Proton beam radiotherapy for choroidal and ciliary body melanoma in the UK-national audit of referral patterns of 1084 cases

INTRODUCTION

Proton beam therapy has been utilised for the treatment of uveal melanoma in the UK for over 30 years, undertaken under a single centre. In the UK, all ocular tumours are treated at one of four centres. We aimed to understand the variation in referral patterns to the UK proton service, capturing all uveal melanoma patients treated with this modality.

METHODS

Retrospective analysis of data regarding all patients treated at the Clatterbridge Proton service between January 2004 and December 2014.

RESULTS

A total of 1084 patients with uveal melanoma were treated. The mean age was 57 years (range 9-90 years), basal diameter of 11.5 mm (range 2.0-23.4 mm) and tumour thickness of 3.9 mm (range 0.1-15.4 mm). The majority were TNM stage I (39%) or II (36%). The distance to the optic nerve varied from 0 to 24.5 mm with 148 (14%) of patients having ciliary body involvement. There were variations in the phenotypic characteristic of the tumours treated with protons from different centres, with London referring predominantly small tumours at the posterior pole, Glasgow referring large tumours often at the ciliary body and Liverpool sending a mix of these groups.

DISCUSSION

In the UK, common indications for the use of proton treatment in uveal melanoma include small tumours in the posterior pole poorly accessible for plaque treatment (adjacent to the disc), tumours at the posterior pole affecting the fovea and large anterior tumours traditionally too large for brachytherapy. This is the first UK-wide audit enabling the capture of all patients treated at the single proton centre.

OP0187 DETERMINING OPTIMAL COOLING AND ADMINISTRATION METHODS FOR CNTX-4975 INTRA-ARTICULAR INJECTION IN SUBJECTS WITH MODERATE TO SEVERE OSTEOARTHRITIS KNEE PAIN

Background:

CNTX-4975 is a highly purified, synthetic capsaicin being developed to provide long-term analgesia after a single intra-articular (IA) injection for patients with moderate to severe osteoarthritis (OA) knee pain. CNTX-4975 IA administration is associated with short-term post-procedural pain that can be attenuated with preemptive joint cooling.

Objectives:

To evaluate cooling and administration procedures for CNTX-4975 IA injection, with goals of balancing patient comfort and ease of use and assessing clinical response 8 weeks after injection.

Methods:

This phase 3, open-label, 8-week study (NCT03661996) enrolled subjects aged 40–95 y with Kellgren-Lawrence grade 1–4, BMI ≤45 kg/m2, and stable, moderate to severe OA knee pain and who failed ≥2 therapies. Subjects were assigned to unilateral/bilateral CNTX-4975 1 mg IA injections as determined by OA pain/joint replacement status, then randomized by study site to 1 of 5 treatment regimens (Figure). The primary outcome measure assessed Breg cooling control vs other cooling regimens on day 1 using a combined sum of 1) pain (0, none; 4, severe) 30 minutes after CNTX-4975 injection; 2) subject satisfaction (SS) with cooling/injection procedures; and 3) investigator satisfaction (IS) with procedures. SS and IS were measured on a 1–7 scale (1, completely dissatisfied; 7, completely satisfied); pain was reverse scored and normalized (1, severe; 7, none) for equal weighting. Geometric mean ratios (GMR) with 95% CIs were constructed for each regimen vs Breg control (ANCOVA); lower 95% CI >0.7 was considered clinically acceptable. Secondary endpoints included percentage of subjects by subject type meeting criteria for Outcome Measures in Rheumatology-Osteoarthritis Research Society International (OMERACT-OARSI) responders 8 weeks after injection. Safety assessments included TEAEs.

Results:

The intent-to-treat population included 848 subjects. The primary combined outcome showed that all cooling and administration regimens were clinically acceptable, with the evaluated cold gel wraps being at least as effective as the Breg circulating ice-water wrap (Table). For subjects with unilateral OA, OMERACT-OARSI response rates were 67% in those with no/mild nonindex knee pain and 81% in those with nonindex knee single joint replacement. For subjects with bilateral knee OA receiving bilateral injections, response rates for index and nonindex knees were 73% and 79%. TEAEs were reported in 22% of subjects; <1% were serious. TEAEs occurring in >2% of subjects were procedural pain (2.9%), arthralgia (2.2%), and nausea (2.1%), with no meaningful differences across groups.

Conclusion:

All cooling regimens for CNTX-4975 IA administration were clinically acceptable and well tolerated, offering feasible options for use in routine practice. Importantly, high levels of clinical response were observed 8 weeks after unilateral or bilateral knee injections for moderate to severe OA knee pain.

Primary Combined Endpoint Outcome in the Index Knee, Normalized Scale, by Cooling and Administration Procedure (ANCOVA Model)

Breg Cooling ControlN=162Gel Pack CoolingN=179Shortened Gel Pack CoolingN=175Single Needle Injection,Gel Pack Cooling,2% LidocaineN=160Single Needle Injection,Gel Pack Cooling,1% LidocaineN=172Mean (SD)17.23 (2.660)18.23 (2.023)16.81 (2.891)17.57 (3.049)16.43 (3.138)Geometric LS Mean (SE)17.18 (1.016)18.26 (1.015)16.48 (1.016)17.40 (1.016)16.00 (1.015)95% CI16.66, 17.7217.74, 18.8015.99, 16.9916.87, 17.9515.53, 16.49Comparison vs Breg CoolingGMR (SE)1.06 (1.022)0.96 (1.022)1.01 (1.022)0.93 (1.022)95% CI1.02, 1.110.92, 1.000.97, 1.060.89, 0.97Clinically Acceptable?YesYesYesYes

LS, least squares; SD, standard deviation; SE, standard error.

GMR lower 95% CI >0.7 considered clinically equivalent.

Disclosure of Interests:

Randall Stevens Shareholder of: Centrexion Therapeutics Corp, Employee of: Centrexion Therapeutics Corp, Peter Hanson Shareholder of: Centrexion Therapeutics Corp, Employee of: Centrexion Therapeutics Corp, Paul Tiseo Employee of: Centrexion Therapeutics Corp, Kimberly Guedes Shareholder of: Centrexion Therapeutics Corp, Employee of: Centrexion Therapeutics Corp, James Campbell Shareholder of: Centrexion Therapeutics Corp, Employee of: Centrexion Therapeutics Corp, James Connolly Employee of: Centrexion Therapeutics Corp, Stephanie Ruggiero Employee of: Centrexion Therapeutics Corp, Meg Corliss Employee of: Centrexion Therapeutics Corp, Valerie Smith Consultant of: Centrexion Therapeutics Corp, Philip G Conaghan Consultant of: AbbVie, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, GSK, Novartis, Pfizer, Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer

Visualising Q - from the bootstrap to interactive graphics

Introduction

The MIDAS (Meaningful Integration of Data Analytics and Services) project is developing a big data platform to maximize the use of health & social care data. The goal is to link data sources to support senior managers & policy makers in delivering services. The project includes 4 case studies, in 4 countries. As part of the evaluation, we need to understand the perspectives of the users, developers, and senior managers involved, and to see how these change over time. We employ Q-methodology, an objective mixed method for the study of human perspectives, to do this. In this paper we describe the use of bootstrap methods, and visualizations to assist in the execution and interpretation of the first round of our Q study.

Methods

A concourse of 36 items was developed from the literature, a logic model for the project, and a series of semi-structured interviews with project participants. Sixteen people (3 female, and 13 male) took part in the Q study, six developers, five managers, two health professionals, and 3 others. The 36 statements on the concourse were ranked online, by each participant, using the HTMLQ software, in order of their agreement with each statement. These are then subjected to a form of factor analysis, but by person, not by statement, using the qmethod package in R.

For each Q-sort 1,000 bootstrap replications were done, using sampling with replacement. A range of visualisations were prepared, using ggplot2.

Results

Visualizations of bias and variability showed modest levels of both, suggesting that the Q-method model fitted well. Interactive visualizations of the factors, and respondents, were done. These showed distinct clusters of respondents, with divergent perspectives on the project. These assisted in making final decisions, both on the number of factors to report on, and the interpretation of those factors.

Further use of advance visualisations is recommended for future Q-studies.

Funded by the European commission under contract 727721

Key messages

Q methodology is useful across many areas of public health, and is a valuable way of studying individual perspectives. Modern statistical visualisation tools can enhance the interpretation of Q methodology studies.

Q-Methodology Evaluation of a European Health Data Analytic End User Framework

Background

MIDAS (Meaningful Integration of Data Analytics and Services) project is developing a big data platform to use a wide range of health and social care data to support better policy making. As part of the project evaluation, we have used Q-methodology, a well established approach, to understand the perspectives of the individual participants on their needs and how the MIDAS system is meeting them, at its current stage of development.

Methods

We defined a concourse of 36 statements relevant to project implementation and goals, by working from a logic model for the evaluation, and structured interviews with project participants. This was delivered online to participants. Analyses were done in the qmethod package. The first q-sort was done at 14 months into the project.

Results

16 people took part, 6 developers, 5 managers, 2 health professionals and 3 others. Three factors were identified in the data. These were tentatively labelled ‘Technical optimism’, ‘End-user focus’ and ‘End-user optimism’. These loaded well onto individuals, and there were few consensus statements. There were significant differences in perspectives between different groups of participants. In particular, two of the developers held opposite perspectives to most other participants on the third perspective identified. This was drawn to the attention of the participants, and a more intensive process of communication was set-up, seeking to reduce the divergence.

Conclusions

A Q-methodological approach to evaluating the implementation of a large and complex health ICT system showed considerable divergence between the perspectives of users, developers, and managers. Such divergences can lead to project failure. Q-methodology is a valuable tool has seldom been used in public health research.

Keywords: Q-Methodology, Public Health, Data Analytics, Decision Support.

Abstract P3-08-04: Withdrawn

This abstract was withdrawn by the authors.

Psychiatrists' letters to general practitioners: choosing the right format

Letters from psychiatrists to general practitioners (GPs) should provide an appropriate content in a format which is easy to write and assimilate. For content, GPs have requested “key items” (diagnosis, suicide risk, treatment, prognosis and follow-up), and an explanation which is educational (Williams & Wallace, 1974; Pullen & Yellowlees, 1985; Margo, 1982). For format, GPs preferred a one page letter with two or three sub-headings in a survey based on one fictitious case (Yellowless & Pullen, 1984). Real letters from psychiatrists in one district averaged one and three quarter pages with four subheadings (Prasher et al, 1992). GPs' opinions about actual changes in the format and content of letters sent to them have not been reported.

Detecting peatland drains with Object Based Image Analysis and Geoeye-1 imagery

BACKGROUND

Peatlands play an important role in the global carbon cycle. They provide important ecosystem services including carbon sequestration and storage. Drainage disturbs peatland ecosystem services. Mapping drains is difficult and expensive and their spatial extent is, in many cases, unknown. An object based image analysis (OBIA) was performed on a very high resolution satellite image (Geoeye-1) to extract information about drain location and extent on a blanket peatland in Ireland. Two accuracy assessment methods: Error matrix and the completeness, correctness and quality (CCQ) were used to assess the extracted data across the peatland and at several sub sites. The cost of the OBIA method was compared with manual digitisation and field survey. The drain maps were also used to assess the costs relating to blocking drains vs. a business-as-usual scenario and estimating the impact of each on carbon fluxes at the study site.

RESULTS

The OBIA method performed well at almost all sites. Almost 500 km of drains were detected within the peatland. In the error matrix method, overall accuracy (OA) of detecting the drains was 94% and the kappa statistic was 0.66. The OA for all sub-areas, except one, was 95-97%. The CCQ was 85%, 85% and 71% respectively. The OBIA method was the most cost effective way to map peatland drains and was at least 55% cheaper than either field survey or manual digitisation, respectively. The extracted drain maps were used constrain the study area CO₂ flux which was 19% smaller than the prescribed Peatland Code value for drained peatlands.

CONCLUSIONS

The OBIA method used in this study showed that it is possible to accurately extract maps of fine scale peatland drains over large areas in a cost effective manner. The development of methods to map the spatial extent of drains is important as they play a critical role in peatland carbon dynamics. The objective of this study was to extract data on the spatial extent of drains on a blanket bog in the west of Ireland. The results show that information on drain extent and location can be extracted from high resolution imagery and mapped with a high degree of accuracy. Under Article 3.4 of the Kyoto Protocol Annex 1 parties can account for greenhouse gas emission by sources and removals by sinks resulting from "wetlands drainage and rewetting". The ability to map the spatial extent, density and location of peatlands drains means that Annex 1 parties can develop strategies for drain blocking to aid reduction of CO₂ emissions, DOC runoff and water discoloration. This paper highlights some uncertainty around using one-size-fits-all emission factors for GHG in drained peatlands and re-wetting scenarios. However, the OBIA method is robust and accurate and could be used to assess the extent of drains in peatlands across the globe aiding the refinement of peatland carbon dynamics .

Abstract P6-09-06: Updating the AJCC TNM staging system a summary of changes

This abstract was withdrawn by the authors.

The role of ADAMTS-13 activity and complement mutational analysis in differentiating acute thrombotic microangiopathies

ESSENTIALS: Molecular diagnostics has improved the differentiation of acute thrombotic microangiopathys (TMAs). Atypical hemolytic uremic syndrome may have features mimicking thrombotic thrombocytopenic purpura. We identified novel complement mutations and a high incidence of CD46, with favorable long term outcomes. Complement mutation analysis in TMA where the diagnosis is unclear and ADAMTS-13 activity is >10%.

BACKGROUND

Differentiation of acute thrombotic microangiopathy (TMA) at presentation has historically been dependent on clinical parameters. Confirmation of thrombotic thrombocytopenic purpura (TTP) is increasingly reliant on demonstrating deficient ADAMTS-13 activity. The identification of alternative complement pathway abnormalities in atypical hemolytic uremic syndrome (aHUS), along with the proven efficacy of terminal complement inhibitors in treatment, has increased the need for rapid differentiation of TTP from aHUS.

OBJECTIVES

We describe the clinical phenotype and nature of complement mutations in a cohort of aHUS patients referred as acute TMAs.

PATIENTS/METHODS

Fourteen consecutive aHUS patients were screened for mutations in C3, CD46, CFH, CFI, and CFB, as well as factor H (FH) antibodies. All aHUS patients had ADAMTS-13 activity > 10%.

RESULTS

Of 14 aHUS patients, 11 (79%) had platelet counts < 30 × 10(9) /L during the acute phase. Median presenting creatinine level was 295 μmol L(-1) , while five (36%) of 14 presented with a serum creatinine level < 200 μmol L(-1) . Alternative complement pathway mutations were detected in 9 (64%) of 14 patients, including CD46 mutations in five (36%) of 14 patients. Patients were identified with novel mutations in CFB and C3 that have not been previously reported.

CONCLUSIONS

We demonstrate that diagnostic differentiation based on platelet count and renal function is insufficient to predict an underlying complement mutation in some aHUS cases. Specifically, we demonstrate a high frequency of functionally significant CD46 mutations which may mimic TTP. ADAMTS-13 activity > 10% in a patient with a TMA should necessitate genetic screening for complement abnormalities.

Acute kidney injury among HIV-infected patients admitted to the intensive care unit

We describe the incidence, associations and outcomes of acute kidney injury (AKI) among HIV-infected patients admitted to the intensive care unit (ICU). We retrospectively analysed 223 admissions to an inner-London, University-affiliated ICU between 1999 and 2012, and identified those with AKI and performed multivariate analysis to determine associations with AKI. Of all admissions, 66% were affected by AKI of any severity and 35% developed stage 3 AKI. In multivariate analysis, AKI was associated with chronic kidney disease (odds ratio [OR] = 3.19; p = 0.014), a previous AIDS-defining illness (OR = 1.93; p = 0.039) and the Acute Physiology and Chronic Health Evaluation (APACHE) II score, (OR = 3.49; p = 0.018, if > 30). No associations were demonstrated with use of anti-retroviral medication (including tenofovir), or an individual's HIV viral load or CD4 count. AKI was associated with higher inpatient mortality and longer duration of ICU admission. Among patients with stage 3 AKI, only 41% were alive 90 days after ICU admission. Among survivors, 74% regained good renal function, the remainder were dependent on renal replacement therapy or were left with significant ongoing renal dysfunction. Of note, many patients had baseline serum creatinine concentrations well below published reference ranges. AKI among HIV-infected patients admitted to ICU carries a poor prognosis.

Suicide, assisted suicide and euthanasia: International perspectives

Suicide, assisted suicide and euthanasia are elusive and controversial issues worldwide. To discuss such issues from only one perspective may be limiting. Therefore, this paper was written by authors from various regions, each of whom has been asked to reflect on the issues. The countries/cultures are: Australia, China, Cuba, Ireland, India, Japan, Russia, South Africa, The Netherlands, North America (Turtle Island) and United States. Historically and today, suicide is viewed differently. Assisted suicide and euthanasia are equally seen from multifarious perspectives. Highlighting development in the Netherlands, Australia's Northern Territory and Japan (ie. the famous Yamanouchi Case), the review shows growing re-examination of the right to die. There appear, however, to be no uniform legal and ethical positions. Further debate and discussion globally is needed to avoid myopic perspectives.

Allergic airway diseases in a tropical urban environment are driven by dominant mono-specific sensitization against house dust mites

Background

Southeast Asian populations are increasingly affected by allergic airway diseases. Etiology and specific causes, however, are still unknown. The aim of this study is therefore to identify allergens and risk factors for the high prevalence of allergic airway disease in the tropical urban environment.

Methods

Symptoms of allergic rhinitis (AR), asthma, and allergic dermatitis were recorded in two independent cohorts of 576 and 7373 ethnic Chinese individuals living in Singapore. Reactivity against common allergens was determined by skin prick tests (SPT); specific immunoglobulin E (sIgE) titers against 12 common allergens, as well as total serum IgE (tIgE), were measured in the smaller cohort.

Results

Immunoglobulin E sensitization was almost exclusively directed against house dust mite (HDM) allergens. More than 80% of individuals were HDM-sIgE positive. Of these, less than 30% also had sIgE for other allergens, and similarly, few of the HDM-sIgE-negative individuals reacted to other allergens. Titers for HDM-sIgE were 8–30 times higher than other non-HDM allergen titers and correlated directly with total serum tIgE levels. Migrants from nontropical countries typically arrived with low or undetectable HDM-sIgE but developed substantial titers in a time-dependent fashion. Importantly, prolonged stay in Singapore also resulted in the manifestation of AR and asthma symptoms, contributing to some of the highest national prevalence rates worldwide.

Conclusion

In a tropical urban environment, the allergic response is dominated by a single allergen class. The mono-specific IgE sensitization against HDM translates into increased prevalence of allergic airway diseases, which now impact a large proportion of the population in Singapore.

ribosort: a program for automated data preparation and exploratory analysis of microbial community fingerprints

ribosort is a computer package for convenient editing of automated ribosomal intergenic spacer analysis (ARISA) and terminal restriction fragment length polymorphism (TRFLP) data. It is designed to eliminate the labourious task of manually classifying community fingerprints in microbial ecology studies. This program automatically assigns detected fragments and their respective relative abundances to appropriate ribotypes. It permits simultaneous sorting of multiple profiles and facilitates direct workflow from TRFLP and ARISA output through to community analyses. ribosort also provides several options to merge repeat profiles of a sample into a single composite profile. By creating a 'ribotypes by samples' matrix ready for statistical analyses, use of the package saves time and simplifies the preparation of DNA fingerprint data sets for statistical analysis. In addition, ribosort performs exploratory analysis on the data by creating multidimensional scaling plots that compare the similarity of sample profiles using the statistical software r.

Abstract PD04-04: What is influencing breast conservation rates in the United States? Data from the National Accreditation Program of Breast Centers

INTRODUCTION: Breast conservation (BC) rates have been utilized as a quality metric, yet mastectomy rates have been noted to be increasing nationwide. The purpose of this study was to evaluate the factors associated with BC in 437 US breast centers surveyed by the National Accreditation Program of Breast Centers (NAPBC).

METHODS: From 2006 to 2010, 437 breast centers across the US were surveyed by the NAPBC. At each center, annual data regarding BC rates were reported in the Survey Application Record (SAR) for patients with Stage 0-II breast cancer. We evaluated characteristics of breast centers including geographic location, volume of patients treated, therapeutic modalities provided, and center organizational relationships. Non-parametric statistical analyses were performed to determine factors associated with BC rates in this cohort.

RESULTS: Among the 437 breast centers surveyed from 2006–2011, data on 77,248 patients with Stage 0-II were reported. The median number of Stage 0-II breast cancer patients per center was 149 (range; 10–891). The median proportion of these patients who underwent BC was 64.8% (range; 33–100%). No significant differences in median BC rate was noted over the six years of the study (range; 64.2% in 2006 – 67.1% in 2011, p = 0.788). However, significant regional variations were noted in median BC rates: 62.2% in the West (N = 59 centers), 63.8% in the South (N = 145 centers), 64.1% in the Midwest (N = 118 centers), and 70.8% in the Northeast (N = 104 centers), p &lt; 0.001. There was no difference noted in BC rates between high volume (≥ 150 Stage 0-II cases/yr) and low volume (&lt; 150 Stage 0-II cases/yr) centers (median 65.1% vs. 64.6%, respectively, p = 0.584). No differences in BC rate was noted between centers that referred vs. provided implant-based (p = 0.259), TRAM flap (p = 0.069), latissimus dorsi flap (p = 0.108) or DIEP/free flap (p = 0.324) reconstruction. Similarly, there was no difference noted in BC rates between centers who referred vs. provided whole breast radiation therapy (p = 0.224) and accelerated partial breast irradiation (p = 0.964). Centers that were affiliated with a hospital (N = 195) had a lower rate of BC than those that were not (n = 232); median 63.9% vs. 66.3%, p = 0.037. The majority of centers surveyed were also accredited by the Commission on Cancer (CoC; N=395); however, no differences were noted between these centers and those who were not CoC accredited in terms of BC rates (64.9% vs. 65.8%, respectively, p = 0.748). In a multivariate linear regression model, both region (p = 0.008) and hospital affiliation (p = 0.004) remained significant independent predictors of BC.

CONCLUSION: Across 437 US breast centers, data from 77,248 patients demonstrate a national BC rate of 64.8%. While the rate does not seem to be varying significantly over time, variation in BC was noted between regions and between centers associated with hospitals vs. not. Rates of BC do not vary, however, by center volume, availability of reconstruction or radiation, nor by CoC accreditation status. These data suggest that patient choice, rather than the availability of radiation and reconstruction, is the driving force in surgical decision-making.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD04-04.

A comparison of the expression of the malignant phenotype in two androgen-independent human prostate cancer cell lines after orthotopic implantation in nude mice

Expression of some features of the malignant phenotype were compared in the DU145 and PC-3M human prostate cancer cell lines after their intraprostatic growth in nude mice. At necropsy, 27/74 (36%) mice injected with DU145 cells and 41/75 (55%) injected with PC-3M cells had either invasive macroscopic tumors, or microscopic intraprostatic tumor cell nests (p = 0.02). Para-aortic lymph node metastases had occurred in 19% of the DU145 cell, and 44% of the PC-3M cell tumor-bearing animals (p = 0.033). Immunohistochemical staining showed high mutant p53 and vascular endothelial growth factor (VEGF) expression by DU145 cells; PC-3M cells did not express detectable p53, and had relatively low VEGF immunohistochemical reactivity. Assays by ELISA established a statistically significant difference in VEGF levels between the cell lines (p < 0.001). Urokinase-like plasminogen activator (uPA) levels, determined by ELISA, were ten-fold higher in the PC-3M cell tumors, as were matrix metalloproteinase-9 (MMP-9) activities assessed by zymography. These findings of high expression of uPA and MMP-9, two key proteolytic enzymes in the invasive/metastatic process, by PC-3M cell prostatic tumors are consistent with their aggressive behavior; the low VEGF levels compared with those in the poorly metastatic DU145 cell tumors suggest that other angiogenic factors may be critical for prostate cancer cell progression in this model.

Subjective memory complaints in community dwelling healthy older people: the influence of brain and psychopathology

OBJECTIVES

Subjective memory complaints (SMC) are common. We aimed to characterize the relationship between psychiatric illness and white matter disease to SMC in a sample of healthy older people.

MEASUREMENTS

Cognitively normal subjects between 55 and 90 years had age-adjusted and education-adjusted Consortium to Establish a Registry for Alzheimer's disease (CERAD) scores ≤1.5 SD from standard mean. ApoE genotyping was performed using polymerase chain reaction. Sixty subjects (30 SMC, 30 controls) underwent 3T MRI, which was rated by two raters blinded to the diagnosis, for periventricular (PVH) and deep white matter hyperintensities (DWMH) using the Fazekas scale. Subjective memory was assessed by asking the participant, Do you feel like your memory or thinking is becoming worse?

RESULTS

Two hundred and fifteen volunteers were assessed. Ninety-six were cognitively normal (mean age 62.5 years). SMC were reported by 52/96 subjects (54%). These were compared with subjects who denied SMC. Participants with a history of depression or anxiety were more likely to have SMC (p = 0.02). The frequency distribution of ApoE4 allele and CERAD scores were similar. White matter load was similar (p ≤ 0.47), with a high prevalence of PVH and DWMH seen (100% and 88% of scans, respectively).

CONCLUSION

Both SMC and white matter disease were common. SMC were associated with a history of depression or anxiety but not with white matter disease. Evaluation for a history of depression and anxiety in people with SMC is supported by these findings.

Diversity-interaction modeling: estimating contributions of species identities and interactions to ecosystem function

We develop a modeling framework that estimates the effects of species identity and diversity on ecosystem function and permits prediction of the diversity-function relationship across different types of community composition. Rather than just measure an overall effect of diversity, we separately estimate the contributions of different species interactions. This is especially important when both positive and negative interactions occur or where there are patterns in the interactions. Based on different biological assumptions, we can test for different patterns of interaction that correspond to the roles of evenness, functional groups, and functional redundancy. These more parsimonious descriptions can be especially useful in identifying general diversity-function relationships in communities with large numbers of species. We provide an example of the application of the modeling framework. These models describe community-level performance and thus do not require separate measurement of the performance of individual species. This flexible modeling approach can be tailored to test many hypotheses in biodiversity research and can suggest the interaction mechanisms that may be acting.

Abdominal and Cardiac Evaluation with Sonography in Shock (ACES): an approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension

BACKGROUND

Non-traumatic undifferentiated hypotension is a common critical presentation in the emergency department. In this group of patients, early diagnosis and goal-directed therapy is essential for an optimal outcome. The usefulness of focused bedside ultrasound is reviewed and a protocol for Abdominal and Cardiac Evaluation with Sonography in Shock (ACES) is proposed.

METHODS

The protocol consists of six windows including cardiac, peritoneal, pleural, inferior vena cava and aortic views, and aims to shorten the time period taken to establish a diagnosis and hence to deliver the most appropriate goal-directed therapy. Its use in seven case examples is described.

RESULTS

In all cases the ACES protocol helped in guiding the initial management while further information was obtained.

CONCLUSION

The six-view ACES protocol is a useful adjunct to clinical examination in patients with undifferentiated hypotension in the emergency department. A prospective randomised trial or multicentre database/registry is needed to investigate the validity and impact of this protocol on the early diagnosis and management of hypotensive patients.

Biodiversity effects on yield and unsown species invasion in a temperate forage ecosystem

BACKGROUND AND AIMS

Current agricultural practices are based on growing monocultures or binary mixtures over large areas, with a resultant impoverishing effect on biodiversity at several trophic levels. The effects of increasing the biodiversity of a sward mixture on dry matter yield and unsown species invasion were studied.

METHODS

A field experiment involving four grassland species [two grasses--perennial ryegrass (Lolium perenne) and cocksfoot (Dactylis glomerata)--and two legumes--red clover (Trifolium pratense) and white clover (Trifolium repens)], grown in monocultures and mixtures in accordance with a simplex design, was carried out. The legumes were included either as single varieties or as one of two broad genetic-base composites. The experiment was harvested three times a year over three years; dry matter yield and yield of unsown species were determined at each harvest. Yields of individual species and interactions between all species present were estimated through a statistical modelling approach.

KEY RESULTS

Species diversity produced a strong positive yield effect that resulted in transgressive over-yielding in the second and third years. Using broad genetic-base composites of the legumes had a small impact on yield and species interactions. Invasion by unsown species was strongly reduced by species diversity, but species identity was also important. Cocksfoot and white clover (with the exception of one broad genetic-base composite) reduced invasion, while red clover was the most invaded species.

CONCLUSIONS

The results show that it is possible to increase, and stabilize, the yield of a grassland crop and reduce invasion by unsown species by increasing its species diversity.

Amygdala protein kinase C epsilon regulates corticotropin-releasing factor and anxiety-like behavior

Corticotropin-releasing factor (CRF), its receptors, and signaling pathways that regulate CRF expression and responses are areas of intense investigation for new drugs to treat affective disorders. Here, we report that protein kinase C epsilon (PKCepsilon) null mutant mice, which show reduced anxiety-like behavior, have reduced levels of CRF messenger RNA and peptide in the amygdala. In primary amygdala neurons, a selective PKCepsilon activator, psiepsilonRACK, increased levels of pro-CRF, whereas reducing PKCepsilon levels through RNA interference blocked phorbol ester-stimulated increases in CRF. Local knockdown of amygdala PKCepsilon by RNA interference reduced anxiety-like behavior in wild-type mice. Furthermore, local infusion of CRF into the amygdala of PKCepsilon(-/-) mice increased their anxiety-like behavior. These results are consistent with a novel mechanism of PKCepsilon control over anxiety-like behavior through regulation of CRF in the amygdala.

Comprehensive analysis of melanoma antigen specific T cell repertoire: EPIMAX (EPItope MAXimum)

3016

Background: We have demonstrated in phase I clinical trial treating 20 patients with metastatic melanoma that dendritic cells (DCs) loaded with killed allogeneic tumor cells can elicit immune and clinical responses. Loading DC vaccines with killed allogeneic tumor cells allows: i) presentation of antigens via both MHC class I and class II, ii) strong help, iii) applicability to any cancer, and iv) loading tumor antigen independent of HLA haplotype of the patient. However, this renders the immunomonitoring step complex as the antigens and their restriction elements are unknown. To address this issue, we developed EPIMAX. Methods: EPIMAX measures simultaneously cell proliferation and secretion of multiple cytokines that distinguish Type 1, Type 2 cytokines and IL-10 secretion using Luminex. Briefly, 5x105 CFSE-labeled PBMCs are plated with peptide pools of overlapping peptide libraries from appropriate antigens. After 48hrs, supernatants are transferred for cytokine determination. After an additional 6 days of culture, cell proliferation is analyzed by flow cytometry after staining for surface markers CD4 and CD8. Results: We demonstrated that EPIMAX permits us to assess: i) Specificity and breadth of induced immune responses, ii) Type of induced immunity (Type I, Type II, IL-10), and iii) Function of specific T cells as measured by cytokine secretion and proliferation. To date 8 patients with stage IV melanoma were analyzed at baseline and after vaccination with DCs loaded with killed allogeneic melanoma cells. We assessed epitopes derived from MART-1, NY-ESO1, TRP-1 and gp100. Analysis of CD8+T cells: We have identified 15 melanoma antigen CD8+T cell epitopes in 8 patients. These include: three Tc0 epitopes (IL2), and twelve Tc1 epitopes triggering IP-10 secretion. Analysis of CD4+T cells: We have identified 15 melanoma antigen CD4+T cell epitopes in 5 patients. These include: nine Th0 epitopes (IL2), four Th1 epitopes (IFNγ) and two Th2 epitopes (IL13). Finally, we analyzed secretion of IL-10 and found thus far IL-10 secreting CD4+T cells in seven patients. Further studies demonstrated that these T cells have regulatory function. Conclusions: EPIMAX permits comprehensive assessment of melanoma antigen specific T cell repertoire.

No significant financial relationships to disclose.

Immune reconstitution sarcoidosis presenting with hypercalcaemia and renal failure in HIV infection

An HIV-positive white man developed hypercalcaemia and renal failure 15 months after starting highly active antiretroviral therapy. Investigations showed systemic sarcoidosis affecting parotids, skin and kidneys. This presentation was thought to be a manifestation of immune reconstitution inflammatory syndrome, and the patient was successfully treated with corticosteroid therapy.

Interest in predictive testing for Parkinson's disease: impact of neuroprotective therapy

As predictive testing for Parkinson's disease (PD) becomes available, it will be important to understand in whom such testing will be used. To address this issue, we conducted a mail survey of 138 first-degree relatives of PD patients. In the absence of treatment, 60% reported that they would either "definitely" or "probably" be interested in predictive testing. In the setting of a clinical trial, this number increased to 71% (p=0.04) and when neuroprotective therapy is available, interest increased to 90% (p<0.001). Interest in predictive testing for PD is moderate in the absence of effective therapy, and goes up significantly when both clinical trial participation and neuroprotective therapy are offered.

Durable clinical responses in patients with metastatic melanoma vaccinated with dendritic cells loaded with killed allogeneic melanoma cells

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Background: We demonstrated that DCs loaded with killed allogeneic tumors can cross-prime tumor-specific naïve CD8+T cells in vitro. Clinically this approach would overcome HLA restriction inherent to peptide vaccines and allow diversification of immune responses including priming of many clones of CD8+ and CD4+ T cells. Methods: Twenty (20) patients with metastatic melanoma were vaccinated with autologous monocyte-derived DCs loaded with killed allogeneic Colo829 melanoma cell line. A total of 8 vaccines were administered at monthly intervals. DCs were generated from monocytes by culturing with GM-CSF and IL-4 and activated by additional culture with TNFα and CD40 ligand. KLH was used as a control antigen. The first patient was accrued December, 2002 and the last November, 2003. Results: DC vaccinations induced durable objective clinical responses in two patients who had progressive metastatic disease after previous cytotoxic chemotherapy. One patient experienced a CR and one patient a PR both remissions have lasted ≥ 20 months. Fourteen patients were alive at 12 months and 9 patients are alive at the end of 2005. The estimated median overall survival is 22 months with a range of 2–31 months. DC vaccination led to elicitation of CD8+T cell immunity specific to MART-1 tissue differentiation antigen, suggesting that cross-priming/presentation of melanoma antigens by the DC vaccines had occurred in vivo. Vaccinations were safe and tolerable. There were no significant adverse events. Conclusions: The present results justify the design of larger follow-up studies to assess the immunological and clinical response to DC vaccines in patients with metastatic melanoma and other malignant diseases.

No significant financial relationships to disclose.

Prospective evaluation of non-radiologist performed emergency abdominal ultrasound for haemoperitoneum

OBJECTIVES

To evaluate non-radiologist performed emergency ultrasound for the detection of haemoperitoneum after abdominal trauma in a British accident and emergency department.

METHODS

Focused assessment with sonography for trauma (FAST) was performed during the primary survey on adult patients triaged to the resuscitation room with suspected abdominal injury over a 12 month period. All investigations were performed by one of three non-radiologists trained in FAST. The ultrasound findings were compared against the investigation of choice of the attending surgeon/accident and emergency physician. The patients were followed up for clinically significant events until hospital discharge or death.

RESULTS

One hundred patients who had sustained blunt abdominal trauma, were evaluated by FAST. Nine true positive scans were detected and confirmed by computed tomography, diagnostic peritoneal lavage, or laparotomy. There was one false positive in this group, giving a sensitivity of 100%, specificity 99%, and positive predictive value of 90%. Ten patients with penetrating injuries were evaluated with a sensitivity and specificity for FAST of 33% and 86% respectively.

CONCLUSIONS

Emergency torso ultrasound for the detection of haemoperitoneum can be successfully performed by trained non-radiologists within a British accident and emergency system. It is an accurate and rapid investigation for blunt trauma, but the results should be interpreted with caution in penetrating injury.