Report of consensus panel 7 from the 11th international workshop on Waldenström macroglobulinemia on priorities for novel clinical trials

Recent advances in the understanding of Waldenström macroglobulinemia (WM) biology have impacted the development of effective novel agents and improved our knowledge of how the genomic background of WM may influence selection of therapy. Consensus Panel 7 (CP7) of the 11th International Workshop on WM was convened to examine the current generation of completed and ongoing clinical trials involving novel agents, consider updated data on WM genomics, and make recommendations on the design and prioritization of future clinical trials. CP7 considers limited duration and novel-novel agent combinations to be the priority for the next generation of clinical trials. Evaluation of MYD88, CXCR4 and TP53 at baseline in the context of clinical trials is crucial. The common chemoimmunotherapy backbones, bendamustine-rituximab (BR) and dexamethasone, rituximab and cyclophosphamide (DRC), may be considered standard-of-care for the frontline comparative studies. Key unanswered questions include the definition of frailty in WM; the importance of attaining a very good partial response or better (≥VGPR), within stipulated time frame, in determining survival outcomes; and the optimal treatment of WM populations with special needs.

Enroller Experience and Parental Familiarity of Disease Influence Participation in a Pediatric Trial

Introduction

Acquiring parental consent is critical to pediatric clinical research, especially in interventional trials. In this study we investigated demographic, clinical, and environmental factors associated with likelihood of parental permission for enrollment in a study of therapies for diabetic ketoacidosis (DKA) in children.

Methods

We analyzed data from patients and parents who were approached for enrollment in the Pediatric Emergency Care Applied Research Network (PECARN) Fluid Therapies Under Investigation in DKA (FLUID) trial at one major participating center. We determined the influence of various factors on patient enrollment, including gender, age, distance from home to hospital, insurance status, known vs new onset of diabetes, glycemic control (hemoglobin A1c), DKA severity, gender of the enroller, experience of the enroller, and time of enrollment. Patients whose parents consented to participate were compared to those who declined participation using bivariable and multivariable analyses controlling for the enroller.

Results

A total of 250 patient/parent dyads were approached; 177 (71%) agreed to participate, and 73 (29%) declined. Parents of patients with previous episodes of DKA agreed to enroll more frequently than those with a first DKA episode (94.3% for patients with 1–2 previous DKA episodes, 92.3% for > 2 previous episodes, vs 64.9% for new onset diabetes and 63.2% previously diagnosed but no previous DKA). Participation was also more likely with more experienced enrollers (odds ratio [95% confidence interval] of participation for an enroller with more than two years’ experience vs less than two years: 2.46 [1.53, 3.97]). After adjusting for demographic and clinical factors, significant associations between participation and both DKA history and enroller experience remained. Patient age, gender, distance of home from hospital, glycemic control, insurance status, and measures of DKA severity were not associated with likelihood of participation.

Conclusion

Familiarity with the disease process (previously diagnosed diabetes and previous experience with DKA) and experience of the enroller favorably influenced the likelihood of parental permission for enrollment in a study of DKA in children.

Hybridisation between dingoes and domestic dogs in proximity to Indigenous communities in northern Australia

In northern Australia, wild dog populations potentially interact with domestic dogs from remote communities, which would create opportunities for disease transmission at the wild-domestic interface. An example is rabies, in the event of an incursion into northern Australia. However, the likelihood of such wild-domestic interactions is ambiguous. Hybridisation analyses based on 23 microsatellite DNA markers were performed on canine-origin scats collected in bushland areas around remote Indigenous communities in the Northern Peninsula Area, Queensland. Sufficient DNA was extracted from 6 of 41 scats to assess the percentage of dingo purity. These scats most likely originated from two 'pure' domestic dogs (0% dingo purity), one hybrid (20% dingo purity) and three 'pure' dingoes (92%-98% dingo purity). The two domestic dog samples were collected in the vicinity of communities. The location of two of the dingo-origin samples provides genetic evidence that dingoes are present in areas close to the communities. The availability of anthropogenic food resources likely creates opportunities for interactions with domestic dogs in the region. The hybrid sample demonstrates the occurrence of antecedent contacts between both populations by means of mating and supports the likelihood of a spatio-temporal overlap at the wild-domestic interface. This represents the first genetic survey involving a wild dog population of equatorial northern Queensland, with evidence of dingo purity. Our results have implications for potential disease transmission within a priority area for biosecurity in northern Australia.

Conservation concerns associated with low genetic diversity for K'gari-Fraser Island dingoes

The dingo population on world heritage-listed K'gari-Fraser Island (K'gari) is amongst the most well-known in Australia. However, an absence of population genetic data limits capacity for informed conservation management. We used 9 microsatellite loci to compare the levels of genetic diversity and genetic structure of 175 K'gari dingo tissue samples with 264 samples from adjacent mainland regions. Our results demonstrated that the K'gari population has significantly lower genetic diversity than mainland dingoes (A_R, H_E, P_AR; p < 0.05) with a fourfold reduction in effective population size (N_e = 25.7 vs 103.8). There is also strong evidence of genetic differentiation between the island and mainland populations. These results are in accordance with genetic theory for small, isolated, island populations, and most likely the result of low initial diversity and founder effects such as bottlenecks leading to decreased diversity and drift. As the first study to incorporate a large sample set of K'gari dingoes, this provides invaluable baseline data for future research, which should incorporate genetic and demographic monitoring to ensure long-term persistence. Given that human-associated activities will continue to result in dingo mortality, it is critical that genetic factors are considered in conservation management decisions to avoid deleterious consequences for this iconic dingo population.

Inter-rater reliability of the radiographic assessment of simple bone cysts

PURPOSE

To develop and evaluate the reliability of an explicit set of parameters and criteria for simple bone cysts (SBCs) and evaluate the reliability of single versus serial chronological reading methods.

METHODS

Radiographic criteria were developed based on the literature and expert consensus. A single anteroposterior/lateral radiograph from 32 subjects with SBC were evaluated by three radiologists. A second reading was then conducted using revised criteria including a visual schematic. In the third reading the same images were assessed but radiologists had access to images from two additional time points. Inter-rater reliability was assessed after each reading using kappa (κ) and percentage agreement for categorical and binary parameters and intra-class correlation coefficient (ICC) for continuous parameters.

RESULTS

Parameters that were revised with more explicit definitions including the visual schematic demonstrated consistent or improved inter-rater reliability with the exception of continuous cortical rim present and cyst location in the metaphysis and mid-diaphysis. Cortical rim displayed only slight reliability throughout (κ= -0.008 to 0.16). All other categorical parameters had a percentage agreement above 0.8 or a moderate (κ= 0.41 to 0.60), substantial (κ = 0.61 to 0.80) or almost perfect inter-rater reliability (κ = 0.81 to 1.0) in at least one reading. All continuous parameters demonstrated excellent inter-rater reliability (ICC > 0.75) in at least one reading with the exception of scalloping (ICC = 0.37 to 0.70). Inter-rater reliability values did not indicate an obviously superior method of assessment between single and serial chronological readings.

CONCLUSION

Explicit criteria for SBC parameters used in their assessment demonstrated improved and substantial inter-rater reliability. Inter-rater reliability did not differ between single and serial chronological readings.

LEVEL OF EVIDENCE

Not Applicable.

Predictors of Physician Confidence to Diagnose Pneumonia and Determine Illness Severity in Ventilated Patients. Australian and New Zealand Practice in Intensive Care (ANZPIC II)

The manner in which elements of clinical history, physical examination and investigations influence subjectively assessed illness severity and outcome prediction is poorly understood. This study investigates the relationship between clinician and objectively assessed illness severity and the factors influencing clinician's diagnostic confidence and illness severity rating for ventilated patients with suspected pneumonia in the intensive care unit (ICU).

A prospective study of fourteen ICUs included all ventilated admissions with a clinical diagnosis of pneumonia. Data collection included pneumonia type – community-acquired (CAP), hospital-acquired (HAP) and ventilator-associated (VAP), clinician determined illness severity (CDIS), diagnostic methods, clinical diagnostic confidence (CDC), microbiological isolates and antibiotic use.

For 476 episodes of pneumonia (48% CAP, 24% HAP, 28% VAP), CDC was greatest for CAP (64% CAP, 50% HAP and 49% VAP, P<0.01) or when pneumonia was considered “life-threatening” (84% high CDC, 13% medium CDC and 3% low CDC, P<0.001). “Life-threatening” pneumonia was predicted by worsening gas exchange (OR 4.8, CI 95% 2.3–10.2, P<0.001), clinical signs of consolidation (OR 2.0, CI 95% 1.2–3.2, P<0.01) and the Sepsis-Related Organ Failure Assessment (SOFA) Score (OR 1.1, CI 95% 1.1–1.2, P<0.001). Diagnostic confidence increased with CDIS (OR 16.3, CI 95% 8.4–31.4, P<0.001), definite pathogen isolation (OR 3.3, CI 95% 2.0–5.6) and clinical signs of consolidation (OR 2.1, CI 95% 1.3–3.3, P=0.001). Although the CDIS, SOFA Score and the Simplified Acute Physiologic Score (SAPS II) were all associated with mortality, the SAPS II Score was the best predictor of mortality (P=0.02).

Diagnostic confidence for pneumonia is moderate but increases with more classical presentations. A small set of clinical parameters influence subjective assessment. Objective assessment using SAPS II Scoring is a better predictor of mortality.

Disease Risk and Mortality Prediction in Intensive Care Patients with Pneumonia. Australian and New Zealand Practice in Intensive Care (ANZPIC II)

This study of ventilated patients investigated pneumonia risk factors and outcome predictors in 476 episodes of pneumonia (48% community-acquired pneumonia, 24% hospital-acquired pneumonia, 28% ventilator-associated pneumonia) using a prospective survey in 14 intensive care units within Australia and New Zealand. For community acquired pneumonia, mortality increased with immunosuppression (OR 5.32, CI 95% 1.58–17.99, P<0.01), clinical signs of consolidation (OR 2.43, CI 95% 1.09–5.44, P=0.03) and Sepsis-Related Organ Failure Assessment (SOFA) scores (OR 1.19, CI 95% 1.08–1.30, P<0.001) but improved if appropriate antibiotic changes were made within three days of intensive care unit admission (OR 0.42, CI 95% 0.20–0.86, P=0.02). For hospital-acquired pneumonia, immunosuppression (OR 6.98, CI 95% 1.16–42.2, P=0.03) and non-metastatic cancer (OR 3.78, CI 95% 1.20–11.93, P=0.02) were the principal mortality predictors. Alcoholism (OR 7.80, CI 95% 1.20–17.50, P<0.001), high SOFA scores (OR 1.44, CI 95% 1.20–1.75, P=0.001) and the isolation of “high risk” organisms including Pseudomonas aeruginosa, Acinetobacter spp, Stenotrophomonas spp and methicillin resistant Staphylococcus aureus (OR 4.79, CI 95% 1.43–16.03, P=0.01), were associated with increased mortality in ventilator-associated pneumonia. The use of non-invasive ventilation was independently protective against mortality for patients with community-acquired and hospital-acquired pneumonia (OR 0.35, CI 95% 0.18–0.68, P=0.002). Mortality was similar for patients requiring both invasive and non-invasive ventilation and non-invasive ventilation alone (21% compared with 20% respectively, P=0.56).

Pneumonia risks and mortality predictors in Australian and New Zealand ICUs vary with pneumonia type. A history of alcoholism is a major risk factor for mortality in ventilator-associated pneumonia, greater in magnitude than the mortality effect of immunosuppression in hospital-acquired pneumonia or community-acquired pneumonia. Non-invasive ventilation is associated with reduced ICU mortality. Clinical signs of consolidation worsen, while rationalising antibiotic therapy within three days of ICU admission improves mortality for community-acquired pneumonia patients.

Incidence, outcomes and outcome prediction of unplanned extubation in critically ill children: An 11year experience

PURPOSE

Unplanned extubation represents loss of control in the ICU, is associated with harm and is used as a measure of quality of care. We evaluated the rates and consequences of unplanned extubation.

MATERIALS AND METHODS

Eligible patients were intubated, <18years, and in ICU. Patient, care-related and environmental characteristics were compared in patients who did and did not receive positive pressure ventilation in the 24h after events. Rates are expressed per 100 intubation-days.

RESULTS

The 11,310 eligible patient-admissions identified were intubated for 75,519days; 410 (3.39%) patients had 458 unplanned extubation events (0.61 events/100 intubation-days). Annual rates of unplanned extubation reduced from 0.98 in 2004 to 0.37 in 2014. Consequences occurred in 245 (53.5%) events and included cardiac arrest in 9 (2%), bradycardia 52 (11%), and stridor 63 (14%). Positive pressure was provided after 263 (57%) events, and was independently associated with pre-event sedative and muscle relaxant drugs, non-use of restraints, respiratory reason for intubation and recent care by more nurses.

CONCLUSION

Unplanned extubation was associated with both significant and no morbidity. Modification of factors including more consistent nurse staffing, restraint use, and increased vigilance in patients with previous events may potentially reduce rates and adverse consequences of unplanned extubation.

Antibody-mediated thyroid dysfunction during T-cell checkpoint blockade in patients with non-small-cell lung cancer

Background

Programmed cell death protein-1 (PD-1) blockade therapies have demonstrated durable responses and prolonged survival in a variety of malignancies. Treatment is generally well tolerated although immune-related adverse events (irAEs) can occur. Autoimmune thyroid dysfunction is among the most common irAE, but an assessment of the clinical, mechanistic, and immunologic features has not been previously described.

Patient and methods

Patients with advanced non-small-cell lung cancer (NSCLC) treated with pembrolizumab at Memorial Sloan Kettering Cancer Center (n = 51) as part of KEYNOTE-001 (NCT01295827) were included. Thyroid function test and anti-thyroid antibodies were assessed prospectively at each study visit, beginning before the first treatment. Frequency of development of thyroid dysfunction, association with anti-thyroid antibodies, clinical course, and relationship with progression-free survival and overall survival to treatment with pembrolizumab was evaluated.

Results

Of 51 patients treated, 3 were hypothyroid and 48 were not at baseline. Ten of 48 [21%, 95% confidence interval (CI) 10% to 35%] patients developed thyroid dysfunction requiring thyroid replacement. Anti-thyroid antibodies were present in 8 of 10 patients who developed thyroid dysfunction, compared with 3 of 38 who did not (80% versus 8%, P < 0.0001). Thyroid dysfunction occurred early (median, 42 days) in the pembrolizumab course, and a majority (6 of 10 patients) experienced brief, transient hyperthyroidism preceding the onset of hypothyroidism; no persistent hyperthyroidism occurred. Both hyperthyroidism and hypothyroidism were largely asymptomatic. Overall survival with pembrolizumab was significantly longer in subjects who developed thyroid dysfunction (hazard ratio, 0.29; 95% CI 0.09-0.94; P = 0.04).

Conclusions

Thyroid dysfunction during pembrolizumab treatment of NSCLC is common and is characterized by early-onset, frequently preceded by transient hyperthyroidism, closely associated with anti-thyroid antibodies, and may be associated with improved outcomes. The presence of antibody-mediated toxicity in T-cell-directed therapy suggests an under-recognized impact of PD-1 biology in modulating humoral immunity.

Challenges to the Meaningful Involvement of HIV-Positive People in the Response to HIV/AIDS in Cambodia, India and Indonesia

This study examines challenges to HIV-positive people's involvement in AIDS policy making and project design and implementation in Asia. Forty-eight interviews were conducted with key players in the HIV sector in Cambodia, India and Indonesia. The major barrier to involvement is AIDS-related stigma. Most people are diagnosed late in infection and have poor access to antiretroviral drugs. The majority of positive people working in HIV/ AIDS have no training in public health or organisational management and few training opportunities are available. Respondents in all countries said NGOs exploit positive people in order to enhance funding opportunities. Representation on policy making bodies is low because the few people well enough to take on these roles often lack the confidence to assert their needs in front of doctors and government officials. Positive activists need advocacy skills to become more effective, encouragement and support to take on roles as educators and counsellors, sustainable incomes, and medication to stay alive.

Pediatric intestinal transplant listing criteria - a call for a change in the new era of intestinal failure outcomes

Current listing indications used for intestinal transplantation (IT) were proposed in 2001. We undertook the present single center study to see if these criteria are still valid. The 2001 criteria (advanced cholestasis, loss of >50% central venous catheter (CVC) sites, ≥2 sepsis/year, ultrashort bowel) were compared in children with intestinal failure in old era-1998-2005 (N = 99) to current era-2006-2012 (N = 91) to predict the need for IT using sensitivity, specificity, NPV and PPV. Two 2001 criteria had poorer predictive value in the current era: Advanced cholestasis (PPV 64% old vs. 40% current era; sensitivity 84% vs. 65%, respectively) and ultrashort bowel (PPV 100% old vs. 9% current era; sensitivity 10% vs. 4%, respectively). Three newly proposed criteria had high predictive value: ≥2 ICU admissions (p = 0.0001, OR 23.6, 95% CI 2.7-209.8), persistent bilirubin >75 mmol/L despite lipid strategies (p = 0.0005, OR 24.0, 95% CI 3.2-177.4), and loss of ≥3 CVC sites (p = 0.0003, OR 33.3, 95% CI 18.8-54.0). There was 98% probability of needing IT when two of these new criteria were present. The 2001 IT criteria have limited predictive ability in the current era and should be revised. A multicenter study is required to validate the findings of this single center experience.

More bang for your monitoring bucks: Detection and reporting of non-indigenous species

'Collect once, use often' is a frequently cited principle in both national and international efforts to promote the collection, archiving and sharing of marine monitoring data. Since the implementation of the Marine Conservation Zone (MCZ) evidence collection programme, 67 recommended MCZ sites have been visited and a suite of marine data collected. Here we present how this dataset was utilised outside of the MCZ programme to identify occurrences of non-indigenous species (NIS) around the UK coast. One hundred and thirty-five aquatic species from the Non-native Species Information Portal (NNSIP) register were used to produce a standard list of NIS against which, infauna and epifaunal data records from the MCZ project were compared. A total of 20 NIS were identified across 42 of the 67 sites surveyed. This study demonstrates that with sufficient coordination and management data collected for other purposes can be easily utilised to address additional policy requirements.

The long-term outcome of patients treated operatively and non-operatively for scoliosis deformity secondary to spina bifida

The purpose of this study was to evaluate the long-term outcome of adults with spina bifida cystica (SBC) who had been treated either operatively or non-operatively for scoliosis during childhood.

We reviewed 45 patients with a SBC scoliosis (Cobb angle ≥ 50º) who had been treated at one of two children’s hospitals between 1991 and 2007. Of these, 34 (75.6%) had been treated operatively and 11 (24.4%) non-operatively. After a mean follow-up of 14.1 years (standard deviation (sd) 4.3) clinical, radiological and health-related quality of life (HRQOL) outcomes were evaluated using the Spina Bifida Spine Questionnaire (SBSQ) and the 36-Item Short Form Health Survey (SF-36).

Although patients in the two groups were demographically similar, those who had undergone surgery had a larger mean Cobb angle (88.0º (sd 20.5; 50.0 to 122.0); versus 65.7º (sd 22.0; 51.0 to 115.0); p < 0.01) and a larger mean clavicle–rib intersection difference (12.3 mm; (sd 8.5; 1 to 37); versus 4.1 mm, (sd 5.9; 0 to 16); p = 0.01) than those treated non-operatively. Both groups were statistically similar at follow-up with respect to walking capacity, neurological motor level, sitting balance and health-related quality of life (HRQOL) outcomes.

Spinal fusion in SBC scoliosis corrects coronal deformity and stops progression of the curve but has no clear effect on HRQOL.

Cite this article: Bone Joint J 2014; 96-B:1244–51

Adult hearing screening: follow-up and outcomes1

PURPOSE

To screen hearing and evaluate outcomes in community-dwelling older adults.

METHOD

Three thousand and twenty-five adults responded to an invitation to be screened by questionnaire, otoscopy, and pure-tone audiometry. Pure-tone average (PTA) >35 dB HL in the worse ear, unilateral hearing loss, or otoscopic findings were the criteria for referral for services. A questionnaire related to compliance with referral recommendations was completed by telephone interview for 160 randomly selected participants after 1-2 years from referral.

RESULTS

The referral rate for audiologic/hearing aid evaluation was 46%, and referral for cerumen removal/medical evaluation was 17%. Of the people referred for audiologic/hearing aid evaluation, 18% tried a hearing aid; 2 years later, 11% were using a hearing aid. Screening recommendations affected participants' decision to seek help. Study participants stated that the screening was helpful, it should be offered to everybody, and they would participate in future screenings.

CONCLUSION

Although adult hearing screening offered timely identification of hearing loss for adults seeking help, follow-up with hearing aid treatment was low.

Dehiscence of the posterior and superior semicircular canal presenting in pregnancy

OBJECTIVE

We present an interesting case of superior and posterior semicircular canal dehiscence in pregnancy.

METHOD

We present a case report and a review of the world literature concerning semicircular canal dehiscence.

CASE REPORT

A 34-year-old woman presented with sound and pressure induced vertigo at 22 weeks gestation. A thinly sliced computed tomography (CT) scan of the petrous temporal bones viewed with coronal reconstructions was performed post-partum. This showed the presence of both left superior canal and posterior canal dehiscence.

CONCLUSION

To our knowledge this is the first reported case of semicircular canal dehiscence in pregnancy. The diagnosis of semicircular canal dehiscence should be suspected in pregnant patients with sound induced vertigo.

Evidence-based guideline update: medical treatment of infantile spasms. Report of the Guideline Development Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society

OBJECTIVE

To update the 2004 American Academy of Neurology/Child Neurology Society practice parameter on treatment of infantile spasms in children.

METHODS

MEDLINE and EMBASE were searched from 2002 to 2011 and searches of reference lists of retrieved articles were performed. Sixty-eight articles were selected for detailed review; 26 were included in the analysis. RECOMMENDATIONS were based on a 4-tiered classification scheme combining pre-2002 evidence and more recent evidence.

RESULTS

There is insufficient evidence to determine whether other forms of corticosteroids are as effective as adrenocorticotropic hormone (ACTH) for short-term treatment of infantile spasms. However, low-dose ACTH is probably as effective as high-dose ACTH. ACTH is more effective than vigabatrin (VGB) for short-term treatment of children with infantile spasms (excluding those with tuberous sclerosis complex). There is insufficient evidence to show that other agents and combination therapy are effective for short-term treatment of infantile spasms. Short lag time to treatment leads to better long-term developmental outcome. Successful short-term treatment of cryptogenic infantile spasms with ACTH or prednisolone leads to better long-term developmental outcome than treatment with VGB.

RECOMMENDATIONS

Low-dose ACTH should be considered for treatment of infantile spasms. ACTH or VGB may be useful for short-term treatment of infantile spasms, with ACTH considered preferentially over VGB. Hormonal therapy (ACTH or prednisolone) may be considered for use in preference to VGB in infants with cryptogenic infantile spasms, to possibly improve developmental outcome. A shorter lag time to treatment of infantile spasms with either hormonal therapy or VGB possibly improves long-term developmental outcomes.

The patient journey of adults with hearing impairment: the patients' views

OBJECTIVE

The term 'patient journey' refers to the experiences and processes the patient goes through during the course of a disease and its treatment. The study explores the perspectives of adults with acquired hearing impairment and to further develop the patient journey template based on the Ida model.

DESIGN

Qualitative approach using thematic analysis and process mapping.

SETTING

Support groups of people with hearing impairment.

PARTICIPANTS

Thirty-two adults with acquired hearing impairment from two hearing impaired groups in Wales. All were hearing aid users.

MAIN OUTCOME MEASURE

Participants worked in small groups to describe their experiences through hearing loss. These data were used to develop a template of the patients' perspective of the journey. This was then compared with the perspective of professionals, and a 'patient journey template for adults with acquired hearing impairment' was developed.

RESULTS

This template identifies seven main phases as follows: (i) pre-awareness; (ii) awareness; (iii) movement; (iv) diagnostics; (v) rehabilitation; (vi) self-evaluation; and (vii) resolution. The study identified a number of new components. The self-evaluation component was not defined by professionals and reflects the need for patients to consider the costs, benefits and alternatives to the approach provided by audiologists. It is important for audiologists to be aware of this.

CONCLUSION

The study highlighted the differences and commonalities in perspectives of professionals and patients. Use of the patient journey can help clinicians to understand the unique experiences their patients go through help them to develop patient-centred treatment.

Relationship between antenatal group B streptococcal vaginal colonization and premature labour

OBJECTIVE

To determine whether a population of pregnant women with group B streptococcal (GBS) vaginal colonization had an increased risk of specific epidemiological and intrapartum risk factors for early onset GBS disease.

SETTING

Tertiary university centre in Ottawa, Ontario.

DESIGN

Hospital-based retrospective cohort study.

METHODS

Pregnant women who gave birth during a four-month period in 1994 were included in the study. Potential GBS risk factors were obtained from a review of medical records. The prevalence of each risk factor in colonized and noncolonized women was examined using chi(2) or Fisher's exact test. Multiple logistic regression was performed.

RESULTS

A total of 986 women, including 94 (9.5%) women colonized with GBS, were studied. The proportion of women younger than 20 years of age in the colonized group was 2.1% (two of 94) versus 4.6% (41 of 891) in the noncolonized group (P=0.28). Similar rates of multiple births were observed among the colonized and noncolonized groups (2.1% [two of 94] versus 2.5% [22 of 891], respectively) (P=0.94). Likewise, there were no significant differences in either group in the prevalence of a previous pregnancy affected by GBS or diabetes mellitus (P=0.82 and P=0.79, respectively). Multivariable analyses indicated that women who were colonized with GBS were more than twice as likely to deliver prematurely (below 37 weeks' gestational age) (odds ratio [OR] 2.43, 95% CI 1.39 to 4.23). Similarly, colonized women were more likely to be febrile during labour (at least 38 degrees C) (OR 5.05, 95% CI 1.70 to 15.02).

CONCLUSION

GBS vaginal colonization was associated with premature labour and intrapartum pyrexia in the population studied. According to Canadian and American guidelines, women with GBS vaginal colonization qualify for intrapartum chemoprophylaxis. The study results suggest that the identification of women at risk of premature labour may be one advantage of early prenatal screening for GBS.

Exploring beyond viral load testing for EBV lymphoproliferation: role of serum IL-6 and IgE assays as adjunctive tests

We examined serum IL-6 and IgE assays as adjuncts to VL monitoring for PTLD. Paediatric solid organ transplant recipients were followed with VL monitoring. VL, IL-6, and IgE assays were compared between PTLD cases and non-cases at <3, 3-6 and >6 months after transplantation. Median IL-6 levels in PTLD cases were 15.5 (2.0-87.1) and 23.3 (2.1-276) pg/mL compared with 3.25 (0.92-114) and 3.5 (0.75-199.25) pg/mL in non-cases at 3-6 and >6 months, respectively (p = 0.006 and p = 0.005). At >6 months, IL-6 levels correlated with VL and PTLD occurrence (Spearman's coefficients = 0.40; p = 0.001 and 0.32; p = 0.003) in univariate analyses. No benefit was derived from performance of IgE levels. The sensitivity and specificity of high VL as a test of PTLD were 76.3% and 92.5%, while the negative predictive value and PPV of VL were 94.9% and 68.4%, respectively. Combining elevated IL-6 with high VL increased the PPV and specificity to 80% and 96.2%, respectively, and improved the receiver operating characteristic curve. Serum IL-6 levels can improve the clinician's ability to identify PTLD, among patients with elevated EBV viral loads.

Clinical features, treatment, and outcome in 108 patients with localized, high-grade synovial sarcoma (SS)

10584

Background: There remains ongoing controversy in the treatment of localized SS, with no clear consensus on routine use of chemotherapy. Methods: Between 1986 and 2007, 93 adult (AP) and 15 pediatric (PP) patients were diagnosed with high grade, localized SS at 2 centres in Toronto. Clinical records and pathology reports were examined. Survival distribution functions were estimated by Kaplan-meier and compared using Log-rank test. Results: Median age for AP and PP was 36 (range 14–76) and 14 (range 0.4–18) years, respectively. Sixty-six (61%) patients had large tumours (> 5 cm), 7 (6.5%) had neuro-vascular invasion, and 10 (9.3%) had bone invasion. 76 (82%) AP and 8 (53%) PP received radiation (RT). 16 (17%) AP and 13 (87%) PP received chemotherapy. All patients underwent definitive surgery with gross total resection; 9 patients (8 PP) had positive margins. Some patients received neoadjuvant chemotherapy, and response was evaluable in 15 patients: 10 SD, 2 PR, 1 CR, 1 PD. Relapse occurred in 32 patients: 28 distant, 3 local only, 1 local + distant. With a median follow-up of 5.6 years, EFS and OS was 72 ± 4.6% and 82 ± 4.2%, respectively and was similar for AP and PP. Patients with tumours > 5 cm had significantly worse EFS (63 ± 6.5%) compared to patients with small tumours (88 ± 5.4%, p=0.02), as did those with bone invasion (47 ± 18 vs.75 ± 4.9, p=0.05). The effect of chemotherapy was assessed in the entire cohort. Of 29 who received chemotherapy, 9 (31%) relapsed, and of 79 who did not receive chemotherapy, 23 (29%) relapsed. In patients with tumours >5 cm, relapse occurred in 41% (7/17) of those who received chemotherapy compared to 37% (18/49) in those that received no chemotherapy. Conclusions: Patients with SS < 5 cm have an excellent chance of cure with surgery and RT. Large tumours and those with evidence of bone invasion have a poor outlook. It is unlikely that chemotherapy contributes to an improvement in survival in SS.

No significant financial relationships to disclose.

The relationship between changes in self-rated quality of life after cochlear implantation and changes in individual complaints

OBJECTIVES

To evaluate the changes in self-rated quality of life (QoL) obtained following cochlear implantation in relation to changes in the individual's complaints.

DESIGN

We have used repeated responses over a period of at least 4 years following implantation so as to examine within-subject relationships.

PARTICIPANTS

Twenty-four consecutive post-lingually deafened patients who had been fitted with cochlear implants between 1991 and December 2000 at the University Hospital of Wales were investigated.

MAIN OUTCOME MEASURES

The open-ended problems questionnaire was used to assess what hearing impaired people themselves considered to be the main problems arising from their hearing loss. The participants were asked to rate the severity of each one of these problems as well as QoL on '0' to '100' visual analogue scales. Both the individual problem ratings and the ratings of QoL were re-administered to the subjects at each follow-up session.

RESULTS

Changes in the rated QoL of all patients were significantly associated with changes in specific complaints, for example, the ability to communicate, feeling of isolation, telephone use, self-confidence, enjoyment of music and watching the TV. Multiple stepwise regression analysis showed that, after implantation, improvements in communication abilities, reduced psychological problems and improvements in abilities of daily life were the key determinants of QoL improvement for individual cochlear implant patients. These key predictors reached a plateau at about 1.5-3 years after cochlear implantation.

CONCLUSIONS

The relationships between changes in specific complaints and the QoL in individual implantees were highlighted. We suggest that cochlear implant outcome measures should continue for at least 3 years after implantation.

Hybrid Optical-Ultrasonic Technique for Biomedical Diagnostics

We report the development of a diagnostic system combining time-resolved fluorescence spectroscopy and ultrasound backscatter microscopy and its application in diagnosis of tumors and atherosclerotic disease. This system allows for concurrent evaluation of distinct compositional, functional, and micro-anatomical features of normal and diseased tissues.

Role of MRI in the differentiation of ADEM from MS in children

BACKGROUND

Acute disseminated encephalomyelitis (ADEM) is typically a monophasic demyelinating disorder. However, a clinical presentation consistent with ADEM can also be the first manifestation of multiple sclerosis (MS), particularly in children. Quantitative analyses of MRI images from children with monophasic ADEM have yet to be compared with those from children with MS, and MRI criteria capable of distinguishing ADEM from MS at onset have yet to be derived.

METHODS

A retrospective analysis of MRI scans obtained at first attack from 28 children subsequently diagnosed with MS and 20 children with ADEM was performed. T2/fluid-attenuated inversion recovery hyperintense lesions were quantified and categorized according to location, description, and size. T1-weighted images before and after administration of gadolinium were evaluated for the presence of black holes and for gadolinium enhancement. Mean lesion counts and qualitative features were compared between groups and analyzed to create a proposed diagnostic model.

RESULTS

Total lesion number did not differentiate ADEM from MS, but periventricular lesions were more frequent in children with MS. Combined quantitative and qualitative analyses led to the following criteria to distinguish MS from ADEM: any two of 1) absence of a diffuse bilateral lesion pattern, 2) presence of black holes, and 3) presence of two or more periventricular lesions. Using these criteria, MS patients at first attack could be distinguished from monophasic ADEM patients with an 81% sensitivity and a 95% specificity.

CONCLUSIONS

MRI diagnostic criteria are proposed that may be useful in differentiating children experiencing the first attack of multiple sclerosis from those with monophasic acute disseminated encephalomyelitis.

MRI in the diagnosis of pediatric multiple sclerosis

BACKGROUND

MRI diagnostic criteria have not yet been adopted for pediatric multiple sclerosis (MS). MRI plays a pivotal role in supporting the diagnosis of MS in adults. We sought to quantitatively define the MRI features of pediatric MS, to determine features that distinguish MS from nondemyelinating relapsing childhood neurologic disorders, and to propose MRI criteria for lesion dissemination in space in children with MS.

METHODS

A retrospective analysis of MRI scans from 38 children with clinically definite MS and 45 children with nondemyelinating diseases with relapsing neurologic deficits (migraine, systemic lupus erythematosus) was performed. For each scan, T2/FLAIR hyperintense lesions were quantified and categorized according to location and size. Mean lesion counts in specific locations were compared between groups to derive diagnostic criteria. Validation of the proposed criteria was performed using MRI scans from a second independent MS cohort (n = 21).

RESULTS

MRI lesion location and size categories differed between children with MS and nondemyelinating controls with a medium to large effect size for most variables. The presence of at least two of the following-five or more lesions, two or more periventricular lesions, or one brainstem lesion-distinguished MS from other nondemyelinating disease controls with 85% sensitivity and 98% specificity.

CONCLUSIONS

We propose modifications to the currently established McDonald MRI criteria for lesion dissemination in space that will enhance the diagnostic accuracy of these criteria for multiple sclerosis in children.