1006 Sleep Problems and Risk of Cancer Incidence and Mortality in the Cardiovascular Health Study (CHS)

Introduction

Even in the absence of a formal diagnosis, sleep problems (SP) are frequently indicative of an underlying sleep disorder, such as obstructive sleep apnea, which may be adversely associated with cancer risk and cancer outcomes.

Methods

We assessed the association of self-reported SP with incident cancer (N=4,997, excluding prevalent cancers) and cancer mortality (N=5849) among the participants of Cardiovascular Health Study (CHS), a population-based study of adults aged >=65 years recruited from 4 US communities. Participants reported SP (daytime sleepiness, observed apnea and snoring) yearly from 1989-1994; these self-reported symptoms have been validated against objective sleep measures assessed within a subset of CHS participants (n= 1240) who received a home polysomnography as part of the Sleep Heart Health Study. Cancer incidence was ascertained through linkage with state cancer registries through 2005; cancer specific death was adjudicated through 2015. We used Cox proportional hazards regression to calculate hazard ratios (HR) and 95% confidence intervals (CI) for associations of baseline SP with subsequent cancer incidence and cancer mortality, adjusting for baseline sociodemographics, lifestyle factors, and medical history.

Results

The mean age (SD) of the study population was 73 (6) years, 56% were female, and 84% were white. The prevalence of SP was 17% for daytime sleepiness, 8% for observed apnea, and 24% for snoring; 63% reported none of the 3 SP. Overall, 1,130 first incident cancers and 1,014 cancer deaths were identified over median follow-up of 12 and 13 years, respectively. Compared to participants who reported no SP, the risk of incident cancer was inversely associated with daytime sleepiness (HR 0.86 [95% CI 0.70-1.04]), observed apnea (HR 0.74 [0.56-1.00]), and snoring (HR 0.80 [0.68-0.95]). Cancer mortality HR (95% CI) estimates were 1.00 (0.82-1.21) for daytime sleepiness, 0.77 (0.57-1.04) for observed apnea, and 0.88 (0.74, 1.04) for snoring.

Conclusion

Symptoms indicating SP reported at baseline were not associated with increased cancer incidence or cancer mortality. Ongoing analyses are focused on the impact of longitudinal SP (time dependent, cumulative average) to ensure an adequate latency period is incorporated into our analysis of the association between SP and cancer risk and mortality.

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NIHT32CA09488017

In Vitro Enzymatic Degradation of Tissue Grafts and Collagen Biomaterials by Matrix Metalloproteinases: Improving the Collagenase Assay

Matrix metalloproteinase-1 and -8 are active during the wound healing and remodelling processes, degrading native extracellular matrix and implantable devices. However, traditional in vitro assays utilize primarily matrix metalloproteinase-1 to mimic the in vivo degradation microenvironment. Herein, we assessed the influence of various concentrations of matrix metalloproteinase- 1 and 8 (50, 100, and 200 U/mL) as a function of pH (5.5 and 7.4) and time (3, 6, 9, 12, and 24 h) on the degradation profile of three tissue grafts (chemically cross-linked Permacol, nonchemically cross-linked Permacol and nonchemically cross-linked Strattice) and a collagen biomaterial (nonchemically cross-linked collagen sponge). Chemically cross-linked and nonchemically cross-linked Permacol samples exhibited the highest resistance to enzymatic degradation, while nonchemically cross-linked collagen sponges exhibited the least resistance to enzymatic degradation. Qualitative and quantitative degradation analysis of all samples revealed a similar degradation profile over time, independently of the matrix metalloproteinase used and its respective concentration and pH. These data indicate that matrix metalloproteinase-1 and matrix metalloproteinase-8 exhibit similar degradation profile in vitro, suggesting that matrix metalloproteinase-8 should be used for collagenase assay.

The past, present and future in scaffold-based tendon treatments

Tendon injuries represent a significant clinical burden on healthcare systems worldwide. As the human population ages and the life expectancy increases, tendon injuries will become more prevalent, especially among young individuals with long life ahead of them. Advancements in engineering, chemistry and biology have made available an array of three-dimensional scaffold-based intervention strategies, natural or synthetic in origin. Further, functionalisation strategies, based on biophysical, biochemical and biological cues, offer control over cellular functions; localisation and sustained release of therapeutics/biologics; and the ability to positively interact with the host to promote repair and regeneration. Herein, we critically discuss current therapies and emerging technologies that aim to transform tendon treatments in the years to come.

The effects of a community-based partnership, Project Access Dallas (PAD), on emergency department utilization and costs among the uninsured

BACKGROUND

Approximately 19% of non-elderly adults are without health insurance. The uninsured frequently lack a source of primary care and are more likely to use the emergency department (ED) for routine care. Improving access to primary care for the uninsured is one strategy to reduce ED overutilization and related costs.

METHODS

A comparison group quasi-experimental design was used to evaluate a broad-based community partnership that provided access to care for the uninsured-Project Access Dallas (PAD)-on ED utilization and related costs. Eligible uninsured patients seen in the ED were enrolled in PAD (n = 265) with similar patients not enrolled in PAD (n = 309) serving as controls. Study patients were aged 18-65 years, <200% of the federal poverty level and uninsured. Outcome measures include the number of ED visits, hospital days and direct and indirect costs.

RESULTS

PAD program enrollees had significantly fewer ED visits (0.93 vs. 1.44; P < 0.01) and fewer inpatient hospital days (0.37 vs. 1.07; P < 0.05) than controls. Direct hospital costs were ∼60% less ($1188 vs. $446; P < 0.01) and indirect costs were 50% less ($313 vs. $692; P < 0.01).

CONCLUSIONS

A broad-based community partnership program can significantly reduce ED utilization and related costs among the uninsured.

Incidental hemangioblastoma of the filum terminale

Filum terminale hemangioblastoma is an extremely rare tumour with only a few case reports in the literature. The natural history is unknown but benign as well as more aggressive presentations have been reported. The authors present the first such lesion discovered incidentally and discuss the available literature.

ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE

OBJECTIVE

To compare the relative efficacy of electroconvulsive therapy (ECT) in psychotic and nonpsychotic patients with unipolar major depression.

METHODS

The outcome of an acute ECT course in 253 patients with nonpsychotic (n = 176) and psychotic (n = 77) unipolar major depression was assessed in the first phase of an ongoing National Institute of Mental Health-supported four-hospital collaborative study of continuation treatments after successful ECT courses. ECT was administered with bilateral electrode placement at 50% above the titrated seizure threshold. The remission criteria were rigorous: a score <or=10 on the 24-item Hamilton Rating Scale for Depression (HRSD) after 2 consecutive treatments, and a decrease of at least 60% from baseline.

RESULTS

The overall remission rate was 87% for study completers. Among these, patients with psychotic depression had a remission rate of 95% and those with nonpsychotic depression, 83%. Improvement in symptomatology, measured by the HRSD, was more robust and appeared sooner in the psychotic patients compared with the nonpsychotic patients.

CONCLUSION

Bilateral ECT is effective in relieving severe major depression. Remission rates are higher and occur earlier in psychotic depressed patients than in nonpsychotic depressed patients. These data support the argument that psychotic depression is a distinguishable nosological entity that warrants separate treatment algorithms.

Phase II study of thalidomide in the treatment of recurrent glioblastoma multiforme

Treatment options and prognosis remains poor for patients with recurrent glioblastoma multiforme. These tumors are highly vascularised and over express angiogenic factors such as vascular endothelial growth factor and may potentially be responsive to antiangiogenic therapies. We present the results of a phase II trial of Thalidomide, an antiangiogenic agent, in the treatment of recurrent glioblastoma multiforme. Patients were treated with 100 mg/day of Thalidomide, increased at weekly intervals by 100 mg to a maximum tolerated dose of 500 mg/d. Forty-two patients were enrolled, with 38 patients being assessable for response and 39 for toxicity. Two patients (5%) achieved a partial response and 16 (42%) had stable disease. The median survival was 31 weeks and the 1-year survival was 35%. Patients who had a partial response or stable disease had either a stabilisation or improvement in quality of life scores or performance status. Overall Thalidomide was well tolerated with no grade 4 toxicities and no treatment related deaths. The median maximum tolerated dose was 300 mg/day. The most common toxicity was fatigue to which patients developed tachyphylaxis. There was no correlation demonstrated with plasma vascular endothelial growth factor levels and response or survival. Thalidomide is a well-tolerated drug that may have some activity in the treatment of recurrent glioblastoma. Optimum dosing with antiangiogenic agents is currently under investigation. Chronic low dose therapy may be required to see conventional responses or improvements in time to progression. The dose required to achieve optimal biological impact may be better defined once we have established reliable surrogate endpoints.

The application of prompt-gamma neutron activation analysis to borehole logging for coal

The PGNAA technique was tested for the in-situ determination of ash, Fe, Si, Al and density of coal seams in water-filled boreholes. The technique is also able to determine in situ the deformation temperature of coals for which a correlation exists between the deformation temperature and the percentage of Al, Si and Fe present in coal. The logging tool employed a 2.5 microg 252Cf neutron source.

Genital injuries following sexual assault of women with and without prior sexual intercourse experience

BACKGROUND

The literature on sexual assault has not directly addressed the question of genital injuries in women without prior sexual intercourse experience. Given the paucity of research and the current importance of physical evidence in the criminal justice system, this study was designed to document the type and site of genital injuries from sexual assault in women without and with prior sexual intercourse experience.

METHODS

The charts were reviewed of 132 women who had been sexually assaulted and had sought medical treatment at the Sexual Assault Care Centre (SACC), Women's College Hospital, Toronto, within 10 days after the assault. Half (66) of the women reported that, at the time of the assault, they had no prior sexual intercourse experience. The Sexual Assault Evidence Kit in each patient's file was reviewed to ascertain the type and location of genital injuries. Types of injuries were classified into 3 categories (nonperforating soft-tissue injuries, lacerations or current bleeding) and locations into 6 categories (labia majora and minora, posterior fourchette and introitus, hymen, vagina, cervix, and anus).

RESULTS

Significantly more women without than with prior sexual intercourse experience had visible genital injuries (65.2% v. 25.8%, p < 0.01). However, of the women without prior experience, only 9.1% had hymenal perforation. Analyses of the data for only women with genital injuries indicated no difference between those without and those with prior sexual intercourse experience in the overall mean number of injured sites (1.65 and 1.47 respectively) or in the mean number of sites with nonperforating soft-tissue injuries (0.349 and 0.706), lacerations (0.953 and 0.471) and bleeding (0.279 and 0.294).

INTERPRETATION

The results suggest that genital injuries are more common in women without prior sexual intercourse experience but that substantial proportions of all women, regardless of their prior sexual experience at the time of assault, will not have visible genital injuries. Emergency department staff and members of the criminal justice system need to be aware of the variable presentation of genital trauma related to sexual assault in women with and without prior sexual intercourse experience.

Interviewing children about trauma: problems with "specific" questions

A methodological ambiguity is described that may well adversely affect the quality of information provided by young child witnesses. Because the information children provide during interviews is sometimes the only evidence in forensic situations, its quality is a serious concern. "Specific" questions are often necessary to elicit enough information, but we describe a confusion between wh- questions (which request particular information) and yes/no questions (which merely require confirmation or disconfirmation). Research in which children are systematically interviewed about stressful medical experiences is reviewed, and we present results of a pilot investigation in which 2- to 13-year-old children were interviewed about traumatic injuries necessitating hospital treatment. Yes/no questions were problematic for preschoolers. Implications for testimony are discussed.

Phytosterolaemia in three unrelated South African families

Phytosterolaemia (beta-sitosterolaemia), a rare, autosomal recessive disorder, has not hitherto been reported in Southern Africa. We report four new homozygous patients, from three unrelated families with significant beta-sitosterolaemia (6.6-11.3%), campesterolaemia (2.2-4.6%) and clearly detectable, though unquantified, levels of cholestanol. Three of the four patients had characteristic cutaneous and tendinous xanthomas within the first decade of life. The fourth patient, a 5 year old, was free of xanthomas despite persistently elevated concentrations of plant sterols in her plasma. All our patients were female bringing the male:female ratio in reported cases to 8:23. All were at or below the 50th percentile for height and weight, and presented at some stage with borderline, hypochromic anaemia associated with red cell abnormalities and thrombocytopaenia. The oldest patient showed suggestive clinical evidence of atherosclerosis affecting her aorta, ileofemoral bifurcation and possibly coronary arteries. All homozygotes responded to a diet restricted in phytosterols and the administration of cholestyramine with falls in plasma sterols of up to 68%. The recent discovery of a possible inherited defect in the synthesis of HMG CoA reductase in patients with phytosterolaemia makes this disorder a model system for studying the biological role of this enzyme in regulating the absorption and clearance of sterols other than cholesterol, and the factors governing the sterol composition of cell membranes.

The automated implantable cardioverter

The automatic implantable cardioverter defibrillatory (AICD) is becoming the treatment of choice for patients with ventricular tachycardia and ventricular fibrillation. The widespread use of the AICD is requiring nurses in a variety of settings to become familiar with the device and device-patient interactions. This article attempts to define specific issues and nursing interventions relative to the AICD.