17th October 2014, Volume 127 Number 1404

General Anaesthetic Modulation of Memory-Related Gene Expression in the Cerebral Cortex

Bell, L.1, Oxton, K.1, Peters, L.1 and Voss, L.2

1Department of Molecular Biology, University of Waikato, Hamilton, NZ. 2Department of Anaesthesia, Waikato Hospital, Hamilton, NZ.

General anaesthetics have been in clinical use since the mid 19th century, having remained one of the most important drugs in medicine by enabling major surgical procedures to be carried out. One of the fundamental outcomes of anaesthesia is amnesia, as this prevents patient recall of events surrounding surgery. However, very little is known about how anaesthetics alter memory function to cause amnesia. The hippocampal region of the brain has been widely investigated for its role in memory formation but the cerebral cortex also has newly recognized importance in memory consolidation and storage processes. Therefore, our research focuses on molecular changes in the cerebral cortex with respect to altered expression patterns of the Arc, Bdnf, CamKIIα, Grin1 and Gjd2 genes. These genes all encode proteins with documented roles in various aspects of memory consolidation and may represent molecular targets for general anaesthetic action. The aim of this research was to investigate the gene expression patterns of Arc, Bdnf, CamKII2α, Grin1 and Gjd2 during periods of anaesthesia induced by sevoflurane, isoflurane and propofol. Real-time quantitative PCR (qPCR) was used to analyse expression of mRNA extracted from the cerebral cortex of mouse brain tissue. As brain activity is reduced during periods of anaesthesia, we expected to see down-regulation of the activity-dependent genes selected for this study. Different age groups of mice were also used for a comparative age-related analysis of anaesthetic effects in the brain. Preliminary results indicate that sevoflurane treatment does not alter expression of the Gjd2 gene but may down-regulate the Grin1 gene. More results are required for statistically significant evaluations to be made about all five genes of interest.

Evaluation of the influence of ethnicity and deprivation on the Hyperthyroid Symptom Scale score in euthyroid patients

Tamatea JAU, Campbell M, Hodgson F, Elston M, Conaglen JV

Introduction: Thyrotoxicosis is a common endocrine disorder with an incidence of 0.2%,1 and when untreated, leads to congestive heart failure, arrhythmias and premature death.2 To measure and compare clinical severity of thyrotoxicosis Klein et al3 developed the “Hyperthyroid Severity Scale” (HSS). This is a 10 item questionnaire that uses a 0-4 point scale, measuring common hyperthyroid symptoms. The HSS has been used in a number of different population groups with thyrotoxicosis (US, 3,4,5 UK,6 Netherlands,7 Bangladesh,8 Brazil,9 Turkey,10, 11 and Italy12), although this clinical scoring system has not previously been used to compare severity between ethnic groups. As the scale reviews general symptoms, there is also the potential for co-morbidities to confound results. Given health disparities seen in Aotearoa/New Zealand for Māori and those with socioeconomic deprivation there is potential for ethnicity and deprivation to affect their HSS score. Locally there has been the suggestion of the possibility of ethnic difference in symptom reporting. While validated for use within hyperthyroid patients the HSS has not been applied to euthyroid patients to ensure accuracy for hyperthyroidism alone, neither has the role of ethnicity or socioeconomic deprivation on the HSS been investigated.

Methods:Convenience sampling within local general practices recruited 60 Māori and 60 non-Māori participants of which 100 participants (47 Māori and 53 non-Māori) were confirmed to be biochemically euthyroid. Each participant completed HSS questionnaires demographic questions regards to ethnicity13, and the eight NZiDep14 questions for socioeconomic status. Two additional items to the HSS score were assessed which were; tremor and hyperdynamic praecordium. The same information were collected on 64 consecutive hyperthyroid participants presenting to an endocrinologist in the Waikato region.

Results: Within the euthyroid group Māori were younger (30years vs 52 years, p<0.0001) and had a different age distribution (p<0.0001) than non-Māori similar to that seen in the general population. The median HSS scores were similar (6 (0-16) vs 4 (0-23), p=0.2) between groups and age-stratification showed no difference (p=0.12) in HSS score between Māori and non-Māori.

The NZiDep 8 point score was divided into those without deprivation (score 0-1, n=112) and those with deprivation (score 2-8, n=50). Within the euthyroid group, those with deprivation were younger (47 years vs 39 years (p=0.021), more likely to be Māori (40% vs 65%, p=0.034) with no gender bias (38% vs 24%; p=0.14). There was a difference in HSS scores between those without deprivation and those with deprivation (median HSS score 3 (0-16) vs 4 (0-27); p= 0.044) but once age-stratified no difference in HSS scores existed between the groups (p=0.15)

When hyperthyroid patients were compared to all euthyroid patients there was no difference in median age (45 years (16-93), 47 years (15-67); p=0.92) or gender (24% male, 33% male; p=0.21). There was a large difference between mean HSS scores (19 (2-47), 5 (0-34); p<0.005). Age-stratification showed a large difference remained within all age groups (p<0.005).

Conclusion: Despite a wide variation in HSS scores in all individuals, the results were able to accurate reflect symptoms consistent with hyperthyroidism when compared to euythroid individuals. Within euthyroid individuals there appears to be no difference between Māori and non-Māori or between high and low NZiDep score individuals.

References:

1. Gibbons V, Conaglen JV, et al. (2008). Epidemiology of thyroid disease in Hamilton (New Zealand) general practice. Aus NZ J Pub Health, 32(5):421–423.

2. Brandt F, Green A, et al. (2011). A critical review and meta-analysis of the association between overt hyperthyroidism and mortality. Euro J of Endocrin, 165(4):491–497

3. Klein I, Trzepacz PT (1988). Symptom rating scale for assessing hyperthyroidism. Arch Intern Med 148:387-90

4. Braverman L, Kloos RT et al (2008). Evaluation of various doses of recombinant human thyrotropin in patients with multinodular goiters. Endocr Pract 14(7):832-9

5. Trzepacz PT, Klein I et al (1989). Graves’ disease: An analysis of thyroid hormone levels and hyperthyroid signs and symptoms. Am J Med 87:558-61

6. Page SR, Sheard CE et al (1996). A comparison of 20 or 40 per day of carbimazole in the initial treatment of hyperthyroidism. Clin Endo 45:511-15

7. Vos XG, Smit N et al (2009). Age and stress as determinants of the severity of hyperthyroidism caused by Graves’ disease in newly diagnosed patients. Euro J Endo 160:193-9

8. Begum F, Ahmed CM et al (2013). Lean body mass-based levothyroxine replacement in young athyrotic patients with differentiated carcinoma of the thyroid. Indian J Endocrinol Metab. 17(2):254-9

9. Graf H, Fast S et al (2011). Modified-release recombinant human TSH (MRrhTSH) augments the effect of (131)I therapy in benign multinodular goiter: results from a multicenter international randomized, placebo-controlled study. J Clin Endocrinol Metab 96(5)1368-76

10. Gunsar F, Yilmaz S et al (2003) Effect of hypo- and hyperthyroidism on gastric myoelectrical activity. Dig Dis Sci 48(4):706-12

11. Kelestimur F, Aksu A (1996) The effect of diltiazem on the manifestations of hyperthyroidism and thyroid function tests. Exp Clin Endocrinol Diabetes 104(1):38-42

12. Biondi B, Fazio S (1994) Control of adrenergic overactivity by beta-blockade improves the quality of life in patients receiving long term suppressive therapy with levothyroxine. J Clin Endcrinol Metab 78(5):1028-33

13. Statistics New Zealand, http://www.stats.govt.nz/surveys_and_methods/methods/classifications-and-standards/classification-related-stats-standards/ethnicity/questionnaire-module.aspx

14. Salmond C, Crampton P (2006) NZiDep: A New Zealand index of socioeconomic deprivation for individuals. Social science and medicine 62(6):1474-85

Breast cancer survival inequity in New Zealand: How much of it is due to demographics, screening, tumour biology, comorbidities and treatment?

Sanjeewa Seneviratne, Ian Campbell, Nina Scott, Ross Lawrenson

Waikato Clinical School, University of Auckland

Abstract:

Introduction: Ethnic disparities in cancer survivals are well known among many populations for a variety of cancers. Underlying reasons for these disparities are complex and poorly understood, but include patient, tumour and healthcare system factors. We investigated on the breast cancer survival disparity between Indigenous Māori and European women in New Zealand and quantified the relative contributions of patient, tumour and healthcare system factors towards this survival disparity.

Methods: All women with newly diagnosed breast cancer in the Waikato, New Zealand between 1999 and 2012 were identified from the Waikato Breast Cancer Register. Cancer specific survival between Māori and NZ European women was compared using Kaplan-Meier survival curves while contributions of different factors towards the survival disparity were quantified with Cox proportional hazard modelling.

Results: Of the total of 2791 women included in this study, 2260 (80.1%) were NZ European and 419 (15%) were Māori. Compared with NZ European women, Māori had a significantly higher age adjusted cancer specific mortality (hazard ratio [HR] =2.02, 95% confidence interval [CI], 1.59-2.58) with significantly lower 5-year (76.1% vs. 86.8%, p<0.001) and 10-year (66.9% vs. 79.9%, p<0.001%) crude cancer-specific survival rates. Stage at diagnosis explained approximately 40% of the survival disparity, while screening, treatment and patient factors (i.e. comorbidity, obesity and smoking) contributed by approximately 15% each. The final model accounted for almost all of the cancer survival disparity between Māori and NZ European women (HR=1.07, 95% CI, 0.80-1.44).

Conclusions: Māori women experience an age-adjusted risk of death from breast cancer, which is more than twice that for NZ European women. Lower screening coverage, delay in diagnosis, inferior quality of treatment and greater patient comorbidity appear to be important factors contributing to survival disparity between Māori and NZ European women.


The use of Not for Resuscitation (NFR) orders on an acute psychogeriatric inpatient unit

Julia Berney 1, Etuini Ma’u 2

1 University of Auckland, New Zealand, 2 Mental Health Services for Older Persons, Waikato Hospital, Hamilton, New Zealand

Aim: Resuscitation decisions are an important consideration in any inpatient setting, including psychiatric units but become more complex when the patient is unable to participate in the process or make informed decisions. Due to dementia or acute mental illness, the decision making capacity of many patients on admission to the psychogeriatric inpatient unit is compromised. The aim of this study is to determine the proportion and characteristics of patients who received a resuscitation order during their admission to the acute psychogeriatric inpatient unit.

Method: We retrospectively reviewed all admissions of >24hours to the Waikato Hospital acute psychogeriatric inpatient unit between January and December 2012 to determine the prevalence of NFR orders and the factors associated with their completion.

Results: 12% of patients had an NFR order, completed on average 11 days after admission. Having an NFR order was associated with the presence of an EPOA (p=.013), use of the MHA during admission (p=.025), being admitted from residential care (p=.039), and level of impairment on admission as measured by the HoNOS impairment subscale (p<.001), behaviour subscale (p=.019) and total HoNOS score (p=.001). The presence of an NFR order was not associated with age (p=.556), gender(p=.056), ethnicity (p=.596), marital status (p=.062), duration of admission (p=.947) or diagnosis of cognitive impairment (p=.056).

Conclusion: Having an EPOA and level of impairment on admission were the factors most associated with the presence of an NFR. Further studies are needed to determine potential psychiatrist and system factors that may be influencing resuscitation decisions.

Two year outcomes of children treated with dextrose gel for neonatal hypoglycaemia: Follow up of the Sugar Babies Study.

DL Harris1, 2, J Ansell2, TY Yu3, B Thompson3, T Wouldes4, JE Harding2 on behalf of the CHYLD study team.

1Newborn Intensive Care Unit, Waikato District Health Board, Hamilton, New Zealand

2Liggins Institute, 3Department of Optometry and Vision Science, 4Department of Psychological Medicine, University of Auckland, Auckland, New Zealand.

Background: Neonatal hypoglycaemia is associated with poor neurodevelopmental outcome. Dextrose gel is an effective treatment for hypoglycaemia, but its long term effects are unknown1.

Aim: To determine two year outcomes of children randomised to dextrose or placebo gel for treatment of neonatal hypoglycaemia.

Methods: At risk babies who became hypoglycaemic (<2.6 mM) were randomised to 40% dextrose or placebo gel. Children were assessed at two years’ corrected age for neurological function and general health (paediatrician assessed); cognitive, language, behaviour and motor skills (Bayley III); executive function; and vision (clinical examination and global motion perception). Primary outcomes were neurosensory disability (cognitive, language or motor score below -1 SD or cerebral palsy or blind or deaf) and processing problem (executive function or global motion perception worse than 1.5 SD from the mean). Data are mean (SD), n (%), or relative risk (RR), 95% confidence interval.

Results: 184 children were assessed; 90/118 (76%) randomised to dextrose and 94/119 (79%) to placebo gel. Mean birth weight was 3093 (803) g and gestation 37.7 (1.6) weeks. 66 children (36%) had neurosensory disability (1 severe, 6 moderate, 59 mild) with similar rates in both groups (dextrose 34 (38%) vs placebo 32 (34%), RR 1.11, 0.75-1.63). Processing difficulty was also similar in both groups (dextrose 8 (10%) vs placebo 16 (18%), RR 0.52, 0.23-1.15).

Discussion: Treatment with dextrose gel appears safe. Neurosensory impairment is common amongst children treated for neonatal hypoglycaemia.

Reference:

1. Harris DL, et al. Dextrose gel for neonatal hypoglycaemia (the Sugar Babies Study). Lancet 382: 2077-83, 2013

SDH deficient phaeochromocytomas and paragangliomas demonstrate increased SSTR2A and SSTR3 expression

Marianne S Elston1,2, Goswin Y Meyer-Rochow2,3, Helen M Conaglen2, Adele Clarkson, 5 Roderick J Clifton-Bligh4, John V Conaglen1,2,Anthony J Gill5

1Department of Endocrinology, Waikato Hospital, Hamilton; 2Waikato Clinical School, University of Auckland; 3Department of Surgery, Waikato Hospital, Hamilton; 4Hormones and Cancer Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney 2065, Australia; 5Department of Anatomical Pathology, Royal North Shore Hospital, Sydney 2065, Australia and Cancer Diagnosis and Pathology Research Group, Kolling Institute of Medical Research, University of Sydney 2006, Australia

Context: Many neuroendocrine tumours, including phaeochromocytomas (PCs) and paragangliomas (PGLs), express one or more somatostatin receptors (SSTR) 1-5. A number of studies have reported SSTR expression in PCs and PGLs. However, receptor expression patterns have been conflicting and until recently specific monoclonal antibodies were not available against SSTR1-5.

Objectives: The aim of this study was to compare SSTR1-5 expression in succinate dehydrogenase (SDH) deficient PCs and PGLs (defined as having absent SDHB immunostaining) to those tumours with normal SDHB staining.

Design: Immunohistochemistry for SDHB and SSTRs 1-5 was performed using specific monoclonal antibodies on archived formalin-fixed paraffin-embedded tissue.

Results: 182 PC/PGLs were included (129 adrenal, 44 extra-adrenal, 9 metastases); 32 tumours were SDH-deficient whereas 150 tumours had positive SDHB staining. SDH-deficient tumours were more likely to demonstrate moderate or strong staining for SSTR2A and SSTR3 when compared to SDH-sufficient tumours (91% vs 49%, p<0.0001 and 50% vs 21%, p=0.0008, respectively). Immunostaining for the other SSTRs was not different between SDH-deficient and tumours with preserved SDHB staining.

Conclusions: SSTR2A and SSTR3 are more likely to be expressed in SDH-deficient PC/PGLs as compared with tumours demonstrating normal SDHB staining pattern. These findings suggest that the role of somatostatin analogue therapy (unlabeled or radiolabeled) should be re-examined in the context of the underlying SDHB immunohistochemistry pattern.

Funding: This work was supported by a Waikato Medical Research Foundation project grant (WMRF grant number 188, 2011) to MSE.

Novartis Pharmaceuticals Ltd for donating the monoclonal antibodies against SSTR1, SSTR3, SSTR 4.

In vitro effects of selenium on DNA damage in BRCA1 cell lines

Mayall, K.1, Peters, L.1, Jameson, M.2, Evans, S.1

1University of Waikato, Hamilton, New Zealand

2 Waikato Hospital, Hamilton, New Zealand

Breast cancer is the most common cancer affecting women worldwide and they have an 11% lifetime risk of developing breast cancer. Selenium (Se) is an essential trace mineral that plays critical roles in maintaining health in humans. The aim of this research was to investigate Se dosage effects on in vitro human breast cancer cells in order to examine cell survival and the level of DNA damage. Two forms of Se compounds were investigated; sodium selenite (inorganic) and methylseleninic acid (MSA, organic). To test this, SUM149PT cells that harbour a 2288delT mutation in BRCA1 were cultured and examined for evidence of toxicity using a colorimetric MTT assay and the single cell gel electrophoresis Comet assay.

The MTT assay demonstrated that this particular BRCA1-mutated cell line is very sensitive to Se (both organic and inorganic forms). The IC50 of sodium selenite and MSA against these cells was 0.09 µM, and 0.045 µM respectively, whereas the IC50 against various other published cancer cell types was in the range of 2.5-50 µM. Preliminary results from the Comet assay show that there is increasing DNA damage when cells are treated with increasing concentrations of sodium selenite (0.025 µM and 0.05 µM).

This particular BRCA1-mutated cell line appears to be extraordinarily sensitive to both Se species. The next step in this research is to investigate other BRCA1-mutated and non-mutated breast cancer cell lines to determine if this sensitivity is specifically linked to BRCA1 mutations. This data has potential clinical implications in the therapy of patients with BRCA1-mutated cancers.

Withdrawal……… from Opioid Prescribing

Kilpatrick K1, Barnard J1, Goddard J1, King S2, Proctor S1, Ragupathy R1, Vickers J1

1Pharmacy Services, Waikato District Health Board, Hamilton

2Inpatient Pain Service, Waikato District Health Board, Hamilton

Introduction

Morphine is the orally administered opioid of choice for severe pain, although other strong opioids such as oxycodone and methadone are also used (1). Oxycodone use in New Zealand has dramatically increased since it became fully subsidised, with most prescribing occurring in hospitals (2, 3, 4).

A previous audit at Waikato Hospital showed oxycodone was not always prescribed according to best practice. This may also apply to prescribing of other strong opioids. A linked programme of audit, intervention and re-audit was therefore conducted to highlight areas for improvement.

Aims

· Conduct a baseline audit to assess prescribing of orally administered strong opioids.

· Design and deliver an intervention to improve opioid prescribing.

· Conduct a final audit to evaluate the effectiveness of the intervention.


Method

Baseline and Final Audit

· Data collected retrospectively from medication charts of patients discharged from two orthopaedic wards

· Data collected over ten consecutive weekdays

· Included prescribing of strong oral opioids only (oxycodone, methadone and morphine)

· Data collected included patient demographics, names of strong oral opioids prescribed, doses and administration frequency. Review dates and maximum doses charted for PRN medicines, and medicines on admission and discharge were also collected

· Exclusion criteria: any patient discharged to convalescent care, other wards or other hospitals

Intervention

· Twenty minute education session delivered to orthopaedic nursing and medical staff on separate occasions. Key points covered included:

· Current situation of increasing oxycodone use worldwide

· Results of baseline audit at Waikato Hospital

· Best practice guidelines recommend morphine first-line for severe pain (1, 5)

· Differences between oxycodone and morphine e.g. oral oxycodone has approximately twice the potency of morphine (oxycodone 5mg = morphine 10mg)

· For acute pain in opioid naïve patients recommend use of immediate release (IR) formulations

· For PRN opioids chart a maximum daily dose

· Regularly review the patient and have a tapering plan

· Opioids on discharge:

a. Communicate with GP and patient

b. Include plan and duration of treatment in discharge summary

Results and Discussion

Patient demographics were similar in both audits. Only 63% of patients were prescribed a strong oral opioid in the final audit, compared with 88% in the baseline audit. This was largely due to a decrease in the proportion of patients prescribed oxycodone (25% versus 39% in the baseline audit), while the proportion prescribed morphine was virtually unchanged.

The proportion of patients on morphine who were prescribed a sustained release formulation decreased from 31% to 13%, and similarly from 26% to 10% for patients on oxycodone. There was very little change in the proportion of patients charted a maximum daily dose for PRN strong opioids or those who had a review date present

There was a modest reduction in the proportion of patients discharged on strong oral opioids. These were almost always included in the discharge summary.
Conclusion

This audit shows medical and nursing staff education can improve prescribing of orally administered strong opioids. Further work is needed to determine if such improvements can be sustained over a longer period, and if the intervention can be extended to other areas.


References

1. WHO’s pain relief ladder [Internet]. Geneva: World Health Organisation; 1986 [cited 2014 Apr 12]. Available from: http://www.who.int/cancer/palliative/painladder/en/

2. Pharmaceutical Management Agency. New pain treatment subsidised for NZers [media release]. Wellington: New Zealand Government; 2005 August. Accessed on 26th May 2014. Available from http://www.pharmac.govt.nz/2005/08/05/050805d.pdf

3. Robinson G, Wilson H. Update on oxycodone: what can primary care do about the problem. Best Practice Journal. 2012 May; 44:8-16

4. Oxycodone: Place in Therapy. Best Practice Journal. 2009 November; 24:28-31

5. Inpatient Pain Service, Waikato District Health Board. Adult Pain Management Handbook, 2nd Ed. 2012

Systematic Review of Minimally Invasive Follicular Thyroid Carcinomas

S Prasad MBChB, G Meyer-Rochow MBChB, FRACS, PhD

Department of General Surgery, Waikato Hospital

Introduction: Minimally Invasive Follicular Thyroid Cancer is an early form of follicular thyroid cancer with an excellent prognosis. It is often detected after diagnostic thyroid lobectomy or as an incidental finding following thyroidectomy for other pathology. Currently there are is a lack of clear guidelines and variable practice for the management of MIFTC.

Aims: We sought to identify risk factors that may affect prognosis and thus influence management of MIFTC. The risk factors reviewed include age of patient, tumour size, and metastases at presentation.

Methods: We performed a literature search looking at studies involving MIFTC patients with prognostic data such as cause specific survival, mortality and metastatic rates. PubMed was used as the search engine with exclusion of studies that had patients with previous history of thyroid cancers, or previous history of thyroid operations, or previous non-thyroid malignancy or previous radioactive iodine.

Following this a qualitative review of the eligible studies was performed by two authors a quantitative analysis was not possible.

Results: Nine case series were isolated after review of 153 abstracts. The data found was heterogenous and there was variable reporting of definitions of MIFTC, treatment strategies and outcomes. Meta-analysis was not possible. Patients with MIFTC tended to be younger with a mean age of 44. The tumour size mean was 3.1 cm. Lymph node metastases rate was 0-3 % and distant metastases on presentation was 0 -9.4%. 10 year cause specific survival ranged from 95.2 – 100%. Age appears to the single most significant factor affecting prognosis.

Conclusion: We suggest that patients less than 45 years old with MIFTC less than 4 cm be treated with lobectomy alone provided no other risk factors such as margin involvement or regional or distant metastases. Patients less than 45 years old with MIFTC more than 4 cm should have a total thyroidectomy. Older patients or patients with other risk factors should be discussed in an MDM setting for adjuvant therapies like RAIA.

References:

1. Kiminori Sugino, Kaori Kameyam, Koichi Ito, Mitsuji Nagahama, Wataru Kitagawa, Hiroshi Shibuya, Keiko Ohkuwa, Yukiko Yano, Takashi Uruno, Junko Akaishi, Akifumi Suzuki, Chie Masaki and Kunihiko Ito. Outcomes and Prognostic Factors of 251 Patients with Minimally Invasive Follicular Thyroid Carcinoma. Thyroid 2012; 22 (8): 798-804

2. Lester D. R. Thompson, M.D. Jacqueline A. Wieneke, M.D. Edina Paal, M.D. R. Allen Frommelt, M.S. Carol F. Adair, M.D. Clara S. Heffess, M.D. A Clinicopathologic Study of Minimally Invasive Follicular Carcinoma of the Thyroid Gland with a Review of the English Literature. Cancer Feb 2001; 91: 505-524