252 VTUESDAYS: A QUALITY IMPROVEMENT PROJECT TO EMBED THROMBOPROPHYLAXIS REVIEWS IN AN INTERMEDIATE CARE REHABILITATION SETTING

Background

Venous Thrombo-Embolism (VTE) can be life-threatening. Risk assessment and mitigation is essential to reduce morbidity and mortality in all clinical settings. Northern Ireland Health and Social Care has a standardised, regional thromboprophylaxis risk assessment tool as part of paper-based drug charts in the acute, secondary care setting. Intermediate care setting drug charts incorporate this same tool. The 30-bedded pilot site cares for step-down patients from the acute hospital setting from surgical, orthopaedic and medical specialties, for those aged over 18 years requiring bed-based rehabilitation. Regularisation of reviews of risk assessments to address changes in VTE risk was identified as a need to avoid under-prescribing and over-prescribing.

Methods

Quality improvement methodology was used. Pre-phase, semi-structured interviews with stakeholders took place. An Ishikawa diagram analysed contributory factors to risks. A Sinek circle distilled intentions. A Clinical Value Compass map considered potential outcomes. A vision of “VTuEsdays” was co-designed. Global and specific aims informed driver diagrams. Plan, Do, Study, Act iterations were used in the implementation phase including a decision support tool to guide the appropriateness of deprescribing on the basis of rehabilitation trajectory and changing VTE risk.

Results

We collected baseline data and implemented education of staff working in the intermediate care centre, utilising the ‘PDSA’ Model to guide changes. A bright and easy to use flowchart was used with the title ‘VTuEsdays’. This encouraged the process of VTE risk assessment and weekly review on a Tuesday. There were improvements in: the completion rate of risk assessment tool; the accuracy of this assessment; the under-prescribing and over-prescribing of thromboprophylaxis.

Conclusion

The “VTuEsdays” themed day helped ameliorate under-prescribing and over-prescribing of thromboprophylaxis in an intermediate care bed-based rehabilitation setting. Quality improvement methodology enables a robust approach to risk mitigation. Similar themed days for regularisation of reassessment of clinical risk management in intermediate care settings could improve different aspects of care.

An exploratory study to investigate animal health and reproductive wastage among Australian meat goat producers

The Australian goat meat industry has grown significantly in the last decade, with the value of exports nearly tripling. However, because carcase weight has remained constant over this time, the drivers of industry growth are price and supply. Animal health and reproduction are key factors contributing to supply and productivity, yet limitations to production management are poorly understood, hampering advice for effective intervention. This exploratory study aims to provide insights into the animal health and reproductive management practices and perceptions among meat goat producers in Australia. To achieve this aim, 20 producers, located in New South Wales, Queensland, Western Australia and Victoria, operating under different production systems were interviewed. The results of this study suggest that animal health management could be improved and that producers perceive a lack of relevant and species-specific information available to help them make informed decisions. Reproductive management and records varied greatly across producers interviewed. Kid loss was identified as an issue, with a 28% estimated average (6%-47% range) of losses from kidding until weaning. Producers identified predation, doe nutrition and mismothering as the biggest contributors to kid loss, with the majority of losses occurring within a week of birth. All producers believed management could minimise kid loss. This study highlights the importance of improving reproductive rates among goat enterprises and provides new information on the current practices within the Australian meat goat industry. This may assist the development of appropriate strategies for improving health and reproductive management and delivery of advice to producers.

Generation of intense and coherent sub-femtosecond X-ray pulses in electron storage rings

Temporally short X-ray pulses are an indispensable tool for the study of electron transitions close to the Fermi energy and structural changes in molecules undergoing chemical reactions which take place on a time-scale of hundreds of femtoseconds. The time resolution of experiments at 3^rd generation light sources which produce intense synchrotron radiation is limited fundamentally by the electron-bunch length in the range of tens of picoseconds. Here we propose a new scheme for the generation of intense and coherent sub-femtoseconds soft X-ray pulses in storage rings by applying the Echo-Enabled Harmonic Generation (EEHG) method. Many issues for obtaining the EEHG structure such as two modulators and a radiator are solved by a paradigm shift in an achromatic storage ring cell. Numerical demonstration of the feasibility of the scheme for the BESSY II beam parameters is presented.

Hybrid triad provides fracture plane stability in a computational model of a Pauwels Type III hip fracture

The study utilized finite element method to determine displacements and stresses in a set of Pauwels Type III femoral neck fractures repaired using 3 techniques (cannulated screws (Triad), sliding hip screw (SHS), and a Hybrid (SHS + cannulated screws). The research found that shear displacement doubled between the 65° and 75° fracture angles regardless of fixation construct. The SHS alone was the least stable construct, with highest construct stresses and shear displacement along the fracture plane. The stability of the Hybrid and Triad constructs were similar, but stress in the Hybrid was lower suggesting it would provide a higher load to failure than the Triad.

Reproductive performance in goats and causes of perinatal mortality: a review

Goat meat production is an expanding industry in Australia. However, there is limited data quantifying the levels of reproductive performance, particularly under extensively grazed rangeland conditions, which would inform interventions to improve performance. This review aimed to quantify the levels of reproduction, time and causes of reproductive wastage in goats. It considers the levels of fertility, fecundity, embryonic loss, fetal loss and post-natal survival reported under Australian conditions, and comparisons are made with international reports. Key management factors that may contribute to reproductive performance include breed, seasonality, nutritional conditions, and weather conditions at kidding. While goats are potentially prolific breeders, in Australia, the variation in weaning rate (kids/doe joined) among properties is large (51–165%), although the causes of this variation are not well defined. Generally, conception and kidding rates are high, although fetal loss associated with undernutrition is more likely in goats than sheep. As with sheep, perinatal losses are generally the largest source of wastage, with an average 20% kid mortality, but this level is influenced by litter size and appears to be higher under extensive rangeland systems. The causes of perinatal kid loss under Australian conditions are similar to those in sheep, with starvation–mismothering–exposure and dystocia or stillbirth the key causes. Studies are needed to accurately quantify the level and causes of reproductive wastage in commercial herds, including a range of management situations, to enable effective interventions to be developed.

Land managers’ and service providers’ perspectives on the magnitude, impact and management of non-domestic grazing pressure in the southern rangelands of Australia

In the southern rangelands of Australia, the capability of land managers to manage total grazing pressure, with support from their service providers, influences resource condition, livestock production and pastoral business profitability. This study investigated the perspectives of people who face the challenge of managing total grazing pressure. Self-administered surveys were used to collect the perspectives of 220 land managers and 46 service providers to total grazing pressure management and the impacts of grazing animals. Land managers and service providers agreed that, on average, 40 to 50% of the total demand for forage is due to non-domestic animals, that a reduction in this component is required, and that current levels are at least double the desirable level. The majority of respondents (>54%) assessed both livestock and non-domestic animals to have a negative impact on soils and pastures. However, livestock were more frequently assessed to have a positive impact on soils and pastures than non-domestic animals. The respondents commonly suggested that the impact livestock have on soils and pastures depends on management. Non-domestic animals were assessed by the majority of respondents to have a negative impact on livestock production and business profitability, apart from unmanaged goats where opinions were divided. Both land managers and service providers used the ‘large negative’ category to describe the impact on livestock production and business profitability more frequently for kangaroos than for any other herbivore. There were significant differences in the respondents’ perspectives among the States. Respondents in New South Wales and Queensland estimated a higher proportion of demand for forage from non-domestic animals than respondents from other States. The respondents in New South Wales also more frequently assessed unmanaged goats to have a positive impact on business profitability compared with the other States. Total grazing pressure management was rated as a high priority issue by 66% of respondents. ‘Improved kangaroo management’ and ‘fencing’ were the two main factors identified with potential to make a substantial difference to total grazing pressure management in the next ten years.

Do concerns about kangaroo management represent an existential threat for the red meat industry in the southern Australian rangelands?

Concerns raised, including those voiced by animal rights and vegan activists, have limited the available practices by landholders in the southern Australian rangelands to effectively control kangaroos and, over time, the actions of these groups may threaten the existence of the livestock industry. This paper draws on interviews with key stakeholders and workshops with technical experts and red meat industry participants to identify strategies to respond to this potentially existential threat. Strategies include establishing platforms and processes for effective stakeholder engagement, establishing a unified and resourced industry ‘voice’ to effectively engage with government and other stakeholders, and ensuring that the industry self-regulates in order to avoid the potential for rogue elements to undermine its credibility and trustworthiness.

Public attitudes to animal welfare and landholder resource limitations: implications for total grazing pressure management in the southern rangelands of Australia

Sustainable grazing in the nationally iconic southern rangelands of Australia requires landholders to actively manage the grazing pressure from both domestic livestock and non-domestic herbivores. Landholders have primary responsibility for controlling the non-domestic herbivores. In doing so, they must meet the Australian public’s expectations for resource conservation (mainly a public good) and animal welfare. Governments are also involved in the management of non-domestic herbivores via native and feral animal legislation and control programs. The Australian public will not accept cruelty to animals, perceived or otherwise. In this paper we explore the challenges faced by landholders in their attempts to manage the grazing pressure from native herbivores, particularly kangaroos, feral goats and feral pigs, while meeting the Australian public’s expectations for animal welfare. Landholders typically live on extensive properties and their capacity to manage these is influenced by high climate variability, low labour availability, commodity price fluctuations and limited capital available for investment in new technologies. The additional requirement to reduce the grazing pressure from kangaroos, feral goats and feral pigs is a significant burden on already time-poor landholders. Hence, there is a critical disparity between landholders’ capacity and their responsibility to effectively manage the non-domestic herbivores on their properties. We suggest that current expectations of landholders to deliver public benefits by publicly acceptable practices are unreasonable. Further, we suggest that governments should accept more responsibility for managing non-domestic grazing pressure. The concept of duty of care to land management provides a means by which a more appropriate division of responsibilities between landholders and government could be achieved to ensure that valued attributes of this iconic Australian landscape are retained.

Stakeholder judgements of the social acceptability of control practices for kangaroos, unmanaged goats and feral pigs in the south-eastern rangelands of Australia

Total grazing pressure (TGP) is a key driver of productivity in livestock systems in the south-eastern rangelands of Australia. Sustainable grazing in these environments requires the management of grazing pressure from kangaroos, unmanaged goats and feral pigs, as well as livestock. Any practices used to control these species must be socially acceptable. Twenty-four semi-structured interviews with individuals drawn from key stakeholder groups were conducted to assess the acceptability of control practices for each of these species. Commercial shooting was the most acceptable control practice for kangaroos with a much lower acceptance of non-commercial shooting. A trap yard (at a water point) was the most acceptable practice for control of unmanaged goats with shooting least acceptable. Ground shooting, trapping and 1080 baiting were the most acceptable practices for control of feral pigs with dogging least acceptable. The two key criteria for social acceptance of control practices by stakeholder group interviewees were humaneness and effectiveness. Acceptance was also influenced by interviewees’ attitudes towards particular species. Interviewees typically distinguished between control of native wildlife and ‘feral’ animals, and between ‘resource’ animals and ‘pest’ animals. Importantly, support for control programs to manage TGP must be justifiable and employ practices that are socially acceptable.

In Vitro Studies on the Fibrinolytic, Thrombolytic and Fibrinogenolytic Properties of a Tissue Plasminogen Activator from Guinea Pig Keratocytes

The fibrinolytic and thrombolytic properties of a tissue plasminogen activator (tPA) purified from the conditioned medium of an established guinea pig keratocyte (GPK) cell line were investigated in in vitro systems and compared with urokinase. Using the fibrin clot lysis assay, GPK activator appears to be similar to human melanoma tPA and not to human urokinase. GPK activator also caused negligible fibrinogen breakdown, when incubated with human plasma at 37° C over 23 hr. Urokinase on the other hand caused significant fibrinogenolysis, under similar conditions. Comparison of the lysis of plasma clots by GPK activator and human urokinase have shown that GPK activator was a much more effective fibrinolytic agent than urokinase, especially at lower concentrations (<50 IU/ml). Studies on the thrombolytic effect of GPK activator on the lysis of aged and cross-linked whole human blood clots and plasma clots hanging in artificially circulating human plasma suggest that GPK activator can lyse both these types of clots equally well. The lysis is dose dependent, attaining complete lysis within 3–6 hr with the concentration of GPK activator in the range of 1–5 μg/ml plasma. It is concluded that GPK activator has a higher fibrinolytic and thrombolytic activity and lower fibrinogenolytic activity than urokinase.

Paired vehicle occupant analysis indicates age and crash severity moderate likelihood of higher severity injury in second row seated adults in frontal crashes

The majority of advances in occupant protection systems for motor vehicle occupants have focused on occupants seated in the front row of the vehicle. Recent studies suggest that these systems have resulted in lower injury risk for front row occupants as compared to those in the second row. However, these findings are not universal. In addition, some of these findings result from analyses that compare groups of front and second row occupants exposed to dissimilar crash conditions, raising questions regarding whether they might reflect differences in the crash rather than the front and second row restraint systems. The current study examines factors associated with injury risk for pairs of right front seat and second row occupants in frontal crashes in the United States using paired data analysis techniques. These data indicate that the occupant seated in the front row frequently experiences the more severe injury in the pair, however there were no significant differences in the rate of occurrence of these events and events where the more severe injury occurs in the second row occupant of the pair. A logistic regression indicated that the likelihood of the more severe injury occurring in the second row seated occupant of the pair increased as crash severity increased, consistent with data from anatomic test dummy (ATD) tests. It also indicated that the second row occupant was more likely to have the more severe injury in the pair if that occupant was the older occupant of the pair. These findings suggest that occupant protection systems which focus on providing protection specifically for injuries experienced by older occupants in the second row in higher severity crash conditions might provide the greatest benefit.

Abstract OT1-4-02: Phase I study of the combination of BKM120 and olaparib for the treatment of high grade serous ovarian cancer (HGSC) and triple negative breast cancer (TNBC)

Background: In vivo synergy of the PI3-kinase inhibitor BKM120 with the PARP inhibitor olaparib has been observed using a mouse model of BRCA1-related breast cancer and sporadic TNBC (Juvekar et al and Ibrahim et al, Cancer Discovery 2012). In addition, olaparib has single agent activity in both HGSC and BRCA-associated breast cancer. The PI3kinase pathway is activated in both TNBC and HGSC (www.cancergenome.nih.gov). These preclinical and clinical data have served as the rationale for this phase I, multi-center study (NCT01623349) combining the oral PARP inhibitor olaparib with the oral PI3-kinase inhibitor BKM120 in patients with recurrent HGSC or recurrent TNBC. This study is being conducted through the Stand Up to Cancer (SU2C)'s Targeting PI3-kinase in Women's Cancers Dream Team.

Study Design: This study has a 3 + 3 design, escalating if 0/3 or 1/6 participants have a dose limiting toxicity (DLT) during the first cycle of therapy (first 28 days). The study objectives are to determine the recommended phase II dose (RP2D) of daily continuous oral olaparib (using the tablet formulation) and BKM120, assess toxicities, safety, and preliminary activity of this combination, and determine pharmacokinetic profiles of both agents. In addition, there are several translational endpoints including elucidation of downstream signaling effects of the PI3-kinase pathway, examination of BRCA1 immunostaining, and assessment of BRCA1 promoter hypermethylation and somatic mutations in BRCA1 and BRCA2 using archived formalin fixed paraffin embedded (FFPE) tissue. Serial IL-8 and circulating DNA levels are also being monitored as well. Eligibility includes a diagnosis of recurrent TNBC or HGSC, PS 0 or 1, measurable or evaluable cancer, and normal lab values and organ function. Prior PARP inhibitor exposure is allowed. In addition, breast cancer or ovarian cancer patients with any histologic subtype are eligible if they have a known germline BRCA1 or BRCA2 mutation. At the RP2D, 10 pts each with a diagnosis of TNBC or HGSC will be enrolled to further determine safety and efficacy profiles in addition to more thoroughly studying translational endpoints. As of June 7, 2013, 16 patients have been enrolled into this study with a planned accrual of approximately 50 patients which may change based on number of dose levels tested during dose escalation. In addition, an amendment is pending that will add a second cohort studying the combination of olaparib and BYL719 based on robust pre-clinical activity observed in murine models which will increase our total accrual. Once this new cohort is open, both arms will enroll simultaneously.

For further information, contact Ursula Matulonis at: umatulonis@partners.org.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT1-4-02.

Burden of Sexual Dysfunction in Women with Breast Cancer

Background: Sexual dysfunction is reported after chemotherapy and endocrine therapies, and causes a substantial burden on women with breast cancer. However, the prevalence and severity of sexual dysfunction in women undergoing therapy for both local and metastatic disease is not well defined. Improved understanding of sexual dysfunction may facilitate enhanced treatment and interventions in patients with breast cancer undergoing active treatment, and in survivors of this disease.Methods: We developed a survey that includes a previously validated questionnaire, the female sexual function index (FSFI), as well as an established measure of health-related quality of life (the EuroQol EQ-5D), and disease-specific items to characterize sexual dysfunction and its causes based on literature review and expert consultations. Anonymous administration of the surveys was conducted in outpatient clinic waiting areas of the Breast Cancer Center at Memorial Sloan-Kettering Cancer Center (MSKCC) and two community centers, under an IRB waiver of consent.Results: During November 2008 through May 2009, 509 women undergoing treatment for breast cancer of all stages were each queried once. The mean age was 51 (range 26-91). 87% reported current or past hormonal treatment, and 82% reported current or past chemotherapy (76% adjuvant; 24% for metastatic disease). Sexual dysfunction attributed to breast cancer or its treatment, defined as an FSFI score &lt;26, was reported by 76% of respondents. Among these women, 316/386 (82%) patients considered their sexual symptoms to be bothersome, with 247/386 (64%) noting moderate or severe levels of bother (score &gt;=5/10). Patients attributed their sexual dysfunction to chemotherapy in 318/373 (85%) of cases; to hormonal therapy in 221/298 (74%) of cases; and to surgery in 331/442 (66%) of cases. Other reported contributors to sexual dysfunction include a new diagnosis of breast cancer by 81% of respondents, anxiety by 82% of respondents, and change in relationship with a partner by 55% of respondents.Conclusion: Sexual dysfunction is prevalent in women treated for breast cancer and should be discussed with patients as a potential adverse effect of therapy. Assessment of sexual symptoms throughout treatment and beyond may facilitate the use of potential interventions such as lubricants, dilators, treatment modification, topical estrogens, and counseling. Future work includes a longitudinal prospective trial to further characterize the etiologies of these symptoms and a randomized controlled trial to evaluate interventions for sexual dysfunction.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1056.

Sexual dysfunction in women with breast cancer: Prevalence and severity

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Background: Sexual dysfunction (SD) is reported after chemotherapy and endocrine therapies, and causes a substantial burden on women with breast cancer. However, the prevalence and severity of SD in this population is not well defined. Improved understanding of SD may allow for enhanced treatment and interventions in patients with breast cancer undergoing active treatment, and in survivors of this disease. Methods: We developed a survey that includes a previously validated questionnaire, the female sexual function index (FSFI), and disease-specific items to characterize SD and its causes based on literature review and expert consultations. Anonymous administration of the surveys was conducted in outpatient clinic waiting areas of the M64/Breast Center Memorial Sloan-Kettering Cancer Center (MSKCC), under an IRB waiver of consent. Results: During November-December 2008, 100 women with breast cancer of any stage were each queried once. The mean age was 52 (range 26–75). 68% reported current or past hormonal treatment, and 63% reported current or past chemotherapy (84% adjuvant; 16% for metastatic disease). SD attributed to breast cancer or its treatment, defined as an FSFI score <26, was reported by 75% of respondents. Among these women, severe symptoms were noted by 38/75 (51%), and moderate by 37/75 (49%). 87/95 (92%) patients considered their sexual symptoms to be bothersome, with 59/95 (62%) noting moderate or severe levels of bother (score >=5/10). Patients attributed their SD to chemotherapy in 52/63 (83%) of cases; to hormonal therapy in 56/68 (82%) of cases; and to surgery in 68/92 (74%) of cases. Other contributors to SD were felt to include anxiety by 83% of respondents, and change in relationship with a partner by 46%. Conclusions: SD is prevalent in women treated for breast cancer and should be discussed with patients as a potential adverse effect of therapy. Assessment of sexual symptoms throughout treatment and beyond may facilitate the use of potential interventions such as lubricants, dilators, treatment modification, topical estrogens, and counseling. A longitudinal prospective trial is planned to further characterize the etiologies of these symptoms.

No significant financial relationships to disclose.

Randomized trial of acupuncture versus sham control for prevention of myelosuppression in patients with gynecologic malignancies

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Background: CIM is a significant toxicity that is treated with cytokine growth factors, dose reductions and/or delays. Preliminary uncontrolled Chinese studies suggest that acupuncture lessens CIM. Methods: Patients (pts) with newly diagnosed or recurrent gyn cancers receiving chemotherapy were eligible. Trial design was a double blinded, randomized trial of active acupuncture or sham for 5 weeks (administered 3x per week). Primary endpoints were first nadir WBC and ANC levels at chemo cycle 2; other endpoints were recovering counts following the cycle 2 nadir, QOL, G-CSF levels, and feasibility. Results: >460 patients were screened. 21 pts were randomized to either active acupuncture (n=11) or sham control (n=10). Median age of the pts was 55 yrs (range: 28–81). 15 pts have completed the acupuncture treatment to provide the baseline and nadir WBC and ANC. Toxicities related to either sham or active acupuncture were minimal. The active pts group showed higher baseline WBC (median: 3,600 vs. 2,600, NS) and ANC (median: 2,269 vs. 1,922, NS) values. The nadir WBC was higher in the pts receiving acupuncture (median 3,600 vs. 2,300) but the difference was not statistically significant after adjusting for the baseline difference (p=0.16). Nadir ANC was higher among the pts receiving acupuncture (median: 2,424 vs. 1,274) but the difference was not statistically significant after adjusting for the baseline difference (p=0.1107). Recovering WBC in the pts receiving acupuncture was higher (median: 8,600 vs. 4,400) after adjusting for the baseline difference (p=0.045). The recovering ANC in the pts receiving acupuncture was higher (median: 6,530 vs. 4,038) but this difference was not statistically significant after adjusting for the baseline difference (p=0.0919). QOL and G-CSF data will be presented at ASCO. Conclusions: Although a larger randomized trial is necessary to determine the effects of acupuncture on CIM, there were consistent trends, and recovering WBC counts were significantly higher in patients receiving acupuncture. Formal evaluation of CAM is vital to confirm potentially clinically meaningful benefits.

No significant financial relationships to disclose.

Phase I/II dose finding study of combination cisplatin and gemcitabine in patients with recurrent cervix cancer

OBJECTIVES

To evaluate the toxicity and efficacy of cisplatin and gemcitabine in women with recurrent cervical cancer.

METHODS

A multi-institutional phase I/II dose finding study of cisplatin and gemcitabine delivered to women with recurrent previously radiated cervical carcinoma.

RESULTS

Twenty eight patients were enrolled. The mean and median age of patients was 51 years (age range 35 to 70 years). Chemotherapy was given on a 28-day cycle; cisplatin was administered at a fixed dose of 50 mg/m(2), day 1 and gemcitabine, days 1, 8, and 15. Gemcitabine doses started at 600 mg/m(2) (dose level 1) and were escalated by 100 mg/m(2)/dose level until 1000 mg/m(2) (dose level 5). Twenty seven patients were evaluable for toxicity and disease response, and 75 cycles of chemotherapy were administered. Toxicities were predominantly hematological; 18% of patients experienced grade 3 anemia, 37% grade 3 and 11% grade 4 leukopenia, 41% grade 3 neutropenia, and 26% grade 3 thrombocytopenia. The maximally tolerated dose (MTD) was not reached. One patient experienced a dose-limiting toxicity on dose level 2 (febrile neutropenia). One patient had a CR and 3 patients had a PR to therapy (15% response rate), 41% of patients had SD, and 44% had progression of cancer. Median survival was 11.9 months.

CONCLUSION

Although this 28-day gemcitabine and cisplatin regimen in recurrent cervix cancer has tolerable toxicity, 21-day regimens are recommended because of improved practicality, higher dose intensity, and higher response rates.

Phase I trial of liposomal doxorubicin and ZD 1839 in patients with refractory gynecological malignancies or metastatic breast cancer

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Background: Liposomal Doxorubicin has activity in both breast and ovarian cancer. Preclinical data reported by several investigators have suggested that ZD1839 acts synergistically with chemotherapy in ovarian cancer cells expressing high levels of EGFR. Given the lack of cross resistance and the different targets for these agents a Phase I trial was initiated examining the safety and the efficacy of the combination of Liposomal Doxorubicin and ZD1839. Methods: Dose limiting toxicity was defined within the first two cycles of treatment. The dose escalation schema was described as such: Results: As of January 2006, 23 patients have been enrolled in this study (GYN = 6; Breast 17). Six patients were enrolled in dose level 1 and no DLTs were observed. Dose level 2 enrolled six patients. One DLT was observed (febrile neutropenia). As defined by protocol an additional 6 patients were accrued to dose level 2. Accrual to dose level 3 began on 11/2005. One patient has completed 2 cycles and no additional DLTs have been noted. MTD has not yet been reached. SAEs have included mental status changes, and two CNS bleeds (believed most likely to be unrelated to study drug combination). Toxicities noted in cycle 3 and above have been mild with the exception of 2 grade 3 and 2 grade 4 toxicities related to skin and GI toxicity. No cardiac toxicity was observed. Doxil dose modifications (cycle 3 +) occurred in 7 patients. Best response to therapy has included 2 PRs and 10 patients with SD. Eleven patients to date have had progressive disease. The trial continues to accrue. Correlative studies including EGFR expression and CECs and PKs (at MTD) are planned. Conclusion: Liposomal Doxorubicin in conjunction with ZD1839 is tolerable regimen in patients with advanced breast and ovarian cancer. To date MTD has not been reached.

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Resisting and promoting new technologies in clinical practice: the case of telepsychiatry

New telecommunications technologies promise to profoundly change the spatial and temporal relationship between health professional and patient. This paper reports results from an ethnographic study of the introduction of a videophone or 'telemedicine' system intended to facilitate faster and more convenient referral of patients with anxiety and depression in primary care, to a community mental health team. We explore the reasons for contest over the telemedicine system in practice, contrasting professionals' critique of the technology in play with a more fundamental problem: the extent to which the telecommunications system threatened deeply embedded professional constructs about the nature and practice of therapeutic relationships.

Knee injuries in motor vehicle collisions: a study of the National Accident Sampling System database for the years 1979-1995

A detailed study of knee injuries recorded in the 1979-1995 National Accident Sampling System database maintained by the National Highway Traffic Safety Administration was conducted. Injuries to other body regions were also considered in order to illustrate the relative frequency of knee injuries. This study demonstrated that knee injuries constitute approximately 10% of all injuries recorded every year. However, the majority of these injuries were of low severity (i.e. contusions, abrasions, lacerations) with an abbreviated injury score (AIS) of 1. Most knee injuries occurred following a frontal collision with no intrusion. The study also indicated most knee fractures occur in crashes where the vehicle velocity differences (deltaVs) were less than 45 kmph, with some occurring at deltaVs as low as 10 kmph. Serious non-fracture knee injuries (i.e. ligament tears) rated AIS 2 accounted for 20 out of every 1000 injuries and predominantly occurred at deltaVs below 25 kmph. In this study it was noted that women were more likely to experience a knee contusion than men. This study further suggests that knee impact scenarios have remained relatively constant over the years as the knee injury rates showed little variation. The rate of lap and shoulder belt use was lower in occupants who experienced a knee injury vs. the rate in the overall database and airbags were present in only a small number of cases. As this study largely included only vehicles without airbags it provides a good baseline for analysis of the influence of the airbag on knee injury trends in the future.

A microbiological survey of Montserrat Island hydrothermal biotopes

In March 1996, a survey of hydrothermal sites on the island of Montserrat was carried out. Six sites (Galway's Soufrière. Gages Upper and Lower Soufrières, Hot Water Pond, Hot River, and Tar River Soufrière) were mapped and sampled for chemical, ATP, and microbial analyses. The hydrothermal Soufrière sites on the slopes of the active Chances Peak volcano exhibited temperatures up to almost 100 degrees C and were generally either mildly acidic at pH 5-7 or strongly acidic at pH 1.5-3, but with some hot streams and pools of low redox potential at pH 7-8. Hot Water Pond sites, comprising a series of heated pools near the western shoreline of the island. were neutral and saline, consistent with subsurface heating of entrained seawater. Biological activity shown by ATP analyses was greatest in near-neutral pH samples and generally decreased as acidity increased. A variety of heterotrophic and chemolithotrophic thermophilic organisms were isolated or observed in enrichment cultures. Most of the bacteria that were obtained in pure culture were familiar acidophiles and neutrophiles, but novel, iron-oxidizing species of Sulfobacillus were revealed. These species included the first mesophilic iron-oxidizing Sulfobacillus strains to be isolated and a strain with a higher maximum growth temperature (65 degrees C) than the previously described moderately thermophilic Sulfobacillus species.

Transient NMDA receptor inactivation provides long-term protection to cultured cortical neurons from a variety of death signals

NMDA receptor antagonists, such as (+)-5-methyl-10, 11-dihydro-5H-dibenzo [a,d] cyclohepten-5,10-imine maleate (MK-801), potently block glutamate-induced neuronal death in myriad in vitro cell models and effectively attenuate ischemic damage in vivo. In this report, a novel role for MK-801 and other NMDA receptor antagonists in preconditioning neurons to withstand a wide range of subsequent lethal insults is described. A brief 30 min exposure to 0.1 microM MK-801, applied up to 96 hr before a "lethal" insult, protected primary cortical neurons from a diverse group of neurotoxic agents, including NMDA, beta-amyloid, staurosporine, etoposide, and oxygen-glucose deprivation. This neuroprotective preconditioning by MK-801 arose from transient NMDA receptor inactivation, because the noncompetitive NMDA receptor antagonists memantine and nylindin and the competitive antagonist AP-5 gave similar effects. MK-801 protection was dependent on new protein synthesis during the first 2 hr, but not from 2 to 5 hr, after MK-801 exposure. The MK-801 transient did not alter the ability of NMDA to trigger normally lethal [Ca(2+)](i) influx 48 hr later, but it did block early downstream signaling events coupled to NMDA neurotoxicity, including PKC inactivation and the activation of calpain. Moreover, MK-801 protected neurons from staurosporine-induced apoptosis, although caspase activation in these cells was unimpeded. It is likely that the stress associated with transient inactivation of NMDA receptors triggered a rapid compensatory survival response that provided long-term protection from a spectrum of insults, inducing apoptotic and nonapoptotic death. The possibility that MK-801 preconditioning blocks an event common to seemingly diverse death mechanisms suggests it will be an important tool for obtaining a clearer understanding of the salient molecular events at work in neuronal death and survival pathways.

Telepsychiatry evaluation in the north-west of England: preliminary results of a qualitative study

A telepsychiatry referral service for patients suffering from anxiety and depression was evaluated from a user perspective. Low-cost video-phones linked a psychiatrist to two general practices in the north-west of England. Quantitative data were collected using a semistructured interview schedule. Twenty-two patients and 13 doctors were interviewed after a video-link consultation. Some users were very positive about the service and recognized its potential benefits, while others were more ambivalent. Patients saw the service as a means of obtaining additional 'expert' advice. General practitioners felt that the service might adversely affect the doctor-patient relationship in psychiatry. Both patients and clinicians recognized that the video-link modified normal interaction. Users need to adapt to this form of communication. An induction session is recommended for both patients and clinicians.

Psychiatry by videophone: a trial service in north west England

In this paper we report on the use of a video link between two general practices and a hospital based mental health team in North West England to provide a trial telepsychiatry service for individuals with depression and anxiety related disorders. Patients (n = 16) took part in an evaluation of the service by both structured questionnaire and semi-structured interview. The results of the evaluation study suggest that patients may be highly critical of telemedicine systems and that they do so not simply on the grounds of the technical quality of video links, but also because the remote link increases the difficulty that the patient faces in expressing deep scated emotional and existential problems. It is not, therefore, simply a matter of technical quality in the link, but also a question of the quality of interpersonal relations perceived by the patient.

Secretion of pancreatic digestive enzymes induced in rats by first-time oral exposure to kidney bean E2L2 lectin is mediated only in part by cholecystokinin (CCK)

The acute effects of kidney bean (Phaseolus vulgaris) E2L2 lectins (PHA) given orally to conscious rats or continually infused into the duodenum of anesthetized rats on blood cholecystokinin (CCK), secretin, and gastrin and on secretion of pancreatic digestive enzymes have been evaluated. PHA increased circulating levels of CCK and secretin but did not alter gastrin. In addition, PHA induced dose-dependent secretion of trypsinogen, chymotrypsinogen, and alpha-amylase by the pancreas in vivo. This pancreas output appeared to be modulated only in part through CCK. Thus pretreatment of rats with a CCK-A receptor antagonist (L-364718) attenuated the immediate (< or = 90 min) pancreas secretory response to PHA but could not prevent a PHA-associated increase in digestive enzyme output in the longer term (after 90 min). In contrast, treatment of rats with L-364718 abolished the stimulatory effects of soyabean trypsin inhibitors on digestive enzyme secretion in both the short and long term. Additional mechanisms or hormones, such as secretin, may play a role in modulating later exocrine pancreas responses to PHA.

Leptin (ob) mRNA and hypothalamic NPY in food-deprived/refed Syrian hamsters

Food deprivation in the laboratory rat decreases plasma leptin and insulin, elevates glucocorticoid concentration, and increases the activity of the neuropeptide Y (NPY) system and feeding drive. In contrast, Syrian hamsters fail to modify feeding behaviour in response to various food scarcity paradigms. Two components of the neuroendocrine-hormonal response to food deprivation, adipose tissue-derived leptin and hypothalamic NPY, are investigated in the Syrian hamster. ob (leptin) mRNA was less abundant in subcutaneous than abdominal adipose tissue, but not to the extent observed in other rodents. Food deprivation for 48 h reduced ob mRNA in inguinal and retroperitoneal white adipose tissue; gene expression was partially restored by refeeding. In contrast, in epididymal fat there was no effect on ob mRNA. NPY concentrations in hypothalamic nuclei were also unaffected by feeding state. The predicted amino acid sequence of leptin from the Syrian hamster was over 90% homologous with Djungarian hamster and mouse sequences, and the leptin receptor gene (OB-R), and specifically the long intracellular splice variant, OB-Rb, was expressed in the same forebrain and hypothalamic regions that have been described in laboratory mice and rats, including hypothalamic arcuate, dorsomedial, and ventromedial nuclei. The failure of food deprivation to affect NPY and feeding behaviour in Syrian hamsters is unlikely to be due to defects in the leptin system, although there may be region-specific differences in the regulation of leptin signaling in laboratory rats and Syrian hamsters.

Short-day weight loss and effect of food deprivation on hypothalamic NPY and CRF mRNA in Djungarian hamsters

The effect of food deprivation on hypothalamic neuropeptide Y (NPY) and corticotropin-releasing factor (CRF) gene expression in the Djungarian hamster was quantified by in situ hybridization. Hamsters housed in short days (SD) for 18 wk decreased body weight by 40% and exhibited 200% increases in both NPY and CRF mRNA when deprived of food for 24 h. Prior gonadectomy in long days (LD) affected neither basal gene expression nor the induction of gene expression by food deprivation. Gene expression in juvenile LD hamsters similar in body weight to SD animals was relatively insensitive to food deprivation of either 24- or 48-h duration or to subsequent refeeding. In juvenile hamsters, food deprivation for 24 but not 48 h decreased ob (obese) gene expression in inguinal but not epididymal white adipose tissue; ob mRNA levels were restored by refeeding. All food-deprived hamsters had reduced plasma insulin concentrations, but plasma cortisol was only elevated in SD food-deprived animals. NPY gene expression was also increased after daily dexamethasone injections in adult LD hamsters. These results suggest that the neuroendocrine consequences of food deprivation in SD Djungarian hamsters are determined by some factor other than absolute body mass such as the size of adipose tissue reserves.

Regulation of galanin gene expression in the hypothalamic paraventricular nucleus of the obese Zucker rat by manipulation of dietary macronutrients

Lean and obese male Zucker rats were fed high fat (72% of energy as fat), high carbohydrate (66% of energy as carbohydrate) or intermediate diets for 4 weeks commencing 1 week after weaning. We examined the effects of these diets on growth rates, plasma insulin and corticosterone titres, and hypothalamic gene expression of 3 appetite-related neuropeptides. Messenger RNA levels for neuropeptide Y (NPY), galanin (GAL) and corticotropin-releasing factor (CRF) in critical hypothalamic locations were measured by in situ hybridization in each brain. Obese rats grew more rapidly and had elevated plasma insulin and corticosterone concentrations relative to their lean littermates. The obese phenotype was also associated with elevated NPY gene expression in the arcuate nucleus of the hypothalamus and increased GAL gene expression in the hypothalamic paraventricular nucleus. There was no effect of diet on NPY or CRF gene expression in either lean or obese rats. However, maintenance on the high fat diet had a significant effect on GAL gene expression in obese but not lean rats: high fat diet significantly reduced mRNA levels in the obese rats. This reduction in GAL mRNA was accompanied by attenuation of the hyperinsulinemia that is characteristic of this genetic obesity.

Hypothalamic NPY and CRF gene expression in the food-deprived Syrian hamster

Because the Syrian hamster, Mesocricetus auratus, does not increase food intake in response to food deprivation, we investigated whether hypothalamic NPY gene expression in this species was sensitive to this imposed state of negative energy balance. In the rat, food deprivation for 48 h resulted in a 150% increase in total preproNPY gene expression in the arcuate nucleus of the hypothalamus (ARC). NPY gene expression in food-deprived Syrian hamsters did not differ significantly from that of ad lib-fed controls, although there was a trend towards increased mRNA levels in the fasted animals. However, food deprivation for 48 h was associated with a rise in preproCRF mRNA in the paraventricular nucleus of the hypothalamus (PVN) of 80-g, but not 150-g, hamsters. The expected reductions in plasma insulin accompanied food deprivation in the Syrian hamster, but cortisol titre was only elevated in the lower body weight group. NPY gene expression in the Syrian hamster appeared, however, to be sensitive to glucocorticoids; daily administration for 28 days of the synthetic glucocorticoid, dexamethasone, increased ARC NPY mRNA levels by 43%. The response of NPYergic and other hypothalamic neuropeptide systems to food deprivation, and the involvement of neuroendocrine substrates in energy homeostasis, may vary between species.