Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Abstract ES8-3: Does breast cancer prevention need an 18th amendment? New evidence on alcohol and breast cancer

Epidemiological studies have consistently supported an association between alcohol consumption and breast cancer risk for many years. Breast cancer guidelines from many societies, including the American Cancer Society, have also discussed reducing alcohol consumption to help prevent breast cancer. So why aren't more women aware of this association? This talk will review the latest evidence, including more recent mechanistic studies, about the association between alcohol intake and breast cancer as well as newer data about the lack of cardio protective benefit of modest alcohol intake. What evidence do we now have about whether the association with breast cancer risk and outcomes after diagnosis varies by time in life and intensity of drinking patterns?

Citation Format: Terry M. Does breast cancer prevention need an 18th amendment? New evidence on alcohol and breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr ES8-3.

Efficacy of a universal smoking cessation intervention initiated in inpatient psychiatry and continued post-discharge: A randomised controlled trial

OBJECTIVE

Interventions are required to redress the disproportionate tobacco-related health burden experienced by persons with a mental illness. This study aimed to assess the efficacy of a universal smoking cessation intervention initiated within an acute psychiatric inpatient setting and continued post-discharge in reducing smoking prevalence and increasing quitting behaviours.

METHOD

A randomised controlled trial was undertaken across four psychiatric inpatient facilities in Australia. Participants ( N = 754) were randomised to receive either usual care ( n = 375) or an intervention comprising a brief motivational interview and self-help material while in hospital, followed by a 4-month pharmacological and psychosocial intervention ( n = 379) upon discharge. Primary outcomes assessed at 6 and 12 months post-discharge were 7-day point prevalence and 1-month prolonged smoking abstinence. A number of secondary smoking-related outcomes were also assessed. Subgroup analyses were conducted based on psychiatric diagnosis, baseline readiness to quit and nicotine dependence.

RESULTS

Seven-day point prevalence abstinence was higher for intervention participants (15.8%) than controls (9.3%) at 6 months post-discharge (odds ratio = 1.07, p = 0.04), but not at 12 months (13.4% and 10.0%, respectively; odds ratio = 1.03, p = 0.25). Significant intervention effects were not found on measures of prolonged abstinence at either 6 or 12 months post-discharge. Differential intervention effects for the primary outcomes were not detected for any subgroups. At both 6 and 12 months post-discharge, intervention group participants were significantly more likely to smoke fewer cigarettes per day, have reduced cigarette consumption by ⩾50% and to have made at least one quit attempt, relative to controls.

CONCLUSIONS

Universal smoking cessation treatment initiated in inpatient psychiatry and continued post-discharge was efficacious in increasing 7-day point prevalence smoking cessation rates and related quitting behaviours at 6 months post-discharge, with sustained effects on quitting behaviour at 12 months. Further research is required to identify strategies for achieving longer term smoking cessation.

Penetrating abdominal injury: UK military experience from the Afghanistan conflict

AIMS

To identify the prevalence, injury patterns and mortality of penetrating abdominal injury in patients treated at the UK Role 3 Medical Treatment Facility (MTF) in Camp Bastion, Afghanistan.

METHODS

All patients with a penetrating abdominal injury were identified from the UK Joint Theatre Trauma Registry (JTTR). Demographics, predicted survival and observed mortality were compared. Sub-group analyses of UK military patients were conducted, comparing changes in survival as the campaign progressed and identifying the anatomical distribution of abdominal injuries.

RESULTS

Between June 2006 and June 2013, 1331 of the 8558 (16%) patients recorded on the JTTR had a penetrating abdominal injury; 393 were UK military, of whom 175 (45%) survived. 71% of UK military fatalities had the maximum New Injury Severity Score (NISS) of 75 compared to 4.6% of UK military survivors. The survival rate of UK military patients increased in the later stages of the campaign. Fatal injury in UK military patients was associated with significant vascular or hepatic injuries.

CONCLUSIONS

This study has defined the epidemiology of penetrating abdominal injury in a modern conflict. Continued training and further research into injury prevention and management will help to ensure that the improved outcomes observed in Afghanistan continue on future operations.

Implementation of a smoke-free policy in an inpatient psychiatric facility: Patient-reported adherence, support, and receipt of nicotine-dependence treatment

The implementation of smoke-free policies in inpatient psychiatric facilities, including patient adherence, mental health nursing staff support, and provision of nicotine-dependence treatment to patients, has been reported to be poor. The extent to which the quality of smoke-free policy implementation is associated with patient views of a policy is unknown. We conducted a cross-sectional survey of 181 patients (53.6%, n = 97 smokers; and 46.4%, n = 84 non-smokers) in an Australian inpatient psychiatric facility with a total smoke-free policy. Smokers' adherence to the policy was poor (83.5% smoked). Only half (53.6%) perceived staff to be supportive of the policy. Most smokers used nicotine-replacement therapy (75.3%); although few received optimal nicotine-dependence treatment (19.6%). Overall, 45.9% of patients viewed the smoke-free policy in the unit as positive (29.9% smokers; 64.3% non-smokers). For smokers, adhering to the ban, perceiving staff to be supportive, and reporting that the nicotine-replacement therapy reduced cravings to smoke were associated with a more positive view towards the smoke-free policy. These findings support the importance of patient adherence, mental health nursing staff support, and adequate provision of nicotine-dependence treatment in strengthening smoke-free policy implementation in inpatient psychiatric settings.

Evaluating the efficacy of an integrated smoking cessation intervention for mental health patients: study protocol for a randomised controlled trial

Background

Smoking rates, and associated negative health outcomes, are disproportionately high among people with mental illness compared to the general population. Smoke-free policies within mental health hospitals can positively impact on patients’ motivation and self-efficacy to address their smoking. However, without post-discharge support, preadmission smoking behaviours typically resume. This protocol describes a randomised controlled trial that aims to assess the efficacy of linking mental health inpatients to community-based smoking cessation supports upon discharge as a means of reducing smoking prevalence.

Methods/Design

Eight hundred participants with acute mental illness will be recruited into the randomised controlled trial whilst inpatients at one of four psychiatric inpatient facilities in the state of New South Wales, Australia. After completing a baseline interview, participants will be randomly allocated to receive either: ‘Supported Care’, a multimodal smoking cessation intervention; or ‘Normal Care’, consisting of existing hospital care only. The ‘Supported Care’ intervention will consist of a brief motivational interview and a package of self-help material for abstaining from smoking whilst in hospital, and, following discharge, 16 weeks of motivational telephone-based counselling, 12 weeks of free nicotine replacement therapy, and a referral to the Quitline. Data will be collected at 1, 6 and 12 months post-discharge via computer-assisted telephone interview. The primary outcomes are abstinence from smoking (7-day point prevalence and prolonged cessation), and secondary outcomes comprise daily cigarette consumption, nicotine dependence, quit attempts, and readiness to change smoking behaviour.

Discussion

If shown to be effective, the study will provide evidence in support of systemic changes in the provision of smoking cessation care to patients following discharge from psychiatric inpatient facilities.

Trial registration

Australian New Zealand Clinical Trials Registry ANZTCN: ACTRN12612001042831. Date registered: 28 September 2012.

The impact of a smoke-free psychiatric hospitalization on patient smoking outcomes: a systematic review

OBJECTIVE

Smoke-free policies have been introduced in inpatient psychiatric facilities in most developed nations. Such a period of supported abstinence during hospitalization may impact smoking behaviours post discharge, yet little quantitative evidence exists. The aim of this review was to provide the first synthesis of the research evidence examining the impact of a smoke-free psychiatric hospitalization on patients' smoking-related behaviours, motivation, and beliefs.

METHODS

We conducted a systematic review of electronic databases PubMed, MEDLINE, PsycINFO, and EMBASE from inception to June 2013. Studies were included if they were conducted in an inpatient psychiatric facility with a smoke-free policy and if they examined any change in patients' smoking-related behaviours, motivation, or beliefs either during admission, post discharge, or both. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias Tool.

RESULTS

Fourteen studies were included in the review. Of the four studies that assessed change in smoking from admission to post discharge, two indicated a significant decline in cigarette consumption up to 3 months post discharge. Positive changes in motivation to quit and beliefs about quitting ability were identified in two studies. One study reported an increase in the rate of quit attempts and one reported a decline in nicotine dependence levels.

CONCLUSIONS

A smoke-free psychiatric hospitalization may have a positive impact on patients' smoking-related behaviours, motivation, and beliefs, both during admission and up to 3 months post discharge. Further controlled studies with more rigorous designs are required to confirm this potential.

Smoking cessation care provision and support procedures in Australian community mental health centers

OBJECTIVE

The study assessed the association of supportive clinical systems and procedures with smoking cessation care at community mental health centers.

METHODS

Managers (N=84) of community mental health centers in New South Wales, Australia, were asked to complete a survey during 2009 about smoking cessation care.

RESULTS

Of the 79 managers who responded, 56% reported that the centers assessed smoking for over 60% of clients, and 34% reported that more than 60% of clients received minimum acceptable smoking cessation care. They reported the use of guidelines and protocols (34%), the use of forms to record smoking status (65%), and the practice of always enforcing smoking bans (52%). Minimum acceptable smoking cessation care was associated with encouraging nicotine replacement therapy for staff who smoke (odds ratio [OR]=9.42), using forms for recording smoking status (OR=5.80), and always enforcing smoking bans (OR=3.82).

CONCLUSIONS

Smoking cessation care was suboptimal, and additional supportive systems and procedures are required to increase its delivery.

Readiness to quit smoking and quit attempts among Australian mental health inpatients

INTRODUCTION

Mental health inpatients smoke at higher rates than general population smokers. However, provision of nicotine-dependence treatment in inpatient settings is low, with barriers to the provision of such care including staff views that patients do not want to quit. This paper reports the findings of a survey of mental health inpatients at a psychiatric hospital in New South Wales, Australia, assessing smoking and quitting motivations and behaviors.

METHODS

Smokers (n = 97) were surveyed within the inpatient setting using a structured survey tool, incorporating the Fagerström Test for Nicotine Dependence, Reasons for Quitting Scale, Readiness and Motivation to Quit Smoking Questionnaire, and other measures of smoking and quitting behavior.

RESULTS

Approximately 47% of smokers reported having made at least one quit attempt within the past 12 months, despite nearly three quarters (71.2%) being classified as in a "precontemplative" stage of change. Multinomial logistic regressions revealed that self-reporting "not enjoying being a smoker" and having made a quit attempt in the last 12 months predicted having advanced beyond a precontemplative stage of change. A high self-reported desire to quit predicted a quit attempt having been made in the last 12 months.

CONCLUSIONS

The majority of smokers had made several quit attempts, with a large percentage occurring recently, suggesting that the actual quitting behavior should be considered as an important indication of the "desire to quit." This paper provides further data supporting the assertion that multimodal smoking cessation interventions combining psychosocial and pharmacological support should be provided to psychiatric inpatients who smoke.

Terminal differentiation and loss of tumorigenicity of human cancers via pluripotency-based reprogramming

Pluripotent cells can be derived from various types of somatic cells by nuclear reprogramming using defined transcription factors. It is, however, unclear whether human cancer cells can be similarly reprogrammed and subsequently terminally differentiated with abrogation of tumorigenicity. Here, using sarcomas we show that human-derived complex karyotype solid tumors: (1) can be reprogrammed into a pluripotent-like state as defined by all in vitro criteria used to define pluripotent stem cells generated from somatic cells; (2) can be terminally differentiated into mature connective tissue and red blood cells; and (3) terminal differentiation is accompanied with loss of both proliferation and tumorigenicity. We go on to perform the first global DNA promoter methylation and gene expression analyses comparing human cancers to their reprogrammed counterparts and report that reprogramming/differentiation results in significant epigenetic remodeling of oncogenes and tumor suppressors, while not significantly altering the differentiation status of the reprogrammed cancer cells, in essence dedifferentiating them to a state slightly before the mesenchymal stem cell differentiation stage. Our data demonstrate that direct nuclear reprogramming can restore terminal differentiation potential to human-derived cancer cells, with simultaneous loss of tumorigenicity, without the need to revert to an embryonic state. We anticipate that our models would serve as a starting point to more fully assess how nuclear reprogramming overcomes the multitude of genetic and epigenetic aberrancies inherent in human cancers to restore normal terminal differentiation pathways. Finally, these findings suggest that nuclear reprogramming may be a broadly applicable therapeutic strategy for the treatment of cancer.

A randomised controlled trial linking mental health inpatients to community smoking cessation supports: a study protocol

BACKGROUND

Mental health inpatients smoke at higher rates than the general population and are disproportionately affected by tobacco dependence. Despite the advent of smoke free policies within mental health hospitals, limited systems are in place to support a cessation attempt post hospitalisation, and international evidence suggests that most smokers return to pre-admission smoking levels following discharge. This protocol describes a randomised controlled trial that will test the feasibility, acceptability and efficacy of linking inpatient smoking care with ongoing community cessation support for smokers with a mental illness.

METHODS/DESIGN

This study will be conducted as a randomised controlled trial. 200 smokers with an acute mental illness will be recruited from a large inpatient mental health facility. Participants will complete a baseline survey and will be randomised to either a multimodal smoking cessation intervention or provided with hospital smoking care only. Randomisation will be stratified by diagnosis (psychotic, non-psychotic). Intervention participants will be provided with a brief motivational interview in the inpatient setting and options of ongoing smoking cessation support post discharge: nicotine replacement therapy (NRT); referral to Quitline; smoking cessation groups; and fortnightly telephone support. Outcome data, including cigarettes smoked per day, quit attempts, and self-reported 7-day point prevalence abstinence (validated by exhaled carbon monoxide), will be collected via blind interview at one week, two months, four months and six months post discharge. Process information will also be collected, including the use of cessation supports and cost of the intervention.

DISCUSSION

This study will provide comprehensive data on the potential of an integrated, multimodal smoking cessation intervention for persons with an acute mental illness, linking inpatient with community cessation support.

An audit of the prevalence of recorded nicotine dependence treatment in an Australian psychiatric hospital

OBJECTIVES

To investigate the prevalence of recorded smoking status, nicotine dependence assessment, and nicotine dependence treatment provision; and to examine the patient characteristics associated with the recording of smoking status.

METHOD

A retrospective systematic medical record audit was conducted of all psychiatric inpatient discharges over a six-month period (1 September 2005 to 28 February 2006), at a large Australian psychiatric hospital, with approximately 2,000 patient discharges per year. A one-page audit tool identifying patient characteristics and prevalence of recorded nicotine dependence treatment, and requiring ICD-10-AM diagnoses coding was used.

RESULTS

From 1,012 identified discharges, 1,000 medical records were available for audit (99%). Documentation of smoking status most frequently occurred on the admission form (28.8%) and diagnoses summary (41.6%). Documentation of nicotine dependence was not found in any record, and recording of any nicotine dependence treatment was negligible (0-0.5%). The rate of recorded smoking status on discharge summaries was 6%. Patients with a diagnosis of alcohol, cannabis, sedative use disorders or asthma were twice as likely to have their smoking status recorded compared to those who did not have these diagnoses.

CONCLUSIONS

Mental health services, by failing to diagnose and document treatment for nicotine dependence, do not conform to current clinical practice guidelines, despite nicotine dependence being the most commonly diagnosed psychiatric disorder.

IMPLICATIONS

Considerable system change and staff support is required to provide an environment where a primary prevention approach such as smoking care can be sustained.

Total smoking bans in psychiatric inpatient services: a survey of perceived benefits, barriers and support among staff

BACKGROUND

The introduction of total smoking bans represents an important step in addressing the smoking and physical health of people with mental illness. Despite evidence indicating the importance of staff support in the successful implementation of smoking bans, limited research has examined levels of staff support prior to the implementation of a ban in psychiatric settings, or factors that are associated with such support. This study aimed to examine the views of psychiatric inpatient hospital staff regarding the perceived benefits of and barriers to implementation of a successful total smoking ban in mental health services. Secondly, to examine the level of support among clinical and non-clinical staff for a total smoking ban. Thirdly, to examine the association between the benefits and barriers perceived by clinicians and their support for a total smoking ban in their unit.

METHODS

Cross-sectional survey of both clinical and non-clinical staff in a large inpatient psychiatric hospital immediately prior to the implementation of a total smoking ban.

RESULTS

Of the 300 staff, 183 (61%) responded. Seventy-three (41%) of total respondents were clinical staff, and 110 (92%) were non-clinical staff. More than two-thirds of staff agreed that a smoking ban would improve their work environment and conditions, help staff to stop smoking and improve patients' physical health. The most prevalent clinician perceived barriers to a successful total smoking ban related to fear of patient aggression (89%) and patient non-compliance (72%). Two thirds (67%) of all staff indicated support for a total smoking ban in mental health facilities generally, and a majority (54%) of clinical staff expressed support for a ban within their unit. Clinical staff who believed a smoking ban would help patients to stop smoking were more likely to support a smoking ban in their unit.

CONCLUSIONS

There is a clear need to more effectively communicate to staff the evidence that consistently applied smoking bans do not increase patient aggression. There is also a need to communicate the benefits of smoking bans in aiding the delivery of smoking cessation care, and the benefits of both smoking bans and such care in aiding patients to stop smoking.

Providing nicotine dependence treatment to psychiatric inpatients: the views of Australian nurse managers

The prevalence of smoking in psychiatric settings remains high. This study aims to describe the views of nurse managers in psychiatric inpatient settings regarding the provision of nicotine dependence treatment, and whether there were associations between such views and the provision of nicotine dependence treatment. A cross-sectional survey was mailed to all public psychiatric inpatient units in New South Wales, Australia, for completion by nurse managers. Of the identified 131 service units, 123 completed questionnaires were returned (94%). Patient-related factors were considered to have a high level of influence on the provision of nicotine dependence treatment: patients requesting assistance to quit (58%), patients being receptive to interventions (52%), and patient health improving with quitting (45%). Units where the respondent reported that nicotine dependence treatment was as important as other roles were more likely to provide nicotine dependence treatment compared to units whose respondents did not hold this view (OR = 0.257, d.f. = 1, P < 0.01). While the results indicate strong support for the provision of nicotine dependence treatment, this support appears qualified by perceived patient readiness to quit, suggesting care is provided selectively rather than systematically. Positioning smoking as an addiction requiring treatment within a traditional curative approach may lead to a health service more conducive to the routine provision of nicotine dependence treatment.

The impact of preoperative breast magnetic resonance imaging (MRI) on surgical decision-making in young patients with breast cancer

Abstract #4012

Recent data suggests that breast MRI is a more sensitive diagnostic test for detecting invasive breast cancer than mammography or breast ultrasound. Breast MRI may be particularly useful in younger premenopausal women with higher density breast tissue for differentiating between dense fibroglandular breast tissue and breast malignancies. The primary objective of this study was to determine the impact of pre-operative breast MRI on surgical decision-making in young women with breast cancer.&#x2028; Methods: A retrospective review of 32 patients with newly diagnosed invasive breast cancer and age ≤ 50 was performed. All patients underwent a physical examination, preoperative mammogram, breast ultrasound, and bilateral breast MRI. Two breast cancer surgeons reviewed the preoperative mammogram report, breast ultrasound report, and physical examination summary for each case and were asked if they would recommend a lumpectomy, quandrantectomy, or mastectomy. A few weeks later, the two surgeons were shown the same information with the breast MRI report and were asked what type of surgery they would now recommend. In each case, MRI was classified by two adjudicators as having affected the surgical outcome in a positive, negative, or neutral fashion. A 'Positive Impact' was defined as the situation where breast MRI detected additional disease that was not found on physical exam, mammogram, or breast ultrasound and led to an appropriate change in surgical management. A 'Negative Impact' was defined as the situation where the breast MRI results led the surgeon to recommend more extensive surgery, with less extensive disease actually found at pathology. 'No Impact' was defined as the situation where MRI findings did not alter surgical recommendations or outcome.&#x2028; Results: The median age was 41.5 years. The pathologic diagnosis was invasive ductal carcinoma in 94% (30/32) and invasive lobular carcinoma in 6% (2/32) of cases. For surgeon A, clinical management was altered in 21/32 (66%) of cases, and for surgeon B, management was altered in 13/32 (41%) of cases. The most common change in surgical decision-making after breast MRI was from breast conserving surgery to a mastectomy. Mastectomy rates were similar between both surgeons after breast MRI. After reviewing the pathology results and comparing them with the breast MRI results, it was determined that breast MRI led to a positive outcome in 13/32 cases (41%). Breast MRI led to no change in surgical management in 15/32 (47%) cases and resulted in a negative change in surgical management in 4/32 (13%) cases. Bilateral breast MRI detected a contralateral breast cancer in 2/32 (6%) patients.&#x2028; Conclusions: Preoperative breast MRI appears to result in a change in surgical management in a significant proportion of younger women. Further research is needed to determine if this change in surgical decision-making will result in improved local control.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4012.

Smoking restrictions and treatment for smoking: policies and procedures in psychiatric inpatient units in Australia

OBJECTIVE

Tobacco smoking is the leading preventable cause of death and disease in Australia. Even though smoking prevalence in the general population has been reduced (20% smoke), prevalence rates remain high among psychiatric inpatients (70%-90%). This study aimed to identify smoking policies and procedures in public psychiatric inpatient units in New South Wales, Australia; the provision of "smoking care" in such units (for example, quit-smoking advice or nicotine replacement therapy); and policies and procedures associated with the assessment of smoking status and provision of smoking care.

METHODS

A cross-sectional survey was mailed to all public psychiatric inpatient units in New South Wales for completion by nurse unit managers.

RESULTS

Of the 131 units, 123 units completed and returned surveys (94%). Over one-third (36%) of respondents reported instances in which inpatients began smoking during their admission. A similar proportion (39%) reported that staff provided cigarettes to patients who smoked when patients' supply was expended. Fifty percent of respondents reported that all patients were assessed for smoking status; however, 70% reported that nicotine dependence was not assessed. Units on which staff adhered to smoking restrictions were three times as likely to assess patients' smoking status as units where staff never adhered to restrictions (odds ratio=3.05, p=.01).

CONCLUSIONS

Inadequate establishment of nonsmoking environments and of smoking restriction enforcement as well as inconsistencies in the provision of smoking care were evident. The findings suggest that failure of psychiatric services to provide smoking care is systemic and not related to particular types of services (for example acute versus nonacute or regional versus metropolitan).

In vivo healing after capsular plication in an ovine shoulder model

Traditionally, arthroscopic management of shoulder instability has been reserved for patients with isolated Bankart lesions without any capsular laxity or injury. To date, there are no animal studies evaluating the healing potential of capsular plication and/or capsulo-labral repair. The purpose of this in vivo animal study was to determine if the histological capsular healing of an open capsular plication simulating an arthroscopic plication is equivalent to the more traditional open capsular shift involving cutting and advancing the capsule. Twenty-six skeletally mature sheep were randomized to either an open capsular plication simulating arthroscopic plication (n = 13), or an open traditional capsular shift (n = 13). A sham operation (n = 4) was also performed involving exposure to visualize the capsule. Normal non-operated control shoulders were also analyzed. A pathologist blinded to the treatment evaluated both hematoxylin and eosin (H&E) sections and polarized light microscopy. Qualitative scoring evaluated fibrosis, mucinous degeneration, fat necrosis, granuloma formation, vascularity, inflammatory infiltrate and hemosiderin (0 to 3 points). Both the capsular plication and open shift groups demonstrated healing by fibrosis at the site of surgical manipulation. There were no statistical differences in the capsular healing responses between the two groups with regard to fibrosis, granuloma formation and vascularity. The open shift group demonstrated significantly more mucinous degeneration (p = 0.038). Fat necrosis was present in 4/13 specimens in the open shift group and none in the capsular plication specimens. Both groups demonstrated disorganized collagen formation under polarized light microscopy. There were no differences between non-operated control specimens and sham surgery specimens. Our findings support the hypothesis that histologic capsular healing is equivalent between the plication group and the open shift group. In addition, the open shift group demonstrated significantly more changes indicative of tissue injury. This basic science model confirms capsular healing after simulated arthroscopic plication, providing support for arthroscopic capsular plication in practice.

Evaluation of a motivational interview for substance use within psychiatric in-patient services

AIMS

To assess the effectiveness of a motivational interview among hospitalized psychiatric patients with comorbid substance use disorder in reducing alcohol and other drug (AOD) use.

DESIGN

Subjects were assigned randomly to receive an individual motivational interview (n=79) or a self-help booklet (control condition; n=81).

SETTING

Subjects were volunteers recruited from a major public psychiatric hospital.

PARTICIPANTS

Subjects met abuse or dependence criteria on the structured clinical interview for diagnosis (SCID) for alcohol, cannabis or amphetamine or they reported hazardous use during the last month of one or more of these drug types on the opiate treatment index (OTI).

INTERVENTION

Either one 30-45-minute motivational interview or brief advice.

MEASUREMENTS

The SCID and OTI were the main measures.

FINDINGS

There was a modest short-term effect of the motivational interview on an aggregate index of alcohol and other drug use (polydrug use on the OTI). Cannabis use remained high among the sample over the 12-month follow-up period.

CONCLUSION

Although motivational interviewing appears feasible among in-patients in psychiatric hospital with comorbid substance use disorders, more extensive interventions are recommended, continuing on an out-patient basis, particularly for cannabis use.

Motivational interviewing among psychiatric in-patients with substance use disorders

OBJECTIVE

There were three aims of the present study: 1) to document patterns of substance misuse among psychiatric in-patients with comorbid alcohol and other drug (AOD) use; 2) to examine associations among psychiatric and substance use diagnoses and readiness to change; and 3) to evaluate the effectiveness of an opportunistic motivational interview on engagement in a Specialist Substance Misuse Service (SSMS).

METHOD

One hundred and sixty subjects were randomly assigned to receive either a motivational interview or no intervention.

RESULTS

Overall, 66.3% of subjects met intervention threshold for cannabis, 60.6% for alcohol and 22.5% for amphetamines. There was a bimodal distribution of stage of change for cannabis use which was associated with age, with precontemplation being associated with older age and less frequent use. Attendance at the SSMS was low and unrelated to intervention status.

CONCLUSION

A different approach to treatment is recommended, including early intervention among cannabis users.

Did men with erectile dysfunction discuss their condition with partner and physicians? A survey of men attending a free call information service

We present data collected among men attending a free call service on information on erectile dysfunction (ED) activated in Italy during the period 1997-1999. Their attitudes towards discussion with their partner and physician about the condition are considered. Each subject, was asked if he was affected by ED (defined as inability to achieve and maintain an erection sufficient for satisfactory sexual performance). In the case of a positive answer, the subject was asked if he had ever discussed his condition with partner or a physician. A total of 12 761 subjects with ED called the service: 7265 (56.9%) reported to have discussed their condition with their partner. The proportion tended to increase with duration of ED, being 47.9% in subjects reporting ED lasting <6 months and 59.9% in those reporting ED lasting >3 y (w(2)(1) trend <0.05). Likewise, the proportion of subjects reporting to have discussed ED with a physician was 50.3% (6416 subjects), being 33.6% in subjects with ED lasting <6 months and 57.9% of those with ED lasting >3 y (w(2)(1) trend, P<0.01).

Outcomes of laparoscopic fundoplication for gastroesophageal reflux disease and paraesophageal hernia

BACKGROUND

Laparoscopic fundoplication has become the standard for operative treatment of gastroesophageal reflux disease (GERD).

METHODS

We reviewed our experience with 1,000 consecutive patients receiving laparoscopic fundoplication for GERD (n = 882) or paraesophageal hernia (n = 118) between October 1991 and July 1999. Patients with achalasia and failed fundoplication were excluded from analysis. All the patients were evaluated preoperatively by upper endoscopy, esophageal manometry, and barium swallow. After 1994, 24-h pH monitoring was performed selectively in patients with extraesophageal symptoms and/or those without erosive esophagitis. There were 490 men 510 women in this review. Their mean age was 49 years. Procedures performed were 360 degrees floppy fundoplication (n = 879), 360 degrees fundoplication without fundus mobilization (Rossetti) (n = 22), 270 degrees posterior fundoplication (n = 96), and anterior fundoplication (n = 2). Esophageal lengthening procedure (Collis gastroplasty) was performed in combination with fundoplication in 15 patients. In seven patients the treatment was converted to open fundoplication.

OUTCOMES

The average length of hospitalization was 2.2 days, and 136 patients stayed longer than 2 days. Major complications occurred in 21 patients: esophageal perforation (n= 10), acute paraesophageal herniation (n = 4), splenic bleeding (n = 2), cardiac arrest (n = 1), pneumonia (n = 3), and testicular abscess (n = 1). Additional operations were required to manage the complications in 14 patients (70%): Four of these procedures were performed emergently, and 10 patients underwent reoperation between 6 h and 10 days. There were three deaths, all of which involved elderly patients with paraesophageal hernia. There were 35 late failures requiring reoperation for recurrence of GERD or development of new symptoms: The treatment of 32 patients was revised laparoscopically, and 4 patients required laparotomy. Beyond 1 year (median follow-up period, 27 months), 94% of the reviewed patients were satisfied with their surgical outcome.

Aneuploidy and isolated mild ventriculomegaly. Attributable risk for isolated fetal marker

BACKGROUND

Does the prenatal ascertainment of isolated mild ventriculomegaly increase the a priori risk for aneuploidy when isolated or not associated with advanced maternal age? Does isolated mild ventriculomegaly increase the risk for pediatric developmental delay?

METHODS

The Wayne State University (WSU) Reproductive Genetics abnormal case data base and the Madigan Army Medical Center (MAMC) experience were reviewed to compare the rates of aneuploidy for cases with fetal ventriculomegaly. Cases were classified by maternal age and associated sonographic markers of aneuploidy. Aneuploidy rates were compared between the isolated ventriculomegaly, ventriculomegaly with advanced maternal age (AMA), and ventriculomegaly associated with multiple anomalies. Rates of aneuploidy were compared to identify association.

RESULTS

A total of 118 cases with ventriculomegaly were identified for comparison. Ninety-four cases were identified in the WSU cohort; 46 demonstrated isolated ventriculomegaly alone, and aneuploidy was present in 3/25 (12%) with invasive fetal testing, 0/24 (0%) cases in the MAMC cohort demonstrated aneuploidy. Isolated mild ventriculomegaly cases at MAMC were identified for further tests.

DISCUSSION

Although the two study populations vary in age and risk distributions, the attributable risk for isolated mild ventriculomegaly poses a counseling conundrum due to the neurodevelopmental implication of this minor dysmorphism more so than its association with aneuploidy.

Safety of 25-hydroxyvitamin D3 as a source of vitamin D3 in layer poultry feed

A target animal safety study investigated the effects of providing 25-hydroxyvitamin D3 (25-OH-D3) in laying hen feed at levels ranging from 0.5 to 10 times the level commonly used for vitamin D3 supplementation in the poultry industry. Following a 28-day preconditioning period, 5 groups of laying hens were fed commercial diets containing 68.9 micrograms of vitamin D3/kg feed (control) or 41.25 (0.5x), 82.5 (1x), 412.5 (5x), or 825 (10x) micrograms of 25-OH-D3/kg feed. The study compared the effects of the control level of vitamin D3 and the various test levels of 25-OH-D3 on health, performance, hematology, and 25-OH-D3 tissue concentrations in laying hens from 0 to 112 d of treatment and on health, performance, gross pathology and histopathology from 113 to 224 d of treatment. Gross pathologic and histopathologic examination of selected tissues after 224 d revealed no lesions attributable to vitamin D toxicity at any level of test material. Concentrations of 25-OH-D3 in edible tissues at 112 d were similar for birds in the control and 1x groups. On the basis of all variables monitored, including body weight gain and feed conversion, the 10x level of 25-OH-D3 produced clear toxicity (but no mortality), the 5x level caused limited threshold toxicity, and the 1x level induced no toxicity. These results indicate that 25-OH-D3 is safe for use in laying hen feed as a source of vitamin D3 at 82.5 micrograms/kg feed (1x), with a margin of safety of approximately 5x between the proposed 1x level and the 5x level (412.5 micrograms/kg feed) that constitutes threshold toxicity in layers.

Safety of 25-hydroxyvitamin D3 as a source of vitamin D3 in turkey rations

A target animal safety study investigated the effects of providing 25-hydroxyvitamin D3 (25-OH-D3) as a replacement for vitamin D3 in pelleted turkey feeds. Five groups of turkeys were fed diets containing vitamin D3 at 68.9 micrograms/kg feed (control) or 25-OH-D3 at concentrations of 49.5 (0.5x), 99 (1x), 495 (5x) or 990 (10x) micrograms 25-OH-D3/kg feed. The effects of 25-OH-D3 or vitamin D3 on performance, health, hematology, gross pathology and tissue concentrations of 25-OH-D3 in female and male turkeys were compared at 112 days of feeding. There was no significant difference from control in pen body weight in any of the groups. When feed conversion was calculated without taking into account body weights of birds that died during the study, there was no significant difference from control in any of the groups. When feed conversion was corrected for mortality, the only significant effect was that females at the 5x level (495 micrograms 25-OH-D3/kg feed) had improved feed conversion. Significantly increased mortality occurred during the study in the 10x (990 micrograms 25-OH-D3/kg feed) male group only. No histomorphologic tissue alterations attributable to dietary administration of 25-OH-D3 were observed in tissues examined at any dietary level of 25-OH-D3. 25-OH-D3 did not adversely affect animal health at the proposed use level of 99 micrograms/kg feed when replacing vitamin D3 in turkey rations. The proposed use level also provides at least a 5-fold margin of safety.

Novel therapies for Helicobacter pylori infection

BACKGROUND

Increasing antibiotic resistance has begun to impair our ability to cure Helicobacter pylori infection.

AIM

To evaluate orally administered novel therapies for the treatment of H. pylori infection.

METHODS

Healthy H. pylori infected volunteers received: (a) hyperimmune bovine colostral immune globulins, (b) an oligosaccharide containing an H. pylori adhesion target, Neu5Aca2-3Galb1-4Glc-(3'-sialyllactose), or (c) recombinant human lactoferrin. Outcome was assessed by urea breath test or histological assessment of the number of H. pylori present.

RESULTS

None of the novel therapies appeared effective and no adverse events occurred.

CONCLUSION

Although in vitro data appeared promising, in vivo results were disappointing. Higher doses, longer duration of therapy, adjunctive acid suppression, or a combination could possibly yield better results.

Prevalence of advance directives and do-not-resuscitate orders in community nursing facilities

OBJECTIVE

To determine the prevalence of advance directives and do-not-resuscitate (DNR) orders in nursing homes and to measure the effect of the Patient Self-Determination Act (PSDA) and patient characteristics on these prevalences.

DESIGN

Cross-sectional study.

SETTING

Eight rural community nursing facilities.

PARTICIPANTS

Six hundred forty-one records of nursing home residents (total census of eight facilities).

RESULTS

The mean age of the residents was 82.6 years and 75% were women. Thirty-seven percent were judged to have decisional capacity. Less than one third of the records revealed an advance directive (standard living will, 11.5%; other written directive, 11.1%; durable power of attorney for health care, 12%). Thirty-six percent had DNR orders. Residents with advance directives were older than those without them. Those residents with advance directives were more likely to have been admitted to the nursing home after the enactment of the PSDA (25.1% before vs 37.9% after enactment; P < .0001). There was substantial variation among facilities in both prevalences. Written rationales for DNR orders were found in only 40% of records.

CONCLUSION

Enactment of the PSDA reflects increased interest in documentation of advance directives. However, in many nursing facilities, the prevalence of advance directives and DNR orders is relatively low. A greater commitment will be required by providers, residents, and their proxies if we are to change this reality.

Refractive corneal surgery with the Draeger rotary microkeratome in human cadaver eyes

BACKGROUND

Instrumentation for performing a uniform lamellar keratoplasty has been undergoing various stages of refinement. Reliable reproduction and uniform thickness and diameter of lamellar resections is required before lamellar refractive keratoplasty can be considered safe and effective.

METHODS

The authors used the Draeger rotary microkeratome with mechanical blade advance for lamellar dissections in 61 human cadaver eyes prepared by injecting Swinger-Kornmehl (SK) solution into the anterior chamber to a pressure of 35 to 40 mm Hg and by soaking for 30 minutes in SK solution. Spacer sizes of 0.25 to 0.40 units were utilized using an anterior lamellar disc diameter estimate between 8.0 and 8.5 mm and a stromal lamellar disc diameter estimate between 5.5 and 6.5 mm. Preoperative pachometry, anterior and stromal lamellar disc thicknesses, and anterior and stromal lamellar disc diameters were measured.

RESULTS

The Draeger unit created anterior lamellar thickness between 100 and 268 microns. Stromal lamellar disc thicknesses were consistently between 90 and 161 microns. The continuous, unidirectional, rotary blade and the uniform mechanical advance of the instrument produced a generally uniform bed as evaluated by scanning electron microscopy, although undulations were still present.

CONCLUSION

The Draeger microkeratome produced regular lamellar dissections; however, predictability of the thickness of the lenticules varied 10% to 20%, and of the diameter, 1.5% to 15%. Predictability improved with experience. This variability may reduce predictability of refractive outcome.

Telephone usage in the hearing-impaired population

The purpose of this project was to determine if the hearing-impaired population reports satisfaction with their ability to converse over the telephone in both aided and unaided situations. For this study, we surveyed 104 hearing-impaired persons using a 43 item questionnaire that investigates problems that hearing-impaired people encounter when using the telephone. The questionnaire also probes the solutions that hearing-impaired people use for overcoming these problems. Of the 91 respondents who wear hearing aids, 55% use their aids while operating the telephone. However, 70% of these respondents reported that coupling the hearing aid to the telephone is problematic. Use of a telephone amplifier was reported by 73% of the sampled population. The majority of the subjects, 75%, indicated an interest in improvements in telephone communications for hearing-impaired people.

Processing the telephone speech signal for the hearing impaired

Speech intelligibility scores from 16 subjects with sensorineural hearing loss were evaluated using a digitized version of the California Consonant Test that was presented via headphones through a 300 to 3000 Hz bandpass filter to simulate the telephone band. Each subject was tested with an unprocessed signal that was frequency-equalized to compensate for the individual's hearing loss, and a signal that was equalized and compressed by the use of a compressor compression technique. Subjects were tested at three sound pressure levels above a pure-tone average threshold for frequencies 1 and 2 kHz. Two digital signal processing techniques designed to compensate for high-frequency hearing loss were examined: frequency domain processing and time domain processing. Frequency domain involved modification of the short-term spectrum obtained through a fast Fourier transform, whereas time domain processing involved passing the signal through a bank of finite impulse response filters. Both techniques showed significant intelligibility improvements (15-30%). In a second experiment, 16 additional subjects with high-frequency hearing loss compared an amplified telephone signal to three processed signals: (1) 6 dB per octave emphasis; (2) a signal frequency equalized for their hearing loss; and (3) a signal that was equalized for their hearing loss and was compressed according to their uncomfortable loudness levels. Most subjects preferred the signal with the 6 dB per octave emphasis.

Laterality, order of report and attention in a dichotic CV syllable task

Lateralisation was measured on a dichotic CV syllable-pairs task under 4 conditions: (1) free attention and report; (2) as in (1) but with subjects required to report location of items; (3) random pre-stimulus and (4) random post-stimulus cuing of the ear to be attended to and reported first. In (1) there were accuracy advantages for the right ear and for first reports after controlling right ear starting bias. After excluding intrusions there was an REA in accuracy for (2) but no starting bias; a similar REA was observed for (3) and (4) but the first report advantage for (2) and (3) was absent for (4) and (4) was less accurate overall. There were more intrusions for (4) and more from the right ear for (2), (3) and (4). Subjects with the highest intrusion rates from the right ear were also the most lateralised to this ear on the measure which excluded intrusions.

Mortality, weight loss and anaemia in Bos taurus calves exposed to Boophilus microplus ticks in the tropics of Colombia

One hundred and sixteen pure-bred Normandy calves previously immunised against babesiosis and anaplasmosis were transported to the Caribbean Coast of Colombia where they divided into 2 equal groups and placed in separate pastures. One group sustained heavy infestation with Boophilus microplus ticks. The second group became lightly infested. The heavily infested calves suffered average losses in body weight of 38 kg and a 48% decrease in mean packed cell volume. Twenty-three (40%) died 16 to 39 days following arrival from severe ixodiasis and babesiosis. Mortality did not occur nor were significant weight losses observed in the group of lightly infested calves.