Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Evaluation of a Deep Image to Image Network (DI2IN) Auto-Segmentation Algorithm across a Network of Cancer Centers

PURPOSE/OBJECTIVE(S)

Due to manual OAR contouring challenges, various automatic contouring solutions have been introduced. Historically, common clinical auto-segmentation algorithms used were atlas based, which required maintaining a library of self-made contours. Searching the collection was computationally intensive and could take several minutes to complete. Deep learning approaches have shown significant benefits compared to atlas-based methods in improving segmentation accuracy and efficiency in auto-segmentation algorithms. This work represents the first multi-institutional study to describe and evaluate an AI algorithm for auto-segmentation of organs at risk (OARs) based on a deep image-to-image network (DI2IN).

MATERIALS/METHODS

The AI-Rad Companion Organs RT (AIRC) algorithm (Siemens Healthineers, Erlangen, Germany) uses a two-step approach for segmentation. In the first step, the target organ region in the optimal input image is extracted using a trained Deep Reinforcement Learning network (DRL), which is then used as input to create the contours in the second step based on DI2IN. The study was initially designed as a prospective single-center evaluation. The automated contours generated by AIRC were evaluated by three experienced board-certified radiation oncologists using a 4-point scale where 4 is clinically usable and 1 requires re-contouring. After seeing favorable results in a single-center pilot study, we decided to expand the study to 6 additional institutions, encompassing 8 additional evaluators for a total of 11 physician evaluators across 7 institutions.

RESULTS

One hundred fifty-six patients and 1366 contours were prospectively evaluated. The 5 most commonly contoured organs were the lung (136 contours, average rating = 4.0), spinal cord (106 contours, average rating = 3.1), eye globe (80 contours, average rating = 3.9), lens (77 contours, average rating = 3.9), and optic nerve (75 contours, average rating = 4.0). The average rating per evaluator per contour was 3.6. On average 124 contours were evaluated by each evaluator. 65% of the contours were rated as 4 and 31% were rated as 3. Only 4% of contours were rated as 1 or 2. 33 organs were evaluated in the study, with 19 structures having a 3.5 or above average rating (ribs, abdominopelvic cavity, skeleton, larynx, lung, aorta, brachial plexus, lens, eye globe, glottis, heart, parotid glands, bladder, kidneys, supraglottic larynx, submandibular glands, esophagus, optic nerve, oral cavity) and the remaining organs having a rating of 3.0 or greater (female breast, proximal femur, seminal vesicles, rectum, sternum, brainstem, prostate, brain, lips, mandible, liver, optic chiasm, spinal cord, spleen). No organ had an average rating below 3.

CONCLUSION

AIRC performed well with greater than 95% of contours accepted by treating physicians with no or minor edits. It supported a fully automated workflow with the potential for time savings and increased standardization with the use of AI-powered algorithms for high quality OAR contouring.

Using Scorecards to Tune Ethos Directive Templates: An ARTIA Cervix Dosimetric Planning Study

PURPOSE/OBJECTIVE(S)

The Adaptive Radiation Therapy Individualized Approach (ARTIA) Cervix clinical trial uses predefined clinical directive templates (CDT) combined with RapidPlan DVH estimations (DVHe) to guide plan optimization in the Ethos treatment planning system. The dosimetric scorecard tool (DST) quantifies improvements in plan quality. This is the first study to utilize the DST to tune an Ethos CDT to improve resulting plan quality.

MATERIALS/METHODS

Iterative replanning was used to modify the draft CDT (CDT-1) in Ethos to generate a new CDT (CDT-2) that maximized the clinical consensus scorecard's total score compared toCDT-1. CDT-2 was established, and resulting plans were compared with and without a DVHe. Additional fixed field IMRT beam geometries were compared between CDT-1 and CDT-2, both with DVHe. After obtaining favorable results when comparing CDT-1 verses CDT-2 for two test cases, 10 additional cases were retrospectively identified and tested.

RESULTS

For the initial test cases, CDT-2 decreased OAR doses without compromising PTV coverage (No DVHe). While both plans met the protocol target guidelines and OAR constraints, the scorecard was able to quantify the improvement with CDT-2 on a test case with a score of 166.1 (78.7%) vs CDT-1, 163.87 (77.6%). When CDT-2 was combined with the DVHe, it still marginally outperformed CDT-1: 168.73 (76%) versus 166.13 (74.8%). Plan quality was further improved by increasing the total number of fields to 19. Combining CDT-2 and DVHe with a 19-field geometry resulted in the greatest benefit at 184.6 (83.2%). This scored higher than the ARTIA-Cervix defined delivery technique of CDT-1 and DVHe, with a 9-field geometry 166.1 (74.8%). The study was expanded to a separate analysis on 10 new cases. The 19-field approach was superior for all 10 cases and CDT-2 achieved a higher score in 7/10 cases. When comparing 9 versus 19 fields, the total optimization and calculation time increased by an average of 1.9 minutes while the beam delivery time increased by an average of 2.8 minutes (+/- 0.1). The average MU/field was 174.3 (total 1568.3) and 129.9 (total 2468) for 9 and 19 fields, respectively. Two test plans were re-optimized and calculated with Ethos 1.1 maintenance release (MR) 1 with both 9 and 19 fields. For case 1, MR 1 resulted in an 8.4% and 6.9% decrease in MU and scored -0.6% and +0.5% for 9 and 19 fields, respectively. For case 2, MR 1 resulted in a 0.8% and 3.1% decrease in MU and scored -3.4% and -0.3% for 9 and 19 fields, respectively.

CONCLUSION

The scorecard allows for easy evaluation of the dosimetric impact of other planning parameters (beam arrangements and use of DVHe) to identify the best approach. Using a scorecard to finely-tune a CDT is expected to improve planning efficiency, decrease intra-institutional plan quality and variability, improve the average calculated plan quality and benefit CBCT-guided ART.

Pelvic Nodal Auto-Segmentation Using a Deep Image to Image Network (DI2IN) Auto-Segmentation Algorithm: Comparing Male vs. Female Pelvis

PURPOSE/OBJECTIVE(S)

Deep Learning approaches have shown significant benefits compared to atlas-based methods in improving segmentation accuracy and efficiency in auto-segmentation algorithms. The AI-Rad Companion Organs RT pelvic nodal auto-segmentation feature was trained and developed for use in the male pelvis. There is no real-world data on its usability in male pelvis and whether it can be used for female pelvic nodal anatomy. This work represents the first multi-institutional study to describe and evaluate an AI algorithm for auto-segmentation of the pelvic nodal region in female patients based on a deep image-to-image network (DI2IN).

MATERIALS/METHODS

The AIRC algorithm uses a two-step approach for segmentation. In the first step, the target organ region in the optimal input image is extracted using a trained Deep Reinforcement Learning network (DRL), which is then used as input to create the contours in the second step based on DI2IN. We retrospectively evaluated AIRC pelvic nodal auto-segmentation in both male and female patients treated at our network of institutions. The automated pelvic nodal contours generated by AIRC were evaluated by one board-certified radiation oncologist, specializing in prostate and gynecologic malignancies. A 4-point scale was used, where 4 is clinically usable and 1 requires re-contouring. Pelvic nodal regions included the right and left side of the common iliac, external iliac, internal iliac, obturator and midline presacral nodes. A chi-squared test was then used to compare the scores of male and female pelvic nodal cases.

RESULTS

Fifty-two female and 51 male patients were included in the study, representing a total of 468 and 447 pelvic nodal regions, respectively. 96% (450 pelvic nodal contours) and 99% (443 pelvic nodal contours) required no or minor edits for female and male patients, respectively (p = 0.004). The right internal iliac was the only nodal group with a statistically significant difference between female (92% requiring no or minor edits) and male (100% requiring no or minimal edits) patients, p = 0.04. The percentage of patients requiring no, or minor edits was 87% (45 patients) and 92% (47 patients) for female and male patients, respectively (p = 0.36).

CONCLUSION

AIRC pelvic nodal auto-segmentation performed very well in both male and female pelvic nodal regions, with the male pelvic nodal regions performing better especially in the right internal iliac nodal group. It is usable in female pelvic nodal regions, with 96% of contours requiring no or minor edits. As auto-segmentation becomes more widespread, it may be important to have equal representation from all genders in training and validation of auto-segmentation algorithms.

Social Media-based Parenting Program for Women With Postpartum Depressive Symptoms: An RCT

OBJECTIVES

To test effects of a social media-based parenting program for mothers with postpartum depressive symptoms.

METHODS

We conducted a randomized controlled trial from December 2019 to August 2021 of a parenting program using Facebook. Women with mild-to-moderate depressive symptoms (Edinburgh Postnatal Depression Scale [EPDS] 10-19) were randomized to the program, plus online depression treatment or depression treatment alone for 3 months. Women completed the EPDS monthly and the Parent-Child Early Relational Assessment, Parenting Stress Index-Short Form, and Parenting Sense of Competence pre- and postintervention. Differences among groups were assessed using intention-to-treat analysis.

RESULTS

Seventy-five women enrolled and 66 (88%) completed the study. Participants were predominantly Black (69%), single (57%), with incomes <$55 000 (68%). The parenting group reported a more rapid decline in depressive symptoms than the comparison group (adjusted EPDS difference, -2.9; 95% confidence interval, -4.8 to -1.0 at 1 month). There were no significant group X time interactions for the Parent-Child Early Relational Assessment, Parenting Stress Index-Short Form, or Parenting Sense of Competence scores. Forty-one percent of women sought mental health treatment for worsening symptoms or suicidality. Women in the parenting group who exhibited greater engagement or reported mental health treatment had greater parenting responsiveness.

CONCLUSIONS

A social media-based parenting program led to more rapid declines in depressive symptoms but no differences in responsive parenting, parenting stress, or parenting competence relative to a comparison group. Social media can provide parenting support for women with postpartum depressive symptoms, but greater attention to engagement and treatment access are needed to improve parenting outcomes.

Dual-chamber paced patients without high-degree AV block at baseline are at higher risk of atrial arrhythmias when inappropriately paced in the right ventricle: a sub-analysis of the EMERALD study

Background/Introduction

Unnecessary right ventricular pacing (RVP) can have deleterious effects including an increased risk of atrial arrhythmia (AA) and heart failure during follow-up (FU) in dual-chamber (DR) paced patients. While previous studies have shown that these increased risks occur with RVP&gt;40%, the EMERALD Study demonstrated an increased risk for RVP&gt;1%. Few data exist on the interaction between the amount of RVP and the presence/absence of high-degree atrio-ventricular block (AVB) as a pacing indication at baseline.

Purpose

The EMERALD (AssEssment of CoMorbiditiEs & Atrial ArRhythmiA Burden In DuaL-Chamber PaceD Patients) Study was a real-world registry designed to assess the impact of RVP burden on the risk of developing persistent/permanent AA (Pers-AA) over 2-year FU. The primary endpoint was the difference in Pers-AA in subjects with high (&gt;40%) and low (&lt;40%) RVP. This sub-analysis aimed to identify the interaction between RVP and the presence/absence of high-degree AVB at baseline in relation to the incidence of Pers-AA.

Methods

EMERALD was a non-interventional, prospective, multi-center registry conducted at 186 centers in 12 countries. Enrolled subjects were implanted with a DR pacemaker according to ESC or ACC/AHA/HRS guidelines. Subjects were excluded if they had a history of Pers-AA. Devices could be implanted as de-novo, replacement or upgrade therapy. Programming was left to the investigators' discretion. Subjects were followed for at least 24 months. Pers-AA was defined as: &gt;22 h/day of AA for &gt;7 consecutive days; Pers-AA diagnosed during any FU visit; AA-related ablation or cardioversion carried out in the FU period. We compared the incidence of Pers-AA between subjects with (n=1529) and without (n=1948) high-degree AVB as a baseline pacing indication.

Results

Eligible FU data were available for n=3477 subjects. The overall population was nearly evenly split - High RVP (47.7%) and Low RVP (52.3%). In the High RVP group, 11.7% experienced at least one Pers-AA episode versus 9.1% in the Low RVP group (p=0.006). In this sub-analysis, the prevalence of RVP&gt;40% was higher in patients with high-degree AVB at baseline (74% vs 26%). Although the incidence of Pers-AA was similar in the group with high-degree AVB at baseline (High RVP 8.7% vs Low RVP 7.4%), in the group without high-degree AVB at baseline, those with High RVP developed a significantly higher incidence of Pers-AA (High RVP 18.2% vs Low RVP 9.5%, p value for interaction 0.0275; Figure 1). An analysis with a newly identified RVP threshold of 1% confirmed a high incidence of Pers-AA only in the group without high-degree AVB at baseline (18% vs 3.5%, p value for interaction 0.2265; Figure 2).

Conclusions

The baseline pacing indication sub-analysis of the EMERALD Study shows that patients without high-degree AVB as a baseline indication are at highest risk of Pers-AA. Efforts should be made to avoid any unnecessary RVP in this subgroup of patients.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): MicroPort CRM (Clamart, France)

Using a co-designed, self-delivered, Avatar-based patient discharge education application to improve acute coronary syndrome patient knowledge

Background

30-day rehospitalisation following heart event among acute coronary syndrome (ACS) patients remains high and is largely contributed by poor disease-related knowledge and self-management, especially in the disadvantaged patient groups such as those with low education levels and inadequate health literacy. Traditional patient education methods fail to address these issues.

Purpose

This study aimed to test a unique consumer co-designed discharge education application (app) on patients' knowledge and its acceptability.

Methods

ACS patients (unstable angina, non-STEMI or STEMI) were recruited from Royal Adelaide Hospital at South Australia during admission, provided with the app via tablet for one-month self-delivered education. The app has undergone a rigorous development process with the substantial engagement of consumers (Figure 1). App content includes the Heart Foundation Six Steps to Cardiac Recovery including disease-related knowledge, risk factor management, and ACS responses, assessed at baseline, followed by first use at discharge and one month later. Patients and cardiac nurses rated the acceptability of the app.

Results

Among 22 Participants 81.8% were male (n=18), with a mean age of 59.7 (10.3) years, 45.5% (n=10) had not completed high school and nearly a quarter of the participants had marginal or below marginal health literacy. The diagnosis included STEMI (n=16, 72.7%) and non-STEMI (n=5, 22.7%). The majority of participants underwent percutaneous coronary intervention (PCI) (n=21, 95.5%)

Significant improvements were observed for overall coronary artery disease knowledge at one month (p=0.003) and the exercise and nutrition domains at discharge (p=0.029; p&lt;0.001) and one month (p=0.02; p=0.003) (Figure 2). Significant improvements were also observed for ACS knowledge and beliefs at discharge (p=0.008; p=0.038) and one month (p&lt;0.001; p=0.025) when ACS response attitude was also significantly improved at one month (p=0.036). Overall acceptability was high at 7.7/10 (n=22 nurses) and 8.3/10 (patients). The participants described the app as `clear, simple, easy to understand, as well as stimulating and interactive, better than a live person'.

Conclusion

This novel, self-delivered Avatar-based ACS discharge education App has the potential to provide discharge education for ACS patients even for those who have low education levels or inadequate health literacy. Results need to be confirmed in a randomised controlled trial.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The National Heart Foundation Australia

Clinical impact of “minimal” right ventricular pacing on atrial arrhythmias: results from the prospective multi-center worldwide EMERALD study

Background/Introduction

Unnecessary right ventricular pacing (RVP), typically the result of pacing forced by the atrio-ventricular delay (AVD), can have deleterious effects such as atrial arrhythmias (AA) and heart failure (HF). Previous studies have shown that these increased risks occur when unnecessary RVP exceeds 40%, leading to the development of pacing modes to reduce the amount of unnecessary RVP and minimize these risks.

Purpose

The EMERALD (AssEssment of CoMorbiditiEs & Atrial ArRhythmiA Burden In DuaL-Chamber PaceD Patients) Study was a real-world registry designed to assess the impact of RVP burden on the risk of developing AA. The primary endpoint was the difference in incidence of persistent/permanent AA in subjects with high (&gt;40%) and low (&lt;40%) RVP.

Methods

EMERALD was a non-interventional, prospective, observational, multi-center registry conducted at 186 centers in 12 countries. The study enrolled subjects without a previous history of persistent or permanent AA implanted with a dual-chamber (DR) pacemaker according to ESC or ACC/AHA/HRS guidelines. Devices could be implanted as de-novo therapy, generator replacement or an upgrade in therapy. All implanted devices were approved for commercial use by local regulatory authorities. Programming was left to the investigators' discretion. Subjects were followed for at least 24 months. Persistent/permanent AA was defined as: a) &gt;22 hours/day of AA for &gt;7 consecutive days; b) permanent/persistent AA diagnosed during any follow-up visit; c) an AA-related ablation carried-out; d) a cardioversion performed during any follow-up visit.

Results

Eligible follow-up data were available for n=3477 subjects with a RVP value. The population was nearly evenly split between High RVP (47.7%) and Low RVP (52.3%). In the High RVP group, 11.7% fulfilled at least one criterion for persistent/permanent AA versus 9.1% in the Low RVP group (p=0.006). The primary endpoint was met. A reanalysis of the data was performed first looking at quartiles of %RVP. Based on this, the threshold of RVP was changed from 40% to 1% (High RVP&gt;1%; Low RVP&lt;1%). Using this new RVP threshold, 13.1% of patients in the High RVP group fulfilled at least 1 criterion for persistent/permanent AA versus 3.4% in the Low RVP group (p&lt;0.0001).

Conclusions

The EMERALD Study confirmed the results of previous studies showing that limiting unnecessary RVP to &lt;40% is beneficial in reducing the risk of AA in unselected DR pacemaker patients. Moreover, it showed for the first time that even small amounts of unnecessary RVP (&gt;1%) significantly increases the risk of AAs, underlining the need to target very low RVP with efficient modes to reduce RVP.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): MicroPort CRM (Clamart, France)

176 A Retrospective Analysis of Non-Muscle Invasive Bladder Cancer (NMIBC) Follow-Up Using Flexible Cystoscopy and the Role of the Charlson Co-Morbidity Index (CCI) in Improving Follow Up

Aim

1. A retrospective analysis of NMIBC follow-up using flexible cystoscopy during COVID-19.

2. Charlson Co-Morbidity Index (CCI) as a method of improving follow up.

Method

Online patient records were reviewed for 153 patients who attended Ayr University Hospital between 01/02/2020 and 01/05/ 2020 for check cystoscopy. We recorded the patients risk category and the number of months lapsed since their previous scope. Follow up schedules were compared with current NICE guidelines. CCI for each patient was calculated.

Results

The majority of the patients sampled had follow up adherent to NICE guidelines. Deviations were secondary to ‘allocation to an incorrect follow up schedule’, ‘late follow up’ and ‘non-compliance’. Incorrect allocation was due to both human error and clinical judgement. Clinical judgement included frail patients thought not to benefit from their current intensive schedule and patients with areas of suspicion warranting an earlier check. CCI scores ranged from 2–11. 25% of had a Charlson score of >6 - this predicts a 0% 10-year survival.

Conclusions

We hypothesise that patients with a CCI > 6 should be considered for less intensive follow up. Their co-morbid status makes them likely unsuitable for intervention if reoccurrence was identified.We are pleased with our current adherence to NICE guidelines. We recognise areas for improvement and have raised these at local meetings. We hope that the CCI can be used to ensure we practice realistic medicine and act in the best of the patient when deciding to follow up.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Design and testing of the safety of the SARUS-CPR hood for novice resuscitators

BACKGROUND AND AIMS

Bystanders should be protected against aerosols, droplets, saliva, blood and vomitus during resuscitation after cardiac arrest The SARUS (safer - airway - resuscitation) CPR airway hood™ is a clear plastic cover and integrated mask that envelopes the head and torso. Our objectives were to test leakage using saline aerosol generation tests, then assess the performance of the hood during mock cardio-pulmonary resuscitation on a manikin.

METHODS

A checklist was validated by comparing the performance of 10 novices against 10 experts during mock resuscitation. Thereafter, 15 novices were tested with and without the hood, in a randomised cross-over study, one week apart.

RESULTS

Laboratory analysis showed a > 99% reduction of saline particles detected 5 cm, 75 cm and 165 cm above volunteers wearing the hood. On manikins, experts scored better compared to novices, 8.5 (0.7) vs 7.6 (1.2), difference (95%CI) 0.9 (0.4-1.3), P = 0.0004. Novice performance was equivalent using the hood and standard equipment, 7.3 (1.4) vs 7.3 (1.1) respectively, difference (90%CI) 0.0 (-0.3 - 0.3), P = 0.90.

CONCLUSION

Aerosol transmission reduced in the breathing zone. Simulated resuscitation by novices was equivalent with and without the hood.

Telehealth Education And Counselling program to optimise secondary prevention of Heart disease for patients with cardiovascular Disease living in Rural Australia: TEACH-RA study

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): SOLVE CHD Collaboration grant

Introduction

The burden of cardiovascular disease (CVD) is rapidly increasing, however, access to secondary prevention in rural areas is limited. Moreover, rural and remote CVD patients have limited access to primary care and other health services to receive ongoing support and post-discharge follow-up, and this may predispose them to insufficient secondary prevention in terms of a high risk of uncontrolled blood pressure and consequent life-threatening complications including coronary heart disease. Therefore, reform of secondary prevention in rural and remote areas is required to improve reach and access for patients living in such areas, and consequently improve clinical and other health outcomes.

Objective

To evaluate the feasibility of an innovative, tailored telehealth education and counselling program to optimise secondary prevention of CVD in patients living in rural areas in South Australia.

Methods

A quasi experimental study will be conducted by recruiting patients from existing database; country access to cardiac health (CATCH) program. Patients with CVD, aged ≥ 18, enrolled into CATCH program and living in rural and remote South Australia. Sample size is calculated using an online tool and is based on the primary endpoint to detect reduced readmission rate in patients with CVD and cardiac events. Patients with acute coronary syndrome/myocardial infarction, revascularisation procedure, stable and unstable angina, post coronary artery bypass grafting, post cardiac valve replacement surgery, and heart failure will be included. The sample size is calculated using online tool with appropriate statistical assumptions, which gives 113. The intervention of this study consists of two components: 1) delivery of a tailored telehealth counselling and education through telephone by a nurse and 2) use of an iPad application for patient education. Primary outcome is readmission for CVD and cardiac events. Secondary outcomes are knowledge of cardiovascular risk factors, lifestyle modification (e.g. smoking, alcohol, diet and physical exercise), medication adherence, health related quality of life and clinical outcomes such as lipid profile and blood pressure.

Conclusion

TEACH-RA study will test the feasibility of a tailored telehealth education and counselling program in patients with cardiac conditions living in rural and remote areas.

Laryngeal pathologies in dysphonic children with Down Syndrome

INTRODUCTION

Down syndrome is the most common chromosomal abnormality and is associated with a higher incidence of congenital heart defects, which often require surgery within the first year of life. Previous studies have found that children with Down syndrome are at higher risk for subglottic stenosis, vocal fold paralysis, and laryngomalacia. The goal of this study is to review children with Down syndrome presenting with dysphonia and to characterize their laryngeal pathologies.

METHODS

A retrospective review was performed of patients with Down syndrome seen at a tertiary pediatric hospital's department of otolaryngology from Jan. 2007-Jul. 2021 for voice-related concerns. Inclusion criteria included age less than 18 years, diagnosis of Trisomy 21, and complaint of dysphonia. The data extracted included history of dysphonia, co-morbidities, demographic information, age at presentation, perceptual voice assessments, voice quality of life scores, acoustic data, laryngoscopic and/or videostroboscopic exams, and surgical procedures.

RESULTS

Twenty-three total patients met the study criteria. Of these children, 13 (57%) were male and 10 (43%) were female. The mean age at first presentation was 4.08 years (range 12 days-16.3 years). Eleven of the 23 patients presented within the first 12 months of life. Sixteen patients were diagnosed with vocal fold immobility, 13 of which were left-sided unilateral immobility and the remaining 3 were bilateral immobility. 5 patients were diagnosed with vocal fold nodules. 12 children in the immobility group had a history of cardiothoracic surgery at our institution. Only 3 patients had Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) assessments, though all three showed overall dysphonia ratings of severely deviant, with roughness and strain scores being the most severe.

DISCUSSION

The most common etiology of dysphonia in our Down syndrome patient population was vocal fold immobility and hypomobility, as opposed to vocal fold nodules (which is the most common in the general pediatric population). The higher likelihood of cardiac surgery in patients with Trisomy 21 may result in the increased incidence of vocal fold immobility. There should be a low threshold to refer dysphonic patients with Down syndrome for laryngoscopic evaluation, as treatment options may be available.

472 A PILOT COLORECTAL AND GERIATRIC MEDICINE (CGM) CLINIC FOR OLDER, FRAIL PATIENTS REFERRED VIA A 2 WEEK WAIT PATHWAY

Introduction

The two week wait (2ww) colorectal referral pathway was introduced to expedite referrals where cancer is suspected, facilitating prompt diagnosis +/− intervention. Older frail patients are referred via this 2ww pathway even when invasive testing and intervention may not be appropriate. These patients may benefit more from holistic assessment than a universally surgical approach. A Colorectal and Geriatric Medicine (CGM) 2ww referral clinic was piloted, delivered by an urgent referral colorectal specialist nurse and an advanced clinical practitioner in geriatric medicine.

Method

Patients &gt;65 years with a Clinical Frailty Scale (CFS) score of 5 or more at referral were directed to the CGM clinic. A telephone consultation was undertaken, incorporating both 2ww assessment and aspects of comprehensive geriatric assessment.

Results

42-patients were reviewed in the clinic. Mean age was 86.1 years and mean CFS 6. 12-patients underwent CT, and 2 CT virtual colonoscopy. No patients underwent endoscopic investigation and 28-patients declined any investigation. Of those who underwent investigation, no cancers were identified. 1 patient was referred on for endosocpic mucosal resection of polyps. 5-patients had severe diverticular disease, which accounted for their symptoms. Medication recommendations were made for 30-patients, some of which led to symptom cessation. Onward referrals were made to a community geriatrician, diabetes and continence teams, and palliative care specialists. 9-patients were identified as meeting criteria for advance care planning. This was commenced during the consultation and communicated back to the referring clinician for further action.

Conclusion

Older, frail patients are often not able, nor wish to undergo, invasive investigations but should not be disadvantaged or delayed in their pathway. Further work is needed to determine the most appropriate referral pathway for this group of patients. Holistic assessment that leads to improvement in symptoms and future planning may not be achievable through a solely surgical assessment.

Age of acquisition effects in recognition without identification tasks

The Age of Acquisition (AoA) effect results in early-acquired words being processed more quickly and accurately than later-acquired words. This effect is argued to result from a gradual development of semantic representations and a changing neural network throughout development (Chang, Y.-N., Monaghan, P., & Welbourne, S., 2019). Some forms of the Recognition Without Identification (RWI) effects have been observed at a perceptual level. The present study used the RWI paradigm to examine whether the AoA effect is located at the perceptual loci. A total of 174 participants were presented a list of pictures (Experiment 1) or words (Experiment 2) followed by a list of mixed early- and late-acquired picture or word fragments that participants had to identify; half of which corresponded to studied words and half of which to unstudied words. Irrespective of whether the item was identified, participants then rated the likelihood that the item appeared in the study phase. In both experiments, results showed that studied items were recognised more accurately than unstudied items, even when they could not be identified and late-acquired items were recognised more than early-acquired items, even when they were not identified. Finally, RWI interacted with the AoA effect only in pictorial stimuli, suggesting that the RWI and AoA effects are located at the perceptual level.

A Mycobacterial Systems Resource for the Research Community

Functional characterization of bacterial proteins lags far behind the identification of new protein families. This is especially true for bacterial species that are more difficult to grow and genetically manipulate than model systems such as Escherichia coli and Bacillus subtilis To facilitate functional characterization of mycobacterial proteins, we have established a Mycobacterial Systems Resource (MSR) using the model organism Mycobacterium smegmatis This resource focuses specifically on 1,153 highly conserved core genes that are common to many mycobacterial species, including Mycobacterium tuberculosis, in order to provide the most relevant information and resources for the mycobacterial research community. The MSR includes both biological and bioinformatic resources. The biological resource includes (i) an expression plasmid library of 1,116 genes fused to a fluorescent protein for determining protein localization; (ii) a library of 569 precise deletions of nonessential genes; and (iii) a set of 843 CRISPR-interference (CRISPRi) plasmids specifically targeted to silence expression of essential core genes and genes for which a precise deletion was not obtained. The bioinformatic resource includes information about individual genes and a detailed assessment of protein localization. We anticipate that integration of these initial functional analyses and the availability of the biological resource will facilitate studies of these core proteins in many Mycobacterium species, including the less experimentally tractable pathogens M. abscessus, M. avium, M. kansasii, M. leprae, M. marinum, M. tuberculosis, and M. ulceransIMPORTANCE Diseases caused by mycobacterial species result in millions of deaths per year globally, and present a substantial health and economic burden, especially in immunocompromised patients. Difficulties inherent in working with mycobacterial pathogens have hampered the development and application of high-throughput genetics that can inform genome annotations and subsequent functional assays. To facilitate mycobacterial research, we have created a biological and bioinformatic resource (https://msrdb.org/) using Mycobacterium smegmatis as a model organism. The resource focuses specifically on 1,153 proteins that are highly conserved across the mycobacterial genus and, therefore, likely perform conserved mycobacterial core functions. Thus, functional insights from the MSR will apply to all mycobacterial species. We believe that the availability of this mycobacterial systems resource will accelerate research throughout the mycobacterial research community.

Optimal Outcomes Reporting (OOR): A New Value-Based Metric for Outcome Reporting Following Cleft Palate Repair

OBJECTIVE

Palatoplasty outcome measurements vary widely among institutions. A standardized outcome metric would help provide quality benchmarks.

DESIGN

Retrospective review of primary palatoplasty patients from 2007 to 2013.

SETTING

Tertiary care children's hospital.

MAIN OUTCOME MEASURES

We created a novel conceptual quality metric called "OOR" (Optimal Outcome Reporting). Optimal Outcome Reporting is designed to reflect the percentage of patients with cleft palate who experience the best outcomes: one operation, velar competence by age 5 years, and no unintended palatal fistula.

RESULTS

Optimal Outcome Reporting was 72.3% (68/94). Eight patients had "suboptimal" outcomes for having undergone more than one operation. Eighteen patients failed for velar incompetence. No additional patients fell out of the algorithm for fistula. A significantly higher proportion of nonsyndromic patients demonstrated an "optimal" result compared to syndromic patients (61/80, 76.3% vs 7/14, 50.0%; P = .04). Patients who required more than one procedure had significantly more clinic visits (32.6 vs 14.9; P < .01) and accrued higher costs compared to "optimal" patients (US$34 019.88 vs US$15 357.25; P < .01).

CONCLUSIONS

Optimal Outcome Reporting represents a novel quality metric that can provide meaningful information for patients with cleft palate. Optimal Outcome Reporting utilization can help cleft centers adopt changes that matter to patients and their families. By allowing for cross-institutional comparisons in a clear and objective manner, OOR can promote competition, innovation, and value in cleft palate care.

Comparative safety profile of chloral hydrate versus other sedatives for procedural sedation in hospitalized infants

BACKGROUND

Given the limited available evidence on chloral hydrate safety in neonatal populations and the discrepancy in chloral hydrate acceptance between the US and other countries, we sought to clarify the safety profile of chloral hydrate compared to other sedatives in hospitalized infants.

METHODS

We included all infants <120 days of life who underwent a minor procedure and were administered chloral hydrate, clonidine, clonazepam, dexmedetomidine, diazepam, ketamine, lorazepam, midazolam, propofol, or pentobarbital on the day of the procedure. We characterized the distribution of infant characteristics and evaluated the relationship between drug administration and any adverse event. We performed propensity score matching, regression adjustment (RA), and inverse probability weighting (IPW) to ensure comparison of similar infants and to account for confounding by indication and residual bias. Results were assessed for robustness to analytical technique by reanalyzing the main outcomes with multivariate logistic regression, a doubly robust IPW with RA model, and a doubly robust augmented IPW model with bias-correction.

RESULTS

Of 650 infants, 497 (76%) received chloral hydrate, 79 (12%) received midazolam, 54 (8%) received lorazepam, and 15 (2%) received pentobarbital. Adverse events occurred in 41 (6%) infants. Using propensity score matching, chloral hydrate was associated with a decreased risk of an adverse event compared to other sedatives, risk difference (95% confidence interval) of -12.79 (-18.61, -6.98), p <  0.001. All other statistical methods resulted in similar findings.

CONCLUSION

Administration of chloral hydrate to hospitalized infants undergoing minor procedures is associated with a lower risk for adverse events compared to other sedatives.

P6213The influence of working-age on attendance to cardiac rehabilitation: a gender comparison

Introduction

Despite guidelines recommending referral to cardiac rehabilitation (CR), attendance remains poor. Literature cites a complexity of clinical, psychological and social factors as barriers to CR attendance and, females may attend less than males. Social factors including work commitments, may influence attendance, with many Australian CR programs offered during office hours, making access difficult. The Australian retirement age for females and males differs; (females >60 years and males >65 years). We hypothesised that working-age may influence attendance to CR.

Purpose

In a CR-referred population this study sought to compare working-age of males and females and the association with CR attendance.

Methods

Data from 24 country and metropolitan CR services between 2013 and 2015 were linked to 49,909 CR-eligible patients defined as, discharged alive with a primary cardiac-related diagnosis and/or interventional procedure, identified through public hospital administrative data (Figure). Only CR-referred patients were included, with males and females categorised by three age groups: <60, 60–65 and >65 years, comparing attendance in univariate analysis. Adjustment for clinical and psychological (International Classification of Disease-10 Australian Modification mental health diagnostic-related group diagnoses) factors were conducted using multi-logistic regression.

Results

Between 2013–2015, 15,089 patients were referred to CR with 4,819 <60 years, 1,943 between 60–65 years and 8,327 >65 years. Of referrals a total of 4,286 (28.4%) attended CR, 1134 (35%) of whom were female. Univariate analysis observed total attendance by age group ranged between 26–32%, with females less likely to attend than males (<60 years; 25.3% v 32.2%, p<0.001, 60–65 years; 29.5% v 33.2%, p=0.130 and >65 years; 23.2% v 23.6%, p<0.001). Multivariate analysis observed more attendance in the 60–65 years group compared to <60 years (odds ratio (OR): 1.15 [95% confidence interval [CI]: 1.00–1.32], p=0.036) with females less likely to attend than males (OR: 0.81, [95% CI; 0.70–0.95], p=0.009). No interaction between the working age classification and gender were observed.

Conclusion

In an Australian cohort, working-age observed no influence on cardiac rehabilitation program attendance, with the period of female retirement age observing a 19% reduction in attendance. Further research on the complexity of factors that may be barriers to attendance is essential to evaluate how to improve cardiac rehabilitation programs to better suit the needs of our cardiac patients.

Acknowledgement/Funding

Flinders University partnership grant and South Australian Department of Health Local Health Networks

Dissecting maternal care: Patterns of maternal parenting in a prospective cohort study

Parental care has a strong impact on neurodevelopment and mental health in the offspring. Although numerous animal studies have revealed that the parental brain is a highly complex system involving many brain structures and neuroendocrine systems, human maternal parenting as a multidimensional construct with cognitive, emotional, and behavioural components has not been characterised comprehensively. This unique multi-method analysis aimed to examine patterns of self-reported and observed parenting from 6 to 60 months postpartum in a cohort of 496 mothers (mean maternal age = 32 years). Self-report questionnaires assessed motivational components of mothering, parenting stress, parenting-related mood, maternal investment, maternal parenting style, mother-child relationship satisfaction, and mother-child bonding at multiple time points. Observed parenting variables included the Ainsworth Sensitivity Scales at 6 and 18 months, the Behavioral Evaluation Strategies Taxonomies at 6 months, an Etch-A-Sketch cooperation task at 48 months, and the Parent-Child Early Relationship Assessment at 60 months. To examine whether different latent constructs underlie these measures of maternal parenting, we conducted an exploratory factor analysis. Self-report measures of parenting correlated only weakly with behavioural observations. Factor analysis on a subsample (n = 197) revealed four latent factors that each explained from 7% to 11% of the variance in the data (32% total variance explained). Based on the loadings of the instruments, the factors were interpreted as: Supportive Parenting, Self-Enjoyment Parenting, Overwhelmed Parenting, and Affectionate Parenting. These factor scores showed specific associations with maternal education and depressive symptoms, as well as with child outcomes, including maternally reported internalising and externalising behavioural problems, school readiness, and child-reported symptoms of mental health. These findings parallel the complexity of the parental brain, suggesting that maternal parenting consists of multiple components, each of which is associated with different maternal characteristics and child outcomes.

Mechanisms of failure and survival of total femoral endoprosthetic replacements

AIMS

The aim of this study was to evaluate the prosthesis characteristics and associated conditions that may modify the survival of total femoral endoprosthetic replacements (TFEPR).

PATIENTS AND METHODS

In all, 81 patients treated with TFEPR from 1976 to 2017 were retrospectively evaluated and failures were categorized according to the Henderson classification. There were 38 female patients (47%) and 43 male patients (53%) with a mean age at diagnosis of 43 years (12 to 86). The mean follow-up time was 10.3 years (0 to 31.7). A survival analysis was performed followed by univariate and multivariate Cox regression to identify independent implant survival factors.

RESULTS

The revision-free survival of the implant was 71% at five years and 63.3% at ten years. Three prostheses reached 15 years without revision. The mean Musculoskeletal Tumor Society score in the group was 26 (23 to 28). The mechanisms of failure were infection in 18%, structural failures in 6%, tumour progression in 5%, aseptic loosening in 2%, and soft-tissue failures in 1%. Prostheses used for primary reconstruction after oncological resections had lower infection rates than revision implants (8% vs 25%; p = 0.001). The rates of infection in silver-coated and non-silver-coated prosthesis were similar (17.4% vs 19.%; p = 0.869). The incidence of hip dislocation was 10%. Rotating hinge prosthesis had a lower failure rate than fixed hinge prosthesis (5.3% vs 11%). After Cox regression, the independent factors associated with failures were the history of previous operations (hazard ratio (HR) 3.7; p = 0.041), and the associated arthroplasty of the proximal tibia (HR 3.8; p = 0.034). At last follow-up, 11 patients (13%) required amputation.

CONCLUSION

TFEPR offers a reliable reconstruction option for massive bone loss of the femur, with a good survival when the prosthesis is used as a primary implant. The use of a rotating hinge at the knee and dual mobility bearing at the hip may be adequate to reduce the risk of mechanical and soft-tissue failures. Infection remains the main concern and there is insufficient evidence to support the routine use of silver-coated endoprosthesis. Cite this article: Bone Joint J 2019;101-B:522-528.

Abstract P3-06-17: Unlocking the transcriptomic potential of formalin-fixed paraffin embedded breast cancer tissues for high-throughput genomic analysis

Background: Transcriptomic analyses of clinical samples can help improve our understanding of disease aetiology, drug effectiveness, assign molecular subtypes and derive prognostic signatures for clinical decision-making. The success of early microarray studies relied heavily on sample quality and predominantly fresh frozen (FF) tissues to generate reliably robust data. The emergence of next-generation microarray and sequencing-based technologies from formalin-fixed paraffin-embedded (FFPE) tissues provides an opportunity to study archival clinical tissues with long-term follow-up. Here we assess 9 technologies, which vary in resolution, cost and RNA requirements, with matched FF and FFPE tissues from the same patient.

Methods: Sequential tumour biopsies were taken pre-treatment and on-treatment (at 14-days and 3-months) from 11 postmenopausal patients with oestrogen receptor positive breast cancer treated with 3 months of neoadjuvant letrozole. Half of each sample was snap frozen in liquid nitrogen and half was FFPE, RNA was extracted from both. Transcriptomic analyses were performed using 9 technologies: Illumina Beadarray, Affymetrix U133A, Affymetrix Clariom S, NanoString nCounter, AmpliSeq Transcriptome, Lexogen QuantSeq and IonXpress RNAseq, Tempo-Seq BioSpyder and Qiagen UPX3'.

Results: Success rates for generating robust expression profiles from FFPE tissues were 100% all except the Illumina BeadChip (22%) and AmpliSeq Transcriptome (83%) , which varied by the age of tissue. With the total number and position of probes/primers/counts varying widely between approaches, in total 7305 genes were represented across all of the whole-genome technologies tested.

Clear batch effects were evident when comparing data from FF and FFPE tissues and when comparing between different technologies. Standard batch correction approaches such as XPN and ComBat minimised technical bias effect and increased the correlations between matched samples (FF and FFPE) to R&gt;0.9, irrespective of the technology used.

When analysed by multi-dimensional scaling following batch correction, samples clustered by treatment time-point. When ranked by expression of 60 proliferation genes, reported by us to change with letrozole treatment, samples ordered again by time-point, consistent with our previous findings, and paired samples clustered together.

Conclusions:

· Robust gene expression profiles can be reliably generated from FFPE tissues and are comparable to those derived from FF tissue using established transcriptomic approaches.

· A range of new technologies are available for the study of FFPE tissues; these vary in cost, resolution and RNA requirements to fit the user's needs.

· Gene expression data from biologically similar studies, generated using different technologies, can be reliably integrated for robust meta-analysis, subject to appropriate batch correction analysis.

Citation Format: Turnbull AK, Selli C, Martinez-Perez C, Fernando A, Renshaw L, Keys J, Figueroa JD, He X, Tanioka M, Munro A, Murphy L, Fawkes A, Clark R, Coutts A, Perou CM, Carey LA, Dixon JM, Sims AH. Unlocking the transcriptomic potential of formalin-fixed paraffin embedded breast cancer tissues for high-throughput genomic analysis [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-06-17.

A retrospective population-based cohort study to evaluate the impact of an older sibling with undescended testis and hypospadias on the known maternal and fetal risk factors for undescended testis and hypospadias in Ontario, Canada, 1997-2007

INTRODUCTION

There are several reported risk factors for undescended testis (UDT) and hypospadias (HYP). Also, a family history of UDT or HYP has not been accounted for in prior studies, and doing so may influence these independent risk estimates.

STUDY DESIGN

A population-based retrospective cohort study was conducted using linked administrative databases in Ontario, Canada, to identify all live male newborns born between 1997 and 2007, and it was determined whether they underwent an orchidopexy or HYP repair within 5 years of birth. Baseline maternal and fetal risk factors were obtained using appropriate ICD codes. A statistical analysis using a generalized estimating equation with a logit link was performed, adjusting for clustering in mothers with a previous child born in the 5 years before the proband with UDT or HYP, to evaluate the adjusted risk factors of UDT and HYP.

RESULTS

A total of 709,968 male infants were followed up from birth for 5 years, of which 5830 underwent an orchidopexy and 2722 had an HYP repair. On multivariable analysis, factors associated with a higher risk of UDT included prematurity, small for gestational age (SGA), associated HYP, gestational hypertension, use of assisted fertility techniques, increased maternal age, Cesarean section, previous sibling with UDT, and disorders of sexual differentiation (DSDs). After adjusting for clustering in mothers with a previous baby with UDT, DSD, associated HYP (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.0-4.1), and a previous sibling with UDT (OR, 3.6; 95% CI, 2.5-5.2) remained significant risk factors. The risk factors on multivariable analysis predicting the risk of HYP included SGA, prematurity, higher income families, and associated anomalies such as UDT. After adjusting for clustering in mothers with a previous sibling with HYP, SGA (OR, 1.8; 95% CI, 1.0-3.1), higher income families (OR, 1.5-1.6), associated UDT (OR, 7.1; 95% CI, 4.9-10.0), and a previous sibling with HYP (OR, 12.8; 95% CI, 9.1-18.1) remained significant risk factors.

DISCUSSION

Studies estimating risk factors for UDT and HYP have used variable methodologies to identify index cases and perform statistical analysis. This study suggests that having an older sibling with UDT or HYP is a significant independent risk factor. Performing an analysis adjusting for clustering in mothers with a previous child with UDT or HYP leads to loss of statistical significance for other described risk factors.

CONCLUSION

Underlying genetic or similar environmental exposures may be a key risk factor for UDT and HYP, which confounds known maternal and fetal risk factors for these anomalies.