Primary outcome reporting in clinical trials for older adults with depression

BACKGROUND

Findings from randomised controlled trials (RCTs) are synthesised through meta-analyses, which inform evidence-based decision-making. When key details regarding trial outcomes are not fully reported, knowledge synthesis and uptake of findings into clinical practice are impeded.

AIMS

Our study assessed reporting of primary outcomes in RCTs for older adults with major depressive disorder (MDD).

METHOD

Trials published between 2011 and 2021, which assessed any intervention for adults aged ≥65 years with a MDD diagnosis, and that specified a single primary outcome were considered for inclusion in our study. Outcome reporting assessment was conducted independently and in duplicate with a 58-item checklist, used in developing the CONSORT-Outcomes statement, and information in each RCT was scored as 'fully reported', 'partially reported' or 'not reported', as applicable.

RESULTS

Thirty-one of 49 RCTs reported one primary outcome and were included in our study. Most trials (71%) did not fully report over half of the 58 checklist items. Items pertaining to outcome analyses and interpretation were fully reported by 65% or more of trials. Items reported less frequently included: outcome measurement instrument properties (varied from 3 to 30%) and justification of the criteria used to define clinically meaningful change (23%).

CONCLUSIONS

There is variability in how geriatric depression RCTs report primary outcomes, with omission of details regarding measurement, selection, justification and definition of clinically meaningful change. Outcome reporting deficiencies may hinder replicability and synthesis efforts that inform clinical guidelines and decision-making. The CONSORT-Outcomes guideline should be used when reporting geriatric depression RCTs.

Heterogeneity across outcomes reported in clinical trials for older adults with depression: a systematic survey

OBJECTIVES

The objective of our study was to identify outcomes reported in trials for older adults with depression, and describe outcome heterogeneity.

STUDY DESIGN AND SETTING

We searched four databases to identify trials assessing any intervention for major depressive disorder among older adults published between 2011 and 2021. We grouped reported outcomes thematically and mapped them onto core outcome areas (physiological/clinical, life impact, resource use, adverse events, and death), and used descriptive analysis to summarize outcome heterogeneity.

RESULTS

There were 434 total outcomes reported by 49 included trials, which were measured using 135 different outcome measurement instruments and grouped into 100 unique outcome terms. Most outcome terms mapped to the physiological/clinical core area (47%), followed by life impact (42%). Over half of all terms (53%) were reported by only a single study. The majority of trials (n=31/49) reported a single, discernable primary outcome. The most commonly reported outcome, "depressive symptom severity" was assessed by 36 studies using 19 different outcome measurement instruments.

CONCLUSION

There is substantial heterogeneity in the outcomes and outcome measurement instruments used in geriatric depression trials. A standard set of outcomes and accompanying measurement tools is necessary to facilitate comparison and synthesis of trial findings.

Delirium and other neuropsychiatric manifestations of COVID-19 infection in people with preexisting psychiatric disorders: a systematic review

BACKGROUND

Psychiatric disorders increase risk of neuropsychiatric disease and poor outcomes, yet little is known about the neuropsychiatric manifestations of COVID-19 in the psychiatric population. The primary objective is to synthesize neuropsychiatric outcomes of COVID-19 in people with preexisting psychiatric disorders.

METHODS

Data were collected during an ongoing review of the impact of pandemics on people with existing psychiatric disorders. All study designs and gray literature were included. Medline, PsychInfo, CINAHL, EMBASE, and MedRx were searched from inception to September 1 2020. Risk of bias was assessed using a published tool that can accommodate all study types. Two independent authors screened the studies and extracted data. Data were narratively synthesized, as there were insufficient data to meta-analyze. Evidence was appraised according to GRADE.

RESULTS

Four case reports were included, comprising 13 participants from three countries. Many large-sample, relevant papers were omitted for not reporting psychiatric history, despite reporting other comorbidities. Included participants (n = 13) were hospitalized with COVID-19 and appeared to meet criteria for delirium. Myoclonus, rigidity, and alogia were also reported. The most commonly reported preexisting psychiatric diagnoses were mood disorders, schizophrenia, and alcohol use disorder.

CONCLUSIONS

People with preexisting psychiatric disorders may experience delirium, rigidity, myoclonus, and alogia during COVID-19 infection; although higher quality and longitudinal data are needed to better understand these phenomena. Relevant COVID-19 literature does not always report psychiatric history, despite heightened neuropsychiatric vulnerability within this population.

TRIAL REGISTRATION

 PROSPERO (CRD42020179611).

Outcomes reported in randomised controlled trials of major depressive disorder in older adults: protocol for a methodological review

INTRODUCTION

Major depressive disorder (MDD or depression) is prevalent among adults aged 65 years and older. The effectiveness and safety of interventions used to treat depression is often assessed through randomised controlled trials (RCTs). However, heterogeneity in the selection, measurement and reporting of outcomes in RCTs renders comparisons between trial results, interpretability and generalisability of findings challenging. There is presently no core outcome set (COS) for use in RCTs that assess interventions for older adults with MDD. We will conduct a methodological review of the literature for outcomes reported in trials for adults 65 years and older with depression to assess the heterogeneity of outcome measures.

METHODS AND ANALYSIS

RCTs evaluating pharmacotherapy, psychotherapy, or any other treatment intervention for older adults with MDD published in the last 10 years will be located using electronic database searches (MEDLINE, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials). Reviewers will conduct title and abstract screening, full-text screening and data extraction of trials eligible for inclusion independently and in duplicate. Outcomes will be synthesised and mapped to core outcome-domain frameworks. We will summarise characteristics associated with trials and outcomes.

ETHICS AND DISSEMINATION

We hope that findings from our methodological review will reduce variability in outcome selection, measurement and reporting and facilitate the development of a COS for older adults with MDD. Our review will also inform evidence synthesis efforts in identifying the best treatment practices for this clinical population. Ethics approval is not required, as this study is a literature review.

PROSPERO REGISTRATION NUMBER

CRD42021244753.

Coincident angle-resolved state-selective photoelectron spectroscopy of acetylene molecules: a candidate system for time-resolved dynamics

The acetylene-vinylidene system serves as a benchmark for investigations of ultrafast dynamical processes where the coupling of the electronic and nuclear degrees of freedom provides a fertile playground to explore the femto- and sub-femto-second physics with coherent extreme-ultraviolet (EUV) photon sources both on the table-top as well as free-electron lasers. We focus on detailed investigations of this molecular system in the photon energy range 19-40 eV where EUV pulses can probe the dynamics effectively. We employ photoelectron-photoion coincidence (PEPICO) spectroscopy to uncover hitherto unrevealed aspects of this system. In this work, the role of excited states of the C2H2+ cation, the primary photoion, is specifically addressed. From photoelectron energy spectra and angular distributions, the nature of the dissociation and isomerization channels is discerned. Exploiting the 4π-collection geometry of the velocity map imaging spectrometer, we not only probe pathways where the efficiency of photoionization is inherently high but also perform PEPICO spectroscopy on relatively weak channels.

The future of precision medicine in opioid use disorder: inclusion of patient-important outcomes in clinical trials

Opioid use has reached an epidemic proportion in Canada and the United States that is mostly attributed to excess availability of prescribed opioids for pain. This excess in opioid use led to an increase in the prevalence of opioid use disorder (OUD) requiring treatment. The most common treatment recommendations include medication-assisted treatment (MAT) combined with psychosocial interventions. Clinical trials investigating the effectiveness of MAT, however, have a limited focus on effectiveness measures that overlook patient-important outcomes. Despite MAT, patients with OUD continue to suffer negative consequences of opioid use. Patient goals and personalized medicine are overlooked in clinical trials and guidelines, thus missing an opportunity to improve prognosis of OUD by considering precision medicine in addiction trials. In this mixed-methods study, patients with OUD receiving MAT (n=2,031, mean age 39.1 years [SD 10.7], 44% female) were interviewed to identify patient goals for MAT. The most frequently reported patient-important outcomes were to stop treatment (39%) and to avoid all drugs (25%). These results are inconsistent with treatment recommendations and trial outcome measures. We discuss theses inconsistencies and make recommendations to incorporate these outcomes to achieve patient-centered and personalized treatment strategies.

Wave propagation and focusing of soft X-rays by spherical bent microchannel plates

Synchrotron radiation sources have been used to study the focusing properties and angular distribution of X-ray radiation at the exit of spherically bent microchannel plates (MCPs). In this contribution it is shown how soft X-ray radiation at energies up to 1.5 keV can be focused by spherically bent MCPs with curvature radii R of 30 mm and 50 mm. For these devices, a focus spot is detectable at a distance between the detector and the MCP of less than R/2, with a maximum focusing efficiency up to 23% of the flux illuminating the MCP. The soft X-ray radiation collected at the exit of microchannels of spherically bent MCPs are analyzed in the framework of a wave approximation. A theoretical model for the wave propagation of radiation through MCPs has been successfully introduced to explain the experimental results. Experimental data and simulations of propagating radiation represent a clear confirmation of the wave channeling phenomenon for the radiation in spherically bent MCPs.

Association between vaping and health outcomes in patients with opioid use disorder: a systematic review protocol

INTRODUCTION

Vaping behaviour has increased in popularity and is particularly important to examine how it effects health outcomes in vulnerable populations, including those with opioid use disorder (OUD). With polysubstance use including cigarette and cannabis use being highly prevalent in the OUD population and cannabis/nicotine increasingly being consumed by vaping, vaping may have an important contribution to health outcomes in these individuals. The primary objective of this review is to systematically assess the literature related to patients with OUD and the effects vaping has shown on their physical and mental health.

METHOD AND ANALYSIS

A systematic search of databases including MEDLINE, Embase, PsycINFO, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Cochrane Clinical Trials Registry, the National Institutes for Health Clinical Trials Registry and the WHO International Clinical Trials Registry Platform from inception to 31 December 2020 will be conducted. Identified citations will be screened by two reviewers to determine eligibility at the title and abstract level, and then at the full text and data extraction phases. Any disagreements in inclusion will be resolved through unblinded discussion by these reviewers, with any remaining disagreements being resolved by a third reviewer. Data collection from eligible studies will be conducted according to the data extraction form tested prior to abstraction. Included studies will be examined for quality and bias and will be meta-analysed where applicable. This protocol is reported in keeping with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines.

ETHICS AND DISSEMINATION

The results for this review will be disseminated through publications in peer-reviewed journals, posters and presentations at scientific conferences. Additionally, we are collaborating with the Canadian Addiction Treatment Centre clinics to help disseminate the findings for this review. As this is a systematic review, no ethics approval is needed.

REVIEW REGISTRATION NUMBER

CRD42020178441.

The Role of Perceived Social Support in the Association Between Stressful Life Events and Suicidal Behavior

Background: Suicide is a serious public health concern for which there have been well-established protective and risk factors reported in literature. There is a lack of evidence on the indirect effects of other variables on these factors. Specifically, the association between stressful life events and suicidal behavior may be affected by perceived social support, but its role in this association is largely uninvestigated. Objectives: Thus, this paper aims to explore the role of perceived social support in the association between stressful life events and suicidal behavior. Perceived social support will be explored as a mediator and as a moderator in this association. Methods: Data were obtained from the Determinants of Suicidal Behavior Conventional and Emergent Risk (DISCOVER), a study conducted to identify risk factors of suicidal behavior. The study participants are individuals with suicide attempts admitted to hospital. Participants (n = 343) were recruited from hospital setting. Suicidal behavior was measured using two outcomes (1) the occurrence of a suicide attempt (2) level of suicide intent as measured by the Pierce Suicide Intent Scale. Perceived social support was measured using the Sarason Social Support Questionnaire. Results: Stressful life events were significantly associated with suicide attempts (OR 1.440, 95% CI 1.440, 1.682, p < 0.001) and perceived social support (B -0.785, 95% CI -1.501, -0.068, p = 0.032). There was no significant mediation effect by perceived social support in the association between stressful life events and suicide attempts (Sobel's test statistic 1.64, p = 0.100). Perceived social support did not moderate the relationship between stressful life events and suicide attempts [(OR 1.007, 95% CI 0.987, 1.027, p = 0.514] or the relationship between stressful life events and level of suicidal intent (B -0.043, 95% CI -0.132, 0.046, p = 0.343). Conclusion: Stressful life events are associated with increased risk of suicide attempts. The study also identified an inverse relationship between stressful life events and perceived social support. These associations were independent of perceived social support. This study highlights the effects of stressful life events on suicide risk is not affected by perceived social support, requiring further investigation into measures to reduce the impact of social stressors on people with risk of suicide.

Genetic determinants of cannabis use: a systematic review protocol

BACKGROUND

With the legalization of cannabis in Canada, there is an increase trend in use. Cannabis has been known to have several health implications, one of which is the development of cannabis use disorder (CUD). CUD is more common in males than females, as well as in certain ethnic groups such as Native Americans. Additionally, both environmental and genetic risk factors have been found for cannabis use. The objective of this systematic review will be to summarize the genetic variants associated with cannabis use which have reached borderline genome-wide significance.

METHODS

This systematic review will incorporate articles that have performed a genome-wide association study (GWAS) investigating cannabis use. MEDLINE, Web of Science, EMBASE, GWAS Catalog, GWAS Central, and NIH Database of Genotype and Phenotype will be searched using a comprehensive search strategy. The quality of genetic association studies (Q-Genie) tool will be utilized to assess the quality of the included studies. All screening and data extraction will occur independently by two authors. If feasible, a random-effects meta-analysis will be conducted on pooled odds ratios of single nucleotide polymorphisms reaching borderline genome-wide significance.

DISCUSSION

This systematic review will synthesize available GWAS on cannabis use. Results from this review will inform and direct further investigation of genetic variants associated with cannabis use.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020176016.

Penning spectroscopy and structure of acetylene oligomers in He nanodroplets

Embedded atoms or molecules in a photoexcited He nanodroplet are well-known to be ionized through inter-atomic relaxation in a Penning process. In this work, we investigate the Penning ionization of acetylene oligomers occurring from the photoexcitation bands of He nanodroplets. In close analogy to conventional Penning electron spectroscopy by thermal atomic collisions, the n = 2 photoexcitation band plays the role of the metastable atomic 1s2s 3,1S He*. This facilitates electron spectroscopy of acetylene aggregates in the sub-Kelvin He environment, providing the following insight into their structure: the molecules in the dopant cluster are loosely bound van der Waals complexes rather than forming covalent compounds. In addition, this work reveals a Penning process stemming from the n = 4 band where charge-transfer from autoionized He in the droplets is known to be the dominant relaxation channel. This allows for excited states of the remnant dopant oligomer Penning-ions to be studied. Hence, we demonstrate Penning ionization electron spectroscopy of doped droplets as an effective technique for investigating dopant oligomers which are easily formed by attachment to the host cluster.

The impact of chronic liver disease in patients receiving active pharmacological therapy for opioid use disorder: One-year findings from a prospective cohort study

INTRODUCTION

Despite the demonstrated benefit of methadone, the incidence opioid-related overdose, and its associated mortality continues to rise at an alarming rate. The impact of high prevalence comorbid features such as chronic liver disease (CLD) on methadone treatment response remain unclear.

AIM

To determine whether CLD is associated with poor response to methadone treatment.

METHODS

Using a well-established multi-center cohort from the Genetics of Opioid Addiction Study (GENOA), we evaluated if presence of CLD among 1234 eligible patients with opioid use disorder receiving methadone treatment impacted health and behavioural responses to treatment. CLD was classified as any liver disorder/dysfunction present for a minimum period of six months. Serial urine toxicology assessments were used to determine treatment response. The effect of CLD was determined using a multi-variable logistic regression model.

RESULTS

CLD was present in 25 % (n = 314) of the population. On average, patients with CLD were found to be older (mean age 44 vs 36 years, p < 0.0001), unemployed (81.8 % vs 61 %, p < 0.0001), and receiving government disability benefits at significantly higher rates (21.9 % vs 11 %, p < 0.0001). Increased levels of physical craving, emotional stress, as well as health risk behaviors were noted in CLD patients. Findings from the multi-variable model demonstrate a 68 % increased risk for dangerous opioid consumption behaviors (Odds Ration [OR]: 1.68, 95 % Confidence Interval [CI] 1.22, 2.31, p = 0.001) among patients with CLD. Methadone dose (OR: 0.76, 95 % CI 0.70, 0.81, p < 0.0001) was shown to be protective with a significant risk reduction of 24 % per 20 mg increase in methadone. Duration in treatment was also found to be protective (OR: 0.99, 95 % CI 0.97, 0.99, p < 0.0001).

CONCLUSION

CLD poses a distinct risk for patients with opioid addiction. Closer drug monitoring, and substance use contingency management should be considered to reduce mortality risk in these patients.

Electrophoretic deposition of polymethylmethacrylate and composites for biomedical applications

For the first time, an electrophoretic deposition (EPD) method has been developed for the deposition of polymethylmethacrylate (PMMA) and PMMA-alumina films for biomedical implant applications. The proposed biomimetic approach was based on the use of a bile salt, sodium cholate (NaCh), which served as a multifunctional solubilizing, charging, dispersing and film-forming agent. Investigations revealed PMMA-Ch^- and PMMA-alumina interactions, which facilitated the deposition of PMMA and PMMA-alumina films. This approach allows for the use of a non-toxic water-ethanol solvent for PMMA. The proposed deposition strategy can also be used for co-deposition of PMMA with other functional materials. The PMMA and composite films were tested for biomedical implant applications. The PMMA-alumina films showed statistically improved metabolic results compared to both the bare stainless steel substrate and pure PMMA films. Alkaline phosphatase (ALP) activity affirmed the bioactivity and osteoconductive potential of PMMA and composite films. PMMA-alumina films showed greater ALP activity than both the PMMA-coated and uncoated stainless steel.

The association between health conditions and cannabis use in patients with opioid use disorder receiving methadone maintenance treatment

BACKGROUND

Cannabis is the most commonly used substance among patients in methadone maintenance treatment (MMT) for opioid use disorder. Current treatment programmes neither screen nor manage cannabis use. The recent legalisation of cannabis in Canada incites consideration into how this may affect the current opioid crisis.

AIMS

Investigate the health status of cannabis users in MMT.

METHOD

Patients were recruited from addiction clinics in Ontario, Canada. Regression analyses were used to assess the association between adverse health conditions and cannabis use. Further analyses were used to assess sex differences and heaviness of cannabis use.

RESULTS

We included 672 patients (49.9% cannabis users). Cannabis users were more likely to consume alcohol (odds ratio 1.46, 95% CI 1.04-2.06, P = 0.029) and have anxiety disorders (odds ratio 1.75, 95% CI 1.02-3.02, P = 0.043), but were less likely to use heroin (odds ratio 0.45, 95% CI 0.24-0.86, P = 0.016). There was no association between cannabis use and pain (odds ratio 0.98, 95% CI 0.94-1.03, P = 0.463). A significant association was seen between alcohol and cannabis use in women (odds ratio 1.79, 95% CI 1.06-3.02, P = 0.028), and anxiety disorders and cannabis use in men (odds ratio 2.59, 95% CI 1.21-5.53, P = 0.014). Heaviness of cannabis use was not associated with health outcomes.

CONCLUSIONS

Our results suggest that cannabis use is common and associated with psychiatric comorbidities and substance use among patients in MMT, advocating for screening of cannabis use in this population.

DECLARATION OF INTEREST

None.

Preliminary evidence that vortioxetine may improve sleep quality in depressed patients with insomnia: a retrospective questionnaire analysis

Insomnia is a frequent symptom in depressed patients. It can present with difficulty in initiating and/or maintaining sleep. We retrospectively evaluated a group of 15 patients affected by major depressive disorder and complaining of insomnia, who started vortioxetine (VOR) treatment for their depressive symptoms. The following questionnaires were captured at baseline and follow-up: Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale and Beck Depression Inventory. Pittsburgh Sleep Quality Index total score significantly decreased between follow-up and baseline (P < 0.01), and in several subitems related to sleep quality and continuity. Moreover, Epworth Sleepiness Scale decreased between follow-up and baseline (P < 0.01). Finally, Beck Depression Inventory reduction was also evident between follow-up and baseline (P < 0.01). This retrospective analysis showing the significant effect of VOR on both depressive symptoms and insomnia in patients showing comorbid major depressive disorder and insomnia invites further research in order to confirm this preliminary evidence. We hypothesize that the VOR mechanism of action may explain the improvement of subjective sleep, other than depressive symptoms.

Topical application of LEVORAG® as first-line treatment for chronic anal fissures: a preliminary multicentric study

AIM

The aim of the present study was to assess the safety and efficacy of this new topical agent as a first line treatment in patients with chronic anal fissures.

METHODS

Nine centres were involved in the study. Patients with chronic anal fissures were recruited and received Levorag® for 40 days. Follow-up visits were conducted at 10, 20 and 40 days from the recruitment. Primary outcome was the healing rate, secondary outcome the reduction of pain at the end of the treatment measured with a VAS scale.

RESULTS

Fifty patients completed the treatment. No adverse events were recorded. 60% of patients healed completely at the end of the treatment. In those that did not heal the reduction of mean VAS values was 60%.

CONCLUSION

The use of Levorag® on patients affected by chronic anal fissures achieved in the short term results similar to those experienced by more classic local treatments without any side effect.

The effect of alpha-lipoic acid on temporary threshold shift in humans: a preliminary study

Noise-induced hearing loss (NHIL) is a significant source of hearing loss in industrialized countries. Recent research on the cellular bases of NIHL has led to new avenues for protection through prophylactic drugs. Although in experimental animal models several compounds have shown a protective effect in NIHL, limited data are available in humans. Many authors are focusing their attention on the role of antioxidant on hearing protection. Alpha-lipoic acid (ALA), an essential cofactor in mitochondrial enzymes, is a novel biological antioxidant and a potent free radical scavenger and, in animal models, it has been shown to protect from age-induced and cisplatin-induced hearing loss. The aim of our study was to evaluate the effect of alpha-lipoic acid on temporary threshold shift measured 2 minutes after the end of exposure (TTS(2)) induced by a 3 kHz tone in young normally hearing subjects. Thirty young normal hearing volunteers served as control subjects. Individuals were randomly assigned to three groups. Group A (10 subjects) subjects were exposed to a 90 dB HL 3 kHz pure tone for 10 min. Group B (10 subjects) subjects were exposed to a 90 dB HL 3 kHz pure tone one hour after oral ingestion of 600 mg of ALA. Group C (10 subjects) were exposed to a 90 dB HL 3 kHz pure tone after 10 days of oral ingestion of 600 mg of ALA. Statistical analysis showed that prior to the exposure the hearing thresholds did not differ significantly among the three groups. TTS(2) of group C was significantly lower that TTS2 of Groups A and B at 6 kHz (p 0.03), and TEOAEs amplitude change after noise exposure was lower for group C compared to Groups A (p = 0.089) and B (p = 0.03). ALA is a powerful lipophilic antioxidant and free radical scavenger currently used in clinical practice. A single dose of 600 mg of dose ALA did not induce any protection on the TTS(2) induced by a 90 dB HL 3 kHz tone, while 10 days of therapeutic dosage assumption of ALA was associated with significant protection at 6 kHz. The results of this study show that a short course of ALA protects from TTS(2) in humans, and therefore further studies are needed to better define the role of ALA in the prevention of noise induced hearing loss.

Single brain metastases from cervical carcinoma: report of two cases and critical review of the literature

Single brain metastases from cervical carcinomas are rare. We report two cases of solitary brain metastases, showing different histological types, which have been excised with microsurgical technique. Neuroendocrine differentiation does not seem to be connected to clinical behavior, indeed a poor prognosis depends on poorly differentiated histological types. In our cases, brain metastases were a late event and they have been successfully excised in microsurgery, thanks to their solitary and resectable nature, and a well-controlled primary disease.

Sarcoma metastatic to the brain: a series of 35 cases and considerations from 27 years of experience

The authors report their 27-year experience regarding 35 cases of supratentorial brain metastasis from sarcoma treated in a single institution: these included ten osteosarcomas, seven leiomyosarcomas, five Ewing sarcomas, four malignant fibrous histiocytomas, three alveolar soft-part sarcomas (ASPS), two rhabdomyosarcomas, one liposarcoma, and three unclassified sarcomas. The first 15 cases of the series have already been described in a previous publication. Median survival after craniotomy was 9.8 months (range: 4-24). In patients with preoperative Karnofsky performance score (KPS) > 60 it was 12.8 months (range: 6.5-24 months) versus 5.4 months for those patients with a KPS < or = 60 (P = 0.01). Eight patients had more than one lesion, six of which were treated in the last ten years. Of the three patients with ASPS, the first two were alive at 15 and 20 months (before being lost to follow-up) whereas the third patient is alive at 24 month follow-up. The authors conclude that surgery is more effective in treating selected patients with sarcoma metastatic to the brain, and that patients with metastasis from ASPS have good prognosis when submitted to surgical treatment. The complete removal of all brain metastases "en bloc" and a KPS > 60 are associated with the best prognosis. Finally, it seems that surgical indications for multiple brain metastases from sarcoma have increased during the last ten years.

Anal endosonography: a survey of equipment, technique and diagnostic criteria adopted in nine Italian centers

BACKGROUND

Anal endosonography (AES) has become an essential part of the pre-operative diagnostic workup in both organic and functional anal diseases.

METHODS

Nine Italian centres with an average volume activity of >10 exams/week each were surveyed with the aim of determining the concordance with respect to indications for the procedure and interpretation of the results.

RESULTS

Overall, anal sepsis, faecal incontinence and anorectal tumours were the more common indications for AES while evacuation dysfunctions and anal pain were not always considered indications. All centres use the same diagnostic criteria for simple and complicated perirectal sepsis and sphincteric defects, but adopt different classifications for stage 1 and stage 2 anal tumours. Participants agreed in that lymph-node staging by AES is less precise than tumour staging, especially after chemoradiation therapy.

CONCLUSIONS

A list of recommendations and guidelines based on the groups's experience has been produced for those radiologists and coloproctologists interested in the use of AES and accreditation of their centres.

The use of a dedicated rectosigmoidoscope for ultrasound staging of tumours of the upper and middle third of the rectum

OBJECTIVE

Tumours of the upper rectum, and many in the middle third, are not accessible to endorectal ultrasound staging because of the difficulty in reaching all sites of the rectum with a rigid probe. The aim of this prospective study was to assess whether using a dedicated rectosigmoidoscope, endorectal ultrasonography (ERUS) can accurately stage any rectal lesion irrespective of its distance from the anal verge.

METHOD

A total of 173 consecutive patients with a primary rectal tumour were included. A rotating, high multifrequency (5.0-10 MHz) endoprobe was introduced through a dedicated rectosigmoidoscope and advanced above the lesion. A computer allowed for three-dimensional (3D) reconstruction of 2D images. Treatment was selected on the basis of 3D-ERUS findings. ERUS staging was correlated with pathological staging.

RESULTS

The depth of invasion was correctly determined by 3D-ERUS in 78.2% of tumours of the lower rectum, 76.4% of tumours extending between the lower and middle third of the rectum, 80.9% of tumours of the middle third of the rectum, 78.5% of tumours extending between the middle and upper third of the rectum and 78.9% of tumours of the upper rectum. The accuracy for the absence of lymph node metastases was 81.2% for tumours of the lower rectum, 78.5% for tumours extending between the lower and middle third of the rectum, 85.7% for tumours of the middle third of the rectum, 83.3% for tumours extending between the middle and upper third of the rectum and 78.5% for tumours of the upper rectum. Analysis showed that there was no difference between the various tumour sites.

CONCLUSION

Our findings indicate that using a dedicated proctosigmoidoscope, tumours of the upper and middle third of the rectum are equally accessible to ultrasonographic evaluation. The distance of the tumour from the anal verge does not influence the accuracy of examinations considered adequate by the operator.

Overall impact of speed-related initiatives and factors on crash outcomes

From December 2000 until July 2002 a package of speed-related initiatives and factors took place in Victoria, Australia. The broad aim of this study was to evaluate the overall impact of the package on crash outcomes. Monthly crash counts and injury severity proportions were assessed using Poisson and logistic regression models respectively. The model measured the overall effect of the package after adjusting as far as possible for non-speed road safety initiatives and socio-economic factors. The speed-related package was associated with statistically significant estimated reductions in casualty crashes and suggested reductions in injury severity with trends towards increased reductions over time. From December 2000 until July 2002, three new speed enforcement initiatives were implemented in Victoria, Australia. These initiatives were introduced in stages and involved the following key components: More covert operations of mobile speed cameras, including flash-less operations; 50% increase in speed camera operating hours; and lowering of cameras' speed detection threshold. In addition, during the period 2001 to 2002, the 50 km/h General Urban Speed Limit (GUSL) was introduced (January 2001), there was an increase in speed-related advertising including the "Wipe Off 5" campaign, media announcements were made related to the above enforcement initiatives and there was a speeding penalty restructure. The above elements combine to make up a package of speed-related initiatives and factors. The package represents a broad, long term program by Victorian government agencies to reduce speed based on three linked strategies: more intensive Police enforcement of speed limits to deter potential offenders, i.e. the three new speed enforcement initiatives just described - supported by higher penalties; a reduction in the speed limit on local streets throughout Victoria from 60 km/h to 50 km/h; and provision of information using the mass media (television, radio and billboard) to reinforce the benefits of reducing low level speeding - the central message of "Wipe Off 5". These strategies were implemented across the entire state of Victoria with the intention of covering as many road users as possible. This study aimed to evaluate the overall effectiveness of the speed-related package. The study objectives were: to document the increased speed camera activity in each speed limit zone and in Melbourne compared with the rest of Victoria; to evaluate the overall effect on crash outcomes of the package; to account as far as possible for the effect on crash outcomes of non-speed road safety initiatives and socio-economic factors, which would otherwise influence the speed-related package evaluation; and to examine speed trends in Melbourne and on Victorian rural highways, especially the proportions of vehicles travelling at excessive speeds. This paper presents the results of the evaluation of the overall impact on crash outcomes associated with the speed-related package, after adjusting as far as possible for the effect of non-speed road safety initiatives and socio-economic factors. D'Elia, Newstead and Cameron (2007) document the study results in full.

Vibroacoustic stimulation in normal term human pregnancy

OBJECTIVE

To examine the effects of vibroacoustic stimulation (VAS) on fetal heart rate (FHR) in term human fetuses by computerized carditocography system.

METHODS

FHR was analyzed 20 min before and 30 min after vibroacoustic stimulation using the Oxford Sonicaid System 8002 for computerized FHR measurement. Recordings were made in 31 uncomplicated pregnancies at 36-42 weeks' gestation.

RESULTS

Vibroacustic stimulation of the fetus evoked a significant increase in all the parameters evaluated (number of fetal movements, of accelerations above 10 and 15 bpm, in high- and low-variability episodes, and in short-term variations). Concerning the effect of behavioural states on the response to VAS, some changes (FHR, high-variability episodes) occurred independently of behavioural states, while other parameters (accelerations >10 and 15 bpm: short-term variation) underwent statistically significant changes only for behavioural states 1F and 2F.

CONCLUSIONS

Our study supports the hypothesis of a significant fetal response in normal term pregnancy, as clearly shown by computerized cardiotocography. The immediate response occurred independently of behavioural states, although some differences were present (mainly for F1 and F2 states) if the evaluation was extended in time.

Genetic thrombophilias and uterine artery Doppler velocimetry and preeclampsia

OBJECTIVE

The aim of this study was to evaluate the correlation between genetic thrombophilic mutations, uterine artery Doppler at 24 weeks of gestation and preeclampsia.

METHODS

In a case control study we performed the genetic analysis for Leiden mutation of factor V gene (FV), G20210A mutation of the prothrombin gene (PT) and C677T polymorphism of the methylenetetrahydrofolate reductase (MTHFR) gene in 103 women that had already attended routine ultrasonography scanner at 20 weeks at our Department.

RESULTS

The frequency of heterozygous carriers of the factor V Leiden was 17.4% in the women with preeclampsia and abnormal artery Doppler compared with 3.12% in the patients with normal pregnancies. This difference was statistically significant (P<0.05). The frequency of mutation G20210A of prothrombin gene was 1.5 vs. 4.3% between women with normal pregnancies and with preeclampsia. This difference is not statistically significant. The frequency of homozygous patients for the C677T mutation of MTHFR gene among the patients with preeclampsia was 21.7% and in the control group was 10.3%, but this difference is not statistically significant. No thrombophilic gene variants were found in women with preeclampsia and normal uterine artery Doppler.

CONCLUSION

We demonstrated the important association between factor V Leiden mutation, abnormal uterine Doppler at 24 weeks and preeclampsia in our population.

[Screening for pre-eclampsia in a low-risk population at 24 weeks: uterine artery Doppler flow velocimetry and genetic variants of factor V, prothrombin and methylenetetrahydrofolate reductase]

AIM

Pre-eclampsia is one of the major causes of maternal and fetal morbidity and mortality. The aim of this study was to evaluate the clinical usefulness of screening of genetic thrombophilic mutations and uterine artery Doppler flow velocimetry at 24 weeks of gestation in the prediction of pre-eclampsia in low risk pregnant women.

METHODS

We performed the genetic analysis for Leiden mutation of factor V gene (FV), G20210A mutation of the prothrombin gene (PT) and C677T polymorphism of the methylenetetrahydrofolate reductase (MTHFR) gene in 103 women that had already attended routine ultrasonography scanner at 24 weeks at our Department.

RESULTS

The frequency of heterozygous carriers of the Leiden FV was 17.4% in women with pre-eclampsia and abnormal artery Doppler flow velocimetry compared with 3.12% in patients with normal pregnancies. This difference was statistically significant (P<0.05). The frequency of mutation G20210A of PT gene was 1.5% vs 4.3% between women with normal pregnancies and with pre-eclampsia. This difference is not statistically significant. The frequency of homozygous patients for the C677T mutation of MTHFR gene among patients with pre-eclampsia was 21.7% and in the control group was 10.3%, but this difference is not statistically significant. No thrombophilic genes variants were found in women with pre-eclampsia and normal uterine artery Doppler flow velocimetry.

CONCLUSION

We demonstrated the important association between FV Leiden mutation, abnormal uterine artery Doppler flow velocimetry at 24 weeks and pre-eclampsia in our low-risk population.

Serum leptin levels and uterine Doppler flow velocimetry at 20 weeks' gestation as markers for the development of pre-eclampsia

Altered Doppler flow velocimetry of the uterine arteries during the second trimester is correlated with the risk of developing pre-eclampsia. Serum levels of leptin, a protein regulating body weight and secreted by the placenta, are higher in women with severe pre-eclampsia. We investigated whether alterations of uterine arteries' Doppler flow velocimetry during the early second-trimester scan were accompanied by changes in leptin levels, and whether these changes might be an early risk factor for pre-eclampsia. We retrospectively selected 50 women with altered uterine artery velocimetry at the second-trimester scan who subsequently developed pre-eclampsia (group A) and 100 women who did not develop pre-eclampsia, divided into two groups: 50 women with normal velocimetry at the second-trimester scan (group B) and 50 women with altered velocimetry at the second-trimester scan (group C). Serum leptin levels during the second and third trimesters and bilateral uterine artery resistance index during the second trimester were evaluated. No differences were observed in serum leptin levels in the second trimester among the three groups. During the third trimester, women in group A showed significantly higher serum leptin levels in comparison with women in groups B and C (p < 0.01). Serum leptin levels do not seem to be a useful early marker for the development of pre-eclampsia in the presence of altered uterine blood flow, and may be a late compensatory mechanism or reflect a generalized response of the trophoblast to hypoxic stimuli.

Prenatal ultrasonographic appearance of esophageal atresia

The authors report a case of esophageal atresia (EA) to help define criteria for prenatal ultrasonographic diagnosis of this malformative pathology.

Spontaneous motor activity in normal fetuses

AIM

The aim of this work was to perform a quantitative analysis of the different activities (mouth, eye and gross body movements) in the fetuses of 15 women with normally evolving pregnancies, and also to show the existence of intrauterine neurological maturation.

METHODS

At 28, 34 and 38 weeks of gestation, 15 fetuses underwent a 60-min ultrasound observation. The data from the activities observed allowed the calculation, for each patient and each type of activity, of incidence, duration and intervals; relation between these and of each fetal activity for each gestational period; and the correlation between the different findings.

RESULTS

The analysis of the data showed only a significant decrease in the incidence of gross body movements and a significant increase in the incidence of mouthing movements between 28 and 38 weeks of gestation. A correlation analysis failed to show any significant correlation between the various activities at 28 weeks, but found a positive correlation between eye, gross body movements and "other mouth movements," and a negative correlation between mouthing activity and the other activities examined at 34 and 38 weeks of gestation.

CONCLUSION

The authors conclude that there is a trend of fetal activities, which is an expression of fetal neurological maturation.

One-step separation from lactose: recovery and purification of major cheese-whey proteins by hydroxyapatite--a flexible procedure suitable for small- and medium-scale preparations

The recovery of cheese-whey proteins and lactose represents an important task both in environmental and in food sciences. Optimization of whey processing requires the quantitative separation of whey proteins from lactose, lower costs, harmless environmental impact, flexibility in protein recovery, and adaptability of the process to type and amount of available whey. Here we present a method based on the use of self-made, low-price, and nontoxic hydroxyapatite for one-step separation of lactose (non adsorbed) from bovine whey proteins (adsorbed). Recovery of proteins can be performed with high flexibility. Total protein fraction can be eluted with 0.4 M phosphate at pH 7.0. In alternative, proteins can be recovered in pairs with 0.4 M phosphate but at different pH's. About 56% of the proteins, primarily alpha-lactalbulmin and IgG, were eluted at pH 5.0. The other major proteins, beta-lactoglobulin and BSA, were eluted at pH 6.0. Fractions eluted with the two first eluants at pH 5.0 and pH 6.0 were applied to a Superdex 75 column for final purification by gel filtration. This method provides flexibility in whey protein recovery and quantitative separation of proteins from lactose before ultrafiltration and nanofiltration.

Expression and function of the homeodomain-containing protein Hex in thyroid cells

The homeodomain-containing protein Hex (also named Prh) is expressed in primitive endoderm (during the early phases of development), in some endoderm-derived tissues and in endothelial and hematopoietic precursors. Hex expression is exting-uished during terminal differentiation of endothelial and hematopoietic cells as well as in adult lung. Previous investigations have demonstrated that Hex is expressed during early thyroid gland development. No information has been reported on Hex expression in adult thyroid gland or on the function of this protein in follicular thyroid cells. These issues represent the focus of the present study. We demonstrate that Hex mRNA is present in rat and human adult thyroid gland as well as in differentiated follicular thyroid cell lines. In FRTL-5 cells TSH reduces Hex expression. In thyroid cell lines transformed by several oncogenes Hex expression is completely abolished. By using co-transfection assays we demonstrate that Hex is a repressor of the thyroglobulin promoter and that it is able to abolish the activating effects of both TTF-1 and Pax8. These data would suggest that Hex may play an important role in thyroid cell differentiation. Protein-DNA interaction experiments indicate that Hex is able to bind sites of the thyroglobulin promoter containing either the core sequence 5'-TAAT-3' or 5'-CAAG-3'. The DNA binding specificity of the Hex homeodomain, therefore, is more 'relaxed' than that observed in the majority of other homeo-domains.

Conservative treatment by angiographic uterine artery embolization of a 12 week cervical ectopic pregnancy

A 32 year old woman, gravid 1, nulliparous, was admitted to our department at 11 weeks and 2 days of gestation after being diagnosed with cervical pregnancy. She was unsuccessfully treated with methotrexate for 5 days. On the fifth day after admission she underwent bilateral uterine artery angiographic embolization followed by vacuum evacuation and curettage of the cervical canal. A Foley catheter was also inserted in the cervical canal and left in place for 4 days. The patient was discharged in good condition on the seventh postoperative day.

Computer-assisted analysis of fetal movements in intrauterine growth retardation (IUGR)

A quantitative analysis of various fetal activities (mouth, eye and gross body movements) was made in 10 IUGR human fetuses. The aim of the study was to see whether IUGR fetuses move differently to normal fetuses. Each real-time ultrasound recording lasted 1 h and the analysis of various activities was carried out during replay of video recordings by means of a specially designed computer program. The following aspects have been investigated: (1) incidence, duration and interval for each of the fetal activities described; (2) the relationship between incidence, duration and interval for each single activity; (3) the correlations between the different activities. The results were compared with a group of 10 fetuses from normal pregnancies. On quantitative evaluation no clear effects due to uncomplicated IUGR could be detected except for median duration of eye movements, which turned out to be longer in the IUGR group. The evaluation of correlations between the characteristics (incidence, duration and interval) of each activity showed a positive correlation between incidence and duration of mouthing movements in the IUGR group, not found in the normal group. The study of the correlation between different fetal activities has shown an inverse correlation between mouthing and other activities in the normal fetuses, not found in the IUGR group. We conclude that in mildly affected fetuses with no evidence of hypoxia, there are no quantitative differences compared to normal fetuses in terms of the motility studied. The only differences found were in relation to the performance of such activities and they could reflect a dysfunction of the central nervous system resulting from a metabolic disturbance.

[Behavioral states. An in utero study]

OBJECTIVE

This study aims to show how a single linear transducer and different state variables can be used to enable accurate identification of behavioural states.

DESIGN

Prospective observation study.

SETTING

Clinic of Obstetrics and Gynaecology III at the "Federico II" University of Naples.

SUBJECTS

Fifteen fetuses of women hospitalized in the Clinic of Gynaecology at the "Federico II" University of Naples at the end of a full-term, uncomplicated, single pregnancy with a reliably dated last menstruation.

METHODS

Ultrasound observation, registration and data processing of various fetal activities in the uterus mouth movements (sucking), other mouth movements, eye movements, gross body movements.

RESULTS

The fetal activities identified correspond exactly to the criteria established for the definition of state variables. An examination of the data thus obtained shows an inverse correlation between mouth movements and the other activities, and a direct correlation between the other three variables we considered.

CONCLUSIONS

The results obtained in our study show that this method can be profitably used to identify the behavioural states, in full-term, uncomplicated pregnancies.

Reliability of antagonistic arch impression in dental prostheses: clinical evaluation of different preimpression preparation procedures

This study compared the influence of different methods of preimpression preparation on the quality of occlusal reproduction in irreversible hydrocolloid impressions. A total of 30 impressions of the lower dental arch of a patient were made with five different preimpression preparation procedures. Stone casts were made and analyzed. Critical comparison showed that the preimpression preparation influenced the quality of the occlusal surface of the cast. Fingerpainting the occlusal surface with fluid hydrocolloid before positioning the loaded impression tray, associated with use of a saliva ejector, reduced the incidence of macroscopic defects on the occlusal surface of the impressions.

A clinical evaluation of In-Ceram crowns

In this investigation, 63 In-Ceram crowns were placed in 45 patients in both dental school and private practice settings. The restorations were observed for a period of 24 to 44 months, with a mean of 37.6 months. Both anterior and posterior teeth were treated and occlusal conditions were recorded. One crown fractured, yielding a 98.4% success rate. The single fracture was attributed to crown preparation geometry.

Considerations on the dynamics of fraud and shoplifting in adult female offenders

This paper compares two groups of adult female offenders involved in shoplifting and fraudulent behaviour. Twenty women were studied whose first offenses occurred in their mid-life period. The major findings conclude that an unresolved mourning or loss in the context of high stress and depression is one of the commonalities in the two groups. Another commonality is that a defined classical role for these women is conflictual and the relationship established with their spouses is a repetition of their relationship with their father. The authors suggest that these types of acting out in general are a depressive equivalent, and a larger sample could duplicate the findings and collect more precise data about the nature of the relationship in the family of origin to help these women feel better in their social role.

[Materials for dies in fixed prosthesis: a comparative in-vitro analysis of their detail-reproducing capacity and of their surface quality]

The authors examine the detail reproduction capacity and surface roughness of 11 commercially available materials [6 plasters (stones?), 2 epoxy resins and 3 polyurethane resins] indicated for the construction of working models with individually extractable dies. The study was performed in vitro according to the method outlined by the ADA in specification no. 19 relating to materials for elastomeric imprints. This specification describes the use of a steel test-block with which it is possible to prepare a master imprint in polyvinylsiloxane. This imprint allows the grooves of the test-block to be reproduced in the form of angular crest which represent the details to be reproduced. Both the master imprint and the samples to be tested were prepared according to the manufactures instructions. The study was performed in three stages: macroscopic analysis, microscopic analysis, profilometric analysis. The macroscopic analysis did not show any differences between the different materials tested. The microscopic analysis showed that when enlarged 40 times the resins revealed a smoother surface than the plasters. The surface quality of plasters was improved by using a hardening solution recommended by the manufacturer as an alternative to water, or by using spacer paint. The plaster materials gave excellent angular definition contrary to the epoxy and polyurethane resins. The use, where advised, of the hardening solution as an alternative to water did not alter this parameter. The electronic profilometer used for the profilometric analysis comprised a diamond sensor which, when run along the surface, recorded all roughness, translating it into chart form.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of intranasal neostigmine on oesophageal motility in man

The effects of intranasally administered neostigmine on oesophageal peristalsis and lower oesophageal sphincter tone were investigated in 21 healthy volunteers. After 30 min of basal recording of oesophageal tracings, neostigmine (3 or 5.4 mg) or the inert vehicle were given. The oesophageal recording was continued for 45-60 min after administration. Neostigmine increased the amplitude and duration of the peristaltic waves without significantly affecting conduction. Lower oesophageal sphincter tone was also increased but post-swallowing relaxation was normal. At the highest dose, the effects of neostigmine lasted 45 min or more. There were no side effects and the heart rate was only slightly slowed. The results suggest that intranasal administration of neostigmine might be clinically useful for stimulation of upper gastrointestinal tract peristalsis.

[Endoscopic treatment of postoperative external pancreatic fistula by means of papillotomy and naso-pancreatic drainage]

External pancreatic fistula is a common complication after pancreatic resection. We report a case successfully treated by endoscopic papillotomy and a naso-pancreatic tube.

[Ultrasonically guided biopsy of the prostate for the diagnosis of carcinoma]

Echoguided biopsy of the prostate is a new method used in the diagnosis of carcinoma. False negatives, which range between 7% and 27% of transperineal biopsies, can be reduced to 11% using ultrasound control. In 50% of cases carcinoma are located in the hypoechogenic area, in 45% in mixed echogenic areas and in 5% in hyperechogenic areas. The diagnosis of carcinoma was performed in 40.7% of patients examined. In conclusion, this method is shown to be a valuable and advisable aid.

Fetal tachypnea: prognostic significance and treatment

We report the case of a pregnant woman with class B diabetes whose fetus, examined in utero by means of real-time ultrasound, showed tachypneic breathing movements. Having considered the clinical course of this case and of those reported in literature, we put forward a hypothesis concerning the pathogenesis and the prognostic significance of fetal tachypnea.