Comparative Effectiveness Analyses of Salvage Prostatectomy and Salvage Radiotherapy Outcomes Following Focal or Whole-Gland Ablative Therapy (High-Intensity Focused Ultrasound, Cryotherapy or Electroporation) for Localised Prostate Cancer

AIMS

Ablative therapy, such as focal therapy, cryotherapy or electroporation, aims to treat clinically significant prostate cancer with reduced treatment-related toxicity. Up to a third of patients may require further local salvage treatment after ablative therapy failure. Limited descriptive, but no comparative, evidence exists between different salvage treatment outcomes. The aim of this study was to compare oncological and functional outcomes after salvage robot-assisted radical prostatectomy (SRARP) and salvage radiotherapy (SRT).

MATERIALS AND METHODS

Data were collected prospectively and retrospectively on 100 consecutive SRARP cases and 100 consecutive SRT cases after ablative therapy failure in a high-volume tertiary centre.

RESULTS

High-risk patients were over-represented in the SRARP group (66.0%) compared with the SRT group (48.0%) (P = 0.013). The median (interquartile range) follow-up after SRARP was 16.5 (10.0-30.0) months and 37.0 (18.5-64.0) months after SRT. SRT appeared to confer greater biochemical recurrence-free survival at 1, 2 and 3 years compared with SRARP in high-risk patients (year 3: 86.3% versus 66.0%), but biochemical recurrence-free survival was similar for intermediate-risk patients (year 3: 90.0% versus 75.6%). There was no statistical difference in pad-free continence at 12 and 24 months between SRARP (77.2 and 84.7%) and SRT (75.0 and 74.0%) (P = 0.724, 0.114). Erectile function was more likely to be preserved in men who underwent SRT. After SRT, cumulative bowel and urinary Radiation Therapy Oncology Group toxicity grade I were 25.0 and 45.0%, grade II were 11.0 and 11.0% and grade III or IV complications were 4.0 and 5.0%, respectively.

CONCLUSION

We report the first comparative analyses of salvage prostatectomy and radiotherapy following ablative therapy. Men with high-risk disease appear to have superior oncological outcomes after SRT; however, treatment allocation does not appear to influence oncological outcomes for men with intermediate-risk disease. Treatment allocation was associated with a different spectrum of toxicity profile. Our data may inform shared decision-making when considering salvage treatment following focal or whole-gland ablative therapy.

198 Immediate Post-Operative PDE5i Therapy Improves Early Erectile Function Outcomes after Robot-Assisted Radical Prostatectomy (RARP)

Aim

To assess whether the timing of post-operative Phosphodiesterase Inhibitor (PDE5i) therapy after Robot Assisted Radical Prostatectomy (RARP) is associated with a change in early erectile function, continence, or safety outcomes.

Method

Data was prospectively collected from a single surgeon in one tertiary centre and retrospectively evaluated. 158 patients were treated with PDE5i therapy post RARP over a two-year period.

Results

There were no significant differences in pre-operative characteristics between the therapy groups. Patients that had bilateral nerve sparing had a mean drop in Erectile Function (EF) score by 5.4 compared to 8.8 in the unilateral group. Additionally, 34.9% of bilateral nerve sparing patients returned to baseline compared to 12.1% of unilateral. Drop in EF scores and percentage return to baseline for unilateral nerve sparing was respectively 9 and 11.1% of immediate (day 1-2), 7 and 14.8% of early (day 3-14) and 9.7 and 9.5% of late (day >14) therapy (p = 0.9 and p = 0.6). For bilateral nerve sparing this was respectively 3.5 and 42.9% immediate therapy, 5.5 and 35.5% early therapy and 7.3 and 25% late therapy (p = 0.017 and p = 0.045). Pad free and social continence was achieved in 54% and 37% of those receiving immediate therapy, 60% and 33% for early therapy and 26% and 54% for late therapy. There were no differences in compliance, complication, or readmission outcomes.

Conclusions

Immediate PDE5i therapy should be considered in patients following nerve sparing RARP in order to maximise functional outcomes, especially in those undergoing bilateral nerve spare.

734 Evaluation of A Webinar Based Surgical Teaching Course (EDUCATE) - A Prospective Cohort Study

Aim

Anecdotal evidence suggests Foundation Year (FY) doctors start surgical rotations with less confidence than medical rotations. The study aimed to determine the effect of a national webinar-based surgical teaching course on participants’ confidence, and to assess attitudes surrounding undergraduate surgical education.

Method

This prospective cohort study is reported with reference to STROBE guidelines and received ethical approval. A series of 15 free-access webinars was developed based on the Royal College of Surgeons Undergraduate Curriculum. An expert-validated questionnaire was used to collect data before and after the course. Inclusion criteria were UK-based medical students and FY doctors who attended at least one webinar. The primary outcome was confidence in completing common tasks during surgical rotations.

Results

Completed pre-course (484) and post-course (352) questionnaires yielded 92 paired samples (63% female). 85% were medical students, representing 29 UK universities, and 15% FY doctors. Mean confidence in assessing, investigating, and implementing initial management of surgical conditions was greater after the intervention (p ≤ 0.001). Mean confidence in managing on-call tasks and starting a surgical FY job was also higher post-course greater (p ≤ 0.001). These improvements correlated with webinar attendance (p ≤ 0.05). 27.1% of participants were satisfied with the quality of undergraduate surgical education. 22.9% agreed that surgical placements prepared them well to manage surgical tasks.

Conclusions

Medical students and FY doctors report low confidence and feel unprepared in managing surgical tasks. Additionally, they report poor satisfaction with undergraduate surgical education. This shortfall may be improved through delivery of a national, accessible, targeted online webinar series and curriculum.

141 New Guidelines to Reduce Unnecessary Blood Tests, Delayed Discharge and Costs Following Robot Assisted Radical Prostatectomy

Objectives

Routine postoperative blood tests (POBT) following robot assisted radical prostatectomy (RARP) are used to evaluate the impact of surgery on pre-existing co-morbidities and to detect early complications. This practice dates back to an era of open surgery, when blood loss and complication rates were higher. We propose new guidelines to improve the specificity of POBT.

Method

The cases of 1040 consecutive patients who underwent a primary or salvage RARP at two large tertiary urology centres in the United Kingdom were retrospectively reviewed to form new guidelines. The new guidelines were prospectively validated in a sample of 300 patients.

Results

Derivation Dataset: 3% and 5% had intra- and post-operative Clavien-Dindo complications, respectively. 15% had clinical concerns postoperatively. 0.9% required perioperative transfusion. 78% had routine blood tests without clinical concerns, none of whom developed a complication. 98% of complications were suspected by clinical judgement. 6% of patients had a discharge delay of ≥ 1 day due to delayed or incomplete blood tests. Validation Dataset: No significant difference existed in complication, clinical concern or transfusion rates between the derivation and validation datasets. Number of POBT requested reduced by 73% (p < 0.001). The new guidelines improved POBT sensitivity for complications from 98% to 100% and specificity from 0% to 74%. Discharge delays reduced from 6% to 0% (p = 0.008). Cost savings were £178 per patient.

Conclusions

Postoperative complications and transfusion following RARP are rare. Routine POBT without clinical indication are unnecessary and inefficient. A guideline-based approach to POBT can reduce costs and optimise discharge without compromising patient safety or care.

283 Salvage Versus Primary Robot-Assisted Radical Prostatectomy: A Propensity-Matched Comparative Effectiveness Study from A High-Volume Tertiary Centre

Aim

Salvage Robot-Assisted Radical Prostatectomy (sRARP) is a potential treatment option for locally recurrent Prostate Cancer after non-surgical primary treatment. There are minimal data comparing outcomes between propensity-matched salvage and primary Robot-Assisted Radical Prostatectomy (RARP). We compare perioperative, oncological, and functional outcomes of sRARP with primary RARP and between sRARP post-whole and focal gland therapy.

Method

1:1 propensity-matched comparison of 146 sRARP with primary RARP from a cohort of 3,852 consecutive patients from a high-volume tertiary centre.

Results

There were no significant differences in patient characteristics between the salvage and primary RARP groups. Grade III-V Clavien-Dindo complication rates were 1.3% and 0% in the salvage and primary groups, respectively (p = 0.310). Median (IQR) follow-up was 16 (10,30) and 21 (13,33) months in the salvage and primary groups, respectively. BCR rates were 30.8% and 13.7% in the salvage and primary groups, respectively (p < 0.001). Pad-free continence rates were 79.1% and 85.4% at two years in the salvage and primary groups, respectively (p = 0.160). ED rates were 95.2% and 77.4% in the salvage and primary groups, respectively (p < 0.001). Comparing the whole gland and focal gland groups, BCR rates were 33.3% and 29.1%, respectively (p = 0.687), pad-free continence rates were 66% and 89.3%, respectively (p = 0.001), and ED rates were 98.3% and 93%, respectively (p = 0.145).

Conclusions

SRARP has similar perioperative but inferior oncological outcomes to primary RARP. Continence rates are similar to primary RARP, but potency is worse. Perioperative and oncological outcomes of sRARP after focal gland therapy are similar but continence outcomes are superior compared to sRARP after whole gland therapy.

81 VIRTUAL: Virtual Interactive Surgical Skills Classroom – An Ongoing Randomized Controlled Trial

Introduction

High costs and inaccessibility are significant barriers to face-to-face basic surgical skills (BSS) training. Virtual classrooms enable the combination of computer-based learning with interactive expert instruction. They may optimise resources and increase accessibility, facilitating larger-scale training with a similar educational benefit. We aim to evaluate the efficacy of virtual BSS classroom training compared to both non-interactive video and face-to-face teaching.

Method

72 medical students will be randomly assigned to three equal intervention groups based on year group and surgical skill confidence. Interventions will be implemented following an instructional video. Group A will practice independently, Group B will receive face-to-face training, and Group C will attend a virtual classroom. Participants will be recorded placing three interrupted sutures with hand tied knots pre- and post-intervention, and Objective Structured Assessment of Technical Skills (OSATS) will be blind marked by two experts. Change in confidence, time to completion and a granular performance score will also be measured. Each intervention’s feasibility and accessibility will be assessed.

Results

Data collection will be completed in January 2021. Significant improvement in OSATS within groups will be indicative of intervention quality. Difference in improvement between groups will determine the relative performance of the interventions.

Conclusions

To our knowledge, this will be the largest randomised control trial investigating virtual BSS classroom training. It will serve as a comprehensive appraisal of the virtual classroom’s suitability as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and in the future.

1420 ViRtual prOficiency Based prOgression for Robotic Training (VROBOT): A Prospective Cohort Study Protocol

Introduction

Robotic surgery is an evolving field that requires specialist training. Historically, robotic surgery training has lacked standardisation. Recently, training centres have introduced proficiency-based modules and curriculums to certify and progress the skills of novice robotic surgeons. However, training tends to be self-directed and non-interactive. Limited interactive teaching does exist but can be inaccessible and expensive. We aim to validate the effectiveness of the current Fundamentals of Robotic Surgery (FRS) training curriculum with the addition of interactive virtual classroom teaching.

Method

16 novice surgical trainees will be assigned to two training groups. The interventions will be implemented following a one-week robotic skills induction. Both groups will receive access to the FRS curriculum for one week. The intervention group will additionally receive virtual classroom robotic skills training. The primary outcome will be the objective performance scores after training using a synthetic model based on task errors, time taken and contact pressure. In week 3, each group will receive the alternate intervention and objective performance scores will be measured to determine the trajectory of scores.

Results

Significant objective performance improvement following the intervention will be indicative of intervention quality.

Conclusions

This will be the first feasibility study evaluating the efficacy of interactive virtual robotic surgery training. It will determine the effect size of virtual classroom training on the development of basic robotic surgical skills in addition to the proficiency-based FRS curriculum. The findings will assist the development and implementation of further resource-efficient virtual robotic surgical skills training programs.

1141 Robotic Assisted Surgery in Horseshoe Kidneys: A Safety and Feasibility Multicentre Case Series

Introduction

Horseshoe kidneys (HSK) are the most common renal fusion abnormality. However, they are only present in 0.2% of the population. Due to anatomical variation in vasculature, ectopia and malrotation, surgery has traditionally been performed via an open approach. We aimed to assess the safety and feasibility of robot-assisted surgery for HSK.

Method

Six patients (four female, two male) with HSKs were operated on between 2016 and 2019 across two high-volume centres by high-volume surgeons. All operations were robot-assisted, with three partial nephrectomies and one nephroureterectomy for renal masses and two benign nephrectomies for non-functioning kidneys. 3D reconstruction using CT renal angiograms was used to help identify vasculature and tumour location (where appropriate).

Results

The median age was 53 years (IQR 47-58.3) and the median BMI was 25 (IQR 25-25.8). Median tumour size in the four patients with renal masses was 35.5 mm (IQR 25.3-44.8). Median console time was 120 minutes (IQR 117-172.5) and the median estimated blood loss was 150 mL (IQR 112.5-262.5). The median pre-operative eGFR was 76 (IQR 70-86.5) and median post-operative eGFR was 65.5 (IQR 59.3-80.8). All operations were uneventful, there were no perioperative transfusions and no complications reported. Length of stay was two days for all patients.

Conclusions

We report the largest series of mixed robotic-assisted surgery on HSK. Robotic surgery is safe and feasible for HSK in high-volume centres with acceptable perioperative outcomes. Further prospective, longer-term, multi-centre studies are required to evaluative if robotic surgery for HSK is superior to open surgery.

O43 Virtual: virtual interactive surgical skills classroom: a randomized controlled trial (protocol)

Introduction

High costs and inaccessibility are significant barriers to face-to-face basic surgical skills (BSS) training. Virtual classrooms enable the combination of computer-based learning with interactive expert instruction. They may optimise resources and increase accessibility, facilitating larger-scale training with a similar educational benefit. We aim to evaluate the efficacy of virtual BSS classroom training compared to both non-interactive video and face-to-face teaching.

Method

72 medical students will be randomly assigned to three equal intervention groups based on surgical skills experience and confidence. Interventions will be implemented following an instructional video. Group A will practice independently, Group B will receive face-to-face training, and Group C will attend a virtual classroom. Participants will be recorded placing three interrupted sutures with hand tied knots pre- and post-intervention. Objective Structured Assessment of Technical Skills (OSATS) will be blind marked by two experts.

Result

Change in confidence, time to completion and a novel granular performance score will also be measured. Each intervention’s feasibility and accessibility will be assessed. Significant improvement in OSATS within groups will be indicative of intervention quality. Difference in improvement between groups will determine the relative performance of the interventions.

Conclusion

This will be the largest randomised control trial investigating virtual BSS classroom training. It will serve as a comprehensive appraisal of the suitability of virtual classrooms as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and beyond.

Take-home Message

This is the first RCT assessing virtual basic surgical skill classroom training and serves as a comprehensive appraisal of the suitability of virtual classrooms as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and in the future.

O50 New guidelines to reduce unnecessary blood tests, delayed discharge and costs following robot assisted radical prostatectomy

Introduction

Routine postoperative blood tests (POBT) are used to evaluate the impact of surgery on pre-existing co-morbidities and to detect early complications. This practice dates back to an era of open surgery, when blood loss and complication rates were higher. We propose new guidelines to improve the specificity of POBT.

Method

The cases of 1040 consecutive patients who underwent a primary or salvage RARP at two large tertiary urology centres in the United Kingdom were retrospectively reviewed, and new guidelines were designed. The guidelines were prospectively validated in a cohort of 300 patients.

Result

Derivation Dataset 3% and 5% had intra- and post-operative Clavien-Dindo complications, respectively. 15% had clinical concerns postoperatively. 0.9% required perioperative transfusion. 78% had routine blood tests without clinical concerns, none of whom developed a complication. 98% of complications were suspected by clinical judgement. 6% of patients had a discharge delay of ≥ 1 days due to delayed or incomplete blood tests.

Validation Dataset No significant difference existed in complication, clinical concern or transfusion rates between the derivation and validation datasets. New guidelines improved sensitivity for complications from 98% to 100% and specificity from 0% to 74%. The number of blood tests requested reduced by 73% (P < 0.001). Discharge delays reduced from 6% to 0% (P = 0.008). Cost savings were £178 per patient.

Conclusion

Postoperative complications and transfusion following RARP are rare. Routine POBT without clinical indication are unnecessary and inefficient. A guideline-based approach to POBT can reduce costs and optimise discharge without compromising patient safety or care.

Take-home Message

Routine postoperative blood tests following robot assisted radical prostatectomy are often unnecessary. A guideline-based approach can reduce costs and optimise patient care.

236 Novel Guidelines to Avoid Routine Blood Tests After Robotic Assisted Radical Prostatectomy (RARP)

Introduction

Patients undergoing RARP commonly require routine post-operative blood tests. This practice dates from an era of open surgery, with increased blood loss and complications. We aim to improve specificity of blood test requests with novel guidelines.

Method

1039 consecutive RARP patients at two tertiary urology centres in the UK were audited. Novel guidelines constructed based on risk stratified evidence from the initial audit were used to prospectively audit 133 patients.

Results

16% had clinical concerns post-operatively. 1% and 4% had an intra- and post-operative complication. Intra- or post-operative clinical judgement flagged post-operative complications in 99.9%. 80% had routine blood tests with no clinical concerns. 6% had delayed discharge due to delayed processing of blood tests. 0.9% received a peri-operative transfusion.

Re-Audit Novel guidelines reduced the number of blood tests requested from 100% to 36%. Specificity in diagnosing a complication improved from 0% to 67%. Discharge delays reduced from 6% to 0% and no post-operative complications were missed (sensitivity 100%).

Conclusions

Routine blood tests, without an indication, did not flag any additional post-operative complications. Blood transfusion is rare for RARP. Novel guidelines to request post-operative blood tests will reduce costs and discharge delays whilst maintaining appropriate patient safety and care.

31 Immediate Post-Operative Phosphodiesterase-5 Inhibitors (PDE5i) Therapy Improves Early Erectile Function Outcomes After Robot Assisted Radical Prostatectomy (RARP)

Introduction

To assess whether the timing of post-RARP PDE5i therapy affects early erectile function, continence, or safety outcomes.

Method

Data from 158 patients treated with PDE5is post-RARP was prospectively collected over two years from a single surgeon at one tertiary centre and retrospectively evaluated. Therapy was started: immediately (day 1-2) in 29%, early (day 3-14) in 37% and late (after day 14) post-op in 34%. EPIC-26 Erectile Function (EF) scores were collected pre-op and post-op after a median 43-day follow-up interval.

Results

Drop in EF scores and percentage return to baseline post unilateral nerve sparing (UNS) compared to bilateral nerve sparing (BNS) RARP was respectively 9 and 11.1% versus 3.5 and 42.9% of immediate therapy, 7 and 14.8% versus 5.5 and 35.5% of early and 9.7 and 9.5% versus 7.3 and 25% of late. Pad free and social continence was achieved in 54% and 37% of those receiving immediate therapy, 60% and 33% for early and 26% and 54% for late.

Conclusions

Immediate post RARP PDE5i therapy may protect EF and should be considered clinically, with more benefits for BNS than UNS patients. Immediate or early, rather than late, PDE5i therapy improved early continence in BNS patients.

429 National Evaluation of Confidence and Preparedness for Surgical Rotations in Medical Students and Foundation Year Doctors

Introduction

Limited published and anecdotal evidence suggests foundation year (FY) doctors start their surgical rotations with lower confidence than medical rotations. This may be due to insufficient undergraduate practical teaching related to common surgical rotations. This study aimed to evaluate the confidence and preparedness for surgical rotations of medical students and FY doctors.

Method

An expert-validated questionnaire was distributed nationally to UK medical students and FY doctors. The primary outcome was confidence in completing common tasks during surgical rotations.

Results

491 participants (84% medical students, 16% FYs) were recruited from 36 UK medical schools. 80% were likely to pursue a career in surgery however only 7% felt confident about starting a surgical FY job. 66% felt neutral or unsatisfied about the quality of medical school surgical teaching, and 80% indicated that placements did not prepare them well to manage common FY surgical tasks. The internal reliability of the questionnaire was high (=0.939).

Conclusions

Medical students and FY doctors lack confidence and preparation for surgical jobs. High-quality, practically grounded educational courses such as the National Surgical Teaching Society (NSTS) webinar curriculum could improve confidence and preparedness for surgical rotations. Further research evaluating the benefits of such courses is warranted.

Techniques and Outcomes of Salvage Robot-Assisted Radical Prostatectomy (sRARP)

BACKGROUND

Salvage Robot-Assisted Radical Prostatectomy (sRARP) has been described as feasible treatment for the management of localised prostate cancer (PCa) recurrence after primary treatment. However, no large reports have published cancer and quality outcomes.

OBJECTIVE

To report perioperative, functional and oncologic outcomes of sRARP in patients with localised PCa recurrence.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively evaluated 106 patients with local recurrence eligible for sRARP.

SURGICAL PROCEDURE

Surgery was performed using the DaVinci Si system similar to the standard approach but with adaptation to the primary treatment.

MEASUREMENTS

Peri-operative outcomes included 90-day complication rate. Functional outcomes included rates of incontinence and erectile dysfunction. Oncological outcomes included tumour staging, margin rate and recurrence.

RESULTS AND LIMITATIONS

Primary treatment was High Intensity Focused Ultrasound (HIFU) in 59 (56%) patients, 27 (25%) radiotherapy, 10 (9%) seed brachytherapy, 8 (8%) solitary androgen deprivation therapy (ADT), one (1%) cryotherapy and one (1%) electroporation / Nanoknife. Median follow-up was 2.1 years. 90-day complication rate was 8%. At two years or more, 50% were fully continent and 33% were socially continent. Continence rates tended to be better after focal compared to whole-gland treatments. Erectile dysfunction was present in 95%. Positive surgical margin rate was 39%. Biochemical recurrence occurred in 13% and local or metastatic recurrence in 11%.

CONCLUSIONS

sRARP is technically more challenging but is a feasible option in high-volume centres for treatment of recurrent PCa. Patients should be counselled that functional outcomes are inferior to primary RARP. Adjustment of surgical technique according to the primary treatment is key for good surgical outcomes.

PATIENT SUMMARY

We report our experience with sRARP for the management of localised PCa recurrence after primary treatment. This represents a feasible approach with acceptable peri-operative complications and cancer outcomes. Functional outcomes are inferior to RARP in the primary setting.

Revisiting the 'sterilising cure' terminology: a call for more patient-centred perspectives on HIV cure-related research

The literature on HIV therapeutics research is rife with terminology associating 'sterilisation' with HIV cure. We find connotations of the word 'sterilising' problematic for the HIV cure research field. In this viewpoint, we review associations of sterilising with concepts of disinfection or cleansing, as well as coerced sterilisation. We discuss emerging findings from socio-behavioural research that show aversion from people living with HIV towards the 'sterilising cure' nomenclature. We call for more collaborations with people with HIV as partners to help define what would be a more acceptable terminology for describing an HIV cure.

Ethical considerations for HIV cure-related research at the end of life

Background

The U.S. National Institute of Allergies and Infectious Diseases (NIAID) and the National Institute of Mental Health (NIMH) have a new research priority: inclusion of terminally ill persons living with HIV (PLWHIV) in HIV cure-related research. For example, the Last Gift is a clinical research study at the University of California San Diego (UCSD) for PLWHIV who have a terminal illness, with a prognosis of less than 6 months.

Discussion

As end-of-life (EOL) HIV cure research is relatively new, the scientific community has a timely opportunity to examine the related ethical challenges. Following an extensive review of the EOL and HIV cure research ethics literature, combined with deliberation from various stakeholders (biomedical researchers, PLWHIV, bioethicists, and socio-behavioral scientists) and our experience with the Last Gift study to date, we outline considerations to ensure that such research with terminally ill PLWHIV remains ethical, focusing on five topics: 1) protecting autonomy through informed consent, 2) avoiding exploitation and fostering altruism, 3) maintaining a favorable benefits/risks balance, 4) safeguarding against vulnerability through patient-participant centeredness, and 5) ensuring the acceptance of next-of-kin/loved ones and community stakeholders.

Conclusion

EOL HIV cure-related research can be performed ethically and effectively by anticipating key issues that may arise. While not unique to the fields of EOL or HIV cure-related research, the considerations highlighted can help us support a new research approach. We must honor the lives of PLWHIV whose involvement in research can provide the knowledge needed to achieve the dream of making HIV infection curable.

Impedance-based sensor for potassium ions

A conductometric sensor for potassium ions in solution is presented. Interdigitated, planar gold electrodes were coated with a potassium-selective polymer membrane composed of a poly(vinyl chloride) matrix with about 65 wt% of plasticiser and 2-5 wt% of a potassium-selective ionophore. The impedance of the membrane was measured, using the electrodes as a transducer, and related to the concentration of potassium in a sample solution in contact with the membrane. Sensitivity was optimised by varying the sensor components, and selectivity for potassium over sodium was also shown. The resulting devices are compact, miniature, robust sensors which, by means of impedance measurements, eliminate the need for a reference electrode. The sensor was tested for potassium concentration changes of 2 mM across the clinically relevant range of 2.7-18.7 mM.

Combining mixed titania morphologies into a complex assembly thin film by iterative block-copolymer-based sol–gel templating

Sol–gel templating combined with iterative spin-coating steps are used to custom-tailor hierarchically structured titania thin films. Using poly(styrene-block-ethylene oxide) P(S-b-PEO) as the structure directing agent, a foam-like structure is combined with nanogranules. Both structural elements are merged into a complex assembly in thin film geometry. The resulting morphology is pictured by SEM and probed with GISAXS. The installed mesoporous titania sandwich structure exhibits holes with a size of 45 nm which makes it promising for applications in photovoltaics or photocatalysis. An optical characterization completes the structural investigation.

Mechanically strained a-Si:H AMOLED driver circuits

This paper examines the variations in performance of amorphous silicon (a-Si:H) thin-film transistor (TFT) pixel driver circuits for active-matrix organic light-emitting diode (AMOLED) displays, which are subject to compressive or tensile mechanical strain. The external strain is induced by bending of the TFT substrate, and is measured by the observed changes in resistance of in-situ strain gauges. Mechanical strain impacts the performance of the circuit in terms of its drive current, which may be attributed to mobility and Fermi energy shifts in the individual TFTs. The effect of strain-induced shifts in the TFTs as a function of strain orientation (longitudinal or transverse) with respect to direction of current flow is also examined. Our measurements show that the variation in the drain current of a longitudinally oriented TFT can be as much as ∼ 1.5% for strains as high as 10−3. Proper layout and circuit design can suppress the effect of strain-induced shifts, and should be taken into consideration when designing stable TFT driver circuits for mechanically flexible AMOLED displays.

Stability of Amorphous Silicon Thin Film Transistors for Analog Circuit Applications

Analog circuits using amorphous silicon thin film transistors offer significant advantages for in situ signal processing in large-area optical and x-ray imagers. However such circuits are susceptible to gate-bias-induced shifts in the threshold voltages of the constituent transistors. In this work, the change of threshold voltage for devices undergoing cycles of stress, relaxation and reverse bias is measured in order to determine the feasibility of resetting the threshold voltage electrically. It is concluded that, although the reverse bias does assist the recovery of the threshold voltage, the process is still not sufficiently rapid. An analog amplifier circuit is then described which uses negative feedback to achieve a gain that is stable to within 6% over a period of 8 hours.

A Novel Device Structure for High Voltage, High Performance Amorphous Silicon Thin-Film Transistors

Conventional high voltage thin-film transistors (HVTFTs) suffer from performance limitations such as low on-current, Vx. shift and large curvature in the linear region of the output characteristics. These limitations are associated with the highly resistive dead region in conventional HVTFT structures. In this paper, we present a novel TFT structure which has a high on-current, improved output characteristics in the linear region, and no Vx, shift. The higher on-current and significant improvement in output characteristics allows faster switching. Elimination of the Vx shift leads to more reliable circuit operation. The new structure is based on the conventional low voltage TFT (LVTFT) structure except that it does not suffer from low-voltage breakdown. The low-voltage breakdown of the gate nitride in conventional LVTFTs is perceived to be due to spiking of the drain metallization into the underlying layers which creates regions of very high electric field. In our novel structure, a higher breakdown is achieved by locating the metal contacts away from the gate edge while keeping the necessary drain to gate overlap through a heavily doped microcrystalline layer. Therefore, the new TFT extends the same performance as LVTFTs to high voltage operation. Furthermore, this structure also enhances the yield and reliability by minimizing the common faults in TFTs such as short circuits between gate, source and drain.

Parental perception of time and decision-making in neonatal research

OBJECTIVE

To assess the impact of time on parental decision-making for research participation for neonates with congenital heart disease.

STUDY DESIGN

Interviews were conducted with 37 parents of 19 neonates with congenital heart disease who were eligible for three different studies: genetic etiology of congenital heart disease, heart rate variability (HRV) and structural and functional cranial magnetic resonance imaging (MRI). All parents were asked the same questions: (1) 'Did you have adequate time to make a decision about research?' and (2) 'Why?' Differences between groups (reporting adequate and inadequate time) were evaluated using Fisher's exact tests; central themes were examined using qualitative analysis.

RESULT

Of those parents who reported having adequate time to make their decision (22 of 37), the majority chose to participate when compared to those who reported inadequate time (genetics study, P<0.01; HRV, P=0.05; MRI, P<0.01). For the parents reporting inadequate time, consistent themes emerged: insufficient time to make an educated choice (n=10), consideration of study logistics (n=8), spouse not present at the time of decision (n=7) and insufficient time to discuss the studies (n=4).

CONCLUSION

Parental perception of adequate time to decide about research participation was associated with parental willingness to enroll the child in research. Despite any time limitations, parents were satisfied with the decisions they made. Optimizing the time available for the parental permission process could enhance research participation in the neonatal period.

Perivascular graft heparin delivery using biodegradable polymer wraps

Heparin remains the gold-standard inhibitor of the processes involved in the vascular response to injury. Though this compound has profound and wide-reaching effects on vascular cells in culture and animal models, its clinical utility has been questionable at best. It is clear that the mode of heparin delivery is critical to its potential and it may well be that routine forms of administration are insufficient to observe benefit given the heparin's short half-life and complex pharmacokinetics. When ingested orally, heparin is degraded to inactive oligomer fragments while systemic administration is complicated by the need for continuous infusion and the potential for uncontrolled hemorrhage. Thus alternative heparin delivery systems have been proposed to maximize regional effects while limiting systemic toxicity. Yet, as heparin is such a potent antithrombotic compound and since existing local delivery systems lack the ability to precisely regulate release kinetics, even site-specific therapy is prone to bleeding. We now describe the design and development of a novel biodegradable system for the perivascular delivery of heparin to the blood vessel wall with well-defined release kinetics. This system consists of heparin-encapsulated poly(DL lactide-co-glycolide) (pLGA) microspheres sequestered in an alginate gel. Controlled release of heparin from this heterogeneous system could be obtained over a period of 25 days in vitro. The experimental variables affecting heparin release from these matrices were investigated. Gel permeation chromatography (GPC) and scanning electron microscopy (SEM) were used to monitor the degradation process and found to correlate well with the release kinetics. Heparin-releasing gels inhibited growth of bovine vascular smooth muscle cells in tissue culture in a dose-dependent manner. Moreover, gel release controlled vascular injury in denuding and interposition vascular graft animal models of disease even when uncontrolled bleeding was evident with standard matrix-type release. This system may therefore provide an effective means of examining the effects of various compounds in the control of smooth muscle cell proliferation in accelerated arteriopathies and also shed light on the biologic nature of these processes.

Intravenous crocetinate prolongs survival in a rat model of lethal hypoxemia

OBJECTIVE

To examine whether a carotenoid, trans-sodium crocetinate, has beneficial effects on hemodynamic status and short-term outcome in a rat model of lethal hypoxemia.

DESIGN

Randomized, placebo-controlled study.

SETTING

Medical school laboratory.

SUBJECTS

Eighteen spontaneously breathing, anesthetized Sprague-Dawley rats (six per group).

INTERVENTIONS

Rats underwent instrumentation to measure blood pressure, aortic and renal blood flow, arterial blood gases, bladder epithelial oxygen tension (by an intraluminal Clark electrode), and hepatic microvascular oxygen tension (measured by porphyrin phosphorescence). After stabilization, the rats were subjected to breathing 10% inspired oxygen concentration. After 10 mins, they were administered 1.25 mL/kg intravenous boluses of either isotonic saline (control), normal strength crocetinate (40 microg/mL), or a concentrated crocetinate solution (60 microg/mL). These boluses were repeated at 30-min intervals until either death or 3 hrs had elapsed.

MEASUREMENTS AND MAIN RESULTS

With the onset of hypoxemia, we observed a rapid reduction in blood pressure and renal blood flow, maintenance of aortic blood flow, an increase in arterial base deficit, and falls in oxygen tensions in arterial blood, bladder epithelium, and hepatic microvasculature. A progressive deterioration in the control rats was noted, with only two of the six animals surviving for 3 hrs. However, all 12 rats in the two crocetinate groups survived for 3 hrs, with hemodynamic stability until 150 mins and a slow decline thereafter.

CONCLUSIONS

Trans-sodium crocetinate improved hemodynamic status and prolonged survival in this model of severe acute hypoxic hypoxia. To our knowledge, this is the first demonstration of an intravenous agent having such an effect.

Drug resistance mutations can effect dimer stability of HIV-1 protease at neutral pH

The monomer-dimer equilibrium for the human immunodeficiency virus type 1 (HIV-1) protease has been investigated under physiological conditions. Dimer dissociation at pH 7.0 was correlated with a loss in beta-sheet structure and a lower degree of ANS binding. An autolysis-resistant mutant, Q7K/L33I/L63I, was used to facilitate sedimentation equilibrium studies at neutral pH where the wild-type enzyme is typically unstable in the absence of bound inhibitor. The dimer dissociation constant (KD) of the triple mutant was 5.8 microM at pH 7.0 and was below the limit of measurement (approximately 100 nM) at pH 4.5. Similar studies using the catalytically inactive D25N mutant yielded a KD value of 1.0 microM at pH 7.0. These values differ significantly from a previously reported value of 23 nM obtained indirectly from inhibitor binding measurements (Darke et al., 1994). We show that the discrepancy may result from the thermodynamic linkage between the monomer-dimer and inhibitor binding equilibria. Under conditions where a significant degree of monomer is present, both substrates and competitive inhibitors will shift the equilibrium toward the dimer, resulting in apparent increases in dimer stability and decreases in ligand binding affinity. Sedimentation equilibrium studies were also carried out on several drug-resistant HIV-1 protease mutants: V82F, V82F/I84V, V82T/I84V, and L90M. All four mutants exhibited reduced dimer stability relative to the autolysis-resistant mutant at pH 7.0. Our results indicate that reductions in drug affinity may be due to the combined effects of mutations on both dimer stability and inhibitor binding.

'Brown bag' medication reviews as a means of optimizing patients' use of medication and of identifying potential clinical problems

BACKGROUND

'Brown bag' medication reviews carried out by community pharmacists collaborating with GPs have become established, in the USA and elsewhere, as an effective means of helping primary care patients to derive maximum benefit from their medicines, of identifying medication-related problems and of reducing wastage of medicines.

OBJECTIVE

We aimed to determine whether 'brown bag' medication review could be used successfully in the UK, and particularly whether it represents an efficient and potentially cost-effective means of identifying medication problems.

METHOD

'Brown bag' medication reviews were carried out on 205 volunteer patients in 23 pharmacies in south-east London. Pharmacists' interventions to improve patients' knowledge and usage of their medicines were analysed. Potential clinical problems identified by pharmacists were analysed in order to identify the drug groups most likely to cause problems.

RESULTS

Interventions were made in 87% of reviews; interventions to improve patients' knowledge of the purpose and correct usage of their drugs were made in 65% of reviews. In 12% of reviews, problems were identified that could potentially result in a hospital admission, and the potential for an improved outcome for the patient if drug therapy was changed was identified in a further 34% of cases. Beta-blockers, NSAIDs and verapamil were identified as being associated with potential problems of the highest clinical significance. Patients taking psychoactive medication were at greatest risk of a medication-related problem from any cause.

CONCLUSION

Pharmacists could contribute to patients' welfare and reduce health care costs by carrying out 'brown bag' medication reviews on behalf of GPs.