Does orthodontic treatment affect caries levels?

Design A prospective cohort study.Exposure/sample selection In 2005/2006, the authors analysed data from participants in a previous oral epidemiological study conducted in 1988/1989. Children whom were clinically examined in the School Dental Clinics in South Australia in 1988/1989 were invited to a follow-up in 2005/2006. Respondents competed a questionnaire concerning their sociodemographic characteristics, dental health behaviours and the receipt of orthodontic treatment, and were invited for a clinical examination. Oral health information concerning decayed, missing and filled teeth (DMFT) and occlusal status using the Dental Aesthetic Index (DAI) were recorded by multiple trained calibrated dentists in accordance with the NIDR procedures. The study obtained ethical approval from the University of Adelaide and maintained informed consent at each stage of the study.Data analysis Data analysis was performed independently by the principle researcher. Analysis involved descriptive statistics, frequency distribution and cross tabulation. Explanatory variables for orthodontic treatment and dental outcomes were investigated for each DAI category using negative binominal regression using the online computer programme 'effect size calculator'. The statistical analysis was preformed using IBM SPSS statistics version 24. All explanatory variables were introduced into the adjusted negative binominal regression models based on their statistical significance from multiple linear regression models, with the p value set at 0.05.Results The response rate for the questionnaire was 34% (n = 632), with 74% (n = 473) of those attending for clinical examination. After exclusions, 24% (n = 448) of those originally contacted participated. Statistically significant differences in clinical outcomes were observed between those who had and had not visited the dentist in the last two years. These outcomes included missing teeth (MT), filled teeth (FT) and a higher DMFT score. In addition, brushing at least twice daily was associated with fewer decayed teeth (DT) and MT (p <0.001). Increased MT was observed among individuals who had orthodontic treatment across all DAI categories except for participants with very severe malocclusion. In this group, there were significantly more MT among the untreated participants (p <0.001). Thirty-five percent (n = 157) of participants reported a history of orthodontic treatment by the age of 30. No statistically significant associations were found between orthodontic treatment and all aspects of DMFT using adjusted models for participant self-reported sociodemographics, dental health behaviours and malocclusion.Conclusions Caries experience does not correlate with previous orthodontic treatment. Sociodemographic variables and dental health behaviours have a greater impact, and are associated with long-term disease outcomes, including numbers of DMFT. Caries experience is also associated with educational attainment and income level, frequency of tooth brushing and dental office attendance. In summary, orthodontic treatment does not provide superior long-term dental health outcomes in relation to caries. The hypothesis that those with previous orthodontic treatment would have lower caries experience was rejected.

10 year comparison of glass ionomer and composite resin restoration materials in class 1 and 2 cavities

Data sources A prospective randomised, double-blinded controlled trial Study selection Those requiring routine dental care in Sihhiye, Turkey were eligible to participate. Eighty-seven participants were identified and assessed for eligibility by calibrated researchers who ensured that the inclusion and exclusion criteria were met. Fifty-nine participants were successfully recruited with an average age of 24 years (range 15-37).Restoration type were randomly allocated [glass ionomer (GI) or composite resin (CR)] using a table of random numbers with software 'Research Randomised Program' and four experimental groups were created.Two dentists with 5 years experience were calibrated by them placing ten trial restorations , which were not included in the study. One hundred and forty restorations were then placed adhering to a strict treatment protocol. Cavities which did not meet the specifications of the criteria were excluded. The study received ethical approval by the Human Ethics in Clinical Research Committee of the University.Data extraction and synthesis Restorations were assessed at baseline (1 week), 1, 2, 3, 4, 5, 6, 8 and 10 years by blinded calibrated examiners with the aid of colour photographs using an objective criteria. Scanning electron microscopy (SEM) analysis was performed for one randomly selected restoration per group at each assessment. Data analysis adhered to the intention-to-treat CONSORT protocol. The restoration retention rates were calculated, and statistical analysis preformed using IBM SPSS version 22.0. The performance of the restorative materials over the study period were analysed with Cochran's Q test, according to USPHS criteria. Whilst the McNemar test was used to assess aspects of each material with baseline for each cavity type in addition to difference between cavity types. Marginal adaption, marginal discolouration and colour scores in each study group were compared with the p value set at 0.05.Results Eighty-seven patients with 203 lesions were included in the study, with 59 (140 lesions) eligible. Eleven patients were excluded for not meeting the inclusion/ exclusion criteria with 17 refusing to participate. Four randomly allocated groups were created at baseline, as combinations of cavity type and restorative material. 86.4% (n=51) of participants were evaluated after 10 years. The cumulative failure rate (CRF) was 3.17%.Marginal discolouration was observed in all groups at 10 years. With a significant difference observed between Class I and Class II cavities with GI restorations (p = 0.022). In addition, a significant change in colour match in GI restorations after 10 years(<0.005) was found.Over the ten-year period, no significant change was observed in terms of marginal adaption, anatomical form, secondary caries, postoperative sensitivity, surface texture, and retention for either restorative material (p >0.05) or with SEM inspections.Conclusions Both GI and CR are suitable and similar restorative materials for class 1 and class 2 cavities. However, differences can occur in colour change within the materials with glass ionomer restorations showing greater colour change from baseline over this period.

Formation and phenotypic characterization of CD49a, CD49b and CD103 expressing CD8 T cell populations in human metastatic melanoma

Integrins α1β1 (CD49a), α2β1 (CD49b) and αEβ7 (CD103) mediate retention of lymphocytes in peripheral tissues, and their expression is upregulated on tumor infiltrating lymphocytes (TIL) compared to circulating lymphocytes. Little is known about what induces expression of these retention integrins (RI) nor whether RI define subsets in the tumor microenvironment (TME) with a specific phenotype. Human metastatic melanoma-derived CD8 TIL could be grouped into five subpopulations based on RI expression patterns: RI^neg, CD49a⁺ only, CD49a⁺CD49b⁺, CD49a⁺CD103⁺, or positive for all three RI. A significantly larger fraction of the CD49a⁺ only subpopulation expressed multiple effector cytokines, whereas CD49a⁺CD103⁺ and CD49a⁺CD49b⁺ cells expressed IFNγ only. RI^neg and CD49a⁺CD49b⁺CD103⁺ CD8 TIL subsets expressed significantly less effector cytokines overall. Interestingly, however, CD49a⁺CD49b⁺CD103⁺ CD8 expressed lowest CD127, and highest levels of perforin and exhaustion markers PD-1 and Tim3, suggesting selective exhaustion rather than conversion to memory. To gain insight into RI expression induction, normal donor PBMC were cultured with T cell receptor (TCR) stimulation and/or cytokines. TCR stimulation alone induced two RI⁺ cell populations: CD49a single positive and CD49a⁺CD49b⁺ cells. TNFα and IL-2 each were capable of inducing these populations. Addition of TGFβ to TCR stimulation generated two additional populations; CD49a⁺CD49b^negCD103⁺ and CD49a⁺CD49b⁺CD103^+. Taken together, our findings identify opportunities to modulate RI expression in the TME by cytokine therapies and to generate subsets with a specific RI repertoire in the interest of augmenting immune therapies for cancer or for modulating other immune-related diseases such as autoimmune diseases.

Are global tuberculosis control targets overlooking an essential indicator? Prolonged delays to diagnosis despite high case detection rates in Yunnan, China

Delay in treating active tuberculosis (TB) impedes disease control by allowing ongoing transmission, and may explain the unexpectedly modest declines in global TB incidence. Even though China has achieved TB control targets under the global Directly Observed Treatment, Short course (DOTS) strategy, TB prevalence in western provinces, including Yunnan, is not decreasing. This cross-sectional study investigates whether prolonged delay in identifying and correctly treating TB patients, which is not routinely monitored, persists even when there is a well-functioning TB control programme and global targets are being met. Records of adult smear-positive pulmonary TB patients diagnosed with between 2006 and 2013 were extracted from the Yunnan Centre for Disease Control electronic database, which contains information on the entire population of TB patients managed across 129 diagnostic centres. Delay was investigated at three stages: delay to DOTS facility (period between symptom onset and first visit to at a CDC unit providing standardized treatment); delay to TB confirmation (period between reaching a CDC unit and confirmation of smear-positive TB) and delay to treatment (period between confirmation of TB and initiation of treatment). Data from 76 486 patients was analysed. Delay to reaching a DOTS facility was by far the largest contributor to total delay to treatment initiation. The median delay to reaching a DOTS facility, to TB confirmation and to treatment was 57 days (IQR 25-112), 2 days (IQR 1-6) and 1 day (IQR 0-1) respectively. Prolonged delays to reaching a facility providing standardized TB care occurred in a substantial subset of the population despite all TB control targets being met; overall, 32% (24 676) of patients experienced a delay of more than 90 days to reaching a DOTS facility. Policies that focus on reducing delays in accessing appropriate health services, rather than only on increasing overall case-detection rates, may result in greater progress towards reducing TB incidence.

Financial barriers and coping strategies: a qualitative study of accessing multidrug-resistant tuberculosis and tuberculosis care in Yunnan, China

BACKGROUND

Tuberculosis (TB) and multidrug-resistance tuberculosis (MDR-TB) pose serious challenges to global health, particularly in China, which has the second highest case burden in the world. Disparities in access to care for the poorest, rural TB patients may be exacerbated for MDR-TB patients, although this has not been investigated widely. We examine whether certain patient groups experience different barriers to accessing TB services, whether there are added challenges for patients with MDR-TB, and how patients and health providers cope in Yunnan, a mountainous province in China with a largely rural population and high TB burden.

METHODS

Using a qualitative study design, we conducted five focus group discussions and 47 in-depth interviews with purposively sampled TB and MDR-TB patients and healthcare providers in Mandarin, between August 2014 and May 2015. Field-notes and interview transcripts were analysed via a combination of open and thematic coding.

RESULTS

Patients and healthcare providers consistently cited financial constraints as the most common barriers to accessing care. Rural residents, farmers and ethnic minorities were the most vulnerable to these barriers, and patients with MDR-TB reported a higher financial burden owing to the centralisation and longer duration of treatment. Support in the form of free or subsidised treatment and medical insurance, was deemed essential but inadequate for alleviating financial barriers to patients. Most patients coped by selling their assets or borrowing money from family members, which often strained relationships. Notably, some healthcare providers themselves reported making financial and other contributions to assist patients, but recognised these practices as unsustainable.

CONCLUSIONS

Financial constraints were identified by TB and MDR-TB patients and health care professionals as the most pervasive barrier to care. Barriers appeared to be magnified for ethnic minorities and patients coming from rural areas, especially those with MDR-TB. To reduce financial barriers and improve treatment outcomes, there is a need for further research into the total costs of seeking and accessing TB and MDR-TB care. This will enable better assessment and targeting of appropriate financial support for identified vulnerable groups and geographic development of relevant services.

A randomised trial of the cool pad pillow topper versus standard care for sleep disturbance and hot flushes in women on endocrine therapy for breast cancer

PURPOSE

Quality of life in women receiving adjuvant endocrine therapy for breast cancer (BC) may be impaired by hot flushes and night sweats. The cool pad pillow topper (CPPT) is a commercial product, promoted to improve quality of sleep disrupted by hot flushes. This study aimed to identify if the CPPT reduces severity of sleep disturbance by minimising effects of hot flushes.

METHODS

This randomised phase II trial, recruited women with BC, on adjuvant endocrine therapy, experiencing hot flushes and insomnia. Participants were randomised (stratified by baseline sleep efficiency score (SES) and menopausal status) to the intervention arm (CPPT + standard care) or control arm (standard care). Participants completed Hospital Anxiety and Depression Scale and Functional Assessment of Cancer Therapy-Breast (FACT-B) questionnaires and fortnightly sleep/hot flush diaries (where responses were averaged over 2-week periods). The primary endpoint was change in average SES from -2 to 0 weeks to 2 to 4 weeks.

RESULTS

Seventy-four pre- (68.9 %) and post-menopausal (31.1 %) women were recruited. Median age was 49.5 years. Endocrine therapies included tamoxifen (93.2 %). Median SES at weeks 2 to 4 improved in both arms but the increase on the intervention arm was almost twice that on the control arm (p = 0.024). There were significantly greater reductions in hot flushes and HADS depression in the intervention arm (p = 0.09 and p = 0.036, respectively). There were no significant differences in FACT-B or HADS anxiety.

CONCLUSION

This study supports the use of the CPPT as an aid to reduce sleep disturbance and the frequency/severity of hot flushes.

Are current case-finding methods under-diagnosing tuberculosis among women in Myanmar? An analysis of operational data from Yangon and the nationwide prevalence survey

Background

Although there is a large increase in investment for tuberculosis control in Myanmar, there are few operational analyses to inform policies. Only 34 % of nationally reported cases are from women. In this study, we investigate sex differences in tuberculosis diagnoses in Myanmar in order to identify potential health systems barriers that may be driving lower tuberculosis case finding among women.

Methods

From October 2014 to March 2015, we systematically collected data on all new adult smear positive tuberculosis cases in ten township health centres across Yangon, the largest city in Myanmar, to produce an electronic tuberculosis database. We conducted a descriptive cross-sectional analysis of sex differences in tuberculosis diagnoses at the township health centres. We also analysed national prevalence survey data to calculate additional case finding in men and women by using sputum culture when smear microscopy was negative, and estimated the sex-specific impact of using a more sensitive diagnostic tool at township health centres.

Results

Overall, only 514 (30 %) out of 1371 new smear positive tuberculosis patients diagnosed at the township health centres were female. The proportion of female patients varied by township (from 21 % to 37 %, p = 0.0172), month of diagnosis (37 % in February 2015 and 23 % in March 2015 p = 0.0004) and age group (26 % in 25–64 years and 49 % in 18–25 years, p < 0.0001). Smear microscopy grading of sputum specimens was not substantially different between sexes. The prevalence survey analysis indicated that the use of a more sensitive diagnostic tool could result in the proportion of females diagnosed at township health centres increasing to 36 % from 30 %.

Conclusions

Our study, which is the first to systematically compile and analyse routine operational data from tuberculosis diagnostic centres in Myanmar, found that substantially fewer women than men were diagnosed in all study townships. The sex ratio of newly diagnosed cases varied by age group, month of diagnosis and township of diagnosis. Low sensitivity of tuberculosis diagnosis may lead to a potential under-diagnosis of tuberculosis among women.

Alterations in lower limb multimuscle activation patterns during stair climbing in female total knee arthroplasty patients

Total knee arthroplasty (TKA) patients commonly experience neuromuscular adaptations that may affect stair climbing competence. This study identified multimuscle pattern (MMP) changes in postoperative female TKA patients during stair climbing with a support vector machine (SVM). It was hypothesized that TKA patients adopt temporal and spectral muscle activation characteristics indicative of muscle atrophy and cocontraction strategies. Nineteen female subjects [10 unilateral sex-specific TKAs, 62.2 ± 8.6 yr, body mass index (BMI) 28.2 ± 5.4 kg/m(2); 9 healthy control subjects, 61.4 ± 7.4 yr, BMI 25.6 ± 2.4 kg/m(2)] were recruited. Surface electromyograms (EMGs) were obtained for seven lower limb muscles of the affected limb of TKA subjects and a randomly assigned limb for control subjects during stair climbing. Stance phase (±30%) EMG data were wavelet transformed and normalized to total power. Data across all muscles were combined to form MMPs and analyzed with a SVM. Statistical analysis was performed with binomial tests, independent group t-tests, or independent group Mann-Whitney U-tests in SPSS (P < 0.05). SVM results indicated significantly altered muscle activation patterns in the TKA group for biceps femoris (recognition rate 84.2%), semitendinosus (recognition rate 73.7%), gastrocnemius (recognition rate 68.4%), and tibialis anterior (recognition rate 68.4%). Further analysis identified no significant differences in spectral activation characteristics between groups. Temporal adaptations, indicative of cocontraction strategies, were, however, evident in TKA MMPs. This approach may provide a valuable tool for clinical neuromuscular function assessment and rehabilitation monitoring.

Influence of cytokines and TLR agonists on CD49a, CD49b and CD103 expression by T cells (CAM4P.152)

Integrins CD49a (alpha1), CD49b (alpha2) and CD103 (alphaE) are highly expressed on tumor infiltrating lymphocytes (TILs) compared to circulating lymphocytes. Interactions of the integrins with known ligands support retention of lymphocytes in peripheral tissues; thus, they may be considered retention integrins (RI). T cells in peripheral tissues expressing RI have a cytotoxic phenotype and RI+ TIL are associated with improved patient survival. Despite their importance in retention of tumor reactive TILs, little is known about pathways inducing RI expression, except that TGFβ induces CD103. We hypothesized that other cytokines, TLR agonists, and T cell receptor (TCR) stimulation can induce RI expression by circulating T cells. We stimulated PBMC with cytokines or TLR agonists after TCR stimulation, and evaluated RI expression by flow cytometry after 2-7 days. Both CD103 and CD49a are induced by TGFβ, most strikingly on activated T cells. IL2 and IL10 also influence CD49a expression. CD49b expression is increased by IL2, IL4 and IL10, although this depends on T cell subset and activation state. TLR2, TLR6 and TLR7 agonists also appear to induce CD49a and CD49b. In conclusion, our results support our hypothesis by showing that RI expression is tightly regulated by cytokine and TCR stimulation. Furthermore these regulating factors have different effects among the RI, suggesting a different role for each.

Feasibility study of a randomised controlled trial to compare (deferred) androgen deprivation therapy and cryotherapy in men with localised radiation-recurrent prostate cancer

BACKGROUND

Salvage therapeutic options for biochemical failure after primary radiation-based therapy include radical prostatectomy, cryoablation, high-intensity focused ultrasound (HIFU), brachytherapy (for post-EBRT patients) and androgen deprivation therapy (ADT). ADT and salvage prostate cryoablation (SPC) are two commonly considered treatment options for RRPC. However, there is an urgent need for high-quality clinical studies to support evidence-based decisions on treatment choice. Our study aims to determine the feasibility of randomising men with RRPC for treatment with ADT and SPC.

METHODS

The randomised controlled trial (CROP) was developed, which incorporated protocols to assess parameters relating to cryotherapy procedures and provide training workshops for optimising patient recruitment. Analysis of data from the recruitment phase and patient questionnaires was performed.

RESULTS

Over a period of 18 months, 39 patients were screened for eligibility. Overall 28 patients were offered entry into the trial, but only 7 agreed to randomisation. The majority reason for declining entry into the trial was an unwillingness to be randomised into the study. 'Having the chance of getting cryotherapy' was the major reason for accepting the trial. Despite difficulty in retrieving cryotherapy temperature parameters from prior cases, 9 of 11 cryotherapy centres progressed through the Cryotherapists Qualification Process (CQP) and were approved for recruiting into the CROP study.

CONCLUSIONS

Conveying equipoise between the two study arms for a salvage therapy was challenging. The use of delayed androgen therapy may have been seen as an inferior option. Future cohort studies into available salvage options (including prostate cryotherapy) for RRPC may be more acceptable to patients than randomisation within an RCT.

Enhancement of high harmonics from plasmas using two-color pump and chirp variation of 1 kHz Ti:sapphire laser pulses

We have investigated resonance effects in high-order harmonic generation (HHG) within laser-produced plasmas. We demonstrate a significantly improved harmonic yield by using two-color pump-induced enhancement and a 1 kHz pulse repetition rate. Together with an increased HHG output, the even harmonics in the cutoff region were enhanced with respect to odd harmonics. We report the observation of a resonance-induced growth in intensity of 20th harmonic in silver plasma (2×), 26th harmonic in vanadium plasma (4×), and 28th harmonic in chromium plasma (5×).

A randomised double-blind placebo-controlled trial to determine the effect of cranberry juice on decreasing the incidence of urinary symptoms and urinary tract infections in patients undergoing radiotherapy for cancer of the bladder or cervix

AIMS

Radical pelvic radiotherapy is one of the main treatment modalities for cancers of the bladder and cervix. The side-effects of pelvic radiotherapy include urinary symptoms, such as urinary frequency and cystitis. The therapeutic effects of cranberry juice in the prevention and treatment of urinary tract infections in general are well documented. The purpose of this study was to evaluate the effectiveness of cranberry juice on the incidence of urinary tract infections and urinary symptoms in patients undergoing pelvic radiotherapy for cancer of the bladder or cervix.

MATERIALS AND METHODS

The study was a placebo-controlled, double-blind design. Participants were randomised to receive cranberry juice, twice a day (morning and night) for the duration of their radiotherapy treatment and for 2 weeks after treatment (6 weeks in total) or a placebo beverage, for the same duration.

RESULTS

The incidence of increased urinary symptoms or urinary tract infections was 82.5% on cranberry and 89.3% on placebo (P=0.240, adjusted odds ratio [cranberry/placebo] 0.48, 95% confidence interval 0.14-1.63).

CONCLUSIONS

The power of the study to detect differences was limited by the below target sample size and poor compliance. Further research is recommended, taking cognisance of the factors contributing to the limitations of this study.

A randomised controlled study of an audiovisual patient information intervention on informed consent and recruitment to cancer clinical trials

Recruitment to cancer clinical trials needs to be improved, as does patient knowledge and understanding about clinical trials, in order for patients to make an informed choice about whether or not to take part. Audiovisual patient information (AVPI) has been shown to improve knowledge and understanding in various areas of practice, but there is limited information about its effect in the cancer clinical trial setting, particularly in relation to consent rates. In this study, 173 patients were randomised to receive either the AVPI, in addition to the standard trial-specific written information, or the written information alone. There was no difference in clinical trial recruitment rates between the two groups with similar study entry rates: 72.1% in the AVPI group and 75.9% in the standard information group. The estimated odds ratio for refusal (intervention/no intervention) was 1.19 (95% CI 0.55-2.58, P=0.661). Knowledge scores increased more in the AVPI group compared to the standard group (P=0.0072). The change in anxiety score between the arms was also statistically significant (P=0.011) with anxiety improving in the intervention arm more than in the no intervention arm. Audiovisual patient information was shown to be a useful tool in improving patient knowledge and anxiety, but further work is necessary in relation to its effect on clinical trial recruitment rates.

1. Communication skills training in orthopaedics

Communication skills have been identified as a key component of medical education by the CanMEDS Project. The objectives of this study were to identify the perceived key components of communication skills from the perspectives of both orthopaedic residents and their program directors, and to understand how these skills are currently taught. This study utilized a mixed methods design. Quantitative data was collected using a 30-item questionnaire, which was distributed to all Canadian orthopaedic residents. Qualitative data was collected through focus groups with orthopaedic residents and semi-structured interviews with orthopaedic program directors. One hundred and nineteen out of three hundred and twenty-five questionnaires were completed (response rate = 37%), twelve residents participated in two focus groups, and 9/16 program directors from across the country were interviewed. The questionnaire reliability had an internal consistency of Cronbach’s alpha = 0.72. An ANOVA of the questionnaire data showed gender and International vs. Canadian medical graduate status to be independent variables to several item responses (P < 0.01). The factor analysis produced a five-factor model accounting for 50% of the variance. Both program directors and residents identified communication skills as being the accurate and appropriate use of language (ie, content skills), not how the communication was presented (ie, process skills). Perceived barriers to communication included time constraints and the need to adapt to the many personalities and types of people encountered daily in the hospital. Residents lack explicit communication skill training, but value developing communication skills in the clinical environment through experiential learning and role modeling. Resident education should focus on developing residents’ process skills in communication. Care should be taken to avoid large-group didactic teaching sessions, which are perceived as ineffective.

Patient understanding of research: developing and testing of a new questionnaire

Lack of understanding or knowledge of research among patients participating in randomized clinical trials (RCTs) is common. However, there is a lack of validated measures to assess the extent of the problem. The aim of this study was to develop and pilot a questionnaire to assess knowledge and understanding of RCTs in the cancer setting. A 13-item four-part questionnaire was developed and piloted with three groups: patients with cancer who had no experience of clinical trials (n=26); patients with cancer who had previously participated in an RCT (n=26) and research nurses (n=26). The groups were compared using non-parametric anova techniques which showed a highly statistically significant difference between the nurses and both patient groups (P<0.001). The difference between the patient groups was not significant (P=0.231). Cronbach's alpha was computed at 0.77. After studying correlation of individual questions and verbatim comments from respondents, one question was removed from the questionnaire, but this did not have a major effect on the properties of the tool. Minor changes were made to six other questions and the revised tool will now be used and further tested in a large randomized controlled trial to improve informed consent in trial participation.

Laser hair removal in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is one of the most common reasons for women to present seeking removal of facial hair, particularly within the UK National Health Service (NHS). In the NHS, there is geographical variation in the number of laser treatments available to women with PCOS, with some units limiting patients to six treatments whilst others allow unlimited treatments. This study aims to assess the effect of number of treatments on women with PCOS.

METHODS

This study prospectively assessed hair counts, hair-free intervals and patient satisfaction in 60 women with PCOS undergoing 3ms pulse duration alexandrite laser treatment.

RESULTS

Following six treatments there was a mean 31+/-38% reduction in hair counts (mean+/-SD; P=0.001). Mean hair-free interval (HFI) increased steadily with treatment, from 1.9 weeks after six treatments to 4.3 weeks after 10 treatments (P=0.001). From the postal questionnaire, after an average of 12 treatments, 31% of patients had a HFI longer than 6 weeks compared to only 2.6% after six treatments (P=0.003). Overall, despite the low hair count reductions, 95% of patients were satisfied with treatment.

CONCLUSION

In women with PCOS, laser treatment is associated with a poorer than expected reduction in hair counts and HFI following treatment. However, offering more than six treatments does have additional benefits in terms of prolonging HFI and overall patient satisfaction with treatment is very high.

Depression and neurocognitive performance in individuals with HIV/AIDS: 2-year follow-up

OBJECTIVES

The aims of this study were to follow a cohort of HIV-infected individuals for 2 years to assess changes in depression and neuropsychological performance over time, to explore the relationship between depression, HIV illness and neuropsychological performance, and to examine the natural history of the effect of highly active antiretroviral therapy (HAART) on depression and neurocognitive performance.

METHODS

HIV-seropositive out-patients were assessed at baseline and at 2-year follow-up. At each assessment, patients were assessed for depression [using the Beck Depression Inventory (BDI) and Structured Clinical Interview (SCID-CV)] and completed a battery of neuropsychological tests including the Cambridge Neuropsychological Test Automated Battery (CANTAB) and the Hopkins HIV Dementia Scale (HDS).

RESULTS

At baseline, 34.8% scored > or =14 on the BDI [> or =14 suggests depressive symptoms (DS)]. The SCID-CV revealed that 27% of participants met the criteria for current mood disorder. Seven per cent of the participants' scores on the HDS indicated HIV-associated cognitive changes. Eighty participants were re-tested at 2-year follow-up and were split into two groups based on BDI scores at baseline. CANTAB results revealed that the cohort were significantly impaired on nine of 10 measures compared with age-matched normative data. Neurocognitive performance significantly improved for participants with no DS at baseline, whereas participants with DS at baseline did not show as much improvement. Multivariate analysis revealed that 40% of the change in cognitive performance was attributable to the variables age, AIDS and HAART regimen.

CONCLUSION

These results suggest a significant decline in depression scores and an improvement in several neurocognitive domains over time, with a relationship between HIV illness, HAART, symptoms of depression and neurocognitive performance.

Malignant spinal cord compression: a retrospective audit of clinical practice at a UK regional cancer centre

Malignant Spinal Cord Compression (MSCC) is a particularly challenging area of cancer care where early diagnosis and expert multiprofessional care and rehabilitation, are paramount in optimising quality of life. This audit reports data collected retrospectively over a period of 12 months on patients with MSCC referred to the West of Scotland Cancer Centre (n = 174). It was carried out to build on the work of the Clinical Resource and Audit Group (CRAG) and to examine current practice for symptom assessment, multiprofessional care and rehabilitation of patients with MSCC admitted to the cancer centre. Areas of concern include poor assessment of pain, the poor ambulatory status of patients on admission and the lack of clear plans for mobilisation and rehabilitation for the majority of patients. Recommendations include the development of regional guidelines for referral, treatment and rehabilitation, and the development of a pathway of care for use in all care settings across the region, together with improvements for use in patient information, staff education, audit and research. These are now being taken forward through the West of Scotland Cancer Network with dedicated funding from Macmillan Cancer Relief.

Colour stability and water-holding capacity of M. longissimus and carcass characteristics in fallow deer (Dama dama) grazed on natural pasture or fed barley

The effects of feeding regimen on carcass characteristics, meat colour and water-holding capacity of M. longissimus were studied in 24 female fallow deer (Dama dama). All animals were farm raised; twelve were grazed on pasture and twelve were fed barley and a small amount of hay prior to slaughter. The animals were slaughtered at two occasions (during the Southern Hemisphere spring); after 19 weeks of feeding (n=12; 6 grazing and 6 barley fed animals; group 1) and after 24 weeks of feeding (n=12; 6 grazing and 6 barley fed animals; group 2). The barley/hay-fed deer had significantly higher body condition scores and carcass weights than the pasture raised group. No difference in meat ultimate pH values between the treatment groups was recorded. The meat from the pasture raised deer had significantly longer colour display life after 2 and 3 weeks of refrigerated storage (+ 2.0 ºC) in vacuum bags. There was no difference in drip loss between the two treatment groups. However, significantly lower drip losses were found in meat from the animals in group 2 compared with the ones in group 1 (P ≤ 0.001). It was concluded that the feeding regimen of the animals is an important factor that contributes to the variation in quality of fresh chilled deer meat (venison), mainly the colour stability and display life of vacuum packaged meat.Abstract in Swedish / Sammanfattning: I denna undersökning ingick 24 dovhjortshindar (Dama dama) för att studera effekterna av olika typer av foder (bete och korn) på slaktkroppskvalitet samt färg och vattenhållande förmåga i köttet (M. longissimus). Alla djur var uppfödda på en hjortfarm, 12 betade gräs och 12 utfodrades med korn och en liten mängd hö före slakt. Djuren slaktades vid två olika tillfällen (under våren på det södra halvklotet); efter 19 veckors utfodring (n=12; 6 betesdjur och 6 kornfodrade djur; grupp 1) och efter 24 veckors utfodring (n=12; 6 betesdjur och 6 kornfodrade djur; grupp 2). De dovhjortar som utfodrats med korn och hö var i bättre kondition och hade högre slaktvikter jämfört med de djur som betat gräs. Ingen skillnad i köttets pH-värde mellan de två utfodringsgrupperna kunde dock påvisas. Köttet från de betande dovhjortarna hade bättre färgstabilitet efter lagring i 2 och 3 veckor (+ 2.0 ºC) i vakuumförpackning. Det fanns ingen skillnad mellan kött från betande och korn/hö-utfodrade djur i vattenhållande förmåga. Däremot hade kött från djur i grupp 2 (slaktade efter 24 veckors utfodring) bättre vattenhållande förmåga jämfört med grupp 1 (P ≤ 0.001). Vi kunde konstatera att de olika fodertyperna påverkade kvaliteten hos färskt kyllagrat kött, framförallt färgstabiliteten hos vakuumförpackat kött.

Evaluation of an information booklet for patients considering participation in phase I clinical trials in cancer

Phase I trials in cancer patients, although essential, are a difficult field of clinical research. A particularly challenging area for all members of the clinical research team is that concerned with information-giving and informed consent leading to patient participation in the trial. An information booklet for patients was written in an attempt to address some of those issues, with the overall aim of improving the informed consent process and influencing patient decision-making. Questions covered in the booklet include: What is a phase I trial? Who can take part? Are there any side-effects or risks involved? What if I say no? The booklet was given to patients prior to consent. On the first day of receiving treatment they were given a questionnaire to evaluate the usefulness and acceptability of the booklet. The results showed the booklet to be generally well accepted by patients and the majority of them perceived the content and volume of information to be appropriate. The booklet did support patient decision-making and the evaluation showed that the optimal time for patients to receive it was prior to the signing of a consent form. Minor amendments have been made to the booklet, which is now given routinely to all patients at the cancer centre who are considering participation in a phase I trial, and is a valuable addition to the informed consent process.

Variables influencing end-of-life care in children and adolescents with cancer

BACKGROUND

The purpose of this study was to describe the variables influencing end-of-life care in children and adolescents dying of cancer.

MATERIALS AND METHODS

Records of 146 children with cancer who died at Children's Hospital were reviewed for demographics, diagnosis, location of death, withdrawal of life support, use of "do not resuscitate" (DNR) orders, and the length of time that those orders were in effect.

RESULTS

Ninety-five patients were evaluated. Fifty-nine died of progressive disease and 36 deaths were therapy-related. Sixty-four percent of disease-related deaths occurred at home with support from home care or hospice. Only 10% of all patients died while receiving maximal aggressive support in the intensive care unit. Age, diagnosis (solid tumor vs. leukemia), cause of death, length of last hospital admission, and the duration of DNR orders had a significant correlation with the place of death and referral to and use of hospice. Thirty-five percent of all patients had hospice support.

CONCLUSIONS

Most children who die of cancer die because of progressive disease at home with hospice support. Do not resuscitate orders were written for most patients who died. End-of-life decisions are influenced by patient diagnosis, cause of death, and age.

Childhood cancer: patterns of protocol participation in a national survey

Cancer is still the chief cause of death by disease in children, ages one to 14. As improved survival rates have been reported for pediatric cancer patients who are treated on controlled clinical trials, it is important to understand the national utilization of such protocols. In 1993, a survey of childhood cancer was conducted by the Commission on Cancer of the American College of Surgeons. Data regarding type of disease, protocol participation, age, sex, race, insurance, and geographical region were voluntarily submitted by more than 200 hospital cancer registries. Included in this study were 2,208 children and adolescents 21 years of age or younger who were diagnosed in 1987, and 2,293 who were diagnosed in 1992. Pediatric centers (i.e., members of the Pediatric Oncology Group or Children's Cancer Group) submitted 55.1% of the cases and other institutions, 44.9%. It was found that more patients treated at pediatric centers were on protocols (53.8%) than were those treated at other institutions (25.1%). In general, the younger the patient (five years of age or younger), the greater the chance of being on protocol (pediatric centers, 63.7%; others, 42.0%), with very poor adolescent protocol participation (pediatric centers, 34.8%; others, 12.1%). Nevertheless, overall protocol participation was still lower than expected, even in children younger than five years of age, and adolescent participation in controlled clinical trials was low and similar to adult figures. The percentage of childhood cancer cases seen at pediatric centers was smaller than in other series. It was concluded that pediatric cancer centers need to continue to encourage patient participation in controlled clinical trials, with special emphasis on adolescents.

The protein kinase C inhibitor CGP41251 suppresses cytokine release and extracellular signal-regulated kinase 2 expression in cancer patients

Components of cell signaling pathways provide important targets for anticancer drugs. Protein kinase C (PKC) is a serine/threonine-specific kinase that regulates cell growth and differentiation. It is also implicated in tumor promotion. The staurosporine analogue CGP41251 is a PKC inhibitor, and it is currently in a Phase I clinical trial for treatment of advanced cancer. However, it is difficult to define its biological activity. We have used two approaches to measure the in vivo biological response to CGP41251: (a) sequential whole blood samples were taken from 27 patients before and during treatment and incubated with mitogen (PHA), and cytokine [tumor necrosis factor (TNF)-alpha and interleukin (IL)-6] release was measured ex vivo; and (b) peripheral blood lymphocytes were isolated from seven of these patients, and the levels of extracellular signal-regulated kinase 2 were measured by Western blotting. Response to PHA was significantly lowered during treatment (P < 0.001 for TNF-alpha production; P < 0.03 for IL-6). This was most evident at 7 and 28 days after the start of treatment in patients receiving higher doses (150-300 mg/day; P = 0.002 and P = 0.02, respectively, for TNF-alpha and P = 0.001 and P = 0.003, respectively, for IL-6 release). Whole blood cytokine production returned to pretreatment levels after drug administration ceased. The levels of extracellular signal-regulated kinase 2 were reduced by 50-97% during treatment in all seven patients tested. These results show for the first time that a PKC inhibitor can block in vivo signaling pathways in cancer patients. The assays we describe complement toxicity studies in selecting relevant doses for Phase II trial of novel agents, particularly when biological activity occurs at doses below those that cause obvious side effects.

Phase I and pharmacokinetic study of DACA (XR5000): a novel inhibitor of topoisomerase I and II. CRC Phase I/II Committee

DACA, also known as XR5000, is an acridine derivative active against both topoisomerase I and II. In this phase I study, DACA was given as a 3-h intravenous infusion on 3 successive days, repeated every 3 weeks. A total of 41 patients were treated at 11 dose levels between 9 mg m(-2) d(-1) and the maximum tolerated dose of 800 mg m(-2) day(-1). The commonest, and dose-limiting, toxicity was pain in the infusion arm. One patient given DACA through a central venous catheter experienced chest pain with transient electrocardiogram changes, but no evidence of myocardial infarction. At the highest dose levels, several patients also experienced flushing, pain and paraesthesia around the mouth, eyes and nose and a feeling of agitation. Other side-effects, such as nausea and vomiting, myelosuppression, stomatitis and alopecia, were uncommon. There was one minor response but no objective responses. DACA pharmacokinetics were linear and did not differ between days 1 and 3. The pattern of toxicity seen with DACA is unusual and appears related to the mode of delivery. It is possible that higher doses of DACA could be administered using a different schedule of administration.

Social support: factors to consider when designing studies that measure social support

Research into the area of social support has been associated with confusion and concern. Much of the previous work in this area has inherent and serious difficulties, especially with regard to measurement issues surrounding the concept and with study design. However, it is paramount that social support research is further developed to allow effective interventions by health care professionals to influence positive outcomes in patient care. It is only by adopting a rigorous approach to social support research that its full potential can be achieved, that it can result in the positive promotion of recovery from mental and physical illness and that it can then become an important tool for the health care professional. This paper aims to clarify research issues relating to social support definition, measurement and study design, including methodology, selection of instruments and analysis. Guidance will be provided concerning the important factors to consider to achieve a well-designed study to measure social support.

Assessment of technical skills transfer from the bench training model to the human model

BACKGROUND

This study examines whether technical skills learned on a bench model are transferable to the human cadaver model.

METHODS

Twenty-three first-year residents were randomly assigned to three groups receiving teaching on six procedures. For each procedure, one group received training on a cadaver model, one received training on a bench model, and one learned independently from a prepared text. Following training, all residents were assessed on their ability to perform the six procedures.

RESULTS

Repeated measures analysis of variance revealed a significant effect of training modality for both checklist scores (F(2,44) = 3.49, P <0.05) and global scores (F(2,44) = 7.48, P <0.01). Post-hoc tests indicated that both bench and cadaver training were superior to text learning and that bench and cadaver training were equivalent.

CONCLUSIONS

Training on a bench model transfers well to the human model, suggesting strong potential for transfer to the operating room.

Cancer surveillance in the U.S.: can we have a national system?

Cancer-related services are consuming ever-increasing health resources; along with this trend, health care costs are rising. As health care planners, researchers, and policymakers formulate strategies to meet this challenge, they are looking to cancer registries and the health information system built around them as collectors of the most extensive information regarding cancer treatment in the U.S. Currently, there are multiple programs collecting and reporting data regarding cancer incidence, morbidity, mortality, and survival. This report profiles cancer surveillance efforts in the U.S. and describes the National Coordinating Council for Cancer Surveillance, which was organized in 1995 to facilitate a collaborative approach among the organizations involved.

Durable remission of locally advanced breast cancer with multimodality management

We treated 20 women with locally advanced breast cancer between January 1991 and September 1996. The treatment regimen included 4 cycles of intensive doxorubicin (30 mg/m2/d on 3 consecutive days every 2 weeks with G-CSF support), followed by appropriate surgery, followed by high dose therapy with cyclophosphamide, carboplatin and thiotepa (STAMP V, CTCb). Of the 20 patients, seven presented with inflammatory breast cancer, three with Stage IIIB, seven with stage IIIA, one with multifocal Stage IIB and two with Stage IV M1 (ipsilateral supraclavicular lymph node involvement) (including one who had an inflammatory primary) disease. Six patients had not undergone mastectomy at the time of entering the protocol. These six received the doxorubicin in a neoadjuvant fashion and were thus evaluable for tumor response. The remaining 14 received doxorubicin as adjuvant therapy prior to intensification and transplantation. All patients underwent local-regional radiation therapy and were placed on oral tamoxifen. Doxorubicin was well tolerated in this schedule with all but three patients receiving all their cycles on schedule. Both BM and PBPC were easily collected after this regimen and, when reinfused, resulted in the prompt recovery of granulocytes (median 11 days to 500 absolute granulocyte count) and platelets (median 13 days to 20,000 platelets). The six patients who received doxorubicin prior to mastectomy all had major clinical responses, but were found to have microscopic focii of breast cancer in the mastectomy specimens. The overall treatment was well tolerated with the exception of one treatment-related death (5%). The overall and relapse free survival are 70% and 58% respectively with a median follow-up of 40 months (range 12-74 months). When the Stage IV patients are censored, the relapse-free survival rate is 69%. In the bone marrow transplant phase of treatment, the major non-hematologic toxicities were stomatitis (70%) and anorexia requiring parental nutrition (75%).

Phase I trials in cancer patients: participants' perceptions

There is controversy surrounding the ethics of performing phase I clinical trials with cancer patients and limited research concerning patients' attitudes when participating in such trials. The aim of this study was to determine how cancer patients perceive phase I clinical trials in reference to trial participation and trial information received. Cancer patients (n = 28) were interviewed 2-4 weeks after consenting to participate, using a questionnaire which contained open and closed questions. Responses were analysed using non-parametric statistical tests. The results demonstrated that although the majority of patients participated in experimental treatment because it offered hope that they might be helped, their expectations from the new drug were realistic. Patients found that there were benefits related to participating in phase I trials and felt that the amount and quality of both nursing and medical care was superior in a phase I trial as compared to standard treatment in non-experimental settings. There were varying opinions among patients with regard to information giving by nursing and medical staff. It can be concluded that phase I trials employing cancer patients can be ethical.

Objective structured assessment of technical skill (OSATS) for surgical residents

BACKGROUND

The technical skill of surgical trainees is not well assessed. This study aimed (1) to compare the reliability of three scoring systems, (2) to compare live and bench formats and (3) to assess construct validity of a test of operative skill.

METHODS

Parallel examinations of operative skill, one using live animals and one using simulations, were developed. Performance was graded using operation-specific checklists, detailed global rating forms and pass/fail judgements. Twenty surgical residents each took both formats.

RESULTS

Disattenuated correlations between live and bench scores were high (0.69-0.72). Mean interrater reliability across stations ranged from 0.64 to 0.72. Internal consistency was moderate to high (alpha: 0.61-0.74) for the live format using the checklist and for live and bench formats using global ratings. Global ratings discriminated between resident levels for both formats (bench: F(2,17) = 4.45, P < 0.05; live: F(2,17) = 3.55, P < 0.05), checklists did not.

CONCLUSION

This preliminary study suggests that the Objective Structured Assessment of Technical Skill can reliably and validly assess surgical skills. Global ratings are a better method of assessment than task-specific checklists. Bench model simulation gives equivalent results to use of live animals for this test format.

The factor V Leiden mutation which predisposes to thrombosis is not common in patients with antiphospholipid syndrome

Antiphospholipid syndrome is associated with venous, arterial, and placental thrombosis, possibly through autoantibody impairment of phospholipid-dependent protein C activation. Recently, a missense mutation in the factor V gene (1691 G-->A) has been identified that results in an abnormal factor V product (1). This mutation, known as the Leiden mutation, causes an amino acid substitution of glutamine for arginine at position 506 in the factor V molecule and renders the protein resistant to proteolytic inactivation by activated protein C and thus predisposes to thrombosis (2, 3). We hypothesized that some individuals with antiphospholipid syndrome may also carry the Leiden mutation, and thus have a "second hit" predisposition to thrombosis. To test this hypothesis, allele-specific hybridization and allele-specific restriction analysis were used to test for the Leiden mutation in thirty women with the antiphospholipid syndrome, 10 of whom had a history of thrombosis. None of the women were heterozygous or homozygous for the factor V mutation. We conclude that the presence of the factor V Leiden mutation is not a prerequisite for the thrombotic events in patients with antiphospholipid syndrome, due to the occurrence of thrombosis seen in patients lacking the factor V mutation.

Nuclei that lack a lamina accumulate karyophilic proteins and assemble a nuclear matrix

Xenopus egg extracts, which support nuclear assembly and DNA replication in vitro, were physically depleted of lamin B3 using monoclonal antibodies linked to magnetic beads. Depleted extracts were still able to support nuclear envelope assembly around demembranated sperm heads but the resulting pronuclei lacked a lamina and were unable to initiate semiconservative DNA replication or to assemble replicases, confirming previous data. Immunoblotting analysis of isolated nuclei and nuclear matrix fractions indicated that lamin-depleted nuclei still accumulated nucleoporins and PCNA. Furthermore, the rate of PCNA uptake was identical in lamin-depleted and control nuclei. However, neither the nucleoporins nor the PCNA was associated with nuclear matrix fractions. The major protein components of sperm pronuclear matrix fractions were characterized by two-dimensional gel electrophoresis. Of these proteins only three out of 22 species, other than the lamins, were significantly reduced in lamin-depleted nuclei, indicating that these nuclei do assemble a nuclear matrix.

Plasmid origin of replication of herpesvirus papio: DNA sequence and enhancer function

Herpesvirus papio (HVP) is a lymphotropic virus of baboons which is related to Epstein-Barr virus (EBV) and produces latent infection. The nucleotide sequence of the 5,775-base-pair (bp) EcoRI K fragment of HVP, which has previously been shown to confer the ability to replicate autonomously, has been determined. Within this DNA fragment is a region which bears structural and sequence similarity to the ori-P region of EBV. The HVP ori-P region has a 10- by 26-bp tandem array which is related to the 20- by 30-bp tandem array from the EBV ori-P region. In HVP there is an intervening region of 764 bp followed by five partial copies of the 26-bp monomer. Both the EBV and HVP 3' regions have the potential to form dyad structures which, however, differ in arrangement. We also demonstrate that a transcriptional enhancer which requires transactivation by a virus-encoded factor is present in the HVP ori-P.