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Background Increased inflammation has been well defined in coronavirus disease 2019 (COVID-19), while definitive pathways driving severe forms of this disease remain uncertain. Neutrophils are known to contribute to immunopathology in infections, inflammatory diseases, and acute respiratory distress syndrome, a primary cause of morbidity and mortality in COVID-19. Changes in neutrophil function in COVID-19 may give insight into disease pathogenesis and identify therapeutic targets. Methods Blood was obtained serially from critically ill COVID-19 patients for 11 days. Neutrophil extracellular trap formation (NETosis), oxidative burst, phagocytosis, and cytokine levels were assessed. Lung tissue was obtained immediately postmortem for immunostaining. PubMed searches for neutrophils, lung, and COVID-19 yielded 10 peer-reviewed research articles in English. Results Elevations in neutrophil-associated cytokines interleukin 8 (IL-8) and interleukin 6, and general inflammatory cytokines IFN-inducible protien-19, granulocyte macrophage colony-stimulating factor (GM-CSF), interleukin 1β, interleukin 10, and tumor necrosis factor, were identified both at first measurement and across hospitalization (P Conclusions Literature to date demonstrates compelling evidence of increased neutrophils in the circulation and lungs of COVID-19 patients. Importantly, neutrophil quantity and activation correlates with severity of disease. Similarly, our data show that circulating neutrophils in COVID-19 exhibit an activated phenotype with enhanced NETosis and oxidative burst.

Objective Using a qualitative design this study aimed to 1) explore the attitudes towards and understanding of osteoarthritis (OA) held by Tasmanian general practitioners (GPs) and orthopaedic surgeons, 2) gain a deeper understanding of conservative and surgical management and 3) identify key barriers and challenges. Design Purposive sampling was used to recruit 17 ​GPs and 10 surgeons from Tasmania, Australia. Semi-structured interviews were audio-recorded, transcribed, coded, and thematically analysed to document understanding of OA, management and treatment decision making. Results GPs and surgeons had a shared understanding of the cause and management of OA which aligned well with evidence-based best practice. Most GPs acknowledged that severity of disease on an X-Ray does not correlate well with symptoms, although some GPs reported always using imaging to support their diagnosis. Conservative management was highly supported by all interviewees, focussing on exercise and/or physiotherapy. Key treatment barriers included managing poor patient understanding of OA, unrealistic expectations for treatment, lack of patient motivation and scepticism towards exercise, and cost and accessibility of conservative treatment options. Surgery was considered a suitable option when conservative management options had been exhausted. Conclusion This study uniquely interviewed GPs and surgeons from the same population, capturing two crucial areas of OA management. Some key barriers to treatment were identified and options for improving treatment include creating opportunities for increased patient education about OA, enhanced accessibility to OA conservative management programs along with improved reimbursement models supporting conservative management as first-line OA treatment.

Author(s): Han, Claudia; Li, Rick; Hansen, Emily; Bennett, Hunter; Poirion, Olivier; Buchanan, Justin; Challacombe, Jean; Fixsen, Bethany; Trescott, Samantha; Schlachetzki, Johannes CM; Preissl, Sebastian; Wang, Allen; O’Connor, Carolyn; Warden, Anna; Shriram, Shreya; Kim, Roy; Nguyen, Celina; Schafer, Danielle; Ramirez, Gabriela; Anavim, Samuel; Johnson, Avalon; Sajti, Eniko; Gupta, Mihir; Levy, Michael; Ben-Haim, Sharona; Gonda, David; Laurent, Louise; Glass, Christopher; Coufal, Nicole | Abstract: The fetal period is a critical time for brain development, characterized by neurogenesis, neural migration, and synaptogenesis 1-3 . Microglia, the tissue resident macrophages of the brain, are observed as early as the fourth week of gestation 4 and are thought to engage in a variety of processes essential for brain development and homeostasis 5-11 . Conversely, microglia phenotypes are highly regulated by the brain environment 12-14 . Mechanisms by which human brain development influences the maturation of microglia and microglia potential contribution to neurodevelopmental disorders remain poorly understood. Here, we performed transcriptomic analysis of human fetal and postnatal microglia and corresponding cortical tissue to define age-specific brain environmental factors that may drive microglia phenotypes. Comparative analysis of open chromatin profiles using bulk and single-cell methods in conjunction with a new computational approach that integrates epigenomic and single-cell RNA-seq data allowed decoding of cellular heterogeneity with inference of subtype- and development stage-specific transcriptional regulators. Interrogation of in vivo and in vitro iPSC-derived microglia models provides evidence for roles of putative instructive signals and downstream gene regulatory networks which establish human-specific fetal and postnatal microglia gene expression programs and potentially contribute to neurodevelopmental disorders.

Introduction. The pathophysiology of infection with SARS-CoV-2 involves the lower airways and host-launched aggressive inflammatory responses leading to exacerbated lung damage in these vital tissues. Early clinical studies found that COVID-19 patients have higher levels of neutrophils in the circulation. Neutrophils are the most abundant leukocyte in circulation and are known to be highly proinflammatory due to production of neutrophil extracellular traps (NETosis). NETs are web-like chromatin structures coated with histones and proteases that both capture and kill invading pathogens. However, while being an effective countermeasure towards foreign microbes, this process also causes undesirable damage in host tissues. Therefore, we sought to characterize NETosis in circulating neutrophils from COVID-19 patients to determine whether this immunological response might be exacerbating or driving the disease state in COVID-19, rather than mitigating the virus. Methods.Blood was drawn daily from critically ill COVID-19 patients (n=16) after consent was obtained. Healthy controls (n=13) were screened for COVID-19 and gave blood once a week. Blood was drawn into lithium heparin tubes (BD Vacutainer). Neutrophils were isolated using PolymorphprepTM(PROGEN) per manufacturer's instructions. Cells were resuspended at 2x106 cells/ml for functional assays. Neutrophils were stimulated with increasing concentrations of PMA (Phorbol 12-myristate 13-acetate) of 2.5nM, 25nM and 250nM to stimulate NETosis via the canonical pathway, and nigericin at 15uM for the non-canonical pathway. NETosis was quantified using the Quant-iT™ PicoGreen™ dsDNA Assay Kit (Invitrogen) and by NET visualization via myeloperoxidase and nuclear staining (using Polyclonal Rabbit Anti-Human Myeloperoxidase by Dako and Hoescht stain by Invitrogen). Results.Functional NETosis assays of circulating neutrophils from COVID-19 patients demonstrate overall increased NETosis determined by increased release of dsDNA. This enhanced NETosis occurred at baseline and after stimulation with PMA when compared to healthy controls (Figure 1A, p

BackgroundIncreased inflammation is a hallmark of COVID-19, with pulmonary and systemic inflammation identified in multiple cohorts of patients. Definitive cellular and molecular pathways driving severe forms of this disease remain uncertain. Neutrophils, the most numerous leukocytes in blood circulation, can contribute to immunopathology in infections, inflammatory diseases and acute respiratory distress syndrome (ARDS), a primary cause of morbidity and mortality in COVID-19. Changes in multiple neutrophil functions and circulating cytokine levels over time during COVID-19 may help define disease severity and guide care and decision making.MethodsBlood was obtained serially from critically ill COVID-19 patients for 11 days. Neutrophil oxidative burst, neutrophil extracellular trap formation (NETosis), phagocytosis and cytokine levels were assessed ex vivo. Lung tissue was obtained immediately post-mortem for immunostaining.ResultsElevations in neutrophil-associated cytokines IL-8 and IL-6, and general inflammatory cytokines IP-10, GM-CSF, IL-1b, IL-10 and TNF, were identified in COVID-19 plasma both at the first measurement and at multiple timepoints across hospitalization (p < 0.0001). Neutrophils had exaggerated oxidative burst (p < 0.0001), NETosis (p < 0.0001) and phagocytosis (p < 0.0001) relative to controls. Increased NETosis correlated with both leukocytosis and neutrophilia. Neutrophils and NETs were identified within airways and alveoli in the lung parenchyma of 40% of SARS-CoV-2 infected lungs. While elevations in IL-8 and ANC correlated to COVID-19 disease severity, plasma IL-8 levels alone correlated with death.ConclusionsCirculating neutrophils in COVID-19 exhibit an activated phenotype with increased oxidative burst, NETosis and phagocytosis. Readily accessible and dynamic, plasma IL-8 and circulating neutrophil function may be potential COVID-19 disease biomarkers.

International audience; We present the largest exome sequencing study of autism spectrum disorder (ASD) to date (n = 35,584 total samples, 11,986 with ASD). Using an enhanced analytical framework to integrate de novo and case-control rare variation, we identify 102 risk genes at a false discovery rate of 0.1 or less. Of these genes, 49 show higher frequencies of disruptive de novo variants in individuals ascertained to have severe neurodevelopmental delay, whereas 53 show higher frequencies in individuals ascertained to have ASD; comparing ASD cases with mutations in these groups reveals phenotypic differences. Expressed early in brain development, most risk genes have roles in regulation of gene expression or neuronal communication (i.e., mutations effect neurodevelopmental and neurophysiological changes), and 13 fall within loci recurrently hit by copy number variants. In cells from the human cortex, expression of risk genes is enriched in excitatory and inhibitory neuronal lineages, consistent with multiple paths to an excitatory-inhibitory imbalance underlying ASD.

Background: Increased inflammation is a hallmark of COVID-19, with pulmonary and systemic inflammation identified in multiple cohorts of patients. Definitive cellular and molecular pathways driving severe forms of this disease remain uncertain. Neutrophils, the most numerous leukocytes in blood circulation, can contribute to immunopathology in infections, inflammatory diseases and acute respiratory distress syndrome (ARDS), a primary cause of morbidity and mortality in COVID-19. Neutrophilia, elevated neutrophil:lymphocyte ratios, and elevated neutrophil-associated cytokines are present in COVID-19, but changes in neutrophil functions have not been characterized. Here we analyzed the functional state of circulating neutrophils in COVID-19. Methods: Blood was obtained from critically ill COVID-19 patients over two weeks and healthy controls across multiple timepoints. Plasma cytokine profiles were assessed by bead array. Neutrophils were isolated and tested ex vivo for oxidative burst, neutrophil extracellular trap formation (NETosis) and phagocytosis. Lung tissue was obtained immediately post-mortem from COVID-19 patients for immunostaining. Results: Elevations in neutrophil-associated cytokines IL-8 and IL-6 were identified in COVID-19 plasma both at the first measurement and across their hospitalization (p < 0.0001). Elevations in cytokines IP-10, GM-CSF, IL-1b, IL-10 and TNF were also present at the first measurement and across hospital stays. Functionally, circulating neutrophils from COVID-19 patients had exaggerated oxidative burst (p < 0.0001), NETosis (p < 0.0001) and phagocytosis (p < 0.0001) relative to controls. Increased NETosis was found to be correlated with both leukocytosis and neutrophilia in COVID-19 patients. Neutrophils and NETs were identified within airways and alveoli in lung parenchyma. While elevations in IL-8 and ANC correlated to COVID-19 disease severity, plasma IL-8 levels alone correlated with death. Conclusions: Circulating neutrophils in COVID-19 exhibit an activated phenotype with increased oxidative burst, NETosis and phagocytosis. Readily accessible and dynamic, plasma IL-8 and circulating neutrophil function can be explored as potential COVID-19 disease biomarkers. Funding Statement: This work was supported by the Department of Veterans Affairs (salary support and VA Merit Award, PI Crotty Alexander) and NIH NHLBI (PI Crotty Alexander). Declaration of Interests: The authors report no conflicts of interest. Ethics Approval Statement: The research protocol was approved by the UCSD, VASDHS and Rady Children’s Hospital institutional review boards (IRBs) and all participants or designated family member gave written informed consent.

This article presents an analysis of interviews with Australian women who had smoked or were currently smoking during pregnancy. It explores how they spoke about their experiences of smoking, cessation and harm minimisation during pregnancy. Eighteen women underwent a single in-depth interview, these were analysed using an iterative thematic method. We found that smoking, cessation and harm minimisation by pregnant women are complex social practices. Participants viewed smoking as a potential risk to fetal health and as an actual risk to their own health and described feeling embarrassed and ashamed of smoking when pregnant. Their opinions about the relative seriousness of health risks posed by smoking when pregnant were often informed by their own personal observations and experiences. Participants used this knowledge to engage in lay epidemiological processes as they rationalised and made sense of the relative risks of smoking, quitting or cutting down. They also sought legitimacy for their claims about the safety of quitting or cutting down in two potentially contradictory ways. These were personal experience/observations and medical advice. Our findings contribute to sociological understanding about lay responses to medical advice on smoking in pregnancy and will be of value to healthcare professionals who work with pregnant women.

Background Fathers’ attitudes and actions can positively or negatively affect mothers’ intentions to breastfeed, breastfeeding duration and exclusivity. In-depth information about fathers’ perspectives on breastfeeding are largely absent in the literature about infant feeding. The objective of this research was to investigate how fathers view breastfeeding. Methods This mixed method study recruited Tasmanian fathers with children

ObjectiveTo investigate mothers’ infant feeding experiences (breastfeeding/formula milk feeding) with the aim of understanding how women experience cessation of exclusive breastfeeding.DesignMultimethod, qualitative study; questionnaire, focus groups and interviews.SettingNorthern and Southern Tasmania, Australia.Participants127 mothers of childbearing age from a broad sociodemographic context completed a questionnaire and participated in 22 focus groups or 19 interviews across Tasmania, 2011–2013.ResultsMothers view breastfeeding as ‘natural’ and ‘best’ and formula milk as ‘wrong’ and ‘unnatural’. In an effort to avoid formula and prolong exclusive breastfeeding, mothers will endure multiple issues (eg, pain, low milk supply, mastitis, public shaming) and make use of various forms of social and physical capital; resources such as father/partner support, expressing breast milk, bottles and dummies. The cessation of exclusive breastfeeding was frequently experienced as unexpected and ‘devastating’, leaving mothers with ‘breastfeeding grief’ (a prolonged sense of loss and failure).Conclusions and implicationsFor many mothers, the cessation of exclusive breastfeeding results in lingering feelings of grief and failure making it harmful to women’s emotional well-being. Reframing breastfeeding as a family practice where fathers/partners are incorporated as breastfeeding partners has the potential to help women negotiate and prolong breastfeeding. Proactive counselling and debriefing are needed to assist women who are managing feelings of ‘breastfeeding grief’.

We present the largest exome sequencing study of autism spectrum disorder (ASD) to date (n=35,584 total samples, 11,986 with ASD). Using an enhanced Bayesian framework to integrate de novo and case-control rare variation, we identify 102 risk genes at a false discovery rate ≤ 0.1. Of these genes, 49 show higher frequencies of disruptive de novo variants in individuals ascertained for severe neurodevelopmental delay, while 53 show higher frequencies in individuals ascertained for ASD; comparing ASD cases with mutations in these groups reveals phenotypic differences. Expressed early in brain development, most of the risk genes have roles in regulation of gene expression or neuronal communication (i.e., mutations effect neurodevelopmental and neurophysiological changes), and 13 fall within loci recurrently hit by copy number variants. In human cortex single-cell gene expression data, expression of risk genes is enriched in both excitatory and inhibitory neuronal lineages, consistent with multiple paths to an excitatory/inhibitory imbalance underlying ASD.

Clinical practice guidelines (CPGs) are a central technique within the evidence-based medicine (EBM) movement. General practice is an area of medicine that seems to be particularly resistant to the use of CPGs. This article contributes to the debates about GPs and CPGs by reflecting on three different Australian studies conducted by the authors in an attempt to better understand variations between GPs’ practices and the recommendations found in relevant CPGs. These projects focused on dementia, chronic obstructive pulmonary disease and hypertension (high blood pressure). A common finding across the three studies was that GPs described how their focus on the whole person and their patients’ priorities and needs meant that the recommendations found in CPGs were not always appropriate or easy to apply. In doing this, our study participants were describing tensions between the holistic/whole person and patient-centred approach of GPs and the narrow disease-specific focus of guidelines. Our work provid...

Copy number variations (CNVs) of the CNTN6 gene - a member of the contactin gene superfamily - have been previously proposed to have an association with neurodevelopmental and autism spectrum disorders. However, no functional evidence has been provided to date and phenotypically normal and mildly affected carriers complicate the interpretation of this aberration. In view of conflicting reports on the pathogenicity of CNVs involving CNTN6 and association with different phenotypes, we, independently, evaluated clinical features of nineteen patients with detected CNV of CNTN6 as part of their clinical microarray analysis at Children's Mercy and Nationwide Children's Hospitals for the period of 2008–2015. The clinical presentations of these patients were variable making it difficult to establish genotype-phenotype correlations. CNVs were inherited in six patients. For thirteen patients, inheritance pattern was not established due to unavailability of parental samples for testing. In three cases CNV was inherited from a healthy parent and in three cases from a parent with neurodevelopmental symptoms. Of the nineteen patients, four had a separate genetic abberation in addition to CNV of the CNTN6 that could independently explain their respective phenotypes. Separately, CNTN6 sequencing was performed on an autism spectrum disorder (ASD) research cohort of 94 children from 80 unrelated families. We found no difference in frequency of rare coding variants between the cohort of patients and controls. We conclude that CNVs involving CNTN6 alone seem to be most likely a neutral variant or a possible modifier rather than a disease-causing variant. Patients with CNVs encompassing CNTN6 could benefit from additional genetic testing since a clinical diagnosis due to a CNV of CNTN6 alone is still questionable.

Frequent non-pathogenic genetic variants may act as moderators of phenotypic severity for complex disorders such as autism spectrum disorder (ASD). We previously identified polymorphisms affecting mRNA expression of candidate genes, including tryptophan hydroxylase 2 (TPH2), dopamine beta hydroxylase (DBH), and dopamine transporter (DAT, SLC6A3). We compare genotypes and (1) clinical response to atomoxetine, (2) scores from the Autism Diagnostic Interview-Revised (ADI-R), and (3) severity of Attention Deficit Hyperactivity Disorder (ADHD) symptoms in a cohort of patients with ASD from multiple study sites. There was no association between CYP2D6 metabolizer status and atomoxetine response. TPH2 rs7305115 genotype was associated with ADI-R Restrictive/Repetitive Behavior score (p = 0.03). DBH rs1611115 genotype was associated with ADI-R Social score (p = 0.002), and Restrictive/Repetitive Behavior score (p = 0.04). The DAT intron 8 5/6 repeat was associated with ADHD symptoms (ABC Hyperactivity p = 0.01 and SNAP ADHD p = 0.03), replicating a previous finding. We find associations between ASD phenotypes and regulatory variants in catecholamine biosynthesis genes. This work may help guide future genetics studies related to ASD.

Autism spectrum disorders (ASD) are more common among boys than girls. The mechanisms responsible for ASD symptoms and their sex differences remain mostly unclear. We previously identified collapsin response mediator protein 4 (CRMP4) as a protein exhibiting sex-different expression during sexual differentiation of the hypothalamic sexually dimorphic nucleus. This study investigated the relationship between the sex-different development of autistic features and CRMP4 deficiency. Whole-exome sequencing detected a de novo variant (S541Y) of CRMP4 in a male ASD patient. The expression of mutated mouse CRMP4S540Y, which is homologous to human CRMP4S541Y, in cultured hippocampal neurons derived from Crmp4-knockout (KO) mice had increased dendritic branching, compared to those transfected with wild-type (WT) Crmp4, indicating that this mutation results in altered CRMP4 function in neurons. Crmp4-KO mice showed decreased social interaction and several alterations of sensory responses. Most of these changes were more severe in male Crmp4-KO mice than in females. The mRNA expression levels of some genes related to neurotransmission and cell adhesion were altered in the brain of Crmp4-KO mice, mostly in a gender-dependent manner. These results indicate a functional link between a case-specific, rare variant of one gene, Crmp4, and several characteristics of ASD, including sexual differences.

The serotonin 2A receptor gene (HTR2A) harbors two functional single nucleotide polymorphisms (SNPs) that are frequent in populations of African and European descent; rs6311, which affects mRNA expression, and rs6314, which changes the amino acid sequence of the encoded protein and affects the signaling properties of the receptor. Multiple clinical associations support a role for these SNPs in cognitive and neuropsychiatric phenotypes, although studies in autism spectrum disorder (ASD) remain equivocal. Here, we tested transmission disequilibrium of rs6311 and rs6314 in a cohort of 158 ASD trios (simplex and multiplex), observing significant under-transmission of the minor "A" allele of rs6311 to offspring with ASD (permuted P = 0.0004). Consistent with our previous findings in the dorsolateral prefrontal cortex of unaffected individuals, rs6311/A decreases expression of HTR2A mRNA with an extended 5' untranslated region (UTR) in the frontopolar cortex in brain samples from 54 ASD patients and controls. Interpreting the clinical results in the context of our mRNA expression analysis, we speculate that any risk associated with rs6311 is conferred by greater expression of the long 5'UTR mRNA isoform. The current study corroborates earlier associations between rs6311 and ASD in a family study, supporting the hypothesis that rs6311 plays a modulatory role in ASD risk.

Issues addressed Physical activity recommendations for adults worldwide advise participation in moderate-intensity physical activity, such as walking, on most days of the week. Younger adults report the lowest prevalence of walking. This mixed-methods study explores the salience of Australia’s activity recommendations around moderate-intensity physical activity, particularly walking, for young Australian adults. Methods Semistructured interviews were conducted with 24 young Australians aged 17–25 years. During interviews, Australia’s physical activity recommendations for adults were explained to participants, highlighting the inclusion of moderate-intensity physical activity such as walking. Participants were asked to comment on the recommendations and walking for physical activity and exercise. Data from interviews underwent an iterative thematic form of analysis. Participants also completed the International Physical Activity Questionnaire (IPAQ) and were asked to complete a pedometer diary. Results No participant was classified as sedentary; twenty three participants reported walking for transport and nine for leisure (IPAQ). During interviews, the majority of participants (n = 20) did not identify walking as physical activity or exercise. Participants focussed on the cardiorespiratory (fitness) benefits associated with physical activity and believed walking was of insufficient intensity to achieve these benefits at their age. Conclusions Walking was considered an everyday activity and of insufficient intensity to achieve any health or fitness benefits. So what? The belief that only vigorous physical activity conveys any fitness benefits may act as a barrier to participation in moderate-intensity physical activity such as walking, particularly among sedentary young people.

Primary Objective: This descriptive review investigated how arts and health programmes and projects in Primary Health Care evaluate their effectiveness. A systematic search was undertaken of articles and reports that reported results from arts and health project and programme evaluations in Primary Health Care settings from 2004 to 2009. Twenty-nine articles or reports met the inclusion criteria. These articles were analysed to identify the characteristics of the evaluations, evaluation tools used, and what the evaluations measured. Main outcomes and results: The review found that a range of different approaches, models and designs are used to evaluate arts and health programmes or projects in Primary Health Care. Questionnaires and interviews were the most common data collection tools used, with a majority of studies using qualitative or mixed methods. The review also identified three main approaches in terms of what factors were measured: measuring the programme objectives, measuring for specific health...

Objective It is recognised that 5% – 10 % of children with macrocephaly and autism spectrum disorder (ASD) and/or intellectual disability (ID) have a heterozygous pathogenic mutation in the PTEN tumour suppressor gene that is associated with PTEN hamartoma tumour syndrome. However, the clinical features and course in children with a pathogenic PTEN mutation are unclear and have not been well documented. Study objectives We undertook a retrospective chart review of children ( PTEN mutations to ascertain clinical findings, clinical course and possible outcomes. Results Clinical and molecular data were collected and analysed for 47 patients with PTEN mutation from 38 eligible families. Macrocephaly (average head circumference of + 5.7 SD) with developmental delay, ID and/or ASD were the most common presenting signs/symptoms (66 %). Clinical features included dermatological findings (66 %), gastrointestinal (GI) symptoms (34 %), ASD diagnosis (50 %), abnormal brain imaging (53 % of those examined) and abnormal thyroid imaging (26 %). Conclusions This is the largest survey of clinical features in children with PTEN pathogenic mutations to date. It confirms earlier reports of increased rates of neurodevelopmental disorders. Dermatological, GI and thyroid abnormalities are age dependent and may not be present at the time of diagnosis, requiring regular monitoring and medical surveillance. Early paediatric diagnosis is important for institution of medical and developmental surveillance as well as for testing other at- risk family members.

The aim of our study was to better understand processes of ongoing smoking or smoking cessation (quitting) following hospitalisation for myocardial infarction or unstable angina (acute cardiac syndromes). In-depth interviews were used to elicit participants’ stories about ongoing smoking and quitting. In total, 18 interviews with smokers and 14 interviews with ex-smokers were analysed. Our findings illustrate the complex social nature of smoking practices including cessation. We found that smoking cessation following hospitalisation for acute cardiac syndromes is to some extent a performative act linked to ‘doing health’ and claiming a new identity, that of a virtuous ex-smoker in the hope that this will prevent further illness. For some ex-smokers hospitalisation had facilitated this shift, acting as a rite of passage and disrupting un-contemplated habits. Those participants who continued to smoke had often considered quitting or had even stopped smoking for a short period of time after hospitalisation; however, they did not undergo the identity shift described by ex-smokers and smoking remained firmly entrenched in their sense of self and the pattern of their daily lives. The ongoing smokers described feeling ashamed and stigmatised because of their smoking and felt that quitting was impossible for them. Our study provides an entry point into the smokers’ world at a time when their smoking has become problematised and highly visible due to their illness and when smoking cessation or continuance carries much higher stakes and more immediate consequences than might ordinarily be the case.

Background Of all births in Australia, 10 % are to young fathers aged less than 24 years. How young fathers experience any breastfeeding and how this is shaped by their social context is poorly understood. Our aim is to increase understanding of the lived experience of young fathers (aged less than 24 years) and to explore the way they speak about breastfeeding in the context of their lives and parenting. Methods This collective case study analysis uses qualitative data from interviews and focus groups with young fathers (aged less than 24 years) and community support staff. The research was undertaken in Tasmania, Australia, March to December 2013. Results Young fathers in our study had complex social and emotional circumstances that meant breastfeeding was not a high priority despite them valuing the health benefits of breastfeeding for their babies. If supported by peers and their community they appear to have a more positive parenting experience. Conclusion Breastfeeding although understood by the young fathers in our study as healthy and desirable is not a priority in their lives. Learning to be a parent and support their partners to breastfeed may be more effectively gained through mentoring and father-to-father localized community based support services.

The purpose of this study was to examine the relationship between risks associated with smoking and the effectiveness of quit-smoking techniques and interest in quitting among pregnant smokers. It was hypothesised that both knowledge of smoking-related harm and knowledge of efficacious smoking cessation methods would be significant predictors of interest in quitting in the next 30 days. This preliminary study involved 72 pregnant smokers who completed a questionnaire assessing smoking-related knowledge and perceived efficacy of cessation methods. Of the 11 smoking-related risks probed, the least acknowledged were those associated with pregnancy and post-natal conditions, with 38% of the sample responding incorrectly to all four of the pregnancy and post-natal conditions probed. Knowledge of the efficacy of smoking medications was also poor: 32.9% of the sample reported believing that all three pharmacotherapies were ineffective for promoting cessation. A high level of knowledge about the harms of smoking was related to an increased intention to quit in the next 30 days (39.5% versus 15.8%; Odds Ratio [OR] = 3.5). Results from this preliminary study showed support for previous research regarding smoking-related knowledge in non-pregnant smokers. Further research in the area is viewed as particularly important to confirm the current results and guide intervention to increase the level of smoking related knowledge in this at-risk group.

Purpose: Because dexamethasone remains a key component of myeloma therapy, we wished to examine the impact of baseline and relapse expression levels of the glucocorticoid receptor gene NR3C1 on survival outcomes in the context of treatment with or without thalidomide. Experimental Design: We investigated the clinical impact of gene expression profiling (GEP)–derived expression levels of NR3C1 in 351 patients with GEP data available at baseline and in 130 with data available at relapse, among 668 subjects accrued to total therapy 2 (TT2). Results: Low NR3C1 expression levels had a negative impact on progression-free survival (PFS; HR, 1.47; P = 0.030) and overall survival (OS; HR, 1.90; P = 0.002) in the no-thalidomide arm. Conversely, there was a significant clinical benefit of thalidomide for patients with low receptor levels (OS: HR, 0.54; P = 0.015; PFS: HR, 0.54; P = 0.004), mediated most likely by thalidomide's upregulation of NR3C1. In the context of both baseline and relapse parameters, post-relapse survival (PRS) was adversely affected by low NR3C1 levels at relapse in a multivariate analysis (HR, 2.61; P = 0.012). Conclusion: These findings justify the inclusion of NR3C1 expression data in the work-up of patients with myeloma as it can significantly influence the choice of therapy and, ultimately, OS. The identification of an interaction term between thalidomide and NR3C1 underscores the importance of pharmacogenomic studies in the systematic study of new drugs. Clin Cancer Res; 18(19); 5499–506. ©2012 AACR.

Aims: The aims of this study were to understand the experience of participation in visual art from the perspective of adults undergoing outpatient physical rehabilitation and to determine whether art has a place in this context. Method: This qualitative study involved interviewing adults who attended a weekly art class run by a qualified art teacher and occupational therapists in an outpatient physical rehabilitation setting. Nine participants with neurological conditions discussed their experience of the programme and the goals they were working towards or had achieved through painting. Findings: The themes that emerged from the study show that art contributed to the participants meeting their individual rehabilitation goals. It also assisted the participants in using time, increasing enjoyment, regaining confidence and planning for engagement in future activities. All these achievements were seen by the participants to contribute to their rehabilitation or recovery. The identified themes align with the aims of rehabilitation and are similar to findings from many other studies investigating the use of art by people affected by illness or disability. Conclusion: The findings of this study inform clinical practice in the use of visual art with clients in rehabilitation and validate its place in a physical rehabilitation programme.

Background:Pedometer measurement of physical activity (PA) has been shown to be reliable and valid in industrialized populations, but its applicability in economically developing Vietnam remains untested. This study assessed the feasibility, stability and validity of pedometer estimates of PA in Vietnam.Methods:250 adults from a population-based survey were randomly selected to wear Yamax pedometers and record activities for 7 consecutive days. Stability and concurrent validity were assessed using intraclass correlation coefficients (ICC) and Spearman correlation coefficients.Results:Overall, 97.6% of participants provided at least 1 day of usable recordings, and 76.2% wore pedometers for all 7 days. Only 5.2% of the sample participants were involved in work activities not measurable by pedometer. The number of steps increased with hours of wear. There was no significant difference between weekday and weekend in number of steps, and at least 3 days of recordings were required (ICC of the 3 days of recordings: men 0.96, women 0.97). Steps per hour were moderately correlated (men r = .42, women r = .26) with record estimates of total PA.Conclusions:It is feasible to use pedometers to estimate PA in Vietnam. The measure should involve at least 3 days of recording irrespective of day of the week.

Summary Background Chronic obstructive pulmonary disease (COPD) is under-diagnosed and diagnosis often occurs late thereby reducing opportunities to prevent deterioration. Investigation of causes has focused on the use of spirometry but the role of attitudes of doctors and patients has not been directly investigated. Methods A cross-sectional study of patients diagnosed with COPD and their general practitioners in two general practices in Tasmania who participated in semi-structured interviews and focus groups. Practice records were examined and patients underwent spirometry, quality of life and symptom assessment. Iterative content analysis identified themes that were compared with quantitative data. Findings For the 32 participating patients, mean recorded duration of COPD was 8.0 (SD 6.8) years and mean FEV 1 % predicted 38.4% (SD 19.8). Qualitative data were obtained from 14 (44%) of patients with COPD (5M/9F) and 16 general practitioners (GPs) (10M/6F). We identified three themes around the diagnosis of COPD in primary care: patients' labels, acquiring and communicating a diagnosis and consequences of delaying or withholding diagnosis. Doctors correctly recognised that patients were unfamiliar with COPD. They intentionally avoided early diagnosis as a result of nihilism and misperception of patients' attitudes. Patients often received the diagnosis from other sources and found delayed diagnosis frustrating. Interpretation Nihilistic attitudes to COPD may explain the disappointing results from promotion of spirometry in primary care. Education about COPD for doctors in primary care is needed and action to increase awareness and understanding of COPD in the community.

ObjectivesTo estimate the prevalence of cessation of exclusive breast feeding at each month up to 6 months and document key factors and cumulative risks associated with exclusive breastfeeding cessation for children aged from 0 to 6 months.MethodsSecondary analysis using a national representative sample of 22 202 mother and infant pairs derived from the 2010 Australian Institute of Health and Welfare cross-sectional survey, the Australian Infant Feeding Survey.ResultsAmong breastfed infants, 49% had ceased exclusive breast feeding before they had reached 2 months of age. In the final Cox proportional hazards model, cessation of exclusive breast feeding was most strongly associated with partners preferring bottle feeding (HR 1.86, 95% CI 1.69 to 20.6) or having no preference (HR 1.37, 95% CI 1.33 to 1.42), regular dummy use (HR 1.35, 95% CI 1.31 to 1.39) and maternal obesity (HR 1.29, 95% CI 1.24 to 1.35). Living within the most disadvantaged areas of Australia (quintile 1) was not strongly associated with cessation (HR 1.08, 95% CI 1.02 to 1.14) compared with least disadvantaged areas. Having three risk factors significantly increased the risk of cessation by 31% (HR 1.31, 95% CI 1.07 to 1.6).ConclusionsThe prevalence of early cessation of exclusive breast feeding is alarmingly high with 50% of infants no longer exclusively breast fed by age 2 months. Given that not one factor is associated with cessation of exclusive breast feeding, the greatest public health impact is likely to be achieved when multiple risk factors are modified or prevented.

The purpose of this study was to test and evaluate the feasibility and clinical acceptability of the use of an infant feeding data collection tool during the scheduled childhood immunisation consultation, and to explore the appropriateness of this consultation as a site for a future intervention aiming to increase exclusive breastfeeding through the provision of advice and support to mothers. This descriptive exploratory (quantitative and qualitative) study used purposeful sampling to enrol five general practices in Hobart, Tasmania. General practitioners (GPs) and practice nurses (PNs) trialled and evaluated a paper-based data collection tool over a 6-week period from May through to June 2011. Twenty-two (13 GPs; 2 GP registrars and 7 PNs) participants trialled and evaluated the data collection tool (n = 54). From the evaluation questionnaire, field notes and informal interviews (n = 7), six conceptual headings emerged: setting; time pressures; resources and collaboration; mothers need to talk; professional exclusion; and lack of collaboration. The scheduled childhood immunisation consultation provides an opportunity for mothers and primary health practitioners to talk briefly about infant feeding and for the collection of infant feeding data. However, the immunisation consultation is not well suited to a breastfeeding support intervention as it is already very busy focusing on immunisation issues. Consideration should be given to the evaluation of a dedicated general practice/primary health ‘infant feeding’ consultation.

Autism is the fastest growing developmental disability in the US, costing more than $90 billion/yr, and is, therefore, extremely important to the DoD. According to the Military Times (Robert Dorr, 8/13/11), autism is the most prevalent special-needs issue in military families. Autism spectrum disorders (ASDs) have a frequency of 1/88 in the general population (1) and an estimated frequency of 1/88 in the military (Organization of Autism Research). Affected children display qualitative impairments in social interaction, expressive and receptive language, and the use of symbolic or imaginative play, with an age of onset before 3 years. In addition, many children display restricted, repetitive, and stereotyped patterns of behaviors. Specific military preparedness issues for families with a child with an ASD include the stress of deployments and frequent moves; early retirement or lack of re-enlistment for family concerns; and limited community resources at many smaller bases. ASDs pose a particularly high level of stress for many military families; however, substantial improvements are attainable through collaborative translational research linked to better care.CORA was initiated in 2006 as a collaboration between Wright-Patterson Air Force Base (WPAFB) and Nationwide Children s Hospital (NCH). The primary purpose of CORA is to develop a comprehensive autism registry for genetic and other studies for military and civilian families in central Ohio.

Background:Leisure-time physical activity is a term used by physical activity researchers to describe physical activity undertaken during nonwork time. In this study we explore how young people speak about physical activity in relation to leisure.Methods:Eight focus groups and one group interview were conducted with 50 participants aged 16−26 years. Participants included males and females, rural and urban dwellers, and a mixture of active/inactive young people. Focus group transcripts underwent an iterative thematic analysis.Results:Participants found it difficult to recognize leisure time activities in their day to day lives and only rarely mentioned their physical activity involvement when asked about leisure time activities. When discussing physical activity study participants commonly focused on high intensity physical activity such as sport and gym use. Three major themes relating to leisure and physical activity were identified: the meanings ascribed to physical activity, the experience of physical activity, and routines of participation.Conclusion:These findings suggest that the relationship between physical activity and leisure is complex and the term leisure with its associated concepts of satisfaction, relaxation and pleasure may not accurately reflect the way young people view their participation in physical activity.

Graft versus host disease (GVHD) commonly induces pathological damage in peripheral target organs such as the skin, liver and gastrointestinal tract leading to well characterized organ-specific clinical manifestations. A number of studies, however, have shown that patients with GVHD can also have behavioral and mood alterations that can affect overall cognitive function and lead to significant impairments in quality of life. The extent to which GVHD contributes to cognitive dysfunction and induces inflammation within the central nervous system (CNS), however, has not been critically examined. To address this question, we conducted studies using two well-defined murine GVHD models [C57BL/6(H-2b)→Balb/c (H-2d) and B10.BR(H-2k)→B6 (H-2b)]. We observed that there was a significant increase in the number of donor-derived CD4+ and CD8+ T cells in the brains of GVHD recipients early (days 7 -14) and late (day 42) post transplantation compared to BM controls. Histological studies revealed activated microglial cells and CD3+ T cell infiltration in the periventricular regions of brains in GVHD recipients that were not present in BM animals. Real time q-PCR analysis also demonstrated significant increases in IFN-γ, TNF-α, and IL-6 mRNA expression indicative of a proinflammatory state. Notably, GVHD animals exhibited behavioral changes in the forced swim test and elevated plus maze which are validated assays of stress coping and anxiety, respectively. Since IL-6, in particular, plays a pivotal role in GVHD pathogenesis in murine models and humans, we examined whether blockade of IL-6 signaling altered neuroinflammation. Animals treated with an anti-IL-6R antibody had a significant reduction in the number of donor-derived CD4+ and CD8+T cells in the brain compared to isotype control-treated mice. Anti-IL-6R treatment of GVHD mice also resulted in significant reductions in IFN-γ, TNF-α, and IL-6 mRNA and normalized behavior in the forced swim test, indicative of a decreased inflammatory response. Since IL-6 is produced by a wide variety of cells, including microglial and T cells, both donor and recipient cells have the potential to modulate GVHD severity within the CNS. To define whether donor or host IL-6 production was most critical for inducing neuroinflammation, experiments were conducted employing IL-6-/- mice as either donors or recipients. Whereas the absence of IL-6 in donor-derived cells had no impact on the degree of inflammation within the CNS, recipient animals that lacked IL-6 had a significant decrease in the number of donor-derived T cells which accumulated in the brain as well as a marked reduction in inflammatory cytokines, indicating that host IL-6 production was critical. To define the downstream pathways of IL-6-mediated CNS inflammation, we examined the role of indoleamine 2,3-dioxygenase (IDO) since IL-6 has been shown to upregulate IDO-1 expression under inflammatory conditions. We observed that IDO-1 mRNA levels were significantly increased in the brains of GVHD animals, and that blockade of IL-6 signaling resulted in a marked decrease in IDO mRNA levels. Additionally, transplantation studies using IDO-/- mice revealed that host, but not donor, IDO production was required for maximal inflammatory effects. Serotoninergic projections to the prefrontal cortex (PFC), in particular, are sensitive to inflammation and contribute to stress coping behavior. Therefore, to further interrogate this pathway, we performed quantitative mass spectrometry of brain extracts from the PFC. We found that tryptophan and 5HT concentrations were not different between BM and GVHD groups. However, there was an increase in the IDO product, kynurenic acid, in GVHD recipients consistent with an increase in brain IDO expression. To provide additional support for the premise that IL-6 effects were mediated through the IDO pathway, recipient mice were treated with either 1-methyltryptophan (1-MT), a completive inhibitor of IDO, or a vehicle control. GVHD mice treated with 1-MT had decreased accumulation of T cells in the brain and normal behavior in the forced swim test, demonstrating that inhibition of IDO abrogated CNS inflammation and behavioral changes in the presence of intact IL-6 signaling. In summary, these studies demonstrate that host IL-6 and IDO regulate inflammation and adversely impact behavioral function within the brain during GVHD through the tryptophan metabolic pathway. Disclosures No relevant conflicts of interest to declare.

This article reports findings from three linked qualitative research projects that explored how Australian general practitioners (GPs) spoke about their experiences in diagnosing dementia and their views on early diagnosis and barriers towards early diagnosis. The authors conducted this research with the aim of elucidating the GP perspective and using this to better understand the process of diagnosing dementia and delays in diagnosing dementia. Twenty-four GPs based in Australia participated in the study (eleven females and thirteen males). Six of these GPs worked in rural practices, eight in a large town and the remainder in urban practices in a capital city. The major themes in GPs' accounts of the diagnosis of dementia could be grouped under the headings of 'recognizing dementia', 'holistic viewpoint', 'family members and patients' and 'medication'. Key findings are that dementia is a complex condition that takes time to diagnose. Diagnosis may involve conflict between GPs, family members/carers and the person with dementia (PWD). GPs did not consider that diagnosing dementia early was particularly important and may in fact be harmful to some patients. They are skeptical about the advantages of dementia medications. GPs assess the need for a formal diagnosis of dementia within the broader context of their older patients' lives. They are more likely to pursue a formal diagnosis in situations where they see it leading to benefits for their patient such as accessing dementia specific services. Increasing the availability of support services for PWD and educating GPs about the benefits of a formal diagnosis of dementia for stakeholders other than PWD, for example family members and carers may increase the likelihood that they will diagnose dementia early.

Background: To increase recognition of airflow obstruction in primary care, we compared two models of spirometry delivery in a target group at risk of chronic obstructive pulmonary disease (COPD). Methods: A 6 month qualitative/quantitative cluster randomised study in eight practices compared opportunistic spirometry by “visiting trained nurses” (TN) with optimised “usual care” (UC) from general practitioners (GPs) for smokers and ex-smokers, aged over 35 years. Outcomes were: spirometry uptake and quality, new diagnoses of COPD and GPs’ experiences of spirometry. Results: In the eligible target population, 531/904 (59%) patients underwent spirometry in the TN model and 87/1130 (8%) patients in the UC model (p

Objective: We have reported that a lifestyle intervention with mothers improved calcium intake and physical activity in both mothers and their children. In this study, we aimed to describe the strategies and approaches used by these mothers to improve their children's calcium intake and physical activity. Design: A qualitative study using semistructured interviews. Setting: Population-based convenience sample. Subjects: A subsample of 39 mothers were taken from a population-based random sample of 354 mothers who had participated in the original osteoporosis-prevention trial. Results: Mothers described specific dietary changes they made to increase their children's calcium intake. They also described strategies for improving calcium intake and physical activity such as raising awareness of the importance of calcium; ensuring calcium-rich foods were accessible; assessing their children's likes and dislikes and working within these; role modelling; information provision; taking a balanced approach to attempting behaviour change; and encouraging activities that they could do with their children. Mothers emphasized the general importance of a balanced diet and lifestyle, rather than just focussing on lifestyle factors specific to osteoporosis prevention. Conclusion: Even without specific guidance, mothers are adept at developing strategies to apply to changing lifestyle behaviours in their children and identifying barriers to change. These results provide information, which could be incorporated into future interventions for lifestyle change in children and also provide further support for considering parent-focused approaches to this problem.

Background. Current pandemic influenza plans to place GPs at the front line of a pandemic influenza response. However, little is known about GPs' perceptions of their role and preparedness in the event of a pandemic occurring. Objective. Our aim was to assess general practice preparedness to respond to pandemic influenza and to identify issues that need to be addressed to enhance preparedness for the next pandemic. Methods. We conducted a series of semi-structured interviews to explore GPs' views regarding their role in responding to pandemic influenza, practice preparedness and planning issues, and the expectations and requirements of GPs for provision of professional services during a pandemic. The subjects were 60 Australian GPs, purposively selected to maximize diversity within the sample. Results. GPs in this study expressed a willingness to provide professional services in a pandemic. The motivation for this was largely altruistic and was in the context of high personal risk of becoming infected. Participants did not have stockpiles of antivirals or personal protective equipment within their practices and felt that government had a duty of care to stockpile on behalf of the general practice workforce. Participants were enthusiastic about receiving further information and training in pandemic preparedness. The most appropriate setting for this was within practices. Conclusions. GPs were willing to provide clinical services in a pandemic. However, appropriate education, training and supply of equipment were necessary to support them in this role. This information will inform further planning for the public health response to pandemic influenza.

Intra-tumoral heterogeneity (ITH) is increasingly viewed as the Achilles heel of treatment failure in malignant disease including multiple myeloma (MM). Most MM patients harbor focal lesions (FL) that are recognized on MRI long before bone destruction is detectable by conventional X-ray examination. Serial MRI examinations show that eventually 60% of patients will achieve resolution of FL (MRI-CR). However, this will lag behind the onset of a clinical CR by 18 to 24 months, thus attesting to the biological differences between FL and diffuse MM growth patterns. Consequently, we performed concurrent gene expression profiling (GEP) analyses of plasma cells (PC) from both random bone marrow (RBM) via iliac crest and FL. Our primary aims were to first compare the molecular profiles of FL vs. RBM, second to determine if ITH existed (as defined molecular subgroup and risk), and finally to investigate if the bone marrow micro-environment (ME) contained a biologically interesting signature. A total of 176 patients were available for this study with a breakdown of: TT3 (n=23), TT4 for low-risk (n=131) and TT5 for high-risk MM (n=22). Regarding the molecular analyses of PCs, GEP-based risk (GEP-70, GEP-5) and molecular subgroup correspondence were examined for commonalties and differences between RBM and FL. A “filtering” approach for ME genes was also developed and bone marrow biopsy (BMBx) GEP data derived from this method is under analysis. PC risk correspondence between FL and RBM was 86% for GEP70 and 88% for the GEP5 model. Additionally, 82% had a molecular subgroup concordance, however, they did differ among subgroups (p=0.020) by Fisher's Exact Test. A lower concordance was noted in the CD2, LB, and PR subgroups (67%, 69%, 73%, respectively). GEP70 and GEP5 risk concordance between RBM and FL samples by molecular subgroup was also examined. The overall correlation coefficients were 0.619 (GEP70) and 0.597 (GEP5). The best correspondence was noted for CD1, MF and PR subgroups especially for the GEP5 model. HY, LB and MS showed intermediate correlations, while CD2 fared worst with values of only 0.322 for GEP70 and 0.267 for GEP5 model. Figure 1 portrays these data in more detail for the GEP70 and GEP5 models. Good correlations were noted between RBM and FL based risk scores in case of molecular subgroup concordance (left panels) in both GEP5 and GEP70 risk models, whereas considerable scatter existed in case of subgroup discordance (right panels). The clinical implications in TT4 regarding RBM and FL derived risk and molecular subgroup information, viewed in the context of standard prognostic baseline variables are portrayed in Table 1. High B2M levels at both cut-points imparted inferior OS and PFS as did low hemoglobin. Although present in 42% of patients, cytogenetic abnormalities (CA) did not affect outcomes. FL-based GEP5-defined high-risk designation conferred poor OS and PFS. B2M>5.5mg/L and FL-derived GEP5 high-risk MM, pertaining to 29% and 11% of patients, survived the multivariate model for both OS and PFS. Next, in examining PC-GEP differences among RBM and FL sites, 199 gene probes were identified with a false discovery rate (FDR) of 1x10-6. Additionally, 55 of the 199 belong to four molecular networks of inter related genes associated with: lipid metabolism, cellular movement, growth and proliferation, and cell-to-cell interactions. Multivariate analysis identified the GEP5 high risk designation of focal lesion PCs to be significantly prognostic with a HR=3.73 (p=0.023).Table 1Cox regression analysis of variables linked to overall and progression-free survival in TT4.Overall SurvivalProgression-Free SurvivalVariablen/N (%)HR (95% CI)P-valueHR (95% CI)P-valueMultivariateB2M > 5.5 mg/L38/130 (29%)3.71 (1.49, 9.22)0.0053.84 (1.58, 9.31)0.003FL GEP5 High Risk14/130 (11%)3.68 (1.19, 11.41)0.0243.73 (1.20, 11.62)0.023HR- Hazard Ratio, 95% CI- 95% Confidence Interval, P-value from Wald Chi-Square Test in Cox RegressionNS2- Multivariate results not statistically significant at 0.05 level. All univariate p-values reported regardless of significance.Multivariate model uses stepwise selection with entry level 0.1 and variable remains if meets the 0.05 level.A multivariate p-value greater than 0.05 indicates variable forced into model with significant variables chosen using stepwise selection. Disclosures: No relevant conflicts of interest to declare.

It is becoming more evident that the bone marrow micro-environment (ME) plays an important role in MM development, progression and treatment response. Studies of the bone ME have largely been limited to in-vitro differentiated cellular subsets. Removing the cells from the from their physiologic cellular environment and manipulating them over an extended period inducing artificial changes results in a significant bias and thus severely limits the applicability of conclusion drawn from those systems to the primary unaltered bone marrow. In order to identify differences between the bone marrow ME of healthy donors and patients with MM we subjected whole BMBx from 378 untreated MM patients and 48 NL subjects, which had been snap frozen immediately after they were taken from the patients, to GEP analysis. Since whole bone marrow biopsies also include plasma cells (PC) we selected probe sets that are unique to the non-PC bone marrow ME. 783 probe sets were selected for having a log2 transformed mean expression > 8 in RNBX (in any of the 7 molecular subgroups CD1, CD2, MF, MS, HY, PR and LB) and < 8 in RNAS (in all molecular subgroups). The training set comprised 242 MM and 40 NL and the test set 136 MM and 8 NL individuals. Approximately 80% of 783 probe sets were differentially expressed between MM and NL samples. We then identified 24 differentially expressed genes to create a gene score, which differentiates between NL and MM samples. ROC plots for the training and test set are depicted in Figure 1a and 1b respectively. Boxplots of 24-gene scores showed minimal overlap between MM and NL in training and test sets (Figure 1c and 1d). 98% of patients were correctly classified as MM or NL by the 24-gene score in the test set (Table 1).Table 1True and predicted Normal and MM samples by 24-probes score in the test set. 133/136 (98%) of MM patients and 8/8 (100%) of Normal patients were classified correctly.Predicted NormalPredicted MMTrue Normal80True MM3133 We hypothesized that, upon achieving CR, the ME signature normalizes gradually reflecting the diminishing submicroscopic tumor burden and MM-inflicted ME alteration. Therefore, we applied the GEP24 model to 428 CR samples treated with Total Therapy 2 and 3 (TT2, TT3). The time course of sampling from onset of CR with annotations of normalized CR (NL-CR) and non-normalized CR (non-NL-CR) is depicted in Figure 4. Within the 1st year of CR, 14% of patients qualified for NL-CR; the corresponding values for years 2, 3 and 4 were 18%, 19%, and 20%, respectively. Normalization of the bone marrow ME was independent of GEP70 defined risk. Investigation of random biopsies from patients with asymptomatic MM (AMM) and monoclonal gammopathy of undetermined significance (MGUS) revealed a distinct stepwise shift of 24-gene score distributions with the transition from NL to MGUS to AMM and ultimately MM (Figure 5). Patients in CR had similar distributions of the 24-gene score as patients with AMM. We conclude that ME GEP provides important clues to MM biology and therapeutic response that has now been quantitated for the first time. Normalization of the bone marrow ME could predict for recovery of normal hematopoiesis. Results will be presented as to whether NL-CR status can serve as a surrogate marker for long-term disease control and cure that can aid in guiding the length of post-CR maintenance therapy. Investigations are also in progress to determine whether ME GEP can capture MDS-associated alterations and thus help in quantitating the risk of such treatment sequelae. Disclosures: No relevant conflicts of interest to declare.

Background Pom is an IMiD® immunomodulatory agent now FDA approved for treatment of patients who have received > 2 prior therapies, including lenalidomide (Len) and bortezomib (Bor), and have demonstrated disease progression on or within 60 days of completion of the last line of therapy. There is limited data evaluating efficacy of Pom in high risk RRMM. Herein, we are reporting the final report on a phase II clinical trial employing Pom in high risk RRMM with prior exposure and/or refractoriness to Len. Methods High risk RRMM was defined by having high risk on gene expression profiling (GEP70 or GEP80 signatures), elevated LDH, or having abnormal metaphase cytogenetics. Cycle #1 Pom was given at 4mg orally Days 1-21 q 4 weeks; in the absence of > PR by IMWG criteria after 2 cycles, dexamethasone (Dex, 4-20 mg orally q week) and/or Bor (1.3 mg/m2 IV days 1,4,8,11) and/or Vorinostat (Vor, 100-200 mg po days 1-21 q 4 weeks) could be added; in the absence of > PR by IMWG criteria after 4 cycles, cyclophosphamide (Cy, 300 mg/m2 q week) could be added. Primary endpoint was progression free survival (PFS) at 1 year, secondary endpoints included overall survival (OS), response rates and duration of response (DoR). Cox regression modeling was employed for univariate and multivariate analyses, Kaplan-Meier curves were used for OS and PFS. Best response was defined as the best response achieved while enrolled (regardless of prior progression, or relapse). Pharmacogenomic analyses using GEP were performed on 18 patients with paired baseline and 48hr post-Pom, using CD138-purified bone marrow plasma cells. Results 71 patients with HRMM were enrolled between May 2010 and August 2012. Baseline patient characteristics included age > 65 years in 45%, cytogenetic abnormalities (CA) in 86%, GEP70 high risk in 14/34 (41%), GEP80 high risk in 28/34 (82%), extramedullary disease in 3/71 (4%) and secondary plasma cell leukemia in 2/71 (3%). 68/71 patients (96%) had a prior autologous stem cell transplant (ASCT), 30/71 (42%) had > 2 ASCT. Patients had received a median of 5 prior lines of therapy (range 1-10). There were 58 (82%) patients with Len-refractory (Len-R) MM, 64 (90%) with Bor-refractory (Bor-R) MM and 53 (75%) with dual-refractory (dual-R) MM prior to enrollment. 34 (48%) patients received > 6 cycles of treatment, 9(13%) received > 12 cycles. Patients who received > 6 cycles, had addition of Dex(67%), Bor+Dex(18%), Bor+Dex+Cy(12%), Bor+Dex+Cy+Vor(3%). As of July 2013, 45 patients (63%) discontinued therapy primarily due to progression or death. 20 (28%) patients achieved > PR as best response (1 Len-R, 2 Bor-R, 6 in dual-R), with median DoR for patients > PR of 1 month (range 0.5-18 months). 58 patients (5 Len-R, 8 Bor-R, 43 dual-R) had > stable disease, giving an overall disease control rate of 82%. Slight PFS benefit was observed in younger patients (HR=0.64, 95% CI: (0.39, 1.06), p=0.098). An increased risk for OS was observed among patients with LDH >= 190 U/L (HR=4.62, 95% CI: (2.28, 9.38), p= 8 mg/L (HR=2.13, 95% CI: (1.03, 4.40), p= 0.041), hemogloblin < 10 g/dL (HR=3.47, 95% CI: (1.66, 7.27), p grade 3 were leukopenia (75%), thrombocytopenia (60%), anemia (44%), infections (26%), dyspnea (19%), hypophosphatemia (20%) and hypocalcemia (19%). OS and PFS at 12 months were 63% and 13%, respectively. Pre/48hr-post POM GEP analyses showed that expression levels of 55 probe-sets (48 genes) were significantly changed in response to POM treatment (false discovery rate 0.01). These genes were related to cell adhesion, inflammatory and hypersensitivity response, such as GAS6, ITGB1, ITGB7, LYN, RAC1, PYCARD, CORO1B, F11R, and DKK1, all with higher expression values observed post POM. IRF4, one of the targets of cereblon (CRBN) previously reported to be critical for myeloma cell survival, was down-regulated post POM treatment (p=0.001,FDR=0.09), suggesting a unique CRBN-dependent anti-myeloma activity for POM Conclusion Pom demonstrates good anti-myeloma activity in a heavily pretreated, GEP-defined high risk RRMM in combination with other anti-myeloma drugs. Given the efficacy in patients with poor prognostic features, there is precedence to evaluate Pom as an IMiD of choice in combination with other novel agents in front line setting for GEP-defined high risk MM. Disclosures: Usmani: Celgene: Consultancy, Research Funding, Speakers Bureau; Onyx: Research Funding, Speakers Bureau. van Rhee:Janssen Research & Development: Research Funding. Barlogie:Millennium: Consultancy, Research Funding; Celgene: Consultancy, Research Funding; MyelomaHealth: Patents & Royalties.

Multicentric Castleman Disease is largely driven by increased signaling in the pathway for the plasma cell growth factor interleukin-6. We hypothesized that interleukin-6/interleukin-6 receptor/gp130 polymorphisms contribute to increased interleukin-6 and/or other components of the interleukin-6 signaling pathway in HIV-negative Castleman Disease patients. The study group was composed of 58 patients and 50 healthy donors of a similar racial/ethnic profile. Of seven polymorphisms chosen for analysis, we observed an increased frequency between patients and controls of the minor allele of interleukin-6 receptor polymorphism rs4537545, which is in linkage disequilibrium with interleukin-6 receptor polymorphism rs2228145. Further, individuals possessing at least one copy of the minor allele of either polymorphism expressed higher levels of soluble interleukin-6 receptor. These elevated interleukin-6 receptor levels may contribute to increased interleukin-6 activity through the trans-signaling pathway. These data suggest that interleukin-6 receptor polymorphism may be a contributing factor in Castleman Disease, and further research is warranted.

Abstract 4083 Background: Pom is a third generation immunomodulatory drug (IMiD) which has demonstrated safety and efficacy in RRMM with prior exposure/resistant to other IMiDs and bortezomib. This is the first report on a phase II clinical trial employing Pomalidomide (Pom) in genomically defined high risk RRMM. Methods: First cycle Pom was given at 4mg orally Days 1–21 every 28 days; dexamethasone (DEX) or bortezomib (BOZ) could be given in absence of PR or better from Cycle #3. In the absence of at least PR, Pom dose was escalated to 5mg. Cox regression modeling was employed for univariate and multivariate analyses, whereas Kaplan-Meier curves were used for overall survival (OS) and progression free survival (PFS). Results: 30 patients with RRMM were enrolled. Baseline characteristics included age >=65yr in 47%, ISS stage >=II was seen in 74% of patients, cytogenetic abnormalities (CA) within 6 months in 79%, and GEP-defined high risk in 66% by GEP70-gene model, 97% by GEP80-gene model, 13% had extramedullary disease (EMD), and 7% had secondary plasma cell leukemia (SPCL). 26/30 patients (87%) had prior autologous stem cell transplant, 23/30 patients (77%) had had at least 2 transplants. 22 patients (73%) had disease progression while on lenalidomide, bortezomib or both within 60 days of enrollment. At least 2 cycle of treatment were administered to 28 (93%) patients enrolled, 20 (67%) patients received >4 cycle of treatment and 16 (53%) received > 6 cycles. 15 patients (50%) discontinued therapy primarily due to progression or death. 5 (17%) patients achieved PR or better as best response. PFS benefit was observed in older patients (HR=0.29, p=0.008), with high LDH presenting an increased risk for OS (HR=14.64, p=0.013.) Most common toxicities, counting all toxicities (>=grade 3) were: thrombocytopenia (63%), leukopenia (63%), anemia (40%), hypophosphatemia (20%) and hypocalcemia (23%). Overall and progression- free survival at 12 months were 64% and 20%, respectively. Conclusions: The present trial is the first investigation evaluating Pom's clinical activity in high risk RRMM and demonstrates good anti-myeloma activity in this heavily pre-treated patient population. Given the activity in poor prognostic clinical features such as EMD and SPCL, there is precedence to evaluate Pom as an IMiD of choice in combination with other novel agents for this subset of RRMM. Download : Download high-res image (30KB) Download : Download full-size image Figure 1 . Kaplan-Meier Estimates of OS and PFS from Cycle 1. Table 1 . Drugs Administered by Cycle. Number of patients receiving given drug combinations in given cycle. (Note: the denominator used for calculating percentages is number of patients who started the cycle. In some columns, percentages do not add up to 100% because data was missing for some patients.) Cycle 1 (n=30) Cycle 2 (n=28) Cycle 3 (n=23) Cycle 4 (n=20) Cycle 5 (n=17) Cycle 6 (n=16) Pom alone 29 (100%) 28 (100%) 12 (52%) 7 (35%) 5 (29%) 4 (25%) Pom + Dex 0 (0%) 0 (0%) 9 (39%) 5 (25%) 5 (29%) 4 (25%) Pom + Vel 0 (0%) 0 (0%) 0 (0%) 1 (5%) 2 (12%) 2 (13%) Pom + Dex + Vel 0 (0%) 0 (0%) 1 (4%) 6 (30%) 4 (24%) 3 (19%) Disclosures: No relevant conflicts of interest to declare.

Background To investigate and examine the factors associated with initiation of, and exclusive breastfeeding at hospital discharge of, late preterm (34 0/7 - 36 6/7 weeks) compared to 37 week gestation (37 0/7 - 37 6/7 week) mother and baby pairs. Methods A retrospective population-based cohort study using a Perinatal National Minimum Data Set and clinical medical records review, at the Royal Hobart Hospital, Tasmania, Australia in 2006. Results Late preterm and 37 week gestation infants had low rates of initiation of breastfeeding within one hour of birth, 31 (21.1%) and 61 (41.5%) respectively. After multiple regression analysis, late preterm infants were less likely to initiate breastfeeding within one hour of birth (OR 0.3 95% CI 0.1, 0.7 p = 0.009) and were less likely to be discharged exclusively breastfeeding from hospital (OR 0.4 95% CI 0.1, 1.0 p = 0.04) compared to 37 week gestation infants. Conclusion A late preterm birth is predictive of breastfeeding failure, with late preterm infants at greater risk of not initiating breastfeeding and/or exclusively breastfeeding at hospital discharge, compared with those infants born at 37 weeks gestation. Stratifying breastfeeding outcomes by gestational age groups may help to identify those sub-populations at greatest risk of premature cessation of breastfeeding.

Abstract 2896 Background: Focal lesions (FL) are a well-recognized consequence of active multiple myeloma (MM), and distinguish it from its antecedent monoclonal gammopathy of undetermined significance (MGUS). We have recently reported on the superior performance of gene expression profiling (GEP) based on random trephine bone marrow aspirate sampling (RS) in distinguishing between 85% of patients with low-risk (LO) MM and 15% with high-risk (HI) MM compared to conventional prognostic variables. MM occasionally presents as macro-focal disease, in which cases RS may be inconclusive because of paucity of malignant cells in the sample. Here we report the comparison of GEP data from paired FL and RS samples from 106 untreated patients. Methods: We identified 106 newly diagnosed patients with paired samples, who were treated on Total Therapy (TT) protocols (3 in TT2, 19 in TT3, 75 in TT4, and 9 in TT5) in our multiple myeloma database. GEP risk scores, molecular subgroup classifications, overall survival (OS), and event-free survival (EFS) were compared and tested with the RS-derived 70-gene risk prediction and molecular subgroup classification models. Results: GEP defined molecular subgroups were correlated in 90 of 106 patients (85%). Looking at GEP-defined risk designation, we found a high degree of correlation between RS and FL samples with 95 of 106 samples showing the same designation (90%). For the 11 patients with divergent GEP designations, 8 (73%) were located at the boundary of the RS GEP risk score cutoff of +0.66 (range +0.43 to +0.84). For these risk designation-divergent patients, FL- but not RS-defined risk determined clinical outcome. Conclusion: Both the 70-gene risk prediction and molecular subgroup classification models can be used in FL-GEP samples. But, more importantly, for patients with RS-GEP risk score close to cutoff boundary (about 14% in our current data sets), FL-GEP provides better risk stratification, suggesting that the FL signal more adequately reflects to disease biology, progression and treatment response in MM. We therefore recommend that, for patients with borderline RS-based GEP risk scores, FL-GEP be used for staging and prognosis assessment in myeloma. Studies are in progress to determine, among multiple FL samples from the same patient, the variability in risk score compared to multiple RS samples. Disclosures: Shaughnessy: Myeloma Health, Celgene, Genzyme, Novartis: Consultancy, Employment, Equity Ownership, Honoraria, Patents & Royalties. Barlogie:Celgene: Consultancy, Honoraria, Research Funding; IMF: Consultancy, Honoraria; MMRF: Consultancy; Millennium: Consultancy, Honoraria, Research Funding; Genzyme: Consultancy; Novartis: Research Funding; NCI: Research Funding; Johnson & Johnson: Research Funding; Centocor: Research Funding; Onyx: Research Funding; Icon: Research Funding.

This article reports a qualitative study investigating patients’ experiences of ongoing smoking or smoking cessation after hospitalisation for an acute coronary syndrome (myocardial infarction or unstable angina) and describes how study participants spoke about the role of their doctors in smoking cessation. We invited individuals who had been admitted to an Australian public hospital in 2005 with a discharge diagnosis of an acute cardiac syndrome and who were smokers at the time of their hospitalisation to participate. Participants underwent a semi-structured interview and ongoing smokers also completed a ‘stages of change’ questionnaire. In total, 35 participants were interviewed, including 14 who were no longer smoking at least 12 months after their admission and 21 who were. Findings gave insight into the ways that cardiac patients perceive smoking cessation advice from their doctors, the perceived stigma of smoking and how lay understandings about smoking and smoking cessation emphasise the role of choice and individual responsibility. Our findings also indicate considerable scope for GPs and other doctors to offer better smoking cessation support to patients with established cardiovascular disease, particularly after a period of hospitalisation when the majority are highly motivated to stop smoking.

Upper respiratory tract infections (URTIs) in children are a frequent presentation in Australian general practice. However, there is limited Australian evidence about why parents decide to consult a doctor for childhood URTIs. Our objective was to design a qualitative pilot study aiming to explore this issue using semi-structured interviews. Interviews were conducted with nine parents. We found that cough, fever and abnormal behaviour of the child prompted a consultation with the general practitioner (GP). Parents sought an examination of their child (in particular "hidden areas" such as ears and throat) and reassurance, rather than antibiotics. They also wanted the GP to suggest practical ways to help alleviate their child's symptoms. The results provide a greater understanding of the fears, concerns and beliefs of parents of children with URTIs and hence may improve the GP - parent consultation. Health providers may be encouraged to address the specific parental concerns emerging from this study.

This article describes results from a community initiated qualitative research project investigating barriers to the provision of care for people with dementia (PWD) and their carers. The study was conducted in a rural remote Tasmanian community ("Cape Coastal"). Focus group discussions were held with family member carers of PWD, members of the Aged Care Assessment Team (ACAT), nurses employed in the local hospital and a local nursing home, community health nurses and local general practitioners. In addition, two semi-structured interviews were conducted with a dementia support worker allocated to service the region and a single family member carer. Barriers to the effective provision of care for PWD and their carers were identified. These were: distance and isolation; perceptions of geographic and professional boundaries including issues of medical dominance; and gaps in health care provider and carers? knowledge about dementia and dementia services. These results demonstrate that while Cape Coastal has many points in common with other rural and remote communities in Australia and in Canada and the United States (Australian Institute of Health and Welfare [AIHW], 2002), it is important to recognise local context when planning and providing services for PWD and other chronic diseases.