Accelerating P300-based neurofeedback training for attention enhancement using iterative learning control: a randomised controlled trial

Objective. Neurofeedback (NFB) training through brain-computer interfacing has demonstrated efficacy in treating neurological deficits and diseases, and enhancing cognitive abilities in healthy individuals. It was previously shown that event-related potential (ERP)-based NFB training using a P300 speller can improve attention in healthy adults by incrementally increasing the difficulty of the spelling task. This study aims to assess the impact of task difficulty adaptation on ERP-based attention training in healthy adults. To achieve this, we introduce a novel adaptation employing iterative learning control (ILC) and compare it against an existing method and a control group with random task difficulty variation.Approach. The study involved 45 healthy participants in a single-blind, three-arm randomised controlled trial. Each group underwent one NFB training session, using different methods to adapt task difficulty in a P300 spelling task: two groups with personalised difficulty adjustments (our proposed ILC and an existing approach) and one group with random difficulty. Cognitive performance was evaluated before and after the training session using a visual spatial attention task and we gathered participant feedback through questionnaires.Main results. All groups demonstrated a significant performance improvement in the spatial attention task post-training, with an average increase of 12.63%. Notably, the group using the proposed iterative learning controller achieved a 22% increase in P300 amplitude during training and a 17% reduction in post-training alpha power, all while significantly accelerating the training process compared to other groups.Significance. Our results suggest that ERP-based NFB training using a P300 speller effectively enhances attention in healthy adults, with significant improvements observed after a single session. Personalised task difficulty adaptation using ILC not only accelerates the training but also enhances ERPs during the training. Accelerating NFB training, while maintaining its effectiveness, is vital for its acceptability by both end-users and clinicians.

Equestrian-Related Musculoskeletal Injuries Presenting to a Chiropractic Practice: A Retrospective Chart Review of 19 Patients

Objective

The purpose of this study was to describe the types of equestrian-related musculoskeletal injuries and their management.

Methods

We retrospectively reviewed the charts of 19 patients who presented with injuries from equestrian activities at a chiropractic practice from December 2000 to December 2020. Deidentified data were extracted from the charts and summarized.

Results

Of the 19 patients, 42.3% presented with acute trauma, 38.5% had overuse injuries, and 19.2% had chronic injuries as a result of previous trauma. We found that 90% of overuse injuries and 18.2% of acute injuries led to chronic conditions that needed ongoing management.

Conclusion

From this sample of patients, there was a high percentage of overuse and chronic injuries for patients who participated in equestrian activities.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

The UK AVATAR 1 and 2 Trials for People with Distressing Voices – Findings and Learning from AVATAR1, and AVATAR2 Developments in Theory and Therapy

Introduction

Many people suffering from psychotic disorders report persistent auditory verbal hallucinations (‘voices’) despite pharmacological and psychological therapy. Interest is growing in approaches that emphasise the personal relationship between the patient and their voice(s). AVATAR therapy is one such approach that uses a digital representation (avatar) of a selected voice to facilitate a three-way discussion between patient, therapist and voice, the therapist speaking either as him/herself or in the digitally transformed voice of the avatar. Objectives: To describe AVATAR therapy and an ongoing multi-centre clinical trial. Methods: Encouraging findings from an earlier controlled trial (AVATAR1) comparing AVATAR therapy and supportive counselling informed our current multi-site cost-effectiveness trial of brief and extended versions of the therapy compared to treatment as usual (AVATAR2). Results: AVATAR1 delivered in 7 weekly sessions resulted in a reduction in the frequency, distress and power of voices that was significantly superior to supportive counselling. Clinical experience suggested that some participants improved in response to the early focus on anxiety while others seemed more responsive to later more formulation-driven approach. These findings led us to the current ongoing three arm clinical trial comprising a brief (6 session) focus on anxiety/assertiveness, an extended (12 session) formulation-driven approach both approaches compared to treatment as usual. Conclusion: Previous AVATAR studies suggest this is a therapy with considerable promise. It can be delivered through widely available laptop computers, usually in clinic but also remotely via existing commercial platforms. The current trial will address questions about dissemination, training and cost-effectiveness in NHS settings.

Disclosure

The digital technology employed in AVATAR therapy is provided by licence for the trial from Avatar Therapy Ltd

Psychotherapy of Biases in Cognition in Schizophrenia: the SlowMo Randomised Controlled Trial for Paranoia, Outcomes and Mechanisms

Reasoning biases, specifically jumping to conclusions and belief inflexibility, may play a causal role in persistent paranoia. SlowMo, a new digitally supported blended cognitive-behavioural therapy, targets these biases. Adopting the terms ‘fast’ and ‘slow thinking’ as a heuristic to support therapy, SlowMo encourages people to notice a tendency to fast thinking, and to slow down for a moment to reduce paranoia. SlowMo therapy is the first digital blended therapy for paranoia, employing face to face therapy sessions with interactive digital content, and using mobile technology to promote generalisation to daily life. We report a randomised controlled trial with N=362 participants with distressing and persistent (3+months) paranoia, comparing 8 sessions of SlowMo plus Treatment as Usual (TAU) with TAU alone. We examined SlowMo’s effectiveness in reducing paranoia and improving reasoning biases; its mechanisms of action; usability; and acceptability (Garety et al., 2021). Outcomes: SlowMo was beneficial for paranoia: 10 /11 paranoia measures at 12 weeks and 8/11 at 24 weeks demonstrated significant effects, and sustained moderate effects were observed on all observer-rated measures of persecutory delusions. Improvements in self-esteem, worry, wellbeing and quality of life were also reported. Mediation: Consistent with the theory-driven design and treatment rationale, improvements in slower thinking were found to mediate change in paranoia at 12- and 24-week follow-ups. However contrary to hypothesis, reduced fast thinking did not mediate change in paranoia, whereas worry did. These findings highlight the potential therapeutic mechanisms of action of SlowMo which which are discussed further. Garety P, Ward T, Emsley R, et al. Effects of SlowMo, a Blended Digital Therapy Targeting Reasoning, on Paranoia Among People With Psychosis: A Randomized Clinical Trial. JAMA Psychiatry. 2021;78(7):714–725. doi:10.1001/jamapsychiatry.2021.0326

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

0917 Designing a Wearable Technology-Based Sleep Intervention To Support Sleep Health Among Adolescents: Using a Participatory Design Approach

Introduction

Sleep problems during adolescence are increasingly common and have been associated with adverse physical and psychological health outcomes. Efforts to improve insufficient sleep among adolescents have resulted in increased sleep knowledge and temporary enhancements in sleep hygiene. Good sleep hygiene is established through the development of daily routines that support healthy sleep. Wearable technology offers a potential solution whereby adolescents can acquire and manage healthy sleep habits. In this study, we are co-designing with adolescents a prototype intervention using wearable technology to promote sustained improvements in their sleep hygiene.

Methods

Guided by participatory design approaches, the ongoing multi-phase mixed methods study is currently being conducted in a metropolitan area in western Canada. In phase 1, sleep data is being collected from a sample of 30 adolescent-parent dyads using wearable sensors (Actigraphy watches) and self-report sleep measures (questionnaires about sleep quality, hygiene, and beliefs and attitudes, as well as their general health) over a 10-day period. In phases 2 and 3, individual interviews and iterative user interface design sessions will be conducted with 25 adolescents.

Results

To date, thirteen adolescents-parent dyads (13-17 years, 9 females; 39-56 years, 11 females) have completed phase 1 of our study. Data analysis is currently being conducted to evaluate sleep onset/offset, total sleep time, wake after sleep onset, sleep efficiency, and sleep schedule differences between adolescents and their parents. Ten adolescents have completed individual interviews in phase 2 of the study. Preliminary qualitative data suggests that youth are aware of the importance of sleep to their overall health. However, they struggle with identifying credible information to act on from the various and sometimes conflicting sources (e.g. online, friends, family).

Conclusion

We anticipate that co-designing a wearable solution with adolescents will lead to a sleep intervention that is more relevant, persuasive, and useful in supporting their sleep health.

Support

This work is supported by the Sensor Technology in Monitoring Movement STiMM Program.

PL3.6 Targeting GSK-3 activity promotes mitotic catastrophe via centrosome destabilisation and enhances the effect of radiotherapy in glioma models

BACKGROUND

Targeting kinases as regulators of cellular processes that drive cancer progression is a promising approach to improve patient outcome in GBM management. The glycogen synthase kinase 3 (GSK-3) plays a role in cancer progression and is known for its pro-proliferative activity in gliomas. The anti-proliferative and cytotoxic effects of the GSK-3 inhibitor AZD2858 were assessed in relevant in vitro and in vivo glioma models to confirm GSK-3 as a suitable target for improved single agent or combination treatments.

MATERIAL AND METHODS

The immortalised cell line U251 and the patient derived cell lines GBM1 and GBM4 were used in in vitro studies including MTT, clonogenic survival, live cell imaging, immunofluorescence microscopy and flow cytometry to assess the cytotoxic and anti-proliferative effects of AZD2858. Observed anti-proliferative effects were investigated by microarray technology for the identification of target genes with known roles in cell proliferation. Clinical relevance of targeting GSK-3 with the inhibitor either for single agent or combination treatment strategies was determined by subcutaneous and orthotopic in vivo modelling. Whole mount mass spectroscopy was used to confirm drug penetration in orthotopic tumour models.

RESULTS

AZD2858 was cytotoxic at low micromolar concentrations and at sub-micromolar concentrations (0.01 - 1.0 μM) induced mitotic defects in all cell lines examined. Prolonged mitosis, centrosome disruption/duplication and cytokinetic failure leading to cell death featured prominently among the cell lines concomitant with an observed S-phase arrest. No cytotoxic or anti-proliferative effect was observed in normal human astrocytes. Analysis of the RNA microarray screen of AZD2858 treated glioma cells revealed the dysregulation of mitosis-associated genes including ASPM and PRC1, encoding proteins with known roles in cytokinesis. The anti-proliferative and cytotoxic effect of AZD2858 was also confirmed in both subcutaneous and orthotopic in vivo models. In addition, combination treatment with AZD2858 enhanced clinically relevant radiation doses leading to reduced tumour volume and improved survival in orthotopic in vivo models.

CONCLUSION

GSK-3 inhibition with the small molecule inhibitor AZD2858 led to cell death in glioma stem cells preventing normal centrosome function and promoting mitotic failure. Normal human astrocytes were not affected by treatment with the inhibitor at submicromolar concentrations. Drug penetration was observed alongside an enhanced effect of clinical radiotherapy doses in vivo. The reported aberrant centrosomal duplication may be a direct consequence of failed cytokinesis suggesting a role of GSK-3 in regulation of mitosis in glioma. GSK-3 is a promising target for combination treatment with radiation in GBM management and plays a role in mitosis-associated events in glioma biology.

Feasibility of a modified Atkins diet in glioma patients during radiation and its effect on radiation sensitization

Background

Gliomas are the most dreaded primary brain tumour because of their dismal cure rates. Ketogenic-type diets (kds) are high-fat, low-protein, and low-carbohydrate diets; the modified Atkins diet (mad) is a less-stringent version of a kd that still generates serum ketones in patients. The purpose of the present study was to retrospectively examine the feasibility of attaining ketosis and the safety of the mad in patients undergoing radiation and chemotherapy treatment for glioma. The rate of pseudoprogression (psp) after treatment was also assessed as a marker of radiation sensitization. To our knowledge, this dataset is the largest published relating to patients with glioma undergoing kd during radiation and chemotherapy.

Methods

We retrospectively studied 29 patients with grades ii-iv astrocytoma following the mad during standard radiation and chemotherapy. Feasibility of attaining ketosis was assessed though levels of beta hydroxybutyrate in blood. Pre- and post-radiation magnetic resonance images were evaluated for psp by a neuroradiologist blinded to patient data.

Results

In the 29 patients who started the mad during radiation, ketosis was achieved in all 29 (100%). No serious adverse events occurred secondary to the mad. Of those 29 patients, 19 had glioblastoma multiforme. Of the latter 19 patients, 11 (58%) showed psp after mad and radiation and temozolomide therapy.

Conclusions

A modified Atkins diet is feasible and safe for glioma patients during radiation and chemotherapy treatment. The mad and resulting ketosis could play a role as a radiation sensitizer.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Acrylamide Production in Autoclaved Rodent Feed

Sterilization of rodent feed by steam autoclaving is a common practice in many research institutions. Often we only considerthe beneficial effects of this process-the reduction of microbial contamination-and forget that the high temperatures andpressures can have negative effects on diet quality. The purpose of our study was to assess both the physical and chemicalchanges to a standard rodent feed autoclaved at multiple sterilization temperatures and the effects of the treated diets on mice. Pelleted NIH31 rodent feed was autoclaved at 4 sterilization temperatures (230, 250, 260, and 270 °F). Feed pellet hardness and the acrylamide concentrations of the diets were tested and compared with irradiated NIH31 feed. Study diets were fed to mice for 28 d, after which tissue samples were collected for analysis of acrylamide, glycidamide (the active metabolite of acrylamide), and genotoxicity. Both feed pellet hardness and acrylamide concentration increased with increasing sterilization temperatures; however, neither affected feed intake or body weight gain. Plasma acrylamide and glycidamide weresignificantly elevated only in mice fed NIH31 diet autoclaved at 270 °F compared with the irradiated feed, whereas urineacrylamide and glycidamide metabolites were significantly elevated in most autoclaved diets. Liver DNA adducts, whichcorrelate with genotoxicity, were significantly elevated in all autoclaved diets compared with the irradiated diet. Institutionsthat autoclave their animal diets should carefully consider the temperatures necessary to achieve feed sterilization and thetype of studies in which these autoclaved diets are used.

Tackling the burden of the hepatitis C virus in the UK: characterizing and assessing the clinical and economic consequences

OBJECTIVES

The hepatitis C virus (HCV) remains a significant public health issue. This study aimed to quantify the clinical and economic burden of chronic hepatitis C in the UK, stratified by disease severity, age and awareness of infection, with concurrent assessment of the impact of implementing a treatment prioritization approach.

STUDY DESIGN AND METHODS

A previously published back projection, natural history and cost-effectiveness HCV model was adapted to a UK setting to estimate the disease burden of chronic hepatitis C and end-stage liver disease (ESLD) between 1980 and 2035. A published meta-regression analysis informed disease progression, and UK-specific data informed other model inputs.

RESULTS

At 2015, prevalence of chronic hepatitis C is estimated to be 241,487 with 22.20%, 33.72%, 17.22%, 16.67% and 10.19% of patients in METAVIR stages F0, F1, F2, F3 and F4, respectively, but is estimated to fall to 193,999 by 2035. ESLD incidence is predicted to peak in 2031. Assuming all patients are diagnosed and treatment is prioritized in F3 and F4 using highly efficacious direct-acting antiviral (DAA) regimens, a 69.85% reduction in ESLD incidence is predicted between 2015 and 2035, and the cumulative discounted medical expenditure associated with the lifetime management of incident ESLD events is estimated to be £1,202,827,444.

CONCLUSIONS

The prevalence of chronic hepatitis C is expected to fall in coming decades; however, the ongoing financial burden is expected to be high due to an increase in ESLD incidence. This study highlights the significant costs of managing ESLD that are likely to be incurred without the employment of effective treatment approaches.

Characterization of Fusarium Strains Recovered From Wheat With Symptoms of Head Blight in Kentucky

Fusarium graminearum species complex (FGSC) members cause Fusarium head blight (FHB) of wheat (Triticum aestivum L.) and small grains in the United States. The U.S. population is diverse and includes several genetically distinct local emergent subpopulations, some more aggressive and toxigenic than the majority population. Kentucky is a transition zone between the Mid-Atlantic and Midwestern wheat production areas. Sixty-eight Fusarium strains were isolated from symptomatic wheat heads from central and western Kentucky and southern Indiana in 2007. A multilocus genotyping assay and a variety of additional molecular markers, including some novel markers developed using the F. graminearum genome sequence, were used to characterize the pathogen population. Five of the isolates were identified as members of two non-FGSC species, F. acuminatum and F. cf. reticulatum, but they did not cause symptoms in greenhouse tests. All the FGSC isolates belonged to the 15-ADON chemotype of F. graminearum. Comparative genetic analysis using variable nuclear tandem repeat (VNTR) markers indicated that the population in Kentucky and Indiana belonged to the dominant North American population, with some diversification likely due to local evolution. Telomere and RFLP fingerprinting markers based on repetitive sequences revealed a high degree of genetic diversity within the population, with unique genotypes found at each location, and multiple genotypes isolated from the same head.

Refitting of the UKPDS 68 risk equations to contemporary routine clinical practice data in the UK

OBJECTIVE

Economic evaluations of new diabetes therapies rely heavily upon the UK Prospective Diabetes Study (UKPDS) equations for prediction of cardiovascular events; however, concerns persist regarding their relevance to current clinical practice and appropriate use in populations other than newly diagnosed patients. This study refits the UKPDS 68 event equations, using contemporary data describing low- and intermediate-risk patients.

RESEARCH DESIGN AND METHODS

Anonymized patient data describing demographics, risk factors and incidence of cardiovascular and microvascular events were extracted from The Health Improvement Network (THIN) database over the 10-year period from 1 January 2000 to 31 December 2009. Following multiple imputation of missing values, accelerated failure-time Weibull regression equations were refitted to produce new coefficients for each risk group. Discriminatory performance was assessed and compared with both UKPDS 68 and UKPDS 82 risk equations, and the implication of coefficient choice within an economic evaluation was assessed using the Cardiff type 2 diabetes model.

RESULTS

When applied to patient-level data, the three sets of coefficients (UKPDS, THIN low-risk and intermediate-risk) lead to fairly consistent predictions of the 5-year risk of events. Exceptions include lower predicted rates of myocardial infarction and higher rates of ischaemic heart disease, congestive heart failure and end-stage renal disease with both sets of revised THIN coefficients compared with UKPDS. Over a modelled lifetime, the coefficients derived from the low-risk data predict fewer total cardiovascular events compared with UKPDS, while those from the intermediate-risk data predict a greater number. The areas under the receiver-operating characteristic curves demonstrated a marginal improvement in the discriminatory performance of the refitted equations. The incremental cost-effectiveness ratio associated with dapagliflozin versus sulphonylurea in addition to metformin changed from £7,708 to £7,519 and £6,906 per QALY gained, using the THIN intermediate- and low-risk coefficients, respectively.

CONCLUSION

The results suggest that while the UKPDS equations perform best in newly diagnosed patients, they may overpredict the lifetime risk in this group and underpredict it in patients with more advanced diabetes. Implementation of the revised coefficients will result in different absolute numbers of predicted diabetes-related events; however, they are not expected to significantly affect the conclusions of economic modelling.

Brain computer interfaces for neurorehabilitation – its current status as a rehabilitation strategy post-stroke

The idea of using brain computer interfaces (BCI) for rehabilitation emerged relatively recently. Basically, BCI for neurorehabilitation involves the recording and decoding of local brain signals generated by the patient, as he/her tries to perform a particular task (even if imperfect), or during a mental imagery task. The main objective is to promote the recruitment of selected brain areas involved and to facilitate neural plasticity. The recorded signal can be used in several ways: (i) to objectify and strengthen motor imagery-based training, by providing the patient feedback on the imagined motor task, for example, in a virtual environment; (ii) to generate a desired motor task via functional electrical stimulation or rehabilitative robotic orthoses attached to the patient's limb – encouraging and optimizing task execution as well as "closing" the disrupted sensorimotor loop by giving the patient the appropriate sensory feedback; (iii) to understand cerebral reorganizations after lesion, in order to influence or even quantify plasticity-induced changes in brain networks. For example, applying cerebral stimulation to re-equilibrate inter-hemispheric imbalance as shown by functional recording of brain activity during movement may help recovery. Its potential usefulness for a patient population has been demonstrated on various levels and its diverseness in interface applications makes it adaptable to a large population. The position and status of these very new rehabilitation systems should now be considered with respect to our current and more or less validated traditional methods, as well as in the light of the wide range of possible brain damage. The heterogeneity in post-damage expression inevitably complicates the decoding of brain signals and thus their use in pathological conditions, asking for controlled clinical trials.

Overrepresentation of multiple birth pregnancies in young infants with four metabolic bone disorders: further evidence that fetal bone loading is a critical determinant of fetal and young infant bone strength

The frequency of multiple birth pregnancies, mostly twin pregnancies, was overrepresented in four different groups of young infants with fractures and bone abnormalities. This finding suggests that fetal bone loading through fetal movement is an important determinant of fetal bone formation and its resultant bone strength.

INTRODUCTION

It has been suggested that intrauterine confinement related to the multiple birth pregnancy (MBP) may lead to an increased risk for fragility fractures in young infants as a result of decreased fetal bone loading.

METHODS

To objectively test this idea, the frequency of MBPs was evaluated in five groups of young infants with bone disorders: (1) infants exposed to prolonged in utero exposure to magnesium, (2) infants with dietary copper deficiency, (3) infants with rickets from vitamin D deficiency, (4) infants with temporary brittle bone disease, and (5) infants with multiple unexplained fractures in which child abuse was the most likely diagnosis.

RESULTS

Compared to a control group and controlled for preterm birth, there was a statistically greater frequency of MBPs in each group.

CONCLUSIONS

The results of this study suggest the following: (a) The overrepresentation of MBPs (95 % twins) in these five groups indicates that fetal bone loading is a critical determinant of fetal bone strength; (b) fetal and young infant bone strength is a multifactorial characteristic; and (c) infants from MBPs are at increased risk for fragility fractures during the first 12 months of life, and thus may be mistakenly diagnosed as victims of child abuse.

Coarse particulate matter and airborne endotoxin within wood stove homes

Emissions from indoor biomass burning are a major public health concern in developing areas of the world. Less is known about indoor air quality, particularly airborne endotoxin, in homes burning biomass fuel in residential wood stoves in higher income countries. A filter-based sampler was used to evaluate wintertime indoor coarse particulate matter (PM₁₀₋₂.₅) and airborne endotoxin (EU/m³, EU/mg) concentrations in 50 homes using wood stoves as their primary source of heat in western Montana. We investigated number of residents, number of pets, dampness (humidity), and frequency of wood stove usage as potential predictors of indoor airborne endotoxin concentrations. Two 48-h sampling events per home revealed a mean winter PM₁₀₋₂.₅ concentration (± s.d.) of 12.9 (± 8.6) μg/m³, while PM₂.₅ concentrations averaged 32.3 (± 32.6) μg/m³. Endotoxin concentrations measured from PM₁₀₋₂.₅ filter samples were 9.2 (± 12.4) EU/m³ and 1010 (± 1524) EU/mg. PM₁₀₋₂.₅ and PM₂.₅ were significantly correlated in wood stove homes (r = 0.36, P < 0.05). The presence of pets in the homes was associated with PM₁₀₋₂.₅ but not with endotoxin concentrations. Importantly, none of the other measured home characteristics was a strong predictor of airborne endotoxin, including frequency of residential wood stove usage.

Improvements to Rapfish: a rapid evaluation technique for fisheries integrating ecological and human dimensions

This paper reports recent developments in Rapfish, a normative, scalable and flexible rapid appraisal technique that integrates both ecological and human dimensions to evaluate the status of fisheries in reference to a norm or goal. Appraisal status targets may be sustainability, compliance with a standard (such as the UN code of conduct for responsible fisheries) or the degree of progress in meeting some other goal or target. The method combines semi-quantitative (e.g. ecological) and qualitative (e.g. social) data via multiple evaluation fields, each of which is assessed through scores assigned to six to 12 attributes or indicators: the scoring method allows user flexibility to adopt a wide range of utility relationships. For assessing sustainability, six evaluation fields have been developed: ecological, technological, economic, social, ethical and institutional. Each field can be assessed directly with a set of scored attributes, or several of the fields can be dealt with in greater detail using nested subfields that themselves comprise multidimensional Rapfish assessments (e.g. the hierarchical institutional field encompasses both governance and management, including a detailed analysis of legality). The user has the choice of including all or only some of the available sustainability fields. For the attributes themselves, there will rarely be quantitative data, but scoring allows these items to be estimated. Indeed, within a normative framework, one important advantage with Rapfish is transparency of the rigour, quality and replicability of the scores. The Rapfish technique employs a constrained multidimensional ordination that is scaled to situate data points within evaluation space. Within each evaluation field, results may be presented as a two-dimensional plot or in a one-dimensional rank order. Uncertainty is expressed through the probability distribution of Monte-Carlo simulations that use the C.L. on each original observation. Overall results of the multidisciplinary analysis may be shown using kite diagrams that compare different locations, time periods (including future projections) and management scenarios, which make policy trade-offs explicit. These enhancements are now available in the R programming language and on an open website, where users can run Rapfish analyses by downloading the software or uploading their data to a user interface.

A CMOS Camera-Based Pulse Oximetry Imaging System

In this paper a CMOS camera-based system for non-contact pulse oximetry imaging in transmission mode is described. Attention is drawn to the current uses of conventional pulse oximetry and the potential application of pulse oximetry imaging to developing objective wound assessment systems.

PD08-02: Targeting BCL-2 Expressing Breast Tumors with BH3-Mimetics – A New Class of Drugs in Breast Cancer?

Background: Impairment of apoptosis is a hallmark of cancer and can result in resistance to chemotherapy. Tumor resistance to apoptosis is frequently acquired through deregulated expression of BCL-2 family members or inactivation of the p53 tumor suppressor pathway. Over-expression of the pro-survival protein BCL-2 is common in breast cancer (where it is readily detected by immunostaining), and has been shown to be an important prognostic marker. A potential role for BCL-2 as a therapeutic target in breast cancer, however, has not been explored. Recently, small molecules termed ‘BH3-mimetics’ have been developed that mimic the action of pro-apoptotic BH3-only proteins. These bind and neutralize pro-survival proteins including BCL-2. Here we have derived a panel of primary breast tumor xenografts (that include basal-like breast tumors) to study the efficacy of the BH3-mimetic ABT-737 combined with docetaxel in targeting BCL-2-positive breast cancer.

Methods and Results: We first studied the expression of BCL-2, pro-survival family members BCL-XL and MCL-1, and the pro-apoptotic protein BIM in tissue microarrays of 197 primary breast tumors, which were subtyped on the basis of ER, PR, HER2, CK5/6 and EGFR expression. BCL-2 was overexpressed in luminal (83.3%), HER2−positive (50.0%), basal-like (18.5%) and ‘marker-null’ (41.4%) breast cancers. BCL-2-positive tumors generally co-expressed BCL-XL (96.2%), MCL-1 (94.7%) and BIM (93.5%). To determine whether the BH3-mimetic ABT-737 (which neutralizes BCL-2, BCL-XL and BCL-W) was effective in targeting BCL-2-expressing breast tumors, we generated a panel of 28 primary breast tumor xenografts in immunocompromised NOG mice. Five xenograft lines (838T, 24T, 315T, 13T and 806T) were selected for further analysis. Four were basal-like, and one (315T) was a luminal B tumor, as determined by gene profiling. Mice bearing tumor xenografts were treated with ABT-737 (50 mg/kg i.p. d1-10), docetaxel (10 mg/kg i.p. d1) or a combination in q21d cycles. Tumor response and overall survival were significantly improved by combination therapy, but only for tumors that expressed elevated levels of BCL-2. Treatment with ABT-737 alone was ineffective, suggesting that ABT-737 sensitized tumors to docetaxel. Combination therapy was accompanied by a marked increase in apoptosis and dissociation of BIM from BCL-2, indicating that a perturbation of BIM complexes may contribute to the activation of the apoptotic cascade. Notably, ABT-737 appeared effective in targeting BCL-2-expressing basal-like tumor xenografts (838T and 24T) harboring p53 mutations.

Discussion: Primary breast tumor xenograft models that recapitulate the phenotype of the primary tumor have been developed as useful ‘proof-of-principle', pre-clinical models. Here we provide the first in vivo evidence that BH3-mimetics can be used to sensitize primary BCL-2-expressing breast tumors to taxane chemotherapy. Our results suggest that elevated BCL-2 expression constitutes a predictive response marker in breast cancer. These findings provide a rationale for the development of clinical protocols using the oral analogue ABT-263 (navitoclax) as an adjunct to taxane chemotherapy in BCL-2-expressing basal-like and luminal breast cancer.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD08-02.

Value of drug-eluting stents after failed percutaneous transluminal angioplasty in the infrapopliteal vessels for the treatment of critical limb ischemia: favorable mid-term patency and limb salvage results

AIM

The endovascular treatment of infrapopliteal arterial disease in the setting of critical limb ischemia (CLI) is increasing in use. In patients in whom percutaneous transluminal angioplasty (PTA) resulted in suboptimal angiographic results, flow limiting dissection or re-coil is thought to limit clinical success. This single-center experience examines the angiographic and clinical results when Drug-Eluting Stents (DES) were placed in a large cohort of patients with CLI after immediate infrapopliteal PTA failure.

METHODS

A retrospective review of a prospectively collected single-center endovascular database was performed. Sixty-seven Rutherford grade 4, 5, and 6 patients were treated between October 2005 and February 2010 with PTA because lack of an acceptable autologous vein for bypass-grafting or severe medical comorbidities precluded them from surgical bypass. The study cohort had suboptimal angiographic results immediately after PTA that was subsequently treated with DES. Patients were then placed on clopidogrel and aspirin indefinitely. Angiographic, clinical, and the results of noninvasive vascular examinations were collected.

RESULTS

In total, 123 stents (94 sirolimus, 27 everolimus, 2 paclitaxel) were placed in 67 patients to treat a total of 84 angiographic lesions. Simultaneous femoral-popliteal intervention was performed in 66% of the patients while 45% of the treated lesions were total occlusions. Lesion length ranged from 17 mm-142 mm (mean 50 mm). Initial technical success was 100%, with all 84 lesions being treated successfully with less than 10% stenosis after stent implantation. Mean follow-up was 20 months (1-42 months) with 6, 12, and 24-month primary patency rates of 90%, 86%, and 72% respectively. Freedom from major amputation was 91.1% (61/67) with all six amputations occurring in the Rutherford grade 6 group (6/11). Overall mortality rate was 19% (13/67) with one death occurring within 30 days.

CONCLUSION

The use of drug-eluting stents following suboptimal PTA for the treatment of infrapopliteal arterial disease in this cohort of patients with CLI produced high primary patency and limb salvage rates supporting the efficacy of this treatment strategy.

The Role of Threat Appraisals and Safety-Seeking Behaviours in Determining Need for Care in Psychosis

Introduction

Van Os et al. (2009) have proposed a Proneness-Persistence-lmpairment model to explain the psychosis continuum, and cognitive models of psychosis have suggested that appraisals of anomalous experiences may be key in determining ‘need for care’.

Objectives

The present study investigated the interaction between appraisals and safety behaviours in the maintenance of impairing psychotic symptoms.

Aims

It was predicted that individuals with psychotic symptoms without a need for care would display fewer threat appraisals and safety behaviours than their clinical counterparts, and that these variables would predict distress.

Methods

The study recruited people with persistent psychotic experiences but who had no-need-for-care (Persistence group; n = 39) and individuals diagnosed with a psychotic disorder who were receiving current treatment (Impairment group; n = 28). The participants were assessed on semi-structured interviews of appraisals and safety behaviours in relation to their psychotic experiences and on anxiety and depression questionnaires.

Results

Both groups had similar levels of psychotic symptoms in the last month, including first rank symptoms. However there was a large significant difference between Impairment and Persistence groups in threat appraisals and safety behaviours, with the Persistence group reporting higher levels of both. A mediation analysis found that threat appraisals mediated the relationship between safety behaviours and anomaly-related distress, suggesting that threat appraisals may maintain anomaly-related distress, a defining feature of Impairment status.

Conclusions

These data provide support for the cognitive model of psychosis, with threat appraisals potentially playing a major role in the transition from non-clinical anomalous experiences to clinical psychotic status.

Preparation of Energetic Metastable Nano-Composite Materials by Arrested Reactive Milling

Highly metastable, nano-scale energetic materials were prepared by Arrested Reactive Milling (ARM). When reactive milling is carried out with materials systems suitable for Self-Propagating High Temperature Synthesis (SHS), reaction between the components occurs spontaneously and violently after a certain period of milling. In this research, metastable nanocom-posites with high energy density, were prepared by arresting the milling process prior to the spontaneous reaction. Products thus obtained are powders with particle sizes in the 10–50 μm range. Individual particles are intimate mixtures of reactive components, comparable to Metast-able Intermolecular Composites (MIC), with near theoretical maximum density. The time of arrest determines the degree of grain refinement and therefore the sensitivity to mechanical, electrical, or thermal initiation. Particle sizes of the product powders can be adjusted by appropriate choice of milling parameters. This paper describes the application of ARM to the material systems Al-Fe2O3 and Al-MoO3. After empirical determination of optimum milling parameters, the reactive composites are structurally characterized by electron microscopy and x-ray diffraction. First results of combustion tests are presented.