Outcomes with Endovascular Treatment of Patients with M2 Segment MCA Occlusion in the Late Time Window

BACKGROUND AND PURPOSE

Randomized trials in the late window have demonstrated the efficacy and safety of endovascular thrombectomy in large-vessel occlusions. Patients with M2-segment MCA occlusions were excluded from these trials. We compared outcomes with endovascular thrombectomy in patients with M2-versus-M1 occlusions presenting 6-24 hours after symptom onset.

MATERIALS AND METHODS

Analyses were on pooled data from studies enrolling patients with stroke treated with endovascular thrombectomy 6-24 hours after symptom onset. We compared 90-day functional independence (mRS ≤ 2), mortality, symptomatic intracranial hemorrhage, and successful reperfusion (expanded TICI = 2b-3) between patients with M2 and M1 occlusions. The benefit of successful reperfusion was then assessed among patients with M2 occlusion.

RESULTS

Of 461 patients, 367 (79.6%) had M1 occlusions and 94 (20.4%) had M2 occlusions. Patients with M2 occlusions were older and had lower median baseline NIHSS scores. Patients with M2 occlusion were more likely to achieve 90-day functional independence than those with M1 occlusion (adjusted OR = 2.13; 95% CI, 1.25-3.65). There were no significant differences in the proportion of successful reperfusion (82.9% versus 81.1%) or mortality (11.2% versus 17.2%). Symptomatic intracranial hemorrhage risk was lower in patients with M2-versus-M1 occlusions (4.3% versus 12.2%, P = .03). Successful reperfusion was independently associated with functional independence among patients with M2 occlusions (adjusted OR = 2.84; 95% CI, 1.11-7.29).

CONCLUSIONS

In the late time window, patients with M2 occlusions treated with endovascular thrombectomy achieved better clinical outcomes, similar reperfusion, and lower symptomatic intracranial hemorrhage rates compared with patients with M1 occlusion. These results support the safety and benefit of endovascular thrombectomy in patients with M2 occlusions in the late window.

Fallibility of tattooing colonic neoplasia ahead of laparoscopic resection: a retrospective cohort study

INTRODUCTION

Precise geographical localisation of colonic neoplasia is a prerequisite for proper laparoscopic oncological resection. Preoperative endoscopic peri-tumoural tattoo practice is routinely recommended but seldom scrutinised.

METHODS

A retrospective review of recent consecutive patients with preoperative endoscopic lesional tattoo who underwent laparoscopic colonic resection as identified from our prospectively maintained cancer database with supplementary clinical chart and radiological, histological, endoscopic and theatre database/logbook interrogation.

RESULTS

Some 210 patients with 'tattooed' colonic neoplasia were identified, of whom 169 underwent laparoscopic surgery (mean age 68 years, median BMI 27.8kg/m2, male-to-female ratio 95:74). The majority of tumours were malignant (149; 88%), symptomatic (133; 79%) and proximal to the splenic flexure (92; 54%). Inaccurate colonoscopist localisation judgement occurred in 12% of cases, 60% of which were corrected by preoperative staging computed tomography scan. A useful lesional tattoo was absent in 11/169 cases (6.5%) being specifically stated as present in 104 operation notes (61%) and absent in 10 (5.9%). Tumours missing overt peritumoral tattoos intraoperatively were more likely to be smaller, earlier stage and injected longer preoperatively (p=0.006), although half had histological ink staining. Eight lesions missing tattoos were radiologically occult. Four (44%) of these patients had on-table colonoscopy, and five (55%) needed laparotomy (conversion rate 55% vs 23% overall, p<0.005) with one needing a second operation to resect the initially missed target lesion. Mean (range) operative duration and postoperative length of stay of those missing tattoos compared with those with tattoos was 200 (78-300) versus 188 (50-597) min and 15.5 (4-22) versus 12(4-70) days (p>0.05).

CONCLUSIONS

Tattoo in advance of attempting laparoscopic resection is vital for precision cancer surgery especially for radiologically unseen tumours to avoid adverse clinical consequence.

Vapour pressure deficit determines critical thresholds for global coffee production under climate change

Our understanding of the impact of climate change on global coffee production is largely based on studies focusing on temperature and precipitation, but other climate indicators could trigger critical threshold changes in productivity. Here, using generalized additive models and threshold regression, we investigate temperature, precipitation, soil moisture and vapour pressure deficit (VPD) effects on global Arabica coffee productivity. We show that VPD during fruit development is a key indicator of global coffee productivity, with yield declining rapidly above 0.82 kPa. The risk of exceeding this threshold rises sharply for most countries we assess, if global warming exceeds 2 °C. At 2.9 °C, countries making up 90% of global supply are more likely than not to exceed the VPD threshold. The inclusion of VPD and the identification of thresholds appear critical for understanding climate change impacts on coffee and for the design of adaptation strategies.

How well do polygenic risk scores identify men at high risk for prostate cancer? Systematic review and meta-analysis

OBJECTIVES

Genome-wide association studies have revealed over 200 genetic susceptibility loci for prostate cancer (PCa). By combining them, polygenic risk scores (PRS) can be generated to predict risk of PCa. We summarize the published evidence and conduct meta-analyses of PRS as a predictor of PCa risk in Caucasian men.

PATIENTS AND METHODS

Data were extracted from 59 studies, with 16 studies including 17 separate analyses used in the main meta-analysis with a total of 20,786 cases and 69,106 controls identified through a systematic search of ten databases. Random effects meta-analysis was used to obtain pooled estimates of area under the receiver-operating characteristic curve (AUC). Meta-regression was used to assess the impact of number of single-nucleotide polymorphisms (SNPs) incorporated in PRS on AUC. Heterogeneity is expressed as I² scores. Publication bias was evaluated using funnel plots and Egger tests.

RESULTS

The ability of PRS to identify men with PCa was modest (pooled AUC 0.63, 95% CI 0.62-0.64) with moderate consistency (I² 64%). Combining PRS with clinical variables increased the pooled AUC to 0.74 (0.68-0.81). Meta-regression showed only negligible increase in AUC for adding incremental SNPs. Despite moderate heterogeneity, publication bias was not evident.

CONCLUSION

Typically, PRS accuracy is comparable to PSA or family history with a pooled AUC value 0.63 indicating mediocre performance for PRS alone.

Decadal climate variability in the tropical Pacific: Characteristics, causes, predictability, and prospects

[Figure: see text].

Improving endovascular access to the target vessel for thrombus aspiration -Use of the wedge device to overcome anatomic hurdles

BACKGROUND AND PURPOSE

Aspiration is a successful technique used in thrombectomy for acute stroke. It is contingent upon the appropriate position of the aspiration catheter, so that it is in contact with the thrombus. However, navigating the craniocervical vasculature is challenging is some patients. The wedge microcatheter (MicroVention®) is designed to reduce the gap between the microcatheter and the SofiaPlus 6F catheter for ease of advancement. The purpose of this study is to describe our initial experience with the wedge microcatheter.

MATERIALS AND METHODS

A retrospective review of 38 consecutive patients in whom the wedge microcatheter was used during thrombectomy was performed to determine whether the wedge microcatheter was successful in delivering the Sofia catheter to the desired location.

RESULTS

We have found this device to be successful in delivering the aspiration catheter to the correct position in 97% (N = 37) of cases. It was used predominantly to pass the origin of branching vessels and also to navigate the tortuous cavernous and petrous segments of the ICA.

CONCLUSION

The wedge microcatheter is a successful tool in delivering the aspiration catheter to the desired vessel for revascularisation.

Fetal medicine specialist experiences of providing a new service of termination of pregnancy for fatal fetal anomaly: a qualitative study

OBJECTIVE

To explore fetal medicine specialists' experiences of caring for parents following a diagnosis of fatal fetal anomaly (FFA) during the implementation of termination of pregnancy (TOP) for FFA for the first time.

DESIGN

Qualitative study.

SETTING

Fetal medicine units in the Republic of Ireland.

POPULATION

Ten fetal medicine specialists from five of the six fetal medicine units.

METHODS

nvivo 12 assisted in the thematic analysis of semi-structured in-depth face-to-face interviews.

MAIN OUTCOME MEASURES

Fetal medicine specialists' experiences of prenatal diagnosis and holistic management of pregnancies complicated by FFA.

RESULTS

Four themes were identified: 'not fatal enough', 'interactions with colleagues', 'supporting pregnant women' and 'internal conflict and emotional challenges'. Fetal medicine specialists feared getting an FFA diagnosis incorrect because of media scrutiny and criminal liability associated with the TOP for FFA legislation. Challenges with the ambiguous and 'restrictive' legislation were identified that 'ostracised' severe anomalies. Teamwork was essential to facilitate opportunities for learning and peer support; however, conflict with colleagues was experienced regarding the diagnosis of FFA, the provision of feticide and palliative care to infants born alive following TOP for FFA. Participants reported challenges implementing TOP for FFA, including the absence of institutional support and 'stretched' resources. Fetal medicine specialists experienced internal conflict and a psychological burden providing TOP for FFA, but did so to 'provide full care for women'.

CONCLUSIONS

Our study identified challenges regarding the suitability of the Irish legislation for TOP for FFA and its rapid introduction into clinical practice. It illustrates the importance of institutional and peer support, as well as the need for supportive management, in the provision of a new service.

TWEETABLE ABSTRACT

The implementation of termination services for fatal fetal anomaly is complex and requires institutional support.

Long-term survival after endoscopic vein harvest for coronary artery bypass grafting

INTRODUCTION

Endoscopic vein harvest is the technique of choice in North America, where it constitutes 80% of conduit harvest for coronary artery bypass grafting. The UK has much lower rates, despite demonstrable perioperative benefits. Concerns about patency and long-term survival are often cited as reasons for poor uptake and evidence in the literature thus far has only addressed mid-term outcomes. We sought to identify the long-term survival of patients undergoing endoscopic vein harvest compared with a contemporaneous cohort of open vein harvest.

MATERIALS AND METHODS

This was a retrospective cohort study of all consecutive patients undergoing isolated coronary artery bypass grafting at a single institution between 2007 and 2017. All-cause long-term mortality was compared using Kaplan-Meier curves and log-rank analysis.

RESULTS

A total of 7,527 patients undergoing coronary artery bypass grafting (1,029 receiving endoscopic vein harvest) were studied. The groups were well matched for preoperative characteristics, except that there were more patients with triple-vessel disease and good left-ventricular function in the endoscopic vein harvest group. There was no statistically significant difference in the long-term survival (p = 0.23). At five years (median follow-up), survival was 86.1% (95% confidence interval 85.3-87.0) in the open vein harvest group compared with 85.5% (95% confidence interval 82.8-88.2) in the endoscopic vein harvest group.

DISCUSSION AND CONCLUSION

Endoscopic vein harvest does not affect long-term survival in an unselected population. The contraindications for minimally invasive vein harvest in coronary artery bypass grafting are increasingly diminishing.

Review of external referrals to a regional stroke centre: it is not just about thrombectomy

AIMS

To determine the experience of a regional stroke referral centre of external referrals for endovascular thrombectomy (EVT) in patients with symptoms of acute ischaemic stroke (AIS) and large vessel occlusion (LVO).

MATERIALS AND METHODS

Data were collected prospectively over two 4-month periods (2017-2018) on consecutive external referrals for EVT. Baseline demographics, imaging findings, and key time parameters were recorded. Reasons for not transferring patients and for not performing EVT were recorded. Key time intervals were calculated and compared between the transferred and non-transferred group with and without intracranial occlusion and between the transferred patients who underwent thrombectomy and those who did not.

RESULTS

Two hundred and sixty-two patients were referred. Sixty-one percent (n=159) were accepted and transferred for treatment. Of those transferred, 86% (n=136) had EVT. Fourteen percent (n=23) were unsuitable for EVT on arrival due to no vessel occlusion (48% n=11), poor Alberta Stroke Program Early CT Score (ASPECTS)/established infarct (30%, n=7) haemorrhage (9%, n=2), and clinical recovery (13% n=3). One hundred and three patients (39%) were ineligible for EVT following phone discussion due to absence of intracranial occlusion (59%, n=61), low ASPECTS (22%, n=23), distal occlusion (4%, n=4), low/improving National Institutes of Health Stroke Scale (NIHSS; 10.7%, n=11), and poor modified Rankin Scale (mRS) at baseline (3%, n=3). Patients with LVO but not transferred had longer onset to hospital arrival time compared with those transferred 151.5 versus 91 minutes (p<0.005), with a trend also toward a longer door to CT/CTA 40 minutes versus 30 minutes (p=0.142).

CONCLUSION

These data provide valuable insights into the service provision of a comprehensive stroke network. The present rates of EVT and futile transfers are modest compared to published data. Access to neuroradiology and specialised stroke assessment is crucial to optimise time to treatment.

A Standardized Aspiration-First Approach for Thrombectomy to Increase Speed and Improve Recanalization Rates

BACKGROUND AND PURPOSE

Direct aspiration is a recognized technique for revascularization in large-vessel ischemic strokes. There is ongoing debate regarding its efficacy compared with stent retrievers. Every delay in achieving revascularization and a decrease in reperfusion rates reduces the likelihood of patients achieving functional independence. We propose a standardized setup technique for aspiration-first for all anterior circulation thrombectomy procedures for increasing speed and recanalization rates.

MATERIALS AND METHODS

We analyzed 127 consecutive patients treated by a standardized approach to thrombectomy with an intention to perform aspiration-first compared with 127 consecutive patients treated with a stent retriever-first approach. Key time metrics evaluated included groin to first angiogram, first angiogram to reperfusion, groin to first reperfusion, and length of the procedure. The degree of successful recanalization (TICI 2b-3) and the number of passes were compared between the 2 groups.

RESULTS

In 127 patients who underwent the standardized technique, the median time from groin puncture to first reperfusion was 18 minutes compared with 26 minutes (P < .001). The duration of the procedure was shorter compared with the stent retriever group (26 minutes in the aspiration first group versus 47 minutes, P < .001) and required fewer passes (mean, 2.4 versus 3.1; P < .05). A higher proportion of patients had a TICI score of 2b-3 in the aspiration-first group compared with stent retriever group (96.1% versus 85.8%, P < .005).

CONCLUSIONS

Our study highlights the increasing speed and recanalization rates achieved with fewer passes in a standardized approach to thrombectomy with an intention to attempt aspiration-first. Any attempt to reduce revascularization time and increase successful recanalization should be used.

El Niño-Southern Oscillation complexity

El Niño events are characterized by surface warming of the tropical Pacific Ocean and weakening of equatorial trade winds that occur every few years. Such conditions are accompanied by changes in atmospheric and oceanic circulation, affecting global climate, marine and terrestrial ecosystems, fisheries and human activities. The alternation of warm El Niño and cold La Niña conditions, referred to as the El Niño-Southern Oscillation (ENSO), represents the strongest year-to-year fluctuation of the global climate system. Here we provide a synopsis of our current understanding of the spatio-temporal complexity of this important climate mode and its influence on the Earth system.

Outcomes of endovascular treatment for acute large-vessel ischaemic stroke more than 6 h after symptom onset

BACKGROUND AND OBJECTIVES

Benefit from endovascular thrombectomy (EVT) for large-vessel occlusion (LVO) acute ischaemic stroke (AIS) is well demonstrated. Furthermore, emerging evidence supports efficacy in appropriately selected patients treated beyond current recommendations of 6 h. We evaluated clinical outcomes in patients undergoing late EVT at our institution.

METHODS

Retrospective review of prospectively collected clinical database on 355 patients who underwent EVT for LVO AIS. Data collected consisted of patient demographics, radiological findings and outcome details. Outcomes, including 90-day functional status, recanalization, symptomatic intracranial haemorrhage (sICH) and 90-day mortality, for patients undergoing EVT <6 h, >6 h, and >7.3 h, were compared.

RESULTS

A total of 355 patients underwent EVT for LVO AIS at our institution during the review period, with 74 (21%) patients treated ≥6 h from symptom onset. Successful recanalization was achieved in 285 (80%) patients, with 228 (81%) achieving a mTICI ≥2b in the <6 h group, and 57 (77%) in the >6 h group (P = 0.429). Ninety-day functional independence (mRS 0-2) was achieved in 162 (46%) patients, with 130 (46%) achieving a mRS of 0-2 in the <6 h group, and 32 (43%) in the >6 h group (P = 0.643). No significant differences were found in rates of sICH or 90-day mortality. No significant differences in functional independence, recanalization rates, sICH or mortality were identified in patients treated with EVT >7.3 h compared to <7.3 h.

CONCLUSIONS

In appropriately selected patients, EVT >6 h was associated with comparable outcomes to those treated <6 h. These data support a physiological approach to patient selection.

ETSON views on R&D priorities for implementation of the 2014 Euratom Directive on safety of nuclear installations

Following the Fukushima-Daiichi accident in 2011, the Council Directive 2014/87/Euratom has reinforced the previous 2009 Directive that had established a Community framework for the safety of nuclear installations. In particular, one new article introduces a high-level EU-wide safety objective of preventing accidents through defence-in-depth and avoiding radioactive releases outside a nuclear installation. For achieving this objective, the research necessary outcomes are mainly a better knowledge of the involved physical phenomena and its capitalization in methodologies and tools such as simulation codes. ETSON, the European Technical Safety Organisation Network, had already identified in its Position Paper in 2011 the main R&D priorities. The present paper underlines that most of these priorities, with a few updates due to progress of knowledge, remain consistent with the objectives of this new Directive. And it illustrates the ETSON involvement through examples of on-going or planned R&D national and international projects.

An exploration of the prevalence and patterns of care for women presenting with mid-trimester loss

BACKGROUND

Mid-trimester loss (MTL) is an area that is poorly defined in the literature and often under reported in clinical practice. The prevalence of MTL in Ireland is uncertain and has a huge impact on the woman, her family and maternity care services.

AIMS

To explore the prevalence and patterns of care for women with MTL in a large Maternity hospital in Ireland.

METHODS

A descriptive, exploratory study was used involving a retrospective chart audit.

RESULTS

220 women presented with MTL over the 3 year data collection period (January 2011-December 2013), giving a rate of 0.8 % of all deliveries. The majority of women had no previous pregnancy losses and were multiparous (i.e., had a previous pregnancy >500 g). The mean gestational age was 17.69 weeks (SD = 2.73). The mean length of hospital stay was 1.89 days. Intra muscular (IM) analgesia was the most commonly (58.5 %) used medication. Follow up hospital care was received in over 78 % of cases. The majority of women were referred the CMS Bereavement and Chaplain services, with a small number (approx. 5 %) referred to the social worker. Over 46.4 % of families availed of the hospital burial service.

CONCLUSIONS

Results suggest the incidence of mid-trimester loss may be slightly lower than the 1 or 2 % of pregnancies reported in the literature. The incidence of mid-trimester loss in multiparous women is approximately twice that of nulliparous women. The referral services offered in the study were utilised by most of the women, as were follow-up clinic appointments.

Neural activity in the suprachiasmatic circadian clock of nocturnal mice anticipating a daytime meal

Circadian rhythms in mammals are regulated by a system of circadian oscillators that includes a light-entrainable pacemaker in the suprachiasmatic nucleus (SCN) and food-entrainable oscillators (FEOs) elsewhere in the brain and body. In nocturnal rodents, the SCN promotes sleep in the day and wake at night, while FEOs promote an active state in anticipation of a predictable daily meal. For nocturnal animals to anticipate a daytime meal, wake-promoting signals from FEOs must compete with sleep-promoting signals from the SCN pacemaker. One hypothesis is that FEOs impose a daily rhythm of inhibition on SCN output that is timed to permit the expression of activity prior to a daytime meal. This hypothesis predicts that SCN activity should decrease prior to the onset of anticipatory activity and remain suppressed through the scheduled mealtime. To assess the hypothesis, neural activity in the SCN of mice anticipating a 4-5-h daily meal in the light period was measured using FOS immunohistochemistry and in vivo multiple unit electrophysiology. SCN FOS, quantified by optical density, was significantly reduced at the expected mealtime in food-anticipating mice with access to a running disk, compared to ad libitum-fed and acutely fasted controls. Group differences were not significant when FOS was quantified by other methods, or in mice without running disks. SCN electrical activity was markedly decreased during locomotion in some mice but increased in others. Changes in either direction were concurrent with locomotion, were not specific to food anticipation, and were not sustained during longer pauses. Reduced FOS indicates a net suppression of SCN activity that may depend on the intensity or duration of locomotion. The timing of changes in SCN activity relative to locomotion suggests that any effect of FEOs on SCN output is mediated indirectly, by feedback from neural or systemic correlates of locomotion.

Randomized controlled trial of asthma risk with paracetamol use in infancy--a feasibility study

BACKGROUND

There is non-experimental evidence that paracetamol (acetaminophen) use may increase the risk of developing asthma. However, numerous methodological issues need to be resolved before undertaking a randomized controlled trial to investigate this hypothesis.

OBJECTIVE

To establish the feasibility of a randomized controlled trial of liberal paracetamol as usually given by parents/guardians vs. a comparator (restricted paracetamol in accordance with WHO guidelines, ibuprofen or placebo), and childhood asthma risk.

METHODS

Questionnaires were completed by parents/guardians of infants admitted to Wellington Hospital with bronchiolitis to assess views about comparator treatments. Subsequently, infants of parents/guardians who provided informed consent were randomized to restricted or liberal paracetamol use for 3 months with paracetamol use recorded.

RESULTS

Of 120 eligible participants, 72 (60%) parents/guardians completed the questionnaire. Ibuprofen, restricted paracetamol and placebo were acceptable to 42 (58%), 29 (40%) and 9 (12%) parents/guardians, respectively. 36 (30%) infants were randomized to restricted or liberal paracetamol. Paracetamol use was greater for the liberal vs. restricted group for reported [Hodges-Lehmann estimator of difference 0.94 mg/kg/day (95% CI 0.2-3.52), P = 0.02] and measured use [Hodges-Lehmann estimator of difference 2.11 mg/kg/day (95% CI 0.9-4.18), P = 0.004]. The median reported and measured use of paracetamol was 2.0-fold and 3.5-fold greater in the liberal vs. restricted group.

CONCLUSIONS AND CLINICAL RELEVANCE

Although separation in paracetamol dosing is likely to be achieved with a liberal vs. restricted paracetamol regime, ibuprofen is the preferred comparator treatment in the proposed RCT of paracetamol use and risk of asthma in childhood.

Neurovascular manifestations in hereditary hemorrhagic telangiectasia: imaging features and genotype-phenotype correlations

BACKGROUND AND PURPOSE

Hereditary hemorrhagic telangiectasia is an autosomal dominant disease that presents in 10%-20% of patients with various brain vascular malformations. We aimed to report the radiologic features (phenotype) and the genotype-phenotype correlations of brain vascular malformations in hereditary hemorrhagic telangiectasia.

MATERIALS AND METHODS

Demographic, clinical, genotypic, and imaging information of 75 patients with hereditary hemorrhagic telangiectasia with brain arteriovenous malformations enrolled in the Brain Vascular Malformation Consortium from 2010 to 2012 were reviewed.

RESULTS

Nonshunting, small, superficially located conglomerates of enhancing vessels without enlarged feeding arteries or draining veins called "capillary vascular malformations" were the most commonly observed lesion (46 of 75 patients; 61%), followed by shunting "nidus-type" brain AVMs that were typically located superficially with a low Spetzler-Martin Grade and a small size (32 of 75 patients; 43%). Direct high-flow fistulous arteriovenous shunts were present in 9 patients (12%). Other types of vascular malformations (dural AVF and developmental venous anomalies) were present in 1 patient each. Multiplicity of vascular malformations was seen in 33 cases (44%). No statistically significant correlation was observed between hereditary hemorrhagic telangiectasia gene mutation and lesion type or lesion multiplicity.

CONCLUSIONS

Depending on their imaging features, brain vascular malformations in hereditary hemorrhagic telangiectasia can be subdivided into brain AVF, nidus-type AVM, and capillary vascular malformations, with the latter being the most common phenotype in hereditary hemorrhagic telangiectasia. No genotype-phenotype correlation was observed among patients with this condition.

Abstract P4-13-06: Association of Age, Obesity and Incident Breast Cancer Phenotypes

Background: Obesity has been shown to be associated with increased risk of breast cancer in postmenopausal women. However, it is unclear whether this risk is isolated to a specific phenotype. We hypothesized that the increased levels of insulin, IGF-1 and estrogens associated with obesity preferentially drive an increased proportion of the luminal A phenotype of breast cancer.

Methods: Between 2008 and 2011, 1001 women were diagnosed with invasive breast cancer at Duke University Medical Center and had weight and height recorded at the time of diagnosis. Tumor phenotypes were based on hormone receptor (HR: ER− and/or PR-positive) and Her2 testing with subtypes defined as follows: Luminal A: HR(+), Her2(−); Luminal B: HR(+), Her2(−); Her2: HR(−), Her2(+); triple negative: HR(−), Her2(−).

Results: Median age of the cohort was 55.7 years; median BMI was 27.7. As expected, increasing BMI was associated with older age, with BMI almost evenly distributed between three groups: ≤ 25, 25–30, and &gt;30. In the overall group, proportion of luminal B, Her2, and triple negative subtypes did not differ by BMI; however the proportion of patients with luminal A cancer increased from 65% for the lowest BMI group to 70% for the highest BMI group. Analysis stratified by age ≤ 40, 40 to 59, and ≥60 years showed a lower proportion of the triple-negative (19% vs. 6% vs. 4%, p &lt; 0.001) and higher proportion of the luminal A (11% vs. 23% vs. 32%; p &lt; 0.001) phenotype with older age group. This finding was limited to women with higher BMI only.

Conclusions: Although there were no trends observed between BMI and incident phenotype in the overall cohort, age stratified analysis revealed striking correlations. High BMI was associated with triple negative phenotype in the youngest age group and luminal A phenotype in older age groups. These results suggest that obesity likely exerts different effects on tumor progression based on patient age and/or menopausal status.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-13-06.

More extreme swings of the South Pacific convergence zone due to greenhouse warming

The South Pacific convergence zone (SPCZ) is the Southern Hemisphere's most expansive and persistent rain band, extending from the equatorial western Pacific Ocean southeastward towards French Polynesia. Owing to its strong rainfall gradient, a small displacement in the position of the SPCZ causes drastic changes to hydroclimatic conditions and the frequency of extreme weather events--such as droughts, floods and tropical cyclones--experienced by vulnerable island countries in the region. The SPCZ position varies from its climatological mean location with the El Niño/Southern Oscillation (ENSO), moving a few degrees northward during moderate El Niño events and southward during La Niña events. During strong El Niño events, however, the SPCZ undergoes an extreme swing--by up to ten degrees of latitude toward the Equator--and collapses to a more zonally oriented structure with commensurately severe weather impacts. Understanding changes in the characteristics of the SPCZ in a changing climate is therefore of broad scientific and socioeconomic interest. Here we present climate modelling evidence for a near doubling in the occurrences of zonal SPCZ events between the periods 1891-1990 and 1991-2090 in response to greenhouse warming, even in the absence of a consensus on how ENSO will change. We estimate the increase in zonal SPCZ events from an aggregation of the climate models in the Coupled Model Intercomparison Project phases 3 and 5 (CMIP3 and CMIP5) multi-model database that are able to simulate such events. The change is caused by a projected enhanced equatorial warming in the Pacific and may lead to more frequent occurrences of extreme events across the Pacific island nations most affected by zonal SPCZ events.

Perceived occupational stress in nurses working in Ireland

BACKGROUND

Stress has been seen as a routine and accepted part of the health care worker's role. There is a lack of research on stress in nurses in Ireland.

AIMS

To examine the levels of stress experienced by nurses working in an Irish teaching hospital and investigate differences in perceived stress levels by ward area and associations with work characteristics.

METHODS

A cross-sectional study design was employed, with a two-stage cluster sampling process. Data collection was by means of a self-administered questionnaire, and nurses were investigated across 10 different wards using the Nursing Stress Scale and the Demand Control Support Scales.

RESULTS

The response rate was 62%. Using outpatients as a reference ward, perceived stress levels were found to be significantly higher in the medical ward, accident and emergency, intensive care unit and paediatric wards (P < 0.05). There was no significant difference between the wards with regard to job strain; however, differences did occur with levels of support, the day unit and paediatric ward reporting the lowest level of supervisor support (P < 0.01). A significant association was seen between the wards and perceived stress even after adjustment (P < 0.05).

CONCLUSIONS

The findings suggest that perceived stress does vary within different work areas in the same hospital. Work factors, such as demand and support, are important with regard to perceived stress. Job control was not found to play an important role.

A study to compare chest X-ray reports on overseas nursing recruits

This study was carried out to assess if there was a difference in the Chest X- ray (CXR) report on recruited nurses carried out overseas and later repeated in Ireland. This study was carried out in two Irish teaching hospitals. The subjects of this study comprised all overseas nurses recruited in each of the two hospitals within the defined period. The total number of subjects recruited from the 2 two centres was 84. Only nurses that had a repeat CXR were included in this study. 6/84 (7%) of the CXR that were initially reported as normal were subsequently reported as abnormal and were later diagnosed as Latent TB. 2/84(2%) of the CXR that were reported as abnormal were subsequently reported as normal. The data collected in this study has demonstrated that there was a significant difference in the CXR report from overseas and the CXR report in Ireland.

An evaluation of Irish cattle herds with inconclusive serological evidence of bovine brucellosis

Since 1998, there has been a steady decline in herd restrictions and de-populations in Ireland due to bovine brucellosis. There is concern that the interpretation of laboratory results may become increasingly problematic, as brucellosis prevalence falls in Ireland. Therefore, the purpose of the current study was to evaluate the infection status of Irish herds and animals with inconclusive serological evidence of bovine brucellosis. During 12 months from September 1, 2004, laboratory and observational epidemiological data were collected from all Irish herds where animal testing identified at least one animal with a complement fixation test (CFT) reading greater than zero and/or a positive result to the indirect enzyme-linked immunosorbent assay (iELISA). Due to the observational nature of the study, we have robust estimates of the relative, but not the absolute, performance of the CFT, iELISA and brucellin skin test (BST). Herds were divided into three categories (Group A, B or C) on the basis of test results at initial assessment. A total of 639 herds were enrolled into the study, and observed for at least two years following enrolment. A rising CFT titre, with a CFT reading of 111 International CFT Units (IU) or greater at the subsequent blood test, was generally associated with herds where other evidence of infection was also available. Knowledge of the CFT reading at the initial and a subsequent blood test proved useful in distinguishing false-positive and true-positive brucellosis results. There was poor correlation between the CFT and iELISA results, and between the CFT and BST results. As a result of this study, national policy has been modified to include re-sampling of all animals with CFT readings of 20 IU or greater. This project has also led to a reduction in the number of herds restricted, as well as restriction duration. It has also contributed to a reduction in the number of herds listed for contiguous tests, and therefore the potential for contiguity testing of false positive results.

Named/designated doctor status and judgement in child-protection scenarios

Four child-protection scenarios were sent to 200 named/designated and non-named/non-designated doctors. The respondents judged each scenario as abuse or accident and indicated their degree of certainty. There was a 71% response rate. There were no significant differences in judgement or degrees of certainty of judgement between the two groups.

Quality and potential utility of ENSO-based forecasts of spring rainfall and wheat yield in south-eastern Australia

Reliable seasonal climate forecasts are needed to aid tactical crop management decisions in south-eastern Australia (SEA). In this study we assessed the quality of two existing forecasting systems, i.e. the five phases of the Southern Oscillation Index (SOI) and a three phase Pacific Ocean sea-surface temperatures (SSTs), to predict spring rainfall (i.e. rainfall from 1 September to 31 November), and simulated wheat yield. The quality of the forecasts was evaluated by analysing four attributes of their performance: their reliability, the relative degree of shift and dispersion of the distributions, and measure of forecast consistency or skill. Available data included 117 years of spring rainfall and 104 years of grain yield simulated using the Agricultural Production Systems Simulator (APSIM) model, from four locations in SEA. Average values of spring rainfall were 102–174 mm with a coefficient of variation (CV) of 47%. Average simulated wheat yields were highest (5609 kg/ha) in Albury (New South Wales) and lowest (1668 kg/ha) in Birchip (Victoria). The average CV for simulated grain yields was 36%. Griffith (NSW) had the highest yield variability (CV = 50%). Some of this year-to-year variation was related to the El Niño Southern Oscillation (ENSO). Spring rainfall and simulated wheat yields showed a clear association with the SOI and SST phases at the end of July. Important variations in shift and dispersion in spring rainfall and simulated wheat yields were observed across the studied locations. The forecasts showed good reliability, indicating that both forecasting systems could be used with confidence to forecast spring rainfall or wheat yield as early as the end of July. The consistency of the forecast of spring rainfall and simulated wheat yield was 60–83%. We concluded that adequate forecasts of spring rainfall and grain yield could be produced at the end of July, using both the SOI and SST phase systems. These results are discussed in relation to the potential benefit of making tactical top-dress applications of nitrogen fertilisers during early August.

Rational design of a multiepitope vaccine encoding T-lymphocyte epitopes for treatment of chronic hepatitis B virus infections

Protein sequences from multiple hepatitis B virus (HBV) isolates were analyzed for the presence of amino acid motifs characteristic of cytotoxic T-lymphocyte (CTL) and helper T-lymphocyte (HTL) epitopes with the goal of identifying conserved epitopes suitable for use in a therapeutic vaccine. Specifically, sequences bearing HLA-A1, -A2, -A3, -A24, -B7, and -DR supertype binding motifs were identified, synthesized as peptides, and tested for binding to soluble HLA. The immunogenicity of peptides that bound with moderate to high affinity subsequently was assessed using HLA transgenic mice (CTL) and HLA cross-reacting H-2(bxd) (BALB/c x C57BL/6J) mice (HTL). Through this process, 30 CTL and 16 HTL epitopes were selected as a set that would be the most useful for vaccine design, based on epitope conservation among HBV sequences and HLA-based predicted population coverage in diverse ethnic groups. A plasmid DNA-based vaccine encoding the epitopes as a single gene product, with each epitope separated by spacer residues to enhance appropriate epitope processing, was designed. Immunogenicity testing in mice demonstrated the induction of multiple CTL and HTL responses. Furthermore, as a complementary approach, mass spectrometry allowed the identification of correctly processed and major histocompatibility complex-presented epitopes from human cells transfected with the DNA plasmid. A heterologous prime-boost immunization with the plasmid DNA and a recombinant MVA gave further enhancement of the immune responses. Thus, a multiepitope therapeutic vaccine candidate capable of stimulating those cellular immune responses thought to be essential for controlling and clearing HBV infection was successfully designed and evaluated in vitro and in HLA transgenic mice.

A Bacillus subtilis fusion protein system to produce soybean Bowman–Birk protease inhibitor

A fusion protein based expression system was developed in the Gram-positive bacterium Bacillus subtilis to produce the soybean Bowman-Birk protease inhibitor (sBBI). The N-terminus of the mature sBBI was fused to the C-terminus of the 1st cellulose binding domain linker (CBD linker) of the BCE103 cellulase (from an alkalophilic Bacillus sp.). The strong aprE promoter was used to drive the transcription of the fusion gene and the AprE signal sequence was fused to the mature BCE103 cellulase for efficient secretion of the fusion protein into the culture medium. It was necessary to use a B. subtilis strain deficient in nine protease genes in order to reduce the proteolytic degradation of the fusion protein during growth. The fusion protein was produced in shake flasks at concentrations >1g/L. After growth, the sBBI was activated by treatment with 2-mercaptoethanol to allow the disulfide bonds to form correctly. An economical and scalable purification process was developed to purify sBBI based on acid precipitation of the fusion protein followed by acid/heat cleavage of the fusion protein at labile Asp-Pro bonds in the CBD linker. If necessary, non-native amino acids at the N- and C-termini were trimmed off using glutamyl endopeptidase I. After purification, an average of 72 mg of active sBBI were obtained from 1L of culture broth representing an overall yield of 21% based on the amount of sBBI activated before purification.

The effectiveness of laceback ligatures: a randomized controlled clinical trial

OBJECTIVE

To evaluate the effects of laceback ligatures on the anteroposterior and vertical position of lower incisors and the mesial position of the lower first molars.

DESIGN

Randomized controlled trial.

SETTINGS

Patients under treatment in the Department of Orthodontics, Royal Bournemouth Hospital, Dorset, during a 6 month period from November 1999 to March 2000.

SUBJECTS

Sixty-two adolescents (mean 13.7 years, range 11.2-16.8 years) with similar malocclusions, requiring extraction of all first premolars, were randomly assigned to experimental (laceback: 30; 12 male, 18 female) and control (non-laceback: 32; 14 male, 18 female) groups.

INTERVENTIONS

Treatment using upper and lower fixed appliances following extraction of four premolars. One group had lacebacks placed, whilst the control group had no lacebacks.

MAIN OUTCOME MEASURES

The participants were examined clinically and radiographically, and lateral cephalograms with radio-opaque tooth markers and lower study casts records were taken when lower fixed appliances were placed (T1) and following sufficient leveling with a 0.018 inch stainless steel round wire (T2). Linear measurements were recorded following digitization of the lateral cephalograms and using a vernier caliper on the study casts. A Student t-test was used to examine differences between the two groups following assessment for normality.

RESULTS

In both groups the lower incisors retroclined during T1-T2; (Mean+/-SD: Experimental -0.53+/-1.9 mm, Control -0.44+/-1.29 mm). There was no statistical significance between the two groups (p = 0.84). The lower incisors extruded in both groups; 0.47+/-0.98 mm in the experimental group and 0.44+/-0.87 mm in the control group. There was no statistical difference between the groups (p = 0.9). The lower first molars showed 0.83 mm greater mesial movement in the experimental group, which was statistically significant (p < 0.05). Labial segment crowding decreased in both groups (experimental -3+/-1.6 mm, control -2.67+/-2.28 mm), the difference between the groups being non-significant (p = 0.51). Arch length decreased in both groups (experimental -2.08+/-2.82 mm , control -2.9+/-3.06 mm), but the difference between them was not significant (p = 0.28)

CONCLUSIONS

In first premolar extraction cases, the lower labial segment does not procline during the leveling stage with the pre-adjusted edgewise appliance and the use of laceback ligatures conveys no difference in the anteroposterior or vertical position of the lower labial segment. Furthermore, the use of laceback ligatures creates a statistically and clinically significant increase in the loss of posterior anchorage.