A Prospective Study Assessing the Efficacy and Toxicity of Stereotactic Body Radiation Therapy for Oligometastatic Bone Metastases

PURPOSE/OBJECTIVE(S)

Stereotactic body radiation therapy (SBRT) is a promising treatment for oligometastatic disease in bone due to its delivery of high dose to target tissue and minimal dose to surrounding tissue. The purpose of this study is to assess efficacy and toxicity of this treatment in patients with previously unirradiated oligometastatic bony disease.

MATERIALS/METHODS

In this prospective phase II trial, patients with oligometastatic bone disease, defined as ≤3 active sites of disease, were treated with SBRT at one of two academic institutions between December 2016 and May 2019. Local progression-free survival (LPFS), progression-free survival (PFS), prostatic specific antigen (PSA) progression, and overall survival (OS) were reported. Treatment-related toxicity was also reported.

RESULTS

A total of 98 patients and 131 lesions arising from various tumor histologies were included in this study. The median age of patients enrolled in the study was 72.8 years (80.6% male, 19.4% female). Median follow-up was 26.7 months. The most common histology was prostate cancer (68.4%, 67/98). The most common dose prescriptions were 27/30 Gy in 3 fractions (26.0%, 34/131), 30 Gy in 5 fractions (19.1%, 25/131), or 30/35 Gy in 5 fractions (16.0%, 21/131). Multiple doses per treatment regimen reflect dose painting employing the lower dose to the clinical target volume (CTV) and higher dose to the gross tumor volume (GTV). Four patients (4.1%, 4/98) experienced local progression at one site for each patient (3.1%, 4/131). Among patients who progressed locally, the median time to local recurrence was 25.8 months (31.0 months among prostate cancer patients, N = 2, and 14.5 months among non-prostate cancer patients, N = 2). Among the entire cohort, 2-year LPFS (including death without local progression) was 85.0%, 2-year PFS (including deaths as well as local, distant, and PSA-based progression) was 47.0%, and 2-year OS was 87.5%. Twenty-seven patients (27.6%, 27/98) developed treatment-related toxicities, and most were Grade 1 (19.4%, 19/98) and 2 (4.1%, 4/98). Four patients (4.1%, 4/98) developed Grade 3 toxicities; there were no Grade 4 toxicities. The most common toxicity was fatigue (10.2%, 10/98). Of 68 treated spine metastases, there were four (5.9%, 4/68) vertebral fractures. Among these four patients, median time to fracture was 23.5 months (range 14.2-39.2 months).

CONCLUSION

Our study supports existing literature in showing that SBRT is effective and tolerable in patients with oligometastatic bone disease. Larger phase III trials are necessary and reasonable to determine long-term efficacy and toxicities.

268 AUDIT: GENERIC PRESCRIBING COMPLIANCE IN AN ACUTE HOSPITAL

Background

Generic prescribing is cost-effective, and evidence suggests that clinical outcomes compared with brand name products are largely equivalent. Hospital guidelines recommend that medications should be prescribed using the approved generic name, not the brand name. There are some exceptions to this. Anecdotal evidence suggests that medication reconciliation for patients on admission to hospital are charted by brand name rather than the generic title. To investigate this we conducted a four-day audit of the prescribing of medications on patients admitted to medical wards in an acute hospital.

Methods

This audit took place over a four-day period. The Kardex of each patient admitted to the three medical wards was reviewed. Patients admitted under cardiology, haematology and oncology were excluded. All medications including whether they were prescribed using the generic or brand name were collected. Statistical analysis was carried out using Microsoft Excel.

Results

A total of 33 kardexes were collected. Two hundred and fifty-seven prescribed medications were reviewed. Ninety-five were charted as brand names and 63% (n=162) were prescribed using the generic name. One hundred and eighteen different categories of medications were prescribed. Enoxaparin was prescribed using the brand name ten times and the generic title three times. The antibiotic Piperacillin/tazobactam was prescribed three times using the brand name and one time using the generic title. Of the eight times atorvastatin was prescribed, it was charted using the generic name seven times (88%).

Conclusion

Almost two-thirds of medications for patients admitted to medical wards are prescribed using generic titles. However, there is room for improvement. Of note, commonly prescribed medications such as enoxaparin and certain antimicrobials were prescribed using the brand name. Opportunities e.g., induction, grand rounds and Non-Consultant Hospital Doctor (NCHD) teaching sessions should be utilised to provide education on the importance of generic prescribing to all NCHDs admitting patients.

"Knowing That I'm Not Necessarily Alone in My Struggles": UK Autistic Performing Arts Professionals' Experiences of a Mentoring Programme

This research examined whether professional mentoring could have a positive effect on the occupational self-efficacy of autistic performing arts professionals. We compared the outcomes of one group who received mentoring to a waitlist control group. 26 participants took part in this study: 15 autistic mentees and 11 mentors, three of whom were also autistic. The mentoring programme was well received and felt to be beneficial by the participating mentees and mentors, particularly regarding gains in mentees' occupational self-efficacy. Professional mentoring also addressed several work-oriented challenges identified by autistic performing arts professionals such as feelings of isolation in the industry and need for consultation and advice on both a professional level, and for mentees with autistic mentors, also a neurodivergent one.

57 POTENTIALLY INAPPROPRIATE MEDICATION USE AND MORTALITY IN PATIENTS WITH COGNITIVE IMPAIRMENT

Background

Potentially inappropriate medications (PIMs are associated with falls, hospitalisation, and cognitive decline. Few studies have investigated the association between PIMs related to cognitive impairment (PIMCog) and mortality in dementia or mild cognitive impairment (MCI).

Methods

This was a retrospective observational study. Patients diagnosed with MCI or dementia (DSM-IV criteria) presenting to a tertiary-referral memory clinic from 2013–2019 were eligible. The primary outcome was all-cause death. Secondary outcomes were vascular death and non-vascular death defined according to formal certification. The primary exposure variable of interest was PIMCog, defined as any medication in the Beers 2015 or STOPP criteria, classified as potentially inappropriate for patients with cognitive impairment. Anticholinergic burden was measured using the anticholinergic cognitive burden (ACB) scale. Polypharmacy was defined as ≥5 medications. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs).

Results

There were 418 patients included (n = 261 dementia, n = 157 MCI). The median age was 79 (interquartile range {IQR} 74–82) and median follow-up was 809 days (IQR 552–1,571). One or more PIMCog was prescribed in 141 patients (33.4%). PIMCog use was associated with all-cause mortality after adjustment for age, sex, dementia severity, Charlson Co-morbidity Index, chronic obstructive pulmonary disease, congestive cardiac failure, and peripheral vascular disease (HR 1.96, 95% CI 1.24–3.09). PIMCog use was associated with vascular death (HR 3.28, 95% CI 1.51–7.11) but not with non-vascular death (HR 1.40 95% CI: 0.78–2.52). Neither an ACB ≥3 (HR 0.87, 95% CI: 0.46–1.64) or polypharmacy (HR 1.87, 95% CI: 0.67–5.24) were associated with death.

Conclusion

The burden of PIMCog use in patients with cognitive impairment is high. PIMCog use is independently associated with all-cause mortality and vascular death. This is a potential modifiable risk factor for death in patients with neurocognitive disorders. Further research is required to independently validate this finding.

92 THE RISE OF SIMULATION BASED TRAINING IN GERIATRIC MEDICINE?

Background

Simulation-based training (SBT) offers opportunities for teaching and learning in safe spaces, while learners navigate the acquisition of these complex skills, and work in clinically-realistic teams, supported by faculty. Geriatric medicine is a diverse speciality, requiring trainees to navigate complex social, medical, and ethical issues, necessitating a multifaceted and interdisciplinary approach. Studies describing SBT in geriatric medicine are limited.

Methods

We hosted an in-situ competition designed to encourage participation in simulation and to develop a simulation faculty network across a hospital group. All healthcare professionals in the hospital group were eligible to enter. Contestants designed a simulation case scenario within a speciality of their choice. Entrants participated in five virtual workshops on core elements of SBT. Six cases were selected to participate in the virtual final. The finalists submitted a video summarising the performance of and evaluation of the learners’ experience of the scenario.

Results

Thirty-four teams submitted initial SBT proposals and participated in the five virtual SBT workshops over a three-week period. Of these,17.6% (n = 6) were geriatric medicine teams, comprising seven geriatric medicine consultants, four advanced nurse practitioners and 13 non-consultant hospital doctors (five registrars, six senior house officers and two interns). Case scenarios submitted by geriatric medicine teams included acute stroke care, diagnosis and management of delirium, management of perioperative delirium post hip fracture and capacity assessment.

Conclusion

The level of interest in SBT generated amongst geriatric medicine faculty and trainees suggests this may be a useful tool to enhance the training experience. SBT offers geriatric medicine trainees the opportunity to practice the technical and non-technical skills required to navigate complex, interdisciplinary and challenging patient scenarios, in a protected environment. In this innovation, we identified a range of geriatric medicine-related topics for which SBT was deemed to be valuable by both faculty and trainees and could be facilitated through in-situ simulation settings.

241 IMPLEMENTATION OF AN INTRACEREBRAL CEREBRAL HAEMORRHAGE CARE BUNDLE

Background

Mortality for Intracerebral haemorrhage (ICH) is 31% (Irish National Audit Stroke, 2019). An ICH care bundle focusing on acute anticoagulation reversal, blood pressure lowering, and a neurosurgical care pathway was associated with improved survival. Translating evidence-based medicine into clinical practice is challenging. The aim of this study was to determine feasibility and outcomes of implementation of a care bundle.

Methods

An ICH care bundle was developed using an iterative process involving expert stakeholder review of the evidence-based literature. A pre-and-post quasi-experimental research design was employed to evaluate this intervention. Baseline data were collected before implementation (January 2016-June 2018). Implementation took place in a staged manner in a single university teaching hospital with multiple ‘Plan Do Study Act cycles’ (June 2018 to January 2021). Data on compliance, process measures and outcomes were collected.

Results

Systolic blood pressure (first 24-hours) and anticoagulant reversal were significantly better controlled post-implementation (χ2 (1, N = 91) = 5.34, P = 0.02), (χ2 (1, N = 25) = 5.85, P = 0.016), respectively. DNAR orders were significantly lower in the post-implementation group (χ2 (1, N = 25) = 5.85, P = 0.029). However, ‘Do Not Actively Resuscitate’ status did not significantly differ when accounting for low GCS as a surrogate measure for poor prognosis (χ2 (1, N = 34) = 0.00, P = 0.966). Modified Rankin Scale on discharge did not differ significantly pre-and-post-implementation (z = −0.075, P = 0.94). A greater proportion of patients survived in the post-implementation group; however, this was not statistically significant (χ2 (1, N = 133) = 0.77, P = 0.38). Length of stay significantly increased post implementation.

Conclusion

An ICH care bundle was developed based on expert stakeholder feedback. The feasibility of implementing this bundle of care was demonstrated in a real-world clinical practice setting. A cluster-randomized trial or a large registry study is the next step to evaluate the overall impact of this care bundle on patient outcomes.

219 IMPROVING DELIRIUM SCREENING AND MANAGEMENT IN POST-ACUTE REHABILITATION: A MULTI-STAGE QUALITY IMPROVEMENT INITIATIVE

Background

There is risk of delirium among older patients on transition from acute care to post-acute rehabilitation (Marcantonio et al. 2003). The 4AT is the recommended delirium detection tool for clinical practice (Tieges et al. 2020). A multi-disciplinary led quality improvement project was undertaken to standardise and improve delirium screening and management in the older person’s rehabilitation service of a post-acute rehabilitation hospital.

Methods

A retrospective audit of medical charts was completed for all patients admitted to a post-acute older person’s rehabilitation service from October 2019 to December 2019. Following that audit, there was a staff education intervention focusing on delirium awareness, screening and management. Furthermore, a dedicated ‘Delirium Champions Group’ was formed with representatives from the multi-disciplinary team. A Delirium Screen pro-forma was developed and implemented by this group. It included an attached 4AT sticker for all new admission medical charts. A post intervention medical chart audit was completed for all admissions to the same ward from October to December 2020.

Results

The pre-intervention chart audit showed 0% compliance with any form of formal delirium screening tool. The majority of patients had at least 2 delirium risk factors at the time of admission. The post-intervention audit recorded 92% compliance with 4AT use at the time of admission as well as full completion of the Delirium Screen pro-forma which included the documentation of risk factors for delirium. The Delirium Champions Group provide ongoing staff education, resources and are now exploring hospital environmental design and its role in delirium prevention.

Conclusion

This initiative lead to a significant improvement in the completion of delirium screening in post-acute rehabilitation. This project had the secondary benefit of prompting the formation of a dedicated delirium improvement group focusing on delirium awareness, screening, documentation, management and ultimately prevention.

A wearable multi-sensor system for real world gait analysis

Gait analysis is commonly performed in standardized environments, but there is a growing interest in assessing gait also in ecological conditions. In this regard, an important limitation is the lack of an accurate mobile gold standard for validating any wearable system, such as continuous monitoring devices mounted on the trunk or wrist. This study therefore deals with the development and validation of a new wearable multi-sensor-based system for digital gait assessment in free-living conditions. In particular, results obtained from five healthy subjects during lab-based and real-world experiments were presented and discussed. The in-lab validation, which assessed the accuracy and reliability of the proposed system, shows median percentage errors smaller than 2% in the estimation of spatio-temporal parameters. The system also proved to be easy to use, comfortable to wear and robust during the out-of-lab acquisitions, showing its feasibility for free-living applications.

The knowledge exchange and dissemination plan of the We Can Quit2 community-based stop-smoking trial

Background

We Can Quit2 was a community-based randomised controlled trial which determined the feasibility and acceptability of We Can Quit (WCQ), a peer delivered stop-smoking programme comprising group support and free Nicotine Replacement Therapy (NRT) tailored to women living in socioeconomically disadvantaged areas in Ireland. Reengagement with key stakeholders took place as part of the trial Knowledge Exchange and Dissemination plan, to discuss strategies to optimise community engagement, recruitment and retention in a future definitive trial (DT), and the policy priorities arising from the trial.

Methods

Community stakeholders involved in trial recruitment and planning, Irish Cancer Society and Health Service Executive representatives were invited to an online interactive workshop in November 2020. Key trial findings were presented. Workshop discussion (field notes) and responses to a post-event anonymous questionnaire informed a list of challenges and suggestions for a future DT and policy development from a community perspective.

Results

Forty-one stakeholders attended the workshop, six completed the questionnaire. Dedicated additional time for community engagement and use of social prescribing as a recruitment tool were recommended. Greater adaptation of trial data and assistance to complete forms were suggested to address low literacy, which was a barrier to recruitment and retention. An intervention boost after WCQ delivery and encouragement of women to join other healthy community programmes to maintain their group, were recommended to facilitate retention and enhance sustainability. Policy priorities were to remove cost and administrative barriers to access NRT and ongoing provision of cessation services tailored to disadvantaged groups.

Conclusions

Important strategies to optimise design of a DT of WCQ effectiveness were recommended. Lessons learned may be relevant to other community-based health interventions in socioeconomically disadvantaged areas.

Key messages

The workshop provided a suitable forum for engagement of community and statutory stakeholders. Knowledge exchange activities facilitated an enhanced research design from a community perspective.

509 POTENTIALLY INAPPROPRIATE MEDICATION USE AND MORTALITY IN PATIENTS WITH COGNITIVE IMPAIRMENT

Introduction

Potentially inappropriate medications (PIMsare associated with falls, hospitalisation, and cognitive decline. Few studies have investigated the association between PIMsrelated to cognitive impairment (PIMCog) and mortality in dementia or mild cognitive impairment (MCI).

Methods

This was a retrospective observational study. Patients diagnosed with MCI or dementia (DSM-IV criteria) presenting to a tertiary-referral memory clinic from 2013–2019 were eligible. The primary outcome was all-cause death. Secondary outcomes were vascular death and non-vascular death defined according to formal certification. The primary exposure variable of interest was PIMCog, defined as any medication in the Beers 2015 or STOPP criteria, classified as potentially inappropriate for patients with cognitive impairment. Anticholinergic burden was measured using the anticholinergic cognitive burden (ACB) scale. Polypharmacy was defined as ≥5 medications. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs).

Results

There were 418 patients included (n = 261 dementia, n = 157 MCI). The median age was 79 (interquartile range {IQR} 74–82) and median follow-up was 809 days (IQR 552–1,571). One or more PIMCog was prescribed in 141 patients (33.4%). PIMCog use was associated with all-cause mortality after adjustment for age, sex, dementia severity, Charlson Co-morbidity Index, chronic obstructive pulmonary disease, congestive cardiac failure, and peripheral vascular disease. (HR 1.96, 95% CI 1.24–3.09). PIMCog use was associated with vascular death (HR 3.28, 95% CI 1.51–7.11) but not with non-vascular death (HR 1.40 95% CI: 0.78–2.52). Neither an ACB ≥3 (HR 0.87, 95% CI: 0.46–1.64) or polypharmacy (HR 1.87, 95% CI: 0.67–5.24) were associated with death.

Conclusion

The burden of PIMCog use in patients with cognitive impairment is high. PIMCog use is independently associated with all-cause mortality and vascular death. This is a potential modifiable risk factor for death in patients with neurocognitive disorders. Further research is required to independently validate this finding.

"The Real Thing I Struggle with is Other People's Perceptions": The Experiences of Autistic Performing Arts Professionals and Attitudes of Performing Arts Employers in the UK

This research examined in-depth the employment experiences of autistic performing arts professionals and the attitudes and adjustments of performing arts employers. We interviewed 18 autistic performing arts professionals and 19 performing arts employers. Autistic performing arts professionals described facing challenges in the workplace. Some autistic professionals had access to support, but the majority felt that there was not enough available and highlighted many ways in which they could be better supported. Performing arts employers varied in their experiences of working with autistic people, many had limited knowledge about autism-specific support or relied on other professionals to provide it. These findings shed light on current unmet support needs of autistic performing arts professionals, and provide key recommendations for research and practice.

Inter-leg Distance Measurement as a Tool for Accurate Step Counting in Patients with Multiple Sclerosis

Step detection is commonly performed using wearable inertial devices. However, methods based on the extraction of signals features may deteriorate their accuracy when applied to very slow walkers with abnormal gait patterns. The aim of this study is to test and validate an innovative step counter method (DiSC) based on the direct measurement of inter-leg distance. Data were recorded using an innovative wearable system which integrates a magneto-inertial unit and multiple distance sensors (DSs) attached to the shank. The method allowed for the detection of both left and right steps using a single device and was validated on thirteen people affected by multiple sclerosis (0 <; EDSS <; 6.5) while performing a six-minute walking test. Two different measurement ranges for the distance sensor were tested (DS₂₀₀: 0-200 mm; DS₄₀₀: 0-400 mm). Accuracy was evaluated by comparing the estimates of the DiSC method against video recordings used as gold standard. Preliminary results showed a good accuracy in detecting steps with half the errors in detecting the step of the instrumented side compared to the non-instrumented (mean absolute percentage error 2.4% vs 4.8% for DS₂₀₀; mean absolute percentage error 2% vs 5.4% for DS₄₀₀). When averaging errors across patients, over and under estimation errors were compensated, and very high accuracy was achieved (E_%<; 1.2% for DS₂₀₀; E_%<; 0.7% for DS₄₀₀). DS₄₀₀ is the suggested configuration for patients walking with a large base of support.

Equality in Breast Cancer Treatment? A Systematic Review of the Utilisation of Primary Treatment Within Priority Population Groups in Australia

Background: Australia has a high standard of health and healthcare compared with many other OECD countries, with life expectancies among the highest in the world. However, this attainment is not reflected equally across all population subgroups within Australia. Translation evidence from clinical trials into practice varies, leading to attenuated effects across subgroups. Variable effects also occur due to differences in access to interventions and cancer treatment services. Priority subgroups can experience poorer access to healthcare and overall health outcomes due, in part, to the influence of social, environmental and political factors Aim: This study aimed to determine the extent to which inequalities exist across subgroups of the Australian population with breast cancer, as relating to cancer treatment (surgery, radiotherapy and chemotherapy). Methods: A systematic literature review was undertaken in December 2017 to identify and quantify the inequalities in treatment utilization across priority subgroups in Australia. MEDLINE, Embase, Scopus, Web of Science and Cumulative Index to Nursing and Allied Health Literature were used to identify the literature. Identification of relevant articles resulted from screening the full text of all articles identified, with each article assessed against predefined inclusion criteria. Quality assessment was used to inform the qualitative synthesis to explore the relationship between priority subgroups and the utilization of primary breast cancer treatment. The protocol for this systematic review was registered with the PROSPERO database on the December 19, 2016. Results: A total of 2030 articles were screened for eligibility, with 29 articles included in the final review. Results highlight an underutilization of breast cancer treatment (surgery, radiotherapy and chemotherapy) across priority subgroups compared with the nonpriority populations, including aboriginal women (4%-15% less likely to receive breast conserving surgery), elderly (9% more likely to have no surgery), women of greater socioeconomic disadvantage (13%-28% less likely to receive breast conserving surgery), and women living remotely (20%-38% less likely to receive breast conserving surgery). Similar differentials in utilization were seen with adjuvant therapies. Conclusion: Evaluation of health services and treatment utilization is an important aspect of cancer control programs. In quantifying the underutilization of health services for breast cancer treatments, it is clear that variations exist in the treatment of breast cancer among priority populations in Australia. Greater understanding of the barriers to treatment among these population groups are needed to minimize inequalities that exist in cancer treatment and cancer outcomes in Australia.

Assessing impact of organised breast screening across small residential areas-development and internal validation of a prediction model

Monitoring screening mammography effects in small areas is often limited by small numbers of deaths and delayed effects. We developed a risk score for breast cancer death to circumvent these limitations. Screening, if effective, would increase post-diagnostic survivals through lead-time and related effects, as well as mortality reductions. Linked cancer and BreastScreen data at four hospitals (n = 2,039) were used to investigate whether screened cases had higher recorded survivals in 13 small areas, using breast cancer deaths as the outcome (M1), and a risk of death score derived from TNM stage, grade, histology type, hormone receptor status, and related variables (M2). M1 indicated lower risk of death in screened cases in 12 of the 13 areas, achieving statistical significance (p < .05) in 5. M2 indicated lower risk scores in screened cases in all 13 areas, achieving statistical significance in 12. For cases recently screened at diagnosis (<6 months), statistically significant reductions applied in 8 areas (M1) and all 13 areas (M2). Screening effects are more detectable in small areas using these risk scores than death itself as the outcome variable. An added advantage is the application of risk scores for providing a marker of screening effect soon after diagnosis.

Syphilis outbreak in Walsall, UK: lessons for control and prevention

An assessment of risk-taking behaviour among men who have sex with men (MSM) attending a sauna venue was undertaken, using a standardized questionnaire, after which outreach screening was introduced targeting MSM. The epidemiology of the continuing outbreak of syphilis was reviewed to determine the factors driving the outbreak and assess the benefit of continuing outreach screening. Findings among the 163 respondents at the sauna included a high rate of casual sex and a tendency not to disclose HIV status. Over 12 months, 51 cases of early syphilis were recorded. Our review showed a decline in incidence in MSM after outreach screening, but an increase in heterosexual spread. Given the frequent anonymous nature of syphilis transmission, traditional contact tracing is ineffective. Outreach screening is required at gay venues and other community settings to target at-risk populations.

Wider minicolumns in autism: a neural basis for altered processing?

Previous studies have found alterations in the columnar organization of the cortex in autism spectrum disorders. Such changes have been suggested to be limited to higher order association areas and to spare primary sensory areas. In addition, evidence from gene-expression studies have suggested that there may be an attenuation of cortical differentiation in autism spectrum disorders. The present study specifically assessed the minicolumns of cells that span the depth of the cortex in a larger sample of autism spectrum disorder cases than have been studied previously, and across a broad age range. The cortical regions to be investigated were carefully chosen to enable hypotheses about cortical differentiation and the vulnerability of association cortex to be tested. Measures of the minicolumnar arrangement of the cortex (minicolumn width, spacing and width of the associated axon bundles) were made in four regions of cortex (primary auditory cortex, auditory association cortex, orbital frontal cortex and inferior parietal lobe) for 28 subjects with autism spectrum disorder and 25 typically developing control subjects. The present study found wider minicolumns in autism spectrum disorder [F(1,28) = 8.098, P = 0.008], which was particularly pronounced at younger ages, providing evidence for an altered developmental trajectory at the microstructural level. In addition, altered minicolumn width was not restricted to higher order association areas, but was also seen in the primary sensory region investigated. Finally, this study found evidence that cortical regional differentiation was still present in autism spectrum disorder [F(3,39) = 5.486, P = 0.003], although attenuated compared to typically developing subjects [F(3,45) = 18.615, P < 0.001]. It is suggested that wider spacing of the minicolumns may relate to the enhanced discrimination seen in some individuals with autism spectrum disorders.

Extracorporeal membrane oxygenation for cardiorespiratory failure in four patients with pandemic H1N1 2009 influenza virus and secondary bacterial infection

We report four patients with pandemic H1N1 2009 influenza virus and secondary bacterial infection who were treated with extracorporeal membrane oxygenation (ECMO) for cardiorespiratory failure. Three of the four patients had profound shock, necessitating support with venoarterial ECMO. Two patients died during ECMO support. The two survivors had prolonged hospital stays, which were complicated by renal failure and limb ischaemia.

Perioperative Plasma Concentrations of Stable Nitric Oxide Products Are Predictive of Cognitive Dysfunction After Laparoscopic Cholecystectomy

In this study our objectives were to determine the incidence of postoperative cognitive dysfunction (POCD) after laparoscopic cholecystectomy under sevoflurane anesthesia in patients aged >40 and <85 yr and to examine the associations between plasma concentrations of i) S-100beta protein and ii) stable nitric oxide (NO) products and POCD in this clinical setting. Neuropsychological tests were performed on 42 ASA physical status I-II patients the day before, and 4 days and 6 wk after surgery. Patient spouses (n = 13) were studied as controls. Cognitive dysfunction was defined as deficit in one or more cognitive domain(s). Serial measurements of serum concentrations of S-100beta protein and plasma concentrations of stable NO products (nitrate/nitrite, NOx) were performed perioperatively. Four days after surgery, new cognitive deficit was present in 16 (40%) patients and in 1 (7%) control subject (P = 0.01). Six weeks postoperatively, new cognitive deficit was present in 21 (53%) patients and 3 (23%) control subjects (P = 0.03). Compared with the "no deficit" group, patients who demonstrated a new cognitive deficit 4 days postoperatively had larger plasma NOx at each perioperative time point (P < 0.05 for each time point). Serum S-100beta protein concentrations were similar in the 2 groups. In conclusion, preoperative (and postoperative) plasma concentrations of stable NO products (but not S-100beta) are associated with early POCD. The former represents a potential biochemical predictor of POCD.

All-fibre photonic crystal distributed Bragg reflector (PC-DBR) fibre laser

We describe an Er3+-doped aluminosilicate core photonic crystal fibre laser incorporating distributed Bragg reflectors written by two-photon 193nm irradiation through an optical phase mask as the feedback elements. The laser is diode pumped at 980nm and evidence of dual linewidth laser operation close to threshold is observed. However, at higher pumping levels gain competition preferentially selects one laser line.

Multiple source generation using air-structured optical waveguides for optical field shaping and transformation within and beyond the waveguide

In this paper we review recent results describing the generation of optical modes within waveguides based on coherent scattering from artificially structured interfaces. The generation of optical waveguide propagation similar to free space propagation enables possible solutions to controlling and shaping optical field generation in free space using coherent scattering of multiple sources. It is shown that the controlled fabrication of such sources can be done simply with air-material structured waveguides such as air-silica structured fibres. Further, the technique of coherent superposition is well known in Fresnel optics, exploiting zone plates to correct the necessary phase adjustments for a desired lens performance. Similarly, in waveguide form this allows fine control of the interference process resulting in the desired mode field and its properties within the waveguide, at the end of the waveguide in the near field regime and well beyond the waveguide into the far field. A factor that can contribute significantly to the coherent scattering within the Fresnel waveguide is resonant-like scattering inside the low index regions since the critical angle of propagation can be very small, increasing Fresnel reflections between interfaces. The results presented here open up a range of hitherto unexplored possibilities in controlling and shaping at first glance disparate phenomena, including free space diffraction.

Propagation in air by field superposition of scattered light within a Fresnel fiber

Propagation of light at 1.5 microm with peak intensity in an air hole is achieved within an air-silica-structured Fresnel waveguide. Thus a simpler fiber design alternative to photonic crystal fibers is possible for high-peak-power propagation with reduced nonlinear interactions. Multiple foci are observed in the far field.

Bragg gratings in air-silica structured fibers

We report on grating writing in air-silica structured optical fibers with pure silica cores by use of two-photon absorption at 193 nm. A decrease in propagation loss with irradiation was observed. The characteristic growth curves were obtained.

Helicoverpa armigera granulovirus interference with progression of H. zea nucleopolyhedrovirus disease in H. zea larvae

Capsular proteins from Helicoverpa armigera granulovirus (HaGV) have previously been shown to enhance H. armigera nucleopolyhedrovirus (HaSNPV) infection in H. armigera larvae. Yet, HaGV and HaS-NPV, as viable viruses, interfered with one another. In our study, we have examined the effects of co-infection of the slow-killing virus HaGV with the fast-killing virus Helicoverpa zea NPV (HzSNPV) on H. zea larvae. The mortality parameter measured was survival time. Virus stocks had 50% lethal concentrations of 3.2x10(-9) g HaGV-infected cadavers (GVC) (HaGV) and 32 occlusion bodies (HzSNPV) per cup. Average survival times were 16.8 and 5.5 days for larvae treated with HaGV and HzSNPV, respectively; death of HzSNPV-treated larvae was as early as 72 h posttreatment. In co-infection experiments in which larvae were treated concurrently with both viruses, the viruses competed in typical fashion for host resources. However, interference with disease progression in HzSNPV-fed larvae occurred even when HaGV was fed to larvae up to 36 h after the NPV, a time at which NPV infection should have been well established in host larvae. At death, co-infected larvae were observed microscopically to be filled with HaGV granules rather than HzSNPV polyhedra. The time study results imply that HaGV might be outcompeting HzSNPV by inhibiting its replication. We also observed that H. zea larvae treated with high dosages of HaGV (> or =3x10(-5) g GVC) were initially stunted but had survival times similar to those of larvae treated with lower dosages.

Cyclophosphamide for the treatment of progressive low-grade astrocytoma: a Pediatric Oncology Group phase II Study

PURPOSE

Results of a phase II trial of cyclophosphamide (CPM) for children with progressive low-grade astrocytoma are reported.

PATIENTS AND METHODS

Fifteen patients with a median age of 39 months (range, 2 to 71) were included in this study. The tumors of 11 children were located in the optic pathway, hypothalamus, or thalamus. Four courses of intravenous CPM 1.2 g/m2 were administered every 3 weeks during the upfront window portion of this protocol. Subsequently, chemotherapy was to continue with CPM, vincristine, and carboplatin for 2 years.

RESULTS

By study design, the first 14 patients were centrally reviewed after completion of the initial 4 CPM courses. Toxicity was primarily hematologic. One patients had a complete response, 8 had stable disease, and 5 had progressive disease (PD). The excessive number of children with PD prompted study closure.

CONCLUSION

CPM as used in this protocol showed insufficient activity against astrocytoma to justify further patient accrual.

Ocular status of boys with fragile X syndrome: a prospective study

PURPOSE

The purpose of this study was to determine whether the high rates of ocular problems described in previous retrospective reports of individuals with fragile X syndrome were present in a prospective sample of young boys. Fragile X syndrome is currently considered the leading hereditary cause of mental retardation, with prevalence estimates of 1:2500 to 1:5000 males.

METHODS

Forty-eight boys with fragile X syndrome between the ages of 2.5 and 11 years were evaluated for ocular abnormalities. They received complete ophthalmic evaluations including assessment of visual acuity, cycloplegic refraction, ocular motility assessment, and dilated fundus examination.

RESULTS

Approximately 25% of the children had clinically significant ocular findings that included refractive errors (17%, primarily hyperopia and astigmatism) and strabismus (8%). Of the 42 children with quantifiable visual acuities, only 1 child, with diagnoses of nystagmus and hyperopia, had a Snellen visual acuity that was not within normal limits for his age. Three of the 5 children with gross measures of visual acuity had clinically significant findings: 2 had hyperopia greater than 3.5 diopters and 1 had esotropia. The other 2 children with gross measures of acuity and the 1 child without visual acuity assessment had cycloplegic refractions of +1.25 to +1.5 and ocular motility appeared normal.

CONCLUSIONS

These results suggest that previous reports of high rates of vision problems, particularly strabismus, in boys with fragile X syndrome may have resulted from selection bias. Although we did observe a higher prevalence of strabismus than that found in the general population (8% vs 0.5% to 1%), the proportion of children having strabismus in our sample was much smaller than that reported in other studies of children with fragile X syndrome (30% to 40%). However, 17% of the sample did have significant refractive errors. In addition to evaluating the ocular motility of children with fragile X syndrome, cycloplegic refraction should also be performed to determine whether refractive problems are present.

Phase II study of carboplatin (CBDCA) in progressive low-grade gliomas

In this study, the authors sought to investigate the response rate and toxicity of carboplatin in patients with progressive low-grade glioma (LGG). Thirty-two patients with progressive LGG were treated with carboplatin at a dosage of 560 mg/m2. Treatment was given at 4-week intervals and continued until the disease progressed, unacceptable toxicity supervened, or for 12 additional courses after achieving maximal response. Patients with stable disease were treated with a total of 12 cycles. All patients were treated as outpatients. Patients were evaluated for response to treatment and toxicity.

All patients received a minimum of two cycles of carboplatin, and were examined for response. A partial response was achieved in nine patients (28%) and a minimal response in two (6%), for an overall response rate of 34% (11 of 32 patients). Eighteen patients (56%) had stable disease. A partial response was achieved in the nine patients after a median of six cycles (range 4-11 cycles), a minimal response was achieved in the two patients after five cycles. Glioma progression was noted in three patients after three, five, and five cycles, respectively. The 11 patients in whom some response was achieved had either an optic pathway tumor or a juvenile pilocytic astrocytoma. Twenty-six of the 32 patients had those characteristics, making the response rate in that group 42% (11 of 26 patients). Thirty-two patients received a total of 387 cycles of chemotherapy. Hematological toxicity was moderate. Twenty-one patients developed thrombocytopenia (platelet count < 50,000/μl); three patients required one platelet transfusion each. Nine patients developed neutropenia (absolute neutrophil count < 500/μl); one developed fever and required administration of antibiotic agents. One dose adjustment in each of the patients prevented further thrombocytopenia and neutropenia. Two patients with stable disease died of respiratory complications. One patient developed Grade III ototoxicity after receiving five cycles, one patient developed hypersensitivity to carboplatin, and none developed nephrotoxicity.

Carboplatin given at a dosage of 560 mg/m2 every 4 weeks has activity in patients with progressive LGG. This drug regimen is relatively simple and well tolerated. Further investigation and longer follow-up study are warranted.

Cloning and sequencing of two enterococcal glpK genes and regulation of the encoded glycerol kinases by phosphoenolpyruvate-dependent, phosphotransferase system-catalyzed phosphorylation of a single histidyl residue

The glpK genes of Enterococcus casseliflavus and Enterococcus faecalis, encoding glycerol kinase, the key enzyme of glycerol uptake and metabolism in bacteria, have been cloned and sequenced. The translated amino acid sequences exhibit strong homology to the amino acid sequences of other bacterial glycerol kinases. After expression of the enterococcal glpK genes in Escherichia coli, both glycerol kinases were purified and were found to be phosphorylated by enzyme I and the histidine-containing protein of the phosphoenolpyruvate:glycose phosphotransferase system. Phosphoenolpyruvate-dependent phosphorylation caused a 9-fold increase in enzyme activity. The site of phosphorylation in glycerol kinase of E. casseliflavus was determined as His-232. Site-specific mutagenesis was used to replace His-232 in glycerol kinase of E. casseliflavus with an alanyl, glutamate, or arginyl residue. The mutant proteins could no longer be phosphorylated confirming that His-232 of E. casseliflavus glycerol kinase represents the site of phosphorylation. The His232 --> Arg glycerol kinase exhibited an about 3-fold elevated activity compared with wild-type glycerol kinase. Fructose 1,6-bisphosphate was found to inhibit E. casseliflavus glycerol kinase activity. However, neither EIIAGlc from E. coli nor the EIIAGlc domain of Bacillus subtilis had an inhibitory effect on glycerol kinase of E. casseliflavus.

Atypical retinal astrocytic hamartoma diagnosed by fine-needle biopsy

BACKGROUND

Retinal astrocytic hamartoma and retinoblastoma may be very similar clinically, and their differentiation in atypical cases can be difficult, even with the use of ancillary methods such as fluorescein angiography, ultrasonography, and computed tomography. To the authors knowledge, fine-needle aspiration biopsy has not been used to diagnose astrocytic hamartoma in such cases.

PATIENTS AND METHODS

A 7-week-old boy had a minimally calcified retinal mass in the macular area of the left eye associated with an extensive secondary retinal detachment. The differential diagnosis included retinal astrocytic hamartoma and retinoblastoma. A transvitreal fine-needle aspiration biopsy was performed.

RESULTS

The cytology of the needle biopsy showed benign spindle and stellate cells, which were compatible with glial cells. The lesion had immunoreactivity for glial fibrillary acidic protein, further supporting the diagnosis of astrocytic tumor.

CONCLUSION

Fine-needle aspiration biopsy is diagnostically useful in unusual cases where the differential diagnosis between retinoblastoma and astrocytic hamartoma is difficult.

Early retinal vessel development and iris vessel dilatation as factors in retinopathy of prematurity. Cryotherapy for Retinopathy of Prematurity (CRYO-ROP) Cooperative Group

OBJECTIVE

To determine whether the extent of retinal vessel development present on early screening examinations for retinopathy of prematurity has prognostic value?

DESIGN

The prospectively collected data from the Multicenter Trial of Cryotherapy for Retinopathy of Prematurity were used to compare the development of acute retinopathy of prematurity and long-term structural and visual outcomes for eyes with differing extents of retinal vessel development.

PATIENT

Study patients had eyes with the following vessel development. In zone I eyes, vessels extended from the disc less than twice the distance from the disc to the macula. In zone II eyes, vessels extended beyond zone I but not to the nasal ora serrata. Transitional eyes had vessels partly in zone I and partly in zone II.

RESULTS

The chance of developing threshold retinopathy of prematurity was inversely related to the early degree of vessel development: 54% for zone I eyes, 25% for transitional eyes, and 8% for zone II eyes. The presence of prominent iris vessels at 34 to 35 weeks of postmenstrual age was associated with increased risk for all three groups; zone I eyes almost always needed treatment (94%). The chance of having an unfavorable anatomic alteration of the posterior fundus, or poor vision at the ages of 1 year and 3 1/2 years, was also inversely related to the degree of early vessel development. Vessel development was an independently important factor even when birth weight, gestational age, and race were considered.

CONCLUSIONS

The degree of early retinal vessel development is a significant predictor of outcome from retinopathy of prematurity. Iris vessel dilatation is an important indication for greater vigilance in following these infants.

A cohort study of transcutaneous oxygen tension and the incidence and severity of retinopathy of prematurity

BACKGROUND

Retinopathy of prematurity is a disease affecting the blood vessels of the retina in premature infants that may result in scarring, retinal detachment, and loss of vision. An association between this condition and the exposure of premature infants to supplemental oxygen has been postulated, but the relation between retinopathy of prematurity and blood oxygen levels has not been defined. The purpose of this study of a cohort of preterm infants was to correlate the incidence and severity of retinopathy of prematurity with the duration of exposure to different ranges of oxygen tension as measured by transcutaneous monitoring (tcPO2).

METHODS

One hundred one premature infants (birth weight, 500 to 1300 g) requiring supplemental oxygen had continuous monitoring of tcPO2. The number of hours during which the tcPO2 was 80 mm Hg or higher was tabulated for each infant during the first four weeks of life.

RESULTS

There was a significant association between the amount of time that the tcPO2 was greater than or equal to 80 mm Hg and the incidence and severity of retinopathy of prematurity. The odds ratio for each 12-hour period in which the tcPO2 was greater than or equal to 80 mm Hg was 1.9 (95 percent confidence interval, 1.2 to 3.0) after adjustment for the following factors: birth weight less than or equal to 1300 g (odds ratio, 2.3 [95 percent confidence interval, 1.6 to 3.4]), five-minute Apgar score of 7 or less (odds ratio, 7.2 [95 percent confidence interval, 2.5 to 21]), and exposure to inspired oxygen at a concentration greater than or equal to 0.4 (odds ratio, 1.0 [95 percent confidence interval, 0.97 to 1.05]). The association was stronger for tcPO2 values of greater than or equal to 80 mm Hg occurring from the second through the fourth week of life; during this period, the adjusted odds ratio for a 12-hour period of such exposure was 3.1 (95 percent confidence interval, 1.6 to 6.1).

CONCLUSIONS

This study supports an association between the incidence and severity of retinopathy of prematurity and the duration of exposure to arterial oxygen levels of 80 mm Hg or higher, measured transcutaneously.

Development of myopia in infants with birth weights less than 1251 grams. The Cryotherapy for Retinopathy of Prematurity Cooperative Group

The authors report on the incidence of myopia in a large group of premature infants with birth weights of less than 1251 g followed as part of the multicenter study of Cryotherapy for Retinopathy of Prematurity. None of the eyes reported here underwent cryotherapy. Eyes were refracted using cycloplegic retinoscopy at 3 months (n = 2916), 12 months (n = 2626), and 24 months (n = 961 at 5 of the 23 centers) after term. Myopia was observed in approximately 20% of the children at each test age. The percentage of high myopia (greater than or equal to 5 diopters) doubled from 2% to 4.6% between 3 and 12 months and remained stable thereafter. Lower birth weight and increasing severity of retinopathy of prematurity (ROP) were strong predictors of myopia and high myopia. In addition, anisometropia, astigmatism, and the presence of posterior pole residua from ROP also were associated with a higher incidence of myopia and high myopia.

Adsorptive stripping voltammetry of F(ab')2 and Fab fragments of anti-mouse immunoglobulin G

The adsorptive stripping voltammetric behaviour of F(ab')2 and Fab fragments of anti-mouse immunoglobulin G is described. Conditions were optimized for the determination of these fragments with respect to accumulation potential, accumulation time, scan rate, pulse amplitude, drop size and electrolyte composition. The F(ab')2 and Fab fragments gave rise to behaviour similar to that reported previously for the intact immunoglobulin.