Fully automated 3D machine learning model for HPV status characterization in oropharyngeal squamous cell carcinomas based on CT images

BACKGROUND

Human papillomavirus (HPV) status plays a major role in predicting oropharyngeal squamous cell carcinoma (OPSCC) survival. This study assesses the accuracy of a fully automated 3D convolutional neural network (CNN) in predicting HPV status using CT images.

METHODS

Pretreatment CT images from OPSCC patients were used to train a 3D DenseNet-121 model to predict HPV-p16 status. Performance was evaluated by the ROC Curve (AUC), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and F1 score.

RESULTS

The network achieved a mean AUC of 0.80 ± 0.06. The best-preforming fold had a sensitivity of 0.86 and specificity of 0.92 at the Youden's index. The PPV, NPV, and F1 scores are 0.97, 0.71, and 0.82, respectively.

CONCLUSIONS

A fully automated CNN can characterize the HPV status of OPSCC patients with high sensitivity and specificity. Further refinement of this algorithm has the potential to provide a non-invasive tool to guide clinical management.

Long-Term Satisfaction of Oral Sedation versus Standard-of-Care Intravenous Sedation for Ocular Surgery

Purpose

Long-term patient satisfaction may influence patients' perspectives of the quality of care and their relationship with their providers. This is a follow up to a comparative effectiveness study investigating oral to intravenous sedation (OIV study). The OIV study found that oral sedation was noninferior in patient satisfaction to standard intravenous (IV) sedation for anterior segment and vitreoretinal surgeries. This study aims to determine if patient satisfaction with oral sedation remained noninferior long term.

Patients and Methods

Patients were re-interviewed using the same satisfaction survey given during the OIV study. Statistical analysis involved t-tests for noninferiority of the long-term mean satisfaction score of oral and IV sedation. We also compared the original mean satisfaction score and the follow-up mean satisfaction score for each type of sedation and for both groups combined.

Results

Participants were interviewed at a median of 1225.5 days (range 754-1675 days) from their surgery. The original mean satisfaction score was 5.26 ± 0.79 for the oral treatment group (n = 52) and 5.27 ± 0.64 for the intravenous treatment group (n = 46), demonstrating noninferiority with a difference in mean satisfaction score of 0.015 (p < 0.0001). The follow-up mean satisfaction score was 5.23 ± 0.90 for oral sedation and 5.60 ± 0.61 for IV sedation, with a difference in the mean satisfaction score of 0.371 (p = 0.2071). Satisfaction scores did not differ between the original mean satisfaction score and the follow-up mean satisfaction score for the oral treatment group alone (p = 0.8367), but scores in the intravenous treatment group increased longitudinally (p = 0.0004).

Conclusion

In this study, long-term patient satisfaction with oral sedation was not noninferior to satisfaction with IV sedation, unlike our findings with short-term patient satisfaction in our original study. Patient satisfaction also remained unchanged over time for the oral treatment group, but patients in the intravenous treatment group reported higher long-term satisfaction with their anesthesia experience compared to the immediate post-operative period.

"They just looked at me like I was human": The experiences of parenting women and providers with substance use disorder treatment

BACKGROUND

The current US addiction treatment system does not effectively meet the needs of pregnant and parenting women with substance use disorder (SUD). The aim of this research was to identify barriers and facilitators to engagement and retention in SUD residential treatment for pregnant and parenting women. This research was part of a co-design process to collaboratively create a more patient-centered long-term residential program.

DESIGN AND METHODS

The study conducted semi-structured individual interviews with both parenting women with lived experience (WWLE) in residential SUD treatment and SUD treatment providers. Interviews aimed to elicit participants' experiences either receiving or providing care. The study team analyzed data in NVivo-12 using a deductive codebook based on the six principles of trauma informed care (TIC).

RESULTS

We conducted a total of 32 interviews (WWLE =13, SUD providers =19). The study identified four major themes: 1) peer relationships provide inspiration and diminish shame; 2) providing individuals safe space to stumble in recovery creates opportunities for growth and builds self-efficacy; 3) reasonable, clear boundaries create a structured, protective environment for early recovery; 4) nonjudgmental connections facilitate engagement and build trust. We identified small pivotal moments along the continuum of care that showed how the elements in the four themes enhanced engagement and retention in treatment. These interactions, along the care continuum, are either structural (workflow process) or relational (interpersonal).

CONCLUSION

This research increases understanding of the interplay of the structural and relational barriers and facilitators to engagement and retention in treatment. These seemingly minor positive or negative interactions along the care continuum are pivotal to fully operationalizing TIC and optimizing women's engagement in treatment. Improvement strategies that integrate the voices of WWLE and collaboratively co-design a more patient-centered system are critical steps to improving engagement in SUD treatment and more equitable SUD treatment services.

Multiparametric machine learning algorithm for human papillomavirus status and survival prediction in oropharyngeal cancer patients

BACKGROUND

Human papillomavirus (HPV) status influences prognosis in oropharyngeal cancer (OPC). Identifying high-risk patients are critical to improving treatment. We aim to provide a noninvasive opportunity for managing OPC patients by training multiple machine learning pipelines to determine the best model for characterizing HPV status and survival.

METHODS

Multi-parametric algorithms were designed using a 492 OPC patient database. HPV status incorporated age, sex, smoking/drinking habits, cancer subsite, TNM, and AJCC 7th edition staging. Survival considered HPV model inputs plus HPV status. Patients were split 4:1 training: testing. Algorithm efficacy was assessed through accuracy and area under the receiver operator characteristic curve (AUC).

RESULTS

From 31 HPV status models, ensemble yielded 0.83 AUC and 78.7% accuracy. From 38 survival models, ensemble yielded 0.91 AUC and 87.7% accuracy.

CONCLUSION

Results reinforce artificial intelligence's potential to use tumor imaging and patient characterizations for HPV status and outcome prediction. Utilizing these algorithms can optimize clinical guidance and patient care noninvasively.

The Role of Oxidative Stress in the Aging Eye

Given the expanding elderly population in the United States and the world, it is important to understand the processes underlying both natural and pathological age-related changes in the eye. Both the anterior and posterior segment of the eye undergo changes in biological, chemical, and physical properties driven by oxidative stress. With advancing age, changes in the anterior segment include dermatochalasis, blepharoptosis, thickening of the sclera, loss of corneal endothelial cells, and stiffening of the lens. Changes in the posterior segment include lowered viscoelasticity of the vitreous body, photoreceptor cell loss, and drusen deposition at the macula and fovea. Age-related ocular pathologies including glaucoma, cataracts, and age-related macular degeneration are largely mediated by oxidative stress. The prevalence of these diseases is expected to increase in the coming years, highlighting the need to develop new therapies that address oxidative stress and slow the progression of age-related pathologies.

The Scholarly Impact of Student Authorship in Ophthalmology

Purpose The H-index (Hi), an author-level metric of scholarly impact, is predictive of future scientific achievement. We sought to analyze the scholarly impact of student authorship on the Hi of corresponding authors (CAs) within a major academic journal in the specialty of ophthalmology.

Materials and Methods We compared the Hi of all unique CAs for manuscripts published in Ophthalmology (Journal of the American Academy of Ophthalmology) in 2008, 2012, and 2016. Data abstraction was completed twice: in October 2018 and March 2021. We further grouped published articles for CAs into those with student authors (StA) and those without (nStA). Primary analysis involved a linear regression analysis with change in Hi from October 2018 to March 2021 as the outcome variable, CA groups as the predictor variable, adjusting for the covariates of baseline Hi, the year when the CA published his or her article, number of research items published in October 2018, and the academic appointment of the CAs. Secondary analysis involved a linear regression analysis with change in Hi from October 2018 to March 2021 as the outcome variable, total number of student authors per CA as the predictor variable, adjusting for the covariates of baseline Hi, the year CA published his or her article, number of research items published in October 2018, and the academic appointment of the CAs.

Results The number of student authors increased from 168 in 2008 to 192 in 2016. Of the 902 articles, 316 articles were co-authored by one or more student authors. The average change in Hi of CAs publishing with student authors (StA, 11.0 ± 14.7) was significantly greater (p < 0.0001) than the change in Hi of CAs publishing without student authors (nStA, 6.2 ± 6.2). As the total number of student authors increased, the change in Hi of CAs increased linearly for all years combined (regression coefficient = 1.70, p-value < 0.0001).

Conclusion CAs publishing with students in the field of ophthalmology have a higher scholarly impact than those publishing without students. The development of programs to integrate students into ophthalmology research early on may encourage their pursuit of a career in ophthalmology, while advancing the careers of their mentors.

A systematic literature review of the management, oncological outcomes and psychosocial implications of male breast cancer

BACKGROUND

Although male breast cancer (MBC) is a rare disease, accounting for <1% of all breast cancers, it has significant oncological, survival and psychosocial implications for patients. The aim of this study is to assess the latest literature in the diagnosis, management, oncological outcomes, and psychosocial impact of MBC.

METHODS

A systematic literature review was conducted using the PRISMA guidelines (Moher et al., 2009) [1] to explore the management of MBC, with particular focus on investigative imaging, surgical management, oncological outcomes, survival, genetic screening and psychosocial effects. Electronic databases were searched for randomised control trials, cohort studies and case series involving more than 10 patients. Imaging and surgical techniques, local and distant disease recurrence, survival, genetic screening and psychosocial implications in the setting of MBC were assessed.

RESULTS

The search criteria identified 199 articles, of which 59 met the inclusion criteria. This included 39,529 patients, with a mean age of 64.5 years (55-71), and a mean follow-up of 66.3 months (26.2-115). Mastectomy remains the most frequently used surgical technique, with an average of 89.6%. Loco-regional and distant recurrence rate was 10.1% and 21.4% respectively. Disease-free survival (DFS) at 5 and 10 years was 66.8% and 54.5% respectively. Disease-specific survival (DSS) at 5 and 10 years was 87.1% and 67.1% respectively. Overall survival (OS) at 5 and 10 years was 72.7% and 50.7% respectively. Genetic screening was conducted in 38.6% of patients of which 4.8% and 15.8% were found to be BRCA1 and BRCA2 carriers respectively. Psychosocial studies were conducted mainly using questionnaire and interview-based methodology focusing primarily on awareness of breast cancer in men, support available and impact on gender identity.

CONCLUSIONS

This review demonstrates that men present with later stage disease with subsequent impact on survival outcomes. There remains a paucity of high-level evidence and prospective studies are required. There is a need for increasing awareness amongst the public and health care professionals in order to improve outcomes and reduce stigma associated with MBC.

Implementation of a Prenatal Naloxone Distribution Program to Decrease Maternal Mortality from Opioid Overdose

INTRODUCTION

Maternal mortality rates have been increasing in the United States for decades. For several years, opioid overdoses have been a leading cause of maternal mortality in several states. New Hampshire (NH) is a particularly severe case, with 50% of all maternal deaths being caused by drug-related overdoses from 2016 to 2017. We report on the implementation of a point-of-care naloxone distribution program for an Ob/Gyn clinic in NH.

METHODS

Naloxone distribution was tracked to measure program implementation. Proportion of patients screened for naloxone need was calculated monthly. Proportion of patients with which discussions about naloxone took place was calculated quarterly. Patient and provider perspectives on the program were captured periodically. Statistical process control charts monitored change over time and evaluated for special-cause variation.

RESULTS

The clinic has distributed 12 doses of naloxone since program implementation in April 2020. Despite the challenges posed by the COVID-19 pandemic, screening for naloxone need has remained at pre-pandemic rates (moving average: 73%), except for a decrease in April-May 2020. Patient-provider discussions about naloxone have also remained at pre-pandemic rates (moving average: 51%). Qualitative feedback from patients and providers has indicated that the program has been well-received by both groups.

DISCUSSION

The purpose of this description is to provide a framework for other Ob/Gyn clinics to use in implementing similar naloxone distribution programs. Although too early to determine whether this intervention will result in a significant decrease in maternal mortality due to opioid overdose in our patients, this measure will continue to be tracked annually. Implementation of a naloxone program in the obstetrical context provides an important way to improve outcomes for a vulnerable perinatal population.

466 Surveillance Flexible Cystoscopy in Bladder Cancer Follow-up

Aim

This study addresses surveillance cystoscopy in patients diagnosed with bladder and upper tract cancer. Managed Clinical Network (MCN) guidelines have clear recommendations for the timetable of follow-up cystoscopy, and we conducted this audit to study regional compliance.

Method

Using a multisite pathology database of bladder cancer cases from 2016, we collected and analysed data on 100 non-muscle invasive bladder cancers. We took the first 10 cases from each month to ensure cross-regional representation. Each case was stratified according to MCN guidelines. Electronic medical records were examined to assess upper tract follow up. We allowed for +/- 1 month each side of the target timeframe.

Results

We had 64 male and 36 female subjects. In our risk categories, we had 31 low risk, 37 intermediate risk and 32 high risk bladder cancers. 67 were new cases, 33 were recurrent tumours.

10 (43.4%) of low-risk and 19 (79.2%) of intermediate-risk patients underwent surveillance cystoscopy earlier than the recommended 12-month timeframe. 18 (78.3%) of low-risk patients continued to have further surveillance cystoscopies after a 12-month disease-free period.

Conclusions

43.4% of low-risk bladder cancer patients are receiving surveillance cystoscopy earlier than recommended. 78.3% of these patients are then undergoing unnecessary procedures following a 12-month disease-free period against regional guidelines and recommendations. This places an increased burden on clinic/theatre time and contributes to patient anxiety surrounding cancer follow-up. Evidence-based medicine guidelines have shown that less is more when it comes to low-grade bladder cancer surveillance. We now need to assess why we are deviating from our own guidelines.

Not just substance use: the critical gap in nutritional interventions for pregnant women with opioid use disorders

OBJECTIVES

Pregnancy is a time when optimization of nutrition is critically important, yet pregnant women with substance use disorders face unique nutritional challenges. The aim of this short communication is to summarize existing knowledge about nutritional interventions used in substance use disorders for pregnant and parenting women with opioid use disorder (OUD) and substance use disorders and to inform program development by maternity care and treatment providers.

STUDY DESIGN

We conducted a narrative review of nutritional interventions for pregnant women with OUD and performed environmental scanning to explore current practice.

METHODS

To gain knowledge about the unique nutritional needs of pregnant women with OUD, we searched the medical literature using Medical Subject Headings terms and key words combining the concepts of nutrition, pregnancy, and substance use. To explore current practice, we interviewed staff of a geographically diverse sample of 35 programs treating women with substance use disorders across the United Stated and Canada on their approach to prenatal nutrition for clients.

RESULTS

Literature review identified two studies evaluating the nutritional status of pregnant women with substance use disorders, but neither described nutritional interventions. Lower body mass index and folate, B12, and iron deficiencies were found in women with OUD compared with women without OUD. Two additional studies integrated nutritional interventions in substance use treatment for non-pregnant populations, resulting in significant improvements in dietary habits and psychological well-being for participants. Of 15 substance use treatment programs that responded to our query, only two incorporated longitudinal nutrition curricula for pregnant women.

CONCLUSIONS

Pregnancy is a time when a healthy diet is critically important for maternal, fetal, and neonatal health; however, pregnant women with OUD are at significant risk of malnutrition. There is an urgent need to address food insecurity and develop targeted nutrition education programs for pregnant women in early recovery.

Abstract OT2-08-01: Personalized breast cancer screening in a population based study: Women Informed to Screen Depending On Measures of risk (WISDOM)

Background: WISDOM is a 100,000 healthy women preference-tolerant, pragmatic study comparing annual to personalized risk-based breast screening. The novelty of WISDOM personalized screening is the integration of previously validated genetic and clinical risk factors (age, family history, breast biopsy results, ethnicity, mammographic density) into a single risk assessment model that directs the starting age, timing, and frequency of screening. The goal of WISDOM is to determine if personalized screening, compared to annual screening, is as safe, less morbid, enables prevention, and is preferred by women. The study is registered on ClinicalTrials.gov, NCT02620852.

Methods: Women aged 40-74 years with no history of breast cancer or DCIS, and no previous double mastectomy can join the study online at wisdomstudy.org. Participants can elect randomization or self-select a study arm, and provide electronic consent and Release for Medical Information using DocuSign. For all participants, 5-year risk of developing breast cancer is calculated according to the Breast Cancer Screening Consortium (BCSC) model. Participants in the personalized arm undergo panel-based mutation testing, and their 5-year risk is calculated using the BCSC score combined with a Polygenic Risk Score (BCSC-PRS) that includes 75 single nucleotide polymorphisms (SNPs, increase to 229) known to increase breast cancer risk. SNPs and mutations (BRCA1, BRCA2, TP53, PTEN, STK11, CDH1, ATM, PALB2, and CHEK2) are assessed by saliva-based testing through Color Genomics. 5-year risk level thresholds are used to stratify for low-, moderate- and high risk. Risk stratification determines age to start, stop, and frequency of screening.

Enrollment: As of July 2018, the WISDOM study is open to all eligible women in California, North Dakota, South Dakota, Minnesota and Iowa. To date, 23,329 eligible women have registered and 14,393 women have consented to participate in the trial. We analyzed 3,255 participants who have completed risk assessment in the personalized arm. The median age was 56 years. 82% were Caucasian, 1% African-American, and 6% Asian. 9% self-reported as Hispanic. We are partnering with health insurers and self-insured companies using coverage with evidence progression. To strengthen generalizability, we are expanding to other states. WISDOM enrollment will continue past 2019.

Feasibility: To evaluate the addition of PRS, we used paired statistical tests (McNemar) to compare the distributions of BCSC, and BCSC-PRS risk estimates around low-risk (&lt;1.3%), and very-high risk (&gt;6%) thresholds, the latter corresponding to 5-year risk of a BRCA mutation carrier. The median 5-year risk was 1.5% (IQR 1.0-2.1%) using the BCSC model, and 1.4% (IQR 0.8-2.5%) using the BCSC-PRS model. The BCSC-PRS model classified more women into the low (&lt;1%) and very high (≥6%) risk categories compared to the BCSC model (p &lt; 0.001).

Conclusions: Our findings demonstrate that incorporating genetic variants into a validated clinical model is feasible and impacts risk classification compared to a model without genetic risk factors. Results at 5 years will reveal if this classification improves healthcare value by reducing screen volumes and costs without jeopardizing outcomes.

Citation Format: Acerbi I, Shieh Y, Madlensky L, Tice J, Ziv E, Eklund M, Blanco A, DeRosa D, Tong B, Goodman D, Nassereddine L, Anderson N, Harvey H, Layton T, Park HL, Petruse A, Stewart S, Wernisch J, Risty L, Koenig B, Sarrafan S, Firouzian R, Kaplan C, Hiatt R, Parker BA, Wenger N, Lee V, Heditsian D, Brain S, Stover Fiscalini A, Borowsky AD, Anton-Culver H, Naeim A, Kaster A, Talley M, van 't Veer LJ, LaCroix A, Wisdom Study and Athena Breast Health Network Investigators and Advocate Partners, Esserman LJ. Personalized breast cancer screening in a population based study: Women Informed to Screen Depending On Measures of risk (WISDOM) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-08-01.

Abstract P3-09-07: Breast cancer risk assessment in a multiethnic patient population

The United States Preventive Services Task Force recommends that women who are at increased risk for breast cancer and at low risk for adverse medication effects should be offered risk-reducing medications, such as tamoxifen or raloxifene, by their clinicians. In addition, the National Comprehensive Cancer Network recommends risk counseling for women with a 5-year risk of ≥1.7% as calculated by the NCI-developed Breast Cancer Risk Assessment Tool (BCRAT, based on the Gail model) or other risk model. Thus, breast cancer risk assessment is important for the identification of women at "high risk" who should be offered risk counseling and potentially intervention. The Athena Breast Health Network, which has served &gt;120,000 breast screening patients across California and the midwest, has integrated breast cancer risk assessment into its clinical breast screening programs. The goal of our study was to characterize breast cancer risk for &gt;10,000 mammography patients in the University of California Irvine Athena Breast Health Network, overall and by race/ethnicity, using several different risk models, including the BCRAT, BCSC, and IBIS models. Our cohort was comprised of 47% non-Hispanic White, 13% non-Hispanic Asian, 38% Hispanic, and 2% women of other race/ethnicities. Using data collected from electronic medical records and self-completed questionnaires, we determined that, as expected, non-Hispanic White and Asian women had higher breast cancer risk scores than Hispanic women for all risk models (5-year risks = 1.51-1.68% and 1.22-1.40% vs. 0.95-1.05%, respectively). In addition, when women were categorized as "increased risk" according to a given risk model if their 5-year risk score was ≥1.7%, the percentages of women at "increased risk" were higher in White women (26.5–42.2%) than in Asian (15.8–28.6%) and Hispanic (6.2–10.7%) women. However, the correlations between risk models were low to moderate in our cohort, overall (Pearson's r = 0.47-0.62) and especially for Asian women (Pearson's r = 0.29-0.49). Our results indicate that using only one risk model in a clinical breast cancer risk assessment program to identify "high risk" women would miss a significant proportion of women who would have been considered "high risk" according to another risk model. Conversely, some women who are identified as "high risk" according to one model may not need risk counseling and intervention since they are not considered "high risk" according to two other models. As our cohort expands and incident breast cancers occur, we will be able to determine which risk model or combination of risk models will have the highest discriminatory accuracy for predicting breast cancer risk in women of different race/ethnicities, which will enable our risk assessment programs to have a more targeted approach to risk counseling and intervention.

Citation Format: Park HL, Columbus A, Athena Breast Health Network Investigators and Advocate Partners, Kelly R, Alvarez A, Goodman D, Larsen K, Ziogas A, Anton-Culver H. Breast cancer risk assessment in a multiethnic patient population [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 P3-09-07.

Alphabetic Entry Procedure with Small Keypads: Key Layout does Matter

Two experiments examined the entry of alphabetic characters on an enhanced telephone system. Size constraints with the overall unit resulted in a small keypad which restricted users to a one or two finger typing strategy. The first experiment compared the standard Sholes arrangement of keys (QWERTY), an alphabetically organized keypad (ABC) and a numeric code method of entry (NC) which utilized the touch telephone numeric pad. Thirty naive subjects were randomly assigned to one of the three conditions. Results showed that the NC method was significantly slower than the other approaches and was rated negatively by subjects. It was concluded that such an approach is unacceptable for a consumer product like the enhanced telephone. Experiment 2 further examined performance and preference for QWERTY versus ABC arrangements. Twenty subjects completed standardized text entry tasks on both arrangements with order counterbalanced. Performance was clearly faster on the QWERTY keypad and subjects recorded an overwhelming preference for it over the ABC arrangement, regardless of their previous keyboard experience. These results extend the superiority of QWERTY over ABC to small keypads and a restricted typing strategy.

Multicenter Australian trial of islet transplantation: improving accessibility and outcomes

Whilst initial rates of insulin independence following islet transplantation are encouraging, long-term function using the Edmonton Protocol remains a concern. The aim of this single-arm, multicenter study was to evaluate an immunosuppressive protocol of initial antithymocyte globulin (ATG), tacrolimus and mycophenolate mofetil (MMF) followed by switching to sirolimus and MMF. Islets were cultured for 24 h prior to transplantation. The primary end-point was an HbA1c of <7% and cessation of severe hypoglycemia. Seventeen recipients were followed for ≥ 12 months. Nine islet preparations were transported interstate for transplantation. Similar outcomes were achieved at all three centers. Fourteen of the 17 (82%) recipients achieved the primary end-point. Nine (53%) recipients achieved insulin independence for a median of 26 months (range 7-39 months) and 6 (35%) remain insulin independent. All recipients were C-peptide positive for at least 3 months. All subjects with unstimulated C-peptide >0.2 nmol/L had cessation of severe hypoglycemia. Nine of the 17 recipients tolerated switching from tacrolimus to sirolimus with similar graft outcomes. There was a small but significant reduction in renal function in the first 12 months. The combination of islet culture, ATG, tacrolimus and MMF is a viable alternative for islet transplantation.

Abstract P4-13-13: Risk Assessment and Personalized Decision Support: The University of California Athena Breast Health Network

Background: The Athena Breast Health Network is a University of California (UC) initiative to drive rapid innovation in patient-centered prevention, screening, and treatment of breast cancer. Athena is a collaborative of the five UC medical centers and UC Berkeley that integrates clinical care and research, rapidly mobilizing data and research to enable continuous improvement in patient care and outcomes. The first initiative of Athena was to implement risk assessment for women being screened for breast cancer and to offer tailored referrals for women found to be at increased risk of developing breast cancer.

Methods: Patients who enroll in Athena complete an electronic questionnaire to collect personal and family history data prior to their mammography screening visit. These data are used to generate multiple risk assessments using the NCCN and USPSTF guidelines, and BCRAT (Gail model). Data on established breast cancer risk factors such as chest wall radiation and history of hormone replacement therapy are also collected and used to identify women at potentially increased risk. Upon enrollment, women are given the opportunity to provide a blood or saliva sample for research purposes.

Women who meet Athena-defined criteria that identify them to be at increased risk receive a referral to a Breast Health Specialist (BHS). The BHS identifies individual patient needs for prevention and screening services, including genetic counseling and testing, provides referrals to a High Risk Breast Clinic or nurse practitioner, and conducts lifestyle modification counseling. BHS have special training in breast cancer risk assessment, and some are licensed genetic counselors. Primary care and/or referring providers are directly informed of risk assessment results through mailings or the electronic medical record.

Results: The recruitment goal enrollment for Athena is 150,000 and to date more than 17,000 women have been enrolled across the five centers. Of those enrolled, 32% indicated that they have a family history of cancer. 56% of the cohort consented to participate in research, and 40% provided a biospecimen for research purposes. Across the five centers, 32 educational outreach sessions about Athena were held, reaching approximately 375 providers.

Public stigma in health and non-healthcare students: attributions, emotions and willingness to help with adolescent self-harm

BACKGROUND

For people who self-harm, there is growing evidence to suggest that services and treatment outcomes can be adversely affected by healthcare staffs' stigmatising attitudes and behaviours. To date, the empirical literature has tended to focus on the attitudes of experienced healthcare professionals working with adults who self-harm. Additionally, there has been few theory or model-driven studies to help identify what healthcare students think and feel about young people who self-harm.

OBJECTIVES

The aim of the present study was to explore the way healthcare and non-healthcare students think and feel about adolescent self-harm behaviour using Corrigan et al.'s [Corrigan, P.W., Markowitz, F.E., Watson, A., Rowan, D., Kubiak, M.A., 2003. An attribution model of public discrimination towards people with mental illness. Journal of Health and Social Behaviour 44, 162-179] attribution model of public discrimination towards people with mental illness.

DESIGN

The study was a questionnaire-based, cross-sectional, survey that consisted of two hypothetical vignettes.

SETTINGS

Two universities in England, United Kingdom.

PARTICIPANTS

One hundred and eighty-four final-year students, covering health (medicine, nursing, clinical psychology) and non-health care (physics) professions.

METHODS

Students were presented with vignettes describing a young female who self-harms. Attributions of controllability were experimentally manipulated across the vignette conditions and students were asked to complete self-report questionnaires measuring attitudes towards self-harm, familiarity with self-harm and social desirability.

RESULTS

Consistent with the public discrimination model, students who believed that a young person was responsible for their self-harm reported higher feelings of anger towards them. Anger, in turn, was associated with a belief in the manipulatory nature of the self-harm and with less willingness to help. Perceived risk was found to be associated with higher levels of anxiety and increased support for the use of coercive and segregatory strategies to manage self-harming behaviour. Gender and student type were important influences on public stigma, with both men and medical students reporting more negative attitudes towards self-harm.

CONCLUSIONS

This study provides evidence that a number of factors may adversely affect the care and treatment received by young people who self-harm, namely: students' causal attributions, the gender and profession of healthcare students, and familiarity with self-harm behaviour. To improve the effectiveness of service provision and treatment outcomes for people who self-harm, it is important that health care service providers and teaching institutions consider the implications of these factors when developing staff and services, and base interventions on theoretical models of stigma and discrimination.

Cognitive demands of error processing

This study used a dual-task methodology to assess attention demands associated with error processing during an anticipation-timing task. A difference was predicted in attention demands during feedback on trials with correct responses and errors. This was addressed by requiring participants to respond to a probe reaction-time stimulus after augmented feedback presentation. 16 participants (8 men, 8 women) completed two phases, the reaction time task only and the anticipation-timing task with the probe RT task. False feedback indicating error and a financial reward manipulation were used to increase relevance of errors. Data supported the hypothesis that error processing is associated with higher cognitive demands than processing feedback denoting a correct response. Individuals responded with quicker probe reaction times during presentation of feedback on correct trials than on error trials. These results are discussed with respect to the cognitive processes which might occur during error processing and their role in motor learning.

Converging evidence for the under-reporting of concussions in youth ice hockey

BACKGROUND

Concussions are potentially serious injuries. The few investigations of prevalence or incidence in youth ice hockey have typically relied on prospective reports from physicians or trainers and did not survey players, despite the knowledge that many athletes do not report probable concussions.

OBJECTIVE

This study sought to compare concussion rates in youth ice hockey that were estimated from a variety of reporting strategies.

METHODS

Rates were calculated from British Columbia Amateur Hockey Association (BCAHA) official injury reports, from direct game observation by minor hockey volunteers (such as coaches and managers), as well as from retrospective surveys of both elite and non-elite youth players. All research was conducted within the BCAHA.

RESULTS

Estimates from official injury reports for male players were between 0.25 and 0.61 concussions per 1000 player game hours (PGH). Concussion estimates from volunteer reports were between 4.44 and 7.94 per 1000 PGH. Player survey estimates were between 6.65 and 8.32 per 1000 PGH, and 9.72 and 24.30 per 1000 PGH for elite and non-elite male youth hockey, respectively.

CONCLUSION

It was found that concussions are considerably under-reported to the BCAHA by youth hockey players and team personnel.

Exercise following a sport induced concussion

OBJECTIVE

To determine if an athlete's capacity to perform exercise is impaired following concussion and whether this would be reflected by an altered heart rate response.

METHODS

Of the 14 concussed athletes, nine missed playing time as a direct result of their concussion and five did not. The concussed athletes performed an exercise protocol on a cycle ergometer within 72 hours of being asymptomatic at rest and a second test at 5 days following the previous assessment. Matched controls (n = 14) were tested using the same time line. The exercise protocol consisted of a 2 minute warm up, 10 minute, low-moderate intensity, steady state exercise session, and a high intensity interval protocol. The interval protocol consisted of a 40 second high intensity bout, followed by a 40 second rest period. This protocol continued until the participant had reached volitional fatigue.

RESULTS

The number of exercise bouts completed was not significantly different from their matched controls. However, concussed athletes who missed playing time had a significantly higher heart rate during the steady state exercise session. During this same period, they also exhibited a greater rise in heart rate over time.

CONCLUSION

These findings indicate that exercise capacity is unaffected in concussed athletes who are asymptomatic at rest. However, their heart rate response to submaximal exercise is increased.

Development and standardization of a rapid, PCR-based method for the detection of Wuchereria bancrofti in mosquitoes, for xenomonitoring the human prevalence of bancroftian filariasis

PCR has recently been studied as a promising tool for monitoring the progress of efforts to eliminate lymphatic filariasis. PCR can be used to test concurrently at least 30 pools, with as many as 40 mosquitoes in each pool, for the presence of filarial larvae. The SspI PCR assay for the detection of Wuchereria bancrofti DNA in pools of mosquitoes has been used since 1994 in a variety of laboratories worldwide. During that time, the original assay has been modified in these different laboratories and no standardized assay currently exists. In an effort to standardize and improve the assay, a meeting was held on 15-16 November 2001, at Emory University in Atlanta, with representatives from most of the laboratories currently using the assay. The first round of testing was designed to test the four most promising methods for DNA extraction from pools of mosquitoes. Two of the four methods stood out as clearly the best and these will be now optimised and evaluated in two further rounds of testing.

Concussions in hockey: there is cause for concern

PURPOSE

The purpose of the study was to document various aspects of concussion in Canadian Amateur hockey including demographics, causes, treatment, and prevention in order to guide future recommendations on how to reduce injury.

METHODS

A detailed prospective and retrospective concussion history was obtained from British Columbia Junior Hockey League players over the course of two seasons (1998-2000).

RESULTS

Higher rates of concussions occur in games versus practice, and there was an overrepresentation of forwards injured versus defensemen or goaltenders. There was between 4.63 and 5.95 concussions per 1000 player/game hours with the average age of the first hockey-related concussion in the 15th year. The greatest cause of concussion was contact with the ice and/or the boards. Fighting was not a major cause of concussion, although other illegal actions such as elbowing were.

CONCLUSIONS

The primary recommendation to reduce the number and severity of concussions is to eliminate plays where there is a demonstrable intent to injure another player. Concussions in hockey are of considerable concern; however, there is now encouraging information with respect to the treatment of these injuries.

Bacterial keratitis after [correction of following] laser in situ keratomileusis

PURPOSE

The development of bacterial keratitis after laser in situ keratomileusis (LASIK) has been described in only a few isolated cases. We report the development of bacterial keratitis as a postoperative complication of LASIK in three subjects.

DESIGN

A retrospective interventional small case series.

PARTICIPANTS

Three patients who underwent LASIK for correction of myopia during July and August 1998 and had bacterial keratitis develop after surgery.

METHODS

Bacterial keratitis was encountered in the operated eyes between 1 and 22 days after surgery. Topical antibiotic therapy was administered. In one eye, which had significant opacification and irregularity of the flap was developed, lamellar keratoplasty was performed.

MAIN OUTCOME MEASURES

Postoperative inflammation was followed clinically and photographically until it resolved. Visual acuity was measured at intervals throughout the follow-up period.

RESULTS

Keratitis resolved within 3 to 16 days of starting antibiotic therapy. The final best-corrected visual acuities were 20/30, 20/15, and 20/25.

CONCLUSIONS

Although infectious keratitis after LASIK is an infrequently reported event, it should be discussed preoperatively with patients as a possible complication.

Electrophysiological evidence for the cumulative effects of concussion

PURPOSE

A study was initiated with the intent of demonstrating the cumulative effects of concussion in junior hockey players using visual event-related potentials and post-concussion syndrome (PCS) self-reports.

METHODS

Players were assessed at the beginning of the season (pre-injury) and at various times post-injury.

RESULTS

The results suggest that players with three or more concussions differed significantly on the several cognitive PCS symptoms as well as for the latency of the P3 response compared to those with no concussion history.

DISCUSSION

Event-related potentials are useful indices of the cumulative damage that can occur following multiple concussions. These measures correlate significantly with cognitive self-reports of PCS symptoms.

CONCLUSIONS

This pattern of results is consistent with the position that each concussion potentially causes brain damage. Cumulative damage can be detected using electrophysiological measures of brain function.

A distinctive clade B HIV type 1 is heterosexually transmitted in Trinidad and Tobago

HIV-1 transmission worldwide is predominantly associated with heterosexual activity, and non-clade B viruses account for the most spread. The HIV-1 epidemic in Trinidad/Tobago and the Caribbean shares many features with such heterosexual epidemics, including a prominent role for coincident sexually transmitted diseases. This study evaluates the molecular epidemiology of HIV-1 in Trinidad/Tobago during a period when abrupt transition from homosexual to heterosexual transmission occurred in the absence of injecting drug use, concomitant with a rapid rise in HIV-1 prevalence in the heterosexual population. Of 31 viral isolates studied during 1987-1995, all cluster with subtype B reference strains. In the analysis of full env genes from 22 early seroconverters, the Trinidad isolates constitute a significant subcluster within the B subtype. The Trinidad V3 consensus sequence differs by a single amino acid from the prototype B V3 consensus and demonstrates stability over the decade of this study. In the majority of isolates, the V3 loop of env contains a signature threonine deletion that marks the lineage of the Trinidad HIV-1 clade B epidemic from pre-1984. No phenotypic features, including syncitium induction, neutralization profiles, and chemokine receptor usage, distinguish this virus population from other subtype B viruses. Thus, although the subtype B HIV-1 viruses being transmitted in Trinidad are genetically distinguishable from other subtype B viruses, this is probably the result of a strong founder effect in a geographically circumscribed population rather than genetic selection for heterosexual transmission. These results demonstrate that canonical clade B HIV-1 can generate a typical heterosexual epidemic.

Naturally acquired anti-alpha Gal antibodies in a murine allograft model similar to delayed xenograft rejection

Antibodies directed against galactose-alpha1,3-galactose (alphaGal) are believed to play an important role in the pathogenesis of delayed xenograft rejection (DXR). This study was designed to determine whether alpha1,3-galactosyltransferase-deficient (Gal KO) mice can naturally acquire a sufficient anti-alphaGal titre to cause the delayed type rejection of alphaGal-expressing hearts. Gal KO mice of various ages were assessed for anti-alphaGal antibody levels. alphaGal-expressing hearts were transplanted heterotopically into these mice and monitored daily. Rejecting and surviving hearts were evaluated histologically. In Gal KO mice greater than 6-month-old, 64% had an anti-alphaGal antibody titre above the background level. When wild-type alphaGal-expressing hearts were transplanted into this group, 45% of grafts rejected within 5 to 13 days. Histological examination of the rejected hearts displayed marked tissue damage and an inflammatory infiltrate of predominantly macrophage/monocytes. Surviving grafts showed preserved morphology. Like humans, Gal KO mice naturally develop anti-alphaGal antibodies with age. The titre in these mice was sufficient to cause a "delayed-type" rejection of a significant proportion of alphaGal-expressing cardiac grafts. This model thus provides an opportunity to investigate the role of naturally acquired anti-alphaGal antibodies in the pathogenesis of DXR.

Early-invasive or early-conservative management of patients with unstable angina or non-Q-wave myocardial infarction

The optimal therapy for non-ST-segment-elevation acute coronary syndromes is the subject of considerable debate: is early catheterization and revascularization (early-invasive strategy) or continued medical therapy unless symptoms are refractory (early-conservative strategy) best? Although several clinical trials have sought to answer this question, the methodologies they employed have been widely criticized, and no consensus has been reached. The new antiplatelet therapies have proved beneficial for primary medical management and as adjuncts to percutaneous interventions. It is not yet clear, however, whether use of these therapies will preferentially benefit one of the treatment strategies.

Age of onset in chronic major depression: relation to demographic and clinical variables, family history, and treatment response

BACKGROUND

The clinical and etiological significance of the early-late onset distinction in chronic major depressive disorder was explored.

METHOD

Subjects were 289 outpatients with DSM-III-R chronic major depression drawn from a multi-site study comparing the efficacy of sertraline and imipramine in the acute and long-term treatment of chronic depression. Patients received comprehensive evaluations using semi-structured interviews and rating scales.

RESULTS

Early-onset chronic major depression was associated with a longer index major depressive episode and higher rates of recurrent major depressive episodes, comorbid personality disorders, lifetime substance use disorders, depressive personality traits, and a history of psychiatric hospitalization. In addition, more early-onset patients tended to have a family history of mood disorders. The early-late onset distinction was not associated with differences in symptom severity, functional impairment, or treatment response.

LIMITATIONS

Family members were not interviewed directly; there were a large number of statistical comparisons; and interrater reliability of the assessments was not evaluated.

CONCLUSIONS

Early-onset chronic major depression has a more malignant course and is associated with greater comorbidity than late-onset chronic major depression.

Meniscus regeneration in a rabbit partial meniscectomy model

Meniscectomy is known to be associated with osteoarthrosis of the knee. The purpose of this study was to compare the natural and augmented repair of menisci in the knees of New Zealand White rabbits. To create a partial defect in the medial meniscus, we used an experimental model that has been well characterized and extensively used in the study of osteoarthrosis and articular cartilage repair. The defect was left untreated or treated with one of the following: a periosteal autograft, a type I collagen sponge, or the same sponge loaded with autologous, bone marrow-derived, cultured mesenchymal stem cells. The natural repair was always incomplete and degenerative changes within these joints were progressive. The periosteal autograft underwent differentiation into a bone and hyaline cartilage composite that was ineffectual as a meniscus and accelerated the degenerative changes in those joints when compared to natural repair controls. There was evidence of a consistent sequence of events in the transformation of the periosteal grafts to a core of cartilage that underwent endochondral ossification. In the last two groups, the collagen sponge functioned as a scaffold that resulted in more abundant repair tissue. The collagen sponge alone supported a largely fibrous repair process. The cultured mesenchymal stem cells were observed to augment the repair process in some specimens to include fibrocartilage histologically similar to normal meniscus. Degenerative changes were present in both of these groups, which indicates that the biomechanical function of the meniscus was not restored, or an irreversible osteoarthrosis cascade was initiated during the repair period. Based on these preliminary studies, further investigation of cell-based meniscus regeneration appears to be warranted.

Determination of the potency of remifentanil compared with alfentanil using ventilatory depression as the measure of opioid effect

BACKGROUND

Remifentanil is a new opioid with properties similar to other mu-specific agonists. To establish its pharmacologic profile relative to other known opioids, it is important to determine its potency. This study investigated the relative potency of remifentanil compared with alfentanil.

METHODS

Thirty young healthy males were administered double-blind remifentanil or alfentanil intravenously for 180 min using a computer-assisted continuous infusion device. Depression of ventilation was assessed by the minute ventilatory response to 7.5% CO2 administered via a "bag in the box" system. The target concentration of the study drug was adjusted to obtain 40-70% depression of baseline minute ventilation. Multiple blood samples were obtained during and following the infusion. The concentration-effect relationship of each drug was modeled, and the concentration needed to provide a 50% depression of ventilation (EC50) was determined.

RESULTS

Only 11 subjects in each drug group completed the study; however, there were sufficient data in 28 volunteers to model their EC50 values. The EC50 (mean and 95% confidence interval) for depression of minute ventilation with remifentanil was 1.17 (0.85-1.49) ng/ml and the EC50 for alfentanil was 49.4 (32.4-66.5) ng/ml.

CONCLUSION

Based on depression of the minute ventilatory response to 7.5% CO2, remifentanil is approximately 40 (26-65) times more potent than alfentanil when remifentanil and alfentanil whole-blood concentrations are compared. As alfentanil is usually measured as a plasma concentration, remifentanil is approximately 70 (41-104) times more potent than alfentanil when remifentanil whole-blood concentration is compared with alfentanil plasma concentration. This information should be used when performing comparative studies between remifentanil and other opioids.

Early- versus late-onset dythymic disorder: comparison in out-patients with superimposed major depressive episodes

BACKGROUND

This study examined the validity of the early-late onset subtyping distinction in dysthymic disorder.

METHODS

Participants were 340 out-patients meeting DSM-III-R criteria for dysthymia and a concurrent major depressive episode (MDE). The sample was drawn from a 12-site double-blind randomized parallel group trial comparing the efficacy of sertraline and imipramine in the treatment of chronic depression. All patients received comprehensive evaluations using semi-structured interviews and rating scales.

RESULTS

73% of the sample met criteria for the early-onset, and 27% for the late-onset, subtype. The early-onset patients had a significantly longer index MDE, significantly higher rates of personality disorders and lifetime substance use disorders, and a significantly greater proportion had a family history of mood disorder. The subgroups did not differ in symptom severity or functional impairment at baseline, nor in response to a 12-week trial of antidepressants.

LIMITATIONS

Further work is needed to extend these findings to dysthymic disorder without superimposed MDEs.

CONCLUSIONS

These results support the distinction between early-onset and late-onset dysthymic disorder.

Antigen-specific antibody responses in lupus patients following immunization

OBJECTIVE

To determine the safety and efficacy of 3 clinically relevant vaccines in patients with systemic lupus erythematosus (SLE).

METHODS

We studied 73 consecutive SLE patients immunized with pneumococcal, tetanus toxoid (TT), and Haemophilus influenzae type B (HIB) vaccines. Patients were evaluated preimmunization and 12 weeks postimmunization for disease activity and immunization side effects.

RESULTS

Eighty-four percent of the SLE patients developed a 4-fold titer increase in response to at least 1 vaccine, with 51% developing a 2-fold titer increase with all 3 vaccines. The majority of SLE patients developed protective levels of antibody to TT (90%) and HIB (88%). Although protective antibody levels could not be determined for pneumococcus, almost half of the patients (47%) developed a 4-fold antibody response. There was a trend toward a lower antibody response in patients with active disease treated with immunosuppressive therapy. Overall lupus disease activity was unaffected by immunization.

CONCLUSION

Immunization is safe in SLE patients, with the overwhelming majority developing protective antibody levels. Therefore, SLE patients should receive immunizations according to the recommendations of the Centers for Disease Control and Prevention and the Immunization Practices Advisory Committee.