The influence of risk factors, biomarkers and care settings on SUDEP counseling

Although sudden unexpected death in epilepsy (SUDEP) is the most feared epilepsy outcome, there is a dearth of SUDEP counseling provided by neurologists. This may reflect limited time, as well as the lack of guidance on the timing and structure for counseling. We evaluated records from SUDEP cases to examine frequency of inpatient and outpatient SUDEP counseling, and whether counseling practices were influenced by risk factors and biomarkers, such as post-ictal generalized EEG suppression (PGES). We found a striking lack of SUDEP counseling despite modifiable SUDEP risk factors; counseling was limited to outpatients despite many patients having inpatient visits within a year of SUDEP. PGES was inconsistently documented and was never included in counseling. There is an opportunity to greatly improve SUDEP counseling by utilizing inpatient settings and prompting algorithms incorporating risk factors and biomarkers.

Cell type specificity of mosaic chromosome 1q gain resolved by snRNA-seq in a case of epilepsy with hyaline protoplasmic astrocytopathy

Introduction

Mosaic gain of chromosome 1q (chr1q) has been associated with malformation of cortical development (MCD) and epilepsy. Hyaline protoplasmic astrocytopathy (HPA) is a rare neuropathological finding seen in cases of epilepsy with MCD. The cell-type specificity of mosaic chr1q gain in the brain and the molecular signatures of HPA are unknown.

Methods

We present a child with pharmacoresistant epilepsy who underwent epileptic focus resections at age 3 and 5 years and was found to have mosaic chr1q gain and HPA. We performed single-nuclei RNA-sequencing (snRNA-seq) of brain tissue from the second resection.

Results

snRNA-seq showed increased expression of chr1q genes specifically in subsets of neurons and astrocytes. Differentially expressed genes associated with inferred chr1q gain included AKT3 and genes associated with cell adhesion or migration. A subpopulation of astrocytes demonstrated marked enrichment for synapse-associated transcripts, possibly linked to the astrocytic inclusions observed in HPA.

Discussion

snRNA-seq may be used to infer the cell type-specificity of mosaic chromosomal copy number changes and identify associated gene expression alterations, which in the case of chr1q gain may involve aberrations in cell migration. Future studies using spatial profiling could yield further insights on the molecular signatures of HPA.

Epilepsy surgery as a treatment option for select patients with PCDH19-related epilepsy

PCDH19 is a common epilepsy gene causing medication resistant epilepsy with fever-related seizures. Traditionally, patients with PCDH19-related epilepsy have not been considered surgical candidates. This retrospective review evaluated three patients with pathogenic variants in PCDH19 who presented with seizures in childhood, had one seizure semiology, became medication resistant, and had concordant imaging, seizure semiology and electrographic findings. All three patients ultimately underwent temporal lobectomy, resulting in seizure freedom. These findings suggest epilepsy surgery can be an effective treatment option for select patients with PCDH19-related epilepsy and a single seizure semiology.

Comparison of Cosyntropin, Vigabatrin, and Combination Therapy in New-Onset Infantile Spasms in a Prospective Randomized Trial

Objective: In a randomized trial, we aimed to evaluate the efficacy of cosyntropin injectable suspension, 1 mg/mL, compared to vigabatrin for infantile spasms syndrome. An additional arm was included to assess the efficacy of combination therapy (cosyntropin and vigabatrin) compared with cosyntropin monotherapy. Methods: Children (2 months to 2 years) with new-onset infantile spasms syndrome and hypsarhythmia were randomized into 3 arms: cosyntropin, vigabatrin, and cosyntropin and vigabatrin combined. Daily seizures and adverse events were recorded, and EEG was repeated at day 14 to assess for resolution of hypsarhythmia. The primary outcome measure was the composite of resolution of hypsarhythmia and absence of clinical spasms at day 14. Fisher exact test was used to compare outcomes. Results: 37 children were enrolled and 34 were included in the final efficacy analysis (1 withdrew prior to treatment and 2 did not return seizure diaries). Resolution of both hypsarhythmia and clinical spasms was achieved in in 9 of 12 participants (75%) treated with cosyntropin, 1/9 (11%) vigabatrin, and 5/13 (38%) cosyntropin and vigabatrin combined. The primary comparison of cosyntropin versus vigabatrin was significant (64% [95% confidence interval 21, 82], P < .01). Adverse events were reported in all 3 treatment arms: 31 (86%) had an adverse event, 7 (19%) had a serious adverse event, and 15 (42%) had an adverse event of special interest with no difference between treatment arms. Significance: This randomized trial was underpowered because of incomplete enrollment, yet it demonstrated that cosyntropin was more effective for short-term outcomes than vigabatrin as initial treatment for infantile spasms.

Development of Self-Healing Cement Slurry through the Incorporation of Dual-Encapsulated Polyacrylamide for the Prevention of Water Ingress in Oil Well

In the present work, a novel cross-linked polymer was synthesized though the anionic polymerization of cyanoacrylate with moisture as an initiator, methylene-bis-acrylamide as a cross-linker, and linseed oil as a spacer. Two layers of the synthesized polymer was coated over polyacrylamide for its homogenous impregnation in Class-G cement slurry for the synthesis of cement core. Fourier Transformation Infrared spectroscopy and X-Ray diffraction spectrum of the synthesized polymer and cement core were obtained to investigate the presence of different functional groups and phases. Moreover, the morphologies of the dual-encapsulated polyacrylamide was observed through scanning electron microscopy. Furthermore, the water-absorption capacity of the synthesized dual-encapsulated polyacrylamide in normal and saline conditions were tested. A cement core impregnated with 16% of dosage of dual-encapsulated polyacrylamide possesses an effective self-healing capability during the water-flow test. Moreover, the maximum linear expansion of the cement core was observed to be 26%. Thus, the impregnation of dual-encapsulated polyacrylamide in cement slurry can exhibit a superior self-healing behavior upon water absorption in an oil well.

0969 Early Life Sleep Disturbance Among Children With Autism Spectrum Disorders: A Questionnaire-based Retrospective Study

Introduction

Autism spectrum disorders(ASD) and sleep has hand to hand relationship and few recently published studies have shown that, disturbed infant sleep is associated with Attention deficit hyperactive disorder and Autism. The aim of the study is to evaluate the sleep disturbance in first year of life among the children with ASD.

Methods

In this case control study, pre-diagnosed ASD children between 3-12 year of age (group 1) and controls; sibling of autistic children and community dwelling children(group 2), were enrolled in between June 2014 to November 2017. After giving consent every child underwent, Detailed Clinical [Childhood Autism rating scale-2(CARS-2)] and Sleep evaluation [Brief Infant sleep Questionnaire (BISQ) - Retrospectively, Child sleep habits questionnaire (CSHQ)].

Results

Sixty children in group1 and 60 in group 2 were enrolled and both groups were age [Median 7(2.5-12) vs. 8.5 (2.5-12), p = 0.14] and sex [53(88.33%) vs. 45(75.00 %), p=0.15] matched. On CHSQ poor sleepers are more common among the group 1[40(66.66%) vs. 20(33.33%), p=.003, respectively]. On BISQ children had severe sleep problems during infancy were significantly more among the group 1 [46(76.66%) vs. 6(10%), p=&lt;.001, respectively]. Duration of nocturnal awakening was significantly correlated (r=0.87, p=.001) with the T score of the CARS-2.

Conclusion

Sleep is significantly disturbed since infancy among children with autism spectrum disorder and duration of nocturnal awakenings during infancy is strongly correlated with severity of autism.

Support

NA

PCDH19-related epilepsy is associated with a broad neurodevelopmental spectrum

OBJECTIVE

To characterize the features associated with PCDH19-related epilepsy, also known as "female-limited epilepsy."

METHODS

We analyzed data from participants enrolled in the PCDH19 Registry, focusing on the seizure-related, developmental, neurobehavioral, and sleep-related features. We evaluated variants for pathogenicity based on previous reports, population databases, and in silico predictions, and included individuals with pathogenic or potentially pathogenic variants. We performed a retrospective analysis of medical records and administered a targeted questionnaire to characterize current or past features in probands and genotype-positive family members.

RESULTS

We included 38 individuals with pathogenic or potentially pathogenic variants in PCDH19: 21 de novo, 5 maternally inherited, 7 paternally inherited, and 5 unknown. All 38 had epilepsy; seizure burden varied, but typical features of clustering of seizures and association with fever were present. Thirty individuals had intellectual disability (ID), with a wide range of severity reported; notably, 8/38 (22%) had average intellect. Behavioral and sleep dysregulation were prominent, in 29/38 (76%) and 20/38 (53%), respectively. Autistic features were present in 22/38 (58%), of whom 12 had a formal diagnosis of autism spectrum disorder. We had additional data from 5 genotype-positive mothers, all with average intellect and 3 with epilepsy, and from 1 genotype-positive father.

SIGNIFICANCE

Our series represents a robust cohort with carefully curated PCDH19 variants. We observed seizures as a core feature with a range of seizure types and severity. Whereas the majority of individuals had ID, we highlight the possibility of average intellect in the setting of PCDH19-related epilepsy. We also note the high prevalence and severity of neurobehavioral phenotypes associated with likely pathogenic variants in PCDH19. Sleep dysregulation was also a major area of concern. Our data emphasize the importance of appropriate referrals for formal neuropsychological evaluations as well as the need for formal prospective studies to characterize the PCDH19-related neurodevelopmental syndrome in children and their genotype-positive parents.

Neurodevelopmental outcomes of preterm infants resuscitated with different oxygen concentration at birth

OBJECTIVE

To compare the neurodevelopmental outcomes at 18 to 21 months corrected age (CA) of infants born at <29 weeks that received room air, an intermediate oxygen concentration or 100% oxygen at the initiation of resuscitation.

STUDY DESIGN

In this retrospective cohort study, we compared neonatal and neurodevelopmental outcomes at 18 to 21 months CA among inborn infants born before 29 weeks' gestation that received room air, intermediate oxygen concentration or 100% oxygen at the initiation of resuscitation.

RESULTS

Of 1509 infants, 445 received room air, 483 received intermediate oxygen concentrations and 581 received 100% oxygen. Compared to infants that received room air, the primary outcome of death or neurodevelopmental impairment (NDI) was not different in intermediate oxygen (adjusted odds ratio (aOR) 1.01; 95% confidence interval (CI) 0.77, 1.34) or 100% oxygen (aOR 1.03; 95% CI 0.78, 1.35). Compared to room air, there was no difference in odds of death or severe NDI in intermediate oxygen (aOR 1.14; 95% CI 0.82, 1.58) or 100% oxygen group (aOR 1.22; 95% CI 0.90, 1.67). The odds of severe NDI among survivors were significantly higher in infants that received 100% oxygen as compared to room air (aOR 1.57, 95% CI 1.05, 2.35).

CONCLUSIONS

We observed no significant difference in the primary composite outcomes of death or NDI and death or severe NDI at 18 to 21 months CA between infants that received room air, intermediate oxygen concentration or 100% oxygen at the initiation of resuscitation. However, use of 100% oxygen was associated with increased odds of severe NDI among survivors as compared to room air.

Twenty-four-hour in-house neonatologist coverage and long-term neurodevelopmental outcomes of preterm infants

Objectives

To compare short- and long-term neurodevelopmental outcomes at 3 years of corrected age of preterm infants cared for by 24-hour in-house staff neonatologists and those cared for by staff neonatologists during daytime only.

Methods

Retrospective analysis of prospectively collected follow-up data on all nonanomalous preterm infants from 1998 to 2004 excluding year 2001 as a washout period. Infants were divided into two groups based on care provided by staff neonatologists: 24-hour in-house coverage (24-hour coverage 1998-2000) and daytime coverage (day coverage 2002-2004). Short- and long-term outcomes were compared.

Results

A total of 387 (78%) of the screened infants were included. Twenty-four-hour coverage (n=179) and day coverage (n=208) groups had a median birth weight (BW) of 875 g (range 470-1250) and 922 g (480-1530; P=0.028), respectively, and both had a median gestational age of 27 weeks. In the day coverage group, a smaller proportion of mothers had chorioamnionitis (20% vs. 30%; P=0.025), received less antibiotics (62% vs. 73%; P=0.023), and infants had fewer cases of confirmed sepsis (14% vs. 23%; P=0.022). In the day coverage group, a larger number of infants had respiratory distress syndrome (87% vs. 77%; P=0.011) and required prolonged mechanical ventilation (median 31 vs. 21 days; P=0.002). The incidence of major neurodevelopmental impairment was not significantly different between the two groups (odds ratio 0.76; 95% confidence interval 0.34-1.65).

Conclusions

Duration of mechanical ventilation was reduced with 24-hour in-house coverage by staff neonatologists. However, 24-hour coverage was not associated with any difference in neurodevelopmental (ND) outcomes at 3-year corrected age.

Colorectal cancer treatment and survival over three decades at four major public hospitals in South Australia: trends by age and in the elderly

Data from registries at four major public hospitals in South Australia indicate increased 5-year disease-specific survivals for colorectal cancer from 48% to 63% between 1980-1986 and 2005-2010. For 80+ year olds, the increase was smaller, from 47% to 52%. Risk of case fatality halved overall, adjusting for age, gender, stage, differentiation and sub-site. Patients aged 80+ years had a lower risk reduction of about a third (hazards ratio: 0.69; 95% confidence limits, 0.52-0.92). Percentages having surgery and other specified treatments were lower for 80+ year olds than younger cases, although increases in treatment intensity occurred in this age range during 1980-2010, as seen in younger ages, in accordance with guidelines. The study illustrates the important feedback clinical registries can provide to clinicians on care patterns and outcomes in their hospital settings. Feedback can be the subject of local deliberations on how to achieve the best outcomes, including in the elderly by considering the best trade-offs between optimal cancer care and accommodations for co-morbidity and frailty. Clinical registry data can be used in comparative effectiveness research in local settings where there are sufficient case numbers.

Integrated Neonatal Support with Placental Transfusion and Resuscitation (Inspire): A Feasibility Study

BACKGROUND: Compromised neonates do not receive placental transfusion (PT), but receive immediate cord clamping to facilitate resuscitation. Animal studies suggest possible benefit of resuscitation during PT.

OBJECTIVES: To study the feasibility of initiating resuscitative care during PT for 90s in preterm infants.

DESIGN/METHODS: We designed a mobile, battery powered resuscitation platform (iNSPiRe) that contains a scale, warm gel mattress, oxygen and air tanks, blender, T piece resuscitator, pulse oximeter (PO), and suction device (Fig. 1). Resuscitative care included initial steps, and respiratory support at 30s following Neonatal Resuscitation Program guidelines. Thermoregulation was maintained using a hat, warmed blankets, and gel mattress. Heart rate was auscultated at 30, 60 and 90s. PO was placed on the right wrist/hand. The cord was clamped at 90s. The baby and platform were mobilized from mother’s bedside to a radiant warmer by one provider, while another provider maintained respiratory support. Once on the warmer, axillary temperature (AT) was measured. Resuscitation interventions and management during first 24 hours were recorded.

RESULTS: Seven infants born vaginally, median (range) gestational age (GA) was 30 weeks (28 to 36) and birth weight 1500g (1270 to 2650), were managed using iNSPiRe. Table 1 shows time (T) to initiate interventions, cord pH and Apgar scores. Five infants received continuous positive airway pressure (CPAP) and one received positive pressure ventilation; none had hypotension, pneumothorax, or received surfactant. No incidence of intraventricular hemorrhage.

CONCLUSION: It is feasible to commence resuscitative care during PT in infants ≥30 weeks' GA for 90s. Further research is needed to assess the feasibility in smaller and sicker preterm infants.

Collapse

Neurodevelopmental Outcomes Following Extensive Cardiopulmonary Resuscitation in the Delivery Room for Infants Born &lt;29 Weeks’ Gestational Age

BACKGROUND: Neurodevelopmental outcomes of preterm infants who receive extensive CPR (ECPR), defined as chest compression with or without epinephrine in the delivery room, remain unclear.

OBJECTIVES: To compare the neurodevelopmental outcomes of preterm infants admitted to Canadian NICUs requiring ECPR versus those who did not require ECPR in the delivery room.

DESIGN/METHODS: Preterm infants born at &lt;29 weeks GA between January 1, 2010 and September 30, 2011 and evaluated at CNFUN centers were retrospectively evaluated. The primary outcome was a composite of death or neurodevelopmental impairment (NDI) at 18-21 months CA defined as presence of any one or more of the following: definitive cerebral palsy or Bayley- III cognitive, language, motor scores &lt;85 on any one of the components or hearing impairment or visual impairment. Demographic factors, neurodevelopmental status including Bayley III cognitive, language and motor scores and sensory impairments were compared between the ECPR and the no ECPR group using univariate and multivariate analyses. RESULTS: Of 2488 eligible infants, 197 (7.9%) received ECPR. 83% of surviving infants had follow-up data. Demographic and outcomes data are summarized below in Table 1 and 2 respectively.

Successful Implementation of a Change in Practice to Optimize Timing of Umbilical Cord Clamping in Preterm Neonates: A Quality Improvement Initiative

BACKGROUND: Natural, also known as delayed, umbilical cord clamping (NCC) is recommended for at least 60 seconds (s) in preterm infants. However, changing the institutional guidelines only may not result in satisfactory adoption and change in practice.

OBJECTIVES: To determine if a structured multidisciplinary educational approach during the implementation of the new guideline of NCC in pre-term infants will result in over 50% compliance rate.

DESIGN/METHODS: The evidence supporting NCC was presented in a grand round to all health care providers involved in maternal-newborn care. A multidisciplinary team comprised of neonatologists, obstetricians, neonatal nurse practitioners, respiratory therapists and nurses developed NCC clinical practice guideline. Local champions at each of the 4 city hospitals were identified to create change in culture and establish lines of open communication between disciplines. Following completion of education of all staff involved in delivery room care, formal implementation of NCC began October 2013 for gestational age (GA) 33-35 weeks, January 2014 for GA ≥28 weeks, and April 2014 for GA ≥26 weeks. Data were collected from October 2013 until April 2015.

RESULTS: Table 1 shows the compliance rates and the proportion of infants who received NCC ≥45s. In addition, we found that 18% of infants 26-32 weeks GA deemed eligible for NCC, received cord clamping at &lt;45s to facilitate resuscitation.

CONCLUSION: Compliance with practice change can be successfully achieved through a structured team approach, establishing open lines of communication, and frequent feedback to the front line members. Further research may lead to more infants qualifying for and resuscitated during NCC.

Collapse

A predictive multi-linear regression model for organic micropollutants, based on a laboratory-scale column study simulating the river bank filtration process

This study investigated relationships between OMP biodegradation rates and the functional groups present in the chemical structure of a mixture of 31 OMPs. OMP biodegradation rates were determined from lab-scale columns filled with soil from RBF site Engelse Werk of the drinking water company Vitens in The Netherlands. A statistically significant relationship was found between OMP biodegradation rates and the functional groups of the molecular structures of OMPs in the mixture. The OMP biodegradation rate increased in the presence of carboxylic acids, hydroxyl groups, and carbonyl groups, but decreased in the presence of ethers, halogens, aliphatic ethers, methyl groups and ring structures in the chemical structure of the OMPs. The predictive model obtained from the lab-scale soil column experiment gave an accurate qualitative prediction of biodegradability for approximately 70% of the OMPs monitored in the field (80% excluding the glymes). The model was found to be less reliable for the more persistent OMPs (OMPs with predicted biodegradation rates lower or around the standard error=0.77d(-1)) and OMPs containing amide or amine groups. These OMPs should be carefully monitored in the field to determine their removal during RBF.

The effect of redox conditions and adaptation time on organic micropollutant removal during river bank filtration: A laboratory-scale column study

This study investigated the redox dependent removal and adaptive behaviour of a mixture of 15 organic micropollutants (OMPs) in laboratory-scale soil columns fed with river water. Three separate pilot systems were used consisting of: (1) two columns, (2) ten columns and (3) twenty two columns to create oxic, suboxic (partial nitrate removal) and anoxic (complete nitrate removal). The pilot set-up has some unique features--it can simulate fairly long residence times (e.g., 45 days using the 22 column system) and reduced conditions developed naturally within the system. Dimethoate, diuron, and metoprolol showed redox dependent removal behaviour with higher biodegradation rates in the oxic zone compared to the suboxic/anoxic zone. The redox dependent behaviour of these three OMPs could not be explained based on their physico-chemical properties (hydrophobicity, charge and molecular weight) or functional groups present in the molecular structure. OMPs that showed persistent behaviour in the oxic zone (atrazine, carbamazepine, hydrochlorothiazide and simazine) were also not removed under more reduced conditions. Adaptive behaviour was observed for five OMPs: dimethoate, chloridazon, lincomycin, sulfamethoxazole and phenazone. However, the adaptive behaviour could not be explained by the physico-chemical properties (hydrophobicity, charge and molecular weight) investigated in this study and only rough trends were observed with specific functional groups (e.g. ethers, sulphur, primary and secondary amines). Finally, the adaptive behaviour of OMPs was found to be an important factor that should be incorporated in predictive models for OMP removal during river bank filtration.

The effect of feed water dissolved organic carbon concentration and composition on organic micropollutant removal and microbial diversity in soil columns simulating river bank filtration

This study investigated organic micropollutant (OMP) biodegradation rates in laboratory-scale soil columns simulating river bank filtration (RBF) processes. The dosed OMP mixture consisted of 11 pharmaceuticals, 6 herbicides, 2 insecticides and 1 solvent. Columns were filled with soil from a RBF site and were fed with four different organic carbon fractions (hydrophilic, hydrophobic, transphilic and river water organic matter (RWOM)). Additionally, the effect of a short-term OMP/dissolved organic carbon (DOC) shock-load (e.g. quadrupling the OMP concentrations and doubling the DOC concentration) on OMP biodegradation rates was investigated to assess the resilience of RBF systems. The results obtained in this study imply that - in contrast to what is observed for managed aquifer recharge systems operating on wastewater effluent - OMP biodegradation rates are not affected by the type of organic carbon fraction fed to the soil column, in case of stable operation. No effect of a short-term DOC shock-load on OMP biodegradation rates between the different organic carbon fractions was observed. This means that the RBF site simulated in this study is resilient towards transient higher DOC concentrations in the river water. However, a temporary OMP shock-load affected OMP biodegradation rates observed for the columns fed with the river water organic matter (RWOM) and the hydrophilic fraction of the river water organic matter. These different biodegradation rates did not correlate with any of the parameters investigated in this study (cellular adenosine triphosphate (cATP), DOC removal, specific ultraviolet absorbance (SUVA), richness/evenness of the soil microbial population or OMP category (hydrophobicity/charge).

Resistance to amoxicillin-clavulanate and its relation to virulence-related factors in Yersinia enterocolitica biovar 1A

Recent studies have reported that the virulence factors (VFs) were detected more frequently in amoxicillin-clavulanate (AMC) susceptible clinical isolates of Escherichia coli. Here, we have evaluated the relationship between VFs and AMC-resistance phenotype in clinical isolates of Y. enterocolitica biovar 1A. The presence/absence of VFs was compared with their minimum inhibitory concentrations for AMC in strains of two serovars. We observed that the strains of the serovar O: 6, 30-6, 31 showed a similar relationship between the number of VFs and resistance to clavulanic acid as in E. coli but not of serovar O: 6, 30. Variations in the promoters/complete coding sequences (CCDSs) of β-lactamase gene (bla A) or the serological characteristics could not account for unusual susceptibility to AMC displayed by the strains of the serovar O: 6, 30. Therefore, we speculate that since the clinical strains of serovar O: 6, 30-6, 31 originated from the environment they were less exposed to antibiotics compared to clinical strains of serovar O: 6, 30. Thus, AMC susceptibility seems to be influenced by factors other than serotypes or promoters/CCDS of β-lactamase genes.

A laboratory-scale column study comparing organic micropollutant removal and microbial diversity for two soil types

This study investigated sorption and biodegradation behaviour of 20 organic micropollutants (OMPs) in lab-scale columns filled with two types of soil (fed with the same water quality) simulating river bank filtration (RBF) under oxic conditions. Retardation factors and OMP biodegradation rates were similar for the two soils that were characterised by a different cationic exchange capacity, organic matter and sand/silt/clay content. This result was supported by the microbial community composition (richness, evenness) of the two soils that became more similar as a result of feeding both columns with the same water quality. This indicates that microbial community composition and thereby OMP removal in soils is primarily determined by the composition of the aqueous phase (organic matter quantity and quality, nutrients) rather than the soil phase. These results indicate that different RBF sites located along the same river may show similar OMP removal (in case of similar water quality and residence time).

CAPSULE

This study shows that the microbial community composition and thus OMP removal is primarily determined by the aqueous phase (water quality) rather than the soil phase.

Testosterone deficiency and quality of life in Australasian testicular cancer survivors: a prospective cohort study

This is the first prospective study in a contemporary Australian/New Zealand population to determine the prevalence of testosterone deficiency in testicular cancer survivors at 12 months from treatment, and any association with poorer quality of life. Hormone assays from 54 evaluable patients in a prospective cohort study revealed biochemical hypogonadism in 18 patients (33%) and low-normal testosterone in 13 patients (24%). We found no association between testosterone levels and quality of life (all P > 0.05). Hypogonadal patients should be considered for testosterone replacement to prevent long-term morbidity.

Accelerated BEP for metastatic germ cell tumours: a multicenter phase II trial by the Australian and New Zealand Urogenital and Prostate Cancer Trials Group (ANZUP)

BACKGROUND

This Australian single-arm, multicenter, phase II trial evaluated feasibility, tolerability and activity of accelerated bleomycin, etoposide and cisplatin (BEP) as first-line chemotherapy for metastatic germ cell tumours.

PATIENTS AND METHODS

Patients were planned to receive cisplatin 20 mg/m(2) and etoposide 100 mg/m(2) days 1-5, and pegfilgrastim 6 mg day 6, all repeated every 2 weeks for four cycles (three cycles for good prognosis). Bleomycin was given at 30 000 IU weekly to a total of 12 doses (9 doses for good prognosis). Primary end point was feasibility, defined as the proportion of patients able to complete the etoposide and cisplatin components of BEP and be eligible to receive a fourth cycle of BEP by day 50.

RESULTS

Twelve poor, 16 intermediate and 15 good prognosis (n = 43) eligible patients were enrolled. Two patients aged >40 years were ineligible and excluded from analyses. The regimen was feasible in 86%, not feasible in 7% and not assessable in 7% of patients. Most common grade 3/4 adverse events were non-neutropenic infection (16%) and febrile neutropenia (12%). Complete response (CR) to chemotherapy and surgery was achieved in 33% poor-prognosis, 81% intermediate-prognosis and 100% good-prognosis patients. At median follow-up of 27 months (range 6-42), the 2-year progression-free survival was 50% for poor-prognosis, 94% for intermediate-prognosis and 92% for good-prognosis patients.

CONCLUSION

Accelerated BEP is feasible and tolerable. Efficacy data appear to be promising. This trial and a similar UK study provide the rationale for a randomised trial comparing accelerated versus standard BEP. Australian New Zealand Clinical Trials Registry Registration number. ACTRN 12607000294459.

Educational barriers of nurses caring for sick and at-risk infants in India

AIM

To gain ideas and information from healthcare providers to optimize the education and clinical practices of nurses caring for sick or at-risk newborns in India.

BACKGROUND

Improving infant survival has been identified as a Millennium Development Goals; however, India still faces many challenges with 3.1 million neonatal deaths and 2.6 million stillbirths annually. Skilled nursing care has been associated with decreased morbidity and mortality in newborns. However, core competencies in newborn care education and training are lacking for nurses.

METHODS

Qualitative data were collected from 12 focus groups with 101 newborn care providers from three areas of India as well as from a 2-day stakeholders' meeting. Data analysis was undertaken using descriptive and thematic content analysis.

RESULTS

Perceived challenges included limited manpower and high nurse turnover, lack of access to evidence-based orientation to newborn care and problems with access to appropriate learner-based, neonatal training. Relevant, ongoing education opportunities, led by nursing leaders were identified to be important solutions.

CONCLUSION

Findings provide insight into the current healthcare system in India with specific reference to the nursing care of at-risk newborns. There is a lack of existing resources to provide standardized and specific orientation curricula for nurses.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Policy makers in health and education need to: support and enact learner-based orientation and continuing educational opportunities as well as ongoing competency-based education programmes; encourage nurse leader involvement and support; and provide sustainable system-related supports. Nurses and other health providers need to work together to influence government policy.

Sorption and biodegradation of organic micropollutants during river bank filtration: a laboratory column study

This study investigated sorption and biodegradation behaviour of 14 organic micropollutants (OMP) in soil columns representative of the first metre (oxic conditions) of the river bank filtration (RBF) process. Breakthrough curves were modelled to differentiate between OMP sorption and biodegradation. The main objective of this study was to investigate if the OMP biodegradation rate could be related to the physico-chemical properties (charge, hydrophobicity and molecular weight) or functional groups of the OMPs. Although trends were observed between charge or hydrophobicity and the biodegradation rate for charged compounds, a statistically significant linear relationship for the complete OMP mixture could not be obtained using these physico-chemical properties. However, a statistically significant relationship was obtained between biological degradation rates and the OMP functional groups. The presence of ethers and carbonyl groups will increase biodegradability, while the presence of amines, ring structures, aliphatic ethers and sulphur will decrease biodegradability. This predictive model based on functional groups can be used by drinking water companies to make a first estimate whether a newly detected compound will be biodegraded during the first metre of RBF or that additional treatment is required. In addition, the influence of active and inactive biomass (biosorption), sand grains and the water matrix on OMP sorption was found to be negligible under the conditions investigated in this study. Retardation factors for most compounds were close to 1, indicating mobile behaviour of these compounds during soil passage. Adaptation of the biomass towards the dosed OMPs was not observed for a 6 month period, implying that new developed RBF sites might not be able to biodegrade compounds such as atrazine and sulfamethoxazole in the first few months of operation.

Resuscitation in resource-limited settings

Intrapartum-related hypoxia leading to deaths and disabilities continues to be a global challenge, especially in resource-limited settings. Primary prevention during labour is likely to have a significant impact, but secondary prevention with focus on immediate basic stabilization at birth can effectively reduce a large proportion of these adverse outcomes as demonstrated in the resource-rich settings. Infants who fail to initiate and establish spontaneous respirations at birth often respond to early interventions such as drying, stimulation, clearing the airways, as well as bag mask ventilation applied within the first minute after birth. Simple resuscitation education such as 'Helping Babies Breathe', which focuses on the very basic steps and pays attention to comprehensive program development with local ownership and accountability, can help transfer competency into clinical practice and lead to sustainable programs impacting neonatal mortality and morbidity.

Histological chorioamnionitis and neurodevelopmental outcome in preterm infants

OBJECTIVE

The objective of this study is to examine the neurodevelopmental outcome at 30 to 42 months corrected age of preterm infants with histological chorioamnionitis (HCA).

STUDY DESIGN

The study design is a retrospective cohort study with a prospective follow-up. All surviving infants with birth gestational age <29 weeks, born between 2000 and 2006, who had a neurodevelopmental assessment at 30 to 42 months corrected age were included. We compared the neurodevelopmental outcomes of infants with or without HCA.

RESULT

Of the 384 infants, 197 (51%) were born to mothers with evidence of HCA. Infants with HCA were of lower gestational age (26 weeks vs 26.6 weeks) and more likely to have intraventricular hemorrhage (27.9% vs 14.4%), periventricular leukomalacia (2.5% vs 0%) and retinopathy of prematurity ≥ stage 3 (31.4% vs 22.4%). On univariate analysis, infants with HCA were more likely to have cerebral palsy (12.6% vs 6.4%, P=0.04). There was no significant difference in the incidence of cognitive delay, deafness, blindness, or total major disabilities between the two groups. After adjusting for perinatal variables, HCA was associated with increased risk of cerebral palsy (odds ratio (OR): 2.45; 95% confidence interval (CI) 1.11 to 5.40), but not for total major disabilities (OR: 1.22; 95% CI: 0.64 to 2.34). There was a trend towards increased risk of cerebral palsy with HCA with funisitis.

CONCLUSION

HCA is associated with increased risk of cerebral palsy at 30 to 42 months corrected age in preterm infants.

Potential triazole derivatives having significant antiepileptic effect- A Review

Triazole is a five membered heterocyclic moiety of two carbon and three nitrogen atom, triazole are present in two isomeric forms, 1,2,4-triazole and 1,2,3-triazole. Alprazolam, Triazolam and Midazolam are established drugs used in epilepsy which have triazole moiety. Epilepsy is the most frequent neurological disorder characterized by excessive temporary neuronal discharge. The overall prevalence of the disease is 1% of the population and up to 50 million people worldwide. The literature shows that different substitution on triazole moiety exhibit potent antiepileptic activity and less/no neurotoxicity. The maximal electroshock seziures test is most widely used in- vivo models among the various screening models of epilepsy. The present article focused on the previous researches on triazole, which include synthesis, spectral characterization and antiepileptic activity of the synthesized triazole derivatives, and we also go for the development of structure activity relationship of the earlier synthesized triazole derivatives with reference to their pharmacological effect.