Locoregional control and toxicity following high-dose hypofractionated and accelerated palliative radiotherapy regimens in breast cancer

AIMS

For patients with locally advanced primary/recurrent breast cancer, radiotherapy is an effective treatment for locoregional control. 36 Gy in 6 Gy once-weekly fractions is a commonly used schedule, but there are no data comparing local control and toxicity between 36 Gy delivered once-weekly versus accelerated schedules of multiple 6 Gy fractions per week. This retrospective study compared local control rates and acute and late toxicity in patients undergoing 30-36 Gy in 6 Gy fractions over 6 weeks versus more accelerated schedules over 2-3 weeks for an unresected breast cancer.

MATERIALS AND METHODS

Patients who received 30-36 Gy in 6 Gy fractions to an unresected breast cancer ± involved lymph nodes between December 2011 and August 2020 were identified. Patients were grouped into once-weekly versus accelerated fractionation schedules. Response rates, local control and toxicity data were analysed.

RESULTS

In total, 109 patients were identified. The median follow-up duration was 46 months. Forty-seven patients (43%) received once-weekly fractions and 62 patients (57%) received accelerated fractionation schedules. There were no significant differences in baseline tumour characteristics between the groups. Eighty-seven per cent of patients had an objective (complete or partial) response (81% in the once-weekly group; 91% in the accelerated group). The median time to local progression was 23.5 months overall (95% confidence interval 17.8-29.2); 23.5 months (95% confidence interval 18.8-28.1) in the once-weekly group and 19.0 months (95% confidence interval 7.0-31.1) in the accelerated group (P = 0.99). Acute toxicity of any grade occurred in 75% of patients (76% in the once-weekly group; 74% in the accelerated group) and grade 3 toxicity occurred in 7% of patients (7% in the once-weekly group; 8% in the accelerated group). There were no associations between the groups and acute or late toxicity grade (P = 0.78 and P = 0.26, respectively), although one grade 4 late toxicity (skin radionecrosis) occurred in a patient who received five fractions a week and therefore this regimen is not recommended. Study limitations included a lack of statistical power analysis, the necessary grouping of all accelerated patients for analysis and a high rate of censored data.

CONCLUSION

There were no apparent differences in response rate, time to local progression or toxicity between patients who received 30-36 Gy in 6 Gy fractions once-weekly compared with twice-weekly as palliative treatment for locally advanced breast cancer. This regimen appears to be a safe alternative and may be preferred by patients.

P046 A review and retrospective case series of paediatric Sjögren’s syndrome from Southern Africa

Background

Paediatric Sjögren’s syndrome (pSS) is an uncommon autoimmune paediatric disease, rarely reported in children in Africa. It remains an important consideration in a child with parotid swelling. Here, we present a retrospective case-series of four patients from a paediatric rheumatology clinic in South Africa and discuss some of the difficulties of diagnosis in our context.

Methods

We performed a retrospective analysis of patients who attend the Red Cross War Memorial Hospital Paediatric Rheumatology clinic between 2010 and 2019.

Result

The four patients diagnosed with Sjögren’s all had varied presentations and disease courses. There were 3 females and 1 male and the ages at diagnosis ranged from 6 to 19 years old. The time to diagnosis was prolonged and ranged from 1 month to 10 years. Two patients with primary pSS presented with extra-articular manifestations of arthritis, abdominal pain and fatigue, followed by dry mouth, dry eyes, parotid swelling and and suggestive histopathology. The remaining 2 patients had a secondary pSS due to juvenile onset SLE and tuberculosis respectively.

Conclusion

In less resourced settings the diagnosis of pSS is often delayed. Both patients with primary pSS had preceding extra-glandular manifestations. In less resourced settings, infectious diseases may present as pSS and associated rheumatic diseases causing secondary pSS must be considered.

Comparison of in silico strategies to prioritize rare genomic variants impacting RNA splicing for the diagnosis of genomic disorders

The development of computational methods to assess pathogenicity of pre-messenger RNA splicing variants is critical for diagnosis of human disease. We assessed the capability of eight algorithms, and a consensus approach, to prioritize 249 variants of uncertain significance (VUSs) that underwent splicing functional analyses. The capability of algorithms to differentiate VUSs away from the immediate splice site as being 'pathogenic' or 'benign' is likely to have substantial impact on diagnostic testing. We show that SpliceAI is the best single strategy in this regard, but that combined usage of tools using a weighted approach can increase accuracy further. We incorporated prioritization strategies alongside diagnostic testing for rare disorders. We show that 15% of 2783 referred individuals carry rare variants expected to impact splicing that were not initially identified as 'pathogenic' or 'likely pathogenic'; one in five of these cases could lead to new or refined diagnoses.

Psychosocial outcomes of peer support for patients with an inherited cardiac condition

Funding Acknowledgements

Type of funding sources: None.

Introduction

Inherited cardiac conditions (ICCs) are feared for their risk of sudden death. Individuals are often young and diagnosed after the sudden death of an apparently healthy family member. A diagnosis can have a profound psychological impact and negative effect on quality of life. Uncertainty surrounding the natural history of some diseases causes anxiety and concern about existing children or starting a family. Necessary lifestyle adjustments are often associated with a sense of isolation during social engagement with peers. Psychological support for such patients is scarce. However, a specialist nurse led peer group support within the ICC service may improve psychological outcomes and empower patients to support others. 

Purpose

To determine the effect of a nurse led peer support group on subjective psychological symptoms for patients with ICCs.

Methods

A pilot specialist nurse support group was established in February 2020 including 30 patients with ICCs. This consisted of a meeting in person followed by 6 subsequent 2 monthly online video meetings. Each session lasted 2 hours and included a talk by a healthcare professional on an ICC related topic, followed by an open forum for group discussion facilitated by the specialist nurse. An online social media chat forum was also developed. After 1 year, a bespoke questionnaire was distributed to all participants enquiring about the effect of group support on anxiety level, sense of isolation, knowledge about their condition and empowerment to support themselves and others. 

Results

21 (70%) patients aged between 20 and 65 years old (mean age 49) responded. Diagnoses included Brugada syndrome, arrhythmogenic cardiomyopathy, dilated cardiomyopathy, hypertrophic cardiomyopathy and long QT syndrome. All participants agreed that the group provided a comfortable platform to ask questions about their condition. 95% of participants were keen to know more about their condition after diagnosis of which 86% agreed that knowledge about their condition had improved since joining the group. 90% of participants experienced anxiety related to their condition before joining the group of which 76% reported reduced levels since joining. 76% felt isolated after their diagnosis of which 86% reported that these feelings had lessened since joining the group. 86% of the group agreed that group discussion empowered them and helped them support other affected individuals. 

Conclusion

A pilot study support group for patients with ICCs reduced anxiety and sense of isolation, improved knowledge, and sense of empowerment and willingness to support other patients in ≥ 80% of attendees. There is potential that patient support groups can be kick started by specialist nurses and subsequently allowed to run by patients themselves. Apart from improving psychological outcomes, such practice may reduce the workload for the ICC multidisciplinary team.

Home infusions of natalizumab for people with multiple sclerosis: a pilot randomised crossover trial

Objective

The delivery of healthcare at home has expanded to intravenous infusions of monoclonal antibodies. A recently developed model of care for home infusions of natalizumab for people with relapsing‐remitting multiple sclerosis was evaluated. This pilot study of home infusions of natalizumab and usual care (attendance in a hospital out‐patients’ clinic) compared safety, feasibility, patient satisfaction, effectiveness and costs.

Methods

In this randomised AB/BA crossover trial, 37 adults were randomised to usual care (n = 19) or home infusions (n = 18). After three infusions, patients crossed over to the alternate treatment for another three infusions. Patient safety outcomes and adherence, satisfaction, quality of life, disability and costs were compared.

Results

No adverse events were recorded from 207 infusions from 35 patients across both home and clinic infusions. There was no difference in adherence (p = 0.71) and infection rates (p = 0.84) between home and clinic settings. Satisfaction with “convenience” of home infusions was significantly greater (p = 0.008) but there were no differences in quality of life measures. Excluding pharmacy, costs were A$74 lower per infusion at home, including A$16 of patients” out‐of‐pocket costs.

Interpretation

There were no differences in safety and effectiveness between clinic and home infusions of natalizumab. The home infusions were shown to be feasible, more convenient and less expensive than usual care. Larger scale studies are required to verify these preliminary findings, particularly around safety and management of hypersensitivity adverse events in the home setting and for equivalence of clinical outcomes.

Localization of Fluorescent Targets in Deep Tissue With Expanded Beam Illumination for Studies of Cancer and the Brain

Imaging fluorescence through millimeters or centimeters of tissue has important in vivo applications, such as guiding surgery and studying the brain. Often, the important information is the location of one of more optical reporters, rather than the specifics of the local geometry, motivating the need for a localization method that provides this information. We present an optimization approach based on a diffusion model for the fast localization of fluorescent inhomogeneities in deep tissue with expanded beam illumination that simplifies the experiment and the reconstruction. We show that the position of a fluorescent inhomogeneity can be estimated while assuming homogeneous tissue parameters and without having to model the excitation profile, reducing the computational burden and improving the utility of the method. We perform two experiments as a demonstration. First, a tumor in a mouse is localized using a near infrared folate-targeted fluorescent agent (OTL38). This result shows that localization can quickly provide tumor depth information, which could reduce damage to healthy tissue during fluorescence-guided surgery. Second, another near infrared fluorescent agent (ATTO647N) is injected into the brain of a rat, and localized through the intact skull and surface tissue. This result will enable studies of protein aggregation and neuron signaling.

Thermal Processing of Chloride-Contaminated Plutonium Dioxide

Over 80 heat treatment experiments have been made on samples of chloride-contaminated plutonium dioxide retrieved from two packages in storage at Sellafield. These packages dated from 1974 and 1980 and were produced in a batch process by conversion of plutonium oxalate in a furnace at around 550 °C. The storage package contained a poly(vinyl chloride) (PVC) bag between the screw top inner and outer metal cans. Degradation of the PVC has led to adsorption of hydrogen chloride together with other atmospheric gases onto the PuO₂ surface. Analysis by caustic leaching and ion chromatography gave chloride contents of ∼2000 to >5000 ppm Cl (i.e., μgCl g^-1 of the original sample). Although there are some subtle differences, in general, there is surprisingly good agreement in results from heat treatment experiments for all the samples from both cans. Mass loss on heating (LOH) plateaus at nearly 3 wt % above 700 °C, although samples that were long stored under an air atmosphere or preexposed to 95% relative humidity atmospheres, gave higher LOH up to ∼4 wt %. The majority of the mass loss is due to adsorbed water and other atmospheric gases rather than chloride. Heating volatilizes chloride only above ∼400 °C implying that simple physisorption of HCl is not the main cause of contamination. Interestingly, above 700 °C, >100% of the initial leachable chloride can be volatilized. Surface (leachable) chloride decreases quickly with heat treatment temperatures up to ∼600 °C but only slowly above this temperature. Storage in air atmosphere post-heat treatment apparently leads to a reequilibration as leachable chloride increases. The presence of a "nonleachable" form of chloride was thus inferred and subsequently confirmed in PuO₂ samples (pre- and post-heat treatment) that were fully dissolved and analyzed for the total chloride inventory. Reheating samples in either air or argon at temperatures up to the first heat treatment temperature did not volatilize significant amounts of additional chloride. With regard to a thermal stabilization process, heat treatment in flowing air at 800 °C with cooling and packaging under dry argon appears optimal, particularly, if thinner powder beds can be maintained. From electron microscopy, heat treatment appeared to have the most effect on degrading the square platelet particles compared to those with the trapezoidal morphology.

The prevalence of community programmes and policies to prevent childhood obesity in a diverse sample of US communities: the Healthy Communities Study

INTRODUCTION

This manuscript describes the prevalence and attributes of community programmes and policies (CPPs) to address childhood obesity documented as occurring in 130 diverse US communities.

METHODS

Key informant interviews (N = 1420) and document abstraction were used to identify and characterize CPPs to promote physical activity and healthy nutrition occurring during a 10-year retrospective study period. Data were collected in 2013-2015 and analysed in 2016.

RESULTS

Across all 130 communities, 9681 distinct CPPs were reported as occurring by key informants. Of these, 5574 (58%) focused on increasing physical activity, 2596 (27%) on improving nutrition and 1511 (16%) on both behaviours. The mean number of CPPs per community was 74.0, with a range of 25 to 295 across all communities. Most CPPs occurred more than once (63%) and on average lasted 6.1 years. The greatest number of reported CPPs occurred in school settings (44%).

CONCLUSIONS

Communities showed a wide range of investment in the amount of CPPs occurring in settings that affect opportunities for children to engage in physical activity and healthy nutrition. The pattern of implementation of CPPs showed variation over time, with an increase in more recent years. This observational study provides new and valuable information about what US communities are doing to prevent childhood obesity.

The longitudinal relationship between community programmes and policies to prevent childhood obesity and BMI in children: the Healthy Communities Study

BACKGROUND

Although a national epidemic of childhood obesity is apparent, how community-based programmes and policies (CPPs) affect this outcome is not well understood.

OBJECTIVES

This study examined the longitudinal relationship between the intensity of CPPs in 130 communities over 10 years and body mass index (BMI) of resident children. We also examined whether these relationships differ by key family or community characteristics.

METHODS

Five thousand one hundred thirty-eight children in grades K-8 were recruited through 436 schools located within 130 diverse US communities. Measures of height, weight, nutrition, physical activity and behavioural and demographic family characteristics were obtained during in-home visits. A subsample of families consented to medical record review; these weight and height measures were used to calculate BMI over time for 3227 children. A total of 9681 CPPs were reported during structured interviews of 1421 community key informants, and used to calculate a time series of CPP intensity scores within each community over the previous decade. Linear mixed effect models were used to assess longitudinal relationships between childhood BMI and CPP intensity.

RESULTS

An average BMI difference of 1.4 kg/m² (p-value < 0.01) was observed between communities with the highest and lowest observed CPP intensity scores, after adjusting for community and child level covariates. BMI/CPP relationships differed significantly by child grade, race/ethnicity, family income and parental education; as well as community-level race/ethnicity.

CONCLUSIONS

These results indicate that, over time, more intense CPP interventions are related to lower childhood BMI, and that there are disparities in this association by sociodemographic characteristics of families and communities.

022 Piloting home infusions of natalizumab: a randomised crossover trial

Introduction

For people with multiple sclerosis, monthly infusions at specialist clinics are time consuming, potentially costly and restrictive. Conversely, increased demand for hospital services is driving innovation, including delivery of care in the home. We developed a rigorous model of care for home infusions of natalizumab, which was evaluated in a randomised crossover trial. This pilot study (i) tested feasibility and safety of home infusions, and (ii) compared acceptability and clinical effectiveness with usual clinic-based care in a hospital outpatients clinic.

Methods

We recruited 37 stable adult patients (at least 6 prior natalizumab infusions and assessed as safe by their neurologist) who were randomised to an AB or BA trial arm. After 3 infusions, patients crossed over to the alternate treatment for another 3 infusions. The following outcomes were assessed treatment adherence, patient safety outcomes, quality of life (Multiple Sclerosis Quality of Life Inventory, MSQLI), and patient satisfaction (Treatment Satisfaction Questionnaire for Medication, TSQM).

Results

Two patients moved out of Adelaide and withdrew. No adverse events resulting from the infusion in either the home or clinic setting were reported. There was no difference between home and clinic in the adherence rate (86/104, 82.7% at home) and (84/103, 81.6% at clinic) (X2=0.0, p=1.0) and number of infections during home care8 compared to clinic10 (X2=0.04, p=0.84). There was no difference in any of the nine sub-scales of the MSQLI (p>0.05). Of the four sub-scales of the TSQM (‘Effectiveness’, ‘Side effects’, ‘Convenience’, ‘Global satisfaction’), patients most recently receiving home care were significantly more satisfied with the Convenience of their treatment (p=0.0008).

Conclusion

Data from the pilot study suggest that delivery of infusions of natalizumab at home is feasible, safe and as effective as the hospital setting. Patients reported that home infusions were more convenient than the clinic.

A review of CDC's Web-based Injury Statistics Query and Reporting System (WISQARS™): Planning for the future of injury surveillance

INTRODUCTION

The Centers for Disease Control and Prevention (CDC) developed the Web-based Injury Statistics Query and Reporting System (WISQARS^TM) to meet the data needs of injury practitioners. In 2015, CDC completed a Portfolio Review of this system to inform its future development.

METHODS

Evaluation questions addressed utilization, technology and innovation, data sources, and tools and training. Data were collected through environmental scans, a review of peer-reviewed and grey literature, a web search, and stakeholder interviews.

RESULTS

Review findings led to specific recommendations for each evaluation question.

RESPONSE

CDC reviewed each recommendation and initiated several enhancements that will improve the ability of injury prevention practitioners to leverage these data, better make sense of query results, and incorporate findings and key messages into prevention practices.

DRO1 influences root system architecture in Arabidopsis and Prunus species

Roots provide essential uptake of water and nutrients from the soil, as well as anchorage and stability for the whole plant. Root orientation, or angle, is an important component of the overall architecture and depth of the root system; however, little is known about the genetic control of this trait. Recent reports in Oryza sativa (rice) identified a role for DEEPER ROOTING 1 (DRO1) in influencing the orientation of the root system, leading to positive changes in grain yields under water-limited conditions. Here we found that DRO1 and DRO1-related genes are present across diverse plant phyla, and fall within the IGT gene family. The IGT family also includes TAC1 and LAZY1, which are known to affect the orientation of lateral shoots. Consistent with a potential role in root development, DRO1 homologs in Arabidopsis and peach showed root-specific expression. Promoter-reporter constructs revealed that AtDRO1 is predominantly expressed in both the root vasculature and root tips, in a distinct developmental pattern. Mutation of AtDRO1 led to more horizontal lateral root angles. Overexpression of AtDRO1 under a constitutive promoter resulted in steeper lateral root angles, as well as shoot phenotypes including upward leaf curling, shortened siliques and narrow lateral branch angles. A conserved C-terminal EAR-like motif found in IGT genes was required for these ectopic phenotypes. Overexpression of PpeDRO1 in Prunus domestica (plum) led to deeper-rooting phenotypes. Collectively, these data indicate a potential application for DRO1-related genes to alter root architecture for drought avoidance and improved resource use.

The Effects of Scaphoid and Colles Casts on Hand Function

Although necessary for bone healing, immobilisation temporarily prevents hand function and may necessitate corrective physiotherapy later. Scaphoid and Colles casts are both commonly used to immobilize scaphoid fractures. Non-union rates are comparable with both casts. The Scaphoid cast incorporates the thumb, whereas the Colles cast leaves the thumb free. We compared the effect of the two casts on hand function in 20 healthy right-hand-dominant volunteers using the Jebsen–Taylor Hand Function Test. Data were obtained through a mixed between and within subject design. Both casts prolonged the time taken to complete the hand function test compared to controls. Testing in the Scaphoid cast took significantly longer than in the Colles cast.

Optically excited nanoscale ultrasonic transducers

In order to work at higher ultrasonic frequencies, for instance, to increase the resolution, it is necessary to fabricate smaller and higher frequency transducers. This paper presents an ultrasonic transducer capable of being made at a very small size and operated at GHz frequencies. The transducers are activated and read optically using pulsed lasers and without physical contact between the instrumentation and the transducer. This removes some of the practical impediments of traditional piezoelectric architectures (such as wiring) and allows the devices to be placed immediately on or within samples, reducing the significant effect of attenuation which is very strong at frequencies above 1 GHz. The transducers presented in this paper exploit simultaneous optical and mechanical resonances to couple the optical input into ultrasonic waves and vice versa. This paper discusses the mechanical and optical design of the devices at a modest scale (a few μm) and explores the scaling of the transducers toward the sub-micron scale. Results are presented that show how the transducers response changes depending on its local environment and how the resonant frequency shifts when the transducer is loaded by a printed protein sample.

Reconstructing Velocities of Migrating Birds from Weather Radar – A Case Study in Computational Sustainability

Bird migration occurs at the largest of global scales, but monitoring such movements can be challenging. In the US there is an operational network of weather radars providing freely accessible data for monitoring meteorological phenomena in the atmosphere. Individual radars are sensitive enough to detect birds, and can provide insight into migratory behaviors of birds at scales that are not possible using other sensors. Archived data from the WSR-88D network of US weather radars hold valuable and detailed information about the continent-scale migratory movements of birds over the last 20 years. However, significant technical challenges must be overcome to understand this information and harness its potential for science and conservation. We describe recent work on an AI system to quantify bird migration using radar data, which is part of the larger BirdCast project to model and forecast bird migration at large scales using radar, weather, and citizen science data.

Recovery rates, enhanced oil recovery and technological limits

Enhanced oil recovery (EOR) techniques can significantly extend global oil reserves once oil prices are high enough to make these techniques economic. Given a broad consensus that we have entered a period of supply constraints, operators can at last plan on the assumption that the oil price is likely to remain relatively high. This, coupled with the realization that new giant fields are becoming increasingly difficult to find, is creating the conditions for extensive deployment of EOR. This paper provides a comprehensive overview of the nature, status and prospects for EOR technologies. It explains why the average oil recovery factor worldwide is only between 20% and 40%, describes the factors that contribute to these low recoveries and indicates which of those factors EOR techniques can affect. The paper then summarizes the breadth of EOR processes, the history of their application and their current status. It introduces two new EOR technologies that are beginning to be deployed and which look set to enter mainstream application. Examples of existing EOR projects in the mature oil province of the North Sea are discussed. It concludes by summarizing the future opportunities for the development and deployment of EOR.

Endoscopic Ultrasound-Fine Needle Aspiration versus Core Biopsy for the Diagnosis of Subepithelial Tumors

Subepithelial lesions are frequently encountered and remain a diagnostic challenge. Imaging of subepithelial lesions using endoscopic ultrasound (EUS) can be helpful in narrowing the differential diagnosis of the lesion; however, definitive diagnosis typically requires tissue. Many methods for acquiring tissue exist including EUS-guided fine needle aspiration, Trucut biopsy, and fine needle biopsy. Obtaining adequate tissue is important for cytologic and histologic exams including immunohistochemical stains, thus a great deal of effort has been made to increase tissue acquisition in order to improve diagnostic yield in subepithelial lesions.

Novel immunologic classification of aspergillosis in adult cystic fibrosis

BACKGROUND

Patients with cystic fibrosis (CF) demonstrate a wide range of hypersensitivity responses to Aspergillus, beyond allergic bronchopulmonary aspergillosis, which require classification.

OBJECTIVE

This study integrated 2 new methods of Aspergillus detection-sputum galactomannan (GM) and real-time PCR-alongside established serologic markers, to reclassify aspergillosis in CF.

METHODS

A total of 146 adult patients with CF had serologic tests (ImmunoCap total IgE, specific Aspergillus fumigatus IgE, and specific A fumigatus IgG), sputum real-time Aspergillus PCR, and sputum GM. Patients were classified by using latent class analysis.

RESULTS

Both RT-PCR and GM were more sensitive than culture in detecting Aspergillus in sputum (culture 37%, RT-PCR 74%, and GM 46%). Intraassay and interassay reproducibility of PCR and GM was excellent. Latent class analysis of triazole-naive patients identified a nondiseased group and 3 disease classes: class 1 (n = 49, 37.7%) represented patients with or without positive RT-PCR but no immunologic response to A fumigatus and negative GM (nondiseased); class 2 (n = 23, 17.7%) represented patients with positive RT-PCR, elevated total and specific A fumigatus IgE/IgG, and positive GM (serologic allergic bronchopulmonary aspergillosis); class 3 (n = 19, 14.6%) represented patients with or without positive RT-PCR, elevated A fumigatus IgE (not IgG), and negative GM (Aspergillus sensitized); and class 4 (n = 39, 30%) represented patients with positive RT-PCR, elevated A fumigatus IgG (not IgE), and positive GM (Aspergillus bronchitis).

CONCLUSIONS

Three distinct classes of aspergillosis in CF were identified by latent class analysis by using serologic, RT-PCR, and GM data. This novel classification will facilitate improved phenotyping, pathogenesis studies, and management evaluations.

Complex trauma and intimate relationships: the impact of shame, guilt and dissociation

BACKGROUND

This study examined dissociation, shame, guilt and intimate relationship difficulties in those with chronic and complex PTSD. Little is known about how these symptom clusters interplay within the complex PTSD constellation. Dissociation was examined as a principle organizing construct within complex PTSD. In addition, the impact of shame, guilt and dissociation on relationship difficulties was explored.

METHODS

Sixty five treatment-receiving adults attending a Northern Irish service for conflict-related trauma were assessed on measures of dissociation, state and trait shame, behavioral responses to shame, state and trait guilt, complex PTSD symptom severity and relationship difficulties.

RESULTS

Ninety five percent (n=62) of participants scored above cut-off for complex PTSD. Those with clinical levels of dissociation (n=27) were significantly higher on complex PTSD symptom severity, state and trait shame, state guilt, withdrawal in response to shame and relationship preoccupation than subclinical dissociators (n=38). Dissociation and state and trait shame predicted complex PTSD. Fear of relationships was predicted by dissociation, complex PTSD and avoidance in response to shame, while complex PTSD predicted relationship anxiety and relationship depression.

LIMITATIONS

The study was limited to a relatively homogeneous sample of individuals with chronic and complex PTSD drawn from a single service.

CONCLUSIONS

Complex PTSD has significant consequences for intimate relationships, and dissociation makes an independent contribution to these difficulties. Dissociation also has an organizing effect on complex PTSD symptoms.

Endoscopic management of malignant bile duct strictures

Malignant biliary obstruction can arise from intrahepatic, extrahepatic, and hilar locations from either primary or metastatic disease. Biliary-enteric surgical bypass has been surpassed in the last 20 years by endoscopic balloon dilation and stenting. The goal of stenting for biliary decompression is to palliate obstructive symptoms; it has not been shown that survival is affected by stenting alone. Novel endoscopic therapies, including photodynamic therapy and radiofrequency ablation, have been evaluated and show promise. Both therapies seem to be safe and effective in the treatment of malignant bile duct strictures but are in need of prospective studies of longer duration.

Can early Burkholderia cepacia complex infection in cystic fibrosis be eradicated with antibiotic therapy?

Introduction: Organisms of the Burkholderia cepacia complex (BCC) are important pathogens in cystic fibrosis (CF). The majority of those who acquire BCC develop chronic infection but it can also result in rapid decline in a significant minority. In addition, chronic infection with Burkholderia cenocepacia in particular is regarded as a contraindication to lung transplantation in many units. Whilst aggressive antibiotic therapy is employed in CF to eradicate Pseudomonas aeruginosa before infection becomes irreversibly established, no formal assessment of such strategies has been previously reported for BCC, despite the apparent widespread adoption of this practice. Methods: UK adult CF centers were surveyed about their current approach to new BCC infection. Outcomes of eradication therapy were assessed in patients attending the Manchester Adult CF Center with new BCC isolates between 1st January 2002 and 1st May 2011. Patients with previous infection with the same strain of BCC were excluded. BCC were identified at the national reference laboratories and confirmed by species-specific PCR and RecA sequencing. Results: Routine use of therapies to attempt eradication of new BCC is commonly used in the UK (12/17 centers who responded). This typically involves a combination of intravenous and nebulised antibiotics. Of 19 eligible cases of new BCC infection, the organism has been eradicated in 7 (37%). Three of these did not receive specific eradication therapy. Of 14 patients who have received eradication therapy and completed follow up, BCC were cleared in only 4 (29%). Conclusions: Attempted eradication of new BCC is a common practice in UK adult CF centers. A minority of patients clear the infection spontaneously and the effects of eradication therapies are at best modest. Early treatment may be associated with better outcomes, though there are insufficient data to support the use of any specific treatment regimen. A prospective, systematic evaluation of treatments and outcomes is required.

Reliability and validity of a single item measure of quality of life scale for adult patients with cystic fibrosis

BACKGROUND

It is important to monitor health related quality of life in order to determine the efficacy of interventions and physical functioning of patients with cystic fibrosis in their daily activities. There is no a single-item global quality of life scale for routine clinical practice for adult patients with cystic fibrosis. We assessed the reliability and validity of a single-item global quality of life scale and compared with the Cystic Fibrosis Quality of Life Questionnaire (CF-QOL) for adult patients with cystic fibrosis.

METHOD

121 (men = 66, women = 55) adult cystic fibrosis patients self-completed the CF-QOL, the Hospital Anxiety Depression Scale, and the single item global quality of life scale at the out patient clinic. 33 (17 women) completed the repeat questionnaires at home within two weeks. Socio-demographic characteristic and lung function data were extracted from the recent medical notes.

RESULTS

Mean (SD) age was 29.6 (8.9) years and mean (SD) forced expiratory volume in 1 second was 2.20 (0.94) litres. The test-retest reproducibility using the intra-class correlation coefficient (ICC) for the CF-QOL was 0.83, 95% confidence interval 0.68 to 0.91. The single item global quality of life ICC score was 0.78, 95% confidence interval 0.59 to 0.88. Concurrent validity of the single-item global quality of life was examined in relation to all items of the CF-QOL, frequent episodes of readmission, anxiety and depression (all, p < 0.01) were moderately correlated.

CONCLUSION

The study provides preliminary evidence that the single-item quality of life scale is acceptable, valid and repeatable for adult patients with cystic fibrosis. It is a promising tool that can be easily incorporated into a routine clinical practice to assess patients' quality of life.