Defining the Transcriptional Landscapes of the Tumor Microenvironment of Cervical and Vaginal Cancers at Single-Cell Resolution

PURPOSE/OBJECTIVE(S)

Malignancies found within vaginal tissue are often diagnosed as cancers of the cervix, vulva, or urethra and are clinically treated with similar modalities. However, the rarity of vaginal cancer may be an artifice of categorization; current treatment paradigms do not take into account tissue-specific mutations and differences in mechanistic pathways intracellularly. Understanding the shared and distinctly different transcriptional profiles of vaginal and cervical tumors at a single-cell resolution will provide insights in vaginal tumor biology and will open avenues for future clinical interventions.

MATERIALS/METHODS

Biopsies of tumor and adjacent normal tissue from 9 patients (3 adenocarcinomas (ADC), 3 squamous cell carcinomas (SCC) from the cervix, and 3 vaginal SCC) were collected and analyzed by single-cell RNA sequencing (scRNA-seq) to compare the tumor, immune, and stromal features of cervical and vaginal cancers.

RESULTS

Collectively, over 50,000 cells were analyzed by scRNA-seq in this study. We performed dimensionality reduction and clustering analysis of the single-cell transcriptomes to identify the major cell types composing the vaginal and cervical tumor tissues. Compared to Cervical SCC, Vaginal SCC tissues showed reduced fractions of macrophages (-2.7 log2-fold; padj < 0.02) and T cells (-3.7 log2-fold; padj < 0.02) by differential cell proportion analysis (RAISIN). Likewise, the vaginal SCC epithelial cell compartments showed downregulation of inflammatory pathways including TNF signaling via NFKB (NES = -5.7, padj = 5.0 × 10-19), IL2 STAT5 signaling (NES = -4.5, padj = 1.6 × 10-12), and interferon gamma response (NES = -4.3, padj = 9.4 × 10-12), among the Hallmark pathway collection. On the other hand, vaginal SCC epithelial cells showed significant upregulation of oxidative phosphorylation (NES = 4.8, padj = 1.7 × 10-17), p53 pathway (NES = 4.2, padj = 1.8 × 10-13), mTORC1 signaling (NES = 4.2, padj = 1.9 × 10-13), and estrogen early and late response (NES = 4.0, padj < 7.5 × 10-12) compared to cervical SCC.

CONCLUSION

These results highlight distinct differences in the cell type composition and cancer epithelial pathways in vaginal vs. cervical SCC. Among upregulated pathways in vaginal SCC, ER and mTORC1 pathway activation may represent targets for therapeutic intervention worthy of further investigation.

Improving Cancer Care by Incorporating the Patient's Voice in Symptom Management (IMPROVE): A Multicenter-Prospective Pilot Study

PURPOSE/OBJECTIVE(S)

IMPROVE is a prospective multicenter pilot study. It evaluates whether routine physician review of patient-reported outcomes measures (PROMs) during radiotherapy alters physicians' perception of cancer patients' treatment-related toxicity and influences symptom management.

MATERIALS/METHODS

We are enrolling patients with thoracic or gastrointestinal cancers amenable to conventional-fractionated radiotherapy. Patients may receive concurrent chemotherapy. Patients report (1) symptoms, using PRO-CTCAE measures, (2) the most burdensome symptom, and (3) how symptoms interfere with daily activities. Patients complete the measures before seeing their physician during each on-treatment visit. During weekly visits and before reviewing the patient's PROMs, physicians rate the symptom burden for each patient from 0 to 10, using available clinical data. These data include vital signs, lab work, physical exams, nursing assessments, and physicians' clinical judgment. After reviewing the patients' PROMs, physicians re-rate each patient's symptom burden and report any changes in recommended interventions. Changes could include (1) additional counseling, (2) new medications or interventions, (3) referrals to other services, or (4) further testing or evaluation. After each patient's course of radiotherapy, providers complete a Clinician Feedback Form about the impact of PROM review on symptom perception and management during treatment. This study commenced November 11, 2020 at a multi-site tertiary academic cancer center (using electronic or paper questionnaires) and July 21, 2021 at a multi-site community cancer center (using paper forms).

RESULTS

To be determined.

CONCLUSION

To be determined.

POS0057 INDUCIBLE REGULATORY SYNOVIAL MACROPHAGES: A PROOF-OF-CONCEPT STUDY FOR A CELL-BASED TARGETED THERAPY FOR RHEUMATOID ARTHRITIS

Background

Infiltration of monocyte-derived macrophages into the synovial tissue (ST) is a hallmark of rheumatoid arthritis (RA) pathology. These macrophages promote inflammation, local joint effusion, and joint damage via the release of cytokines, oxygen reactive species, and tissue damaging enzymes. However, balancing these, are the ‘regulatory’ macrophages with inflammation-resolving properties, characterised by expression of CD206 and MerTK, dominant within the ST of healthy individuals as well as RA patients in remission (1). Indeed, these cells are believed to actively contribute to the maintenance of remission.

Macrophages are known to exhibit remarkable phenotypic plasticity and understanding the role of this characteristic in regulating inflammation and pathology remains a major challenge, as does the characterization of factors in the microenvironment such as the synovium that control such macrophage characteristics. Importantly, whether the infiltrating, inflammatory macrophages of the RA ST similarly exhibit such phenotypic plasticity, and whether this occurs during the process of reaching remission, remains to be studied.

Objectives

We investigated the phenotypic plasticity of inflammatory synovial macrophages from patients with RA in vitro, investigating their ability to convert from an inflammatory macrophage population into ‘regulatory’ CD206+MerTK+ macrophages. These findings will provide a proof-of-concept as to the utility of these macrophage for a cell-based therapy in resolving inflammation in patients with RA, and will likely extend our understanding of the mechanisms of action of currently used therapeutics.

Methods

Synovial fluid (SF) mononuclear cells were obtained from patients with active early RA (<1 year; fulfilling 2010 ACR/EULAR classification criteria). Cryopreserved SFMCs were cultured for 48hr in the presence of 10 ng/mL interferon(IFN)γ, 50 ng/mL dexamethasone, 10 μg/mL Infliximab, or diluent. Following culture, cells were immunostained and analysed using a Beckman Coulter CytoFLEX flow cytometer and FlowJo software. SF macrophages were characterised by expression of CD14, CD45, CD68 (Figure 1A), and proportions of CD206+ MerTK+ macrophages measured.

Figure 1.

Synovial fluid CD68+macrophage plasticity in vitro. (A) Gating strategy depicting CD68+ CD45+CD14+ SF macrophage determination. (B) Proportions of CD206 and MerTK-expressing SF macrophages after 48hr culture in the presence of 10 ng/mL IFNγ, 50 ng/mL dexamethasone or 10 µg/mL Infliximab, or absence. Data are representative of 5 individual experiments. Data were analysed by two-way ANOVA followed by Dunnett’s multiple comparison test, *p<0.05.

Results

Prior to culture, the CD68+ macrophage populations present in SF were found to be predominantly CD206-MerTK-. After 48 hours of culture, in the absence of any stimulus, there was an increase in proportions of CD206+MerTK+ macrophages. Treatment with either dexamethasone or anti-TNF (Infliximab) resulted in a further increase in proportions of CD206+ MerTK+, M2-like macrophages. In contrast, culture with IFNγ induced a reduction in this population. Importantly, we found that the generated CD206+MerTK+ macrophages were phenotypically stable in culture following removal of these differentiating agents.

Conclusion

Our findings demonstrate that inflammatory SF cells are indeed able to polarise to regulatory, CD206+MerTK+ macrophages in vitro. The findings provide further mechanistic insights into the basis for the therapeutic benefits of glucocorticoids and TNF inhibitors, as well as providing initial proof-of-concept in the use of regulatory macrophages as a cellular-based therapy or therapeutic target for patients with RA.

References

[1]Alivernini S, MacDonald L, Elmesmari A, et al., Distinct synovial tissue macrophage subsets regulate inflammation and remission in rheumatoid arthritis. Nature Medicine. 2020;26(8):1295-306 10.1038/s41591-020-0939-8.

Disclosure of Interests

None declared

Abstract 30: Trends Of Telehealth Utilization Among Cardiovascular Disease Patients Before And During The Covid-19 Pandemic And Cost Analysis

Objectives: To determine the costs and trends of telehealth utilization before and during the COVID-19 pandemic for patients with cardiovascular diseases (CVD).

Methods: We calculated the proportions of patients with CVD who used telehealth before (January 2019-February 2020) and during (March 2020-April 2021) the pandemic using MarketScan Commercial Claims and Encounters. We compared the trends of telehealth utilization among CVD patients by sex, age, claim type, payment plan, and rural/urban status. We calculated mean, SD, median, and IQR of total and average telehealth costs.

Results: The results show that telehealth utilization spiked in March 2020 and further rapidly increased and peaked in April 2020. Telehealth utilization increased from 0.021% in March 2019 to 6.7% in March 2020 and from 0.024% in April 2019 to 39.8% in April 2020. After peaking in April 2020, telehealth utilization rapidly fell in May-June 2020 and then gradually decreased before rebounding in October-December 2020. It resumed the decline through April 2021 remained much higher than the prepandemic level. Telehealth utilization was higher during the pandemic for females than males; for younger age groups (aged 18-44 or 45-64) than older age group (aged 65+); for commercial claims than Medicare supplemental insurance; for capitated insurance plans than non-capitated insurance plans; and for patients in urban areas than rural areas. From March 2020-February 2021, the mean (SD) telehealth cost per visit was $115.7 (66) (median [IQR], $104.8 [$75.8-$139.4]), with patient out-of-pocket cost $25.5 (42.8) (median [IQR], $10 [$0-$30]), insurance cost $90.4 (71.0) (median [IQR], $83 [$45.3-$121.3]), and the mean (SD) number of telehealth utilizations per patient was 1.67 (1.8) (median [IQR], 1 [1-2]).

Conclusions: Policymakers, health care practitioners, and insurance companies should be aware of trends and costs of telehealth utilization among patients with CVD. Our results show that telehealth would facilitate better management of CVD. Our results may inform future policies and practices to meet the increased demand for telehealth.

What are the essential components of antenatal care? A systematic review of the literature and development of signal functions to guide monitoring and evaluation

BACKGROUND

Antenatal care (ANC) is one of the key care packages required to reduce global maternal and perinatal mortality and morbidity.

OBJECTIVES

To identify the essential components of ANC and develop signal functions.

SEARCH STRATEGY

MESH headings for databases including Cinahl, Cochrane, Global Health, Medline, PubMed and Web of Science.

SELECTION CRITERIA

Papers and reports on content of ANC published from 2000 to 2020.

DATA COLLECTION AND ANALYSIS

Narrative synthesis of data and development of signal function through 7 consensus-building workshops with 184 stakeholders.

MAIN RESULTS

A total of 221 papers and reports are included from which 28 essential components of ANC were extracted and used to develop 15 signal functions with the equipment, medication and consumables required for implementation of each. Signal functions for the prevention and management of infectious diseases (malaria, HIV, tuberculosis, syphilis and tetanus) can be applied depending on population disease burden. Screening and management of pre-eclampsia, gestational diabetes, anaemia, mental and social health (including intimate partner violence) are recommended universally. Three signal functions address monitoring of fetal growth and wellbeing, and identification and management of obstetric complications. Promotion of health and wellbeing via education and support for nutrition, cessation of substance abuse, uptake of family planning, recognition of danger signs and birth preparedness are included as essential components of ANC.

CONCLUSIONS

New signal functions have been developed which can be used for monitoring and evaluation of content and quality of ANC. Country adaptation and validation is recommended.

Feeding forage or concentrates early in life influences rumen fermentation, metabolic response, immune function and growth of Wagyu × Friesian calves

Context Early life nutrition of calves influences their performance later in life. There is limited literature demonstrating the effects of rearing dairy calves in early life on milk with either exclusively forage or concentrate starter diets on metabolic and immune function and post-weaning growth and body composition on a pasture only diet. Aim This study evaluated the effects of feeding Wagyu × Holstein Friesian calves a forage starter (FS) or a concentrate starter (CS) for the first 14 weeks of rearing on rumen fermentation, blood metabolites, immune function, growth and body composition to Week 41. Methods Group-housed calves (Wagyu × Friesian, 10 calves per group, three groups per treatment) were fed milk (2 L per calf twice daily) until Week 7, then transitioned to once a day milk feeding until weaning by Week 9, with ad libitum access to either FS or CS. All calves were transferred to graze ryegrass pastures a week after transitioning to once daily milk feeding, with starter feeds removed gradually by Week 14. Thereafter, calves were reared together on pasture until Week 41. Results Solid feed intake was lower in FS than CS calves during the first 7 weeks. Total short chain fatty acids were lower, but acetate to propionate ratio and rumen pH were higher in FS than CS calves at Week 7, with no differences observed at Week 12 or 30. Plasma β-hydroxybutyrate an indicator of ketogenic ability of the rumen in developing calves was higher in FS vs CS calves at weaning. Further, FS calves had lower concentrations of circulating non-esterified fatty acids compared with CS calves at weaning. Compared with CS calves, FS calves grew slower for the first 14 weeks which was associated with lower plasma IGF-1 levels. However, FS calves had greater average daily gain after 14 weeks when on pasture and had similar plasma IGF-1 at 30 weeks and similar body weight and body composition (muscle and subcutaneous fat deposition) by Week 41 compared to CS calves. Conclusions These results indicate that offering a FS starter has better prepared calves for weaning onto pasture and potentially improved utilisation of forage post-weaning to achieve similar muscle and fat deposition and overall liveweight in both groups by 41 weeks. Implications Dairy beef calves can be successfully reared using forage as the only solid feed source without affecting their growth performance on pasture until 10 months of age. Rearing calves using forage will contribute to reducing the usage of concentrate feeds in pastoral dairy-beef production systems and provide an opportunity to fulfil the market requirements and standards for grain-free beef production.

Effect of weaning age on growth, mammary gland development, and immune function in Holstein Friesian calves fed conserved alfalfa (FiberStart)

This study aimed to evaluate intake, body growth, and the development of the rumen, mammary gland, and immune system in Holstein Friesian calves reared for 100 d on the commercially available feed FiberStart (conserved alfalfa, Medicago sativa; Fiber Fresh Feeds Ltd., Reporoa, New Zealand) and fed calf milk replacer (CMR) for either 56 or 91 d. Eighty calves (40 bulls and 40 heifer calves) were reared indoors in groups (n = 5 of the same sex/pen). All calves were fed 4 L of CMR/d (175 g/L of CMR) in 2 feeds/d for the first 10 d and then 1 feed/d until d 49 or 84. The calves were gradually weaned by d 56 (earlier weaned; n = 8 pens) and d 91 (later weaned; n = 8 pens). All calves were fed FiberStart ad libitum as the only solid feed source from d 1 to 100 of the study. Irrespective of treatment, all calves had similar body weights at d 0 (40.9 ± 3.0 kg) and d 49 (74.2 ± 5.1 kg) of the study. Calf sex had no effect on intake, growth, blood, and immune system parameters. Earlier-weaned calves consumed 18% more solid feed dry matter but had 16% lower body weight gain (28.9 vs. 38.5 kg, respectively) from d 56 to 100 relative to later-weaned calves, resulting in different body weight at 100 d (104 vs. 121 ± 1.3 kg). Although earlier-weaned calves could compensate for the loss of CMR dry matter and crude protein intake from d 56 to 100 by increasing forage intake, they were unable to compensate for the loss of energy from the CMR by increasing solid feed consumption. Plasma β-hydroxybutyrate concentrations were 52% greater in earlier-weaned calves than in later-weaned calves at d 84, indicating greater metabolic activity of the rumen wall. The duration of CMR feeding had no influence on humoral or cell-mediated immune functions of the calves, as evidenced by a lack of effect on antivaccine antibody responses as well as on immune gene expression. Earlier- versus later-weaned heifer calves had 5% lower mammary gland mass, indicating that greater energy supply increased mammary mass. The results of this experiment demonstrate the ability to artificially rear dairy calves on a conserved alfalfa as the only solid feed. Furthermore, earlier weaning off CMR promotes solid feed intake and an associated increase in blood β-hydroxybutyrate, an indicator of rumen development, but increasing the duration of CMR feeding improves growth and mammary gland mass by d 100. The implications of these findings on lifetime growth, health, and milk production in dairy heifers warrant further investigation.

Neuroleptic prescribing in an adolescent psychiatric in-patient unit

The Royal College of Psychiatrists' consensus statement suggests that prescribing high dose antipsychotic medication in children and adolescents should rarely be necessary. Our objective was to study the prescribing of antipsychotic medication in a regional adolescent unit during a three-year period. We found that antipsychotic prescribing on this unit is common in psychotic disorders and often high closes are required. This is not in keeping with the recommendations of the consensus statement. Review of clinical practice on other adolescent units is needed, together with a more comprehensive evaluation of the outcome of psychotic disorders in this age group.

Milk production and composition, nitrogen utilization, and grazing behavior of late-lactation dairy cows as affected by time of allocation of a fresh strip of pasture

Eighty late-lactation dairy cows were used to examine the effects of allocating a new pasture strip of a sward based on ryegrass (Lolium perenne L.) in the morning (a.m.; ∼0730 h) or in the afternoon (p.m.; ∼1530 h) on milk production and composition, nitrogen (N) utilization, and grazing behavior. Cows grazed the same pasture strips for 24 h and were offered the same daily herbage allowance. Herbage composition differed among treatments; p.m. herbage had greater dry matter (DM; 22.7 vs. 19.9%), organic matter (OM; 89.5 vs. 88.9%), and water-soluble carbohydrate (10.9 vs. 7.6%) concentrations and lesser crude protein (20.5 vs. 22.2%) and neutral detergent fiber (48.8 vs. 50.4%) concentrations compared with a.m. herbage. Total fatty acids (FA), α-linolenic acid, and polyunsaturated FA (PUFA) were greater in a.m. herbage, whereas monounsaturated FA were greater in p.m. herbage. Estimates of herbage DM intake did not differ among treatments. Daily milk yields and milk fat and milk protein concentrations were similar among treatments, whereas milk fat (684 vs. 627 g/cow), milk protein (545 vs. 505 g/cow), and milk solids (milk fat + milk protein) yields (1,228 vs. 1,132 g/cow) tended to be greater for cows on p.m. herbage. Rumenic acid and total PUFA in milk were greater for cows on a.m. herbage, whereas oleic acid was greater for cows on p.m. herbage. Estimates of urinary N excretion (g/d) did not differ among treatments, but urinary N concentrations were greater for cows on a.m. herbage (5.85 vs. 5.36 g/L). Initial herbage mass (HM) available (kg of DM/ha) and instantaneous HM disappearance rates (kg of DM/ha and kg of DM/h) did not differ, but fractional disappearance rates (0.56 vs. 0.74 per hour for a.m. vs. p.m., respectively) differed. Under the current conditions, timing of pasture strip allocation altered the herbage nutrient supply to cows; allocating a fresh strip of pasture later in the day resulted in moderate increases in milk and milk solids yields in late-lactation dairy cows. Conversely, a greater concentration of precursor FA in a.m. herbage resulted in a greater concentration of beneficial FA in milk, compared with cows on p.m. herbage.

Comparison of ultraviolet light-emitting diodes and low-pressure mercury-arc lamps for disinfection of water

Ultraviolet (UV) light-emitting diodes (LEDs) emitting at 260 nm were evaluated to determine the inactivation kinetics of bacteria, viruses, and spores compared to low-pressure (LP) UV irradiation. Test microbes were Escherichia coli B, a non-enveloped virus (MS-2), and a bacterial spore (Bacillus atrophaeus). For LP UV, 4-log10 reduction doses were: E. coli B, 6.5 mJ/cm(2); MS-2, 59.3 mJ/cm(2); and B. atrophaeus, 30.0 mJ/cm(2). For UV LEDs, the 4-log10 reduction doses were E. coli B, 6.2 mJ/cm(2); MS-2, 58 mJ/cm(2); and B. atrophaeus, 18.7 mJ/cm(2). Microbial inactivation kinetics of the two UV technologies were not significantly different for E. coli B and MS-2, but were different for B. atrophaeus spores. UV LEDs at 260 nm are at least as effective for inactivating microbes in water as conventional LP UV sources and should undergo further development in treatment systems to disinfect drinking water.

Distinct health behavior and psychosocial profiles of young adult survivors of childhood cancers: a mixed methods study

BACKGROUND

We used a mixed-methods approach to examine health behavior profiles of young adult cancer survivors and characterize related sociodemographic and psychosocial factors.

METHODS

We conducted a mail-based survey assessing sociodemographics, cancer treatment, health behaviors (e.g., tobacco use, physical activity), healthcare provider interactions, and psychosocial factors (e.g., Profile of Moods States [POMS]) among 106 young adult survivors from a southeastern cancer center and semi-structured interviews among a subset of 26.

RESULTS

A k-means cluster analysis using eight health behaviors yielded three distinct health behavior profiles: high risk (n = 25), moderate risk (n = 39), and low risk (n = 40). High risks had the highest current alcohol, tobacco, and marijuana use; physical activity; and number of sexual partners (p's < 0.001). They had higher symptoms of POMS tension-anxiety, depression-dejection, fatigue-inertia, and confusion-bewilderment (p's < 0.05). Moderate risks had lowest physical activity (p < 0.05) but otherwise had moderate health behaviors. Low risks had the lowest alcohol, tobacco, and marijuana use and fewest sexual partners (p's < 0.05). They had the lowest levels of tension-anxiety, depression-dejection, fatigue-inertia, and confusion-bewilderment (p's < 0.05). Qualitative interviews showed that cancer had a range of effects on health behaviors and variable experiences regarding how healthcare providers address these behaviors.

CONCLUSIONS

Assessing health behavior profiles, rather than individual health behaviors, is informative in characterizing young adult cancer survivors and targeting survivorship care.

IMPLICATIONS FOR CANCER SURVIVORS

Young adult cancer survivors demonstrate distinct health behavior profiles and are differentially impacted by the experience of cancer. Healthcare providers should be consistently intervening to ensure that survivors understand their specific health risks.

Abstract 139: Costs to Implement Components of Stroke Systems of Care Under the Paul Coverdell National Acute Stroke Program

Objective: During 2012-2015, the Centers for Disease Control and Prevention’s (CDC) Paul Coverdell National Acute Stroke Program (PCNASP) funded state health departments to improve the quality of stroke care in key clinical settings. The objective of this study was to assess costs for health departments and partners implementing PCNASP newly established programs.

Methods: We developed Excel-based data collection instruments to collect costs associated with implementing stroke systems of care from volunteer PCNASP-funded health departments. Nine PCNASP-funded health departments were eligible based on program characteristics, six of which agreed to participate; five focused on pre- and in-hospital stroke care, and one also included transitions to post-hospital settings. These health departments partnered with a total of 467 organizations in their six states (37 to 125 partners per state). We used an activity-based costing approach to allocate costs across primary program activities: data collection, linkage, and management; clinical guidance and expertise; quality improvement (QI); building and maintaining partnerships; program evaluation; and administration. We collected costs to the health departments paid directly by PCNASP funds, in-kind contributions from the health department, and in-kind contributions from partners. Four of the six health departments received in-kind contributions from select partners. We analyzed costs by resource category (labor; materials, travel, services, equipment; contracts, consultants; overhead) and program activities across three settings: pre-hospital, in-hospital, and post-hospital.

Results: Six health departments reported grant expenditures averaging $991,549 (ranging from $790,123 to $1,298,160) per health department over 36 months. Three of those health departments reported health department in-kind contributions averaging $374,439 (ranging from $5,805 to $1,394,097) for the same 36 months. Health departments reported greatest expenditures on labor (46%, ranging from 15% to 79%) and contracts and consultants (37%, ranging from 5% to 76%). Across program activities, health departments incurred costs for QI (37%, ranging from 17% to 60%); administration (19%, ranging from 7% to 39%); data (17%, ranging from 15% to 79%); partnerships (10%, ranging from 2% to 23%); clinical guidance (9%, ranging from 4% to 16%); and evaluation (8%, ranging from 4% to 15%). Four health departments collected in-kind contributions for 22 partners. Partners had average in-kind contributions of $373,211 (ranging from $1,040 to $1,421,729).

Conclusion: Results from this study highlight key cost drivers of implementing components of stroke systems of care. This study was the first to comprehensively document actual costs of implementing QI for stroke systems of care across multiple programs and can inform future planning efforts.

Abstract B55: Distinct health behavior and psychosocial profiles of young adult cancer survivors: A mixed methods study

Background: Young adult cancer survivors do not respond similarly to the experience of cancer. Thus, we investigated health behavior profiles of young adult cancer survivors and characterize associated sociodemographic and psychosocial characteristics.

Methods: A cross-sectional survey assessed sociodemographics, cancer treatment, health behaviors (e.g., alcohol use, tobacco use, physical activity [PA]), healthcare provider interaction, and psychosocial factors for 106 participants from a southeastern cancer center. In-depth semi-structured interviews with a sub-sample of 26 participants were conducted.

Results: For the quantitative study, participants were 22.13 (SD=3.18) years old; 51.0% (n=53) male; and 78.8% (n=82) White. They had the following diagnoses: Hodgkin's lymphoma (23.1%); non-Hodgkin's lymphoma (8.7%); Burkitt's lymphoma (3.8%); acute lymphoblastic leukemia (16.3%); acute myelogenous leukemia (2.9%); blastoma (5.8%); sarcoma (10.6%); thyroid cancer (9.6%); and other (19.2%). Average time since diagnosis was 8.42 (SD=5.73) years. A k-means cluster analysis indicated three distinct clusters based on health behavior profiles that corresponded to high, moderate, and low risk behaviors. The clusters differed significantly in relation to current alcohol use, binge drinking, tobacco use, marijuana use, PA, and number of sex partners (p's&lt;0.001). The High Risk group (n=25) had the highest current use of alcohol, tobacco, and marijuana and the most past-year sexual partners (p's&lt;0.001). However, they had the greatest PA (p&lt;0.001). The High Risk cluster was older than the Low Risk group but younger than Moderate Risk group, and gender composition was mostly male. Compared to the other groups, the High Risk were more likely to have significant depressive symptoms per the Patient Health Questionnaire – 9 item (p=0.052) and had the highest Profile of Moods States (POMS) scores for tension-anxiety (p=0.004), depression-dejection (p=0.018), fatigue-inertia (p=0.033), and confusion-bewilderment (p=0.022). The Moderate Risk group (n=39) had the lowest levels of PA (p&lt;0.001) but was not distinct regarding the other health behaviors. They were the oldest (p&lt;0.001), most likely to be female (p=0.005), were the most likely to be employed (p=0.012), were least likely to be on their parent's insurance (p=0.012), and had the most time lapse since their initial diagnosis (p&lt;0.001). This group also had the least depressive symptoms (p=0.052). The Low Risk group (n=40) reported the lowest current alcohol use, binge drinking, tobacco use, and marijuana use, as well as the lowest number of past-year sexual partners (p's&lt;0.001). This group was the youngest (p&lt;0.001), the most likely to be students (p=0.012), the most likely to be on public insurance (p=0.012), and the most recently diagnosed (p&lt;0.001). This cluster had the lowest POMS scores for tension-anxiety (p=0.004), depression-dejection (p=0.018), fatigue-inertia (p=0.033), and confusion-bewilderment (p=0.022). In qualitative interviews, participants reported that their experience with cancer decreased positively or negatively affected their health behaviors, and some reported no impact. Some participants reported minimal or no assessment or intervention related to substance use, physical activity, or nutrition. On the other hand, some reported that providers assessed and intervened on these health behaviors. Many participants expressed interest in having up-to-date information and education available through various reputable sources. Participants discussed a variety of communication channels and the need for expertise and reliability of the material presented.

Conclusions: Greater efforts should be made by providers to routinely and systematically examine substance use, PA, and nutrition as well as mental health and social support among this population. In addition, disseminable and cost-effective programs to support providers in doing so are needed.

Citation Format: Carla J. Berg, Kincaid Lowe, Cam Escoffery, Ann Mertens. Distinct health behavior and psychosocial profiles of young adult cancer survivors: A mixed methods study. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B55.

Physical Activity and Fruit and Vegetable Intake among Black and White Female College Students at Two- and Four-Year Colleges and Universities

OBJECTIVE

We compared fruit and vegetable (FV) intake, physical activity (PA), and overweight/ obesity among Black and White females attending two- and four-year colleges.

METHODS

We recruited 24,055 students at six colleges in the Southeast to complete an online survey, yielding 4840 responses (20.1% response rate). The current analyses focused on the 2276 Black and White females.

RESULTS

Binary logistic regression analyses indicated that recommended FV intake among White females was associated with greater extraversion (Odds Ratio [OR] = 1.05, 95% Confidence Interval [CI] 1.00, 1.11, p = 0.05) and greater conscientiousness (OR = 1.08, CI 1.02, 1.14, p = 0.01), whereas among Black females correlates included greater openness to experience (OR = 1.08, CI 1.01, 1.15, p = 0.03). Ordinal logistic regression analyses indicated that, among White females, greater PA was associated with attending a four-year college (Beta = 0.27, CI 0.01, 0.53, p = 0.04), whereas among Black females, correlates were with younger age (Beta = 0.01, CI 0.17, 0.03, p = 0.003) and greater emotional stability (Beta = 0.07, CI 0.01, 0.13, p = 0.02). Binary logistic regression analyses indicated that, among White females, being overweight or obese was associated with older age (OR = 1.08, CI 1.01, 1.16, p = 0.03), attending a two-year college (OR = 1.62, CI 1.22, 2.16, p = 0.001), and lower satisfaction with life (OR = 0.96, CI 0.94, 0.98, p = 0.002), whereas among Black females, being overweight or obese was associated with older age (OR = 1.87, CI 1.10, 1.28, p < 0.001).

CONCLUSIONS

Identifying factors related to obesity-related factors is critical in developing interventions targeting factors associated with overweight and obesity among Black and White females attending two- and four-year colleges. Moreover, understanding different college settings and the contextual factors associated with overweight/obesity is critical.

Sociodemographic, Psychosocial, and Health Behavior Risk Factors Associated with Sexual Risk Behaviors among Southeastern US College Students

Objectives

We examined correlates of 1) being a virgin; 2) drug or alcohol use prior to the last intercourse; and 3) condom use during the last intercourse in a sample of college students.

Methods

We recruited 24,055 students at six colleges in the Southeast to complete an online survey, yielding 4840 responses (20.1% response rate), with complete data from 4514.

Results

Logistic regression indicated that correlates of virginity included being younger (p < 0.001), male (p = 0.01), being White or other ethnicity (p < 0.001), attending a four-vs. two-year school (p < 0.001), being single/never married (p < 0.001), lower sensation seeking (p < 0.001), more regular religious service attendance (p < 0.001), lower likelihood of smoking (p < 0.001) and marijuana use (p = 0.002), and less frequentdrinking (p < 0.001). Correlates of alcohol or drug use prior to most recent intercourse including being older (p = 0.03), being White (p < 0.01), attending a four-year college (p < 0.001), being homosexual (p = 0.041) or bisexual (p = 0.011), having more lifetime sexual partners (p = 0.005), lower satisfaction with life (p = 0.004), greater likelihood of smoking (p < 0.001) and marijuana use (p < 0.001), and more frequent drinking (p < 0.001). Correlates of condom use during the last sexual intercourse including being older (p = 0.003), being female (p < 0.001), being White (p < 0.001), attending a two-year school (p = 0.04), being single/never married (p = 0.005), being homosexual or bisexual (p = 0.04), and a more frequent drinking (p = 0.001).

Conclusions

Four-year college attendees were more likely to be a virgin but, if sexually active, reported higher sexual risk behaviors. These nuances regarding sexual risk may provide targets for sexual health promotion programs and interventions.

Adults with intellectual disabilities and challenging behaviour: the costs and outcomes of in- and out-of-area placements

BACKGROUND

People with severe challenging behaviour are vulnerable to exclusion from local services and removal to out-of-area placements if locally available supported accommodation is insufficient to meet their needs. There are concerns about the high costs and potentially poorer outcomes of out-of-area placements but relatively little is known about how costs and outcomes compare with provision for a similar population placed locally.

METHODS

Costs, quality of care and a wide range of quality of life outcomes for 38 people with intellectual disabilities and challenging behaviour living in-area and 38 similar people living out-of-area were compared. The two groups were matched as far as possible on risk factors for out-of-area placement. The out-of-area group represented two-thirds of the total number of people who originated from the territory served by the largest specialist health service in Wales and were placed in residential settings at least 10 miles beyond its boundaries.

RESULTS

There was a mixed pattern of quality of care and quality of outcome advantages between the two types of setting, although in-area placements had a greater number of advantages than out-of-area placements. Unexpectedly, out-of-area placements had lower total costs, accommodation costs and daytime activity costs.

CONCLUSIONS

No overall conclusion could be reached about cost-effectiveness. A number of potential reasons for the differences in cost were identified. Although additional resources may be needed to provide in-area services for those currently placed out-of-area, government policy to provide comprehensively for those who want to live locally, irrespective of their needs, appears to be attainable.

Abstract P4-09-05: Long Term Follow-Up of Breast Cancer Patients of the Swedish Cancer Institute Breast Cancer Research Registry

Background: Since 1990 the Swedish Cancer Institute Breast Cancer Research Registry has accrued over 10,900 cases with a 92% follow-up rate. We analyzed the incidence of recurrence over time to evaluate the appropriate duration of our long term follow-up. Methods:

Patients with stages 1-3 disease were selected for study. Stages 0 and 4 disease, and neo-adjuvant treatment patients were excluded. The incidence and time to recurrence was compared with tumor grade [Bloom Richardson (BR) score], hormone receptor, HER2 status, stage, number of positive lymph nodes, surgery, radiation therapy, chemotherapy, hormone therapy and menopausal status. Results:

The recurrence rate was 7.8% (740/9455) of which 68% (500) occurred in the first 5 years, 24% (179) occurred between 5 and 10 years, and 8% (61) occurred after 10 years. Factors that had a significant (P&lt;0.05) relationship with the incidence of and time to recurrence were: stage, grade, hormone receptor status, number of positive lymph nodes, hormone therapy and radiation therapy. In the hormone receptor negative group, 15% (181/1205) recurred - 86% within 5 years, 12% between 5 and 10 years and 1.7% over 10 years. In the hormone receptor positive group, 7.3% (522/7201) recurred - 62% within 5 years, 28% between 5 and 10 years and 10% over 10 years. Of the patients with negative nodes, 4.7% (255/5405) recurred - 65% within 5 years, 27% within 5 to 10 years and 7.5% over 10 years. For the patients with 1 - 3 nodes positive, 12.6% (222/1769) recurred - 67% within 5 years, 24% between 5 and 10 years and 10% over 10 years. For 4-9 nodes positive, 25.3% (121/478) recurred - 79% within 5 years, 20% between 5 and 10 years and 6.6% over10 years. For greater than 10 nodes positive, 40.9% (92/225) recurred - 75% within the first 5 years, 20% between 5 and 10 years and 5.4% over 10 years. A BR score of 3-5 resulted in 2.0% (32/1574) recurrences - 63% within 5 years, 25% between 5 and 10 years and 13% over 10 years. A BR score of 6-7 resulted in 5.1% (131/2559) recurrences - 73% within 5 years, 26% between 5 and 10 years and 1.5% over 10 years. A BR score of 8-9 resulted in 11.3% (179/1581) recurrences - 89% within 5 years, 10% between 5 and 10 years and 0.6% over 10 years. Conclusion:

The incidence of recurrence and the rate of recurrence of breast cancer was greatest for tumors that were hormone receptor negative, had a high number of positive lymph nodes and were high grade (BR 8-9). The incidence of recurrence after 10 years was under 0.5% overall and under 1.0% for most groups. The exception was patients with over 10 nodes positive (2.2%). However, patients with low grade (BR 3-5), hormone receptor positive or 1-3 positive lymph nodes, or patients treated with total mastectomy without irradiation or hormone therapy had over 10% of their recurrences occur after 10 years. The old adage that after ten years one is cured does not apply to these low risk patients. Nor does it apply to the high risk patients although their outlook is markedly improved by 10 years.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-09-05.

Vacuolation of sensory ganglion neuron cytoplasm in rats with long-term exposure to organophosphates

Cytoplasmic vacuolation of sensory neurons has been reported to occur within the dorsal root ganglia in studies investigating various neuropathic conditions including the effects of neurotoxic chemicals. In this study, we investigated this lesion in adult (98-119 days old) male Long-Evans rats, after multiple exposures to two organophosphates (tri-ortho-tolyl phosphate [TOTP] and chlorpyrifos) and the modifying effects of concurrent corticosterone. Tri-ortho-tolyl phosphate was administered by gavage (75, 150, or 300 mg/kg) every other day between days 14 and 28 and between days 49 and 63, chlorpyrifos (60 mg/kg) was administered subcutaneously on days 7 and 42, and corticosterone was provided in the drinking water throughout the study at a concentration of 400 microg/mL. Although relatively uncommon, there was an increase in frequency of cytoplasmic vacuoles seen in treatment groups having multiple exposures to TOTP. They were characterized as peripherally located, single-limiting membrane-bound structures in the neuronal perikarya. There was no associated cell death, even when vacuoles were large. This is the initial report of an association of this change following exposure to neurotoxic organophosphates.

Kinematic differences between normal and low arched feet in children using the Heidelberg foot measurement method

The purpose of this study was to investigate the kinematics of normal arched and low arched feet in children and use this data to quantify the differences between the two foot types during walking gait. Multi-segment foot motion was measured, using the Heidelberg foot measurement method (HFMM), for 25 normal arched feet and 27 low arched feet in 9-12-year-old children. The kinematic differences in the foot between the two groups during walking were relatively small, except for the medial arch and forefoot supination angles. The magnitude of the medial arch angle was approximately 10 degrees greater in the low arched group than the normal arched group throughout the gait cycle. There was a significant difference found in the forefoot supination angle (p<0.03), relative to the midfoot, between the two groups at initial heel strike, and maximum and minimum values throughout the gait cycle. The values for the normal group were significantly higher in all these angles indicating that the forefoot of the low arched foot remains less pronated during the gait cycle. There was no significant difference in the motion of the rearfoot between the two foot types. The results of this study provide normative values for children's feet and highlight the mechanical differences in flexible flat feet in this age group. This data contributes to knowledge on foot kinematics in children and will be valuable for future research on the structure, function and potential treatment of the flexible flat foot.

Acceptability of blood and blood substitutes

Alternatives to donor blood have been developed in part to meet increasing demand. However, new biotechnologies are often associated with increased perceptions of risk and low acceptance. This paper reviews developments of alternatives and presents data, from a field-based experiment in the UK and Holland, on the risks and acceptance of donor blood and alternatives (chemical, genetically modified and bovine). UK groups perceived all substitutes as riskier than the Dutch. There is a negative association between perceived risk and acceptability. Solutions to increasing acceptance are discussed in terms of implicit attitudes, product naming and emotional responses.

Challenging behaviours: prevalence and topographies

BACKGROUND

Variations in reported prevalence of challenging behaviour indicate the need for further epidemiological research to support accurate planning of future service provision.

METHODS

All services providing for people with learning disabilities across seven unitary authorities, with a total population of 1.2 million, were screened to identify people with challenging behaviour. Interviews were conducted with primary carers to gain data on identified individuals' characteristics and support. Measures designed for a similar study conducted in Manchester University were incorporated to allow direct comparison with earlier findings, together with standardized tools to assess adaptive behaviour and social impairment.

RESULTS

In total, 4.5 (2.5-7.5) people per 10 000 population were rated as seriously challenging, representing 10% (5.5-16.8%) of the learning disability population; the most prevalent general form was other difficult/disruptive behaviour, with non-compliance being the most prevalent topography. The majority showed multiple behaviours and multiple topographies within each general behaviour category. Also identified were substantial numbers of additional people reported as presenting challenging behaviours at lower degrees of severity.

CONCLUSIONS

Prevalence rates for seriously challenging behaviours were comparable to those reported in the earlier studies, thus confirming previous findings. The prevalence of less serious challenging behaviour also has major clinical significance and emphasizes the need for enhanced understanding and skills among personnel within primary- and secondary-tier health, education and social care services, and for strengthening the capacity of community teams to provide behavioural expertise.

Predictors, costs and characteristics of out of area placement for people with intellectual disability and challenging behaviour

BACKGROUND

Out of area placements for people with challenging behaviour represent an expensive and often ineffective strategy for meeting the needs of this service user group.

METHODS

More than 800 agencies and service settings in a large area of South Wales were screened to identify children and adults with challenging behaviour against a number of defined operational criteria. Detailed data on identified individuals and the services they received were collected by interviewing key informants. Univariate and multivariate statistics were employed to identify predictors of out of area placement.

RESULTS

In total, 1458 people were identified. Full data were available for 901 participants, 97 of whom were placed out of area. Predictors of out of area placement included behaviours resulting in physical injury and exclusion from service settings, a history of formal detention under the mental health act, the presence of mental health problems, a diagnosis of autism and higher total score on the Adaptive Behaviour Scale. Out of area placements were typically of high cost, and associated with only limited evidence of improved service quality.

CONCLUSIONS

Identifying predictors for out of area placement can be used to highlight deficiencies in local services and individuals at increased risk of exclusion from local services.

Association of unmet needs for support services with medication use and adherence among HIV-infected individuals in the southeastern United States

Unmet needs for services, such as housing and psychiatric treatment, are relatively common among HIV-infected individuals; however, the effects of different types of unmet needs on health-care outcomes are not well understood. This study describes unmet psychosocial needs and their relationship with health-care outcomes among individuals receiving HIV care in the southeastern US (n=526). We used multivariate logistic regression to examine the association of seven categories of unmet needs with HIV medication use and adherence. Most participants (84.5%) reported at least one service need in the past year. Nearly half (47%) of participants with service needs reported that at least one need was not met. Participants with one or more unmet needs were less likely to be taking any HIV medications (p = 0.007) and reported poorer medication adherence (p=0.013). The specific unmet needs for benefits (including Social Security, health insurance and prescription coverage) (p = 0.006) and a support group (p=0.040) were associated with being less likely to be taking any HIV medications. Unmet need for mental health-related counseling was associated with poorer medication adherence (p=0.003). Study findings regarding the high level of unmet need and the association of unmet need with poorer outcomes illustrate the importance of interventions to address these needs.

A comparison of goal attainment scaling and the Canadian Occupational Performance Measure for paediatric rehabilitation research

PURPOSE

To investigate the relative utility of Canadian Occupational Performance Measure (COPM) (adapted for children) and Goal Attainment Scaling (GAS) as outcome measures for paediatric rehabilitation.

METHODS

A two-group pre-post design investigated the impact of a 3-month programme. Forty-one children with spastic hemiplegic cerebral palsy (mean 3.9 years; GMPM level 1; 21 boys, 10 girls) were randomized to occupational therapy only and occupational therapy plus one Botulinum Toxin A injection. The latter was considered a 'proven' intervention for the purpose of this instrumentation study. Intervention impact was investigated using GAS and COPM. Instrument sensitivity, convergent validity, goal/problem profiles and administration were evaluated.

RESULTS

Both instruments were sensitive to within group change and detected significant between group change. Likert scale coding for GAS scores was more sensitive than the traditional weighted GAS or COPM. Different constructs were measured by each instrument. COPM was more time efficient in training, development and administration.

CONCLUSION

Study aim, logistic and resource factors should guide the choice of COPM and/or GAS instruments as both are sensitive to change with a proven intervention and both evaluate different constructs.

Treatment and management of challenging behaviours in congregate and noncongregate community-based supported accommodation

OBJECTIVES

To compare the nature and prevalence of use of procedures employed to treat and manage challenging behaviours across two approaches to providing community-based supported accommodation for people with intellectual disabilities (ID) and severe challenging behaviour: noncongregate settings where the minority of residents have challenging behaviour, and congregate settings where the majority of residents have challenging behaviour.

SETTING

Community-based supported accommodation for people with ID and challenging behaviour.

DESIGN

Longitudinal matched groups design.

MAIN OUTCOME MEASURES

The nature and prevalence of use of procedures employed to treat and manage challenging behaviours. Observed and reported severity of challenging behaviours.

RESULTS

Both types of settings were associated with low prevalence of use of behavioural technologies for the reduction of challenging behaviour (less than 15% of participants). In contrast, high proportions of participant received antipsychotic medication in both noncongregate (56%) and congregate (80%) settings. Congregate settings were associated with the increased use of physical restraint as a reactive management strategy, with over half of participants being in receipt of physical restraint by two or more members of staff.

DISCUSSION

Changes in reported and observed challenging behaviour over a 10-month period were slight. The use of evidence-based behavioural technologies for the reduction of challenging behaviour may have led to better outcomes.

Characterisation of the expression of a novel constitutive maize promoter in transgenic wheat and maize

A novel constitutive promoter from the maize histone H2Bgene was recently identified. In this study, we characterised H2B promoter activity in both wheat and maize tissues using the gusA reporter gene and two synthetic versions of the pat (phosphinothricin acetyl transferase) selectable marker gene, namely mopat and popat. Analyses of transgenic plants showed that the H2B promoter is able to drive the expression of gusA to strong, constitutive levels in wheat and maize tissues. Using an H2B:mopat construct and phosphinothricin selection, we recovered transgenic wheat plants at efficiencies ranging from 0.3% to 7.4% (mean 1.6%), and the efficiency of selection ranged from 40% to 100% (mean 77.7%). In another application, H2B was combined with the maize Ubi-1 or the maize Adh-1 intron to drive the expression of mopat and popat. Transformation efficiencies with the Ubi-1 intron were between 1.4- to 16-fold greater than with the Adh-1 intron. However, the use of either of the introns was necessary for the recovery of transgenic plants. Mopat gave higher transformation efficiencies and induced higher levels of PAT protein in maize tissues than popat.

Responsiveness to staff support: evaluating the impact of individual characteristics on the effectiveness of active support training using a conditional probability approach

BACKGROUND

Active support training was fully conducted in 38 community houses accommodating 106 adults with intellectual disabilities (ID; group 1), but not in a further 36 accommodating 82 adults with ID (group 2). The aims of the present study were to analyse whether staff became more effective in supporting resident activity after the implementation of active support, and whether there was evidence of differential responsiveness by people with differing status in relation to adaptive behaviour, psychiatric diagnosis, challenging behaviour or autism.

METHODS

Observations of staff:resident interaction and resident engagement in activity were taken before and after active support training. Changes in Yule's Q statistics, indicating the likelihood that resident engagement in activity followed staff giving residents verbal instruction or non-verbal assistance, were compared for the two groups. In addition, changes in similar statistics were compared for residents within group 1: (1) with Adaptive Behaviour Scale (ABS) scores above and below 180; and (2) with and without severe challenging behaviour, the triad of social impairments and mental illness.

RESULTS

Yule's Q for engagement given non-verbal assistance significantly increased post-training among group 1, but not among group 2. Similar significant increases were found among group 1 residents with ABS scores below 180 without challenging behaviour, with and without the triad of social impairments, and without mental illness, but not with an ABS score above 180, with challenging behaviour and with mental illness.

CONCLUSION

The present analysis reinforces previous studies on the effectiveness of active support training for adults with more severe ID (i.e. with ABS scores below 180). Active support was as effective for people with the triad of social impairments as for those without it. However, the effectiveness of support offered to people with challenging behaviour or mental illness did not significantly increase.

The adaptive behavior scale-residential and community (part I): towards the development of a short form

A potential 24-item short form (SABS) of the 73-item Adaptive Behavior Scale-Residential and Community (Part I) (ABS-RC2; Nihira et al., 1993a, b) was developed, based on data from two diverse UK samples of adults with intellectual disabilities living in residential services (n = 560 and 254). SABS factor and total scores showed good internal reliability in both samples (alpha 0.89-0.98), and were highly correlated with their full ABS-RC2 Part I equivalents (r = 0.97-0.99). Regression equations were calculated for SABS factor and total scores against their full ABS-RC2 Part I equivalents. Levels of agreement between predicted quartile scores (derived from the regression equations) and actual full ABS-RC2 Part I quartile scores were high (kappa 0.75-0.89; percentage agreement 82%-92%). It is concluded that the SABS is a potentially useful research tool, although further work is clearly needed to establish the reliability and cross-cultural validity of the instrument.

Evaluation of the dissemination of active support training in staffed community residences

Our aim was to replicate Active Support, a staff training intervention designed to increase the assistance given to adults with severe mental retardation living in community residences in order to increase their participation in activities. Training was conducted in 38 residences, involving 303 staff members and 106 persons with mental retardation. Active Support resulted in significant increases in assistance and engagement in activity. Significant correlations between participant abilities, receipt of assistance, and levels of engagement were found. Active Support was found to be of greater benefit to people with lower adaptive behavior and to have a diminishing value for people with higher adaptive behavior, implying that its implementation should be matched to the support needs of residents.

Attitudinal effects of degrading themes and sexual explicitness in video materials

This study examined the independent and interactive effects of sexual explicitness and degrading themes toward women on mens' attitudes following exposure to video presentations of male-female interactions. Subjects were 83 male college students who viewed video vignettes under one of four stimulus conditions: (a) sexually explicit/degrading, (b) sexually explicit/nondegrading, (c) nonexplicit/degrading, and (d) nonexplicit/nondegrading. Results revealed that men exposed to degrading material, regardless of explicitness, were significantly more likely to express attitudes supportive of rape, while explicitness had no significant main or interactive effect on these attitudes. Further, the interaction of explicitness with degradation was found to impact scores on a measure of sexual callousness. Theoretical and clinical implications of these findings are discussed.

The effectiveness of staff support: evaluating active support training using a conditional probability approach

Active Support, a package of procedures which includes activity planning, support planning, and training on providing effective assistance, was introduced in five community residences serving 19 adults with severe mental retardation following a multiple baseline design. Real-time observational data were collected on the level of assistance residents received from staff and their engagement in activity. Active Support was shown in a companion paper (Jones et al., 1999) to increase the levels of assistance residents received and their engagement in activity. Increased assistance was particularly experienced by the behaviorally less able and the disparity in activity between the more and less able was reduced. In the analysis presented here, the effectiveness of assistance was evaluated before and after Active Support training by calculating the likelihood of engagement occurring given the occurrence of assistance. This likelihood was represented by the statistic, Yule's Q. Yule's Q significantly increased following Active Support training, an increase that was maintained at follow-up. The increased effectiveness of assistance was related to other research findings on the relationship between staff: resident interaction patterns and resident behavior.

Opportunity and the promotion of activity among adults with severe intellectual disability living in community residences: the impact of training staff in active support

Active support, a package of procedures which includes activity planning, support planning and training on providing effective assistance, was introduced in five community residences serving 19 adults with severe intellectual disability following a multiple baseline design. The residents were directly observed to ascertain the level of assistance they received from staff and their engagement in activity. The introduction of active support increased the levels of assistance residents received, their engagement in domestic activities and their total engagement in activity. The intervention did not affect the level of social engagement. Across individuals, increases in assistance and engagement in activity were significantly and positively correlated. Both were significantly inversely related to resident adaptive behaviour. At baseline, staff gave more attention and assistance to people who were behaviourally more able. After the introduction of active support, receipt of attention was unrelated to adaptive behaviour and the behaviourally less able received more assistance. The disparity in activity between the more and less able was reduced. Gains were maintained in the majority of houses.

Effect of fly control on trachoma and diarrhoea

BACKGROUND

Domestic flies are accepted vectors of diarrhoea, but their role in trachoma transmission has never been quantified and no study has shown that fly control decreases the prevalence of trachoma. We assessed the effect of fly control on public health in a pilot study in Gambian villages.

METHODS

We studied two pairs of villages--one pair in the 1997 wet season, and one pair in the 1998 dry season. For each pair, deltamethrin was sprayed for 3 months to control flies in one village whilst the other was used as a control. Fly populations were monitored with traps. We surveyed trachoma at baseline and at 3 months, and collected daily data on diarrhoea in children aged between 3 months and 5 years.

FINDINGS

Fly control decreased numbers of muscid flies by around 75% in the intervention villages compared with controls. Trachoma prevalence was similar at baseline (wet season, prevalence in intervention village 8.8% vs control 12.2%; dry season, 18.0% vs 16.0%), but after 3 months of fly control there were 75% fewer new cases of trachoma in the intervention villages (wet season 3.7% vs 13.7%; dry season 10.0% vs 18.9%; rate ratio and relative risk of pooled data 0.25 [adjusted 95% CI 0.09-0.64], p=0.003). There was 22% less childhood diarrhoea in the wet season (14% vs 19%, period prevalence ratio 0.78 [0.64-0.95], p=0.01), and 26% less diarrhoea in the dry season (6% vs 8%; 0.74 [0.34-1.59], p=0.60) compared with controls.

INTERPRETATION

Muscid flies are important vectors of trachoma and childhood diarrhoea in The Gambia. Deltamethrin spray is effective for fly control and may be useful for reducing trachoma and diarrhoea in some situations, but further research on sustainable fly-control methods is needed.

Service support to people in Wales with severe intellectual disability and the most severe challenging behaviours: processes, outcomes and costs

A survey of people with severe intellectual disability and the most severe challenging behaviour in Wales identified five adults living in family homes, 17 in new specialist community housing and 19 in traditional services. With the omission of two people from the latter group and with a restricted collection of data for people living in the family home, the present study explored service input, outcome and costs across the three setting types. Process and outcome indicators for the family home group, who received little service input, were better than those for the traditional service group, although less good than those for the community house group. The specialist community home model produced significant gains over the traditional services in virtually all areas. Across the residential data set as a whole, there was no association between staff:resident ratios and severity of disability or between costs and severity of disability. This was largely true of the service types separately. There was a relationship between costs and service quality. However, this association was underpinned by gross differences between community houses and traditional settings. Costs, processes and outcomes ceased to be related when the two residential types were considered separately. Although higher costs of new community services compared to traditional services may be set against improved outcomes, high costs within the former could not be related to benefit. Outcome indicators were generally related to each other, suggesting that high quality in one sense was matched by high quality in other senses. Outcome was significantly associated with the ability of residents. Outcome indicators also tended to be related to observed staff performance, which was independent of resident ability. Therefore, outcome may be considered as dually determined by differences in resident ability and in what staff did.

The characteristics and residential situations of people with severe intellectual disability and the most severe challenging behaviour in Wales

A total population study of people in Wales with severe intellectual disability and the most severe challenging behaviour was undertaken to identify their characteristics, and the nature of their residential arrangements and service support. Forty-one participants were identified: five living in family homes, 17 in community housing, 17 in hospitals and two in hostels. The family home group had slightly higher adaptive behaviour scores than residents in community housing. Both groups had significantly higher scores than the hospital and hostel residents combined. Assessments of challenging behaviour showed the groups to be similar and to have a considerable range and extent of severely problematic behaviour. Co-occurrence of several forms of frequent severe problem behaviour was the norm and there was a marked association with social impairment. The five people living in their family homes had nominated service keyworkers, but reported professional input was low. The residential situations comprised two main service types: (1) traditional services, which were characterized by large living unit and facility size, atypical architectural design, relative isolation from the community, a greater level of buildings adaptations, low staff:resident ratios, a relatively high percentage of qualified staff, and a relative absence of systematic approaches to goal planning and structured activity; and (2) new community houses, which were characterized by small size, domestic design, location within the community, a lower level of buildings adaptations, much higher staff:resident ratios, and less emphasis on qualified staff but a greater emphasis on systematic working methods. Community settings were similar in having 'specialist' resident groupings based on challenging behaviour or conditions like autism in which challenging behaviours are common. A policy to provide for people with these characteristics being resettled from traditional settings in this way seems to have been established.

EMLA cream effectively reduces the pain of spinal needle insertion

BACKGROUND AND OBJECTIVE

EMLA cream is an effective topical anesthetic, which is commonly used for analgesia during venous cannulation in the pediatric population. This study was designed to compare the efficacy of EMLA cream with that of infiltration with lidocaine in relieving the pain associated with administration of spinal anesthesia.

METHODS

The patient population consisted of 41 ASA status I and II women scheduled for postpartum tubal ligation. Spinal anesthesia was administered with a 25-gauge spinal needle via a 20-gauge introducer. The patients were randomly allocated to receive either EMLA cream for a minimum of 30 minutes or infiltration with 3 mL of 1% lidocaine prior to spinal needle insertion. Pain during spinal needle insertion was assessed immediately after each procedure by a 10-cm visual analog scale.

RESULTS

Pain scores were significantly lower in the EMLA group (mean, 1.5) than in the lidocaine group (mean, 3.52) (P < .001). The number of patients satisfied with the method of analgesia was significantly higher in the EMLA than in the lidocaine group (90% vs 55%, P < .05).

CONCLUSION

EMLA cream is an effective alternative to lidocaine infiltration for analgesia during the administration of spinal anesthesia when using a 25-gauge spinal needle via a 20-gauge introducer. Application of EMLA cream for at least 30 minutes prior to spinal needle insertion is adequate to provide good analgesia during needle insertion.

Challenging behaviour: the effectiveness of specialist support teams

Two specialist community services for people with learning disabilities and challenging behaviour were evaluated over approximately 3 years. Intervention effectiveness was assessed with respect to changes in subjects' skills, challenging behaviours, mental health and quality of life, and to changes in staff morale. Subjects assessed as having challenging behaviour but not referred for specialist input were also studied. Comparison of changes in referred and non-referred samples over time showed minor differences only, indicating little intervention effect and demonstrating stability in the comparison sample. Analysis of the two services separately yielded different results. Positive client change was evident with respect to one service, whilst little change was noted with respect to the other. There was little evidence to suggest that either service had any effect on staff morale. Differences between the two services in terms of structure, staffing characteristics and operational policies are discussed as possible factors in the differential results obtained. A major issue raised by the study concerns the quality of settings from which the subjects were referred for specialist support. This is discussed as a factor which may limit the effectiveness of specialist input.