Stakeholders' views of the introduction of assistive technology in the classroom: How family-centred is Australian practice for students with cerebral palsy?

BACKGROUND

With family-centred care widely recognized as a cornerstone for effective assistive technology service provision, the current study was undertaken to investigate to what extent such approaches were used by schools when assistive technology assessments and implementation occurred in the classroom.

METHOD

In this cross-sectional study, we compare survey results from parents (n = 76), school staff (n = 33) and allied health professionals (n = 65) with experience in the use of high-tech assistive technology. Demographic characteristics and the stakeholders' perceived helpfulness and frequency attending assessment and set-up sessions were captured. To evaluate how family-centred the assistive technology services were perceived to be, the parents filled out the Measure of Processes of Care for Caregivers, and the professionals completed the Measure of Processes of Care for Service Providers. Descriptive statistics and one-way analysis of variance were used to conduct the data analysis.

RESULTS

Findings show that parents are more involved during the assessment stage than during the implementation and that classroom teachers are often not involved in the initial stage. Speech pathologists in particular are seen to be to a great extent helpful when implementing assistive technology in the classroom. This study found that family-centred service is not yet fully achieved in schools despite being endorsed in early intervention and disability services for over 20 years. No statistically significant differences were found with respect to school staff and allied health professionals' roles, their years of experience working with students with cerebral palsy and the scales in the Measure of Processes of Care for Service Providers.

CONCLUSION

To enhance the way technology is matched to the student and successfully implemented, classroom teachers need to be fully involved in the whole assistive technology process. The findings also point to the significance of parents' involvement, with the support of allied health professionals, in the process of selecting and implementing assistive technology in the classroom.

Exploratory phase II evaluation of cabozantinib in recurrent/metastatic uterine carcinosarcoma (CS): A study of the Princess Margaret, Chicago, and California phase II consortia

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Background: Carcinosarcoma (CS) is a rare ( < 5%) aggressive subtype of endometrial cancer (EC). Patients (pts) with progression on platinum-based chemotherapy (CTX) have limited options, there is no standard 2ndline treatment and median progression-free survival (PFS) is < 2months (mt), 6-mt PFS less than 20%. Limited molecular data on CS aligns with epithelial EC, providing rationale for evaluating similar strategies such as targeting MET and angiogenesis. Cabozantinib (cabo) is multi-targeted tyrosine kinase inhibitor against MET, VEGFR, TIE2, RET, AXL and KIT. Methods: PHL-86 (NCI#9322/NCT01935934) is a multi-centre, non-randomized, phase II trial of cabo (60 mg oral daily dose on a 28-day cycle) in EC pts recurring within a year of adjuvant CTX or with progression after 1stline of CTX for metastatic disease. Pts with rare histology including CS, were enrolled in an exploratory cohort. Activity of interest for further evaluation was defined as 4 responses (either partial response [PR] or 12-wk PFS) out of 10 pts of a given histotype. CT scans were performed after cycle 3 and every 2 cycles thereafter. Results: From 2013 to 2016, 32 pts were treated in the exploratory cohort, 19 pts with CS. Median age was 66 years (range 25-75); prior treatment included CTX (17: 1 line, 6: 2 lines) and/or radiation (11). Fifteen pts were evaluable for response, with 1 PR (7%) and 8 pts with 12-wk PFS (53%). Median PFS was 3 mt (95% CI: 2.7 – 4.6) with estimated 6-mt PFS of 13% (2 to 33%). Toxicity evaluation is available for 19 pts. Common events were fatigue and GI upset. Most frequent > Grade3 toxicities were hypertension (5), anemia (4), diarrhea (2). Four pts had GI fistula (2) or perforation (2). Mutation profiling in archival tissue showed TP53 (73%), PIK3CA (40%), KRAS (27%), PTEN(13%) with > 1 mutation present in 14/15 pts analyzed. The 1 pt with no somatic mutations had a PR (31% decrease) on cabo (PFS 6.7mt). Conclusions: Cabo in CS cohort met the predefined endpoint for further evaluation and compares favourably with other agents in this poor prognosis disease. Larger studies are required to define depth and durability of response and identify relevant biomarkers. Clinical trial information: NCT01935934.

A phase II clinical trial of metformin as a cancer stem cell targeting agent in stage IIc/III/IV ovarian, fallopian tube, and primary peritoneal cancer

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Background: Epidemiologic and preclinical studies suggest that Metformin has antitumor effects which may be due to an impact on cancer stem-like cells (CSC). We present a phase II trial of metformin administered in combination with chemotherapy for patients with advanced stage epithelial ovarian cancer (EOC). Primary endpoints were 18 month progression free survival (PFS) and CSC number in Metformin treated tumors. Methods: Thirty-eight patients with confirmed stage IIC(n=1)/III(n=25)/IV(n=12) EOC were treated with either neoadjuvant metformin followed primary debulking surgery and adjuvant Metformin+chemotherapy, or neo-adjuvant metformin+chemotherapy, followed by interval debulking and adjuvant chemotherapy+Metformin. Patients were evaluated for side effects, PFS and overall survival (OS). Metformin treated tumors were evaluated for the presence of CSC via FACS and sphere assays. Results: Thirty-two patients (84%) completed at least six cycles of metformin+chemotherapy. Metformin was well tolerated with only one grade III/IV treatment-related adverse event (3%) noted. Common adverse effects were diarrhea (18%) and nausea (16%). Eighteen month PFS was 65.4% (95% confidence interval 47.9-78.3), Median PFS was 21.7 months (CI-17-26.7). Estimated three year OS was 73.5% (CI-54.7-84.3) with median OS not reached after a media follow-up of 33 months. Finally, tumors treated with metformin were noted to have a 3-fold decrease in ALDH+ CSC at baseline, increased sensitivity to Cisplatin in vitro, and a reduced ability to amplify ALDH+ CSC with passage in vitro. Conclusions: This is the first prospective study of Metformin in EOC patients. Translational studies confirm an impact of metformin on CSC. Metformin was well tolerated and outcome results were favorable, supporting the use of Metformin in phase-III studies. Clinical trial information: NCT01579812.

Phase II study of cabozantinib (cabo) in patients (pts) with recurrent/metastatic endometrial cancer (EC): A study of the Princess Margaret, Chicago, and California phase II consortia

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Background: Recurrent/metastatic EC has a poor prognosis with no standard 2ndline therapy. Cabo is a multi-targeted kinase inhibitor of MET, VEGFR, TIE2, AXL & KIT, relevant in epithelial-stromal cross-talk. The role of MET/HGF in aggressive EC biology, where transient benefit of VEGF-targeting is due to MET/HGF, TIE2 & AXL, provides rationale for MET targeting in EC. Methods: PHL86 (NCI#9322/NCT01935934) is a multi-centre, phase II trial of cabo (60mg oral daily dose) in pts with EC recurring within a year of adjuvant chemotherapy (ctx), or with progression after 1 line of ctx for metastatic disease. Experimental (E) cohort was stratified by histology (serous (SER) vs endometroid (END)) in a Simon two-stage design for co-primary endpoints of response rate ( > 30%) & 12-week progression-free-survival (PFS) ( > 55%). Activity was defined as > 7 partial responses (PRs) or > 15 instances of 12 wk-PFS in 36 pts. Pts with rare histology EC were treated in a parallel exploratory (Ex) cohort. Results: From May 2013 to Nov 2016, 102 pts (E: 71; Ex: 31) have been treated with cabo after prior radiation (59) and/or ctx (no. lines: 1(77); 2(22)). Cabo was well tolerated with common toxicities of fatigue, nausea, diarrhea & hand-foot syndrome. Most frequent Grade 3/4 toxicity was hypertension (32/101 pts). Fistula/perforation occurred in 4 of 71 SER/END pts & 4 of 31 Ex pts; no risk factors were identified. In 33 END pts, 6 PRs & 24 instances of > 12-wk PFS were observed; median PFS is 4.8 mths (95% CI: 4.4 – 6.4) with estimated 6-mth PFS of 43% (95% CI: 27 to 59%). In 34 SER pts, 4 PRs & 20 instances of > 12-wk PFS were observed; median PFS is 4.0 mths (95% CI: 2.7 – 4.7) with estimated 6-mth PFS of 30% (95% CI: 15 to 46%). 4 pts have had PFS > 12 mths, 1 SER pt remains on study after 25mths. Mutational analysis demonstrated presence of KRAS with PTEN or PIK3CA mutations in 9 (SER/END) pts, of whom 8/9 pts met 12-wk PFS endpoint, with a median PFS 5.9 mth (4.1 to 15.4). Conclusions: Cabo has single agent activity in END and SER EC with durable disease control. Concurrent mutation in KRAS/PTEN/PIK3CA may enrich for response. The current data support further evaluation of cabo in EC. Clinical trial information: NCT01935934.

Involvement and comfort of gynecologic oncologists in the treatment of pediatric, adolescent, and young adult patients with gynecologic malignancies

OBJECTIVE

To investigate the provision of care for pediatric and adolescent patients by gynecologic oncologists.

METHODS

The present prospective cross-sectional study enrolled attending physicians and fellows specializing in gynecologic oncology from the USA during December 2012 and January 2013. A 33-question survey collecting demographic data and details of participant opinions on existing practices was distributed to potential respondents. Survey responses were aggregated and descriptive analyses were performed.

RESULTS

The survey was distributed to 1252 physicians and 178 (14.2%) surveys were returned; 105 (59.0%) participants thought that the care of patients aged younger than 21 years should be included in their practice. Only 7 (3.9%) participants had received formal training in caring for pediatric patients and young adults; however, 85 (47.8%) felt this should be incorporated into formal fellowship training. Multidisciplinary teams were reported to be the best method for caring pediatric patients by 160 (88.9%) participants but only 42 (23.6%) participants reported that multidisciplinary teams were involved in pediatric gynecologic oncology care at their institutions.

CONCLUSION

Gynecologic oncologists wanted to be involved in pediatric care and open dialogue between specialists could help in the provision of optimal, longitudinal care to these patients. Furthermore, the incorporation of formal pediatric patient-focused training into gynecologic oncology fellowship programs should be considered.

Variations in gynecologic oncology training in low (LIC) and middle income (MIC) countries (LMICs): Common efforts and challenges

Gynecologic cancer, cervical cancer in particular, is disproportionately represented in the developing world where mortality is also high. Screening programs, increased availability of chemotherapy, and an awareness of HIV-related cancers have in part accelerated a need for physicians who can treat these cancers, yet the infrastructure for such training is often lacking. In this paper, we address the variations in gynecology oncology training in LMICs as well as the ubiquitous challenges, in an effort to guide future agendas.

Principles of Treatment for Borderline, Micropapillary Serous, and Low-Grade Ovarian Cancer

Borderline ovarian tumors (BOTs) are less common than epithelial ovarian cancers (EOCs). Low-grade EOCs (LG-EOCs) occur even less frequently than BOTs. After primary therapy, recurrence rates of BOTs and LG-EOCs are significantly lower and the stage-adjusted survival is higher than for high-grade EOCs. Thus, determining the best management in terms of traditional ovarian cancer staging and debulking procedures is more challenging and has been recently brought to question. This article reviews the particulars of BOTs and LG-EOCs, their similarities and differences, and how they are best managed and treated, and emphasizes the major role of surgery and the controversial role of chemotherapy. Because these tumors disproportionately affect younger women, this review addresses ovarian preservation in circumstances when fertility or hormonal preservation is desired.

Broad autism spectrum and obsessive-compulsive symptoms in adults with the fragile X premutation

OBJECTIVE

Clinical observations and a limited number of research studies provide evidence that the fragile X premutation may confer risk for autism, executive dysfunction, and psychopathology. The link to autism spectrum symptoms and social cognition deficits with the premutation remains uncertain, and thus was the focus of the present investigation.

METHOD

Our sample included 131 individuals, 42 men/22 women with the FMR1 premutation (mean age = 31.83 ± 8.59 years) with a normal neurological exam, and 48 men/19 women healthy age-matched controls (mean age = 29.48 ± 7.29 years). Individuals completed a comprehensive neuropsychological battery with additional assessments for social cognition, broad autism spectrum, and obsessive-compulsive (OC) symptoms.

RESULTS

Premutation carriers self-reported higher rates of autism-related symptoms (Autism Quotient; p = .001). Among males only, premutation carriers showed more atypical social interaction (p < .001) and stereotyped behavior (p = .014) during standardized clinical examination on the Autism Diagnostic Observation Schedule (ADOS) relative to controls. Female premutation carriers reported significantly higher rates of OC symptoms compared to control females (p = .012). Molecular measures defining the expanded premutation (FMR1 CGG repeat length and/or mRNA) were significantly associated with a measure of theory of mind (Reading the Mind in the Eyes Task).

CONCLUSIONS

The results of this study indicate a higher rate of broad autism spectrum symptoms in some males with the premutation and provide evidence for an obsessive-compulsive subtype in female premutation carriers.

The legal and ethical implications of therapeutic privilege - is it ever justified to withhold treatment information from a competent patient?

This article examines the standard of disclosure, set by law, of risks of treatment and alternative procedures that should normally be disclosed to patients. Therapeutic privilege has been recognized by the courts as an exception to this standard of disclosure. It provides a justification for withholding such information from competent patients in the interests of patient welfare. The article explores whether this justification is either legally or ethically defensible. In assessing patient welfare, the health care professional is required to consider the patient's overall best interests - but this is not limited to an assessment of medical best interests. It is contended that the health care professional is neither qualified nor justified in making such a judgement, as the law recognizes that a competent adult patient determines her own best interests. This is not possible without sufficient information of risks to inform the decision.

How medical students learn ethics: an online log of their learning experiences

Medical students experience ethics learning in a wide variety of formats, delivered not just through the taught curriculum. An audit of ethics learning was carried out at a medical school through a secure website over one academic year to determine the quantity and range of medical ethics learning in the undergraduate curriculum and compare this with topics for teaching described by the Institute of Medical Ethics (IME) (2010) and the General Medical Council's (GMC) Tomorrow's Doctors (2009). The online audit captured the participants' reflections on their learning experiences and the impact on their future practice. Results illustrate the opportunistic nature of ethics learning, especially in the clinical years, and highlight the reality of the hidden curriculum for medical students. Overall, the ethics learning was a helpful and positive experience for the participants and fulfils the GMC and IME curriculum requirements.

Naturally occurring heavy radioactive elements in the geothermal microcosm of the Los Azufres (Mexico) volcanic complex

The Los Azufres geothermal complex of central Mexico is characterized by fumaroles and boiling hot-springs. The fumaroles form habitats for extremophilic mosses and ferns. Physico-chemical measurements of two relatively pristine fumarolic microcosms point to their resemblance with the paleo-environment of earth during the Ordovician and Devonian periods. These geothermal habitats were analysed for the distribution of elemental mass fractions in the rhizospheric soil (RS), the native volcanic substrate (VS) and the sediments (S), using the new high-sensitivity technique of polarized x-ray energy dispersive fluorescence spectrometry (PEDXRF) as well as instrumental neutron activation analysis (INAA) for selected elements. This work presents the results for the naturally occurring heavy radioactive elements (NOHRE) Bi, Th and U but principally the latter two. For the RS, the density was found to be the least and the total organic matter content the most. Bi was found to be negligibly present in all substrate types. The average Th and U mass fractions in the RS were higher than in the VS and about equal to their average mass fractions in the S. The VS mass fraction of Th was higher, and of U lower, than the mass fractions in the earth's crust. In fact for the fumaroles of one site, the average RS mass fractions of these elements were higher than the averaged values for S (without considering the statistical dispersion). The immobilization of the NOHRE in the RS is brought about by the bio-geochemical processes specific to these extremophiles. Its effectiveness is such that despite the small masses of these plants, it compares with, or may sometimes exceed, the immobilization of the NOHRE in the S by the abiotic and aggressive chemical action of the hot-springs. These results indicate that the fumarolic plants are able to transform the volcanic substrate to soil and to affect the NOHRE mass fractions even though these elements are not plant nutrients. Mirrored back to the paleo times when such plant types were ubiquitous, it would mean that the first plants contributed significantly to pedogenesis and the biogeochemical recycling of even the heaviest and radioactive elements. Such plants may potentially be useful for the phytostabilisation of soil moderately contaminated by the NOHRE. Furthermore where applicable, geochronology may require taking into account the influence of the early plants on the NOHRE distributions.