The Relation Between Discipline Identity and Academic Achievement Within a Marketized Higher Education Context: A Serial Mediation Model of Approaches to Learning and Course Complaints

Social-psychological dimensions of learning are under-researched, but they affect student achievement. Within a marketized higher education context in England, United Kingdom, this study examined whether the relation between students’ social identities as members of their discipline and academic achievement could be further understood by considering the mediating roles of approaches to learning and frequency of making course complaints. Undergraduates (N = 679) completed a questionnaire to assess these constructs. As expected, approaches to learning and course complaining both acted as serial mediators of the link between discipline identification and academic achievement: stronger discipline identification was related to more deep approaches to learning, less complaining, and higher achievement, whereas weaker discipline identification was related to more surface approaches to learning, more complaining, and lower achievement. The findings suggest that addressing these social-psychological aspects of learning could improve students’ academic achievement.

P15.11.A 18F-Fluciclovine PET/CT to distinguish radiation necrosis from tumour progression in brain metastases treated with stereotactic radiosurgery: results of a prospective pilot study

Background

Amino acid PET radiopharmaceutical, 18F-fluciclovine, shows increased uptake in brain tumors relative to normal tissue and may be a useful tool for detecting recurrent brain metastases. Here, we report results from a prospective pilot study evaluating the use of 18F-fluciclovine PET/CT to distinguish radiation necrosis from tumour progression among patients with brain metastases treated with stereotactic radiosurgery (SRS).

Material and Methods

The primary objective was to estimate the accuracy of 18F-fluciclovine PET/CT in distinguishing radiation necrosis from tumour progression. The trial included adults with brain metastases who underwent SRS and presented with a follow up MRI brain (with DSC MR perfusion) which was equivocal for radiation necrosis versus tumour progression. Within 30 days of equivocal MRI brain, patients underwent an 18F-fluciclovine PET/CT (Siemens mCT) acquired 5-15 min post-injection with images generated by PSF reconstruction. Quantitative metrics for each lesion were documented and lesion to normal brain SUVmean ratios were calculated. The reference standard for diagnosis of radiation necrosis vs tumour progression was clinical follow up with MRI brain every 2-4 months until multidisciplinary consensus or tissue confirmation.

Results

Of 16 patients enrolled between 7/2019-11/2020, 1 patient died prior to diagnosis, allowing 15 evaluable subjects with 20 lesions. Primary histology was NSCLC in 9 (45%) lesions, breast in 7 (35%), melanoma in 3 (15%), and endometrial in 1 (5%). The final diagnosis was radiation necrosis in 16 (80%) lesions and tumour progression in 4 (20%). SUVmax was a statistically significant predictor of tumour progression (P = 0.011), with higher SUVmax values indicative of tumour progression. The area under the ROC curve was 0.833 (95% CI: 0.590, 1.0). A cutoff of 4.3 provided a sensitivity to identify tumour progression of 1.0 (4/4) and specificity to rule out tumour progression of 0.63 (10/16). SUVmean (P = 0.018), SUVpeak (P = 0.007), and SUVpeak/normal (P = 0.002) also reached statistical significance as predictors of tumour progression, with higher SUVmax values indicative of tumour progression. SUVmax/normal (P = 0.1) and SUVmean/normal (P = 0.5) were not statistically significant. The AUC for SUVmax was not significantly higher than the AUCs for the other quantitative variables (P-values > 0.2).

Conclusion

In this prospective pilot study, 18F Fluciclovine PET/CT demonstrated promising accuracy to distinguish radiation necrosis from tumour progression among patients with brain metastases previously treated with SRS. Using SUVmax, a cutpoint of 4.3 provided a sensitivity of 1.0 and specificity of 0.63. Confirmatory phase II and III studies are ongoing.

Effect of foot orthoses vs sham insoles on first metatarsophalangeal joint osteoarthritis symptoms: a randomized controlled trial

OBJECTIVES

To compare contoured foot orthoses to sham flat insoles for first MTP joint OA walking pain.

DESIGN

This was a participant- and assessor-blinded, sham-controlled, multi-centre randomized clinical trial set in community-based private practices. Eighty-eight adults aged ≥45 years with symptomatic radiographic first MTP joint OA were randomized to receive contoured foot orthoses (n = 47) or sham flat insoles (n = 41), worn at all times when wearing shoes for 12 weeks. Primary outcome was change in first MTP joint walking pain (11-point numerical rating scale (NRS), 0-10) over 12 weeks. Secondary outcomes included additional first MTP joint and foot pain measures, physical function, quality of life and physical activity. Separate linear regression models for primary and secondary outcomes on treatment group were fit, adjusting for the outcome at baseline and podiatrist. Other measures included adverse events.

RESULTS

88 participants were randomized and 87 (99%) completed the 12-week primary outcome. There was no evidence foot orthoses were superior to sham insoles for reducing pain (mean difference -0.3 NRS units (95% CI -1.2 to 0.6), p = 0.53). Similarly, foot orthoses were not superior to sham on any secondary outcomes. Sensitivity analyses yielded similar results. Adverse events were generally minor and transient.

CONCLUSION

Contoured foot orthoses are no more effective than flat sham insoles for the clinical management of first MTP joint OA. Given the dearth of evidence on treatments for first MTP joint OA, further research is needed to identify effective management approaches for this common and debilitating condition.

"It's the single best thing I've done in the last 10 years": a qualitative study exploring patient and dietitian experiences with, and perceptions of, a multi-component dietary weight loss program for knee osteoarthritis

OBJECTIVE

Explore patient and dietitian experiences with a multi-component dietary weight loss program for knee osteoarthritis to understand enablers and challenges to success at 6-months.

DESIGN

Qualitative study embedded within a randomised controlled trial. Semi-structured individual interviews with 24 patients with knee osteoarthritis who undertook, and five dietitians who supervised, a weight management program (involving a ketogenic very low calorie diet (VLCD), video consultations, educational resources) over 6 months. Data were thematically analysed.

RESULTS

Five themes were developed: (1) ease and convenience of program facilitated adherence (structure and simplicity of the meal replacements; not feeling hungry on diet; convenience of consulting via video) (2) social and professional support crucial for success (encouragement from partner, family, and friends; guidance from, and accountability to, dietitian; anxiety around going at it alone) (3) program was engaging and motivating (determination to stick to program; rapid weight loss helped motivation) (4) holistic nature of program was important (suite of high-quality educational resources; exercise important to compliment weight loss) (5) rewarding experience and lifelong impact (improved knee pain and function; positive lifestyle change).

CONCLUSIONS

Patients and dietitians described positive experiences with the weight management program, valuing its simplicity, effectiveness, and convenience. Support from dietitians and a comprehensive suite of educational resources, incorporated with an exercise program, were considered crucial for success. Findings suggest this multi-component dietary program is an acceptable weight loss method in people with knee osteoarthritis that may benefit symptoms. Strategies for supporting long-term independent weight management should be a focus of future research.

Cognitive processing speed in multiple sclerosis clinical practice: association with patient-reported outcomes, employment and magnetic resonance imaging metrics

BACKGROUND AND PURPOSE

To analyze the relationship between cognitive processing speed, patient-reported outcome measures (PROMs), employment and magnetic resonance imaging (MRI) metrics in a large multiple sclerosis cohort.

METHODS

Cross-sectional clinical data, PROMs, employment and MRI studies within 90 days of completion of the Processing Speed Test (PST), a technology-enabled adaptation of the Symbol Digit Modalities Test, were collected. MRI was analyzed using semi-automated methods. Correlations of PST score with PROMs and MRI metrics were examined using Spearman's rho. Wilcoxon rank sum testing compared MRI metrics across PST score quartiles and linear regression models identified predictors of PST performance. Effects of employment and depression were also investigated.

RESULTS

In 721 patients (mean age 47.6 ± 11.4 years), PST scores were significantly correlated with all MRI metrics, including cord atrophy and deep gray matter volumes. Linear regression demonstrated self-reported physical disability, cognitive function, fatigue and social domains (adjusted R²  = 0.44, P < 0.001) as the strongest clinical predictors of PST score, whereas that of MRI variables included T2 lesion volume, whole-brain fraction and cord atrophy (adjusted R²  = 0.42, P < 0.001). An inclusive model identified T2 lesion volume, whole-brain fraction, self-reported upper extremity function, cognition and social participation as the strongest predictors of PST score (adjusted R²  = 0.51, P < 0.001). There was significant effect modification by depression on the relationship between self-reported cognition and PST performance. Employment status was associated with PST scores independent of age and physical disability.

CONCLUSION

The PST score correlates with PROMs, MRI measures of focal and diffuse brain injury, and employment. The PST score is a feasible and meaningful measure for routine multiple sclerosis care.

Dormancy dampens the microbial distance-decay relationship

Much of Earth's biodiversity has the capacity to engage in dormancy, a reversible state of reduced metabolic activity. By increasing resilience to unfavourable conditions, dormancy leads to the accumulation of 'seed banks'. These reservoirs of genetic and phenotypic diversity should diminish the strength of environmental filtering and increase rates of dispersal. Although prevalent among single-celled organisms, evidence that dormancy influences patterns of microbial biogeography is lacking. We constructed geographical and environmental distance-decay relationships (DDRs) for the total (DNA) and active (RNA) portions of bacterial communities in a regional-scale 16S rRNA survey of forested ponds in Indiana, USA. As predicted, total communities harboured greater diversity and exhibited weaker DDRs than active communities. These observations were robust to random resampling and different community metrics. To evaluate the processes underlying the biogeographic patterns, we developed a platform of mechanistic models that used the geographical coordinates and environmental characteristics of our study system. Based on more than 10⁶ simulations, our models approximated the empirical DDRs when there was strong environmental filtering along with the presence of long-lived seed banks. By contrast, the inclusion of dispersal generally decreased model performance. Together, our findings support recent theoretical predictions that seed banks can influence the biogeographic patterns of microbial communities. This article is part of the theme issue 'Conceptual challenges in microbial community ecology'.

Estimating sleep parameters using an accelerometer without sleep diary

Wrist worn raw-data accelerometers are used increasingly in large-scale population research. We examined whether sleep parameters can be estimated from these data in the absence of sleep diaries. Our heuristic algorithm uses the variance in estimated z-axis angle and makes basic assumptions about sleep interruptions. Detected sleep period time window (SPT-window) was compared against sleep diary in 3752 participants (range = 60-82 years) and polysomnography in sleep clinic patients (N = 28) and in healthy good sleepers (N = 22). The SPT-window derived from the algorithm was 10.9 and 2.9 minutes longer compared with sleep diary in men and women, respectively. Mean C-statistic to detect the SPT-window compared to polysomnography was 0.86 and 0.83 in clinic-based and healthy sleepers, respectively. We demonstrated the accuracy of our algorithm to detect the SPT-window. The value of this algorithm lies in studies such as UK Biobank where a sleep diary was not used.

Comprehensive Radiotherapy for Advanced Hodgkin's Disease Refractory to Chemotherapy

Seven patients with advanced nodular sclerosing Hodgkin's disease who relapsed after initial intensive combination chemotherapy were selected for individualized pathologic restaging and comprehensive radiotherapy. One patient failed to respond completely to mantle-field irradiation and no further staging or radiotherapy was undertaken. Six other patients underwent staging laparotomy and received total nodal irradiation including prophylactic lung irradiation (5 cases) and hepatic irradiation (3 cases). Irradiation was well tolerated. Complete remission was achieved by 5 patients and 2 continue in remission 29+ and 32+ months after beginning of irradiation. Five of the 7 patients remain alive. This study indicates that comprehensive irradiation is a relatively well tolerated and effective treatment for carefully selected patients with advanced Hodgkin's disease who have relapsed after combination chemotherapy. For selected patients, pathologic restaging and comprehensive radiotherapy can be considered as an alternative to further chemotherapy.

Prevalence of Traumatic Findings on Routine MRI in a Large Cohort of Professional Fighters

BACKGROUND AND PURPOSE

Previous studies investigating MR imaging abnormalities among fighters have had small sample sizes. This investigation assessed a large number of fighters using the same conventional sequences on the same scanner.

MATERIALS AND METHODS

Conventional 3T MR imaging was used to assess 499 fighters (boxers, mixed martial artists, and martial artists) and 62 controls for nonspecific WM changes, cerebral microhemorrhage, cavum septum pellucidum, and cavum vergae. The lengths of the cavum septum pellucidum and cavum vergae and the ratio of cavum septum pellucidum to the septum pellucidum lengths were assessed.

RESULTS

The prevalence of nonspecific WM changes was similar between groups. Fighters had a prevalence of cerebral microhemorrhage (4.2% versus 0% for controls, P = .152). Fighters had a higher prevalence of cavum septum pellucidum versus controls (53.1% versus 17.7%, P < .001) and cavum vergae versus controls (14.4% versus 0%, P < .001). The lengths of the cavum septum pellucidum plus the cavum vergae (P < .001), cavum septum pellucidum (P = .025), and cavum septum pellucidum to the septum pellucidum length ratio (P = .009) were higher in fighters than in controls. The number of fights slightly correlated with cavum septum pellucidum plus cavum vergae length (R = 0.306, P < .001) and cavum septum pellucidum length (R = 0.278, P < .001). When fighters were subdivided into boxers, mixed martial artists, and martial artists, results were similar to those in the whole-group analysis.

CONCLUSIONS

This study assessed MR imaging findings in a large cohort demonstrating a significantly increased prevalence of cavum septum pellucidum among fighters. Although cerebral microhemorrhages were higher in fighters than in controls, this finding was not statistically significant, possibly partially due to underpowering of the study.

Acute Cytotoxic and Vasogenic Edema after Subarachnoid Hemorrhage: A Quantitative MRI Study

BACKGROUND AND PURPOSE

The mechanism of early brain injury following subarachnoid hemorrhage is not well understood. We aimed to evaluate if cytotoxic and vasogenic edema are contributing factors.

MATERIALS AND METHODS

A retrospective analysis was conducted in patients with SAH undergoing diffusion-weighted MR imaging within 72 hours of onset. Apparent diffusion coefficient values derived from DWI were evaluated by using whole-brain histograms and 19 prespecified ROIs in patients with SAH and controls with normal findings on MRI. Cytotoxic edema observed outside the ROIs was assessed in patients with SAH. The average median ADC values were compared between patients with SAH and controls and patients with SAH with mild (Hunt and Hess 1-3) versus severe early brain injury (Hunt and Hess 4-5).

RESULTS

We enrolled 33 patients with SAH and 66 controls. The overall average median whole-brain ADC was greater for patients with SAH (808 × 10^-6 mm²/s) compared with controls (788 × 10^-6 mm²/s, P < .001) and was higher in patients with SAH across ROIs after adjusting for age: cerebral gray matter (826 versus 803 × 10^-6 mm²/s, P = .059), cerebral white matter (793 versus 758 × 10^-6 mm²/s, P = .023), white matter tracts (797 versus 739 × 10^-6 mm²/s, P < .001), and deep gray matter (754 versus 713 × 10^-6 mm²/s, P = .016). ADC values trended higher in patients with Hunt and Hess 4-5 versus those with Hunt and Hess 1-3. Early cytotoxic edema was observed in 13 (39%) patients with SAH and was more prevalent in those with severe early brain injury (87.5% of patients with Hunt and Hess 4-5 versus 24.0% of those with Hunt and Hess 1-3, P = .001).

CONCLUSIONS

Age-adjusted ADC values were globally increased in patients with SAH compared with controls, even in normal-appearing brain regions, suggesting diffuse vasogenic edema. Cytotoxic edema was also present in patients with SAH and correlated with more severe early brain injury.

Automated MRI Volumetric Analysis in Patients with Rasmussen Syndrome

BACKGROUND AND PURPOSE

Rasmussen syndrome, also known as Rasmussen encephalitis, is typically associated with volume loss of the affected hemisphere of the brain. Our aim was to apply automated quantitative volumetric MR imaging analyses to patients diagnosed with Rasmussen encephalitis, to determine the predictive value of lobar volumetric measures and to assess regional atrophy differences as well as monitor disease progression by using these measures.

MATERIALS AND METHODS

Nineteen patients (42 scans) with diagnosed Rasmussen encephalitis were studied. We used 2 control groups: one with 42 age- and sex-matched healthy subjects and the other with 42 epileptic patients without Rasmussen encephalitis with the same disease duration as patients with Rasmussen encephalitis. Volumetric analysis was performed on T1-weighted images by using BrainSuite. Ratios of volumes from the affected hemisphere divided by those from the unaffected hemisphere were used as input to a logistic regression classifier, which was trained to discriminate patients from controls. Using the classifier, we compared the predictive accuracy of all the volumetric measures. These ratios were used to further assess regional atrophy differences and correlate with epilepsy duration.

RESULTS

Interhemispheric and frontal lobe ratios had the best prediction accuracy for separating patients with Rasmussen encephalitis from healthy controls and patient controls without Rasmussen encephalitis. The insula showed significantly more atrophy compared with all the other cortical regions. Patients with longitudinal scans showed progressive volume loss in the affected hemisphere. Atrophy of the frontal lobe and insula correlated significantly with epilepsy duration.

CONCLUSIONS

Automated quantitative volumetric analysis provides accurate separation of patients with Rasmussen encephalitis from healthy controls and epileptic patients without Rasmussen encephalitis, and thus may assist the diagnosis of Rasmussen encephalitis. Volumetric analysis could also be included as part of follow-up for patients with Rasmussen encephalitis to assess disease progression.

Hysteroscopy in the diagnosis of postmenopausal bleeding

Postmenopausal bleeding (PMB) accounts for 5% of gynaecology referrals. Investigations should exclude malignancy and pre-malignancy, and diagnose the benign conditions that need treatment. The three modalities that are most commonly used are transvaginal ultrasound scan (TVS), endometrial biopsy (EB) and hysteroscopy. Most authors agree that the first-line investigation should be TVS, followed by endometrial assessment (EB or hysteroscopy) if the endometrial thickness is >4 mm. When scanning demonstrates the possibility of pathology, outpatient hysteroscopy and biopsy are the gold standard for investigating the endometrial cavity. Focal pathology can be removed during the hysteroscopy, thereby reducing hospital admissions and costs.

Do postmenopausal women with thickened endometrium on trans-vaginal ultrasound in the absence of vaginal bleeding need hysteroscopic assessment? A Pilot Study

We aimed to determine the incidence of endometrial cancer in a cohort of postmenopausal women with thickened endometrium but no bleeding referred for hysteroscopy and determine the risk estimate of cancer using a cut-off of > 11 mm. This retrospective study of asymptomatic postmenopausal women with thickened endometrium on trans-vaginal scan referred for hysteroscopy was performed using data from 2008 to 2010. In total 63 women were identified. 2 cases of endometrial cancer were identified with an incidence of 3.17%. 22 cases had endometrial thickness (ET) > 11 mm of which 2 were malignant giving a risk estimate for endometrial cancer of 9.1%. 61 women had benign pathology, 40.98% had atrophic endometrium and 59.02% had benign polyp. In conclusion, the incidence of endometrial cancer in postmenopausal women with thickened endometrium on transvaginal scan without vaginal bleeding is low and ET of 11 mm or more seems realistic to use as a cut-off for referral for hysteroscopy.

Does the gender of the bully/victim dyad and the type of bullying influence children's responses to a bullying incident?

Children's responses to bullying are context related; they will vary depending on the specific bullying episode. The aim of the present study was to explore whether children's responses to bullying vary depending on the gender of the bully and victim and the type of bullying portrayed. In total, 437 children aged 9-11 years from four primary schools in the UK took part in the study. Each child read a story about one child bullying another. There were 12 different versions of the story, varying the type of bullying (verbal, physical, or relational/indirect) and the gender of the bully and victim (i.e., male bully-female victim, female bully-male victim, male bully-male victim, female bully-female victim). Each child was randomly allocated to one of the 12 stories. After reading the story the children then responded to a series of questions to assess their perceptions of the victim and bully and situation. Overall females liked the bully more than males; females also reported liking the female victim more than the male victim and females were more likely than males to intervene with a female victim. The bullying was viewed as more serious, more sympathy was shown to the victim, and there was a greater likelihood of intervention when the incident involved a female bully. There was less liking for the bully if the situation involved a female victim of physical bullying. The findings are explained in terms of social identity theory and social norms about typical male and female behavior.

An illustration of simple sequence analysis with reference to the agonistic behaviour of four strains of laboratory mouse

Many authors have assumed that the functions of behavioural elements may be deduced from the sequence in which they occur. This study explains from basic principles a simple procedure, based of the X(2) test, for analysing behavioural sequences. The formation of groups of "similar" elements (cluster analysis) and their interpretation is discussed with reference to the agonistic behaviour of individually-housed male mice from four different strains. Associations between elements are found to be consistent with the functions assigned them by previous authors though strain differences in behavioural organisation are evident. Behav. Processes 11: 365-388.

High-resolution MRI vessel wall imaging: spatial and temporal patterns of reversible cerebral vasoconstriction syndrome and central nervous system vasculitis

BACKGROUND AND PURPOSE

High-resolution MR imaging is an emerging tool for evaluating intracranial artery disease. It has an advantage of defining vessel wall characteristics of intracranial vascular diseases. We investigated high-resolution MR imaging arterial wall characteristics of CNS vasculitis and reversible cerebral vasoconstriction syndrome to determine wall pattern changes during a follow-up period.

MATERIALS AND METHODS

We retrospectively reviewed 3T-high-resolution MR imaging vessel wall studies performed on 26 patients with a confirmed diagnosis of CNS vasculitis and reversible cerebral vasoconstriction syndrome during a follow-up period. Vessel wall imaging protocol included black-blood contrast-enhanced T1-weighted sequences with fat suppression and a saturation band, and time-of-flight MRA of the circle of Willis. Vessel wall characteristics including enhancement, wall thickening, and lumen narrowing were collected.

RESULTS

Thirteen patients with CNS vasculitis and 13 patients with reversible cerebral vasoconstriction syndrome were included. In the CNS vasculitis group, 9 patients showed smooth, concentric wall enhancement and thickening; 3 patients had smooth, eccentric wall enhancement and thickening; and 1 patient was without wall enhancement and thickening. Six of 13 patients had follow-up imaging; 4 patients showed stable smooth, concentric enhancement and thickening; and 2 patients had resoluton of initial imaging findings. In the reversible cerebral vasoconstriction syndrome group, 10 patients showed diffuse, uniform wall thickening with negligible-to-mild enhancement. Nine patients had follow-up imaging, with 8 patients showing complete resolution of the initial findings.

CONCLUSIONS

Postgadolinium 3T-high-resolution MR imaging appears to be a feasible tool in differentiating vessel wall patterns of CNS vasculitis and reversible cerebral vasoconstriction syndrome changes during a follow-up period.

Identification of Lactobacillus strains with probiotic features from the bottlenose dolphin (Tursiops truncatus)

Aims

In order to develop complementary health management strategies for marine mammals, we used culture-based and culture-independent approaches to identify gastrointestinal lactobacilli of the common bottlenose dolphin, Tursiops truncatus.

Methods and Results

We screened 307 bacterial isolates from oral and rectal swabs, milk and gastric fluid, collected from 38 dolphins in the U.S. Navy Marine Mammal Program, for potentially beneficial features. We focused our search on lactobacilli and evaluated their ability to modulate TNF secretion by host cells and inhibit growth of pathogens. We recovered Lactobacillus salivarius strains which secreted factors that stimulated TNF production by human monocytoid cells. These Lact. salivarius isolates inhibited growth of selected marine mammal and human bacterial pathogens. In addition, we identified a novel Lactobacillus species by culture and direct sequencing with 96·3% 16S rDNA sequence similarity to Lactobacillus ceti.

Conclusions

Dolphin-derived Lact. salivarius isolates possess features making them candidate probiotics for clinical studies in marine mammals.

Significance and Impact of the Study

This is the first study to isolate lactobacilli from dolphins, including a novel Lactobacillus species and a new strain of Lact. salivarius, with potential for veterinary probiotic applications. The isolation and identification of novel Lactobacillus spp. and other indigenous microbes from bottlenose dolphins will enable the study of the biology of symbiotic members of the dolphin microbiota and facilitate the understanding of the microbiomes of these unique animals.

Application of a computerized language lateralization index from FMRI by a group of clinical neuroradiologists

BACKGROUND AND PURPOSE

Deriving accurate language lateralization from fMRI studies in the clinical context can be difficult, with 10%-20% incorrect conclusions. Most interpretations are qualitative, performed by neuroimaging experts. Quantitative lateralization has been widely described but with little implementation in the clinical setting and is disadvantaged by the use of arbitrary threshold techniques. We investigated the application and utility of a nonthreshold CLI, in a clinical setting, as applied by a group of practicing neuroradiologists.

MATERIALS AND METHODS

Twenty-two patients with known language lateralization (11 left and 11 nonleft dominant) had their images reviewed by 8 neuroradiologists in 2 settings, all randomized, once by using a CLI and once without using a CLI. For each review, neuroradiologists recorded their impressions of lateralization for each language sequence, the overall lateralization conclusion, their impression of scan quality and noise, and the subjective confidence in their conclusion.

RESULTS

The inter-rater κ for lateralization was 0.64, which increased to 0.70 with the use of CLI. The group accuracy of overall lateralization was 78%, which increased to 81% with the use of a CLI. Using a CLI removed 2 instances of significant errors, with a neuroradiologist's impression of left lateralization in a patient with known right lateralization. Using a CLI had no effect on examinations with conclusions formed with either high confidence or no confidence.

CONCLUSIONS

Although the overall clinical benefit of a CLI is modest, the most significant impact is to reduce the most harmful misclassification errors, particularly in fMRI examinations that are suboptimal.

Voxel-based morphometric MRI post-processing in MRI-negative focal cortical dysplasia followed by simultaneously recorded MEG and stereo-EEG

We aim to report on the usefulness of a voxel-based morphometric MRI post-processing technique in detecting subtle epileptogenic structural lesions. The MRI post-processing technique was implemented in a morphometric analysis program (MAP), in a 30-year-old male with pharmacoresistant focal epilepsy and negative MRI. MAP gray-white matter junction file facilitated the identification of a suspicious structural lesion in the right frontal opercular area. The electrophysiological data by simultaneously recorded stereo-EEG and MEG confirmed the epileptogenicity of the underlying subtle structural abnormality. The patient underwent a limited right frontal opercular resection, which completely included the area detected by MAP. Surgical pathology revealed focal cortical dysplasia (FCD) type IIb. Postoperatively the patient has been seizure-free for 2 years. This study demonstrates that MAP has promise in increasing the diagnostic yield of MRI reading in challenging patients with "non-lesional" MRIs. The clinical relevance and epileptogenicity of MAP abnormalities in patients with epilepsy have not been investigated systematically; therefore it is important to confirm their pertinence by performing electrophysiological recordings. When confirmed to be epileptogenic, such MAP abnormalities may reflect an underlying subtle cortical dysplasia whose complete resection can lead to seizure-free outcome.

Fair-Weather or Foul-Weather Friends? Group Identification and Children’s Responses to Bullying

Research with adults shows that negative ingroup behavior can affect identification with the group, but also that the way in which members respond to negative events is moderated by prior levels of identification. Research with children shows that how strongly they identify with a group influences how they react to group-level bullying. The authors integrate these findings by examining how a bullying incident affects children’s group identification. Children aged 7–8 and 10–11 years were randomly assigned to either a perpetrator group or a target group. They read a scenario describing a target group member being bullied by members of the perpetrator group. The perpetrator group had a norm of behaving either kindly or unkindly to other children. How strongly children in the perpetrator group identified with their group was influenced by group norm and by initial in-group identification. Identification was higher when the group was normatively kind rather than unkind, but only among children whose initial identification was high.

Ganging up or sticking together? Group processes and children's responses to text-message bullying

Drawing on social identity theory and intergroup emotion theory (IET), we examined group processes underlying bullying behaviour. Children were randomly assigned to one of three groups: a perpetrator's group, a target's group, or a third party group. They then read a gender-consistent scenario in which the norm of the perpetrator's group (to be kind or unkind towards others) was manipulated, and an instance of cyberbullying between the perpetrator's group and a member of the target's group was described. It was found that group membership, group norms, and the proposed antecedents of the group-based emotions of pride, shame, and anger (but not guilt) influenced group-based emotions and action tendencies in ways predicted by social identity and IET. The results underline the importance of understanding group-level emotional reactions when it comes to tackling bullying, and show that being part of a group can be helpful in overcoming the negative effects of bullying.

Effect of a prescan patient-radiologist encounter on functional MR image quality

BACKGROUND AND PURPOSE

A substantial number of clinical fMRI examinations inadequately assess language localization or lateralization, usually due to patient movement and suboptimal participation. We hypothesized that a prescan interview of the patient by the radiologist would reduce the fraction of nondiagnostic scans.

MATERIALS AND METHODS

A single noise score for each acquisition was produced from time-series data on the basis of a weighted sum of 22 factors. Scores were recorded as the following quartiles: 0-5 = excellent, 5-10 = adequate, 10-15= marginal, and >15 = unacceptable. This measure was evaluated for 202 consecutive fMRI patients: 96 without and 106 with a physician prescan interview. The data were analyzed to compute the fraction of all nondiagnostic sequences and entire studies and were compared between the 2 groups. Image-noise characteristics included the SDs of linear and angular displacements of the head and the number of time-series outliers caused by focal motion.

RESULTS

Of 999 sequences acquired, 539 had a prescan interview. The mean noise score significantly decreased for both individual sequence (from 7.9 to 6.3, P = <.001) and study-based (from 7.7 to 6.2, P = .05) methods. The fraction of sequences or studies scored as unacceptable decreased for sequence-based (from 15.2% to 10.9%, P = .04) and study-based (from 9.4% to 1.9%, P = .02) analyses. SDs of head motion decreased for linear (by 12%-14%, P < .01) and angular displacement (by 38%-48%, P < .001). The number of time-series spikes decreased by 10% (P = .004).

CONCLUSIONS

We report that a prescan physician-patient interview modestly but significantly reduces fMRI noise scores. These results support the newly added billable costs of professional intervention before fMRI scans.

Abstract PD08-03: Competing Causes of Mortality vs. Breast Cancer Mortality at 5-Years among 9766 Postmenopausal Women with Hormone Receptor Positive Early Breast Cancer Treated on the TEAM Study of Adjuvant Hormonal Therapy

Background: The TEAM (Tamoxifen Exemestane Adjuvant Multinational) trial is a contemporary multinational study of the effects of 5 years of adjuvant hormonal therapy, either exemestane (E) or tamoxifen switching to E (TàE). Five-year results were presented at SABCS 2009 showing no difference in outcome between E vs TàE (Rea D, SABCS Abstract 11), thus giving us the opportunity to analyze the causes of mortality in the entire population of 9766 women.

Methods: Postmenopausal women with hormone receptor positive (HR+) early breast cancer (BC) were randomized to E or TàE for 5 years after completion of surgery, adjuvant chemotherapy (when indicated), and radiation therapy based on local guidelines. All data were collected and analyzed at the Central Data Center in Leiden. The primary outcome of DFS as well as safety and other secondary outcomes were analyzed in 2009 after 1285 events had occurred to trigger the analysis. Results: Between 2001 and January 2006, 9766 women were randomized; 100% were HR+, 50% had node negative disease, 68% received adjuvant radiotherapy, and 36% received adjuvant chemotherapy. The median follow-up was 5.1 years with over 60% of women having been followed for 5 or more years. Among 961 deaths, 568 (59%) were caused by BC and 393 (41%) by causes other than BC. The cumulative incidence of death from BC vs. other causes at 5-years for all women and by nodal status is as follows (see table):

There was a general relationship with non-breast cancer deaths and increasing age at diagnosis (≥70 years), as expected. Non-breast cancer causes of mortality included second malignancy (105); cardiac (71), cerebral (33), or pulmonary (28) events; miscellaneous other causes (105); and unknown (51).

Conclusions: Among 9766 postmenopausal women with HR+ BC treated with contemporary hormonal strategies following standard primary treatment, the probability of death from causes other than BC was nearly as high as the probability of dying from BC.

A case of verocytotoxin-producing Escherichia coli O157 from a private barbecue in South East England

The following case report describes a cluster of Escherichia coli O157 cases in the United Kingdom related to undercooked beef at a barbecue, resulting in an intensive care admission in France with haemolytic uraemic syndrome and highlighting the need to cook beef properly.

Rate, type, and cost of invasive interventions for uterine myomas in Germany, France, and England

STUDY OBJECTIVE

The objective of our study was to quantify the rate, type, and cost of interventions for uterine myomas to payers in Germany, France, and England.

DESIGN

Computations using data from national hospital activity databases.

DESIGN CLASSIFICATION

II-3.

SETTING

Hospital admissions in Germany, France, and England.

PATIENTS

Women admitted for a surgical or radiologic intervention for uterine myomas.

INTERVENTIONS

Surgical or radiologic interventions for uterine myomas.

MEASUREMENTS AND MAIN RESULTS

We identified the number and type of hospital admissions involving surgical or radiologic interventions for uterine myomas, through the analysis of national hospital activity databases from each country. We calculated the costs of these hospitalizations to payers in these countries using the diagnosis-related group reimbursement rates. In 2005, the number (rate) of hospital admissions involving interventions for uterine myomas was 64 299 (1.53/1000 women) in Germany, 37 787 (1.17/1000 women) in France, and 18 274 (0.71/1000 women) in England. The annual costs of these interventions to payers were euro212 313 090 in Germany, euro73 278 270 in France (excluding surgeon and anesthetist fees for interventions in the private sector), and euro52 674 672 in England. The percentage of interventions for uterine myomas that included a hysterectomy was 84.9% in Germany, 59.7% in France, and 64.1% in England.

CONCLUSION

The number of admissions and costs associated with interventions for uterine myomas are substantial in the 3 European countries studied. Hysterectomy is the most frequent surgical intervention used to treat uterine myomas. The results in this article provide useful information for policy makers wishing to evaluate the cost effectiveness and budget impact of new, less invasive interventions.

Survival and safety of exemestane versus tamoxifen after 2-3 years' tamoxifen treatment (Intergroup Exemestane Study): a randomised controlled trial

BACKGROUND

Early improvements in disease-free survival have been noted when an aromatase inhibitor is given either instead of or sequentially after tamoxifen in postmenopausal women with oestrogen-receptor-positive early breast cancer. However, little information exists on the long-term effects of aromatase inhibitors after treatment, and whether these early improvements lead to real gains in survival.

METHODS

4724 postmenopausal patients with unilateral invasive, oestrogen-receptor-positive or oestrogen-receptor-unknown breast cancer who were disease-free on 2-3 years of tamoxifen, were randomly assigned to switch to exemestane (n=2352) or to continue tamoxifen (n=2372) for the remainder of a 5-year endocrine treatment period. The primary endpoint was disease-free survival; overall survival was a secondary endpoint. Efficacy analyses were intention-to-treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN11883920.

RESULTS

After a median follow-up of 55.7 months (range 0-89.7), 809 events contributing to the analysis of disease-free survival had been reported (354 exemestane, 455 tamoxifen); unadjusted hazard ratio 0.76 (95% CI 0.66-0.88, p=0.0001) in favour of exemestane, absolute benefit 3.3% (95% CI 1.6-4.9) by end of treatment (ie, 2.5 years after randomisation). 222 deaths occurred in the exemestane group compared with 261 deaths in the tamoxifen group; unadjusted hazard ratio 0.85 (95% CI 0.71-1.02, p=0.08), 0.83 (0.69-1.00, p=0.05) when 122 patients with oestrogen-receptor-negative disease were excluded.

CONCLUSIONS

Our results suggest that early improvements in disease-free survival noted in patients who switch to exemestane after 2-3 years on tamoxifen persist after treatment, and translate into a modest improvement in overall survival.

Ambulatory hysteroscopy: evidence-based guide to diagnosis and therapy

Healthcare providers are facing increasing demands for improvement in quality of life for patients. Improvements in service provision for women are being ensured by the introduction of minimally invasive technologies into all spheres of gynaecologic practice. Ambulatory hysteroscopy (direct endoscopic visualization of the endometrial cavity) is an extremely exciting and rapidly advancing field of gynaecologic practice. It advanced dramatically during the 1990s, shifting the focus in healthcare away from inpatient diagnosis and treatment. Hysteroscopy is used extensively in the evaluation of common gynaecological problems that were previously evaluated with blind and inaccurate techniques (e.g. premenopausal menstrual disorders, infertility and postmenopausal bleeding). It allows direct visualization of the uterine cavity and the opportunity for targeted biopsy, safe removal of endometrial polyps, and treatment of submucous fibroids, septa and adhesions. Ambulatory hysteroscopy is safe, with a low incidence of serious complications; it has a small failure rate. There is a general consensus that hysteroscopy is the current gold standard for evaluating intrauterine pathology, including submucous myomas, polyps, hyperplasia and cancer. Hysteroscopy in the ambulatory setting appears to have an accuracy and patient acceptability equivalent to inpatient hysteroscopy under general anaesthetic. The primary goal of this chapter is to provide a high-quality, evidence-based text on ambulatory diagnostic and operative hysteroscopy. The chapter includes in-depth analysis of the indications for outpatient hysteroscopy, its contraindications, the accuracy of diagnostic hysteroscopy, relevant risk management issues and, training and teaching.

Scar formation after stereotactic vacuum-assisted core biopsy of benign breast lesions

AIM

To evaluate scar formation of impalpable breast lesions with benign histological outcome using stereotactic 11-gauge vacuum-assisted core biopsy (VACB).

MATERIALS AND METHODS

Two hundred and ten lesions with benign histology for which follow-up mammograms were available, were assessed for scar formation at the biopsy site. All biopsies were performed using stereotactic VACB with 11-gauge needle. The incidence of post-biopsy scar formation and the number of specimens removed were determined.

RESULTS

In 4.3% (9/210) of the lesions for which a biopsy was performed with 11-gauge directional vacuum-assisted technique, the follow-up mammogram revealed a scar formation. Of these, six were minimal scars, two were moderate scars and one was a marked scar. Minimal and moderate scars were diagnosed on imaging only. However, the case with marked scar formation required tissue diagnosis to rule out malignancy.

CONCLUSION

Although uncommon, scar formation can be seen in the follow-up mammograms after percutaneous breast biopsies. It is important that the radiologist interpreting follow-up mammograms is aware of the features of this lesion and its relationship to the biopsy procedure.

The effect of intrauterine environment and low glomerular number on the histological changes in diabetic glomerulosclerosis

AIMS/HYPOTHESIS

We tested the hypothesis that diabetic glomerulosclerosis would develop more rapidly in animals with fewer glomeruli.

METHODS

We studied the female offspring of Wistar rats that had been fed a low-protein diet (LPD) containing 6% protein or a normal-protein diet (NPD) containing 18% protein during pregnancy. Streptozotocin diabetes was induced at 12 weeks and animals were killed at 40 weeks.

RESULTS

Non-diabetic LPD offspring were of lower birthweight than the NPD offspring (5.19+/-0.64 vs 6.45+/-0.67 g, p<0.001) and had fewer glomeruli (27,402+/-3,137 vs 34,203+/-6,471, p<0.05). Glomerular volume correlated inversely with glomerular number (r=-0.64, p=0.035), but total glomerular filtration surface area was reduced in the LPD animals (4,770+/-541 vs 5,779+/-1,302 mm(2), p=0.05). Other renal structural and functional parameters were similar. In LPD and NPD diabetic animals, glomerular volume and basement membrane width were significantly increased compared to their respective controls. Podocyte density was lowest in the LPD diabetic animals (not significant), and the area covered by each podocyte was greater in the LPD diabetic group (2.40+/-0.693 x10(-3) mm(2)) than in the LPD control group (1.68+/-0.374 x10(-3) mm(2), p<0.001) and in the NPD diabetic animals (1.71+/-0.291 x 10(-3) mm(2), p<0.05). There was no difference in any other structural or functional parameter between the LPD and NPD diabetic animals.

CONCLUSIONS/INTERPRETATION

A decrease in glomerular number was not deleterious to renal structure and function over 40 weeks in this animal model. Further work in models with progressive renal impairment and hypertension is necessary to clarify the impact of glomerular number on the development of renal disease.

Randomized Phase III Study of Docetaxel Compared With Paclitaxel in Metastatic Breast Cancer

Purpose

This randomized, controlled, multicenter, open-label, phase III study compared docetaxel versus paclitaxel in patients with advanced breast cancer that had progressed after an anthracycline-containing chemotherapy regimen.

Patients and Methods

Patients (n = 449) were randomly assigned to receive either docetaxel 100 mg/m2(n = 225) or paclitaxel 175 mg/m2(n = 224) on day 1, every 21 days until tumor progression, unacceptable toxicity, or withdrawal of consent.

Results

In the intent-to-treat population, both the median overall survival (OS, 15.4 v 12.7 months; hazard ratio [HR], 1.41; 95% CI, 1.15 to 1.73; P = .03) and the median time to progression (TTP, 5.7 months v 3.6 months; HR, 1.64; 95% CI, 1.33 to 2.02; P < .0001) for docetaxel were significantly longer than for paclitaxel, and the overall response rate (ORR, 32% v 25%; P = .10) was higher for docetaxel. These results were confirmed by multivariate analyses. The incidence of treatment-related hematologic and nonhematologic toxicities was greater for docetaxel than for paclitaxel; however, quality-of-life scores were not statistically different between treatment groups over time.

Conclusion

Docetaxel was superior to paclitaxel in terms of OS and TTP. ORR was higher for docetaxel. Hematologic and nonhematologic toxicities occurred more frequently in the docetaxel group. The global quality-of-life scores were similar for both agents over time.

Monitoring trends in obesity in South Wales using routine data

AIM

To use existing data on height and weight of 5 year old children, routinely recorded annually as part of the school entry medical, to monitor trends in obesity over the last 16 years in three South Wales localities.

METHODS

Body mass index (BMI) and percentage of children over the cut off points for being overweight or obese proposed by the International Obesity Task Force were determined in 46,073 children who had height, weight, and sex recorded each school year (between 1986/87 and 2001/02) on the National Child Health Computer System held at the Swansea NHS Trust.

RESULTS

With the exception of one year, the coverage for BMI measurements ranged between 87% and 99%. The accuracy of measurement and data entry was identified as suspect in some cases, and although some data entry errors could be corrected, 14% of BMI measurements were inadmissible. Logistic regression analysis of BMI trends in the remainder showed that the percentage of 5 year olds classified as overweight or obese had increased significantly over the time period and that the rate of change in girls was significantly greater than that in boys.

CONCLUSION

Overweight and obese children have increased in frequency in this population. The Child Health Computer System is potentially a valuable source of information on the health status of populations and should be capable of monitoring trends in obesity. However, accuracy of measurement and data entry need to be improved, and the system, to be useful on a national basis, needs to be amalgamated at a higher level than individual NHS Trusts.

Endocrine treatment options for advanced breast cancer--the role of fulvestrant

For many years, tamoxifen has been the 'gold standard' amongst anti-oestrogen therapies for breast cancer. However, the selective aromatase inhibitors (AIs), anastrozole, letrozole and exemestane, have demonstrated advantages over tamoxifen as first-line treatments for advanced disease. Anastrozole is also more effective as an adjuvant treatment in early, operable breast cancer and is being increasingly used in the adjuvant setting. Generally, the selective oestrogen receptor modulators (SERMs), such as toremifene, droloxifene, idoxifene, raloxifene, and arzoxifene, show minimal activity in tamoxifen-resistant disease and show no superiority over tamoxifen as first-line treatments. In addition to these agents, other treatment options for advanced disease include high-dose oestrogens and progestins. Response rates for high-dose oestrogens and tamoxifen are similar, but the use of oestrogens is limited by their toxicity profile. Consequently, there is a need for new endocrine treatment options for breast cancer, particularly for use in disease that is resistant to tamoxifen or AIs. Fulvestrant ('Faslodex') is a new type of steroidal oestrogen receptor (ER) antagonist that downregulates cellular levels of the ER and progesterone receptor and has no agonist activity. This paper reviews the key efficacy and tolerability data for fulvestrant in postmenopausal women in the context of other endocrine therapies and explores the potential role of fulvestrant within the sequencing of endocrine therapies for advanced breast cancer.