The affect of personality traits and decision-making style on postoperative quality of life and distress in patients undergoing pelvic exenteration.

AIM: Our aim was to identify whether personality traits and decision-making styles affect quality of life (QoL) outcomes and levels of psychological distress following pelvic exenteration (PE). METHOD: Patients undergoing PE between 2008 and 2015 were identified from a prospectively maintained database at a single quaternary referral centre. Patients were invited to complete two validated questionnaires, with the Big Five inventory being used to assess personality traits and the Melbourne Decision Making Questionnaire to determine decision-making style. Data on QoL outcomes and distress from the prospectively established database were utilized. QoL with respect to both physical and mental health components was measured using Short Form 36 version 2 (SF-36v2) and the Functional Assessment of Cancer Therapy - Colorectal (FACT-C). Distress was measured using the Distress Thermometer. Postoperative pain scores were also measured using SF-36v2. RESULTS: Of the 93 patients eligible for participation, 42 returned the study questionnaire. On multivariate analysis, neuroticism was the most significant predictor of poorer QoL and increased levels of distress, consistent across all of the measures utilized and at the different time points used. Other personality traits showed an isolated statistically significant impact upon QoL. There were no significant findings with respect to decision-making style. Apart from neuroticism, the most significant predictor of QoL was the number of major complications for the patient. CONCLUSION: Patients demonstrating neurotic personality traits show poorer QoL outcomes and higher levels of distress following PE. Identification of these patients would allow targeted pre- and postoperative intervention to improve outcomes following PE.

The effects of flunixin meglumine and hoof trimming on lying behavior, locomotion, and milk production in lame and nonlame lactating dairy cows.

Hoof trimming is used to prevent and treat lameness in dairy cows; however, hoof trimming itself increases daily time spent lying down, possibly due to discomfort. We hypothesized that treatment of lame and nonlame cows with an anti-inflammatory analgesic drug at the time of hoof trimming would mitigate discomfort, thereby improving locomotion scores and reducing post-trimming increases in lying time. We further hypothesized that drug treatment would improve post-trimming milk production. Our objective was to determine the effects of treatment with the nonsteroidal anti-inflammatory drug flunixin meglumine (2.2 mg/kg of BW) at the time of hoof trimming on locomotion, lying times, and milk production in lame and nonlame lactating dairy cows. All cows were filmed for locomotion scoring 1 d before and 1, 8, and 28 d after hoof trimming. Daily time spent standing and lying was recorded for 4 d before and 4 wk after hoof trimming, and daily milk production was recorded for 1 wk before and 8 wk after trimming. Thirty minutes before hoof trimming, an intravenous injection of flunixin meglumine (n = 34) or isotonic sterile saline solution (n = 34) was administered to each cow. Then, all cows had their hooves trimmed using the Dutch method. The same treatment was repeated 24 h after hoof trimming. Cows were categorized using baseline locomotion scores as lame (score ≥3/5) or nonlame (score <3/5). Drug treatment did not affect post-trimming changes in locomotion scores, daily lying times, or milk production. In both treatment groups, most cows had the same lameness status (lame or nonlame) at baseline and after treatment, and there was no difference between groups in the number of cows that changed lameness status over time. Lame cows (n = 21) had no significant changes in lying times over the course of the study, whereas nonlame cows (n = 47) had mean daily lying times that were significantly higher than baseline all 4 wk after trimming. Hoof trimming in nonlame cows should be scheduled for a time when increased lying behavior after trimming can be accommodated.

Pushing the boundaries of pelvic exenteration by maintaining survival at the cost of morbidity.

BACKGROUND: Pelvic exenteration (PE) provides a potentially curative option for advanced or recurrent malignancy confined to the pelvis. A clear (R0) resection margin is the strongest prognostic factor predicting long-term survival, driving most technical advances in PE surgery. The aim of this cohort study was to describe changing trends in extent of resection, postoperative complications, mortality and overall survival after PE surgery. METHODS: Consecutive patients who underwent PE for advanced or recurrent pelvic malignancy at a single institution in Sydney, Australia, were identified. The cohort was divided into three groups based on time periods reflecting annual surgical volume: 1994-2006 (20 or fewer procedures per year), 2007-2013 (21-50 procedures per year) and 2014-2017 (over 50 procedures per year). Primary outcomes were extent of resection, postoperative complications, 60-day mortality and 3-year overall survival. Secondary outcomes were patient characteristics, receipt of neoadjuvant therapy and duration of hospital stay. RESULTS: There were increases over time in rates of lateral and posterior compartment resections (P < 0·001), and bony pelvis (P = 0·002) and neurovascular (P < 0·001) excision. For patients undergoing reconstruction, the proportion receiving vertical rectus abdominus myocutaneous flaps increased significantly (P = 0·005). Rates of wound infection, dehiscence, and abdominal and pelvic collections increased over the study interval. Short-term mortality decreased, and 1- and 3-year survival rates improved. CONCLUSION: Technical and surgical advancements have led to more complex PE resections, with R0 and mortality rates improving with higher annual volume. There were associated increases in intraoperative blood loss and postoperative morbidity.

ANTECEDENTES: La exenteración pélvica (pelvic exenteration, PE) ofrece una opción potencialmente curativa para el cáncer localmente avanzado o la recidiva de la neoplasia limitada a la pelvis. Un margen de resección libre (R0) es el factor pronóstico más importante que predice la supervivencia a largo plazo, lo que ha impulsado la mayoría de los avances técnicos en la cirugía de la PE. El objetivo de este estudio de cohortes fue describir el cambio en la tendencia relativa a la extensión de la resección, las complicaciones postoperatorias, la mortalidad y la supervivencia global después de la cirugía de la PE. MÉTODOS: Se identificaron pacientes intervenidos de forma consecutiva a los que se practicó una PE por neoplasia pélvica avanzada o recidivante en una sola institución en Sydney, Australia. La cohorte se dividió en tres grupos según períodos de tiempo que reflejan el volumen quirúrgico anual: 1994-2006 (≤ 20 casos por año), 2007-2013 (21-50 casos por año) y 2014-2017 (> 50 casos por año). Los criterios de valoración principal fueron la extensión de la resección, las complicaciones postoperatorias, la mortalidad a los 60 días y la supervivencia a los tres años. Los criterios de valoración secundarios fueron las características del paciente, la administración de tratamiento neoadyuvante y la duración de la estancia hospitalaria. Las tendencias se evaluaron mediante pruebas de χ2 o ANOVA de una vía. RESULTADOS: Los porcentajes de resección de los compartimentos lateral y posterior, pelvis ósea así como de escisión neurovascular aumentaron con el tiempo (P < 0,01). Entre los pacientes en los que se hizo una reconstrucción, el porcentaje de colgajos miocutáneos verticales del recto del abdomen aumentó significativamente (P = 0,005). Las tasas de infección de herida, dehiscencia y colecciones abdominales y pélvicas aumentaron durante el período de estudio. La mortalidad a corto plazo disminuyó y la supervivencia a 1 y 3 años mejoró durante el período de estudio. CONCLUSIÓN: Los avances técnicos y quirúrgicos han permitido realizar resecciones de PE más complejas, mejorando las tasas de resección R0 y de mortalidad al aumentar el volumen anual de intervenciones. Al mismo tiempo se han observado incrementos en las pérdidas intraoperatorias de sangre, en las reconstrucciones y en la morbilidad postoperatoria.

Magnetic resonance spectroscopy in very preterm-born children at 4 years of age: developmental course from birth and outcomes.

PURPOSE: Brain metabolites show very rapid maturation over infancy, particularly following very preterm (VPT) birth, and can provide an index of brain injury. The utility of magnetic resonance imaging (MRS, magnetic resonance spectroscopy) in predicting outcome in VPT-born infants is largely limited to 2-year outcomes. We examined the value of MRS in VPT followed longitudinally to 4 years. METHODS: MRS datasets were acquired in 45 VPT infants (< 32 weeks gestational age) longitudinally: at birth, at term-equivalent and at 4 years of age. Using LCModel analyses in a basal ganglia voxel, we investigated metabolite ratios as a function of age, brain injury and outcome. We also studied a full-term (FT) cohort at 4 years and compared group differences with outcome. RESULTS: We found significant age-related changes in many brain metabolites in infancy, including phosphocreatine (CR)/phosphocholine (CHO), N-acetylaspartylglutamate (NAA)/CHO, myoinositol (INS)/CHO and INS/CR; there were no significant MRS differences between VPT and FT groups at 4 years of age, or differences at 4 years as a function of early brain injury or outcome. The rate of change in metabolite ratios from VPT birth to term-equivalent age did not predict outcome in the VPT children at 4 years. CONCLUSION: Brain metabolite ratios measured in VPT-born infants have shown associations with short-term outcomes, but these correlations did not extend to early childhood nor predict cognitive sequelae. The most frequently reported poor outcome in VPT-born children is cognitive difficulties starting at early school age. MRS metrics early in the infant's life do not appear to predict these longer-term outcomes.

Gum chewing aids bowel function return and analgesic requirements after bowel surgery: a randomized controlled trial.

AIM: The aim was to compare the effectiveness of chewing sugar-free gum after bowel resection on bowel function and length of stay. METHOD: This was a randomized controlled trial of patients undergoing elective open or laparoscopic bowel surgery, who were allocated into two groups: a chewing gum group (CG); or a nonchewing gum group (NG). Primary outcomes were time to discharge (length of hospital stay [LOS]), time to first flatus (TFF) and time to first bowel motion (TBM). Secondary outcomes were complication rates, pain and total morphine equivalent (TMEq) medication for 7 days after the procedure. RESULTS: Between 2010 and 2013, 162 patients were randomized; four were excluded, leaving 158 in the study (82 in the CG and 76 in the NG). There was no difference in LOS between the CG (5.8 days) and the NG (6.1 days) (P = 0.403) or in the median TFF between the CG (42.0 h) and the NG (58.0 h) (P = 0.076). The median TBM was lower in the CG (40.0 h) than in the NG (90.0 h) (P = 0.002). There was no difference in intra-operative complications between the CG (9%) and the NG (9%) (P = 0.901) or in early postoperative complications (44% for CG and 55% for NG) (P = 0.131). There was no difference in TMEq at 24 h postprocedure, but the CG had reduced TMEq from days 2 to 7 post procedure and for the 7-day total. Pain was higher among patients in the NG on day 3. CONCLUSION: Chewing sugar-free gum resulted in an earlier return to bowel function and decreased analgesic requirements. There was no decrease in overall LOS or postoperative complications.

A randomized controlled trial of four different regimes of biofeedback programme in the treatment of faecal incontinence.

AIM: Biofeedback is an established, effective and non-invasive treatment for faecal incontinence (FI). The aim was to compare the effectiveness of four different biofeedback treatment regimes. METHOD: This was a randomized control trial of patients with FI, stratified into two groups (metropolitan and rural) and then randomized into two subgroups (groups 1 and 2 within metropolitan, groups 3 and 4 within rural) with varying face-to-face and telephone biofeedback components. All patients received standardized counselling and education, dietary modification and the use of anti-diarrhoeal medications. Group 1 received four monthly face-to-face biofeedback treatments, groups 2 and 3 received one face-to-face biofeedback followed by telephone biofeedback and group 4 received a one-off face-to-face biofeedback treatment. Primary outcomes were patient-assessed severity of FI and quality of life as assessed by the 36-item Short Form Health Survey and direct questioning of objectives. Secondary outcomes included St Mark's incontinence score, anxiety, depression and anorectal physiology measures (resting, squeeze pressures; isotonic, isometric fatigue times). RESULTS: Between 2006 and 2012, 351 patients were recruited. One patient died leaving 350 for analysis. 332 (95%) were women. Mean age was 60 (SD = 14). All groups had significant improvements in FI, quality of life, incontinence score and mental status (P < 0.001 each). There were no differences in improvements in FI between groups although patient satisfaction was less with reduced face-to-face contact. There were modest improvements in isotonic and isometric fatigue times suggesting improved sphincter endurance (both P < 0.001). CONCLUSION: Biofeedback is effective for FI. Although face-to-face and telephone biofeedback is not necessary to improve FI, it is important for patient satisfaction.

Evidence-practice gaps in lung cancer: A scoping review.

Lung cancer is a significant international health problem. Aligning clinical practice with evidence-based guideline recommendations has the potential to improve patient outcomes. This scoping review describes evidence-practice gaps across the diagnostic and management care pathway for lung cancer. We conducted searches of online databases Medline, PsychInfo, Cinahl and the Cochrane Library to identify studies published between 2008 and 2012. Of 614 articles screened, 65 met inclusion criteria. We identified seven evidence-practice gaps: (1) delays in timely diagnosis and referral; (2) curative and (3) palliative treatments are under-utilised; (4) older age and co-morbidities influence the use of treatments; (5) the benefits of multidisciplinary team review are not available to all lung cancer patients; (6) psychosocial needs are unmet; and (7) early referral to palliative care services is under-utilised. The scoping review highlighted three key messages: (1) there are significant challenges in the timely diagnosis and referral of lung cancer; (2) curative and palliative treatments, psychosocial support and palliative care are under-utilised in lung cancer management; and (3) variations in treatment utilisation appear to be associated with non-disease factors such as patient characteristics, provider practices and the organisation of health care services. Future research should focus on designing interventions to overcome variations in care.

Short communication: Behavioral evaluation of the analgesic effect of flunixin meglumine in lame dairy cows.

The objective of this study was to evaluate the effect of flunixin meglumine treatment on lameness pain in dairy cows. Twenty-four lactating Holstein cows were enrolled in the study based on visual observation of abnormal locomotion. The primary measurement endpoint was weight-shifting between the rear limbs. Weight-shifting was calculated as the standard deviation of the weight borne on the rear limbs over a 15 min period; this value correlates directly with lameness pain in dairy cows. After collecting baseline weight-bearing data, we randomly assigned cows to 1 of 2 treatment groups: 2.2 mg/kg body weight flunixin meglumine (2 mL/45 kg) or an equivalent volume of isotonic sterile saline solution. Weight-bearing data were collected from each cow at 2, 6, 12, and 24 h after a single intravenous drug treatment. Mean locomotion scores over the 2 d before treatment were 2.38/5 in the flunixin-treated group and 2.43/5 in the saline-treated control group; these values were not significantly different. Weight-shifting values were also not significantly different on either pretreatment day. Cows treated with flunixin meglumine showed significantly less weight-shifting between the rear limbs at 6, 12, and 24 h after treatment compared with saline-treated controls, providing evidence that flunixin meglumine alleviates lameness-associated pain.

Cost-effectiveness of pelvic exenteration for locally advanced malignancy.

BACKGROUND: The rising cost of healthcare is well documented. The purpose of this study was to determine the cost-effectiveness of pelvic exenteration (PE). METHODS: Consecutive patients referred for consideration of PE between 2008 and 2011 were recruited into a prospective non-randomized study that compared quality of life (QoL) between patients who did or did not undergo PE. Information on QoL and cost (in Australian dollars, AUD) was collected at baseline, during admission and up to 24 months after discharge. QoL data were converted into a utility-based measure. Quality-adjusted life-years (QALYs) were calculated. Bottom-up costing was performed. The incremental cost-effectiveness ratio (ICER) was calculated per life-year saved and per QALY. RESULTS: There were 174 patients with sufficient data for analysis. Of these, 139 underwent PE. R0 was achieved in 78·4 per cent of patients. The survival rate at 24 months after PE was 74·8 per cent compared with 43 per cent in those without exenteration (P = 0·001). Treatment costs were significantly higher for patients who had PE compared with those who did not (mean AUD 137 407 versus 79 174; P < 0·001). The ICER was AUD 124 147 (95 per cent c.i. 71 585 to 261 876) per life-year saved and AUD 227 330 (109 974 to 1 100 449) per QALY. Curative PE (R0) was found to be more cost-effective than non-curative PE (R1/R2), with an ICER of AUD 101 518 (60 105 to 200 428) versus 390 712 (74 368 to 82 256 739) per life-year saved. CONCLUSION: Treatment of advanced pelvic cancers is expensive regardless of the treatment intent. For a cost difference of only AUD 58 000 (€38 264), PE offers a chance of cure, and improves survival and QoL.

On the calculation of solubilities via direct coexistence simulations: Investigation of NaCl aqueous solutions and Lennard-Jones binary mixtures.

Direct coexistence molecular dynamics simulations of NaCl solutions and Lennard-Jones binary mixtures were performed to explore the origin of reported discrepancies between solubilities obtained by direct interfacial simulations and values obtained from the chemical potentials of the crystal and solution phases. We find that the key cause of these discrepancies is the use of crystal slabs of insufficient width to eliminate finite-size effects. We observe that for NaCl crystal slabs thicker than 4 nm (in the direction perpendicular to the interface), the same solubility values are obtained from the direct coexistence and chemical potential routes, namely, 3.7 ± 0.2 molal at T = 298.15 K and p = 1 bar for the JC-SPC/E model. Such finite-size effects are absent in the Lennard-Jones system and are likely caused by surface dipoles present in the salt crystals. We confirmed that µs-long molecular dynamics runs are required to obtain reliable solubility values from direct coexistence calculations, provided that the initial solution conditions are near the equilibrium solubility values; even longer runs are needed for equilibration of significantly different concentrations. We do not observe any effects of the exposed crystal face on the solubility values or equilibration times. For both the NaCl and Lennard-Jones systems, the use of a spherical crystallite embedded in the solution leads to significantly higher apparent solubility values relative to the flat-interface direct coexistence calculations and the chemical potential values. Our results have broad implications for the determination of solubilities of molecular models of ionic systems.

A mortality risk prediction model for older adults with lymph node-positive colon cancer.

Clinicians are less likely to recommend adjuvant chemotherapy for older adults based on their age alone. This study aimed to develop a mortality risk model to assist treatment decision making by identifying patients who are unlikely to live to benefit from chemotherapy. All lymph node-positive colon cancer patients ≥65 years who received surgery in New South Wales, Australia in 2007/2008 were identified using a linked population-based dataset (n = 1550). A model predicting 1-year all-cause mortality was built using multilevel logistic regression. Risk scores derived from model factors were summed for each patient. One-year mortality was 11.5%. The risk model consisted of 14 factors, including comorbidities, hospital admission factors and other markers of frailty or health status. People with a total score of 0, 1 or 2 were considered at low risk (predicted 1-year mortality of 2.9%), those scoring 3 to 8 at medium risk (7.4% mortality) and those scoring 9 or above at high risk (24.7% mortality). The model had good discrimination (area under the receiver operating characteristic curve = 0.788, 95% confidence interval: 0.752-0.825) and calibration (P = 0.46). The risk model accurately predicts mortality for this cohort and could be useful in shifting the emphasis in chemotherapy decision making from chronological age to the identification of those of any age who will benefit.

Quality of life and other patient-reported outcomes following exenteration for pelvic malignancy.

BACKGROUND: Pelvic exenteration is highly radical surgery offering the only potential cure for locally advanced pelvic cancer. This study compared quality of life and other relevant patient-reported outcomes over 12 months for patients who did and those who did not undergo pelvic exenteration. METHODS: Consecutive patients referred for consideration of pelvic exenteration completed clinical and patient-reported outcome assessments at baseline, hospital discharge (exenteration patients only), and 1, 3, 6, 9 and 12 months. Outcomes included cancer-specific quality of life (Functional Assessment of Cancer Therapy - Colorectal; FACT-C), physical and mental health status (Short Form 36 version 2), psychological distress (Distress Thermometer), and pain (study-specific composite) scores. Linear mixed modelling compared trajectories between exenteration and no-exenteration groups. RESULTS: Among 182 patients, 148 (81.3 per cent) proceeded to exenteration. There were no baseline differences between the two groups. Among patients who had exenteration, the mean FACT-C score at baseline of 93.0 had reduced by 14·4 points at hospital discharge, but increased to 86·7 at 1 month after surgery and continued to improve, returning to baseline by 9 months. For patients in the no-exenteration group, FACT-C scores decreased between baseline and 1 month, increased slowly to 6 months and then began to decline at 9 months. There were few statistically or clinically significant differences in any patient-reported outcomes between the groups. CONCLUSION: Quality of life and related patient-reported outcomes improve rapidly after pelvic exenteration surgery. For 9 months after surgery, these outcomes are comparable with those of similar do patients who do not have surgery; thereafter, there is a decline in patients who do not have exenteration. Pelvic exenteration can be performed with acceptable quality of life and patient-reported outcomes.

Identifying indicators of colorectal cancer care coordination: a Delphi study.

AIM: Care coordination is an important aspect of the quality of cancer care but is difficult to evaluate due to the lack of valid and reliable measures. This study was conducted to identify a set of objective measures of colorectal cancer care coordination that could be included in a medical record audit tool. METHOD: A two-stage Delphi study was conducted to gain consensus among a national panel of experts about the validity of 41 potential indicators of colorectal cancer care coordination that had been identified during a literature review. The expert panel comprised 20 members from the National Health and Medical Research Colorectal Cancer Guidelines Working Party plus representatives from cancer nursing/coordination, general practice and cancer consumers. RESULTS: Consensus was reached on the validity of 15 of 41 potential indicators, including those that focused on practical aspects of communication (legibility, clarity, content and timeliness of hospital discharge letters, documentation of outcomes of multidisciplinary team meetings) and appropriateness (documentation of preoperative consultation with a stoma therapist, discussions and referrals for adjuvant therapy for appropriate patients, and treatment by an experienced colorectal surgeon). There was lack of consensus on the validity of indicators relating to access to and efficiency of services. CONCLUSION: The study has identified a core set of measures considered to be valid indicators of colorectal cancer care coordination. A medical record audit based on these measures could be used to monitor adequacy of cancer care coordination and will complement subjective measures based on self-reported experiences of patients and carers.

Patient and clinician preferences for surgical and medical treatment options in ulcerative colitis.

AIM: When treating patients with refractory ulcerative colitis (UC), the choice between escalating medical management or surgery can be difficult. The aim of this study was to quantify the preferences of patients and clinicians for the treatment options in UC. METHOD: Ulcerative colitis outpatients were interviewed to measure their preferences for five scenarios examining the management of acute and chronic UC, using a prospective measure of preference method that generates two utility scores: willingness and amount of expected life to trade or gamble. A self-administered questionnaire was mailed to Australian and New Zealand colorectal surgeons and gastroenterologists. RESULTS: Fifty-five patients (26 medical and 29 surgical), 91 surgeons and 78 gastroenterologists were surveyed. In the acute setting, 89% of patients, 69% of gastroenterologists and 55% of surgeons were willing to trade part of their life expectancy to avoid a permanent stoma, while for chronic disease 71% of patients were prepared to trade to avoid an operation with a permanent stoma compared with 55% for an operation with a pouch (P = 0.01). Both patients and gastroenterologists were more prepared to gamble or trade to avoid any surgery than were colorectal surgeons. All groups were aligned in their decision to undergo yearly colonoscopy surveillance rather than to undergo definitive surgery that would result in a stoma. CONCLUSION: Patient preferences for the treatment of UC were more aligned to those of gastroenterologists than those of colorectal surgeons. Despite postoperative studies revealing an equal quality of life for pouch and stoma patients, this study confirmed that a pouch is the preferred surgical option.

Assessment of abdominoperineal resection rate as a surrogate marker of hospital quality in rectal cancer surgery.

BACKGROUND: Rates of abdominoperineal resection (APR) have been suggested as a solitary surrogate marker for comparing overall hospital quality in rectal cancer surgery. This study investigated the value of this marker by examining the associations between hospital APR rates and other quality indicators. METHODS: Hospital-level correlations between risk-adjusted APR rates for low rectal cancer and six risk-adjusted outcomes and six care processes were performed (such as 30-day mortality, complications, timely treatment). The ability of APR rates to discriminate between hospitals' performance was examined by means of hospital variance results in multilevel regression models and funnel plots. RESULTS: A linked population-based data set identified 1703 patients diagnosed in 2007 and 2008 who underwent surgery for rectal cancer. Some 15.9 (95 per cent confidence interval (c.i.) 14.2 to 17.6) per cent of these patients had an APR. Among 707 people with low rectal cancer, 38.2 (34.6 to 41.8) per cent underwent APR. Although risk-adjusted hospital rates of APR for low rectal cancer varied by up to 100 per cent, only one hospital (1 per cent) fell outside funnel plot limits and hospital variance in multilevel models was not very large. Lower hospital rates of APR for low rectal cancer did not correlate significantly with better hospital-level outcomes or process measures, except for recording of pathological stage (r = -0.55, P = 0.019). Patients were significantly more likely to undergo APR for low rectal cancer if they attended a non-tertiary metropolitan hospital (adjusted odds ratio 2.14, 95 per cent c.i. 1.11 to 4.15). CONCLUSION: APR rates do not appear to be a useful surrogate marker of overall hospital performance in rectal cancer surgery.

Activin B is produced early in antral follicular development and suppresses thecal androgen production.

Little is known about the role of activin B during folliculogenesis. This study investigated the expression levels of activin/inhibin subunits (ßA, ßB, and α), steroid enzyme, and gonadotrophin receptors in theca (TC) and granulosa cells (GC) by QPCR and activin A and B and inhibin A protein levels in follicular fluid (FF) of developing sheep follicles during estrus and anestrus. The effect of activin B on androgen production from primary TC cultures in vitro was also assessed. During folliculogenesis, in anestrus and estrus, FF activin B concentrations and thecal and GC activin ßB mRNA levels decreased as follicle diameter increased from 1-3 to >6  mm regardless of estrogenic status. Estrogenic preovulatory follicles had reduced concentrations of FF activins B and A, and TC and GCs expressed higher levels of activin ßA mRNA at 3-4  mm, and TCs more inhibin α mRNA at >4  mm stages of development compared with nonestrogenic follicles. Activin B decreased androstenedione production from primary TCs in vitro, an effect blocked by inhibin A. Thus, sheep follicles 1-3  mm in diameter contained high FF levels of activin B, which decreased as the follicle size increased, and, like activin A, suppressed thecal androgen production in vitro, an effect blocked by inhibin. Furthermore, the theca of large estrogenic follicles expressed high levels of inhibin α and activin ßA mRNA suggesting local thecal derived inhibin A production. This would inhibit the negative effects of thecal activins B and A ensuring maximum androgen production for enhanced estradiol production by the preovulatory follicle(s).

Elemental and non-elemental olfactory learning in Drosophila.

Brain complexity varies across many orders of magnitude between animals, and it is often assumed that complexity underpins cognition. It is thus important to explore the cognitive capacity of widely used model organisms such as Drosophila. We systematically investigated the fly's ability to learn discriminations involving compound olfactory stimuli associated with shock. Flies could distinguish binary mixtures (AB+ CD-), including overlapping mixtures (AB+ BC-). They could learn positive patterning (AB+A- B-) but could not learn negative patterning (A+ B+ AB-) or solve a biconditional discrimination task (AB+ CD+ AC- BD-). Learning about the elements of a compound (AB+) was not affected by prior conditioning of one of the elements (A+ AB+): flies do not exhibit blocking in this task. We compare these results with the predictions from simulation of several well-known theoretical models of learning, and find none are fully consistent with the overall pattern of observed behaviour.

Quantifying postdischarge unmet supportive care needs of people with colorectal cancer: a clinical audit.

AIM: There are limited data concerning the unmet needs experienced by patients with colorectal cancer. The aim of this study was to identify unmet supportive care needs of people with colorectal cancer following discharge from hospital. METHOD: Health service utilization was used as a measure of expressed unmet need. A retrospective case note review was conducted of 521 patients surgically treated for colorectal cancer at Royal Prince Alfred Hospital, Sydney, between 1 January 2004 and 31 December 2007. Case notes maintained by a cancer nurse specialist were reviewed to identify postdischarge occasions-of-service where unmet need was expressed. Logistic regression was conducted to investigate predictors of unmet need. RESULTS: Of 521 patients, 219 (42%) patients had unmet supportive care needs, of which 50% of all needs was found in the physical domain. Twenty-six per cent of unmet needs was expressed within the first week following discharge from hospital after cancer surgery; however, 21% persisted after 6 months. Multivariate analysis indentified that in this cohort, younger age predicted the expression of an unmet need (AOR, 0.97; 95% CI, 0.96-0.99). People with rectal cancer remained significantly more likely to require more than one contact with the nurse to satisfy a need (AOR, 2.80; 95% CI, 1.60-5.01) and to report a physical need (AOR, 3.56; 95% CI, 2.03-6.27). CONCLUSION: This study has shown that auditing the interactions of a cancer nurse with patients can provide information about unmet supportive care needs, which can be used to develop relevant supportive care services or interventions for people with colorectal cancer.

What is important in cancer care coordination? A qualitative investigation.

Although it is widely recognised that better coordination of cancer care holds considerable potential to improve patients' experience of care and their outcomes, there is no agreed definition of the term 'care coordination' or consensus as to what it entails. An explorative descriptive qualitative study was undertaken to explore the views and experiences of key stakeholders to identify the key components of cancer care coordination. We conducted semi-structured individual and focus groups interviews with patients (n= 20) who have been treated for any cancer and carers (n= 4) as well as clinicians (n= 29) involved in cancer care, using open-ended questions. Data were collected until saturation of concepts was reached. A phenomenological approach based on grounded theory was used to explore the participants' experiences and views. Seven key components were identified: organisation of patient care, access to and navigation through the healthcare system, the allocation of a 'key contact' person, effective communication and cooperation among the multidisciplinary team and other health service providers, delivery of services in a complementary and timely manner, sufficient and timely information to the patient and needs assessment. The components of cancer care coordination identified provide an empirical basis for the development of metrics and interventions to improve this aspect of cancer care.

Massively parallel sequencing is unlocking the potential of environmental trace evidence.

Massively parallel sequencing (MPS) has revolutionised the field of genomics enabling substantial advances in human DNA profiling. Further, the advent of MPS now allows biological signatures to be obtained from complex DNA mixtures and trace amounts of low biomass samples. Environmental samples serve as ideal forms of contact trace evidence as detection at a scene can establish a link between a suspect, location and victim. Many studies have applied MPS technology to characterise the biodiversity within high biomass environmental samples (such as soil and water) to address questions related to ecology, conservation, climate change and human health. However, translation of these tools to forensic science remains in its infancy, due in part to the merging of traditional forensic ecology practices with unfamiliar DNA technologies and complex datasets. In addition, people and objects also carry low biomass environmental signals which have recently been shown to reflect a specific individual or location. The sensitivity, and reducing cost, of MPS is now unlocking the power of both high and low biomass environmental DNA (eDNA) samples as useful sources of genetic information in forensic science. This paper discusses the potential of eDNA to forensic science by reviewing the most explored applications that are leading the integration of this technology into the field. We introduce novel areas of forensic ecology that could also benefit from these tools with a focus on linking a suspect to a scene or establishing provenance of an unknown sample and discuss the current limitations and validation recommendations to achieve translation of eDNA into casework.