Landscape of Baseline and Acquired Genomic Alterations in Circulating Tumor DNA with Abemaciclib Alone or with Endocrine Therapy in Advanced Breast Cancer

PURPOSE

To identify potential predictors of response and resistance mechanisms in patients with hormone receptor-positive (HR+), HER2-negative (HER2-) advanced breast cancer (ABC) treated with the cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitor abemaciclib ± endocrine therapy (ET), baseline and acquired genomic alterations in circulating tumor DNA (ctDNA) were analyzed and associated with clinical outcomes.

EXPERIMENTAL DESIGN

MONARCH 3: postmenopausal women with HR+, HER2- ABC and no prior systemic therapy in the advanced setting were randomly assigned to abemaciclib or placebo plus nonsteroidal aromatase inhibitor (NSAI). nextMONARCH: women with HR+, HER2- metastatic breast cancer that progressed on/after prior ET and chemotherapy were randomly assigned to abemaciclib alone (two doses) or plus tamoxifen. Baseline and end-of-treatment plasma samples from patients in MONARCH 3 and nextMONARCH (monotherapy arms) were analyzed to identify somatic genomic alterations. Association between genomic alterations and median progression-free survival (mPFS) was assessed.

RESULTS

Most patients had ≥1 genomic alteration detected in baseline ctDNA. In MONARCH 3, abemaciclib+NSAI was associated with improved mPFS versus placebo+NSAI, regardless of baseline alterations. ESR1 alterations were less frequently acquired in the abemaciclib+NSAI arm than placebo+NSAI. Acquired alterations potentially associated with resistance to abemaciclib ± NSAI included RB1 and MYC.

CONCLUSIONS

In MONARCH 3, certain baseline ctDNA genomic alterations were prognostic for ET but not predictive of abemaciclib response. Further studies are warranted to assess whether ctDNA alterations acquired during abemaciclib treatment differ from other CDK4/6 inhibitors. Findings are hypothesis generating; further exploration is warranted into mechanisms of resistance to abemaciclib and ET. See related commentary by Wander and Bardia, p. 2008.

Epidemiologic trends and risk factors associated with the decline in mortality from coronary heart disease in the United States, 1990-2019

BACKGROUND

Despite the decline in the rate of coronary heart disease (CHD) mortality, it is unknown how the 3 strong and modifiable risk factors - alcohol, smoking, and obesity -have impacted these trends. We examine changes in CHD mortality rates in the United States and estimate the preventable fraction of CHD deaths by eliminating CHD risk factors.

METHODS

We performed a sequential time-series analysis to examine mortality trends among females and males aged 25 to 84 years in the United States, 1990-2019, with CHD recorded as the underlying cause of death. We also examined mortality rates from chronic ischemic heart disease (IHD), acute myocardial infarction (AMI), and atherosclerotic heart disease (AHD). All underlying causes of CHD deaths were classified based on the International Classification of Disease 9th and 10th revisions. We estimated the preventable fraction of CHD deaths attributable to alcohol, smoking, and high body-mass index (BMI) through the Global Burden of Disease.

RESULTS

Among females (3,452,043 CHD deaths; mean [standard deviation, SD] age 49.3 [15.7] years), the age-standardized CHD mortality rate declined from 210.5 in 1990 to 66.8 per 100,000 in 2019 (annual change -4.04%, 95% CI -4.05, -4.03; incidence rate ratio [IRR] 0.32, 95% CI, 0.41, 0.43). Among males (5,572,629 CHD deaths; mean [SD] age 47.9 [15.1] years), the age-standardized CHD mortality rate declined from 442.4 to 156.7 per 100,000 (annual change -3.74%, 95% CI, -3.75, -3.74; IRR 0.36, 95% CI, 0.35, 0.37). A slowing of the decline in CHD mortality rates among younger cohorts was evident. Correction for unmeasured confounders through a quantitative bias analysis slightly attenuated the decline. Half of all CHD deaths could have been prevented with the elimination of smoking, alcohol, and obesity, including 1,726,022 female and 2,897,767 male CHD deaths between 1990 and 2019.

CONCLUSIONS

The decline in CHD mortality is slowing among younger cohorts. The complex dynamics of risk factors appear to shape mortality rates, underscoring the importance of targeted strategies to reduce modifiable risk factors that contribute to CHD mortality.

Ramucirumab plus erlotinib versus placebo plus erlotinib in previously untreated EGFR-mutated metastatic non-small-cell lung cancer (RELAY): exploratory analysis of next-generation sequencing results

BACKGROUND

Ramucirumab plus erlotinib (RAM + ERL) demonstrated superior progression-free survival (PFS) over placebo + ERL (PBO + ERL) in the phase III RELAY study of patients with epidermal growth factor receptor (EGFR)-mutated metastatic non-small-cell lung cancer (EGFR+ mNSCLC; NCT02411448). Next-generation sequencing (NGS) was used to identify clinically relevant alterations in circulating tumor DNA (ctDNA) and explore their impact on treatment outcomes.

PATIENTS AND METHODS

Eligible patients with EGFR+ mNSCLC were randomized 1 : 1 to ERL (150 mg/day) plus RAM (10 mg/kg)/PBO every 2 weeks. Liquid biopsies were to be prospectively collected at baseline, cycle 4 (C4), and postdiscontinuation follow-up. EGFR and co-occurring/treatment-emergent (TE) genomic alterations in ctDNA were analyzed using Guardant360 NGS platform.

RESULTS

In those with valid baseline samples, detectable activating EGFR alterations in ctDNA (aEGFR+) were associated with shorter PFS [aEGFR+: 12.7 months (n = 255) versus aEGFR-: 22.0 months (n = 131); hazard ratio (HR) = 1.87, 95% confidence interval (CI) 1.42-2.51]. Irrespective of detectable/undetectable baseline aEGFR, RAM + ERL was associated with longer PFS versus PBO + ERL [aEGFR+: median PFS (mPFS) = 15.2 versus 11.1 months, HR = 0.63, 95% CI 0.46-0.85; aEGFR-: mPFS = 22.1 versus 19.2 months, HR = 0.80, 95% CI 0.49-1.30]. Baseline alterations co-occurring with aEGFR were identified in 69 genes, most commonly TP53 (43%), EGFR (other than aEGFR; 25%), and PIK3CA (10%). PFS was longer in RAM + ERL, irrespective of baseline co-occurring alterations. Clearance of baseline aEGFR by C4 was associated with longer PFS (mPFS = 14.1 versus 7.0 months, HR = 0.481, 95% CI 0.33-0.71). RAM + ERL improved PFS outcomes, irrespective of aEGFR mutation clearance. TE gene alterations were most commonly in EGFR [T790M (29%), other (19%)] and TP53 (16%).

CONCLUSIONS

Baseline aEGFR alterations in ctDNA were associated with shorter mPFS. RAM + ERL was associated with improved PFS outcomes, irrespective of detectable/undetectable aEGFR, co-occurring baseline alterations, or aEGFR+ clearance by C4. aEGFR+ clearance by C4 was associated with improved PFS outcomes. Monitoring co-occurring alterations and aEGFR+ clearance may provide insights into mechanisms of EGFR tyrosine kinase inhibitor resistance and the patients who may benefit from intensified treatment schedules.

Growth performance and total tract digestibility in broiler chickens fed different corn hybrids

The aim of the present study was to investigate the variability in nutrient digestibility associated with corn genetic background and its influence on the feeding value for broiler chickens. A total of 960 1-day-old male broiler chicks (Ross 308) were distributed in eight treatments, with 12 pens per treatment and 10 birds per pen in a 42-day study. Eight corn samples (Variety 1 to Variety 8) were selected based on their nutrient composition. A fixed amount of each corn (577 g/kg in the starter diets and 662 g/kg in the finisher diets) was used to formulate feeds. Diets were offered ad libitum in pellet form. Performance parameters were determined at d 21 and d 42, and excreta samples collected at d 21 to determine energy, organic matter and dry matter (DM) whole-tract digestibility. The results revealed a decrease (P < 0.05) in body weight (BW) and feed intake in birds fed variety 8 compared to other varieties at d 21. The lowest whole tract DM and energy apparent digestibility were also observed for the variety 8 diet (P < 0.05), together with varieties 3 and 5. Energy digestibility was higher in varieties 2, 4 and 7 (P < 0.05). Multivariate analysis revealed that corn protein concentration was positively correlated with vitreousness (r = 0.60, P = 0.054) and the arabinose:xylose ratio (r = 0.67, P < 0.05) and negatively correlated with starch (r = -0.62, P < 0.05). Soluble non-starch polysaccharide content was negatively correlated with the protein solubility index (r = -0.88, P < 0.05). In addition, corn protein concentration was negatively correlated (P < 0.05) with 21-d BW (r = -0.71) and weight gain (r = -0.62). In conclusion, the corn genetic background influenced the nutrient digestibility and growth performance of broiler chickens. The content and nature of the non-starch polysaccharides were found to be two of the main factors affecting the solubility and availability of nutrients in corn, and could be the reason for the negative effects on the performance of broiler chickens as shown in the present study.

Acquired genomic alterations in circulating tumor DNA from patients receiving abemaciclib alone or in combination with endocrine therapy

3519

Background: An understanding of the mechanisms of acquired resistance to CDK4 & 6 inhibitors, either alone or with endocrine therapy (ET), is an unmet need. Abemaciclib is a CDK4 & 6 inhibitor approved for treatment of HR+, HER2- advanced breast cancer (ABC). Here we evaluated acquired genomic alterations detected in circulating tumor DNA (ctDNA) from patients (pts) treated with abemaciclib + nonsteroidal aromatase inhibitor (AI) or placebo + AI in MONARCH 3 or abemaciclib monotherapy in nextMONARCH 1. Methods: MONARCH 3 randomized postmenopausal women with HR+, HER2- ABC with no prior systemic therapy in the advanced setting to abemaciclib (150 mg Q12H) or placebo + AI. nextMONARCH 1 randomized women with HR+, HER2- metastatic breast cancer who had progressed on or after prior ET and CT to abemaciclib (150 mg Q12H) + tamoxifen, abemaciclib (150 mg Q12H), or abemaciclib (200 mg Q12H) + loperamide. Plasma from pts in the abemaciclib or placebo + AI arms (MONARCH 3) or abemaciclib monotherapy arms (nextMONARCH 1) was analyzed by the Guardant360 assay to identify potential tumor-related genomic alterations including point mutations, indels, amplifications, and fusions acquired at EOT in comparison with baseline. Results: For MONARCH 3, commonly acquired alterations at EOT included ESR1 (17%), TP53 (10%), EGFR (8%), FGFR1 (7%), and PDGFRA (7%) in the abemaciclib + AI arm, and ESR1 (31%), TP53 (10%), and BRCA1 (7%) in the placebo + AI arm. Acquired alterations more frequent for abemaciclib + AI pts included RB1 (6%), MYC (5%), and AR (5%), compared to 0% in the placebo + AI arm (p = 0.008 RB1; p = 0.015 MYC or AR). In contrast, acquired ESR1 alterations were less frequent with abemaciclib + AI vs placebo + AI (17% vs 31%, p = 0.038). In nextMONARCH 1, the most commonly acquired alterations with abemaciclib monotherapy were in TP53 (10%), EGFR (9%), RB1 (9%), MYC (9%), and MET (8%). In addition, acquired alterations in ESR1 (6%) and AR (3%) were also found. PIK3CA alterations were not frequently acquired (abemaciclib + AI 1%, placebo + AI 6%, abemaciclib monotherapy 5%). Conclusions: Acquired genomic alterations potentially associated with emerging mechanisms of resistance to abemaciclib alone or in combination with AI may include RB1, MYC, or AR alterations, while the acquisition of ESR1 alterations was less common in pts treated with abemaciclib + AI compared to placebo + AI. These findings are hypothesis-generating and provide insight into mechanisms of resistance to abemaciclib vs ET. Clinical trial information: NCT02246621, NCT02747004 .

Influence of autolyzed whole yeast and yeast components on broiler chickens challenged with salmonella lipopolysaccharide

The objective of this study was to assess the effect of dietary yeast products on broiler chickens challenged with salmonella lipopolysaccharide (LPS). The chicks were divided into 8 treatments with 6 replicates and 9 birds per replicate. The treatments consisted of a positive control (PC) [without supplementation and not challenged]; negative control (NC) [without supplementation but challenged]; whole yeast and challenged; yeast cell wall and challenged; yeast glucan and challenged; yeast mannan and challenged; zinc bacitracin and challenged; and Salinomycin and challenged. Whole yeast or Yeast cell wall was included at 2.0 g/kg diet. Yeast glucan or mannan was added at 0.20 g/kg diet. Zinc bacitracin (ZNB) and Salinomycin (SAL) was included at 50 and 60 ppm, respectively. Dietary treatments had no effect (P > 0.05) on feed intake (FI) at day 10. Supplementation with yeast and its derivatives improved (P < 0.05) body weight gain (BWG) and feed conversion ratio (FCR) on day 10. On days 24 and 35, LPS challenge declined FI, BWG, FCR, and flock uniformity (day 28) in the NC group compared to the PC group. Yeast products and antibiotics improved (P < 0.05) FI, BWG, FCR, and flock uniformity in LPS-challenged birds. On day 24, spleen weight increased while bursa weight decreased in the NC group relative to the PC group; this effect was reversed (P < 0.05) by feeding all yeasts and antibiotics. On day 24, application of all the dietary treatments ameliorated the changes observed in white blood cell, lymphocyte and monocyte counts as well as albumin and immunoglobulin G of NC birds. On day 35, all yeasts additives, ZNB and SAL improved (P < 0.05) the meat yield of broilers challenged with LPS. In conclusion, supplementation of diets with yeast and its derivatives can ameliorate the negative effects of salmonella LPS challenge on broiler chicks, thus improving the performance, flock uniformity, and meat yield.

Dietary hydrolysed yeast cell wall extract is comparable to antibiotics in the control of subclinical necrotic enteritis in broiler chickens

1. The aim of this study was to examine the effect of yeast cell wall (YCW) on performance and physiological responses of broiler chickens under subclinical necrotic enteritis challenge.2. Six treatments in a 2 × 3 factorial arrangement (non-challenged or challenged plus no supplement, YCW or antibiotics (AB)) was used. Each treatment was replicated eight times with 12 birds per replicate. The treatments included: (1) Positive control (PC; no additive, not challenged); (2) Negative control (NC; no additive, with challenge); (3) YCWN = yeast cell wall (2.0 g/kg diet, not challenged; (4) YCWC = yeast cell wall (2.0 g/kg diet, challenged); (5) ABN = zinc bacitracin 50 ppm + Salinomycin 60 ppm, not challenged); (6) ABC = zinc bacitracin 50 ppm + Salinomycin 60 ppm, challenged).3. Eimeria challenge at 9 d of age did not affect feed intake (FI), body weight gain (BWG), FCR or liveability at 10 d. The BWG and FCR at 10 d were greater (P < 0.05) in birds fed YCW or AB (AB) diets relative to the PC or NC groups. On 24 and 35 d, FI, BWG, FCR and flock uniformity (28 d) were greater (P < 0.05) in the challenged groups fed YCW or AB diets compared to NC group.4. Supplementation with YCW ameliorated the negative effects of NE on liver, spleen and bursa weight of birds.5. Necrotic enteritis challenge decreased (P < 0.05) caecal Lactobacillus and Bifidobacterium spp. counts, and increased ileum lesion score and caecal Clostridium perfirngens counts. This was reversed by the addition of either YCW or AB.6. Supplementation with YCW and AB resulted to a greater (P < 0.05) dressing percentage and meat yield (35 d).7. The results indicated that YCW plays a vital role in improving the physiological response and performance of broiler chickens under subclinical necrotic enteritis challenge.

Willingness to pay for policies to reduce future deaths from climate change: evidence from a British survey

OBJECTIVES

Without urgent action, climate change will put the health of future populations at risk. Policies to reduce these risks require support from today's populations; however, there are few studies assessing public support for such policies. Willingness to pay (WtP), a measure of the maximum a person is prepared to pay for a defined benefit, is widely used to assess public support for policies. We used WtP to investigate whether there is public support to reduce future health risks from climate change and if individual and contextual factors affect WtP, including perceptions of the seriousness of the impacts of climate change.

STUDY DESIGN

A cross-sectional British survey.

METHODS

Questions about people's WtP for policies to reduce future climate change-related deaths and their perceptions of the seriousness of climate change impacts were included in a British survey of adults aged 16 years and over (n=1859). We used contingent valuation, a survey-based method for eliciting WtP for outcomes like health which do not have a direct market value.

RESULTS

The majority (61%) were willing to pay to reduce future increases in climate change-related deaths in Britain. Those regarding climate change impacts as not at all serious were less willing to pay than those regarding the impacts as extremely serious (OR 0.04, 95% CI 0.02-0.09). Income was also related to WtP; the highest-income group were twice as likely to be willing to pay as the lowest-income group (OR 2.14, 95% CI 1.40-3.29).

CONCLUSIONS

There was public support for policies to address future health impacts of climate change; the level of support varied with people's perceptions of the seriousness of these impacts and their financial circumstances. Our study adds to evidence that health, including the health of future populations, is an outcome that people value and suggests that framing climate change around such values may help to accelerate action.

The Period protein homolog LIN-42 regulates germline development in C. elegans

Germline stem cells are maintained in the distal region of the C. elegans gonad. These cells undergo mitotic divisions, and GLP-1/Notch signaling dictates whether they remain in this state. The somatic distal tip cell (DTC) caps the end of the distal gonad and is essential for maintenance of the germline mitotic zone. As germ cells move away from the DTC they exit mitosis and enter early meiotic prophase. Here we identify the Period protein homolog LIN-42 as a new regulator of germline development in C. elegans. LIN-42 is expressed in almost all somatic cells including the DTC, and LIN-42 functions as a transcription factor in the heterochronic pathway and to regulate molting. We found that the mitotic proliferative zone size in the distal gonad was significantly reduced by ~25% in lin-42 mutants compared to WT N2 worms. A lin-42 mutation also reduced the mitotic proliferative zone size caused by glp-1 partial loss-of-function and gain-of-function alleles. LIN-42 mediates this effect, at least in part, by regulating expression of the GLP-1/Notch ligand LAG-2. We further show that lin-42 expression itself is regulated by ATX-2, which promotes germline proliferation and is the homolog of the RNA binding protein ataxin-2 that is implicated in human neurodegenerative diseases. Altogether our results establish a new role for the conserved, important Period protein homolog LIN-42 in regulating early germline development. These results also suggest that in addition to regulating behavioral rhythms, the circadian clock plays an important role in communicating environmental signals to essential reproductive pathways.

Qualitative experiences of disengagement in assertive outreach teams, in particular for "black" men: Clinicians' perspectives

This study is a follow-on study to a study into the experiences of disengagement from mental health services for men who described their ethnic identity as "black." The aim of this study was to understand the same phenomenon from a clinician's perspective. WHAT IS KNOWN ON THE SUBJECT?: Literature highlights that people from ethnic minority backgrounds experience some difficulties engaging with mental health services; Disengagement from mental health services is a complex phenomenon that occurs for a variety of different reasons; Only one paper previously has investigated clinicians' perspective on disengagement from mental health services; WHAT THE STUDY ADDS TO EXISTING KNOWLEDGE?: This study demonstrates that clinicians are aware that stigma and medication impact upon engagement with mental health services, which were also important components of the patients experience. A finding of the former study was that patients' attitudes towards mental health services change over time, with patients engaging more as they get older, a finding was supported by wider literature. However, in this study, the participants were not certain that this was the case. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The implications for practice from this study are that staff should persist with efforts to reduce the stigma surrounding mental health, carefully consider the significance and impact of medication and have an awareness of how patients' attitudes towards mental illness and mental health services change and develop over time. Continued support for an AO approach to practice for people who find it difficult to engage with services, where a multidisciplinary "team" approach can focus on service user-centred recovery goals and a positive space for collaboration.

ABSTRACT

Introduction Engagement with services is often poor amongst people with severe mental health problems, yet key to improving clinical outcomes. Aims This study explores the perception of clinicians on patients with severe mental health problems, in particular the experiences of black men, who disengage from mental health services. Method Two focus groups consisting of a combined total of twelve, mainly white, experienced clinicians in the UK were recruited. Transcripts were analysed using interpretative phenomenological analysis. Results Clinicians understood that patients' awareness of stigma impacted upon engagement with mental health services. Clinicians were aware that medication negatively impacted on engagement. The passage of time was perceived as impacting upon engagement. Discussion The perspectives of the clinicians in this study and the experiences of the patients in a former study converged. The participants had an understanding of the complexities that black men faced when engaging with mental health services. Implications for practice This is the first study to highlight that AOT staff need to be aware of the key role that stigma plays in engagement in treatment, continue to focus on efforts to reduce the stigma surrounding mental health, consider the significance medication and be aware of how patients' attitudes towards mental health services develop over time.

Predicting the nutritional quality of feed ingredients for pigs using near-infrared spectroscopy (NIRS) and chemical analysis

Capacity to routinely, accurately and cost-effectively measure variation in the nutritional quality of feed ingredients before diet formulation represents a fundamental pillar of sustainable pork production worldwide. Factors driving sustainable pork production include pork price, feed cost, utilisation of co-products and downgraded raw materials and variation in pork production, with all being related to the definition and ultimate nutritional quality of feed ingredients. The present paper defines rapid measures of nutritional quality in feed ingredients for pigs and demonstrates the range that can exist in these parameters, specifically digestible energy of cereal grains and the reactive-lysine concentration of oilseed meals. It provides an overview of the development of near-infrared spectroscopy (NIRS) calibrations for key nutritional-quality parameters and how they are being applied by the pork industry. Adjunct ways to measure nutritional quality of feed ingredients for pigs such as the glucose-release index and how these can be used in conjunction with NIRS are reviewed. The paper reports advanced correlation analysis between chemical components and digestible-energy concentration of cereals, and how these could be used for screening of NIRS outliers, and discusses future opportunities for application of nutritional-quality analysis using NIRS calibrations, including feed intake and portable solutions. Using advanced NIRS calibrations for digestible energy in cereals and reactive lysine in oilseed meals, pork producers will ensure that they make best use of limited resources and, as a consequence, pork will remain a nutritionally accretive food source for increasingly discerning consumers worldwide.

Social determinants and lifestyles: integrating environmental and public health perspectives

OBJECTIVE

Industrialization and urbanization have been associated with an epidemiological transition, from communicable to non-communicable disease, and a geological transition that is moving the planet beyond the stable Holocene epoch in which human societies have prospered. The lifestyles of high-income countries are major drivers of these twin processes. Our objective is to highlight the common causes of chronic disease and environmental change and, thereby, contribute to shared perspectives across public health and the environment.

STUDY DESIGN

Integrative reviews focused on social determinants and lifestyles as two 'bridging' concepts between the fields of public health and environmental sustainability.

METHODS

We drew on established frameworks to consider the position of the natural environment within social determinants of health (SDH) frameworks and the position of social determinants within environmental frameworks. We drew on evidence on lifestyle factors central to both public health and environmental change (mobility- and diet-related factors). We investigated how public health's focus on individual behaviour can be enriched by environmental perspectives that give attention to household consumption practices.

RESULTS

While SDH frameworks can incorporate the biophysical environment, their causal structure positions it as a determinant and one largely separate from the social factors that shape it. Environmental frameworks are more likely to represent the environment and its ecosystems as socially determined. A few frameworks also include human health as an outcome, providing the basis for a combined public health/environmental sustainability framework. Environmental analyses of household impacts broaden public health's concern with individual risk behaviours, pointing to the more damaging lifestyles of high-income households.

CONCLUSION

The conditions for health are being undermined by rapid environmental change. There is scope for frameworks reaching across public health and environmental sustainability and a shared evidence base that captures the health- and environmentally damaging impacts of high-consumption lifestyles.

Learning Problems Among Children of Refugee Background: A Systematic Scoping Review

BACKGROUND: Learning problems are common, affecting up to one in ten children, occurring within the dynamic, multidimensional context of family, school, community and broader sociocultural environment. Refugee children have, by definition, experienced forced migration, and multiple transitions, and ongoing socioeconomic and cultural challenges that may have cumulative risk factors for learning problems and educational disadvantage.

OBJECTIVES: To review the prevalence and major determinants of learning problems in resettled refugee children and available evidence on their educational outcomes.

DESIGN/METHODS: A scoping review using Arksey and O'Malley’s framework for scoping studies was employed (a systematic search, selection, extraction, analysis and reporting strategy) to identify the prevalence, major determinants of learning problems and educational achievement in resettled refuge children. Relevant studies were identified from searches of MEDLINE, EMBASE, PubMed, CINAHL PsycInfo, and ERIC. Inclusion criteria were peer-reviewed articles in English addressing the prevalence and/or determinants of learning problems in refugee children. Two independent authors conducted abstract and full text article review. The data was extracted systematically and analysed using Arksey and O'Malley’s descriptive analytical method for scoping studies.

RESULTS: A total of 2002 studies were identified and 28 studies met the inclusion criteria to be included in the review. No information was available on the prevalence of specific learning issues, language disorders, or autism spectrum disorders. Included studies found refugee children to possess significant ‘resource’ factors that promote learning success and had similar academic outcomes compared to their native-born peers. Prevalence data were limited, with single studies informing most of the reported estimates. Eight studies examined the impact of trauma on learning identifying mental health issues, personal risk behaviours and lower school performance as key risk factors. Key resource factors were strong family ties, absence of racial discrimination, and school safety.

CONCLUSION: This review provides prevalence estimates for learning problems in refugee children, and highlights key ‘risk’ and ‘resource’ factors. This review provides paediatricians recommendations on how best to identify learning strengths and challenges in refugee children, to better advocate for support in achieving academic success. This review advocates for a larger experimental based research measuring educational outcomes in refugee children. Further research is needed to better define the prevalence of learning problems among children of refugee background and to map out the learning progress longitudinally.

Use of clinical guidelines: perspectives from clinicians in paediatric and maternity hospitals in Kabul, Afghanistan

This study explored the perceived value, role and reported use of clinical guidelines by clinicians in urban paediatric and maternity hospital settings, and the effect of current implementation strategies on clinician attitudes, knowledge and behaviour. A total of 63 clinicians from 7 paediatric and maternity hospitals in Kabul, Afghanistan participated in structured focus groups; content analysis methodology was used for identification and analysis of key themes. Seven sets of guidelines, protocols or standards were identified (including 5 WHO-endorsed guidelines). However, most are failing to achieve high levels of use. Factors associated with guideline use included: clinician involvement in guideline development; multidisciplinary training; demonstrable results; and positive clinician perceptions regarding guideline quality and contextual appropriateness. Implementation activities should fulfil 3 major objectives: promote guideline awareness and access; stimulate motivation among clinical guideline users; and actively facilitate adherence to guidelines.

A randomised, blinded, crossover study to assess the efficacy of a feed supplement in alleviating the clinical signs of headshaking in 32 horses

REASONS FOR PERFORMING STUDY

Feed supplements are commonly used by owners to alleviate headshaking; however, randomised, controlled trials are required to assess their efficacy.

OBJECTIVE

To determine the efficacy of a feed supplement for alleviation of the clinical signs of headshaking using a randomised, blinded, placebo-controlled trial.

METHODS

Using a crossover design, 44 horses previously diagnosed with chronic idiopathic headshaking received both the supplement and a matching placebo per os for 28 days with a washout period between of 14 days. Video recordings were taken at rest and exercise prior to the study and at the end of both periods of treatment. The degree of headshaking was assessed in a blinded, randomised manner by 2 veterinary surgeons. At the same time points, owners completed a questionnaire to assess the severity of headshaking signs. A Wilcoxon signed rank test was used to compare the scores while on supplement and placebo.

RESULTS

Using the video assessments, there was no significant difference between scores while on supplement compared with placebo (P = 0.7). Using the questionnaire responses, there was no significant difference between scores for any activity when the placebo and the supplement were compared with each other. However, owners reported significant improvement during all activities for both placebo and supplement compared with pretreatment scores.

CONCLUSIONS AND POTENTIAL RELEVANCE

The supplement offered no benefit over a placebo in alleviating the clinical signs of headshaking. There appeared to be a significant proxy placebo effect when the outcome was based on subjective owner perception of clinical signs. This study demonstrated no beneficial effect of this supplement on the clinical signs of headshaking. The study did show a significant placebo effect, thereby highlighting the necessity of properly conducted, randomised controlled trials, with blinding, to assess true treatment effects in trials in animals.

Childcare use and inequalities in breastfeeding: findings from the UK Millennium Cohort Study

BACKGROUND

UK breastfeeding rates are low and socially distributed. Childcare provides a potential setting for breastfeeding promotion. However, little is known about the association between childcare and breastfeeding in different socio-economic groups.

METHODS

Using data from a contemporary UK cohort of infants (n=18,050) the authors calculated RR for breastfeeding for at least 4 months according to informal childcare (care by friends, grandparents, other relatives, etc) and formal childcare (eg, nurseries, crèches), both lasting at least 10 h a week and commencing before the age of 4 months, compared to being cared for 'only by a parent' (this includes childcare for less than 10 h a week), overall and by socio-economic group.

RESULTS

Compared to being looked after only by a parent, informal (RR 0.51 (95% CI 0.43 to 0.59)) and formal (0.84 (0.72 to 0.99)) childcare was associated with a reduced likelihood of breastfeeding. For informal childcare, both part-time and full-time care was associated with a reduced risk of breastfeeding, whereas for formal care, only full-time formal childcare was associated with a reduced likelihood of breastfeeding. The reduced likelihood of breastfeeding in informal childcare was similar across all socio-economic groups, whereas for formal childcare the reduced likelihood was only seen for mothers from managerial and professional backgrounds (0.76 (0.62 to 0.94)), those who had a degree (0.71 (0.58 to 0.86)) and couple families (0.79 (0.66 to 0.94)). In contrast, lone mothers were more likely to breastfeed if their infant was cared for in formal childcare (1.65 (1.04 to 2.63)).

CONCLUSIONS

Informal childcare was associated with a reduced likelihood of breastfeeding for all groups of mothers. Formal childcare arrangements were only associated with a reduced likelihood of breastfeeding if used full-time by more advantaged families.

P4-08-03: Serum Autoantibodies to Breast Cancer Associated Antigens Reflect Tumor Biology: An Opportunity for Early Detection & Prevention?

Autoantibodies (AABs) are produced as an immune response to abnormal ('non-self') cancer antigens. Previous studies have reported that AABs can be measured in the blood long before cancers are presently diagnosed, e.g., up to 4 years before screening mammography identified breast cancers and up to 5 years before screening CT detected lung cancers. EarlyCDT™-Lung is currently available as an aid to early detection of lung cancer in high risk patients and measures a panel of seven AABs to general cancer antigens and also lung cancer (LC) specific antigens. These AABs have previously been reported to be associated with the two main types of LC i.e., non-small cell and small cell LC. This study looked at AABs to 4 general cancer antigens to evaluate whether their levels reflected different biology in primary breast tumors.

Methods

770 patients presented with primary breast cancer to three centers (Nottingham, UK n=323; Munich, Germany n=320; Oklahoma, USA n=127); the median ages and ranges were 61 (26-82), 61 (20-88) & 65 (54-84) years, respectively. All had serum samples taken post-diagnosis and pre-treatment. The tumors were well characterized for histological grade, estrogen receptor (ER), progesterone receptor (PgR) and HER2 status. Serum samples were tested for AABs to four generic cancer antigens(Ags) (p53, SOX2, NY-ESO-1 and Annexin1) originally included as part of Oncimmune's EarlyCDT™-Lung assay. The AABs were measured by ELISA on the Oncimmune platform, and the EarlyCDT™-Lung cutoffs were used to determine positivity.

Results

131/770 (17%) of primary breast cancers showed elevated AAB levels to one or more of the limited panel of four generic antigens. Positivity for each AAB was correlated with histological grade, ER, PgR and HER2 status. The results, which were similar for each of the three centres, were combined, and the results are shown in Table 1 below.

Does the home environment influence inequalities in unintentional injury in early childhood? Findings from the UK Millennium Cohort Study

BACKGROUND

Children from disadvantaged backgrounds are more likely to experience unintentional injuries and poor home environments. The aim of this study was to explore the home environment as a potential mediator between socioeconomic circumstances and unintentional injuries, in the UK Millennium Cohort Study (n=14 378).

METHODS

RRs and 95% CIs for being injured in the home between age 9 months and 3 years were estimated according to four measures of socioeconomic circumstances: social class, maternal education, lone parenthood status and tenure. Proxy indicators of housing quality (build type, storey, garden access, rooms per capita, central heating and presence of damp) and safety equipment use (use of fireguards, safety gates, electric socket covers and smoke alarms) were then controlled for in order to observe potential mediation.

RESULTS

Children from routine and manual backgrounds were more likely to be injured than those from managerial and professional backgrounds (RR=1.33, 95% CI 1.21 to 1.47), as were children of lone parents (compared with couple families) (RR=1.23, 95% CI 1.12 to 1.36), those whose mothers had no educational qualifications (compared with a degree) (RR=1.42, 95% CI 1.24 to 1.63) and those living in socially rented accommodation (compared with owned/mortgaged homes) (RR=1.35, 95% CI 1.24 to 1.46). However, controlling for the indicators of housing quality and safety equipment use did not alter the elevated risk of injury experienced by children from less advantaged backgrounds.

CONCLUSIONS

In this contemporary UK cohort, proxy indicators of the home environment did not appear to explain socioeconomic inequalities in injuries. Research exploring alternative explanations for inequalities in injuries could help contribute to the design or adaptation of policies to reduce them.

Does childcare influence socioeconomic inequalities in unintentional injury? Findings from the UK Millennium Cohort Study

BACKGROUND

In recent decades the proportion of infants and young children being cared for in childcare has increased. Little is known about the impact that non-parental care has on childhood unintentional injury and whether this varies by socioeconomic group.

METHODS

Using data from a contemporary UK cohort of children at age 9 months (N = 18 114) and 3 years (N = 13 718), Poisson regression was used to explore the association between childcare type (parental, informal, formal) and the risk of unintentional injury, overall and by socioeconomic group.

RESULTS

At age 9 months there was no overall association between childcare and injury. However, when stratifying the analyses, infants from higher socioeconomic groups were less likely to be injured if they were cared for in formal childcare (compared with being cared for only by a parent), whereas those from lower social groups were more likely to be injured. At age 3 years informal childcare was associated with an increased risk of injury overall; in the stratified analyses this increased risk occurred only in less affluent groups. Formal childcare was no longer associated with injury at age 3 in any strata.

CONCLUSIONS

Previous findings have shown that childcare can have a positive influence on childhood injury; however, a recent Unicef report highlighted that a lack of access to high-quality childcare could lead to a widening of inequalities. Our analyses indicate that childcare does have the potential to widen inequalities in injury; further research is required to understand why childcare has a differential impact on unintentional injury and how this might be prevented.

The social context of parenting 3-year-old children with developmental delay in the UK

BACKGROUND

Children with intellectual or developmental disability have significantly poorer health and mental health than their non-disabled peers and are at high risk of social exclusion. The aim of the present paper is to provide information on the circumstances in which 3-year-old children at risk of intellectual or developmental disability are growing up in the UK.

METHODS

Secondary analysis of data on 12 689 families in English-speaking monolingual households from the first two waves of the UK's Millennium Cohort Study. A total of 440 children (3% of the weighted sample) were identified as being developmentally delayed.

RESULTS

When compared with other children, children with developmental delays were more disadvantaged on every indicator of social and economic disadvantage examined. Two out of three children with developmental delays had been exposed to repeated disadvantage as measured by income poverty, material hardship, social housing and receipt of means-tested benefits. The effect of repeated disadvantage on the risk of developmental delay remained after account was taken of parental education and occupational status.

CONCLUSIONS

Young children with delayed development in the UK are likely to be exposed to repeated socio-economic disadvantage. Implications for policy and understanding the nature of the link between poverty and child disability are discussed.

Socio-economic position, household composition, health status and indicators of the well-being of mothers of children with and without intellectual disabilities

BACKGROUND

Many previous studies have reported that mothers of children with intellectual disabilities (IDs) are more likely to show signs of psychological distress and have lower well-being than mothers of 'typically developing' children. Our aim was to estimate the extent to which these differences may be accounted for by between-group differences in socio-economic position.

METHODS

This study involved secondary analysis of happiness, self-esteem and self-efficacy variables in a nationally representative sample of 6954 British mothers with dependent children under the age of 17 years, 514 of whom were supporting a child with an ID.

RESULTS

Mothers of children with IDs reported lower levels of happiness, self-esteem and self-efficacy than mothers of children without IDs. Statistically controlling for differences in socio-economic position, household composition and maternal characteristics fully accounted for the between-group differences in maternal happiness, and accounted for over 50% of the elevated risk for poorer self-esteem and self-efficacy.

CONCLUSIONS

A socially and statistically significant proportion of the increased risk of poorer well-being among mothers of children with IDs may be attributed to their increased risk of socio-economic disadvantage.

Childhood disadvantage and health inequalities: a framework for policy based on lifecourse research

Tackling health inequalities is moving up the policy agenda of richer societies like the UK, with governments looking for evidence to guide policy review and development. Observational studies of how childhood disadvantage compromises health in adulthood are an important part of the evidence base, but are largely inaccessible to the policy community. We develop a framework which captures the findings of these studies. Our framework highlights how disadvantage in childhood adversely affects both socio-economic circumstances and health in adulthood through a set of interlocking processes. Key among these are children's developmental health (their physical, cognitive and emotional development) and health behaviours, together with the associated educational and social trajectories. In breaking down the link between childhood disadvantage and adult health into its constituent elements, the framework provides a basis for understanding where and how policies can make a difference. The paper argues that the process of policy review and development needs to include both new programmes and the mainstream policies in which they are embedded.

Cigarette consumption and socio-economic circumstances in adolescence as predictors of adult smoking

AIM

To investigate effects of cigarette consumption level and socio-economic circumstances during adolescence on adult smoking.

METHODS

1958 British birth cohort (all births 3-9 March 1958). Logistic regression used to predict (i) smoking at 41 years and (ii) persistent smoking (at 23, 33 and 41 years) from cigarette consumption and socio-economic circumstances at 16 years, indicated by social class and educational qualifications.

RESULTS

Of 6537 subjects with full smoking history, 30% smoked at 16 years, 23% smoked at 41 years and 19% smoked at 23, 33 and 41 years (persistent smokers). Heavier smokers at 16, 23 and 33 years were more likely to smoke at 41 years than lighter smokers. The odds ratio (OR) of smoking at 41 years was 2.5 for men and 3.0 for women who smoked >/=60 cigarettes/week at age 16, relative to <20 cigarettes/week. Subjects from manual social backgrounds and those with no qualifications had elevated risks of being a smoker at 41 years or a persistent smoker. These effects were robust to adjustment for adolescent consumption level (e.g. adjusted OR for no qualifications was 3.8). However, adolescent consumption level modified the effect of educational achievements. Among lighter adolescent smokers, those gaining higher qualifications had lower prevalence of smoking at 41 years (16%) than men with no qualifications (83%); among heavier adolescent smokers, prevalence was more similar for subjects with higher (56%) and no qualifications (69%).

CONCLUSIONS

Socio-economic background appears to influence adult smoking behaviour separately from adolescent cigarette consumption which is a recognized measure of nicotine dependence. There was some evidence that effects of early nicotine dependence are modified by educational achievements.

Primary compliance with medication prescribed for paediatric patients discharged from a regional hospital

OBJECTIVE

To establish the rate of primary compliance with medication of children discharged from the paediatric ward of a regional hospital.

METHODS

All paediatric admissions to a regional hospital for a 14-week period from April to July 2000 were studied. Patient data were collected for those paediatric inpatients discharged on medication. Written prescriptions kept by the local Aboriginal Medical Service and computerized data from local pharmacies were collected and the numbers filled were compared to ward discharge prescriptions.

RESULTS

There were 160 medical paediatric admissions. The median admission age was 19 months. There was no difference in patient sex, number of drugs prescribed, diagnosis of infection, mean age or the proportion of children under 2 years, between filled and unfilled prescriptions. In total, 49 prescriptions were filled from a total of 65 written (75%). This figure compares unfavourably with that of the metropolitan tertiary referral centre.

CONCLUSIONS

: Primary compliance was suboptimal, with the majority of unfilled prescriptions being for antibiotics. These findings suggest that a remediable cause of treatment failure may be primary non-compliance with medication in regional settings.

Reducing environmental pollution using animal feed enzymes

The global livestock population is estimated to be close to 4 billion animals, and to produce around 500 million tons of manure annually (Baidoo, 2003). This is expected to increase in the future with the projected greater demand for meat for human consumption. The problem of manure disposal is exacerbated by the concentration of animal production in increasingly large units, to obtain economies of scale and keep up with the demand for cheap food. The primary environmentalfactors are manure volume, manure nitrogen and phosphorus contents, methane production and odour (Jongbloed and Lenis, 1998). Legislation in many regions now restricts the amount of manure that can be applied per hectare, to prevent environmental pollution (Centner, 2001; Pellini and Morris, 2001). There are a number of strategies the animal production industry can take to reduce environmental impact. These include taking steps to improve the efficiency of conversion of feed into edible products, reduce feed wastage and formulate diets that more closely satisfy animal requirements for specific nutrients. At present 50-80% of the nitrogen and phosphorus fed to animals are not utilized but are excreted via manure and urine to the environment (Baidoo, 2003). Biotechnology could play a very important role in reducing the environmental impact of animal production. Examples include the development of animals more efficient at converting nutrients into edible products, and of higher quality, more digestible feedstuffs. Biotechnology can also be used to produce a range of feed additives that can improve the efficiency of animal production, including for example recombinant somatrophin, amino acids and enzymes. This paper summarizes a series of four experiments looking at the effects of microbial xylanase or phytase supplementation on excretion in swine and poultry. This summary indicates that the inclusion of these enzymes in animal feeds can reduce manure volume by up to 14%, and nitrogen and phosphorus outputs by up to 13% and 70%, respectively.