Infection prevention and control in CT Part 1: An Australian study of roles, responsibilities and practices

INTRODUCTION

The computed tomography (CT) suite presents Infection Prevention and Control (IPC) risks for staff and patients. This is the first of a two-part series on IPC in the CT setting and reports on Australian baseline data related to intravenous contrast media administration and the use of power injectors in the CT suite, including knowledge sources related to the delivery of contrast media. The second part provides insights into CT staff's perceptions of high-risk scenarios for non-adherence to standard or transmission-based precautions.

METHODS

The study employed an online survey design, directed at radiographers and radiology nurses working in Australia. The survey included questions relating to CT workplace staffing and equipment, contrast media use and occupational roles, and knowledge sources used for infection control and contrast injectors.

RESULTS

Overall, 160 study participants completed the survey (radiographers: n = 138, 86.3%; nurses: n = 22, 13.7%). Differences were identified between public and private practice. Public hospitals completed more contrast-enhanced scans, and with dual injecting systems, operated and cleaned by radiographers and nurses. Private clinics generally used single-system, power injectors. Radiographers and nurses relied heavily on their colleagues and product guidelines for IPC information. IPC teams were uncommon in private clinics, very common in public departments and 50% of respondents had undertaken IPC training in the last 12 months.

CONCLUSION

Insights into use and duties of professionals delivering intravenous contrast media administration using power injectors in the CT suite will help to inform decision-making processes on IPC education strategies and map risk.

IMPLICATION FOR PRACTICE

Future research should focus on how radiology workers in CT perceive IPC risk and/or might vary from best practice, which has direct clinical implications for safety if contamination, or incorrect information is routinely applied.

Infection prevention and control in CT Part 2: Radiographers' and radiology nurses' perceptions of high-risk scenarios contributing to non-adherence to IPC protocols

INTRODUCTION

Adherence to standard and transmission-based precautions in the computed tomography (CT) setting is central to effective infection prevention and control (IPC), yet there is limited evidence about medical imaging (MI) professionals' self-reported predictors of IPC breaches. This is the second of a two-part series on IPC in the CT setting. Part 1 reported on Australian baseline data relating to intravenous contrast media administration and power injectors. Part 2 presents Australian radiographers' and radiology nurses' perceptions of clinical situations that reduce adherence to standard and transmission-based precautions in CT.

METHODS

A self-administered survey was distributed to Australian radiographers and radiology nurses working in CT. Responses to an open-ended question "If I was to not adhere to the standard and transmission-based precautions in the CT department, it is most likely when …" was analysed using inductive coding for themes, followed by deductive analysis mapped to the Systems Engineering Initiative for Patient Safety (SEIPS) model.

RESULTS

Study participants (n = 136) were radiographers (n = 119; 87.5%) and nurses (n = 17; 12.5%). 'Four themes were derived from the inductive analysis: (1) high-risk working conditions, (2) compliance with good practice, (3) attitudes and practice, and (4) quality of communication. Deductive analysis, using the SEIPS domains revealed that predominant issues related to 'Tasks' (43.7%) and 'Organisation' (30.6%) followed by issues related to 'Person' (16.9%), 'Tools and technology' (6.9%) and 'Environment' (1.9%).

CONCLUSION

Multi-faceted pressures on radiology staff may compromise adherence to standard and transmission-based precautions in CT. Task difficulty, time pressures whilst undertaking tasks, and reduced staffing could lead to lower adherence to standard and transmission-based precautions.

IMPLICATIONS FOR PRACTICE

Future studies that focus on evaluation of 'Tasks' and 'Organisation' domains of the SEIPS model may provide further insights to non-adherence behaviours in MI.

Non-nutritive sweetened beverages versus water after a 52-week weight management programme: a randomised controlled trial

BACKGROUND/OBJECTIVE

Sugar-sweetened beverages are a substantial source of dietary sugar that can contribute to weight gain and the risk of type 2 diabetes. Dietary guidelines recommend non-nutritive sweetened (NNS) beverages to reduce sugar consumption, however, there is a need for long-term randomised controlled trials on their use. We aimed to compare the effects of NNS beverages and water on body weight during weight loss and maintenance in a behavioural weight management programme.

METHODS

In this parallel-group, open-label, controlled equivalence trial, adults with a BMI of 27-35 kg/m2 who regularly consumed cold beverages were randomised 1:1 to water or NNS beverages. Participants underwent a group behavioural weight management programme comprising weekly (during the 12-week weight-loss phase) then monthly (during the 40-week weight-maintenance phase) meetings. The primary endpoint was weight change at week 52 (equivalence: two-sided P > 0.05). Secondary endpoints included changes in anthropometrics, cardiometabolic risk factors, appetite and activity levels.

RESULTS

Of 493 participants randomised (water: n = 246; NNS beverages: n = 247), 24.1% were NNS-naïve. At week 52, water and NNS beverages were non-equivalent, with significantly greater weight loss in the NNS beverages group. Participants consuming water maintained a weight loss of 6.1 kg over 52 weeks versus 7.5 kg with NNS beverages (difference [90% CI]: 1.4 kg [-2.6, -0.2]; p < 0.05).

CONCLUSIONS

During a 52-week behavioural weight management programme, water and NNS beverages were non-equivalent, with weight loss maintained to a statistically greater extent with NNS beverages compared with water. However, this difference was not clinically significant.

CLINICAL TRIAL REGISTRATION

This trial is registered with ClinicalTrials.gov: NCT02591134.

Effects of non-nutritive sweetened beverages versus water after a 12-week weight-loss program: A randomized controlled trial

OBJECTIVE

The aim of this study was to compare non-nutritive sweetened (NNS) beverages versus water for weight loss after a 12-week behavioral weight-management program.

METHODS

This is an ongoing, 2-year, parallel-group, open-label, controlled equivalence trial; week-12 data are reported. Adults with BMI of 27 to 35 kg/m2 who regularly drank cold beverages were randomized 1:1 to intention-to-treat water or NNS beverages while undergoing a weekly 12-week group behavioral weight-management program. Weight change to week 12 was the primary end point (equivalence: two-sided p > 0.05); changes in waist and hip circumference, blood pressure, glycemic control markers, fasting lipid profiles, liver function tests, hunger (visual analog scale), sugar and sweetener consumption, and activity levels were secondary end points.

RESULTS

Overall, 493 participants were randomized (water: n = 246; NNS beverages: n = 247); 24.1% were NNS beverage naïve. Weight change was equivalent with water versus NNS beverages (-5.6 vs. -5.8 kg; difference [90% CI]: -0.2 kg [-0.7 to 0.4]). There were no significant differences between groups for secondary end points except reductions in waist circumference (greater with NNS beverages vs. water), glycated hemoglobin, and consumption of any type of sweetener (both greater with water vs. NNS beverages).

CONCLUSIONS

Weight loss was equivalent with NNS beverages and water following a 12-week behavioral weight-management program.

Characterization of childhood trauma, hippocampal mediation and Cannabis use in a large dataset of psychosis and non-psychosis individuals

BACKGROUND

Cannabis use (CA) and childhood trauma (CT) independently increase the risk of earlier psychosis onset; but their interaction in relation to psychosis risk and association with endocannabinoid-receptor rich brain regions, i.e. the hippocampus (HP), remains unclear. The objective was to determine whether lower age of psychosis onset (AgePsyOnset) is associated with CA and CT through mediation by the HP volumes, and genetic risk, as measured by schizophrenia polygene scores (SZ-PGRS).

METHODS

Cross-sectional, case-control, multicenter sample from 5 metropolitan US regions. Participants (n = 1185) included 397 controls not affected by psychosis (HC); 209 participants with bipolar disorder type-1; 279 with schizoaffective disorder; and 300 with schizophrenia (DSM IV-TR). CT was assessed using the Childhood Trauma Questionnaire (CTQ); CA was assessed by self-reports and trained clinical interviewers. Assessment included neuroimaging, symptomatology, cognition and calculation of the SZ polygenic risk score (SZ-PGRS).

RESULTS

In survival analysis, CT and CA exposure interact to be associated with lower AgePsyOnset. At high CT or CA, CT or CA are individually sufficient to affect AgePsyOnset. CT relation with AgePsyOnset is mediated in part by the HP in CA users before AgePsyOnset. CA before AgePsyOnset is associated with higher SZ-PGRS and correlated with younger age at CA usage.

DISCUSSION

CA and CT interact to increase risk when moderate; while severe CT and/or CA abuse/dependence are each sufficient to affect AgePsyOnset, indicating a ceiling effect. Probands with/out CA before AgePsyOnset differ on biological variables, suggesting divergent pathways to psychosis.

FUNDING

MH077945; MH096942; MH096913; MH077862; MH103368; MH096900; MH122759.

Patient Preparation and Radiation Protection Guidance for Adult Patients Undergoing Radioiodine Treatment for Thyroid Cancer in the UK

Radioactive iodine is a highly effective treatment for thyroid cancer and has now been used in clinical practice for more than 80 years. In general, the treatment is well tolerated. However, it can be logistically quite complex for patients due to the need to reduce iodine intake and achieve high levels of thyroid-stimulating hormone prior to treatment. Radiation protection precautions must also be taken to protect others from unnecessary radiation exposure following treatment. It has been well documented by thyroid cancer patient support groups that there is significant variation in practice across the UK. It is clear that some patients are being asked to observe unnecessarily burdensome restrictions that make it more difficult for them to tolerate the treatment. At the instigation of these support groups, a multidisciplinary group was assembled to examine the evidence and generate guidance on best practice for the preparation of patients for this treatment and the management of subsequent radiation protection precautions, with a focus on personalising the advice given to individual patients. The guidance includes advice about managing particularly challenging situations, for example treating patients who require haemodialysis. We have also worked together to produce a patient information leaflet covering these issues. We hope that the guidance document and patient information leaflet will assist centres in improving our patients' experience of receiving radioactive iodine. The patient information sheet is available as Supplementary Material to this article.

Bowel Lengthening Procedures in Children with Short Bowel Syndrome: A Systematic Review

INTRODUCTION

 The aims of the study are to systematically assess and critically appraise the evidence concerning two surgical techniques to lengthen the bowel in children with short bowel syndrome (SBS), namely, the longitudinal intestinal lengthening and tailoring (LILT) and serial transverse enteroplasty (STEP), and to identify patient characteristics associated with a favorable outcome.

MATERIALS AND METHODS

 MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched from inception till December 2019. No language restriction was used.

RESULTS

 In all, 2,390 articles were found, of which 40 were included, discussing 782 patients. The median age of the patients at the primary bowel lengthening procedure was 16 months (range: 1-84 months). Meta-analysis could not be performed due to the incomparability of the groups, due to heterogeneous definitions and outcome reporting. After STEP, 46% of patients weaned off parenteral nutrition (PN) versus 52% after LILT. Mortality was 7% for STEP and 26% for LILT. Patient characteristics predictive for success (weaning or survival) were discussed in nine studies showing differing results. Quality of reporting was considered poor to fair.

CONCLUSION

 LILT and STEP are both valuable treatment strategies used in the management of pediatric SBS. However, currently it is not possible to advise surgeons on accurate patient selection and to predict the result of either intervention. Homogenous, prospective, outcome reporting is necessary, for which an international network is needed.

Virtue signalling and the Condorcet Jury theorem

One might think that if the majority of virtue signallers judge that a proposition is true, then there is significant evidence for the truth of that proposition. Given the Condorcet Jury Theorem, individual virtue signallers need not be very reliable for the majority judgment to be very likely to be correct. Thus, even people who are skeptical of the judgments of individual virtue signallers should think that if a majority of them judge that a proposition is true, then that provides significant evidence that the proposition is true. We argue that this is mistaken. Various empirical studies converge on the following point: humans are very conformist in the contexts in which virtue signalling occurs. And stereotypical virtue signallers are even more conformist in such contexts. So we should be skeptical of the claim that virtue signallers are sufficiently independent for the Condorcet Jury Theorem to apply. We do not seek to decisively rule out the relevant application of the Condorcet Jury Theorem. But we do show that careful consideration of the available evidence should make us very skeptical of that application. Consequently, a defense of virtue signalling would need to engage with these findings and show that despite our strong tendencies for conformism, our judgements are sufficiently independent for the Condorcet Jury Theorem to apply. This suggests new directions for the debate about the epistemology of virtue signalling.

39 Virtual Clinics in Foot & Ankle Surgery: Patient and Clinician Perceptions and Review of The Literature

Aim

The COVID 19 worldwide pandemic has led to the popularisation of, “Virtual” clinics. Within orthopaedics, little is known about the use of virtual clinics within foot and ankle surgery, specifically.

Method

A cross sectional observation study of patients and clinicians in response to virtual clinics in foot and ankle surgery. Patients seen in a virtual clinic were contacted from two weeks after their consultation by telephone with a 12-point questionnaire. Demographic information was also collected. Clinicians in foot and ankle also completed a 10-point questionnaire.

Results

100 patient responses were collected. Patient satisfaction with virtual clinics was positive, 65% were very happy (Likert scale rating 5). &gt;90% of patients felt they received enough information, felt involved, felt it was helpful and knew who to contact if there was a problem. However, 79% would still prefer a face-to-face consultation. 22% would have preferred a video consultation. Clinician responses were more cautious, 60% were neither happy nor unhappy (Likert scale rating 3). Virtual clinics may be faster for the clinician.

Conclusions

Virtual clinics may be more convenient for patients with high satisfaction levels but represent significant clinical challenges for foot and ankle surgeons. Elements of virtual clinics may persist post pandemic, particularly in routine follow up patients. Virtual clinics are not appropriate for new patient referrals.

Virtual clinics in foot and ankle surgery: patient and clinician perceptions

BACKGROUND

The worldwide COVID-19 pandemic has led to the popularisation of 'virtual' clinics. In orthopaedics, little is known about the use of virtual clinics within foot and ankle surgery, specifically.

METHODS

A cross-sectional observation study of patients and clinicians in response to virtual clinics in foot and ankle surgery. Patients seen in a virtual clinic were contacted by telephone from two weeks after their consultation and asked to complete a 12-point questionnaire. Demographic information was also collected. Clinicians in foot and ankle completed a 10-point questionnaire.

RESULTS

One hundred patient responses were collected. Patient satisfaction with virtual clinics was positive, with 65% of respondents reporting they were very happy (Likert scale rating 5). More than 90% of patients felt they received enough information, felt involved, felt the virtual clinic was helpful and knew who to contact if there was a problem. However, 79% would still prefer a face-to-face consultation, and 22% would have preferred a video consultation. Clinician responses were more cautious, with 60% stating they were neither happy nor unhappy (Likert scale rating 3). Virtual clinics may be faster for the clinician.

CONCLUSIONS

Virtual clinics may be more convenient for patients, with high satisfaction levels reported, but represent significant clinical challenges for foot and ankle surgeons. Elements of virtual clinics may persist post pandemic, particularly in routine follow-up. Virtual clinics are not appropriate for new patient referrals.

Reference Protocol to Assess Analytical Performance of Higher Order Structural Analysis Measurements: Results from an Interlaboratory Comparison

Measurements of protein higher order structure (HOS) provide important information on stability, potency, efficacy, immunogenicity, and biosimilarity of biopharmaceuticals, with a significant number of techniques and methods available to perform these measurements. The comparison of the analytical performance of HOS methods and the standardization of the results is, however, not a trivial task, due to the lack of reference protocols and reference measurement procedures. Here, we developed a protocol to structurally alter and compare samples of somatropin, a recombinant biotherapeutic, and describe the results obtained by using a number of techniques, methods and in different laboratories. This, with the final aim to provide tools and generate a pool of data to compare and benchmark analytical platforms and define method sensitivity to structural changes. Changes in somatropin HOS, induced by the presence of zinc at increasing concentrations, were observed, both globally and at more localized resolution, across many of the methods utilized in this study and with different sensitivities, suggesting the suitability of the protocol to improve understanding of inter- and cross-platform measurement comparability and assess analytical performance as appropriate.

THEIA™ development, and testing of artificial intelligence-based primary triage of diabetic retinopathy screening images in New Zealand

AIM

To develop and evaluate an artificial intelligence triage system with high sensitivity for detecting referable diabetic retinopathy and maculopathy, while maintaining high specificity for non-referable disease, for clinical implementation within the New Zealand national diabetic retinopathy screening programme.

METHODS

The THEIA™ artificial intelligence system for retinopathy and maculopathy screening, was developed at Toku Eyes using routinely collected retinal screening datasets from two of the largest district health boards in Auckland, New Zealand: the Auckland District Health Board and the Counties Manukau District Health Board. All retinal images from consecutive individuals receiving retinal screening between January 2009 and December 2018 were used. Images were labelled as non-sight-threatening, potentially referable or sight-threatening for New Zealand implementation, or as referable (potentially referable + sight-threatening)/non-referable (non-sight-threatening) for global comparison.

RESULTS

Data from 32 354 unique people with diabetes (63 843 when including multiple visits) were available, of which 95-97%, 0.9-2.4% and 1.1-3.1% were categorized as non-sight-threatening, potentially referable and sight-threatening, respectively. Using the referable/non-referable categories, THEIA achieved overall sensitivity of 94% (95% CI 92-95) in the Auckland District Health Board and 95% (95% CI 92-97) in the Counties Manukau District Health Board datasets, while preserving specificity of 63% (95% CI 62-64) for the Auckland District Health Board and 61% (95% CI 60-62) for the Counties Manukau District Health Board. Implementing THEIA into a New Zealand national diabetic screening programme could significantly reduce the manual grading load.

CONCLUSION

THEIA, an artificial intelligence tool to assist in clinical decision-making, tailored to the needs of the New Zealand national diabetic screening programme, delivered high sensitivity for detecting referable retinopathy within the multi-ethnic New Zealand population with diabetes.

Clinical characteristics and long-term outcome of E. coli-associated granulomatous ileocolitis in dogs: five cases (2010-2014)

OBJECTIVES

To describe the clinical characteristics and long-term outcome of Escherichia coli-associated granulomatous ileocolitis in dogs.

METHODS

Retrospective review of medical records from dogs with periodic acid-Schiff positive (PAS+) granulomatous ileocolitis and mucosally invasive E. coli in the ileum and colon. Initial bacterial colonisation was evaluated using fluorescence in situ hybridization (FISH) in all dogs and corroborated with colonic and/or ileal culture, when performed.

RESULTS

Four boxer dogs and 1 French Bulldog with PAS+ granulomatous ileocolitis (GIC) were evaluated. All dogs had chronic diarrhoea refractory to empirical therapy. Ileocolonoscopy revealed mucosal haemorrhage and ulceration in the ileum (3/4) and colon (5/5). E. coli were visualised as clusters within the ileal and colonic mucosa. Complete (CR, 4/5) or partial (PR, 1/5) clinical response to fluoroquinolones was noted in all dogs within 30 days. CR was sustained in three of four dogs (median disease-free interval 40 months, range 16 to 60). Two dogs relapsed while receiving fluoroquinolones. Repeat biopsy isolated multidrug-resistant, mucosally invasive E. coli in the ileum (1/2) and colon (2/2). Targeted antimicrobial therapy was associated with long-term PR (78 months) in both dogs.

CLINICAL SIGNIFICANCE

Concurrent E. coli-associated granulomatous inflammation in the ileum and colon did not impart a poor clinical outcome or lack of response to the conventional standard of care for granulomatous colitis in dogs that were aggressively diagnosed and treated. Clinical outcome was influenced by antimicrobial resistance, with response dependent upon antimicrobial therapy informed by susceptibility testing.

Accelerated repetitive transcranial magnetic stimulation in the treatment of post-concussion symptoms due to mild traumatic brain injury: a pilot study

Objective: To investigate the feasibility, tolerability, and efficacy of twice-daily, low frequency (LF) repetitive transcranial magnetic stimulation (rTMS) over the right dorsolateral prefrontal cortex (DLPFC) in the reduction of chronic post-concussion symptoms (PCS) in patients who have suffered a mild traumatic brain injury (mTBI).Methods: 15 patients with mTBI received 30 sessions of twice-daily LF rTMS (1 Hz) over the right DLPFC. Post-concussion symptoms, pain, disability, fatigue, apathy, agitation, and mood were assessed by a psychiatrist pre- and post-treatment. Cognitive testing was also performed pre-, mid-, and post-rTMS.Results: All participants completed treatment with no serious adverse events. Significant improvements were observed in overall post-concussion symptoms, disability and pain ratings, as well as depression and anxiety symptoms. There was no significant change in overall executive functioning, fatigue severity, apathy, or agitation. Cognitive testing revealed improvements in verbal fluency, working memory, selective attention, and cognitive processing speed.Conclusions: This small-sample pilot study suggests that twice-daily, LF rTMS over the right DLPFC can be safely and tolerably applied and has the potential to improve post-concussion symptoms as well as elements of mood and cognition in patients with mTBI. Larger, sham-controlled studies will be important to confirm these observations.

Effects of Intranasal Epinephrine on Cerebrospinal Fluid Epinephrine Pharmacokinetics, Nasal Mucosa, Plasma Epinephrine Pharmacokinetics, and Cardiovascular Changes

PURPOSE

We aimed to assess intranasal (IN) epinephrine effects on cerebrospinal fluid (CSF) absorption, nasal mucosa quality, plasma epinephrine pharmacokinetics (PK), and cardiovascular changes in dogs.

METHODS

CSF epinephrine concentration was measured and nasal mucosa quality was evaluated after IN epinephrine 4 mg and one or two 4 mg doses (21 min apart), respectively. Maximum plasma concentration [C_max], time to C_max [T_max], area under the curve from 0 to 120 min [AUC_0-120], and cardiovascular effects were evaluated after epinephrine IN (4 and 5 mg) and intramuscular (IM; 0.3 mg). Clinical observations were assessed.

RESULTS

After epinephrine IN, there were no changes in CSF epinephrine or nasal mucosa. C_max, T_max, and AUC_1-120 were similar following epinephrine IN and IM. Epinephrine IN versus IM increased plasma epinephrine at 1 min (mean ± SEM, 1.15 ± 0.48 for 4 mg IN and 1.7 ± 0.72 for 5 mg IN versus 0.47 ± 0.11 ng/mL for 0.3 mg IM). Epinephrine IN and IM produced similar heart rate and ECG results. Clinical observations included salivation and vomiting.

CONCLUSIONS

Epinephrine IN did not alter CSF epinephrine or nasal tissue and had similar cardiovascular effects as epinephrine IM. Epinephrine IN rapidly increased plasma epinephrine concentration versus epinephrine IM.

Schizophrenia: A five-year follow-up of patient outcome following psycho-education for caregivers

Introduction

There is evidence that psycho-education courses for caregivers of individuals with schizophrenia improve the short-term outcome of the condition. However, most of the outcome studies are limited to two-year follow-up.

Materials and methods

This study is a five-year retrospective case-control follow-up of an original cohort of 63 patients and their 101 caregivers who completed a six-week Caregiver Psycho-education Programme (CPP) for schizophrenia and psychosis between 2002 and 2005, and 60 controls, matched for age, gender and severity of their psychotic illness.

Results

Patients whose caregivers learned more from the six-week psycho-education course had a significantly longer time to relapse (P = 0.04) and a significantly shorter length of stay during their first relapse (P < 0.05). Patients whose caregivers attended the six-week psycho-education course (regardless of how much the caregivers learned) had a significantly better outcome than controls. This included a significantly smaller number of relapses (P < 0.01), longer time to relapse (P < 0.01), shorter length of stay during their first relapse (P < 0.01) and smaller number of bed days over five years (P < 0.01). The odds ratio of controls relapsing, although insignificant at one year, was 4.13 (1.85–9.21) at five years. Outcome was not affected by either the numbers of caregivers attending for each patient, or caregiver gender.

Discussion and conclusions

This study, which is among the first to examine outcome over five years, supports the efficacy of psycho-education for caregivers in improving outcome for patients. Caregivers should be encouraged to take up psycho-education where it is available.

Intranasal epinephrine effects on epinephrine pharmacokinetics and heart rate in a nasal congestion canine model

BACKGROUND

Histamine release and vasodilation during an allergic reaction can alter the pharmacokinetics of drugs administered via the intranasal (IN) route. The current study evaluated the effects of histamine-induced nasal congestion on epinephrine pharmacokinetics and heart rate changes after IN epinephrine.

METHODS

Dogs received 5% histamine or saline IN followed by 4 mg epinephrine IN. Nasal restriction pressure, epinephrine concentration, and heart rate were assessed. Maximum concentration (Cmax), area under plasma concentration-time curve from 1 to 90 min (AUC1-90), and time to reach Cmax (Tmax) were measured. Clinical observations were documented.

RESULTS

In the 12 dogs in this study, nasal congestion occurred at 5-10 min after IN histamine administration versus no nasal congestion after IN saline. After administration of IN epinephrine, IN histamine-mediated nasal congestion was significantly reduced to baseline levels at 60, 80, and 100 min. There were no significant differences in Cmax and AUC1-90 between histamine and saline groups after IN epinephrine delivery (3.5 vs 1.7 ng/mL, p = 0.06, and 117 vs 59 ng/mL*minutes, p = 0.09, respectively). After receiving IN epinephrine, the histamine group had a significantly lower Tmax versus the saline group (6 vs 70 min, respectively; p = 0.02). Following IN epinephrine administration, the histamine group showed rapidly increased heart rate at 5 min, while there was a delayed increase in heart rate (occurring 30-60 min after administration) in the saline group. Clinical observations included salivation and emesis.

CONCLUSION

IN histamine led to more rapid epinephrine absorption and immediately increased heart rate compared with IN saline. IN epinephrine decreased histamine-induced nasal congestion.

Intranasal epinephrine in dogs: Pharmacokinetic and heart rate effects

Epinephrine is the standard of care for the treatment of severe allergy and anaphylaxis. Epinephrine is most often administered through the intramuscular (IM) route via autoinjector. The current study aimed to evaluate an alternative method of epinephrine treatment through intranasal (IN) delivery in dogs. The pharmacokinetic (PK) parameters of maximum plasma concentration (Cmax ), time to reach maximum plasma concentration (Tmax ), and area under the plasma concentration-time curve from 0 to 90 minutes (AUC0-90 ) were observed after IN epinephrine (2, 3, 4, 5, 10, and 20 mg) and IM epinephrine via autoinjector (0.15 and 0.3 mg) for 90 minutes. Heart rate effects were measured after IN (2 and 5 mg) and IM (0.15 and 0.3 mg) epinephrine administration. IN epinephrine (5 mg) demonstrated significantly greater plasma epinephrine concentration at 1 minute as compared with IM epinephrine (0.3 mg) (1.68 ± 0.65 ng/mL vs 0.21 ± 0.08 ng/mL, P = .03). There were no significant differences in Cmax , Tmax , and AUC0-90 between 2-mg IN and 0.15-mg IM epinephrine or between 5-mg IN and 0.3-mg IM epinephrine. IN epinephrine reduced heart rate increases, as compared to IM epinephrine. IN and IM epinephrine were both well-tolerated. Overall, IN epinephrine demonstrated advantages over IM epinephrine, including the rapid increase in plasma epinephrine and lack of increased heart rate over time.

Quantifying Target Occupancy of Small Molecules Within Living Cells

The binding affinity and kinetics of target engagement are fundamental to establishing structure-activity relationships (SARs) for prospective therapeutic agents. Enhancing these binding parameters for operative targets, while minimizing binding to off-target sites, can translate to improved drug efficacy and a widened therapeutic window. Compound activity is typically assessed through modulation of an observed phenotype in cultured cells. Quantifying the corresponding binding properties under common cellular conditions can provide more meaningful interpretation of the cellular SAR analysis. Consequently, methods for assessing drug binding in living cells have advanced and are now integral to medicinal chemistry workflows. In this review, we survey key technological advancements that support quantitative assessments of target occupancy in cultured cells, emphasizing generalizable methodologies able to deliver analytical precision that heretofore required reductionist biochemical approaches.

No evidence of ongoing HIV replication or compartmentalization in tissues during combination antiretroviral therapy: Implications for HIV eradication

HIV persistence during combination antiretroviral therapy (cART) is the principal obstacle to cure. Mechanisms responsible for persistence remain uncertain; infections may be maintained by persistence and clonal expansion of infected cells or by ongoing replication in anatomic locations with poor antiretroviral penetration. These mechanisms require different strategies for eradication, and determining their contributions to HIV persistence is essential. We used phylogenetic approaches to investigate, at the DNA level, HIV populations in blood, lymphoid, and other infected tissues obtained at colonoscopy or autopsy in individuals who were on cART for 8 to 16 years. We found no evidence of ongoing replication or compartmentalization of HIV; we did detect clonal expansion of infected cells that were present before cART. Long-term persistence, and not ongoing replication, is primarily responsible for maintaining HIV. HIV-infected cells present when cART is initiated represent the only identifiable source of persistence and is the appropriate focus for eradication.

Small non-uniform basal crystal fields in HVPE free-standing GaN:Mg as evidenced by angular dependent and frequency-dependent EPR

We studied thin-film and free-standing Mg-doped GaN using multi-frequency electron paramagnetic resonance (EPR) at 3-3.5 K and 9.4-130 GHz. Free-standing samples exhibit a highly anisotropic intensity, varying by a factor of 20 from 0° to 60°. In contrast, the intensity of the thin-film samples is significantly more isotropic, varying by no more than 10% over the same range of angles. The angular dependent intensity can be modeled in both free-standing and thin-film samples similarly to the g-factor anisotropy reported for thin films, supporting the theoretical predictions that the hole is on a basal site around the Mg acceptor. In addition, frequency-dependent transmission EPR measurements reveal a distribution of [Formula: see text] in free-standing samples, indicating that the local basal crystal field is non-uniform.

B-34 Correspondence of Latent Neurophysiological and Neurocognitive Profiles to Psychosis Biotypes

Objective

The Bipolar-Schizophrenia Network on Intermediate Phenotypes (B-SNIP) Consortium has developed a novel classification system for psychotic-spectrum disorders that emphasizes objective and neurobiologically valid measures. However, these ‘biotypes’ were created based on a lengthy battery of tests including electroencephalography (EEG), which is time-consuming to administer and not widely available in most clinical settings. The aim of the present study was to evaluate the degree to which classifications obtained using only cognitive and eye tracking paradigms correspond with the biotypes, which would allow for a more efficient approach to diagnosis of psychotic-spectrum disorders that could feasibly be implemented in a clinical setting.

Method

This study utilized latent profile analysis to identify distinct profiles in 683 patients diagnosed with schizophrenia, schizoaffective, or bipolar with psychosis and compared the solution to previously assigned biotypes.

Results

A 3-profile solution provided the best fit for the data (p = .02) and the profiles were characterized by varying degrees of cognitive and sensorimotor impairment. The most impaired profile accurately classified 58.1% of the probands in the most impaired biotype; the least impaired profile classified 63.4% of the least impaired biotype. The intermediate profile did not discriminate between biotypes.

Conclusions

Using composite scores to represent general cognition, eye tracking, and inhibitory control led to better classification of individuals at neurocognitive extremes, but not intermediate levels. These results suggest that the EEG findings are essential to better classify psychosis probands with intermediate impairment and contribute unique variance that may be clinically significant in classifying a subset of psychotic patients in treatment settings.

Bioelectric impedance vector analysis (BIVA) in hospitalised children; predictors and associations with clinical outcomes

BACKGROUND

Clinical use of bioelectric impedance is limited by variability in hydration. Analysis of raw bioelectric impedance vectors (BIVA), resistance (R), reactance (Xc) and phase angle (PA) may be an alternative for monitoring disease progression/treatment. Clinical experience of BIVA in children is limited. We investigated predictors of BIVA and their ability to predict clinical outcomes in children with complex diagnoses.

METHODS

R, Xc and PA were measured (BODYSTAT Quadscan 4000) on admission in 108 patients (4.6-16.8 years, mean 10.0). R and Xc were indexed by height (H) and BIVA-SDS for age and sex calculated using data from healthy children. Potential predictors and clinical outcomes (greater-than-expected length-of-stay (LOS), complications) were recorded.

RESULTS

Mean R/H-SDS was significantly higher (0.99 (SD 1.32)) and PA-SDS lower (-1.22 (1.68))) than expected, with a wide range for all parameters. In multivariate models, the Strongkids risk category predicted R/H-SDS (adjusted mean for low, medium and high risk = 0.49, 1.28, 2.17, p = 0.009) and PA-SDS (adjusted mean -0.52, -1.53, -2.36, p = 0.01). BIVA-SDS were not significantly different in patients with or without adverse outcomes.

CONCLUSIONS

These complex patients had abnormal mean BIVA-SDS suggestive of reduced hydration and poor cellular health according to conventional interpretation. R/H-SDS was higher and PA-SDS lower in those classified as higher malnutrition risk by the StrongKids tool. Further investigation in specific patient groups, including those with acute fluid shifts and using disease-specific outcomes, may better define the clinical role of BIV.

Trends in vaccine investment in middle income countries

Although a proven and effective preventive health measure, childhood immunization programs remain vulnerable to budgetary pressures. Sustainable financing of immunization programs is an important issue that presents a challenge for middle-income countries (MIC) in particular, in part due to technological advances meaning more vaccines are available. This study aimed to analyse trends in immunization program investment across 15 MIC selected based on availability of data, income level classification, and regional representativeness. We assessed investment trends in relation to vaccine coverage, vaccine access, and broader health indicators. Immunization and expenditure data were obtained from the World Health Organisation (WHO) database and the WHO UNICEF Joint Reporting Form and WHO Vaccine Product, Price and Procurement from 2006-2016. We calculated a weighted average index of vaccine commitment (WAIVC) based on vaccine coverage, vaccine scope, and weighted by vaccine innovation measured by approximating vaccine expenditure. Correlation analyses were conducted between immunization expenditure per-capita and each WAIVC, infant mortality and life expectancy. Correlation analyses at a global and individual country level indicate an improvement in immunization access, vaccination commitment measured by WAIVC, and scope of available vaccines in countries with sustained increases in vaccination funding. Increases in national immunization expenditure were correlated with reduced infant mortality and increased life expectancy. Vaccine expenditure comprises a small proportion (less than 2%) of total healthcare spending and has not uniformly increased in accordance with the scope of available vaccines. The present analysis supports the premise that countries with consistent increases in vaccine expenditure have increased vaccine coverage and commitment measured by WAIVC and improved broader health outcomes, indicating the value of sustained investment in vaccination for improved population health. The benefits of vaccine expenditure in this holistic fashion are critical to inform policy decisions on national budget allocation for vaccine funding.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

European Diploma in Anaesthesiology and Intensive Care in Spain: Results for the part 1 and part 2 exams in the last five years. Are we going in the right direction?

BACKGROUND

The European Diploma in Anaesthesiology and Intensive Care (EDAIC) has become a standard of quality among Spanish anaesthesiologists. The aim of this retrospective observational study was to assess the results of Spanish participants for the Part1 and Part2 exams over a recent five years period from 2012 to 2016 and 2013 to 2017, respectively.

MATERIAL AND METHODS

After obtaining the authorization from the European Society of Anaesthesiology, the results of both parts of the EDAIC exams were anonymously analysed for five years. We analysed the number of registrations, the pass rates, the cause for failure and the mean scores for basic sciences (paperA of part1 exam and the two first vivas of part2 exam) and clinical anaesthesia and intensive care (paperB of part1 exam and the two last vivas of part2 exam). Quantitative variables were analysed using the one-way analysis of variance, and qualitative variables using the chi-square test for trends. The level of statistical significance was set at P<.05.

RESULTS

For the written part1 exam, 1,189 of a total of 10,954 candidates (10.85%) were registered in Spanish centres, reflecting the global growth of the exam (P=.29). The pass rate was 62.1%, with no significant differences from other countries (P=.38). Basic sciences were involved in 84.1% of failing candidates. Mean scores were 71.74±5.98% for basic science (paperA) and 74.48±4.29% for clinical anaesthesiology (paperB). Regarding the part2 exam, 72.4% of the candidates who had passed the part1 exam registered for the oral part2, with a pass rate of 62.7% versus 62.2% in the rest of the world (P=.91). Failing in the basic sciences sections of the part2 resulted in 93.8% of candidates failing the part2 exam. Bad fails were registered in 56 (31.5%) of failing candidates, of which 71.3% occurred in the basic sciences vivas. Isolated bad fails only occurred in 7 (3.9%) cases.

CONCLUSIONS

The evolution of the EDAIC in Spain has been very similar to evolution of the EDAIC in the rest of the world. Further efforts to improve knowledge in basic sciences and better preparation in the technique of oral examination should improve the pass rate of the EDAIC examinations from an ever-increasing cohort of candidates.

Frequency-Swept Integrated and Stretched Solid Effect Dynamic Nuclear Polarization

We investigate a new time domain approach to dynamic nuclear polarization (DNP), the frequency-swept integrated solid effect (FS-ISE), utilizing a high power, broadband 94 GHz (3.35 T) pulse EPR spectrometer. The bandwidth of the spectrometer enabled measurement of the DNP Zeeman frequency/field profile that revealed two dominant polarization mechanisms, the expected ISE, and a recently observed mechanism, the stretched solid effect (S²E). At 94 GHz, despite the limitations in the microwave chirp pulse length (10 μs) and the repetition rate (2 kHz), we obtained signal enhancements up to ∼70 for the S²E and ∼50 for the ISE. The results successfully demonstrate the viability of the FS-ISE and S²E DNP at a frequency 10 times higher than previous studies. Our results also suggest that these approaches are candidates for implementation at higher magnetic fields.

Abstract OT2-04-01: An open label, phase II trial of continuous low-irradiance photodynamic therapy (CLIPT) using verteporfin for the treatment of cutaneous breast cancer metastases

Background

Cutaneous metastases occur in approximately 20% of patients (pts) with metastatic breast cancer (mBC) and can be highly symptomatic and distressing. Radiation therapy is frequently used, but progression often occurs quickly. Systemic therapies are also typically used, but also often result in limited benefit. Photodynamic therapy is a promising approach with encouraging results in small studies. Here we will evaluate a novel Continuous Low-Irradiance Photodynamic Therapy (CLIPT) system that emits 690nm LED via a handheld Power Pack attached to a single-use sterile Light Patch to deliver a total energy level of 20J/cm2. Verteporfin (Visudyne®) is a photosensitizer approved for ophthalmological use that, when combined with CLIPT, generates activated oxygen species which can destroy tumor cells with limited normal tissue reaction.

Methods

This open label, Phase 2 study will evaluate the efficacy and safety of CLIPT with verteporfin in 15 patients with cutaneous lesions from mBC. Patients will receive a single IV injection of Verteporfin on day 1. The 9x9cm Light Patch with an adhesive border is placed over the treatment site and attached to the CLIPT portable Power Pack. The patient turns the device on at home 6 hours after the Verteprofin injection and it automatically turns off after 24 hours. The patient then removes the Light Patch and returns to clinic on day 3. The primary endpoint is objective response rate (RR) at 3 weeks following CLIPT using a modified RECIST which accounts for nodular or diffuse plaque-like lesions. Response will be confirmed by independent dermatologist review. Secondary endpoints include RR at 2, 8 and 12 weeks, toxicity, and quality of life (using FACT-B and Brief Pain Inventory). A novel Participant Symptom Scale (PSS) will also be used in which the first 8 patients will list their most distressing symptoms from cutaneous metastases and score the severity of the symptoms from 1 to 10. The six most common symptoms among the first 8 patients will then be used in the PSS for the remaining 7 patients. The PSS will be assessed at baseline and at subsequent visits to explore any improvement in severity of symptoms after treatment with CLIPT. Patients who derive clinical benefit may be retreated up to 3 times to the same or different region. Eligible patients will have: cutaneous metastases from mBC with measurable disease by protocol defined modified RECIST 1.1, ≥ 1 line of prior systemic or local therapy for mBC, ≥ 14 days from prior systemic therapy or 60 days from radiation to target lesion, and no expectation for systemic therapy for ≥ 14 days after CLIPT. RR will be reported with 95% CI. With 15 patients, if ≥ 3 responses (RR ≥ 20%) are observed, the null hypothesis of RR ≤ 5% will be rejected. At the time of abstract submission, 4 patients have been accrued. Clinical Trials Reg: NCT02939274

Citation Format: Isakoff SJ, Rogers GS, Hill S, McMullen P, Habin KR, Chen ST, Bartenstein DW, Barry W, Overmoyer BA. An open label, phase II trial of continuous low-irradiance photodynamic therapy (CLIPT) using verteporfin for the treatment of cutaneous breast cancer metastases [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT2-04-01.

Introducing genomics into cancer care

A national view