The Family-Check-Up® Autism Implementation Research (FAIR) Study: protocol for a study evaluating the effectiveness and implementation of a family-centered intervention within a Canadian autism service setting

Introduction

Prevalence rates of emotional and behavior problems (EBP) in autistic children and youth are high (40-70%), and often cause severe and chronic impairment. Furthermore, autistic children are also more likely to experience family "social-ecological" adversity compared to neurotypically developing peers, including social isolation, child maltreatment, caregiver mental illness, and socioeconomic risk. These family stressors increase the risk of co-occurring EBP among autistic children and can often impede access to evidence-based care, thus amplifying long-term health inequities for autistic children and their caregivers. In the current autism services landscape, there are few scalable, evidence-based programs that adequately address these needs. The Family Check-Up (FCU®) is a brief, strength-based, and tailored family-centered intervention that supports positive parenting and explicitly assesses the social determinants of child and family mental health within an ecological framework. Studies have demonstrated long-term positive child and caregiver outcomes in other populations, but the FCU® has not been evaluated in families of autistic children and youth. Therefore, we aimed to evaluate FCU® implementation within an established, publicly funded Autism Program in Ontario, Canada, with delivery by autism therapists, to demonstrate sustainable effectiveness within real-world settings.

Methods

In this study, we outline the protocol for a hybrid implementation-effectiveness approach with two key components: (1) A parallel-arm randomized controlled trial of N = 80 autistic children/youth (ages 6-17 years) and high levels of EBP and their caregivers. Primary and secondary outcomes include child EBP, and caregiver well-being and parenting. (2) A mixed methods implementation study, to describe facilitators and barriers to implementation of the FCU® within an autism service setting.

Discussion

Scalable, ecologically focused family-centered interventions offer promise as key components of a public health framework aimed at reducing mental health inequities among autistic children, youth, and their caregivers. Results of this study will inform further program refinement and scale-up.

Vertebral Dose Sparing during Lung and Esophageal Radiation Therapy

PURPOSE/OBJECTIVE(S)

The vertebral bodies contain approximately 20-25% of all bone marrow in the body. Lymphopenia is a known negative prognostic factor in thoracic malignancies. Studies have previously demonstrated that patients receiving radiation to the lumbar spine and/or pelvis have shown increased fat deposition/bone marrow scarring following therapy, which leads to long term immunosuppressive effects. In anticipation for an open clinical trial, and based on previously published work, we explored whether retrospectively constraining the thoracic bone marrow is practically feasible and leads to minimal increase in dose to the remaining OARs (Organs at Risk).

MATERIALS/METHODS

Patients with previously treated thoracic cancer were included in this study. The thoracic bone marrow was contoured using PET scan to verify avid areas and a new plan was created. Guideline constraints for the thoracic bone marrow were V10 (<300cc), V20 (<200 cc), and V30 (<150cc). If bone marrow optimization caused a violation of standard OAR guidelines, then the bone marrow constraints were not met. The median changes in thoracic bone marrow and OARs (lung, heart, spinal cord) were compared with the Wilcoxon sign rank test for non-parametric paired samples.

RESULTS

We included 20 patients, 10 with esophageal cancer and 10 with NSCLC (Non-Small Cell Lung Cancer). Only three cases were able to meet the prespecified bone marrow constraints after optimization (15%). Bone marrow median V10 was reduced by 20cc (-8.16%). Larger changes were seen in V20 and V30 dose-volume reductions, with decreases of 35.3 and 32.3 cc (-16.4% and -21.3%), respectively. There was a significant reduction (p<0.001) for V30, V20, and V10. Though most experienced a decrease in mean heart dose, there was an overall median increase of 21.00 cGy, attributable to a single outlier (P = 1). Median cord dose was decreased by 418.5 cGy. There was a minimal non-significant increase in median Lung V20 of 0.76% as well as minimal median increase in the mean lung dose (7 cGy).

CONCLUSION

This retrospective dosimetric analysis reveals that bone marrow can be optimized. While not able to meet thresholds predictive of minimizing Grade 4 lymphopenia, dose reduction can safely be done with minimal increase in values known to cause toxicity in the heart, lungs, and cord. Though radiation dosage to the thoracic vertebrae was not eliminated entirely, significant decreases in median dosages were achieved without compromising OAR dose. Bone marrow sparing should be considered when feasible and this planning technique is currently being used in an open prospective trial.

POS0701 ANIFROLUMAB, AN ANTI-INTERFERON-Α RECEPTOR MONOCLONAL ANTIBODY IN SYSTEMIC LUPUS ERYTHEMATOSUS- A META ANALYSIS

Background:

Type I interferons such as Anifrolumab have been implicated in Systemic lupus erythematosus (SLE) pathogenesis on the basis of increased interferon-stimulated gene expression and genetic susceptibility. Little is known regarding its efficacy and safety profile.

Objectives:

To assess the efficacy and safety of Anifrolumab in patients with SLE.

Methods:

Electronic databases (PubMed, Embase, Scopus, Cochrane) were searched from inception until December 15th, 2020. Unadjusted odds ratios (OR) were calculated from dichotomous data using Mantel Haenszel (M-H) random-effects with statistical significance to be considered if the confidence interval excludes 1 and p<0.05. The primary outcome of interest was British Isles Lupus Assessment Group (BILAG)-based Composite Lupus Assessment (BICLA). Secondary outcomes included the proportion of patients who achieved an SLE responder index of 4 (SRI-4) reduction of 50% or more in the Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI), reductions in the glucocorticoid dose and adverse effects.

Results:

A total of three studies1,2,3 with 839 participants (Anifrolumab=372, Placebo=467) were included in our analysis. Follow-up duration was at week 52. A statistically significant different was observed in the Anifrolumab arm in terms of BICLA response (OR 0.44 95%CI 0.34-0.59;p < 0.00001, I2=4), ≥50% reduction in CLASI activity score (OR 0.36 95%CI 0.21-0.60;p=0.0001, I2=0), glucocorticoid reduction (OR 0.41 95%CI 0.28-0.59;p<0.00001; I2=0) and SRI-4 response (OR 0.52 95% CI 0.30-0.90; p=0.02, I2=75). However, Adverse events were less likely in the placebo arm as compared to Anifrolumab (OR 1.54 95%CI 1.05-2.25; p=0.03; I2=0).

Conclusion:

Anifrolumab was found to be more effective than placebo for the management of SLE, but may also cause more severe adverse effects.

References:

[1]Morand EF, Furie R, Tanaka Y, Bruce IN, Askanase AD, Richez C, Bae SC, Brohawn PZ, Pineda L, Berglind A, Tummala R; TULIP-2 Trial Investigators. Trial of Anifrolumab in Active Systemic Lupus Erythematosus. N Engl J Med. 2020 Jan 16;382(3):211-221. doi: 10.1056/NEJMoa1912196. Epub 2019 Dec 18. PMID: 31851795.

[2]Furie R, Khamashta M, Merrill JT, Werth VP, Kalunian K, Brohawn P, Illei GG, Drappa J, Wang L, Yoo S; CD1013 Study Investigators. Anifrolumab, an Anti-Interferon-α Receptor Monoclonal Antibody, in Moderate-to-Severe Systemic Lupus Erythematosus. Arthritis Rheumatol. 2017 Feb;69(2):376-386. doi: 10.1002/art.39962. PMID: 28130918; PMCID: PMC5299497.

[3]Furie RA, Morand EF, Bruce IN, et al. Type I interferon inhibitor anifrolumab in active systemic lupus erythematosus (TULIP-1): a randomised, controlled, phase 3 trial. Lancet Rheumatol 2019; 1(4):e208-e219.

Disclosure of Interests:

None declared

Clinical outcomes of combined surgical treatment of medial epicondylitis and cubital tunnel syndrome

Surgical results for treatment of medial epicondylitis and cubital tunnel syndrome are generally satisfactory when performed alone. However, our experience suggests a combined procedure is associated with inferior outcomes. A retrospective review was conducted of consecutive surgical cases of medial epicondylectomy/debridement and ulnar nerve decompression during a single operation at our institution from March 2008 to February 2017 using CPT codes. Thirty combined procedures were identified in 29 patients. Fourteen patients and 15 elbows returned to clinic for evaluation at average 4.3 years after surgery (8 men, 6 women, mean age 45.1 years). A Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, visual analogue pain scale (VAS), and physical examination were performed. The data was stratified by type of ulnar nerve procedure and analyzed. Three of fifteen elbows underwent in situ ulnar nerve decompression, and twelve of 15 had transposition, five subcutaneous and seven submuscular. The mean DASH score for in situ decompression was significantly higher than that of transposition (68.2 vs. 13.1). The average visual pain score for patients whom underwent in situ decompression was significantly higher than that of those with ulnar nerve transposition (8.0 vs. 1.2). All other physical exam measures demonstrated no significant difference between the two groups. In situ ulnar nerve decompression in the setting of medial epicondylectomy/debridement may be associated with inferior clinical outcomes in comparison to ulnar nerve transposition. Further studies are needed to validate the results of our study and inform management.

Interactions of organic acids with vancomycin-resistant Enterococcus faecium isolated from community wastewater in Texas

AIMS

Investigate the interactions of organic acids (OAs), acetic, butyric, citric, formic, lactic and propionic acid against 50 Gram-positive vancomycin-resistant Enterococcus faecium (VRE) strains to determine whether pH, undissociated or dissociated acid forms correlate with bacterial inhibition.

METHODS AND RESULTS

Concentrations of undissociated and dissociated OAs at the molar minimum inhibitory concentrations (MIC_M s) of the VRE were calculated using the Henderson-Hasselbalch equation. The pH at the MIC_M s of all VRE strains against acetic, butyric, formic and propionic acids was similar, 4·66 ± 0·07, but there was a 1·1 pH unit difference for all six OAs. Inhibition of VRE by all six OAs did not appear to be solely dependent on pH or on the undissociated OA species. The inhibition of VRE by all six dissociated acids was within Δ = 3·1 mmol l^-1 .

CONCLUSIONS

Vancomycin-resistant Enterococcus faecium inhibition correlated with the dissociated OA species. A small decrease in the concentration of the dissociated OAs from optimum may result in allowing VRE strains to escape disinfection.

SIGNIFICANCE AND IMPACT OF THE STUDY

When an OA is used to disinfect VRE strains, the concentration of the dissociated OA should be carefully controlled. A concentration of at least 20 mmol l^-1 dissociated OA should be maintained when disinfecting VRE.

Safety of Recombinant Human Factor XIII in a Cynomolgus Monkey Model of Extracorporeal Blood Circulation

Factor XIII (FXIII) is a thrombin-activated plasma coagulation factor critical for blood clot stabilization and longevity. Administration of exogenous FXIII to replenish depleted stores after major surgery, including cardiopulmonary bypass, may reduce bleeding complications and transfusion requirements. Thus, a model of extracorporeal circulation (ECC) was developed in adult male cynomolgus monkeys ( Macaca fascicularis) to evaluate the nonclinical safety of recombinant human FXIII (rFXIII). The hematological and coagulation profile in study animals during and after 2 h of ECC was similar to that reported for humans during and after cardiopulmonary bypass, including observations of anemia, thrombocytopenia, and activation of coagulation and platelets. Intravenous slow bolus injection of 300 U/kg (2.1 mg/kg) or 1000 U/kg (7 mg/kg) rFXIII after 2 h of ECC was well tolerated in study animals, and was associated with a dose-dependent increase in FXIII activity. No clinically significant effects in respiration, ECG, heart rate, blood pressure, body temperature, clinical chemistry, hematology (including platelet counts), or indicators of thrombosis (thrombin:antithrombin complex and D-Dimer) or platelet activation (platelet factor 4 and beta-thromboglobulin) were related to rFXIII administration. Specific examination of brain, heart, lung, liver, and kidney from rFXIII-treated animals provided no evidence of histopathological alterations suggestive of subclinical hemorrhage or thrombosis. Taken as a whole, the results demonstrate the ECC model suitably replicated the clinical presentation reported for humans during and after cardiopulmonary bypass surgery, and do not suggest significant concerns regarding use of rFXIII in replacement therapy after extracorporeal circulation.

Late Stage Huntington's Disease: Effect of Treating Specific Disabilities

Huntington's disease is an hereditary degenerative condition resulting, eventually, in physical and mental, behavioural and emotional disability. Four severely affected patients were included in a multiple-baseline, single-case experimental design study to test the hypothesis that occupational therapy for specific activities would Improve function in those activities. There was no evidence of improvement resulting from specific treatment of activities over the 8-month observation period. However, only one patient deteriorated and, therefore it is possible that the occupational therapy input had a generalised effect In preventing the deterioration of activities, it is concluded that, in the severe form of Huntington's disease, intensive therapy for specific activities does not result in Improvement and that a more general programme may be more productive.

Preliminary study of measurements of sway in an elderly community population

Postural control seems to deteriorate with advancing age but it is not clear why this happens. As part of a larger epidemiological study of community elderly, a representative sample of 85 people aged 75 and over living at home had assessments of physical and psychological function and measurements of sway and base of support carried out, using a portable force plate. Sway increased with increasing age but there was no difference in sway between men and women. Significant positive associations were found between greater sway and impaired visual acuity, poor nutritional state and reduced mobility. Subjects with various physical impairments tended to have worse balance. Subjects who had had falls did not sway more than non-fallers, but subjects with symptoms of 'dizziness' had a significantly smaller base of support and larger sway than those without, demonstrating an association between objectively impaired balance and subjective symptoms of imbalance.

The efficacy of music for stimulation in prolonged coma — four single case experiments

Four pilot studies using single case experimental design were carried out to examine the immediate effect of music as a form of stimulation in the treatment of patients in persistent vegetative state. In two of the studies there were significant behaviour changes which suggested increased arousal, one showed decreased arousal after the stimulation period and one no change.

PragmatiX: An Interactive Tool for Visualizing the Creation Process Behind Collaboratively Engineered Ontologies

With the emergence of tools for collaborative ontology engineering, more and more data about the creation process behind collaborative construction of ontologies is becoming available. Today, collaborative ontology engineering tools such as Collaborative Protégé offer rich and structured logs of changes, thereby opening up new challenges and opportunities to study and analyze the creation of collaboratively constructed ontologies. While there exists a plethora of visualization tools for ontologies, they have primarily been built to visualize aspects of the final product (the ontology) and not the collaborative processes behind construction (e.g. the changes made by contributors over time). To the best of our knowledge, there exists no ontology visualization tool today that focuses primarily on visualizing the history behind collaboratively constructed ontologies. Since the ontology engineering processes can influence the quality of the final ontology, we believe that visualizing process data represents an important stepping-stone towards better understanding of managing the collaborative construction of ontologies in the future. In this application paper, we present a tool - PragmatiX - which taps into structured change logs provided by tools such as Collaborative Protégé to visualize various pragmatic aspects of collaborative ontology engineering. The tool is aimed at managers and leaders of collaborative ontology engineering projects to help them in monitoring progress, in exploring issues and problems, and in tracking quality-related issues such as overrides and coordination among contributors. The paper makes the following contributions: (i) we present PragmatiX, a tool for visualizing the creation process behind collaboratively constructed ontologies (ii) we illustrate the functionality and generality of the tool by applying it to structured logs of changes of two large collaborative ontology-engineering projects and (iii) we conduct a heuristic evaluation of the tool with domain experts to uncover early design challenges and opportunities for improvement. Finally, we hope that this work sparks a new line of research on visualization tools for collaborative ontology engineering projects.

Randomized control of extracorporeal shock wave therapy versus placebo for chronic decubitus ulceration

Objective: To assess whether extracorporeal shock wave therapy increases the rate of healing in chronic decubitus ulceration.

Design: Double-blind randomized cross-over study.

Setting: A large, long-stay hospital specializing in the management of people with complex neurological disabilities.

Subjects: The total population of available patients with chronic neurological conditions and chronic decubitus ulceration who met the inclusion criteria.

Interventions: Ulcers were randomized into receiving either the extracorporeal shock wave therapy or the placebo for a four-week period, followed by a two-week ‘washout’ period followed by a four-week period of the cross-over treatment/ placebo.

Main measures: Measurement of the area of the ulceration. For each observation the average of three measurements were taken.

Results: Nine ulcers (in eight patients) were included in the study: five on the buttocks/sacrum/trochanter and four on the feet/ankles. All those with static chronic ulcers showed improved healing starting 6—8 weeks after the start of extracorporeal shock wave therapy, whether treated first with the placebo or the therapy.

Conclusions: Extracorporeal shock wave therapy has a potential part to play in the treatment of chronic skin ulceration.

Sex effects of interleukin-6 deficiency on neuroinflammation in aged C57Bl/6 mice

High levels of Interleukin-6 (IL-6) are associated with an increased risk of dementia in the elderly and can increase neuroinflammation in mice. Dementia is more frequent in females, and IL-6 is regulated by estrogen, suggesting that elevated IL-6 levels may contribute to neuroinflammation and dementia particularly in women. Therefore we hypothesized that IL-6 deficient ((-/-)) female mice would have lower aging-related neuroinflammation than wild type (WT). We quantified neuroinflammatory markers which are affected by aging, and regulated by both estrogen and IL-6; glial fibrillary acidic protein (GFAP), myelin basic protein (MBP), interferon gamma (IFNgamma), lipid peroxidation (MDA), and synaptic density (SNAP25) and in IL-6(-/-) and WT C57Bl/6 mice. To determine age effects we used mid-age (18months) and old-age (24months) mice, and to determine region specific effects we used the hippocampus which is impaired in dementia and the cerebellum which is unimpaired in dementia. Unexpectedly, there were no effects of IL-6 deficiency on GFAP, MDA or SNAP25 levels in females, but IL-6 deficiency was associated with lower cerebellar MBP (p<0.05) levels. Interestingly, the old-aged IL-6(-/-) males had higher GFAP and MDA levels (p<0.05) in both the hippocampus and cerebellum, in addition to a greater body weight than WT. We suggest that IL-6 is important for promoting myelin synthesis in aged females, and that drugs which inhibit the synthesis of IL-6 in males may inadvertently affect fatty acid metabolism and augment aging-related neuroinflammation.

Varied prevalence of Clostridium difficile in an integrated swine operation

The objectives of this study were to compare the prevalence of Clostridium difficile (Cd) among different age and production groups of swine in a vertically integrated swine operation in Texas in 2006 and to compare our isolates to other animal and human isolates. Results are based on 131 Cd isolates from 1008 swine fecal samples and pork trim samples (overall prevalence of 13%). The prevalence (number positive/number tested in production type) of Cd was different between the groups (P<or=0.001), and was highest among suckling piglets at 50.0% (61/122), followed by 23.8% (34/143) for lactating sows and effluent from the farrowing barn, 8.4% (10/119) for nursery, 6.5% (4/62) for pork products, 3.9% (15/382) for grower-finisher, and 3.9% (7/180) for breeding boars and sows. Of the 131 isolates, 122 were positive by PCR for both toxins A (tcdA) and B (tcdB) genes, 129 isolates harbored a 39 base pair deletion in the tcdC gene, 120 isolates were toxinotype V, and all 131 of the isolates were positive for the binary toxin gene cdtB. All isolates were resistant to cefoxitin, ciprofloxacin, and imipenem, whereas all were sensitive to metronidazole, piperacillin/tazobactam, amoxicillin/clavulanic acid, and vancomycin. The majority of isolates were resistant to clindamycin; resistant or intermediate to ampicillin; and sensitive to tetracycline and chloramphenicol. There was an increased (P</=0.001) number of isolates for the timeframe of September to February compared to March to August.

Planktonic and biofilm communities from 7-day-old chicken cecal microflora cultures: characterization and resistance to Salmonella colonization

Information implicating bacterial biofilms as contributory factors in the development of environmental bacterial resistance has been increasing. There is a lack of information regarding the role of biofilms within the microbial ecology of the gastrointestinal tract of food animals. This work used a continuous-flow chemostat model derived from the ceca of 7-day-old chicks to characterize these communities and their ability to neutralize invasion by Salmonella enterica serovar Typhimurium. We characterized and compared the biofilm and planktonic communities within these microcosms using automated ribotyping and the Analytical Profile Index biotyping system. Eleven species from eight different genera were identified from six culture systems. Klebsiella pneumoniae was isolated from all planktonic communities and four of the biofilm communities. Three of the communities resisted colonization by Salmonella enterica serovar Typhimurium, two communities suppressed growth, and one community succumbed to colonization. In cultures that resisted colonization, no Salmonella could be isolated from the biofilm; in cultures that succumbed to colonization, Salmonella was consistently found within the biofilms. This study was one of a series that provided a molecular-based characterization of both the biofilm and planktonic communities from continuous-flow culture systems derived from the cecal microflora of chicks, ranging in age from day-of-hatch to 14 days old. The one common factor relating to successful colonization of the culture was the presence of Salmonella within the biofilm. The capacity to sequester the introduced Salmonella into the biofilm appears to be a contributing factor to the inability of these cultures to withstand colonization by the Salmonella.

Folic acid use in pregnancy and embryo selection

OBJECTIVE

Folic acid supplement use is recommended in pregnancy to reduce the risk of neural tube defect but concerns have been raised that increasing folic acid intake may select for embryos with genotypes that increase disease risk in the offspring. Our aim was to test for this effect.

DESIGN

Observational prospective cohort study.

SETTING

Aberdeen Maternity Hospital.

POPULATION OR SAMPLE

Women born before the introduction of folic acid advice (1970-80) and carrying singleton pregnancies (n = 1234) and their offspring (n = 1083) born after (2001-03).

METHODS

We measured the genotype (MTHFR C677T and A1298C, MTR A2756G, MTRR A66G and TCN G776C) of mothers and their offspring, maternal supplement intake, intake of folate and vitamin B12 from natural foods and maternal blood folate and B12 status at 19 weeks of gestation.

MAIN OUTCOME MEASURES

B vitamin related genotype of the offspring.

RESULTS

There were no significant differences in any of the five genotype frequencies between mothers and their babies. There was no deviation from Hardy-Weinberg equilibrium in either generation and no change in the frequency of doubly homozygous MTHFR variants (677 TT/1298 CC). The genotype of the offspring was not related to maternal periconceptual supplement use, folate intake from foods or plasma and red cell folate measured at 19 weeks of gestation.

CONCLUSIONS

We found no evidence to support the concern that folic acid fortification or supplement use in pregnancy results in selection of deleterious genotypes.