82 Timely Prescribing of Regular Medications in General Surgery

Aim

It’s crucial that regular medications are prescribed in a timely manner for hospital inpatients. Missed or delayed doses of critical medications (insulin, anti-parkinsonian medication, antiepileptics and steroids) can compromise patient safety. This audit, with two closed-loop cycles, aimed to improve prescribing on surgical wards.

Method

Data was gathered from >48 adult non-elective general surgery patients pre- and post-intervention with four outcomes measured, listed in results. Data was re-collected after one month and the cycle repeated one year later.

Interventions:

Results

Average time for prescribing regular medications improved from 13hrs to 11.2hrs in the first cycle and 22.5hrs to 13.1hrs in the second cycle.

Percentage of patients with critical medications prescribed on admission improved by 50% in the first cycle and remained at 100% pre- and post-intervention in the second cycle.

Percentage of patients who missed medication due to delayed prescribing reduced by 11% in the first cycle and 16% in the second cycle.

Percentage of patients who had regular medications prescribed before pharmacy medicines reconciliation improved by 9% in the first cycle and 28% in the second cycle.

Conclusions

In both cycles, all measurements experienced improvements. Largest improvements were in the 2nd cycle with the addition of educational posters. SCR access improves ability to prescribe regular medications. Educational posters act as effective visual aids. Both can be recommended.

Abstract P5-12-11: M2 macrophages increase after neoadjuvant HER2 targeted chemotherapy

Purpose: Recent observations suggest a positive association between the presence of tumor-associated myeloid and lymphoid immune cells and clinical responses to HER2 therapies. The specific immune cell composition of HER2+ tumors and the effects of therapy on the tumor immune microenvironment remains poorly understood; limiting efforts to effectively direct immunomodulatory agents in HER2+ breast cancer. We sought to assess the feasibility of a multiplex immunofluorescence strategy to characterize the immune milieu of HER2+ tumors, pre and post treatment. Methods: We conducted a feasibility study using the Perkin Elmer OPAL multiplex dye chemistry for immunofluorescence of tumor, myeloid, and lymphoid cells in pretreatment biopsy and surgical resection tissues of 11 patients who received neoadjuvant HER2 antibody with chemotherapy. Two panels of up to 6 antibodies were studied including a predominantly myeloid panel targeting CD80, CD68, CD163, CD206, PD-L1, and cytokeratin; and a 'lymphoid/proliferation' panel targeting FoxP3, cytokeratin, Granzyme B, CD4, CD8, and Ki67. For paired samples, analysis of pre/post differences were analyzed using two tailed, t-test. Results: 100% of the pre-treatment biopsy samples yielded high quality immune and tumor cell immunofluorescence profiles for both panels. In contrast, post treatment specimens were more challenging. For the post treatment tissues, ˜25% of specimens failed to yield results in at least one panel. As shown in Table 1, the %CD206+ M2 type macrophage population increased between pre and post treatment (p=0.012). This was reflected in a decrease in the M1:M2 ratio and variability in the ratio in favor of M2 (median 0.34 [IQR = 1.01] to 0.11 [IQR=0.10], p=0.0003). In the lymphoid panel, we observed a non-significant reduction in % FoxP3+CD4 T cells with less variability between patients post treatment and a significant decrease in total CD8+ T cells. Further, there was a significant reduction in %Granzyme B positive T cells (median 6.63 to <1%, p=0.02) and non-significant decrease in proliferating (Ki67+) T cells post treatment. PD-L1 expression was low in both pre and post specimens.

MarkerSampleMinMedianMaxIQR%CD206+ Mono/MacPre1.358.7135.8911.05%CD206+ Mono/MacPost25.438.9777.621.54M1/M2 RatioPre0.110.342.141.01M1/M2 RatioPost0.030.110.210.1%Ki67+ T cellsPre0.137.9220.0411.06%Ki67+ T cellsPost04.5621.836.31%PD-L1+ MyeloidPre01.0512.060.95%PD-L1+ MyeloidPost00.554.261.47%Granzyme B T cellsPre2.926.6333.727.2%Granzyme B T cellsPost00.892.481.73%FoxP3+ CD4 +Pre01.6456.0416.44%FoxP3+ CD4 +Post01.166.824.14#Total CD8+ T cellsPre5788,36635,42615,744#Total CD8+ T cellsPost121,3717,9043,658

Conclusions: Multiplex immune profiling is a practical approach to characterize the tumor immune microenvironment in biopsy and post treatment specimens. Neoadjuvant HER2 targeted chemotherapy significantly shifts the myeloid population to an M2 (immunosuppressive) phenotype with evidence for a reduction in the number of Ki67 and Granzyme B+ T cells. These preliminary results suggest immunomodulatory agents that are able to induce or maintain an M1 polarized tumor microenvironment may have utility to enhance long term anti-tumor immunity in HER2 disease.

Citation Format: Thompson PA, Uhlik M, Preece C, Gorden K, Harrison B, Graff J, Stopeck A. M2 macrophages increase after neoadjuvant HER2 targeted chemotherapy [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-12-11.

Abstract B29: Innate immune modulation: The novel immunotherapeutic Imprime PGG triggers the anti-cancer immunity cycle in concert with tumor-targeting, anti-angiogenic and checkpoint inhibitor antibodies

Cancer immunotherapeutics largely focus on awakening T cell mediated recognition and eradication of tumor cells. Indeed, checkpoint inhibitor antibodies (e.g. pembrolizumab) unleash T cells already involved in anti-cancer responses and have shown remarkable clinical activity, though only in ~20-30% of solid tumor patients. Numerous approaches are being explored to enhance the percent of patients who benefit from checkpoint inhibitor therapies. Chief amongst these are the innate immune modulating therapies collectively designated as PAMPs- pathogen- associated molecular patterns. PAMPs operate as the critical non-self signals that, in response to pathogen infection, ignite the function of the innate immune system to trigger the immunity cycle. TLR and STING agonists acts as PAMPs and reflect bacterial and viral danger signals that can drive dendritic cell maturation, enhancing T cell function. These agents are in development in combination with other immunotherapies, including checkpoint inhibitors, but inspire intolerable cytokine storms and are thereby limited to direct intra-tumoral delivery approaches. We therefore sought to discover and develop a novel, systemically administered PAMP- Imprime PGG (Imprime). Ex vivo studies with whole blood from healthy human donors show that Imprime consistently elicits the activation of innate immune cells. M2 state macrophages repolarize, showing increased expression of M1 markers (CD86, PD-L1) with coincident reduction in M2 markers (CD163, CD206). Dendritic cells (DCs) mature, showing enhanced surface expression of CD80, CD86 and MHC class II. Functionally, the antigen presentation capability of these re-polarized macrophages and activated DCs is substantially enhanced and drives the robust expansion of co-cultured CD8 T cells as well as the marked upregulation of the potent anti-tumor cytokine interferon gamma. In preclinical tumor studies, Imprime is administered IV and profoundly enhances the efficacy of numerous antibody therapies. Using the B16 experimental metastasis model, we show that Imprime (administered IV) synergizes with the anti-TRP1 tumor-targeting antibody TA-99, nearly eradicating B16 metastases as measured by visual counts, TRP-1 RT-PCR and in situ immunofluorescence for TRP1. In the H441 and H1299 non-small cell lung cancer xenografts, Imprime synergizes with the anti-VEGFR2 antibody DC101 to flat-line tumor growth. In the MC-38, CT-26 and 4T-1 syngeneic tumor models, Imprime synergizes with both anti-PD-1 and PD-L1 checkpoint inhibitor antibodies to repress tumor growth and/or to eradicate cancer lesions. In situ imaging of these preclinical tumor tissues repeatedly shows that Imprime instigates a re-orientation of the immune microenvironment, promoting an M1 state (e.g. increased iNOS2, decreased Arginase 1), as well as the influx of myeloid cells and, in the syngenic models, CD8 T cells. In clinical trials in > 400 total patients to date, Imprime has been safely administered by IV infusion (4mg/kg over 2 hours) and has repeatedly shown evidence for efficacy in combination with tumor targeting or anti-angiogenic antibodies. Studies with checkpoint inhibitor antibodies are slated to begin summer of 2016. We now provide the first evidence in healthy human volunteers that Imprime (IV- 4mg/kg, 2 hours) drives the same innate immune activation events evident in the preclinical studies (e.g. chemokine and cytokine release, PD-L1 and CD86 upregulation) verifying that the clinical dose activates the innate immune system. Together, these preclinical and clinical studies provide evidence that the novel PAMP, Imprime PGG, can be safely administered systemically and can drive the critical innate immune activation necessary to spark the anti-cancer immunity cycle.

Citation Format: N Bose, K Gorden, A Chan, A Jonas Bykowski, N Ottoson, D Walsh, X Qiu, B Harrison, T Kangas, K Fraser, R Fulton, S Leonardo, M Uhlik, J Graff. Innate immune modulation: The novel immunotherapeutic Imprime PGG triggers the anti-cancer immunity cycle in concert with tumor-targeting, anti-angiogenic and checkpoint inhibitor antibodies. [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology and Immunotherapy; 2016 Oct 20-23; Boston, MA. Philadelphia (PA): AACR; Cancer Immunol Res 2017;5(3 Suppl):Abstract nr B29.

Phosphatase specificity and pathway insulation in signaling networks

Phosphatases play an important role in cellular signaling networks by regulating the phosphorylation state of proteins. Phosphatases are classically considered to be promiscuous, acting on tens to hundreds of different substrates. We recently demonstrated that a shared phosphatase can couple the responses of two proteins to incoming signals, even if those two substrates are from otherwise isolated areas of the network. This finding raises a potential paradox: if phosphatases are indeed highly promiscuous, how do cells insulate themselves against unwanted crosstalk? Here, we use mathematical models to explore three possible insulation mechanisms. One approach involves evolving phosphatase KM values that are large enough to prevent saturation by the phosphatase's substrates. Although this is an effective method for generating isolation, the phosphatase becomes a highly inefficient enzyme, which prevents the system from achieving switch-like responses and can result in slow response kinetics. We also explore the idea that substrate degradation can serve as an effective phosphatase. Assuming that degradation is unsaturatable, this mechanism could insulate substrates from crosstalk, but it would also preclude ultrasensitive responses and would require very high substrate turnover to achieve rapid dephosphorylation kinetics. Finally, we show that adaptor subunits, such as those found on phosphatases like PP2A, can provide effective insulation against phosphatase crosstalk, but only if their binding to substrates is uncoupled from their binding to the catalytic core. Analysis of the interaction network of PP2A's adaptor domains reveals that although its adaptors may isolate subsets of targets from one another, there is still a strong potential for phosphatase crosstalk within those subsets. Understanding how phosphatase crosstalk and the insulation mechanisms described here impact the function and evolution of signaling networks represents a major challenge for experimental and computational systems biology.

Application of a decision analytic framework for adoption of clinical trial results: are the data regarding TARGIT-A IORT ready for prime time?

The results from randomized clinical trials are often adopted slowly. This practice potentially prevents many people from benefiting from more effective care. Provide a framework for analyzing clinical trial results to determine whether and when early adoption of novel interventions is appropriate. The framework includes the evaluation of three components: confidence in trial results, impact of early, and late adoption if trial results are reversed or sustained. The adverse impact of early adoption, and the opportunity cost of late adoption are determined using Markov modeling to simulate the impact of early and late adoption in terms of quality of life years and resources gained or lost. We applied the framework to the TARGIT-A randomized clinical trial comparing intraoperative radiation (IORT) to standard external beam radiation (EBRT) and considered these results in the context of trials comparing endocrine therapy with and without radiation therapy in postmenopausal women. Confidence in the TARGIT-A trial 4 year results is high because the peak hazard for local recurrence in the trial is between 2 and 3 years. This is consistent with most trials, and no second peak has been observed in similar patient populations, suggesting that the TARGIT-A trial results are stable. The interventions offer approximately equivalent life expectancy. If IORT local recurrences rate were as high as 10 % at 10 years (which is higher than expected), we would project only 0.002 fewer expected life years (less than 1 day) compared to EBRT if IORT is adopted early. However, there is a $1.7 billion opportunity cost of waiting an additional 5 years to adopt IORT in low risk, hormone-receptor-positive, postmenopausal women. EBRT costs an additional $1467 in indirect costs per patient. Applying an evaluative framework for the adoption of clinical trial results to the TARGIT-A IORT therapy trial results in the assessment that the trial results are stable, early adoption would lead to minimal adverse impact, and substantially less resource use. Both IORT and no radiation are reasonable strategies to adopt.

Prognostic factors and survival after resection of colorectal liver metastasis in the era of preoperative chemotherapy: an 11-year single-centre study

INTRODUCTION

A variety of factors have been identified in the literature which influence survival following resection of colorectal liver metastases (CRLM). Much of this literature is historical, and its relevance to contemporary practice is not known. The aim of this study was to identify those factors which influence survival during the era of preoperative chemotherapy in patients undergoing resection of CRLM in a UK centre.

METHODS

All patients having liver resection for CRLM during an 11-year period up to 2011 were identified from a prospectively maintained database. Prognostic factors analysed included tumour size (≥5 or <5 cm), lymph node status of the primary tumour, margin positivity (R1; <1 mm), neo-adjuvant chemotherapy (for liver), tumour differentiation, number of liver metastases (≥4), preoperative carcinoembryonic antigen (CEA; ≥200 ng/ml) and whether metastases were synchronous (i.e. diagnosed within 12 months of colorectal resection) or metachronous to the primary tumour. Overall survival (OS) was compared using Kaplan-Meier plots and a log rank test for significance. Multivariate analysis was performed using a Cox regression model. Statistical analysis was performed in SPSS v19, and p < 0.05 was considered to be significant.

RESULTS

432 patients underwent resection of CRLM during this period (67% male; mean age 64.5 years), and of these, 54 (13.5%) had re-resections. The overall 5-year survival in this series was 43% with an actuarial 10-year survival of 40%. A preoperative CEA ≥200 ng/ml was present in 10% of patients and was associated with a poorer 5-year OS (24 vs. 45%; p < 0.001). A positive resection margin <1 mm was present in 16% of patients, and this had a negative impact on 5-year OS (15 vs. 47%; p < 0.001). Tumour differentiation, number, biliary or vascular invasion, size, relationship to primary disease, nodal status of the primary disease or the use of neo-adjuvant chemotherapy had no impact on OS. Multivariate analysis identified only the presence of a positive resection margin (OR 1.75; p < 0.05) and a preoperative CEA ≥200 ng/ml (OR 1.88; p < 0.01) as independent predictors of poor OS.

CONCLUSION

Despite the wide variety of prognostic factors reported in the literature, this study was only able to identify a preoperative CEA ≥200 ng/ml and the presence of tumour within 1 mm of the resection margin as being of value in predicting survival. These variables are likely to identify patients who may benefit from intensive follow-up to enable early aggressive treatment of recurrent disease.

Evidence for pleiotropism and recent selection in the PLAG1 region in Australian Beef cattle

A putative functional mutation (rs109231213) near PLAG1 (BTA14) associated with stature was studied in beef cattle. Data from 8199 Bos taurus, Bos indicus and Tropical Composite cattle were used to test the associations between rs109231213 and various phenotypes. Further, 23 496 SNPs located on BTA14 were tested for association with these phenotypes, both independently and fitted together with rs109231213. The C allele of rs109231213 significantly increased hip height, weight, net food intake, age at puberty in males and females and decreased IGF-I concentration in blood and fat depth. When rs109231213 was fitted as a fixed effect in the model, there was an overall reduction in associations between other SNPs and these traits but some SNPs remained associated (P < 10(-4) ). Frequency of the mutant C allele of rs109231213 differed among B. indicus (0.52), B. taurus (0.96) and Tropical Composite (0.68). Most chromosomes carrying the C allele had the same surrounding 10 SNP haplotype, probably because the C allele was introgressed into Brahman from B. taurus cattle. A region of reduced heterozygosity surrounds the C allele; this is small in B. taurus but 20 Mb long in Brahmans, indicating recent and strong selection for the mutant allele. Thus, the C allele appears to mark a mutation that has been selected almost to fixation in the B. taurus breeds studied here and introduced into Brahman cattle during grading up and selected to a frequency of 0.52 despite its negative effects on fertility.

Effect of germination temperatures on proteolysis of the gluten-free grains rice and buckwheat during malting and mashing

This study examined the performance of rice and buckwheat when malted under various temperature conditions and for different lengths of time. The mashed malts produced from both rice and buckwheat contained a wide spectra of sugars and amino acids that are required for yeast fermentation, regardless of malting temperature. At the germination temperatures of 20, 25, and 30 °C used, production of reducing sugars and free amino nitrogen (FAN) followed similar patterns. This implies that temperature variations, experienced in different countries, will not have an adverse effect on the production and release of amino acids and sugars, required by yeast during fermentation, from these grains. Such consistency in the availability of yeast substrates is likely to reduce differences in processing when these malts are used for brewing. This study revealed that, while rice malt consistently produced more maltose than glucose, buckwheat malt gave several times more glucose than maltose, across all germination temperatures. Buckwheat malt also produced more soluble and free amino nitrogen than rice malt. Unlike sorghum, which has gained wide application in the brewing industry for the production of gluten-free beer, the use of rice and buckwheat is minimal. This study provides novel information regarding the potential of rice and buckwheat for brewing. Both followed similar patterns to sorghum, suggesting that they could play a similar role to sorghum in the brewing industry. Inclusion of rice and buckwheat as brewing raw materials will increase the availability of suitable materials for use in the production of gluten-free beer, potentially making it more sustainable, cheaper, and more widely available.

Risk factors for childhood asthma deaths from the UK Eastern Region Confidential Enquiry 2001-2006

BACKGROUND

Confidential enquiries into asthma deaths can identify inadequacies in medical management and factors which contribute to patients' death.

AIMS

To identify risk factors for paediatric asthma deaths over a 6-year period.

METHODS

Observational case-series study of paediatric asthma deaths between 2001-2006 in the UK Eastern Region. Hospital, primary care and post-mortem data were obtained for every child (≤17 yrs) with asthma recorded on the death certificate, and a detailed questionnaire was completed. Information was obtained on asthma severity, medications, hospital admissions, GP and hospital follow-up, adherence, psychosocial / behavioural factors, allergies, details of the terminal attack and precipitating factors.

RESULTS

20 children (10 male; 8-17 yrs; median: 11.5 yrs) died of asthma between 2001-2006. 9/20 had mild to moderate asthma (BTS/ SIGN criteria), 10/20 had severe asthma and 1 child was not known to have asthma. 13/20 were clinically atopic. Only 3 had undergone allergy assessment. 10/20 died between June and August. 12/20 children had adverse psychosocial and behavioural factors. 7/20 children were on non-combination long-acting β2-agonist (LABA) treatment without inhaled corticosteroids (ICS).

CONCLUSIONS

Almost half the deaths occurred in children with mild/moderate asthma. We recommend that allergic factors and seasonal allergy should be identified early, non-combination LABAs avoided, and speculate that overuse of short-acting β2-agonists (SABAs) may indicate non-adherence with ICS. Asthma deaths in children can be avoided if risk factors are identified early.

Effect of germination temperatures on proteolysis of the gluten-free grains sorghum and millet during malting and mashing

Our study showed that sorghum and millet followed a similar pattern of changes when they were malted under similar conditions. When the malt from these cereals was mashed, both cereal types produced wide spectra of substrates (sugars and amino acids) that are required for yeast fermentation when malted at either lower or higher temperatures. At the germination temperatures of 20, 25, and 30 °C used in malting both cereal types, production of reducing sugars and that of free amino nitrogen (FAN) were similar. This is an important quality attribute for both cereals because it implies that variation in temperature during the malting of sorghum and millet, especially when malting temperature is difficult to control, and also reflecting temperature variations, experienced in different countries, will not have an adverse effect on the production and release of amino acids and sugars required by yeast during fermentation. Such consistency in the availability of yeast food (substrates) for metabolism during fermentation when sorghum and millet are malted at various temperatures is likely to reduce processing issues when their malts are used for brewing. Although sorghum has gained wide application in the brewing industry, and has been used extensively in brewing gluten-free beer on industrial scale, this is not the case with millet. The work described here provides novel information regarding the potential of millet for brewing. When both cereals were malted, the results obtained for millet in this study followed patterns similar to those of sorghum. This suggests that millet, in terms of sugars and amino acids, can play a role similar to that of sorghum in the brewing industry. This further suggests that millet, like sorghum, would be a good raw material for brewing gluten-free beer. Inclusion of millet as a brewing raw material will increase the availability of suitable materials (raw material sustainability) for use in the production of gluten-free beer, beverages, and other products. The availability of wider range of raw materials will not only help to reduce costs of beer production, but by extension, the benefit of reduced cost of production can be gained by consumers of gluten-free beer as the product would be cheaper and more widely available.

Who should be offered sperm banking for fertility preservation? A survey of UK oncologists and haematologists

BACKGROUND

Fertility after cancer therapy is a significant quality-of-life concern for many patients, their partners and families. Authoritative guidance states that men whose fertility may be affected by impending therapies should be offered sperm banking. Yet some patients are not offered this opportunity and are thereby disadvantaged. We sought to understand oncologists' and haematologists' decision making concerning sperm-banking referrals.

DESIGN

We surveyed all oncologists and haematologists on the Royal College of Radiotherapists' Faculty of Oncology and British Society for Haematology circulation lists.

RESULTS

From 2357 across all specialties, 499 responses were received: 253 haematologists and 246 oncologists (21% response rate). Twenty-one percent of respondents were unaware of local policies on sperm banking and 42% considered that sperm banking should be offered to more patients. Respondents' decisions reveal either assumptions about patients' needs based on characteristics such as age, sexual orientation and severity of illness or the influence of their own moral conclusions upon their patients. The survey identified paucity of training for clinicians, information for patients and systematic recording of discussions about fertility.

CONCLUSIONS

A robust care infrastructure supporting male fertility storage is needed urgently to include targeted information for cancer clinicians and patients, identified individuals responsible for coordination and documentation of discussions with patients.

THE QUANTITATIVE EFFECT OF X-RAYS ON ASCORBIC ACID IN SIMPLE SOLUTION AND IN MIXTURES OF NATURALLY OCCURRING COMPOUNDS

Data on the x-ray induced reaction of ascorbic acid in simple inorganic solution, in solutions containing serum albumin, in plasma, and in muscle have been presented. The reaction occurred in the presence of serum albumin and in human plasma but was relatively small in excised rat muscle.

Effect of the introduction of a lumbar-puncture sticker and teaching manikin on junior staff documentation and performance of paediatric lumbar punctures

BACKGROUND

Performing a lumbar puncture in an unwell child can cause anxiety in both the parent and the junior doctor. There is increasing evidence of post-lumbar-puncture complications in this age group.

AIMS

To improve the documentation, consent for and technical performance of paediatric lumbar punctures to 100% of the required standard within 3 months.

SETTING

The paediatric emergency department of a the Royal North Shore Hospital (University of Sydney, Sydney, Australia).

PARTICIPANTS

Paediatric emergency staff, including residents, registrars and consultants.

METHODS

Medical records of 40 consecutive children who had undergone a lumbar puncture in the 6 months before the introduction of the lumbar-puncture proforma were reviewed. After introduction of the proforma, the records of 25 consecutive patients were reviewed to assess changes in the outcome measures. Before introduction of the proforma, junior medical staff were instructed in the procedure using specialised lumbar puncture manikins (Baby Stap; Laerdel, USA).

RESULTS

Before introduction of the proforma, the median number of documented indicators was 4, out of a maximum of 12. There was almost no documentation of parental consent, patient complications and analgesia. Introduction of the proforma resulted in a highly marked increase to a median of 12 documented indicators per patient (p<0.01, 95% confidence interval 6 to 8).

CONCLUSIONS

The introduction of a lumbar-puncture proforma and formal teaching sessions using a paediatric manikin led to a marked improvement in the documentation of paediatric lumbar-punctures. Lumbar-punctures can be performed only by accredited medical officers who have achieved competency on the lumbar-puncture teaching manikin.

A pilot study to compare the use of prototypes of multipositional paediatric walking sticks and tripods with conventional sticks and tripods by children with cerebral palsy

BACKGROUND

The researchers (B.H. and B.T.) designed prototypes of a walking stick and a tripod termed Multipositional Paediatric Walking Aids for children with cerebral palsy (CP). The design won the 'Jenx Award for Innovation in Paediatric Physiotherapy'. The object of this study was to ascertain whether the prototypes had any benefit over conventional designs in children with CP.

METHODS

A small case series within-subject comparison design was used. There were four periods, AABA, each 4 weeks in length. Prototypes were used during period B. Eight children with CP between 4 and 11 years were recruited, four used sticks and four used tripods. Following an orthopaedic assessment, each child had assessments at the commencement of the study and every 4 weeks thereafter: (1) Energy used while walking using Physiological Cost Index (PCI). (2) Motor abilities using (a) Gross Motor Function Measure (GMFM-88) and (b) Gross Motor Performance Measure (GMPM). (3) Hand/forearm position recorded on a visual analogue. (4) Parent/child questionnaire.

RESULTS

Physiological Cost Index improved overall when the prototypes were used suggesting the amount of energy used when walking with the prototypes was less than with conventional sticks/tripods. GMFM-88 and GMPM results improved for some but not all children. Results for PCI, GMFM and GMPM were not statistically significant. The hand/forearm position of stick users consistently improved at assessment 4. Questionnaire results indicated that stick users preferred the prototypes.

CONCLUSION

Multipositional sticks/tripods may have benefits over conventional sticks/tripods. Children using sticks rather than tripods preferred the prototypes. The study demonstrates the need to undertake scientifically controlled trials before marketing new equipment.

The advisory process for anticancer drug regulation: a global perspective

PURPOSE

This paper summarizes the role of external advisors in oncology drug development and regulation from a global perspective.

DESIGN

Recently, representatives from the United States Food and Drug Administration, European Medicines Agency, the Japanese Pharmaceuticals and Medical Devices Agency, the Australian Therapeutic Goods Administration and Health Canada held a meeting in conjunction with the American Society of Clinical Oncology meeting. The role of external advisors in oncology drug development and regulation in each of these jurisdictions was presented and discussed.

RESULTS

All regulatory bodies described have experience with two forms of outside expertise: advice from individual experts and advice from a group of experts assembled as an advisory group. Regulatory jurisdictions use individual experts variably. In some regions, individual experts provide advice based on knowledge and experience during the drug development phase or in the planning phase for the submission of a drug registration package. In other regions, these individuals serve as external evaluators with the primary responsibility for the review of a clinical trials package submitted for drug registration. Advisory boards have been formalized in all jurisdictions discussed. Advisory boards have a role in discussing specific applications as well as broad policy issues. A common theme is a composition of a core panel of experts with augmentation by additional expertise as needed for consideration of specific scientific questions. In all jurisdictions, advisory board recommendations are not binding on the regulatory body.

CONCLUSIONS

Global oncology drug development and registration involves the use of experts by regulatory authorities. The types of experts needed, the expert's role and the transparency of the advisory process reflect the individual needs in different regions.

An ongoing Confidential Enquiry into asthma deaths in the Eastern Region of the UK, 2001-2003

INTRODUCTION

The Eastern Region Confidential Enquiry into asthma deaths started in 2001. It incorporates the Norwich and East Anglian Enquiries started in 1988 and 1992, respectively. The aim of this study was to analyse all asthma deaths in the Eastern region between 2001 and 2003, to elicit any factors contributing to the patients' deaths, and to make comparisons with the previous Norwich and East Anglian data.

METHOD

Patient details were obtained for all deaths in the Eastern Region under the age of 65 with asthma recorded in the first part of the death certificate. Patients' notes were reviewed by members of the Working Group - a consultant chest physician and a general practitioner (GP). In most cases, the patient's GP was contacted. Data were obtained on the patients' asthma care, asthma severity, terminal attack, psychosocial and behavioural factors, allergies, precipitating factors, and post-mortem findings. The quality of medical care was assessed and compared with national guidelines.

RESULTS

Total study population was 5.25 million. Only 57/95 notified deaths (60%) were confirmed as asthma deaths. 311 asthma deaths have been studied between 1988 and 2003. In 2001-2003, male:female ratio was 3:2. Further data were unavailable on three cases. 53% of patients had severe asthma and 21% moderately severe disease. In 19 cases (33%) at least one significant co-morbid disease was present. Monthly death rates peaked in August, with a smaller peak in April. In 11 cases (20%), mostly males aged under 20, the final attack was sudden and 10/11 occurred between April and August. In 81% of cases there were significant behavioural and/or psychosocial factors such as poor compliance (61%), smoking (46%), denial (37%), depression (20%) and alcohol abuse (20%). The overall medical care of the patient was appropriate in 33% of cases.

CONCLUSIONS

Between 1988 and 2003 there was a downward trend in asthma mortality rate in East Anglia. In 2001-2003, misclassification of deaths attributed to asthma was still common. Most patients who die of asthma have severe asthma. In 81% of cases, behavioural and psychosocial factors contributed to the patient's death. In 80% of deaths the final attack was not sudden, and may have been preventable. Almost all sudden deaths occurred between April and August, suggesting a seasonal allergic cause. In two-thirds of asthma deaths, medical management failed to comply with national guidelines. 'At-risk' asthma registers in primary care may improve recognition and management of 'at-risk' patients.

The meaning and experience of being a stroke survivor: an interpretative phenomenological analysis

PURPOSE

To investigate the meaning and experience of being a stroke survivor.

METHOD

Qualitative in-depth semi-structured interviews were conducted with 10 stroke survivors (five face-to-face and five e-mail interviews). The interview data were transcribed verbatim (these were pre-transcribed in e-mail exchange) and analysed using Interpretative Phenomenological Analysis.

RESULTS

Four themes emerged from the analysis: Disrupted embodiment and the loss of self; Invisibility of emotional difficulties; Gender, romance and sexuality; and Social interaction. These themes, respectively, revealed that participants often had difficulties with psychological adaptation to the physically disabling aspects of their stroke; they experienced enduring and disabling emotional difficulties; they had a particular concern for the viability and maintenance of romantic and sexual relationships; and they often became socially withdrawn, resulting in an increased pressure on familial caregivers.

CONCLUSION

The findings of the present work suggest the need for post-stroke counselling regarding romantic and sexual relationships, as well as promoting acceptance of some of the physical disabilities that come with having a stroke and encouraging positive self-regard. There would also appear to be a need to address the issue of social withdrawal and familial relationships, perhaps when health professionals convey information regarding the person's stroke, and in counselling targeted specifically at family caregivers.

Fine needle aspiration cytology in the diagnosis of uncommon types of lymphoma

AIMS

Fine needle aspiration (FNA) cytology is an accepted means of diagnosing and typing common forms of lymphoma, particularly small lymphocytic lymphoma, follicular lymphoma, and large B cell lymphoma. However, its usefulness for diagnosing less common forms of lymphoma is not clearly established and this study was designed to examine this.

METHODS

The study reviewed the FNAs of suspected lymphomas collected over a period of approximately five years.

RESULTS

FNA samples were available for 138 definite lymphomas; most were common forms of B cell lymphoma. However, there was also one Burkitt lymphoma (BL), two Burkitt-like large B cell lymphomas, 15 classic Hodgkin lymphomas (HLs), two nodular lymphocyte predominant Hodgkin lymphomas, four mantle cell lymphomas, two mediastinal (thymic) large B cell lymphomas (MLBCLs), 11 peripheral T cell lymphomas (PTCLs), and five T cell rich large B cell lymphomas (TCRLBCLs).

CONCLUSIONS

FNA diagnosis of BL was possible with immunoflow cytometry (IFC), cell block immunohistochemistry (IHC), and cell block fluorescent in situ hybridisation for c-myc alteration. It was difficult to make a definite diagnosis of HL and MLBCL on FNA alone. Both tend to be sclerotic tumours and FNA tends to yield scanty neoplastic cells. The FNA diagnosis of PTCL depended on cell block IHC; IFC was not usually useful. TCRLBCL did not show light chain restriction on IFC of FNA samples, probably because of frequent reactive B cells in the tumour. Thus, HL, MLBCL, and TCRLBCL are often difficult to diagnose accurately on FNA cytology, even when using IFC and cell block IHC.

Multiphase Flow Metering: Current Trends and Future Developments

Distinguished Author Series articles are general, descriptive representations that summarize the state of the art in an area of technology by describing recent developments for readers who are not specialists in the topics discussed. Written by individuals recognized as experts in the area, these articles provide key references to more definitive work and present specific details only to illustrate the technology. Purpose: to inform the general readership of recent advances in various areas of petroleum engineering.

Abstract

Over the last decade, the development, evaluation, and use of multiphase-flow-metering (MFM) systems have been a major focus for the oil and gas industry worldwide. Many alternative metering systems have been developed, but none can be referred to as generally applicable or universally accurate. Both established and novel technologies suitable to measure the flow rates of gas, oil, and water in three-phase flow are reviewed and assessed within this framework. Technologies already implemented in various commercial meters then are evaluated in terms of operational and economical advantages or shortcomings from an operator's point of view. The lessons learned about the practical reliability, accuracy, and use of available technology are discussed. As operators now realize, use of MFM systems (MFMSs) is essential in exploiting marginal fields. A new approach to flow assurance, deepwater developments, downhole/seabed separation systems, and wet-gas fields is foreseen. The authors suggest where additional research to develop the next generation MFM devices will be focused to meet the as yet unsolved problems.

Brief History

The first commercial MFMSs appeared approximately 10 years ago, as a result of several multiphase metering research projects in the early 1980s. The driving force to develop MFM technology was the forecast decline of production from the major North Sea fields, accompanied by the necessity to tie backfuture smaller discoveries to existing infrastructure. Increasing gas and waterfractions, inherent in a mature producing province, would create more-unstable flow conditions in existing production facilities and require more-flexible multiphase solutions.

In less than a decade, MFM has become accepted in the field and is beginning to be considered as a primary metering solution for new field developments.

MFM Applications

Within the oil and gas industry, it is generally recognized that MFM could lead to great benefits in terms of the following.1,2,3

Layout of Production Facilities.

The use of MFMs reduces the hardware needed for onshore, offshore topside, and offshore subsea applications. Of primary importance is the removal of a dedicated test separator for well-testing applications. Use of MFM (with its smaller footprint) for topside applications minimizes platform space and load requirements for well-testing operations. Finally, costly well-testing lines can be stripped from the production facilities, which may be of vital importance for unmanned locations, deepwater developments, and satellite fields.

Well Testing.

Conventional test separators are expensive and require much time to monitor each well's performance because of the time required to reach stabilized flow conditions. It is particularly important in deepwater developments, because of the exceptional length of the flowlines. In such cases, production from individual wells connected to the same manifold may be monitored by use of a dedicated test line to avoid shutting down all the wells, then testing them one by one (with considerable production loss). However, the expense of a separate flowline may be prohibitive, hence the advantages of MFM installed in the subsea manifold. Test separators have an accuracy between approximately 5 and10% (currently achievable with MFMSs) but require regular intervention by trained personnel and cannot provide continuous well monitoring. Another disadvantage of conventional well testing with conventional separators is that well performance suffers after shutdown cycles related to well testing. Often, wells tested on a regular basis require more-frequent workovers to maintain their production rates.

Use of MFMSs for exploration-well testing4 provides satisfactory flow measurements without separation of the phases. It is claimed that they can be used to monitor the well during its cleanup flow (traditionally, this flow information is lost because the well stream is not directed through the test separator). Added value is represented by improved control of the drawdown applied to the formation, the pressure transient, and shortened flow periods.

Reservoir Management.

MFMSs provide real-time, continuous data to enable operators to characterize field and reservoir performance better and react faster. Changes in gas/oil ratio or water cut can be detected and quantified immediately, where as traditional test separators provide information about only cumulative volumes at discrete points in time.

The assignment by linkage mapping of four genes from human chromosome 22 to bovine chromosome 5 and 17

Polymerase chain reaction oligonucleotides were designed to amplify bovine specific sequences for four genes that are located on human chromosome 22 (HSA22): crystallin beta A4 (CRY B A4), parvalbumin (PVALB), tissue inhibitor of metalloproteinase 3 (TIMP3) and matrix metalloproteinase 11 (MMP11). Single strand conformation analysis of these bovine gene fragments defined polymorphisms within a population of three large half-sib families of three F1 Charolais x Brahman sires and a composite herd comprising an equal proportion of Africander, Brahman, Hereford and Shorthorn breeds (CSIRO pedigree). The DNA marker genotypes were used to define linkage associations to other DNA markers already placed on the CSIRO linkage map. The genes TIMP3 and PVALB were assigned to BTA5 and CRYbetaA4 and MMP11 to BTA17.

What is the natural history of rheumatoid arthritis?

Inflammatory polyarthritis can be a self-limiting disease, develop into rheumatoid arthritis (RA) or differentiate into another form of chronic arthritis. It remains a clinical and scientific challenge to understand the relationship between these phenotypes, determine their aetiologies and predict the course and outcome for individual patients. Even patients labelled as having RA show a wide spectrum of clinical phenotypes. Disease definition is a major problem in studying the aetiology of RA as currently used classification criteria were derived using patients with established disease. RA is thought to result from the combination of genetic susceptibility and exposure to an appropriate environmental trigger. The genetic component is probably oligogenic. The association with HLA has been known for over 25 years. RA is now thought to be associated with a conserved sequence of amino acids in a number of HLA-DRB1 alleles, called the RA shared epitope. However, the shared epitope appears to be associated with RA chronicity and severity more than with susceptibility. Other potential RA susceptibility genes include IL-1, aromatase, corticotropin-releasing hormone and a region on the X chromosome. Hormonal and reproductive factors also influence RA susceptibility and severity. RA is more common in women than men, especially before the menopause. Men may be protected by hormonal factors and require a stronger genetic component to develop disease. Although infectious triggers of RA have long been suspected, no definitive evidence has been obtained. Previous blood transfusion, smoking and obesity are also possible risk factors. Chronicity and remission are important aspects of the natural history of early RA. Although we can identify patients at risk of adverse prognosis with some accuracy, we remain unable to predict remission. Functional disability and radiological damage are the most studied outcomes in RA. Radiological damage often occurs early in the course of RA, but patients may show erosion for the first time several years after symptom onset. Many studies have demonstrated a relationship between HLA and features of severe RA in established patients. This appears to be related to gene dosage.

Time to first occurrence of erosions in inflammatory polyarthritis: results from a prospective community-based study

OBJECTIVE

To examine the time of occurrence of first radiographic erosions in a cohort of patients with inflammatory polyarthritis.

METHODS

Patients were recruited through the Norfolk Arthritis Register, which follows up patients annually. Patients with features of rheumatoid arthritis (other than erosions) sufficient, together with erosions, to meet the American College of Rheumatology (formerly, the American Rheumatism Association) 1987 revised criteria were requested to undergo radiographic examinations of the hands and feet at the first and/or second annual followup visits. All patients were requested to undergo radiographic examinations at the fifth annual followup visit. The most recent erosion-free radiograph was identified for 416 eligible patients, and these data were used to derive the duration of disease since the recalled date of onset of first symptoms. The rate of occurrence of first erosions was then determined (as a cumulative prevalence and as an incidence rate using Poisson regression) from analysis of followup films. Patients were assumed to be free of erosions at symptom onset.

RESULTS

The cumulative prevalence of erosions in patients whose first film was obtained 12-24 months after disease onset was 36%, equivalent to an incidence rate of 24.5/1,000 patient-months. We identified 3 analysis groups of patients who were free of erosions based on films obtained 12-24 months, 24-36 months, and 36-60 months since the recalled date of onset of first symptoms. New erosions were observed in all 3 groups, with cumulative prevalences of 23%, 28%, and 47%, respectively. These were equivalent to first-erosion incidence rates/1,000 patient-months of 5.4 (95% confidence interval [95% CI] 3.8-83), 6.8 (95% CI 4.7-10.0), and 13.0 (95% CI 8.9-19.2), respectively.

CONCLUSION

Many patients with erosive disease first develop their erosions >2 years from disease onset.

Lessons from an international survey of paper cases of 10 real patients from an early arthritis clinic. CRI (Club Rhumatismes et Inflammation) Group

OBJECTIVE

To determine how experts would classify 10 early-arthritis cases (7 atypical) and to study discrepancies in diagnoses relative to ACR criteria for rheumatoid arthritis (RA) or ESSG criteria for spondyloarthropathy (SpA).

METHODS

Ten real cases (5 met ACR criteria for RA, 6 ESSG criteria for SpA, 3 both and 2 neither) followed for 28.5 +/- 4.8 months were sent as paper cases to 20 international and 12 French experts. Each expert selected a diagnosis among 8 possible choices and rated it on a 0-10 confidence scale. For each case, 3 analog scales (0-100 mm) were used to indicate the probability of RA, SpA or undifferentiated arthritis (UA).

RESULTS

Experts often disagreed about diagnoses (up to 5 different diagnoses for a given case, with a mean of 3.9 per case). Similarly, expert opinions on probabilities for RA and SpA differed widely, with great overlap between confidence for RA, SpA and UA. Fulfilment of ACR or ESSG criteria was poorly related to the experts' diagnosis and evaluation of probabilities for RA and SpA. However, UA was a relatively infrequent choice (19%).

CONCLUSIONS

There was no general consensus about the nosology of early RA and SpA. Classification of atypical early arthritis was not resolved by currently available criteria for RA and SpA. This may have implications for therapy in early disease.

Remacemide hydrochloride: a placebo-controlled, one month, double-blind assessment of its safety, tolerability and pharmacokinetics as adjunctive therapy in patients with epilepsy

Forty patients (33 male, 7 female) with refractory epilepsy were randomized to receive ascending weekly doses of adjunctive remacemide hydrochloride in a b.i.d. or q.i.d. regimen, or placebo for up to 1 month. Assessments included routine physical examination and laboratory tests, recording of adverse events and seizure frequency, and neuropsychological tests. Trough plasma concentrations of concomitant AEDs were measured at weekly intervals. Trough plasma concentrations of remacemide and its desglycinyl metabolite were measured before each dose increment, and complete 24-hour profiles were measured at steady state following administration of 600 mg day(-1)and 1200 mg day(-1). A daily dose of 1200 mg was well tolerated in a q.i.d. regimen and up to 800 mg was well tolerated in a b.i.d. regimen. The most common adverse events were dizziness, diplopia, dyspepsia and abdominal pain. On some occasions, these were considered to be related to raised concentrations of concomitant AEDs. No adverse effects were observed on seizure frequency. Neuropsychology tests revealed no significant changes. Remacemide and the desglycinyl metabolite demonstrated dose proportional pharmacokinetics over the dose range tested.

A placebo-controlled, double-blind cross-over trial of adjunctive one month remacemide hydrochloride treatment in patients with refractory epilepsy

The efficacy, safety and pharmacokinetics of adjunctive remacemide hydrochloride, a novel, low-affinity non-competitive NMDA receptor channel blocker, were investigated in 28 adult patients with refractory epilepsy. This was a randomized double-blind placebo-controlled cross-over study with five 4-week periods (baseline, treatment 1, washout, treatment 2, washout). Baseline median seizure frequency was reduced by 33% following adjunctive remacemide hydrochloride 150 mg q.i.d. for 4 weeks compared with placebo (P= 0.041). Seizure frequency was reduced by > or =50% in 30% of patients treated with remacemide hydrochloride compared with 9% on placebo. Mean plasma concentration of concomitant carbamazepine increased by approximately 15% following adjunctive remacemide hydrochloride. There was no correlation between increased plasma carbamazepine and reduced seizure frequency. Remacemide hydrochloride was well tolerated and only three patients withdrew due to adverse events (two remacemide hydrochloride, one placebo). Two patients died unexpectedly from their epilepsy during placebo treatment; both deaths were considered by the investigators to be unrelated to earlier remacemide hydrochloride treatment. This first specific efficacy investigation with adjunctive remacemide hydrochloride demonstrated anticonvulsant effects in patients with refractory epilepsy. More extensive clinical investigation is justified.