatment was not found to have any effect on outcome. Subjects were revealed to have low knowledge scores, but mainly positive attitudes towards acupuncture treatment. Almost two thirds of the sample felt inadequately prepared for their treatment. Statistical analysis disclosed that neither attitudes nor knowledge influenced response to acupuncture.

Discordance in latent tuberculosis (TB) test results in patients with end-stage renal disease

OBJECTIVES

This natural experiment was designed to assess the impact of exposure to an active case of tuberculosis (TB) on a group of immunosuppressed individuals, with end-stage renal disease over an extended follow-up.

STUDY DESIGN

Close contacts of people with sputum smear-positive Mycobacterium tuberculosis are at high risk of infection, particularly immunosuppressed individuals. An infectious TB healthcare worker worked in a renal dialysis unit for a month before diagnosis, with 104 renal dialysis patients, was exposed for ≥8 h.

METHODS

Patients were informed and invited for screening 8-10 weeks postexposure. They either underwent standard two-step assessment with tuberculin skin test (TST) and QuantiFERON^®-TB Gold (Cellestis GmbH; QFN) interferon-gamma release assay (IGRA) or after consent, enrolled in a study where these two tests were performed simultaneously with T-SPOT^®-TB (Oxford Immunotec Ltd; TSPOT). Patients within the study were followed up for 2 years from exposure, with QFN and TSPOT repeated at months 3 and 6 from the first testing.

RESULTS

Of 104 exposed individuals, 75 enrolled in the study. There was a high degree of discordance among QFN, TSPOT and TST. This was seen at both the first time point and also over time in subjects who were retested. No patients had active TB at the baseline testing. None received treatment for latent TB infection. Over the following 2 years, no one developed TB disease.

CONCLUSION

This study suggests that there is a low risk of progression to active TB in low-incidence countries even in high-risk groups. This plus the degree of the test result discordance emphasises the complexities of managing TB in such settings as it is unclear which of these tests, if any, provides the best diagnostic accuracy.

Healing of Circular Defects in the Rabbit Medial Meniscus Can Occur Spontaneously and Is not Improved by Intra-Articular Hyaluronic Acid

The aim of this study was to determine the effects of intra-articular hyaluronic acid on meniscal healing. Circular defects, 1.0 mm in diameter, were made in the anterior third of the medial meniscus in rabbits. In one joint, 0.4 ml hyaluronic acid (Healon®) was instilled, and in the contralateral (control) joint, 0.4 ml Ringer’s saline. Four rabbits were killed after four, eight and 12 weeks and the menisci examined histologically. By eight weeks most of the lesions had healed by filling with hyaline-like cartilage. Healing was not improved by hyaluronic acid treatment. The repair tissue stained strongly with alcian blue, and the presence of type II collagen, keratan sulphate, and chondroitin sulphate was demonstrated by immunohistochemical localisation. In contrast to the circular defects, longitudinal incisions made in the medial menisci of a further six rabbits did not show any healing after 12 weeks, indicating that the shape of the lesion largely determined the potential for healing.

The effect of hyaluronic acid on meniscal healing was tested in a rabbit model. With one millimeter circular lesions in the medial meniscus, healing by filling with hyalinelike cartilage was not significantly affected by the application of hyaluronic acid intra-articularly at the time of surgery, compared to saline controls, as assessed histologically four, eight and 12 weeks after the operation.

First Chemical Characterization of Refractory Black Carbon Aerosols and Associated Coatings over the Tibetan Plateau (4730 m a.s.l)

Refractory black carbon (rBC) aerosol is an important climate forcer, and its impacts are greatly influenced by the species associated with rBC cores. However, relevant knowledge is particularly lacking at the Tibetan Plateau (TP). Here we report, for the first time, highly time-resolved measurement results of rBC and its coating species in central TP (4730 m a.s.l), using an Aerodyne soot particle aerosol mass spectrometer (SP-AMS), which selectively measured rBC-containing particles. We found that the rBC was overall thickly coated with an average mass ratio of coating to rBC (R_BC) of ∼7.7, and the coating species were predominantly secondarily formed by photochemical reactions. Interestingly, the thickly coated rBC was less oxygenated than the thinly coated rBC, mainly due to influence of the transported biomass burning organic aerosol (BBOA). This BBOA was relatively fresh but formed very thick coating on rBC. We further estimated the "lensing effect" of coating semiquantitatively by comparing the measurement data from a multiangle absorption photometer and SP-AMS, and found it could lead to up to 40% light absorption enhancement at R_BC > 10. Our findings highlight that BBOA can significantly affect the "lensing effect", in addition to its relatively well-known role as light-absorbing "brown carbon."

A prospective cohort study assessing the appearance of retrieved aesthetic orthodontic archwires

OBJECTIVES

To investigate the appearance of three esthetic nickel titanium (NiTi) wires after 6 weeks of intra-oral cycling and to determine the association between objective and subjective measures of esthetics.

SETTING AND SAMPLE POPULATION

A prospective cohort study was undertaken involving participants undergoing upper fixed orthodontic appliance treatment with ceramic brackets.

MATERIALS AND METHODS

Fifty participants were assigned to one of three groups of NiTi esthetic wires (American Orthodontics Ever White™, Forestadent Biocosmetic™ and GAC High Aesthetic™), with wires retrieved after 6 weeks in situ. Participants completed a bespoke questionnaire exploring perceptions of wire esthetics. Objective measurement of coating loss was undertaken using a custom arch wire jig.

RESULTS

American Orthodontics Ever White™ had the greatest mean coating loss (50.7%) followed by Forestadent Biocosmetic™ (6%), with GAC High Aesthetic TM undergoing minimal loss (0.07%) (P < .001). The majority of coating loss with the American Orthodontics Ever White™ wires arose in the anterior region while Forestadent Biocosmetic™ wires and GAC High Aesthetic™ wires exhibited coating loss posteriorly (P < .001). These findings were reflected in the subjective assessment with a negative correlation found between coating loss and final Visual Analogue Scale scores (P < .001).

CONCLUSIONS

Considerable esthetic variation between arch wires following 6 weeks of intraoral cycling was identified in this prospective cohort study. Intraoral cycling has a negative impact on participant perception of arch wire esthetics, and objective and subjective assessment of wire esthetics appears to be consistent.

Ochromobactrum intermedium: an emerging opportunistic pathogen-case of recurrent bacteraemia associated with infective endocarditis in a haemodialysis patient

We describe the first clinical case report of infective endocarditis related to Ochrobactrum intermedium infection. The case involved a 23-year-old man receiving dialysis via an internal jugular long-term haemodialysis catheter. He improved with a prolonged course of meropenem and minocycline. Ochrobactrum spp. are recognized as rare emerging opportunistic pathogens.

Regional Influence of Aerosol Emissions from Wildfires Driven by Combustion Efficiency: Insights from the BBOP Campaign

Wildfires are important contributors to atmospheric aerosols and a large source of emissions that impact regional air quality and global climate. In this study, the regional and nearfield influences of wildfire emissions on ambient aerosol concentration and chemical properties in the Pacific Northwest region of the United States were studied using real-time measurements from a fixed ground site located in Central Oregon at the Mt. Bachelor Observatory (∼2700 m a.s.l.) as well as near their sources using an aircraft. The regional characteristics of biomass burning aerosols were found to depend strongly on the modified combustion efficiency (MCE), an index of the combustion processes of a fire. Organic aerosol emissions had negative correlations with MCE, whereas the oxidation state of organic aerosol increased with MCE and plume aging. The relationships between the aerosol properties and MCE were consistent between fresh emissions (∼1 h old) and emissions sampled after atmospheric transport (6-45 h), suggesting that biomass burning organic aerosol concentration and chemical properties were strongly influenced by combustion processes at the source and conserved to a significant extent during regional transport. These results suggest that MCE can be a useful metric for describing aerosol properties of wildfire emissions and their impacts on regional air quality and global climate.

Septic arthritis of the temporomandibular joint as a complication of acute otitis media in a child: A rare case and the importance of real-time PCR for diagnosis

We document the case of a 7-year-old boy who presented with pain in his left ear and trismus after a diagnosis of acute otitis media one week previously. His blood inflammatory markers were raised and magnetic resonance imaging (MRI) showed significant left temporomandibular joint effusion and partial attenuation of the left mastoid. A clinical diagnosis of septic arthritis of the TMJ was made and the patient was commenced on broad-spectrum antibiotics. Analysis using real time PCR enabled identification of the offending organism, confirmation of the diagnosis and antibiotic treatment to be specifically tailored for treatment.

Volatility of primary organic aerosol emitted from light duty gasoline vehicles

Primary organic aerosol (POA) emitted from light duty gasoline vehicles (LDGVs) exhibits a semivolatile behavior in which heating the aerosol and/or diluting the aerosol leads to partial evaporation of the POA. A single volatility distribution can explain the median evaporation behavior of POA emitted from LDGVs but this approach is unable to capture the full range of measured POA volatility during thermodenuder (TD) experiments conducted at atmospherically relevant concentrations (2-5 μg m(-3)). Reanalysis of published TD data combined with analysis of new measurements suggest that POA emitted from gasoline vehicles is composed of two types of POA that have distinctly different volatility distributions: one low-volatility distribution and one medium-volatility distribution. These correspond to fuel combustion-derived POA and motor oil POA, respectively. Models that simultaneously incorporate both of these distributions are able to reproduce experimental results much better (R(2) = 0.94) than models that use a single average or median distribution (R(2) = 0.52). These results indicate that some fraction of POA emitted from LDGVs is essentially nonvolatile under typical atmospheric dilution levels. Roughly 50% of the vehicles tested in the current study had POA emissions dominated by fuel combustion products (essentially nonvolatile). Further testing is required to determine appropriate fleet-average emissions rates of the two POA types from LDGVs.

Real-time emission factor measurements of isocyanic acid from light duty gasoline vehicles

Exposure to gas-phase isocyanic acid (HNCO) has been previously shown to be associated with the development of atherosclerosis, cataracts and rheumatoid arthritis. As such, accurate emission inventories for HNCO are critical for modeling the spatial and temporal distribution of HNCO on a regional and global scale. To date, HNCO emission rates from light duty gasoline vehicles, operated under driving conditions, have not been determined. Here, we present the first measurements of real-time emission factors of isocyanic acid from a fleet of eight light duty gasoline-powered vehicles (LDGVs) tested on a chassis dynamometer using the Unified Driving Cycle (UC) at the California Air Resources Board (CARB) Haagen-Smit test facility, all of which were equipped with three-way catalytic converters. HNCO emissions were observed from all vehicles, in contrast to the idealized laboratory measurements. We report the tested fleet averaged HNCO emission factors, which depend strongly on the phase of the drive cycle; ranging from 0.46 ± 0.13 mg kg fuel(-1) during engine start to 1.70 ± 1.77 mg kg fuel(-1) during hard acceleration after the engine and catalytic converter were warm. The tested eight-car fleet average fuel based HNCO emission factor was 0.91 ± 0.58 mg kg fuel(-1), within the range previously estimated for light duty diesel-powered vehicles (0.21-3.96 mg kg fuel(-1)). Our results suggest that HNCO emissions from LDGVs represent a significant emission source in urban areas that should be accounted for in global and regional models.

Raised levels of metal ions in the blood in patients who have undergone uncemented metal-on-polyethylene Trident-Accolade total hip replacement

The issues surrounding raised levels of metal ions in the blood following large head metal-on-metal total hip replacement (THR), such as cobalt and chromium, have been well documented. Despite the national popularity of uncemented metal-on-polyethylene (MoP) THR using a large-diameter femoral head, few papers have reported the levels of metal ions in the blood following this combination. Following an isolated failure of a 44 mm Trident-Accolade uncemented THR associated with severe wear between the femoral head and the trunnion in the presence of markedly elevated levels of cobalt ions in the blood, we investigated the relationship between modular femoral head diameter and the levels of cobalt and chromium ions in the blood following this THR. A total of 69 patients received an uncemented Trident-Accolade MoP THR in 2009. Of these, 43 patients (23 men and 20 women, mean age 67.0 years) were recruited and had levels of cobalt and chromium ions in the blood measured between May and June 2012. The patients were then divided into three groups according to the diameter of the femoral head used: 12 patients in the 28 mm group (controls), 18 patients in the 36 mm group and 13 patients in the 40 mm group. A total of four patients had identical bilateral prostheses in situ at phlebotomy: one each in the 28 mm and 36 mm groups and two in the 40 mm group. There was a significant increase in the mean levels of cobalt ions in the blood in those with a 36 mm diameter femoral head compared with those with a 28 mm diameter head (p = 0.013). The levels of cobalt ions in the blood were raised in those with a 40 mm diameter head but there was no statistically significant difference between this group and the control group (p = 0.152). The levels of chromium ions in the blood were normal in all patients. The clinical significance of this finding is unclear, but we have stopped using femoral heads with a diameter of ≤ 36 mm, and await further larger studies to clarify whether, for instance, this issue particularly affects this combination of components.

Gas-phase CO2 subtraction for improved measurements of the organic aerosol mass concentration and oxidation degree by an aerosol mass spectrometer

The Aerodyne aerosol mass spectrometer (AMS) has been widely used for real-time characterization of the size-resolved chemical composition of sub-micrometer aerosol particles. The first step in AMS sampling is the pre-concentration of aerosols while stripping away the gas-phase components, which contributes to the high sensitivity of this instrument. The strength of the instrument lies in particle phase measurement; however, ion signals generated from gas-phase species can influence the interpretation of the particle-phase chemistry data. Here, we present methods for subtracting the varying contributions of gas-phase carbon dioxide (CO2) in the AMS spectra of aerosol particles, which is critical for determining the mass concentration and oxygen-to-carbon (O/C) ratio of organic aerosol. This report gives details on the gaseous CO2 subtraction analysis performed on a high-resolution time-of-flight aerosol mass spectrometer (HR-ToF-AMS) data set acquired from sampling of fresh and diluted vehicle emissions. Three different methods were used: (1) collocated continuous gas-phase CO2 measurement coupled with periodic filter tests consisting of sampling the same particle-free air by the AMS and the CO2 analyzer, (2) positive matrix factorization (PMF) analysis to separate the gas- and particle-phase signals of CO2(+) at m/z 44, and (3) use of the particle time-of-flight (PTOF) size-resolved chemical information for separation of gas- and particle-phase signals at m/z 44. Our results indicate that these three different approaches yield internally consistent values for the gas/particle apportionment of m/z 44, but methods 2 and 3 require certain conditions to be met to yield reliable results. The methods presented are applicable to any situation where gas-phase components may influence the PM signal of interest.

Real-time black carbon emission factor measurements from light duty vehicles

Eight light-duty gasoline low emission vehicles (LEV I) were tested on a Chassis dynamometer using the California Unified Cycle (UC) at the Haagen-Smit vehicle test facility at the California Air Resources Board in El Monte, CA during September 2011. The UC includes a cold start phase followed by a hot stabilized running phase. In addition, a light-duty gasoline LEV vehicle and ultralow emission vehicle (ULEV), and a light-duty diesel passenger vehicle and gasoline direct injection (GDI) vehicle were tested on a constant velocity driving cycle. A variety of instruments with response times ≥0.1 Hz were used to characterize how the emissions of the major particulate matter components varied for the LEVs during a typical driving cycle. This study focuses primarily on emissions of black carbon (BC). These measurements allowed for the determination of BC emission factors throughout the driving cycle, providing insights into the temporal variability of BC emission factors during different phases of a typical driving cycle.

C-reactive protein predicts fatigue independently of depression in breast cancer patients prior to chemotherapy

Heightened inflammatory activity has been proposed as a mechanism for the development of cancer-related fatigue (CRF), a common and distressing condition that can negatively affect quality of life. Inflammation is also implicated in the pathogenesis of depression, and depression is a strong predictor of CRF. Thus, the role of the pro-inflammatory cytokine network in CRF may be mediated by depression or both conditions may share similar underlying physiological processes. The current study investigated associations between fatigue, depression and inflammatory cytokine (IFN-γ, IL-6, TNF-α) and CRP concentrations, as well as kynurenine pathway (KP) activation, in 61 breast cancer patients prior to chemotherapy. Changes in inflammatory markers and KP activation over time were also explored, and associations with changes in fatigue and depression were examined. Higher levels of CRP were significantly correlated with fatigue and depression before chemotherapy; nevertheless, CRP predicted fatigue independently of depression. Although greater kynurenine concentrations were associated with increased immune activation, there was no evidence that the KP played a role in fatigue or depression. Furthermore, no relationships emerged between either fatigue or depression and IFN-γ, IL-6, or TNF-α before chemotherapy. Nevertheless, kynurenine levels pre- and post-treatment significantly predicted changes in depression, suggesting that heightened KP activation may contribute to depressive symptoms in patients treated for cancer. In addition, IL-6 significantly covaried with fatigue. These preliminary findings provide some support for the idea that low-grade inflammation contributes to the development of CRF, independently of depression; however, there was no evidence that this is mediated by KP activity.

A prospective study comparing contamination rates between a novel mid-stream urine collection device (Peezy) and a standard method in renal patients

INTRODUCTION

It is imperative that laboratories receive uncontaminated urine samples to avoid giving false-positive results and reduce antimicrobial use.

AIM

The aim of the study was to investigate a novel urine collection device (Peezy) in a renal outpatient clinic to determine whether it reduced contamination of urine samples.

METHODS

The novel device was used in 420 renal transplant recipients and the results were compared with 424 matched historical controls, who used the standard method of urine collection. High epithelial cell counts on microscopy and mixed urine cultures were used to identify contaminated samples.

RESULTS

Peezy increased the rates of both epithelial cells and mixed growths in the urine samples when compared with the historical controls.

CONCLUSIONS

Further randomised studies in other more generalisable populations need to be performed.

Predictors of fatigue in cancer patients before and after chemotherapy

Fatigue is a debilitating and common condition in cancer patients. This study examined pretreatment predictors of fatigue before chemotherapy and also assessed whether these could prospectively predict fatigue posttreatment. A total of 100 patients completed questionnaires assessing psychological factors, physical activity and sleep. A subsample of 26 participants wore actigraphs to objectively assess sleep/wake and activity/rest. Fatigue was measured pretreatment and posttreatment and at follow-up several months later. Greater pretreatment pain, depression, stress and sleep disruption significantly predicted greater fatigue before chemotherapy, explaining 55 percent of the variance. Pretreatment fatigue significantly predicted post-treatment fatigue. No other significant prospective predictors of posttreatment fatigue emerged.

Assessing patients' beliefs about their cancer-related fatigue: validation of an adapted version of the Illness Perception Questionnaire

Cancer-related fatigue (CRF) is a common and distressing side-effect of cancer treatment. The present study developed a brief version of the Illness Perception Questionnaire (IPQ) for assessing patients' representations of CRF. Cancer patients and survivors (n = 155) completed a revised version of the IPQ as well as measures of fatigue severity at two different time-points. Confirmatory factor analysis at both Time 1 and 2 showed that the seven-factor solution based on the Self-Regulation Model fit the data adequately and factorial invariance over the two time-points was supported. The resulting subscales exhibited good internal consistency and test-retest reliability. The adapted version of the IPQ shows promise for the assessment of patient perceptions regarding CRF. The scale may be able to be used clinically to identify if patients have inaccurate or unhelpful representations of CRF and to help tailor interventions for persistent fatigue in cancer survivors.

Characterisation of amyloid-induced inflammatory responses in the rat retina

Amyloid-induced inflammation is thought to play a critical and early role in the pathophysiology of Alzheimer's disease. As such, robust models with relevant and accessible compartments that provide a means of assessing anti-inflammatory agents are essential for the development of therapeutic agents. In the present work, we have characterised the induction of inflammation in the rat retina following intravitreal administration of amyloid-beta protein (Aβ). Histology and mRNA endpoints in the retina demonstrate Aβ1-42-, but not Aβ42-1-, induced inflammatory responses characterised by increases in markers for microglia and astrocytes (ionised calcium-binding adaptor molecule 1 (iba-1), GFAP and nestin) and increases in mRNA for inflammatory cytokines and chemokines such as IL1-β, MIP1α and TNFα. Likewise, analysis of vitreal cytokines also revealed increases in inflammatory cytokines and chemokines, including IL1-β, MIP1α and MCP1, induced by Aβ1-42 but not Aβ42-1. This profile of pro-inflammatory gene and protein expression is consistent with that observed in the Alzheimer's disease brain and suggest that this preclinical model may provide a useful relevant tool in the development of anti-inflammatory approaches directed towards Alzheimer's disease therapy.

External quality assessment scheme for parasite serology; a review of the scheme design and performance

Background

An external quality assessment (EQA) scheme for parasite serology was introduced in April 2005 as a tool to measure how well laboratories were performing in parasite serodiagnosis.

Aim and Methods

To review the scheme design and performance from its beginning until January 2008.

Results

The numbers of participating laboratories gradually increased during the review period and was 28 in January 2008. The results showed that the standard of reporting was extremely high and there was an encouraging trend towards improvement in the overall percentage of correct reports. The most common error made was the returning of false negative results for Strongyloides antibodies.

Conclusion

It is hoped that this scheme will lead to a more standardised approach to the serological diagnosis of parasitic infection.

Methodological issues related to assessing and measuring quality of life in patients with cancer: implications for patient care

Consideration of quality-of-life issues by all members of the healthcare team is essential in caring for people with cancer. In cancer research, quality of life is generally classified as health-related quality of life or individual quality of life. This paper discusses the instruments used to measure quality-of-life outcomes, and the relevance of such findings for healthcare staff in planning and providing effective and patient-centred care. Visual analogue scales (VASs) and questionnaires are commonly used to measure quality of life; however, both types of instruments are criticized because the content may not be relevant to individual patients, and do not distinguish differences between statistical and clinical significances in the findings. Using a combination of questionnaires and VASs may overcome some of these criticisms. In order to interpret the difference between statistical and clinical significance of findings and the associated implications for patient care, a mixed-methods approach to data collection is recommended in quality-of-life studies. This provides meaning and understanding to the quantitative data and individual perspectives on patients' experiences of having cancer. Information from such studies may also be more effective in helping healthcare staff identify relevant issues when planning cancer care services at individual, local and national level.

Immune effects of decreasing low-molecular weight hemoglobin components of hemoglobin-based oxygen carriers (HBOC) in a swine model of severe controlled hemorrhagic shock

Hemoglobin-based oxygen carriers (HBOCs) show potential as safe, efficacious, pre-hospital resuscitation fluids. The major criticism of HBOC-201 is its vasoactive property, attributed partially to low-molecular weight (low-MW) tetrameric/dimeric (TD) hemoglobin (Hb) in HBOC solution. Here we sought to determine whether resuscitation with decreasing concentrations of low-MW Hb component of HBOC affects immune responses in hemorrhagic swine. 28 anesthetized swine underwent a soft muscle crush and controlled hemorrhage of 55% blood volume, followed by resuscitation with HBOC containing 31%, 2%, or 0.4% low-MW Hb in four 10 ml/kg infusions at 20, 30, 45 and 60 minutes before hospital arrival at 75 minutes. IL-10, cell activation and adhesion markers and CD4:CD8 ratio remained unchanged in all 3 groups compared to baseline. Leukocyte apoptosis was equally elevated across all groups. Purification from 31% to 0.4% low-MW Hb in HBOC solution did not alter immune effects in a swine model of severe controlled hemorrhagic shock.

Discrepancy in CD3-Transmembrane Peptide Activity between In Vitro and In Vivo T-Cell Inhibition

Electrostatic amino acid interactions between receptor subunits within the T-cell antigen receptor (TCR) transmembrane domain are critical for the formation of the TCR-CD3 complex. Core peptide, a short peptide corresponding to the TCR-alpha transmembrane region, containing two positively charged amino acids, is known to inhibit T-cell function in vitro and in vivo. The aim of this study was to examine peptides corresponding to the syntactic transmembrane CD3 region binding to TCR-alpha for their ability to inhibit T-cell activation in vitro and in vivo. Three peptides matching the transmembrane sequence of CD3-delta, -epsilon and -gamma were synthesized and tested in different biological in vitro and in vivo systems for their effect on T-cell activity. The CD3-peptides had no impact on T-cell function in vitro, but surprisingly, decreased signs of inflammation in the adjuvant arthritis rat model in vivo. Preliminary evidence suggests that peptides with CD3 transmembrane-derived sequences can inhibit an immune response as assessed by adjuvant-induced arthritis. The lack of in vitro activity may lead to a wasteful disregard of active compounds in the process of drug discovery and development.

Hormone-replacement therapy use, but not race, impacts the resting and exercise-induced GH response in postmenopausal women

OBJECTIVE

This study examined the effect of hormone-replacement therapy (HRT) use on the incremental GH response to aerobic exercise in postmenopausal women and established whether racial differences in the GH response were seen at rest and in response to exercise.

METHODS

13 white (n = 6, HRT; n = 7, no HRT) and seven black women (no HRT) were studied on two occasions, a control day and an exercise day (30 min at 70% VO(2)max on a cycle ergometer). Blood was sampled every 10 min for a 4-h period and analyzed for GH using an ultrasensitive chemiluminescent assay.

RESULTS

The mean 4-h GH concentration was higher on both study days in the HRT women than the non-HRT users. The integrated GH concentrations were greater in the HRT women both at rest and in response to exercise (rest, 352 +/- 53 min microg l(-1); exercise, 711 +/- 57 min microg l(-1); P < 0.01) than in the non-HRT women (rest, 157 +/- 87 min microg l(-1); exercise, 248 +/- 94 min microg l(-1)). The incremental GH response was greater in the HRT users than in the non-HRT women (358 +/- 130 versus 90.8 +/- 94 min microg l(-1), respectively; P < 0.05). GH-production rate during the 4-h period was greater in the HRT women than in the non-HRT women (P < 0.01), due to an increase in the GH mass secreted/pulse (P < 0.05), with no change in GH pulse number or GH half-life. No racial differences in the mean 4-h GH concentrations or integrated GH concentrations were found at rest or in response to exercise.

CONCLUSION

HRT use resulted in a greater incremental exercise response compared with non-HRT users, due to changes in the secretory pulse characteristics in the HRT users. This study also demonstrated that no racial differences exist at rest and in response to exercise in the morning hours.

Cysteine metabolism and whole blood glutathione synthesis in septic pediatric patients

OBJECTIVE

To investigate whole body in vivo cysteine kinetics and its relationship to whole blood glutathione (GSH) synthesis rates in septic, critically ill pediatric patients and controls.

DESIGN

Prospective cohort study.

SETTING

Multidisciplinary intensive care unit and pediatric inpatient units at a children's hospital.

PATIENTS

Ten septic pediatric patients and ten controls (children admitted to the hospital for elective surgery).

INTERVENTIONS

Septic patients (age, 31 months to 17 yrs) and controls (age, 24 months to 21 yrs) received a 6-hr primed, constant, intravenous tracer infusion of l-[1-13C]cysteine. Blood samples were obtained to determine isotopic enrichment of plasma cysteine and whole blood [1-13C]cysteinyl-glutathione by gas-chromatography mass spectrometric techniques. The plasma flux and oxidation rate of cysteine and the fractional and absolute synthesis rates of GSH were determined. Septic patients received variable protein and energy intake, as per routine clinical management, and controls were studied in the early postabsorptive state.

MEASUREMENTS AND MAIN RESULTS

Plasma cysteine fluxes were increased in the septic patients when compared with the controls (68.2 +/- 17.5 [sd] vs. 48.7 +/- 8.8 micromol x kg(-1) x hr(-1); p <.01), and the fraction of plasma cysteine flux associated with oxidative disposal was similar among the groups. The absolute rates of GSH synthesis in whole blood were decreased (p <.01) in the septic patients (368 +/- 156 vs. 909 +/- 272 micromol x L(-1) x day(-1)). The concentration of whole blood GSH also was decreased in the septic group (665.4 +/- 194 vs. 1059 +/- 334 microM; p <.01)

CONCLUSIONS

Whole blood glutathione synthesis rates are decreased, by about 60%, in critically ill septic children receiving limited nutritional support. Plasma cysteine fluxes and concentration of cysteine were increased in the septic patients, suggesting a hypermetabolic state with increased protein breakdown. The mechanisms whereby GSH synthesis rates are decreased in these patients are probably multifactorial, presumably involving an inflammatory response in the presence of limited nutritional support. The role of nutritional modulation and the use of cysteine prodrugs in maintaining GSH concentration and synthesis remain to be established.

Randomized trial comparing the efficacy of a novel manual breast pump with a standard electric breast pump in mothers who delivered preterm infants

OBJECTIVE

The benefits of human milk for preterm infants are widely recognized, yet technological advances in milk expression have been slow. We compared the efficacy of a standard electric pump (EP; Egnell) used in 94% of United Kingdom neonatal units with a novel manual pump (MP; Avent ISIS) designed to operate more physiologically by simulating the infant's compressive action on the areola during breastfeeding.

METHODS

We randomized 145 women who delivered infants of <35 weeks' gestation to use the MP or the EP and measured total milk volume expressed while using the randomized pump during the infant's hospital stay, pattern of milk output and creamatocrit of milk expressed during a test period in the second week, and pump characteristics by maternal questionnaire.

RESULTS

Mothers who used the EP, who frequently double pumped, showed shorter expression times but produced no more milk than mothers who used the MP. When both pumped sequentially, however, mothers who used the MP showed significantly greater milk flow and total volume over 20 minutes. Creamatocrit was unaffected by pump type. The MP was rated significantly higher than the EP on 5 major characteristics.

CONCLUSIONS

When compared on equal terms (sequential pumping), mothers who used the MP showed greater milk flow, perhaps reflecting more physiologic pump design. Even with double pumping, mothers who used the EP did not advantage their infants with greater milk production. We believe that this novel, effective MP, preferred by mothers and costing a fraction of the EP price, reflects a significant advance in milk expression for high-risk infants.breast pumps, randomized trial, preterm infants.

Randomized study comparing the efficacy of a novel manual breast pump with a mini-electric breast pump in mothers of term infants

The objective of this study was to compare the efficacy of a mini-electric pump (MEP) and a novel manual breast pump (MP) designed to operate more physiologically. Sixty term breastfeeding mothers used the MP and MEP in randomized order 8 weeks postpartum, expressing for 10 minutes from each breast. Milk volume, fat content, and pattern of milk flow were measured. Mothers rated pump characteristics by questionnaire. There was no significant difference in the milk volume or fat content when mothers used the pumps in randomized order. The MP was rated significantly better overall and more comfortable and pleasant to use. Significantly more mothers kept the MP than the MEP. Despite the greater complexity and expense of the MEP, the pumps showed similar efficacy. The MP was preferred by mothers. The novel, more physiological operation of the MP represents an advance in milk expression technology.