Preserving the self with artificial intelligence using VIPCare-a virtual interaction program for dementia caregivers

Introduction

Assistive technology is increasingly used to support the physical needs of differently abled persons but has yet to make inroads on support for cognitive or psychological issues. This gap is an opportunity to address another-the lack of contribution from theoretical social science that can provide insights into problems that cannot be seen. Using Affect Control Theory (ACT), the current project seeks to close that gap with an artificially intelligent application to improve interaction and affect for people with Alzheimer's Disease and Related Dementias (ADRD). Using sociological theory, it models interactions with persons with ADRD based on self-sentiments, rather than cognitive memory, and informs a cellphone-based assistive tool called VIPCare for supporting caregivers.

Methods

Staff focus groups and interviews with family members of persons with ADRD in a long-term residential care facility collected residents' daily needs and personal histories. Using ACT's evaluation, potency, and activity dimensions, researchers used these data to formulate a self-sentiment profile for each resident and programmed that profile into the VIPCare application. VIPCare used that profile to simulate affectively intelligent social interactions with each unique resident that reduce deflection from established sentiments and, thus, negative emotions.

Results

We report on the data collection to design the application, develop self-sentiment profiles for the resident, and generate assistive technology that applies a sociological theory of affect to real world management of interaction, emotion, and mental health.

Discussion

By reducing trial and error in learning to engage people with dementia, this tool has potential to smooth interaction and improve wellbeing for a population vulnerable to distress.

Outflows from the youngest stars are mostly molecular

The formation of stars and planets is accompanied not only by the build-up of matter, namely accretion, but also by its expulsion in the form of highly supersonic jets that can stretch for several parsecs1,2. As accretion and jet activity are correlated and because young stars acquire most of their mass rapidly early on, the most powerful jets are associated with the youngest protostars3. This period, however, coincides with the time when the protostar and its surroundings are hidden behind many magnitudes of visual extinction. Millimetre interferometers can probe this stage but only for the coolest components3. No information is provided on the hottest (greater than 1,000 K) constituents of the jet, that is, the atomic, ionized and high-temperature molecular gases that are thought to make up the jet's backbone. Detecting such a spine relies on observing in the infrared that can penetrate through the shroud of dust. Here we report near-infrared observations of Herbig-Haro 211 from the James Webb Space Telescope, an outflow from an analogue of our Sun when it was, at most, a few times 104 years old. These observations reveal copious emission from hot molecules, explaining the origin of the 'green fuzzies'4-7 discovered nearly two decades ago by the Spitzer Space Telescope8. This outflow is found to be propagating slowly in comparison to its more evolved counterparts and, surprisingly, almost no trace of atomic or ionized emission is seen, suggesting its spine is almost purely molecular.

The diverse chemistry of protoplanetary disks as revealed by JWST

Early results from the James Webb Space Telescope-Mid-InfraRed Instrument (JWST-MIRI) guaranteed time programs on protostars (JOYS) and disks (MINDS) are presented. Thanks to the increased sensitivity, spectral and spatial resolution of the MIRI spectrometer, the chemical inventory of the planet-forming zones in disks can be investigated with unprecedented detail across stellar mass range and age. Here, data are presented for five disks, four around low-mass stars and one around a very young high-mass star. The mid-infrared spectra show some similarities but also significant diversity: some sources are rich in CO2, others in H2O or C2H2. In one disk around a very low-mass star, booming C2H2 emission provides evidence for a "soot" line at which carbon grains are eroded and sublimated, leading to a rich hydrocarbon chemistry in which even di-acetylene (C4H2) and benzene (C6H6) are detected. Together the data point to an active inner disk gas-phase chemistry that is closely linked to the physical structure (temperature, snowlines, presence of cavities and dust traps) of the entire disk and which may result in varying CO2/H2O abundances and high C/O ratios >1 in some cases. Ultimately, this diversity in disk chemistry will also be reflected in the diversity of the chemical composition of exoplanets.

POS0017 SEVERE GENERALIZED EDEMA AS INITIAL PRESENTING SYMPTOM IN POLYMYOSITIS

Background

53 year old female developed pain and swelling of the metacarpophalangeal and proximal interphalangeal joints of both hands. She was diagnosed to have possible inflammatory arthropathy since her workup showed elevated inflammatory markers with CRP 2.2 and ESR 35. Rheumatoid factor and antiCCP antibody were negative. She was treated with hydroxychloroquine, methotrexate followed by leflunomide. She had non pitting edema around both ankles at initial presentation which later spread to the thighs, abdomen and chest. There was no erythema of the skin, tenderness or skin rash. BNP was normal at 58. TSH was normal. Echocardiogram was normal. Blood and urine cultures were negative. CT scan of the chest, abdomen and pelvis showed moderate subcutaneous edema. She was noted to have elevated liver enzymes with AST 438 and ALT 245. Hepatitis panel was negative. Smooth muscle antibody and antimitochondrial antibody were negative. Ultrasound abdomen showed diffusley increased echogenicity throughout the liver. Liver biopsy showed mildly active steatohepatitis centrizonal and portal/periportal fibrosis. ANA was positive 1:640 speckled pattern. ENA showed a positive antiRNP antibody. ANCA was negative. CK was elevated at 853 U/L. Myomarker panel was negative for antiJo, Anti Mi2, antiSRP, antiNXP and anti Ku antibodies. She had a workup for malignancy including CT chest, abdomen and pelvis, mammogram and colonoscopy which were negative.

Objectives

About 4 months after she presented with edema, she developed progressive proximal muscle weakness of both lower extremities which later involved both upper extremities. She also had neck muscle weakness. She also complained of difficulty swallowing. Swallow evaluation was normal. She did not have any skin rashes.

Methods

Concentric needle electromyography showed abnormal spontaneous activity; small amplitude and often polyphasic motor unit action potentials, along with increased recruitment pattern in tibialis anterior, vastus lateralis, medial gastrocnemius, tibialis posterior and short head biceps femoris muscle in the left lower extremity. The findings were suggestive of myopathy. She underwent a muscle biopsy from the left deltoid muscle which showed dense perimysial and endomysial lymphoplasmacytic inflammatory infiltrates with degenerating myofibers.

Results

Patient has proximal muscle weakness in both upper and lower extremities along with elevated CK, EMG findings suggestive of an underlying myopathy and biopsy evidence of inflammation and a diagnosis of polymyositis was made.She was initiated on treatment with a tapering course of prednisone starting at 60 mg daily. Her edema has improved. Liver function tests and CK have improved. Muscle strength has improved in both upper extremities with some residual weakness in the proximal muscles of lower extremities.

Conclusion

Patient presented with severe generalized edema as the initial presenting symptom of polymyositis. Rheumatologists should be aware of subcutaneous edema as a presenting manifestation of inflammatory myopathy and may precede the development of muscle weakness. Previously reported cases of edematous inflammatory myopathy were mostly dermatomyositis. This case demonstrates that polymyositis could also present as subcutaneous edema.

References:

[1] O Gorelik 1, D Almoznino-Sarafian, I Alon, M J Rapoport, G Goltsman, M Herbert, D Modai, N Cohen. Acute inflammatory myopathy with severe subcutaneous edema, a new variant? Report of two cases and review of the literature. Rheumatol Int (2001) 20: 163-166.

[2] Chai Y, Bertorini TE, Li YD, Mitchell C, Guan H (2011). Limb edema and anasarca associated with severe dermatomyositis: report of four cases. Neuromuscul Disord 21:439–442.

Disclosure of Interests

None declared

VIPCare: Understanding the support needed to create affective interactions between new caregivers and residents with dementia

Introduction

In this paper, we study the support needed by professional caregivers of those with dementia, and present a first step toward development of VIPCare, a novel application with the goal of assisting new caregivers at care-centres in interacting with residents with dementia.

Methods

A mixed-methods study including two questionnaires, two focus groups, and seven co-design sessions with 17 professional caregivers was conducted to (a) understand caregivers’ challenges/approaches used to reduce negative interactions with persons with dementia, (b) identify the existing gaps in supporting information for improving such interactions, and (c) co-design the user interface of an application that aims to help improve interactions between a new professional caregiver and persons with dementia. A pre-questionnaire assessed knowledge of smartphones and attitude toward technology. A post-questionnaire provided an initial evaluation of the designed user interface.

Results

Focus groups emphasized the importance of role-playing learned through trial and error. The layout/content of the application was then designed in four iterative paper-prototyping sessions with professional caregivers. An iOS/Android-based application was developed accordingly and was modified/improved in three iterative sessions. The initial results supported efficiency of VIPCare and suggested a low task load index.

Conclusions

We presented a first step toward understanding caregiver needs and developing an application that can help reduce negative interactions between professional caregivers and those with dementia.

P3133Single parasternal long axis echocardiography by briefly trained health workers using handheld devices for detection of rheumatic heart disease: a prospective study of diagnostic accuracy

Introduction

Echocardiographic screening can detect rheumatic heart disease (RHD) in high-risk populations,but is limited by reliance on highly-trained experts and equipment. We sought to determine the diagnostic utility of an ultra-abbreviated single parasternal-long-axis-sweep of the heart (SPLASH) echocardiography protocol to detect RHD, performed by briefly-trained health workers.

Methods

In Timor-Leste and Northern Australia, individuals aged 5–20y were offered school-based echocardiographic screening. Health workers completed online modules followed by one-week of practical training, logging 50 echocardiograms prior to study. The index test was SPLASH, performed and reported by health workers using handheld GE V-scan devices. The index test was abnormal if any mitral or aortic regurgitation was detected. The reference test was a comprehensive echocardiogram, performed by an echocardiographers or cardiologist on a GE Vivid-Q, reported according to World Heart Federation criteria. The diagnostic accuracy of the index test was determined.

Results

2590 subjects underwent index and reference tests. Prevalence of definite RHD was 3.2% (83/2590). Sensitivity and specificity of index test were 0.75 (95% CI 0.64–0.83) and 0.77 (95% CI 0.75–0.78) respectively for detection of any definite RHD, and 0.91 (95% CI 0.74–0.98) and 0.76 (95% CI 0.74–0.78) respectively for detection of moderate or severe RHD.

Conclusion

Health workers using SPLASH detected the vast majority of moderate and severe RHD cases, but lacked sensitivity for detection of mild RHD. Further analysis is underway to evaluate the learning curve and other performance indicators of health workers performing and interpreting echocardiograms. This will allow refinement of SPLASH protocol and augmentation of health worker training to increase detection rates and accuracy for future population screening initiatives.

Acknowledgement/Funding

Heart Foundation Australia Vanguard Grant, Menzies HOT-NORTH pilot project grant, Snow Foundation, Rotary, Bawinanga Aboriginal Corporation, Mala'la

Biomimetic hydroxyapatite/collagen composite drives bone niche recapitulation in a rabbit orthotopic model

Synthetic osteoinductive materials that mimic the human osteogenic niche have emerged as ideal candidates to address this area of unmet clinical need. In this study, we evaluated the osteoinductive potential in a rabbit orthotopic model of a magnesium-doped hydroxyapatite/type I collagen ​(MHA/Coll) composite. The composite was fabricated to exhibit a highly fibrous structure of carbonated MHA with 70% (±2.1) porosity and a Ca/P ratio of 1.5 (±0.03) as well as a diverse range of elasticity separated to two distinct stiffness peaks of low (2.35 ​± ​1.16 ​MPa) and higher (9.52 ​± ​2.10 ​MPa) Young's Modulus. Data suggested that these specific compositional and nanomechanical material properties induced the deposition of de novo mineral phase, while modulating the expression of early and late osteogenic marker genes, in a 3D in vitro model using human bone marrow-derived mesenchymal stem cells (hBM-MSCs). When tested in the rabbit orthotopic model, MHA/Col1 scaffold induction of new trabecular bone mass was observed by DynaCT scan, only 2 weeks after implantation. Bone histomorphometry at 6 weeks revealed a significant amount of de novo bone matrix formation. qPCR demonstrated MHA/Coll scaffold full cellularization in vivo and the expression of both osteogenesis-associated genes (Spp1, Sparc, Col1a1, Runx2, Dlx5) as well as hematopoietic (Vcam1, Cd38, Sele, Kdr) and bone marrow stromal cell marker genes (Vim, Itgb1, Alcam). Altogether, these data provide ​evidence of the solid osteoinductive potential of MHA/Coll and its suitability for multiple approaches of bone regeneration.

Abstract MIP-070: THE IMPACT OF HBO1 IN OVARIAN CANCER

Epithelial ovarian cancer (OC) is now the fifth leading cause of cancer death among women in the U.S. and the leading cause of death in gynecological cancers. OC comprises a variety of tumor types (histotypes) that differ in morphology, prognosis, etiology and molecular biology. Despite the knowledge of OC heterogeneity, current treatment strategies are very similar, and unfortunately, very ineffectual. New approaches, to inhibit OC growth and progression are therefore being sought, with few obvious targets for directed therapy. Currently, large–scale gene expression, DNA copy number and mutational screens have not been able to pinpoint new high frequency drugable targets.

Epigenetic therapy conceives a whole genome approach, potentially circumventing the reliance on therapies that target infrequently mutated genes. Histone acetyl–transferases like GCN5 and PCAF have been targeted in cancer previously, and the main purpose of this study is to assess the role of one such acetyl–transferase, Histone acetyl–transferase binding to origin of replication complex 1” (HBO1, also known as KAT7 and MYST2) in the progression of OC. HBO1 is a histone acetyltransferase (HAT) that plays important roles in diverse molecular processes including DNA replication, transcription and DNA repair. Importantly, HBO1 is overexpressed in primary cancers (breast, testis, ovarian), although the molecular basis of its role is still unclear.

To better understand HBO1's role in OC, we characterized its expression in well–defined OC cell lines both at the mRNA and protein level. Observed in vitro patterns of HBO1 expression correlate well with previous observations; HBO1 is overexpressed in several OC cell lines. Interestingly, the serous histotype generally shows the highest expression. Thus far, we have now analyzed HBO1's downstream regulatory pathways in several OC cell lines through use of siRNA knock–down coupled to microarray analysis. Comparisons of the various datasets have revealed pathways common to all cell lines studied, as well as distinction.

Our approach aims to identify known epigenomic signatures that may be associated with HBO1 binding and downstream signaling which may drive differentiation toward the most advanced stages of the disease. Translating this new information through epigenetic targeting and structural inhibition may lead to novel, next–generation therapies for this most complex of disease presentations.

Citation Format: M.Quintela, L.Francis, D.H.Sieglaff, P.Webb, S.Conlan. THE IMPACT OF HBO1 IN OVARIAN CANCER [abstract]. In: Proceedings of the 11th Biennial Ovarian Cancer Research Symposium; Sep 12-13, 2016; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(11 Suppl):Abstract nr MIP-070.

How is the sustainability of chronic disease health programmes empirically measured in hospital and related healthcare services?-a scoping review

OBJECTIVES

Programmes to address chronic disease are a focus of governments worldwide. Despite growth in 'implementation science', there is a paucity of knowledge regarding the best means to measure sustainability. The aim of this review was to summarise current practice for measuring sustainability outcomes of chronic disease health programmes, providing guidance for programme planners and future directions for the academic field.

SETTINGS

A scoping review of the literature spanning 1985-2015 was conducted using MEDLINE, CINAHL, PsychINFO and The Cochrane Library limited to English language and adults. Main search terms included chronic disease, acute care, sustainability, institutionalisation and health planning. A descriptive synthesis was required. Settings included primary care, hospitals, mental health centres and community health.

PARTICIPANTS

Programmes included preventing or managing chronic conditions including diabetes, heart disease, depression, respiratory disease, cancer, obesity, dental hygiene and multiple chronic diseases.

PRIMARY AND SECONDARY OUTCOME MEASURES

Outcome measures included clarifying a sustainability definition, types of methodologies used, timelines for assessment, criteria levels to determine outcomes and how methodology varies between intervention types.

RESULTS

Among 153 abstracts retrieved, 87 were retained for full article review and 42 included in the qualitative synthesis. Five definitions for sustainability outcome were identified with 'maintenance of programme activities' most frequent. Achieving sustainability was dependent on inter-relationships between various organisational and social contexts supporting a broad scale approach to evaluation. An increasing trend in use of mixed methods designs over multiple time points to determine sustainability outcomes was found.

CONCLUSIONS

Despite the importance and investment in chronic disease programmes, few studies are undertaken to measure sustainability. Methods to evaluate sustainability are diverse with some emerging patterns in measurement found. Use of mixed methods approaches over multiple time points may serve to better guide measurement of sustainability. Consensus on aspects of standardised measurement would promote the future possibility of meta-analytic syntheses.

Genetic and morphological features of human iPSC-derived neurons with chromosome 15q11.2 (BP1-BP2) deletions

BACKGROUND

Copy number variation on chromosome 15q11.2 (BP1-BP2) causes deletion of CYFIP1, NIPA1, NIPA2 and TUBGCP5; it also affects brain structure and elevates risk for several neurodevelopmental disorders that are associated with dendritic spine abnormalities. In rodents, altered cyfip1 expression changes dendritic spine morphology, motivating analyses of human neuronal cells derived from iPSCs (iPSC-neurons).

METHODS

iPSCs were generated from a mother and her offspring, both carrying the 15q11.2 (BP1-BP2) deletion, and a non-deletion control. Gene expression in the deletion region was estimated using quantitative real-time PCR assays. Neural progenitor cells (NPCs) and iPSC-neurons were characterized using immunocytochemistry.

RESULTS

CYFIP1, NIPA1, NIPA2 and TUBGCP5 gene expression was lower in iPSCs, NPCs and iPSC-neurons from the mother and her offspring in relation to control cells. CYFIP1 and PSD95 protein levels were lower in iPSC-neurons derived from the CNV bearing individuals using Western blot analysis. At 10 weeks post-differentiation, iPSC-neurons appeared to show dendritic spines and qualitative analysis suggested that dendritic morphology was altered in 15q11.2 deletion subjects compared with control cells.

CONCLUSIONS

The 15q11.2 (BP1-BP2) deletion is associated with reduced expression of four genes in iPSC-derived neuronal cells; it may also be associated altered iPSC-neuron dendritic morphology.

Characterisation of porcine dermis scaffolds decellularised using a novel non-enzymatic method for biomedical applications

Off-the-shelf availability of tissue-engineered skin constructs, tailored by different combinations of reagents to produce a highly preserved biological matrix is often the only means to help patients suffering skin damage. This study assessed the effect of five different decellularisation methods on porcine dermal scaffolds with regard to matrix composition, biomechanical strength, and cytotoxicity using an in vitro biocompatibility assay. Results demonstrated that four out of the five tested decellularisation protocols were efficient in producing acellular scaffolds. Nevertheless, decellularisation method using osmotic shock without enzymatic digestion showed to be efficient not only in removing cellular material and debris from dermal scaffolds but was also beneficial in the preservation of extracellular matrix components (glycosaminoglycans and collagen). Histological assessment revealed that the dermal architecture of coarse collagen bundles was preserved. Examinations by scanning electron microscopy and transmission electron microscopy showed that the arrangement and ultrastructure of collagen fibrils in the scaffolds were retained following non-enzymatic method of decellularisation and also after collagen crosslinking using genipin. Moreover, this decellularised scaffold was not only shown to be biologically compatible when co-cultured with bone marrow-derived mesenchymal stem cells and fibroblasts, but also stimulated the cells to release trophic factors essential for tissue regeneration.

Current concepts in C3 glomerulopathy

Complement component 3 glomerulopathy (C3G) is a recently defined entity comprising of dense deposit disease and C3 glomerulonephritis. The key histological feature is the presence of isolated C3 deposits without immunoglobulins. Often masqueradng as some of the common glomerulonephritides this is a prototype disorder occurring from dysregulated alternate complement pathway with recently identified genetic defects and autoantibodies. We review the pathophysiology, clinical features, and diagnostic and treatment strategies.

Tetracycline-encapsulated P(3HB) microsphere-coated 45S5 Bioglass(®)-based scaffolds for bone tissue engineering

Bioglass(®)-based scaffolds for bone tissue engineering have been developed, which can also serve as carriers for drug delivery. For this, P(3HB) microspheres (PMSs) loaded with tetracycline were fabricated and immobilised on the scaffold surfaces by a modified slurry dipping technique. The sustained drug delivery ability in simulated body fluid was confirmed by using UV-Vis absorption spectroscopy measurements. The MTT assay using mouse fibroblast cells provided evidence that the tetracycline loaded microspheres produced in this study show limited cytotoxicity. The scaffolds developed in this work provide mechanical support, adequate 3D surface roughness, bioactivity and controlled drug delivery function, and are thus interesting candidates for bone tissue engineering applications.

Interleukin-1β enhances cartilage-to-cartilage integration

The failure of cartilages to fuse, particularly in the case of articular cartilage under conditions of repair is due to morphological and structural constraints of the tissue. Factors that impede integration include, non-vascularisation, low cellularity, and proteoglycan in the surrounding extracellular matrix acting as a natural barrier to cellular migration. We hypothesised that brief activation of a catabolic cascade by cytokines followed by culture under anabolic conditions would promote tissue fusion in a ring-disk model of cartilage integration. Our results show that transient exposure to 10 ng mL(-1) interleukin-1β, followed by two weeks post-culture under anabolic conditions, enhanced cartilage-cartilage integration compared to untreated explants. Quantitative PCR analysis of catabolism-related genes ADAMTS4 and MMP13 showed both were transiently upregulated and these findings correlated with evidence of extracellular matrix remodelling. At the level of histology, we observed chondrocytes readily populated the interfacial matrix between fused explants in interleukin-1β treated explants, whereas in control explants this region was relatively acellular in comparison. Catabolic cytokine treated explants exhibited 29-fold greater adhesive strength (0.859 MPa versus 0.028 MPa, P 〈 0.05) than untreated counterparts. Collectively, our results demonstrate that a single short catabolic pulse followed by an anabolic response is sufficient to generate mechanically robust, integrative cartilage repair.

Sustained remission of systemic lupus erythematosus related calciphylaxis

Calciphylaxis continues to present a clinical challenge for patient management. As in this case, it can be associated with connective tissue disease (CTD) such as systemic lupus erythematosus (SLE). Unlike previous reported cases, long-term remission has been attained. This provides some insight into methods of therapy as well as potential pathogenic models for this disease.

A cohort study of post-weaning multisystemic wasting syndrome and PCV2 in 178 pigs from birth to 14 weeks on a single farm in England

Our hypothesis was that pigs that develop post-weaning multisystemic wasting syndrome (PMWS) are detectable from an early age with signs of weight loss and other clinical and serological abnormalities. Therefore, the objective of this study was to investigate the temporally varying and fixed events linked with the clinical incidence of PMWS by comparing affected and unaffected pigs in a cohort of 178 male piglets. Piglets were enrolled at birth and examined each week. Samples of blood were collected at regular intervals. The exposures measured were porcine circovirus type 2 (PCV2) antibody titres in all 178 and PCV2 antigen in a subset of 75 piglets. We also observed piglet health and measured their weight, and a post-mortem examination was performed by an external laboratory on all pigs between 6 and 14 weeks of age that died. From the cohort, 14 (8%) pigs died from PMWS and 4% from other causes. A further 37 pigs between 6 and 14 weeks of age died from PMWS (30) and ileitis and other causes (7). PMWS was only apparent in pigs from 1 to 2 weeks before death when they wasted rapidly. There were no other characteristic clinical signs and no obvious gross clinical lesions post-mortem. There was no strong link with PCV2 antibody throughout life but PCV2 antigen level was higher from 4 to 6 weeks of age in pigs that died from PMWS compared with pigs that died from other causes.

Hypoglycaemic complications with diabetes mellitus management: the predominant adverse drug reaction presenting to the Accident and Emergency Department of The University Hospital of the West Indies

Evaluation of adverse drug reactions (ADRs) is important to the assessment of risk factors in an aim to ensure maximum benefits of drug therapy. This study was done to assess the types of ADRs presenting to the Accident and Emergency department (A&E) of the University Hospital of the West Indies. Admissions to the A&E associated with drugs were followed on a weekly basis for 19 weeks from October 2007 to February 2008 using the patient logbook. Medical records of patients with suspected ADRs were collected and evaluated by an Emergency Medicine Consultant of A & E to confirm the occurrence of ADRs and the suspected drug. Of the 8170 admissions to A&E, 48 (0.6%) were related to ADRs, with most occurring in females and the mean age (+/- standard error) was 58.9 (+/- 3.4) years. Drug induced hypoglycaemia accounted for 28 (56.3%) cases of ADRs and included mainly patients on insulin, with or without a sulphonylurea therapy. Most of these diabetic patients also had co-morbidities and were on multi-drug therapy (18). Allergic reactions accounted for 10 (21%) of the ADR outcomes. Other drugs accounting for ADRs included cardiovascular drugs (10.4%), analgesic/anti-inflammatory medications (8.3%), drugs acting on the central nervous system (8.3%) and anti-infectives (8.3%). It is concluded that drug-induced hypoglycaemia is the major ADR presenting to the A&E of the University Hospital of the West Indies; it is a preventable ADR and therefore further investigation should evaluate possible factors attributed to the occurrences.

Audit of eosinophilic oesophagitis in children post-liver transplant

Pediatric liver transplantation has proven so successful that 10-yr survival post-transplantation is in excess of 70% and following transplantation, emphasis of medical care switches from life saving to promotion of good quality of life. EE is an increasingly recognised phenomenon in the general population. Eosinophilic disorders of the GI tract are increasingly recognised in patient's post-solid organ transplantation but the contribution of EE to morbidity in this population has not been addressed to date. The objective of this study was to identify the incidence of EE in children receiving liver transplantation by the QLTS over the last 15.5 yr. Comprehensive review of medical records of all liver transplant recipients during study period via cross-checking procedural and electronic laboratory results was performed. All oesophageal biopsies reporting mucosal inflammation were reviewed. EE can be diagnosed when oesophageal biopsy reveals > or =5 eosinophils per HPF; however, we used a cut-off of 20 eosinophils per HPF, which is in accordance with current opinion. In the 159 children who received DD OLT, 130 survived and four have been diagnosed with EE (3%). Only 34 are currently followed in Queensland and all four patients diagnosed are in this cohort representing 12% of our follow-up clinic. Many patients are followed elsewhere so occurrence of EE in our total surviving population is an underestimate. EE is clinically important in the post-liver transplant community. Children post-OLT who have upper GI symptoms should be considered for endoscopic evaluation and biopsy to exclude EE.

Massage therapy in the workplace: reducing employee strain and blood pressure

AIM

Assess the effects of workplace-based massage therapy on physiological and psychological outcomes.

METHODS

We used afield experiment in which 28 participants were randomly assigned into either an experimental (n = 14) or control (n = 14) group. The experimental group received weekly massage treatments at work for a four week period while the control group did not.

RESULTS

Both strain and blood pressure were significantly reduced during treatment for the experimental group but not for the control group.

CONCLUSIONS

This study provides initial support for the effectiveness of workplace-based massage therapy as part of a comprehensive workplace health strategy.

Mutactimycin E, a new anthracycline antibiotic with gram-positive activity

Resistance to currently available antibiotics has become a widely recognized crisis in the medical community. To address this, many companies and researchers are refocusing their attention towards natural products, which have an excellent track record of producing effective antibacterial drugs. The AMRI natural product library was screened for activity against multi-drug resistant Staphylococcus aureus (MDRSA). The active samples were counter screened for cytotoxicity against the human hepatocellular carcinoma HepG2 cell line to determine an in vitro therapeutic index (in vitro TI). Those samples with a high in vitro TI were selected for fractionation and dereplication. This led to the discovery of a new anthracycline structure. This metabolite, named mutactimycin E (1), exhibited moderate activity against several gram positive organisms. Here we report the isolation, structure elucidation and biological activities of this new compound.

Neopyrrolomycins with broad spectrum antibacterial activity

Three new antibiotics, neopyrrolomycins B (1), C (2), and D (3), with potent activity against Gram-positive pathogens were discovered. They exhibited MIC values < 1 microg/mL versus a number of resistant strains. The compounds were obtained from the ethyl acetate extracts of a Streptomyces sp. after purification by column chromatography and RP-HPLC. Their structures were elucidated using X-ray crystallography (1) and NMR spectroscopy (2 and 3).

Citreamicins with potent gram-positive activity

Two new xanthone antibiotics, citreamicin delta (1) and epsilon (2), with potent activity against Gram-positive pathogens including multidrug-resistant Staphylococcus aureus (MDRSA) were discovered. Compounds 1 and 2 exhibited MIC values < 1 microg/mL versus a number of resistant strains. The compounds were obtained from EtOAc extracts of Streptomyces vinaceus and were purified by countercurrent chromatography and reversed-phase HPLC. Their structures were elucidated using primarily NMR and mass spectroscopy.

Prognosis value of hormonal and HER2 receptors on overall survival (OS) and disease-free interval (DFI) in metastatic breast cancer (MBC)

1077

Background: In MBC, positive HR constitute a favourable prognostic factor and predict response to an hormonal therapy. Conversely HER-2 overexpression is an adverse prognostic factor associated with a more aggressive tumor. In this retrospective study we analysed overall survival (OS) and disease-free interval (DFI) of three phenotypes: HR-/HER-2- (triple negative); HR+/HER-2- (luminal) and HER-2 overexpression (HER-2+). Methods: We evaluated 511 patients with a MBC treated at Centre Jean Perrin from 1973 to 2006. A comparative lecture of oestrogenic, progestative and HER-2 receptors was performed by IHC. At present, HR and HER-2 status were re-evaluated on 166 initial tumor sample of this data base by two pathologists (study currently ongoing). Median age of patients was 54.8 years. 120 (23.6%) patients were directly metastatic (M1), 391 (76.4%) relapsed distantly (M0). Metastatic patients received a median number of 2 lines of chemotherapy (range, 0–14) and/or a median number of 1 line (range, 0–8) of hormonotherapy. 92 (55.4%) patients had a luminal phenotype, 48 patients (28.9%) were HER-2+ and 26 patients (15.7%) were triple negative. Results: Among these 166 tumors, OS was significantly different between these three populations (p=0.00056). DFI variation was not signicant (p=0.083). These data showed that: - Luminal phenotype had the better OS (median survival of 36.5 months) and DFI (51.09 months) - HER-2+ phenotype (33 of 48 patients were treated with trastuzumab from 1999) had an intermediate prognostic on OS (median survival of 31.1 months) and DFI (42.2 months) - Triple negative phenotype had a poor prognostic on OS (median survival of 12.8 months) and the worse DFI (32.64 months) Conclusions: In metastatic breast cancer, luminal phenotype patients had the best OS; HER-2+ phenotype (treated by herceptin) had an intermediate OS, and triple negative phenotype had the worse OS.

No significant financial relationships to disclose.

Compound odontoma causing airway obstruction of the newborn: a case report

A newborn presented with acute airway obstruction secondary to a compound odontoma of the hard palate/nasal floor. This is the first case recorded in the literature. We review the pathology of compound odontomas and discuss the management of this rare and interesting case.

The use of acetic acid in magnification chromocolonoscopy for pit pattern analysis of small polyps

BACKGROUND AND STUDY AIMS

The role of acetic acid spray during magnification chromocolonoscopy has not previously been evaluated. We aimed to compare the accuracy of predicting polyp histology at magnification colonoscopy, using acetic acid and indigo carmine, either alone or in combination.

PATIENTS AND METHODS

A total of 46 consecutive patients with polyps detected during colonoscopy which measured 10 mm or less were alternately divided into two groups. In group A patients, 1.5 % acetic acid was applied to the mucosa first, followed by indigo carmine spray; in group B patients, the order was reversed. The pit pattern was assessed after application, in real time. All the lesions were resected and examined histologically.

RESULTS

Altogether, 37 adenomas and 36 hyperplastic polyps were evaluated. In group A, the diagnostic accuracy after spraying with acetic acid was 95 %, which increased to 98 % after application of indigo carmine. In group B, the accuracy after indigo carmine application was 83 %. After subsequent spraying with acetic acid, images were enhanced in 70 % of patients, with an increase in accuracy to 97 %. The mean time required to obtain an initial clear image with the first dye was 14 seconds for both groups.

CONCLUSIONS

This is the first description of the use of acetic acid for pit pattern analysis of colonic polyps. Its ease of use, low cost, and safety, together with its excellent accuracy in the assessment of polyp pit patterns suggest that this method could easily be applied to routine magnification colonoscopy.

Predictive value of human chorionic gonadotrophin beta-hCG in early pregnancy after assisted conception

OBJECTIVE

This study was designed to evaluate the predictive value of beta-hCG levels in predicting the pregnancy outcome.

METHODS

A retrospective analysis was done on 423 pregnant patients following assisted conception (stimulated in vitro fertilization [SIVF] and stimulated intra uterine insemination [SIUI]). These were monitored with plasma beta-hCG on day +18 post hCG injection. Ongoing pregnancy was defined as greater than 20 weeks.

RESULTS

Four hundred twenty three patients had a positive serum quantitative beta-hCG level 18 days post hCG injection. Of these 321 (75.9%) were ongoing pregnancies. The spontaneous miscarriages were 98 (23.2%), and four ectopic pregnancies were recorded. Of the successful pregnancies, 279 were single births, and 42 were multiple births (15.1%), that is either twins (31) or triplets (11). Tables were calculated to help predicting the pregnancy outcome.

CONCLUSIONS

It can be shown that +18 levels of beta-hCG in cases of assisted conception are useful and provide predictive information concerning pregnancy outcome which should be helpful for the staff and the infertility patients.

Insights from outstanding rural internal medicine residency rotations at the University of Washington

PURPOSE

Despite being well suited to provide the breadth of care needed in rural areas, few general internists become rural physicians. Little formal rural residency training is available and no formal curricula exist. For over 25 years the University of Washington School of Medicine has provided elective WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) rural residency rotations to expose residents to the rewards and challenges of rural practice. This study identified the characteristics of outstanding rural residency rotations.

METHOD

The key preceptors at three outstanding rural residency sites were interviewed about their experiences, teaching strategies, and opinions about curriculum. Their responses were categorized. Seven university-based residents and eight training at WWAMI sites recorded and rated the value of over 1,500 learning encounters.

RESULTS

The preceptors agreed that outstanding rotations were led by enthusiastic preceptors who served as role models for excellence. These preceptors provided residents with meaningful responsibilities and emphasized independent decision making based on the history and physical examination. They stressed supervised independence and self-directed learning with frequent structured feedback for residents. The residents rated the learning value of patient encounters in rural locations significantly higher than that of those in university clinics.

CONCLUSIONS

Exceptional rural residency experiences involve excellent role models who provide meaningful responsibility and emphasize core skills using a learner-centered approach. Rural training experiences should be supported, and the suggestions of outstanding preceptors should be used to develop and disseminate a curriculum that will better prepare residents for rural practice.

Role of the dinB gene product in spontaneous mutation in Escherichia coli with an impaired replicative polymerase

We isolated several new mutator mutations of the Escherichia coli replicative polymerase dnaE subunit alpha and used them and a previously reported dnaE mutation to study spontaneous frameshift and base substitution mutations. Two of these dnaE strains produce many more mutants when grown on rich (Luria-Bertani) than on minimal medium. A differential effect of the medium was not observed when these dnaE mutations were combined with a mismatch repair mutation. The selection scheme for the dnaE mutations required that they be able to complement a temperature-sensitive strain. However, the ability to complement is not related to the mutator effect for at least one of the mutants. Comparison of the mutation rates for frameshift and base substitution mutations in mutS and dnaE mutS strains suggests that the mismatch repair proteins respond differently to the two types of change. Deletion of dinB from both chromosome and plasmid resulted in a four- to fivefold decrease in the rate of frameshift and base substitution mutations in a dnaE mutS double mutant background. This reduction indicates that most mistakes in replication occur as a result of the action of the auxiliary rather than the replicative polymerase in this dnaE mutant. Deletion of dinB from strains carrying a wild-type dnaE had a measurable effect, suggesting that a fraction of spontaneous mutations occur as a result of dinB polymerase action even in cells with a normal replicative polymerase.

Nutrition and HIV infection: experience in Zimbabwe: interview with Lynde Francis. Interview by John S. James

For years Lynde Francis has run an AIDS service organization in Harare, Zimbabwe, where few patients can afford antiretrovirals, so nutritional improvement is often the only treatment available. In this interview she explains what she has found to be helpful. While specific nutritional advice will vary, depending on many factors, we believe that readers should be aware of this treatment experience.

Evidence for Association of a Viroid with Tapping Panel Dryness Syndrome of Rubber (Hevea brasiliensis)

Tapping panel dryness (TPD) is one of the most destructive maladies affecting rubber plantations and is becoming a matter of serious concern. Reduced latex yield leading to total drying of the tapping panel is the obvious symptom. The cause of TPD syndrome is unknown but has been mostly attributed to abiotic causes. In India, the high yielding commercial clone RRII 105 is affected by TPD, leading to enormous losses. We have observed that TPD-affected trees show symptoms of bark scaling, cracking, drying, necrotic streaking, and browning of internal bark leading to the decay of internal tissues. Often prominent abnormal bulges on the lower part of tree trunks occur where the first panel begins to dry. Investigations on TPD-affected rubber samples did not reveal the association of fungus, bacterium, virus, or a protozoan. Total nucleic acid extracts purified from leaf and bark tissues of affected samples and analyzed by polyacrylamide gel electrophoresis under denaturing conditions of low salt and high temperature showed the presence of nucleic acids similar in electrophoretic mobility to low molecular weight (LMW) RNA, of ~359 nucleotides such as potato spindle tuber viroid (PSTVd). The LMW nucleic acid detected from TPD-affected samples was found to be RNA based on its sensitivity to RNase and insensitivity to DNase, phenol, and heat treatments. The LMW RNA was purified and cloned in a pUC 19-derived vector by using primers specific to PSTVd (1). The cloned DNA, when random labeled and used as probe reacted specifically to nucleic acid extracts from TPD-affected rubber trees but not from healthy tissue in dot-blot hybridization assays. Based on the above findings, a viroid etiology for TPD syndrome is proposed. Reference: (1) R. A. Owens, A. T. Candresse, and T. O. Diener. Virology 175:238, 1990.

[Behavior characterization of a model of Huntington's disease in rats, induced by quinolinic acid]

INTRODUCTION

Huntington's disease (HD) is a progressive neurodegenerative disorder, characterized by severe degeneration of basal ganglia neurons. Behavioral symptoms of HD include abnormal, uncontrollable and constant choreiform movements, impaired cognitive function and emotional disturbance.

OBJECTIVE

In order to explore the changes of cognitive and motor functions induced by quinolinate lesion we realized this experiment.

MATERIALS AND METHODS

We studied the behavior of rats with unilateral quinolinate induced lesions of the medial striatum. Intact 3 months old male rats (n = 23) were trained in the Morris Water Maze during three consecutive days, eight trials/day (acquisition), and before surgery they were randomly assigned either to intact or lesion groups. Fifteen days after the lesion the rats were tested using retention test (one day/four trials, with the escape platform in the same position as in acquisition test), on the next three days the rats were tested in the transfer test (three days/eight trials-day, with the platform in the new position). The Paw reaching test and the asymmetrical rotational behavior test in respond to amphetamine were also tested in these rats.

RESULTS

Lesioned animals exhibited deficient retrieval of stored memories of visuospatial skills and impaired transfer of learning. In relation with motor activity the lesioned rats showed a profound impairment in the skill of the left forelimb for reaching food compared with its right forelimb as well as with the forelimb abilities of intact rats. The lesioned animals showed significant rotational behavior induced by amphetamine agonist, ipsilateral to the lesioned striatum.

CONCLUSIONS

These results are consistent with the notion that the striatal degeneration could sufficiently account for the cognitive abnormalities associated with HD, and with the key role played by basal ganglia in enabling voluntary and postural adjustment of the movements.

Chemotherapy reduces the prevalence of asthma symptoms in children with cancer: implications for the role of airway inflammation in asthma

OBJECTIVE

Asthma is common in Australian children, with a prevalence of 30%. Airway inflammation is an important determinant of asthma symptoms. Chemotherapy used for the treatment of many childhood cancers suppresses inflammation. The prevalence of asthma symptoms in children treated with chemotherapy is unknown.

METHODOLOGY

We therefore performed a survey of symptoms of asthma in children attending the oncology clinic at John Hunter Children's Hospital during the first 6 months of 1996.

RESULTS

Fifty children aged 1-17 years were surveyed. Thirty-two of the children were in remission and had completed treatment with chemotherapy and 18 were currently undergoing treatment with chemotherapy. There was no significant difference in the prevalence of asthma in children before, during and after chemotherapy (26%, 22% and 34%), or in the prevalence of asthma in their siblings (28%). No child was classified as having persistent asthma while on chemotherapy and there was a significant reduction in the requirement for preventive asthma drugs 12% versus 0% (P = 0.03) being reported during chemotherapy.

CONCLUSION

The prevalence of asthma in children who develop cancer is similar to their siblings and the same as the population as a whole. While asthma symptoms do not disappear completely during chemotherapy, the severity of asthma symptoms is less, with no need for asthma preventive treatment. The immunosuppressive side effects of the chemotherapy used in the treatment of childhood cancer appear to induce a remission in asthma symptoms. The ongoing requirement for bronchodilator therapy in patients whilst on chemotherapy suggests airway hyperreactivity persists in children while they are on chemotherapy. Prospective study of the airways of this group of patients promises to provide insights into the relationships between airway hyperreactivity, airway inflammation and asthma.

Suspected infection in children with cancer

The microbiology and severity of suspected infections in children with cancer admitted to the John Hunter Children's Hospital was determined in order to assess whether any alteration to the infection treatment protocol was required. All children with cancer aged 1-17 years who had an episode of suspected or proven infection that required parenteral treatment at John Hunter Children's Hospital (JHCH) during 1994/95 were reviewed. Thirty-seven children were treated for cancer at JHCH; 62 admissions for suspected infection which involved 26 children were reviewed. Sixteen of these children had a permanent central line. Children with a central line had an increase in the number of days of inpatient treatment required for the treatment of suspected infection, and they had more episodes of infection. A pathogen was isolated more frequently with blood cultures being positive more often and gram-positive species were methicillin resistant more often. These differences were not statistically significant. A pathogen was isolated in 52% of admissions. Sixteen pathogens were gram positive; 12 were gram negative, two were fungal and two were viral. Blood cultures were positive in 21 of 62 admissions, skin swabs in four admissions, urine cultures in three admissions, stool in two admissions and one species was isolated from an epidural catheter tip and from the sputum. In 16% of admissions, the identified organism was resistant to the initial empirical therapy of tobramycin and piperacillin. In a further 13%, flucloxacillin was added to the empirical regimen when a sensitive Staphylococcus was identified. No significant differences between the culture-negative and culture-positive groups were observed in admission pulse, fever or admission neutrophil count. However, those patients with a central line had a higher incidence of having a pathogen isolated if their temperature was > 39.5 degrees C. The median length of stay was longer for patients with a pathogen isolated on blood culture. Admission blood cultures were positive in 53% of admissions with an initial neutrophil count > 1000 x 10(9)/mL. Each of these children had a central line. Only one child died of infection during the 2-year study period. This review supports the observations that gram-positive infection is now more common than gram-negative infection in children with cancer. Despite the management advantages a permanent central line affords it is clear those children with a central line have an increased rate of infection and there needs to be caution in their use. The most important is the observation that any fever > 39.5 degrees C in a child with a central line is likely to be associated with a documented infection irrespective of the neutrophil count. The clinical outcomes observed in the present study indicate that tobramycin and piperacillin are effective empirical treatments for suspected infection in children with cancer.