Inadequate pelvic radiographs: implications of not getting it right the first time

Introduction Pelvic radiography is a frequent investigation. European guidelines aim to ensure appropriate use and adequate quality. When initial images are inadequate, repeat radiographs are often required, which may have significant patient safety and economic implications. Objectives The study aimed to assess the adequacy of pelvic imaging across three orthopaedic centres, to identify causes for inadequate imaging and to establish the cost of inadequate imaging from financial and patient safety perspectives. Methods Pelvic radiographs were identified on Picture Archiving and Communication System software at three UK hospitals. Radiographs were assessed against European guidelines and indications for repeat imaging were analysed. Results A total of 1,531 sequential pelvic radiographs were reviewed. The mean age of patients was 60 years (range 5 months to 101 years). Of this total, 51.9% of images were suboptimal, with no significant difference across the three hospitals (P > 0.05). Hospital 3 repeated radiographs in 6.3% of cases, compare with 18.1% and 19.7% at hospitals 1 and 2, respectively (P > 0.05). Hospital 3 identified pathology missed on the initial radiograph in 1% of cases, compared with 5.4% and 5.5% at hospitals 1 and 2, respectively (P > 0.05). Out-of-hours imaging is associated with a higher rate of suboptimal quality (69.1%) compared with normal working hours (51.3%; P = 0.006). Adequacy rates vary with age (χ ² = 43.62, P < 0.001). Risk of having a suboptimal radiograph increases above the age of 60-years (χ ² = 4.45, P < 0.05). The annual cost of repeat radiographs was £56,200 per hospital. Discussion and conclusion High rates of pelvic radiograph inadequacy can lead to missed pathology and the requirement for repeat imaging, which has significant patient safety and financial implications. Risk factors for inadequate radiographs include older patients and those having out-of-hours imaging.

Abstract NTOC-097: VACCINATION TARGETING INSULIN–LIKE GROWTH FACTOR BINDING PROTEIN–2 (IGFBP–2) IN ADVANCED OVARIAN CANCER: SAFETY, IMMUNOGENICITY, AND SURVEILLANCE, EPIDEMIOLOGY, AND END RESULTS (SEER) COMPARISON

BACKGROUND: Immunization against self-antigens can induce regulatory responses that inhibit desirable Type 1 antitumor immune responses. Deletion of epitopes that favor a regulatory phenotype may improve the efficacy of therapeutic vaccines. We have developed a novel IGFBP-2 targeting DNA plasmid vaccine that selectively induces Type 1 immunity. IGFBP-2 regulates invasiveness and metastases in ovarian cancer. Eradication of ovarian cancer cells expressing IGFBP-2 through effective immunization could prevent disease relapse or metastasis.

METHODS: Twenty-five patients with advanced stage or recurrent ovarian cancer treated to complete remission after primary or salvage therapy received 3 monthly doses of an IGFBP-2 DNA vaccine in a single-arm, non-randomized study. ELISPOT and flow cytometry were used to characterize antigen specific T-cell responses. Serum antibodies were measured using ELISA and Western blot. The SEER database was reviewed to identify women diagnosed between 2006 and 2012 matched for age, year of diagnosis and stage of diagnosis. The difference between dates of diagnosis and enrollment (lead time) was calculated for each patient receiving vaccine. Only SEER patients who survived at least as long as the lead time of their matches plus an additional 6 months were kept for analysis. In cases where this resulted in no SEER matched patients, unmatched vaccine patients were excluded. Overall survival (OS) was analyzed using Cox models and the Kaplan-Meier method.

RESULTS: 206 adverse events (AE) were recorded. Fatigue (12%) and injection site reactions (12%) were the most common. 97% of AE were grades 1-2, 3% grade 3, and no grades 4 or 5. In preliminary immune analysis (16 patients), IGFBP-2 specific T-cell precursor frequencies are significantly elevated over baseline levels at 4 (p&lt;0.01) and 6 (p&lt;0.001) months. T-regulatory cells were not increased over the levels measured in a control reference population. No patients developed new IGFBP-2 specific antibody responses after immunization suggesting a lack of Th2 augmentation. Median OS for the matched SEER group (n=754) was 11 months. Matched IGFBP-2 vaccinated patients (n=20) have yet to reach median OS, but the lower 95% confidence limit is 27.3 months (p&lt;0.0001).

CONCLUSIONS: IGFBP-2 Th1 selective immunization is well tolerated, generates significant Type I immunity, and may demonstrate clinical efficacy.

Citation Format: John B. Liao, Denise L. Cecil, Yushe Dang, Kelsey K. Baker, Kelsie J. Ovenell, Jessica Reichow, Stephanie Parker, Doreen M. Higgins, Jennifer S. Childs, Elizabeth K. Broussard, Andrew L. Coveler, Lupe G. Salazar, Barbara A. Goff, Mary W. Redman, Mary L. Disis. VACCINATION TARGETING INSULIN–LIKE GROWTH FACTOR BINDING PROTEIN–2 (IGFBP–2) IN ADVANCED OVARIAN CANCER: SAFETY, IMMUNOGENICITY, AND SURVEILLANCE, EPIDEMIOLOGY, AND END RESULTS (SEER) COMPARISON [abstract]. In: Proceedings of the 11th Biennial Ovarian Cancer Research Symposium; Sep 12-13, 2016; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(11 Suppl):Abstract nr NTOC-097.

Management practices associated with stress in cattle on western Canadian cow-calf operations: A mixed methods study

Handling, weaning, and euthanasia are some of the most stressful practices performed on cow-calf operations. Although strategies to minimize stress exist, their use on western Canadian cow-calf operations is unknown. The objectives were to describe current stress-associated practices on western Canadian cow-calf operations, describe producer and operation demographics associated with the use of nonabrupt weaning methods, and explore producer perceptions toward these practices. A questionnaire focusing on stressful management practices was delivered to 109 cow-calf producers in western Canada. Fifteen respondents were purposively selected for individual interviews. The majority of producers reported calves less than 1 wk of age were handled by manual restraint (87%) and those older than 1 wk of age were handled using a cattle squeeze or table. Most producers performed abrupt weaning (70%). Interviewees often mentioned that cost and logistics were major factors in deciding on a weaning strategy. Pasture availability and facilities were viewed as constraints toward the adoption of a nonabrupt weaning method. Animal stress was considered, as producers expressed concern that nonabrupt weaning methods may cause increased stress because of the additional handling required. Producers conveyed that animal age was a major factor that impacted weaning stress and that improved animal performance might motivate them to adopt a nonabrupt weaning strategy. Producers also expressed reluctance to change previously successful traditional approaches. Of respondents, 13% did not euthanize cattle on farm and 8% did not confirm death. Producers interviewed reported that the decision to euthanize cattle on farm was difficult and that veterinary advice was often considered. Factors that influenced their decision to euthanize included the animal's likelihood of recovery and degree of pain and distress. Finally, producers explained that they considered whether the animal was salvageable and able to be transported. Identification of common methods of handling provides focus for future research to determine optimal handling strategies. Identified barriers to nonabrupt weaning may be addressed through research, extension, or policy to encourage the adoption of weaning methods that could improve animal welfare. Confirmation of death after euthanasia was identified as an area that needs to be addressed by producer education to minimize animal stress during on-farm euthanasia.

A review of a pleural service

This paper reviews the organisation and outcomes of a pleural service, specifically geared towards the management of malignant pleural effusions, in a district general hospital in the north east of England. We summarise the evidence behind local anaesthetic thoracoscopy and indwelling pleural catheters. We then summarise the review of our service, including a discussion around complications.

Calibration with confidence: a principled method for panel assessment

Frequently, a set of objects has to be evaluated by a panel of assessors, but not every object is assessed by every assessor. A problem facing such panels is how to take into account different standards among panel members and varying levels of confidence in their scores. Here, a mathematically based algorithm is developed to calibrate the scores of such assessors, addressing both of these issues. The algorithm is based on the connectivity of the graph of assessors and objects evaluated, incorporating declared confidences as weights on its edges. If the graph is sufficiently well connected, relative standards can be inferred by comparing how assessors rate objects they assess in common, weighted by the levels of confidence of each assessment. By removing these biases, 'true' values are inferred for all the objects. Reliability estimates for the resulting values are obtained. The algorithm is tested in two case studies: one by computer simulation and another based on realistic evaluation data. The process is compared to the simple averaging procedure in widespread use, and to Fisher's additive incomplete block analysis. It is anticipated that the algorithm will prove useful in a wide variety of situations such as evaluation of the quality of research submitted to national assessment exercises; appraisal of grant proposals submitted to funding panels; ranking of job applicants; and judgement of performances on degree courses wherein candidates can choose from lists of options.

Results of the ICTuS 2 Trial (Intravascular Cooling in the Treatment of Stroke 2)

BACKGROUND AND PURPOSE

Therapeutic hypothermia is a potent neuroprotectant approved for cerebral protection after neonatal hypoxia-ischemia and cardiac arrest. Therapeutic hypothermia for acute ischemic stroke is safe and feasible in pilot trials. We designed a study protocol to provide safer, faster therapeutic hypothermia in stroke patients.

METHODS

Safety procedures and 4°C saline infusions for faster cooling were added to the ICTuS trial (Intravascular Cooling in the Treatment of Stroke) protocol. A femoral venous intravascular cooling catheter after intravenous recombinant tissue-type plasminogen activator in eligible patients provided 24 hours cooling followed by a 12-hour rewarm. Serial safety assessments and imaging were performed. The primary end point was 3-month modified Rankin score 0,1.

RESULTS

Of the intended 1600 subjects, 120 were enrolled before the study was stopped. Randomly, 63 were to receive hypothermia plus antishivering treatment and 57 normothermia. Compared with previous studies, cooling rates were improved with a cold saline bolus, without fluid overload. The intention-to-treat primary outcome of 90-day modified Rankin Score 0,1 occurred in 33% hypothermia and 38% normothermia subjects, odds ratio (95% confidence interval) of 0.81 (0.36-1.85). Serious adverse events occurred equally. Mortality was 15.9% hypothermia and 8.8% normothermia subjects, odds ratio (95% confidence interval) of 1.95 (0.56-7.79). Pneumonia occurred in 19% hypothermia versus 10.5% in normothermia subjects, odds ratio (95% confidence interval) of 1.99 (0.63-6.98).

CONCLUSIONS

Intravascular therapeutic hypothermia was confirmed to be safe and feasible in recombinant tissue-type plasminogen activator-treated acute ischemic stroke patients. Protocol changes designed to reduce pneumonia risk appeared to fail, although the sample is small.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01123161.

The effect of instrument lubricant on the diametral tensile strength and water uptake of posterior composite restorative material

OBJECTIVES

This in-vitro study investigated the effect of 'instrument lubricants' used during placement of composite restorative material, on the diametral tensile strength (DTS) and water uptake of composite specimens.

METHODS

300 posterior composite cylindrical specimens were manufactured: 60 with each instrument lubricant (ethanol, 3-step, 2-step and 1-step 'bonding agent') and 60 with no lubricant (controls). Each set of 60 specimens was evenly allocated to one of the following test groups (n=100/group): Group 1 - tested for DTS immediately after manufacture; Groups 2 and 3 - tested for DTS after immersion in phosphate-buffered saline (PBS) for 1 and 12-weeks respectively, using a Universal Instron machine. Water uptake was assessed gravimetrically. Data were statistically analysed with two-way ANOVA and Tukey's post hoc test (α=0.05).

RESULTS

The mean DTS and percentage weight change of composite specimens ranged between 32.49-53.14MPa and 0.51-1.36% and varied with lubricant used and time incubated in PBS. All control groups exhibited significantly higher DTS (MPa) (groups 1-3: 53.17±1.78; 50.64±1.85; 45.17±1.77) and lower percentage weight change (groups 2-3: 0.51±0.03; 0.61±0.01) than specimens placed with an instrument lubricant, with significant differences between certain lubricant groups.

CONCLUSION

Data from the present study suggest that the use of instrument lubricant may adversely effect the DTS and water uptake of composite restorative material.

CLINICAL SIGNIFICANCE

The use of instrument lubricants to aid composite placement is widespread however based on the data obtained it is suggested that discontinuing or limiting the use of instrument lubricants, and if necessary using the 'bonding agent' from a 3-step adhesive system is recommended as results suggest this has the least deleterious effect upon material properties.​.

The burden of bone, native joint and soft tissue infections on orthopaedic emergency referrals in a city hospital

Introduction Bone, native joint and soft tissue infections are frequently referred to orthopaedic units although their volume as a proportion of the total emergency workload has not been reported previously. Geographic and socioeconomic variation may influence their presentation. The aim of this study was to quantify the burden of such infections on the orthopaedic department in an inner city hospital, determine patient demographics and associated risk factors, and review our current utilisation of specialist services. Methods All cases involving bone, native joint and soft tissue infections admitted under or referred to the orthopaedic team throughout 2012 were reviewed retrospectively. Prosthetic joint infections were excluded. Results Almost 15% of emergency admissions and referrals were associated with bone, native joint or soft tissue infection or suspected infection. The cohort consisted of 169 patients with a mean age of 43 years (range: 1-91 years). The most common diagnosis was cellulitis/other soft tissue infection and the mean length of stay was 13 days. Two-thirds of patients (n=112, 66%) underwent an operation. Fifteen per cent of patients were carrying at least one blood borne virus, eleven per cent were alcohol dependent, fifteen per cent were using or had been using intravenous drugs and nine per cent were homeless or vulnerably housed. Conclusions This study has shown that a significant number of patients are admitted for orthopaedic care as a result of infection. These patients are relatively young, with multiple complex medical and social co-morbidities, and a long length of stay.

Evaluation of antimicrobial photodynamic therapy with indocyanine green and curcumin on human gingival fibroblast cells: An in vitro photocytotoxicity investigation

Recent investigations have suggested that antimicrobial photodynamic therapy (aPDT) can be an alternative treatment for the management of periodontal infections. However, currently there is very limited data regarding the photocytotoxicity of this method on human gingival fibroblast (HuGu) cells.

AIM

The in vitro optimal concentrations of indocyanine green (ICG) and curcumin as photosensitizers (PSs) and the irradiation time of diode laser emission were evaluated by assessing the photocytotoxicity of the treatment on HuGu cells.

MATERIALS AND METHOD

Monolayers of HuGu cells were incubated with various final concentrations of ICG (500, 750, 1000, 1250, 1500, 1750, and 2000μg/ml) and curcumin (3, 4, 5, 10, and 20mM). Three exposure times of the diode laser (30s, 60s, and 2×30s irradiation with an interval of 1min between each) and one of exposure time of 5min for LED were tested; cell viability was determined using neutral red assay. Chlorhexidine (CHX) as a gold standard antimicrobial agent for periodontal disease was considered as a control group.

RESULTS

ICG and curcumin significantly reduced HuGu cell viability at concentrations below 1000μg/ml and 10mM, respectively (P<0.01). Cytotoxicity was higher when the cells were treated for 2×30s irradiation with an interval of 1min and then again exposed to the laser for 30s (2% and 0.1%). CHX demonstrated no significant reduction in HuGu cell survival.

CONCLUSION

Photocytotoxicity is influenced by PS concentration, exposure time of PS, and time of irradiation. High doses of ICG and curcumin with lowest exposure time of light source and without cytotoxic effects may be an effective strategy for aPDT as an alternative treatment for periodontal disease.

Mental health literacy: focus on developing countries

Mental health literacy refers to knowledge and beliefs about mental disorders which aid their recognition, management and prevention. This is a non-systematic review of published articles on mental health literacy in the general population and among primary healthcare workers, in particular, in developing countries, sourced from Medline, PsychInfo and African Healthline databases (1990-2006). Our review of the literature suggests that public knowledge about mental disorders as medical conditions, and their evidence based treatment strategies, in developing countries may be generally poorly or inaccurately understood. The review also reveals that improving the mental health literacy among primary health care professionals is imperative. Poor mental health literacy can be an obstacle to providing treatment for those in need, and is of particular concern in low and middle-income countries where mental health services are already scarce. It is likely that strategies for improvement will need to be comprehensive and innovative, taking advantage of opportunities and meeting challenges faced in the developing world.

Endochondral Growth Defect and Deployment of Transient Chondrocyte Behaviors Underlie Osteoarthritis Onset in a Natural Murine Model

OBJECTIVE

To explore whether aberrant transient chondrocyte behaviors occur in the joints of STR/Ort mice (which spontaneously develop osteoarthritis [OA]) and whether they are attributable to an endochondral growth defect.

METHODS

Knee joints from STR/Ort mice with advanced OA and age-matched CBA (control) mice were examined by Affymetrix microarray profiling, multiplex polymerase chain reaction (PCR) analysis, and immunohistochemical labeling of endochondral markers, including sclerostin and MEPE. The endochondral phenotype of STR/Ort mice was analyzed by histologic examination, micro-computed tomography, and ex vivo organ culture. A novel protocol for quantifying bony bridges across the murine epiphysis (growth plate fusion) using synchrotron x-ray computed microtomography was developed and applied.

RESULTS

Meta-analysis of transcription profiles showed significant elevation in functions linked with endochondral ossification in STR/Ort mice (compared to CBA mice; P < 0.05). Consistent with this, immunolabeling revealed increased matrix metalloproteinase 13 (MMP-13) and type X collagen expression in STR/Ort mouse joints, and multiplex quantitative reverse transcriptase-PCR showed differential expression of known mineralization regulators, suggesting an inherent chondrocyte defect. Support for the notion of an endochondral defect included accelerated growth, increased zone of growth plate proliferative chondrocytes (P < 0.05), and widespread type X collagen/MMP-13 labeling beyond the expected hypertrophic zone distribution. OA development involved concomitant focal suppression of sclerostin/MEPE in STR/Ort mice. Our novel synchrotron radiation microtomography method showed increased numbers (P < 0.001) and mean areal growth plate bridge densities (P < 0.01) in young and aged STR/Ort mice compared to age-matched CBA mice.

CONCLUSION

Taken together, our data support the notion of an inherent endochondral defect that is linked to growth dynamics and subject to regulation by the MEPE/sclerostin axis and may represent an underlying mechanism of pathologic ossification in OA.

Abstract WMP64: Door to Groin Puncture Times in Patients Managed on a Mobile Stroke Unit: Pilot Data

Introduction: The BEST-MSU study is an ongoing comparison of management of acute ischemic stroke (AIS) on a mobile stroke unit (MSU) versus standard management (SM) by emergency medical services. Recent trials have demonstrated that intra-arterial therapy (IAT) is safe and effective in select AIS patients. MSU management may allow prescreening and reduce door to groin puncture time (DTG).

Objective: The purpose of this analysis is to look at IAT metrics in order to determine the sample size needed to compare MSU versus SM.

Methods: Using preliminary data including data from the unblinded "run-in" phase, we identified 12 AIS patients (5/15/14-6/30/15) evaluated by MSU within 4.5 hours from last-seen-normal who went on to IAT. We report DTG and calculated the sample size needed to show a reduction of at least 30 minutes. We also did a preliminary analysis of DTG trends over time.

Results: Baseline characteristics and clinical variables for our pilot patients are found in the table. In cases when the MSU pre-notified the inpatient stroke team and the patient was taken straight to CTA scan from the ambulance, DTG were 80 and 66 minutes. In general, over time the frequency of patients on MSU who underwent IAT increased and DTG decreased (Figure) but small sample size precludes statistical conclusions. Given the mean DTGs and variability, to be 80% confident with a 5% significance level that the MSU will shorten these times by at least 30 minutes, 46 patients will be needed in each group.

Conclusion: MSU management may reduce DTG, but further study is needed to detect any difference between MSU and SM, as well as to address longterm outcomes.

Abstract TP362: Early Hematoma Enlargement in Intracerebral Hemorrhage Patients on the Mobile Stroke Unit

Introduction: Hematoma enlargement (HE) in intracerebral hemorrhage (ICH) possibly occurs soon after onset but is not captured due to delays in imaging. The Mobile Stroke Unit (MSU) can identify ICH patients in the prehospital setting and can increase our understanding of ICH patients in the first hour of onset.

Methods: This was a prospective, observational study to examine patients within 4 hours of symptom onset and early HE in ICH due to hypertension and/or coagulopathies. A baseline head CT (HCT) was performed on the MSU, followed by a 1-hour HCT at the destination hospital. Patients during MSU control weeks were included but not required to have a 1-hour HCT. Blood pressure was treated to a systolic goal of <150mmHg. Hematoma volume (HV) was measured by the ABC/2 method. HE was defined as an increase in HV by >6cc or >30% between scans. Patients were categorized by time to first HCT (≤61min, 62-120min, and 120-270min). Overall HE for each group was calculated using the scan nearest to 24 hours. HE on the 1-hour HCT was calculated for the ≤61min group and for the all patients collectively. The additional HE between the 1-hour HCT and scan nearest to 24 hours was also captured.

Results: Twenty-three patients (19 MSU) were included. Four of 8 (50%) patients in the ≤61min group, 3/7 (42.9%) in the 62-120min group, and 3/8 (37.5%) in the 120-270min group had HE in the first 24hrs, p=1.0 (Figure 1). Among the patients who had a 1-hour HCT, the incidence of HE over the first hour in the ≤61min group was 0.4 (2/5) and 0.36 (4/11) for all 3 groups. Additional HE beyond the 1-hour HCT occurred in only 1/9 patients (no follow up scan in 2 patients).

Conclusion: There was a high incidence of HE 1 to 2 hours after onset in ICH patients. This period may be an optimal window for treatment. Limitations include a small sample size and confounding due to early intervention in the MSU group. A larger study is currently ongoing.

Benefits of Stroke Treatment Using a Mobile Stroke Unit Compared With Standard Management: The BEST-MSU Study Run-In Phase

BACKGROUND AND PURPOSE

Faster treatment with intravenous tissue-type plasminogen activator (tPA) is likely to improve outcomes. Optimizing prehospital triage by mobile stroke units (MSUs) may speed treatment times. The Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit (BEST-MSU) study was launched in May 2014 using the first MSU in the United States to compare stroke management using an MSU versus standard management (SM). Herein, we describe the results of the prespecified, nonrandomized run-in phase designed to obtain preliminary data on study logistics.

METHODS

The run-in phase consisted of 8 MSU weeks when all-patient care occurred on the MSU and 2 SM weeks when the MSU nurse met personnel on scene or at the emergency department to ensure comparability with MSU patients. Telemedicine was independently performed in 9 MSU cases.

RESULTS

Of 130 alerts, 24 MSU and 2 SM patients were enrolled. Twelve of 24 MSU patients received tPA on board; 4 were treated within 60 minutes of last seen normal, and 4 went on to endovascular treatment. There were no hemorrhagic complications. Four had primary intracerebral hemorrhage. Agreement on tPA eligibility between the onsite and telemedicine physician was 90%.

CONCLUSIONS

The run-in phase provided a tPA treatment rate of 1.5 patients per week, assured us that treatment within 60 minutes of onset is possible, and enabled enrollment of patients on SM weeks. We also recognized the opportunity to assess the effect of the MSU on endovascular treatment and intracerebral hemorrhage. Challenges include the need to control biased patient selection on MSU versus SM weeks and establish inter-rater agreement for tPA treatment using telemedicine.

A case of granulomatous slack skin cutaneous T-cell lymphoma: PET/CT imaging findings

A 24-year-old female presented with granulomatous slack skin (GSS) cutaneous T-cell lymphoma. The patient underwent systemic chemotherapy. Owing to the development of several chemotherapy-related complications, therapy was discontinued. Subsequently, disease progression was noted clinically. Our patient’s disease progression was clearly demonstrated by 18F-fludeoxyglucose positron emission tomography (PET)/CT findings. PET/CT imaging findings of GSS have not yet previously been reported. In this report, we present PET/CT characteristics of a patient with GSS.

Implementing a mobile stroke unit program in the United States: why, how, and how much?

IMPORTANCE

There are many ways a mobile stroke unit (MSU) might prove valuable for patients with ischemic and hemorrhagic stroke, such as earlier recognition, more accurate triage, improved management of blood pressure and other critical physiological variables, and eventually earlier implementation of effective therapies. The MSU may be particularly valuable for treatment of patients with acute ischemic stroke with tissue plasminogen activator (tPA) within 4.5 hours of symptom onset, the most evidence-based effective emergency treatment for the most prevalent stroke diagnosis.

OBJECTIVES

To review existing data on prehospital stroke treatment, especially relevant to MSU technology, to identify gaps in our understanding of MSU feasibility, especially relevant to applying the MSU strategy in the United States, and to describe the Houston MSU program and clinical trial.

EVIDENCE REVIEW

Published data from English-language journals in PubMed from 1995 to present reviewing early treatment with tPA and prehospital stroke evaluation and treatment.

FINDINGS

The MSU may result in an overall shift toward earlier evaluation and treatment with tPA, particularly into the first hour after symptom onset, leading to substantially better outcomes. As a result of improved clinical outcomes owing to earlier treatment, the costs of an MSU program may be offset by a reduction in the costs of long-term stroke care and an increase in quality-adjusted life-years, thereby supporting more widespread use of this technology. To make MSU deployment more practical, the vascular neurologist aboard the MSU must be replaced by a remote vascular neurologist connected to the MSU by telemedicine, reducing manpower requirements and costs.

CONCLUSIONS AND RELEVANCE

The MSU strategy could dramatically transform the way acute stroke is managed in the United States. A prospective study evaluating the logistics, outcomes, and cost-effectiveness of this approach is needed and under way.

An in-vacuo optical levitation trap for high-intensity laser interaction experiments with isolated microtargets

We report on the design, construction, and characterisation of a new class of in-vacuo optical levitation trap optimised for use in high-intensity, high-energy laser interaction experiments. The system uses a focused, vertically propagating continuous wave laser beam to capture and manipulate micro-targets by photon momentum transfer at much longer working distances than commonly used by optical tweezer systems. A high speed (10 kHz) optical imaging and signal acquisition system was implemented for tracking the levitated droplets position and dynamic behaviour under atmospheric and vacuum conditions, with ±5 μm spatial resolution. Optical trapping of 10 ± 4 μm oil droplets in vacuum was demonstrated, over timescales of >1 h at extended distances of ∼40 mm from the final focusing optic. The stability of the levitated droplet was such that it would stay in alignment with a ∼7 μm irradiating beam focal spot for up to 5 min without the need for re-adjustment. The performance of the trap was assessed in a series of high-intensity (10(17) W cm(-2)) laser experiments that measured the X-ray source size and inferred free-electron temperature of a single isolated droplet target, along with a measurement of the emitted radio-frequency pulse. These initial tests demonstrated the use of optically levitated microdroplets as a robust target platform for further high-intensity laser interaction and point source studies.

Abstract 52: Establishing the First Mobile Stroke Unit in the United States

Background: A Mobile Stroke Unit (MSU) delivers Emergency Department (ED) care in the pre-hospital setting. We describe establishing the first MSU in the U.S.

Methods: A full time Medical Director and Project Manager took ownership of the project. A funding plan was developed to build,staff and supply the unit for 3 years. An ambulance company donated a standard ambulance. MSU build-out began after purchase of the CT scanner. A consortium of stakeholders was formed including leaders of the stroke programs and EDs of the city’s 3 Comprehensive Stroke Centers (CSCs) and Houston Emergency Medical Services (EMS). Policies and procedures were developed to obtain both state and city health department licensing and inspection, and an accountability system to maintain the unit to standards. Radiation safety certification was obtained from the state health department. Radiation safety experts inspected the vehicle,obtained rad. measurements and designed safety procedures,confirming minimal risk. Insurance on the vehicle and all equipment was obtained.

Staffing was hired,and a secure location to park the MSU with electrical hook-up and an office were located. An EMS education program was carried out and communication pathway developed enabling immediate MSU dispatch within a 5 mile radius following a 911 call, as well as for first-responders to activate the MSU. A study protocol was written to evaluate logistics,cost-effectiveness,telemedicine (TM) vs. on-scene decisions and patient outcomes. A HIPPA-compliant technology grid enabled viewing of CT images by the TM team and receiving hospital radiologist.

Results: The MSU effort began in March 2013 and the MSU received Feb 4, 2014. The Houston MSU is a standard 12’ ambulance staffed by a neurologist and registered nurse with stroke expertise, CT tech, and paramedic, with TM connectivity, responding to acute stroke dispatches daily from 8a-6p. All MSU management is standard of care; patient consent is not required except to include patient data. This includes a non-con head CT, point of care labs, blood pressure management and if necessary advanced life support.

Conclusion: The Houston MSU treated its first patient on May16,2014, and is carrying out acute stroke treatment within 10-18 minutes of arrival on location.

Abstract T P57: TEG Does Not Correlate with Clot Subtype or Clinical Response to tPA

Background: Thromboelastography (TEG) measures coagulation status in venous blood. tPA thrombolysis is affected by multiple variables including whether clots are erythrocyte or platelet-rich. We hypothesized that TEG would correlate with clot subtype and response to tPA including rapid clinical improvement (RCI), recanalization, and hemorrhagic transformation (HT).

Methods: 176 acute ischemic stroke patients between 11/09 and 06/14 treated with tPA were prospectively enrolled. Venous blood for TEG was drawn before and 10 minutes after tPA bolus. Pre-tPA measures of speed and strength of clot formation (R, Delta, K, Angle, MA, and G) and post-tPA measure of clot lysis (LY30) were analyzed. Hyperdense artery (HDA) on CT was a biomarker for erythrocyte-rich clot. RCI was defined as 8 point improvement on NIHSS or total NIHSS of 0,1 at 36 hours. HT was defined as any blood on follow up imaging within 36 hours. Recanalization was defined as resolution of baseline vascular occlusion on follow up CT or MR angiogram within 36 hours. Multivariable linear regression models compared TEG parameters after adjusting for potential confounding and interactive effects.

Results: No differences in pre- or post-tPA TEG were found between patients with (n=32) or without (n=102) RCI. Also, there was no correlation between TEG and HDA on CT. Clot strength was decreased in patients with recanalization (lower MA and G, p = 0.02 and p = 0.03). Clotting was slightly prolonged (longer delta, p = 0.046) in patients with HT.

Discussion: Our data do not show a robust association between TEG and clot subtype or clinical response to tPA. It is likely that arterial clot lysis is determined by factors unrelated to coagulation status as measured by TEG in the venous circulation. Though we found a correlation between TEG and recanalization, the number of patients with recanalization data was too small to detect an effect on clinical outcome. Similar to our previous findings, speed of clot formation may be related to risk of bleeding.

Conclusion: It is unlikely that TEG will be useful in guiding tPA therapy. Future research should focus on local arterial influences on clot lysis. Further study of TEG in hemorrhage is indicated.

Clot Strength as Measured by Thrombelastography Correlates with Platelet Reactivity in Stroke Patients

OBJECTIVE

Platelet reactivity may be important in the management of patients with stroke. However, degree of platelet reactivity has not been correlated with Thrombelastography (TEG(®)) parameters in stroke. We sought to detect a correlation between TEG(®) values and clot platelet reactivity in ex vivo clots of stroke patients.

METHODS

We collected venous blood from 40 patients with stroke. TEG(®) measurements were carried out and residual clots were fixed in 10% formalin immediately following completion of TEG(®). The formalin specimens were embedded in paraffin blocks, cut at 4 micrometers, and stained with CD 61 (immunohistochemical stain used to detect platelets) with appropriate controls. Under light microscopy, three pathologists blinded to TEG(®) results independently graded CD61 intensity (how aggregated/intense the CD61 stained) into a low and high group, as a proposed measurement representing the platelet reactivity of the clot. We compared pre-tPA-TEG(®) values among groups with different CD 61 intensities.

RESULTS

After adjusting for confounding factors, we found statistically significant correlation between CD61 staining and several TEG(®) parameters (Delta and CD61 staining intensity (p=0.047); Angle and CD61 staining intensity grade (p=0.04); and G and CD61 staining intensity grade (p=0.04)).

CONCLUSIONS

Clot strength on TEG(®) as measured by Delta, Angle, and G correlates with a clot with greater platelet reactivity.

Consequences of a missed ankle dislocation in an adolescent

Ankle dislocation without associated malleolar fracture(s) remains a rare presentation, especially in adolescence. Identified and treated promptly, these injuries can result in good to excellent outcome. We present an anterior ankle dislocation in a 14 year old, missed for approximately 12 months, necessitating multiple surgical interventions to provide a pain-free and stable joint. A review of the current literature is also provided.

The founding charter of the Genomic Observatories Network

The co-authors of this paper hereby state their intention to work together to launch the Genomic Observatories Network (GOs Network) for which this document will serve as its Founding Charter. We define a Genomic Observatory as an ecosystem and/or site subject to long-term scientific research, including (but not limited to) the sustained study of genomic biodiversity from single-celled microbes to multicellular organisms.An international group of 64 scientists first published the call for a global network of Genomic Observatories in January 2012. The vision for such a network was expanded in a subsequent paper and developed over a series of meetings in Bremen (Germany), Shenzhen (China), Moorea (French Polynesia), Oxford (UK), Pacific Grove (California, USA), Washington (DC, USA), and London (UK). While this community-building process continues, here we express our mutual intent to establish the GOs Network formally, and to describe our shared vision for its future. The views expressed here are ours alone as individual scientists, and do not necessarily represent those of the institutions with which we are affiliated.