0947 Parent-Perceived Sleep Problems and Sleep Goals in Infants and Toddlers: A Global Sample

Introduction

The aim of this study was to assess parent perceptions of sleep problems in young children and parent-identified areas of change in a global sample.

Methods

Caregivers (95.6% mothers) of 1555 infants/toddlers (birth-37 mos; M=12.2 mos; 49.5% male) completed an online survey, representing Indonesia (n=187), Japan (n=718), New Zealand (n=231), Singapore (n=199), and Thailand (n=221). The survey included an abbreviated version of the Brief Infant Sleep Questionnaire, and a list of potential sleep-related areas of change.

Results

36.9% reported a perceived sleep-problem, whereas 92.9% indicated an area of desired change related to their child’s sleep. In terms of areas of change, 82.5% endorsed bedtime/how child falls asleep, 70.0% nighttime sleep, and 57.8% related to the morning. As expected, 99.7% of parents who endorsed a problem indicated a desired change compared to 88.9% who did not perceive a problem, p < .001. Those who noted a problem were more likely to endorse a change at bedtime (92.5%) and during the night (90.1%), compared to the morning (68.8%). There were country-based differences, with caregivers in New Zealand (47.0%) and Singapore (44.2%) more likely to report a child sleep problem compared to Thailand (35.3%), Japan (34.1%) and Indonesia (29.4%), p < .001. No differences were noted in parent-report of desired change across Japan, New Zealand, Singapore, and Thailand (94-96%) but were significantly higher than Indonesia (83.4%).

Conclusion

Although one-third of parents of young children in a global sample indicate a perceived sleep problem, almost all parents wish to change something about their child’s sleep, primarily relate to bedtime and during the night. Sleep education and assessment delivered by health care providers should focus not only on what families consider to be “problematic,” but also what families would like to modify, or improve, about their child’s sleep within a developmentally appropriate framework.

Support

Johnson & Johnson Consumer Inc., Skillman, NJ, USA.

Cost-effectiveness of physical fitness training for stroke survivors

Background Physical fitness is impaired after stroke, yet fitness training after stroke reduces disability. Several international guidelines recommend that fitness training be incorporated as part of stroke rehabilitation. However, information about cost-effectiveness is limited. Methods A decision tree model was used to estimate the cost-effectiveness of a fitness programme for stroke survivors vs. relaxation (control group). This was based on a published randomised controlled trial, from which evidence about quality of life was used to estimate Quality Adjusted Life Years. Costs were based on the cost of the provision of group fitness classes within local community centres and a cost per Quality Adjusted Life Year was calculated. Results The results of the base case analysis found an incremental cost per Quality Adjusted Life Year of £2,343. Conclusions Physical fitness sessions after stroke are a cost-effective intervention for stroke survivors. This information will help make the case for the development of new services.

Marine plastics threaten giant Atlantic Marine Protected Areas

There has been a recent shift in global perception of plastics in the environment, resulting in a call for greater action. Science and the popular media have highlighted plastic as an increasing stressor [1,2]. Efforts have been made to confer protected status to some remote locations, forming some of the world's largest Marine Protected Areas, including several UK overseas territories. We assessed plastic at these remote Atlantic Marine Protected Areas, surveying the shore, sea surface, water column and seabed, and found drastic changes from 2013-2018. Working from the RRS James Clark Ross at Ascension, St. Helena, Tristan da Cunha, Gough and the Falkland Islands (Figure 1A), we showed that marine debris on beaches has increased more than 10 fold in the past decade. Sea surface plastics have also increased, with in-water plastics occurring at densities of 0.1 items m^-3; plastics on seabeds were observed at ≤ 0.01 items m^-2. For the first time, beach densities of plastics at remote South Atlantic sites approached those at industrialised North Atlantic sites. This increase even occurs hundreds of meters down on seamounts. We also investigated plastic incidence in 2,243 animals (comprising 26 species) across remote South Atlantic oceanic food webs, ranging from plankton to seabirds. We found that plastics had been ingested by primary consumers (zooplankton) to top predators (seabirds) at high rates. These findings suggest that MPA status will not mitigate the threat of plastic proliferation to this rich, unique and threatened biodiversity.

Non-isothermal drying kinetics of human feces

The non-isothermal drying behavior and kinetics of human feces (HF) were investigated by means of thermogravimetric analysis to provide data for designing a drying unit operation. The effect of heating rate and blending with woody biomass were also evaluated on drying pattern and kinetics. At low heating rate (1 K/min), there is effective transport of moisture, but a higher heating rate would be necessary at low moisture levels to reduce drying time. Blending with wood biomass improves drying characteristics of HF. The results presented in this study are relevant for designing non-sewered sanitary systems with in-situ thermal treatment.

Preliminary Examinations of Concussion in Older Adults

Purpose

This study sought to investigate whether concussion in older adults improves through evaluating their performance on the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) and Vestibular/Ocular-Motor Screen (VOMS) across visits and to describe and better characterize concussion in this at-risk population.

Methods

We conducted a retrospective review of medical records for 69 older adult patients (40 females, 29 males) that presented to a concussion specialty clinic. Participants averaged 64.71 (SD=4.1) years in age and presented within 6-998 days of injury (SD=170.9). Demographics and clinical data were recorded at intake through last appointment. Descriptive analysis, including frequencies, means, and standard deviations were performed as well as paired T-test to compare mean scores for first and last visit. Statistical significance was determined by two-sided p-values <.05.

Results

Twenty out of 69 participants (29%) reported a previous concussion. Concussion symptom severity scores at participants’ first clinic visit averaged 56.19 (SD=26.56) compare with 39.51 (SD=25.53) at their final clinic visit. When comparing ImPACT data, all scores improved comparatively from Visit 1 to Last Visit (P values =0.000-0.014); all VOMS total scores improved as well (P =0.00-0.047). The most frequent primary profile among participants was Vestibular (31.9%).

Conclusion

Older adults diagnosed with concussion showed improvement on ImPACT scores and their symptom severity scores decreased. The most frequent primary concussion profile at initial visit was Vestibular. Further research with this at-risk population is needed.

Comparison of Clinical Outcomes Following Patients' First and Second Concussions

Purpose

The objective of this study was to examine differences in self-reported symptoms, neurocognitive performance, and vestibular-ocular insufficiencies between patients’ first and second concussions. A secondary purpose was to explore the role of risk factors on recovery.

Methods

We conducted a retrospective medical chart review of 73 (32-M/41-F) patients aged 15.69 (SD=1.67) years from a concussion specialty clinic with two separate concussions (84.9% of 1st and 79.5% of 2nd sport-related) that occurred between August 2010 and April 2018. Clinical outcomes included the PCSS, ImPACT, and the Vestibular/Ocular Motor Screening (VOMS). A series of paired samples t-tests were used to compare clinical outcomes along with chi-square analyses for risk factor associations.

Results

Verbal memory scores were higher following the second (M=80.67, SD=15.3) (M=76.32, SD=15.65) (t[73]=–2.18, p=.03) concussion. Visual motor processing speed was faster following the second concussion (M=35.04, SD= 7.90) (M=31.35, SD=7.63) (t[73]=–5.72, p<.001). There were no other significant differences observed. Recovery time was similar for the first (61.07, SD=58.41.5) and second (67.91 SD=70.10) respectively, t(70)=–.91, p=.37. There was no relationship between any risk factors, and recovery time for either injury with the exception a significant association between gender and recovery time (>21 days) with the 1st injury for females (χ2, N=73)=10.58, p=.001.

Conclusion

Findings suggest that a second concussion does not result in more pronounced symptoms, worse neurocognitive performance, or increased deficits on vestibular/ocular performance and/or longer recovery time. The only significant risk factor to a recovery over 21 days included gender.

Reliability and Consistency of the Vestibular/Ocular Motor Screening (VOMS) Assessment Near Point of Convergence (NPC) Trials

Purpose

To examine the reliability of near point of convergence (NPC) across three trials and determine if one trial of NPC is adequate to identify receded NPC post-concussion.

Methods

Participants included 263 concussed patients (64.3% male; age=16.92±3.49 years) evaluated within 21 days of injury. NPC was measured in centimeters from the tip of the nose using a fixation stick and a Gulick anthropometric tape measure. A two-way, mixed effect, absolute agreement intraclass correlation coefficient (ICC 3,1) was conducted to evaluate reliability across the three trials. A chi-square analysis examined consistency of NPC classification (normal/abnormal) on the initial trial compared to average across three trials.

Results

Reliability of the three trials was high (.91 [95%CI, .89–.93]). Agreement between Trial 1 classification and classification based on average of all three trials was high (96.2%). Of the 10 participants who were classified differently for Trial 1 compared to average trials, 8 had borderline (e.g., 4–6 cm) measurements on the first trial.

Conclusion

NPC measurement across trials is reliable for the overall sample, but those who fell well below (i.e. 0–1cm) or well above (>8cm) clinical cutoffs on the first trial were almost always below or above respective cutoffs on the average convergence (>99%). Results suggest it is important to measure NPC across multiple trials for patients with initial borderline measurement.

Non-isothermal thermogravimetric kinetic analysis of the thermochemical conversion of human faeces

The "Reinvent the Toilet Challenge" set by the Bill & Melinda Gates Foundation aims to bring access to adequate sanitary systems to billions of people. In response to this challenge, on-site sanitation systems are proposed and being developed globally. These systems require in-situ thermal treatment, processes that are not well understood for human faeces (HF). Thermogravimetric analysis has been used to investigate the pyrolysis, gasification and combustion of HF. The results are compared to the thermal behaviour of simulant faeces (SF) and woody biomass (WB), along with the blends of HF and WB. Kinetic analysis was conducted using non-isothermal kinetics model-free methods, and the thermogravimetric data obtained for the combustion of HF, SS and WB. The results show that the devolatilisation of HF requires higher temperatures and rates are slower those of WB. Minimum temperatures of 475 K are required for fuel ignition. HF and SF showed similar thermal behaviour under pyrolysis, but not under combustion conditions. The activation energy for HF is 157.4 kJ/mol, relatively higher than SS and WB. Reaction order for HF is lower (n = 0.4) to WB (n = 0.6). In-situ treatment of HF in on-site sanitary systems can be designed for slow progressive burn.

Hyperphosphatemic familial tumoral calcinosis secondary to fibroblast growth factor 23 (FGF23) mutation: a report of two affected families and review of the literature

Hyperphosphatemic familial tumoral calcinosis (HFTC), secondary to fibroblast growth factor 23 (FGF23) gene mutation, is a rare genetic disorder characterized by recurrent calcified masses. We describe young Lebanese cousins presenting with HFTC, based on a retrospective chart review and a prospective case study. In addition, we present a comprehensive review on the topic, based on a literature search conducted in PubMed and Google Scholar, in 2014 and updated in December 2017. While the patients had the same previously reported FGF23 gene mutation (homozygous c.G367T variant in exon 3 leading to a missense mutation), they presented with variable severity and age of disease onset (at 4 years in patient 1 and at 23 years in patient 2). A review of the literature revealed several potential patho-physiologic pathways of HFTC clinical manifestations, some of which may be independent of hyperphosphatemia. Most available treatment options aim at reducing serum phosphate level, by stimulating renal excretion or by inhibiting intestinal absorption. HFTC is a challenging disease. While the available medical treatment has a limited and inconsistent effect on disease symptomatology, surgical resection of calcified masses remains the last resort. Research is needed to determine the safety and efficacy of FGF23 replacement or molecular therapy, targeting the specific genetic aberration. Hyperphosphatemic familial tumoral calcinosis is a rare genetic disorder characterized by recurrent calcified masses, in addition to other visceral, skeletal, and vascular manifestations. It remains a very challenging disease.

Impact of fouling, cleaning and faecal contamination on the separation of water from urine using thermally driven membrane separation

In this study, membrane distillation is evaluated as a technology for non-sewered sanitation, using waste heat to enable separation of clean water from urine. Whilst membrane fouling was observed for urine, wetting was not evident and product water quality met the proposed discharge standard, despite concentration of the feed. Fouling was reversible using physical cleaning, which is similar to previous membrane studies operating without pressure as the driving force. High COD reduction was achieved following faecal contamination, but mass transfer was impeded and wetting occurred which compromised permeate quality, suggesting upstream intervention is demanded to limit the extent of faecal contamination. (100 words).

Baseline gut microbiota predicts clinical response and colitis in metastatic melanoma patients treated with ipilimumab

Background

Ipilimumab, an immune checkpoint inhibitor targeting CTLA-4, prolongs survival in a subset of patients with metastatic melanoma (MM) but can induce immune-related adverse events, including enterocolitis. We hypothesized that baseline gut microbiota could predict ipilimumab anti-tumor response and/or intestinal toxicity.

Patients and methods

Twenty-six patients with MM treated with ipilimumab were prospectively enrolled. Fecal microbiota composition was assessed using 16S rRNA gene sequencing at baseline and before each ipilimumab infusion. Patients were further clustered based on microbiota patterns. Peripheral blood lymphocytes immunophenotypes were studied in parallel.

Results

A distinct baseline gut microbiota composition was associated with both clinical response and colitis. Compared with patients whose baseline microbiota was driven by Bacteroides (cluster B, n = 10), patients whose baseline microbiota was enriched with Faecalibacterium genus and other Firmicutes (cluster A, n = 12) had longer progression-free survival (P = 0.0039) and overall survival (P = 0.051). Most of the baseline colitis-associated phylotypes were related to Firmicutes (e.g. relatives of Faecalibacterium prausnitzii and Gemmiger formicilis), whereas no colitis-related phylotypes were assigned to Bacteroidetes. A low proportion of peripheral blood regulatory T cells was associated with cluster A, long-term clinical benefit and colitis. Ipilimumab led to a higher inducible T-cell COStimulator induction on CD4+ T cells and to a higher increase in serum CD25 in patients who belonged to Faecalibacterium-driven cluster A.

Conclusion

Baseline gut microbiota enriched with Faecalibacterium and other Firmicutes is associated with beneficial clinical response to ipilimumab and more frequent occurrence of ipilimumab-induced colitis.

Recruitment of Labelled Monocytes by Experimental Venous Thrombi

Objective. Infusing monocytes that have been stimulated to produce fibrinolytic activators and factors that regulate cell proliferation, migration and maturation, might enhance venous thrombus resolution. The aim of this study was to determine the time course of infused monocyte recruitment into venous thrombus in an appropriate model of this disease. Design and Methods. Thrombus was induced in the inferior vena cava of male Wistar rats using reduced flow (80-90% stenosis). The vessel wall was examined at 1hr by scanning electron microscopy. Resolving thrombi with surrounding vena cava were obtained at 1, 7, 14 and 21 days after induction (n = 8). Sections, taken at 0.5 mm intervals (10-15 sections per thrombus), were stained using haematoxylin, Martius Scarlet Blue and antibodies against monocytes, platelets and fibrin. Sections from human venous thrombi (n = 4) were similarly stained. The area occupied by monocytes (in relative pixel units, RPU) was determined using computer aided image analysis. Peripheral rat blood monocytes were extracted, fluorescently labelled and injected intravenously into 7 rats prior to thrombus induction. Vena cava with thrombus was harvested 1 h, 2, 3, 4, 7, 14 and 25 days after induction and their fluorescence measured. The fluorescent content of the caval wall and thrombus was analysed in greater detail at 2 and 25 days after thrombus induction (n = 4 at each time interval). Results. Experimental thrombi were structurally similar to human thrombus and resolved within 14-21 days. Scanning electron microscopy showed minimal endothelial damage at 1 h with signs of early thrombus formation (platelet, red cell leukocyte and fibrin deposition). Neutrophils were the predominant leukocyte in the thrombus at 1 day, with monocytes making up only 0.3% (0.04% sem) of the area of the thrombus. There was a steady increase in thrombus monocyte content and by 21 days the percentage area of thrombus covered by monocytes had increased by over 35 fold to 11.5% (2.3% sem) (p <0.001). Initially, monocytes appeared around the edge of the thrombus and became more evenly distributed through the thrombus as resolution progressed. Labelled monocytes could be found in the circulation up to 1 week after infusion. The fluorescent content (RPU) of the thrombus increased over 25 days (mean RPU At 2 days 0.012, sem 0.005; mean RPU at 25 days 1.062, sem 0.252, p = 0.008). The number of labelled monocytes in the vessel wall peaked at 2 days and decreased thereafter.

Changes in the Levels of Soluble Adhesion Molecules and Coagulation Factors in Patients with Deep Vein Thrombosis

Current biochemical markers of thrombosis, such as d-dimer, are of little value in demonstrating the presence of thrombus postoperatively, as their levels are elevated by surgery. Thrombosis involves adhesive interactions between the endothelium, platelets and leukocytes. The aim of the study was to determine which of a panel of haemostatic and adhesion factors are altered by the presence of thrombus, but not by surgery. These factors were measured in 20 patients with established spontaneous DVTs, 13 patients having hip replacement surgery and 28 control patients. Circulating levels of P-selectin, VCAM-1 and tissue factor were found to be increased when thrombus was present (p <0.018, p <0.0001, p <0.0028 respectively), but were not altered by surgery. The significance of these circulating factors in venous thrombosis remains to be established, but it is conceivable that they are the product of increased leukocyte trafficking and activity. Assay of VCAM-1, in particular, may be of use in the early detection of venous thrombi in postoperative patients.

Inflammatory gastrointestinal diseases associated with PD-1 blockade antibodies

BACKGROUND

Immune check-point blockade agents have shown clinical activity in cancer patients but are associated with immune-related adverse events that could limit their development. The aim of this study was to describe the gastrointestinal immune-related adverse events (GI-irAE) in patients with cancer treated with anti-PD-1.

METHODS

this is a retrospective study of consecutive adult patients who had a suspected GI-irAE due to anti-PD-1 antibodies between 2013 and 2016. Patients were recruited through a pharmacovigilance registry. Patients' data were reviewed by a multidisciplinary committee that included gastroenterologists, oncologists and a pathologist. Quantitative variables are described by median (range), qualitative variable by frequency (percentage).

RESULTS

Forty-four patients were addressed to a Gastroenterology unit for a suspected GI-IrAE. Twenty patients had a confirmed GI-irAE related to anti-PD-1, which occurred 4.2 months (0.2; 22.1) after the initiation of anti-PD-1. GI-IrAE incidence rate under anti-PD-1 treatment was estimated to be 1.5%. Among patients with GI-IrAE, main symptoms were diarrhoea (n = 16, 80%), abdominal pain (n = 13, 65%), nausea and vomiting (n = 11, 55%), intestinal obstruction (n = 1, 5%), and haematochezia (n = 2, 10%). No patient had colectomy. Four distinct categories of GI-irAE were observed: acute colitis (n = 8, 40%), microscopic colitis (n = 7, 35%), upper gastrointestinal tract inflammation (n = 4, 20%) and pseudo-obstruction (n = 1, 5%). Response rates to corticosteroids were 87.5% (7/8) in acute colitis, 57% (4/7) in microscopic colitis and 75% (3/4) in upper gastrointestinal tract inflammation. Median time to resolution was 36 days (6-172) in acute colitis, and 98 days (42-226) in microscopic colitis.

CONCLUSION

This study suggests that GI-irAE are different and less frequent with anti PD-1 than with anti CTLA-4.

Validation of the "Security Needs Assessment Profile" for measuring the profiles of security needs of Chinese forensic psychiatric inpatients

Mapping forensic psychiatric services with the security needs of patients is a salient step in service planning, audit and review. A valid and reliable instrument for measuring the security needs of Chinese forensic psychiatric inpatients was not yet available. This study aimed to develop and validate the Chinese version of the Security Needs Assessment Profile for measuring the profiles of security needs of Chinese forensic psychiatric inpatients. The Security Needs Assessment Profile by Davis was translated into Chinese. Its face validity, content validity, construct validity and internal consistency reliability were assessed by measuring the security needs of 98 Chinese forensic psychiatric inpatients. Principal factor analysis for construct validity provided a six-factor security needs model explaining 68.7% of the variance. Based on the Cronbach's alpha coefficient, the internal consistency reliability was rated as acceptable for procedural security (0.73), and fair for both physical security (0.62) and relational security (0.58). A significant sex difference (p=0.002) in total security score was found. The Chinese version of the Security Needs Assessment Profile is a valid and reliable instrument for assessing the security needs of Chinese forensic psychiatric inpatients.