Localized thermonuclear bursts from accreting magnetic white dwarfs.

Nova explosions are caused by global thermonuclear runaways triggered in the surface layers of accreting white dwarfs1-3. It has been predicted4-6 that localized thermonuclear bursts on white dwarfs can also take place, similar to type-I X-ray bursts observed in accreting neutron stars. Unexplained rapid bursts from the binary system TV Columbae, in which mass is accreted onto a moderately strong magnetized white dwarf from a low-mass companion, have been observed on several occasions in the past 40 years7-11. During these bursts, the optical/ultraviolet luminosity increases by a factor of more than three in less than an hour and fades in around ten hours. Fast outflows have been observed in ultraviolet spectral lines7, with velocities of more than 3,500 kilometres per second, comparable to the escape velocity from the white dwarf surface. Here we report on optical bursts observed in TV Columbae and in two additional accreting systems, EI Ursae Majoris and ASASSN-19bh. The bursts have a total energy of approximately 10-6  times than those of classical nova explosions (micronovae) and bear a strong resemblance to type-I X-ray bursts12-14. We exclude accretion or stellar magnetic reconnection events as their origin and suggest thermonuclear runaway events in magnetically confined accretion columns as a viable explanation.

Genetics of canine myxomatous mitral valve disease.

Myxomatous mitral valve disease (MMVD) is the most common heart disease and cause of cardiac death in domestic dogs. MMVD is characterised by slow progressive myxomatous degeneration from the tips of the mitral valves onwards with subsequent mitral valve regurgitation, and left atrial and ventricular dilatation. Although the disease usually has a long asymptomatic period, in dogs with severe disease, mortality is typically secondary to left-sided congestive heart failure. Although it is not uncommon for dogs to survive long enough in the asymptomatic period to die from unrelated causes; a proportion of dogs rapidly advance into congestive heart failure. Heightened prevalence in certain breeds, such as the Cavalier King Charles Spaniel, has indicated that MMVD is under a genetic influence. The genetic characterisation of the factors that underlie the difference in progression of disease is of strong interest to those concerned with dog longevity and welfare. Advanced genomic technologies have the potential to provide information that may impact treatment, prevalence, or severity of MMVD through the elucidation of pathogenic mechanisms and the detection of predisposing genetic loci of major effect. Here we describe briefly the clinical nature of the disorder and consider the physiological mechanisms that might impact its occurrence in the domestic dog. Using results from comparative genomics we suggest possible genetic approaches for identifying genetic risk factors within breeds. The Cavalier King Charles Spaniel breed represents a robust resource for uncovering the genetic basis of MMVD.

Evaluation of esmolol for heart rate control in patients with acute aortic dissection.

PURPOSE: Acute aortic dissection is a serious and life-threatening condition that requires prompt, effective management. The purpose of this study was to evaluate the efficacy and safety of esmolol for heart rate control in patients with acute aortic dissection in the Emergency Department (ED). METHODS: This was a retrospective, descriptive analysis of patients treated for type A or type B acute aortic dissection in the ED at an academic medical center. The primary outcome was the proportion of patients achieving strict (≤60 bpm) or lenient (≤80 bpm) heart rate control within the first 60 min of therapy at the study site. The primary safety endpoint was the incidence of hypotension, defined as a systolic blood pressure of <90 mmHg or a mean arterial pressure of ≤60 mmHg. RESULTS: Of 266 patients screened, 40 patients met inclusion criteria. Thirty-three patients (82.5%) attained lenient rate control within the first 60 min of esmolol therapy. Eleven patients (27.5%) achieved a strict heart rate goal within the first 60 min of esmolol therapy. Five patients (12.5%) experienced an episode of hypotension during the first 3 h of esmolol therapy. CONCLUSION: In patients treated with esmolol infusion for acute aortic dissection, a lenient HR goal was achieved in most patients. In contrast, esmolol was not associated with attainment of strict HR control in most patients included in this sample. Further studies are warranted to evaluate the exact role of esmolol in acute aortic dissection in a larger patient population.

Building on existing tools to improve chronic disease prevention and screening in public health: a cluster randomized trial.

BACKGROUND: The BETTER (Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care) intervention was designed to integrate the approach to chronic disease prevention and screening in primary care and demonstrated effective in a previous randomized trial. METHODS: We tested the effectiveness of the BETTER HEALTH intervention, a public health adaptation of BETTER, at improving participation in chronic disease prevention and screening actions for residents of low-income neighbourhoods in a cluster randomized trial, with ten low-income neighbourhoods in Durham Region Ontario randomized to immediate intervention vs. wait-list. The unit of analysis was the individual, and eligible participants were adults age 40-64 years residing in the neighbourhoods. Public health nurses trained as "prevention practitioners" held one prevention-focused visit with each participant. They provided participants with a tailored prevention prescription and supported them to set health-related goals. The primary outcome was a composite index: the number of evidence-based actions achieved at six months as a proportion of those for which participants were eligible at baseline. RESULTS: Of 126 participants (60 in immediate arm; 66 in wait-list arm), 125 were included in analyses (1 participant withdrew consent). In both arms, participants were eligible for a mean of 8.6 actions at baseline. At follow-up, participants in the immediate intervention arm met 64.5% of actions for which they were eligible versus 42.1% in the wait-list arm (rate ratio 1.53 [95% confidence interval 1.22-1.84]). CONCLUSION: Public health nurses using the BETTER HEALTH intervention led to a higher proportion of identified evidence-based prevention and screening actions achieved at six months for people living with socioeconomic disadvantage. TRIAL REGISTRATION: NCT03052959 , registered February 10, 2017.

What is a prevention visit? A qualitative study of a structured approach to prevention and screening - the BETTER WISE project.

BACKGROUND: This qualitative study is a sub-component of BETTER WISE, a comprehensive and structured approach that proactively addresses chronic disease prevention, screening, and cancer survivorship, including screening for poverty and addressing lifestyle risks for patients aged 40 to 65. Patients (n = 527) from 13 primary care clinics (urban, rural, and remote) in Alberta, Ontario, and Newfoundland & Labrador, Canada agreed to participate in the study and were invited to a one-hour prevention visit delivered by a Prevention Practitioner (PP) as part of BETTER WISE. We identified the key components of a BETTER WISE prevention visit based on patients' and primary care providers' perspectives. METHODS: Primary care providers (PPs, physicians and their staff) participated in 14 focus groups and 19 key informant interviews to share their perspectives on the BETTER WISE project. Of 527 patients who agreed to participate in the study and were invited for a BETTER WISE prevention visit with a PP, we received 356 patient feedback forms. We also collected field notes and memos and employed thematic analysis using a constant comparative method focusing on the BETTER WISE prevention visit. RESULTS: We identified four key themes related to a BETTER WISE prevention visit: 1) Creating a safe environment and building trust with patients: PPs provided sufficient time and a safe space for patients to share what was important to them, including their concerns related to poverty, alcohol consumption, and mental health, topics that were often not shared with physicians; 2) Providing personalized health education: PPs used the BETTER WISE tools to provide patients with a personalized overview of their health status and eligible screening; 3) Non-judgmental empowering of patients: Instead of directing patients on what to do, PPs evoked patients' preferences and helped them to set goals (if desired); and 4) Integrating care for patients: PPs clarified information from patients' charts and surveys with physicians and helped patients to navigate resources within and outside of the primary care team. CONCLUSIONS: The results of this study underscore the importance of personalized, trusting, non-judgmental, and integrated relationships between primary care providers and patients to effectively address chronic disease prevention, screening, and cancer survivorship as demonstrated by the BETTER WISE prevention visits. TRIAL REGISTRATION: This qualitative study is a sub-component of the BETTER WISE pragmatic, cRCT, trial registration ISRCTN21333761 (date of registration 19/12/2016).

The potential impact of post-COVID symptoms in the healthcare sector.

BACKGROUND: The phenomenon of post-COVID syndrome (PCS) is evolving from an abstract array of non-specific symptoms to an identifiable clinical entity of variable severity. Its frequency and persistence have implications for service delivery and workforce planning. AIMS: This study was aimed to assess the prevalence of symptoms consistent with PCS and the subjective degree of recovery in a cohort of healthcare workers, focusing on those who have returned to work. METHODS: A study population of 1176 was surveyed when attending for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody testing. Two sub-groups were identified: those with known (i.e. diagnosed on PCR testing) and assumed (i.e. antibody evidence of previous infection) SARs-CoV-2 infection, at least 12 weeks prior to the study. Each group was asked about their subjective degree of recovery and the nature of their persistent symptoms. Results were analysed via excel and SPSS. RESULTS: In total, 144 employees showed PCR evidence of previous infection, with 139 of these being infected at least 12 weeks prior to the study. Of these 139, only 19% (n = 26) reported feeling 100% recovered, and 71% reported persistent symptoms. Of those with assumed SARS-CoV-2 infection (n = 78), 32 (41%) were truly asymptomatic since the commencement of the pandemic, while 46 (59%) described symptoms suggestive of possible infection at least 12 weeks prior to the study. Of this latter group, 23% (n = 18) also reported residual symptoms. CONCLUSIONS: PCS is prevalent among this group, including those not previously diagnosed with COVID-19. Its' frequency and duration present challenges to employers with regards to the management of work availability and performance.

Procedural Pain in Hospitalized Neonates in Kenya.

PURPOSE: The study was conducted to understand the nature and frequency of painful procedures and use of analgesia in neonatal units in Kenya. DESIGN AND METHODS: Descriptive prospective study was conducted in a regional Level I and a university-affiliated Level II neonatal unit in Western Kenya. Two hundred term and preterm neonates who were hospitalized during the first day of life were recruited. A validated checklist was used to audit medical charts of hospitalized neonates. Painful procedures and pain treatment interventions accompanying all procedures performed during the first seven days of hospitalization were documented. Descriptive statistics, t-tests and χ2 were usedto determine frequency and factors influencing the frequency of procedures. RESULTS: A total of 1693 painful procedures (mean = 1.6 ± 1.1) were performed with most of them being tissue-damaging (n = 1291) including intravenous cannulation and intramuscular injection. Neonates were less likely to undergo procedures if there were born at term (RR 0.85; 95% CI, 0.76-0.95, p = .003) but more likely to experience procedures if admitted in a higher level of care (RR 1.57, 95% CI, 1.43-1.74, p < .001). Only one procedure was accompanied by analgesia. CONCLUSIONS: Neonates underwent few but highly invasive procedures without analgesia. Prematurity and a high level of care predisposed neonates to a higher burden of pain. IMPLICATIONS: Our findings underscore the urgent need for development of context-specific clinical practice guidelines on procedural pain treatment in sub-Saharan Africa.

A multicentre randomised phase III trial comparing pembrolizumab versus single-agent chemotherapy for advanced pre-treated malignant pleural mesothelioma: the European Thoracic Oncology Platform (ETOP 9-15) PROMISE-meso trial.

BACKGROUND: Malignant pleural mesothelioma (MPM) is an aggressive malignancy characterised by limited treatment options and a poor prognosis. At relapse after platinum-based chemotherapy, single-agent chemotherapy is commonly used and single-arm trials of immune-checkpoint inhibitors have demonstrated encouraging activity. PATIENTS AND METHODS: PROMISE-meso is an open-label 1:1 randomised phase III trial investigating the efficacy of pembrolizumab (200 mg/Q3W) versus institutional choice single-agent chemotherapy (gemcitabine or vinorelbine) in relapsed MPM patients with progression after/on previous platinum-based chemotherapy. Patients were performance status 0-1 and unselected for programmed cell death ligand 1 (PD-L1) status. At progression, patients randomly assigned to receive chemotherapy were allowed to crossover to pembrolizumab. The primary end point was progression-free survival (PFS), assessed by blinded independent central review (BICR). Secondary end points were overall survival (OS), investigator-assessed PFS, objective response rate (ORR), and safety. Efficacy by PD-L1 status was investigated in exploratory analyses. RESULTS: Between September 2017 and August 2018, 144 patients were randomly allocated (pembrolizumab: 73; chemotherapy: 71). At data cut-off [20 February 2019, median follow-up of 11.8 months (interquartile range: 9.9-14.5)], 118 BICR-PFS events were observed. No difference in BICR-PFS was detected [hazard ratio = 1.06, 95% confidence interval (CI): 0.73-1.53; P = 0.76], and median BICR-PFS (95% CI) for pembrolizumab was 2.5 (2.1-4.2), compared with 3.4 (2.2-4.3) months for chemotherapy. A difference in ORR for pembrolizumab was identified (22%, 95% CI: 13% to 33%), over chemotherapy (6%, 95% CI: 2% to 14%; P = 0.004). Forty-five patients (63%) assigned to chemotherapy received pembrolizumab at progression. With follow-up to 21 August 2019 [17.5 months: (14.8-19.7)], no difference in OS was detected between groups (HR = 1.12, 95% CI: 0.74-1.69; P = 0.59), even after adjusting for crossover. Pembrolizumab safety was consistent with previous observations. Exploratory efficacy analyses by PD-L1 status demonstrated no improvements in ORR/PFS/OS. CONCLUSION: This is the first randomised trial evaluating the efficacy of pembrolizumab in MPM patients progressing after/on previous platinum-based chemotherapy. In biologically unselected patients, although associated with an improved ORR, pembrolizumab improves neither PFS nor OS over single-agent chemotherapy.

Neurophysiological assessment of joint nociceptors in the rat medial meniscus transection model of post-traumatic osteoarthritis.

OBJECTIVE: Meniscal injury is a common prelude to post-traumatic osteoarthritis (PTOA). Joint nerves can become damaged in arthritic joints leading to the manifestation of neuropathic pain. Both PTOA and neuropathic pain are more common in females; however, it is unknown whether the neural processing of joint pain is sex-specific. DESIGN: Male and female Wistar rats (230-286g) underwent unilateral medial meniscus transection (MMT) and allowed to recover for 28 days. Pain development was assessed over the time course by von Frey hair algesiometry and dynamic weight bearing. Recordings from joint primary afferents was carried out by electrophysiology at end-stage disease. Nerve damage and ß-endorphin levels were also compared between MMT and sham operated animals. RESULTS: Male MMT rats exhibited significant pain behaviour compared to sham control. Evoked afferent firing rate was heightened in male MMT animals. Female PTOA rats did not show signs of pain behaviour on each of the test days and the neurophysiological properties of their nociceptors was not different from control. Peripheral neuropathy was observed in about 30% of axons from male MMT animals compared to 15% in females. Systemic ß-endorphin levels in female PTOA rats was 91.0 ± 10.4 pg/mL and only 49.0 ± 5.0 pg/mL in males. CONCLUSIONS: Secondary allodynia and joint pain were observed in male but not female MMT rats. Joint nociceptors were sensitized in PTOA males but not in females. This lack of pain in females may be due to the absence of a peripheral neuropathy and greater endogenous opioid production.

Impact and Mechanism of Covid-19 on Mental Health and Wellbeing.

The Covid-19 pandemic has brought unprecedented pressure to healthcare systems worldwide, resulting in significant and precipitous changes in demand, burden and method of delivery. The psychosocial impact of this crisis is likely to increase over the course of the pandemic, peak later than medical cases and endure for longer thereby significantly exceeding medical morbidity. It will have far reaching impact on the individual, their family and their care providers. Frontline healthcare workers and those with pre-existing mental health difficulties are recognised at increased risk. Now that the initial surge has been expertly curtailed, it is essential that urgent consideration is now directed towards the mental health implications of the current outbreak and ensure that we are as ready for the increased MH needs of the community as we were for the intensive medical care.

Transforming the One Health workforce: lessons learned from initiatives in Africa, Asia and Latin America.

The capacity to effectively and efficiently address threats to public and animal health requires an adequately trained workforce. A prerequisite for this is an effective plan for building the capacity of both private and public health workers. Yet capacity building and workforce development within One Health collaboration remain challenging for a number of reasons, including competing priorities, sectorspecific funding and a lack of trust and communication across sectors. Practical considerations, such as differences in language and culture, and working across time zones and geography, also have a considerable influence. Consequently, previous attempts to build capacity have traditionally lacked the attributes necessary for effective development and sustainability, such as continuity and systematic coordination of the learning process. Through the presentation and analysis of two recently implemented workforce development programmes, the authors highlight effective characteristics of workforce initiatives to build capacity. Such programmes can play a strategic role in developing, coordinating and supporting systematic and sustainable training for One Health and Veterinary Services performance on a regional and global scale.

La capacité d'apporter une réponse efficace et efficiente aux dangers qui menacent la santé publique et la santé animale est indissociable de l'existence de ressources humaines dotées d'un niveau de formation adéquat. Pour garantir ce niveau il est nécessaire de planifier au préalable le renforcement des capacités des personnels des secteurs public et privé de la santé. Le développement des capacités et des compétences des ressources humaines dans le cadre d'une collaboration Une seule santé demeure toutefois une entreprise difficile pour plusieurs raisons, notamment la concurrence entre priorités, le caractère spécifiquement sectoriel de certains financements et le manque de confiance et de communication entre secteurs. Des considérations pratiques peuvent également avoir une influence considérable, par exemple les différences de langue et de culture et le fait de travailler dans des fuseaux horaires et des contextes géographiques différents. Par le passé, les tentatives de renforcement des capacités étaient dépourvues des attributs indispensables à un développement efficace et durable, en particulier la continuité et la coordination systématique du processus d'apprentissage. À travers la description et l'analyse de deux programmes récents de renforcement des compétences, les auteurs mettent en avant les paramètres nécessaires à un développement efficace des capacités des ressources humaines. Des programmes de ce type peuvent jouer un rôle stratégique majeur pour concevoir, coordonner et soutenir la formation systématique et durable des Services vétérinaires et des intervenants Une seule santé afin de développer leurs compétences à l'échelle régionale et mondiale.

Para poder combatir con eficacia y eficiencia las amenazas que pesan sobre la salud pública y la sanidad animal hay que contar con recursos humanos debidamente formados. Un requisito previo al efecto es disponer de un plan eficaz para capacitar al personal de salud tanto privado como público. Sin embargo, la capacitación y el perfeccionamiento del personal como parte de la colaboración en clave de Una sola salud siguen siendo objetivos problemáticos por diversos motivos, en particular la existencia de prioridades encontradas, el hecho de que los fondos vayan destinados específicamente a uno u otro sector y la falta de confianza y comunicación entre los sectores. También influyen sensiblemente consideraciones de índole práctica como las diferencias de idioma y cultura o la dificultad de trabajar en distintas franjas horarias y zonas geográficas. De ahí que tradicionalmente las tentativas realizadas para crear capacidad vinieran careciendo de los atributos necesarios para resultar eficaces y deparar frutos duraderos, atributos tales como la continuidad y la coordinación sistemática del proceso de aprendizaje. Presentando y analizando dos programas de perfeccionamiento del personal implantados en fechas recientes, los autores destacan las características que debe reunir una iniciativa de capacitación de los recursos humanos para ser eficaz. Los programas de este tipo pueden cumplir una función estratégica a la hora de implantar, coordinar y secundar actividades sistemáticas y sostenibles de formación en clave de Una sola salud con objeto de constituir Servicios Veterinarios eficaces a escala regional y mundial.

Mothers' Perceptions about Pain in Hospitalized Newborn Infants in Kenya.

PURPOSE: Explore views of mothers about pain and pain treatment practices in hospitalized newborn infants. DESIGN AND METHODS: A Qualitative descriptive study using photo-elicitation technique was conducted in a level I and a level II neonatal units in Kenya. Fifteen semi-structured interviews were conducted with mothers of hospitalized infants. The interviews were audio-recorded, transcribed verbatim and analysed using inductive content analysis approach. RESULTS: Mothers described the experience of witnessing their infants undergo painful procedures as emotionally and psychologically traumatic. Participants felt helpless for not being able to protect their infants from pain a situation which was made worse by health care providers who appeared less concerned about pain relief during procedures. Mothers' views demonstrated a good understanding of pain-relief strategies; they identified strategies that health care providers should routinely use to relief pain in hospitalized infants. Furthermore, participants desired to be involved in comforting their infants during clinical procedures. CONCLUSION: Repeated and untreated painful procedures continue to define the hospitalisation experience of newborn infants despite the presence of mothers who desire to be involved in comforting their infants during procedures. PRACTICE IMPLICATION: Minimizing the burden of pain and using pain-relieving interventions could reduce parental stress and optimize parental role attainment following hospitalisation.

Knee-high compression socks minimize head-up tilt-induced cerebral and cardiovascular responses following dynamic exercise.

In healthy individuals during a non-exercised state, knee-high compression socks (CS) may reduce the magnitude of lower limb venous pooling during orthostasis but are not effective at minimizing the incidence of pre-syncopal symptoms. However, exaggerated reductions in cerebral blood flow velocity (CBV) and cardiac stroke volume (SV) occur during passive head-up tilt (HUT) testing following dynamic exercise. It is unknown if CS can minimize post-exercise HUT-induced decrements in CBV and SV in this population. To test the hypothesis that CS will attenuate the reductions in SV and CBV during 60° HUT following 60 minutes of moderate-intensity (60% VO2 peak) cycling exercise. Ten healthy volunteers (22.6 ± 2.1 years, 24.1 ± 2.5 kg/m2 ) completed pre- and post-exercise 15-minute HUT tests during randomized CS and Control (no CS) conditions. Changes in blood pressure (finger plethysmography), SV (Modelflow® method), and CBV (Transcranial Doppler) were measured during HUT and preceding supine rest periods. Pre-exercise HUT-induced similar (all, P > .47) reductions in SV (Control; -23.1 ± 11.5%, CS; -20.5 ± 10.9%) and CBV (Control; -18.1 ± 6.3%, CS; -15.3 ± 9.0%). However, larger post-exercise decreases in SV and CBV during HUT were observed in the Control versus CS condition. Specifically, CS attenuated the drop in SV (Control: -32.9 ± 5.6%, CS: -24.3 ± 11.6%; P = .01) and CBV (Control: -25.1 ± 5.8%, CS: -17.6 ± 7.8%; P = .02) during the post-exercise HUT test. These results indicate that CS attenuated HUT-induced reductions in SV and CBV following moderate-intensity cycling exercise and suggest that CS may be an effective countermeasure to reduce the incidence of post-exercise syncope in vulnerable populations.

The Predictive Ability of Pre-Operative Magnetic Resonance Imaging to Detect Pathological Outcomes in Prostate Cancer

Aims Accurate preoperative knowledge of tumour stage is important in preoperative planning at radical prostatectomy (RP). The aim of this study was to assess the predictive ability of multiparametric MRI for detecting pathological outcomes. Methods A retrospective review was performed of all patients who underwent RP over a 4 year period. Results Preoperative MRI was reported as showing T3 or T4 disease in 26(17.9%) out of 145 patients undergoing RP. Of these, 10(6.9%) had ECE (extra-capsular extension) and 1(0.7%) had SVI (seminal vesicle invasion) on final histology. The sensitivity and specificity of MRI for detecting ECE were 27.3% and 87.6%, respectively. The sensitivity and specificity of MRI for detecting SVI were 11.1% and 97.8%, respectively. The positive predictive values for determining ECE and SVI were 45.5% and 25%, respectively and negative predictive values were 75.9% and 94.4%. Conclusion MRI has good specificity but poor and heterogeneous sensitivity for predicting T3 disease in RP specimen.

The BLT1 Inhibitory Function of α-1 Antitrypsin Augmentation Therapy Disrupts Leukotriene B4 Neutrophil Signaling.

Leukotriene B4 (LTB4) contributes to many inflammatory diseases, including genetic and nongenetic forms of chronic obstructive pulmonary disease. α-1 Antitrypsin (AAT) deficiency (AATD) is characterized by destruction of lung parenchyma and development of emphysema, caused by low AAT levels and a high neutrophil burden in the airways of affected individuals. In this study we assessed whether AATD is an LTB4-related disease and investigated the ability of serum AAT to control LTB4 signaling in neutrophils. In vitro studies demonstrate that neutrophil elastase is a key player in the LTB4 inflammatory cycle in AATD, causing increased LTB4 production, and associated BLT1 membrane receptor expression. AATD patients homozygous for the Z allele were characterized by increased neutrophil adhesion and degranulation responses to LTB4. We demonstrate that AAT can bind LTB4 and that AAT/LTB4 complex formation modulates BLT1 engagement and downstream signaling events, including 1,4,5-triphosphate production and Ca(2+) flux. Additionally, treatment of ZZ-AATD individuals with AAT augmentation therapy decreased plasma LTB4 concentrations and reduced levels of membrane-bound neutrophil elastase. Collectively, these results provide a mechanism by which AAT augmentation therapy impacts on LTB4 signaling in vivo, and not only reinforces the utility of this therapy for resolving inflammation in AATD, but supports useful future clinical applications in treatment of other LTB4-related diseases.

A randomised assessment of the use of a quality of life questionnaire with or without intervention in patients attending a thoracic cancer clinic.

The study examined the impact of using a quality of life (QoL) questionnaire during a clinic to identify QoL issues and to improve QoL. 138 patients were randomised (1:1:1) to either (1) an Intervention group that completed the European Organisation for Research and Treatment of Cancer-Core Quality of Life Questionnaire and Lung Cancer Module (EORTC QLQ-C30 and LC13) at baseline and received feedback during a clinic, (2) an Attention group that completed the questionnaire at baseline without feedback and (3) a Control group that did not complete the questionnaire. All patients completed the same questionnaire 6 weeks later and a contact diary during the study period. There was a significant difference between the Intervention and Control groups for the mean number of QoL issues identified at baseline (4.69 vs. 2.81, P = 0.006) and the mean number of actions taken (4.41 vs. 2.46, P = 0.004). At 6 weeks, there was no difference between the groups in global QoL (Intervention vs. Control group, P = 0.596; Attention vs. Control, P = 0.973). The results suggest that the completion of the EORTC QLQ-C30 LC13 with feedback improves communication and increases the number of QoL issues identified and actions taken. However, the intervention does not impact on QoL per se. Clinicaltrials.gov: NCT01213745.

PTH [1-34]-induced alterations predispose the mandibular condylar cartilage to mineralization.

OBJECTIVE: To study the effects of intermittent parathyroid hormone (PTH [1-34]) on the mandibular condylar cartilage (MCC) and subchondral bone in adult female mice. MATERIALS AND METHODS: Twenty-two, 20-week-old female mice were used for in vivo experiments. The experimental mice (n=11) received daily intraperitoneal injections of PTH [1-34] for 3 weeks, while control mice (n=11) received intraperitoneal injections of 0.9% saline solution. Mice were euthanized and then micro-computed tomography (micro-CT); histology and immunostaining were carried out to assess the response. RESULTS: Intermittent PTH [1-34] led to early MCC breakdown and surface irregularities. Micro-CT analyses indicated that PTH [1-34] treatment led to increased bone volume fraction, tissue density and trabecular thickness, while decreasing the trabecular spacing. Histological analyses showed decreased proteoglycan secretion, increased bone turnover (TRAP staining) and increased mineralization. Furthermore, PTH [1-34] treatment showed increased apoptosis of the cells. Our immunohistochemistry showed increased expression of pSMAD158 in the MCC and subchondral bone with PTH administration, whereas sclerostin (SOST) expression was decreased. CONCLUSIONS: Intermittent PTH [1-34] results in early mineralization of the MCC, which may result in cartilage degeneration. Our results identified a novel mechanism by which PTH [1-34] induces alteration in the microarchitecture of the MCC and the subchondral bone.

The role of family physicians in cancer care: perspectives of primary and specialty care providers.

BACKGROUND: Currently, the specific role of family physicians (fps) in the care of people with cancer is not well defined. Our goal was to explore physician perspectives and contextual factors related to the coordination of cancer care and the role of fps. METHODS: Using a constructivist grounded theory approach, we conducted telephone interviews with 58 primary and cancer specialist health care providers from across Canada. RESULTS: The participants-21 fps, 15 surgeons, 12 medical oncologists, 6 radiation oncologists, and 4 general practitioners in oncology-were asked to describe both the role that fps currently play and the role that, in their opinion, fps should play in the future care of cancer patients across the cancer continuum. Participants identified 3 key roles: coordinating cancer care, managing comorbidities, and providing psychosocial care to patients and their families. However, fps and specialists discussed many challenges that prevent fps from fully performing those roles: ■ The fps described communication problems resulting from not being kept "in the loop" because they weren't copied on patient reports and also the lack of clearly defined roles for all the various health care providers involved in providing care to cancer patients.■ The specialists expressed concerns about a lack of patient access to fp care, leaving specialists to fill the care gaps. The fps and specialists both recommended additional training and education for fps in survivorship care, cancer screening, genetic testing, and new cancer treatments. CONCLUSIONS: Better communication, more collaboration, and further education are needed to enhance the role of fps in the care of cancer patients.

Uptake of a 21-gene expression assay in breast cancer practice: views of academic and community-based oncologists.

PURPOSE: Advances in personalized medicine have produced novel tests and treatment options for women with breast cancer. Relatively little is known about the process by which such tests are adopted into oncology practice. The objectives of the present study were to understand the experiences of medical oncologists with multigene expression profile (gep) tests, including their adoption into practice in early-stage breast cancer, and the perceptions of the oncologists about the influence of test results on treatment decision-making. METHODS: We conducted a qualitative descriptive study involving interviews with medical oncologists from academic and community cancer centres or hospitals in 8 communities in Ontario. A 21-gene breast cancer assay was used as the example of gep testing. Qualitative analytic techniques were used to identify the main themes. RESULTS: Of 28 oncologists who were approached, 21 (75%) participated in the study [median age: 43 years; 12 women (57%)]. Awareness and knowledge of gep testing were derived from several sources: international scientific meetings, participation in clinical studies, discussions with respected colleagues, and manufacturer-sponsored meetings. Oncologists observed that incorporating gep testing into their clinical practice resulted in several changes, including longer consultation times, second visits, and taking steps to minimize treatment delays. Oncologists expressed divergent opinions about the strength of evidence and added value of gep testing in guiding treatment decisions. CONCLUSIONS: Incorporation of gep testing into clinical practice in early-stage breast cancer required oncologists to make changes to their usual routines. The opinions of oncologists about the quality of evidence underpinning the test affected how much weight they gave to test results in treatment decision-making.