CORRELATION BETWEEN DIGNITY, EMPATHY AND EMPLOYEE PRODUCTIVITY AMONG WORKERS IN PRIVATE HOSPITALS IN RIVERS STATE

Background and aim

Workplace humanization, when effectively managed can be instrumental in steering an organization towards efficient, and effective work processes. It is on this backdrop that this study aimed at determining the inter-relationship between employee productivity, dignity and empathy.

Materials and methods

This was a cross-sectional study that identified the relationship between the study variables. It was conducted among 233 randomly selected employees of private hospitals in Port Harcourt, Rivers State, Nigeria. A self-administered structured questionnaire was used to assess the study variables. Data analysis was conducted using the Statistical Package for Social Sciences (SPSS) software and the relationship between variables tested using the Spearman correlation test. Statistical significance was set at 0.05.

Results

The indicators of employee dignity, empathy and productivity were found to have high mean values which were above the threshold of 2.0. A strong positive significant correlation was found to exist between dignity and task accomplishment (r2: 0.796, p-value: <0.001) as well as empathy and task accomplishment (r2: 0.843, p-value: <0.001). Also, a moderate positive statistically significant correlation was found to exist between dignity and service quality (r2=0.373, p-value: <0.001) as well as between employee empathy and service quality (r2= 0.402, p-value: <0.001).

Conclusion and Recommendations

The dignity of an employee alongside empathy as measures of work humanization are significant correlates of employee productivity which can be exploited for organizational growth. It is recommended that organizations through institutionalized policies can successfully manage their workplace for optimal productivity via improved employee dignity and empathy as a means of increasing job satisfaction and reduce brain drain.

Neuroimaging, clinical and life course correlates of normal-appearing white matter integrity in 70-year-olds

We investigate associations between normal-appearing white matter microstructural integrity in cognitively normal ∼70-year-olds and concurrently measured brain health and cognition, demographics, genetics and life course cardiovascular health. Participants born in the same week in March 1946 (British 1946 birth cohort) underwent PET-MRI around age 70. Mean standardized normal-appearing white matter integrity metrics (fractional anisotropy, mean diffusivity, neurite density index and orientation dispersion index) were derived from diffusion MRI. Linear regression was used to test associations between normal-appearing white matter metrics and (i) concurrent measures, including whole brain volume, white matter hyperintensity volume, PET amyloid and cognition; (ii) the influence of demographic and genetic predictors, including sex, childhood cognition, education, socio-economic position and genetic risk for Alzheimer's disease (APOE-ɛ4); (iii) systolic and diastolic blood pressure and cardiovascular health (Framingham Heart Study Cardiovascular Risk Score) across adulthood. Sex interactions were tested. Statistical significance included false discovery rate correction (5%). Three hundred and sixty-two participants met inclusion criteria (mean age 70, 49% female). Higher white matter hyperintensity volume was associated with lower fractional anisotropy [b = -0.09 (95% confidence interval: -0.11, -0.06), P < 0.01], neurite density index [b = -0.17 (-0.22, -0.12), P < 0.01] and higher mean diffusivity [b = 0.14 (-0.10, -0.17), P < 0.01]; amyloid (in men) was associated with lower fractional anisotropy [b = -0.04 (-0.08, -0.01), P = 0.03)] and higher mean diffusivity [b = 0.06 (0.01, 0.11), P = 0.02]. Framingham Heart Study Cardiovascular Risk Score in later-life (age 69) was associated with normal-appearing white matter {lower fractional anisotropy [b = -0.06 (-0.09, -0.02) P < 0.01], neurite density index [b = -0.10 (-0.17, -0.03), P < 0.01] and higher mean diffusivity [b = 0.09 (0.04, 0.14), P < 0.01]}. Significant sex interactions (P < 0.05) emerged for midlife cardiovascular health (age 53) and normal-appearing white matter at 70: marginal effect plots demonstrated, in women only, normal-appearing white matter was associated with higher midlife Framingham Heart Study Cardiovascular Risk Score (lower fractional anisotropy and neurite density index), midlife systolic (lower fractional anisotropy, neurite density index and higher mean diffusivity) and diastolic (lower fractional anisotropy and neurite density index) blood pressure and greater blood pressure change between 43 and 53 years (lower fractional anisotropy and neurite density index), independently of white matter hyperintensity volume. In summary, poorer normal-appearing white matter microstructural integrity in ∼70-year-olds was associated with measures of cerebral small vessel disease, amyloid (in males) and later-life cardiovascular health, demonstrating how normal-appearing white matter can provide additional information to overt white matter disease. Our findings further show that greater 'midlife' cardiovascular risk and higher blood pressure were associated with poorer normal-appearing white matter microstructural integrity in females only, suggesting that women's brains may be more susceptible to the effects of midlife blood pressure and cardiovascular health.

Cortical tau is associated with microstructural imaging biomarkers of neurite density and dendritic complexity in Alzheimer's disease

INTRODUCTION

In Alzheimer's disease (AD), hyperphosphorylated tau is closely associated with focal neurodegeneration, but the mechanism remains uncertain.

METHODS

We quantified cortical microstructure using neurite orientation dispersion and density imaging in 14 individuals with young onset AD. Diffusion tensor imaging measured mean diffusivity (MD). Amyloid beta and tau positron emission tomography were acquired and associations with microstructural measures were assessed.

RESULTS

When regional volume was adjusted for, in the medial temporal lobe there was a significant negative association between neurite density and tau (partial R2  = 0.56, p = 0.008) and between orientation dispersion and tau (partial R2  = 0.66, p = 0.002), but not between MD and tau. In a wider cortical composite, there was an association between orientation dispersion and tau (partial R2  = 0.43, p = 0.030), but not between other measures and tau.

DISCUSSION

Our findings are consistent with tau causing first dendritic pruning (reducing dispersion/complexity) followed by neuronal loss. Advanced magnetic resonance imaging (MRI) microstructural measures have the potential to provide information relating to underlying tau deposition.

A diagrammatic summary of updated NICE melanoma guidance: A simple way to mitigate human factors in MDTs and clinics

National Institute for Health and Care Excellence (NICE) has published an updated guideline on melanoma assessment and management in July 2022, which has included recommendation on BRAF analysis of primary melanoma tissue samples, staging with sentinel lymph node biopsy, guidance on patient follow-up as well as surveillance imaging requirement based on patients' melanoma stages. However, very often, assimilating this considerable amount of information in an efficient and accurate way can be challenging, especially in the setting of a busy multidisciplinary team (MDT) meeting. Human factors are well recognised as a key principle to mitigate against mistakes and human errors and thereby aiming to optimise patient care. To date, there is very limited literature available on the subject of the role of human factors in the context of MDT meetings. In recent years, the numbers and complexity of patients in cancer MDT meetings have grown significantly. Long MDT meetings could lead to distraction, loss of attention span, miscommunication, missed information, and hence increasing the risk of clinical error. We present a diagrammatic summary of the most recent NICE guidance for melanoma follow-up that is currently being used locally in our department. This aims to offer clarity and ease of use to help health care professionals to check patients' treatment pathways. It can also be included in patients' medical record for annotation or reference in future follow-up clinics, which is a simple measure to mitigate the risks of human factors, as well as ensuring consistency in continuity of patient care.

Abstract 2755: Identification of novel GPX4 inhibitors using global transcriptional reporters

Induction of Ferroptosis is a promising strategy for treating therapy-resistant tumors including mesenchymal tumor types. We performed a phenotypic screen to identify small molecules that induce ferroptosis in mesenchymal cancer cells by screening for compounds whose toxicity could be rescued by the lipophilic antioxidant Ferrostatin-1. To identify compounds that induce GPX4-mediated ferroptosis, we identified several pharmacodynamic biomarkers specific to GPX4 inhibition using our nascent RNA sequencing platform, which allows for time-resolved snapshots of global transcription. We measured the transcriptional changes that occur in the hours following inhibition of GPX4 and identified HMOX1 as a robust biomarker of GPX4i-induced ferroptosis in mesenchymal cancer cell lines. Using HMOX1-induction as a guide, we uncovered a small number of compounds as potential GPX4 inhibitors. One such compound was validated as a bonafide GPX4 inhibitor through a variety of biochemical assays and selected for a hit-to-lead campaign. In addition to standard medicinal chemistry strategies, we are currently employing a newly-developed global transcriptional reporter system to stratify several novel series of GPX4 inhibitors by their transcriptional signatures. This approach represents a unique strategy for determining on- and off- target effects of a compound and for defining structure activity relationships within a chemical series.

Citation Format: Timothy Read, Zoe Winigrad, Ardeshir Goliaei, Cole Liechty, Carter Grochala, Leah Damon, John Dickson, Jason Harris, Casey Pham, Jenna Rimel, Christy Rhine, Dave Simpson, Eric Martin, Joey Azofeifa. Identification of novel GPX4 inhibitors using global transcriptional reporters [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 2755.

Operationalizing the centiloid scale for [18F]florbetapir PET studies on PET/MRI

INTRODUCTION

The Centiloid scale aims to harmonize amyloid beta (Aβ) positron emission tomography (PET) measures across different analysis methods. As Centiloids were created using PET/computerized tomography (CT) data and are influenced by scanner differences, we investigated the Centiloid transformation with data from Insight 46 acquired with PET/magnetic resonanceimaging (MRI).

METHODS

We transformed standardized uptake value ratios (SUVRs) from 432 florbetapir PET/MRI scans processed using whole cerebellum (WC) and white matter (WM) references, with and without partial volume correction. Gaussian-mixture-modelling-derived cutpoints for Aβ PET positivity were converted.

RESULTS

The Centiloid cutpoint was 14.2 for WC SUVRs. The relationship between WM and WC uptake differed between the calibration and testing datasets, producing implausibly low WM-based Centiloids. Linear adjustment produced a WM-based cutpoint of 18.1.

DISCUSSION

Transformation of PET/MRI florbetapir data to Centiloids is valid. However, further understanding of the effects of acquisition or biological factors on the transformation using a WM reference is needed.

HIGHLIGHTS

Centiloid conversion of amyloid beta positron emission tomography (PET) data aims to standardize results.Centiloid values can be influenced by differences in acquisition.We converted florbetapir PET/magnetic resonance imaging data from a large birth cohort.Whole cerebellum referenced values could be reliably transformed to Centiloids.White matter referenced values may be less generalizable between datasets.

EANM guidelines for PET-CT and PET-MR routine quality control

We present guidelines by the European Association of Nuclear Medicine (EANM) for routine quality control (QC) of PET-CT and PET-MR systems. These guidelines are partially based on the current EANM guidelines for routine quality control of Nuclear Medicine instrumentation but focus more on the inherent multimodal aspect of the current, state-of-the-art PET-CT and PET-MR scanners. We briefly discuss the regulatory context put forward by the International Electrotechnical Commission (IEC) and European Commission (EC) and consider relevant guidelines and recommendations by other societies and professional organizations. As such, a comprehensive overview of recommended quality control procedures is provided to ensure the optimal operational status of a PET system, integrated with either a CT or MR system. In doing so, we also discuss the rationale of the different tests, advice on the frequency of each test and present the relevant MR and CT tests for an integrated system. In addition, we recommend a scheme of preventive actions to avoid QC tests from drifting out of the predefined range of acceptable performance values such that an optimal performance of the PET system is maintained for routine clinical use.

Perfusion Imaging and Inflammation Biomarkers Provide Complementary Information in Alzheimer's Disease

BACKGROUND

Single photon emission tomography (SPECT) can detect early changes in brain perfusion to support the diagnosis of dementia. Inflammation is a driver for dementia progression and measures of inflammation may further support dementia diagnosis.

OBJECTIVE

In this study, we assessed whether combining imaging with markers of inflammation improves prediction of the likelihood of Alzheimer's disease (AD).

METHODS

We analyzed 91 participants datasets (Institutional Ethics Approval 20/NW/0222). AD biomarkers and markers of inflammation were measured in cerebrospinal fluid. Statistical parametric mapping was used to quantify brain perfusion differences in perfusion SPECT images. Logistic regression models were trained to evaluate the ability of imaging and inflammation markers, both individually and combined, to predict AD.

RESULTS

Regional perfusion reduction in the precuneus and medial temporal regions predicted Aβ42 status. Increase in inflammation markers predicted tau and neurodegeneration. Matrix metalloproteneinase-10, a marker of blood-brain barrier regulation, was associated with perfusion reduction in the right temporal lobe. Adenosine deaminase, an enzyme involved in sleep homeostasis and inflammation, was the strongest predictor of neurodegeneration with an odds ratio of 10.3. The area under the receiver operator characteristic curve for the logistic regression model was 0.76 for imaging and 0.76 for inflammation. Combining inflammation and imaging markers yielded an area under the curve of 0.85.

CONCLUSIONS

Study results showed that markers of brain perfusion imaging and markers of inflammation provide complementary information in AD evaluation. Inflammation markers better predict tau status while perfusion imaging measures represent amyloid status. Combining imaging and inflammation improves AD prediction.

Biomarkers of Inflammation Increase with Tau and Neurodegeneration but not with Amyloid-β in a Heterogenous Clinical Cohort

Background: Neuroinflammation is an integral part of Alzheimer’s disease (AD) pathology. Inflammatory mediators can exacerbate the production of amyloid-β (Aβ), the propagation of tau pathology and neuronal loss. Objective: To evaluate the relationship between inflammation markers and established markers of AD in a mixed memory clinic cohort. Methods: 105 cerebrospinal fluid (CSF) samples from a clinical cohort under investigation for cognitive complaints were analyzed. Levels of Aβ 42, total tau, and phosphorylated tau were measured as part of the clinical pathway. Analysis of inflammation markers in CSF samples was performed using multiplex immune assays. Participants were grouped according to their Aβ, tau, and neurodegeneration status and the Paris-Lille-Montpellier (PLM) scale was used to assess the likelihood of AD. Results: From 102 inflammatory markers analyzed, 19 and 23 markers were significantly associated with CSF total tau and phosphorylated tau levels respectively (p <  0.001), while none were associated with Aβ 42. The CSF concentrations of 4 inflammation markers were markedly elevated with increasing PLM class indicating increased likelihood of AD (p <  0.001). Adenosine deaminase, an enzyme involved in sleep homeostasis, was the single best predictor of high likelihood of AD (AUROC 0.788). Functional pathway analysis demonstrated a widespread role for inflammation in neurodegeneration, with certain pathways explaining over 30% of the variability in tau values. Conclusion: CSF inflammation markers increase significantly with tau and neurodegeneration, but not with Aβ in this mixed memory clinic cohort. Thus, such markers could become useful for the clinical diagnosis of neurodegenerative disorders alongside the established Aβ and tau measures.

Advanced quantitative evaluation of PET systems using the ACR phantom and NiftyPET software

PURPOSE

A novel phantom-imaging platform, a set of software tools, for automated and high-precision imaging of the American College of Radiology (ACR) positron emission tomography (PET) phantom for PET/magnetic resonance (PET/MR) and PET/computed tomography (PET/CT) systems is proposed.

METHODS

The key feature of this platform is the vector graphics design that facilitates the automated measurement of the knife-edge response function and hence image resolution, using composite volume of interest templates in a 0.5 mm resolution grid applied to all inserts of the phantom. Furthermore, the proposed platform enables the generation of an accurate μ $\mu$ -map for PET/MR systems with a robust alignment based on two-stage image registration using specifically designed PET templates. The proposed platform is based on the open-source NiftyPET software package used to generate multiple list-mode data bootstrap realizations and image reconstructions to determine the precision of the two-stage registration and any image-derived statistics. For all the analyses, iterative image reconstruction was employed with and without modeled shift-invariant point spread function and with varying iterations of the ordered subsets expectation maximization (OSEM) algorithm. The impact of the activity outside the field of view (FOV) was assessed using two acquisitions of 30 min each, with and without the activity outside the FOV.

RESULTS

The utility of the platform has been demonstrated by providing a standard and an advanced phantom analysis including the estimation of spatial resolution using all cylindrical inserts. In the imaging planes close to the edge of the axial FOV, we observed deterioration in the quantitative accuracy, reduced resolution (FWHM increased by 1-2 mm), reduced contrast, and background uniformity due to the activity outside the FOV. Although it slows convergence, the PSF reconstruction had a positive impact on resolution and contrast recovery, but the degree of improvement depended on the regions. The uncertainty analysis based on bootstrap resampling of raw PET data indicated high precision of the two-stage registration.

CONCLUSIONS

We demonstrated that phantom imaging using the proposed methodology with the metric of spatial resolution and multiple bootstrap realizations may be helpful in more accurate evaluation of PET systems as well as in facilitating fine tuning for optimal imaging parameters in PET/MR and PET/CT clinical research studies.

Utility of 18F-fluorodeoxyglucose positron emission tomography in presurgical evaluation of patients with epilepsy: A multicenter study

OBJECTIVE

18F-Fluorodeoxyglucose positron emission tomography (FDG-PET) is widely used in presurgical assessment in patients with drug-resistant focal epilepsy (DRE) if magnetic resonance imaging (MRI) and scalp electroencephalography (EEG) do not localize the seizure onset zone or are discordant.

METHODS

In this multicenter, retrospective observational cohort study, we included consecutive patients with DRE who had undergone FDG-PET as part of their presurgical workup. We assessed the utility of FDG-PET, which was defined as contributing to the decision-making process to refer for resection or intracranial EEG (iEEG) or to conclude surgery was not feasible.

RESULTS

We included 951 patients in this study; 479 had temporal lobe epilepsy (TLE), 219 extratemporal epilepsy (ETLE), and 253 epilepsy of uncertain lobar origin. FDG-PET showed a distinct hypometabolism in 62% and was concordant with ictal EEG in 74% in TLE and in 56% in ETLE (p < .001). FDG-PET was useful in presurgical decision-making in 396 patients (47%) and most beneficial in TLE compared to ETLE (58% vs. 44%, p = .001). Overall, FDG-PET contributed to recommending resection in 78 cases (20%) and iEEG in 187 cases (47%); in 131 patients (33%), FDG-PET resulted in a conclusion that resection was not feasible. In TLE, seizure-freedom 1 year after surgery did not differ significantly (p = .48) between patients with negative MRI and EEG-PET concordance (n = 30, 65%) and those with positive MRI and concordant EEG (n = 46, 68%). In ETLE, half of patients with negative MRI and EEG-PET concordance and three quarters with positive MRI and concordant EEG were seizure-free postsurgery (n = 5 vs. n = 6, p = .28).

SIGNIFICANCE

This is the largest reported cohort of patients with DRE who received presurgical FDG-PET, showing that FDG-PET is a useful diagnostic tool. MRI-negative and MRI-positive cases with concordant FDG-PET results (with either EEG or MRI) had a comparable outcome after surgery. These findings confirm the significance of FDG-PET in presurgical epilepsy diagnostics.

Real world evaluation of artificial intelligence echocardiography image guidance and acquisition with novice scanners in multiple clinical settings

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Caption Health, US

OnBehalf

Beacon Hospital Research Institute

Background

Cardiac echocardiographic scanning requires significant training and experience. The FDA approved Caption Echocardiography system uses a deep learning artificial intelligence software that guides novice scanners to optimal position and then automatically acquires the highest quality image. Further advances to this novel technology have allowed for immediate calculation of left ventricular ejection fraction directly from these images.

Methods

Following only brief training, we sought to evaluate study quality by novice scanners in four clinical settings, both acute and ambulatory – the Emergency Department, Intensive Care Unit, Heart Failure clinic, and the Oncology Day Unit. 120 patients (30 per clinical area) were recruited and underwent 2 echo scans – one by a novice scanner using the Caption AI system, and one by an expert scanner using the same ultrasound system but without AI guidance. Both studies were evaluated blindly and independently side by side by 3 accredited experts judging diagnostic quality. ‘AutoEF’ measurements were compared with expert scanners measurements by Simpson’s biplane technique.

Results

120 patients with mean age 62.04 years old (range 18 – 92)  were enrolled, consisting of 30 from each clinical area. 8 novice scanners – nursing staff and junior doctors – scanned 15 patients each, allowing their first 3 cases to be excluded. 75% of patients were male. BMI ranged from 18 – 37 with mean 27.48. Image quality allowed left ventricular function to be sufficiently captured in 97.5% of studies, right ventricular function in 95% and outrule of pericardial effusion in 97.5%. ‘AutoEF’ was determined in 88.3% of studies and matched the expert measurement in 84% of cases. Blinded expert assessment found that 60% of Caption studies were of equal or better quality than the experienced sonographer scan.

Conclusion

The Caption AI technology safely allows novice users to provide efficient and accurate point of care echo in differing clinical settings to a standard comparable to expert scanners, and automatically determines left ventricular ejection fraction.

Survival Outcome with Routine Clinical Use of 82Rb PET/CT Myocardial Blood Flow (MBF) Quantification

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): NIHR Biomedical Research Centre, University College London Hospitals

Background

The prognostic value of 82Rb PET/CT derived myocardial blood flow (MBF) is increasingly recognised in both general and specific cardiovascular populations.

Purpose

This study investigates the prognostic potential of MBF in a large cohort of patients undergoing routine 82Rb PET/CT examination.

Methods

1148 consecutive patients (687 males, mean age 64 +/- 12 years) whom had been referred for 82Rb PET/CT examination in a single centre were included in this study.  All patients completed a stress 82Rb PET/CT with adenosine infusion, paired with a rest study.  Dynamic PET acquisitions were performed in both. Cardiovascular risk factors were documented as per clinical routine. Images were checked for quality and analysed using a proprietary software by an experienced operator to derive MBF parameters.  Overall survival was recorded following the study.

Results

Median follow-up period was 71 +/- 28 months.  Mean survival was 121 (95% CI: 118-124) months. On univariate analysis, global myocardial flow reserve &lt;1.77 was associated with a higher all-cause mortality (p &lt; 0.001). Other parameters including higher age (&gt; =76 years), lower BMI (&lt;21), qualitative abnormality on the myocardial perfusion scan (MPS), low hyperaemic ejection fraction on the gated studies (stress &lt; 37 and rest &lt; 34). Patients being on cardiac glycosides and diuretics were also significant predictor of poor prognosis (p &lt; 0.001) on univariate analysis, presumably reflecting underlying arrhythmia and heart failure. A multivariate Cox regression analysis (step-wise Forward Wald), comprising of the above significant univariate markers, highlighted global myocardial flow reserve (HR: 2.6, 95%CI: 1.8-3.6, p &lt; 0.001), age (HR: 2.8, 95%CI: 2.0-3.9, p &lt; 0.001),, BMI (HR: 2.7, 95%CI: 1.7-4.1, p &lt; 0.001),, ejection fraction (stress - HR: 3.3, 95%CI: 2.3-4.8, p &lt; 0.001), MPS (HR: 1.5, 95%CI: 1.1-2.1, p = 0.024), and patients on diuretics (HR: 1.8, 95%CI: 1.2-2.5, p = 0.003) were independent predictors of overall survival (overall model: p &lt; 0.001)

Discussion

We show that high volume routinely derived MBF in patients undergoing 82Rb PET/CT is a strong predictor of mortality and independent of other risk factors. This has important clinical implication for measuring not only interventional treatment but also measuring the effect of lifestyle and medical strategies.

Exenatide once weekly over 2 years as a potential disease-modifying treatment for Parkinson's disease: protocol for a multicentre, randomised, double blind, parallel group, placebo controlled, phase 3 trial: The 'Exenatide-PD3' study

INTRODUCTION

Parkinson's disease (PD) is a common neurodegenerative disorder with substantial morbidity. No disease-modifying treatments currently exist. The glucagon like peptide-1 receptor agonist exenatide has been associated in single-centre studies with reduced motor deterioration over 1 year. The aim of this multicentre UK trial is to confirm whether these previous positive results are maintained in a larger number of participants over 2 years and if effects accumulate with prolonged drug exposure.

METHODS AND ANALYSIS

This is a phase 3, multicentre, double-blind, randomised, placebo-controlled trial of exenatide at a dose of 2 mg weekly in 200 participants with mild to moderate PD. Treatment duration is 96 weeks. Randomisation is 1:1, drug to placebo. Assessments are performed at baseline, week 12, 24, 36, 48, 60, 72, 84 and 96 weeks.The primary outcome is the comparison of Movement Disorders Society Unified Parkinson's Disease Rating Scale part 3 motor subscore in the practically defined OFF medication state at 96 weeks between participants according to treatment allocation. Secondary outcomes will compare the change between groups among other motor, non-motor and cognitive scores. The primary outcome will be reported using descriptive statistics and comparisons between treatment groups using a mixed model, adjusting for baseline scores. Secondary outcomes will be summarised between treatment groups using summary statistics and appropriate statistical tests to assess for significant differences.

ETHICS AND DISSEMINATION

This trial has been approved by the South Central-Berkshire Research Ethics Committee and the Health Research Authority. Results will be disseminated in peer-reviewed journals, presented at scientific meetings and to patients in lay-summary format.

TRIAL REGISTRATION NUMBERS

NCT04232969, ISRCTN14552789.

What scans we will read: imaging instrumentation trends in clinical oncology

Oncological diseases account for a significant portion of the burden on public healthcare systems with associated costs driven primarily by complex and long-lasting therapies. Through the visualization of patient-specific morphology and functional-molecular pathways, cancerous tissue can be detected and characterized non-invasively, so as to provide referring oncologists with essential information to support therapy management decisions. Following the onset of stand-alone anatomical and functional imaging, we witness a push towards integrating molecular image information through various methods, including anato-metabolic imaging (e.g., PET/CT), advanced MRI, optical or ultrasound imaging.

This perspective paper highlights a number of key technological and methodological advances in imaging instrumentation related to anatomical, functional, molecular medicine and hybrid imaging, that is understood as the hardware-based combination of complementary anatomical and molecular imaging. These include novel detector technologies for ionizing radiation used in CT and nuclear medicine imaging, and novel system developments in MRI and optical as well as opto-acoustic imaging. We will also highlight new data processing methods for improved non-invasive tissue characterization. Following a general introduction to the role of imaging in oncology patient management we introduce imaging methods with well-defined clinical applications and potential for clinical translation. For each modality, we report first on the status quo and, then point to perceived technological and methodological advances in a subsequent status go section. Considering the breadth and dynamics of these developments, this perspective ends with a critical reflection on where the authors, with the majority of them being imaging experts with a background in physics and engineering, believe imaging methods will be in a few years from now.

Overall, methodological and technological medical imaging advances are geared towards increased image contrast, the derivation of reproducible quantitative parameters, an increase in volume sensitivity and a reduction in overall examination time. To ensure full translation to the clinic, this progress in technologies and instrumentation is complemented by advances in relevant acquisition and image-processing protocols and improved data analysis. To this end, we should accept diagnostic images as “data”, and – through the wider adoption of advanced analysis, including machine learning approaches and a “big data” concept – move to the next stage of non-invasive tumour phenotyping. The scans we will be reading in 10 years from now will likely be composed of highly diverse multi-dimensional data from multiple sources, which mandate the use of advanced and interactive visualization and analysis platforms powered by Artificial Intelligence (AI) for real-time data handling by cross-specialty clinical experts with a domain knowledge that will need to go beyond that of plain imaging.

Metabolic lesion-deficit mapping of human cognition

In theory the most powerful technique for functional localization in cognitive neuroscience, lesion-deficit mapping is in practice distorted by unmodelled network disconnections and strong 'parasitic' dependencies between collaterally damaged ischaemic areas. High-dimensional multivariate modelling can overcome these defects, but only at the cost of commonly impracticable data scales. Here we develop lesion-deficit mapping with metabolic lesions-discrete areas of hypometabolism typically seen on interictal 18F-fluorodeoxyglucose PET imaging in patients with focal epilepsy-that inherently capture disconnection effects, and whose structural dependence patterns are sufficiently benign to allow the derivation of robust functional anatomical maps with modest data. In this cross-sectional study of 159 patients with widely distributed focal cortical impairments, we derive lesion-deficit maps of a broad range of psychological subdomains underlying affect and cognition. We demonstrate the potential clinical utility of the approach in guiding therapeutic resection for focal epilepsy or other neurosurgical indications by applying high-dimensional modelling to predict out-of-sample verbal IQ and depression from cortical metabolism alone.

Associations between blood pressure across adulthood and late-life brain structure and pathology in the neuroscience substudy of the 1946 British birth cohort (Insight 46): an epidemiological study

BACKGROUND

Midlife hypertension confers increased risk for cognitive impairment in late life. The sensitive period for risk exposure and extent that risk is mediated through amyloid or vascular-related mechanisms are poorly understood. We aimed to identify if, and when, blood pressure or change in blood pressure during adulthood were associated with late-life brain structure, pathology, and cognition.

METHODS

Participants were from Insight 46, a neuroscience substudy of the ongoing longitudinal Medical Research Council National Survey of Health and Development, a birth cohort that initially comprised 5362 individuals born throughout mainland Britain in one week in 1946. Participants aged 69-71 years received T1 and FLAIR volumetric MRI, florbetapir amyloid-PET imaging, and cognitive assessment at University College London (London, UK); all participants were dementia-free. Blood pressure measurements had been collected at ages 36, 43, 53, 60-64, and 69 years. We also calculated blood pressure change variables between ages. Primary outcome measures were white matter hyperintensity volume (WMHV) quantified from multimodal MRI using an automated method, amyloid-β positivity or negativity using a standardised uptake value ratio approach, whole-brain and hippocampal volumes quantified from 3D-T1 MRI, and a composite cognitive score-the Preclinical Alzheimer Cognitive Composite (PACC). We investigated associations between blood pressure and blood pressure changes at and between 36, 43, 53, 60-64, and 69 years of age with WMHV using generalised linear models with a gamma distribution and log link function, amyloid-β status using logistic regression, whole-brain volume and hippocampal volumes using linear regression, and PACC score using linear regression, with adjustment for potential confounders.

FINDINGS

Between May 28, 2015, and Jan 10, 2018, 502 individuals were assessed as part of Insight 46. 465 participants (238 [51%] men; mean age 70·7 years [SD 0·7]; 83 [18%] amyloid-β-positive) were included in imaging analyses. Higher systolic blood pressure (SBP) and diastolic blood pressure (DBP) at age 53 years and greater increases in SBP and DBP between 43 and 53 years were positively associated with WMHV at 69-71 years of age (increase in mean WMHV per 10 mm Hg greater SBP 7%, 95% CI 1-14, p=0·024; increase in mean WMHV per 10 mm Hg greater DBP 15%, 4-27, p=0·0057; increase in mean WMHV per one SD change in SBP 15%, 3-29, p=0·012; increase in mean WMHV per 1 SD change in DBP 15%, 3-30, p=0·017). Higher DBP at 43 years of age was associated with smaller whole-brain volume at 69-71 years of age (-6·9 mL per 10 mm Hg greater DBP, -11·9 to -1·9, p=0·0068), as were greater increases in DBP between 36 and 43 years of age (-6·5 mL per 1 SD change, -11·1 to -1·9, p=0·0054). Greater increases in SBP between 36 and 43 years of age were associated with smaller hippocampal volumes at 69-71 years of age (-0·03 mL per 1 SD change, -0·06 to -0·001, p=0·043). Neither absolute blood pressure nor change in blood pressure predicted amyloid-β status or PACC score at 69-71 years of age.

INTERPRETATION

High and increasing blood pressure from early adulthood into midlife seems to be associated with increased WMHV and smaller brain volumes at 69-71 years of age. We found no evidence that blood pressure affected cognition or cerebral amyloid-β load at this age. Blood pressure monitoring and interventions might need to start around 40 years of age to maximise late-life brain health.

FUNDING

Alzheimer's Research UK, Medical Research Council, Dementias Platform UK, Wellcome Trust, Brain Research UK, Wolfson Foundation, Weston Brain Institute, Avid Radiopharmaceuticals.

Does quantification have a role to play in the future of bone SPECT?

Routinely, there is a visual basis to nuclear medicine reporting: a reporter subjectively places a patient's condition into one of multiple discrete classes based on what they see. The addition of a quantitative result, such as a standardised uptake value (SUV), would provide a numerical insight into the nature of uptake, delivering greater objectivity, and perhaps improved patient management.For bone scintigraphy in particular quantification could increase the accuracy of diagnosis by helping to differentiate normal from abnormal uptake. Access to quantitative data might also enhance our ability to characterise lesions, stratify and monitor patients' conditions, and perform reliable dosimetry for radionuclide therapies. But is there enough evidence to suggest that we, as a community, should be making more effort to implement quantitative bone SPECT in routine clinical practice?We carried out multiple queries through the PubMed search engine to facilitate a cross-sectional review of the current status of bone SPECT quantification. Highly cited papers were assessed in more focus to scrutinise their conclusions.An increasing number of authors are reporting findings in terms of metrics such as SUVmax. Although interest in the field in general remains high, the rate of clinical implementation of quantitative bone SPECT remains slow and there is a significant amount of validation required before we get carried away.

Underestimation of 68Ga PET/CT SUV caused by activity overestimation using default calibrator settings

PURPOSE

A PET/CT scan of a uniformly filled ⁶⁸Ga phantom resulted in an unexpectedly low SUV_mean of 0.88. A potential contributing cause of underestimation of ⁶⁸Ga SUV is overestimation of ⁶⁸Ga activity in the Radionuclide Calibrator associated with the PET/CT scanner. To investigate this, a Radionuclide Calibrator cross-calibration exercise was performed.

METHODS

A source of ⁶⁸Ga was measured in 5 Capintec CRC-55tR calibrators using the pre-set ⁶⁸Ga calibrator factor of 416, and a Veenstra VDC-505 calibrator using a factor recommended by the manufacturer. The source was then measured in an externally located Fidelis Secondary Standard Radionuclide Calibrator. Manual adjustments were made to the Capintec calibrator factors to match the decay corrected Fidelis measurement, followed by a repeat PET/CT scan of a uniform ⁶⁸Ga phantom.

RESULTS

The cross-calibration results showed that the 5 Capintec calibrators systematically overestimated ⁶⁸Ga activity by 7.8-9.4% (mean 8.5%) compared to the Fidelis. The calibrator factors were adjusted to 456-464 to match the Fidelis measurement, and the repeat phantom scan resulted in a SUV_mean of 0.97, within the local tolerance of 1.00 ± 5%. The result for the Veenstra calibrator was within the tolerance of ±5%.

CONCLUSIONS

Underestimation of ⁶⁸Ga SUV was primarily caused by overestimation of ⁶⁸Ga activity using the pre-set calibrator factor setting on a Capintec CRC-55tR. Improvement in quantification accuracy was achieved by adjusting the ⁶⁸Ga calibrator factor based upon a cross-calibration exercise. We recommend SUV checks using a uniform phantom and regular calibrator cross-calibration exercises for all isotopes used for quantitative PET/CT imaging.

Quantitative SPECT: the time is now

Background

Quantification is one of the key benefits of nuclear medicine imaging. Recently, driven by the demand for post radionuclide therapy imaging, quantitative SPECT has moved from relative and semiquantitative measures to absolute quantification in terms of activity concentration, and yet further to normalised uptake using the standard uptake value (SUV). This expansion of quantitative SPECT has the potential to be a useful tool in the nuclear medicine armoury, but key factors must be addressed before it can meet its full potential.

Discussion

Quantitative SPECT should address an unmet clinical need and give metrics that are clinically meaningful. Using the technique in a similar manner to PET with longitudinal assessments of disease in terms of SUV is one example that meets these criteria. Having metrics that are evaluated to ensure that they are correct, that are optimised to maximise their sensitivity, and that are transferrable to allow multi-centre learning and applicability to all users of the technology are other areas of quantitative SPECT that need to be addressed and that have specific challenges associated with them. Finally, ensuring quantitative SPECT is cost-effective in times when healthcare budgets are being squeezed is also very important.

Conclusion

Quantitative SPECT offers the possibility to continue and expand the potential of quantitative nuclear medicine applications. The time is now to ensure that our community works together to make this potential a reality.

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.

Neonatal conjunctivitis in the New Zealand Midland region

AIMS

To assess the incidence of chlamydial and gonorrhoeal neonatal conjunctivitis (CON and GON), across six district health boards in the greater Midland region of New Zealand.

METHODS

All positive nucleic acid amplification test (NAAT) eye swabs for Chlamydia trachomatis and NAAT and bacterial eye swabs for Neisseria gonorrhoeae in infants under one year of age were retrieved from three laboratories from 2013-2016. Incidence density rates were calculated using births information from Statistics New Zealand. A subgroup analysis of Waikato and Tairāwhiti cases were further analysed.

RESULTS

Calculated rates for the Greater Midland region are CON, 145.9 per 100,000 births/year and GON, 3.79 per 100,000 births/year. For Tairāwhiti and Waikato, the incidence of CON is 2.5 times greater in Māori than non-Māori (95% CI 1.3-5.1, P<0.01). There was no significant difference in mean NZDep13 for Māori vs non-Māori. Mean maternal age at birth was 20.

CONCLUSIONS

Greater Midland region rates of CON and GON are higher compared to other international reported rates. For Tairāwhiti and Waikato, rates of CON are significantly higher in Māori than non-Māori, although there is no difference in mean NZDep13 scores between Māori and non-Māori. CON appears to be a condition of babies of young mothers with higher deprivation.

A virtual patient model for mechanical ventilation

BACKGROUND AND OBJECTIVES

Mechanical ventilation (MV) is a primary therapy for patients with acute respiratory failure. However, poorly selected ventilator settings can cause further lung damage due to heterogeneity of healthy and damaged alveoli. Varying positive-end-expiratory-pressure (PEEP) to a point of minimum elastance is a lung protective ventilator strategy. However, even low levels of PEEP can lead to ventilator induced lung injury for individuals with highly inflamed pulmonary tissue. Hence, models that could accurately predict peak inspiratory pressures after changes to PEEP could improve clinician confidence in attempting potentially beneficial treatment strategies.

METHODS

This study develops and validates a physiologically relevant respiratory model that captures elastance and resistance via basis functions within a well-validated single compartment lung model. The model can be personalised using information available at a low PEEP to predict lung mechanics at a higher PEEP. Proof of concept validation is undertaken with data from four patients and eight recruitment manoeuvre arms.

RESULTS

Results show low error when predicting upwards over the clinically relevant pressure range, with the model able to predict peak inspiratory pressure with less than 10% error over 90% of the range of PEEP changes up to 12 cmH₂O.

CONCLUSIONS

The results provide an in-silico model-based means of predicting clinically relevant responses to changes in MV therapy, which is the foundation of a first virtual patient for MV.

Comparative effects of in ovo versus subcutaneous administration of the Marek's disease vaccine and pre-placement holding time on the post-hatch performance of Ross 708 broilers1,2,3

Effects of 2 types of methods of administration (moa; in ovo or s.c.) of the Marek's disease (MD) vaccine and 4 and 18 h pre-placement holding times (pht) on the performance of male broilers through 48 d of age were investigated. Ross 708 broiler hatching eggs (3,900) were either in ovo-vaccinated at 18 d of incubation or chicks from eggs that were not in ovo-injected were vaccinated s.c. at hatch, and chicks from each moa group were held for one of the 2 pht. In ovo injections (50 μL) were delivered by a commercial multi-egg injector and s.c. injections (0.2 mL) were delivered by an automatic pneumatic s.c. injector. Sixteen birds were assigned to each of 15 replicate floor pens belonging to each of the 4 moa and pht combination groups. Mortality and BW gain were determined at weekly intervals, and feed consumption and conversion were determined in the zero to 14, 14 to 28, 28 to 42, and 42 to 48 d age intervals. No interactive effects between moa and pht were observed for any variable, and mortality was not significantly affected by moa or pht. The 14 to 28 d feed consumption and 14 to 21 d BW gain of s.c.-vaccinated birds were lower than that of in ovo-vaccinated birds, and the increase in pht from 4 to 18 h decreased feed consumption through 28 d post hatch and BW gain through 35 d post hatch. Overall, the performances of male Ross 708 broilers through 48 d of age in response to in ovo and s.c. injections of the MD vaccine were comparable, and delays in hatchling placement should be less that 18 h in duration. Furthermore, despite the decrease in BW gain through 35 d associated with the reduction in feed consumption through 28 d in response to the 14 h increase in pht, in ovo injection did not exacerbate the effect of the increase in pht.

Do drugs offering only PFS maintain quality of life sufficiently from a patient's perspective? Results from AVALPROFS (Assessing the 'VALue' to patients of PROgression Free Survival) study

Purpose

Trials of novel drugs used in advanced disease often show only progression-free survival or modest overall survival benefits. Hypothetical studies suggest that stabilisation of metastatic disease and/or symptom burden are worth treatment-related side effects. We examined this premise contemporaneously using qualitative and quantitative methods.

Methods

Patients with metastatic cancers expected to live > 6 months and prescribed drugs aimed at cancer control were interviewed: at baseline, at 6 weeks, at progression, and if treatment was stopped for toxicity. They also completed Functional Assessment of Cancer Therapy (FACT-G) plus Anti-Angiogenesis (AA) subscale questionnaires at baseline then monthly for 6 months.

Results

Ninety out of 120 (75%) eligible patients participated: 41 (45%) remained on study for 6 months, 36 progressed or died, 4 had treatment breaks, and 9 withdrew due to toxicity. By 6 weeks, 66/69 (96%) patients were experiencing side effects which impacted their activities. Low QoL scores at baseline did not predict a higher risk of death or dropout. At 6-week interviews, as the side effect severity increased, patients were significantly less inclined to view the benefit of cancer control as worthwhile (X² = 50.7, P < 0.001). Emotional well-being initially improved from baseline by 10 weeks, then gradually returned to baseline levels.

Conclusion

Maintaining QoL is vital to most patients with advanced cancer so minimising treatment-related side effects is essential. As side effect severity increased, drugs that controlled cancer for short periods were not viewed as worthwhile. Patients need to have the therapeutic aims of further anti-cancer treatment explained honestly and sensitively.

Electronic supplementary material

The online version of this article (10.1007/s00520-018-4273-3) contains supplementary material, which is available to authorized users.

Metaplastic Breast Cancer Masquerading as Liposarcoma of the Breast: A Case Report following Oncoplastic Treatment

Mammary liposarcoma is among the rarest of breast tumours. Here we report the presentation, macroscopic, microscopic, and immunohistochemical features of an extremely rare case of metaplastic carcinoma with extensive pleomorphic liposarcomatous differentiation. A 47-year-old woman presented with bilateral grade III breast ptosis and a 3 × 4 cm mass in the lower outer quadrant of the left breast. Mammography and ultrasound confirmed a well-defined mass. A core biopsy performed was diagnosed as pleomorphic liposarcoma. Microscopically, this was a well-defined, lobulated tumour comprising solid sheets of large pleomorphic and spindle cells with bizarre forms, vacuolated cytoplasm, and ample mitoses. Atypical lipoblasts were easily identifiable. Due to the strong, though patchy, cytokeratin expression, the diagnosis of metaplastic carcinoma with pleomorphic liposarcomatous differentiation was made. Extensive sampling, careful search for a biphasic pattern, ductal carcinoma in situ, and/or epithelial differentiation, and a panel of broad-spectrum cytokeratins are essential to establish the diagnosis.

Comparative effects of in ovo versus subcutaneous administration of the Marek's disease vaccine and pre-placement holding time on the processing yield of Ross 708 broilers

Effects of the in ovo (i.o.) or subcutaneous (s.c.) method of administration (moa) of the Marek's disease (MD) vaccine and 4 or 18 h pre-placement holding time (pht) on the processing yield of male broilers through 49 d of age (doa) were investigated. Ross 708 broiler hatching eggs (3,900) were either i.o.-vaccinated at 18 d of incubation or chicks from eggs that were not i.o.-vaccinated were s.c.-vaccinated at hatch. The i.o. injections (50 μL) were delivered by a commercial multi-egg injector and s.c. injections (200 μL) were delivered by an automatic pneumatic s.c. injector. The pht was imposed on chicks after vaccination. Sixteen birds were initially assigned to each of 15 replicate floor pens belonging to each of the moa and pht combination groups and were grown out through 48 doa. At 48 doa, 6 birds were randomly selected from each replicate pen and were weighed and fasted for 16 h before being processed. At 49 doa, whole carcass, fat pad, breast muscle, and tenders muscles weights were recorded. Whole carcass weight as a percentage of live BW, and fat pad, breast muscle, and tenders muscles weights as percentages of both live and whole carcass weights were calculated. Upon subjection of the data to a 2 × 2 factorial analysis, only a main effect due to moa was observed for tenders muscles weight as a percentage of live and whole carcass weights. Tenders muscles weight as a percentage of both live (P ≤ 0.010) and whole carcass (P ≤ 0.004) weight was higher in birds hatched from eggs that received i.o. rather than s.c. vaccinations. In conclusion, in comparison to s.c. vaccination, i.o. vaccination increased relative tenders weight yield, whether or not broilers were held for 4 or 18 h prior to placement. Therefore, with regard to broiler processing yield, i.o. and s.c. vaccinations were safe for the administration of the MD vaccine, with i.o. vaccination displaying a slight potential advantage.

Hydroxychloroquine Effectiveness in Reducing Symptoms of Hand Osteoarthritis: A Randomized Trial

Background

Synovitis is believed to play a role in producing symptoms in persons with hand osteoarthritis, but data on slow-acting anti-inflammatory treatments are sparse.

Objective

To determine the effectiveness of hydroxychloroquine versus placebo as an analgesic treatment of hand osteoarthritis.

Design

Randomized, double-blind, placebo-controlled clinical trial with 12-month follow-up. (ISRCTN registry number: ISRCTN91859104).

Setting

13 primary and secondary care centers in England.

Participants

Of 316 patients screened, 248 participants (82% women; mean age, 62.7 years) with symptomatic (pain ≥4 on a 0- to 10-point visual analogue scale) and radiographic hand osteoarthritis were randomly assigned and 210 (84.7%) completed the 6-month primary end point.

Intervention

Hydroxychloroquine (200 to 400 mg) or placebo (1:1) for 12 months with ongoing usual care.

Measurements

The primary end point was average hand pain during the previous 2 weeks (on a 0- to 10-point numerical rating scale [NRS]) at 6 months. Secondary end points included self-reported pain and function, grip strength, quality of life, radiographic structural change, and adverse events. Baseline ultrasonography was done.

Results

At 6 months, mean hand pain was 5.49 points in the placebo group and 5.66 points in the hydroxychloroquine group, with a treatment difference of -0.16 point (95% CI, -0.73 to 0.40 point) (P = 0.57). Results were robust to adjustments for adherence, missing data, and use of rescue medication. No significant treatment differences existed at 3, 6, or 12 months for any secondary outcomes. The percentage of participants with at least 1 joint with synovitis was 94% (134 of 143) on grayscale ultrasonography and 59% on power Doppler. Baseline structural damage or synovitis did not affect treatment response. Fifteen serious adverse events were reported (7 in the hydroxychloroquine group [3 defined as possibly related] and 8 in the placebo group).

Limitation

Hydroxychloroquine dosage restrictions may have reduced efficacy.

Conclusion

Hydroxychloroquine was no more effective than placebo for pain relief in patients with moderate to severe hand pain and radiographic osteoarthritis.

Primary Funding Source

Arthritis Research UK.

Centralization of Services: Standard Setting and Outcomes

Objective

To test specific standards set in the newly established cleft lip and palate service in three regions of the U.K. The standards relate to record collection and outcomes.

Design

Retrospective analysis.

Patients

Records of 31 children, 5 years of age, who were born in 1997 with complete unilateral clefts of lip and palate and were treated by surgeons in three regions.

Main outcome measures

Record collection standards were measured by collecting dental study models. Outcomes were measured with the 5-Year-Old Index.

Results

Of the 31 subjects, 52% had excellent and good outcomes. The 31 cases represented 62% of the total records collected.

Conclusions

The three regions examined fell short of the standards set, but the outcomes were improved compared with previous national outcomes. The failings in record collection need to be rectified. This study provides baseline data for further development of cleft services within three regions.

Neural breathing pattern in newborn infants pre- and postextubation

AIM

To describe the neural breathing pattern before and after extubation in newborn infants.

METHODS

Prospective, observational study. In infants deemed ready for extubation, the diaphragm electrical activity (EAdi) was continuously recorded from 30 minute before to two hours after extubation.

RESULTS

Total of 25 neonates underwent 29 extubations; 10 extubations resulted in re-intubation within 72 hours. Postextubation, there was an increase in peak EAdi (EAdi-max) and EAdi-delta (peak minus minimum EAdi) in both groups. The pre- to postextubation change in EAdi-max (8.9-11.1 μv) and EAdi-delta (6-8 μv) was less in the failure group in comparison with the change in EAdi-max (10.2-13.4 μv) and EAdi-delta (6.3-10.6 μv) in the success group, (p = 0.02 and 0.01, respectively).

CONCLUSION

In our neonatal cohort, extubation failure was associated with a smaller increase in peak and delta EAdi after extubation. If confirmed, these findings indicate an important cause of extubation failure in preterm infants.