The CT Swirl Sign Is Associated with Hematoma Expansion in Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

Hematoma expansion is an independent determinant of poor clinical outcome in intracerebral hemorrhage. Although the "spot sign" predicts hematoma expansion, the identification requires CT angiography, which limits its general accessibility in some hospital settings. Noncontrast CT, without the need for CT angiography, may identify sites of active extravasation, termed the "swirl sign." We aimed to determine the association of the swirl sign with hematoma expansion.

MATERIALS AND METHODS

Patients with spontaneous intracerebral hemorrhage between 2007 and 2014 who underwent an initial and subsequent noncontrast CT at a single center were retrospectively identified. The swirl sign, on noncontrast CT, was defined as iso- or hypodensity within a hyperdense region that extended across 2 contiguous 5-mm axial CT sections.

RESULTS

A total of 212 patients met the inclusion criteria. The swirl sign was identified in 91 patients with excellent interobserver agreement (κ = 0.87). The swirl sign was associated with larger initial hematoma (P < .001) and earlier initial CT (P < .001) and hematoma expansion (P = .028). Multivariable regression modeling demonstrated that if one assumed similar initial hematoma volume, onset-to-first scan, and time between CT scans, the median absolute hematoma growth was 5.77 mL (95% CI, 2.37-9.18 mL; P = .001) and relative growth was 35.6% (95% CI, 18.5%-52.6%; P < .001) higher in patients with the swirl sign compared with those without.

CONCLUSIONS

The NCCT swirl sign was reliably identified and is associated with hematoma expansion. We propose that the swirl sign be included in risk stratification of intracerebral hemorrhage and considered for inclusion in clinical trials.

Abstract B73: Examining colorectal cancer screening barriers and facilitators though a cultural lens: A mixed methods study of Chinese and Korean Americans

Background: Among Asian Americans, colorectal cancer (CRC) is the third most common cancer and second leading cause of cancer death. Although screening has been found to significantly reduce CRC mortality, Chinese and Korean Americans continue to report lower CRC screening rates than White and African Americans. Therefore, this study aims to examine the barriers and facilitators of CRC screening, taking into account a cultural perspective, in these underserved populations.

Methods: We employed a mixed methods study to gain further understanding regarding CRC screening behaviors among Asian Americans. Specifically, we collected quantitative data through surveys from 120 participants, who were self-identified Chinese and Korean Americans, aged 50 years and over. Multivariable-adjusted logistic regression was conducted to analyze survey data, independently assessing for receipt of colonoscopy and fecal occult blood test (FOBT). In addition, qualitative data from 17 key informant interviews (with physicians, health department employees, patient navigators, and community leaders) and 12 focus groups (n=120) were transcribed, translated to English, back-translated to ensure accuracy, coded, and analyzed for salient themes.

Results: Based on focus group findings, major cultural themes influencing CRC screening included language- and health-related attitudes and beliefs. In particular, participants identified having limited English proficiency, low health literacy, and reliance on children for translation as being key barriers. Thus, participants emphasized the importance of having linguistically appropriate services, such as patient navigators. Additional barriers included fearing a CRC diagnosis, having fatalistic views of CRC, and facing stigma towards cancer. In addition, quantitative analysis found that individuals who believed screening is not needed when asymptomatic were less likely to receive a colonoscopy (Odds Ratio (OR): 0.02; 95% Confidence Interval (CI): 0.002-0.23) and FOBT (OR: 0.16; 95% CI: 0.03-0.72). These findings were supported by key informants and focus group participants, who expressed that Chinese and Koreans often times do not prioritize preventive healthcare and believe that seeking healthcare is not necessary when symptoms are not noticeable. Moreover, this study corroborated previous findings of non-cultural factors influencing CRC screening such as cost, insurance, knowledge, and time -some of which were influenced by underlying cultural attitudes and beliefs. Patient-physician communication was another key influential factor. For instance, those having a doctor talk about [(OR: 6.1; 95% CI: 2.4-15.4) for colonoscopy; (OR: 3.1; 95% CI: 1.1-8.5) for FOBT)] or recommend CRC screening [(OR: 6.6; 95% CI: 2.6-16.7) for colonoscopy; (OR: 4.0; 95% CI: 1.4-11.2) for FOBT)] were more likely to have received screening.

Conclusions: Receipt of CRC screening is influenced by cultural and non-cultural factors, both of which need to be addressed in order to increase screening uptake among Chinese and Korean Americans. These findings can inform the development of more effective CRC screening programs and interventions that are culturally and linguistically tailored to these populations.

Citation Format: Sunmin Lee, Mary Jung, Xiaoxiao Lu, Jamie Sim, Diane Ng. Examining colorectal cancer screening barriers and facilitators though a cultural lens: A mixed methods study of Chinese and Korean Americans. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B73.

Neck and shoulder muscle activity during standardized work-related postural tasks

The aim of the present study was to assess the activity levels of the sternocleidomastoid muscle and upper trapezius muscle during static postures under controlled and standardized conditions, and to determine whether the muscle activity differed between sexes. Electromyographic (EMG) activity was recorded unilaterally from the sternocleidomastoid and upper trapezius muscle in 17 participants whilst they were performing various postural tasks. EMG amplitude was measured by the root mean square values of the raw signals and normalized to peak maximum contractile values for each muscle (%MVC). The intensity of muscle activity was ranked as light (<3%MVC), moderate (3%MVC ≤ EMG ≤ 8%MVC), and substantial (>8%MVC). During most tasks the two muscles contracted light to moderately. Head leaning and shoulder shrugging postures yielded substantial muscle activity in both muscles. Muscle activity did not differ significantly between male and female participants (F = 3.1; p = 0.078). Our findings provided normative values, which will enhance future studies of muscle activity during work in a natural, unrestrained environment.

Quinolizidine alkaloids obtained byPedicularis semibarbata (Scrophulariaceae) fromLupinus fulcratus (Leguminosae) fail to influence the specialist herbivoreEuphydryas editha (Lepidoptera)

Pedicularis semibarbata is apparently an obligate hemiparasite of coniferous trees. It is also a facultative parasite ofLupinus fulcratus from which we find that it obtains quinolizidine alkaloids, principally α-isolupanine. As a result, a single population ofP. semibarbata contains both alkaloidrich and alkaloid-free plants. The butterflyEuphydryas editha naturally oviposits on both plant types. This butterfly population, which is the principal herbivore attackingP. semibarbata at this site, is known to contain two morphs. Individuals of a specialist morph discriminate when ovipositing among individualP. semibarbata plants and produce offspring that survive better on accepted than on rejected plants. Those of a generalist morph accept allP. semibarbata plants and produce offspring that survive equally well on plants accepted or rejected by the discriminating morph. Because of the existence of this complex variation among the butterflies, the presence of naturally laid eggs on alkaloid-containing plants still leaves the possibility that the alkaloids may defend the plants against the specialist morph. In experiments on both oviposition preference and larval performance in early instars, we failed to detect any correlation between alkaloid content of a plant and either its acceptability to or suitability for the discriminating morph of the insect. Alkaloid presence in the host-plant population, achieved through root parasitism, is currently neither subject to strong insect-mediated selection nor a major cause of selection on the insects.

Would CLSI M53-A have helped in the diagnosis of HIV in Canada? Results of the performance of Canadian laboratories participating in a recent NLHRS proficiency testing panel containing HIV-1 antigen positive (antibody negative) and HIV-2 samples

INTRODUCTION

The Clinical and Laboratory Standards Institute recently published M53-A, Criteria for Laboratory Testing and Diagnosis of Human Immunodeficiency Virus (HIV) Infection; Approved Guideline (2011), which includes a state of the art algorithm for identifying HIV-1 acute and HIV-2 infections. To assess the ability of Canadian laboratories to detect these sample types and the impact of M53-A, the National Laboratory for HIV Reference Services distributed a special proficiency testing panel.

METHODS

HIVS425-2012Nov22 was sent to 42 laboratories across Canada. It contained one HIV negative sample (B), two HIV-1 positive samples (A and E), one HIV-2 positive sample (C) and one HIV-1/2 antibody negative-HIV-1 antigen positive sample (D). Data was collected and analyzed using DigitalPT; a standardized on-line tool.

RESULTS

Forty-one laboratories returned results. Sample B (HIV negative) was identified by 95% of laboratories (39/41) and samples A and E (HIV-1 positive) by 98% (40/41). No laboratory identified sample C as HIV-2 positive, although 85% (35/41) detected reactivity prompting a referral for further testing. The remaining laboratories identified sample C as HIV-1 positive (4), indeterminate (1) or gave no final status (1). Sample D (HIV antibody negative-antigen positive) was correctly identified by two laboratories as HIV-1 antigen positive while 78% (32/41) detected reactivity, recommending further testing. One laboratory did not provide a final status. Alarmingly, six laboratories called this sample HIV negative.

CONCLUSION

Although there is a high quality of HIV testing across Canada, introduction of the M53-A guideline would further improve the ability of laboratories to diagnose HIV-1 acute and HIV-2 infection.

Abstract P5-18-14: Cardiac monitoring during adjuvant trastuzumab therapy for breast cancer

Background: Adjuvant trastuzumab improves survival in HER2+ breast cancer. Cardiac toxicity is an important potential side effect. We report real world practice patterns in cardiac monitoring and outcomes during adjuvant trastuzumab therapy in Ontario.

Methods: A cohort of female patients diagnosed with early breast cancer from Jan 1, 2006 to Dec 31, 2007 and who received trastuzumab was identified retrospectively through linkage of provincial administrative and registry databases. Demographic, pathology, treatment, hospital admissions, claims for cardiac tests (MUGA or echo), and outcomes were extracted for individuals. Pre-existing cardiac disease (CHF, MI, angina, valve disorder, arrhythmia, cardiomyopathy) and risk factors (diabetes, lipid disorder, hypertension) were classified using ICD-10 codes. Appropriate cardiac monitoring definitions were based on published trials and expert opinion. Symptomatic cardiac toxicity was defined as a physician claim or hospital admission with a cardiac diagnosis occurring within 2 years of the first trastuzumab dose. Asymptomatic cardiac toxicity was defined as temporary or permanent cessation of trastuzumab with additional cardiac tests. Patients were categorized into treatment groups: G1 received at least 17 doses (standard 3-weekly administration for 51 weeks) with no complications; G2 stopped early for non-cardiac reasons (no additional cardiac tests); G3 had symptomatic or asymptomatic cardiac toxicity. Analyses of patient, treatment and system factors possibly affecting cardiac monitoring and toxicity were performed.

Results: 1,357 patients diagnosed with early breast cancer between 2006–7 received trastuzumab (median = 18 doses). 77% received anthracyclines; 4.1% had at least 1 cardiac risk factor. The majority (91%) had a baseline cardiac test, including 96% of those with cardiac risks. Geographic region was associated with baseline testing, but multivariable analysis of other factors including urbanicity, left lateral radiation, age, income, and anthracycline use, did not explain the variation in baseline testing patterns. The majority, 81%, had ≥3 cardiac tests, 62.2% had ≥4. Cardiac monitoring was deemed appropriate in 80.7% of patients without cardiac events, and 73.4% in those with symptomatic or asymptomatic cardiac events. Multivariable analysis revealed duration of trastuzumab to be the most significant factor associated with appropriateness of cardiac monitoring (G1 - OR 0.62, p = 0.018, 95% CI 0.45–0.92; G3 - OR 4.56, p &lt; 0.001, 95% CI 2.47–8.42). 297 patients (22%) experienced symptomatic (7%) or asymptomatic (15%) cardiac toxicity. Duration of trastuzumab (&lt;17 doses; OR 6.47, p &lt; 0.001, 95% CI 4.79–8.75) was associated with cardiac toxicity.

Conclusions: The majority of early breast cancer patients that received adjuvant trastuzumab in Ontario between 2006–7 had cardiac monitoring consistent with clinical trials. Cardiac toxicity in this real world population, as defined by our database analysis, was unexpectedly higher than reported in trials. Shorter duration of trastuzumab was associated with cardiac toxicity, likely reflecting the practice of stopping trastuzumab in the presence of cardiac events.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-18-14.

A prototype 64-electrode stimulator in 65 nm CMOS process towards a high density epi-retinal prosthesis

This paper presents a highly flexible 64-electrode stimulator using 65 nm CMOS process fabricated as a stage towards a 1024-electrode epi-retinal prosthesis, which aims to restore partial vision in patients suffering from eye diseases such as retinitis pigmentosa (RP) and age-related macular degradation (AMD). The stimulator drives 64 electrodes with many flexible features, which are necessary before making a complete 1024-electrode implant chip. Each electrode driver can provide a bi-phasic stimulus current with fully programmable parameters such as amplitude, pulse duration, inter-phase gap, and stimulation rate. The electrode driver operates in an alternately pull-push manner with only one current source working at a time, which helps reduce headroom voltage while controlling charge balance at the active electrode. The stimulator varies both stimulus current amplitude and stimulation rate to represent phosphene brightness. The stimulus current amplitude starts from the tissue depolarization threshold with 64 different levels. The selection of active and return electrodes is arbitrary, any electrodes and any number of them can be selected at any time. The power consumption of the stimulator is 400 μW excluding the stimulus power. Measurement results verify correct operation. The stimulator is easily scaled up to drive 1024 electrodes.

Informational stories: a complementary strategy for patients and caregivers with brain metastases

Objective

We compared the efficacy of a story-based writing style with that of a fact-based writing style for educational material on brain metastases.

Methods

Identical informational content on four topics—radiation therapy, side effects, steroid tapering, and palliative care—was constructed into equivalent story-based and fact-based materials. The content and reader preference for style were evaluated using a questionnaire of 20 + 1 items. Cancer patients and caregivers were invited to evaluate the materials.

Results

A total of 47 participants completed the questionnaire. The recorded preferences for facts, stories, or both were 42%, 7%, and 51% respectively (p = 0.0004). The fact-based materials were rated superior in providing factual information (for example, discussion of treatment, side effects) and selected general characteristics (clarity of information, for instance). A rating trend suggested that story-based materials were superior in describing “how it feels to have brain metastases” (21/40 fact-based vs. 26/43 story-based) and “how brain metastases affected a spouse” (17/41 fact-based vs. 21/47 story-based), and in being “sensitive to the frustrations of a patient with brain metastases” (25/40 fact-based vs. 30/44 story-based).

Conclusions

Half the participants preferred to read both fact-based and story-based materials. A combined story-based and fact-based educational resource may be more effective in conveying sensitive information and should be further investigated.

Binge eating, mood, and quality of life in youth with type 2 diabetes: baseline data from the today study

OBJECTIVE

The current study examines the prevalence of binge eating and its association with adiposity and psychosocial functioning in a large, diverse sample of youth with type 2 diabetes.

RESEARCH DESIGN AND METHODS

In the TODAY study, 678 (mean age 14.0 years; 64.9% girls) of the 704 youth randomized to the study completed a self-report measure of eating disorder symptoms and were categorized as nonovereaters, overeaters, subclinical binge eaters, or clinical binge eaters.

RESULTS

Youth with clinical (6%) and subclinical (20%) levels of binge eating had significantly higher levels and rates of extreme obesity, global eating disorder and depressive symptoms, and impaired quality of life.

CONCLUSIONS

These findings highlight the importance of evaluating youth with type 2 diabetes for the presence of binge eating. Future research is needed to determine the cumulative effects of disordered eating, obesity, and psychosocial distress on adherence to lifestyle change recommendations and longitudinal response to treatment.

A fully flexible stimulator using 65 nm CMOS process for 1024-electrode epi-retinal prosthesis

This paper presents a fully flexible stimulator using 65 nm CMOS process for a 1024-electrode epi-retinal prosthesis. The stimulator can select any number of electrodes at any time and also supports both mono-polar and multi-polar stimulation. Furthermore, the stimulator supports a wide range of stimulus parameters. A novel feature is that the electrode driver operates in an alternately pull-push manner, which helps reduce headroom voltage while guaranteeing charge balance at the active electrode. The use of positive supplies instead of both positive and negative supplies simplifies CMOS circuit design. The current distribution between two nearby simultaneously active electrode groups was investigated and measurement result showed a maximum current crosstalk of 8%.

Tetanus antibody protection among HIV-infected US-born patients and immigrants

INTRODUCTION

Public health initiatives to immunize children and adults have effectively reduced the number of tetanus cases in the USA. However, in the Third National Health and Nutrition Examination Survey (NHANES III), immigrants from Mexico had a 67% nonprotective anti-tetanus antibody (ATA) level. Less work has been conducted among other vulnerable populations such as human immunodeficiency virus (HIV)-infected patients. The objective of this study was to measure ATA levels among the HIV immigrant population compared with US-born HIV-infected patients.

METHODS

A convenience sample of 158 HIV-infected individuals was recruited to determine the levels of ATA. A nonprotective level of ATA was defined as below 0.15 IU/ml.

RESULTS

Among the HIV-infected patients, 72% (114/158) were born in the USA. A total of 17% (27/158) lacked protective levels of ATA. A total of 6.1% (7/114) of those born in the USA lacked protection, compared to 45% (20/44) born outside the USA (p < 0.0001).

CONCLUSION

The results illustrate that the country of birth is an important predictor of ATA protection, even among HIV-infected patients.

Role of Tc-99m DMSA (V) scanning and serum calcitonin monitoring in the management of medullary thyroid carcinoma

INTRODUCTION

Medullary thyroid carcinoma (MTC) is a rare disease. Serum calcitonin levels and Tc-99m DMSA (V) scans are used in the follow-up of these patients after surgical resection. We present our experience in the follow-up of these patients at a tertiary institution.

METHODS

A retrospective review of the medical records was performed. Patients with histologically-proven MTC, and who had serum calcitonin assays and DMSA (V) scans in their postoperative follow-up, were included.

RESULTS

There were 17 patients with 56 DMSA (V) scans. Four out of seven patients with elevated preoperative calcitonin measurements had calcitonin normalisation within six months of surgery, and have remained disease-free. Two patients had persistently elevated calcitonin levels after six months, which predated positive DMSA (V) scans. Results of DMSA (V) scans and serum calcitonin levels were concordant in 38 of 48 instances (79.2 percent) and discordant in 10 of 48 instances (20.8 percent). Sensitivity of DMSA (V) scans for detecting recurrence was 71.4 percent. There were no false-positive scans.

CONCLUSION

Serum calcitonin level is a sensitive and specific indicator of disease recurrence in postoperative follow-up of patients with MTC. Early (within six months) normalisation of calcitonin levels postsurgery may predict subsequent disease-free status. Discordant results between serum calcitonin levels and DMSA (V) scans may be due to undetectable lesions and follow-up scans or alternative radionuclide imaging may be required.

Pain characteristics and demographics of patients attending a university-affiliated pain clinic in Toronto, Ontario

BACKGROUND

Pain clinics tend to see more complex chronic pain patients than primary care settings, but the types of patients seen may differ among practices.

OBJECTIVE

The aim of the present observational study was to describe the pain and demographic characteristics of patients attending a university-affiliated tertiary care pain clinic in Toronto, Ontario.

METHODS

Data were collected on 1242 consecutive new patients seen over a three-year period at the Comprehensive Pain Program in central Toronto.

RESULTS

Musculoskeletal problems affecting large joints and the spine were the predominant cause of pain (more prevalent in women), followed by neuropathic disorders (more prevalent in men) in patients with recognizable physical pathology. The most affected age group was in the 35- to 49-year age range, with a mean pain duration of 7.8 years before the consultation. While 77% of the Comprehensive Pain Program patients had relevant and detectable physical pathology for pain complaints, three-quarters of the overall study population also had significant associated psychological or psychiatric comorbidity. Women, in general, attended the pain clinic in greater numbers and had less apparent physical pathology than men. Finally, less than one in five patients was employed at the time of referral.

CONCLUSIONS

The relevance of the data in relation to other pain clinics is discussed, as well as waiting lists and other barriers faced by chronic pain patients, pain practitioners and pain facilities in Ontario and Canada.

Is there a link between breast cancer and abortion: a review of the literature

The hormonal changes that take place in pregnancy cause breast tissue to proliferate and differentiate. Abortion interrupts this process and may leave the proliferated, undifferentiated breast tissue at higher risk of carcinogenesis. This review explains the supposed difference in effects of induced and spontaneous abortion upon the breast tissue and examines the literature for a link with breast cancer. Additional subcategories examined include parity, number of abortions, gestation, and maternal age at abortion. A comparison of retrospective and prospective studies is made and possible sources of bias are identified. There is no evidence to support a link between spontaneous abortion and breast cancer. Absence of a link with induced abortion is less clear, and further research should concentrate on investigating any relationship. We suggest that prospective research is used, with point of entry at first termination.