Citizen science through a recreational underwater diving project supports the collection of large-scale marine litter data: The Oceania case study

In recent years, a growing body of literature on seafloor macro-litter has been produced worldwide. However, the spatial coverage of these studies is still limited and highly unbalanced, resulting in considerable knowledge gaps in some regions. To address this lack of information in Oceania, we extracted data from the Citizen Science project Dive Against Debris® to characterize marine debris collected by volunteer scuba divers on the coastal seafloor. Overall, the average litter density was 58.22 items/100m2, with plastics accounting for approximately 50 % of the total abundance and Single Use Plastics accounting for nearly 17 %. Notably, 36 % of the total litter abundance consisted of lost Fishing Gear including fishing lines, sinkers, baits and hooks as the most abundant debris items. To reduce lost fishing gear, clean-up initiatives by divers along with management actions such as education programs for fishermen, gear restrictions and the identification of designated fishing sites are recommended.

Knowledge of cytomegalovirus and available prevention strategies in pregnancy: a cross-sectional study in Portugal

OBJECTIVE

Maternal and fetal congenital infection by cytomegalovirus (CMV) during pregnancy is the leading infectious cause of neurologic impairment and hearing loss. Efforts at limiting CMV exposure are based on hygienic measures. This study assessed the relationship between CMV knowledge and pregnant women's time perspective as per the Zimbardo Time Perspective Inventory (ZTPI) scale.

METHODS

We conducted a prospective descriptive study at a secondary-care Portuguese hospital between October to November 2021. All consecutive pregnant women in antenatal third-trimester appointments were included. The questionnaire included: sociodemographic data, knowledge about CMV, and the ZTPI scale, validated to our population. The number of correct answers in the knowledge section of the questionnaire was tallied to determine the individual knowledge score (KS). We investigated patients subjective perceptions of CMV infection during pregnancy, CMV knowledge, and CMV serologic status of pregnant women.

RESULTS

We enrolled 96 pregnant women. 81.0% had not previously heard about CMV and only 8.8% had heard about it through their obstetrician. No significant association between awareness of CMV and education level was detected. 16.0% of pregnant women declared that they were aware of the hygienic measures for CMV. The CMV serology was performed in 21.3% of those enrolled in the preconception assessment, and 13.8% proved to be immune. From the time perspective, half of the women displayed a future-oriented attitude. Future-oriented women had significantly higher KS. No significant association was found between KS and education level, age, or previous pregnancy. There was a significant association between KS and women that work in health care.

CONCLUSIONS

Most patients had no knowledge of CMV. Being a medical professional and having a future-oriented outlook increases knowledge about CMV. Primary health care and obstetrics doctors may play a crucial role in informing pregnant women of antenatal appointments. The CMV serology coverage is scarce in this sample. This study constitutes a first step toward raising the awareness of the general population about CMV.

CNS-3 status remains an independent adverse prognosis factor in children with acute lymphoblastic leukemia (ALL) treated without cranial irradiation: Results of EORTC Children Leukemia Group study 58951

AIM

To evaluate the prognostic significance of initial central nervous system (CNS) involvement of children with acute lymphoblastic leukemia (ALL) enrolled in the EORTC 58951 trial.

PATIENTS AND METHODS

From 1998 to 2008, 1930 ALL patients were included in the randomized EORTC 58951 trial. Overall treatment intensity was adjusted according to known prognostic factors including the level of minimal residual disease after induction treatment. CNS-directed therapy comprised four to 11 courses of i.v. methotrexate (5g/m²), and 10 to 19 intrathecal chemotherapy injections, depending on risk group and CNS status. Cranial irradiation was omitted for all patients.

RESULTS

The overall 8-year event-free survival (EFS) and overall survival (OS) rates were 81.3% and 88.1%, respectively. In the CNS-1, TPL+, CNS-2, and CNS-3 groups, the 8-year EFS rates were 82.1%, 77.1%, 78.3%, and 57.4%, respectively. Multivariable analysis indicated that initial CNS-3 status, but not CNS-2 or TLP+, was an independent adverse predictor of outcome. The 8-year incidence of isolated CNS relapse was 1.7% and of isolated or combined CNS relapse it was 3.7%. NCI high-risk group, male sex, CNS-2 and CNS-3 status were independent predictors for a higher incidence of any CNS relapse.

CONCLUSIONS

CNS-3 status remains associated with poor prognosis and requires intensification of both systemic and CNS-directed therapy. This trial was registered at https://clinicaltrials.gov/under/NCT00003728.

First list of parasitoids in flies of medical, veterinary, and forensic importance in Rio Grande do Sul - Brazil

Necrophagous flies are of great importance for human and animal health. In places where their development occurs, parasitoids can be used as a tool to control these dipterans. In Brazil, the fauna of these parasitoids has been investigated in some regions. However, in Rio Grande do Sul, it is known the occurrence of only one species. Thus, this study aimed to create the first list of parasitoids in flies of medical and veterinary importance in Southern Brazil. Collections took place in the municipality of Pelotas (31º 42' S; 52º 18' W). Three replicates consisting of a 500 g bovine liver chunk placed in a tray were exposed to open air for 20 days. Then pupae were individualized and observed until their emergence. We identified 4,882 adult flies of Calliphoridae, Fanniidae, Muscidae, and Sarcophagidae. 4,040 parasitoids emerged, belonging to eight species, of which Nasonia vitripennis, Spalangia cameroni, Spalangia chontalensis, and Tachinephagus zealandicus are new records in Rio Grande do Sul state. Also, three undescribed species of the genus Aphaereta were collected. In spite of being the first attempt to inventory the fauna of hymenopteran parasitoids, this study may help in the development of management programs of these dipterans in the region.

Intracranial subdural haematoma following dural puncture accidental: clinical case

Intracranial subdural hematoma is a rare, but potentially lethal complication of neuraxial procedures. Considering the high frequency of neuraxial techniques in the obstetric population, parturients are more susceptible to this fearful complication. The diagnosis is often masked and delayed because it shares similar clinical characteristics with posdural puncture headache, with headache being the most common symptom. This case report describes a timely diagnosis and successful management of an intracranial subdural hematoma, after unintentional dural puncture during labour epidural analgesia. Postpartum headache following epidural analgesia, remains a clinical challenge for the caring team, requiring a close follow-up and awareness for non-benign causes that require prompt management, avoiding devastating consequences.

Jackhammer esophagus: Prevalence and demographic, clinical, and manometric characteristics

INTRODUCTION AND AIMS

Jackhammer esophagus is a recently identified motility disorder. Experience with the novel pathologic condition has been reported in different studies but there is little information on the subject in Latin America. Our case series conducted in Bogota, Colombia, describes the prevalence of jackhammer esophagus and its demographic, clinical, and manometric characteristics.

MATERIALS AND METHODS

A retrospective, observational, cross-sectional study included consecutive patients diagnosed with jackhammer esophagus that were referred for high-resolution esophageal manometry. Their clinical and manometric records were reviewed, and the pertinent information for the present study was collected.

RESULTS

Within the study period, 6,445 patients were evaluated with esophageal manometry, 27 of whom were diagnosed with jackhammer esophagus (prevalence of 0.42%). The majority of those patients were women (n=17, 63%) in the sixth decade of life. The most common symptom was regurgitation (n=17, 63%), followed by dysphagia (n=15, 56%). The mean distal contractile integral was 9,384 (5,095-18,546) mmHg·s·cm. Dysphagia was more common in patients >60 years of age (79%, p <.01) and regurgitation was more frequent in patients <60 years of age (92%, p <.03).

CONCLUSIONS

The present study is the first to characterize the prevalence of jackhammer esophagus and its demographic, clinical, and manometric characteristics in Latin American patients. The prevalence of jackhammer esophagus in our study population was considerably lower than that reported in international case series. Our findings suggest that there are important geographic differences in the epidemiology and clinical presentation of jackhammer esophagus, compared with data from other international centers.

False memory syndrome: A review and emerging issues, following a clinical report

False Memory Syndrome (FMS) is caused by memories of a traumatic episode, most commonly childhood sexual abuse, which are objectively false, but in which the person strongly believes. These pseudomemories usually arise in the context of adult psychotherapy and are often quite vivid and emotionally charged. FMS is rare and sometimes could be confused with psychotic disorder and malingering. The infrequency with which it is encountered makes this syndrome a diagnostic challenge. Failure to diagnose can lead to significant morbidity.

We studied a 26-year-old female with no prior Psychiatric history who started to recall vivid memories of sexual abuse perpetrated by her father, following few sessions of clinical hypnosis. She presented a low mood, disorganized behaviour and aggressivity towards her father when she was admitted to our ward. After a normal CT brain scan and lab tests and a meticulous clinical history, the clinical diagnosis was made. She was successfully managed with supportive psychotherapy combined with mood stabilizer medications.

This case illustrates the unknown field between memory and confabulation and the value of a complete history. Physicians should be alert and keep an open mind about this iatrogenic disorder. Research is needed on the identification of memory mechanisms, specific situations and personality factors involved in this syndrome.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Deregulated miRNAs in osteoporosis: effects in bone metastasis

Starting from their role exerted on osteoblast and osteoclast differentiation and activity pathways, microRNAs (miRNAs) have been recently identified as regulators of different processes in bone homeostasis. For this purpose, in a recent review, we highlighted, as deregulated miRNAs could be involved in different bone diseases such as osteoporosis. In addition, recent studies supported the concept that osteoporosis-induced bone alterations might offer a receptive site for cancer cells to form bone metastases, However, to date, no data on specific-shared miRNAs between osteoporosis and bone metastases have been considered and described to clarify the evidence of this link. The main goal of this review is to underline as deregulated miRNAs in osteoporosis may have specific roles in the development of bone metastases. The review showed that several circulating osteoporotic miRNAs could facilitate tumor progression and bone-metastasis formation in several tumor types, i.e., breast cancer, prostate cancer, non-small-cell lung cancer, esophageal squamous cell carcinoma, and multiple myeloma. In detail, serum up-regulation of pro-osteoporotic miRNAs, as well as serum down-regulation of anti-osteoporotic miRNAs are common features of all these tumors and are able to promote bone metastasis. These results are of key importance and could help researcher and clinicians to establish new therapeutic strategies connected with deregulation of circulating miRNAs and able to interfere with pathogenic processes of osteoporosis, tumor progressions, and bone-metastasis formation.

Deregulated miRNAs in bone health: Epigenetic roles in osteoporosis

MicroRNA (miRNA) has shown to enhance or inhibit cell proliferation, differentiation and activity of different cell types in bone tissue. The discovery of miRNA actions and their targets has helped to identify them as novel regulations actors in bone. Various studies have shown that miRNA deregulation mediates the progression of bone-related pathologies, such as osteoporosis. The present review intends to give an exhaustive overview of miRNAs with experimentally validated targets involved in bone homeostasis and highlight their possible role in osteoporosis development. Moreover, the review analyzes miRNAs identified in clinical trials and involved in osteoporosis.

Influence of yeasts of the genus Saccharomyces and not Saccharomyces in elaboration of white wines

Traditionally the Serra Gaúcha region, in the state of Rio Grande do Sul, is known as a barn productor of excellent quality wines. The aromatic complexity of wine in general, and white wine in particular, is what is essential to satisfy an increasingly demanding consumer. Among the most used techniques to achieve this purpose is the addition of yeasts of different genres, thus providing a range of aromatic characteristics that are accentuated in it. In this sense, the objective of this work was to evaluate the use of different strains of yeasts in white wines of Riesling Italic variety, made from grapes grown in the Serra Gaúcha region, in the state of Rio Grande do Sul. Based on the results, it was possible to observe that there were no significant differences between the treatments in relation to the variables pH, total acidity and alcoholic degree. However, with respect to the fermentation yield, T3 was the treatment that obtained the best performance, reaching the ideal density (below 1000 g.cm3) in the course of 6 to 7 days, followed by treatments T1 (Saccharomyces cerevisae) and T5 (Levulia pulcherrima) (7 to 8 days), with treatments T2 (Saccharomyces cerevisaecerevisae) and T4 (Torulaspora delbrueckii), which had the lowest performance (9 to 10 days). The T4 treatment was also the one that presented a higher amount of residual sugars, which proves the less activity of this yeast in more alcoholic means. All the yeasts used have a low production of volatile acidity, but the lowest concentration was Saccharomyces cerevisae cerevisae, used in treatment T2 (0.1 gL−1), and the other treatments presented higher concentrations (0, 4 to 0.5 gL−1), although it is still within the parameters considered ideal for obtaining quality white wines. T2 was also the treatment with lower concentrations of glycerol (5.1 g.L−1). This compound is mainly formed by glyceropyruvic fermentation through the metabolism of yeasts at the beginning of alcoholic fermentation, usually being produced by the first 50 grams of fermented sugars, which may indicate a greater activity of this yeast in this fermentation period. In general, we can say that all the yeasts used have the potential to produce quality white wines, since they had good fermentation yields, satisfactory production of alcohol and glycerol, and low production of volatile acidity.

Engineered exosomes: A new promise for the management of musculoskeletal diseases

BACKGROUND

Exosomes are nanovesicles actively secreted by potentially all cell types, including tumour cells, with the primary role of extracellular systemic communication mediators, both at autocrine and paracrine levels, at short and long distances. Recently, different studies have used exosomes as a delivery system for a plethora of different molecules, such as drugs, microRNAs and proteins. This has been made possible thanks to the simplicity in exosomes engineering, their great stability and versatility for applications in oncology as well as in regenerative medicine.

SCOPE OF REVIEW

The aim of this review is to provide information on the state-of-the-art and possible applications of engineered exosomes, both for cargo and specific cell-targeting, in different pathologies related to the musculoskeletal system.

MAJOR CONCLUSIONS

The use of exosomes as therapeutic agents is rapidly evolving, different studies explore drug delivery with exosomes using different molecules, showing an enormous potential in various research fields such as oncology and regenerative medicine.

GENERAL SIGNIFICANCE

However, despite the significant progress made by the different studies carried out, currently, the use of exosomes is not a therapeutic reality for the considerable difficulties to overcome.

Gene therapy for chondral and osteochondral regeneration: is the future now?

Gene therapy might represent a promising strategy for chondral and osteochondral defects repair by balancing the management of temporary joint mechanical incompetence with altered metabolic and inflammatory homeostasis. This review analysed preclinical and clinical studies on gene therapy for the repair of articular cartilage defects performed over the last 10 years, focussing on expression vectors (non-viral and viral), type of genes delivered and gene therapy procedures (direct or indirect). Plasmids (non-viral expression vectors) and adenovirus (viral vectors) were the most employed vectors in preclinical studies. Genes delivered encoded mainly for growth factors, followed by transcription factors, anti-inflammatory cytokines and, less frequently, by cell signalling proteins, matrix proteins and receptors. Direct injection of the expression vector was used less than indirect injection of cells, with or without scaffolds, transduced with genes of interest and then implanted into the lesion site. Clinical trials (phases I, II or III) on safety, biological activity, efficacy, toxicity or bio-distribution employed adenovirus viral vectors to deliver growth factors or anti-inflammatory cytokines, for the treatment of osteoarthritis or degenerative arthritis, and tumour necrosis factor receptor or interferon for the treatment of inflammatory arthritis.

EGFR amplification and expression in oral squamous cell carcinoma in young adults

The aim of this study was to investigate epidermal growth factor receptor (EGFR) gene alterations in two groups of patients with oral squamous cell carcinoma (OSCC) (a test group of subjects aged ≤40 years and a control group of subjects aged ≥50 years) and to associate the results with EGFR immunostaining, clinicopathological features, and the prognosis. Sixty cases of OSCC were selected (test group, n=21; control group, n=39). The tissue microarray technique was applied to ensure the uniformity of results. Gene amplification was analyzed by fluorescence in situ hybridization (FISH), and immunohistochemical staining for EGFR was analyzed using an automated imaging system. EGFR amplification was higher in the test group than in the control group (P=0.018) and was associated with advanced clinical stage (P=0.013), regardless of age. Patients with EGFR overexpression had worse survival rates, as did patients who had T3-T4 tumours and positive margins. EGFR overexpression has a negative impact on disease progression. Despite the higher amplification of EGFR in young adults, it does not significantly impact the survival rates of affected patients.

Nanogel-antimiR-31 conjugates affect colon cancer cells behaviour

Soft nanogels, produced by electron beam irradiation, are conjugated to the inhibitor of miR-31, an important molecule in colorectal cancer progression. AntimiR-31 interacts with its biological target in vitro, without being detached from the nanogel.

Comparative analysis of three histologic grading methods for squamous cell carcinoma of the lip

OBJECTIVES

The aim of this study was to evaluate three histologic grading methods for squamous cell carcinoma (SCC) of the lip, the conventional three-grade model proposed by the World Health Organization, tumor budding and depth of invasion (BD) model, and histologic risk assessment (HRA) model, and to correlate them with prognosis.

MATERIALS AND METHODS

Fifty-three patients with lip SCC were evaluated.

RESULTS

The mean age was 65 years, 69.8% of the participants were men, and 66.0% of the patients had early-stage tumors. Using the BD and conventional three-grade methods, 52.8% and 64.2% of the cases were graded as low risk, respectively. The HRA model graded 54.7% of the cases as medium risk. In the BD model, the higher histologic grade was associated with worse prognosis (P = 0.045). Overall survival at 5 years was 87.8%. Tumor size (T3 + T4) and lymph node involvement (N+) were associated with reduced overall survival and recurrence-free survival (RFS) (P = 0.002 and 0.005; 0.007 and 0.01, respectively). Surgical treatment combined with radiotherapy was associated with lower RFS (P = 0.03).

CONCLUSIONS

High-grade lip SCC in advanced stages is associated with a poor prognosis. The BD model is a simple and effective tool for the prognostic evaluation of lip SCC.

Patients' and Spouses' Contribution Toward Adherence to Self-Care Behaviors in Type 2 Diabetes

This article focuses on patients' and partners' variables regarding adherence to self-care, in recently diagnosed patients with Type 2 diabetes. One hundred four patients and partners were included. Instruments answered were Family Inventory of Life Events and Changes (family stress), Family Crisis Oriented Personal Evaluation Scales (family coping), Revised Dyadic Adjustment Scale (dyadic adjustment), Multidimensional Diabetes Questionnaire (partner support) and Hospital Anxiety and Depression Scale (psychological morbidity). Results showed adherence to diet to be positively predicted by patient dyadic adjustment and patient positive support and negatively by partner depression and partner negative support. Adherence to exercise was predicted by patient's family stress and negatively by partner anxiety. Adherence to glucose monitoring was predicted by partner positive support. Psychological variables were not associated with adherence to foot care. Finally, positive partner support moderated the relationship between family stress and dyadic adjustment in patients. The results emphasize the need to treat the patient in the context of the dyad. Future research should focus on partners' specific instrumental behaviors that promote patients' self-care behaviors.

The management of chronic rupture of the Achilles tendon

We hypothesised that a minimally invasive peroneus brevis tendon transfer would be effective for the management of a chronic rupture of the Achilles tendon. In 17 patients (three women, 14 men) who underwent minimally invasive transfer and tenodesis of the peroneus brevis to the calcaneum, at a mean follow-up of 4.6 years (2 to 7) the modified Achilles tendon total rupture score (ATRS) was recorded and the maximum circumference of the calf of the operated and contralateral limbs was measured. The strength of isometric plantar flexion of the gastrocsoleus complex and of eversion of the ankle were measured bilaterally. Functional outcomes were classified according to the four-point Boyden scale.

At the latest review, the mean maximum circumference of the calf of the operated limb was not significantly different from the pre-operative mean value, (41.4 cm, 32 to 50 vs 40.6 cm, 33 to 46; p = 0.45), and not significantly less than that of the contralateral limb (43.1 cm, 35 to 52; p = 0.16). The mean peak torque (244.6 N, 125 to 367) and the strength of eversion of the operated ankle (149.1 N, 65 to 240) were significantly lower (p < 0.01) than those of the contralateral limb (mean peak torque 289, 145 to 419; strength of eversion: 175.2, 71 to 280). The mean ATRS significantly improved from 58 pre-operatively (35 to 68) to 91 (75 to 97; 95% confidence interval 85.3 to 93.2) at the time of final review. Of 13 patients who practised sport at the time of injury, ten still undertook recreational activities.

This procedure may be safely performed, is minimally invasive, and allows most patients to return to pre-injury sport and daily activities.

Cite this article: Bone Joint J 2015;97-B:353–7.

The Determinants of Place of Death: An Evidence-Based Analysis

BACKGROUND

According to a conceptual model described in this analysis, place of death is determined by an interplay of factors associated with the illness, the individual, and the environment.

OBJECTIVES

Our objective was to evaluate the determinants of place of death for adult patients who have been diagnosed with an advanced, life-limiting condition and are not expected to stabilize or improve.

DATA SOURCES

A literature search was performed using Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid Embase, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), and EBM Reviews, for studies published from January 1, 2004, to September 24, 2013.

REVIEW METHODS

Different places of death are considered in this analysis-home, nursing home, inpatient hospice, and inpatient palliative care unit, compared with hospital. We selected factors to evaluate from a list of possible predictors-i.e., determinants-of death. We extracted the adjusted odds ratios and 95% confidence intervals of each determinant, performed a meta-analysis if appropriate, and conducted a stratified analysis if substantial heterogeneity was observed.

RESULTS

From a literature search yielding 5,899 citations, we included 2 systematic reviews and 29 observational studies. Factors that increased the likelihood of home death included multidisciplinary home palliative care, patient preference, having an informal caregiver, and the caregiver's ability to cope. Factors increasing the likelihood of a nursing home death included the availability of palliative care in the nursing home and the existence of advance directives. A cancer diagnosis and the involvement of home care services increased the likelihood of dying in an inpatient palliative care unit. A cancer diagnosis and a longer time between referral to palliative care and death increased the likelihood of inpatient hospice death. The quality of the evidence was considered low.

LIMITATIONS

Our results are based on those of retrospective observational studies.

CONCLUSIONS

The results obtained were consistent with previously published systematic reviews. The analysis identified several factors that are associated with place of death.

Ascaris lumbricoides infection in urban schoolchildren: specific IgE and IL-10 production

BACKGROUND

Helminth infections and allergies are diseases with intense Th2 lymphocytes participation and characterised by a high IgE and Interleukin-(IL) IL-4, IL-5 production and eosinophilia. However, helminths also induce IL-10 production, which may alter the outcome of allergic diseases in infected patients.

OBJECTIVE

This experimental study analyses the relationship between IL-10 production by cell culture from geohelminth infected and non-infected children and specific IgE to Ascaris lumbricoides (Asc) or Blomia tropicalis (BT).

METHODS

IL-10 content in supernatant from peripheral blood mononuclear cell culture from nine helminth infected and eleven non-infected patients was determined by ELISA after in vitro stimulation with Asc or BT extracts.

RESULTS

A positive association was observed between total IgE levels and anti-Ascaris and anti-Blomia tropicalis specific IgE, independent of infection status. For both helminth-infected and non-infected groups, there was no difference in IL-10 production in response to Asc extract, even though anti-Ascaris IgE levels were higher in the latter group. In response to BT stimulus, a lower production of IL-10 by the geohelminth-infected group was observed, but with no relationship between IL-10 production and specific IgE to BT.

CONCLUSION

The results suggest that anti-Ascaris IgE in non-infected patients may be associated to a resistance to parasites. Levels of specific IgE to parasite antigens or B. tropicalis allergen were not impaired by IL-10 production in children from an urban area in which geohelminthiasis is endemic.

An intragenic ERG deletion is a marker of an oncogenic subtype of B-cell precursor acute lymphoblastic leukemia with a favorable outcome despite frequent IKZF1 deletions

Oncogenic subtypes in childhood B-cell precursor acute lymphoblastic leukemia (BCP-ALL) are used for risk stratification. However, a significant number of BCP-ALL patients are still genetically unassigned. Using array-comparative genomic hybridization in a selected BCP-ALL cohort, we characterized a recurrent V(D)J-mediated intragenic deletion of the ERG gene (ERG(del)). A breakpoint-specific PCR assay was designed and used to screen an independent non-selected cohort of 897 children aged 1-17 years treated for BCP-ALL in the EORTC-CLG 58951 trial. ERG(del) was found in 29/897 patients (3.2%) and was mutually exclusive of known classifying genetic lesions, suggesting that it characterized a distinct leukemia entity. ERG(del) was associated with higher age (median 7.0 vs. 4.0 years, P=0.004), aberrant CD2 expression (43.5% vs. 3.7%, P<0.001) and frequent IKZF1 Δ4-7 deletions (37.9% vs. 5.3%, P<0.001). However, ERG(del) patients had a very good outcome, with an 8-year event-free survival (8-y EFS) and an 8-year overall survival of 86.4% and 95.6%, respectively, suggesting that the IKZF1 deletion had no impact on prognosis in this genetic subtype. Accordingly, within patients with an IKZF1 Δ4-7 deletion, those with ERG(del) had a better outcome (8-y EFS: 85.7% vs. 51.3%; hazard ratio: 0.16; 95% confidence interval: 0.02-1.20; P=0.04). These findings have implications for further stratification including IKZF1 status.

Evidence for a common progenitor of epithelial and mesenchymal components of the liver

Tissues of the adult organism maintain the homeostasis and respond to injury by means of progenitor/stem cell compartments capable to give rise to appropriate progeny. In organs composed by histotypes of different embryological origins (e.g. the liver), the tissue turnover may in theory involve different stem/precursor cells able to respond coordinately to physiological or pathological stimuli. In the liver, a progenitor cell compartment, giving rise to hepatocytes and cholangiocytes, can be activated by chronic injury inhibiting hepatocyte proliferation. The precursor compartment guaranteeing turnover of hepatic stellate cells (HSCs) (perisinusoidal cells implicated with the origin of the liver fibrosis) in adult organ is yet unveiled. We show here that epithelial and mesenchymal liver cells (hepatocytes and HSCs) may arise from a common progenitor. Sca+ murine progenitor cells were found to coexpress markers of epithelial and mesenchymal lineages and to give rise, within few generations, to cells that segregate the lineage-specific markers into two distinct subpopulations. Notably, these progenitor cells, clonally derived, when transplanted in healthy livers, were found to generate epithelial and mesenchymal liver-specific derivatives (i.e. hepatocytes and HSCs) properly integrated in the liver architecture. These evidences suggest the existence of a 'bona fide' organ-specific meso-endodermal precursor cell, thus profoundly modifying current models of adult progenitor commitment believed, so far, to be lineage-restricted. Heterotopic transplantations, which confirm the dual differentiation potentiality of those cells, indicates as tissue local cues are necessary to drive a full hepatic differentiation. These data provide first evidences for an adult stem/precursor cell capable to differentiate in both parenchymal and non-parenchymal organ-specific components and candidate the liver as the instructive site for the reservoir compartment of HSC precursors as yet non-localized in the adult.

Optic atrophy 1 mediates mitochondria remodeling and dopaminergic neurodegeneration linked to complex I deficiency

Mitochondrial complex I dysfunction has long been associated with Parkinson's disease (PD). Recent evidence suggests that mitochondrial involvement in PD may extend beyond a sole respiratory deficit and also include perturbations in mitochondrial fusion/fission or ultrastructure. Whether and how alterations in mitochondrial dynamics may relate to the known complex I defects in PD is unclear. Optic atrophy 1 (OPA1), a dynamin-related GTPase of the inner mitochondrial membrane, participates in mitochondrial fusion and apoptotic mitochondrial cristae remodeling. Here we show that complex I inhibition by parkinsonian neurotoxins leads to an oxidative-dependent disruption of OPA1 oligomeric complexes that normally keep mitochondrial cristae junctions tight. As a consequence, affected mitochondria exhibit major structural abnormalities, including cristae disintegration, loss of matrix density and swelling. These changes are not accompanied by mitochondrial fission but a mobilization of cytochrome c from cristae to intermembrane space, thereby lowering the threshold for activation of mitochondria-dependent apoptosis by cell death agonists in compromised neurons. All these pathogenic changes, including mitochondrial structural remodeling and dopaminergic neurodegeneration, are abrogated by OPA1 overexpression, both in vitro and in vivo. Our results identify OPA1 as molecular link between complex I deficiency and alterations in mitochondrial dynamics machinery and point to OPA1 as a novel therapeutic target for complex I cytopathies, such as PD.

Cost-effectiveness of interventions for chronic obstructive pulmonary disease (COPD) using an Ontario policy model

In July 2010, the Medical Advisory Secretariat (MAS) began work on a Chronic Obstructive Pulmonary Disease (COPD) evidentiary framework, an evidence-based review of the literature surrounding treatment strategies for patients with COPD. This project emerged from a request by the Health System Strategy Division of the Ministry of Health and Long-Term Care that MAS provide them with an evidentiary platform on the effectiveness and cost-effectiveness of COPD interventions. After an initial review of health technology assessments and systematic reviews of COPD literature, and consultation with experts, MAS identified the following topics for analysis: vaccinations (influenza and pneumococcal), smoking cessation, multidisciplinary care, pulmonary rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation for acute and chronic respiratory failure, hospital-at-home for acute exacerbations of COPD, and telehealth (including telemonitoring and telephone support). Evidence-based analyses were prepared for each of these topics. For each technology, an economic analysis was also completed where appropriate. In addition, a review of the qualitative literature on patient, caregiver, and provider perspectives on living and dying with COPD was conducted, as were reviews of the qualitative literature on each of the technologies included in these analyses. The Chronic Obstructive Pulmonary Disease Mega-Analysis series is made up of the following reports, which can be publicly accessed at the MAS website at: http://www.hqontario.ca/en/mas/mas_ohtas_mn.html. Chronic Obstructive Pulmonary Disease (COPD) Evidentiary Framework. Influenza and Pneumococcal Vaccinations for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Smoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Community-Based Multidisciplinary Care for Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Pulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Long-Term Oxygen Therapy for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Noninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Noninvasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Hospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Home Telehealth for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Cost-Effectiveness of Interventions for Chronic Obstructive Pulmonary Disease Using an Ontario Policy Model. Experiences of Living and Dying With COPD: A Systematic Review and Synthesis of the Qualitative Empirical Literature. For more information on the qualitative review, please contact Mita Giacomini at: http://fhs.mcmaster.ca/ceb/faculty_member_giacomini.htm. For more information on the economic analysis, please visit the PATH website: http://www.path-hta.ca/About-Us/Contact-Us.aspx. The Toronto Health Economics and Technology Assessment (THETA) collaborative has produced an associated report on patient preference for mechanical ventilation. For more information, please visit the THETA website: http://theta.utoronto.ca/static/contact.

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is characterized by chronic inflammation throughout the airways, parenchyma, and pulmonary vasculature. The inflammation causes repeated cycles of injury and repair in the airway wall— inflammatory cells release a variety of chemicals and lead to cellular damage. The inflammation process also contributes to the loss of elastic recoil pressure in the lung, thereby reducing the driving pressure for expiratory flow through narrowed and poorly supported airways, in which airflow resistance is significantly increased. Expiratory flow limitation is the pathophysiological hallmark of COPD. Exacerbations of COPD contribute considerably to morbidity and mortality, and impose a burden on the health care system. They are a leading cause of emergency room visits and hospitalizations, particularly in the winter. In Canada, the reported average cost for treating a moderate exacerbation is $641; for a major exacerbation, the cost is $10,086.

OBJECTIVE

The objective of this study was to evaluate the cost-effectiveness and budget impact of the following interventions in moderate to very severe COPD, investigated in the Medical Advisory Secretariat Chronic Obstructive Pulmonary Disease Mega-Analysis Series: smoking cessation programs in moderate COPD in an outpatient setting: – intensive counselling (IC) versus usual care (UC). – nicotine replacement therapy (NRT) versus UC. – IC + NRT versus placebo. – bupropion versus placebo; multidisciplinary care (MDC) teams versus UC in moderate to severe COPD in an outpatient setting; pulmonary rehabilitation (PR) versus UC following acute exacerbations in moderate to severe COPD; long-term oxygen therapy (LTOT) versus UC in severe hypoxemia in COPD in an outpatient setting; ventilation: – noninvasive positive pressure ventilation (NPPV) + usual medical care versus usual medical care in acute respiratory failure due to an acute exacerbation in severe COPD in an inpatient setting. – weaning with NPPV versus weaning with invasive mechanical ventilation in acute respiratory failure due to an acute exacerbation in very severe COPD in an inpatient setting.

METHODS

A cost-utility analysis was conducted using a Markov probabilistic model. The model consists of different health states based on the Global Initiative for Chronic Obstructive Lung Disease COPD severity classification. Patients were assigned different costs and utilities depending on their severity health state during each model cycle. In addition to moving between health states, patients were at risk of acute exacerbations of COPD in each model cycle. During each cycle, patients could have no acute exacerbation, a minor acute exacerbation, or a major exacerbation. For the purposes of the model, a major exacerbation was defined as one that required hospitalization. Patients were assigned different costs and utilities in each model cycle, depending on whether they experienced an exacerbation, and its severity. Starting cohorts reflected the various patient populations from the trials analyzed. Incremental cost-effectiveness ratios (ICERs)—that is, costs per quality-adjusted life-year (QALY)—were estimated for each intervention using clinical parameters and summary estimates of relative risks of (re)hospitalization, as well as mortality and abstinence rates, from the COPD mega-analysis evidence-based analyses. A budget impact analysis was also conducted to project incremental costs already being incurred or resources already in use in Ontario. Using provincial data, medical literature, and expert opinion, health system impacts were calculated for the strategies investigated. All costs are reported in Canadian dollars.

RESULTS

All smoking cessation programs were dominant (i.e., less expensive and more effective overall). Assuming a base case cost of $1,041 and $1,527 per patient for MDC and PR, the ICER was calculated to be $14,123 per QALY and $17,938 per QALY, respectively. When the costs of MDC and PR were varied in a 1-way sensitivity analysis to reflect variation in resource utilization reported in the literature, the ICER increased to $55,322 per QALY and $56,270 per QALY, respectively. Assuming a base case cost of $2,261 per year per patient for LTOT as reported by data from the Ontario provincial program, the ICER was calculated to be $38,993 per QALY. Ventilation strategies were dominant (i.e., cheaper and more effective), as reflected by the clinical evidence of significant in-hospital days avoided in the study group. Ontario currently pays for IC through physician billing (translating to a current burden of $8 million) and bupropion through the Ontario Drug Benefit program (translating to a current burden of almost $2 million). The burden of NRT was projected to be $10 million, with future expenditures of up to $1 million in Years 1 to 3 for incident cases. Ontario currently pays for some chronic disease management programs. Based on the most recent Family Health Team data, the costs of MDC programs to manage COPD were estimated at $85 million in fiscal year 2010, with projected future expenditures of up to $51 million for incident cases, assuming the base case cost of the program. However, this estimate does not accurately reflect the current costs to the province because of lack of report by Family Health Teams, lack of capture of programs outside this model of care by any data set in the province, and because the resource utilization and frequency of visits/follow-up phone calls were based on the findings in the literature rather than the actual Family Health Team COPD management programs in place in Ontario. Therefore, MDC resources being utilized in the province are unknown and difficult to measure. Data on COPD-related hospitalizations were pulled from Ontario administrative data sets and based on consultation with experts. Half of hospitalized patients will access PR resources at least once, and half of these will repeat the therapy, translating to a potential burden of $17 million to $32 million, depending on the cost of the program. These resources are currently being absorbed, but since utilization is not being captured by any data set in the province, it is difficult to quantify and estimate. Provincial programs may be under-resourced, and patients may not be accessing these services effectively. Data from the LTOT provincial program (based on fiscal year 2006 information) suggested that the burden was $65 million, with potential expenditures of up to $0.2 million in Years 1 to 3 for incident cases. From the clinical evidence on ventilation (i.e., reduction in length of stay in hospital), there were potential cost savings to the hospitals of $42 million and $12 million for NPPV and weaning with NPPV, respectively, if the study intervention were adopted. Future cost savings were projected to be up to $4 million and $1 million, respectively, for incident cases.

CONCLUSIONS

Currently, costs for most of these interventions are being absorbed by provider services, the Ontario Drug Benefit Program, the Assistive Devices Program, and the hospital global budget. The most cost-effective intervention for COPD will depend on decision-makers’ willingness to pay. Lack of provincial data sets capturing resource utilization for the various interventions poses a challenge for estimating current burden and future expenditures.

Photodynamic therapy as adjunctive therapy for morpheaform basal cell carcinoma

The authors decided to evaluate the possible use of methyl-aminolevulinate photodynamic therapy (MAL-PDT) as adjunctive therapy for morpheaform basal cell carcinoma prior to standard surgical excision in order to reduce tumor size and volume and to facilitate surgical treatment. It was observed that MAL-PDT may be an option as an adjunctive therapy prior to standard surgical excision of morpheaform basal cell carcinoma, leading to less invasive surgery.

End of life in the neonatal intensive care unit

PURPOSE

Death at the beginning of life is tragic but not uncommon in neonatal intensive care units. In Portugal, few studies have examined the circumstances surrounding the final moments of neonates. We evaluated the care given to neonates and their families in terminal situations and the changes that had occurred one decade later.

DESIGN AND METHODS

We analyzed 256 charts in a retrospective chart review of neonatal deaths between two periods (1992-1995 and 2002-2005) in a level III neonatal intensive care unit.

RESULTS

Our results show differences in the care of dying infants between the two periods. The analysis of the 2002-2005 cohort four years revealed more withholding and withdrawing of therapeutic activities and more effective pain and distress relief; however, on the final day of life, 95.7% of the infants received invasive ventilatory support, 76.3% received antibiotics, 58.1% received inotropics, and 25.8% received no opioid or sedative administration. The 2002-2005 cohort had more spiritual advisor solicitation, a higher number of relatives with permission to freely visit and more clinical meetings with neonatologists. Interventions by parents, healthcare providers and ethics committees during decision-making were not documented in any of the charts. Only eight written orders regarding therapeutic limitations and the adoption of palliative care were documented; seven (87.5%) were from the 2002-2005 cohort. Parental presence during death was more frequent in the latter four years (2002-2005 cohort), but only 21.5% of the parents wanted to be present at that moment.

CONCLUSION

Despite an increase in the withholding and withdrawing of therapeutic activities and improvements in pain management and family support, many neonates still receive curative and aggressive practices at the end of life.