Intrafraction Imaging Can Replace the Midtreatment Cone Beam Tomography for Lung Stereotactic Ablative Radiation Therapy Patients for Increased Treatment Efficiency

Purpose

To determine the feasibility of replacing the mid treatment cone beam computed tomography (MT CBCT) image with Intrafraction Imaging (IFI) acquired concurrently during dose delivery in lung Stereotactic Ablative Body Radiation therapy (SABR) patients, and thus improve treatment efficiency.

Methods and Materials

A review of departmental imaging data was performed on ten lung SABR patients treated with dual arc volumetric modulated arc therapy (VMAT) on an Elekta Versa HD linear accelerator with XVI imaging software.IFI data was extracted and a database of the translational (TX, TY, TZ) and the rotational (RX, RY, RZ) position errors was created for retrospective comparison, with the values of the MT CBCT for the same patients, treated between March 2021 and March 2022 at our center. The data was evaluated for correlation between the values in all 6° of freedom.

Results

The inter-class correlation (ICC) coefficient for Tx was 0.89 (95% CI, 0.80-0.94), Ty was 0.69 (95% CI, 0.49-0.82), Tz was 0.89 (95% CI, 0.82-0.95) in the translational planes, and Rx was 0.79 (95% CI, 0.65-0.88), Ry was 0.79 (95% CI, 0.65-0.88), and Rz was 0.91 (95% CI, 0.84-0.95) in rotational planes.The Bland-Altman (BA) statistics for Tx had a bias of -1.22 × 10-3, with an upper limit of agreement (UOA) of 0.07, and a lower limit of agreement (LOA) of -0.07, for Ty the bias was 0.01 (UOA: 0.18; LOA: -0.16), Tz bias was 2.6 × 10-3(UOA: 0.10; LOA: -0.09), Rx bias was 0.09 (UOA: 0.82; LOA: -0.64), Ry bias was -0.04 (UOA: 1.08; LOA: -1.16) and Rz was -0.03 (UOA: 0.44; LOA: -0.51).

Conclusions

The ICC was excellent for Tx, Tz, Rx, y, z, and good for Ty. The data demonstrated promising correlation between IFI and MT CBCT values, and therefore supports the use of IFI for clinical decision making and improving treatment efficiency.

Maternal and neonatal health outcomes for First Nations Australian women and children: A retrospective cohort study in a Western Sydney metropolitan tertiary referral centre

AIM

To analyse key pregnancy and birth outcomes for First Nations women and children at a Western Sydney metropolitan tertiary referral centre.

METHODS

The birth and health-determining characteristics of 470 First Nations infants born at Nepean Hospital in 2018 and their mothers were included in a retrospective audit and compared with a contemporaneous control group of 470 infants and their mothers.

RESULTS

Mothers of First Nations infants had significantly higher rates of socioeconomic disadvantage (P < 0.001), psychosocial vulnerability (P < 0.007), mental illness (P < 0.001), teenage pregnancy (P < 0.001), smoking (45.6% vs. 19.4%, P < 0.001) and drug and alcohol use than control mothers (P < 0.001, P < 0.048). First Nations peoples did not have increased rates of maternal morbidity, nor any difference in rates of Caesarean section, resuscitation at birth, NICU admission, preterm birth or low birth weight in multivariable analysis. However, multivariable analysis demonstrated significant associations between low birth weight and maternal smoking (P < 0.001), hypertension (P < 0.01) and drug use (P < 0.01).

CONCLUSIONS

Despite challenges facing First Nations mothers and infants, our study found no significant difference in maternal morbidity nor adverse birth outcomes for First Nations infants. The study occurred in the context of culturally specific, First Nations-led antenatal and infant services. Future studies should further investigate relationships between participation in these services and health outcomes. This could identify strengths and areas for improvement in current services, with the goal of further improving outcomes for First Nations peoples through targeted health services that address their psychosocial vulnerabilities and support women to make healthy choices during pregnancy.

Prophylaxis to Prevent Cardiotoxicity in Patients Receiving Anthracycline for Breast Cancer: A Combined Bayesian and Frequentist Network Meta-Analysis of Randomised Controlled Trials

BACKGROUND

The benefits in survivorship gained with anthracycline (ANT)-based chemotherapies for breast cancer are unfortunately mitigated for some patients by irreversible cardiotoxicity. Randomised controlled trials (RCTs) have explored multiple cardioprotection options, however, it remains unclear which drug is most effective in preserving left ventricular ejection fraction (LVEF). This study aimed to perform a systematic review and network meta-analysis, using Bayesian and frequentist approaches, of RCTs evaluating cardioprotective agents.

METHODS

Two authors searched four databases (CENTRAL, Cochrane Reviews, MEDLINE, SCOPUS), to find RCTs evaluating cardioprotective agents. Trial populations were limited to patients with breast cancer without prior ANT exposure. The primary outcome was mean LVEF change pre and post ANT dosing. Our primary analysis utilised a Bayesian approach, while our sensitivity analysis used frequentist methodology (Prospero registration number CRD42020199580).

RESULTS

From 4,007 search results, we identified 12 RCTs, with their various trial arms considered separately-nine beta-blocker (BB), two angiotensin-converting enzyme inhibitor /angiotensin receptor blockers [(AA)+BB=AABB], one AA, one spironolactone, one statin-evaluating 1,126 patients (age 50.5 years). Bayesian network meta-analysis showed no difference in LVEF preservation between AA (1.3%, 95% credible interval [-0.20, 2.9]), BB (0.77, [-0.21, 1.8]), AABB (0.84 [-1.1, 2.8]), spironolactone (0.72, [-2.3, 3.7]) or statin (0.60, [-2.4, 3.6]) when compared against placebo. However, the frequentist analysis showed benefits from using AA (mean difference, 1.32% [0.32, 2.33]) and BB (mean difference, 0.76% [0.12, 1.4]).

CONCLUSIONS

There is insufficient evidence to support prophylactic cardioprotection to prevent EF reduction. However, frequentist analysis suggested that AA or BBs provide cardioprotection. Thus, for those already on other anti-hypertensives, switching to AA or BBs could be considered.

Sex differences in risk factors for incident peripheral artery disease hospitalisation or death: Cohort study of UK Biobank participants

BACKGROUND

Women with peripheral artery disease (PAD) often have atypical symptoms, late hospital presentations, and worse prognosis. Risk factor identification and management are important. We assessed sex differences in associations of risk factors with PAD.

METHODS

500,207 UK Biobank participants (54.5% women, mean age 56.5 years) without prior hospitalisation of PAD at baseline were included. Examined risk factors included blood pressure, smoking, diabetes, lipids, adiposity, history of stroke or myocardial infarction (MI), socioeconomic status, kidney function, C-reactive protein, and alcohol consumption. Poisson and Cox regressions were used to estimate sex-specific incidence of PAD hospitalisation or death, hazard ratios (HRs), and women-to-men ratios of HRs (RHR) with confidence intervals (CIs).

RESULTS

Over a median of 12.6 years, 2658 women and 5002 men had a documented PAD. Age-adjusted incidence rates were higher in men. Most risk factors were associated with a higher risk of PAD in both sexes. Compared with men, women who were smokers or had a history of stroke or MI had a greater excess risk of PAD (relative to those who never smoked or had no history of stroke or MI): RHR 1.18 (95%CI 1.04, 1.34), 1.26 (1.02, 1.55), and 1.50 (1.25, 1.81), respectively. Higher high-density lipoprotein cholesterol (HDL-C) was more strongly associated with a lower risk of PAD in women than men, RHR 0.81 (0.68, 0.96). Compared to HDL-C at 40 to 60 mg/dL, the lowest level of HDL-C (≤40 mg/dL) was related to greater excess risk in women, RHR 1.20 (1.02, 1.41), whereas the highest level of HDL-C (>80 mg/dL) was associated with lower risk of PAD in women, but higher risk in men, RHR 0.50 (0.38, 0.65).

CONCLUSIONS

While the incidence of PAD was higher in men, smoking and a history of stroke or MI were more strongly associated with a higher risk of PAD in women than men. HDL-C was more strongly associated with a lower risk of PAD in women than men.

Kidney Adverse Events Associated with Immune Checkpoint Inhibitor Therapy: A Systematic Review and Bayesian Network Meta-Analysis

BACKGROUND

The blockade of immune regulatory sites, CTLA-4, PD-1, and PD-L1 with Immune Checkpoint Inhibitors has revolutionized survival outcomes in cancer patients. However, immune checkpoint inhibitors are associated with a range of immune related adverse events. The aim of this network meta-analysis is to evaluate severe adverse kidney events in patients with oncological or hematological malignancy receiving monotherapy, dual therapy or combined therapy treatment with immune checkpoint inhibitors when compared to either placebo or standard chemotherapy.

METHODS

Phase III Randomized Control Trials reporting severe grade (3-5) adverse kidney events were identified across five electronic databases from inception to May 2022. This was supplemented with hand searching of medical journals and the National Clinical Trials registry. A Bayesian network meta-analysis was performed for: acute kidney injury, hypertension, chronic kidney disease and the composite of all acute kidney adverse events. The results are reported as per PRISMA guidelines.

RESULTS

95 randomized control trials reported severe grade adverse kidney events. The risk of developing severe acute kidney injury is higher among patients who received PD-1 plus chemotherapy (OR 1.8 [95% CrI 1.4 to 2.5]) and PD-L1 plus chemotherapy (OR 1.80 [95% CrI 1.2 to 2.7]) compared to standard chemotherapy and placebo (94 studies, 63, 357 participants). The risk of developing the composite of all severe acute kidney adverse events is higher among patients who received PD-1 plus chemotherapy (OR 1.6 [95% CrI 1.1 to 2.3]) and PD-L1 plus chemotherapy (OR 1.7 [95% CrI 1.1 to 2.8) when compared to standard chemotherapy and placebo (95 studies, 63, 973 participants).

CONCLUSIONS

The combined regimen of PD-1 + chemotherapy and PD-L1 + chemotherapy was associated with higher incidence of severe acute kidney injury and the composite of all severe acute kidney adverse events.

Sex differences in long-term survival after intensive care unit treatment for sepsis: A cohort study

OBJECTIVE

To determine the effect of sex on sepsis-related ICU admission and survival for up to 3-years.

METHODS

Retrospective cohort study of adults admitted to Australian ICUs between 2018 and 2020. Men and women with a primary diagnosis of sepsis were included. The primary outcome of time to death for up to 3-years was examined using Kaplan Meier plots. Secondary outcomes included the duration of ICU and hospital stay.

RESULTS

Of 523,576 admissions, there were 63,039 (12·0%) sepsis-related ICU admissions. Of these, there were 50,956 patients (43·4% women) with 3-year survival data. Men were older (mean age 66·5 vs 63·6 years), more commonly received mechanical ventilation (27·4% vs 24·7%) and renal replacement therapy (8·2% vs 6·8%) and had worse survival (Hazard Ratio [HR] 1·11; 95% Confidence Interval [CI] 1·07 to 1·14, P<0·001) compared to women. The duration of hospital and ICU stay was longer for men, compared to women (median hospital stay, 9.8 vs 9.4 days; p<0.001 and ICU stay, 2.7 vs 2.6 days; p<0.001).

CONCLUSION

Men are more likely to be admitted to ICU with sepsis and have worse survival for up to 3-years. Understanding causal mechanisms of sex differences may facilitate the development of targeted sepsis strategies.

Incidental maternal findings on fetal MRI

AIM

To evaluate the type and frequency of maternal findings incidentally identified during fetal magnetic resonance imaging (MRI).

MATERIALS AND METHODS

A retrospective single-centre study was undertaken which included all consecutive fetal MRI studies performed between July 2017 and May 2021 at a tertiary institution. Two fellowship-trained radiologists reviewed the studies independently to determine the type and frequency of incidental maternal findings of both no clinical significance (requiring no further follow-up) and of clinical significance (requiring further follow-up, work-up, and/or management). Differences in acquisition were resolved by two-reader consensus. Non-diagnostic MRI examinations or abdominal MRI examinations indicated for maternal complications were excluded from review.

RESULTS

A total of 455 consecutive fetal MRI examinations performed in 429 women were included. Mean age was 30 years (SD 5.5 years). At least one incidental maternal finding was identified in 58% (265/455) of studies. Umbilical hernias (35%), maternal hydronephrosis (19%), and maternal hydro-ureter (15%) were the most common. Only two studies (0.5%) showed clinically significant incidental maternal findings (pancreatic pseudocyst and ovarian cyst).

CONCLUSIONS

Incidental maternal findings are common on fetal MRI but rarely require further follow-up, work-up, and/or management.

Obstetric risk factors for anal sphincter trauma in a urogynecological population

INTRODUCTION AND HYPOTHESIS

Obstetric anal sphincter tears are the single major modifiable risk factor for anal incontinence (AI) in women. We undertook a retrospective observational study in a tertiary urogynecology unit to describe the prevalence of sonographic anal sphincter defects in a urogynecological population and investigate obstetric risk factors.

METHODS

Files of women seen for investigation of pelvic floor disorders between January 2014 and May 2021 were reviewed. Sonographic defects of the external anal sphincter were analyzed using stored 4D ultrasound imaging data. Explanatory parameters were number of vaginal births, delivery mode, age at first vaginal birth, and birthweight of the first vaginally born baby.

RESULTS

Of 3,037 women seen during the inclusion period, data were missing in 219, leaving 2,818. AI was reported by 508 (18%), with a mean St Marks score of 11 (1-23) and a mean bother score of 5.9 (0-10). External sphincter defects were detected in 945 women (34%), with a "residual defect" in 343 (12%). The strongest risk factors for a residual defect were first vaginal birth and forceps, with higher-order multiparity adding risk. On multivariate analysis, forceps and vaginal parity >5 remained significant predictors, as opposed to age at first birth and birthweight of the firstborn.

CONCLUSIONS

In this observational study in urogynecological patients, 12% showed a residual EAS defect on imaging. The most obvious risk factors for the diagnosis of a residual defect on exo-anal imaging were the first vaginal birth and forceps, with higher-order vaginal parity conveying additional risk.

Cardioprotection against cardiac dysfunction from breast cancer chemotherapy: a bayesian and frequentist network meta-analysis of randomised controlled trials

Background

Anthracyclines (ANT) are the cornerstone of multiple chemotherapy regimens but at the risk of potential cardiotoxicity. Previous RCTs have tested the prophylactic effects of multiple cardioprotective agents to prevent ANT-related cardiotoxicity. Unfortunately, attempts to combine RCT findings in previous meta-analyses have been heterogeneous, creating further uncertainty. There remains an unmet need to determine the role of cardio-protective agents in breast cancer.

Purpose

To assess the comparative efficacy of cardioprotective drugs in patients with breast cancer using both Bayesian and frequentist analyses of randomised controlled trials

Methods

We performed a systematic review using four databases (CENTRAL, Cochrane Reviews, MEDLINE, SCOPUS), to find RCTs evaluating cardio protective drugs in breast cancer patients without prior ANT exposure. The population included was anthracycline naïve, and trials were excluded if cardio-protective agents were commenced post anthracycline treatment. The primary outcome was a mean change in LVEF pre and post ANT dosing. Results were pooled with both Bayesian and frequentist approaches using random effects models in R statistical software.

Results

We identified 12 RCTs from 2807 search results (n=1126, Age 51 years, ANT dose 412m/m2, baseline LVEF 62.6%) with comparisons including beta-blockers (BB) (n=9), Angiotensin Converting Enzyme inhibitors (ACEi)/Angiotensin Receptor Blockers (ARB) (n=3), combination BB + AA (n=2), spironolactone (n=1) and statins (n=1). All included trials had either intermediate or high risk of bias, with marked heterogeneity in ANT dosing and LVEF monitoring. Overall, our Bayesian network meta-analysis showed no statistically significant difference in mean LVEF preservation between AA (1.3%, 95% credible interval [−0.20, 2.9]), BB (0.77, [−0.21, 1.8]), AABB (0.84 [−1.1, 2.8]), SPR (0.72, [−2.3, 3.7]) or statin (0.60, [−2.4, 3.6]) when compared against placebo. After ranking for efficacy, ACEi/ARBs achieved the most protection against LVEF decline of 1.3% [95% CI: −0.2, 2.9] although still not significant. Conversely, frequentist analysis showed benefit in using AA (Standardised Mean Difference (SMD) 1.32% [0.32, 2.33]) and BB (SMD 0.76% [0.12, 1.4]).

Conclusion

Bayesian analysis demonstrated no difference in LVEF with cardio-protective agents. In contrast, frequentist analysis showed that AA and BB may provide significant cardio-protection. The quality of RCT data to date is limited by a high risk of bias and significant heterogeneity between RCA reporting. Larger trials with clear population definition are required to determine whether any drug class provides benefit in this setting.

Funding Acknowledgement

Type of funding sources: None.

Sexual difficulties in old age and Person-Centered Therapy: A qualitative study with older adults

Introduction

Sexual well-being (SWB) of the older population can be significantly influenced by age (1) and sexual difficulties (2).

Objectives

Through qualitative research, this study focused on sexual themes that affect the SWB addressed by the older people in person-centered therapy.

Methods

Twenty-five older adults, aged between 65 and 82 years and residents on the community participated in this study.

Results

The results revealed eight main themes for these participants: Absence of a partner, family interference, dissatisfaction with the body, cleanliness and body care, problems in sexual function, physical violence, problems in sexual communication and fear of contracting sexually transmitted diseases. The most discussed themes were the absence of a partner, problems with sexual function and dissatisfaction with the body.

Conclusions

This study highlights the importance of exploring the sexual difficulties that the older population feels in relation to their SWB. 1.von Humboldt S et al. Sexual expression in old age: How older adults from different cultures express sexually? Sex Res Social Policy. 2020;1-15. 2.von Humboldt S et al. Are older adults satisfied with their sexuality? Outcomes from a cross-cultural study. Educ Gerontol. 2020;46:284-293.

Disclosure

No significant relationships.

The meaning in life and smart technology of older adults during the Covid-19 pandemic: A cross-cultural qualitative study

Introduction

The exponential increase of the older segment of the population (1) is coinciding with the growing challenges of a digital society in different socio-cultural contexts (2).

Objectives

This exploratory study aims to analyze older adult perspectives of how smart technology influenced their meaning in life during the Covid-19 Public Health Emergency period, using qualitative research at a cross-national level.

Methods

Three hundred and fifty one community-dwelling older participants aged 65-87 years were included in the study. Participants were Italian, Mexican, Portuguese and Spanish. All the narratives went through a process of content analysis.

Results

Findings of content analysis produced six themes: Meaningful relations, rewarding activities, spirituality, health and safety-related support, self-growth, and physical activity. Smart technology was important in promoting significant relations for Mexican older adults (71.3%), rewarding activities for Portuguese older adults (57.1%), spirituality for Spanish older participants (71.6%), and physical activity for Italian older adults (29.5%).

Conclusions

This study indicated that smart technology during the Health Emergency period was important for the meaning in life of older populations, mostly by facilitating meaningful relations, rewarding activities and spirituality. Future interventions with older adults during pandemic periods should consider the diversity of themes associated with increasing older adult well-being, from a cross-cultural perspective. 1. von Humboldt S & Leal I. The old and the oldest old: Do they have different perspectives on adjustment to aging?. Int J Gerontol; 9:156-160. 2. von Humboldt S et al. Does spirituality really matter? - A study on the potential of spirituality to older adult’s adjustment to aging. Jpn Psychol Res, 56;114-125.

Disclosure

No significant relationships.

Older adults and sexual well-being: A qualitative study in Portugal and Slovenia

Introduction

Beyond living longer, it is increasingly important to live with more and better health during aging (1). Sexual well-being (SWB) was found to contribute to health and well-being in old age and is highly under-researched in the older population (2).

Objectives

This study aims to analyze SWB in a cross-cultural way through older Portuguese and Slovenian older samples.

Methods

We interviewed 136 older participants with an average age of 71.6 years old. Participants were Portuguese and Slovenian and lived in the community. Participants were subjected to semi-structured interviews and these were subjected to a content analysis process.

Results

The content analysis indicated nine themes related to SWB: self-reported good health; demonstrations of love; non-sexual joint activities; overall well-being and quality of life; partner support; positive self-image; being independent and active; sexual compatibility; and masturbation. Portuguese older adults experience their SWB associated mainly with self-reported good health and demonstrations of love, while Slovenians older adults associate their SWB mainly with non-sexual joint activities and overall well-being and quality of life.

Conclusions

The themes found in this study are fundamental evidence for cultural interventions and guidelines outlining in the context of sexual health in aging, mainly due to the scarcity of knowledge of SWB among older adults. 1.von Humboldt S et al. Sexual expression in old age: How older adults from different cultures express sexually? Sex Res Social Policy. 2020;1-15. 2.von Humboldt S et al. Are older adults satisfied with their sexuality? Outcomes from a cross-cultural study. Educ Gerontol. 2020;46:284-293.

Disclosure

No significant relationships.

Different cultures and sexual unwellness in older adults: A qualitative study with older populations from Slovenia and Portugal

Introduction

Oder adults have been stereotyped (1), both explicitly and implicitly, as being asexual or naturally lacking sexual desires (2).

Objectives

The objective of this study is to analyse the perspectives of sexual unwellness (SU) of Portuguese and Slovenian older adults.

Methods

A qualitative research was carried out, in which these perceptions were analysed at a cultural level. Methods: The sample of this study consisted of 136 older participants, between 65 and 96 years of age. Participants were of two different nationalities and lived in the community. Participants were interviewed, and all interviews were carried out through the process of literal transcription and subsequent content analysis.

Results

Eight key mutually exclusive themes emerged from the interviews: unavailability of partner; traditional values; body restrictions; low self-esteem and well-being; poor social support; dissatisfaction with physical appearance; pain during sex; and difficulties meeting new people. Unavailability of partner was the most important theme (17.9%) for the studied sample and specifically among Portuguese participants. Conversely, difficulties meeting new people was the least reported theme (6.8%) for the entire sample. For Slovenians traditional values were most relevant with respect to feeling sexually unwell.

Conclusions

Older adults from two different countries reported diverse sexual experiences. Eight mutual-exclusive themes were extensively illustrated. 1.von Humboldt S et al. Sexual expression in old age: How older adults from different cultures express sexually? Sex Res Social Policy. 2020;1-15. 2.von Humboldt S et al. Are older adults satisfied with their sexuality? Outcomes from a cross-cultural study. Educ Gerontol. 2020;46:284-293.

Disclosure

No significant relationships.

Negative emotions associated with self-growth among older adults during the COVID-19 pandemic

Introduction

The Covid-19 pandemic appeared globally (1), thus affecting the self-growth of the older population (2).

Objectives

The aim of this study is to identify and analyze the negative emotions felt during the pandemic, as well as their impact on self-growth of 226 older individuals of four nationalities: Mexican, Italian, Portuguese and Spanish.

Methods

Thus, a transnational qualitative survey was carried out. A content analysis was performed.

Results

Seven negative emotions were reported, namely: fear, sadness, anger, grief, annoyance, loneliness and shame. These emotions were considerably associated with the following themes: (1) Sharing experiences; (2) Availability of the partner; (3) Spirituality and religion; (4) Be active; (5) Interest in new projects; (6) Civic participation; (7) Sexual activity. Older participants with Mexican and Italian nationality reported that sharing experiences as the most relevant topic, while for the Portuguese and Spanish participants, having a partner available was more important.

Conclusions

This study demonstrated that negative emotions cooperated with the self-growth of older individuals during the Covid-19 pandemic. The heterogeneity of experiences lived by each culture was highlighted, underlining the positive side of negative emotions and their strong connection with the self-growth of the older people. 1.von Humboldt S et al. Smart technology and the meaning in life of older adults during the Covid-19 public health emergency period: A cross-cultural qualitative study. Int Rev Psychiatry, 2020; 1-10. 2. von Humboldt S et al. Does spirituality really matter? - A study on the potential of spirituality to older adult’s adjustment to aging. Jpn Psychol Res, 56;114-125.

Disclosure

No significant relationships.

Older portuguese and mexican adults and sexual well-being? A cross-cultural qualitative study

Introduction

A cross-cultural qualitative study about older portuguese and mexican adults and sexual well-being.

Objectives

Sexual well-being (SWB) refers to the subjective emotional and cognitive evaluation of the quality of the individual's sexuality, it plays a relevant role in quality of life and health promotion on old age and has cross-cultural implications. The aim of this study is to analyse comparatively the perspectives of older adults on their SWB in Portugal and Mexico.

Methods

Data were collected from 86 Portuguese and 80 Mexican community-dwelling participants aged 65 years and older, using a semi-structured interview protocol. Older adults were inquired about their perceptions on what contributes to their sexual well-being. Socio-demographic data were also enquired. Content analysis was used to identify key themes.

Results

Outcomes indicated eight themes: eroticism, supportive relationship, positive self-concept, health and self-care, romance, active life, tenderness and care, and no pain and no pregnancy restrictions, for both samples. Eroticism was the most frequent theme reported by Portuguese participants (31.4%) and health and self-care were the most frequent theme reported by Mexican participants (26.5%).

Conclusions

The empirical results of this study indicated that SWB is strongly influenced by socio-cultural and psychosocial values. This cross-cultural comparison between Portugal and Mexico contributes to understand this concept in old age with different perspectives and place a scenario for future culture-adapted interventions and comprehensive policies.

Disclosure

No significant relationships.

The impact of impulsivity on weight loss after bariatric surgery: a systematic review

BACKGROUND

Impulsivity has been shown to be associated with obesity through links to pathological eating behavior such as binge eating. The recent literature suggests that impulsivity is linked to poorer outcomes post-bariatric surgery. Impulsivity can be measured in various ways and comprises of three broad domains: impulsive choice, impulsive action, and impulsive personality traits. The aim of this systematic review is to synthesize the current evidence on the impact of impulsivity on post-bariatric surgery weight loss.

METHODS

A literature review was performed in February 2020. Original studies investigating the relationship between impulsivity and weight loss post-bariatric surgery were evaluated.

RESULTS

Ten studies with a total of 1246 patients were analyzed. There were four case-control, four prospective observational and two retrospective observational studies. The postoperative follow-up ranged from 0.5 to 12 years. Eight studies measuring trait impulsivity did not show any association with weight loss post-bariatric surgery, although two studies reported an indirect effect of impulsivity on weight loss mediated via pathological eating behavior. Assessment of impulsive action by two studies showed that post-bariatric surgery weight loss is affected by impulsive action.

CONCLUSION

Impulsivity may adversely affect postoperative outcomes after bariatric surgery. However, this may be specific to state impulsivity or impulsive action rather than trait impulsivity. Patients with a higher state impulsivity may benefit from closer follow-up post-bariatric surgery, as well as cognitive behavioral therapies targeting cognitive control over food.

LEVEL OF EVIDENCE

Level I, systematic review.

Evaluation of biliary ductal anatomy in potential living liver donors: comparison between MRCP and Gd-EOB-DTPA-enhanced MRI

PURPOSE

To compare magnetic resonance cholangiopancreatography (MRCP) and Gd-EOB-DTPA-enhanced MRI in the evaluation of the biliary anatomy in potential living liver donors (LLDs).

METHODS

A retrospective study was conducted in a tertiary care liver transplant center after obtaining ethics and institutional approvals. A total of 42 potential LLD MRI examinations were performed between November 2013 and March 2016. All patients underwent a standard MRI protocol which included MRCP and Gd-EOB-DTPA-enhanced MRI sequences in a single session. Three abdominal MR radiologists independently reviewed the studies and completed a customized data collection sheet for each MR sequence. The readers subjectively scored the bile duct visualization on each MR sequence on a Likert scale and classified the biliary anatomic configuration. Statistical analysis was performed using intraclass correlation coefficient and the McNemar Chi-square (χ ²) test.

RESULTS

The 42 potential LLDs included 22 males and 20 females with an age range of 18-60 years. There was 'good' or 'excellent' inter-reader agreement on either MRI examination for the visualization of the first- and second-order ducts and the majority of third-order ducts. 'Good' inter-reader agreement on Gd-EOB-DTPA-enhanced MRI and 'fair' inter-reader agreement on MRCP was noted for the left third-order medial duct. There was significantly better visualization of the cystic duct, left hepatic duct, and right second-order ducts on Gd-EOB-DTPA-enhanced MRI compared with MRCP. A 12.6% improvement in classifying the biliary branch pattern was also observed on Gd-EOB-DTPA-enhanced MRI compared with MRCP (P = 0.03).

CONCLUSION

Gd-EOB-DTPA-enhanced MRI provides additional diagnostic confidence over MRCP in the evaluation of the biliary ductal anatomy in potential LLDs.

Negative regulation of signal transducer and activator of transcription-3 signalling cascade by lupeol inhibits growth and induces apoptosis in hepatocellular carcinoma cells

Background:

Constitutive activation of signal transducer and activator of transcription signalling 3 (STAT3) has been linked with survival, proliferation and angiogenesis in a wide variety of malignancies including hepatocellular carcinoma (HCC).

Methods:

We evaluated the effect of lupeol on STAT3 signalling cascade and its regulated functional responses in HCC cells.

Results:

Lupeol suppressed constitutive activation of STAT3 phosphorylation at tyrosine 705 residue effectively in a dose- and time-dependent manner. The phosphorylation of Janus-activated kinases (JAKs) 1 and 2 and Src was also suppressed by lupeol. Pervanadate treatment reversed the downregulation of phospho-STAT3 induced by lupeol, thereby indicating the involvement of a phosphatase. Indeed, we observed that treatment with lupeol increased the protein and mRNA levels of SHP-2, and silencing of SHP-2 abolished the inhibitory effects of lupeol on STAT3 activation. Treatment with lupeol also downregulated the expression of diverse STAT3-regulated genes and decreased the binding of STAT3 to VEGF promoter. Moreover, the proliferation of various HCC cells was significantly suppressed by lupeol, being associated with substantial induction of apoptosis. Depletion of SHP-2 reversed the observed antiproliferative and pro-apoptotic effects of lupeol.

Conclusions:

Lupeol exhibited its potential anticancer effects in HCC through the downregulation of STAT3-induced pro-survival signalling cascade.

Value of subtraction MRI in assessing treatment response following image-guided loco-regional therapies for hepatocellular carcinoma

AIM

To compare contrast-enhanced subtraction magnetic resonance imaging (MRI) with contrast-enhanced standard MRI in assessing treatment response following loco-regional therapies for hepatocellular carcinoma (HCC).

METHOD AND MATERIALS

Institutional review board approval was obtained and informed consent was waived for this retrospective study. All patients were analysed from our institution's liver tumour database that had loco-regional HCC therapy and the following: (1) a contrast-enhanced MRI ≤6 weeks post-treatment, (2) an unenhanced T1-weighted high-signal treatment zone (TZ) ≥1 cm, (3) follow-up contrast-enhanced MRI performed ≥6 months post-treatment. Randomized standard and subtraction TZ datasets were independently assessed by three blinded radiology readers for either complete treatment necrosis or residual disease. The standard of reference (SOR) comprised a consensus read by two radiologists with knowledge of the follow-up MRI and all available clinical data. Statistical analyses were performed using receiver operating characteristics (ROC), t-test, and kappa statistic.

RESULTS

Twenty-six patients (19 male and seven female patients; mean age 60 years, standard deviation 10.9 years, range 46-88 years) had a total of 45 corresponding HCCs and TZs. For ROC, the area under the curve (AUC) was 0.93 (subtraction protocol) versus 0.90 (standard protocol; p = 0.49). For the t-test, the mean reader confidence level was 4.4, 3.6, and 4.4 (subtraction protocol) versus 3, 3, and 3.7 (standard protocol; p ≤ 0.011). The kappa statistic for reader-to-SOR agreement was 0.83, 0.63, and 0.71 (subtraction protocol) versus 0.51, 0.36, and 0.64 (standard protocol).

CONCLUSION

Subtraction MRI significantly improves the reader confidence level in the assessment of treatment response following loco-regional therapies for HCC.

Technical inadequacies of peripheral contrast-enhanced magnetic resonance angiography: incidence, causes and management strategies

AIM

To assess the incidence, causes and effects of technical inadequacies in peripheral contrast-enhanced magnetic resonance angiography (CE-MRA) and to discuss relevant management strategies.

MATERIALS AND METHODS

A retrospective analysis of 249 peripheral CE-MRA examinations was performed using the radiology department's RIS/PACS (radiology information system/picture archiving and communication system) database. All failed or technically inadequate MRAs were reviewed. In cases that underwent further imaging by conventional angiography (CA), we assessed if relevant arterial disease had been masked on the MRA.

RESULTS

Of the 249 examinations, 215 (86.3%) were technically satisfactory while 34 (13.7%) were a combination of technical inadequacies [29 cases (11.6%)] and examination failures [five cases (2%)]. The causes of technical inadequacies were: (1) venous contamination (13 cases; 5.2%), (2) motion-induced subtraction artefact (eight cases; 3.2%), (3) stent-induced artefact (four cases; 1.6%), (4) inadequate scan coverage (two cases; 0.8%), and (5) contrast timing error (two cases; 0.8%). The causes of failed examinations were: (1) inability to tolerate lying in the scanner (three cases; 1.2%) and (2) inability to fit into the scanner (two cases; 0.8%). Fifteen (44.1%) of the 34 cases underwent further imaging by CA, and in eight of these there was significant arterial disease that was missed on the MRA.

CONCLUSION

Technical inadequacies occur in a small but significant proportion of peripheral CE-MRAs and can mask significant arterial disease. Knowledge of the potential causes of technical problems and the relevant management options is important for quality assurance and for limiting the need for an alternative investigation.

Currarino triad: Characteristic appearances on magnetic resonance imaging and plain radiography

The Currarino triad is a complex anomaly consisting of an anorectal malformation, a sacral bone defect and a presacral mass. It was first described in 1981 and since then, approximately 250 cases have been reported. Radiology has an important part to play in the diagnosis of this entity, as the imaging features are characteristic. We report a case of Currarino triad in an infant who presented with intractable constipation and discuss relevant MRI and plain radiography findings.

Can follow-up radiography for acute scaphoid fracture still be considered a valid investigation?

AIM

To determine whether follow-up radiography is a valid diagnostic investigation in patients with suspected acute scaphoid fractures and normal initial radiographs.

MATERIALS AND METHODS

Fifty sets of radiographs (initial and follow-up) were independently assessed by four expert observers for the presence or absence of a scaphoid fracture. Magnetic resonance imaging (MRI), performed in all cases, was used as the gold standard to determine the sensitivity, specificity, positive and negative predictive values of the observers' assessment of the follow-up radiograph. In addition, the reliability among observers of the follow-up radiograph was determined by reliability variance analysis.

RESULTS

Of the 50 sets of radiographs, 35 patients had a scaphoid fracture and 15 were normal, as established from MRI report. For individual observer's assessment of the follow-up radiograph, sensitivities of 11, 9, 43 and 49%; specificities of 93, 93, 87 and 80%; positive predictive values of 80, 75, 88 and 85%; and negative predictive values of 31, 30, 39 and 40%. A reliability coefficient of more than 60% is needed for a diagnostic test to be considered reliable. Overall, the inter-observer reliability coefficient was 33%, with pair-wise inter-observer coefficients ranging from 18-53%.

CONCLUSION

With poor sensitivity, poor negative predictive value and poor reliability, follow-up radiography cannot be considered a valid diagnostic examination for the detection of scaphoid fracture in patients with normal initial radiographs.

A history of total mercury in edible muscle of fish from lakes in northern Canada

Subsistence fishing has been an important source of food for Native People in northern Canada since prehistoric time. Measurements of the levels of mercury in edible muscle of northern fish have been undertaken for over three decades in efforts to evaluate the risks of consuming northern fish. This report summarizes the data obtained from 7974 fish of 25 species from sites distributed from the Yukon to Labrador. The most abundant species were lake trout, lake whitefish, arctic char, walleye, northern pike and burbot. The question being asked was essentially "Are the fish safe to eat?" The results were used to support decisions on fishing and consumption of fish. They were sorted in several ways, into concentration ranges corresponding to human consumption guidelines, into political jurisdictions and into types of bedrock geology. Overall walleye, northern pike and lake trout, usually exceeded the subsistence consumption guideline of 0.2 microg g-1 total mercury and often exceeded the higher guideline of 0.5 microg g-1 total mercury for commercial sales of fish. Mercury in burbot, another facultative predator, was often lower but several still exceeding a guideline. Arctic char collections were mostly from anadromous populations and these had very low levels of mercury, presumably reflecting marine food sources. Lake whitefish were among the cleanest fish examined with 69 of 81 collections falling in the lowest range. Most collections were from sites in sedimentary rock. However a few sites were in metamorphic, intrusive or volcanic rocks and these, taken together, tended to have a higher proportion of sites in the higher ranges of mercury. These results indicate a widespread problem with mercury in subsistence fisheries for predator species of fish with the problem being most problematic for Nunavut.

Elevated mercury concentrations in fish in lakes in the Mackenzie River Basin: the role of physical, chemical, and biological factors

During the mid-1990s and through the early 2000s, researchers determined that elevated mercury concentrations were a common occurrence in predatory fish in many lakes in the Mackenzie River Basin (MRB), located in northern Canada. Here we present the results of studies investigating factors contributing to higher mercury concentrations in fish in many of these lakes. Twenty-two percent of lake trout, 33% of northern pike, and 50% of walleye populations had mean mercury concentrations >0.5 microg/g, the guideline for the commercial sale of fish. Higher mercury concentrations were strongly associated with the relatively old age of MRB predatory fish; mean age ranged from 7.6 to 24.9 years for the three species. In contrast, none of the lake trout sampled in eight lakes further south in northern Saskatchewan and Alberta had mean mercury concentrations >0.5 microg/g; fish also were younger (mean age 6 years for the 8 lakes). Mercury concentrations in MRB fish generally increased with fish length, age, and trophic feeding although the nature of these relationships varied with the lake. Mean length was a good predictor of mean mercury concentrations in walleye populations across the study lakes but not for whitefish, lake trout, and pike; age was a good predictor for lake trout and walleye. Mercury concentrations in water and invertebrates were similar to those observed in more southerly regions where fish do not have elevated mercury concentrations. Mercury concentrations tended to be higher in fish in smaller vs. larger lakes and as a probable consequence of higher summer epilimnion temperatures, which favour a higher net methylation rate, and higher mercury and methyl mercury concentrations in water which enter these lakes from the watershed. Increasing fishing pressures on MRB lakes may be a means of reducing mean fish age, improving growth rates, and decreasing mercury body burdens. Increased global warming may result in higher mercury concentrations in fish through increased water temperatures, a longer ice free season, and increased release of stored mercury from the watershed into these lakes.

Modelling the leaching of Pb, Cd, As, and Cr from cementitious waste using PHREEQC

A leaching model was developed using the United States Geological Survey public domain PHREEQC geochemical package to simulate the leaching of Pb, Cd, As, and Cr from cementitious wastes. The model utilises both kinetic terms and equilibrium thermodynamics of key compounds and provides information on leachate and precipitate speciation. The model was able to predict the leaching of Pb, Cd, As, and Cr from cement in the presence of both simple (0.1 and 0.6M acetic acid) and complex municipal landfill leachates. Heavy metal complexation by the municipal landfill leachate was accounted for by the introduction of a monoprotic organic species into the model. The model indicated Pb and As were predominantly incorporated within the calcium silicate hydrate matrix while a greater portion of Cd was seen to exist as discrete particles in the cement pores and Cr (VI) existed mostly as free CrO4(2-) ions. Precipitation was found to be the dominant mechanism controlling heavy metal solubility with carbonate and silicate species governing the solubility of Pb and carbonate, silicate and hydroxide species governing the solubility of Cd. In the presence of acetic acid, at low pH values Pb and Cd acetate complexes were predominant whereas, at high pH values, hydroxide species dominated. At high pH values, the concentration of As in the leachate was governed by the solubility of Ca3(AsO4)2 with the presence of carbonate alkalinity competing with arsenate for Ca ions. In the presence of municipal landfill leachate, Pb and Cd organic complexes dominated the heavy metal species in solution. The reduction of As and Cr in municipal landfill leachate was crucial for determining aqueous speciation, with typical municipal landfill conditions providing the reduced forms of As and Cr.

Evaluating the applicability of regulatory leaching tests for assessing the hazards of Pb-contaminated soils

Soil contamination is a major environmental problem due to the ecological threat it poses. In this work, electron probe microanalysis (EPMA), X-ray diffraction (XRD), and leaching studies were employed to explain the different leaching behaviors of non-stabilized and stabilized soils. The applicability of the leaching fluids used in the toxicity characteristic leaching procedure (TCLP) and Australian Standards, AS 4439.1-1997 for assessing the hazards of contaminated soils was investigated as was the leaching of lead from soil stabilized by cement and buffered phosphate techniques. The results showed Pb speciation in the soil highly influenced metal leaching. The synthetic leaching fluids were unable to provide a reliable estimation of Pb concentration in the municipal landfill leachate (ML) due to the absence of organic ligands capable of forming stable complexes with the lead. Water provided the closest representation of lead leaching from the non-stabilized and phosphate stabilized soils while sodium tetraborate buffer was found to be suitable for cement-stabilized soil in a non-putrescible landfill leachate system. A comparison of stabilization methods revealed that the buffered phosphate technique was more suitable for stabilizing the lead in the soil relative to cement stabilization.

Comparison between acetic acid and landfill leachates for the leaching of Pb(II), Cd(II), As(V), and Cr(VI) from cementitious wastes

The Toxicity Characteristic Leaching Procedure (TCLP) has been widely used to characterize the suitability of solid wastes for disposal in landfills. However, the widespread application of this test for the assessment of wastes disposed in different landfill types is often questionable. This paper investigates the leaching profiles of cement-stabilized heavy metal ions, namely, Pb (II), Cd (II), As(V), and Cr(VI), using acetic acid and leachates from municipal and nonputrescible Australian landfill sites. The leaching profiles of Pb, Cd, As, and Cr using acetic acid were found to be similar to the nonputrescible landfill leachate and differed markedly from the municipal solid waste (MSW) leachate. The additional presence of high amounts of organic and inorganic compounds in the municipal landfill leachate influenced the leaching profiles of these metal ions as compared to the acetic acid and the nonputrescible systems. It is postulated that the organic compounds present in the municipal landfill leachate formed complexes with the Pb and Cd, increasing the mobility of these ions. Moreover, the organic compounds in the municipal landfill leachate induced a reducing environment in the leachate, causing the reduction of Cr(VI) to Cr(III). It was also found that the presence of carbonates in the municipal landfill leachate affected the stability of calcium arsenate, with the carbonate competing with arsenate for calcium at high pH, forcing arsenate into the solution.

Evaluating the applicability of a modified toxicity characteristic leaching procedure (TCLP) for the classification of cementitious wastes containing lead and cadmium

Having the toxicity characteristic leaching procedure (TCLP) as a starting point, this study examined the effect of the various leaching parameters on the leaching of Pb and Cd from cementitious wastes. Using modified TCLP procedures, the parameters investigated were the acid concentration, leaching duration, particle size of the crushed waste, liquid to solid ratio, and the acid type. The main finding was that the final leachate pH controls the leachability of metals due to its influence on their solubility. The high alkalinity of cementitious waste buffers the leachate at a pH where most metals become insoluble. The TCLP was found to result in an unrealistic condition for cementitious wastes due to the high resultant leachate pH.

Evaluating the applicability of a modified toxicity characteristic leaching procedure (TCLP) for the classification of cementitious wastes containing lead and cadmium

Having the toxicity characteristic leaching procedure (TCLP) as a starting point, this study examined the effect of the various leaching parameters on the leaching of Pb and Cd from cementitious wastes. Using modified TCLP procedures, the parameters investigated were the acid concentration, leaching duration, particle size of the crushed waste, liquid to solid ratio, and the acid type. The main finding was that the final leachate pH controls the leachability of metals due to its influence on their solubility. The high alkalinity of cementitious waste buffers the leachate at a pH where most metals become insoluble. The TCLP was found to result in an unrealistic condition for cementitious wastes due to the high resultant leachate pH.

Developing the nurse's role in rehabilitation

BACKGROUND

This article reviews literature on developing the role of nurses in rehabilitation. It explains why the nurse's role in rehabilitation should be allowed to develop, and suggests ways that nurses might achieve their potential in this field. The author presents a meta-analysis of rehabilitation nursing, and uses this synthesis to make suggestions for the development of the service. Issues are raised to provoke thought and discussion.

CONCLUSION

It is clear from the literature that nurses have an integral role in rehabilitation, but that the boundaries of the role are not clearly defined. Nurses should have access to more education and training, which will help them show evidence of their influence and effectiveness.

Performance on tests of frontal lobe function reflect general intellectual ability

Recent studies have indicated that performance on tests of frontal lobe function are highly associated with general intellectual ability (g). Some authors have even claimed that the available evidence does not support a more specific account of frontal lobe function than to provide a general intellectual function for the performance of goal directed tasks. We examined the relationship between performance on the WAIS-R (as a measure of g) and performance on standard tests of frontal lobe function in 123 healthy individuals. Our results demonstrate that in healthy individuals (i) performance on the most popular tests of frontal lobe function shares significant variance, and (ii) a large proportion of that shared variance is highly associated with performance on the Wechsler Adult Intelligence Scales-Revised (WAIS-R), so that the tests are similar to the extent that they measure g. Performance on the Modified Card Sorting Test (MCST), however, is not related to g. The results support the claim that many tests of frontal lobe function measure primarily a non-specific intellectual function but also indicate that some tests, like the MCST, may be assessing more specific cognitive operations.

Childhood trauma, dissociation and self-harming behaviour: a pilot study

OBJECTIVE

Childhood trauma is known to be an important antecedent in those who engage in deliberate self-harm (DSH). We aimed to explore the mediating mechanisms between childhood trauma and subsequent DSH in a sample of women detained in a high secure setting.

METHOD

From a previous incidence study into DSH, we subdivided a group of 50 women as follows: non-harmers (N = 13), infrequent harmers (N = 22) and frequent harmers (N = 15). These three groups were then compared on several measures believed to be associated with DSH.

RESULTS

The frequency of DSH was related to low self-esteem, increased dissociation, anger (both inwardly and outwardly directed), impulsivity, and a history of sexual and physical abuse. When these variables were entered into a path analytic model exploring the relationship between childhood trauma and subsequent DSH, two paths emerged: one major path which linked childhood sexual abuse to DSH via increased dissociation and another, more minor association, linking childhood sexual abuse via reduced self-esteem.

CONCLUSION

This study shows a strong association between high levels of dissociation and an increased frequency of self-harming behaviour. This association is theoretically plausible and has therapeutic implications.