Optimizing the Integration of a Biopesticide (Bacillus subtilis QST 713) with a Single-Site Fungicide (Benzovindiflupyr) to Reduce Reliance on Synthetic Multisite Fungicides (Captan and Mancozeb) for Management of Apple Scab.

Apple scab is one of the most economically important diseases of apple in temperate production regions. In the absence of durable host resistance in commercially preferred cultivars, considerable applications of fungicides are needed to manage this disease. With the sequential development of resistance to nearly all classes of single-site fungicides in the apple scab pathogen Venturia inaequalis, synthetic multisite fungicides, such as mancozeb and captan, often comprise the core of chemical management programs for apple scab. Although these fungicides have demonstrable benefits for both disease and fungicide resistance management, the sustainability movement within agriculture aims to reduce reliance on such fungicides because of their broader environmental impacts. In this study, we establish a framework to enhance the feasibility of chemical management programs that do not rely on use of synthetic multisite protectant fungicides to manage apple scab. Specifically, we wish to evaluate chemical programs that integrate the biopesticide Bacillus subtilis QST 713 (Serenade Opti) in rotation with benzovindiflupyr (Aprovia), a single-site fungicide belonging to the class of succinate dehydrogenase inhibitors (SDHI), to circumvent the need for applications of synthetic multisite fungicides. During implementation of these programs, disease incidence data were taken at biweekly intervals. Regardless of the seasonal challenges presented in the 2 years of this study, when Bacillus subtilis QST 713 was used in place of captan and mancozeb mixtures, we did not observe any significant differences (P > 0.05) in development of apple scab symptoms between any of the management programs for the vertical axis or super spindle orchards in either year. This potential for substituting synthetic multisite fungicides with biopesticides is best realized when the programs are used with a decision support system in a super spindle planting system, where trees have reduced canopy densities. This 2-year study shows the potential to achieve adequate disease control using the integration of SDHI fungicides and biological controls without the use of synthetic multisite fungicides.

The tip of the iceberg: incompleteness of measles reporting during a large outbreak in The Netherlands in 2013-2014.

Measles is a notifiable disease, but not everyone infected seeks care, nor is every consultation reported. We estimated the completeness of reporting during a measles outbreak in The Netherlands in 2013-2014. Children below 15 years of age in a low vaccination coverage community (n = 3422) received a questionnaire to identify measles cases. Cases found in the survey were matched with the register of notifiable diseases to estimate the completeness of reporting. Second, completeness of reporting was assessed by comparing the number of susceptible individuals prior to the outbreak with the number of reported cases in the surveyed community and on a national level.We found 307 (15%) self-identified measles cases among 2077 returned questionnaires (61%), of which 27 could be matched to a case reported to the national register; completeness of reporting was 8.8%. Based on the number of susceptible individuals and number of reported cases in the surveyed community and on national level, the completeness of reporting was estimated to be 9.1% and 8.6%, respectively. Estimating the completeness of reporting gave almost identical estimates, which lends support to the credibility and validity of both approaches. The size of the 2013-2014 outbreak approximated 31 400 measles infections.

Evolving imaging techniques for staging axillary lymph nodes in breast cancer.

The presence and extent of axillary nodal metastases at the time of breast cancer diagnosis is a critical factor in disease prognosis and plays a central role in deciding the best treatment for patients. Accurate assessment of the axilla is therefore an essential component in staging breast cancer. Over the years, axillary staging has evolved from surgical axillary lymph node dissection (ALND), with its numerous associated long-term complications, to the much less-radical surgical sentinel lymph node excision biopsy (SLNB), the current reference standard. In parallel, radiological staging of the axilla has become increasingly more useful as our knowledge and techniques have improved. Preoperative axillary ultrasound is used widely to stage patients with breast cancer, providing an evaluation of node morphology and allowing targeted biopsy of abnormal nodes. This is important in helping stratify which patients should proceed directly to ALND and which should undergo SLNB first. Grey-scale ultrasound on its own is not perfect and can over- and underestimate axillary disease. Newer ultrasound techniques such as elastography may help to improve diagnostic confidence when visually assessing axillary nodes; for example, in more accurately assessing the extent of axillary disease burden or in differentiating benign reactive nodes from malignant nodes in equivocal cases. The use of intradermal "microbubbles" has shown great promise in being able to locate and biopsy the sentinel lymph node under ultrasound guidance, and raises the possibility that in the future such techniques may obviate the need for surgical SLNB in select patient populations.

Effects of Consecutive Streptomycin and Kasugamycin Applications on Epiphytic Bacteria in the Apple Phyllosphere.

Antibiotic applications are essential for fire blight management in the eastern United States. Recently, streptomycin-resistant Erwinia amylovora strains were found in New York. There are growing concerns that streptomycin resistance may develop from postbloom streptomycin applications in local orchards. Our goal was to investigate the impacts of increasing streptomycin and kasugamycin applications on bacterial epiphyte community composition and antibiotic resistance in the phyllosphere of 'Idared' apple plantings in 2014 and 2015. Rinsate samples from leaves treated with 0, 3, 5, and 10 applications of streptomycin and kasugamycin were collected to isolate, enumerate, and identify epiphytic bacterial species. The majority of isolated epiphytic bacteria were identified as Pantoea agglomerans and fluorescent Pseudomonas spp., whereas E. amylovora was rarely found. Overall, postbloom streptomycin use did not result in an increased recovery of streptomycin-resistant E. amylovora. However, other streptomycin-resistant epiphytes (P. agglomerans and Pseudomonas spp.) did increase with increasing streptomycin applications. Increasing kasugamycin applications reduced the overall number and percentage of streptomycin-resistant epiphytes in the phyllosphere, which has important implications regarding the use of kasugamycin in orchards where streptomycin resistance is a concern.

Exploring Diversity and Origins of Streptomycin-Resistant Erwinia amylovora Isolates in New York Through CRISPR Spacer Arrays.

Streptomycin is the most effective and widely used chemical control in the eastern United States for blossom blight of apple caused by Erwinia amylovora; however, resistance to this antibiotic has been a concern in New York since 2002. From 2011 to 2014, statewide collections of E. amylovora were conducted resulting in the isolation of streptomycin-resistant (SmR) E. amylovora from several commercial orchards. Further genetic analysis of isolates was necessary to understand the origins and the diversity of these bacteria. Clustered regularly interspaced short palindromic repeat (CRISPR) spacer sequencing was employed to explore the diversity and possible origins of New York SmR E. amylovora isolates. The spacer array CR1, CR2, and CR3 regions of 27 SmR E. amylovora isolates and 76 streptomycin-sensitive (SmS) E. amylovora isolates were amplified and subsequently sequenced, revealing 19 distinct CRISPR spacer profiles for New York isolates. The majority of SmR E. amylovora isolates had the same CRISPR profile as SmR E. amylovora isolates discovered in 2002. This may infer that eradication efforts in 2002 failed and the bacterial populations continued to spread throughout the state. Several CRISPR profiles for SmR E. amylovora were identical to SmS E. amylovora collected from the same orchards, leading to the hypothesis that resistance may be developing within New York. Profiles not unique to New York were identical to many isolates from the Midwestern, eastern, and western United States, implying that streptomycin resistance may be due to the introduction of SmR E. amylovora from other regions of the United States. The increased understanding as to how SmR E. amylovora isolates are introduced, evolve, or have become established afforded by CRISPR profiling has been useful for disease management and restricting the movement of streptomycin resistance in New York.

Prevalence of Streptomycin-Resistant Erwinia amylovora in New York Apple Orchards.

Resistance to streptomycin in Erwinia amylovora was first observed in the United States in the 1970s but was not found in New York until 2002, when streptomycin-resistant (SmR) E. amylovora was isolated from orchards in Wayne County. From 2011 to 2014, in total, 591 fire blight samples representing shoot blight, blossom blight, and rootstock blight were collected from 80 apple orchards in New York. From these samples, 1,280 isolates of E. amylovora were obtained and assessed for streptomycin resistance. In all, 34 SmR E. amylovora isolates were obtained from 19 individual commercial orchards. The majority of the resistant isolates were collected from orchards in Wayne County, and the remaining were from other counties in western New York. Of the 34 resistant isolates, 32 contained the streptomycin resistance gene pair strA/strB in the transposon Tn5393 on the nonconjugative plasmid pEA29. This determinant of streptomycin resistance has only been found in SmR E. amylovora isolates from Michigan and the SmR E. amylovora isolates discovered in Wayne County, NY in 2002. Currently, our data indicate that SmR E. amylovora is restricted to counties in western New York and is concentrated in the county with the original outbreak. Because the resistance is primarily present on the nonconjugative plasmid, it is possible that SmR has been present in Wayne County since the introduction in 2002, and has spread within and out of Wayne County to additional commercial growers over the past decade. However, research is still needed to provide in-depth understanding of the origin and spread of the newly discovered SmR E. amylovora to reduce the spread of streptomycin resistance into other apple-growing regions, and address the sustainability of streptomycin use for fire blight management in New York.

Being overweight is associated with hippocampal atrophy: the PATH Through Life Study.

BACKGROUND: The prevalence of obesity has increased dramatically in the past two decades, with major implications for individual well-being, population health and the economy. Of particular concern is the risk obesity presents for brain health and its consequences in an ageing population. These associations and their time course are not well understood, particularly after middle age. The aim of this study was to investigate whether being overweight/obese or having an increasing body weight is associated with hippocampal atrophy in early old age. METHODS: Participants were 420 unimpaired (Mini-Mental State Examination >26) individuals aged 60-64 years, living in the community and taking part in a large prospective study of ageing over an 8 year follow-up. Magnetic resonance imaging scans were collected at three assessments and the hippocampus was manually traced by expert neuroscientists. Multi-level analyses assessing the relationship between body mass index (BMI) and hippocampal atrophy over 8 years while controlling for important covariates were conducted. RESULTS: Analyses showed that BMI was negatively associated with left (coefficient: -10.65 mm(3); s.e. 4.81; P=0.027) and right (coefficient: -8.18 mm(3); s.e. 4.91; P=0.097) hippocampal volume at the first assessment. Over the follow-up period, those with a higher BMI experienced greater hippocampal atrophy and more so in the left (P=0.001) than in the right (P=0.058) hippocampus. CONCLUSIONS: The findings from this study provide important evidence indicating that being overweight or obese is associated with poorer brain health. These results are consistent with those of previous animal and human studies and further stress the importance of reducing the rate of obesity through education, population health interventions and policy.

Understanding the elevated suicide risk of female soldiers during deployments.

BACKGROUND: The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) has found that the proportional elevation in the US Army enlisted soldier suicide rate during deployment (compared with the never-deployed or previously deployed) is significantly higher among women than men, raising the possibility of gender differences in the adverse psychological effects of deployment. METHOD: Person-month survival models based on a consolidated administrative database for active duty enlisted Regular Army soldiers in 2004-2009 (n = 975,057) were used to characterize the gender × deployment interaction predicting suicide. Four explanatory hypotheses were explored involving the proportion of females in each soldier's occupation, the proportion of same-gender soldiers in each soldier's unit, whether the soldier reported sexual assault victimization in the previous 12 months, and the soldier's pre-deployment history of treated mental/behavioral disorders. RESULTS: The suicide rate of currently deployed women (14.0/100,000 person-years) was 3.1-3.5 times the rates of other (i.e. never-deployed/previously deployed) women. The suicide rate of currently deployed men (22.6/100,000 person-years) was 0.9-1.2 times the rates of other men. The adjusted (for time trends, sociodemographics, and Army career variables) female:male odds ratio comparing the suicide rates of currently deployed v. other women v. men was 2.8 (95% confidence interval 1.1-6.8), became 2.4 after excluding soldiers with Direct Combat Arms occupations, and remained elevated (in the range 1.9-2.8) after adjusting for the hypothesized explanatory variables. CONCLUSIONS: These results are valuable in excluding otherwise plausible hypotheses for the elevated suicide rate of deployed women and point to the importance of expanding future research on the psychological challenges of deployment for women.

Occupational differences in US Army suicide rates.

BACKGROUND: Civilian suicide rates vary by occupation in ways related to occupational stress exposure. Comparable military research finds suicide rates elevated in combat arms occupations. However, no research has evaluated variation in this pattern by deployment history, the indicator of occupation stress widely considered responsible for the recent rise in the military suicide rate. METHOD: The joint associations of Army occupation and deployment history in predicting suicides were analysed in an administrative dataset for the 729 337 male enlisted Regular Army soldiers in the US Army between 2004 and 2009. RESULTS: There were 496 suicides over the study period (22.4/100 000 person-years). Only two occupational categories, both in combat arms, had significantly elevated suicide rates: infantrymen (37.2/100 000 person-years) and combat engineers (38.2/100 000 person-years). However, the suicide rates in these two categories were significantly lower when currently deployed (30.6/100 000 person-years) than never deployed or previously deployed (41.2-39.1/100 000 person-years), whereas the suicide rate of other soldiers was significantly higher when currently deployed and previously deployed (20.2-22.4/100 000 person-years) than never deployed (14.5/100 000 person-years), resulting in the adjusted suicide rate of infantrymen and combat engineers being most elevated when never deployed [odds ratio (OR) 2.9, 95% confidence interval (CI) 2.1-4.1], less so when previously deployed (OR 1.6, 95% CI 1.1-2.1), and not at all when currently deployed (OR 1.2, 95% CI 0.8-1.8). Adjustment for a differential 'healthy warrior effect' cannot explain this variation in the relative suicide rates of never-deployed infantrymen and combat engineers by deployment status. CONCLUSIONS: Efforts are needed to elucidate the causal mechanisms underlying this interaction to guide preventive interventions for soldiers at high suicide risk.

Sociodemographic and career history predictors of suicide mortality in the United States Army 2004-2009.

BACKGROUND: The US Army suicide rate has increased sharply in recent years. Identifying significant predictors of Army suicides in Army and Department of Defense (DoD) administrative records might help focus prevention efforts and guide intervention content. Previous studies of administrative data, although documenting significant predictors, were based on limited samples and models. A career history perspective is used here to develop more textured models. METHOD: The analysis was carried out as part of the Historical Administrative Data Study (HADS) of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). De-identified data were combined across numerous Army and DoD administrative data systems for all Regular Army soldiers on active duty in 2004-2009. Multivariate associations of sociodemographics and Army career variables with suicide were examined in subgroups defined by time in service, rank and deployment history. RESULTS: Several novel results were found that could have intervention implications. The most notable of these were significantly elevated suicide rates (69.6-80.0 suicides per 100 000 person-years compared with 18.5 suicides per 100 000 person-years in the total Army) among enlisted soldiers deployed either during their first year of service or with less than expected (based on time in service) junior enlisted rank; a substantially greater rise in suicide among women than men during deployment; and a protective effect of marriage against suicide only during deployment. CONCLUSIONS: A career history approach produces several actionable insights missed in less textured analyses of administrative data predictors. Expansion of analyses to a richer set of predictors might help refine understanding of intervention implications.

Hebbian learning from higher-order correlations requires crosstalk minimization.

Activity-dependent synaptic plasticity should be extremely connection specific, though experiments have shown it is not, and biophysics suggests it cannot be. Extreme specificity (near-zero "crosstalk") might be essential for unsupervised learning from higher-order correlations, especially when a neuron has many inputs. It is well known that a normalized nonlinear Hebbian rule can learn "unmixing" weights from inputs generated by linearly combining independently fluctuating nonGaussian sources using an orthogonal mixing matrix. We previously reported that even if the matrix is only approximately orthogonal, a nonlinear-specific Hebbian rule can usually learn almost correct unmixing weights (Cox and Adams in Front Comput Neurosci 3: doi: 10.3389/neuro.10.011.2009 2009). We also reported simulations that showed that as crosstalk increases from zero, the learned weight vector first moves slightly away from the crosstalk-free direction and then, at a sharp threshold level of inspecificity, jumps to a completely incorrect direction. Here, we report further numerical experiments that show that above this threshold, residual learning is driven instead almost entirely by second-order input correlations, as occurs using purely Gaussian sources or a linear rule, and any amount of crosstalk. Thus, in this "ICA" model learning from higher-order correlations, required for unmixing, requires high specificity. We compare our results with a recent mathematical analysis of the effect of crosstalk for exactly orthogonal mixing, which revealed that a second, even lower, threshold, exists below which successful learning is impossible unless weights happen to start close to the correct direction. Our simulations show that this also holds when the mixing is not exactly orthogonal. These results suggest that if the brain uses simple Hebbian learning, it must operate with extraordinarily accurate synaptic plasticity to ensure powerful high-dimensional learning. Synaptic crowding would preclude this when inputs are numerous, and we propose that the neocortex might be distinguished by special circuitry that promotes extreme specificity for high-dimensional nonlinear learning.

Investigating communication in cancer consultations: what can be learned from doctor and patient accounts of their experience?

This study investigated how doctors and patients diagnosed with advanced incurable cancer experienced the disclosure of bad news. The intention was to gain contrasting perspectives of the processes involved in oncology consultations. Sixteen doctors and 16 patients from a cancer centre in the UK participated in the study. A series of consultations were observed and audio recorded, and the perspectives of doctors, patients and relatives were investigated through semi-structured interviews. Participants were invited to describe how they experienced and felt about the disclosure of information over a period of time following a specific consultation. Analysis was based on a constant comparative method. This research suggests that patients control what they do or do not do with information to meet their own needs and objectives, but doctors do not necessarily appreciate this. Doctors do not always prepare patients for what is happening to them in an active open awareness context, and this can be stressful for some patients. The results indicate that communication is not just about one person making decisions. They also indicate that in many cases more success could be gained from finding out how patients prefer to manage and control the exchange of bad news, at different points, through their care pathway.

The effects of multivitamin supplementation on mood and general well-being in healthy young adults. A laboratory and at-home mobile phone assessment.

Previous research has suggested that multivitamin (MV) supplementation may be associated with beneficial effects for mood and general well-being, although treatment durations have typically been less than 90 days, samples have often been restricted to males only and acute effects have not been adequately differentiated from chronic effects. In the current study a MV supplement containing high levels of B-vitamins was administered daily to 138 healthy young adult participants between the ages of 20 and 50 years over a 16-week period. Chronic mood measures (GHQ-28, POMS, Chalder fatigue, PILL, Bond-Lader and custom visual analogue scales) were administered pre-dose at baseline, 8- and 16-weeks. Changes in Bond-Lader and VAS in response to a multi-tasking framework (MTF) were also assessed at 8- and 16-weeks. For a subset of participants, at-home mobile-phone assessments of mood were assessed on a weekly basis using Bond-Lader and VAS. No significant treatment effects were found for any chronic laboratory mood measures. In response to the MTF, a significant treatment x time interaction was found for STAI-S, with a trend towards a greater increase in stress ratings for male participants in the MV group at 16 weeks. However, this finding may have been attributable to a larger proportion of students in the male MV group. In contrast, at-home mobile-phone assessments, where assessments were conducted post-dose, revealed significantly reduced stress, physical fatigue and anxiety in the MV group in comparison to placebo across a number of time points. Further research using both acute and chronic dosing regimens are required in order to properly differentiate these effects.

Bone morphogenetic protein-3 is a negative regulator of bone density.

Bone morphogenetic proteins (BMPs) are members of the transforming growth factor-beta (TGF-beta) superfamily. Many BMPs are produced in bone and show osteogenic activity, suggesting that they may be determinants of bone mass. BMP3 was originally purified from bone as osteogenin, which induces osteogenic differentiation. Recombinant BMP3 (rhBMP3) has no biological activity, however, leaving its role in skeletal growth unclear. Here we show that BMP3 is an antagonist of osteogenic BMPs: BMP3 dorsalizes Xenopus laevis embryos, inhibits BMP2-mediated induction of Msx2 and blocks BMP2-mediated differentiation of osteoprogenitor cells into osteoblasts. These effects appear to be mediated through activin receptors. Finally, Bmp3(-/-) mice have twice as much trabecular bone as wild-type littermates, indicating that BMP3, the most abundant BMP in adult bone, is a negative determinant of bone density.

A common peripheral blood gene set for diagnosis of operational tolerance in pediatric and adult liver transplantation.

To identify biomarkers of operational tolerance in pediatric and adult liver transplant recipients, transcriptional profiles were examined from 300 samples by microarrays and Q-PCR measurements of blood specimens from pediatric and adult liver transplant recipients and normal tissues. Tolerance-specific genes were validated in independent samples across two different transplant programs and validated by Q-PCR. A minimal set of 13 unique genes, highly expressed in natural killer cells (p = 0.03), were significantly expressed in both pediatric and adult liver tolerance, irrespective of different clinical and demographic confounders. The performance of this gene set by microarray in independent samples was 100% sensitivity and 83% specificity and the AUC was 0.988 for only three genes by Q-PCR. 26% of adults and 64% of children with excellent liver allograft function, on minimal or dual immunosuppression, showed high prediction scores for tolerance. Novel peripheral transcriptional profiles can be identified in operational tolerance in pediatric and adult recipients of liver allografts, suggesting a high incidence of a pro-tolerogenic phenotype in stable patients on chronic immunosuppression. Given the high incidence of viral infections and malignancies in liver transplant recipients, this gene set provides an important monitoring tool that can move the field toward personalized and predictive medicine in organ transplantation.

Proprotein Convertase Subtilisin Kexin 9 (PCSK9) and nonHDL particles rise during normal pregnancy and differ by BMI.

BACKGROUND: Serum lipids, including total cholesterol (TC), triglycerides (TG), and low-density lipoprotein cholesterol (LDL-c), increase during pregnancy. Serum Proprotein Convertase Subtilisin Kexin 9 (PCSK9) is a vital regulator in lipoprotein metabolism. Circulating PCSK9 downregulates the LDL receptor on the surface of liver cells inhibiting clearance of LDL-c. OBJECTIVE: To determine the influence of weeks of pregnancy and obesity on circulating levels of essential lipid lipoproteins and PCSK9 in women with normal, uncomplicated pregnancies and deliveries. METHODS: We performed a comprehensive lipid and lipoprotein profile during each trimester of pregnancy in 70 mostly Caucasian women with uncomplicated normal pregnancies and deliveries. Based on their first trimester BMI, we placed them into one of three categories: (<25 kg/m2 n=23, 25-30 kg/m2 n=25, or >30 n=22) kg/m2. Cholesterol, triglycerides, LDL cholesterol (LDL-c), non-HDL particles, and lipoprotein(a) were measured by spectrophotometry, ion mobility, and immunoturbidimetric assays. Elisa assay determined PCSK9 (active and total). Homeostatic Model Assessment (HOMA-IR) assessed insulin resistance in the second and third trimesters of pregnancy. RESULTS: Total and active PCSK9, LDL-c, and nonHDL particle concentrations were higher than reported for non-pregnant normal values, increased after the first trimester of pregnancy, and were highest from mid-gestation to the last trimester of pregnancy in the overweight and the obese. CONCLUSION: PCSK9 levels rise as normal pregnancy progresses. Levels are higher in persons who are obese, even after adjustment for insulin resistance. Defining normal PCSK9 levels during pregnancy must adjust for gestational age and BMI.

Of mice and rats: key species variations in the sexual differentiation of brain and behavior.

Mice and rats are important mammalian models in biomedical research. In contrast to other biomedical fields, work on sexual differentiation of brain and behavior has traditionally utilized comparative animal models. As mice are gaining in popularity, it is essential to acknowledge the differences between these two rodents. Here we review neural and behavioral sexual dimorphisms in rats and mice, which highlight species differences and experimental gaps in the literature, that are needed for direct species comparisons. Moving forward, investigators must answer fundamental questions about their chosen organism, and attend to both species and strain differences as they select the optimal animal models for their research questions.

Temperature-related natural selection in a wind-pollinated tree across regional and continental scales.

Adaptive genetic variation is a key factor in evolutionary biology, but the detection of signatures of natural selection remains challenging in nonmodel organisms. We used a genome scan approach to detect signals of natural selection in the Black alder (Alnus glutinosa), a widespread wind-pollinated tree. Gene flow through pollen dispersal is believed to be high in this species, and we therefore expected to find a clear response to natural selection. In combination with two different landscape genetic approaches, we determined which environmental variables were most associated with the inferred selection. This analysis was performed on a regional scale (northern Belgium) and on a continental scale (Europe). Because climate-related differences are much more pronounced at the continental scale, we expected to find more selection-sensitive genetic markers across Europe than across northern Belgium. At both spatial scales, a substantial number of genetic loci were considered outliers, with respect to neutral expectations, and were therefore identified as selective. Based on results from our combined approach, four putative selective loci (or 2.5%) were recovered with high statistical support. Although these loci seemed to be associated with different environmental variables, they were mainly temperature-related. Our study demonstrates that the use of complementary methods in landscape genetics allows the discovery of selective loci which otherwise might stay hidden. In combination with a genome scan, the selective loci can be verified and the nature of the selection pressure can be identified.

Randomized cross-over trial comparing inpatient and outpatient administration of high-dose cisplatin.

BACKGROUND/AIMS: Treatment with high-dose cisplatin (HDC) previously required inpatient (IP) admission with overnight hospitalization, but recently practice has shifted to outpatient (OP) therapy. We aimed to determine whether it is preferable to give HDC as an IP or OP using a two-period cross-over trial. METHODS: Eligible patients were starting chemotherapy with ≥2 cycles of HDC (≥100 mg/dose) and were suitable for OP treatment. All patients received an IP cycle and OP cycle: the order was randomly allocated. Pre-hydration, anti-emetics and chemotherapy were identical for IP and OP. Post-hydration varied by group (3 L normal saline (NS) for IP, 2 L NS for OP). The primary outcome was patient preference for IP versus OP treatment. Secondary outcomes included aspects of health-related quality of life, adverse events (dose delays and reductions, elevated creatinine and unplanned readmissions) and resource use. RESULTS: Fifty-nine patients were randomized, 53 completed two cycles of HDC. Most patients preferred OP treatment (36 vs 13, P = 0.002). There were no significant differences in patients' ratings of nausea, vomiting, fatigue, anxiety, depression or overall quality of life. Adverse events were few and unrelated to IP versus OP treatment. Nursing time was longer for IP than OP (163 vs 104 min, P < 0.001). CONCLUSION: OP treatment was preferred by most patients, appeared safe and used less resources.