Care navigation addresses issues of tele-mental health acceptability and uptake in rural and remote Australian communities

INTRODUCTION

People living in rural and remote areas face substantial barriers to accessing timely and appropriate mental health services. In the Bowen Basin region of Queensland, Australia, barriers include: limited local providers, long waiting lists, unreliable telecommunication, and reluctance to trial telehealth. Isaac Navicare is a new, community co-designed care navigation service which addresses these barriers by coupling care navigation with supported telehealth, and referrals to mental health providers and other supports. We aimed to understand the reach and effectiveness of Isaac Navicare in improving access to mental health services and address an evidence gap on strategies for improving telehealth acceptability.

METHODS

This mixed-methods implementation science evaluation used the RE-AIM Framework. It involved a client database review, survey and semi-structured interviews with service users during the 12-month pilot from November 2021.

RESULTS

197 clients (128 adults, 69 minors) were referred to Navicare during the pilot. Half of adult clients were unemployed, meaning referral options were limited to low-cost or bulk-billed services. Participants described Navicare as supportive and effective in helping to access timely and appropriate mental health supports. Most clients who expressed a treatment modality preference selected face-to-face (n = 111, 85.4%), however most referrals were for telehealth (n = 103, 66.0%) due to a lack of suitable alternatives. The rapport and trust developed with the care navigator was critical for increasing willingness to trial telehealth. Barriers to telehealth included privacy issues, technical difficulties, unreliable internet/phone, and perceived difficulties developing therapeutic rapport. The supported telehealth site was under-utilised. The majority (88.3%, n = 182) of referrals to Navicare were from local health or community service providers or schools.

DISCUSSION

Coupling supportive, individualised care navigation with tele-mental health provider options resulted in increased uptake and acceptance of telehealth. Many barriers could be addressed through better preparation of clients and improving promotion and uptake of the supported telehealth site.

CONCLUSION

Attitudes towards telehealth have changed during the COVID-19 pandemic, however although the need exists, barriers remain to uptake. Telehealth alone is not enough. Coupling telehealth with other supports such as care navigation improves acceptance and uptake.

Screening Non-neutralizing Anti-idiotype Antibodies Against a Drug Candidate for Total Pharmacokinetic and Target Engagement Assay

Non-neutralizing anti-idiotype antibodies against a therapeutic monoclonal antibody (mAb) play a crucial role in the creation of total pharmacokinetic (PK) assays and total target engagement (TE) assays during both pre-clinical and clinical development. The development of these anti-idiotype antibodies is challenging. In this study, we utilized a hybridoma platform to produce a variety of anti-idiotype antibodies against GSK2857914, a humanized IgG1 anti-BCMA monoclonal antibody. The candidate clones were evaluated using surface plasmon resonance (SPR) and bio-layer interferometry (BLI) for binding affinity, binding profiling, matrix interference, and antibody pairing determination. We discovered that three anti-idiotype antibodies did not prevent BCMA from binding to GSK2857914. All three candidates demonstrated high binding affinities. One of the three exhibited minimal matrix inference and could pair with the other two candidates. Additionally, one of the three clones was biotinylated as a capture reagent for the total PK assay, and another was labeled with ruthenium as a detection reagent for both the total PK assay and total TE assay. The assay results clearly show that these reagents are genuine non-neutralizing anti-idiotypic antibodies and are suitable for total PK and TE assay development. Based on this and similar studies, we conclude that the hybridoma platform has a high success rate for generating non-neutralizing anti-idiotype antibodies. Our methodology for developing and characterizing non-neutralizing anti-idiotype antibodies to therapeutic antibodies can be generally applied to any antibody-based drug candidate's total PK and total TE assay development.

Identification and tentative removal of collagen glue in Palaeolithic worked bone objects: implications for ZooMS and radiocarbon dating

Collagen glue has been used for nearly two centuries to consolidate bone material, although its prevalence in museum collections is only now becoming visible. Identifying and removing collagen glue is crucial before the execution of any geochemical or molecular analyses. Palaeolithic bone objects from old excavations intended for radiocarbon dating were first analysed using ZooMS (Zooarchaeology by Mass Spectrometry) to identify the animal species, however peaks characteristic of both cattle and whale were discovered. Two extraction methods for ZooMS were tested to identify the authentic animal species of these objects, which revealed that these were originally whale bone objects that had been consolidated with cattle collagen glue. This is the first time animal collagen glue has been identified in archaeological remains with ZooMS, illustrating again the incredible versatility of this technique. Another technique, Fourier Transform Infrared Spectroscopy in Attenuated Total Reflectance mode (FTIR-ATR), was also tested if it could rapidly identify the presence of collagen glue in archaeological bone material, which was not the case. Two other cleaning methods were tested to remove bone glue contamination prior to radiocarbon dating, along with two modified collagen extraction methods for ZooMS. These methods were applied to bone blank samples (FmC = 0.0031 ± 0.0002, (n = 219), 47 336 ± 277 yr BP) that were experimentally consolidated with collagen glue and to the Palaeolithic bone material (ca. 15 000 and 12 000 yr BP). The experimental bone blanks produced excellent 14C ages, suggesting the cleaning methods were successful, however the 14C ages for some of the Palaeolithic material remained too young considering their contextual age, suggesting that the collagen glue contamination had most likely cross-linked to the authentic collagen molecule. More research is needed in order to gain a deeper understanding of the occurrence and elimination of cross-linked collagen-based glues in material from museum collections.

New Frontiers in Diabetes Care: Quality Improvement Study of a Population Health Team in Rural Critical Access Hospitals

BACKGROUND

Rural populations are older, have higher diabetes prevalence, and have less improvement in diabetes-related mortality rates compared to urban counterparts. Rural communities have limited access to diabetes education and social support services.

OBJECTIVE

Determine if an innovative population health program that integrates medical and social care models improves clinical outcomes for patients with type 2 diabetes in a resource-constrained, frontier area.

DESIGN/PARTICIPANTS

Quality improvement cohort study of 1764 patients with diabetes (September 2017-December 2021) at St. Mary's Health and Clearwater Valley Health (SMHCVH), an integrated health care delivery system in frontier Idaho. The United States Department of Agriculture's Office of Rural Health defines frontier as sparsely populated areas that are geographically isolated from population centers and services.

INTERVENTION

SMHCVH integrated medical and social care through a population health team (PHT), where staff assess medical, behavioral, and social needs with annual health risk assessments and provide core interventions including diabetes self-management education, chronic care management, integrated behavioral health, medical nutritional therapy, and community health worker navigation. We categorized patients with diabetes into three groups: patients with two or more PHT encounters during the study (PHT intervention), one PHT encounter (minimal PHT), and no PHT encounters (no PHT).

MAIN MEASURES

HbA1c, blood pressure, and LDL over time for each study group.

KEY RESULTS

Of the 1764 patients with diabetes, mean age was 68.3 years, 57% were male, 98% were white, 33% had three or more chronic conditions, and 9% had at least one unmet social need. PHT intervention patients had more chronic conditions and higher medical complexity. Mean HbA1c of PHT intervention patients significantly decreased from baseline to 12 months (7.9 to 7.6%, p < 0.01) and sustained reductions at 18 months, 24 months, 30 months, and 36 months. Minimal PHT patients decreased HbA1c from baseline to 12 months (7.7 to 7.3%, p < 0.05).

CONCLUSION

The SMHCVH PHT model was associated with improved hemoglobin A1c among less well-controlled patients with diabetes.

Predictors of compassion satisfaction and compassion fatigue in health care workers providing health and rehabilitation services in rural and remote locations: A scoping review

INTRODUCTION

A better understanding of the predictors of compassion satisfaction and compassion fatigue in health care workers in rural and remote communities is needed to inform preventative interventions for this sector of the health workforce.

OBJECTIVE

To identify predictors of compassion satisfaction and compassion fatigue in health care workers providing health and rehabilitation services in rural and remote locations.

DESIGN

A scoping review informed by Arksey and O'Malley's five-stage framework and the scoping review protocol of the PRISMA-ScR statement.

FINDINGS

The search yielded 946 articles, and 34 full texts were screened for eligibility, leaving 12 studies meeting the inclusion criteria. No studies on workers providing rehabilitation services were identified. Three studies assessed possible predictors of compassion satisfaction and compassion fatigue in health care workers, and all studies evaluated burnout. The most studied predictor variables were age, gender, profession and workload.

DISCUSSION

This study identified potential risk and protective factors for health care workers that are likely relevant to those providing rehabilitation services in rural locations. Little is known about possible predictors of compassion satisfaction and compassion fatigue in professionals working in rural and remote areas outside of medicine and nursing or health care workers in rural community-based settings.

CONCLUSION

Research examining predictors of compassion satisfaction and compassion fatigue in rehabilitation health care workers working in rural and remote locations is scant. Research that identifies risk and protective factors in this rapidly growing sector of the health care workforce is needed to inform the development of interventions that promote professional quality of life.

Epigenetics of Neurotrauma

Epigenetic changes have been linked to a host of disease states. Besides the physiological function of epigenetic changes in regulating cellular function, recent data indicates that key changes in epigenetic activity also play an important pathophysiologic role following neurotrauma specifically. Such manifestations occur through the activation or silencing of different genes. Histone methylation has emerged as a critical component of this process and can be selectively modulated after injury. Pre-clinical studies have resulted in key discoveries regarding specific methylation sites of interest. This focused review highlights some of these early findings and their relationship to clinical outcomes. These findings suggest areas of future investigation and discovery in the quest to develop ideal biomarkers and methods to utilize them in developing therapeutic interventions.

32 SIMULATION-BASED EDUCATION FOR ACUTE STROKE

Background

Acute stroke requires efficient multi-disciplinary collaboration to deliver time-sensitive treatment in a prompt and effective manner. The European Stroke Organization (ESO) recommends simulation-based education (SBE) for stroke care. Studies have shown SBE improves door-to-needle times, which predict better patient outcomes.

SimStars was a competition, run by the National Doctors Training and Planning leads for the South-SouthWest Hospitals Group, to develop in-situ SBE scenarios.

We developed a SBE program for acute stroke in an Irish teaching hospital.

Methods

Medical doctors and nursing staff are included in the SBE scenario as candidates/target learners. Patients are played by role-players. Anonymised data and neuroimaging from real patients is utilized to maximize fidelity to real life. Other participants, such as paramedics, can be included to facilitate scenarios as required.

Candidates are briefed before each scenario. Clear learning objectives are set. All participants are provided with a script outlining their roles. Candidates are appraised using standard evaluation forms. A de-brief is undertaken to reinforce learning objectives.

Results

We qualified for the final of SimStars by establishing a SBE program for acute stroke, including a video of a simulated scenario that can be utilized for demonstration purposes. 100% of candidates who have participated in the SBE program so far have stated that it made a valuable contribution to their learning in the field of stroke care.

Conclusion

Stroke has been described as an exemplar of how SBE may benefit training along an entire clinical pathway. Scenarios can be adapted to cover an endless variety of stroke-related situations. SBE has been shown to improve hyper-acute clinical pathway performance and outcomes.

Emerging Therapeutic Potential of Mesenchymal Stem/Stromal Cells in Preeclampsia

PURPOSE OF REVIEW

Preeclampsia is a dangerous pregnancy condition affecting both the mother and offspring. It is a multifactorial disease with poorly understood pathogenesis, lacking effective treatments. Maternal immune response, inflammation and oxidative stress leading to endothelial dysfunction are the most prominent pathogenic processes implicated in preeclampsia development. Here, we give a detailed overview of the therapeutic applications and mechanisms of mesenchymal stem/stromal cells (MSCs) as a potential new treatment for preeclampsia.

RECENT FINDINGS

MSCs have gained growing attention due to low immunogenicity, easy cultivation and expansion in vitro. Accumulating evidence now suggests that MSCs act primarily through their secretomes facilitating paracrine signalling that leads to potent immunomodulatory, pro-angiogenic and regenerative therapeutic effects. MSCs have been studied in different animal models of preeclampsia demonstrating promising result, which support further investigations into the therapeutic effects and mechanisms of MSC-based therapies in preeclampsia, steering these therapies into clinical trials.

Technology-facilitated care coordination in rural areas: What is needed?

BACKGROUND

Health is poorer in rural areas and a major challenge is care coordination for complex chronic conditions. The HITECH and 21^st Century Cure Acts emphasize health information exchange which underpins activities required to improve care coordination.

OBJECTIVE AND METHODS

Using semi-structured interviews and surveys, we examined how providers experience electronic health information exchange during care coordination since these Acts were implemented, with a focus on rural settings where health disparities exist. We used a purposive sample that included primary care, acute care hospitals, and community health services in the United States.

FINDINGS

We identified seven themes related to care coordination and information exchange: 'insufficient trust of data'; 'please respond'; 'just fax it'; 'care plans'; 'needle in the haystack'; 're-documentation'; and 'rural reality'. These gaps were magnified when information exchange was required between unaffiliated electronic health records (EHRs) about shared patients, which was more pronounced in rural settings.

CONCLUSION

Policy and incentive modifications are likely needed to overcome the observed health information technology (HIT) shortcomings. Rural settings in the United States accentuate problems that can be addressed through international medical informatics policy makers and the implementation and evaluation of interoperable HIT systems.

The Berkeleylactones, Antibiotic Macrolides from Fungal Coculture

A carefully timed coculture fermentation of Penicillium fuscum and P. camembertii/clavigerum yielded eight new 16-membered-ring macrolides, berkeleylactones A-H (1, 4, 6-9, 12, 13), as well as the known antibiotic macrolide A26771B (5), patulin, and citrinin. There was no evidence of the production of the berkeleylactones or A26771B (5) by either fungus when grown as axenic cultures. The structures were deduced from analyses of spectral data, and the absolute configurations of compounds 1 and 9 were determined by single-crystal X-ray crystallography. Berkeleylactone A (1) exhibited the most potent antimicrobial activity of the macrolide series, with low micromolar activity (MIC = 1-2 μg/mL) against four MRSA strains, as well as Bacillus anthracis, Streptococcus pyogenes, Candida albicans, and Candida glabrata. Mode of action studies have shown that, unlike other macrolide antibiotics, berkeleylactone A (1) does not inhibit protein synthesis nor target the ribosome, which suggests a novel mode of action for its antibiotic activity.

ProNGF, a cytokine induced after myocardial infarction in humans, targets pericytes to promote microvascular damage and activation

proNGF and p75NTR are induced following fatal myocardial infraction and are required for the development of microvascular injury.

Treatment of acute cardiac ischemia focuses on reestablishment of blood flow in coronary arteries. However, impaired microvascular perfusion damages peri-infarct tissue, despite arterial patency. Identification of cytokines that induce microvascular dysfunction would provide new targets to limit microvascular damage. Pro–nerve growth factor (NGF), the precursor of NGF, is a well characterized cytokine in the brain induced by injury. ProNGF activates p75 neurotrophin receptor (p75^NTR) and sortilin receptors to mediate proapoptotic responses. We describe induction of proNGF by cardiomyocytes, and p75^NTR in human arterioles after fatal myocardial infarction, but not with unrelated pathologies. After mouse cardiac ischemia-reperfusion (I-R) injury, rapid up-regulation of proNGF by cardiomyocytes and p75^NTR by microvascular pericytes is observed. To identify proNGF actions, we generated a mouse expressing a mutant Ngf allele with impaired processing of proNGF to mature NGF. The proNGF-expressing mouse exhibits cardiac microvascular endothelial activation, a decrease in pericyte process length, and increased vascular permeability, leading to lethal cardiomyopathy in adulthood. Deletion of p75^NTR in proNGF-expressing mice rescues the phenotype, confirming the importance of p75^NTR-expressing pericytes in the development of microvascular injury. Furthermore, deficiency in p75^NTR limits infarct size after I-R. These studies identify novel, nonneuronal actions for proNGF and suggest that proNGF represents a new target to limit microvascular dysfunction.

Endoscopic gastric submucosal transplantation of islets (ENDO-STI): technique and initial results in diabetic pigs

The results of transplantation of human donor islets into the portal vein (PV) in patients with diabetes are encouraging. However, there are complications, for example, hemorrhage, thrombosis and an immediate loss of islets through the 'instant blood-mediated inflammatory reaction' (IBMIR). The gastric submucosal space (GSMS) offers potential advantages. Islets were isolated from adult pigs. Recipient pigs were made diabetic by streptozotocin. Donor islets were injected into the GSMS through a laparotomy (Group 1A, n = 4) or endoscopically (Group 1B, n = 8) or into the PV through a laparotomy (Group 2, n = 3). The pigs were followed for a maximum of 28 days. Monitoring of C-peptide in Group 1 indicated that there was minimal immediate loss of islets whereas in Group 2 there was considerable loss from IBMIR. In Group 1, there were significant reductions in mean blood glucose and mean exogenous insulin requirement between pretransplantation and 20 days posttransplantation. In Group 2, there was no significant reduction in either parameter. Insulin-positive cells were seen in the GSMS in Group 1, but not in the liver in Group 2. Endoscopic gastric submucosal transplantation of islets (ENDO-STI) offers a minimally invasive and quick approach to islet transplantation, avoids IBMIR and warrants further exploration.

Neuronal release of proBDNF

Pro-brain-derived neurotrophic factor (proBDNF) and mature BDNF utilize distinct receptors to mediate divergent neuronal actions. Using new tools to quantitate endogenous BDNF isoforms, we found that mouse neurons secrete both proBDNF and mature BDNF. The highest levels of proBDNF and p75 were observed perinatally and declined, but were still detectable, in adulthood. Thus, BDNF actions are developmentally regulated by secretion of proBDNF or mature BDNF and by local expression of p75 and TrkB.

Endoscopic ultrasound-guided fine-needle aspiration for diagnosis of solid pseudopapillary tumors of the pancreas: a multicenter experience

BACKGROUND AND STUDY AIMS

Solid pseudopapillary tumors of the pancreas are rare, low-grade, epithelial neoplasms that are usually discovered incidentally in young women. Distinguishing solid pseudopapillary tumors from other pancreatic tumors, especially pancreatic endocrine tumors, can be challenging. The role of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in this context remains unclear. The purpose of this study was to describe the endoscopic ultrasound features of solid pseudopapillary tumors and the role of EUS-FNA in the preoperative diagnosis of these tumors.

PATIENTS AND METHODS

Patients from five tertiary referral centers with surgically confirmed solid pseudopapillary tumors who had undergone preoperative EUS-FNA were included. The endoscopic ultrasound findings, cytologic descriptions, immunostaining results, operative records, surgical pathology, and results of the most recent clinical follow-up were reviewed.

RESULTS

A total of 28 patients were identified (four men [14 %], 24 women [86 %], mean age +/- standard deviation [SD] 35 +/- 10 years). Solid pseudopapillary tumors had been found as incidental findings on cross-sectional imaging in 50 % of cases. The mean tumor size +/- SD was 42 +/- 19.5 mm and the majority were located in the pancreatic body and tail. The endoscopic ultrasound report described a well-defined, echo-poor mass in 86 %; the tumors were solid in 14 patients (50 %), mixed solid and cystic in 11 patients (39 %), and cystic in three patients (11 %). A preoperative diagnosis of solid pseudopapillary tumor was made in 21 patients (75 %) on the basis of EUS-FNA cytology. Surgical resection was performed in all cases. Laparoscopic resection was performed in eight of these patients (29 %).

CONCLUSIONS

A solid pseudopapillary tumor should be included in the differential diagnosis of any well-demarcated, echo-poor, solid or mixed solid/cystic pancreatic lesion seen during endoscopic ultrasound, particularly in young women. The diagnostic accuracy of EUS-FNA for solid pseudopapillary tumors was 75 % in this study. A definitive preoperative diagnosis can guide the surgical approach in selected cases.

Effects of age on ventilatory threshold and peak oxygen uptake normalised for regional skeletal muscle mass in Japanese men and women aged 20–80 years

Ventilatory threshold (VT) is an important predictor of cardiorespiratory fitness, such as peak oxygen uptake (VO2peak) and is a valuable index of aerobic exercise intensity. However, little is known about the role of skeletal muscle (SM) mass in the age-associated decline of VT. Therefore, the present study was performed to investigate the effects of age on cardiopulmonary fitness normalised for regional SM mass in 1,463 Japanese men and women, and to determine the relevance of VT normalised to SM mass based on age and gender. Total, trunk and thigh SM mass were measured using an ultrasound method, while VO2peak and VT were determined during treadmill walking. VO2peak was estimated using the predicted maximum heart rate (HR) and the HR-VO2 relationship for sub-maximal treadmill walking. There were significant negative correlations between VT normalised for body mass and age in men and women (P < 0.001). Age-associated declines were also observed in VT normalised for body mass in both men and women; however, VT normalised for SM mass was not significantly different with age. Significant correlations were also observed between thigh SM mass and VT in both men and women. These results suggest that thigh SM mass is closely associated with VO2peak and/or VT in both men and women, and the decrease in VT with age is predominantly due to an age-related decline of SM mass. Moreover, this study provides normative cardiorespiratory fitness data regarding VT normalised SM mass in healthy men and women aged 20-80 years.

Yield of endoscopic ultrasound-guided fine-needle aspiration of bile duct lesions

BACKGROUND AND STUDY AIMS

It is still difficult to differentiate reliably between benign and malignant biliary tract lesions. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has added to the diagnostic power of EUS for other gastrointestinal tumors. A retrospective analysis of experience with FNA sampling of bile duct lesions was therefore carried out.

PATIENTS AND METHODS

All EUS-FNA procedures for bile duct masses or strictures were analyzed at our tertiary referral center from May 2000 through October 2002. Data for EUS findings, the results of EUS-FNA, and tissue sampling at surgery were included. EUS-FNA procedures were carried out using a 22-gauge needle. An experienced cytopathologist was present during FNA in all but three cases. Clinical follow-up details were recorded when available for patients in whom a suitable diagnostic gold standard was not available for comparison.

RESULTS

A total of 35 patients underwent EUS-FNA of bile duct lesions during the study period. There were no complications. Data for EUS-FNA of bile duct masses or strictures and tissue obtained at surgery were available for 23 patients. If positive cytology at surgical pathology is taken as the gold standard, EUS-FNA has a diagnostic yield for cancer of 100 % (if atypia/inconclusive findings in the FNA sample are regarded as benign). Eleven patients had a definite malignancy on surgical pathology. Of these 11 patients, five had a finding of malignancy on EUS-FNA, giving a sensitivity of 45 % (if FNA cytology reported as atypia/inconclusive is regarded as benign). Twelve patients had findings of no malignancy from tissue obtained at surgery. Of these 12 patients, nine had benign pathology and three had atypia/inconclusive findings in the EUS-FNA sample (specificity of 100 % if atypia/inconclusive findings are considered benign). A further 12 patients did not have surgical specimens for comparison with EUS-FNA results. Four patients had definite findings of malignancy on EUS-FNA alone, and one patient had FNA findings suspicious for malignancy. Seven patients had negative or equivocal EUS-FNA results. These 12 patients are described but excluded from further analysis, as a gold standard was not available for comparison. However, clinical follow-up data were available for eight of these 12 patients, and in each case the follow-up findings were compatible with previous benign or malignant EUS-FNA findings.

CONCLUSIONS

The practice of EUS-FNA has improved the diagnostic yield of EUS. These results suggest that it is a safe and useful procedure for investigating biliary masses or strictures that have hitherto caused considerable diagnostic confusion, especially in patients with negative brush cytology findings. The possibility of false-negative findings remains, but core biopsy needles may improve the situation. The results of further studies are awaited.

Complete response to neoadjuvant chemoradiation for rectal cancer does not influence survival

BACKGROUND

Up to 30% of patients with locally advanced rectal cancer have a complete clinical or pathologic response to neoadjuvant chemoradiation. This study analyzes complete clinical and pathologic responders among a large group of rectal cancer patients treated with neoadjuvant chemoradiation.

METHODS

From 1987 to 2000, 141 consecutive patients with biopsy-proven, locally advanced rectal cancer were treated with preoperative 5-fluorouracil-based chemotherapy and radiation. Clinical restaging after treatment consisted of proctoscopic examination and often computed tomography scan. One hundred forty patients then underwent operative resection, with results tracked in a database. Standard statistical methods were used to examine the outcomes of those patients with complete clinical or pathologic responses.

RESULTS

No demographic differences were detected between either clinical complete and clinical partial responders or pathologic complete and pathologic partial responders. The positive predictive value of clinical restaging was 60%, and accuracy was 82%. By use of the Kaplan-Meier life table analysis, clinical complete responders had no advantage in local recurrence, disease-free survival, or overall survival rates when compared with clinical partial responders. Pathologic complete responders also had no recurrence or survival advantage when compared with pathologic partial responders. Of the 34 pathologic T0 tumors, 4 (13%) had lymph node metastases.

CONCLUSIONS

Clinical assessment of complete response to neoadjuvant chemoradiation is unreliable. Micrometastatic disease persists in a proportion of patients despite pathologic complete response. Observation or local excision for patients thought to be complete responders should be undertaken with caution.

Neoadjuvant chemoradiation for rectal cancer: analysis of clinical outcomes from a 13-year institutional experience

OBJECTIVE

To examine clinical outcomes in patients receiving neoadjuvant chemoradiation for locally advanced rectal adenocarcinoma.

SUMMARY BACKGROUND DATA

Preoperative radiation therapy, either alone or in combination with 5-fluorouracil-based chemotherapy, has proven both safe and effective in the treatment of rectal cancer. However, data are lacking regarding which subgroups of patients benefit from the therapy in terms of decreased local recurrence and increased survival rates.

METHODS

A retrospective chart review was performed on 141 consecutive patients who received neoadjuvant chemoradiation (5-fluorouracil +/- cisplatin and 4,500-5,040 cGy) for biopsy-proven locally advanced adenocarcinoma of the rectum. Surgery was performed 4 to 8 weeks after completion of chemoradiation. Standard statistical methods were used to analyze recurrence and survival.

RESULTS

Median follow-up was 27 months, and mean age was 59 years (range 28-81). Mean tumor distance from the anal verge was 6 cm (range 1-15). Of those staged before surgery with endorectal ultrasound or magnetic resonance imaging, 57% of stage II patients and 82% of stage III patients were downstaged. The chemotherapeutic regimens were well tolerated, and resections were performed on 140 patients. The percentage of sphincter-sparing procedures increased from 20% before 1996 to 76% after 1996. On pathologic analysis, 24% of specimens were T0. However, postoperative pathologic T stage had no effect on either recurrence or survival. Positive lymph node status predicted increased local recurrence and decreased survival.

CONCLUSIONS

Neoadjuvant chemoradiation is safe, effective, and well tolerated. Postoperative lymph node status is the only independent predictor of recurrence and survival.

Primary lymphoma of the esophagus in a chronically immunosuppressed patient with hepatitis C infection: case report and review of the literature

Adenocarcinoma and squamous cell carcinoma account for the vast majority of esophageal malignancies. Other malignancies that can involve the esophagus include melanoma, sarcoma, and lymphoma. Gastrointestinal involvement with lymphoma has a variable incidence, as reported in the literature. However, primary involvement, as defined by Dawson, is extremely rare. Lymphoma has been linked to immunosuppressive conditions (such as AIDS), medications, and transplantation. We present what we believe to be the first case of primary esophageal lymphoma in a patient on long-term immunosuppression with azathioprine who was also infected with the hepatitis C virus (HCV). HCV has been postulated to have a relationship with B cell lymphomas.

Benchmarking pathology services: implementing a longitudinal study

This paper details the benchmarking process and its application to the activities of pathology laboratories participating in a benchmark pilot study [the Royal College of Pathologists of Australasian (RCPA) Benchmarking Project]. The discussion highlights the primary issues confronted in collecting, processing, analysing and comparing benchmark data. The paper outlines the benefits of engaging in a benchmarking exercise and provides a framework which can be applied across a range of public health settings. This information is then applied to a review of the development of the RCPA Benchmarking Project. Consideration is also given to the nature of the preliminary results of the project and the implications of these results to the on-going conduct of the study.

Endoscopic band ligation of Dieulafoy's lesion: report of two cases and review of the literature

Two cases of endoscopic band ligation as lone therapy for Dieulafoy's lesions are presented. Neither patient has experienced further gastrointestinal bleeding; one patient has been followed for 27 months. Endoscopic band ligation is an alternative and attractive treatment modality for Dieulafoy's lesions.

Pediatric idiopathic anaphylaxis: experience with 22 patients

Idiopathic anaphylaxis in the pediatric population is being increasingly recognized, with symptoms (and therefore classifications) the same as those described in adults. We present a series of 22 patients with special attention to considerations relatively unique to the pediatric population. Prednisone, hydroxyzine, and albuterol were used to control symptoms and induce remission. No deaths occurred during treatment. One adolescent who presented with corticosteroid-dependent idiopathic anaphylaxis was diagnosed with undifferentiated somatoform-idiopathic anaphylaxis. Local physician reluctance to participate in management complicated care for some patients.

Maternal immunization to Gov system alloantigens on human platelets

BACKGROUND

Immunization to platelet alloantigens can occur during pregnancy or after the transfusion of blood components. Platelet alloantibodies can cause neonatal alloimmune thrombocytopenia and posttransfusion purpura. Transfusion-induced alloimmunization to a novel platelet alloantigen system, Gov, expressed on the 175-kDa glycosyl phosphatidylinositol-anchored platelet glycoprotein, CD109, was previously described. This report describes three unrelated patients who were alloimmunized to Gov(a) or Gov(b) during pregnancy.

STUDY DESIGN AND METHODS

Platelets were typed by using radioimmunoprecipitation for HPA-1a, -3a, -5a, -5b, Gov(a), and Gov(b) and by polymerase chain reaction-restriction fragment length polymorphism for HPA-1a, -1b, -3a, and -3b. Maternal sera were screened for platelet antibodies by using radioimmunoprecipitation and the antigen capture assay.

RESULTS

Patients 1 and 2 were investigated after the diagnosis of neonatal alloimmune thrombocytopenia in their children, and alloantibodies specific for Gov(b) and Gov(a), respectively, were detected in maternal serum. Serum from patient 3, who had mild idiopathic thrombocytopenia purpura with no detectable autoantibody, was found to contain alloantibodies to Gov(b) and to HPA-5b, presumably as a result of immunization during pregnancy. Platelet typings confirmed that the patients were at risk for alloimmunization to the respective antigen.

CONCLUSION

This report of three cases of maternal alloimmunization to antigens in the Gov system indicates that immunization can occur via placental transfer of antigen and that Gov system alloantibodies may be associated with neonatal alloimmune thrombocytopenia.

Left ventricular hypertrophy and QT dispersion in hypertension

The interlead variation in QT length on a standard electrocardiograph reflects regional repolarization differences in the heart. To investigate the association between this interlead variation (QT dispersion) and left ventricular hypertrophy, we subjected 100 untreated subjects to 12-lead electrocardiography and echocardiography. Additionally, 24 previously untreated subjects underwent a 6-month treatment study with ramipril and felodipine. In the cross-sectional part of the study, QT dispersion corrected for heart rate (QTc dispersion) was significantly correlated with left ventricular mass index (r = .30, P < .01), systolic pressure (r = .30, P < .01), the ratio of peak flow velocity of the early filling wave to peak flow velocity of the atrial wave (E/A ratio) (r = -.22, P = .02), isovolumic relaxation time (r = .31, P < .01), and age (r = .21, P < .04). In the treatment part of the study, lead-adjusted QTc dispersion decreased from 24 to 19 milliseconds after treatment, and after a subsequent 2 weeks of drug washout remained at 19 milliseconds (P < .01). The changes in left ventricular mass index at these stages were 144, 121, and 124 g/m2 (P < .01). Systolic pressure decreased from 175 to 144 mm Hg and increased again to 164 mm Hg after drug washout (P < .01). The E/A ratio (0.97, 1.02, and 1.02; P = 69) and isovolumic relaxation time (111, 112, and 112; P = .97) remained unchanged through the three assessment points. In conclusion, QT dispersion is increased in association with an increased left ventricular mass index in hypertensive individuals. Antihypertensive therapy with ramipril and felodipine reduced both parameters. If an increased QT dispersion is a predictor of sudden death in this group of individuals, then the importance of its reduction is evident.

Hereditary pancreatitis is caused by a mutation in the cationic trypsinogen gene

Hereditary pancreatitis (HP) is a rare, early-onset genetic disorder characterized by epigastric pain and often more serious complications. We now report that an Arg-His substitution at residue 117 of the cationic trypsinogen gene is associated with the HP phenotype. This mutation was observed in all HP affected individuals and obligate carriers from five kindreds, but not in individuals who married into the families nor in 140 unrelated individuals. X-ray crystal structure analysis, molecular modelling, and protein digest data indicate that the Arg 117 residue is a trypsin-sensitive site. Cleavage at this site is probably part of a fail-safe mechanism by which trypsin, which is activated within the pancreas, may be inactivated; loss of this cleavage site would permit autodigestion resulting in pancreatitis.

Neutralising antibodies after streptokinase treatment for myocardial infarction: a persisting puzzle

OBJECTIVE

To determine the development of titres of streptokinase (SK) neutralising antibodies after a single dose of SK, to establish when titres decrease to levels at which a second dose might be effective.

DESIGN

Analyses of blood samples taken from patients at intervals after SK administration.

SETTING

Australian public hospital.

PATIENTS

104 patients with acute myocardial infarction who were treated with SK and 27 controls who were not.

OUTCOME MEASURE

SK neutralising antibodies were measured once in each of the 27 controls and on 166 occasions in the 104 treated patients.

RESULTS

Titres of SK neutralising antibodies rose after SK administration but returned to control levels by 2 years.

CONCLUSIONS

SK might be effective again as a thrombolytic agent as early as 2 years after a single dose. These results are at variance with most previously published data and the reasons for this are not clear. Data evaluating patency rates after standard doses of streptokinase in patients with increased titres of neutralising antibodies are necessary before re-exposure to streptokinase can be recommended.