New Zealand experience with implementation of the ESO-ESMO consensus guidelines for advanced breast cancer-report of achievements and lessons learned.

BACKGROUND: People with advanced breast cancer (ABC) in New Zealand (NZ) have a poorer five-year survival than their peers in other developed countries. Comparisons of ABC care in NZ with other countries suggest that NZ is sometimes out of line with international standards and that inequities exist within the NZ healthcare system. Our aim was to develop nationwide consensus guidelines for diagnosis and treatment of ABC that are uniquely suited for the NZ context and can be applied across the nation. We describe the process of creating, voting on, and disseminating the guidelines, and provide insight into how we can better optimize these processes for the NZ context in the future. METHODS: The ABC5 ESO-ESMO consensus guidelines were used and adapted to the NZ clinical context. A panel of breast cancer clinicians voted on these guidelines using the same model of membership representation as ABC5. OUTCOME: Overall consensus was equally high between ABC5 and ABC-NZ. Four NZ specific guidelines were introduced. The European-style panel discussion needs some adaptations for the NZ situation and a wider and more thorough consultation process, before voting begins, is preferred. The NZ Breast Special Interest Group has endorsed and agreed to take ownership of these and future guidelines and to facilitate the next iteration of the ABC-NZ guidelines meeting. CONCLUSIONS: The process was successful in creating the guidelines but can be improved in future meetings to streamline the process of creating and updating guidelines in the manner most suited to the NZ context and audience.

The treatment of segmental tibial fractures: does patient preference differ from surgeon choice?

INTRODUCTION: Segmental tibial fractures are complex injuries with a prolonged recovery time. Current definitive treatment options include intramedullary fixation or a circular external fixator. However, there is uncertainty as to which surgical option is preferable and there are no sufficiently rigorous multi-centre trials that have answered this question. The objective of this study was to determine whether patient and surgeon opinion was permissive for a randomised controlled trial (RCT) comparing intramedullary nailing to the application of a circular external fixator. MATERIALS AND METHODS: A convenience questionnaire survey of attending surgeons was conducted during the United Kingdom's Orthopaedic Trauma Society annual meeting 2017 to determine the treatment modalities used for a segmental tibial fracture (n=63). Patient opinion was obtained from clinical patients who had been treated for a segmental tibial fracture as part of a patient and public involvement focus group with questions covering the domains of surgical preference, treatment expectations, outcome, the consent process and follow-up regime (n=5). RESULTS: Based on the surgeon survey, 39% routinely use circular frame fixation following segmental tibial fracture compared to 61% who use nail fixation. Nail fixation was reported as the treatment of choice for a closed injury in a healthy patient in 81% of surgeons, and by 86% for a patient with a closed fracture who was obese. Twenty-one percent reported that they would use a nail for an open segmental tibia fracture in diabetics who smoked, whilst 57% would opt for a nail for a closed injury with compartment syndrome, and only 27% would use a nail for an open segmental injury in a young fit sports person. The patient and public preference exercise identified that sleep, early functional outcomes and psychosocial measures of outcomes are important. CONCLUSION: We concluded that a RCT comparing definitive fixation with an intramedullary nail and a circular external fixator is justified as there remains uncertainty on the optimal surgical management for segmental tibial fractures. Furthermore, psychosocial factors and early post-operative outcomes should be reported as core outcome measures as part of such a trial.

Metabotropic glutamate receptor antagonist, (R,S)-alpha-methyl-4-carboxyphenyglycine, blocks two distinct forms of long-term potentiation in area CA1 of rat hippocampus.

The necessity of metabotropic glutamate receptors (mGluRs) in the induction of long-term potentiation (LTP) has recently been questioned. We examined the effect of (R,S)-alpha-methyl-4-caboxyphenylglycine (MCPG), a selective mGluR antagonist, on two independent forms of LTP. One form induced by a 25 Hz/1 s tetanus is solely N-methyl-D-aspartate (NMDA) receptor-dependent. The other form induced by four 200 Hz/0.5 s bursts in the presence of APV is NMDA receptor-independent. In both paradigms the presence of MCPG prevented the induction of LTP by afferent activation.

Multideterminant role of calcium in hippocampal synaptic plasticity.

Hippocampal CA1 cells possess several varieties of long-lasting synaptic plasticity: two different forms of long-term potentiation (LTP) and at least one form of long-term depression (LTD). All forms of synaptic plasticity are induced by afferent activation, all involve Ca2+ influx, all can be blocked by Ca2+ chelators, and all activate Ca(2+)-dependent mechanisms. The question arises as how different physiological responses can be initiated by activation of the same second messenger. We consider two hypotheses which could account for these phenomena: voltage-dependent differences in cytosolic Ca2+ concentration acting upon Ca2+ substrates of differing Ca2+ affinities and compartmentalization of the Ca2+ and its substrates.