Cost analysis of orthognathic surgery: outpatient care versus inpatient care

With limited healthcare resources, it is important to provide the right level and form of care. The aim of this study was to determine whether selected single-jaw orthognathic surgery in outpatient care (OPC) generates lower healthcare costs than in inpatient care (IPC). The costs of surgically assisted rapid maxillary expansion (SARME), Le Fort I osteotomy (LFI), and bilateral sagittal split osteotomy (BSSO) were calculated for 165 patients, 107 treated in OPC and 58 in IPC. Additionally, costs for revisits, emergency visits, emergency phone calls, re-operations, and plate removal during the first 12 months postoperatively were recorded. The total mean costs of the different operations including revisits, emergency visits, and phone calls were 34.2-48.8% lower in OPC than in IPC at 12 months postoperatively. Operation costs were lower for LFI in OPC (P = 0.009) and for SARME in IPC (P = 0.007). Anaesthesia costs were lower for LFI (P < 0.001) and BSSO (P < 0.001) in OPC, and there were fewer revisits (P = 0.001) and lower costs (P = 0.002) after LFI in OPC compared to IPC. This study showed that selected single-jaw orthognathic surgeries in outpatient care are associated with lower healthcare costs compared to inpatient care.

Chilblain-like lesions (COVID-19 toes) have the same impact on family members than psoriasis systemically treated: insights from a case-control study targeting the pediatric population

OBJECTIVE

COVID-19 toes represent the main dermatological COVID-19 cutaneous manifestation in pediatric patients. Its diagnosis exposes the whole family to social stigma and this aspect was not previously evaluated.

PATIENTS AND METHODS

This was a multicenter, case-control, observational study that compared the family impact of COVID-19 toes vs. psoriasis (PsO). We enrolled 46 pediatric patients (23 with psoriasis and 23 with COVID-19 toes, age and gender matched) and their parents/caregivers that had to fill the Dermatitis Family Impact (DFI) questionnaire.

RESULTS

DFI index did not differ significantly between both subgroups (p=0.48), and in psoriatic patients did not correlate with both Psoriasis Area Severity Index (PASI) (p=0.59) and itch-VAS (p=0.16).

CONCLUSIONS

COVID-19 toes, a transitory dermatosis, exerted a similar impact/perturbation on family dynamics than PsO, a well-known stigmatizing, chronic inflammatory dermatosis.

Who moves in vulnerable Caribbean neighborhoods? Positive deviance for physical activity: Findings from the Jamaica health and Lifestyle Survey 2017 (JHLS III)

Decreased physical activity (PA) has been associated with residents living in neighborhoods perceived as being disordered or having high crime levels. What is unknown are the characteristics of individuals who engage in moderate to vigorous levels of PA (MVPA) despite living in these vulnerable neighborhoods, or who may be referred to as positive deviants (PD). We examined the factors associated with PD for PA among Jamaicans. Between 2016 and 2017 the Jamaica Health and Lifestyle Survey, a cross-sectional nationally representative survey (n = 2807), was conducted on individuals aged 15 years and older. Regression analyses were performed to identify associations with PD, defined using engagement in MVPA among persons living in vulnerable neighborhoods (N = 1710). Being female (odds ratio [OR]a = 0.64 (0.48, 0.86); p = 0.003), obese while living in an urban area (ORa = 0.39; 95 % CI = 0.26, 0.59; p < 0.0001), unemployed (ORa = 0.53; 95 % CI = 0.39, 0.73; p < 0.0001), or a student (ORa = 0.62; 95 % CI = 0.39, 0.98); p = 0.041) was associated with a significantly lower likelihood of PD, while having a personal medical history of at least one chronic disease significantly increased likelihood (ORa = 1.43; 95 % CI = 1.08, 1.90; p = 0.014). Taking a PD approach may be one angle to consider in trying to determine what is working and for whom, so that this may be harnessed in policy, prevention and intervention programming to increase PA.

Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial

BACKGROUND

The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported.

OBJECTIVE

To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia.

DESIGN

Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505).

SETTING

46 U.S. and Canadian hospitals.

PARTICIPANTS

Patients aged 50 years or older undergoing hip fracture surgery.

INTERVENTION

Spinal or general anesthesia.

MEASUREMENTS

Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care.

RESULTS

A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups.

LIMITATION

Missing outcome data and multiple outcomes assessed.

CONCLUSION

Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute.

SARS-CoV-2, Lung Protective Ventilation, Low Middle Income Countries, and Pediatric Intensivists as Cross Disciplinary Knowledge Translation and Implementation Science Specialists

Purpose

We hypothesized that despite the low incidence of severe SARS-CoV-2 infections in children in Guyana, due to their specific skillset in lung protective ventilation, our Pediatric Intensivists were uniquely positioned to address significant training and readiness gaps in our colleagues attending a surging critically ill Adult COVID-19 patient population.

Methods & Materials

In Guyana, there are few clinicians trained in Critical-Care Medicine (CCM). The high incidence of ventilator dependence in seriously ill SARS-CoV2 patients, combined with a dearth of CCM practitioners competent in complex mechanical ventilation management left Guyana ill prepared to manage these patients. This knowledge deficit was further exacerbated in that many clinicians at our National Infectious Diseases Hospital were co-opted into CCM roles from other specialties with little to no CCM training. We have a very small core of Pediatric Surgical Critical Care Medicine staff that was formally trained in PCCM outside of Guyana. This core was instrumental in establishing a unique and formal Pediatric Critical-Care Medicine Micro-Modular Fellowship (PCCM-MMF) program that allowed the creation of Guyana's only Pediatric ICU. A significant number of that core are also involved in Guyana‘s National COVID Task Force. Given that all graduates of our PCCM-MMF program are extensively trained in Lung Protective Ventilation, it was very appropriate to utilize them to augment Adult critical care capacity. Thirty physicians with primarily adult practices and little to no previous knowledge of ventilator management were enrolled in a multi-modal triphasic mechanical ventilation short course facilitated by PCCM staff.

Results

We were able to rapidly enable two cohorts of 15 Adult clinicians to competently address critical knowledge deficits and staffing shortfalls. We improved morbidity and mortality amongst our mechanically ventilated adult COVID-19 patients, as well as relieved significant multifactorial caregiver strain.

Conclusion

Our successful utilization of PCCM staff as Mechanical Ventilation didactic and clinical educators for an Adult patient population carries implications for cross disciplinary Knowledge Translation and Implementation Science in a wide variety of practice milieus. We are actively pursuing research opportunities to further experiment with other skill sets incorporated in our PCCM Micro-Modular Fellowship and welcome potential collaborators.

POS0804 OUTCOMES OF SURGICALLY RESECTED THORACIC AORTITIS: RESULTS FROM A PROSPECTIVE MULTI-CENTRE REGISTRY

Background:

Inflammatory thoracic aortitis is a cause of aneurysm and is often diagnosed incidentally following aortic replacement surgery. It may be due to systemic diseases such as giant cell arteritis (GCA) and Takayasu arteritis (TAK) or a topographically isolated variant termed clinically isolated aortitis (CIA). While CIA is identified in 2-12% of thoracic aortic surgical pathology,1 its short-term post-operative outcome is unknown.

Objectives:

This study was undertaken to examine the short-term post-operative mortality and morbidity of patients with surgically resected thoracic aortitis compared to those with non-inflammatory thoracic aortic aneurysms and assess if outcomes varied based on post-operative corticosteroid therapy.

Methods:

The study was based at three tertiary referral hospitals in Sydney, Australia, for the years 2004-2018. Prospectively collected data was accessed from a national surgical registry for all patients who underwent thoracic aortic aneurysm replacement. Aortitis patients were identified from histopathology records.

Inpatient medical records were reviewed to categorise aortitis cases as CIA, GCA, TAK or other aortitis and to audit the use of corticosteroids. Outcomes were compared between aortitis cases and the non-inflammatory cohort using logistic regressions, controlling for age, sex, year of procedure, and hospital.

Results:

41 aortitis cases were identified from the cohort of 1119 surgical patients (3.7%). 27 (66%) met criteria for CIA, 11 (27%) for GCA, 2 (5%) for TAK, and 1 (2%) for Other. 8 (20%) received corticosteroid therapy for aortitis.

Compared with non-inflammatory patients, the aortitis cohort was predominantly female (54% vs 28%, p < 0.01), older (mean 70 vs 62 years, p < 0.01), and had higher rates of hypertension (83% vs 67%, p = 0.03) and pre-operative immunosuppression (10% vs 1%, p < 0.01).

There was no difference (p > 0.05) between the aortitis and the non-aortitis groups for 30-day mortality (7% vs 7%), composite significant morbidity (15% vs 22%), composite infection (10% vs 6%), return to theatre for bleeding (7% vs 13%), stroke (5% vs 5%) or readmission (12% vs 10%). Similar results were also seen for CIA and the aortitis subgroup who did not receive corticoid steroid therapy when compared to the non-aortitis group (table 1).

Table 1.

30-day mortality and morbidity

Non-aortitisAll aortitisAortitis, not treated for aortitisCIAn=1078n=41n=33n=27%n%n%n%nMortality770736241Stroke557526241Return to theatre bleed13137736241Composite morbidity22241156155113Composite infection66910493113Readmission10108125124113

Note: Differences in outcomes between the aortitis groups and the no aortitis group were modelled using logistic regression, controlling for age, sex, year of procedure, and hospital. There were no statistically significant differences in outcomes (p > 0.05).

CIA; clinically isolated aortitis. Composite morbidity; an outcome comprised of return to theatre for bleeding, stroke, new renal failure, acute myocardial infarction or aortic dissection. Composite infection; an outcome comprised of 30-day pneumonia, septicaemia, deep sternal wound infection or deep thoracotomy infection.

Conclusion:

The finding of thoracic aortitis following aortic replacement surgery does not affect short-term post-operative mortality or morbidity. Corticosteroid therapy in the immediate post-operative period did not impact upon short-term outcomes.

References:

[1]Quimson L, Mayer A, Capponi S, et al. Comparison of aortitis versus noninflammatory aortic aneurysms among patients who undergo open aortic aneurysm repair. Arthritis Rheum 2020;72:1154-59.

Disclosure of Interests:

None declared

Transcriptomic responses associated with kidney injury and repair in acute decompensated heart failure

Background

The discovery of new markers for acute kidney injury (AKI) in acute decompensated heart failure (ADHF) has been hampered by an incomplete understanding of the pathological processes underlying AKI in ADHF.

Purpose

In a sheep model of ADHF, we investigated changes in kidney gene expression in response to the development of, and recovery from, ADHF.

Methods

We collected serial kidney biopsies from 6 sheep prior to rapid cardiac pacing (day 0), after development of ADHF (pacing @220bpm for 14 days), and at the end of a 25-day (non-pacing) recovery period. Serial biopsies were supplemented with kidney samples collected post-mortem from animals undergoing a similar pacing/recovery protocol, giving a total of 11 “baseline” (B), 13 “heart failure” (HF) and 8 “recovery” (R) samples. We prepared RNA-Sequencing libraries using total RNA and Illumina TruSeq stranded mRNA library kits. Hormonal, haemodynamic, biochemical and urine measurements were also performed in all sheep before, during, and after development of ADHF. The study followed the principles of laboratory animal care and was approved by our institution's Animal Ethics Committee.

Results

We observed profound changes in hormonal, haemodynamic, biochemical and urine measures of cardio-renal injury in all sheep, confirming simulation of the peripheral consequences of ADHF, including clinically-relevant kidney dysfunction. This occurred in conjunction with altered kidney expression of 982 genes during ADHF development and 1,807 genes during ADHF recovery (p adj.&lt;0.05, Fig 1). During ADHF development, changes in kidney gene expression were associated with activation of the pro-inflammatory p38 MAPK pathway and repression of several anti-inflammatory and reno-protective pathways, including eNOS signalling (all p adj.&lt;0.001). In contrast, during ADHF recovery, changes in kidney gene expression were associated with reactivation of reno-protective pathways repressed during ADHF development, activation of anti-fibrotic pathways (including PTEN signalling) and repression of pathways that mediate inflammation and renal injury (including NF-kB signalling, all p adj.&lt;0.001). Among 431 ADHF “responsive” genes (i.e. those that increased during ADHF development and decreased during ADHF recovery, or vice versa, Fig. 1), 37 genes encoded proteins detectable in plasma or urine and may represent markers of kidney repair in ADHF. Although most gene expression changes were transient, 192 genes remained altered after 4-weeks recovery (p adj.&lt;0.05, Fig 1). Of these, 13 genes were predicted to encode proteins detectable in plasma or urine and may represent persistent markers of kidney injury in ADHF.

Conclusion

Our data provide the first insight into the gene pathways associated with kidney injury and repair in ADHF, in an established ovine model. Understanding the pathological processes underlying AKI in ADHF may enable discovery of novel markers for monitoring kidney injury and repair in ADHF.

Figure 1. Genes altered in the kidney in ADHF

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Health Research Council of New Zealand, Heart Foundation of New Zealand

Oligodendrocyte precursor cells present antigen and are cytotoxic targets in inflammatory demyelination

Oligodendrocyte precursor cells (OPCs) are abundant in the adult central nervous system, and have the capacity to regenerate oligodendrocytes and myelin. However, in inflammatory diseases such as multiple sclerosis (MS) remyelination is often incomplete. To investigate how neuroinflammation influences OPCs, we perform in vivo fate-tracing in an inflammatory demyelinating mouse model. Here we report that OPC differentiation is inhibited by both effector T cells and IFNγ overexpression by astrocytes. IFNγ also reduces the absolute number of OPCs and alters remaining OPCs by inducing the immunoproteasome and MHC class I. In vitro, OPCs exposed to IFNγ cross-present antigen to cytotoxic CD8 T cells, resulting in OPC death. In human demyelinated MS brain lesions, but not normal appearing white matter, oligodendroglia exhibit enhanced expression of the immunoproteasome subunit PSMB8. Therefore, OPCs may be co-opted by the immune system in MS to perpetuate the autoimmune response, suggesting that inhibiting immune activation of OPCs may facilitate remyelination.

Postoperative pain profile in 10-15-year-olds after bilateral extraction of maxillary premolars

PURPOSE

To study pain perception in 10-15-year-olds, during and after uncomplicated extractions of bilateral maxillary premolars. The study investigated pain's natural course and made comparisons between the first and second extractions.

METHODS

31 Swedish children in need of orthodontic treatment were identified and consecutively enrolled. Tooth extractions followed a standardised protocol and the two teeth were extracted with at least 10 days between. The participants rated pain intensity using visual analogue scale (VAS) at 14 different time points from treatment and 7 days forward.

RESULTS

The pain intensity profile followed the same pattern for all patients. Pain intensity peaked 2 h after extractions (mean VAS_PI 27.3, SD 20.8; median 23.0) when moderate pain intensity (VAS_PI ≥ 40) was registered for 16 (28%) of 57 cases. After that, there was a rapid decrease in pain intensity notable already at 4 h after extractions. There were no statistically significant differences in any VAS_PI measurements between the first and second extractions, sexes, or different age groups.

CONCLUSIONS

The majority of the participants who undergo uncomplicated bilateral extraction of maxillary premolars experience mild to moderate levels of postoperative pain during a short period of time, with no differences between the first and second extractions. Bilateral tooth extractions is a suitable model for further studies on pain management.

Environmental risk assessment of metformin and its transformation product guanylurea. I. Environmental fate

Metformin (MET) is a pharmaceutical with very high use worldwide that is excreted in unchanged form, leading to concern about potential aquatic life impacts associated with MET, and its primary transformation product guanylurea (GUU). This study presents, in two companion papers, a risk assessment following internationally accepted guidelines of MET and GUU in surface water based on literature data, previously unpublished studies, and a new degradation test that resolves conflicting earlier results. Previous studies have shown that MET is removed during sewage treatment, primarily through transformation to GUU. In addition, measurements in WWTPs suggest that MET is not only transformed to GUU, but that GUU is further biodegraded. A prolonged inherent biodegradation test strongly suggests not only primary transformation of MET to GUU, but also subsequent full mineralization of GUU, with both degradation phases starting after a clear lag phase. MET may partition from surface water to sediment, where both transformation to GUU and in part mineralization is possible, depending on the presence of competent degrading microorganisms. In addition, MET may form non-extractable residues in sediments (12.8-73.5%). Both MET and GUU may be anaerobically degraded during sludge digestion, in soils or in sediments. Bioconcentration factor (BCF) values in crops and most plants are close to 1 suggesting low bioaccumulation potential, moreover, at least some plants can metabolize MET to GUU; however, in aquatic plants higher BCFs were found, up to 53. Similarly, neither MET nor GUU are expected to bioaccumulate in fish based on estimated values of BCFs ≤3.16.

Environmental risk assessment of metformin and its transformation product guanylurea: II. Occurrence in surface waters of Europe and the United States and derivation of predicted no-effect concentrations

Metformin (MET), CAS 1115-70-4 (Metformin hydrochloride), is an antidiabetic drug with high usage in North America and Europe and has become the subject of regulatory interest. A pharmaceutical industry working group investigated environmental risks of MET. Environmental fate and chronic effects data were collated across the industry for the present risk assessment. Predicted environmental concentrations (PECs) for MET were modeled for the USA and Europe using the PhATE and GREAT-ER models, respectively. PECs were compared with measured environmental concentrations (MECs) for the USA and Europe. A predicted no effect concentration (PNEC) of 1 mg/L for MET was derived by deterministic procedures, applying an assessment factor of 10 to the lowest no observed effect concentration (i.e., 10 mg/L) from multiple chronic studies with algae, daphnids and fish. The PEC/PNEC and MEC/PNEC risk characterization ratios were <1, indicating no significant risk for MET with high Margins of Safety (MOS) of >868. MET is known to degrade during wastewater treatment to guanylurea (GUU, CAS 141-83-3), which we have shown to further degrade. There are no GUU toxicity data in the literature; hence, chronic studies for GUU were conducted to derive a PNEC of 0.16 mg/L. PECs were derived for GUU as for MET, plus MECs were retrieved from the literature. The PEC/PNEC and MEC/PNEC risk characterization ratios for GUU were also <1, with an MOS of >6.5. Based on standard risk assessment procedures for both MET and its transformation product GUU, there is no significant risk to aquatic life.

Necrotic liver induces pyroptosis through caspase-1 in eosinophils

During sterile inflammatory reactions, damage associated molecular patterns (DAMPS) are released from necrotic cells and recruit immune cells to the sites of tissue injury. We found that necrotic liver homogenates, when injected intraperitoneally, can recruit large numbers of immune cells. Among these immune cells were activated eosinophils. While eosinophils are well known to accumulate in the lungs of asthmatics or in response to helminths and parasites, several studies have shown the presence of eosinophils in liver biopsies of drug-induced liver injury, primary biliary cirrhosis, chronic hepatitis C, hepatic allograft rejection, and liver fibrosis. The prevalence of eosinophilic infiltrates in the liver points to a correlation between infiltration and disease outcome. Our results demonstrated eosinophil activation upon exposure to necrotic liver components. Exposure to necrotic liver cells induced eosinophil degranulation as measured by expression of CD107a and eosinophil peroxidase release into the supernatant as measured by ELISA. Further study of eosinophil activation during necrotic liver exposure showed IL-1β and IL-18 release as well as cell death. All of these responses were dependent upon caspase-1 activation. Caspase-1 mediated cell death accompanied by IL-1β and IL-18 release are hallmarks of pyroptosis, an inflammatory cell death pathway. We verified eosinophil pyroptosis in vivo using a liver fibrosis model involving Schistosoma mansoni infected mice. Eosinophils extracted from S. mansoni infected livers showed caspase-1 activation and cytokine release indicating that these cells undergo pyroptosis in vivo in response to hepatocyte injury.

Childhood adversity and midlife suicidal ideation

BACKGROUND

Childhood adversity predicts adolescent suicidal ideation but there are few studies examining whether the risk of childhood adversity extends to suicidal ideation in midlife. We hypothesized that childhood adversity predicts midlife suicidal ideation and this is partially mediated by adolescent internalizing disorders, externalizing disorders and adult exposure to life events and interpersonal difficulties.

METHOD

At 45 years, 9377 women and men from the UK 1958 British Birth Cohort Study participated in a clinical survey. Childhood adversity was prospectively assessed at the ages of 7, 11 and 16 years. Suicidal ideation at midlife was assessed by the depressive ideas subscale of the Revised Clinical Interview Schedule. Internalizing and externalizing disorders were measured by the Rutter scales at 16 years. Life events, periods of unemployment, partnership separations and alcohol dependence were measured through adulthood.

RESULTS

Illness in the household, paternal absence, institutional care, parental divorce and retrospective reports of parental physical and sexual abuse predicted suicidal ideation at 45 years. Three or more childhood adversities were associated with suicidal ideation at 45 years [odds ratio (OR) 4.31, 95% confidence interval (CI) 2.67-6.94]. Psychological distress at 16 years partially mediated the associations of physical abuse (OR 3.41, 95% CI 2.29-5.75), sexual abuse (OR 4.99, 95% CI 2.90-11.16) with suicidal ideation. Adult life events partially mediated the association of parental divorce (OR 6.34, 95% CI -7.16 to 36.75) and physical (OR 9.59, 95% CI 4.97-27.88) and sexual abuse (OR 6.59, 95% CI 2.40-38.36) with suicidal ideation at 45 years.

CONCLUSIONS

Adversity in childhood predicts suicidal ideation in midlife, partially mediated by adolescent internalizing and externalizing disorders, adult life events and interpersonal difficulties. Understanding the pathways from adversity to suicidal ideation can inform suicide prevention and the targeting of preventive interventions.

PET/CT in the Evaluation of Response to Treatment of Liver Metastases from Colorectal Cancer with Bevacizumab and Irinotecan

The present approach at our institution for the treatment of patients with colorectal (CRC) cancer and with liver metastases planned for metastasectomy is the neoadjuvant administration of Bevacizumab with Irinotecan based therapy. Metabolic imaging of tumor viability with 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET), and simultaneous anatomic localization provided by low-dose non-enhanced computed tomography (CT), can be obtained in a combined modality FDG-PET/CT scan. The purpose of this study was to evaluate the possible contribution of FDG-PET/CT as a surrogate marker to evaluate treatment response of liver metastases in vivo. This is a retrospective evaluation of 18F-FDG PET and CT findings in the first seven consecutive patients. FDG-PET/CT scans were performed before the start of the neoadjuvant and after four cycles of therapy, just prior to surgery. Results were compared to concurrent contrast-enhanced CT, when required, and pathology. Response to treatment was determined according to RECIST size criteria obtained from data from thin (3–5mm) slice CT, and changes in uptake of 18F-FDG uptake on PET.

A total of 20 liver lesions were evaluated in seven patients. Overall, 6/7 patients had favorable response to treatment, and only one had progression of disease. One patient was found to be inoperable at surgery. Biopsy was obtained in 1/4 lesions in this patient, while pathology was unable for the remaining three lesions. As such, pathologic validation of findings was available for 17/20 lesions. Complete response (CR) was evident on FDG-PET in 10/17 (58%) lesions, whereas only 4/17(23%) were deemed CR by CT. Similarly, only 1/17 (6%) lesion appeared stable by FDG-PET criteria, whereas three (18%) were termed stable disease (SD) according to size on CT.

FDG-PET findings correlated better than CT with pathology, and were more indicative of pathology. Overall PET/CT correctly predicted necrosis at pathology in 70% vs. 35% by CT. Our results suggest that 18F-FDG PET may be instrumental for predicting the pathologic response to Bevacizumab based therapy.

Use of acute and chronic ecotoxicity data in environmental risk assessment of pharmaceuticals

For many older pharmaceuticals, chronic aquatic toxicity data are limited. To assess risk during development, scale-up, and manufacturing processes, acute data and physicochemical properties need to be leveraged to reduce potential long-term impacts to the environment. Aquatic toxicity data were pooled from daphnid, fish, and algae studies for 102 active pharmaceutical ingredients (APIs) to evaluate the relationship between predicted no-effect concentrations (PNECs) derived from acute and chronic tests. The relationships between acute and chronic aquatic toxicity and the n-octanol/water distribution coefficient (D(OW)) were also characterized. Statistically significant but weak correlations were observed between toxicity and log D(OW), indicating that D(OW) is not the only contributor to toxicity. Both acute and chronic PNEC values could be calculated for 60 of the 102 APIs. For most compounds, PNECs derived from acute data were lower than PNECs derived from chronic data, with the exception of steroid estrogens. Seven percent of the PNECs derived from acute data were below the European Union action limit of 0.01 μg/L and all were anti-infectives affecting algal species. Eight percent of available PNECs derived from chronic data were below the European Union action limit, and fish were the most sensitive species for all but 1 API. These analyses suggest that the use of acute data may be acceptable if chronic data are unavailable, unless specific mode of action concerns suggest otherwise.

Risk perception and psychological morbidity in men at elevated risk for prostate cancer

OBJECTIVE

As prostate-specific antigen (psa) makes prostate cancer (pca) screening more accessible, more men are being identified with conditions that indicate high risk for developing pca, such as elevated psa and high-grade intraepithelial neoplasia (hgpin). In the present study, we assessed psychological well-being and risk perception in individuals with those high-risk conditions.

METHODS

A questionnaire consisting of a psychological symptom survey, a trait risk-aversion survey, and a cancer-specific risk perception survey was administered to 168 patients with early-stage localized pca and 69 patients at high risk for pca (n = 16 hgpin, n = 53 psa > 4 ng/mL). Analysis of variance was used to examine differences in psychological well-being and appraisal of risk between the groups.

RESULTS

Compared with the pca group, the high-risk group perceived their risk of dying from something other than pca to be significantly lower (p = 0.007). However, pca patients reported significantly more clinically important psychological symptoms.

CONCLUSIONS

The identification of prostate conditions that predict progression to cancer might not result in the psychological symptoms commonly experienced by pca patients, but does appear to be related to a distorted perception of the disease's mortal risk. Patients with pca experience reduced psychological well-being, but better understand the risks of pca recurrence and death. Education on the risks and outcomes of pca can help at-risk men to view health assessments with reduced worry.

Health economic analyses of domiciliary dental care and care at fixed clinics for elderly nursing home residents in Sweden

OBJECTIVES

Dental care for elderly nursing home residents is traditionally provided at fixed dental clinics, but domiciliary dental care is an emerging alternative. Longer life expectancy accompanied with increased morbidity, and hospitalisation or dependence on the care of others will contribute to a risk for rapid deterioration of oral health so alternative methods for delivering oral health care to vulnerable individuals for whom access to fixed dental clinics is an obstacle should be considered. The aim was to analyse health economic consequences of domiciliary dental care for elderly nursing home residents in Sweden, compared to dentistry at a fixed clinic.

METHODS

A review of relevant literature was undertaken complemented by interviews with nursing home staff, officials at county councils, and academic experts in geriatric dentistry. Domiciliary dental care and fixed clinic care were compared in cost analyses and cost-effectiveness analyses.

RESULTS

The mean societal cost of domiciliary dental care for elderly nursing home residents was lower than dental care at a fixed clinic, and it was also considered cost-effective. Lower cost of dental care at a fixed dental clinic was only achieved in a scenario where dental care could not be completed in a domiciliary setting.

CONCLUSIONS

Domiciliary dental care for elderly nursing home residents has a lower societal cost and is cost-effective compared to dental care at fixed clinics. To meet current and predicted need for oral health care in the ageing population alternative methods to deliver dental care should be available.

Abstract P1-01-20: Intra-operative sentinel node imaging with a portable gamma camera in breast cancer

Introduction: Access to nuclear medicine department and sentinel node imaging remain an issue in number of hospitals. Preoperative Scintigrams are performed to confirm uptake of radioactivity and localisation of nodes in centres where facilities are available. Sentinella® (Oncovision, Valencia, Spain) is a recently introduced portable imaging gamma camera used intraoperatively to produce real time visual localisation of SLNs. Sentinella® was tested in a controlled laboratory environment and we report the first use of this technique in breast cancer patients from UK.

Methods: In the laboratory setting our aim was to compare the sensitivity and spatial resolution of the Sentinella® and a conventional gamma camera (cGC) used for sentinel node imaging by comparing it with the performance of a GE multi-purpose rectangular (MPR) conventional single head gamma camera normally used for sentinel node imaging. A simulator containing seeds 10kBq, 100kBq, 500kBq of radiocolloid Tc, mimicking SLN, were used. Seeds were placed at several depths in the axilla, at 3cm, 5cm and 8cm from the skin. Sentinella was placed first at 10cm and then 1cm away from the axilla and images were recorded at 1min and at 2.5min for every position. The cGC was placed 20 cm away from the simulator.

Results: 68 Sentinella® images and 34 cGC images obtained from the simulated axilla. Sentinella® resolution is comparable with the cGC for objects close to the camera i.e. ∼ 5 cm, but reduces rapidly as it's moved away from the camera. For distances up to about 7 cm the Sentinella® with the blue collimator is more sensitive than the cGC. Sentinella detects high radioactivity (500 kBq) faster than cGC (1 vs 2.5min). In cases of low radioactivity (10kBq) Sentinella® was equally accurate and faster than cGC, when placed close to the skin. Identification of different number of beads with varying radioactivity was similar in Sentinella and cGC. Sentinella scans of the axilla were obtained in 85 patients undergoing SLNB. All patients had a preoperative lymphoscintigram. Serial Sentinella scans were obtained after removal of every hot node. Sentinella scans correlated with all the lymphoscintigrams in the 85 cases studied. Serial decay in activity was seen with removal of every hot node. Extra nodes were picked up in 6/85 cases after the axilla was found silent using hand held gamma probe. In 2/85 cases extra nodes found had cancer that led to axillary clearance. Sentinella scans were extremely useful in differentiating between a hot sentinel node and signal from injection site in upper outer quadrants of small sized breasts.

Conclusion: Sentinella is accurate and fast in detecting radioactivity in the axilla. The anatomical shape of its collimator allows the operator to place it close to the axilla thus increasing sensitivity in cases of low radioactivity. Our independent tests and initial patient data confirm the excellent sensitivity and specificity. It's major advantage is that it can be used by surgeons to scan for residual nodes before completion of the procedure. It can resolve the problem of centres that do not have nuclear medicine departments. This portable gamma camera can definitely replace the use of conventional lymphoscintigrams saving time and money both for patients and the Hospital.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-01-20.

Radiological diagnosis of periapical bone tissue lesions in endodontics: a systematic review

This systematic review evaluates the diagnostic accuracy of radiographic methods employed to indicate presence/absence and changes over time of periapical bone lesions. Also investigated were the leads radiographic images may give about the nature of the process and the condition of the pulp in nonendodontically treated teeth. Electronic literature search included the databases PubMed, Embase and CENTRAL from January 1950 to June 2011. All languages were accepted provided there was an abstract in English. The MeSH terms were 'Cone beam computed tomography (CBCT)', 'Radiography, panoramic', 'Periapical diseases', 'Dental pulp diseases', 'Sensitivity and specificity', 'receiver operating characteristics (ROC) curve', 'Cadaver', 'Endodontics' and 'Radiography dental'. Two reviewers independently assessed abstracts and full text articles. An article was read in full text if at least one of the two reviewers considered an abstract to be potentially relevant. Altogether, 181 articles were read in full text. The GRADE approach was used to assess the quality of evidence of each radiographic method based on studies of high or moderate quality. Twenty-six studies fulfilled criteria set for inclusion. None was of high quality; 11 were of moderate quality. There is insufficient evidence that the digital intraoral radiographic technique is diagnostically as accurate as the conventional film technique. The same applies to CBCT. No conclusions can be drawn regarding the accuracy of radiological examination in identifying various forms of periapical bone tissue changes or about the pulpal condition.

Abstract P1-01-25: Sentinella® an Alternative for Conventional Scintigram and a Modality To Improve Intra-Operative Localisation of Sentinel Nodes in Breast Cancer

Sentinel Lymph Node (SLN) biopsy is now a standard practice for staging of the axilla in early breast cancer. Access to nuclear medicine department and sentinel node imaging reamins an issue in number of hospitals in the UK and many parts of the word Sentinella® is a new portable imaging camera used intraoperatively to produce real time visual localisation of Sentinel nodes. Sentinella® was tested in a controlled laboratory environment at our centre and we report the first use of this novel technique in Breast cancer patients from UK.

Methods: Sensitvity and spatial resolution of Sentinella® mobile gamma camera was compared with a CGC (conventional single headed gamma camera) normally used for sentinel node imaging. Spatial resolution was measured by calculating the full width half maximum (FWHM) of a line profile measured perpendicular to the image of a capillary tube filled with high activity concentration technetium-99m pertechnetate. Next a special simulator mimicking the axilla was planted with seeds containing radiocolloid Tc, mimicking lymph nodes. Seeds were placed at varying depths in the axilla. For each combination of depths and radioactivity images with Sentinella® and CGC were obtained. Sentinella® scans of the axilla was also obtained in 50 patients undergoing SLNB to correlate with the preoperative scintigrams and determine presence of any residual hot nodes after use of the standard hand held gamma probe.If hot areas suggesting residual lymph nodes were detected, further exploration was carried out until no further residual activity was noted. Results

Sentinella® resolution is comparable with the CGC for objects close to the camera i.e. ∼ 5 cm, but reduces rapidly as you move away from the camera. For distances up to about 7 cm the Sentinella® with the blue collimator is more sensitive than the CGC.

68 Sentinella® images and 34 CGC images obtained from the simulated axilla. Sentinella detects high radioactivity (500 kBq) faster than CGC (1 vs 2.5min). In cases of low radioactivity (10kBq) Sentinella® was equally accurate and faster than cGC, when placed close to the skin. Identification of different number of beads with varying radioactivity was similar in Sentinella and CGC.

Sentinella® scans correlated with all the lymphoscintigrams in demonstrating hot lymph nodes in all the 50 cases. Sentinella® scans demonstrated a serial decay in activity with removal of every hot node and its LED guided localisation helped in detecting residual nodes. Sentinella® picked up extra nodes in 5/50 cases (10%) after the axilla was found silent using hand held gamma probe.In 2/50 (4%) cases extra nodes found using Sentinella® had presence of cancer that led to a complete Axillary clearance

Conclusion: The initial patient and laboratory data confirms the excellent sensitivity and specificity of the machine in localisation of radioactive nodes. This new imaging technique will increase our pick up of sentinel lymph nodes intraoperatively that are missed due to inadequate visualisation and provide an alternative to static scintigram imaging. This would be particularly useful in centres that do not have nuclear medicine facilities on site.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-25.

Generation of pathogenic T(H)17 cells in the absence of TGF-β signalling

CD4(+) T-helper cells that selectively produce interleukin (IL)-17 (T(H)17), are critical for host defence and autoimmunity. Although crucial for T(H)17 cells in vivo, IL-23 has been thought to be incapable of driving initial differentiation. Rather, IL-6 and transforming growth factor (TGF)-β1 have been proposed to be the factors responsible for initiating specification. Here we show that T(H)17 differentiation can occur in the absence of TGF-β signalling. Neither IL-6 nor IL-23 alone efficiently generated T(H)17 cells; however, these cytokines in combination with IL-1β effectively induced IL-17 production in naive precursors, independently of TGF-β. Epigenetic modification of the Il17a, Il17f and Rorc promoters proceeded without TGF-β1, allowing the generation of cells that co-expressed RORγt (encoded by Rorc) and T-bet. T-bet(+)RORγt(+) T(H)17 cells are generated in vivo during experimental allergic encephalomyelitis, and adoptively transferred T(H)17 cells generated with IL-23 without TGF-β1 were pathogenic in this disease model. These data indicate an alternative mode for T(H)17 differentiation. Consistent with genetic data linking IL23R with autoimmunity, our findings re-emphasize the importance of IL-23 and therefore may have therapeutic implications.

Anticancer activity of botanical compounds in ancient fermented beverages (review)

Humans around the globe probably discovered natural remedies against disease and cancer by trial and error over the millennia. Biomolecular archaeological analyses of ancient organics, especially plants dissolved or decocted as fermented beverages, have begun to reveal the preliterate histories of traditional pharmacopeias, which often date back thousands of years earlier than ancient textual, ethnohistorical, and ethnological evidence. In this new approach to drug discovery, two case studies from ancient Egypt and China illustrate how ancient medicines can be reconstructed from chemical and archaeological data and their active compounds delimited for testing their anticancer and other medicinal effects. Specifically, isoscopoletin from Artemisia argyi, artemisinin from Artemisia annua, and the latter's more easily assimilated semi-synthetic derivative, artesunate, showed the greatest activity in vitro against lung and colon cancers. In vivo tests of these compounds previously unscreened against lung and pancreatic cancers are planned for the future.

Current status and advances in management of early breast cancer

Breast cancer is the most common female cancer. Worldwide, more than a million women are diagnosed every year. However despite this increase, the mortality rate is declining. This is due to combination of factors including early diagnosis and effective treatment. This manuscript which is presented in two sections outlines the current status in management of early breast cancer. Section 1 focuses on the advances in diagnosis and surgical treatment of breast cancer and give an overview of the histopathological aspects. The focus of section 2 is on advances on adjuvant treatment of breast cancer including radiotherapy, chemotherapy and endocrine treatment.