Immune biomarker evaluation of sequential tyrosine kinase inhibitor and nivolumab monotherapies in renal cell carcinoma: the phase I TRIBE trial

Background

Predictive biomarkers for immune checkpoint blockade in the second-line treatment of metastatic renal cell carcinoma (mRCC) are lacking.

Materials and methods

Patients with histologically confirmed RCC who started nivolumab after at least 4 months of tyrosine kinase inhibitors (TKIs) were recruited for this study. Serial tissue and blood samples were collected for immune biomarker evaluation. The primary endpoint was to determine the association of specific T-cell subsets with clinical outcomes tested using Wilcoxon rank sum for clinical benefit rate (CBR) and log-rank test for progression-free survival (PFS).

Results

Twenty patients were included in this trial with a median age of 64 years and followed-up for a median of 12 months. The median PFS for patients who received TKI was 13.8 months, while for those subsequently treated with nivolumab following TKI therapy, the median PFS was 2.6 months. CBR of nivolumab was 20% with two partial responses. Functionally active programmed cell death protein 1+ CD4+ T cells were enriched in non-responders (q = 0.003) and associated with worse PFS on nivolumab (P = 0.04). Responders showed a significant reduction in the effector CD4+T-cell (TEF) fraction compared to non-responders at 3 months on nivolumab (0.40 versus 0.80, P = 0.0005). CD127+CD4+ T cells were enriched in patients who developed immune-related adverse effects (q = 0.003). Using in-house validated multiplex immunohistochemistry for six markers, we measured tumour-associated immune cell densities in tissue samples. Responders to nivolumab showed a significantly higher mean of immune cell densities in tissue samples compared to non-responders (346 versus 87 cells/mm2, P = 0.04).

Conclusions

In this small study, analysis of tissue-based and peripheral blood immune cell subsets predicted clinical outcomes of nivolumab. Further studies are warranted with larger populations to validate these observations.

5 Tear proteins in premature babies at risk of retinopathy of prematurity

This feasibility study aimed to investigate the feasibility of collecting and analysing tear proteins from preterm infants at risk of retinopathy of prematurity (ROP). Additionally, we sought to identify any tear proteins which might be implicated in the pathophysiology of ROP.Eligible infants were those undergoing ROP screening without other ocular pathology. Tear samples were obtained by Schirmer's test strips coincident with routine ROP screening. Mass spectrometry was used for proteomic analysis. All participants' parents gave written, informed consent.Samples were collected from 12 infants, including two sets of twins. Gestation ranged from 25+6 to 31+1 weeks. Median postnatal age at sampling was 30.5 days (range 19 to 66). One infant developed self-limiting ROP. An adequate sample for protein analysis was obtained from each infant. 701 proteins were identified; 261 proteins identified in the majority of tear samples, including several common tear proteins, were used for analyses.Increased risk of ROP as determined by G-ROP prediction criteria was associated with an increase in lactate dehydrogenase B (LDH-B) chain protein in tears. Older, more mature infants demonstrated increased concentration of immunoglobulin complexes within their tear samples and two sets of twins in the cohort showed exceptionally similar proteomes, supporting validity of the analysis.Tear sampling by Schirmer test strips and subsequent proteomic analysis in preterm infants is feasible. A larger study is required to investigate the potential use of tear proteomics in early identification of ROP.

Evaluation of treatment delays in hepatopancreatico-biliary surgery during the first COVID-19 wave

INTRODUCTION

The COVID-19 pandemic has caused oncological services worldwide to face unprecedented challenges resulting in treatment disruption for surgical patients. Hepatopancreatico-biliary (HPB) cancers are characterised by rapid disease progression. This study aims to assess delays in receiving surgery for this patient cohort during the first COVID-19 wave.

METHODS

Patients undergoing surgery between April and July 2020 (COVID-19 period) were compared with a control group from the preceding year. Delay in receiving surgery was defined as more than 50 days between referral and surgery date. Statistical analysis was carried out to evaluate predictors of delay and short-term outcomes.

RESULTS

During the COVID-19 and pre-COVID-19 periods, 94 and 115 patients underwent surgery, respectively. No patients contracted COVID-19 postoperatively. Some 118 patients waited more than 50 days for surgery versus 91 who received surgery within 50 days from referral. Independent predictors for surgical delay were undergoing surgery in the COVID-19 era (odds ratio (OR) 2.2, 95% confidence interval (CI) 1.2-4.1; p=0.015), referral pathway (OR 35.1, 95% CI 4.2-296; p=0.001) and presenting pathology (OR 8.3, 95% CI 1.2-56.1; p=0.03). Short-term outcomes were comparable between groups.

CONCLUSIONS

Patient referral pathway and presenting pathology may contribute to delays in undergoing HPB cancer surgery during COVID-19 outbreaks. It is hoped that a better understanding of these factors will aid in designing shifts in healthcare policy during future pandemic outbreaks.

The SECURE STAIRS Framework: Preliminary Evaluation of Trauma Informed Training Developments Within the Children and Young People's Secure Estate

The SECURE STAIRS framework promotes trauma informed understanding and training across the workforce to inform work with children and young people. A component of the framework is the 'Trauma Informed Practice with Children and Young People in Secure Settings' (TIPSS) training programme for multidisciplinary staff. Between November 2020 and May 2021, a total of 123 members of multidisciplinary staff from a Secure Children's Home (SCH) in the North East of England attended five-day TIPSS training. A pre-post repeated measures design was adopted. Paired samples t-tests were used to analyse pre- and post- questionnaires regarding self-reported levels of (i) knowledge, (ii) understanding and (iii) confidence across Attachment and Developmental Trauma, Understanding Complex Behaviour and Trauma Informed Care training modules. Staff reported significant (p ≤ .001) post-training improvements in knowledge, understanding, and confidence across all three training modules. Implications of findings are discussed, and further developments outlined.

Pregnancy rate and reproductive hormones in humpback whale blubber: Dominant form of progesterone differs during pregnancy

To better understand reproductive physiology of humpback whales Megaptera novaeangliae that reside in Hawai'i and Alaska, enzyme immunoassays were validated for both progesterone and testosterone in free-ranging and stranded animals (n = 185 biopsies). Concentrations were analyzed between different depths of large segments of blubber taken from skin to muscle layers of stranded female (n = 2, 1 pregnant, 1 non-pregnant) and male (n = 1) whales. Additionally, progesterone metabolites were identified between pregnant (n = 1) and non-pregnant (n = 3) females using high pressure liquid chromatography (HPLC). Progesterone concentrations were compared between juvenile (i.e., sexually immature), lactating, and pregnant females, and male whales, and pregnancy rates of sexually mature females were calculated. Based on replicate samples from ship struck animals collected at 7 depth locations, blubber containing the highest concentration of progesterone was located 1 cm below the skin for females, and the highest concentration of testosterone was in the skin layer of one male whale. HPLC of blubber samples of pregnant and non-pregnant females contain different immunoreactive progesterone metabolites, with the non-pregnant female eluate comprised of a more polar, and possibly conjugated, form of progesterone than the pregnant female. In females, concentrations of progesterone were highest in the blubber of pregnant (n = 28, 28.6 ± 6.9 ng/g), followed by lactating (n = 16, 0.9 ± 0.1 ng/g), and female juvenile (n = 5, 1.0 ± 0.2 ng/g) whales. Progesterone concentrations in male (n = 24, 0.6 ng/g ± 0.1 ng/g) tissues were the lowest all groups, and not different from lactating or juvenile females. Estimated summer season pregnancy rate among sexually mature females from the Hawai'i stock of humpback whales was 0.562 (95 % confidence interval 0.528-0.605). For lactating females, the year-round pregnancy rate was 0.243 (0.09-0.59), and varies depending on the threshold of progesterone assumed for pregnancy in the range between 3.1 and 28.5 ng/g. Our results demonstrate the synergistic value added when combining immunoreactive assays, HPLC, and long-term sighting histories to further knowledge of humpback whale reproductive physiology.

A policy-driven framework for conserving the best of Earth's remaining moist tropical forests

Tropical forests vary in composition, structure and function such that not all forests have similar ecological value. This variability is caused by natural and anthropogenic disturbance regimes, which influence the ability of forests to support biodiversity, store carbon, mediate water yield and facilitate human well-being. While international environmental agreements mandate protecting and restoring forests, only forest extent is typically considered, while forest quality is ignored. Consequently, the locations and loss rates of forests of high ecological value are unknown and coordinated strategies for conserving these forests remain undeveloped. Here, we map locations high in forest structural integrity as a measure of ecological quality on the basis of recently developed fine-resolution maps of three-dimensional forest structure, integrated with human pressure across the global moist tropics. Our analyses reveal that tall forests with closed canopies and low human pressure typical of natural conditions comprise half of the global humid or moist tropical forest estate, largely limited to the Amazon and Congo basins. Most of these forests have no formal protection and, given recent rates of loss, are at substantial risk. With the rapid disappearance of these 'best of the last' forests at stake, we provide a policy-driven framework for their conservation and restoration, and recommend locations to maintain protections, add new protections, mitigate deleterious human impacts and restore forest structure.

Use of surrogate species to cost-effectively prioritize conservation actions

Conservation efforts often focus on umbrella species whose distributions overlap with many other flora and fauna. However, because biodiversity is affected by different threats that are spatially variable, focusing only on the geographic range overlap of species may not be sufficient in allocating the necessary actions needed to efficiently abate threats. We developed a problem-based method for prioritizing conservation actions for umbrella species that maximizes the total number of flora and fauna benefiting from management while considering threats, actions, and costs. We tested our new method by assessing the performance of the Australian federal government's umbrella prioritization list, which identifies 73 umbrella species as priorities for conservation attention. Our results show that the federal government priority list benefits only 6% of all Australia's threatened terrestrial species. This could be increased to benefit nearly half (or 46%) of all threatened terrestrial species for the same budget of AU$550 million/year if more suitable umbrella species were chosen. This results in a 7-fold increase in management efficiency. We believe nations around the world can markedly improve the selection of prioritized umbrella species for conservation action with this transparent, quantitative, and objective prioritization approach.

Optimising Radium 223 Therapy for Metastatic Castration-Resistant Prostate Cancer -5-year Real-World Outcome: Focusing on Treatment Sequence and Quality of Life

AIMS

Real-world evidence of radium 223 (Ra-223) for the treatment of men with metastatic castration-resistant prostate cancer is emerging. In this prospective single-centre service evaluation, we report for the first time in the UK, real-world quality of life (QoL) and survival outcomes, including the sequencing impact, in 228 treated patients. We aim to share our 5-year experience on how to optimise Ra-223 treatment.

MATERIALS AND METHODS

Patients who received Ra-223 therapy between 2014 and 2018 at the Northern Centre for Cancer Care, Newcastle upon Tyne, UK were included in this evaluation. Demographics, clinical characteristics, blood parameters, treatment sequencing and QoL data using abbreviated Functional Assessment of Cancer Therapy-Prostate questionnaires were prospectively collected and analysed.

RESULTS

In total, 228 patients were included; median age 72 years (51-87). The medium overall survival was 11.1 months. Overall survival in post-chemotherapy and chemotherapy-naïve patients was 8.1 and 12.3 months, respectively (P = 0.02, hazard ratio 1.52, 95% confidence interval 1.06-2.17); in pre-enzalutamide and post-enzalutamide patients was 11.3 and 10.4 months, respectively (P = 0.65, hazard ratio 0.92, 95% confidence interval 0.63-1.33); in pre-abiraterone and prednisolone and post-abiraterone and prednisolone patients was 11.8 and 10.5 months, respectively (P = 0.08, hazard ratio 0.74, 95% confidence interval 0.51-1.06); in this latter group, the fracture rate was 24% (15/63). QoL post Ra-223 (n = 101 evaluated) showed that pain scores improved in 54%, there was no change in 17% and pain scores worsened in 30% of treated patients. Overall QoL scores showed a similar trend. QoL was not significantly associated with overall survival.

CONCLUSIONS

Ra-223 palliates pain and improves disease-related QoL in most patients in the real-world setting. Our survival outcome is comparable with other real-world studies. Chemotherapy-naïve patients seemed to have better survival than those who received prior chemotherapy. No significant survival differences were observed between pre- and post-abiraterone and prednisolone or enzalutamide patients. The fracture rate in the post-abiraterone and prednisolone group seemed to be high. Bone health evaluation and protection should be incorporated as standard of care.

Seasonal distribution and foraging occurrence of Cook Inlet beluga whales based on passive acoustic monitoring

A paucity of information on the basic biology and ecology of Cook Inlet beluga whales Delphinapterus leucas remains a decade after the species was listed as endangered in 2008. The causes of its continued decline remain unclear. This lack of knowledge limits our understanding of, and ability to manage, potential threats impeding the recovery of this endangered population. Seasonal distribution and foraging ecology, particularly during winter, are currently among the most basic gaps in knowledge. Therefore, we conducted a year-round passive acoustic monitoring program from 2008-2013, monitoring 13 locations within the belugas’ critical habitat. We identified seasonal occurrence patterns across years at most locations. Detections were higher in the upper inlet during summer, peaking in known concentration areas. The occurrence of whales in the upper inlet when ice coverage peaked during winter was more prevalent than previously suggested. We documented seasonal differences in foraging habitat preference, with foraging behavior more prevalent during summer, particularly near upper inlet rivers, than during winter. Foraging peaks coincided with the presence of different anadromous fish runs from spring to fall. Low levels of feeding activity in winter suggest a lack of feeding aggregation areas, feeding in non-monitored offshore waters, or increased effort on benthic prey. These results represent a substantial contribution to our knowledge of Cook Inlet beluga seasonal distribution and foraging ecology, which will strengthen conservation and management strategies and thus more effectively promote recovery of this endangered population.

Diagnosis of Accommodative Spasm Aided by Handheld Photoscreener

We report a case of accommodative spasm in an 8-year-old girl discovered by handheld photoscreener. The patient was found to have a Chiari I malformation, and managed with atropine drops and reading glasses, ultimately with improvement in her symptoms. We believe this to be the first case of accommodative spasm diagnosis aided by the use of a handheld photoscreener.

Pathological findings and survey for pathogens associated with reproductive failure in perinatal Steller sea lions Eumetopias jubatus

Steller sea lions (SSLs) Eumetopias jubatus experienced a population decline in the 1960s, leading to the listing of the western stock as endangered and the eastern stock as threatened under the US Endangered Species Act. A decrease of births in the western stock beginning in the late 1960s indicates that reproductive failure may have contributed to the decline. We evaluated the role pathogens play in spontaneous abortions, premature births and neonatal deaths in SSLs. Archived tissues from carcasses (n = 19) collected in Alaska from 2002 to 2015 were tested by PCR for Coxiella burnetii, Brucella spp., Chlamydia and morbilliviruses. Animals examined included 47% premature pups, 32% aborted fetuses, 11% neonates and 11% intrauterine fetuses. Gross necropsy and histology findings were summarized in the context of the PCR findings. Tissues were negative for Chlamydia and C. burnetii. Brucella spp. were detected in the lung tissues of 3 animals, including 1 positive for the ST27 strain, the first detection of Brucella spp. DNA in SSLs. Phocine distemper virus was detected in 3 animals in 2 skin lesions and 1 placenta by hemi-nested diagnostic qRT-PCR. Both skin and the placental lesions had vesiculoulcerative changes, and 1 skin lesion contained inclusion bodies in syncytia and upon histologic examination, suggesting that the lesions may be associated with an infection reminiscent of phocine distemper virus, the first in SSLs. We highlight the continuing need for disease surveillance programs to improve our understanding of the prevalence and potential population impacts of these infectious disease agents for pinnipeds in Alaskan waters.

Global humid tropics forest structural condition and forest structural integrity maps

Remotely sensed maps of global forest extent are widely used for conservation assessment and planning. Yet, there is increasing recognition that these efforts must now include elements of forest quality for biodiversity and ecosystem services. Such data are not yet available globally. Here we introduce two data products, the Forest Structural Condition Index (SCI) and the Forest Structural Integrity Index (FSII), to meet this need for the humid tropics. The SCI integrates canopy height, tree cover, and time since disturbance to distinguish short, open-canopy, or recently deforested stands from tall, closed-canopy, older stands typical of primary forest. The SCI was validated against estimates of foliage height diversity derived from airborne lidar. The FSII overlays a global index of human pressure on SCI to identify structurally complex forests with low human pressure, likely the most valuable for maintaining biodiversity and ecosystem services. These products represent an important step in maturation from conservation focus on forest extent to forest stands that should be considered "best of the last" in international policy settings.

[Compliance of nursing professional practices related to drug preparation and administration: A cross-sectional and longitudinal descriptive study]

OBJECTIVES

Evaluate the compliance of practices of nursing professionals related to the preparation and administration of drugs in 2018. Discuss the evolution of compliance practices from 2014 to 2018.

METHODS

Prospective transversal observational study. Based on an observation grid with 55 compliance criteria, we conducted direct observation of medication doses prepared and administered by nursing professionals. For each compliance criterion, the auditor could indicate whether the practice was compliant, non-compliant or not applicable. A convenience target of 250 observations has been set.

RESULTS

A total of 252 doses of drugs were observed between March 1, 2018 and April 29, 2018. Drug doses were observed by day (52 %), evening (30 %) or night (18 %) mainly nurses (80 %) working on regular shifts (94 %). Just over half of the doses required preparation by a nurse (58 %) and almost half of the doses were administered parenterally (48 %). In 2018, the observed compliance rate of the drug circuit ranged from 25.0 % to 86.3 %.

CONCLUSION

This descriptive study shows a compliance rate of practices of nursing professionals related to the preparation and administration of drugs, which varies from 25.0 % to 86.3 % by observed stage of the drug circuit. 2018. The study identified 15 action actions for continuous improvement.

Stranding trends of Steller sea lions Eumetopias jubatus 1990-2015

Distinct population segments of Steller sea lion (SSL) Eumetopias jubatus have experienced different population trends over the last 5 decades, rendering the need for retrospective study. By identifying long-term stranding trends of SSLs we can develop a better understanding of factors contributing to mortality that may affect SSL population dynamics. We characterized spatial and temporal trends of SSL strandings (n = 1507) in Alaska, Oregon, and Washington, USA, over a 25 yr period. Stranding reports were obtained from the Alaska and Northwest Region’s Marine Mammal Stranding Networks. Temporal trends were assessed by identifying seasonal patterns across all years (1990-2015), analyzing sex, age class, body length, and characterizing signs of human interaction including factors contributing to mortality. An apparent increase in strandings occurred after 2000, likely due to increased stranding response effort resulting from increased federal grant awards. Adult males were the most frequently stranded sex and age class in the Alaska (AK) and Northwest (NW) Regions. Clear seasonality trends were evident, with the greatest reported stranding occurrences during the spring and summer. Gunshot wounds and fishery interactions accounted for a large proportion (90%) of human interaction cases. In Alaska, the southeast region had the highest number of strandings. In the NW Region, Oregon had the highest documented strandings. Despite caveats associated with stranding data, our findings suggest rapid timing of continued stranding response is imperative for a better understanding of cause-specific mortality trends and other factors contributing to stranding events.

Increased sediment loads cause non-linear decreases in seagrass suitable habitat extent

Land-based activities, including deforestation, agriculture, and urbanisation, cause increased erosion, reduced inland and coastal water quality, and subsequent loss or degradation of downstream coastal marine ecosystems. Quantitative approaches to link sediment loads from catchments to metrics of downstream marine ecosystem state are required to calculate the cost effectiveness of taking conservation actions on land to benefits accrued in the ocean. Here we quantify the relationship between sediment loads derived from landscapes to habitat suitability of seagrass meadows in Moreton Bay, Queensland, Australia. We use the following approach: (1) a catchment hydrological model generates sediment loads; (2) a statistical model links sediment loads to water clarity at monthly time-steps; (3) a species distribution model (SDM) factors in water clarity, bathymetry, wave height, and substrate suitability to predict seagrass habitat suitability at monthly time-steps; and (4) a statistical model quantifies the effect of sediment loads on area of seagrass suitable habitat in a given year. The relationship between sediment loads and seagrass suitable habitat is non-linear: large increases in sediment have a disproportionately large negative impact on availability of seagrass suitable habitat. Varying the temporal scale of analysis (monthly vs. yearly), or varying the threshold value used to delineate predicted seagrass presence vs. absence, both affect the magnitude, but not the overall shape, of the relationship between sediment loads and seagrass suitable habitat area. Quantifying the link between sediment produced from catchments and extent of downstream marine ecosystems allows assessment of the relative costs and benefits of taking conservation actions on land or in the ocean, respectively, to marine ecosystems.

Seroprevalence of Brucella antibodies in harbor seals in Alaska, USA, with age, regional, and reproductive comparisons

Populations of harbor seal Phoca vitulina in the Gulf of Alaska have dramatically declined during the past 4 decades. Numbers of seals in Glacier Bay, in southeast Alaska, USA, have also declined despite extensive protection. Causes of the declines and slow recovery are poorly understood. Brucellosis is a zoonotic disease that adversely affects reproduction in many domestic species. We measured the seroprevalence of Brucella antibodies in 554 harbor seals in 3 Alaska locations: Prince William Sound (PWS), Glacier Bay (GB), and Tracy Arm Fords Terror (TAFT) Wilderness Area. Objectives included testing for regional, sex, age, and female reproductive state differences in Brucella antibody seroprevalence, persistence in titers in recaptured seals, and differences in titers between mother seals and their pups. Overall, 52% of adults (AD), 53% of subadults (SA), 77% of yearlings (YRL), and 26% of <5 mo old pups were seropositive. Matched mother-pup samples were consistent with dependent pups acquiring maternal passive immunity to Brucella. Results show higher seroprevalence (64%) for AD and SA seals in the depressed and declining populations in PWS and GB than in TAFT (29%). Lactating females were less likely to be seropositive than other AD females, including pregnant females. Further research is needed to seek evidence of Brucella infection in Alaskan harbor seals, identify effects on neonatal viability, and assess zoonotic implications for Alaska Natives who rely on harbor seals for food.

Simple rules can guide whether land- or ocean-based conservation will best benefit marine ecosystems

Coastal marine ecosystems can be managed by actions undertaken both on the land and in the ocean. Quantifying and comparing the costs and benefits of actions in both realms is therefore necessary for efficient management. Here, we quantify the link between terrestrial sediment runoff and a downstream coastal marine ecosystem and contrast the cost-effectiveness of marine- and land-based conservation actions. We use a dynamic land- and sea-scape model to determine whether limited funds should be directed to 1 of 4 alternative conservation actions—protection on land, protection in the ocean, restoration on land, or restoration in the ocean—to maximise the extent of light-dependent marine benthic habitats across decadal timescales. We apply the model to a case study for a seagrass meadow in Australia. We find that marine restoration is the most cost-effective action over decadal timescales in this system, based on a conservative estimate of the rate at which seagrass can expand into a new habitat. The optimal decision will vary in different social–ecological contexts, but some basic information can guide optimal investments to counteract land- and ocean-based stressors: (1) marine restoration should be prioritised if the rates of marine ecosystem decline and expansion are similar and low; (2) marine protection should take precedence if the rate of marine ecosystem decline is high or if the adjacent catchment is relatively intact and has a low rate of vegetation decline; (3) land-based actions are optimal when the ratio of marine ecosystem expansion to decline is greater than 1:1.4, with terrestrial restoration typically the most cost-effective action; and (4) land protection should be prioritised if the catchment is relatively intact but the rate of vegetation decline is high. These rules of thumb illustrate how cost-effective conservation outcomes for connected land–ocean systems can proceed without complex modelling.

Many coastal marine ecosystems are threatened by anthropogenic activities, but often, the best way to restore and protect these important ecosystems is unclear. Conventional wisdom suggests that the 2 most effective conservation actions to benefit coastal marine ecosystems are implementation of marine protected areas or, alternatively, reduction of land-based threats. Active marine restoration is typically considered a low-priority option, in part due to high costs and low success rates. But does this conventional wisdom hold up to closer scrutiny? We developed a model to ask: should we restore or protect, on either the land or in the ocean, to maximise the extent of coastal marine ecosystems? We based the model on seagrass meadows and adjacent catchments in Queensland, Australia. Surprisingly, we found that direct, active marine restoration can be the most cost-effective approach to maximising extent of marine ecosystems over longer (decades-long) timescales. There is, however, substantial uncertainty in our understanding of the dynamics of complex linked land–sea ecosystems. Further, geomorphological and ecological conditions vary geographically. Therefore, we also used the model to investigate how uncertainty in key parameters affects decision-making outcomes. Our results can be used to guide investment into coastal marine conservation in the absence of complex, region-specific modelling.

Effect of Ichthyophonus on blood plasma chemistry of spawning Chinook salmon and their resulting offspring in a Yukon River tributary

Ichthyophonus is a protozoan parasite of Alaska Chinook salmon Oncorhynchus tshawytscha. In this study, we determined whether spawning Chinook salmon in the Yukon River drainage exhibited a measurable stress response (i.e. elevated plasma cortisol concentrations) and detectable changes in selected blood plasma chemistry parameters when infected with Ichthyophonus. The resulting alevin were also analyzed for any differences in blood plasma chemistry caused by parental infection with Ichthyophonus. In 2010, 2011, and 2012, spawning adult Chinook salmon were collected from the Salcha River, Alaska, USA, and the prevalence of Ichthyophonus in these fish was 7.8, 6.3, and 8.3%, respectively. Fish with no clinical signs of Ichthyophonus and Ichthyophonus-positive parents were cross-fertilized to investigate potential second-generation effects as a result of Ichthyophonus infection. We found no significant difference in cortisol concentrations in blood plasma between Ichthyophonus-positive and -negative adults or between alevin from Ichthyophonus-positive and -negative parents. There were no significant differences in blood plasma parameters (e.g. alanine aminotransferase, creatine kinase, glucose) of Ichthyophonus-negative and -positive adults, with the exception of aspartate aminotransferase, which was significantly higher in plasma of Ichthyophonus-negative adults. All clinical chemistry parameters for alevin resulting from both Ichthyophonus-negative and -positive parents were not significantly different. Based on this study, which has a limited sample size and low prevalence of Ichthyophonus, offspring of Chinook salmon appear to suffer no disadvantage as a result of Ichthyophonus infection in their parents on the Salcha River.

Reference Intervals of Mineral Elements in Plasma of Anesthetized Free-Ranging Adult Females of South American Sea Lion, Otaria flavescens

Levels of zinc (Zn), copper (Cu), potassium (K), calcium (Ca), magnesium (Mg), and phosphorus (P) in plasma of Otaria flavescens females (n = 29) were evaluated. Reference intervals were established for each element, being the first report for this species.

Comparison of Information Available in the Medication Profile of an Electronic Health Record and the Inpatient Best Possible Medication History in a Mother and Child Teaching Hospital Center

BackgroundMedication reconciliation (MedRec) can improve patient safety. In Canada, most provinces are implementing electronic health records (EHR). The Quebec Health Record (QHR) can theoretically be used for medication reconciliation. However, the quantity and the quality of information available in this EHR have not been studied. ObjectivesThe main objective was to compare the quantity and quality of the information collected between the inpatient best possible medication history (BPMH) and the QHR.   MethodsThis is a descriptive prospective study conducted at CHU Sainte-Justine, a 500-bed tertiary mother-and-child university hospital center. All inpatients from May 19-26, 2015 were considered for inclusion. Every prescription line in the BPMH and QHR were compared. ResultsThe study included 344 patients and 1,039 prescription lines were analyzed. The medications' name and dosing were more often available in the QHR (95%) than in the BPMH (61%). Concordance between the medication names between QHR and BPMH was found in 48% of the prescription lines; this rate fell to 29% when also factoring daily dosage.  ConclusionsThis study suggests that the QHR can provide high-quality information to support the MedRec hospital process. However, it should be used as a second source to optimize the BPMH obtained from a thorough interview with the patient and/or his or her family. More studies are required to confirm the most optimal way to integrate the QHR to the MedRec process in hospitals.

[Selection and optimal sequence of critical elements for medication review: A simulation with hospital pharmacy residents]

OBJECTIVES

The main objective of this study was to compare the responses of pharmacy residents regarding critical steps for medication order review, in the presence or absence of clinical pharmacists on patient care units, to describe the sequence of these steps and to compare them to an optimal sequence. The secondary objectives were to test this sequence in a simulation and to assess the residents' level of agreement on medication order review.

METHODS

Twenty-two validation steps were selected from guidelines. A simulation on order review was organized in three steps: selecting elements judged to be necessary or not for the order review critical path, then organizing this sequence in chronological order, implementation of this critical path on two simulated practical cases, resident perceptions about order review in their training.

RESULTS

Forty-one residents participated in the activity. Responses were heterogeneous regarding the elements' sequence and the time required for the review of a simulated case (3-13minutes). A majority of residents considered that their training was insufficient (29/41), that pharmacists validated differently (27/41), and that it was impossible to review the 22 proposed items for each prescription (30/41).

CONCLUSIONS

This article highlights heterogeneous medication order review practices among pharmacy residents, due to a lack of training in their curriculum according to them. It is essential to acquire medication order review standard both locally and nationally.

Initial experience with a telemeterized gait analysis system

The M I E gait analysis system has been developed to allow a range of objective gait measurements to be readily obtained in a clinical setting. The equipment and its use are described together with a series of repeatability studies. The results suggest that the system is easy to operate and sufficiently reliable for use in clinical departments.

[Assessment of perception about medication reconciliation among healthcare professionals at Saint-Justine hospital]

OBJECTIVES

Our main objective is to assess nurses and doctors perception about medication reconciliation.

METHODS

This is a descriptive and cross-sectional study. We have created three surveys, one for each health worker (nurses, doctors, resident, pharmacists). Each survey consists of single or multi-choice closed questions. A four-point Likert scale was used to collect the perception. Descriptive statistics have been calculated.

RESULTS

A total of 114 nurses, 98 doctors and residents and 26 pharmacists from all care services, replied to the survey. The majority of doctors (58%), pharmacists (60%) and nurses (52%) recognized the relevance and utility of medication reconciliation in healthcare safety. However, few healthcare professionals (6% of doctors, 13% of nurses et 46% of pharmacists) know that medication reconciliation is a required organizational practice. Only 25% of doctors always consult the best possible medication history after a patient admission while the majority do not use it because of unreliability issues. So, there have been some major changes to optimize medication reconciliation process in our hospital.

CONCLUSION

This study shows a increasing interest to medication reconciliation by healthcare professionals. However, the use of medication reconciliation remains marginal.

[Failure mode and effects analysis (FMEA) of insulin in a mother-child university-affiliated health center]

CONTEXT AND OBJECTIVES

Insulin is a high-alert drug. The main objective of this descriptive cross-sectional study was to evaluate the risks associated with insulin use in healthcare centers. The secondary objective was to propose corrective measures to reduce the main risks associated with the most critical failure modes in the analysis.

METHODS

We conducted a failure mode and effects analysis (FMEA) in obstetrics-gynecology, neonatology and pediatrics.

RESULTS

Five multidisciplinary meetings occurred in August 2013. A total of 44 out of 49 failure modes were analyzed. Nine out of 44 (20%) failure modes were deemed critical, with a criticality score ranging from 540 to 720.

DISCUSSION

Following the multidisciplinary meetings, everybody agreed that an FMEA was a useful tool to identify failure modes and their relative importance. This approach identified many corrective measures.

CONCLUSION

This shared experience increased awareness of safety issues with insulin in our mother-child center. This study identified the main failure modes and associated corrective measures.

Skeletal findings in the first 12 months following initiation of glucocorticoid therapy for pediatric nephrotic syndrome

Incident vertebral fractures and lumbar spine bone mineral density (BMD) were assessed in the 12 months following glucocorticoid initiation in 65 children with nephrotic syndrome. The incidence of vertebral fractures was low at 12 months (6 %) and most patients demonstrated recovery in BMD Z-scores by this time point.

INTRODUCTION

Vertebral fracture (VF) incidence following glucocorticoid (GC) initiation has not been previously reported in pediatric nephrotic syndrome.

METHODS

VF was assessed on radiographs (Genant method); lumbar spine bone mineral density (LS BMD) was evaluated by dual-energy X-ray absorptiometry.

RESULTS

Sixty-five children were followed to 12 months post-GC initiation (median age, 5.4 years; range, 2.3-17.9). Three of 54 children with radiographs (6 %; 95 % confidence interval (CI), 2-15 %) had incident VF at 1 year. The mean LS BMD Z-score was below the healthy average at baseline (mean ± standard deviation (SD), -0.5 ± 1.1; p = 0.001) and at 3 months (-0.6 ± 1.1; p < 0.001), but not at 6 months (-0.3 ± 1.3; p = 0.066) or 12 months (-0.3 ± 1.2; p = 0.066). Mixed effect modeling showed a significant increase in LS BMD Z-scores between 3 and 12 months (0.22 SD; 95 % CI, 0.08 to 0.36; p = 0.003). A subgroup (N = 16; 25 %) had LS BMD Z-scores that were ≤-1.0 at 12 months. In these children, each additional 1,000 mg/m(2) of GC received in the first 3 months was associated with a decrease in LS BMD Z-score by 0.39 at 12 months (95 % CI, -0.71 to -0.07; p = 0.017).

CONCLUSIONS

The incidence of VF at 1 year was low and LS BMD Z-scores improved by 12 months in the majority. Twenty-five percent of children had LS BMD Z-scores ≤-1.0 at 12 months. In these children, LS BMD Z-scores were inversely associated with early GC exposure, despite similar GC exposure compared to the rest of the cohort.

A comparison of treatment approaches for bilateral congenital nasolacrimal duct obstruction

PURPOSE

To compare the clinical outcomes of two treatment approaches for bilateral nasolacrimal duct obstruction (NLDO) in infancy.

DESIGN

Multicenter, randomized clinical trial.

METHODS

We studied 57 infants between the ages of 6 and <10 months who had bilateral NLDO. Participants were randomized to receive either (1) immediate office-based probing within two weeks (n = 31) or (2) 6 months of observation and nonsurgical management followed by surgical facility-based probing for unresolved cases (n = 26). Treatment success was defined as the absence of clinical signs of NLDO (epiphora, increased tear lake, mucous discharge) in both eyes on masked examination at 18 months of age.

RESULTS

In the observation and deferred facility probing group, resolution without surgery occurred by 6 months after randomization in both eyes for 14 participants (56%), in one eye for 5 (20%), and in neither eye for 6 (24%). Eight participants in the observation and deferred facility probing group underwent facility probing (one of whom later had a second facility probing). Four participants in the immediate office probing group later underwent an additional procedure in a surgical facility. In the immediate office probing group, treatment success at 18 months of age occurred in both eyes for 19 of 29 (66%) participants and in one eye for 3 (10%); in the observation and deferred facility probing group, treatment success occurred in both eyes for 19 of 25 (76%) participants and in one eye for 3 (12%) (difference in success = -10%; 95% CI = -35% to 14%).

CONCLUSIONS

Both the immediate office probing approach and the observation and deferred facility probing approach are successful and reasonable treatment options for infants with bilateral NLDO.

Microstructure-statistics-property relations of anisotropic polydisperse particulate composites using tomography

In this paper, a systematic method is presented for developing microstructure-statistics-property relations of anisotropic polydisperse particulate composites using microcomputer tomography (micro-CT). Micro-CT is used to obtain a detailed three-dimensional representation of polydisperse microstructures, and an image processing pipeline is developed for identifying particles. In this work, particles are modeled as idealized shapes in order to guide the image processing steps and to provide a description of the discrete micro-CT data set in continuous Euclidean space. n-point probability functions used to describe the morphology of mixtures are calculated directly from real microstructures. The statistical descriptors are employed in the Hashin-Shtrikman variational principle to compute overall anisotropic bounds and self-consistent estimates of the thermal-conductivity tensor. We make no assumptions of statistical isotropy nor ellipsoidal symmetry, and the statistical description is obtained directly from micro-CT data. Various mixtures consisting of polydisperse ellipsoidal and spherical particles are prepared and studied to show how the morphology impacts the overall anisotropic thermal-conductivity tensor.

De novo Cryoglobulinaemic Mononeuritis Multiplex during Treatment of Chronic Hepatitis C Infection: A Viral Effect or Induced by Pegylated Interferon Alpha?

Cryoglobulinaemic mononeuritis multiplex (MNM) is an extrahepatic manifestation of chronic hepatitis C virus (HCV) infection for which interferon-based antiviral therapy is currently the treatment of choice. Rarely MNM can be associated with HCV treatment though generally in the setting of pre-existing cryoglobulinaemia and detectable HCV viraemia. We report an unusual case of de novo MNM occurring late during the course of pegylated interferon and ribavirin therapy for chronic HCV infection, following a prolonged period of viral suppression. The patient had no evidence of cryoglobulinaemia prior to HCV treatment and undetectable HCV RNA levels at the time of presentation with MNM. The case raises the possibility that MNM could develop as an adverse immunomodulatory effect of pegylated interferon therapy.

The aqueduct of Sylvius: a sonographic landmark for neural tube defects in the first trimester

OBJECTIVES

To describe a new first-trimester sonographic landmark, posterior displacement of the midbrain and aqueduct of Sylvius, which may be useful in early screening for neural tube defects.

METHODS

This was a prospective study of 457 normal fetuses at 11 + 0 to 13 + 6 weeks' gestation. We measured the distance from the posterior border of the aqueduct of Sylvius to the anterior border of the occiput (AOS-to-occiput distance) in the axial plane and created a reference range. In the nine fetuses with abnormal midbrain position identified in the first trimester and with neural tube defect subsequently confirmed, we analyzed ultrasound images to determine the position of the aqueduct of Sylvius.

RESULTS

The lower limit of normal AOS-to-occiput distance (mean minus 2 SD) ranged from 1.7 mm at a crown-rump length (CRL) of 45 mm to 3.7 mm at a CRL of 84 mm. In the nine cases with abnormal position of the midbrain and confirmed neural tube defect, juxtaposition of the midbrain to the occiput was the clue to diagnosis of the spinal abnormality. In all nine cases, the AOS-to-occiput distance was below the established normal range.

CONCLUSIONS

Examination of the midbrain in an axial plane may prove a reliable marker for the first-trimester diagnosis of neural tube defects. In contrast to recently reported subtle changes in the mid-sagittal view of the posterior cranial fossa, axial imaging of the midbrain reveals striking displacement of this structure, with virtual juxtaposition to the occiput, in fetuses with confirmed open spina bifida. This anatomical distortion of the midbrain can be quantified by measurement of the AOS-to-occiput distance.

Plasma cortisol and thyroid hormone concentrations in pre-weaning Australian fur seal pups

The hormonal factors that influence development from birth to weaning in otariid seals is still largely unknown. In the present study, a suite of thyroid hormones and cortisol were measured in Australian fur seal pups in order to determine baseline concentrations as well as to describe their endocrinology over this critical developmental period. A cross-section of newborn pups from a breeding colony located on Kanowna Island, Australia were sampled at six different times over the course of the 10 month lactation period. Sample times were designed to correspond to periods of heightened physiological change during pre-weaning development: post-natal, pre-molt, the initiation of molt, mid-molt, period of peak milk intake and weaning. Results indicate that the greatest hormonal changes were associated with the post-natal stage and molt, with molt showing the greatest changes, as has been reported for several species of pinnipeds. Two forms of thyroid hormones analyzed (Total T(4), and Free T(3)), increased with the initiation of the molt, and Free T(3) exhibited a second increase that was associated with the period of peak milk intake. The T(3):T(4) ratio was significantly lower during the initiation of molt than either pre- or mid-molt. The study was able to describe physiological change during the first year of life in Australian fur seals as well as document basal concentrations of thyroid hormones and cortisol in pups of this species.

Changes of gastric histology in patients with erosive oesophagitis receiving long-term lansoprazole maintenance therapy

BACKGROUND

Changes in gastric histology associated with long-term maintenance therapy with lansoprazole for erosive oesophagitis have not been well described.

AIM

To evaluate the effect on gastric histology of long-term dose-titrated lansoprazole administered as maintenance therapy for up to 82 months in patients with erosive oesophagitis.

METHODS

Sequential gastric biopsy specimens were obtained for evaluation of histological changes and Helicobacter pylori infection status.

RESULTS

Active and chronic inflammation improved from baseline to final visit in a majority of patients receiving long-term therapy with lansoprazole, irrespective of baseline H. pylori infection status. Reductions in active inflammation in the gastric body and antrum were seen in 53% (17/32) and 67% (20/30) of H. pylori-positive patients, respectively, and in 88% (7/8) and 86% (12/14) of H. pylori-negative patients, respectively. Reductions in chronic inflammation in the gastric body and antrum were seen in 38% (12/32) and 47% (15/32) of H. pylori-positive patients, respectively, and in 58% (70/121) and 57% (68/120) of H. pylori-negative patients, respectively. No clinically meaningful increases in hyperplasia, dysplasia, neoplasia, intestinal metaplasia or atrophy were observed during the follow-up period.

CONCLUSIONS

Lansoprazole administered as maintenance therapy for up to 6 years in patients with erosive oesophagitis demonstrated gastric mucosal safety and was well tolerated.