Expert eValuation of Efficacy and Rationality of Vildagliptin "EVER-Vilda": An Indian Perspective

Vildagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor is effective in reducing HbA1c levels in patients with type 2 diabetes (T2DM) when administered as monotherapy, dual or triple combination therapy. In India, Vildagliptin is commonly prescribed in T2DM patients because it reduces mean amplitude of glycemic excursion (MAGE), has lower risk of hypoglycemia and is weight neutral. Early combination therapy with vildagliptin and metformin is effective and well-tolerated in patients with T2DM, regardless of age or ethnicity. In view of already existing data on vildagliptin and the latest emerging clinical evidence, a group of endocrinologists, diabetologists and cardiologists convened for an expert group meeting to discuss the role and various combinations of vildagliptin in T2DM management. This practical document aims to guide Physicians and Specialists regarding the different available strengths and formulations of vildagliptin for the initiation and intensification of T2DM therapy.

Intensive Blood Pressure Management Preserves Functional Connectivity in Patients with Hypertension from the Systolic Blood Pressure Intervention Randomized Trial

BACKGROUND AND PURPOSE

The Systolic Blood Pressure Intervention (SPRINT) randomized trial demonstrated that intensive blood pressure management resulted in slower progression of cerebral white matter hyperintensities, compared with standard therapy. We assessed longitudinal changes in brain functional connectivity to determine whether intensive treatment results in less decline in functional connectivity and how changes in brain functional connectivity relate to changes in brain structure.

MATERIALS AND METHODS

Five hundred forty-eight participants completed longitudinal brain MR imaging, including resting-state fMRI, during a median follow-up of 3.84 years. Functional brain networks were identified using independent component analysis, and a mean connectivity score was calculated for each network. Longitudinal changes in mean connectivity score were compared between treatment groups using a 2-sample t test, followed by a voxelwise t test. In the full cohort, adjusted linear regression analysis was performed between changes in the mean connectivity score and changes in structural MR imaging metrics.

RESULTS

Four hundred six participants had longitudinal imaging that passed quality control. The auditory-salience-language network demonstrated a significantly larger decline in the mean connectivity score in the standard treatment group relative to the intensive treatment group (P = .014), with regions of significant difference between treatment groups in the cingulate and right temporal/insular regions. There was no treatment group difference in other networks. Longitudinal changes in mean connectivity score of the default mode network but not the auditory-salience-language network demonstrated a significant correlation with longitudinal changes in white matter hyperintensities (P = .013).

CONCLUSIONS

Intensive treatment was associated with preservation of functional connectivity of the auditory-salience-language network, while mean network connectivity in other networks was not significantly different between intensive and standard therapy. A longitudinal increase in the white matter hyperintensity burden is associated with a decline in mean connectivity of the default mode network.

Deprescribing psychotropic medicines for behaviours that challenge in people with intellectual disabilities: a systematic review

BACKGROUND

Clear evidence of overprescribing of psychotropic medicines to manage behaviours that challenges in people with intellectual disabilities has led to national programmes within the U.K. such as NHS England's STOMP to address this. The focus of the intervention in our review was deprescribing of psychotropic medicines in children and adults with intellectual disabilities. Mental health symptomatology and quality of life were main outcomes.

METHODS

We reviewed the evidence using databases Medline, Embase, PsycINFO, Web of Science, CINAHL and Open Grey with an initial cut-off date of 22nd August 2020 and an update on 14th March 2022. The first reviewer (DA) extracted data using a bespoke form and appraised study quality using CASP and Murad tools. The second reviewer (CS) independently assessed a random 20% of papers.

RESULTS

Database searching identified 8675 records with 54 studies included in the final analysis. The narrative synthesis suggests that psychotropic medicines can sometimes be deprescribed. Positive and negative consequences were reported. Positive effects on behaviour, mental and physical health were associated with an interdisciplinary model.

CONCLUSIONS

This is the first systematic review of the effects of deprescribing psychotropic medicines in people with intellectual disabilities which is not limited to antipsychotics. Main risks of bias were underpowered studies, poor recruitment processes, not accounting for other concurrent interventions and short follow up periods. Further research is needed to understand how to address the negative effects of deprescribing interventions.

TRIAL REGISTRATION

The protocol was registered with PROSPERO (registration number CRD42019158079).

Impact of dysglycemia and obesity on the brain in adolescents with and without type 2 diabetes: A pilot study

OBJECTIVE

Both diabetes and obesity can affect the brain, yet their impact is not well characterized in children with type 2 (T2) diabetes and obesity. This pilot study aims to explore differences in brain function and cognition in adolescents with T2 diabetes and obesity and nondiabetic controls with obesity and lean controls.

RESEARCH DESIGN AND METHODS

Participants were 12-17 years old (5 T2 diabetes with obesity [mean HgbA1C 10.9%], 6 nondiabetic controls with obesity and 10 lean controls). Functional MRI (FMRI) during hyperglycemic/euglycemic clamps was performed in the T2 diabetes group.

RESULTS

When children with obesity, with and without diabetes, were grouped (mean BMI 98.8%), cognitive scores were lower than lean controls (BMI 58.4%) on verbal, full scale, and performance IQ, visual-spatial and executive function tests. Lower scores correlated with adiposity and insulin resistance but not HgbA1C. No significant brain activation differences during task based and resting state FMRI were noted between children with obesity (with or without diabetes) and lean controls, but a notable effect size for the visual-spatial working memory task and resting state was observed.

CONCLUSIONS

In conclusion, our pilot study suggests that obesity, insulin resistance, and dysglycemia may contribute to relatively poorer cognitive function in adolescents with T2 diabetes and obesity. Further studies with larger sample size are needed to assess if cognitive decline in children with obesity, with and without T2 diabetes, can be prevented or reversed.

A new benchmark of soft X-ray transition energies of Ne , CO 2 , and SF 6 : paving a pathway towards ppm accuracy

ABSTRACT

A key requirement for the correct interpretation of high-resolution X-ray spectra is that transition energies are known with high accuracy and precision. We investigate the K-shell features of Ne , CO 2 , and SF 6 gases, by measuring their photo ion-yield spectra at the BESSY II synchrotron facility simultaneously with the 1s-np fluorescence emission of He-like ions produced in the Polar-X EBIT. Accurate ab initio calculations of transitions in these ions provide the basis of the calibration. While the CO 2 result agrees well with previous measurements, the SF 6 spectrum appears shifted by ∼ 0.5 eV, about twice the uncertainty of the earlier results. Our result for Ne shows a large departure from earlier results, but may suffer from larger systematic effects than our other measurements. The molecular spectra agree well with our results of time-dependent density functional theory. We find that the statistical uncertainty allows calibrations in the desired range of 1-10 meV, however, systematic contributions still limit the uncertainty to ∼ 40-100 meV, mainly due to the temporal stability of the monochromator energy scale. Combining our absolute calibration technique with a relative energy calibration technique such as photoelectron energy spectroscopy will be necessary to realize its full potential of achieving uncertainties as low as 1-10 meV.

Chiari III Malformation on Prenatal and Postnatal Imaging Complicated by Syndrome of Inappropriate Secretion of Anti-diuretic Hormone (SIADH) and Serratia marcescens Meningitis

Among various types of Chiari malformations (CMs), CM III is the most infrequently encountered. In this article, we present a case of CM III with occipital cephalocele appreciated on both prenatal imaging and postnatal follow-up MRI. This case illustrates not only the evolution of this malformation from the in-utero images of fetal MRI to the newborn MRI but also highlights the complications that may accompany this diagnosis such as hydrocephalus and infection. The patient also developed syndrome of inappropriate secretion of anti-diuretic hormone (SIADH). The most current thoughts on the pathophysiology of this entity are also reviewed along with an approach to the differential diagnosis and treatment.

A physician associate-led clinic for people with severe mental illness in the United Kingdom

OBJECTIVE

To evaluate an enhanced physical health clinic led by physician associates (PAs) for patients with severe mental illness.

METHODS

A guidance and data collection tool was developed to support and document the outcomes of the PA-led enhanced physical health clinic.

RESULTS

The clinic led to diagnoses of diabetes, hyperlipidemia, and hematologic abnormalities. One patient was started on metformin, two patients started a prediabetes program with their general practitioner, one patient started simvastatin, one patient switched from cigarettes to e-cigarettes, and one patient switched from olanzapine to aripiprazole because of metabolic adverse reactions. Three patients intended to contact the National Health Service for cancer screening for which they were eligible but they had not taken up.

CONCLUSIONS

PAs can be integrated into a community mental health multidisciplinary team and support the physical health of people with severe mental illness. Mental health trusts should consider roles for PAs in their workforce planning.

Comparison between Simple and Classical Techniques to Create Closed Pneumoperitoneum

Background Closed method of pneumoperitoneum using Veress needle is an established technique. Classical closed technique is popular. Simple technique is a modified closed technique. Objective To compare the classical and simple techniques of closed pneumoperitoneum. Method This study was conducted in the department of urology, Bir hospital from August 1st 2019 to March 30th 2021. Total 114 patients were randomized into simple and classical technique of creating closed pneumoperitoneum. Time taken for creation of pneumoperitoneum, complications and failure of creating pneumoperitoneum in each group noted and analyzed. Chi square test, Fischer exact test and student t test were used and p < 0.05 considered significant. Result Among 114 patients, 61 in simple and 53 in classical technique allocated. In simple technique, mean age was 42.98±18.21 years, BMI was 21.84±2.57 kg/m2 , mean time for pneumoperitoneum creation was 108.07±21.14 seconds. In classical technique, mean age was 40.15±17.58 years, BMI was 21.94±2.54 (kg/m2 ), mean time for pneumoperitoneum creation was 189.70±32.21 seconds. Mean time was less in simple technique than classical technique (p < 0.001). Complication rate observed was 6% in each technique (p=0.797) with cumulative rate of 10%. Omental injury was seen in 3.2% in simple technique and 5.6% in classical technique (p=0.662). Retroperitoneal insufflation was seen in 6.5% in simple technique and 5.6% in classical technique (p=0.842). No failed pneumoperitoneum was observed in both groups. Conclusion Simple technique is as effective, reproducible and safe method as classical technique of creating closed pneumoperitoneum.

Parietal Encephalocele With Fenestrated Superior Sagittal Sinus and Persistent Falcine Sinus

We present a case of a newborn with a fenestrated superior sagittal sinus and persistent falcine sinus with a parietal encephalocele. The patient was born full-term without any associated pregnancy complications other than meconium-stained amniotic fluid at delivery. Following delivery, MRI brain demonstrated midline parietal encephalocele, persistent falcine sinus, fenestration of the superior sagittal sinus at the level of the encephalocele, subependymal heterotopia, and thick tectum. The patient underwent resection and repair on day 2 of life. MRI performed at 15 weeks of life showed a mild increase in the size of lateral ventricles. The patient did not require a ventriculoperitoneal shunt. This is a novel case that provides a valuable contribution to the existing body of literature about congenital encephalocele associated with persistent falcine sinus, fenestrated superior sagittal sinus, subependymal heterotopia, and thick tectum. 

Association of clinical factors and recent anticancer therapy with COVID-19 severity among patients with cancer: a report from the COVID-19 and Cancer Consortium

BACKGROUND

Patients with cancer may be at high risk of adverse outcomes from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We analyzed a cohort of patients with cancer and coronavirus 2019 (COVID-19) reported to the COVID-19 and Cancer Consortium (CCC19) to identify prognostic clinical factors, including laboratory measurements and anticancer therapies.

PATIENTS AND METHODS

Patients with active or historical cancer and a laboratory-confirmed SARS-CoV-2 diagnosis recorded between 17 March and 18 November 2020 were included. The primary outcome was COVID-19 severity measured on an ordinal scale (uncomplicated, hospitalized, admitted to intensive care unit, mechanically ventilated, died within 30 days). Multivariable regression models included demographics, cancer status, anticancer therapy and timing, COVID-19-directed therapies, and laboratory measurements (among hospitalized patients).

RESULTS

A total of 4966 patients were included (median age 66 years, 51% female, 50% non-Hispanic white); 2872 (58%) were hospitalized and 695 (14%) died; 61% had cancer that was present, diagnosed, or treated within the year prior to COVID-19 diagnosis. Older age, male sex, obesity, cardiovascular and pulmonary comorbidities, renal disease, diabetes mellitus, non-Hispanic black race, Hispanic ethnicity, worse Eastern Cooperative Oncology Group performance status, recent cytotoxic chemotherapy, and hematologic malignancy were associated with higher COVID-19 severity. Among hospitalized patients, low or high absolute lymphocyte count; high absolute neutrophil count; low platelet count; abnormal creatinine; troponin; lactate dehydrogenase; and C-reactive protein were associated with higher COVID-19 severity. Patients diagnosed early in the COVID-19 pandemic (January-April 2020) had worse outcomes than those diagnosed later. Specific anticancer therapies (e.g. R-CHOP, platinum combined with etoposide, and DNA methyltransferase inhibitors) were associated with high 30-day all-cause mortality.

CONCLUSIONS

Clinical factors (e.g. older age, hematological malignancy, recent chemotherapy) and laboratory measurements were associated with poor outcomes among patients with cancer and COVID-19. Although further studies are needed, caution may be required in utilizing particular anticancer therapies.

CLINICAL TRIAL IDENTIFIER

NCT04354701.

POS0598 COMPARISON OF INJECTION SITE REACTIONS AND INJECTION SITE ERYTHEMA BETWEEN YLB113 AND ETANERCEPT REFERENCE PRODUCT FROM PHASE 3 ACTIVE COMPARATOR STUDY (STUDY NO. YLB113-002)

Background:

YLB113 is an etanercept biosimilar approved in all indications of its etanercept Reference Product (RP). Therapeutic equivalence in terms of clinical efficacy, safety and immunogenicity was previously demonstrated in a pivotal multicenter, double-blind, randomized, parallel-group, active-control, comparative study (YLB113-002) in rheumatoid arthritis (RA) subjects.1,2 Similar incidence of treatment emergent adverse events (TEAEs) was seen in both treatment arms except for injection site reactions (ISRs) and injection site erythema (ISE), both of which were less frequent in subjects treated with YLB113.

Objectives:

This post-hoc analysis was performed to further evaluate the differences in the incidence of ISRs and ISE during the 24 week treatment when the subjects with RA were treated with 50 mg of YLB113 or RP given once a week as a SC injection along with methotrexate.

Methods:

Safety analysis set (263 in YLB113 arm and 254 in RP arm) was considered for this analysis.

Local reactions at the site of injection were assessed at each of eight study visits.

The number of subjects who experienced ISRs and ISE were statistically compared for YLB113 and RP. The risk difference and 95% confidence interval (CI) were computed between arms to understand the magnitude of difference in the incidence of events. The statistical significance of between group difference was tested using chi-square test.

Results:

The result of this analysis showed a statistically significant difference in the incidences of ISRs and ISE between subjects who received YLB113 and RP. The risk difference between YLB113 and RP arms for ISR was -9.98% (95% CI, WALD -14.81%, -5.15%) and, for ISE it was -7.94% (95% CI, WALD -11.96%, - 3.92%; Table 1). This could be possibly explained by the absence of latex in the syringe needle cap of YLB113.3

Table 1.

Differences in ISRs and ISEs between YLB113 and Reference Product (RP)

EventYLB113N=263RPN=254YLB113 vs RPNo of subjects with events [n(%)]No of subjects with events[n(%)])Risk Diff (95%CI, WALD)P-value (Chi-Square)Injection-site reactions10 (3.8%)35 (13.8%)-9.98% (-14.81%, -5.15%)<0.0001Injection-site erythema5 (1.9%)25 (9.8%)-7.94% (-11.96%, -3.92%)0.0001

Conclusion:

YLB113 has shown statistically significant lower incidences of ISRs (P-value <0.0001) and ISEs (P value 0.0001) compared to RP. This property may translate to a better acceptability by patients.

References:

[1]EULAR Abstract AB0416 (2019). Ann Rheum Dis, volume 78, supplement 2, year 2019, page A1670.

[2]Yamanaka H, Kamatani N, Tanaka Y, et al. A Comparative Study to Assess the Efficacy, Safety, and Immunogenicity of YLB113 and the Etanercept Reference Product for the Treatment of Patients with Rheumatoid Arthritis. Rheumatol Ther. 2020;7(1):149-163.

[3]Viatris Etanercept Summary of Product Characteritics May 2020.

Disclosure of Interests:

Dimitris Stefanidis Employee of: Viatris GmbH

Sr. Director, Global Medical Affairs Lead, Immunology Biosimilars, Unmesh G Employee of: Viatris, Juan Sánchez-Bursón: None declared, Chirag Shah Shareholder of: As an employee, Shareholder of Lupin LTD, Employee of: Employee of Lupin LTD, Dhananjay Bakhle Shareholder of: As part of Employee Stock Options Plan from Lupin LTD, Employee of: Employee of Lupin LTD

POS0604 LONG TERM SAFETY AND TOLERABILITY WITH ETANERCEPT BIOSIMILAR (YLB113), RESULTS FROM A 2-YEAR OPEN LABEL EXTENSION STUDY (STUDY NO. YLB113-003)

Background:

Eligible subjects with moderate-to-severely active rheumatoid arthritis (RA) who completed a phase 3 double-blind comparative efficacy and safety study (Study No. YLB113-002; Yamanaka et al, 2019) of 50 mg etanercept biosimilar (YLB113) or etanercept reference product (RP) by subcutaneous administration with concomitant MTX treatment for 52 weeks, were enrolled in this open label extension (OLE) study (Study No. YLB113-003) to assess the long-term safety and tolerability of YLB113 through to 3 years.

Objectives:

This OLE study aimed to evaluate the long-term safety of YLB113 administration in subjects with RA who received RP or YLB113 in a phase 3 active comparator study. The main parameters assessed were safety and tolerability in terms of adverse events (AEs) and injection site reactions (ISRs), incidence of immunogenicity and efficacy as DAS28 improvement (disease activity score in 28 joints).

Methods:

Subjects received 50 mg of YLB113 subcutaneously once every 1 to 2 weeks. Safety was assessed by AEs after study drug administration, ISRs, physical examination findings, and immunogenicity. Efficacy (DAS28 score) was assessed at the time of transition to the OLE study (Week 0), and at weeks 12, 24, 48, 72, 96 and at the end of the study.

Results:

201 (Full analysis set [FAS]) subjects received the study drug and 184 subjects completed the study (91.5% completion rate). The average drug exposure in 94 subjects who continued to receive YLB113 and completed the study (94.0% completion rate) and 90 subjects who switched from RP to YLB113 and completed the study (89.1% completion rate) was 103 weeks providing the long-term drug exposure data of YLB113.

The CTCAE Grade of TEAEs and ADRs observed were Grade 2 or less in severity (with no Grade ≥3). The overall incidence of ISRs was 10.0% (20/201 subjects) 77 events. All the ISRs reported were Grade 1 except for one Grade 2.

An overview of the AEs experienced by the subjects is summarized in the Table 1.

Table 1.

Overview of Adverse events in OLE study

FASn (%)Number of eventsNumber of subjects201-Treatment emergent adverse events (TEAEs)188(93.5)975Adverse drug reactions (ADRs)82(40.8)221Serious adverse events (SAEs)21(10.4)27Serious adverse drug reactions (SADRs)7(3.5)7AEs leading to premature study discontinuation4(2.0)6ADRs leading to premature study discontinuation3(1.5)4SAEs leading to premature study discontinuation3(1.5)4SADRs leading to premature study discontinuation2(1.0)2

n - number of subjects with at least 1 AE in the category

The mean DAS28 (mean ± S.D.) of 2.22 ± 0.95 at the study transition was 2.10 ± 0.91 at Week 72 and 2.06 ± 0.89 at the end of the study. It was confirmed that DAS28 slightly decreased with time after the study transition and continued until the end of the study. The average DAS28 value remained low even with long-term administration of YLB113, suggesting that the effects of the study drug was sustained (Figure 1).

Figure 1.

DAS28 over time with YLB113 N: Number of subjects. * The administration period at the study completion differs for each subject, because the study transition time differs for each subject.

cts who tested positive for anti-drug antibodies (ADA) at least once in the OLE study were 1.0% (2/200 subjects). All ADA were transient and disappeared at study completion. Such transient ADA formation was reported in the phase 3 study as well. In the phase 3 study, ADA formation was more frequent in subjects who received RP at 24 weeks, but all subjects were negative in the OLE study after switching. Therefore, switching did not affect immunogenicity.

Conclusion:

The safety, efficacy and immunogenicity profile of YLB113 was maintained over the long-term through to 3 years. Switching from RP to YLB113 did not impact safety or immunogenicity.

References:

[1]Yamanaka H, Kamatani N, Tanaka Y, et al. A Comparative Study to Assess the Efficacy, Safety, and Immunogenicity of YLB113 and the Etanercept Reference Product for the Treatment of Patients with Rheumatoid Arthritis. Rheumatol Ther. 2020 Mar;7(1):149-163.

Disclosure of Interests:

Yamanaka Hisashi Speakers bureau: YL Biologics Ltd, Consultant of: YL Biologics Ltd, Yoshiya Tanaka Speakers bureau: Received speaking fees and/or honoraria from Daiichi-Sankyo, Eli Lilly, Novartis, YL Biologics, Bristol-Myers, Eisai, Chugai, Abbvie, Astellas, Pfizer, Sanofi, Asahi-kasei, GSK, Mitsubishi-Tanabe, Gilead, Janssen., Grant/research support from: Received research grants from Abbvie, Mitsubishi-Tanabe, Chugai, Asahi-Kasei, Eisai, Takeda, Daiichi-Sankyo., Toshihiko Hibino: None declared, Chirag Shah Shareholder of: Lupin LTD, Employee of: Lupin LTD, Dhananjay Bakhle Shareholder of: As part of Employee Stock Options Plan of Lupin LTD, Employee of: Lupin LTD, Dimitris Stefanidis Employee of: Sr. Director, Global Medical Affairs Lead, Immunology Biosimilars for Viatris GmbH

Absolute throughput calibration of multiple spherical crystals for the Orion High-REsolution X-ray spectrometer (OHREX)

We present absolute throughput analysis of several crystals for the Orion High-REsolution X-ray (OHREX) imaging crystal spectrometer using ray tracing and experimental measurements. The OHREX spectrometer is a high-resolution x-ray spectrometer designed to measure spectral line shapes at the Orion laser facility. The spectrometer is fielded with up to two spherical crystals simultaneously covering two independent spectral ranges. Each crystal has a nominal radius of curvature of R = 67.2 cm and is fielded at a nominal Bragg angle of 51.3°. To cover different bands of interest, several different crystals are available, including Ge (111), KAP, and several cuts of quartz, whose resolving power λ/Δλ exceeds 10 000. The calibrated response of the available crystals has previously been reported from measurements at the EBIT-I electron beam ion trap at Lawrence Livermore National Laboratory. Here, we model the absolute throughput of each crystal using ray tracing and verify the results using experimental data for the quartz (101¯1) crystal.

High-Precision Determination of Oxygen K_{α} Transition Energy Excludes Incongruent Motion of Interstellar Oxygen

We demonstrate a widely applicable technique to absolutely calibrate the energy scale of x-ray spectra with experimentally well-known and accurately calculable transitions of highly charged ions, allowing us to measure the K-shell Rydberg spectrum of molecular O_{2} with 8 meV uncertainty. We reveal a systematic ∼450  meV shift from previous literature values, and settle an extraordinary discrepancy between astrophysical and laboratory measurements of neutral atomic oxygen, the latter being calibrated against the aforementioned O_{2} literature values. Because of the widespread use of such, now deprecated, references, our method impacts on many branches of x-ray absorption spectroscopy. Moreover, it potentially reduces absolute uncertainties there to below the meV level.

Medicines reconciliation in primary care: a study evaluating the quality of medication-related information provided on discharge from secondary care

Objectives

Medicines reconciliation is an effective way of reducing errors at transitions of care. Much of the focus has been on medicines reconciliation at point of admission to hospital. Our objective was to evaluate medicines reconciliation after discharge from hospital by assessing the quality of information regarding medicines within discharge summaries and determining whether the information provided regarding medicines changes were acted on within 7 days of receiving the discharge information.

Methods

A retrospective collaborative evaluation of medicines-related discharge information by Clinical Commissioning Group (CCG) pharmacists using standardised data collection tools. Outcomes of interest included compliance with national minimum standards for medication-related information on discharge summaries, such as allergies, changes to medication regimen, minimum prescription standards, for example, dose, route, formulation and duration, and medicines reconciliation by the primary care team. Data were analysed centrally.

Results

43 CCGs covering each of the four National Health Service regions in England participated in the study and submitted data for 1454 patients and 10 038 prescribed medicines. The majority of medication details were stated in accordance with standards with the exception of indication (11.7% compliance), formulation (60.3% compliance) and instructions of ongoing use (72.5% compliance). Documentation about changes was poor: 1550/3164 (49%) newly started medicines, 186/477 (39%) dose changes and 420/738 (57%) stopped medicines had a reason documented. Changes were not acted on within 7 days of receiving the discharge information for 12.5% of patients.

Conclusions

Our evaluation revealed overall good compliance with discharge medication documentation standards, but a number of changes to medicines during hospitalisation were not fully communicated or documented on the discharge summary or actioned in the general practice after discharge.

PRIMARY PIGMENTED NODULAR ADRENOCORTICAL DISEASE (PPNAD) PRESENTING AS CUSHING SYNDROME IN A CHILD AND REVIEW OF LITERATURE

Cushing syndrome in the paediatric age group is very difficult to diagnose due to atypical presenting features in children. Primary pigmented nodular adrenocortical disease (PPNAD) is a rare cause of ACTH-independent Cushing syndrome in children and it has characteristic gross and microscopic pathologic features. We report a case of PPNAD in a 16-year-old boy who was evaluated in our hospital with chief complaints of poor height velocity and rapid weight gain for 2-3 years before presentation. Proper evaluation showed ACTH-independent Cushing syndrome with normal imaging. Total bilateral adrenalectomy was performed followed by hormones replacement. 6 months after surgery, significant acceleration of height velocity was noticed. Patient also lost body weight and developed secondary sexual characteristics.

Transforming mental well-being for people with diabetes: research recommendations from Diabetes UK's 2019 Diabetes and Mental Well-Being Workshop

AIMS

To identify key gaps in the research evidence base that could help to improve the mental well-being of people with diabetes, and to provide recommendations to researchers and research funders on how best to address them.

METHODS

A 2-day international research workshop was conducted, bringing together research experts in diabetes and in mental health, people living with diabetes and healthcare professionals.

RESULTS

The following key areas needing increased financial investment in research were identified: understanding the mechanisms underlying depression; understanding the multifactorial impact of social stigma; improving the language used by healthcare professionals; supporting people who find it difficult to engage with their diabetes; supporting significant others; supporting people with diabetes and eating disorders; improving models of care by learning from best practice; the potential benefits of screening and managing diabetes distress in routine diabetes care pathways; primary prevention of mental health issues at the time of diagnosis of diabetes; establishing the effectiveness of diabetes therapies on mood and other mental health issues; and understanding the impact of current diabetes technologies on mental health. Research recommendations as to how to address each of these priority areas were also developed.

CONCLUSIONS

This inaugural position statement outlines recommendations to address the urgent unmet need related to the mental well-being of people living with diabetes, and calls on the research community and funders to develop research programmes and strategies to reduce this need.

An audit of mammographic screen detected lesions of uncertain malignant potential (B3) diagnosed on initial image guided needle biopsy: how has our practice changed over 10 years?

AIM

To review all cases of B3 lesion diagnosed at initial image-guided needle biopsy over two 5-year cohorts to identify upgrade rates to malignancy and the effect of changing guidance on the management of such lesions.

MATERIALS AND METHODS

Data was collected retrospectively. Mammographic features, biopsy type and management were recorded for each lesion. Upgrade rates for each B3 histological category were quantified. Statistical analysis was performed using SPSS.

RESULTS

There were 224 cases in 2005-2010 and 240 cases in 2010-2015. Mammographically 211 lesions were microcalcifications, 182 masses, 65 distortions and six asymmetric densities with no difference in the mammographic features in the two cohorts. Two hundred and eight 14 G core biopsies and 256 initial vacuum-assisted biopsies were performed. There was a statistically significant reduction in benign surgical biopsies and an increase in second-line vacuum biopsy/excision in the latter cohort, with no significant change in the upgrade rate. There was an overall 6% upgrade to invasive malignancy and 13% upgrade to ductal carcinoma in situ (DCIS). The upgrade rates for the following histological categories were atypical intraductal epithelial proliferation (AIDEP) 33.2% (21/63); classical (not pleomorphic) in situ lobular neoplasia (ISLN) 18.2% (6/33); flat epithelial hyperplasia (FEA) 21.7% (20/92); papilloma with atypia 53.8% (7/13), without atypia 12.1% (8/66); and radial scar/complex sclerosing lesion with atypia 16.7% (2/12), and without atypia 7.9% (6/76).

CONCLUSION

Upgrade rates remain high for some histological categories even with first-line use of vacuum biopsy. Management of borderline lesions should be considered carefully in a multidisciplinary meeting. In many cases, the need for diagnostic surgical excision has been replaced by image-guided vacuum sampling.

Abstract P5-15-02: Evaluating the cost of endocrine therapy vs. radiation therapy alone for low risk hormone positive early stage breast cancer in elderly patients

Objective: Elderly patients with low-risk hormone-positive breast cancer are at risk of over treatment. Avoidance of radiation therapy (RT) in favor of endocrine therapy alone was first heralded as the optimal conservative strategy due to logistical simplicity, low acute sequelae and a reduction of contralateral cancers not seen with RT. However, long-term use of aromatase inhibitors (AI) is not without costs and morbidity, often leading to low compliance and notable late effects. We therefore performed a cost-effectiveness analysis to compare the outcomes and costs between AI for five years without RT versus hypofractionated RT alone without endocrine therapy.

Materials and Methods: Using data from available phase III trials and meta-analyses, we constructed a patient-level microsimulation Markov decision model to replicate the comparative outcomes between the strategies above from the societal perspective among 200,000 simulated patients. Five years of anastrozole was compared to a 15-fraction hypofractionated whole breast RT course without boost in a cohort of patients with low-risk disease as defined by CALGB 9343 entry criteria. Noncompliance with AI was modeled from recent population-based data. Relative effectiveness on ipsilateral breast tumor recurrence and contralateral breast cancers were based off the NSABP B-21 trial, adjusted to match the modern outcomes demonstrated in CALGB 9343 and PRIME II with further adjustment for AI over tamoxifen (ATAC, EBCTCG meta-analysis). Indirect costs of travel were accounted for, as were the costs of common and serious side-effects from RT (dermatitis, fibrosis, second malignancy, heart disease) and AI (arthralgia, hot flashes, osteopenia, fracture, thrombosis). A 1-year cycle time and lifetime horizon were used, with all costs adjusted to 2018 US dollars and extracted primarily from Medicare reimbursement data. The primary measure of efficacy was the quality-adjusted life-year (QALY) with age-adjusted utilities extracted from the literature. Half-cycle correction and a 3% discount rate were applied. Probabilistic sensitivity analysis was used to vary all parameters simultaneously.

Results: On average, RT was approximately $3,981 more expensive than endocrine therapy over the lifetime horizon. Under a number of assumptions, RT appeared similar in long-term effectiveness to AI therapy, with a difference of less than 0.03 quality-adjusted life years. Given the low value of the denominator in the incremental cost-effectiveness ratio (ICER), RT did not meet the formally defined $100,000/QALY threshold. On one-way sensitivity analysis, the ICER was particularly sensitive to the incidence and impact of salvage strategies for recurrence, treatment of contralateral breast cancers, cardiac events and fracture rates.

Conclusions: Modeling with the available evidence suggests it is likely that quality-of-life after RT-alone is nearly identical to an AI-alone strategy but associated with a small increase in cost. These results suggest select patients at risk of noncompliance can safely be treated with RT-alone rather than AI alone. Given the relative pros and cons of each strategy, RT-alone should be considered for select elderly low-risk breast patients.

Citation Format: Ward MC, Vicini F, Chadha M, Pierce L, Recht A, Hayman J, Thaker N, Khan A, Keisch M, Shah C. Evaluating the cost of endocrine therapy vs. radiation therapy alone for low risk hormone positive early stage breast cancer in elderly patients [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-15-02.

Abstract P2-11-13: Meta-analysis of local recurrence of invasive breast cancer after electron intraoperative radiotherapy

Background: Electron intraoperative radiotherapy (IORT) can be used during breast conservation surgery to treat early-stage invasive breast cancer. While IORT may be an attractive alternative to traditional post-operative radiotherapy for many patients, its effectiveness in preventing local recurrence is still being evaluated. Using data from current clinical and observational studies, we aimed to assess the impact of single-fraction electron IORT on local recurrence rates.

Methods: Studies on single-fraction electron IORT during breast conservation surgery were identified through a search of PubMed and Google Scholar, as well as secondary referencing. Local recurrence rate was the main outcome of interest. Protocols from each publication were assessed for potential sources of heterogeneity. A meta-analysis of proportions, using binomial distribution to model the within-study variability and a random effects model, was conducted to estimate a pooled local recurrence rate. In order to estimate a 5-year recurrence rate, we applied a single-sample Poisson-normal model to model the probability of events occurring during a fixed period of time (60 months).

Results: A total of 13 independent publications were identified for abstraction. The analysis demonstrated a pooled monthly local recurrence rate of 0.02% per person-month (95% CI: 0.00 – 0.06%) for the studies with &lt; 5 years of follow-up, 0.03% per person-month (0.02 – 0.06%) for studies with ≥ 5 years of follow-up, and 0.02% per person-month (0.01 – 0.04%) overall. Based on this model, the predicted 5-year recurrence rate is 2.7%, with a 95% confidence interval of 1.9% - 3.7%.

Conclusions: According to the published literature, the rate of breast cancer local recurrence after electron IORT was 0.02% per person-month; with an adjusted 5-year recurrence rate of 2.7%. These findings support the recent guidelines from the American Society for Radiation Oncology (ASTRO) supporting the use of electron IORT in low-risk patients.

Citation Format: Harness J, Shah C, Brooks E, Via C, Vicini F. Meta-analysis of local recurrence of invasive breast cancer after electron intraoperative radiotherapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-11-13.

Abstract P3-14-09: Low rates of chronic breast cancer related lymphedema (BCRL) in a cohort of high-Risk patients undergoing prospective surveillance with bioimpedance spectroscopy (BIS)

Background: We report outcomes using prospective BIS surveillance in a high-risk cohort of patients who all underwent axillary lymph node dissection (ALND).

Methods: From 8/2010 through 12/2016, 206 consecutive patients were evaluated with BIS as part of a prospective surveillance program. 30 underwent ALND and constitute the study population. The program included pre-operative BIS measurement as well as post-operative assessments at regular intervals. Patients with L-Dex readings increasing by more than 10 from baseline were considered to have subclinical BCRL and treated with an over-the-counter (OTC) compression sleeve for 4 weeks. For the purpose of this analysis, additional high-risk features were defined as receipt of axillary radiation, a high body mass index (BMI) or the use of taxane based chemotherapy. Chronic BCRL was defined as the need for complex decongestive physiotherapy (CDP).

Results: Median follow-up was 36 months (range: 4.8-122.1 months). The median number of nodes removed was 18 (range: 5-32) and the median number of positive nodes was two. The median age for the cohort was 57.5 years old with 70% of patients undergoing mastectomy and the remainder breast conserving therapy. With respect to additional high-risk features, 77% also received taxane-based chemotherapy, 62% axillary irradiation, and 48% had an elevated BMI. Overall, 86% of patients had at least one additional high-risk feature, 70% at least two, and 23% had all three additional high-risk features. Seven patients (23%) had an elevated L-Dex score at some point during follow-up and underwent intervention with an OTC sleeve for 4 weeks. To date, no patients have required CDP at any time.

Conclusions: Prospective surveillance with BIS in a high-risk cohort of patients all undergoing ALND (plus additional high-risk features) led to no patients requiring CDP. These excellent findings are consistent with growing data supporting the use of BIS in prospective BCRL surveillance programs.

Citation Format: Kaufman D, Shah C, Vicini F. Low rates of chronic breast cancer related lymphedema (BCRL) in a cohort of high-Risk patients undergoing prospective surveillance with bioimpedance spectroscopy (BIS) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-14-09.

Abstract P3-14-08: The impact of a structured surveillance protocol using bioimpedance spectroscopy (BIS) on preventing breast cancer related lymphedema (BCRL) in high-Risk patients

Background: We evaluated the impact of structured surveillance using bioimpedance spectroscopy (BIS) to prevent clinical BCRL in a group of high-risk (axillary lymph node dissection) patients.

Methods: From April 2010 through November 2016, 93 patients who were treated with axillary lymph node dissection (ALND) were prospectively monitored with BIS using L-Dex (Impedimed). Patients received a pre-operative baseline L-Dex measurement followed by post-operative assessments at regular intervals. An elevated L-Dex score was defined as an increase of ≥10 points above baseline (considered subclinical BCRL). Intervention consisted of applying an over the counter (OTC) sleeve for 4 weeks followed by re-evaluation. The need for complete decongestive physiotherapy (CDP) represented a surrogate for the development of clinically significant, chronic BCRL.

Results: Median follow-up was 24 months (range: 0.3-206.4 months). The median number of nodes removed was 19 (range: 5-41) and the median number of positive nodes was 3. Median age was 53 years old. Eighty five percent of patients underwent mastectomy and the remainder breast conserving therapy. 55% of patients received taxane based chemotherapy, 24% received some form of axillary RT (15% high tangents and 9% comprehensive regional nodal RT) and 74% had an elevated body mass index (BMI, &gt; 25). Overall, 75% of these patients had at least one additional high-risk feature, 48% had at least two, and 6% had 3 (either taxane chemotherapy, axillary RT or elevated BMI). Thirty-three patients (35.4%) developed an elevated L-Dex score at some point during follow up. Overall, 10 patients (11%) required CDP at any point after treatment.

Conclusions: The results of this analysis support previously published data on the efficacy of prospective BCRL surveillance and early intervention using BIS. Of the 93 high-risk patients prospectively followed and managed in this structured BCRL protocol, 11% required CDP. These results compare favorably to all contemporary studies reporting BCRL rates in high-risk patients.

Citation Format: Whitworth P, Cooper A, Shah C, Vicini F. The impact of a structured surveillance protocol using bioimpedance spectroscopy (BIS) on preventing breast cancer related lymphedema (BCRL) in high-Risk patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-14-08.

Abstract P6-12-03: Utilization of bioimpedance spectroscopy in the prevention of chronic breast cancer related lymphedema

Background: With improved breast cancer outcomes, an increasing focus on sequelae of treatment as part of survivorship has emerged. Breast cancer related lymphedema (BCRL) represents one such sequelae. Increasing data and recent NCCN guidelines support the use of prospective BCRL surveillance to allow for early detection and intervention as a method to reduce chronic, irreversible BCRL. Therefore, this study was performed to evaluate the impact early detection and treatment of BCRL in breast cancer patients undergoing prospective surveillance with bioimpedance spectroscopy (BIS).

Methods: From 8/2010 through 12/2016, 206 patients were evaluated with BIS as part of a prospective surveillance program.The protocol included pre-operative assessment with BIS as well as post-operative assessments with BIS at regular intervals. Patients with L-Dex readings increasing by more than 10 from baseline were considered to have subclinical BCRL and treated with a compression sleeve for 4 weeks. For the purpose of this analysis, high-risk was defined as receipt of ALND, regional nodal irradiation, or taxane chemotherapy. Chronic BCRL was defined as the need for complex decongestive physiotherapy.

Results: A total of 206 patients were analyzed, with a mean age of 61 years old and a median follow up of 25.9 months. Overall, 17% of patients had least one high-risk feature, 8% had two factors, and 7% had all three factors. A total of 21 patients (9.8%) were diagnosed with subclinical BCRL. Increased rates of subclinical BCRL were seen in patients undergoing ALND (23% vs. 7%, p=0.01) with ALND and receipt of RNI associated with development of subclinical BCRL. At last follow-up, no patients had persistent, chronic BCRL following early, conservative intervention measures.

Conclusions: The results of this study support prospective surveillance and early treatment utilizing BIS. Intervention triggered by subclinical BCRL detection with an elevated L-Dex score was associated with a very low rate of chronic BCRL.

Citation Format: Kaufman D, Shah C, Vicini F. Utilization of bioimpedance spectroscopy in the prevention of chronic breast cancer related lymphedema [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-03.

Abstract AP30: PHASE IB/II WITH EXPANSION OF PATIENTS AT THE MTD STUDY OF OLAPARIB PLUS WEEKLY (METRONOMIC) CARBOPLATIN AND PACLITAXEL IN RELAPSED OVARIAN CANCER PATIENTS

BACKGROUND: We established the olaparib tablet maximum tolerated dose (MTD) at 150 mg bid, dose limiting toxicities (DLT's) and response to therapy or carboplatin, paclitaxel and olaparib tablet given simultaneously, reported at ASCO 2014. This abstract will include data from both the phase 1b and the phase 2 expansion.

METHODS: A total of 54 subjects were evaluated in this trial, 14 in phase 1b and 40 in phase 2. Eligibility required measurable disease, adequate organ function and ECOG performance status of ~ 2. Subjects had to have failed first line platinum containing chemotherapy. BRCA testing was conducted as available. Subjects received the metronomic therapy of paclitaxel 60mg/m2 IV and carboplatin AUC 2 IV weekly, 3 weeks out of 4, and olaparib tablets at 150 mg bid administered orally for 3 consecutive days (D1-D3) every week for each cycle. Subjects were assessed for toxicity and response according to the protocol. Subjects that reached a confirmed complete remission were transitioned to olaparib tablets only, 300 mg bid until disease progression.

RESULTS: Median age was 58 and median number of prior regimens was 4. There have been no deaths due to the study regimen. One patient had grade 4 neutropenia and an allergic reaction to carboplatin. The common grade 3/4 toxicities were caused by the chemotherapy (neutropenia. anemia and thrombocytopenia). Two patients had mild GI toxicities. One patient had a skin rash. There was no evidence of cardiac, hepatic, or pulmonary toxicities in any of these patients. 25% of subjects had a complete remission (CR), 31% had PR, 23% had SD and 21% had

PD. Of the 13 CRs, 4 were BRCA negative. PFS median for BRCA positive subjects is 12.6 months vs 4.8 months for BRCA negative subjects. OS median for BRCA positive subjects is 24 months vs 16 months for BRCA negative subjects. All of the CR's are alive.

CONCLUSION: Olaparib tablet can be safely administered simultaneously with a weekly regimen of carboplatin and paclitaxel in heavily pretreated ovarian cancer patients. Olaparib appears to be highly effective in BRCA positive subjects. This is the first successful combination of olaparib tablets with carboplatin and paclitaxel that has been well tolerated.

Citation Format: Rivkin SE, Moon J, Iriarte D, Sloan H, Wiseman C, Klee M, Ference K, Drescher C, Veljovich D, Bondurant A, Peters W, Jiang P, Goodman G, Park M, Fer M, Shah C, Johnston E, Kaplan H, Wahl T, Ellis E. PHASE IB/II WITH EXPANSION OF PATIENTS AT THE MTD STUDY OF OLAPARIB PLUS WEEKLY (METRONOMIC) CARBOPLATIN AND PACLITAXEL IN RELAPSED OVARIAN CANCER PATIENTS [abstract]. In: Proceedings of the 11th Biennial Ovarian Cancer Research Symposium; Sep 12-13, 2016; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(11 Suppl):Abstract nr AP30.

Multiple unusual lung etiologies in a child with acute lymphocytic leukemia

Granulomatous lung disease is a rare and perplexing differential in pediatrics. Pulmonary Cryptococcus falls into the differential but is not high on the list, particularly in a non-AIDS patient. Methotrexate (MTX) is a commonly used agent for chemotherapy in oncology and has been documented to cause lung injury in both patients with rheumatologic and oncologic diseases. Our patient had chronic cough and then developed an opportunistic infection resulting in respiratory failure. Lung biopsy showed two underlying unusual diagnoses: MTX lung injury and cryptococcal pneumonia. His case is presented with particular attention to his prolonged road to diagnosis.

Abstract OT3-07-01: A randomized trial evaluating bioimpedance spectroscopy vs. tape measurement in the prevention of lymphedema following breast cancer treatment

Background: Breast cancer related lymphedema (BCRL) represents a common treatment associated complication following surgery, radiation and/or chemotherapy. Increasing data has demonstrated the ability of new diagnostic modalities to detect BCRL in the subclinical phase of the process allowing for early intervention.

Trial Design: This 2-group stratified randomized clinical trial evaluates the effectiveness of bioimpedance spectroscopy (BIS) for early detection and prevention of BCRL compared to tape measurement (TM). Baseline assessments are made pre-operatively. Two-months post-op, patients are censored out if they have developed any of the exclusion conditions, did not have a mastectomy, axillary dissection, &gt;6 sentinel nodes removed, radiation therapy, or taxane. Remaining patients are randomized within site to either BIS or TM; monitored at 3 to 6-month intervals up to 36-months post-op for a change over baseline specified to trigger a compression sleeve & gauntlet intervention. Cohort trigger thresholds are change of ≥10 L-Dex units or 5 to &lt;10% volume. If the intervention is triggered, measurements by the other method are taken before initiating the 4-week intervention. Post intervention, patients are monitored only with TM. Volume change of ≥10% results in study removal and physician referral. At the 2 study endpoints (36 month visit or volume change of ≥10%) measurements are taken with each method.

Eligibility Criteria: Inclusion criteria: ≥ 18 with histologically confirmed stage I-III breast cancer (BC) or DCIS with planned surgery. Exclusion criteria include history of BC therapy or lymphedema.

Specific Aims: The primary hypothesis is that subclinical detection of BCRL with BIS and early intervention will reduce the rate of lymphedema progression (as measured by referral to complex decongestive physiotherapy) compared to TM. Secondary outcomes include BCRL risk factors, quality of life, and time to treatment.

Statistical Methods: Sample size and powering were based on the hypothesis that BIS would reduce progression rate by 20%. A rate of 50% progression in the TM group was used as the standard. 1100 patients will be enrolled to result in randomized groups of 100 (Total N=200) Statistics include relative risks with respective bootstrapped 95% C.I. and Cochran-Mantel-Haenszel tests.

Present Accrual and Target Accrual: Overall, the study target or expected enrollment as of the end of March 31, 2016 was 690 participants, 534 were actually enrolled (actual accrual 77% of target). Accrual at the study sites ranged from 15 to 104% of target.

Contact Information: Sheila Ridner: 615-322-0831, Sheila.ridner@vanderbilt.edu

Support: ImpediMed Limited, ImpediMed, Inc. and medi USA.

Citation Format: Ridner S, Shah C, Dietrich M, Vicini F. A randomized trial evaluating bioimpedance spectroscopy vs. tape measurement in the prevention of lymphedema following breast cancer treatment [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT3-07-01.

Common pattern of gray-matter abnormalities in drug-naive and medicated first-episode schizophrenia: a multimodal meta-analysis

Studies of schizophrenia at drug-naive state and on antipsychotic medication have reported a number of regions of gray-matter (GM) abnormalities but the reports have been inconsistent. The aim of this study was to conduct multimodal meta-analysis to compare the cross-sectional voxel-based morphometry studies of brain GM in antipsychotic-naive first-episode schizophrenia (AN-FES) and those with antipsychotic treatment within 1 year (AT-FES) to determine the similarities and differences in these groups. We conducted two separate meta-analyses containing 24 studies with a sample size of 801 patients and 957 healthy controls. A multimodal meta-analysis method was used to compare the findings between AN-FES and AT-FES. Meta-regression analyses were done to determine the influence of different variables including age, duration of illness, and positive and negative symptom scores. Finally, jack-knife analyses were done to test the robustness of the results. AN-FES and AT-FES showed common patterns of GM abnormalities in frontal (gyrus rectus), superior temporal, left hippocampal and insular cortex. GM in the left supramarginal gyrus and left middle temporal gyrus were found to be increased in AN-FES but decreased in AT-FES, whereas left median cingulate/paracingulate gyri and right hippocampus GM was decreased in AN-FES but increased in AT-FES. Findings suggest that both AN-FES and AT-FES share frontal, temporal and insular regions as common anatomical regions to be affected indicating these to be the primary regions of GM abnormalities in both groups.

Preparation, characterization and in vitro antioxidative potential of synbiotic fermented dairy products

The present study, evaluates the antioxidative potential of two synbiotic dairy products viz. synbiotic lassi with honey and whey based synbiotic drink with inulin and orange juice, along with their physicochemical and microbiological activity during storage period. Antioxidative potential of raw ingredients and probiotic cultures used to prepare synbiotic products was also evaluated. Synbiotic lassi with honey was prepared using Streptococcus thermophilus MTCC 5460 (MD2) and Lactobacillus helveticus MTCC 5463 (V3) as probiotics and honey as prebiotic. For preparation of whey based synbiotic drink, Lactobacillus helveticus MTCC 5463 and inulin were used as probiotic and prebiotic, respectively and orange juice was also incorporated. Titratable acidity and pH of both synbiotic products followed a similar pattern of increase or decrease during storage. Furthermore, no major changes were observed in viability of probiotic cultures under storage conditions adapted. The hydroxyl radical scavenging activity of synbiotic lassi with honey was found to significantly decrease from 107.76 to 79.41 % at the end of storage whereas, the activity of whey based synbiotic drink was 100.32 % which declined sharply to 79.21 % on 7th day but further increased to 102.59 % on 14th day. The DPPH (α, α-Diphenyl-β-Picrylhydrazyl) radical scavenging activity of freshly prepared synbiotic lassi with honey was 28.43 % which decreased to 23.03 % on 7th day while for whey based synbiotic drink decreased from 26.85 % (0 day) to 17.12 % (7th day) and continued to decline. Moreover, probiotic strains used for synbiotic preparation also demonstrated good antioxidative activity.

Compton polarimeter for 10-30 keV x rays

We present a simple and versatile polarimeter for x rays in the energy range of 10-30 keV. It uses Compton scattering in low-Z materials such as beryllium or boron carbide. The azimuthal distribution of the scattered x rays is sampled by an array of 12 silicon PIN diodes operated at room temperature. We evaluated the polarimetry performance using Monte-Carlo simulations and show experimental results.

How nurses contribute to medicines reconciliation

The process of obtaining an up-to-date and accurate patient medication list, medicines reconciliation (MedRec), is vital to ensuring patient safety. Despite its high status as a patient safety issue, and the efforts made to drive and implement robust MedRec processes, further efforts are required to identify and disseminate best practice (Greenwald et al 2010). This article outlines some of the principles involved in conducting effective MedRec and invites interested nurses to join a working group that aims to develop a best-practice toolkit.