Adaptation of Remote Symptom Monitoring Using Electronic Patient-Reported Outcomes for Implementation in Real-World Settings

PURPOSE

Despite evidence of clinical benefits, widespread implementation of remote symptom monitoring has been limited. We describe a process of adapting a remote symptom monitoring intervention developed in a research setting to a real-world clinical setting at two cancer centers.

METHODS

This formative evaluation assessed core components and adaptations to improve acceptability and fit of remote symptom monitoring using Stirman's Framework for Modifications and Adaptations. Implementation outcomes were evaluated in pilot studies at the two cancer centers testing technology (phase I) and workflow (phase II and III) using electronic health data; qualitative evaluation with semistructured interviews of clinical team members; and capture of field notes from clinical teams and administrators regarding barriers and recommended adaptations for future implementation.

RESULTS

Core components of remote symptom monitoring included electronic delivery of surveys with actionable symptoms, patient education on the intervention, a system to monitor survey compliance in real time, the capacity to generate alerts, training nurses to manage alerts, and identification of personnel responsible for managing symptoms. In the pilot studies, while most patients completed > 50% of expected surveys, adaptations were identified to address barriers related to workflow challenges, patient and clinician access to technology, digital health literacy, survey fatigue, alert fatigue, and data visibility.

CONCLUSION

Using an implementation science approach, we facilitated adaptation of remote symptom monitoring interventions from the research setting to clinical practice and identified key areas to promote effective uptake and sustainability.

The painting of a patient: Provider representations of patient fitness and preferences in multi-disciplinary tumor board meetings

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Background: Pancreatic cancer treatment can involve multiple treatment modalities (e.g. chemotherapy, surgery, radiation) that vary greatly in intensity and timing. The most intense treatments are associated with substantial toxicity and only recommended for medically ‘fit’ patients regardless of age. Despite evidence-based guidelines demonstrating the benefit of including the geriatric assessment (GA) and patient preferences, these may not be formally included in multidisciplinary tumor boards (MDTBs) where treatment decisions are often made. Methods: This qualitative study evaluated MDTB meetings at a single institution between November 2021 and February 2022 for inclusion of fitness and patient preferences. Discussions of patients with stage I-IV pancreatic cancer were identified for inclusion. These recordings were transcribed and analyzed using NVivo for recurring themes and exemplary quotes regarding how providers characterize patients’ fitness and present their preferences to the board. Results: Thirteen MDTB meetings including 50 individuals with stage I-IV pancreatic cancer were included. Descriptions of patient fitness largely consisted of the presentation of common demographic traits such as age and gender. Additional context, primarily focused on occupation, comorbidities, and patient attitudes, was provided when demographic information did not align with perceived fitness level; for example “He’s 60 years old. He’s actually very strong. He used to, or he does, work in landscaping”. There was no formal inclusion of GA data. Explicit references to patient preferences or agentive decision-making only occurred in 19 cases; 11 referring to the patient’s (non-)interest in clinical trials, 3 denying additional testing (tone suggesting non-compliance), and 7 specifically referring to treatment type preference (e.g. surgery vs. chemotherapy). Conclusions: At present, MDTB treatment discussions primarily rely on shared understandings of the cultural significance and meaning of various demographic traits and rarely reference patient-reported preferences or fitness when determining the best pathway for patient care. Further work is needed to understand how to better formally incorporate fitness and preferences into decision-making.

“It sounds very negative”: Patient perspectives on de-escalation of treatment concept and language

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Background: As the combination of systemic and targeted chemotherapies is associated with severe adverse side effects and long-term health complications, there is interest in reducing treatment intensity for patients with early-stage breast cancer (EBC). Currently, this approach is being described as “de-escalation,” though there is some concern that this language and framing are not well understood or preferred by patients. Methods: We collected qualitative interview data from twenty-four patients with Stage II-III breast cancer and sixteen patient advocates. Interviews explored interest in participation in clinical trials testing reduced amounts of chemotherapy, reactions to the word “de-escalation,” and preferred ways to describe this approach and its anticipated benefits. Interviews were audio-recorded and transcribed, and researchers used qualitative content analysis to code for dominant themes. Results: Twenty-three participants (57.5%) expressed interest in participating in a trial of reduced chemotherapy. However, 60% of participants had a negative response to the word “de-escalation,” including 78% of respondents that said they were interested in the concept. To describe this approach, respondents tend to prefer words like “personalization,” “optimization,” or “reduced chemotherapy.” Participants also expressed the importance of provider-patient communication, clear and simple language, sharing the decision-making process, and continued support throughout and after treatment in their consideration of trials testing lower amounts of chemotherapy. Conclusions: Among individuals with EBC, there is significant interest in alleviating treatment-related toxicity by reducing chemotherapeutic intensity. Patients are more apt to feel comfortable participating in trials testing this approach if they are framed in terms of customizing treatment to the individual patient and added benefit—reduced toxicities, higher quality of life during treatment and lower risk of long-term complications—rather than in terms of taking treatments away or doing less than the standard of care. “De-escalation” is not an ideal word to describe these trials as many associate this word with giving up in the war against cancer. Instead, participants prefer positive, patient-centered language. This information will be useful to providers in considering how best to describe de-escalation clinical trials to eligible patients in ways that avoid therapeutic misconception and facilitate the shared decision-making process regarding treatment.

Identification of target population in the implementation of navigator-delivered home ePRO for patients with cancer receiving treatment

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Background: One key challenge of practice transformation activities, such as remote symptom monitoring (RSM) using electronic patient reported outcomes (ePROs), is identification of patients starting treatment. In real-world settings, reliance on referrals is likely to miss patients. We describe the difficulties encountered in patient identification and the subsequent changes implemented in protocol to remediate this. Methods: We conducted two PDSA cycles focused on identification and engagement of patients for RSM at the Mitchel Cancer Institute (MCI). Target patient capture was > 75%. Modifications to the patient identification process were documented. Schedules of physicians participating in the RSM program were reviewed from 6/2021 – 5/2022 to identify eligible patients. Patients were considered eligible if they were starting chemotherapy, targeted therapy, or immunotherapy. Patients seeking a second opinion were excluded. Patient demographics, cancer type, cancer stage, and PROs were abstracted from electronic health records and the PRO platform (Carevive). Initial clinic roll-out was conducted in gynecologic oncology, with expansion to breast and thoracic oncology in 10/2021 and 3/2022, respectively. The proportion of eligible patients approached per month was reported.Results: In the first PDSA cycle, the eligibility criteria was defined. Although clinical trials included advanced disease, non-clinical staff screening expressed concern about determining advanced vs. early-stage disease. Thus, inclusion criteria was broadened to include all patients starting treatments. From 6/2021 –8/2021, navigators identified patients by screening patients who presented for chemo-education visits. The navigation team approached 23 patients during this period. However, this process didn’t identify all eligible patients as not all patients beginning treatment received chemo-education visits. In PDSA Cycle 2, the process for new patient contact from initial call for appointment through treatment was reviewed. The implementation team screened all patients in a physician’s schedule a week prior to the office visit as well as on the day of visit. This updated process identified all eligible patients starting either intravenous or oral chemotherapy. The recruitment process was modified to screen the physician schedules rather than chemo educator visits. From 9/2022-5/22, the proportion of eligible patients identified and approached remained high at 100%. This methodological screening process helped the navigation team identify all eligible patients in an efficient manner and they reported comfort in expanding to additional disease teams. Conclusions: Systematic screening of physician schedules can be successfully leveraged for patient identification and reduce time spent manually screening for eligible patients by non-clinical navigators. Clinical trial information: NCT04809740.

Sociodemographic difference in patients who enroll and decline remote symptom monitoring (RSM)

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Background: Remote symptom monitoring (RSM) using patient-reported outcomes has been shown to reduce symptom burden and hospitalizations in clinical trials. However, little is known about how willing patients are to participate in remote symptom monitoring in real-world settings, particularly for vulnerable patient populations. This study aims to compare characteristics of cancer patients enrolled vs. patients who declined enrollment into RSM. Methods: This prospective study used data that assessed the characteristics of patients who enrolled vs. patients who declined enrollment into RSM. Inclusion criteria included participants’ age ≥18 with cancer who received chemotherapy, targeted therapy, or immunotherapy at the University of Alabama at Birmingham. Race and ethnicity (Black or African American, White, Asian, other and unknown), sex, cancer type (breast, gastrointestinal [GI], genitourinary [GU], gynecological [GYNX], head and neck, leukemia, lymphoma, melanoma, myeloma and other), urban/rural residence, Area Deprivation Index (ADI), and insurance type (Medicaid, Medicare, none, other and private) were abstracted from electronic medical records (EMR) and PRO platform (Carevive). Descriptive statistics were calculated using frequencies and percentages for categorical variables and medians and interquartile ranges for continuous variables. Differences in enrollment status characteristics were calculated using measures of effect size such as Cramer’s V. Results: Of the 307 patients, two thirds of patients were female (71%); 25% were Black or African American and 66% were White patients; 15% lived in an area of higher disadvantage. For insurance, 46%, 26%, 10%, 8%, and 9% of patients had Private, Medicare, Medicaid, other insurance, and no insurance, respectively. The proportion of patients who declined enrollment was higher for males than females (22% vs. 10%), Black or African American than White (18% vs 13%); and having Medicare than private insurance (22% vs. 10%). Compared to those who enrolled, patients who declined enrollment were more often to be male (V:0.2), Black or African American (V:0.1); and have Medicare insurance (V:0.2). Patients enrolled vs. declined in RSM had similar ADI scores (V:0.01). Conclusions: This study demonstrates that potentially vulnerable patients, including Black patients and those with public insurance, have lower RSM engagement. Future analysis is needed to understand participation barriers and how to better engage diverse populations to ensure optimal healthcare delivery to all patients.

Academic and community physician perspectives on breast cancer biomarker use in clinical trials

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Background: Biomarkers are regularly utilized to select treatment within cancer clinical trials. However, there remains a lack of understanding regarding physician perspectives on what data is needed for physicians to comfortably use these markers to escalate or de-escalate chemotherapy. Methods: Semi-structured qualitative interviews with medical oncologists from different academic and community-based cancer centers were conducted to investigate perspectives on the utilization of biomarkers to de-escalate chemotherapy. Key topics explored included: (1) physician preference for biology-based (e.g. genomic profiles) vs. response-based (e.g. complete pathologic response) biomarkers, and (2) importance of personal familiarity with biomarkers. Interviews were audio-recorded and transcribed. Two independent coders analyzed transcripts using a constant comparative method in NVivo to identify major themes. Analysis was stratified by practice-type to elucidate differences between oncologists at academic and community practices. Results: Of the 39 participating physicians, 51% practiced in an academic setting and 49% practiced in a community setting. The majority of physicians (67% overall, 77% community, 59% academic) did not have a preference for biology-based vs. response-based biomarkers, if the data is equally strong and clinical use is appropriate for the clinical context (e.g. patient subtype). Many physicians were reassured by achieving a real-time therapeutic response, with 23% of physicians preferring response-based biomarkers. One physician stated, “I am still more comfortable with a real-time, well-validated biomarker, response marker, than I am with an overall predictive marker for a population”. In contrast, 10% (all academic) preferred biology-based biomarkers. One physician commented “I think the biology is probably more attractive because that potentially allows you to avoid treatment, whereas pathCR they've already had to get treatment to get there”. The majority of academic physicians (55%) felt that strong data was more important than personal familiarity with regards to implementation of novel biomarkers, as noted by one who stated, “As long as there's good data, I don't care.” 15% of community physicians shared a similar view. The majority of community physicians (54%) voiced familiarity to be more important in their comfort with biomarker use as noted by one physician who stated, “I think things I’m already familiar with, I'm more inclined to feel good about”. 18% of academic physicians held a similar perspective. Conclusions: Academic and community physicians’ perspectives regarding use of novel biomarkers overlap, with multiple factors playing a role in how these biomarkers are used in decision-making. Future research is needed to understand the impact of biomarker selection on clinical trial enrollment.

Trajectory of symptoms reported in remote symptom monitoring over the course of oncology treatment for gynecologic cancers

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Background: Patients now have the ability to utilize electronic patient reported outcomes (ePROs) for remote symptom monitoring (RSM). This analysis seeks to better understand trajectory of reported symptoms during treatment for patients with gynecologic cancer participating in RSM. Methods: We approached patients with gynecological cancer initiating treatment at the Mitchell Cancer Institute (MCI) between 7/1/21-4/30/2022. Patients were eligible if they were starting chemotherapy, targeted therapy, or immunotherapy for a new cancer. Patients seeking a second opinion were excluded. Enrolled patients received symptom survey (PRO-CTCAE questions) via text or email once per week. Initially, only severe alerts were forwarded to the clinical care team; moderate alerts were forwarded to clinical teams once they were comfortable with alert management. Patients completed symptom assessments for 24 weeks or until withdrawal. Patient age at enrollment, race, sex, cancer type, cancer stage, and PROs were abstracted from electronic health records and the PRO platform (Carevive). Descriptive statistics were calculated using frequencies and percentages for categorical variables and median and interquartile ranges (IQR) for continuous variables. Results: A total of 60 female patients with gynecological cancer were enrolled; 33% were Black or African American and 67% were White; median age was 61 years (IQR 53-68). Seventy-eight percent (47/60) of patients reported 379 symptoms with at least one moderate or severe alert during this time period; 32% considered moderate and 68% considered severe. Overall, the most frequently reported symptom was pain (29%). At baseline (week 0), 14% and 41% of 56 patients reported moderate symptoms and severe symptoms, respectively. Symptom burden decreased over time with 4% and 7% of 27 patients who completed a survey at 12 weeks reporting moderate and severe symptoms. Specific symptom trajectories followed similar patterns. Conclusions: In our sample, patients reported the majority of symptoms during the first three months of treatment. Symptom trajectory decreased with time, suggesting symptoms are being effectively monitored and addressed by the clinical teams engaging in RSM. Future research is needed to understand if symptom improvement translates to increased quality of life, decreased hospitalizations, and increased survival for patients, as well as lessen the burden of call volume on the clinical team.

Peeling back the curtain: The impact of patient and provider race on clinical trial enrollment

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Background: Optimization clinical trials testing less intense treatments are becoming more prominent in oncology due to the availability of better prognostic tools and targeted therapies. In addition to previously documented barriers, these trials are likely to face new barriers from engaging racially diverse populations due to the potential of an increased recurrence risk with reducing treatment. However, little is known about the role of race in decision-making for optimization clinical trials amongst physicians and patients. Methods: This qualitative study included a subset analysis on the influence of race in decision-making for participation in trials testing less chemotherapy. This analysis is part of a larger study, which included semi-structured interviews with patients, patient advocates, and physicians assessing barriers and facilitators to trial participation. Interviews were transcribed, and four coders evaluated transcripts for key themes and exemplary quotes using NVivo. Results: 79 participants (24 patients with breast cancer, 16 patient advocates, and 39 physicians) participated; 30% of patients and patient advocates and 26% of physicians were BIPOC (Black, Indigenous, and People of Color). Several key barriers traditionally associated with Black race were noted amongst both patients and physicians, including aggressive biology (e.g. triple negative breast cancer), younger age, socioeconomic challenges, and lack of trust in physicians and clinical trials. One physician noted, “Taking someone who already has a mistrust of medical care and talking to them about a trial of cutting medical care back, it’s challenging.” While some physicians explicitly acknowledged the role of race in decision-making, often linking race to these barriers, the majority of physicians independently highlighted these barriers while denying the explicit impact of race. Black patients noted similar barriers including emphasizing the role of having triple negative breast cancer, being young, the influence of financial strain, and medical mistrust. One Black patient commented, “I was a triple negative, and that kind was more prone to African American women, usually we don’t really survive from it as well as other races do.” Another Black woman commented, “I had a lot of family and friends that were worried that I was going to be a “guinea pig”. In contrast, White patients heavily emphasized the role of trust in their physicians when making decisions. A White woman stated the following, “I would have done whatever they (doctors) told me was the best thing to do.”. Conclusions: Factors associated with Black race can play both an overt and subconscious role in patient and provider decision-making about participation in optimization clinical trials. Multi-level interventions are needed to address these specific barriers to ensure representative participation in clinical trials for all patient populations.

Adaptation of remote symptom monitoring using electronic patient-reported outcomes for implementation in real-world settings

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Background: Despite evidence of clinical benefits, widespread implementation of remote symptom monitoring has been limited. We describe a process of adapting a remote symptom monitoring intervention developed in a research setting to a real-world clinical setting at two cancer centers. Methods: This formative evaluation assessed core components and adaptations to improve acceptability and fit of remote symptom monitoring using Stirman’s Framework for Modifications and Adaptations. Implementation outcomes were evaluated in pilot studies at the two cancer centers testing technology (Phase I) and workflow (Phase II and III) using electronic health data; qualitative evaluation with semi-structured interviews of clinical team members; and capture of field notes from clinical teams and administrators regarding barriers and recommended adaptations for future implementation. Results: Core components of remote symptom monitoring included electronic delivery of surveys with actionable symptoms, patient education on the intervention, a system to monitor survey compliance in real-time, the capacity to generate alerts, training nurses to manage alerts, and identification of personnel responsible for managing symptoms. In the pilot studies, while most patients completed > 50% of expected surveys, adaptations were identified to address barriers related to workflow challenges, patient and clinician access to technology, digital health literacy, survey fatigue, alert fatigue, and data visibility. Conclusions: Using an implementation science approach, we facilitated adaptation of remote symptom monitoring interventions from the research setting to clinical practice and identified key areas to promote effective uptake and sustainability.

Nursing strategies to improve alert closure for remote symptom monitoring

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Background: For successful remote symptom monitoring using patient-reported outcomes, nurses should respond to alerts in a timely fashion. Where clinical trials utilized research staff for alert management, the shift to standard-of-care delivery necessitates that this responsibility be added as a task to an already strained nursing workforce. Little is known about strategies to engage nurses to improve timeliness of alert management. Methods: In this quality improvement initiative, we aimed to improve timeliness of alert closures generated by moderate or severe symptoms within a remote symptom monitoring program. Optimal closure was defined as < 48 hours, which was consistent with institutional requirements for response to patient phone calls. A continuous quality improvement approach, with multiple Plan Do Study Act (PDSA) cycles was conducted. Data was captured from the electronic medical record and PRO platform (Carevive). Descriptive statistics included frequencies and percentages. The proportion of alerts closed each month < 48 hours, 48-72 hours, 3-7 days, and > 7 days were reported overall and by disease team (i.e., major cancer types). Surveys not closed were considered > 7 days. The timing of strategies to improve nursing engagement were documented and evaluated for impact on alert closure. Results: From June 1, 2021-May 31, 2022, 1121 moderate or severe alerts were generated from 234 patients. Disease teams had variable remote symptom monitoring start dates: breast, leukemia, and limited gynecologic (prior to 6/2021); myeloma and gastrointestinal (7/2021); genitourinary (10/2021); head and neck (12/2021); melanoma (2/2022); and Lymphoma (4/2022). In 6/2021, the overall alert closure at < 48 hours, 48-72 hours, 3-7 days, and > 7 days was 57%, 4%, 14%, and 25% respectively (n = 28). To improve alert closures, several key strategies were deployed to improve alert closure times including disease-specific reporting and meetings with nursing leadership (10/2021); identification of a nurse champion, creation of “cheat sheets” to remind nurses how to close alerts, and individualized calls with nurses with open alerts (1/2022), and inclusions of requirement to close alerts in nursing newsletters (2/2022). Overall, alert closure less than 48 hours improved to 61% by 12/2021 (n = 97) and to 69% by 5/2022 (n = 167). Disease group alert closure varied, with higher closure more commonly in teams with greater duration of use, such as breast cancer team with an alert closure of 85% < 48 hours in May 2022. Conclusions: Key nursing engagement strategies improve alert closure for remote symptom monitoring programs implemented in real-world settings.

Physician perspectives on extrapolating data from trials testing less-intense treatment to underrepresented populations

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Background: Clinical trials provide the foundation for evidence-based practices, yet trial participants are often not representative of all patients. Historically, clinical trials involved adding novel agents to standard of care to improve survival. There has been a shift to an individualized approach with testing less intense treatment, yet vulnerable patient groups are at risk for underrepresentation. Little is known about physician perspectives on implementing less intense treatment approaches for patients who are not represented in sufficient number to draw conclusions on subpopulations. Methods: Open-ended, individual qualitative interviews with medical oncologists from different cancer centers exploring their perspectives on trials that test less intense treatment for patients with cancer. Interviews were audio-recorded and transcribed. Four independent coders utilized a content analysis approach to analyze transcripts using NVivo. Major themes and exemplary quotes were extracted. Results: Of the 39 participating physicians, 61.5% felt comfortable extrapolating, 30.8% were hesitant, and 7.7% would not feel comfortable extrapolating trial outcomes to underrepresented populations. One physician noted, “We've been extrapolating for as long as I can remember and certainly that I've been in practice; so we do need to do better there, but extrapolation is only natural with what we have.” Facilitators of comfort included sentiment that “biology is biology”, such that the cancer characteristics were what mattered; the strength of the evidence from the trial overall; inclusion of subset analysis on underrepresented populations; and prior experience making decisions with limited data. Barriers to extrapolation included the potential harm over the patient’s lifetime; concerns about groups that had minimal participants; application specifically to younger patients; and extending findings to racially and ethnically diverse populations. Oncologists highlighted the need for shared decision-making when applying study results to underrepresented populations. They also expressed concerns about study findings being applied to patients who would have been ineligible in the original trials. Universally, broader inclusion in trials testing lowering chemotherapy is desired. Conclusions: The majority (92%) of physicians report that they would extrapolate clinical trial results to patients poorly represented in de-escalation trials, while expressing concerns about applicability to specific subpopulations based on tumor characteristics (e.g. stage, biology) and patient demographics (e.g. age, race). Further work is needed to increase clinical trial representation of diverse populations to safely and effectively optimize treatment for patients with cancer.

Hesitancy and malignancy: Vaccine hesitancy among individuals with cancer

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Background: The World Health Organization cited vaccine hesitancy as one of 2019’s top ten threats to global health, a threat that has been further exacerbated by COVID-19 pandemic. Existing COVID-19 vaccine hesitancy research focuses on the general population, but less is known about the specific concerns of medically vulnerable populations, including individuals with cancer. Methods: This cross-sectional analysis used data that assessed likelihood of COVID-19 vaccination (likely vs unlikely/unsure) among past or current patients with cancer from a nationwide survey administered in December 2020 by the Patient Advocate Foundation (PAF), a non-profit organization that provides case management and financial aid to patients diagnosed with a chronic illness. Inclusion criteria included previous or current cancer treatment, aged ≥ 19, and a valid e-mail address. Age, sex, race/ethnicity, and urban/rural residence were abstracted from the PAF database. Respondents self-reported education level, employment status, trust in media regarding COVID-19 pandemic, and media viewership on COVID-19 vaccine development. The Group-Based Medical Mistrust Scale assessed respondents’ level of mistrust in medical providers based on ethnicity. Likelihood of COVID-19 vaccine acceptance was evaluated using risk ratios (RR) and 95% confidence intervals (CI) from modified Poisson regression models with robust error variance. All variables were included in our model. Results: Of 429 respondents, 48% were unlikely/unsure about accepting the COVID-19 vaccine, primarily due to concerns about vaccine safety (32%) and worry about health conditions (12%). When compared to those likely to accept COVID-19 vaccine, respondents who were unlikely/unsure were more often Black, Indigenous, or People of Color (40% vs. 23%), aged 36-55 (40% vs. 29%), and female (80% vs. 65%). In adjusted analysis, Black respondents were 55% less likely to accept a COVID-19 vaccine, when compared to White respondents (RR 0.55; 95% CI 0.4-0.8). When compared to those who did not follow the media regarding COVID-19 vaccine development, those who followed the media very closely were 4.5 times more likely to accept a COVID-19 vaccine (RR 4.5; 95% CI 1.6-13.2). Respondents who reported below average trust in the media were 60% less likely to accept a COVID-19 vaccine (RR 0.6; 95% CI 0.5-0.8), compared to those who reported above average trust in the media. Conclusions: Despite being at high risk of COVID-19 morbidity and mortality, a substantial proportion of under-resourced individuals with cancer were unlikely/unsure about vaccination, exposing a significant disconnect between risk of severe disease and vaccine acceptance. Our analysis also reveals a need to assess for and debunk misinformation to increase vaccine enthusiasm among medically vulnerable populations.

Australian women's perceptions and practice of sleep position in late pregnancy: An online survey

BACKGROUND

Going-to-sleep in the supine position in later pregnancy (≥28 weeks) has been identified as a risk factor for stillbirth. Internationally, public awareness campaigns have been undertaken encouraging women to sleep on their side during late pregnancy.

AIM

This study aimed to identify sleep practices, attitudes and knowledge in pregnant women, to inform an Australian safe sleeping campaign.

METHODS

A web-based survey of pregnant women ≥28 weeks' gestation conducted from November 2017 to January 2018. The survey was adapted from international sleep surveys and disseminated via pregnancy websites and social media platforms.

FINDINGS

Three hundred and fifty-two women participated. Five (1.6%) reported going to sleep in the supine position. Most (87.8%) had received information on the importance of side-sleeping in pregnancy. Information was received from a variety of sources including maternity care providers (186; 66.2%) and the internet (177; 63.0%). Women were more likely to report going to sleep on their side if they had received advice to do so (OR 2.3; 95% CI 1.0-5.1). Thirteen (10.8%) reported receiving unsafe advice, including changing their going-to-sleep position to the supine position.

DISCUSSION

This indicates high level awareness and practice of safe late-pregnancy going-to-sleep position in participants. Opportunities remain for improvement in the information provided, and understanding needs of specific groups including Aboriginal and Torres Strait Islander women.

CONCLUSION

Findings suggest Australian women understand the importance of sleeping position in late pregnancy. Inconsistencies in information provided remain and may be addressed through public awareness campaigns targeting women and their care providers.

Abstract PD3-10: Patient perspectives on chemotherapy de-escalation: “Don’t de-escalate! I don’t want to die!”

Introduction: Given excellent survival outcomes in breast cancer and new methods to predict treatment response, oncologists are interested in de-escalating the amount of chemotherapy delivered to patients. This is particularly important in the setting of COVID-19, where patient perspectives of de-escalation may be altered by perception of COVID-19 risk.Methods: This concurrent mixed methods study included (1) semi-structured interview data from patients with breast cancer treated at the University of Alabama at Birmingham and patient advocates from nationally representative advocacy organizations (10/2019-5/2020) and (2) cross-sectional survey data from a nationwide sample of women with breast cancer (11/19-12/2019). Questions evaluated interest in de-escalation study participation, perceived barriers/facilitators to participation, and language describing de-escalation. Participant perspectives surrounding COVID-19 impact on de-escalation were elicited in interviews post 3/2020.Results: Quantitative and qualitative findings were synergistic. Interviews were conducted with 40 female participants (24 patients, 16 patient advocates). Participant ages ranged from 33-79 years old; 30% were minorities; 35% didn’t have a college degree. Common barriers to acceptance of de-escalation included fear of recurrence, worry about decision regret, lack of clinical trial interest, and dislike for the focus on less treatment. Fear of recurrence was the most commonly expressed barrier, with one participant stating, “I’m just afraid it wouldn’t get it all”. Common facilitators included trust in the physician, toxicity avoidance, monitoring with the option of increasing treatment intensity, perception of good prognosis, and impact on daily life. Participants interviewed during the COVID-19 pandemic (n=16) expressed substantial virus-related fear, including fear of exposure, fear of infecting their personal contacts or health care team, fear of cancer-related complications, and fear about their immunocompromised state. These fears contributed to participants perspective on de-escalation, as highlighted by participants stating, “I wouldn't worry about getting the chemo as much as I would worry about getting the virus” and “Less is more for me right now”.Of 91 survey respondents (69% response rate), median age was 58 years (interquartile range [IQR] 48-69), 86% had early stage breast cancer. Many (43%) patients were not interested in participation in a study testing lower doses of chemotherapy than standard of care. Patients not interested in participating were more often unmarried (55% vs. 32%, V=.23), disabled (56% vs. 40%, V=.17), or diagnosed with early stage cancer (45% vs. 22%, V=.14). Barriers to participation included fear of cancer recurrence (85%) and regret about the decision to receive less chemotherapy if the cancer were to recur (79%). Few patients (19%) considered clinical trials themselves as a barrier. Patients were interested in participation due to lessened physical side effects of treatment (82%), lessened long-term problems related to treatment (76%), and lessened impact on daily life (72%). The most popular terminology describing chemotherapy de-escalation was “lowest effective chemotherapy dose” (53%); no patients preferred the term “de-escalation.”

Conclusion: Fear of recurrence is a common barrier to de-escalation clinical trial participation in patients with breast cancer. Fears may be altered for patients considering treatment during the COVID-19 pandemic. Trust in the physician and use of patient-generated language, such as “customized” instead of “de-escalation”, are potential areas for future interventions engaging patients in trials.

Citation Format: Gabrielle Rocque, Courtney P. Williams, Courtney J. Andrews, Kathleen Gallagher, Timothy C. Childers, Kimberly D. Wiseman, Alan Balch, Stacey A. Ingram, Thelma Brown, Tara Kaufman, Nadine Tung, Mary Lou Smith, Antonio C. Wolff, Angela DeMichele, Lynn Wagner. Patient perspectives on chemotherapy de-escalation: “Don’t de-escalate! I don’t want to die!” [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD3-10.

Implementation and evaluation of a quality improvement initiative to reduce late gestation stillbirths in Australia: Safer Baby Bundle study protocol

BACKGROUND

In 2015, the stillbirth rate after 28 weeks (late gestation) in Australia was 35% higher than countries with the lowest rates globally. Reductions in late gestation stillbirth rates have steadily improved in Australia. However, to amplify and sustain reductions, more needs to be done to reduce practice variation and address sub-optimal care. Implementing bundles for maternity care improvement in the UK have been associated with a 20% reduction in stillbirth rates. A similar approach is underway in Australia; the Safer Baby Bundle (SBB) with five elements: 1) supporting women to stop smoking in pregnancy, 2) improving detection and management of fetal growth restriction, 3) raising awareness and improving care for women with decreased fetal movements, 4) improving awareness of maternal safe going-to-sleep position in late pregnancy, 5) improving decision making about the timing of birth for women with risk factors for stillbirth.

METHODS

This is a mixed-methods study of maternity services across three Australian states; Queensland, Victoria and New South Wales. The study includes evaluation of 'targeted' implementer sites (combined total approximately 113,000 births annually, 50% of births in these states) and monitoring of key outcomes state-wide across all maternity services. Progressive implementation over 2.5 years, managed by state Departments of Health, commenced from mid-2019. This study will determine the impact of implementing the SBB on maternity services and perinatal outcomes, specifically for reducing late gestation stillbirth. Comprehensive process, impact, and outcome evaluations will be conducted using routinely collected perinatal data, pre- and post- implementation surveys, clinical audits, focus group discussions and interviews. Evaluations explore the views and experiences of clinicians embedding the SBB into routine practice as well as women's experience with care and the acceptability of the initiative.

DISCUSSION

This protocol describes the evaluation of the SBB initiative and will provide evidence for the value of a systematic, but pragmatic, approach to strategies to reduce the evidence-practice gaps across maternity services. We hypothesise successful implementation and uptake across three Australian states (amplified nationally) will be effective in reducing late gestation stillbirths to that of the best performing countries globally, equating to at least 150 lives saved annually.

TRIAL REGISTRATION

The Safer Baby Bundle Study was retrospectively registered on the ACTRN12619001777189 database, date assigned 16/12/2019.

Survey of Australian maternity hospitals to inform development and implementation of a stillbirth prevention 'bundle of care'

BACKGROUND

'Bundles of care' are being implemented to improve key practice gaps in perinatal care. As part of our development of a stillbirth prevention bundle, we consulted with Australian maternity care providers.

OBJECTIVE

To gain the insights of Australian maternity care providers to inform the development and implementation of a bundle of care for stillbirth prevention.

METHODS

A 2018 on-line survey of hospitals providing maternity services included 55 questions incorporating multiple choice, Likert items and open text. A senior clinician at each site completed the survey. The survey asked questions about practices related to fetal growth restriction, decreased fetal movements, smoking cessation, intrapartum fetal monitoring, maternal sleep position and perinatal mortality audit. The objectives were to assess which elements of care were most valued; best practice frequency; and, barriers and enablers to implementation.

RESULTS

227 hospitals were invited with 83 (37%) responding. All proposed elements were perceived as important. Hospitals were least likely to follow best practice recommendations "all the time" for smoking cessation support (<50%), risk assessment for fetal growth restriction (<40%) and advice on sleep position (<20%). Time constraints, absence of clear guidelines and lack of continuity of carer were recognised as barriers to implementation across care practices.

CONCLUSIONS

Areas for practice improvement were evident. All elements of care were valued, with increasing awareness of safe sleeping position perceived as less important. There is strong support from maternity care providers across Australia for a bundle of care to reduce stillbirth.

Using weather indices to predict survival of winter wheat in a cool temperate environment

Seven years of winter survival data for winter wheat ( Triticum aestivum L.) were collected on a loam soil located on the Central Experimental Farm at Ottawa, Ontario (45 degrees 23'N, 75 degrees 43'W). The site was low-lying and subject to frequent winter flooding and ice-sheet formation. Two cultivars, a soft white and a hard red winter wheat, were planted in September. Crop establishment was measured in late fall and the percentage survival was measured in April of the following year. Meteorological data, which were available from the nearby weather site, were used to develop a large set of monthly weather indices that were felt to be important for winter survival. The objective of the study was to use genetic selection algorithms and artificial neural networks to select a subset of critical weather factors and topographic features and to model winter survival. The six weather indices selected were the total rain depth for December (mm), the total rain depth for February (mm), the number of days of the month with snow on the ground for January, the extreme minimum observed daily air temperature for March ( degrees C), the number of days of the month with snow on the ground for March, and the number of days of April with a daily maximum air temperature greater than 0 degrees C. It was found 89% of the variation in winter survival could be explained by these six weather indices, the cultivar, elevation and plot location.

Endothelin-1 expression in long-term cultures of fetal rat calvarial osteoblasts: regulation by BMP-7

Endothelin-1 (ET-1) is a vasoactive peptide that modulates bone metabolism via regulatory effects on osteoblasts, chondrocytes, and osteoclasts. While ET-1 may circulate in the blood stream, tissue-specific expression of this peptide is more physiologically relevant. In the present study we measured ET-1 synthesis in sections of fetal rat calvaria (FRC) and in cultured FRC osteoblasts. Regulation of ET-1 synthesis in FRC osteoblasts by bone morphogenetic protein-7 (BMP-7) and transforming growth factor-beta1 (TGF-beta1) also was examined. Immunohistochemical analysis revealed ET-1 staining in calvarial osteoblasts, endothelial cells, and osteocytes. ET-1 mRNA expression was detected in cultured FRC cells and ET-1 peptide was present in conditioned media. During long-term culture of FRC cells (26 days) ET-1 peptide production rose sharply and peaked during the time of cellular proliferation (Days 0-3) then returned to baseline levels by Day 18, when mineralized nodules were forming. Treatment of FRC cells with BMP-7 enhanced ET-1 levels by three-fold on Day 3 and enhanced nodule formation by 15-fold on Day 26. To determine whether ET-1 was involved in an autocrine manner in BMP-7-induced nodule formation, cells were cultured in the presence of BMP-7 and BQ-123, an ET(A) receptor antagonist. BQ-123 had no effect on nodule formation in control or BMP-7-treated cells, indicating that osteoblast-derived ET-1 regulates other cell types in vivo during the bone formation process.

Cloning and characterization of glyoxalase I from soybean

Glyoxalase I and glutathione transferase (GST) are two glutathione-dependent enzymes which are enhanced in plants during cell division and in response to diverse stress treatments. In soybean, a further connection between these two enzymes has been suggested by a clone (Accession No. X68819) resembling a GST being described as a glyoxalase I. To characterize glyoxalase I in soybean, GmGlyox I resembling the dimeric enzyme from animals has been cloned from a cDNA library prepared from soybean suspension cultures. When expressed in Escherichia coli, GmGlyox I was found to be a 38-kDa dimer composed of 21-kDa subunits and unlike the enzyme from mammals showed activity in the absence of metal ions. GmGlyox I was active toward the hemithioacetal adducts formed by reacting methylglyoxal, or phenylglyoxal, with glutathione, homoglutathione, or gamma-glutamylcysteine, showing no preference for homoglutathione adducts over glutathione adducts, even though homoglutathione is the dominant thiol in soybean. When the clone X68819 was expressed in E. coli, the respective recombinant enzyme was active as a GST rather than a glyoxalase and was termed GmGST 3. GmGST 3 was active as a homodimer (45 kDa) composed of 26-kDa subunits and showed a preference for glutathione over homoglutathione when conjugating 1-chloro-2,4-dinitrobenzene. Both enzymes are associated with cell division in soybean cultures, but GmGST 3 (0.4% total protein) was 40 times more abundant than GmGlyox I (0.01%).

An open, randomized comparison of alfentanil, remifentanil and alfentanil followed by remifentanil in anaesthesia for craniotomy

We studied 52 adults undergoing elective craniotomy, allocated randomly to one of three opioid treatments: alfentanil 50 micrograms kg-1 followed by 0.833 microgram kg-1 min-1 until dural closure (group Alf.); alfentanil 50 micrograms kg-1 followed by 0.833 microgram kg-1 min-1 for 2 h, then remifentanil 0.25 microgram kg-1 min-1 (group Alf.-Remi.); or remifentanil 1 microgram kg-1 followed by 0.5 microgram kg-1 min-1 reducing to 0.25 microgram kg-1 min-1 after craniotomy (group Remi.). Anaesthesia was maintained with infusion of propofol and 66% nitrous oxide in oxygen. Infusions of propofol and remifentanil were stopped at head bandaging. Group Remi. had the least intraoperative haemodynamic responses and group Alf. the most (P < 0.05). Times to tracheal extubation and obey commands were similar in all groups. In all patients in group Alf.-Remi. and group Remi., the trachea was extubated 27 min from the end of anaesthesia; three patients in group Alf. were slower to recover. Use of analgesia in the recovery room and time to transfer to the neurosurgical unit were similar in the three groups.

Administration to humans of ORG 21465, a water soluble steroid i.v. anaesthetic agent

Ten male volunteers received a 1-min i.v. infusion of a new water soluble steroid anaesthetic agent, ORG 21465. Individuals received doses ranging from 0.8 to 1.8 mg kg-1. All subjects experienced venous pain at the site of injection; those receiving 1.0 mg kg-1 or more became anaesthetized. There was no evidence of histamine release and apnoea did not occur. Excitatory phenomena were observed in all subjects and were dose related; no spikes were seen on the EEG. Pharmacokinetic analysis supported a three-compartment (non-weight-related) model with compartmental volumes V1, V2 and V3 of 4.31, 14.2 and 89.4 litre, respectively. Clearance from the central compartment V1 was 1.55 litre min-1. Inter-compartmental clearances Q1 and Q2 were 2.54 and 1.79 litre min-1. We found that ORG 21465 was an effective anaesthetic in humans. The relationship between sedation, anaesthesia and excitation requires further exploration.

Substrate and thiol specificity of a stress-inducible glutathione transferase from soybean

An RT-PCR-derived clone encoding a stress-inducible glutathione transferase (GSTGm1) from soybean has been overexpressed in E. coli. The enzyme was active as the dimer GSTGm1-1 and showed GST and glutathione peroxidase activity toward diverse xenobiotics, including analogues of natural stress-metabolites. The selective herbicides, fomesafen and acifluorfen, were conjugated more actively with homoglutathione (hGSH), the major thiol in soybean, than with glutathione (GSH). No thiol preference was shown with the related herbicide, fluorodifen, while GSH was preferred with metolachlor and most non-herbicide substrates. Similar thiol-dependent specificities were observed in GST preparations from plants of varying GSH/hGSH content.

Telephone-related lightning injury

OBJECTIVE

To review reported telephone-related lightning injuries, outline the mechanisms of injury and suggest treatment strategies.

DATA SOURCES

Cases notified to Telecom Australia and an extensive search of the literature.

DATA SYNTHESIS

There is a dearth of literature on telephone-related lightning injury. Some reports note it in passing, others describe single incidents. Case reports from Australia provide detail sufficient for review, and the general principles which govern management of such injuries are presented.

CONCLUSION

Telephone-related lightning injury is not rare. Practitioners should be aware of the uniqueness of lightning injury and the complexity of its assessment. A research program aimed at further elucidation of the detail of this injury is proceeding.

Metabolic acclimation to hypoxia in winter cereals : low temperature flooding increases adenylates and survival in ice encasement

Cold hardened seedlings of winter wheat (Triticum aestivum L. em Thell) show an hypoxic hardening response: an exposure to low temperature flooding increases the tolerance of plants to a subsequent ice encasement exposure. Seedlings of winter barley (Hordeum vulgare L.) do not show such a response in similar experimental conditions. During ice encasement, there are general declines in adenylate energy charge (AEC), total adenylates and ATP:ADP ratios in the crown tissues of two winter wheat cultivars, and a winter barley, but rates of decline are faster in the barley. When the ice period is preceded by low temperature flooding of the whole plant, levels of the adenylate components are raised significantly in the wheats, and to a lesser extent in the barley. The survival of plants in ice preceded by flooding is related to the increased initial level of adenylates at the onset of the ice encasement stress, and the maintenance of higher levels of adenylates and ATP in the early stages of ice encasement as a result of accelerated rates of glycolysis. Higher survival of both winter wheat and barley plants during ice encasement in the light is also associated with significantly higher levels of AEC and adenylates in the early stages of ice encasement.

Telephone-mediated lightning injury: an Australian survey

Each year in Australia, about 60 people report injuries attributable to lightning surges while using a telephone during nearby thunderstorms. This paper presents information about such incidents and describes a retrospective survey of more than 300 telephone users reporting injuries possibly attributable to lightning. Questionnaires yielded 132 usable responses, and the results were analysed to identify the extent and nature of the lightning injuries. These are compared with direct strike injuries. Three distinct telephone-mediated lightning strike syndromes are identified (statistically) among the victims.

Congenital malaria in Papua New Guinea

The incidence of malarial infection in pregnant women at delivery, their corresponding infants and umbilical cords and a control group of non-pregnant women were investigated in the Madang region of Papua New Guinea. Anti-malarial antibody titres were measured in maternal and paired cord sera. Parasitaemia occurred in 18/73 (24.7%) of non-pregnant females compared with 15/51 (29.4%) of pregnant females. Malarial parasites were found in 7/48 (14.6%) cord blood samples and in 4/52 (7.7%) samples of the infant's peripheral blood, indicating transplacental transmission. Infection with Plasmodium falciparum was commoner in pregnant than non-pregnant females, and accounted for all the cord and infant infections. A significant correlation was found between anti-malarial IgG antibodies in paired maternal and cord bloods. There was an association between umbilical cord infection and low levels of cord antibody. Clinical malaria developed in at least one out of the 7 cases in which placental transfer of parasites was known to have occurred. This study suggests that transfer of parasites across the placenta is a common event in Papua New Guinea. Further consideration should be given to treatment with anti-malarial drugs of infants with cord or peripheral blood parasitaemia or, indeed, of all infants of mothers with parasitaemia.

Changes in adenine nucleotides and energy charge in isolated winter wheat cells during low temperature stress

Adenylate energy charge (AEC) and adenine nucleotide levels of isolated winter wheat (Triticum aestivum L. cv Kharkov 22 MC) cells exposed to various low temperature stresses were determined. During ice encasement at -1 degrees C, nucleotide levels decreased gradually in approximate relation to a decline in cell viability. AEC values remained high even after 5 weeks of icing when cell viability was severely reduced. When isolated cell suspensions were exposed to various cooling and freezing regimes ranging from -10 to -30 degrees C, cell damage was dependent on the minimum temperature imposed and the duration of exposure to the freezing stress. The levels of all three adenine nucleotides declined with increasing severity of the imposed stress, but AEC values remained high even at -30 degrees C when nearly all of the cells were killed. The addition of 10 millimolar Ca(2+) to cell suspensions enhanced survival during low temperature stresses, but did not influence nucleotide levels other than through its effect on cell viability. These results indicate that impairment of the ion transport system during the early stages of ice encasement prior to a detectable decline in cell viability cannot be attributed to changes in the adenylate energy charge system of the cell.

Effect of low temperature and calcium on survival and membrane properties of isolated winter wheat cells

Isolated cells obtained by enzymic digestion of young primary leaves of cold-hardened, dark-grown Kharkov winter wheat (Triticum aestivum L.) were exposed to various low temperature stresses. The initial uptake of (86)Rb was generally decreased by increasing concentrations of Ca(2+), but after longer periods of incubation, the inhibiting effect of high Ca(2+) levels diminished. Viability of isolated cells suspended in water declined rapidly when ice encased at -1 degrees C, while in the presence of 10 millimolar Ca(2+) viability declined only gradually over a 5-week period. Ice encasement markedly reduced (86)Rb uptake prior to a significant decline in cell viability or increased ion efflux. Cell damage increased progressively when the icing temperature was reduced from -1 to -2 and -3 degrees C, but the presence of Ca(2+) in the suspending medium reduced injury. Cell viability and ion uptake were reduced to a greater extent following slow cooling than after rapid cooling to subfreezing temperatures ranging from -10 to -30 degrees C. The results from this study support the view that an early change in cellular properties due to prolonged ice encasement at -1 degrees C involves the ion transport system, whereas cooling to lower subfreezing temperatures for only a few hours results in more general membrane damage, including loss of semipermeability of the plasma membrane.

Physiological and metabolic responses of winter wheat to prolonged freezing stress

Survival and cold hardiness declined gradually when cold-hardened Fredrick winter wheat (Triticum aestivum L.) was maintained at -6 degrees C for several weeks. Moisture content of crown and root tissue did not change significantly during this period. Uptake of O(2) and accumulation of (86)Rb by root tissue declined abruptly upon exposure to -6 degrees C, whereas a concomitant negative effect of freezing on these metabolic processes was not observed in crown tissue. Electron spin resonance spectroscopic analysis of microsomal membrane preparations from crown tissue revealed no evidence of gross changes in the physical properties of the bulk lipids even when seedlings were killed. The results provide biochemical evidence that seedling damage due to prolonged exposure to a mild freezing stress is due to disruption of key metabolic process in the root while cells within the crown remain viable.

Ventilatory effects of nitrous oxide during continuous infusion of fentanyl or alfentanil

Two groups of eight patients received infusions of either fentanyl at 3 micrograms kg-1 h-1 or alfentanil at 20 micrograms kg-1 h-1 as supplements to 66% N2O in oxygen anaesthesia, during and after body surface surgery. At the end of surgery, the N2O was reduced to 50% and after measurement of ventilatory frequency, minute ventilation, and the ventilatory response to carbon dioxide, N2O was discontinued. The opioid infusions were continued for a further hour and the ventilatory measurements repeated. Both sets of measurements were compared with preoperative values. Minute ventilation (P less than 0.01), frequency (P less than 0.01) and the response to carbon dioxide (P less than 0.01) were reduced during the infusion of fentanyl with N2O; with fentanyl alone, minute ventilation (P less than 0.05) and the response to carbon dioxide (P less than 0.01) were reduced but to a lesser degree. The elimination of nitrous oxide from the inspired gas mixture produced an increase in frequency (P less than 0.05) and increases in the slope (P less than 0.01) and ventilation at 7.3 kPa (P less than 0.025) of the carbon dioxide response curve. Minute ventilation (P less than 0.01) frequency (P less than 0.05) and response to carbon dioxide (P less than 0.01) were all reduced during the infusion of alfentanil with nitrous oxide; with alfentanil alone, minute ventilation (P less than 0.01), tidal volume (P less than 0.05), the slope (P less than 0.025) and the ventilation at 7.3 kPa (P less than 0.01) of the carbon-dioxide response curve were still reduced.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficiency of cold hardiness induction by desiccation stress in four winter cereals

A number of defined desiccation treatments without low temperature exposure were able to induce freezing tolerance in 20 cultivars of winter cereals. A maximal degree of freezing tolerance was induced in epicotyls at 24 degrees C in 24 hours at 40% relative humidity in rye and wheat, 7 days at 54% RH in barley, and 4 days at 70% RH in oats. Freezing tolerance was not correlated to water content of the plants after desiccation treatment but was related to the genetic capacity of the cultivars to frost harden. Levels of freezing tolerance induced by desiccation were similar to those induced by cold acclimation in rye and wheat, but considerably less in barley and oats. This is associated with a more rapid desiccation injury in barley and oats, precluding the completion of the hardening process.

Dose-response relationships for infusions of Althesin or methohexitone

A technique is described for the determination of equipotent rates of infusion of intravenous hypnotic agents. Two end points have been defined; the rates needed to suppress the initial response to the surgical incision in 50% (ED50) and 95% (ED95) of patients receiving continuous infusion anaesthesia to supplement 67% nitrous oxide in oxygen. For patients aged 20-60 years, and premedicated with morphine 0.15 mg/kg intramuscularly, the ED50 values for Althesin (as alphaxalone) and methohexitone by infusion were 13.7 and 48.8 micrograms/kg/minute respectively. The ED95 values were 18.1 and 75.9 micrograms/kg/minute. For patients of a similar age premedicated with diazepam 10 mg orally, the ED50 values for Althesin and methohexitone were 18.5 and 66.0 micrograms/kg/minute respectively; while the ED95 values were 24.2 and 80.8 micrograms/kg/minute.

Interactions among Flooding, Freezing, and Ice Encasement in Winter Wheat

Exposure of winter wheat (Triticum aestivum L.) to various combinations of flooding and freezing stresses induces much greater damage than the individual stresses. Cold-hardened plants flooded for 1 week or exposed to -6 degrees C for 1 week show 100% survival, while survival of plants exposed to both stresses simultaneously is reduced by 20 to 30%, and cold hardiness decreases by several degrees. The level of nonstructural carbohydrates increases in crown tissue during cold acclimation, but decreases when the plants are exposed to flooding or to -6 degrees C for 1 week. The respiratory capacity of crown tissue segments declines when the plants are stressed. Uptake of (86)Rb by the roots of intact seedlings declines after exposure to either freezing or flooding, whereas passive efflux of amino acids is observed after freezing but not following flooding. This study has shown that detectable stress-induced metabolic changes occur in winter wheat before the applied stress is severe enough to reduce survival.

Membrane properties of isolated winter wheat cells in relation to icing stress

Isolated cell preparations of winter wheat (Triticum aestivum L.) were utilized to examine the effect of ice encasement at -1 degrees C and exposure to ethanol on metabolic and biochemical properties of cells. Following icing and ethanol treatments, passive efflux of amino acids increased gradually with duration of exposure to the stress, and closely paralleled the decline in viability of cells. In contrast, uptake of (86)Rb declined much more rapidly than viability following exposure to icing or ethanol. Electron spin resonance spectroscopy studies revealed no significant change in molecular ordering within the cell membranes following icing or exposure to ethanol, whereas a small but significant increase in order was detected in the noniced controls. O(2) consumption by isolated cells declined only gradually due to icing and ethanol treatments, and remained relatively high even when cell viability was severely reduced. These results indicate that the plasma membrane is a primary site of injury during ice encasement and that damage to the ion transport system is the earliest manifestation of this injury.

Refractive changes in children under general anesthesia

Twenty-five pediatric patients were refracted without topical cycloplegic agents following induction of halothane anesthesia. Comparison of the intraoperative refraction with a preoperative, outpatient, cycloplegic refraction revealed a variable increase in myopia ranging from 0.25 to 5.50 diopters under general anesthesia. Several patients showed a significant asymmetry in myopic shift between fellow eyes, suggesting that a central accommodative mechanism may not be entirely responsible for the refractive changes observed.

Ultrastructural and Enzymic Studies of Cell Membranes from Ice-encased and Noniced Winter Wheat Seedlings

A marked increase in the amount of cisternal-like cytoplasmic membranes was observed after ice encasement of winter wheat (Triticum aestivum L.) seedlings. Linear sucrose gradients were employed to separate the various membrane components of the microsomal membrane fraction. NADH- and NADPH-cytochrome c reductase, two specific enzyme markers for plant endoplasmic reticulum (ER) were used to locate the ER in the linear gradients. The identity of the ER fraction was confirmed by determining the effect of EDTA and Mg(2+) in the preparative media on the distribution of NADH- and NADPH-cytochrome c reductase activity within the gradient. In the presence of EDTA which dissociates ribosomes from ER, peaks of activity for the two enzymes were observed at a density corresponding to that for "smooth" ER. When the media also contained an appropriate concentration of Mg(2+) to maintain the attachment of ribosomes to the ER, the peaks of activity for the enzymes shifted to a density corresponding to that for "rough" ER. NADH-cytochrome c reductase activity was similar for 24 C-grown and 2 C-grown iced seedlings, but significantly lower for 2 C noniced seedlings. No preferential increase in uptake of radioactive leucine or choline in the ER was observed during ice encasement. The accumulation of electron microscopically visible membrane arrays was not inhibited by the presence of protein synthesis inhibitors at concentrations which severely inhibited incorporation of [1-(14)C]leucine into membrane protein, but did not affect survival and growth of the seedlings. These observations indicate that the apparent proliferation of ER during ice encasement does not result from net membrane synthesis, but rather from reorganization of existing membrane elements within the cell.

Metabolic and ultrastructural changes associated with flooding at low temperature in winter wheat and barley

Cold-hardened winter wheat (Triticum aestivum L. cv. Fredrick) and winter barley (Hordeum vulgare L. cv. Dover) were exposed to total flooding at 2 C. Dover seedlings were damaged more quickly than Fredrick, and after 3 weeks of flooding the survival of Dover was reduced to 10% and Fredrick to about 50%. Tissue moisture was slightly greater in Dover than Fredrick throughout the 4-week flooding period. Carbon dioxide and ethanol accumulated throughout the 4-week flooding period in both cultivars. Lactic acid increased rapidly during the 1st week of flooding, and remained relatively constant during the remainder of the flooding period. Oxygen consumption of seedling shoot tissue after exposure to flooding declined abruptly after only 1 day of flooding, but recovered somewhat during the subsequent 2 weeks. The effect of flooding was more pronounced on the ultrastructure of Dover than Fredrick. Although proliferation of endoplasmic reticulum was observed in the early stages of flooding in both cultivars, the occurrence of distinct parallel arrays and concentric whorls of membranes was prevalent in the flooded barley. Severe ultrastructural damage to a large proportion of apical cells in both cultivars was observed after 2 to 3 weeks of flooding.

Toxicity of Anaerobic Metabolites Accumulating in Winter Wheat Seedlings during Ice Encasement

Ice encasement damages cold-hardened winter wheat without major disruption of cellular organelles. CO(2) accumulates during total ice encasement to higher levels in Kharkov than in less hardy Fredrick wheat. Partial ice encasement and exposure to a nitrogen atmosphere at -1 C allows greater CO(2) accumulation but neither treatment is as damaging as total ice encasement. Lactic acid accumulates to low levels only during the 1st day of encasement and thereafter remains constant. Exposure of plants to a combination of 50% CO(2) and 5% ethanol reduces survival, with a cultivar difference similar to that found in ice-encased plants. Plants in CO(2) and ethanol show a proliferation of membranes and nuclear condensation similar to that in cells of ice-encased plants. Permeability increases markedly in the presence of CO(2) and ethanol, to levels similar to or greater than those of iced plants. Ethanol alone does not increase permeability but in combination with CO(2) raises permeability of the less hardy Fredrick, although not of Kharkov, but reduces survival of both cultivars. A comparison of the endogenous levels of ethanol, CO(2), and lactic acid at the 50% kill point of plants due to ice encasement or due to externally supplied metabolite indicates that only CO(2) accumulates to independently toxic levels. Permeability and ultrastructural evidence suggest that CO(2) and ethanol in combination are the agents reducing plant viability during ice encasement.

The relation between structure and function of bile ducts in man, some laboratory animals and the Adelie penguin

The biliary trees of man, dog, cat, rabbit, rat, guinea pig and penguin were examined in histological sections and by latex casts. The trees of man, dog, and cat were similar with only minor differences. Tubulo-alveolar glands were present in all three species around large intrahepatic ducts and in large portal tracts there were zones of ductules (areas with many small bile ducts), surrounded by small vessels with no apparent relation to hepatocytes. Both these features were present in the guinea pig and tubulo-alveolar glands were present in the penguin liver. The biliary epithelium of the rat was comparatively simple but that of the rabbit appeared to be highly specialized. An estimation of the complexity of the biliary tree was obtained in the mammals by comparing the circumference of small portal venous branches with the circumference of the accompanying bile ducts, and obtaining a ratio. Man, dog, and cat had fewer and smaller bile ducts than the other species. The literature on the rate of formation and composition of bile in the species studied here was reviewed and it appears that the physiology of bile secretion can be related to the morphology of the biliary tree.

Metabolic and Ultrastructural Changes in Winter Wheat during Ice Encasement Under Field Conditions

The effect of ice encasement on the physiological, metabolic, and ultrastructural properties of winter wheat (Triticum aestivum L.) grown under field conditions was examined by artificially encasing winter wheat in ice during early winter. Cold hardiness and survival of ice-encased seedlings declined less rapidly in Kharkov, a cold-hardy cultivar than in Fredrick, a less hardy cultivar. Ethanol did not accumulate in non-iced seedlings, but increased rapidly upon application of an ice sheet. Lactic acid accumulated in both cultivars during late autumn, prior to ice encasement, and elevated levels of lactic acid were maintained throughout the winter in seedlings from both iced and non-iced plots. The rate of O(2) consumption of shoot tissue of seedlings from non-iced plots remained relatively constant throughout the winter, but declined rapidly in seedlings from ice encased plots. Major ultrastructural changes did not occur in shoot apex cells of non-iced winter wheat seedlings during cold hardening under field conditions. However, the imposition of an ice cover in early January resulted in a proliferation of the endoplasmic reticulum membrane system of the cells, frequently resulting in the formation of concentric whorls of membranes, often enclosing cytoplasmic organelles. Electrondense areas within the cytoplasm which appeared to be associated with the expanded endoplasmic reticulum were also frequently observed.

Spontaneous and bile salt stimulated bile secretion in the Adelie penguin (Pygoscelis adeliae)

The flow rate and ionic composition of bile during spontaneous secretion were measured in anaesthetized penguins in which the enterohepatic circulation had been interrupted and with i.v. injection of saline to replace secretory loss. During the first two hours the rate of flow increased, and then remained relatively constant for a further two and a half hours. During this time the concentration of bile salt fell, but the concentrations of other ions showed small fluctuations only. Sodium taurocholate increased the rate of bile flow and the excretion of ions, except that of bicarbonate. Sodium taurolithocholate initially produced cholestasis but later apparently increased bile flow and had an overall choleretic effect. It is suggested that the active excretion of bicarbonate ions by the bile ducts is the predominant regulator of bile secretion in the penguin.

Mitochondrial Activity and Ethanol Accumulation in Ice-encased Winter Cereal Seedlings

Cold-hardened dark-grown seedlings of winter wheat (Triticum aestivum L.) and winter rye (Secale cereale L.) are killed during total encasement in ice at -1 C at a rate related to the initial cold hardiness of the cultivars. Few plants remain alive after 7 days of encasement. Nonhardened seedlings are rapidly killed in ice. The respiratory properties of mitochondria isolated from plants after increasing periods of ice encasement decline slowly, and activity is little impaired when intact plants are about 50% killed. Electron microscopy indicates that mitochondrial structure is not disrupted until 3 weeks of ice encasement. Ethanol accumulates in hardened and nonhardened plants in ice, but at levels which are not toxic to the plants.