7 LEARNING FROM THE FALLS ANALYSIS OF OLDER PEOPLE ADMITTED TO AN IRISH POST-ACUTE REHABILITATION SERVICE

Background

Thirty percent of community-dwelling older adults fall each year with 10% suffering a severe injury often resulting in hospital admission. To deliver effective falls prevention a thorough falls history is required. The objective of this study was to complete a SPLATT (symptoms before fall, previous falls, location of fall, activity at time of fall, time of day and trauma sustained) analysis of falls that resulted in an acute hospital admission reported by older people on admission to the post-acute rehabilitation unit.

Methods

Older people admitted to rehabilitation post fall that resulted in acute admission were included in this study. The SPLATT analysis was completed on OT initial assessment. Data was anonymized and recorded using Microsoft excel.

Results

A total of 61 falls were included in the analysis. Participants were all older people admitted to post-acute rehabilitation (female= 48, male= 13). 93% reported no symptoms before their fall. Almost half (43%) had experienced previous falls. Most falls (51%) happened at home with most of these (29%) occurring in the bedroom. A significant proportion (30%) happened in the community. The most common cause of fall was a loss of balance (32%) while completing a reaching or functional task. Most falls (87%) happened during the day but of those who fell at night, 62.5% occurred while trying to use the toilet. The majority (82%) of the falls lead to a significant trauma – hip fracture.

Conclusion

The results of this study supports that falls prevention interventions for rehabilitation service users should incorporate functional training both at home and in the community. The individual SPLATT analysis could support the design of a falls prevention intervention tailored to the person’s needs and history.

Case Report: Thrombotic-Thrombocytopenic Purpura Following Ipilimumab and Nivolumab Combination Immunotherapy for Metastatic Melanoma

A man in his early 50s presented with small bowel obstruction, requiring emergency laparoscopic small bowel resection for the metastatic melanoma of the jejunum with no identifiable primary lesion. One week after his first treatment with ipilimumab and nivolumab, he presented with diffuse abdominal pain, constipation, and fatigue. A computerized tomography scan did not identify a cause for his symptoms. This was rapidly followed by thrombocytopenia on day 11 and then anemia. He commenced intravenous corticosteroids for a suspected diagnosis of immune-related thrombocytopenia. On day 15, a generalized onset motor seizure occurred, and despite plasmapheresis later that day, the patient died from fatal immune-related thrombotic thrombocytopenic purpura (TTP). This was confirmed with suppressed ADAMTS13 (<5%) testing on day 14. Immune-related TTP is a rare and, in this case, fatal immune- related adverse event. Further studies are required to identify additional immunosuppressive management for immune-related TTP.

Análise Físico-Química e Resistência ao Cisalhamento de Zircônia em Cimentos Resinosos Após Tratamento com Plasma Não-Térmico e/ou Primer

O objetivo deste estudo foi caracterizar a superfície de Y-TZP tratadas com NTP, primer para ligas metálicas ou a associação entre esses dois métodos, e avaliar o efeito desses tratamentos na resistência de união entre Y-TZP e dois cimentos resinosos. Discos de Y-TZP foram distribuídos em cinco grupos: Co (sem tratamento), Pr (primer), NTP (plasma de metano), Pr + NTP e NTP + Pr. Os discos foram cimentados em substratos de resina composta utilizando Panavia F2.0 ou RelyX U200. As análises de resistência ao cisalhamento (n 10) foram realizadas antes e após termociclagem. Os dados foram submetidos à ANOVA um e três fatores e teste de Bonferroni (a0,05). NTP reduziu a energia de superfície e a rugosidade dos discos de Y-TZP. As análises de morfologia e químicas mostraram a presença da película fina orgânica, o que melhorou significativamente os resultados de resistência de ligação quando foi utilizado Rely X U200, enquanto que o tratamento com primer foi mais eficaz com Panavia F2.0. A termociclagem reduziu significativamente os resultados de resistência de união dos grupos NTP e Pr + NTP cimentados com Rely X U200 e os grupos Pr e NTP + Pr cimentados com Panavia F2.0. O plasma não térmico melhorou a união entre Rely X U200 e Y-TZP e também parece ser resistente à degradação hidrolítrica, enquanto que o Panavia F2.0 apresentou os maiores valores de união quando associado ao primer.Palavras-chave: Resistência ao Cisalhamento. Cimentos Resinosos. Plasma de Pressão Atmosférica Não-Térmica.

University Hospital Waterford: 5-year experience of cutaneous melanoma

INTRODUCTION

The incidence of cutaneous melanoma (CM) continues to rise in Ireland. Despite significant advances in melanoma molecular therapy, surgery remains the mainstay of treatment for CM. The University Hospital Waterford (UHW) prospectively maintained CM registry was established in 2010.

AIM

To summarize 5-year experience (2010-2015) of primary CM presenting to UHW.

METHODS

Data were retrospectively obtained from a central electronic pathology and radiology repository augmented by HIPE data and theatre logs. Data collected included patient demographics and clinico-pathological characteristics, specimen number, size, anatomical location, melanoma subtype, Breslow thickness, Clark's level, ulceration, and mitosis.

RESULTS

592 CMs were managed in UHW during the study period. Overall, females comprised the majority of cases with mean age at presentation 60.78 ± 18.29 years. The most commonly affected anatomical location was the lower limb (26.7%) followed by the back (15.1%), upper limb (15.07%), and face (14.40%). Superficial spreading and lentigo maligna were the most common histological subtype accounting for 19.8 and 20%, respectively. Overall, the mean Breslow depth was 2.4 ± 3.7 mm with corresponding Clark's Level III. Sentinel lymph node positivity was 39/103 (37.89%) most commonly located in the axilla (53.8%) and groin (30.7%).

CONCLUSION

There has been a steady increase in the number of cutaneous melanoma presentations over the past 5-years to the South East Cancer Centre. Patients are managed best by prompt surgical excision and multidisciplinary management. Our results are in keeping with international standards and work continues in determining overall 5-year survival and recurrence rates.

Predicting carotid artery disease and plaque instability from cell-derived microparticles

OBJECTIVES

Cell-derived microparticles (MPs) are small plasma membrane-derived vesicles shed from circulating blood cells and may act as novel biomarkers of vascular disease. We investigated the potential of circulating MPs to predict (a) carotid plaque instability and (b) the presence of advanced carotid disease.

METHODS

This pilot study recruited carotid disease patients (aged 69.3 ± 1.2 years [mean ± SD], 69% male, 90% symptomatic) undergoing endarterectomy (n = 42) and age- and sex-matched controls (n = 73). Plaques were classified as stable (n = 25) or unstable (n = 16) post surgery using immunohistochemistry. Blood samples were analysed for MP subsets and molecular biomarkers. Odds ratios (OR) are expressed per standard deviation biomarker increase.

RESULTS

Endothelial MP (EMP) subsets, but not any vascular, inflammatory, or proteolytic molecular biomarker, were higher (p < .05) in the unstable than the stable plaque patients. The area under the receiver operator characteristic curve for CD31(+)41(-) EMP in discriminating an unstable plaque was 0.73 (0.56-0.90, p < .05). CD31(+)41(-) EMP predicted plaque instability (OR = 2.19, 1.08-4.46, p < .05) and remained significant in a multivariable model that included transient ischaemic attack symptom status. Annexin V(+) MP, platelet MP (PMP) subsets, and C-reactive protein were higher (p < .05) in cases than controls. Annexin V(+) MP (OR = 3.15, 1.49-6.68), soluble vascular cell adhesion molecule-1 (OR = 1.64, 1.03-2.59), and previous smoking history (OR = 3.82, 1.38-10.60) independently (p < .05) predicted the presence of carotid disease in a multivariable model.

CONCLUSIONS

EMP may have utility in predicting plaque instability in carotid patients and annexin V(+) MPs may predict the presence of advanced carotid disease in aging populations, independent of established biomarkers.

A new ultra-high-vacuum variable temperature and high-magnetic-field X-ray magnetic circular dichroism facility at LNLS

X-ray magnetic circular dichroism (XMCD) is one of the most powerful tools for investigating the magnetic properties of different types of materials that display ferromagnetic behavior. Compared with other magnetic-sensitive techniques, XMCD has the advantage of being element specific and is capable of separating the spin and magnetic moment contributions associated with each element in the sample. In samples involving, for example, buried atoms, clusters on surfaces or at interfaces, ultrathin films, nanoparticles and nanostructures, three experimental conditions must be present to perform state-of-the-art XMCD measurements: high magnetic fields, low temperatures and an ultra-high-vacuum environment. This paper describes a new apparatus that can be easily installed at different X-ray and UV beamlines at the Brazilian Synchrotron Light Laboratory (LNLS). The apparatus combines the three characteristics described above and different methods to measure the absorption signal. It also permits in situ sample preparation and transfer to another chamber for measurement by conventional surface science techniques such as low-energy electron diffraction (LEED), reflection high-energy electron diffraction (RHEED), X-ray photoelectron spectroscopy (XPS) and X-ray photoelectron diffraction (XPD). Examples are given of XMCD measurements performed with this set-up on different materials.

Preoperative selection of symptomatic breast cancer patients appropriate for lymphatic mapping and sentinel node biopsy

BACKGROUND

This study examines whether preoperative ultrasound-assessed tumour diameter and diagnostic core biopsy-determined grade can be used to select those most likely to benefit from SLNB (i.e. those that are "node negative") before their definitive operation.

METHODS

Breast ultrasound (US) and a simultaneous core biopsy was performed in all patients at their initial presentation, and their estimates of tumor size and grade compared with the final pathological specimen (FPS).

RESULTS

Of the T1 group 47% had lymphatic metastases as did 49% of those with grade I or II cancers. By combining these measures, however, subgroups of patients with lower rates of nodal metastases were identified (32% of patients with T1, non-grade III disease had lymphatic disease while only 15% of those with T < 1.5 cm, non-grade III cancers had such metastases).

CONCLUSION

Combination of the US and ultrasound guided core biopsy (UGCB) may however identify subgroups unlikely to have axillary disease that are therefore suitable for SLNB.

Validation of lymphatic mapping and sentinel node biopsy in patients with symptomatic breast cancer

BACKGROUND

Lymphatic mapping and sentinel node biopsy in breast cancer aims to allow lymph node negative women to avoid axillary clearance by providing a minimally invasive means of staging the axilla. However, before its implementation into routine clinical practice, initiating departments must verify their expertise in each of the surgical, radiological and pathological components necessary for its successful performance. Here, we present our validation experience.

METHODS

Thirty patients with breast cancer of any stage (but without clinical axillary lymphadenopathy) undergoing definitive resection of their primary tumour underwent lymphatic mapping (using blue dye alone or in combination with radioisotope) and sentinel node biopsy concurrent with standard level II axillary clearance over a ten month period.

RESULTS

All patients had sentinel nodes identified intraoperatively. The sentinel node in 29 patients correctly predicted the status of axillary involvement. One patient had non-sentinel nodal disease without metastases being identified in their sentinel node. Such a single false negative out of thirty patients is considered acceptable by current guidelines.

CONCLUSION

Validation of expertise in sentinel node identification and analysis is feasible over a relatively short period of time in a regional symptomatic breast unit. We now feel confident in offering this procedure to selected patients with breast cancer in our catchment area in place of routine axillary clearance.

Surface modification with phosphoric acid of SiO2/Nb2O5 prepared by the sol-gel method: structural-textural and acid sites studies and an ion exchange model

In this work, the structural and textural properties of the SiO2/Nb2O5 system prepared by the sol-gel method and then modified by phosphoric acid were studied. The different materials were prepared, with three different mol % Nb2O5 (2.5, 5.0, and 7.5 mol %), and calcined in the temperature range of 423-1273 K. BET specific surface area determinations, scanning electron microscopy connected to a X-ray emission analyzer, Fourier transform infrared spectroscopy, and X-ray photoelectron spectroscopy (XPS) were used for the investigation. For the lowest temperature of calcination (423 K), the mesopores and micropores of the modified material were blocked, resulting in a decrease of the specific surface area compared to the SBET values obtained for the SiNb matrix. Under intermediate temperatures of calcination (423-873 K), the modified material acquired textural stability. By XPS analysis, the presence of the dihydrogenphosphate species was identified, the P/Nb atomic ratios being independent of the thermal treatment. 31P magic angle spinning NMR confirmed the XPS data and also showed that the chemical shift of the (H2PO4)- ions strongly depended on the crystallization degree of the Nb2O5. Structural thermal stability was also shown by the presence of Brønsted acid sites in the modified material calcined at high temperature (1273 K). The thermal stability is directly associated with obtainment of the same value for K+ exchange capacity (0.74 mmol g(-1), average value) for the modified materials calcined at 423 and 1273 K. The chemical analyses of phosphorus for the modified materials were made by using the inductively coupled plasma. The value was 0.36 mmol g(-1), corroborating the presence of (H2PO4)- ions. The ion exchange isotherms presented an S-shaped form characteristic of energetically heterogeneous ion exchangers, permitting application of a model of fixed polydentate centers, in which ion exchange took place.

Complete screening and quasiatomic MVV auger line shapes due to double core ionization

MVV spectra of Rh, Pd, and Ag were measured with and without ionization of their L3 levels. Extra (MMMVV) structure corresponds to the M45M45-->M45VV transition following the L3M45M45 transition. We interpret the MMMVV structure for Pd as quasiatomic in nature from its similarity to the corresponding Ag spectral shape and from its agreement with atomic calculations. The Pd quasiatomic MMMVV spectrum arises from a two final-state hole bound state in the Pd d band filled by screening of the core holes. These findings represent the first unambiguous observation of the influence of complete screening on spectral features.

Association of tumour necrosis factor alpha and its receptors with thymidine phosphorylase expression in invasive breast carcinoma

Angiogenesis is an essential requirement for tumour growth and metastasis and is regulated by a complex network of factors produced by both stromal cells and neoplastic cells within solid tumours. The cytokine tumour necrosis factor alpha (TNF-alpha) and the enzyme thymidine phosphorylase (TP) are two factors known to promote tumour angiogenesis. We have demonstrated recently that high numbers of tumour-associated macrophages (TAMs) are significantly associated with increased tumour angiogenesis and poor prognosis in invasive carcinoma of the breast. We have also shown that TAMs are a major source of TNF-alpha in invasive breast carcinomas, and that macrophage-like stromal cells as well as tumour cells synthesize TP in such tumours. However, little is known of the factors that regulate the production or activity of these factors in the tumour microenvironment. As TNF-alpha has been shown to up-regulate TP expression in tumour cells in vitro we performed an immunohistochemical study to investigate the possibility that TNF-alpha may be involved in the regulation of TP expression by malignant breast epithelial cells in vivo. To do this, we used a cocktail of non-neutralizing monoclonal anti-TNF-alpha antibodies to visualize both TNF-alpha-expressing macrophages and TNF-alpha bound to its receptors on tumour cells and endothelial cells in a series of 93 invasive carcinomas of the breast. A semiquantitative grading system was then used to compare these staining patterns with that for TP in the same biopsies. TNF-alpha immunoreactivity was also compared with various important tumour variables known to relate to outcome in this disease (microvessel density, node status, grade, stage, receptor status and macrophage infiltration), as well as relapse-free and overall survival data for these patients. Our data show significant positive correlations between TNF-alpha bound to its receptors on tumour cells and: (1) TP protein production by tumour cells, and (2) axillary lymph node status (i.e. metastasis). These results suggest that tumour cell responsiveness to TNF-alpha produced by neighbouring TAMs may play a part in the regulation of TP expression by tumour cells as well as their metastatic behaviour. This may explain, in part, the relationship between increased macrophage infiltration and angiogenesis in breast cancer, and further supports the contention that TAMs may represent an important target for future anti-angiogenic therapies.

Reassessment of the interaction between a worksite hypertension program and private physicians

We investigated how nurse practitioners attending at worksite hypertension clinics were perceived as care providers by both patients enrolled in the clinics and their private physicians. This study indicates a very favorable attitude towards nurse practitioners from both patients and private practitioners and gives additional support for the utilization of nurse practitioners as effective health care providers in the management of common and chronic illness.

Predictors of long-term compliance in attending a worksite hypertension programme

Variables such as patient's anxiety, knowledge, number of medication changes, medication-induced side-effects and programme-derived benefits and conveniences have been reported or theorised to be important determinants of patient's attendance at worksite hypertension programmes. This study investigates whether these variables have predictive value in differentiating compliers from noncompliers attending a union-sponsored worksite hypertension programme for at least five years. Scores were created from a questionnaire distributed to 243 patients with a response rate of 98%. Compliance was defined as missing < or = 25% of scheduled clinic appointments. By discriminant statistical analysis scores for patient's anxiety, knowledge, number of medication changes, medication side-effects, perceived benefits and conveniences failed to show any predictive value for patient's compliance with appointment keeping.

Incidence of hypercholesterolemia in the active duty Navy population in 1986

A National Institutes of Health Consensus Conference recently advocated lowering the serum cholesterol levels required to diagnose moderate and severe hypercholesterolemia. We reviewed 998 active duty United States Navy personnel who underwent routine physical examinations with determinations of serum cholesterol. Analysis of the data revealed a gradual rise in mean serum cholesterol with increasing age. Moderate elevation of serum cholesterol ranged from 11.3% to 34.6% of the study group, depending on age. Severe hypercholesterolemia was also age dependent and occurred in 2.0% to 9.3% the group. Dietary and cholesterol-binding agents have been shown to reduce the occurrence of myocardial infarction in subjects with cholesterol greater than 265 mg/dl. The incidence of Navy personnel with serum cholesterol above this level ranged from 2 to 10%. It is likely that intervention with dietary or medical therapy would prevent the development or delay the occurrence of coronary artery disease in a large number of active duty U.S. Navy personnel.