Effectiveness of intervention focused on vocational course vocabulary in post-16 students with (developmental) language disorder

BACKGROUND

People with language disorders (including developmental language disorder-DLD) often struggle to learn new words and, for young adults, this could affect their success in future work. Therefore, it is crucial to support their learning of career-specific vocabulary. However, little published evidence exists regarding the effectiveness of speech and language intervention for older adolescents and young adults with (developmental) language disorder (D)LD within a post-16 provision.

AIMS

To investigate whether for students with (D)LD in a post-16 environment, the addition of direct individual intervention from a speech and language therapist (SLT) teaching course-specific vocabulary leads to more progress than just in-course teaching on bespoke vocabulary measures.

METHODS & PROCEDURES

A total of 28 college-aged students (11 female and 17 male) with (D)LD (aged 16.0-19.9) participated in a within-participant study comparing progress with explicit vocabulary intervention plus in-course teaching versus in-course teaching alone. The participants were assessed at four time points (3 months pre-intervention, immediately pre- and post-intervention, 3.5 months after intervention) using bespoke vocabulary assessments with an equal number of nouns, verbs and adjectives. All participants received one-to-one vocabulary intervention from their usual SLT for 30 min per week for 9 weeks. The intervention had four main components: (1) to identify intervention focus, (2) to recap previously taught terms (using an online flashcard program), (3) to explicitly teach new words using word maps to help with: creating definition and pictorial representation, identification of word class and investigation of phonological and morphological properties, and (4) to add new words, with their definition and pictorial representation to online flashcard program.

OUTCOMES & RESULTS

The results showed a stable baseline, then during the intervention term significant progress on words targeted only in lessons and significantly greater progress on words targeted both in lessons and SLT sessions. Progress was maintained for 14 weeks. Individuals with initially lower scores showed smaller intervention effects. In general, performance was higher on verbs and on the definition recognition task and lower on the production tasks, but all tasks improved with intervention.

CONCLUSIONS & IMPLICATIONS

Direct one-to-one vocabulary intervention with an SLT can lead to significant gains in knowledge of course-specific terminology for college-aged students with (D)LD. The effectiveness of speech and language therapy services for this age group in a wider range of areas of language and social communication should also be investigated.

WHAT THIS PAPER ADDS

What is already known on this subject Very few services exist for young adults with DLD, despite their persisting language difficulties and the detrimental impact of these on their academic attainment and employment prospects. Most careers involve specific vocabulary which is crucial to executing a role successfully and these need to be learned by those looking to move into these careers. However, children, adolescents and adults with DLD struggle to learn new words and may need help in this area. What this study adds to existing knowledge The young adults with (D)LD received 9 weeks of intervention targeting individualized course-specific vocabulary (nouns, verbs and adjectives), using word maps to focus on word forms, definitions, morphologically related words and syntactic information such as word class and how to use the word in a sentence. An online learning tool provided regular spaced retrieval practice of previously taught words and their definitions. The participants showed significant progress with learning course-specific vocabulary from attending lessons. However, they made significantly greater progress on those words which were also targeted in individual SLT sessions, regardless of word class. Progress was maintained over 14 weeks. What are the potential or actual clinical implications of this work? Direct one-to-one vocabulary intervention with an SLT can lead to significantly greater gains in the acquisition of targeted course-specific terminology for young adults with (D)LD than the vocabulary teaching available in lessons. Individual intervention delivered by SLTs should therefore be offered to this age group of students with (D)LD to maximize their ability to access the academic curriculum and their future careers. Indeed, the broader role of SLTs in helping these young adults to access the world of work and independent living should be further investigated and supported.

A Multi-Modal Remote Clinical Skills Mini-Course Utilizing a Teaching TeleOSCE

In the setting of the coronavirus pandemic, medical schools across the world transitioned to a remote learning curriculum with the challenge of developing innovative methods to teach clinical skills. During the pandemic, we designed a 2-week remote clinical skills mini-course for third year medical students. The focus was on clinical reasoning, counseling, and the following the Association of American Medical Colleges (AAMC) Core Entrustable Professional Activities (EPAs): 1 (history and physical exam), 2 (prioritize a differential diagnosis), 3 (recommend and interpret diagnostic tests), and 5 (document a clinical encounter). A multi-modal approach included large and small group virtual case-based discussions, a teaching TeleOSCE (Objective Structured Clinical Examination), and feedback on patient note skills. Students were asked to self-assess their skills before and after the course based on the core EPAs, counseling skills, and overall preparedness for United States Medical Licensing Exam (USMLE) Step 2 Clinical Skills exam. Students demonstrated statistically significant increases in mean self-rated scores in all areas except interpreting results of basic studies. They found the teaching TeleOSCE and feedback on their notes the most useful. Future curricula will consider integration of peer-peer remote OSCE practice sessions as well as faculty feedback for individualized learning plans. Lessons learned will be useful for remote structured clinical skills courses in the setting of the pandemic.

Regulation of gene expression by translation factor eIF5A: Hypusine-modified eIF5A enhances nonsense-mediated mRNA decay in human cells

Nonsense-mediated mRNA decay (NMD) couples protein synthesis to mRNA turnover. It eliminates defective transcripts and controls the abundance of certain normal mRNAs. Our study establishes a connection between NMD and the translation factor eIF5A (eukaryotic initiation factor 5A) in human cells. eIF5A modulates the synthesis of groups of proteins (the eIF5A regulon), and undergoes a distinctive two-step post-translational modification (hypusination) catalyzed by deoxyhypusine synthase and deoxyhypusine hydroxylase. We show that expression of NMD-susceptible constructs was increased by depletion of the major eIF5A isoform, eIF5A1. NMD was also attenuated when hypusination was inhibited by RNA interference with either of the two eIF5A modifying enzymes, or by treatment with the drugs ciclopirox or deferiprone which inhibit deoxyhypusine hydroxylase. Transcriptome analysis by RNA-Seq identified human genes whose expression is coordinately regulated by eIF5A1, its modifying enzymes, and the pivotal NMD factor, Upf1. Transcripts encoding components of the translation system were highly represented, including some encoding ribosomal proteins controlled by alternative splicing coupled to NMD (AS-NMD). Our findings extend and strengthen the association of eIF5A with NMD, previously inferred in yeast, and show that hypusination is important for this function of human eIF5A. In addition, they advance drug-mediated NMD suppression as a therapeutic opportunity for nonsense-associated diseases. We propose that regulation of mRNA stability contributes to eIF5A's role in selective gene expression.

Assessing Emotional Suffering in Palliative Care: Use of a Structured Note Template to Improve Documentation

CONTEXT

Documentation of the emotional or psychological needs of seriously ill patients receiving specialty palliative care is endorsed by the "Measuring What Matters" project as a quality performance metric and recommended for use by hospice and palliative care programs for program improvement.

OBJECTIVES

The aim of this study was to increase the proportion of inpatient palliative care team encounters in which emotional or psychological needs of patients and family members were documented and to qualitatively enrich the nature of this documentation.

METHODS

This is a mixed-methods retrospective study of 200 patient charts reviewed before and after implementation of a structured note template (SmartPhrase) for palliative care encounters. Patterns of documentation of emotional needs pre- and post-implementation were assessed quantitatively and qualitatively using thematic analysis.

RESULTS

A total of 158 of 200 pre-intervention charts and 185 of 200 post-intervention charts included at least one note from the palliative care team. Documentation of emotional assessment increased after SmartPhrase implementation (63.9% [101 of 158] vs. 74.6% [138 of 185]; P < 0.03). Qualitative analysis revealed a post-intervention reduction in the use of generic phrases ("emotional support provided") and an increase in the breadth and depth of emotion-related documentation.

CONCLUSION

A structured note template with a prompt for emotional assessment increases the overall quantity and richness of documentation related to patient and family emotions. However, this documentation remains mostly descriptive. Additional prompting for documentation of recommendations to address identified emotional needs, and the use of screening tools for depression and anxiety, when appropriate, may be necessary for clinically meaningful quality improvements in patient care.

Drug-Based Lead Discovery: The Novel Ablative Antiretroviral Profile of Deferiprone in HIV-1-Infected Cells and in HIV-Infected Treatment-Naive Subjects of a Double-Blind, Placebo-Controlled, Randomized Exploratory Trial

Antiretrovirals suppress HIV-1 production yet spare the sites of HIV-1 production, the HIV-1 DNA-harboring cells that evade immune detection and enable viral resistance on-drug and viral rebound off-drug. Therapeutic ablation of pathogenic cells markedly improves the outcome of many diseases. We extend this strategy to HIV-1 infection. Using drug-based lead discovery, we report the concentration threshold-dependent antiretroviral action of the medicinal chelator deferiprone and validate preclinical findings by a proof-of-concept double-blind trial. In isolate-infected primary cultures, supra-threshold concentrations during deferiprone monotherapy caused decline of HIV-1 RNA and HIV-1 DNA; did not allow viral breakthrough for up to 35 days on-drug, indicating resiliency against viral resistance; and prevented, for at least 87 days off-drug, viral rebound. Displaying a steep dose-effect curve, deferiprone produced infection-independent deficiency of hydroxylated hypusyl-eIF5A. However, unhydroxylated deoxyhypusyl-eIF5A accumulated particularly in HIV-infected cells; they preferentially underwent apoptotic DNA fragmentation. Since the threshold, ascertained at about 150 μM, is achievable in deferiprone-treated patients, we proceeded from cell culture directly to an exploratory trial. HIV-1 RNA was measured after 7 days on-drug and after 28 and 56 days off-drug. Subjects who attained supra-threshold concentrations in serum and completed the protocol of 17 oral doses, experienced a zidovudine-like decline of HIV-1 RNA on-drug that was maintained off-drug without statistically significant rebound for 8 weeks, over 670 times the drug's half-life and thus clearance from circulation. The uniform deferiprone threshold is in agreement with mapping of, and crystallographic 3D-data on, the active site of deoxyhypusyl hydroxylase (DOHH), the eIF5A-hydroxylating enzyme. We propose that deficiency of hypusine-containing eIF5A impedes the translation of mRNAs encoding proline cluster ('polyproline')-containing proteins, exemplified by Gag/p24, and facilitated by the excess of deoxyhypusine-containing eIF5A, releases the innate apoptotic defense of HIV-infected cells from viral blockade, thus depleting the cellular reservoir of HIV-1 DNA that drives breakthrough and rebound.

TRIAL REGISTRATION

ClinicalTrial.gov NCT02191657.

Characteristics of Children With Primary Congenital Glaucoma Receiving Trabeculotomy and Goniotomy

PURPOSE

To describe the groups of patients who received trabeculotomy or goniotomy for the treatment of primary congenital glaucoma (PCG) regarding age at treatment, intraocular pressure (IOP) outcome, and medication burden.

METHODS

A retrospective chart review of patients with PCG seen at Rutgers New Jersey Medical School, Newark, New Jersey, from 1998 to 2012 was conducted. Inclusion criteria were patients who received trabeculotomy or goniotomy with at least 9 months of follow-up. Presenting examination, surgical intervention, IOP, and number of medications at 1 and 2 years postoperatively were recorded. Absolute and qualified success, defined as IOP greater than 5 and less than 21 mm Hg without and with medications, respectively, was determined.

RESULTS

Fifty eyes of 29 patients were diagnosed as having PCG. Of those, 25 eyes received trabeculotomy or goniotomy, with 19 fulfilling inclusion criteria. Average age at the time of trabeculotomy was 8 months versus 21 months for patients undergoing goniotomy. Mean IOP was significantly reduced (P < .001) for both trabeculotomy and goniotomy by 29.5% at 1 year and 33.3% at 2 years. There was no significant difference in IOP control between trabeculotomy and goniotomy groups. Patients in the goniotomy group were treated with significantly more medications before and after surgery compared to patients receiving trabeculotomy (P < .01), resulting in a greater rate of absolute success in trabeculotomy at 1 and 2 years.

CONCLUSIONS

Patients with PCG who underwent trabeculotomy had higher IOP and were treated at an earlier age than those who had goniotomy. Both effectively lowered IOP up to 2 years with greater medication burden in patients receiving goniotomy.

A multicenter study of 30 days complications after deceased donor liver transplantation in the model for end-stage liver disease score era

Knowledge of risk factors for posttransplant complications is likely to improve patient outcomes. Few large studies of all early postoperative complications after deceased donor liver transplantation (DDLT) exist. Therefore, we conducted a retrospective, cohort study of 30-day complications, their risk factors, and the impact on outcomes after DDLT. Three centers contributed data for 450 DDLTs performed from January 2005 through December 2009. Data included donor, recipient, transplant, and outcome variables. All 30-day postoperative complications were graded by the Clavien-Dindo system. Complications per patient and severe (≥ grade III) complications were primary outcomes. Death within 30 days, complication occurrence, length of stay (LOS), and graft and patient survival were secondary outcomes. Multivariate associations of risk factors with complications and complications with LOS, graft survival, and patient survival were examined. Mean number of complications/patient was 3.3 ± 3.9. At least 1 complication occurred in 79.3%, and severe complications occurred in 62.8% of recipients. Mean LOS was 16.2 ± 22.9 days. Graft and patient survival rates were 84% and 86%, respectively, at 1 year and 74% and 76%, respectively, at 3 years. Hospitalization, critical care, ventilatory support, and renal replacement therapy before transplant and transfusions during transplant were the significant predictors of complications (not the Model for End-Stage Liver Disease score). Both number and severity of complications had a significant impact on LOS and graft and patient survival. Structured reporting of risk-adjusted complications rates after DDLT is likely to improve patient care and transplant center benchmarking. Despite the accomplished reductions in transfusions during DDLT, opportunities exist for further reductions. With increasing transplantation of sicker patients, reduction in complications would require multidisciplinary efforts and institutional commitment. Pretransplant risk characteristics for complications must factor in during payer contracting.

Impact of an emergency medicine clerkship on students' perceptions of emergency medicine

PURPOSE

To determine the impact of an emergency medicine (EM) clerkship on senior (4th year) medical students' perceptions of the EM specialty.

SUBJECTS AND METHODS

This was a pre/posttest observational study in a mandatory 4-week EM clerkship. Students were anonymously surveyed pre- and postclerkship regarding perceptions of EM. The survey used 24 statements grouped across four domains: 1) student EM clerkship expectations/experiences, 2) perceptions regarding EM physicians, 3) perceptions regarding patients in the emergency department (ED), and 4) EM as a desirable career. Data were analyzed using paired-sample t-tests, and comparisons made using McNemar's χ (2) test.

RESULTS

A total of 385 of 407 students (94.6%) completed the pre- and postclerkship survey. There was no significant difference between mean ratings before and after related to perceptions regarding EM physicians (3.71 versus 3.71), ED patients (3.80 versus 3.76), or EM as a desirable career (3.88 versus 3.84). However, ratings regarding clerkship expectations/experiences decreased (3.88 versus 3.56, P=0.001). Of the 292 students that ranked their top three specialties in both pre- and postclerkship surveys, 46 (16%) included EM as a top choice preclerkship, with 31 of these maintaining this interest postclerkship. Conversely, 12 students (5%) became interested in EM postclerkship. Some survey-statement ratings were influenced and varied by urban versus community clerkship-rotation site.

CONCLUSION

A mandatory senior EM clerkship did not significantly change overall students' perceptions regarding EM. Students with an interest in EM rated domains higher than those not interested, though there may have been an overall decline in perceptions related to clerkship expectations and experiences. Larger, multisite studies may help identify aspects of the field or EM clerkship that influence a student's ultimate career choice.

Pharmacokinetics and pharmacodynamics of three formulations of firocoxib in healthy horses

The objectives of this study were to compare the pharmacokinetics and COX selectivity of three commercially available formulations of firocoxib in the horse. Six healthy adult horses were administered a single dose of 57 mg intravenous, oral paste or oral tablet firocoxib in a three-way, randomized, crossover design. Blood was collected at predetermined times for PGE2 and TXB2 concentrations, as well as plasma drug concentrations. Similar to other reports, firocoxib exhibited a long elimination half-life (31.07 ± 10.64 h), a large volume of distribution (1.81 ± 0.59L/kg), and a slow clearance (42.61 ± 11.28 mL/h/kg). Comparison of the oral formulations revealed a higher Cmax , shorter Tmax , and greater AUC for the paste compared to the tablet. Bioavailability was 112% and 88% for the paste and tablet, respectively. Maximum inhibition of PGE2 was 83.76% for the I.V. formulation, 52.95% for the oral paste formulation, and 46.22% for the oral tablet formulation. Pharmacodynamic modeling suggests an IC50 of approximately 27 ng/mL and an IC80 of 108 ng/ mL for COX2 inhibition. Inhibition of TXB2 production was not detected. This study indicates a lack of bioequivalence between the oral formulations of firocoxib when administered as a single dose to healthy horses.

Protocol of a cluster randomized trial of an educational intervention to increase knowledge of living donor kidney transplant among potential transplant candidates

Background

The best treatment option for end-stage renal disease is usually a transplant, preferably a live donor kidney transplant (LDKT). The most effective ways to educate kidney transplant candidates about the risks, benefits, and process of LDKT remain unknown.

Methods/design

We report the protocol of the Enhancing Living Donor Kidney Transplant Education (ELITE) Study, a cluster randomized trial of an educational intervention to be implemented during initial transplant evaluation at a large, suburban U.S. transplant center. Five hundred potential transplant candidates are cluster randomized (by date of visit) to receive either: (1) standard-of-care (“usual”) transplant education, or (2) intensive education that is based upon the Explore Transplant series of educational materials. Intensive transplant education includes viewing an educational video about LDKT, receiving print education, and meeting with a transplant educator. The primary outcome consists of knowledge of the benefits, risks, and process of LDKT, assessed one week after the transplant evaluation. As a secondary outcome, knowledge and understanding of LDKT are assessed 3 months after the evaluation. Additional secondary outcomes, assessed one week and 3 months after the evaluation, include readiness, self-efficacy, and decisional balance regarding transplant and LDKT, with differences assessed by race. Although the unit of randomization is the date of the transplant evaluation visit, the unit of analysis will be the individual potential transplant candidate.

Discussion

The ELITE Study will help to determine how education in a transplant center can best be designed to help Black and non-Black patients learn about the option of LDKT.

Trial registration

Clinicaltrials.gov number NCT01261910

Cardiopulmonary bypass has a modest association with cancer progression: a retrospective cohort study

Background

Given their frequency of occurrence in the United States, cancer and heart disease often coexist. For patients requiring open-heart surgery, this raises concern that the use of cardiopulmonary bypass (CPB) may cause a transient immunosuppression with the potential to promote the spread and growth of coexisting cancer cells. This study examined the association of cardiopulmonary bypass with cancer progression in a large population-based setting using linked data from several state-wide registries.

Methods

A retrospective cohort study of cancer risk, stage, and mortality in 43,347 patients who underwent coronary artery bypass graft (CABG) surgery with and without CPB in New Jersey between 1998–2004 was conducted. A competing risk analogue of the Cox proportional hazards model with propensity score adjustment and regression on the cause-specific hazard was used to compute relative risk ratios (95% confidence intervals [CIs]) for patients undergoing CABG surgery with and without CPB.

Results

An increased risk for overall cancer incidence (17%) and cancer-specific mortality (16% overall, 12% case fatality) was observed; yet these results did not reach statistical significance. Of 11 tumor-specific analyses, an increased risk of skin melanoma (1.66 [95% CI, 1.08-2.55: p=0.02]) and lung cancer (1.36 [95% CI, 1.02-1.81: p=0.03]) was observed for patients with pump versus off-pump open-heart surgery. No association was found with cancer stage.

Conclusions

These results suggest that there may be a relationship between CPB and cancer progression. However, if real, the effect is likely modest at most. Further research may still be warranted with particular focus on skin melanoma and lung cancer which had the strongest association with CPB.

Selective laser trabeculoplasty: Does energy dosage predict response?

Background:

Selective laser trabeculoplasty (SLT) is a widely used treatment for open angle glaucoma, producing sustained reductions of intraocular pressure (IOP). The aim of this study was to evaluate the long-term relationship between SLT energy dosage and IOP reduction.

Materials and Methods:

A retrospective review was performed for patients receiving primary SLT therapy, with inclusion of subjects treated with 360° of SLT. Energy settings were collected upon treatment and IOP was collected at baseline up to 36 months. Pearson's correlation coefficient was used to determine whether there was a significant correlation between SLT energy and IOP reduction at all time points. Kaplan-Meier analysis with log-rank test was performed to determine the differences in IOP reduction ≥20% from baseline among those treated with low (<85 mJ), medium (85-105 mJ), and high (>105 mJ) energy SLT.

Results:

A total of 104 eyes (75 patients) were included. The mean total SLT energy was 93.73 mJ (standard deviation (SD) = 21.83 mJ, range: 34.4-122 mJ). A significant positive correlation (P ≤ 0.05) between the amount of energy delivered and IOP reduction was found at all time points. Log-rank test showed a significant difference in IOP reduction ≥20% from baseline between the three energy groups, with low energy patients experiencing failure at an earlier time (P = 0.05).

Conclusions:

Within the range of total energy examined, there is a positive correlation between total energy used and amount of pressure reduction achieved at up to 3 years of follow-up. This may be useful in determining the optimal energy dosage for maximum effect for patients receiving SLT.

Drug-induced reactivation of apoptosis abrogates HIV-1 infection

HIV-1 blocks apoptosis, programmed cell death, an innate defense of cells against viral invasion. However, apoptosis can be selectively reactivated in HIV-infected cells by chemical agents that interfere with HIV-1 gene expression. We studied two globally used medicines, the topical antifungal ciclopirox and the iron chelator deferiprone, for their effect on apoptosis in HIV-infected H9 cells and in peripheral blood mononuclear cells infected with clinical HIV-1 isolates. Both medicines activated apoptosis preferentially in HIV-infected cells, suggesting that the drugs mediate escape from the viral suppression of defensive apoptosis. In infected H9 cells, ciclopirox and deferiprone enhanced mitochondrial membrane depolarization, initiating the intrinsic pathway of apoptosis to execution, as evidenced by caspase-3 activation, poly(ADP-ribose) polymerase proteolysis, DNA degradation, and apoptotic cell morphology. In isolate-infected peripheral blood mononuclear cells, ciclopirox collapsed HIV-1 production to the limit of viral protein and RNA detection. Despite prolonged monotherapy, ciclopirox did not elicit breakthrough. No viral re-emergence was observed even 12 weeks after drug cessation, suggesting elimination of the proviral reservoir. Tests in mice predictive for cytotoxicity to human epithelia did not detect tissue damage or activation of apoptosis at a ciclopirox concentration that exceeded by orders of magnitude the concentration causing death of infected cells. We infer that ciclopirox and deferiprone act via therapeutic reclamation of apoptotic proficiency (TRAP) in HIV-infected cells and trigger their preferential elimination. Perturbations in viral protein expression suggest that the antiretroviral activity of both drugs stems from their ability to inhibit hydroxylation of cellular proteins essential for apoptosis and for viral infection, exemplified by eIF5A. Our findings identify ciclopirox and deferiprone as prototypes of selectively cytocidal antivirals that eliminate viral infection by destroying infected cells. A drug-based drug discovery program, based on these compounds, is warranted to determine the potential of such agents in clinical trials of HIV-infected patients.

White matter impairment in the speech network of individuals with autism spectrum disorder

Impairments in language and communication are core features of Autism Spectrum Disorder (ASD), and a substantial percentage of children with ASD do not develop speech. ASD is often characterized as a disorder of brain connectivity, and a number of studies have identified white matter impairments in affected individuals. The current study investigated white matter integrity in the speech network of high-functioning adults with ASD. Diffusion tensor imaging (DTI) scans were collected from 18 participants with ASD and 18 neurotypical participants. Probabilistic tractography was used to estimate the connection strength between ventral premotor cortex (vPMC), a cortical region responsible for speech motor planning, and five other cortical regions in the network of areas involved in speech production. We found a weaker connection between the left vPMC and the supplementary motor area in the ASD group. This pathway has been hypothesized to underlie the initiation of speech motor programs. Our results indicate that a key pathway in the speech production network is impaired in ASD, and that this impairment can occur even in the presence of normal language abilities. Therapies that result in normalization of this pathway may hold particular promise for improving speech output in ASD.

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We used diffusion tensor imaging to measure white matter (WM) tracts in autism.

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Autistic participants were high-functioning individuals with normal language skills.

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WM between left supplementary motor and premotor areas is impaired in autism.

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This tract is believed to be involved in the initiation of speech articulation.

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Speech production may be impaired in the absence of language deficits in autism.

SU-E-T-412: Can Cyberknife SBRT Be an Alternative to Brachytherapy for Cervical Cancer Treatment?

PURPOSE

To investigate the effectiveness of stereotactic body radiation therapy (SBRT) with Cyberknife for treatment of squamous cell carcinoma (SCCa) of cervix that are commonly treated with brachytherapy.

METHODS

SCCa of cervix is routinely treated with external beam radiation therapy (EBRT) followed by brachytherapy. Common practice is to use high-dose- rate (HDR) brachytherapy, mainly with Ir-192; however, low-dose-rate (LDR) brachytherapy with Cs-137 is also used. Three of our patients with cervical SCCa who were chosen to have LDR brachytherapy (Cs-137 with tandem and ovoids) could not tolerate the prolonged treatment or applicator placement. All these patients previously received 45Gy (1.8Gy/fratction) from EBRT and well tolerated. Planned LDR treatment dose and time were for patient-1: 42.63Gy in 73.5hr, patient-2: 42.34Gy in 73hr, patient-3: 41.76Gy in 72hr. Delivered LDR dose and time were: 3.75Gy in 6.5hr, OGy in Ohr, and 17.3Gy in 19.8hr, for patient-1, -2 and -3, respectively. Two of the three patients tolerated LDR treatment partially; the second patient could not tolerate the applicator, which required immediate removal after placement. Treatments were completed with Cyberknife SBRT (CK-SBRT)doses of 25Gy, 15Gy and 25Gy for patient-1, -2 and -3, respectively; all had 5Gy/fraction and 3fractions/week. Prescriptions were at 80% isododelines; CTV coverages were 96.6%, 99.9% and 100% for patient-1, -2 and -3, respectively.

RESULTS

Till their last follow-up in February 2012, all three patients were doing fine clinically without any evidence of disease; none of these patients had any complications that could be related to CK-SBRT.

CONCLUSIONS

Appears that CK-SBRT can be a viable treatment alternative to brachytherapy. CK-SBRT may also be more appealing to patients and physicians for a variety of reasons such as out-patient procedure, shorter treatment time, no need for operating room, and no need for applicator insertion and tolerance. However, extensive clinical study is warranted in this regard.

SU-E-T-422: Lung SBRT Using Cyberknife: Technique and Treatment Outcome

PURPOSE

At East Carolina University, we have been treating primary and secondary lung cancers with Cyberknife stereotactic body radiotherapy (CK- SBRT) since February 2009. Till October 2011, we have treated a total of 79 patients (83 sites). In this study, we present our experience in CK-SBRT and clinical outcome of the treated patients.

METHODS

Of the 79 patients, 43 were female; age of the whole patient population ranged 33.2-89.7yrs (median=73.2yrs). Patients treated for primary lung cancer (n=57) had severe chronic obstructive pulmonary disease (COPD) and were not surgical candidates. Cyberknife robotic system with tracking techniques (Synchrony=52, XsiteLung=22, XsightSpine=5) were used. Majority of the patient (n=52) had multiple gold fiducials placed (1-6 placed; 1-4 tracked per patient) either percutaneously or bronchoscopically. CT images were used for dosimetric planning, by medical physicists, using Cyberknife MultiPlan software. Prescription doses were 25Gy-55Gy in 3-5 fractions (mean=48.2Gy, median=50Gy); doses were prescribed mainly to 80% isodoseline (range=75-96%, mean=81.4%). PTV margin varied from 0-7mm (mean±SD=3.2±1.4mm), based on the tumor locations; breathing patterns and cancer type. Dosimetric coverage of GTV and PTV were (mean±SD): 97.8±5% and 94.7±6.9%, respectively. The treatment response was assessed using either a CT or a PET scan or both.

RESULTS

The median follow up was 13.1months (range 0.3-31.9 months). Overall response rate was 98.8% (CR=73.5%). Local failure free survival at one year was 84% for primary (n=57), 76% for recurrent (n=16) lung cancer and 100% for metastatic (n=10) tumors. The toxicity rate was low with one patient reported to have chest wall pain and one patient developed grade 3-4 radiation pneumonitis.

CONCLUSIONS

In most of the cases tight PTV margins were used. Since the prescriptions were at 80% isodeose line with more than 94% PTV coverage, the treatment outcome appeared reasonable. Further study relating PTV margin, dosimetric coverage, and treatment outcome is in progress.

Human immunodeficiency virus infection in advanced maternal age gravidas

Our study compares perinatal outcomes among HIV(+) versus HIV(-) advanced maternal aged (AMA) women. A retrospective cohort study of AMA deliveries from 2000 to 2009 was performed. HIV(+) (group A) women were compared to temporally matched HIV(-) (group B) women. Demographics, medical comorbidities, HIV treatment, and delivery data were collected. SAS was used for data analysis with p<0.05 considered significant. Seventy-one patients per study group were reviewed; for group A, the mean CD4 count near delivery was 507±363; 75% (34/45) had viral load ≤400 in the third trimester and 58% were on a protease inhibitor regimen. HIV(+) women had significantly higher preterm delivery (PTD) <37 weeks (A: 40.85%, B: 16.90%, p=0.0016). Logistic regression performed revealed that the odds of PTD was 2.83 (CI 1.22-6.54) for HIV(+) and 4.02 (CI 1.27-12.72) for drug use independent of other factors. The pathophysiology of PTD among HIV(+) AMA women warrants prospective examination to better define the causal relationship.

Self-reported non-adherence to immune-suppressant therapy in liver transplant recipients: demographic, interpersonal, and intrapersonal factors

Adherence to immune suppressants and follow-up care regimen is important in achieving optimal long-term outcomes after organ transplantation. To identify patients most at risk for non-adherence, this cross-sectional, descriptive study explores the prevalence and correlates of non-adherence to immune-suppressant therapy among liver recipients. Anonymous questionnaires mailed consisted of the domains: (i) adherence barriers to immune suppressants, (ii) immune suppressants knowledge, (iii) demographics, (iv) social support, (v) medical co-morbidities, and (vi) healthcare locus of control and other beliefs. Overall response was 49% (281/572). Data analyzed for those transplanted within 10 yr of study reveal 50% (119/237) recipients or 9.2/100 person years reporting non-adherence. Non-adherence was reported highest in the 2-5 yr post-transplant phase (69/123, 56%). The highest immune-suppressant non-adherence rates were in recipients who are: divorced (26/34, 76%, p=0.0093), have a history of substance or alcohol use (42/69, 61%, p=0.0354), have mental health needs (50/84, 60%, p=0.0336), those who missed clinic appointments (25/30, 83%, p<0.0001), and did not maintain medication logs (71/122, 58%, p=0.0168). Respondents who were non-adherent with physician appointments were more than four and a half times as likely (OR 4.7, 95% CI 1.5-14.7, p=0.008) to be non-adherent with immune suppressants. In conclusion, half of our respondents report non-adherence to immune suppressants. Factors identified may assist clinicians to gauge patients' non-adherence risk and target resources.

Imputing supertrees and supernetworks from quartets

Inferring species phylogenies is an important part of understanding molecular evolution. Even so, it is well known that an accurate phylogenetic tree reconstruction for a single gene does not always necessarily correspond to the species phylogeny. One commonly accepted strategy to cope with this problem is to sequence many genes; the way in which to analyze the resulting collection of genes is somewhat more contentious. Supermatrix and supertree methods can be used, although these can suppress conflicts arising from true differences in the gene trees caused by processes such as lineage sorting, horizontal gene transfer, or gene duplication and loss. In 2004, Huson et al. (IEEE/ACM Trans. Comput. Biol. Bioinformatics 1:151-158) presented the Z-closure method that can circumvent this problem by generating a supernetwork as opposed to a supertree. Here we present an alternative way for generating supernetworks called Q-imputation. In particular, we describe a method that uses quartet information to add missing taxa into gene trees. The resulting trees are subsequently used to generate consensus networks, networks that generalize strict and majority-rule consensus trees. Through simulations and application to real data sets, we compare Q-imputation to the matrix representation with parsimony (MRP) supertree method and Z-closure, and demonstrate that it provides a useful complementary tool.

Hemorrhagic complications of external ventricular drainage

OBJECTIVE

Despite the widespread use of external ventricular drainage (EVD), the frequency of associated hemorrhagic complications remains unclear. This retrospective study examined the frequency of hemorrhagic complications of EVD and attempted to discern associated risk factors.

METHODS

Treatment records from 160 patients admitted during a 2.5-year period who required EVD placement were reviewed. Indications for placement of EVD included acute complications of cerebrovascular disease (n = 94), traumatic brain injury (n = 36), primary hydrocephalus (n = 16), and tumor (n = 14). Patients received either a 3.0 or 2.5-mm outer diameter ventricular catheter (n = 82 and 78, respectively). Postinsertion computed tomographic scans were obtained within 24 hours on all patients and were analyzed for any new hemorrhage related to the ventricular catheter. Patient age, sex, catheter type, and dimensions of hemorrhage were also analyzed.

RESULTS

The incidence of EVD-related hemorrhage was 33 +/- 0.04%. However, the incidence of detectable change in the clinical neurological examination was 2.5%. A significant proportion of EVD-related hemorrhages were small (<4 cm), punctate, intraparenchymal hematomas. Patients with cerebrovascular disease exhibited an increased incidence (39%) of hemorrhage. The mean volume of intraparenchymal hemorrhage was larger in patients who received the 2.5-mm ventricular catheter, as well as those admitted for cerebrovascular disease.

CONCLUSION

Hemorrhagic complications of EVD placement are more common than previously suspected. Admitting diagnosis seems to have an effect on the development of an associated hemorrhage and its size. Catheter gauge has an effect on hematoma volume. Most of the hemorrhages seen on postinsertion computed tomographic scans do not cause detectable changes in the clinical examination.

Effect of pregnancy and human immunodeficiency virus infection on intracellular interleukin-2 production patterns

Human immunodeficiency virus type 1 (HIV-1) infection decreases the production of interleukin-2 (IL-2) from CD4+ and CD8+ T cells. Recombinant IL-2 (rIl-2) has been given to HIV-infected individuals to generate significant increases in CD4+ T-cell counts. There are limited data regarding the effects of pregnancy and HIV infection on IL-2 production in humans. To investigate the effects of human pregnancy, HIV infection, and HIV therapy on IL-2 production, we evaluated 61 women. Intracellular IL-2 production by CD4+ T cells from nonpregnant HIV-infected women was significantly lower than in that in uninfected women (45% +/- 8% versus 52% +/- 8%, P = 0.04). In contrast, there was no difference in levels of intracellular IL-2 production between HIV-infected and uninfected pregnant women. These observations suggest that pregnancy may down-regulate IL-2 production regardless of HIV infection status. Future studies should evaluate IL-2 production patterns in larger cohorts of women so that the physiological significance of IL-2 down-regulation in pregnancy can be further evaluated. This information is essential to assess the possible use of IL-2 supplementation therapy as a means of enhancing immune responses among HIV-infected pregnant women.

Procollagen-derived biomarkers in malignant ascites of ovarian cancer. Independent prognosticators for progression-free interval and survival

OBJECTIVE

Matrix formation is a hallmark of solid tumor biology. Circulating antigens of structural matrix proteins should reflect this fact, yet are subject to systemic variables. We propose that if measured regionally, in a cancer-induced extravascular fluid pool such as malignant ascites of ovarian cancer, the same antigens retain their conceptual advantage as surrogate markers for tumor biology.

METHODS

In malignant ascites obtained at staging laparatomy of 35 women with ovarian cancer, the protein-normalized levels of the C-terminal propeptide of procollagen type I (pnPICP) and the N-terminal propeptide of procollagen type III (pnPIIINP) were determined. Using univariate and multivariate analysis, we examined these parameters, their (pnPIIINP/pnPICP) quotient, and clinical criteria (FIGO stage, age, residual tumor, histology, and tumor grade) for impact on progression-free interval and survival.

RESULTS

The absolute level of pnPIIINP was the single most powerful independent factor impacting on survival, its P value being distinctly below (P = 0.0005 vs 0.003) and its risk ratio distinctly above (15 vs 2.5) residual tumor after debulking surgery. The relative level of pnPIIINP, i.e. (pnPIIINP / pnPICP), impacted on the likelihood of recurrence even more than residual tumor. By Kaplan-Meier analysis, cutoff values for the absolute or relative pnPIIINP level significantly discriminated patients with shortened survival or progression-free interval, respectively.

CONCLUSIONS

Since malignant ovarian epithelium itself forms collagen type III, and since collagen type III is a solid-phase regulator of angiogenesis, we propose that ascitic pnPIIINP is a fluid-phase indicator for angiogenic activity in ovarian cancer and thus represents a tumor virulence index.

Genomic regions controlling vernalization and photoperiod responses in oat

Oat genotypes vary for photoperiod and vernalization responses. Vernalization often promotes earlier flowering in fall-sown but not spring-sown cultivars. Longer photoperiods also promote earlier flowering, and the response to longer photoperiods tends to be greater in cultivars from higher latitudes. To investigate the genetic basis of photoperiod and vernalization responses in oat, we mapped QTLs for flowering time under four combinations of photoperiod and vernalization treatments in the Ogle x TAM O-301 mapping population in growth chambers. We also mapped QTLs for flowering time in early spring and late-spring field plantings to determine the genetic basis of response to early spring planting in oat. Three major flowering-time QTLs (on linkage groups OT8, OT31 and OT32) were detected in most conditions. QTLs with smaller effects on flowering were less-consistently observed among treatments. Both vernalization-sensitive and insensitive QTLs were discovered. Longer photoperiod or vernalization alone tended to decrease the effects of flowering-time QTLs. Applied together, longer photoperiod and vernalization interacted synergistically, often on the same genomic regions. Earlier spring planting conferred an attenuated vernalization treatment on seeds. The major flowering-time QTLs mapped in this study matched those mapped previously in the Kanota x Ogle oat mapping population. Between these two studies, we found a concordance of flowering-time QTLs, segregation distortion, and complex genetic linkages. These effects may all be related to chromosomal rearrangements in hexaploid oat. Comparative mapping between oat and other grasses will facilitate molecular analysis of vernalization response in oat.

Rates of evolution in ancient DNA from Adélie penguins

Well-preserved subfossil bones of Adélie penguins, Pygoscelis adeliae, underlie existing and abandoned nesting colonies in Antarctica. These bones, dating back to more than 7000 years before the present, harbor some of the best-preserved ancient DNA yet discovered. From 96 radiocarbon-aged bones, we report large numbers of mitochondrial haplotypes, some of which appear to be extinct, given the 380 living birds sampled. We demonstrate DNA sequence evolution through time and estimate the rate of evolution of the hypervariable region I using a Markov chain Monte Carlo integration and a least-squares regression analysis. Our calculated rates of evolution are approximately two to seven times higher than previous indirect phylogenetic estimates.

Vitamin profile of 563 gravidas during trimesters of pregnancy

OBJECTIVE

Gestation imposes metabolic stress on the mother which heightens as pregnancy progresses. The need for quantifying circulating vitamins is important for identifying pitfalls in metabolic imbalance and nutritional status. For this reason we wanted to analyze blood vitamin concentrations of B12, thiamin, biotin, pantothenate, B6, niacin, riboflavin, folate, vitamins A, C, E and total carotenes to determine if imbalances occur during the trimesters of pregnancy.

METHODS

We randomly selected 563 gravidas who volunteered for this study from the obstetrical clinic of New Jersey Medical School; 132 were in 1st trimester, 198 were in 2nd trimester, and 233 were in 3rd trimester. All were healthy, taking a good diet and supplemented with vitamins. Blood, from an antecubital vein, was analyzed for thiamin, biotin, B12, B6, pantothenate, riboflavin, nicotinate, folates, vitamins A, E, C and total carotenes. Gravidas were classified as being normovitaminemic, hypervitaminemic or hypovitaminemic compared with blood vitamins seen in healthy non-pregnant, non-vitamin supplemented women.

RESULT

Hypervitaminemic levels of folate, biotin, pantothenate and riboflavin were found during any trimester of pregnancy due to vitamin supplementation. Despite the vitamin supplementation, a high percent of vitamin A, B6, niacin. thiamin and B 12 hypovitaminemia was noted during pregnancy trimesters. An especially high percentage of niacin deficiency was seen during the 1st trimester; it worsened in later trimesters; B12 deficits increased during the late trimesters. Combination deficits of niacin, thiamin, vitamins A, B6, B12 were noted in each of the trimesters.

CONCLUSIONS

Despite vitamin supplementation, a vitamin profile of pregnancy indicates that vitamin deficits exist during the trimesters. Also, combination hypovitaminemias of deficient vitamins were noted; this indicates that a vitamin deficit during pregnancy does not occur in isolation.

Antiretroviral resistance mutations among pregnant human immunodeficiency virus type 1-infected women and their newborns in the United States: vertical transmission and clades

To assess the impact of antiretroviral resistance on perinatal transmission prevention efforts, human immunodeficiency virus type 1 (HIV-1) genotypic resistance testing was done for 220 HIV-1-infected, zidovudine (AZT)-exposed pregnant women and 24 of their infected infants. The women were prospectively enrolled in 4 US cities in 1991-1997. Phylogenetic and sequencing analyses revealed 5 women with non-clade B infections traced to western African origins. AZT-associated mutations were detected in 17.3% of pregnant women, whereas genotypic resistance to nonnucleoside reverse-transcriptase inhibitors and protease inhibitors was infrequent. No significant association was detected between perinatal transmission and the presence of either AZT or nucleoside reverse-transcriptase inhibitor resistance-associated mutations. AZT resistance mutations were detected in 2 (8.3%) neonatal samples, but the mutation pattern was not identical to the mother's. Although no effect of viral resistance on mother-infant transmission was demonstrated, the advent of more-potent drug classes and the potential for the rapid emergence of resistance warrant prospective surveillance.

Males' evolutionary responses to experimental removal of sexual selection

We evaluated the influence of pre- and post-copulatory sexual selection upon male reproductive traits in a naturally promiscuous species, Drosophila melanogaster. Sexual selection was removed in two replicate populations through enforced monogamous mating with random mate assignment or retained in polyandrous controls. Monogamous mating eliminates all opportunities for mate competition, mate discrimination, sperm competition, cryptic female choice and, hence, sexual conflict. Levels of divergence between lines in sperm production and male fitness traits were quantified after 38-81 generations of selection. Three a priori predictions were tested: (i) male investment in spermatogenesis will be lower in monogamy-line males due to the absence of sperm competition selection, (ii) due to the evolution of increased male benevolence, the fitness of females paired with monogamy-line males will be higher than that of females paired with control-line males, and (iii) monogamy-line males will exhibit decreased competitive reproductive success relative to control-line males. The first two predictions were supported, whereas the third prediction was not. Monogamy males evolved a smaller body size and the size of their testes and the number of sperm within the testes were disproportionately further reduced. In contrast, the fitness of monogamous males (and their mates) was greater when reproducing in a non-competitive context: females mated once with monogamous males produced offspring at a faster rate and produced a greater total number of surviving progeny than did females mated to control males. The results indicate that sexual selection favours the production of increased numbers of sperm in D. melanogaster and that sexual selection favours some male traits conferring a direct cost to the fecundity of females.