InterCarb: A Community Effort to Improve Interlaboratory Standardization of the Carbonate Clumped Isotope Thermometer Using Carbonate Standards

Increased use and improved methodology of carbonate clumped isotope thermometry has greatly enhanced our ability to interrogate a suite of Earth-system processes. However, interlaboratory discrepancies in quantifying carbonate clumped isotope (Δ47) measurements persist, and their specific sources remain unclear. To address interlaboratory differences, we first provide consensus values from the clumped isotope community for four carbonate standards relative to heated and equilibrated gases with 1,819 individual analyses from 10 laboratories. Then we analyzed the four carbonate standards along with three additional standards, spanning a broad range of δ47 and Δ47 values, for a total of 5,329 analyses on 25 individual mass spectrometers from 22 different laboratories. Treating three of the materials as known standards and the other four as unknowns, we find that the use of carbonate reference materials is a robust method for standardization that yields interlaboratory discrepancies entirely consistent with intralaboratory analytical uncertainties. Carbonate reference materials, along with measurement and data processing practices described herein, provide the carbonate clumped isotope community with a robust approach to achieve interlaboratory agreement as we continue to use and improve this powerful geochemical tool. We propose that carbonate clumped isotope data normalized to the carbonate reference materials described in this publication should be reported as Δ47 (I-CDES) values for Intercarb-Carbon Dioxide Equilibrium Scale.

Management of recurrent implantation failure by gonadotropin-releasing hormone agonist and aromatase inhibitor suppression, in women without evidence of endometriosis

Endometriosis is common among those with infertility, although many cases go undiagnosed. This study was performed to determine whether empiric treatment with two months of depo-leuprolide 3.75 mg monthly (dep-GnRH-ag) and letrozole 5 mg daily improves pregnancy outcomes in patients with at least two unexplained failed embryo transfers (ETs) but without a previous diagnosis of endometriosis. A retrospective cohort study was performed with subjects who failed at least two good quality ET. The study excluded women with a known history of endometriosis or ovarian cysts (possible endometriomas). Subjects (N = 38) were treated with dep-GnRH-ag and letrozole pre-cycle. Matched women (N = 37) who did not receive either pretreatment served as a control group. Data were compared by non-paired T-tests and multivariate logistic regression to control for confounding effects. Demographic data, hormonal profiles, and ovarian reserve parameters were similar between the two groups. The treated group had failed more embryo transfers (3.5 ± 1.7 vs. 2.0 ± 1.3, p = .01) than the controls. When adjusting for the number of MII oocytes collected, number of blastocysts developed and number of blastocysts transferred, there were more pregnancies (24/38 vs. 11/37, p = .02) and ongoing pregnancies (18/38 vs. 9/37, p = .03) in the treated group. Patients with multiple unexplained failed ET may have undiagnosed endometriosis and may benefit from pretreatment with dep-GnRH-ag and letrozole. These results would benefit from being subjected to a randomized prospective study.

Insights into targeting young male drivers with anti-speeding advertising: An application of the Step approach to Message Design and Testing (SatMDT)

In Australia, young drivers aged 17-25 years comprise 13% of the population yet account for 22% of all road deaths with young males over-represented in such trauma. Speeding represents a major contributing factor and advertising campaigns have long focused on promoting anti-speeding messages in the effort to reduce drivers' speeds. Positioned within a larger program of research aimed at developing, piloting, and evaluating a range of theoretically-informed anti-speeding messages, the current study reports results relating to the final phase of the research, the evaluation. Six messages were devised in accordance with the guiding framework, the Step approach to Message Design and Testing ([SatMDT]; Lewis et al., 2016) and based on the findings emerging from earlier qualitative and quantitative studies within the program of research. N=938 licensed drivers (n=455 males, 48%) aged 17-62 years completed an online survey. To ensure a controlled test of the persuasiveness of the message content, the messages were presented in an audio-based format and thus were devoid of potential confounds, such as images. The messages sought to address a particular belief (i.e., behavioural, normative, control) and to focus either on emphasising the positive aspects which make speeding less likely or challenging the negative aspects which make speeding more likely. Thus, key to this evaluation was to test the persuasiveness of the message content in terms of the particular belief and focus it was addressing. Participants were randomly assigned to either the Control condition (i.e., no exposure to a message) or the Intervention condition (i.e., exposed to one of the six messages presented as an audio-recorded message within the survey). Persuasiveness was assessed via a range of outcome measures including both direct (i.e., third-person perceptions, message rejection) as well as indirect measures (i.e., intentions, willingness to speed). Age, gender, and message type were independent variables (IVs), together with issue involvement as a covariate (or IV) in the study's analyses. Overall, positive persuasive effects, and a relative absence of any negative, dissuasive effects, were found for two messages, Glass Cars and The Lift. These messages addressed the same salient belief, control beliefs, with the former emphasising the factors which discourage speeding and the latter message challenging those factors which encourage speeding. The implications of the findings are discussed in terms of the insights they offer for the key content of future anti-speeding messages.

Abstract P5-01-01: Real-time imaging of lymph node metastasis in response to systemic ezrin inhibitor treatment in breast cancer

Lymph node (LN) metastasis is a key driver of recurrence and survival in breast cancer (BC) patients. However, the mechanisms of metastatic dissemination of tumour cells from LNs to distant sites and their predictors of response to systemic therapy remain poorly understood, mainly due to a lack of non-invasive in vivo imaging models. We have recently described ezrin, a pro-metastatic crosslinker protein, as a regulator of tumour lymphangiogenesis and metastasis in BC (Breast Cancer Res. 2014; 16(5): 438). Furthermore, we demonstrated significant association of high ezrin expression with lymphovascular invasion in a cohort (n=63) of premenopausal patients with invasive BC (p =0.024). These findings prompted us to examine the role of ezrin in migration and invasion of metastatic tumour cells in LNs and their response to ezrin-targeted therapy. Using a locally accrued LN positive patient cohort (n=94), we demonstrated a significant association between high ezrin levels and reduced recurrence-free survival (univariate Log-rank test, p=0.033), suggesting that ezrin is a potential predictor of relapse in LN positive BC. To address the mechanistic role of ezrin in LN metastasis, we developed a novel intravital imaging model using a lymphatic reporter transgenic mouse (B6-prox1-mOrange2-pA-BAC) to examine the response of tumour-draining LN to anti-ezrin systemic therapy in real time. Next, we tested the effects of a small molecule ezrin inhibitor (NSC668394) in vitro and observed significant suppression of ezrin activation (p-T567) and cancer cell invasive phenotype. Intravital imaging of inguinal LN metastases, derived from subcutaneously implanted breast adenocarcinoma E0771-LMV (lung metastatic variant) cells, demonstrated significant reduction in mobility and invasiveness (Mann Whitney, p<0.0001) of metastatic cells following systemic treatment with NSC668394 (0.5 mg/kg at 24h and 8h prior to imaging). Interestingly, LN metastases engagement by host T cell (CD3+) was notably increased, whereas T cell mobility was not affected by ezrin inhibition. Our findings present a novel non-invasive imaging model to study the LN metastasis response to anti-cancer therapy in real time, and provide new insight into the role of ezrin as a potential anti-metastatic target in BC.

(Supported by CRS, CIHR, CBCF, BCAK, Queen's SRC).

Citation Format: Ghaffari A, Hoskin V, Mullins G, Greer P, Kiefer F, Madarnas Y, SenGupta S, Elliott B. Real-time imaging of lymph node metastasis in response to systemic ezrin inhibitor treatment in breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-01-01.

84 PORCINE EMBRYOS UTILIZE SMALL AMOUNTS OF PYRUVATE, LACTATE, AND GLUCOSE IN VITRO

Porcine embryo culture systems are suboptimal to the in vivo environment, and significant effort has been made to improve development to the blastocyst stage in vitro. Since metabolism of the early embryo has many similarities to the Warburg effect, our goal was to determine the role of glucose on development, gene expression, and metabolism of other energy substrates in the blastocyst stage embryo. Pig embryos were in vitro produced and cultured in MU1 containing pyruvate, lactate, amino acids, and either 0, 7.5, 15, or 250 µM glucose, N = 1164, 4 replications. There was no difference in blastocyst percentage between the 0 µM and 7.5 µM glucose (34% ± 6.5 v. 29% ± 8.2), but there was a decrease in development in response to 15 and 250 µM compared with 0 µM glucose (25% ± 8.5, 23% ± 8.7 v. 34% ± 6.5; P ≤ 0.01). Glucose transporters (SLC2A1 and SLC2A2) and hexokinases (HK1 and HK2) were analysed by qPCR to detect differences in gene expression, 3 replicates containing 10 blastocyst pools. The abundance of both HK1 and HK2 was decreased in blastocysts cultured with 7.5 µM glucose compared with 0 µM (P ≤ 0.04). Glucose transporters were not affected by glucose supplementation (P ≥ 0.5). Metabolic data were collected to determine if embryos were adjusting their energy substrate use in response to glucose. Two assays were completed to determine lactate and pyruvate consumption or release into the media by embryos, in comparison with media without embryos. In vitro-produced embryos were cultured in MU1 with 0 or 7.5 µM glucose N = 360, 4 replications. Both treatments consumed lactate, but there were no differences between treatments (6.8 ± 9.4 pmol/blastocyst/h v. 12.5 ± 1.6 pmol/blastocyst/h; P = 0.6). Blastocysts cultured in 7.5 µM glucose consumed pyruvate, whereas blastocysts without glucose produced pyruvate (–0.34 ± 0.3 pmol/blastocyst/h v. 0.73 ± 0.2 pmol/blastocyst/h; P < 0.01). It has been suggested that fructose is a more efficient replacement for glucose in pig embryo culture. Therefore, we produced pig embryos in vitro and cultured these embryos in MU1, MU1 + 2 mM glucose, or MU1 + 2 mM fructose to the blastocyst stage, 4 replications, N = 389. Again, there was a decrease in embryos that developed to the blastocyst stage in 2 mM glucose compared with MU1 control blastocysts (26% ± 5.8 v. 11% ± 2.5; P = 0.001), but there was only a trend for a decrease in development in response to 2 mM fructose (17 ± 2.3%; P = 0.06). There was no difference in total cell number between MU1, 2 mM glucose, and 2 mM fructose (30.6 ± 2.2, 30.5 ± 3.7, and 32.6 ± 3.0, respectively; P ≥ 0.9) 3 replications, N = 32. Because there is very little consumption of lactate and very low levels of pyruvate are being consumed when glucose is present, it does not appear that any of these energy substrates are major players for the developing pig embryo. Future experiments should be conducted to determine other means of energy production and metabolism in these embryos. The research was funded by Food for the 21st Century.

Emergence and spread of predominantly community-onset Clostridium difficile PCR ribotype 244 infection in Australia, 2010 to 2012

We describe an Australia-wide Clostridium difficile outbreak in 2011 and 2012 involving the previously uncommon ribotype 244. In Western Australia, 14 of 25 cases were community-associated, 11 were detected in patients younger than 65 years, 14 presented to emergency/outpatient departments, and 14 to non-tertiary/community hospitals. Using whole genome sequencing, we confirm ribotype 244 is from the same C. difficile clade as the epidemic ribotype 027. Like ribotype 027, it produces toxins A, B, and binary toxin, however it is fluoroquinolone-susceptible and thousands of single nucleotide variants distinct from ribotype 027. Fifteen outbreak isolates from across Australia were sequenced. Despite their geographic separation, all were genetically highly related without evidence of geographic clustering, consistent with a point source, for example affecting the national food chain. Comparison with reference laboratory strains revealed the outbreak clone shared a common ancestor with isolates from the United States and United Kingdom (UK). A strain obtained in the UK was phylogenetically related to our outbreak. Follow-up of that case revealed the patient had recently returned from Australia. Our data demonstrate new C. difficile strains are an on-going threat, with potential for rapid spread. Active surveillance is needed to identify and control emerging lineages.

Musculoskeletal health of subjects with hemophilia A treated with tailored prophylaxis: Canadian Hemophilia Primary Prophylaxis (CHPS) Study

BACKGROUND

Full-dose prophylaxis is very effective at minimizing joint damage but is costly. Tailored prophylaxis has been proposed as a way of reducing costs while still protecting joints.

OBJECTIVE

To report detailed findings in index joints of 56 subjects with severe hemophilia A entered into the Canadian Hemophilia Prophylaxis Study, and treated with tailored prophylaxis, after 13 years.

METHODS

Boys with severe hemophilia A (< 2% factor) and normal joints were enrolled between the ages of 1 and 2.5 years. Initial treatment consisted of once-weekly factor infusions, with the frequency escalating in a stepwise fashion when breakthrough bleeding occurred. During the first 5 years, subjects were examined every 3 months using the modified Colorado Physical Evaluation (PE) scale; subsequently, every 6 months. The Childhood Health Assessment Questionnaire (CHAQ) was administered at each visit.

RESULTS

Median age at study entry was 19 months (range 12-30 months); median follow-up was 92 months (range 2-156). The median PE score was 2, 3 and 3 at ages 3, 6 and 10 years. Persistent findings were related to swelling, muscle atrophy and loss of range of motion. The median score for each of these items (for the six index joints) was 0 at ages 3, 6 and 10 years. The median overall CHAQ score was 0 at ages 3, 6 and 10 years, indicating excellent function.

CONCLUSIONS

Canadian boys treated with tailored primary prophylaxis exhibit minimal joint change on physical examination and minimal functional disability.

The central role of myostatin in skeletal muscle and whole body homeostasis

Myostatin is a powerful negative regulator of skeletal muscle mass in mammalian species. It plays a key role in skeletal muscle homeostasis and has now been well described since its discovery. Myostatin is capable of inducing muscle atrophy via its inhibition of myoblast proliferation, increasing ubiquitin-proteasomal activity and downregulating activity of the IGF-Akt pathway. These well-recognized effects are seen in multiple atrophy causing situations, including injury, diseases such as cachexia, disuse and space flight, demonstrating the importance of the myostatin signalling mechanism. Based on this central role, significant work has been pursued to inhibit myostatin's actions in vivo. Importantly, several new studies have uncovered roles for myostatin distinct from skeletal muscle size. Myostatin has been suggested to play a role in cardiomyocyte homeostasis, glucose metabolism and adipocyte proliferation, all of which are examined in detail below. Based on these effects, myostatin inhibition has potential to be widely utilized in many Western diseases such as chronic obstructive pulmonary disease, type II diabetes and obesity. However, if myostatin inhibitors are to successfully translate from bench-top to bedside in the near future, awareness must be raised on these non-traditional effects of myostatin away from skeletal muscle. Indeed, further research into these novel areas is required.

Intermittent exercise with and without hypoxia improves insulin sensitivity in individuals with type 2 diabetes

CONTEXT

Hypoxia and muscle contraction stimulate glucose transport activity in vitro. Exercise and hypoxia have additive effects on insulin sensitivity in type 2 diabetics (T2D).

OBJECTIVE

The objective of the study was to examine the effectiveness of intermittent exercise with and without hypoxia on acute- and moderate-term glucose kinetics and insulin sensitivity in T2D.

SETTING

The study was conducted at a university research center.

DESIGN, PARTICIPANTS, AND INTERVENTIONS

Eight male T2D patients completed the following: 1) 60 min of continuous exercise at 90% lactate threshold in hypoxia (HyEx60); 2) intermittent exercise at 120% lactate threshold, separated by periods of passive recovery (5:5 min) in hypoxia [Hy5:5; O₂ ∼ 14.7 (0.2)%]; and 3) intermittent exercise (5:5 min) at 120% lactate threshold in normoxia (O₂ ∼ 20.93%).

MAIN OUTCOME MEASURES

Glucose appearance and glucose disappearance, using an adapted non-steady-state one-compartment model were measured. Homeostasis models of insulin resistance (HOMA(IR)), fasting insulin resistance index (FIRI), and β-cell function were calculated 24 and 48 h after exercise conditions.

RESULTS

Glucose disappearance increased from baseline (1.85 mg/kg · min⁻¹) compared with 24 h (2.01 min/kg · min⁻¹) after HyEx60 (P = 0.031). No difference was noted for both Hy5:5 (P = 0.064) and normoxia (P = 0.385). Hy5:5 demonstrated improvements in HOMA(IR) from baseline [d 1, 6.20 (0.40)] when comparisons were made with d 2 [4.83 (0.41)] (P = 0.0013). HOMA(IR) and FIRI improved in the 24 h (HOMA(IR), P = 0.002; FIRI, P = 0.003), remaining reduced 48 h after HyEx60 (HOMA(IR), P = 0.028; and FIRI, P = 0.034).

CONCLUSION

HyEx60 offered the greatest improvements in acute and moderate-term glucose control in T2D. Intermittent exercise stimulated glucose disposal and improved post-exercise insulin resistance, which was enhanced when exercise was combined with hypoxia (Hy5:5). The data suggest a use of hypoxic exercise in treatment of T2D.

The effect of hypoxia and work intensity on insulin resistance in type 2 diabetes

CONTEXT

Hypoxia and muscle contraction stimulate glucose transport in vitro. We have previously demonstrated that exercise and hypoxia have an additive effect on insulin sensitivity in type 2 diabetics.

OBJECTIVES

Our objective was to examine the effects of three different hypoxic/exercise (Hy Ex) trials on glucose metabolism and insulin resistance in the 48 h after acute hypoxia in type 2 diabetics.

DESIGN, PARTICIPANTS, AND INTERVENTIONS

Eight male type 2 diabetics completed 60 min of hypoxic [mean (sem) O(2) = ∼14.7 (0.2)%] exercise at 90% of lactate threshold [Hy Ex(60); 49 (1) W]. Patients completed an additional two hypoxic trials of equal work, lasting 40 min [Hy Ex(40); 70 (1) W] and 20 min [Hy Ex(20); 140 (12) W].

MAIN OUTCOME MEASURES

Glucose rate of appearance and rate of disappearance were determined using the one-compartment minimal model. Homeostasis models of insulin resistance (HOMA(IR)), fasting insulin resistance index and β-cell function (HOMA(β-cell)) were calculated at 24 and 48 h after trials.

RESULTS

Peak glucose rate of appearance was highest during Hy Ex(20) [8.89 (0.56) mg/kg · min, P < 0.05]. HOMA(IR) and fasting insulin resistance index were improved in the 24 and 48 h after Hy Ex(60) and Hy Ex(40) (P < 0.05). HOMA(IR) decreased 24 h after Hy Ex(20) (P < 0.05) and returned to baseline values at 48 h.

CONCLUSIONS

Moderate-intensity exercise in hypoxia (Hy Ex(60) and Hy Ex(40)) stimulates acute- and moderate-term improvements in insulin sensitivity that were less apparent in Hy Ex(20). Results suggest that exercise duration and not total work completed has a greater influence on acute and moderate-term glucose control in type 2 diabetics.

Abstract P2-06-11: Ramifications of HER2/ER/PR Guidelines from ASCO/CAP for Translational Cancer Research Using a Cohort from a Tertiary Care Centre in Ontario

Background: A transdisciplinary team from basic science, pathology, clinical and biostatistics was assembled to establish a framework with which to take novel laboratory biomarkers and targets to clinical validation. Human epidermal growth factor receptor (HER2), estrogen (ER) and progesterone (PR) receptor are of important prognostic and predictive value and drivers of systemic therapy for breast cancer (BC). As a first step, the current ASCO/CAP guidelines were used to re-assign centrally reviewed tumour specimens and compare to the clinically assigned scores for ER/PR and HER2.

Methods: With REB approval, a cohort of 62 cases of non-metastatic invasive BC with banked tumour specimens was assembled between 2005 and 2007. Clinico-pathological information for each case was retrospectively obtained from the medical file and entered into an anonymized database. Full section slides were originally stained by routine immunohistochemistry (IHC). Categorical clinical scores for ER/PR (negative-neg/weak/positive-pos) were compared to the continuous scores assigned in a blinded fashion using ASCO/CAP criteria (% pos/H-score). Categorical clinical scores obtained with duplicate IHC antibody staining of full sections for HER2 (neg/equivocal-eq/pos) were compared to those obtained from IHC assessments of triplicate 6mm cores in a tissue microarray (TMA) that were assigned to be neg/eq/pos using ASCO/CAP criteria. A senior breast pathologist adjudicated discordant specimens. Exact Fisher tests were used to compare the two sets of categorical assessments.

Results: Mean age was 43.5 years, (range 29-49). The majority of the cohort (59.7%) had N0 disease and received adjuvant chemotherapy (74.2%); 72.6% of the cohort was alive at the time of this analysis. Score means and ranges of ER/PR are displayed below. Two of 16 clinically ER neg cases (12.5%) were rescored as pos and 0/43 clinically ER pos cases were rescored as neg, P&lt;0.0001. Two of 13 clinically PR neg cases (15.4%) were rescored as pos and 4/46 clinically PR pos cases (8.7%) were rescored as neg, (P&lt;0.0001). HER2 status was reassessed for 51 cases, 41 of which (80%) had concordant scores (P&lt;0.0001). Thirty-nine (76%) cases were classified as HER2 neg on TMA, 7 of which (18%) were eq on routine IHC and neg by fluorescence in situ hybridization. In routine IHC, 15.7% of tumours were eq. Four TMA cases were eq (7.8%%); with routine IHC, one of these was neg, one eq, and two were pos. Eight patients were HER2 pos in both assessments.

ER/PR scores

Conclusions: Systemic therapy recommendations could be impacted in a small but substantive number of cases by the methodology used for biomarker assessment and scoring, particularly near threshold values. This study illustrates that the scoring criteria used may be an important contributor to variability in correlative biomarker studies. Consideration should be given to routine systematic reassessment with continuous scoring for biomarker data proposed for use in correlative science studies.

The Preventing Australian Football Injuries with Exercise (PAFIX) Study: a group randomised controlled trial

Background:

Knee injuries are a major injury concern for Australian Football players and participants of many other sports worldwide. There is increasing evidence from laboratory and biomechanically focused studies about the likely benefit of targeted exercise programmes to prevent knee injuries. However, there have been few international studies that have evaluated the effectiveness of such programmes in the real-world context of community sport that have combined epidemiological, behavioural and biomechanical approaches.

Objective:

To implement a fully piloted and tested exercise training intervention to reduce the number of football-related knee injuries. In so doing, to evaluate the intervention’s effectiveness in the real-world context of community football and to determine if the underlying neural and biomechanical training adaptations are associated with decreased risk of injury.

Setting:

Adult players from community-level Australian Football clubs in two Australian states over the 2007–08 playing seasons.

Methods:

A group-clustered randomised controlled trial with teams of players randomly allocated to either a coach-delivered targeted exercise programme or usual behaviour (control). Epidemiological component: field-based injury surveillance and monitoring of training/game exposures. Behavioural component: evaluation of player and coach attitudes, knowledge, behaviours and compliance, both before and after the intervention is implemented. Biomechanical component: biomechanical, game mobility and neuromuscular parameters assessed to determine the fundamental effect of training on these factors and injury risk.

Outcome measures:

The rate and severity of injury in the intervention group compared with the control group. Changes, if any, in behavioural components. Process evaluation: coach delivery factors and likely sustainability.

Clostridium difficile-associated diarrhoea

Clostridium difficile is an important nosocomial pathogen and the most frequently diagnosed cause of infectious hospital-acquired diarrhoea. Toxigenic strains usually produce toxin A and toxin B, which are the primary virulence factors of C. difficile. Some recently described strains produce an additional toxin, an adenosine-diphosphate ribosyltransferase known as binary toxin, the role of which in pathogenicity is unknown. There has been concern about the emergence of a hypervirulent fluoroquinolone-resistant strain of C. difficile in North America and Europe. The use of fluoroquinolone antimicrobials appears to be acting as a selective pressure in the emergence of this strain. In this review, we describe the current state of knowledge about C. difficile as a cause of diarrhoeal illness.

Long-term protective effect of mature DC-LAMP+ dendritic cell accumulation in sentinel lymph nodes containing micrometastatic melanoma. An EORTC Melanoma group study

8509

Background: In a previous immunohistochemical study of dendritic cells (DCs) in sentinel lymph nodes (SLNs) draining regressing melanomas we found that the accumulation of mature DC-LAMP+ DCs in SLNs was associated with local expansion of antigen- specific memory effector cytotoxic T lymphocytes and the absence of metastasis in downstream lymph nodes. The aim of this study was to investigate the prognostic importance of the maximal density of mature DCs in SLNs using the anti-DC LAMP antibody. Methods: 458 consecutive patients with micrometastatic melanoma within SLNs and 3 yrs follow-up after SLN procedure or death within 3 yrs were eligible for analysis. Semi-quantitative evaluation of mature DCDC-LAMP+ maximum density was made as follows: the slide was examined at intermediate magnification (x100) to select the area containing the maximum number of DC-LAMP+ DCs, the number of DC-LAMP+ cells per mm2 was then determined at high magnification (x400) in 3 mm2 in high density areas. Results were reported as number of cells /mm2. The maximal density of mature DC-LAMP+ DCs was evaluated by three independent observers and categorized into three classes (<100/mm2, 100- <200/mm2, ≥200/mm2) according to previously reported cutpoints. Results: There was excellent inter-observer reproducibility for maximum density of mature DC-LAMP+ DCs scores (kappa score = 0.82). There were differences in the maximal density scores and staining intensity according to the center (P<0.001). The higher the mature DC density in the SLN the longer the duration of survival [p=0.047; hazard ratio (95% CI) = 0.70 (0.50–1.00)]. Conclusions: This study is the first to report the prognostic value of DC-LAMP+ DC counts in SLNs containing metastatic melanoma. Patients with a high density of mature DCs (≥200/mm2) have the lowest risk of death. It also provides evidence that a lack of DC maturation in the SLNs is important in biological facilitation of melanoma progression.

No significant financial relationships to disclose.

Biomechanics and tennis

Success in tennis requires a mix of player talent, good coaching, appropriate equipment, and an understanding of those aspects of sport science pertinent to the game. This paper outlines the role that biomechanics plays in player development from sport science and sport medicine perspectives. Biomechanics is a key area in player development because all strokes have a fundamental mechanical structure and sports injuries primarily have a mechanical cause.

The political ecology of health: perceptions of environment, economy, health and well-being among ‘Namgis First Nation

Informed by Mayer's (Progr. Hum. Geogr 20 (1996) 441) political ecology of disease framework, this paper investigates First Nation's perceptions of the links between environment, economy and health and well-being. A case study of 'Namgis First Nation (Alert Bay, British Columbia, Canada) is used to explore the risks and benefits of salmon aquaculture for British Columbia's First Nations. Analysis of interview data (n = 23) indicates strong links between reduced access to environmental resources, marginal participation in the economy, and declining community health and well being. Results suggest that aquaculture development has further decreased the community's access to environmental resources, thereby restricting those economic, social, and cultural activities that determine good health and well-being for this community.

New method of serological testing for Mycobacterium avium subsp. paratuberculosis (Johne's disease) by flow cytometry

Johne's disease (JD) or paratuberculosis, caused by Mycobacterium avium subsp. paratuberculosis (MAP), is one of the most widespread and economically important diseases of livestock and wild ruminants worldwide. Attempts to control JD have proven inordinately difficult due to low levels of sensitivity by currently available diagnostic tests, which are also incapable of detecting prepatent MAP infections. In the present work, we describe the use of a flow cytometry method (FCM) for serological diagnosis of subclinical and clinical JD in cattle. The FCM was capable of distinguishing MAP-infected from MAP-non-infected cattle as well as MAP from M. scrofulaceum and M. avium subsp. avium. Results of the FCM were compared to that of a commercially available ELISA using 82 serum samples from JD-positive and JD-negative dairy and beef cattle farms that were separated into the following groups: (1) sera from a JD-free farm; (2) sera from JD-positive farms that had tested negative by ELISA; and (3) sera from JD-positive farms that tested JD-positive by ELISA. The FCM found that groups 1-3 were 6.6%, 73.3%, and 97.3% positive for MAP infections, respectively. By using 30 fecal culture-negative samples from a JD-free farm and 21 fecal culture-positive samples from JD-positive farms, diagnostic sensitivity and specificity of the FCM were calculated to be 95.2% and 96.7%, respectively. A retrospective study of 10 JD-positive cows showed that the FCM detected MAP infections 6-44 months earlier than the fecal culture test. Further, the FCM specifically detected MAP infections in serum samples as early as 170 days after experimental inoculation of calves with MAP and did not react with calves inoculated with other mycobacteria. Production of IgG against MAP was detected by FCM in all the calves inoculated with MAP 240 days after inoculation, whereas positive anti-MAP IgG production was not detected in control calves or calves experimentally infected with M. avium subsp. avium or M. bovis. The FCM assay is rapid and is completed in less than 4 h. Moreover, the FCM is objective, technically easy and can be automated for handling large numbers of samples. This novel assay might form the basis of a highly sensitive and subspecies-specific test for the diagnosis of JD.

The validity of a four week self-recall of sports injuries

The ability of sports injury studies to provide reliable incidence estimates depends on accurate injury data. One of the most commonly used methods of collecting injury data is through self-report, but the validity of such information is largely unknown. This study validated a four week self-report sports injury recall against a range of external sources including hospital records, health practitioner records, and third parties. Cases were drawn from the larger, Western Australian Sports Injury Study (WASIS). This study demonstrates acceptable to good levels of agreement between self-report and more objective data in relation to details such as the nature and body part injured, and the level of injury treatment sought (kappa = 0.48 to 0.78). However, self-reported injury severity did not agree with the Injury Severity Score classification of severity.

Incidence and risk factors for injury in non-elite Australian Football

This paper identifies the risk and protective factors for injury in non-elite Australian Football. Five hundred and thirty five non-elite Australian footballers completed a baseline questionnaire at the commencement of the 1997 preseason. Participants were telephoned each month during the 1997 and 1998 playing seasons to provide details of their exposure at training and games and any injury experiences in the previous four weeks. The incidence of injury in this study was 24 injuries per 1000 player hours. The risk factors for injury were identified as: not wearing sports-specific football boots (IRR 1.40, 95% CI 1.03-1.90); an existing back pathology (IRR 1.29, 95% CI 1.10-1.51); excessive foot pronation (IRR 1.29, 95% CI 1.07-1.56); and extroverted behaviour (IRR 1.01, 95% CI 1.00-1.03). Cooling down after training (IRR 0.95, 95% CI 0.90-0.99) and not being injured in the previous 12 months (IRR 0.73, 95% CI 0.61-0.88) were found to be protective against injury. This study found that there was a high risk of injury associated with playing Australian Football at a community level. Further research is required to gain an understanding of the mechanisms by which the identified risk factors influence injury risk in community level Australian Football.

Technique effects on upper limb loading in the tennis serve

The purpose of this study was to compare the shoulder and elbow joint loads during the tennis serve. Two synchronised 200 Hz video cameras were used to record the service action of 20 male and female players at the Sydney 2000 Olympics. The displacement histories of 20 selected landmarks, were calculated using the direct linear transformation approach. Ball speed was recorded from the stadium radar gun. The Peak Motus system was used to smooth displacements, while a customised inverse-dynamics program was used to calculate 3D shoulder and elbow joint kinematics and kinetics. Male players, who recorded significantly higher service speeds (male = 183 km hr(-1): female = 149 km hr(-1)) recorded significantly higher normalised and absolute internal rotation shoulder torque at the position when the arm was maximally externally rotated (MER) (male = 4.6% and 64.9 Nm: female = 3.5% and 37.5 Nm). A higher absolute elbow varus torque (67.6 Nm) was also recorded at MER, when compared with the female players (41.3 Nm). Peak normalised horizontal adduction torque (male = 7.6%: female = 6.5%), normalised shoulder compressive force (male = 79.6%: female = 59.1%) and absolute compressive force (male = 608.3 N: female = 363.7 N), were higher for the male players. Players who flexed at the front knee by 7.6 degrees, in the backswing phase of the serve, recorded a similar speed (162 km hr(-1)), and an increased normalised internal rotation torque at MER (5.0%), when compared with those who flexed by 14.7 degrees. They also recorded a larger normalised varus torque at MER (5.3% v 3.9%) and peak value (6.3% v 5.2%). Players who recorded a larger knee flexion also recorded less normalised and absolute (4.3%, 55.6 Nm) peak internal rotation torque compared with those with less flexion (5.6%, 63.9 Nm). Those players who used an abbreviated backswing were able to serve with a similar speed and recorded similar kinetic values. Loading on the shoulder and elbow joints is higher for the male than female players, which is a reason for the significantly higher service speed by the males. The higher kinetic measures for the group with the lower knee flexion means that all players should be encouraged to flex their knees during the backswing phase of the service action. The type of backswing was shown to have minimal influence on service velocity or loading of the shoulder and elbow joints.

The effect of a fast bowling harness in cricket: an intervention study

The influence of a bowling harness, as a training aid, was assessed as a means of modifying bowling technique. Thirty-three 13-year-old bowlers received a standardized 15 min of bowling coaching twice a week for 8 weeks. They were randomly assigned to one of two groups. The 13 participants in the intervention group used the bowling harness throughout the coaching, while also receiving verbal and visual feedback. The 20 participants in the non-harness group received the same visual and verbal feedback. Three-dimensional videography (200 Hz) of each player's bowling action enabled the calculation of transverse plane shoulder alignment counter-rotation, separation angle, lateral flexion and hyperextension of the trunk before and after the intervention. The restriction applied by the harness produced a significant reduction (P= 0.006) in separation angle and forced the bowler to adopt a position at back-foot impact that reduced the 'twist' in the spine. However, it had no effect on restricting other aspects of trunk movement during the critical phases of the bowling action. No significant long-term modifications to technique were found after the coaching intervention when players were assessed without the harness.

The measurement of shoulder alignment in cricket fast bowling

The aim of this study was to compare thoracic spine alignment with two- and three-dimensional calculations of shoulder alignment (defined as a line joining the acromion processes of the right and left scapula) when all measures were projected onto the transverse plane. A six-camera Vicon system was used to reconstruct three markers positioned on the plane of the thorax such that the orthogonal vector to the thoracic spine, projected onto the transverse plane, was used as a virtual shoulder alignment during cricket fast bowling. This same measurement system was used to calculate the three-dimensional line between the acromion processes projected onto the transverse plane. These acromion markers were also used to calculate the two-dimensional transverse plane alignment of the shoulders from images recorded by a video camera positioned above ball release. All cameras operated at 50 Hz. A significant association was recorded between thorax alignment and the three- (0.97) and two-dimensional (0.87) shoulder alignment estimations at back-foot impact. The strength of association remained at front-foot impact, when correlations of 0.89 (three-dimensional) and 0.84 (two-dimensional) were recorded. However, at ball release, non-significant associations of 0.58 (three-dimensional) and 0.41 (two-dimensional), representing shoulder alignment differences of approximately 10 degrees, were recorded. The 95% limits of agreement comparisons for shoulder alignment at back-foot impact, front-foot impact and ball release produced mean random errors for the two comparisons of 9.5 degrees, 11.7 degrees and 22.5 degrees respectively. Three- and two-dimensional transverse plane projections of shoulder alignment are reasonable estimates of thorax alignment at back-foot impact and front-foot impact but not at ball release.

Cost-effective clinical pathways at the Alfred Hospital: international lessons from Bayside Health, Australia

The paper "Caring about carepaths" by Pearson and Macintosh (2001) is an interesting article for those considering the implementation of clinical pathways. The authors have attempted to describe the experiences and lessons learned in trying to introduce clinical pathways at Cairns Base Hospital (CBH). The paper is not a research report. Rather, it is a story of what was hoped to be achieved versus what actually was achieved. Hence, the term "experiment" was used in a non-technical sense. In our commentary of that paper below, we also outline our own experience in clinical pathways at The Alfred by way of comparison, drawing upon lessons learnt that may be of interest to other hospitals.

Double-strand breaks and translocations in cancer

The correct repair of double-strand breaks (DSBs) is essential for the genomic integrity of a cell, as inappropriate repair can lead to chromosomal rearrangements such as translocations. In many hematologic cancers and sarcomas, translocations are the etiological factor in tumorigenesis, resulting in either the deregulation of a proto-oncogene or the expression of a fusion protein with transforming properties. Mammalian cells are able to repair DSBs by pathways involving homologous recombination and nonhomologous end-joining. The analysis of translocation breakpoints in a number of cancers and the development of model translocation systems are beginning to shed light on specific DSB repair pathway(s) responsible for the improper repair of broken chromosomes.

Bioterrorism, physician education, and the Internet

To meet the challenges of bioterrorism, the practicing physician must have information that is authoritative, specific, and timely with respect to any outbreaks or suspected outbreaks of bioterrorism. Educational activities for physicians and other health care workers are important. In the United States, bioterrorism was not an issue until October 2001, and bioterrorism disease organisms are not ones commonly dealt with in civilian health care. Web sites that satisfy these information and educational requirements are discussed.