Aboriginal and Torres Strait Islander youth suicide mortality and previous mental health, suicidality and service use in Queensland, Australia, from 2001 to 2021

BACKGROUND

The current study aimed to compare current suicide rates, trends, previous treatment, suicidality and mental health diagnoses for First Nations and non-Indigenous young people who died by suicide.

METHODS

Age-specific suicide rates (ASSRs) were calculated per 100,000 persons/year using suicides aged 10-19 years in the Queensland Suicide Register. Rate Ratios (RRs) and 95 % CIs compared ASSRs for First Nations and non-Indigenous youth dying by suicide in Queensland, Australia, from 2001 to 2018. Risk ratios (RiskR) with 95 % CIs compared characteristics between First Nations and non-Indigenous youth suicides. Joinpoint regression was used to identify any changes in trends and annual percentage change (APC) in suicides with 95 % CIs.

RESULTS

The First Nations youth ASSR was 24.71 deaths per 100,000 persons/year, 4.5 times the non-Indigenous ASSR (95 % CI = 3.74-5.38, p < 0.001). Both non-Indigenous and First Nations suicide trends were stable with no joinpoints (APC: 0.3 %, 95 % CI: -1.6-2.2, p = 0.78; APC: 0.9 %, 95 % CI: -0.2-2.1, p = 0.11). Less than a quarter (23.9 %) of First Nations young people had ever received mental health treatment, significantly fewer than non-Indigenous youth (RiskR = 0.80, 95 % CI = 0.71-0.90, p < 0.001). Similarly, in the three months preceding their death, only 14.5 % of First Nations young people had received mental health treatment (RiskR = 0.89, 95 % CI = 0.83-97, p = 0.015).

LIMITATIONS

Reported mental illness, suicidality and help-seeking could be underreported due to concealment from family or police.

CONCLUSIONS

The current study finds no change in the gap between the First Nations and Non-Indigenous youth suicide rates nor evidence of decrease in the First Nations youth suicide rate. There is a need for alternative approaches to Indigenous youth suicide prevention, such as assertive outreach models outside of traditional triage and mental health systems to proactively build trusting relationships with young people in communities to identify young people needing support.

ARTIA-Cervix: A Prospective Clinical Trial to Assess Patient Reported Intestinal Toxicity with Adaptive External Beam Radiation Therapy in the Treatment of Cervical Cancer

PURPOSE/OBJECTIVE(S)

Chemoradiation (CRT) remains the standard of care for locally advanced cervical cancer. As recent large phase III trials (OUTBACK, CALLA) reported no difference in primary survival outcomes when novel agents were added to CRT, technological advancements continue to be a focus for improving outcomes. Daily imaging has enabled margin reduction on the cervix, uterus and lymph nodes, which can lower radiation dose to bowel and potentially reduce RT-related symptoms. Daily adaptive RT (ART) combines daily imaging with online dosimetry replanning, allowing for decreased margins on the target. A pre-planning study showed bowel V40Gy and V45Gy reductions of 252 cc to140 cc and 167 cc to 43 cc, respectively. ARTIA-Cervix is a single-arm, prospective, multi-institutional, international clinical trial investigating the potential of ART to decrease patient-reported acute gastrointestinal (GI) toxicity.

MATERIALS/METHODS

Planned enrollment is 125 subjects with up to 8 sites participating. Eligibility criteria include locally advanced node-negative cervical cancer FIGO stages IB2-3B. Treatment will consist of cisplatin-based CRT with daily ART, followed by image-guided brachytherapy. Subjects will receive 25 fractions ART at 1.8 Gy per day for a total of 45 Gy. The primary study objective is reduction of patient-reported GI toxicity as measured by PRO-CTCAE score ≥3 at the conclusion of ART. Secondary objectives include patient-reported GU toxicity and sexual quality of life, the development of radiation dosimetry models predicting toxicity, physician-reported toxicities, 2-year disease free survival, and adaptive workflow metrics. Powering of the study and sample size calculation are based on the hypothesis that ART will decrease patient-reported acute GI toxicity from historical rates of 33% to 20% (13% effect size).

RESULTS

This study opened to enrollment on April 28th, 2022. The total study duration will be approximately 5 years.

CONCLUSION

ARTIA-Cervix is an international, prospective clinical trial designed to evaluate reduction of treatment-related GI toxicity through daily online ART. The results of this clinical study will add to the growing body of evidence supporting clinical decisions about utilization of ART technologies.

ARTIA-Bladder: Daily Online Adaptive Short-Course Radiation Therapy (RT) and Concurrent Chemotherapy for Muscle-Invasive Bladder Cancer (MIBC): A Prospective Trial of an Individualized Approach for Reducing Bowel and Bladder Toxicity

PURPOSE/OBJECTIVE(S)

Concurrent chemo-radiotherapy is commonly prescribed for muscle-invasive bladder cancer (MIBC). Post hoc analysis of two large, randomized trials found that hypofractionation improves loco-regional control (LRC) vs. standard fractionation in this population. A challenge in traditional image-guided radiotherapy of the bladder is that daily changes in bladder position and size requires large margins to ensure target coverage. This makes it difficult to spare uninvolved bladder from high-dose treatment, increases the risk of bowel toxicity, and results in historical rates of acute G3+ toxicity exceeding 20-30%. Daily online adaptive RT (ART) may enable reduced, personalized margins that maintain target coverage while reducing dose to OARs. This prospective clinical trial will test whether: 1) participants undergoing ART for MIBC have a lower rate of acute G3+ GI/GU toxicity compared with the 31% historical control rate (Stage III BC2001 trial), and 2) 2-year LRC with ART will be non-inferior to historical controls (75%).

MATERIALS/METHODS

This multi-national trial will enroll 165 adult subjects with stage cT2-T4aN0M0 urothelial MIBC. Subjects will have undergone an attempt at maximal transurethral resection of bladder tumor. Patients with clinically involved nodes or G2+ GI or G3+ GU symptoms/conditions at baseline are ineligible. Concurrent with chemotherapy, participants will receive (at the discretion of the investigator) either 55 Gy in 20 fx to whole-bladder or 46 Gy in 20 fx to whole-bladder plus simultaneous in-field boost of 55 Gy in 20 fx to tumor bed. A personalized ITV will be derived for each subject based on bladder expansion, as assessed on two CT simulations separated by 30 min. Daily ART will be attempted for all subjects. The primary endpoint is acute G3+ GI/GU toxicity. Secondary endpoints are LRC; quality of life (EORTC QLQ-BLM30, EPIC 26 bowel and urinary); global function (EQ-5D-5L ); 2-year disease-free, bladder intact event-free, and overall survival; 2-year bladder cancer-specific mortality; NTCP model of acute GI toxicity for hypofractionated bladder RT; workflow feasibility of ART; improved target coverage ± reduced dose to critical OARs vs. non-ART dosimetry; acute G3+ GI/GU toxicity rate in subjects with ≥75% of their treatments as ART; and acute G3+ GI/GU toxicity in the cohort treated with partial bladder boost. Exploratory translational and correlative endpoints will also be examined.

RESULTS

This trial opened to enrollment on Feb 2, 2023; the study duration is expected to be 4-5 years.

CONCLUSION

This prospective clinical trial will provide robust clinical data to inform healthcare providers' decisions on the use of daily online ART and hypofractionation as a bladder preservation strategy for this population.

Daily Adaptive vs. Non-Adaptive External Beam Radiation Therapy with Concurrent Chemotherapy for Locally Advanced Non-Small Cell Lung Cancer (NSCLC): A Prospective Randomized Trial of an Individualized Approach for Toxicity Reduction (ARTIA-Lung)

PURPOSE/OBJECTIVE(S)

Radiotherapy (RT) with concurrent chemotherapy is a standard treatment for Stage III NSCLC. However, radiation pneumonitis incidence increases rapidly with volume of lung irradiated, and esophagitis increases with dose to the esophagus. Both conditions can have adverse impacts on patients' quality of life. Daily online adaptive RT (ART) may allow for reduced normal tissue doses due to smaller margins around the target, as well as target size reduction with tumor response. This prospective, randomized controlled trial tests the hypothesis that the proportion of study participants who experience score ≥3 PRO-CTCAE cough, dyspnea, or dysphagia will be at least 20% lower with daily ART than with non-adapted RT.

MATERIALS/METHODS

Enrollment goals are 244 subjects at up to 10 cancer centers worldwide. Eligibility criteria include stage IIIA-IIIC (AJCC v8) NSCLC; baseline grade 0-2 dyspnea, cough, and dysphagia; and no contralateral hilar or supraclavicular/cervical lymph node involvement. Subjects will be randomized (1:1) to CBCT-based daily ART or non-adapted RT using IMRT or VMAT delivering 60-66 Gy in 30-33 fractions with concurrent platinum doublet chemotherapy. Adjuvant immunotherapy with durvalumab is permitted. Follow-up for study participants will be for 1-year post-completion of chemoRT. Study endpoints include: frequency of PRO-CTCAE score ≥3 cough, dyspnea, or dysphagia from randomization to 30 days post-chemoRT; patient-reported quality of life (FACT-L and EQ-5D-5L questionnaires); percentage of lung receiving ≥20 Gy; mean doses to lung, heart, and esophagus; primary tumor response on CT or PET-CT (RECIST v1.1); local disease progression; and incidence of grade ≥2 pneumonitis within 1 year. Stratification factors are the treating institution and the presence of contralateral mediastinal lymph node metastases (associated with increased volume of irradiated lung). Interim analyses for futility and superiority will be performed when the primary endpoint data have been collected for 50% of evaluable participants.

RESULTS

This study opened to enrollment on 20 October 2022 and is expected to be completed in approximately 3 years.

CONCLUSION

This prospective, randomized clinical trial rigorously evaluates the impacts of daily online ART on radiation pneumonitis, esophagitis, and quality of life in patients with advanced NSCLC. It will collect standard tumor response and disease progression metrics to assure that reduced margins do not have an adverse impact on outcomes. Online ART is emerging as an innovative approach enabling increased sparing of normal tissues. The results of this clinical study will support evidence-based clinical decisions around ART technologies.

Development and validation of a sleep questionnaire, SNoRE 3.0, to evaluate sleep in companion dogs

Disturbances in the sleep-wake cycle are a debilitating, yet rather common condition not only in humans, but also in family dogs. While there is an emerging need for easy-to-use tools to document sleep alterations (in order to ultimately treat and/or prevent them), the veterinary tools which yield objective data (e.g. polysomnography, activity monitors) are both labor intensive and expensive. In this study, we developed a modified version of a previously used sleep questionnaire (SNoRE) and determined criterion validity in companion dogs against polysomnography and physical activity monitors (PAMs). Since a negative correlation between sleep time and cognitive performance in senior dogs has been demonstrated, we evaluated the correlation between the SNoRE scores and the Canine Dementia Scale (CADES, which includes a factor concerning sleep). There was a significant correlation between SNoRE 3.0 questionnaire scores and polysomnography data (latency to NREM sleep, ρ = 0.507, p < 0.001) as well as PAMs' data (activity between 1:00 and 3:00 AM, p < 0.05). There was a moderate positive correlation between the SNoRE 3.0 scores and the CADES scores (ρ = 0.625, p < 0.001). Additionally, the questionnaire structure was validated by a confirmatory factor analysis, and it also showed an adequate test-retest reliability. In conclusion the present paper describes a valid and reliable questionnaire tool, that can be used as a cost-effective way to monitor dog sleep in clinical settings.

Validation of non-invasive assessment of myocardial work in aortic stenosis: improvements by modifying the method for estimating the left ventricular pressure waveform

Introduction

Non-invasive myocardial work (MW) index incorporates strain by speckle-tracking echocardiography (STE) and individually estimated left ventricular pressure (LVP) curves to calculate the area of the pressure strain loop without the need for invasive LVP measurements. The method was validated in patients without aortic stenosis (AS) where a reference pressure curve is adjusted for individually measured aortic and mitral valve events and the peak LVP is defined by the brachial artery cuff pressure. Before applying this method in patients with AS, potential limitations which can influence the area of the pressure strain loop, such as the LVP curve profile, correct scaling of peak LVP and correct assessment of aortic events must be addressed.

Purpose

The present study aimed to assess the impact of the potential limitations specific to patients with AS and thereby the validity of non-invasive MW index in patients with AS.

Methods

In 20 patients with severe AS we obtained simultaneous LVP, by a micromanometer-tipped catheter, and strain by STE. For each patient, LVP curve estimations were done using three different models: 1. The established LVP reference model based on patients without AS. 2. Enhancement of the established LVP reference model by defining aortic valve opening with diastolic cuff pressure. 3. A new AS specific LVP reference model based on our current invasive measurements. Valvular events were determined by 2D and Doppler echocardiography, and peak LVP estimated as a sum of mean trans-aortic gradient and systolic cuff pressure. Estimated LVP curve tracings were thereafter directly compared with simultaneous invasive measurements (Figure 1). Furthermore, area of the pressure-strain loops using the different estimations of LVP curve were calculated to assess MW and compared to simultaneous invasive measurements for direct comparison.

Results

All three methods had excellent average correlation coefficient between estimated and invasively measured LVP traces. However, estimations with the AS specific reference curve and those enhanced with incorporation of diastolic pressure for aortic valve opening had a higher correlation coefficient (r=0.99, p&lt;0.001) and a more physiological profile during early systole compared to that of the previously validated reference curve (r=0.96, p&lt;0.001) (Figure 1). Furthermore, there was an excellent correlation (r=0.98, p&lt;0.001) and good agreement between MW calculated with all three non-invasive estimation methods and invasive LVP (Figure 2).

Conclusions

The present study is the first to confirm the validity of non-invasive MW in patients with AS. Furthermore, a AS specific reference curve and the enhanced reference curve incorporating diastolic cuff pressure to define aortic valve opening both increased the accuracy of the estimated LVP curve and hence estimation of MW. This could be pivotal when assessing AS patients with marked regional differences such as LBBB or regional ischaemia.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Oslo University Hospital Rikshospitalet

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Technology-enabled multidisciplinary team in-reach for oral corticosteroid stewardship and optimizing care of suspected airways disease exacerbations

Overuse of corticosteroids is an important problem not only in asthma but also the management of other airways diseases including bronchiectasis and COPD and results in associated risks of serious side effects and irreversible harm. We report a pilot using an in-reach solution to review patients, optimise their care and facilitate early discharge. We discharged >20% of our patients immediately, which is potentially a significant reduction in hospital bed use and, most importantly, through this approach we were able to establish early diagnosis and reduce inappropriate oral corticosteroid use.

Rationale and study design for lifestyle intervention in preparation for pregnancy (LIPP): A randomized controlled trial

INTRODUCTION

Maternal obesity increases neonatal risk for obesity and metabolic syndrome later in life. Prior attempts to break this intergenerational obesity cycle by limiting excessive gestational weight gain have failed to reduce neonatal adiposity. Alternatively, pre-conception lifestyle interventions may improve the in utero metabolic milieu during early pregnancy leading to improved fetal outcomes. This randomized controlled trial (RCT) is evaluating whether a lifestyle intervention to reduce weight and improve maternal metabolism in preparation for pregnancy (LIPP) attenuates neonatal adiposity, compared to standard medical advice.

MATERIAL AND METHODS

Overweight/class 1 obese women after a previous pregnancy, ~12 weeks postpartum, preparing for a subsequent pregnancy, will be block randomized (1:1) to either LIPP or standard of care in a parallel design. Randomization is stratified by lactation status and overweight vs. class 1 obesity. The LIPP program consists of intensive short-term weight loss followed by weight maintenance until conception using supervised exercise and a low glycemic Mediterranean diet.

PRIMARY OUTCOMES

Group differences in neonatal adiposity at birth assessed by PEA POD and placental mitochondrial lipid metabolism.

SECONDARY OUTCOMES

Group differences in maternal pregravid and gestational body composition, insulin sensitivity, β-cell function, fasting metabolic and inflammatory biomarkers, and overall quality of life. Exploratory outcomes include umbilical cord blood insulin resistance, lipid profile and inflammation.

DISCUSSION

This RCT will determine the efficacy of maternal weight loss prior to pregnancy on reducing neonatal adiposity. Findings may change standard obstetrical care by providing Level 1 evidence on lifestyle interventions improving neonatal outcomes for women planning for pregnancy.

CLINICAL TRIAL REGISTRATION

NCT03146156.

Utility of state-level influenza disease burden and severity estimates to investigate an apparent increase in reported severe cases of influenza A(H1N1) pdm09 - Arizona, 2015-2016

The Arizona Department of Health Services identified unusually high levels of influenza activity and severe complications during the 2015-2016 influenza season leading to concerns about potential increased disease severity compared with prior seasons. We estimated state-level burden and severity to compare across three seasons using multiple data sources for community-level illness, hospitalisation and death. Severity ratios were calculated as the number of hospitalisations or deaths per community case. Community influenza-like illness rates, hospitalisation rates and mortality rates in 2015-2016 were higher than the previous two seasons. However, ratios of severe disease to community illness were similar. Arizona experienced overall increased disease burden in 2015-2016, but not increased severity compared with prior seasons. Timely estimates of state-specific burden and severity are potentially feasible and may provide important information during seemingly unusual influenza seasons or pandemic situations.

Maternal pre-pregnancy obesity and child neurodevelopmental outcomes: a meta-analysis

This review examined evidence of the association between maternal pre-pregnancy overweight/obesity status and child neurodevelopmental outcomes. PubMed and PsycINFO databases were systematically searched for empirical studies published before April 2017 using keywords related to prenatal obesity and children's neurodevelopment. Of 1483 identified papers, 41 were included in the systematic review, and 32 articles representing 36 cohorts were included in the meta-analysis. Findings indicated that compared with children of normal weight mothers, children whose mothers were overweight or obese prior to pregnancy were at increased risk for compromised neurodevelopmental outcomes (overweight: OR = 1.17, 95% CI [1.11, 1.24], I²  = 65.51; obese: OR = 1.51; 95% CI [1.35, 1.69], I²  = 79.63). Pre-pregnancy obesity increased the risk of attention deficit-hyperactivity disorder (OR = 1.62; 95% CI [1.23, 2.14], I²  = 70.15), autism spectrum disorder (OR = 1.36; 95% CI [1.08, 1.70], I²  = 60.52), developmental delay (OR = 1.58; 95% CI [1.39, 1.79], I²  = 75.77) and emotional/behavioural problems (OR = 1.42; 95% CI [1.26, 1.59], I²  = 87.74). Given the current obesity prevalence among young adults and women of childbearing age, this association between maternal obesity during pregnancy and atypical child neurodevelopment represents a potentially high public health burden.

Ski and snowboard school programs: Injury surveillance and risk factors for grade-specific injury

The objective of our study was to evaluate incidence rates and profile of school program ski and snowboard-related injuries by school grade group using a historical cohort design. Injuries were identified via Accident Report Forms completed by ski patrollers. Severe injury was defined as those with ambulance evacuation or recommending patient transport to hospital. Poisson regression analysis was used to examine the school grade group-specific injury rates adjusting for risk factors (sex, activity, ability, and socioeconomic status) and accounting for the effect of clustering by school. Forty of 107 (37%) injuries reported were severe. Adolescents (grades 7-12) had higher crude injury rates (91 of 10 000 student-days) than children (grades 1-3: 25 of 10 000 student-days; grades 4-6: 65 of 10 000 student-days). Those in grades 1-3 had no severe injuries. Although the rate of injury was lower in grades 1-3, there were no statistically significant grade group differences in adjusted analyses. Snowboarders had a higher rate of injury compared with skiers, while higher ability level was protective. Participants in grades 1-3 had the lowest crude and adjusted injury rates. Students in grades 7-12 had the highest rate of overall and severe injuries. These results will inform evidence-based guidelines for school ski/snowboard program participation by school-aged children.

The impact of new national guidance for the public health management of enteric fever in England

OBJECTIVES

New guidance was published in England in February 2012 to support the public health management of enteric fever and reduce the risks of secondary transmission. The new guidance was evaluated to assess: STUDY DESIGN: Quantitative and qualitative evaluation of the implementation of new public health guidance.

METHODS

A qualitative review of all non-travel-related cases from February 2010 to January 2014 to compare the risk of secondary transmission before and after the guidance introduction; an audit of clearance sampling for each case and their contacts reported in London from February 2012-January 2015 to compare with a previous London audit; and an online user survey in November 2014.

RESULTS

The proportions of non-travel cases reported before and after the introduction of the new guidance were similar, 6% in 2010-2012 compared to 7% in 2012-2014 (P = 0.33). There was a 32% reduction in the number of clearance samples required for cases and the estimated period of exclusion from work or school was reduced from 54 days to 16 days. Compliance in case clearance improved from 53% to 90% and contact screening compliance improved from 42% to 80%. The targeted screening of contacts led to a significantly higher positive yield (3.6% from 1.5%, P = 0.003). All symptomatic co-travellers presented to a healthcare professional, suggesting that screening could be restricted to those in risk groups for transmission. Feedback from users highlighted additional areas, such as management of large organised groups of co-travellers and those diagnosed abroad, which has informed the update of the national guidance.

CONCLUSIONS

The new guidance has not led to an increase in secondary transmission of enteric fever in England and findings have been used to inform an update of the guidance. The new guidance also represents a reduced burden of investigation and thus a likely reduced cost to patients, healthcare professionals, laboratories and environmental health officers.

Letrozole may be a valuable maintenance treatment in high-grade serous ovarian cancer patients

OBJECTIVES

Endocrine therapy is used as maintenance in estrogen receptor (ER) positive breast cancers and has been proposed in low-grade serous ovarian cancers (LGSOC). Here we examine a rationale for its use as maintenance in high-grade serous ovarian cancers (HGSOC).

METHODS

We accessed the TCGA PANCAN dataset to evaluate the expression of ESR1. ESR1 expression data on all cancers (n=8901) and HGSOC (n=527) were followed by investigation of ER expression via immunohistochemistry (IHC) (n=4071). The same was performed in an independent cohort for matched primary and recurrent HGSOC (n=80). Finally, newly diagnosed ER+ HGSOC patients were offered a maintenance therapy with Letrozole.

RESULTS

ESR1 was strongly expressed in similar levels in HGSOC as in breast cancer. We found a strong ER expression via IHC in both the primary and matched recurrent HGSOC, particularly in the Platinum-resistant subgroup. The additional use of Letrozole as maintenance treatment was associated with a significantly prolonged recurrence free interval (after 24months 60% when taking Letrozole versus 38.5% in the control group; p=0.035; RFS: IC₅₀ reached by one subject versus 13.2months). This effect was also present in patients treated additionally with Bevacizumab; 20.8% of patients had no recurrence after 12months compared to 87.5% when taking Letrozole in addition to Bevacizumab (p=0.026).

CONCLUSIONS

Primary HGSOC have a slightly higher ESR1 than and a similar ER expression breast cancer where aromatase inhibitor maintenance is routine for decades. Here we demonstrate evidence for the usefulness of Letrozole in HGSOC, particularly in patients with chemotherapy resistance or residual disease.

The Effect of Brassica Vegetable Consumption on Caffeine Metabolism in Humans

Ten healthy volunteers were used in two studies investigating the effect of short-term Brassica consumption on caffeine metabolism. In the first study volunteers were given three Brassica-containing meals, the last one 3 h prior to caffeine administration. In the second study volunteers were given two Brassica-containing meals and then fasted overnight before caffeine administration.

In both studies the mean plasma half-life of caffeine was reduced by approximately 20% following a Brassica diet, suggesting that Brassica vegetables stimulate caffeine metabolism.

When caffeine was given 3 h after the last meal, plasma caffeine concentrations over 6 h, were increased by up to 27% on the Brassica diet compared to controls. This may be due to a transient increased permeability of the intestine to caffeine, immediately following Brassica consumption. This effect was not seen in the second study where there was a 12-h period between the last meal and caffeine administration.

There was large interindividual variation in the effect of the Brassica diet on caffeine metabolism.

Wasted septal work in left ventricular dyssynchrony: a novel principle to predict response to cardiac resynchronization therapy

Aims

Cardiac resynchronization therapy (CRT) in heart failure is limited by many non-responders. This study explores whether degree of wasted left ventricular (LV) work identifies CRT responders.

Methods and results

Twenty-one patients who received CRT according to guidelines were studied before and after 8 ± 3 months. By definition, segments that shorten in systole perform positive work, whereas segments that lengthen do negative work. Work was calculated from non-invasive LV pressure and strain by speckle tracking echocardiography. For each myocardial segment and for the entire LV, wasted work was calculated as negative work in percentage of positive work. LV wall motion score index (WMSI) was assessed by echocardiography. Response to CRT was defined as ≥15% reduction in end-systolic volume (ESV). Responder rate to CRT was 71%. In responders, wasted work for septum was 117 ± 102%, indicating more negative than positive work, and decreased to 14 ± 12% with CRT (P < 0.01). In the LV free wall, wasted work was 19 ± 16% and showed no significant change. Global LV wasted work decreased from 39 ± 21 to 17 ± 7% with CRT (P < 0.01). In non-responders, there were no significant changes. In multiple linear regression analysis, septal wasted work and WMSI were the only significant predictors of ESV reduction (β = 0.14, P = 0.01; β = 1.25, P = 0.03). Septal wasted work together with WMSI showed an area under the curve of 0.86 (95% confidence interval 0.71–1.0) for CRT response prediction.

Conclusion

Wasted work in the septum together with WMSI was a strong predictor of response to CRT. This novel principle should be studied in future larger studies.

Evaluation of a point-of-care blood test for identification of Ebola virus disease at Ebola holding units, Western Area, Sierra Leone, January to February 2015

Current Ebola virus disease (EVD) diagnosis relies on reverse transcription-PCR (RT-PCR) technology, requiring skilled laboratory personnel and technical infrastructure. Lack of laboratory diagnostic capacity has led to diagnostic delays in the current West African EVD outbreak of 2014 and 2015, compromising outbreak control. We evaluated the diagnostic accuracy of the EVD bedside rapid diagnostic antigen test (RDT) developed by the United Kingdom's Defence Science and Technology Laboratory, compared with Ebola virus RT-PCR, in an operational setting for EVD diagnosis of suspected cases admitted to Ebola holding units in the Western Area of Sierra Leone. From 22 January to 16 February 2015, 138 participants were enrolled. EVD prevalence was 11.5%. All EVD cases were identified by a positive RDT with a test line score of 6 or more, giving a sensitivity of 100% (95% confidence interval (CI): 78.2-100). The corresponding specificity was high (96.6%, 95% CI: 91.3-99.1). The positive and negative predictive values for the population prevalence were 79.0% (95% CI: 54.4-93.8) and 100% (95% CI: 96.7-100), respectively. These results, if confirmed in a larger study, suggest that this RDT could be used as a 'rule-out' screening test for EVD to improve rapid case identification and resource allocation.

Chordomas at High Prevalence in the Captive Population of the Endangered Perdido Key Beach Mouse (Peromyscus polionotus trissyllepsis)

The Perdido Key beach mouse (Peromyscus polionotus trissyllepsis) is a critically endangered subspecies of the oldfield mouse. The captive population, currently maintained by 3 Florida zoos, is entirely derived from just 3 wild-caught ancestor mice. Necropsy and histopathology revealed chordoma of the vertebral column in 38 of 88 (43%) mice. The tumors were locally expansile and invasive masses of large physaliferous (vacuolated) cells with small, round, hyperchromatic nuclei, similar to the "classic" form of chordomas described in humans. Primary tumors rarely contained small amounts of bone and cartilaginous matrix, characteristic of the "chondroid" form. Neoplastic cells contained abundant granules positive by the periodic acid-Schiff reaction. Brachyury and cytokeratin AE1/AE3 were detected in neoplastic cells by immunohistochemistry, but uncoupling protein 1 was not identified. Primary tumors occurred along the entire vertebral column--cervical, 5 of 38 (13%); thoracic, 16 (42%); lumbar, 13 (34%); and sacral, 10 (26%)--and 10 (26%) mice had multiple primary masses. Metastases to the lungs were noted in 13 of the 38 (34%) mice. Mice diagnosed with chordomas postmortem ranged from 424 to 2170 days old, with a mean of 1399 days. The prevalence of chordoma was not significantly different between males (n = 23 of 50; 46%) and females (n = 15 of 38; 39%).

Promoting resilience and wellbeing through an outdoor intervention designed for Aboriginal adolescents

INTRODUCTION

Aboriginal people in Canada (First Nations, Inuit and Métis) have a lower health status compared to the Canadian population. There is a particular concern about the mental health and wellbeing of First Nations adolescents living on reserves. Interventions following principles of outdoor education and adventure therapy appear to be an appropriate fit for this population. These approaches have proven effective in non-Aboriginal populations, yet there is very little evidence on the efficacy of these types of program for Aboriginal adolescents. The primary purpose of this study was to evaluate the impact of an outdoor adventure leadership experience (OALE) on the resilience and wellbeing of First Nations adolescents from one reserve community. The secondary purposes were to explore whether this impact was sustainable, and whether there were any intervening factors that may have influenced the impact.

METHODS

The collaborative research team used a mixed-method design to evaluate the 10-day OALE for adolescents from Wikwemikong Unceded Indian Reserve in northern Ontario, Canada. The main outcome assessed was resilience, measured by self-report, using the 14-Item Resilience Scale (RS-14). Several other exploratory measures assessed other aspects of health and well-being. The questionnaire package was administered at three different time periods: (T1) one day before the OALE; (T2) one month after the OALE; and (T3) one year after the OALE. The Mental Component Score (MCS) of the SF-12v2 was used to confirm any changes in resilience. Open-ended questions were appended to the questionnaire at the 1-year point to identify any intervening factors that may have impacted any changes in resilience and wellbeing. The primary analysis compared mean RS-14 scores at T1 with those at T2. Responses to the open-ended questions were analyzed using content analysis.

RESULTS

Over two summers (2009 and 2010), 73 youth 12-18 years of age from Wikwemikong participated in a standardized 10-day OALE program. This represented 15% of the on-reserve population of adolescents in this age range. Survey responses from 59 (80.8%) participants were available for analysis at T1, compared to 47 (64.4%) at T2 and 33 (45.2%) at T3. The mean RS-14 score was 73.65 at baseline, and this improved 3.40 points (p=0.011) between T1 and T2. However, the resilience scores at T3 (1 year post-OALE) had a mean of 74.19, indicating a return back to pre-OALE levels. The mean MCS score at T1 was 48.23 and it improved over the subsequent two time periods. Several intervening factors reported at T3 may have influenced the decrease in resilience scores from T2 to T3. These included changes in family living situation, death in the family, and other life stressors that occurred over the course of the year.

CONCLUSIONS

Outcome scores from this study provide a unique glimpse into the self-reported health and wellbeing for adolescents within one First Nations community in Canada. The OALE program was beneficial in promoting resilience for adolescents in Wikwemikong over the short-term. Future studies are necessary to assess whether the OALE (or similar outdoor type interventions) are effective within other communities.