Methods for the Clinical Validation of Digital Endpoints: Protocol for a Scoping Review Abstract

BACKGROUND

Clinical trials often use digital technologies to collect data continuously outside the clinic and use the derived digital endpoints as trial endpoints. Digital endpoints are also being developed to support diagnosis, monitoring, or therapeutic interventions in clinical care. However, clinical validation stands as a significant challenge, as there are no specific guidelines orienting the validation of digital endpoints.

OBJECTIVE

This paper presents the protocol for a scoping review that aims to map the existing methods for the clinical validation of digital endpoints.

METHODS

The scoping review will comprise searches from the electronic literature databases MEDLINE (PubMed), Scopus (including conference proceedings), Embase, IEEE (Institute of Electrical and Electronics Engineers) Xplore, ACM (Association for Computing Machinery) Digital Library, CENTRAL (Cochrane Central Register of Controlled Trials), Web of Science Core Collection (including conference proceedings), and Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports. We will also include various sources of gray literature with search terms related to digital endpoints. The methodology will adhere to the Joanna Briggs Institute Scoping Review and the Guidance for Conducting Systematic Scoping Reviews.

RESULTS

A search for reviews on the existing evidence related to this topic was conducted and has shown that no such review was previously undertaken. This review will provide a systematic assessment of the literature on methods for the clinical validation of digital endpoints and highlight any potential need for harmonization or reporting of methods. The results will include the methods for the clinical validation of digital endpoints according to device, digital endpoint, and clinical application goal of digital endpoints. The study started in January 2023 and is expected to end by December 2023, with results to be published in a peer-reviewed journal.

CONCLUSIONS

A scoping review of methodologies that validate digital endpoints is necessary. This review will be unique in its breadth since it will comprise digital endpoints collected from several devices and not focus on a specific disease area. The results of our work should help guide researchers in choosing validation methods, identify potential gaps in the literature, or inform the development of novel methods to optimize the clinical validation of digital endpoints. Resolving these gaps is the key to presenting evidence in a consistent way to regulators and other parties and obtaining regulatory acceptance of digital endpoints for patient benefit.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/47119.

The Challenges of Setting Up a Clinical Study with the New European Union Medical Device Regulation

N/a.

Predictors for NYHA recovery and 1-year mortality after mitral TEER

Background

Mitral regurgitation (MR) is the second-most frequent valvular heart disease in Europe and frequently aggravates heart failure (HF) symptoms. Mitral transcatheter-edge-to-edge repair (TEER) can be considered in eligible patients, for both primary (in inoperable cases) or secondary severe MR. However, intervention is not advised in severe comorbid patients in whom it is not expected to prolong survival for over 1 year.

Purpose

Evaluate characteristics associated with HF New York Heart Association (NYHA) class recovery, and one-year all-cause mortality after mitral TEER for severe MR.

Methods

All mitral TEER procedures for primary and secondary MR conducted in a single-centre between 2014 and 2020 were retrospectively analyzed. The primary endpoint was defined as a reduction of at least one NYHA class in the first month after intervention, and a secondary endpoint considered a recovery of at least two NYHA classes. Survival status 12 months after mitral TEER was also consulted. Clinical, echocardiographic and blood-analysis data were explored as characteristics associated with the endpoints defined, using Pearson's Chi-squared test, Wilcoxon rank sum test and Fisher's exact test, as appropriate. A p<0.05 was considered statistically significant.

Results

From 103 mitral TEER procedures, 86 (83%) had full information about pre- and post-intervention NYHA class, as well as survival status at 12 months. There was a higher proportion of primary MR among NYHA non-responders (47% versus 25%, p=0.034), but no differences for secondary MR. Higher surgical risk patients (EuroSCORE II) tended to have exhibit more NYHA recovery, though not reaching statistical significance (p=0.068). Both a more advanced NYHA class at baseline and lower N-terminal pro-brain natriuretic peptide (NTproBNP) levels were linked to a higher symptomatic recovery (2048 versus 5676pg/ml, p<0.001). Also, persisting MR after TEER of at least grade 3/4 was more frequent in non-NYHA responders. Regarding NYHA improvement of at least two classes, it was observed in 13% patients, and these also had a more advanced NYHA class at baseline and lower NTproBNP basal levels, and exhibited a lower estimated systolic pulmonary artery pressure and inferior vena cava (IVC) diameter. Finally, 10 (11.6%) of mitral TEER patients died in the first 12 months, and no statistically significant associations were found regarding pre-intervention characteristics and survival.

Conclusions

This study suggests that three-fifths of severe MR improve their NYHA class after TEER, but only one-fourth for primary MR. Earlier intervention – with lower NTproBNP levels, less severe pulmonary hypertension, and lower IVC diameters – is associated with more symptomatic HF improvement. All-cause mortality in the first year is still significant, exposing a need for better patient selection. However, these findings represent exploratory deductions of a relatively low number, single-centre, patients.

Funding Acknowledgement

Type of funding sources: None.

Understanding Mental Health Professionals' Perspectives and Practices Regarding the Implementation of Digital Mental Health: Qualitative Study

BACKGROUND

Despite the potential of digital mental health to provide cost-effective mental health care, its adoption in clinical settings is limited, and little is known about the perspectives and practices of mental health professionals regarding its implementation or the factors influencing these perspectives and practices.

OBJECTIVE

This study aims to characterize in depth the perspectives and practices of mental health professionals regarding the implementation of digital mental health and explore the factors affecting such perspectives and practices.

METHODS

A qualitative study using in-depth semistructured interviews with Portuguese mental health professionals (N=13)-psychologists and psychiatrists-was conducted. The transcribed interviews were thematically analyzed.

RESULTS

Mental health professionals deemed important or engaged in the following practices during the implementation of digital mental health: indication evaluation, therapeutic contract negotiation, digital psychological assessment, technology setup and management, and intervention delivery and follow-up. Low-threshold accessibility and professionals' perceived duty to provide support to their clients facilitated the implementation of digital mental health. Conversely, the lack of structured intervention frameworks; the unavailability of usable, validated, and affordable technology; and the absence of structured training programs inhibited digital mental health implementation by mental health professionals.

CONCLUSIONS

The publication of practice frameworks, development of evidence-based technology, and delivery of structured training seem key to expediting implementation and encouraging the sustained adoption of digital mental health by mental health professionals.

Development and Evaluation of the Usefulness, Usability, and Feasibility of iNNOV Breast Cancer: Mixed Methods Study

BACKGROUND

Despite the efficacy of psychosocial interventions in minimizing psychosocial morbidity in breast cancer survivors (BCSs), intervention delivery across survivorship is limited by physical, organizational, and attitudinal barriers, which contribute to a mental health care treatment gap in cancer settings.

OBJECTIVE

The aim of this study is to develop iNNOV Breast Cancer (iNNOVBC), a guided, internet-delivered, individually tailored, acceptance and commitment therapy-influenced cognitive behavioral intervention program aiming to treat mild to moderate anxiety and depression in BCSs as well as to improve fatigue, insomnia, sexual dysfunction, and health-related quality of life in this group. This study also aims to evaluate the usefulness, usability, and preliminary feasibility of iNNOVBC.

METHODS

iNNOVBC was developed using a user-centered design approach involving its primary and secondary end users, that is, BCSs (11/24, 46%) and mental health professionals (13/24, 54%). We used mixed methods, namely in-depth semistructured interviews, laboratory-based usability tests, short-term field trials, and surveys, to assess iNNOVBC's usefulness, usability, and preliminary feasibility among these target users. Descriptive statistics were used to characterize the study sample, evaluate performance data, and assess survey responses. Qualitative data were recorded, transcribed verbatim, and thematically analyzed.

RESULTS

Overall, participants considered iNNOVBC highly useful, with most participants reporting on the pertinence of its scope, the digital format, the relevant content, and the appropriate features. However, various usability issues were identified, and participants suggested that the program should be refined by simplifying navigation paths, using a more dynamic color scheme, including more icons and images, displaying information in different formats and versions, and developing smartphone and tablet versions. In addition, participants suggested that tables should be converted into plain textboxes and data visualization dashboards should be included to facilitate the tracking of progress. The possibility of using iNNOVBC in a flexible manner, tailoring it according to BCSs' changing needs and along the cancer care continuum, was another suggestion that was identified.

CONCLUSIONS

The study results suggest that iNNOVBC is considered useful by both BCSs and mental health professionals, configuring a promising point-of-need solution to bridge the psychological supportive care gap experienced by BCSs across the survivorship trajectory. We believe that our results may be applicable to other similar programs. However, to fulfill their full supportive role, such programs should be comprehensive, highly usable, and tailorable and must adopt a flexible yet integrated structure capable of evolving in accordance with survivors' changing needs and the cancer continuum.

Mapping mental healthcare professionals’ journey towards digital mental health adoption: A qualitative study

Introduction

Digital Mental Health holds strategic potential in fulfilling populations’ mental healthcare unmet needs, enabling convenient and equitable access to mental healthcare. However, despite strong evidence of efficacy, uptake by mental healthcare providers remains low and little is known about factors influencing adoption and its interrelationship throughout the Digital Mental Health adoption process.

Objectives

This study aimed at gaining in-depth understanding of factors influencing adoption and mapping its interrelationship along different stages of the Digital Mental Health adoption process.

Methods

This work adopted a qualitative approach consisting of in-depth semi-structured interviews with 13 mental healthcare professionals, including both psychologists and psychiatrists. The interviews were transcribed and analysed thematically, following Braun and Clarke’s method.

Results

In this communication, we will describe how digital technology is currently used by clinicians to deliver mental healthcare. We identify potential factors influencing Digital Mental Health adoption and characterize the different identified stages inherent to this appropriation process: i) Pondering appropriate use; ii) Contractualizing the therapeutic relationship; iii) Performing online psychological assessment; iv) Adapting and/or developing interventions; v) Delivering Digital Mental Health interventions; and vi) Identifying training unmet needs. A discussion on how different factors and its interrelationship impact the adoption process will also be performed.

Conclusions

By characterizing mental healthcare providers journey throughout the Digital Mental Health adoption process, we intend to inform ecosystem stakeholders, such as researchers, policy makers, societies and industry, on key factors influencing adoption, so policies, programs and interventions are developed in compliance with this knowledge and technology is more easily integrated in clinical practice.

AB0510 THE ROLE OF BONE SCINTIGRAPHY FOR THE FOLLOW-UP EVALUATION OF INFLAMMATORY ACTIVITY IN PATIENTS WITH SERONEGATIVE SPONDYLOARTHRITIS

Background:

The use of bone scintigraphy (Sc) in spondyloarthritis (SpA) as a technique for diagnosis, assessment of activity and treatment decision has been questioned by the scientific community. Due to its low cost compared to Magnetic Resonance Imaging - MRI (the gold standard)1, some studies proposed to evaluate Sc’s diagnostic accuracy. These studies have shown that Sc has a low diagnostic sensitivity of 50-55%2. Also, there is a poor correlation between symptoms and scintigraphic uptake3. We aimed to evaluate the use of Sc for management and follow-up of patients with SpA.

Objectives:

To determine if Sc activity correlates with patients’ complaints (peripheral and axial), inflammatory markers, disease activity scores and whether it influenced physicians’ treatment decisions during the follow-up of the disease.

Methods:

We performed a retrospective review of all patients at our department with SpA with at least one Sc from 2018 to 2020. The following variables were analyzed: demographic data, spondyloarthropathy subtype (ankylosing, enteropathic, psoriatic and undifferentiated SpA), axial or peripheral pain, Sc findings (inflammatory vs no-inflammatory activity), inflammatory markers (sedimentation rate - ESR and C-Reactive Protein - CRP), disease activity scores within one year since the Sc (Ankylosing Spondylitis Disease Activity Score with Erythrocyte Sedimentation Rate - ASDAS-ESR and Bath Ankylosing Spondylitis Disease Activity Index - BASDAI) and treatment at the time of the Sc (non-steroidal anti-inflammatory drugs, conventional synthetic disease-modifying antirheumatic drugs (DMARDs), target synthetic DMARDs and biologic DMARD. Treatment decisions (escalation, de-escalation or maintenance) in accordance to Sc results were also reviewed.

We used the non-parametric Mann-Whitney’s U test for comparisons between ordinal or numerical variables. For correlations between categorical variables we used the Fisher’s exact test and the χ2-independence test. Tests with p < 0.05 were statistically significant.

Results:

Fifty-five patients were reviewed, 75% women; median age of 48 years. Seventy-one percent had ankylosing SpA, 15% enteropathic SpA, 5% psoriatic SpA, 5% undifferentiated and 4% reactive SpA. Sixty-two percent of the patients had both axial and peripheral pain and 24% only axial complaints. Sixty-two percent of the patients had a Sc with no inflammatory changes, 27% had peripheral and 25% had axial inflammatory changes; 15% had evidence of both peripheral and axial inflammation. For ankylosing SpA, the median ASDAS-ESR was 2.89 and according to the BASDAI, 66% had active disease. The median CRP and ESR in patients with inflammatory vs a normal Sc was not different (p=0.02 vs p=0.36, respectively). Similarly, Sc findings were not correlated with patients’ axial (p=0.10) or peripheral pain (p=1.0), neither with the ASDAS-ESR (p=0.29) or the BASDAI (p=0.29). There was no correlation between inflammatory activity in Sc and the decision to maintain, escalate or de-escalate treatment (p=0.65), including the decision to start a biological DMARD (p=1.0) or to switch between biological DMARDs (p=0.19).

Conclusion:

There was no correlation between Sc findings and ESR, patients’ complaints, disease activity or treatment decisions. Considering previous research showing a low diagnostic sensitivity, our findings seem to support a limited role of bone Sc for the follow-up and management of patients with seronegative SpA.

References:

[1]Khmelinskii N, Regel A, Baraliakos X. The Role of Imaging in Diagnosing Axial Spondyloarthritis. Front Med. 2018;5. doi:10.3389/fmed.2018.00106

[2]Poddubnyy D. Classification vs diagnostic criteria: the challenge of diagnosing axial spondyloarthritis. Rheumatology. 2020;59(Supplement_4):iv6-iv17. doi:10.1093/rheumatology/keaa250

[3]Shim JS, Kim C, Ryu JJ, Choi SJ. Correlation between TM joint disease and rheumatic diseases detected on bone scintigraphy and clinical factors. Sci Rep. 2020;10(1):4547. doi:10.1038/s41598-020-60804-x

Disclosure of Interests:

None declared.

Pooled safety analysis of baricitinib in adult patients with atopic dermatitis from 8 randomized clinical trials

BACKGROUND

Janus kinase (JAK) inhibition is a new mode of action in atopic dermatitis (AD); clarity about drug class safety considerations in the context of AD is important. Baricitinib, an oral, reversible, selective inhibitor of JAK1/JAK2, is in late-stage development for adult patients with moderate-to-severe AD.

OBJECTIVE

To report pooled safety data for baricitinib in patients with moderate-to-severe AD in the clinical development program including long-term extension (LTE) studies.

METHODS

This analysis included patient-level safety data from six double-blinded, randomized, placebo-controlled studies (one phase 2 and five phase 3), one double-blinded, randomized, LTE study and one open-label LTE study, reported in three data sets: placebo-controlled, 2-mg - 4-mg extended and All-bari AD. Safety outcomes include treatment-emergent adverse events, adverse events of special interest and abnormal laboratory changes. Proportions of patients with events and incidence rates were calculated.

RESULTS

Data were collected for 2531 patients who were given baricitinib for 2247 patient-years (median duration 310 days). The frequency of serious infections, opportunistic infections and conjunctival disorders was low and similar between treatment groups in the placebo-controlled period. The most common serious infections were eczema herpeticum [n = 11, incidence rates (IR) = 0.5], cellulitis (n = 6, IR = 0.3) and pneumonia (n = 3, IR = 0.1). There were four opportunistic infections (IR = 0.2). No malignancies, gastrointestinal perforations, positively adjudicated cardiovascular events or tuberculosis were reported in the placebo-controlled period in baricitinib-treated patients. Frequency of herpes simplex was higher in the 4-mg group (6.1%) vs. the 2-mg (3.6%) and placebo group (2.7%); IRs in the extended data set (2-mg IR = 9.6; 4-mg IR = 14.5) were lower vs. the placebo-controlled data set (2-mg IR = 12.4; 4-mg IR = 21.3). In the All-bari AD data set, there were two positively adjudicated major adverse cardiovascular events (2-mg group): two venous thrombosis events (4-mg group) and one death.

CONCLUSION

This integrated safety analysis in patients with moderate-to-severe AD confirms the established safety profile of baricitinib.

Antidepressant-like Effect of Baccharis Ilimita in the Forced Swimming Test in Mice

The aim of the present work was to investigate if flowers extract (FE) and leaf extract (LE) of Baccharis ilimita (Asteraceae) induced antidepressant-like effect. Previous phytochemical investigations have shown the presence of structurally and biogenetically diverse secondary metabolites in this gene, such as flavonoids, diterpenes and triterpenes. Male Swiss mice were injected with FE and LE (12.5; 25.0 or 50.0 mg/kg; i.p.) or saline (S) and after 30 min, they were tested in the forced swimming test (FST). The results showed that FE and LE (50 mg/kg) decreased the duration of immobility time in comparison to the control group (S: 114.8s ± 10.23; FE50: 47.52s ± 9.45; LE50: 53.36s ± 10.38). However, the 12.5 and 25.0 mg/kg doses had no effect on the immobility time in comparison to the control group. The FE and LE did not produce any change in ambulation in mice when tested in an open field. The imipramine (IMP; 15.0 mg/kg i.p.) was used as the positive control. Our results suggested that FE and LE of Baccharis ilimita presents antidepressant-like effect in mice. Such results suggest that the antidepressant-like effect may be attributed at lest partially the flavonoids or the interaction of the active(s) principle(s) present in this plant.

Descritores:

Baccharis ilimita. Forced swimming test. Depression. Mice.

The Practical Work of Ensuring Effective Use of Serious Games in a Rehabilitation Clinic: A Qualitative Study

Background

Many rehabilitation clinics adopted serious games to support their physiotherapy sessions. Serious games can monitor and provide feedback on exercises and are expected to improve therapy and help professionals deal with more patients. However, there is little understanding of the impacts of serious games on the actual work of physiotherapists.

Objective

This study aimed to understand the impact of an electromyography-based serious game on the practical work of physiotherapists.

Methods

This study used observation sessions in an outpatient rehabilitation clinic that recently started using a serious game based on electromyography sensors. In total, 44 observation sessions were performed, involving 3 physiotherapists and 22 patients. Observation sessions were documented by audio recordings or fieldnotes and were analyzed for themes using thematic analysis.

Results

The findings of this study showed that physiotherapists played an important role in enabling the serious game to work. Physiotherapists briefed patients, calibrated the system, prescribed exercises, and supported patients while they played the serious game, all of which amounted to relevant labor.

Conclusions

The results of this work challenge the idea that serious games reduce the work of physiotherapists and call for an overall analysis of the different impacts a serious game can have. Adopting a serious game that creates more work can be entirely acceptable, provided the clinical outcomes or other advantages enabled by the serious game are strong; however, those impacts will have to be assessed on a case-by-case basis. Moreover, this work motivates the technology development community to better investigate physiotherapists and their context, offering implications for technology design.

Translating research on quality improvement in five European countries into a reflective guide for hospital leaders: the 'QUASER Hospital Guide'

OBJECTIVE

The aim was to translate the findings of the QUASER study into a reflective, dialogic guide to help senior hospital leaders develop an organization wide QI strategy.

DESIGN

The QUASER study involved in depth ethnographic research into QI work and practices in two hospitals in each of five European countries. Three translational stakeholder workshops were held to review research findings and advise on the design of the Guide. An extended iterative process involving researchers from each participant country was then used to populate the Guide.

SETTING

The research was carried out in two hospitals in each of five European countries.

PARTICIPANTS

In total, 389 interviews with healthcare practitioners and 803 hours of observations.

INTERVENTION

None.

MAIN OUTCOME MEASURE

None.

RESULTS

The QUASER Hospital Guide was designed for leadership teams to diagnose their organization's strengths and weaknesses in the eight QI challenges. The Guide supports organizational dialogue about QI challenges, enables leaders to share perspectives, and helps teams to develop solutions to their situated problems. The Guide includes extensive examples of QI strategies drawn from the data and is published online and on paper.

CONCLUSIONS

The QUASER Hospital Guide is empirically based, draws on a dialogical approach to Organizational Development and complexity science and can facilitate hospital leadership teams to identify the best solutions for their organization.

Canine ovarian gonadoblastoma with dysgerminoma overgrowth: a case study and literature review

BACKGROUND

Gonadoblastoma (GB) is a rare mixed germ cell-sex cord-stromal tumour, first described in humans, commonly found in dysgenetic gonads of intersex patients that have a Y chromosome. However, this entity in not recognized in the WHO classification of tumours of genital system of domestic animals. Herein, we describe a case of ovarian gonadoblastoma with proliferation of dysgerminoma and sex cord-stromal tumour components, in a phenotypically and cytogenetically normal bitch.

CASE PRESENTATION

A 17-year-old cross-breed bitch had a firm, grey-white multinodular mass in the left ovary. The tumour was submitted to histopathological examination and Y chromosome detected through karyotype analysis and PCR studies. Microscopically, the ovary was almost replaced by an irregular neoplasm composed of three distinct, intermixed elements: dysgerminoma, mixed germ cell-sex cord-stromal tumour resembling human GB and a proliferative sex cord-stromal tumour component. The germ cells of gonadoblastoma and dysgerminoma components were immunoreactive for c-KIT. Sex cord-stromal cells of gonadoblastoma were immunoreactive for α-inhibin. The sex cord-stromal tumour was immunoreactive for AE1/AE3, occasionally for α-inhibin and negative for epithelial membrane antigen (EMA). The karyotype was 78, XX and PCR analysis confirmed the absence of the Y chromosome.

CONCLUSION

Based on these findings, a diagnosis of gonadoblastoma with proliferation of dysgerminoma and sex cord-stromal tumour was made. This is the first case of ovarian gonadoblastoma in a female dog.

Incorporation of Cró thermal water in a dermocosmetic formulation: cytotoxicity effects, characterization and stability studies and efficacy evaluation

OBJECTIVE

Development of cosmetic formulations to provide a controlled release of hydrophilic active compounds from mineral medicinal waters constitutes an attractive challenge. The objective of this study was the development and the characterization of a dermocosmetic gel formulation with Cró thermal water, from Beira Interior of Portugal, as a major functional ingredient.

METHODS

Concentrations of mineral chemical elements of Cró thermal water were previously determined by inductively coupled plasma-optical emission spectrometry or mass spectrometry and cytotoxicity assays using thermal water were carried out on normal human dermal fibroblasts (NHDF) cells. Then, the Cró thermal water was included (more than 90%) in a developed gel formulation that was characterized through rheological and texture analysis and submitted to stability assays during 30 days. The effects on the skin volunteers, namely skin pH, the degree of hydration, transepidermal water loss and skin relief, were evaluated through non-invasive biometric techniques. A gel formulation including purified water was used as a control.

RESULTS

Cró thermal water is rich on several chemical elements in particular sodium, silica, potassium and calcium besides some trace elements, with important functions for the skin. NHDF cells adhered and proliferated in the presence of thermal water confirming the biocompatibility of the major component of the gel formulation. The developed gel formulation based on thermal water resulted in an improvement of textural parameters, comparing with the purified water-based one. Significant improvements in the cutaneous biometric parameters (degree of hydration, transepidermal water loss and skin relief) of volunteers were also registered for the gel formulation containing thermal water.

CONCLUSION

This study demonstrated for the first time the potential benefits of Cró thermal water in a gel formulation to be used in cosmetic and dermatological applications.

Bioactivity of Acanthus mollis - Contribution of benzoxazinoids and phenylpropanoids

ETHNOPHARMACOLOGICAL RELEVANCE

Acanthus mollis is a plant native to the Mediterranean region, traditionally used as diuretic, anti-inflammatory and soothing of the mucous membranes of the digestive and urinary tract and externally as healing of wounds and burns, also demonstrating analgesic and anti-inflammatory activities. However, studies focused on its phytochemical composition as well as scientific proof of Acanthus mollis efficacy are scarce.

AIM OF THE STUDY

The proposed work aims to perform a phytochemical characterization and evaluation of the therapeutic potential of Acanthus mollis, based on biological properties that support its traditional uses.

MATERIAL AND METHODS

In this study, an 96% ethanol extract from Acanthus mollis leaves was obtained and its phytochemical composition evaluated using High Performance Liquid Chromatography with Photodiode Array Detector coupled to Electrospray Ionization Mass Spectrometry (HPLC-PDA-ESI/MSⁿ). The chemical structure of the compound isolated was elucidated using ¹H and ¹³C Nuclear Magnetic Resonance (NMR), ¹H-correlation spectroscopy (¹H-COSY), heteronuclear single quantum correlation (HSQC) and heteronuclear multiple-bond correlation (HMBC). The quantification of the constituents was performed using two external standards (2,4-dihydroxy-1,4-benzoxazin-3-one and verbascoside). The antioxidant activity was determined by the 2,2-diphenyl-1-pycrylhydrazyl (DPPH) assay. Anti-inflammatory activity was determined measuring the inhibition of nitric oxide production by RAW 264.7 macrophages stimulated with the TLR4 agonist lipopolysaccharide (LPS) and through lipoxygenase (LOX) inhibition assay. The cytotoxicity was screened on two lines (RAW 264.7 and HaCaT) using the resazurin assay.

RESULTS

Compounds such as verbascoside and its derivatives, as well as benzoxazinoids were found as the main constituents. A percentage of 5.58% was verified for the 2,4-dihydroxy-1,4-benzoxazin-3-one (DIBOA) derivatives. DIBOA was the main compound of the extract. Significant concentrations were also found for phenylpropanoids, which constitute about 4.39% of the total compounds identified. This extract showed antioxidant capacity against DPPH (IC₅₀ = 40.00 ± 1.59 μg/mL) and superoxide anion (IC₅₀ = 29.42 ± 1.99 μg/mL). It also evidenced anti-inflammatory potential in RAW 264.7 macrophages, presenting capacity for nitric oxide reduction (IC₅₀ = 28.01 μg/mL). Moreover, in vitro studies have shown that this extract was able to inhibit the lipoxygenase, with an IC₅₀ of 104.39 ± 4.95 µg/mL. Importantly, all effective concentrations were devoid of cytotoxicity in keratinocytes, thus highlighting the safety of the extract for the treatment of skin inflammatory related diseases. Concerning macrophages it was also possible to disclose concentrations showing anti-inflammatory activity and without cytotoxicity (up to 30 µg/mL). The benzoxazinoid DIBOA demonstrated a considerable anti-inflammatory activity suggesting its important contribution to this activity.

CONCLUSIONS

These results corroborate the anti-inflammatory properties traditionally attributed to this plant. Among the compounds identified in this study, benzoxazinoids exhibited a significant anti-inflammatory activity that was never previously described. Ethanol seems to be a good option for the extraction of these bioactive compounds, since relevant antioxidant/anti-radical and anti-inflammatory activities were found for this extract.

Equine ocular mast cell tumor: histopathological and immunohistochemical description

This report describes an ocular mast cell tumor in a 13-year-old female sport horse. Clinical examination revealed a solitary firm mass located in the ocular mucosa, protruding from behind the left lower eyelid. The lesion was surgically removed and submitted to histopathology. Microscopically, the mass was composed of sheets of well-differentiated neoplastic round cells circumscribed by delicate connective tissue. Positive Giemsa and Toluidine Blue staining confirmed the presence of cytoplasmic granules. Neoplastic cells showed strong membranous and mild diffuse cytoplasmic immunoreactivity for c-KIT and a low KI-67 proliferative index. Based on these findings, a diagnosis of ocular mast cell tumor was made. Six months after surgical removal, no evidence of ocular lesion recurrence was detected.

Using institutional theory to analyse hospital responses to external demands for finance and quality in five European countries

Objectives

Given the impact of the global economic crisis, delivering better health care with limited finance grows more challenging. Through the lens of institutional theory, this paper explores pressures experienced by hospital leaders to improve quality and constrain spending, focusing on how they respond to these often competing demands.

Methods

An in-depth, multilevel analysis of health care quality policies and practices in five European countries including longitudinal case studies in a purposive sample of ten hospitals.

Results

How hospitals responded to the financial and quality challenges was dependent upon three factors: the coherence of demands from external institutions; managerial competence to align external demands with an overall quality improvement strategy, and managerial stability. Hospital leaders used diverse strategies and practices to manage conflicting external pressures.

Conclusions

The development of hospital leaders’ skills in translating external requirements into implementation plans with internal support is a complex, but crucial, task, if quality is to remain a priority during times of austerity. Increasing quality improvement skills within a hospital, developing a culture where quality improvement becomes embedded and linking cost reduction measures to improving care are all required.

Adenosine A(2A) receptors are necessary and sufficient to trigger memory impairment in adult mice

BACKGROUND AND PURPOSE

Caffeine (a non-selective adenosine receptor antagonist) prevents memory deficits in aging and Alzheimer's disease, an effect mimicked by adenosine A2 A receptor, but not A1 receptor, antagonists. Hence, we investigated the effects of adenosine receptor agonists and antagonists on memory performance and scopolamine-induced memory impairment in mice.

EXPERIMENTAL APPROACH

We determined whether A2 A receptors are necessary for the emergence of memory impairments induced by scopolamine and whether A2 A receptor activation triggers memory deficits in naïve mice, using three tests to assess short-term memory, namely the object recognition task, inhibitory avoidance and modified Y-maze.

KEY RESULTS

Scopolamine (1.0 mg·kg(-1) , i.p.) impaired short-term memory performance in all three tests and this scopolamine-induced amnesia was prevented by the A2 A receptor antagonist (SCH 58261, 0.1-1.0 mg·kg(-1) , i.p.) and by the A1 receptor antagonist (DPCPX, 0.2-5.0 mg·kg(-1) , i.p.), except in the modified Y-maze where only SCH58261 was effective. Both antagonists were devoid of effects on memory or locomotion in naïve rats. Notably, the activation of A2 A receptors with CGS 21680 (0.1-0.5 mg·kg(-1) , i.p.) before the training session was sufficient to trigger memory impairment in the three tests in naïve mice, and this effect was prevented by SCH 58261 (1.0 mg·kg(-1) , i.p.). Furthermore, i.c.v. administration of CGS 21680 (50 nmol) also impaired recognition memory in the object recognition task.

CONCLUSIONS AND IMPLICATIONS

These results show that A2 A receptors are necessary and sufficient to trigger memory impairment and further suggest that A1 receptors might also be selectively engaged to control the cholinergic-driven memory impairment.

[Patient treated with sub-mental intubation for maxillofacial trauma]

Maxillo-facial traumas are frequent and most often occur in young patients. Naso-tracheal or orotracheal intubation may be contraindicated in case of combined occlusal fracture and nasal or ethmoido-nasal fracture. This study was carried out a clinical case of a patient treated at the Lille University Hospital for a maxillofacial trauma associating fracture of nose and maxilla. The purpose was to assess the reliability of submental intubation as an alternative to tracheotomy. Submental intubation is a reliable single and safe technique allowing an one-stage surgical treatment in case of complex association of fractures without using tracheotomy. Its use should be implemented on a larger scale.

Talking about quality: exploring how 'quality' is conceptualized in European hospitals and healthcare systems

BACKGROUND

Conceptualization of quality of care - in terms of what individuals, groups and organizations include in their meaning of quality, is an unexplored research area. It is important to understand how quality is conceptualised as a means to successfully implement improvement efforts and bridge potential disconnect in language about quality between system levels, professions, and clinical services. The aim is therefore to explore and compare conceptualization of quality among national bodies (macro level), senior hospital managers (meso level), and professional groups within clinical micro systems (micro level) in a cross-national study.

METHODS

This cross-national multi-level case study combines analysis of national policy documents and regulations at the macro level with semi-structured interviews (383) and non-participant observation (803 hours) of key meetings and shadowing of staff at the meso and micro levels in ten purposively sampled European hospitals (England, the Netherlands, Portugal, Sweden, and Norway). Fieldwork at the meso and micro levels was undertaken over a 12-month period (2011-2012) and different types of micro systems were included (maternity, oncology, orthopaedics, elderly care, intensive care, and geriatrics).

RESULTS

The three quality dimensions clinical effectiveness, patient safety, and patient experience were incorporated in macro level policies in all countries. Senior hospital managers adopted a similar conceptualization, but also included efficiency and costs in their conceptualization of quality. 'Quality' in the forms of measuring indicators and performance management were dominant among senior hospital managers (with clinical and non-clinical background). The differential emphasis on the three quality dimensions was strongly linked to professional roles, personal ideas, and beliefs at the micro level. Clinical effectiveness was dominant among physicians (evidence-based approach), while patient experience was dominant among nurses (patient-centered care, enough time to talk with patients). Conceptualization varied between micro systems depending on the type of services provided.

CONCLUSION

The quality conceptualization differed across system levels (macro-meso-micro), among professional groups (nurses, doctors, managers), and between the studied micro systems in our ten sampled European hospitals. This entails a managerial alignment challenge translating macro level quality definitions into different local contexts.

CREB critically regulates action potential shape and duration in the adult mouse ventricle

The cAMP response element binding protein (CREB) belongs to the CREB/cAMP response element binding modulator/activating transcription factor 1 family of cAMP-dependent transcription factors mediating a regulation of gene transcription in response to cAMP. Chronic stimulation of β-adrenergic receptors and the cAMP-dependent signal transduction pathway by elevated plasma catecholamines play a central role in the pathogenesis of heart failure. Ion channel remodeling, particularly a decreased transient outward current (I(to)), and subsequent action potential (AP) prolongation are hallmarks of the failing heart. Here, we studied the role of CREB for ion channel regulation in mice with a cardiomyocyte-specific knockout of CREB (CREB KO). APs of CREB KO cardiomyocytes were prolonged with increased AP duration at 50 and 70% repolarization and accompanied by a by 51% reduction of I(to) peak amplitude as detected in voltage-clamp measurements. We observed a 29% reduction of Kcnd2/Kv4.2 mRNA in CREB KO cardiomyocytes mice while the other I(to)-related channel subunits Kv4.3 and KChIP2 were not different between groups. Accordingly, Kv4.2 protein was reduced by 37% in CREB KO. However, we were not able to detect a direct regulation of Kv4.2 by CREB. The I(to)-dependent AP prolongation went along with an increase of I(Na) and a decrease of I(Ca,L) associated with an upregulation of Scn8a/Nav1.6 and downregulation of Cacna1c/Cav1.2 mRNA in CREB KO cardiomyocytes. Our results from mice with cardiomyocyte-specific inactivation of CREB definitively indicate that CREB critically regulates the AP shape and duration in the mouse ventricle, which might have an impact on ion channel remodeling in situations of altered cAMP-dependent signaling like heart failure.

Dance! Don't Fall - preventing falls and promoting exercise at home

Falling is a serious danger to older adults that is usually only addressed after a person has fallen, when doctors administer clinical tests to determine the patient's risk of falling again. Having the technological capability of performing fall risk assessment tests with a smartphone, the authors set out to design a mobile application that would enable users to monitor their risk themselves and consequently prevent falls from occurring. The authors conducted a literature review and two observation sessions before beginning the iterative design process that resulted in the Dance! Don't Fall (DDF) game, a mobile application that enables users to both monitor their fall risk and actively reduce it through fun and easy exercise.

A longitudinal, multi-level comparative study of quality and safety in European hospitals: the QUASER study protocol

BACKGROUND

although there is a wealth of information available about quality improvement tools and techniques in healthcare there is little understanding about overcoming the challenges of day-to-day implementation in complex organisations like hospitals. The 'Quality and Safety in Europe by Research' (QUASER) study will investigate how hospitals implement, spread and sustain quality improvement, including the difficulties they face and how they overcome them. The overall aim of the study is to explore relationships between the organisational and cultural characteristics of hospitals and how these impact on the quality of health care; the findings will be designed to help policy makers, payers and hospital managers understand the factors and processes that enable hospitals in Europe to achieve-and sustain-high quality services for their patients.

METHODS/DESIGN

in-depth multi-level (macro, meso and micro-system) analysis of healthcare quality policies and practices in 5 European countries, including longitudinal case studies in a purposive sample of 10 hospitals. The project design has three major features: • a working definition of quality comprising three components: clinical effectiveness, patient safety and patient experience • a conceptualisation of quality as a human, social, technical and organisational accomplishment • an emphasis on translational research that is evidence-based and seeks to provide strategic and practical guidance for hospital practitioners and health care policy makers in the European Union. Throughout the study we will adopt a mixed methods approach, including qualitative (in-depth, narrative-based, ethnographic case studies using interviews, and direct non-participant observation of organisational processes) and quantitative research (secondary analysis of safety and quality data, for example: adverse incident reporting; patient complaints and claims).

DISCUSSION

the protocol is based on the premise that future research, policy and practice need to address the sociology of improvement in equal measure to the science and technique of improvement, or at least expand the discipline of improvement to include these critical organisational and cultural processes. We define the 'organisational and cultural characteristics associated with better quality of care' in a broad sense that encompasses all the features of a hospital that might be hypothesised to impact upon clinical effectiveness, patient safety and/or patient experience.

Human papillomavirus as a risk factor in oral carcinogenesis: a study using in situ hybridization with signal amplification

INTRODUCTION

It is still controversial whether human papillomavirus (HPV) can be considered a risk factor in oral carcinogenesis. The aim of this study was to detect HPV DNA in 50 cases diagnosed as oral leukoplakias, with different degrees of epithelial dysplasia, and as oral squamous cell carcinomas, using in situ hybridization with signal amplification (CSA-ISH).

METHODS

HPV DNA was assessed in paraffin sections using CSA-ISH with a wide-spectrum biotinylated DNA probe. In HPV-positive cases, genotyping with specific probes to HPV types 6/11, 16/18 and 31/33 was performed.

RESULTS

The overall prevalence of HPV infection was 24%, markedly higher than that found in the control group. Results showed a discrete proportional relationship in the indices found in leukoplakia with no dysplasia, leukoplakia with dysplasia, and squamous cell carcinoma, but this was not statistically significant. When separating the group of leukoplakia by degrees of dysplasia, this relation of proportion was not observed. In genotyping, HPV types 16/18 were the most prevalent, and types 6/11 were only found in groups of mild or no dysplasia.

CONCLUSION

The results suggest that HPV is not likely to play a role in the progression of malignant transformation in oral lesions. Nevertheless, the increased prevalence of HPV infection compared to normal oral mucosa and the fact that high-risk HPV types were the most frequently identified do not allow the exclusion of HPV as a risk factor in oral carcinogenesis.

Direct analysis of human blood (mothers and newborns) by energy dispersive X-ray fluorescence

This work is an application of energy dispersive X-ray fluorescence (EDXRF) as analytical technique for trace element determination in human tissues. Potassium (K), calcium (Ca), iron (Fe), copper (Cu), zinc (Zn), bromine (Br), rubidium (Rb) and lead (Pb) were determined directly in blood samples from 66 mothers at delivery after full-term pregnancies. The corresponding 66 cord-blood samples of the newborns were also analysed, in order to find element correlations between maternal and newborn blood at birth. The studied samples were obtained from mothers aged between 15 and 39 years old, the gestational age being between 35 and 41 weeks and the newborns' weight between 2.310 and 4.310 kg. Samples were lyophilised and analysed without any chemical treatment. Very low levels of Pb were found both in maternal and fetal cord blood samples. Cu values ranged from 3 to 13 microg g-1, both for mothers and children. A correlation between Cu and Fe concentrations in maternal and fetal cord blood was found. Zn is considered as one of the key elements in newborn health. Concentrations between 10 and 40 microg g-1 were measured. A positive correlation between Br levels in mothers and children was observed. Positive correlations for mothers were observed between Zn and Rb as well as K and Fe. The corresponding correlations in fetal cord blood samples were not observed, however positive correlations were found between Ca and K; Cu and Fe. The mean concentrations for each element were similar in maternal and in fetal cord blood, except for Cu and Zn, being higher in maternal samples. No correlations between element concentrations and pathologies of the mothers were observed.

Dermatomycoses caused by Nattrassia mangiferae in São Paulo, Brazil

Nattrassia mangiferae formerly known as Hendersonula toruloidea, is a phaeoid coelomycete described by Nattrass in 1933. We report five cases of N. mangiferae infections in São Paulo, Brazil. This fungus was isolated from interdigital lesions on the feet in one patient, toenails in three cases and fingernails in the other one. The infections were initially considered to be caused by a dermatophyte. Although there are only a few cases described in the medical literature, the five cases reported suggest that N. mangiferae should be taken into consideration in the differential diagnosis of tinea pedis infections.

Domino liver transplant: influence on the number of donors and transplant coordination

The shortage of organs forces coordinators to seek new forms of generating organs for transplantation of the increasing numbers of patients on waiting lists. A recent technique called sequential transplant or domino liver transplant (DLT) allows the transplantation of a patient with chronic liver disease by implantation of a full-size liver derived from a patient with familial amyloidosis polyneuropathy (FAP) who receives a cadaveric graft. Therefore, it is possible to transplant two patients with only one cadaveric liver. The present report illustrates the use of this technique for the first time in our country, thereby increasing the number of hepatic transplants by 25%.

Trace elements determination by energy dispersive X-ray fluorescence (EDXRF) in human placenta and membrane: a comparative study

This work is an application of energy dispersive X-ray fluorescence (EDXRF) as an analytical technique for trace elemental determination in human membrane and placenta and elemental concentrations correlations in both tissues. Whole samples were collected during the delivery from healthy mothers and full-term pregnancies. The age of the mother was between 25 and 40 years old, and the weight of the infants ranged from 2.56 to 4.05 kg. Samples were lyophilised and analysed without any chemical treatment. No significant differences in elemental content of placenta and membrane samples were observed except for Ca. Very low levels of Se, As and Pb were observed in all the analysed samples. Zn, considered as one of the key elements in newborn health, was not significantly different in the analysed samples, all of which originated from healthy mothers and healthy babies. The obtained values agree with the literature except for Ca, which is much higher in the studied samples.

[Evaluation of analgesia after cesarean section]

OBJECTIVE

The aim of this study was to evaluate the efficacy of post-caesarean analgesia comparing three techniques most frequently used.

PATIENTS AND METHODS

For three months all pregnant women submitted to elective or urgent caesarean section, under general or regional anaesthesia, were evaluate with a total of 129 parturient. These parturient were divided into three groups with different techniques of postoperative analgesia: Group 1 (n = 26) received intravenous pethidine and paracetamol per os, group 2 (n = 58) received epidural morphine and group 3 (n = 45) epidural morphine and intravenous propacetamol. Pain was assessed at rest and during mobilisation using a scale of 0-without pain, 1-mild pain, 2-moderate pain and 3-severe pain. Overall satisfaction was assessed with a verbal qualitative scale of very good, good, sufficient and bad. Side effects were analysed.

RESULTS

The records of pain at rest and during mobilisation were significantly lower with epidural analgesia compared with intravenous pethidine. There were no significant differences between groups 2 and 3. Similar results were observed in the degree of satisfaction. For 50% of parturient of epidural analgesia (groups 2 and 3) and only 4% of intravenous pethidine (group 1) the analgesic technique was very good. Propacetamol and epidural morphine (group 3) had better pain scores (very good and good) when compared with morphine alone (group 2) but there were no significant differences. Epidural morphine was associated with more pruritus.

CONCLUSION

From this study we are able to conclude that epidural morphine offers a good quality of analgesia with better satisfaction and minimal side effects.

Sensory organ generation in the chicken inner ear: contributions of bone morphogenetic protein 4, serrate1, and lunatic fringe

The chicken inner ear is a remarkably complex structure consisting of eight morphologically distinct sensory organs. Unraveling how these sensory organs are specified during development is key to understanding how such a complex structure is generated. Previously, we have shown that each sensory organ in the chicken inner ear arises independently in the rudimentary otocyst based on Bone morphogenetic protein 4 (Bmp4) expression. Here, we compare the expression of Bmp4 with two other putative sensory organ markers, Lunatic Fringe (L-fng) and chicken Serrate1 (Ser1), both of which are components of the Notch signaling pathway. L-fng and Ser1 expression domains were asymmetrically distributed in the otic cup. At this early stage, expression of L-fng is similar to Delta1 (Dl1), in an anteroventral domain apparently corresponding to the neurogenic region, while Ser1 is expressed at both the anterior and posterior poles. By the otocyst stage, the expression of both L-fng and Ser1 largely coincided in the medial region. All presumptive sensory organs, as identified by Bmp4 expression, arose within the broad L-fng- and Ser1-positive domain, indicating the existence of a sensory-competent region in the rudimentary otocyst. In addition, there is a qualitative difference in the levels of expression between L-fng and Ser1 such that L-fng expression was stronger in the ventral anterior, whereas Ser1 was stronger in the dorsal posterior region of this broad domain. This early difference in expression may presage the differences among sensory organs as they arise from this sensory competent zone.

An audit of European training in obstetrics and gynaecology

During 1997, The European Network of Trainees in Obstetrics and Gynaecology (ENTOG) circulated a questionnaire to audit training in Europe. Results describe number and gender in each country, access to training, duration of training, tutor/tutee scheme, logbooks, minimum curriculum, assessment, criteria for accreditation, training abroad, final examination, hospital inspection, subspecialty, academic training, and career progression. Quality of life is tried to address with questions relating to salary, working hours, maternity leave, annual leave and study leave. EBCOG has drawn up recommendations to try and achieve a standardisation of quality of training whilst fully understanding that complete standardisation of training is not a realistic possibility due to social, cultural and ethical differences. A repeat audit is planned after 3 years to close the feedback loop.

Randomized comparison between intravaginal misoprostol and dinoprostone for cervical ripening and induction of labor

OBJECTIVE

We sought to evaluate the efficacy and safety of intravaginal misoprostol and dinoprostone for labor induction.

STUDY DESIGN

One hundred eighty-nine women with singleton term pregnancies and unfavorable cervices were randomly assigned to receive intravaginal misoprostol or dinoprostone. The outcome variables were change in Bishop score, time from application to active phase of labor and delivery, fetal and maternal morbidity, and the incidence of cesarean deliveries.

RESULTS

The interval from application of the initial dose to the beginning of the active phase of labor was 9.8 +/- 5.8 and 14.2 +/- 10.2 hours (P <.01), and the interval from initial dose to delivery was 15.3 +/- 9.8 and 19.1 +/- 13.2 hours (P =.027) for the misoprostol and dinoprostone groups, respectively. There were no significant differences in Bishop score change, cesarean delivery rate, and the incidence of tachysystole, hypersystole, and hyperstimulation. No maternal and neonatal adverse effects were noted.

CONCLUSION

Intravaginal misoprostol is more effective than intravaginal dinoprostone for labor induction in low-risk patients at term with unfavorable cervices.

Fever of undetermined origin in patients with the acquired immunodeficiency syndrome in Brazil: report on 55 cases

The medical records of patients with AIDS admitted to a general hospital in Brazil from 1989 to 1997 were reviewed retrospectively with the aim at defining the frequency and etiology of fever of undetermined origin (FUO) in HIV-infected patients of a tropical country and to evaluate the usefulness of the main diagnostic procedures. 188 (58.4%) out of 322 patients reported fever at admission to hospital and 55 (17.1%) had FUO. Those with FUO had a mean CD4+ cell count of 98/ml. A cause of fever was identified for 45 patients (81.8%). Tuberculosis (32.7%), Pneumocystis carinii pneumonia (10.9%), and Mycobacterium avium complex (9.1%) were the most frequent diagnoses. Other infectious diseases are also of note, such as cryptococcal meningitis (5.5%), sinusitis (3.6%), Salmonella-S. mansoni association (3.6%), disseminated histoplasmosis (3.6%), neurosyphilis (1.8%), and isosporiasis (1.8%). Four patients had non-Hodgkin's lymphoma (7.3%). We conclude that an initial aggressive diagnostic approach should be always considered because biopsies (lymph node, liver and bone marrow) produced the highest yield in the diagnosis of FUO and the majority of the diagnosed diseases are treatable. The association of diseases is common and have contributed to delay the final diagnosis of FUO in most cases. In our study area the routine request of hemocultures for Salmonella infection and the investigation of cryptococcal antigen in the serum should be considered.

Induction of labor with intravaginal administration of misoprostol

OBJECTIVE

The purpose of this study was to evaluate the efficacy and safety of intravaginal misoprostol for labor induction.

METHODS

110 singleton term pregnancies with or without rupture of membranes were enrolled. Fractionated doses of misoprostol were applied (50-100 microg), every 6 h until a maximum of three doses or beginning of labor.

RESULTS

The average interval (+/- S.D.) from vaginal application to the beginning of active labor and to delivery were, respectively, 9.5 +/- 5.7 h and 14.8 +/- 9.5 h. Failed labor induction was observed in two cases (2%). Cesarean section rate was 14%. The incidence of tachysystole was 18% and hypersystole 4%, but these situations were associated with abnormal fetal heart rate pattern (hyperstimulation) in only 3%. No maternal side effects and neonatal adverse effects were noted.

CONCLUSIONS

Intravaginal misoprostol administration with low doses is an effective and safe method for labor induction in term pregnancies, with or without rupture of membranes.

Second primitive malignant tumour in patients with gynaecological cancer

OBJECTIVE

The purpose of this study was to characterise the occurrence of multiple primitive gynaecological malignant neoplasias, restricted to the genital tract and breast or associated with other organs, and to detect which types of association are most frequent concerning location, histology and staging.

POPULATION AND METHODS

The records of patients with gynaecological cancer at the Portuguese Institute of Oncology--Lisbon Centre, between 1986 and 1993 were used in this study.

RESULTS

Of the 10,746 women with gynaecological cancer, 91 (0.8%) were found to have a second primitive malignant neoplasia. Of these neoplasias, 64% (58 cases) were also located at a gynaecological site. The most frequent associations were endometrium/breast (13 cases), bilateral breast (12 cases) and ovary/endometrium (11 cases). The majority of primitive multiple gynaecological tumours were synchronous. Regarding gynaecological cancer and non-gynaecological cancer, in 28 cases (31%), the most common non-gynaecological location was the colon/rectum. Five patients had triple tumours.

CONCLUSION

Although these situations are relatively rare the possibility of multiple primitive cancers should be considered with the presence of malignant tumours in two or more organs. This distinction between multiple primitive or metastatic cancers could be important for treatment as well as prognosis.

Aeroallergens and work-related respiratory symptoms among office workers

OBJECTIVE

We sought to determine the association between office workers' respiratory tract symptoms and immediate skin test reactions with exposure to fungal and house dust mite aeroallergens at their work sites.

METHODS

An initial prevalence survey was conducted among 1102 full-time workers in six mechanically ventilated, air-conditioned, nonindustrial buildings in downtown Montreal. Detailed environmental measures of 214 subjects' work sites were determined. Half of the workers reported frequent work-related respiratory tract symptoms on the initial survey. Participants simultaneously underwent allergy skin prick testing and completed a second self-administered questionnaire.

RESULTS

Contaminant levels were low and not associated with symptoms in the great majority of workers. For approximately 17% of workers, symptoms were associated with exposure to total concentrations of house dust mite allergen greater than 1 microg/gm floor dust (odds ratio [OR], 5.0; 95% confidence interval [CI], 1.3, 19.5]) or to detectable airborne Alternaria allergens in their offices (OR, 3.3; 95% CI, 1.2, 9.4 and in the ventilation system supplying their offices (OR, 3.9; 95% CI, 1.6, 9.6). Workers with positive skin test reactions to Alternaria extract were exposed at their work site to airborne Alternaria allergen (OR, 4.4; 95% CI, 1.4, 14.5) and cited significantly more respiratory symptoms on both questionnaires. Detection of airborne Alternaria allergen at work sites was significantly associated with detection in the ventilation system (OR, 4.0; 95% CI, 1.4,10.9); this was in turn associated with lower efficiency filters.

CONCLUSIONS

Potentially avoidable exposure to aeroallergens accounted for symptoms in a small subgroup of office workers with frequent work-related respiratory tract symptoms.

The expression domain of two related homeobox genes defines a compartment in the chicken inner ear that may be involved in semicircular canal formation

Homeobox-containing genes encode a class of proteins that control patterning in developing systems, in some cases by acting as selector genes that define compartment identity. In an effort to demonstrate a similar role for such genes during ear development in the chicken, we present a detailed expression study of two related homeobox-containing genes, SOHo-1 and GH6, using in situ hybridization. At otocyst stages the two genes define a broad lateral domain of expression, which may represent a developmental compartment. Three-dimensional computer reconstructions of SOHo-1 expression at these and later stages revealed that the lateral domain becomes progressively restricted to the three semicircular canals. Thus, SOHo-1 and GH6 are among a small group of markers for a specific structural component of the inner ear. The gene expression domain initially includes the sensory regions of the semicircular canals, known as the cristae ampullaris, but none of the other four sensory organs which were recognizable by BMP4 expression during early morphogenesis (stages 19-24). Significantly, two of the sensory organs (the superior and posterior cristae) were found at the limits, or boundaries, of the SOHo-1/GH6 expression domain, suggesting that compartment boundaries may be involved in specifying sensory organ location as well as identity. Maintained expression at the boundaries may aid in specifying the location of canal outgrowth. These concepts are presented as a formal model which emphasizes that patterning information could be provided at the boundaries of gene expression domains in the inner ear.