Stereotactic Radiosurgery for Small Intact Brain Metastasis: A Comparative Evaluation of 3 Different Single Fraction Prescription Doses

PURPOSE/OBJECTIVE(S)

While single-fraction stereotactic radiosurgery (SRS) in the treatment of small brain metastases (SBM, ≤ 2 cm) is well established, prescription dosing varies considerably across institutions and clinical trials. The choice of prescription dose is a delicate balance between local failure (LF) and radiation necrosis (RN) risks. In the modern era, historically-established dosing thresholds may no longer be applicable. To evaluate the impact of prescription dose on outcomes, we performed a comparative analysis of patients with SBM treated with definitive SRS using three different prescriptions, at a single tertiary institution.

MATERIALS/METHODS

Consecutive patients with intact SBM treated with SRS from January 2017 and December 2021 were analyzed. Baseline patient characteristics and dosing parameters were abstracted from the medical record. To limit the integral brain dose when treating multiple brain metastases, the institutional practice was to reduce prescription dose as the total number of lesions increased (i.e., 24 Gy for ≤10 lesions, 22 Gy for 11-20, and 20 Gy for >20). A per lesion analysis, where each lesion was followed from the date of SRS to the last follow-up, was conducted with primary endpoints of LF and RN. Gray's test was used to compare the cumulative incidence of the LF and RN, with death as a competing risk. Factors affecting LF were analyzed using Cox hazard regression analysis.

RESULTS

A total of 1318 SBM in 250 patients received SRS and met the inclusion criteria. The median age was 62 years (range: 18-90), median KPS was 90 (range: 50-100) and 66% were female. The most common primary tumors were lung (55.5%) and breast cancers (26.4%). With a median follow-up of 12 months, 136 (11%) LF in 44 patients and 70 (5.7%) RN events in 46 patients occurred. The actuarial 1-year cumulative rate of LF was lower in lesions treated with 24 Gy (6.4%, 95% CI: 4.7-8.6%) or 22 Gy (5.8%, 95% CI: 3.7-8.7%) compared to 20 Gy (15.4%, 95% CI: 10.9-20.5%) (p<0.01). 22 Gy and 24 Gy prescription doses were associated with a 44% and 52% reduction in risk in LF compared to 20 Gy (HR: 0.56; 95% CI: 0.36-0.9; p = 0.01 and HR: 0.48; 95% CI: 0.31-0.74; p<0.01, respectively). In a subset analysis of radiosensitive tumors, 1-year LF rate was still lower with 24 Gy (7.4%, 95% CI: 5.3-9.9%) and 22 Gy (6.1%, 95% CI: 3.7-9.4%) than 20 Gy (15.7%, 95% CI: 11.2-21%) (p = 0.01). The cumulative 1-year RN rate numerically declined with dose, but was not statistically significantly different, with 3.6% (95% CI: 2.3-5.3%) for 24 Gy, 2.6% (95% CI: 1.3-4.8%) for 22 Gy and 1.4% (95% CI: 0.4-3.7%) for 20 Gy.

CONCLUSION

Patients treated with single fraction SRS to intact SBM were at increased risk of LF with prescription doses of 20 Gy compared to 22-24 Gy, without an increased risk of RN. Even in patients with radiosensitive histologies, higher LF rates were still observed following 20 Gy compared to 22-24 Gy.

A Comparison of Local Failure and Necrosis Following Different Radiosurgery Strategies for Large Brain Metastases

PURPOSE/OBJECTIVE(S)

Large brain metastases (LBMs) are associated with poor local control with single-fraction stereotactic radiosurgery (SRS) alone. Various alternative strategies have been developed, including fractionated SRS (FSRS) and staged SRS (SSRS) for intact LBMs, and resection with postoperative-SRS (postop-SRS) or preoperative-SRS (preop-SRS) for operable LBMs. The objective of this study is to compare local failure (LF) and radiation necrosis (RN) outcomes among these four management strategies to determine the optimal treatment paradigm.

MATERIALS/METHODS

Consecutive patients diagnosed with LBM (≥2 cm in maximum dimension) between July 2017 and January 2022 and treated with one of the aforementioned strategies at a single tertiary institution were evaluated. All immobilization, target contouring, margins, dose- and prescription selection followed pre-defined institutional guidelines. Primary endpoints included LF, symptomatic RN, or a composite endpoint of these two variables. Gray's test was used to compare the cumulative incidence of the LF and the composite endpoint, with death as a competing risk.

RESULTS

A total of 234 LBMs in 188 consecutive patients met the inclusion criteria. The median age was 65 years (range: 31-98), the median KPS was 80 (range: 50-100), and 58% were female. The most common primary tumors were lung (48%) and breast cancer (17%). The median maximum tumor diameter was 3.0 cm (range: 2.0-5.6). 47 (20%) lesions were treated with FSRS, 66 (28%) with SSRS, 74 (32%) with postop-SRS, and 47 (20%) with preop-SRS. With a median follow-up of 12 months, 22 (9%) LF and 11 (5%) RN events occurred. The 6-month and 1-year cumulative incidences of LF for the entire cohort were 5% (95% CI: 3%-9%) and 8% (95% CI: 5%-12%), respectively. The 6-month and 1-year LF rates were 4% (95% CI: 1%-13%) and 8% (95% CI: 3%-20%) for FSRS; 8% (95% CI: 3%-20%) and 8% (95% CI: 3%-20%) for SSRS; 7% (95% CI: 3%-15%) and 8% (95% CI: 3%-16%) for postop-SRS; 0 and 7% (95% CI: 2%-20%) for preop-SRS (p>0.05). The 1-year OS rates were favorable in resected patients (61% for postop-SRS and 82% for preop-SRS) compared to SRS alone strategies (45% for FSRS and 56% for SSRS) (p = 0.004). Similarly, RN events were significantly lower in resected patients treated with either bimodality approach (0 for postop-SRS and 4% for preop-SRS) than SRS standalone strategies (9% for FSRS and 8% SSRS) (p = 0.024). At 12 months, the cumulative probabilities of the composite endpoint were 13% (95% CI: 5%-25%) for FSRS, 15% (95% CI: 7%-25%) for SSRS, 9% (95% CI: 3%-17%) for postop-SRS, and 12% (95% CI: 4%-24%) for preop-SRS and not significantly different between the groups.

CONCLUSION

For medically operable patients with surgically resectable LBMs, a strategy of surgery and SRS, regardless of timing, is associated with favorable local control and reduced risk for RN. For unresected patients, either SSRS or FSRS is associated with similar local control, but slightly higher RN risk. Prospective comparative evaluation is warranted.

CNS Control after First-Line Osimertinib in Patients with Metastatic EGFR-Mutant NSCLC

PURPOSE/OBJECTIVE(S)

Although osimertinib (osi) has excellent intracranial activity in EGFR-mutant metastatic non-small cell lung cancer (NSCLC), there is no consensus regarding whether to continue osi for central nervous system (CNS) control with second-line chemotherapy (chemo) at the time of systemic progression. We aimed to compare CNS outcomes after first-line osi in patients receiving second-line chemo with or without continuation of osi.

MATERIALS/METHODS

We retrospectively reviewed patients with EGFR-mutant NSCLC with brain metastases (BrM) at the time of initiating first-line osi who experienced progression and started second-line chemo. Cumulative incidence of local and distant CNS progression, and extracranial (EC) progression was calculated from time of second-line chemo initiation with death as a competing risk. Overall survival (OS) was analyzed using Kaplan-Meier.

RESULTS

We included 52 patients with a median follow up of 9.6 months (range 0.4-36.4). Median OS and CNS progression-free survival (PFS) from the time of starting second-line chemo was 12.5 months (95% CI 8.1-16.9), and 5.3 months (95% CI 3.35-7.26), respectively. The 1-year cumulative incidence of local, distant CNS progression, any CNS progression, and EC progression was 14.4% (95% CI 4.5-24.2), 42.8% (95% CI 22.8-56.8), 42.8% (95% CI 22.8-56.8) and 66.8% (95% CI 53.5-80.2), respectively. After progression on first-line osi, 25 (48.1%) and 27 patients (51.9%) continued and discontinued osi, respectively. Patients who continued osi had significantly higher BrM burden than those who did not, with 17 (68%), 3 (12%), and 5 (20%) versus 26 (96%), 0, and 1 (3.7%) patient having <10 or >11 parenchymal brain lesions, or leptomeningeal disease (LMD) at the time of second line therapy, respectively (p<0.01). In those who continued osi vs those who did not, median OS (10.8 vs 12.5 months; p = 0.37), median intracranial PFS (5.3 vs 4.8 months; p = 0.99), 1-year cumulative incidence of local (8.4% versus 20 % p = 0.26), and 1-year distant CNS progression (24.8% vs 60%; p = 0.08) was not significantly different. CNS complications such as symptomatic, hospitalizations, and steroid initiation for CNS disease, and progression of LMD were not significantly different between the two groups. Eventually, 10 patients underwent salvage RT post first-line osi and median time to salvage RT was 7.8 months (range 2-9.4). Of patients who underwent salvage RT, 2 patients (20%) had continued osi with second-line chemo. Twelve patients (44.4%) who did not continue osi eventually re-started osi for progressive disease.

CONCLUSION

Patients who continued osi had significantly higher BrM tumor burden. Despite these patients being at higher risk for CNS progression, time to CNS progression and incidence of CNS complications were not significantly different in the two cohorts. Patients who discontinued osi were more likely to undergo salvage RT. Continuation of osi may allow patients to defer salvage RT.

Combined osmotic pretreatment and hot air drying: Evaluation of drying kinetics and quality parameters of adajamir (Citrus assamensis)

Adajamir (Citrus assamensis) is a highly perishable but nutritional fruit. Hot air drying is ubiquitous in food preservation but not quality friendly. However, drying pretreatments play an indispensable role preserving fruits and vegetables. The aim of this study was, therefore, to reveal the hot air drying kinetics of osmotically pretreateated adajamir and investigate the quality parameters (total phenolic contents, antioxidant capacity, and vitamin C). Adajamir slices were subjected to osmotic pretreatment (10% sucrose, 10% fructose, and 2% NaCl), subsequently, dried in a hot air dryer at 50 °C, 30% relative humidity (RH), and with a velocity of 1 ms-1. The drying kinetics were studied using three mathematical models: Newtonian model, Henderson and Pabis model, and Page model. The result depicted that effective diffusivity was highest (9.5 ± 0.2a × 10-6 m2s-1) in untreated samples compared to the treated samples, and the Page model was the one with the best fitness to explain the drying behavior. Regarding quality, the pretreatments provided better retention of all quality parameters compared to the untreated samples. In addition, osmotic treatment with sucrose had the best quality retention capability. The study will contribute to the optimization of thermal processing parameters in fruit dehydration. Eventually, this research will expedite future research pertinent to innovative combined drying techniques of citrus fruit.

Economic evaluation of tele-resuscitation intervention on emergency department pediatric visits in the Niagara Region, Canada a pilot study

Introduction

The use of telemedicine in critical care is emerging, however, there is a paucity of information surrounding the costs relative to health gains in the pediatric population. This study aimed to estimate the cost-effectiveness of a pediatric tele-resuscitation (Peds-TECH) intervention compared to the usual care in five community hospital emergency departments (EDs). Using a decision tree analysis approach with secondary retrospective data from a 3-year time period, this cost-effectiveness analysis was completed.

Methods

A mixed methods quasi-experimental design was embedded in the economic evaluation of Peds-TECH intervention. Patients aged <18 years triaged as Canadian Triage and Acuity Scale 1 or 2 at EDs were eligible to receive the intervention. Qualitative interviews were conducted with parents/caregivers to explore the out-of-pocket (OOP) expenses. Patient-level health resource utilization was extracted from Niagara Health databases. The Peds-TECH budget calculated one-time technology and operational costs per patient. Base-case analyses determined the incremental cost per year of life lost (YLL) averted, and additional sensitivity analysis confirmed the robustness of the results.

Results

Odds ratio for mortality among cases was 0.498 (95% CI: 0.173, 1.43). The average cost of a patient receiving the Peds-TECH intervention was $2,032.73 compared to $317.45 in usual care. In total, 54 patients received the Peds-TECH intervention. Fewer children died in the intervention group resulting in 4.71 YLL. The probabilistic analysis revealed an incremental cost-effectiveness ratio of $64.61 per YLL averted.

Conclusion

Peds-TECH appears to be a cost-effective intervention for resuscitating infants/children in hospital emergency departments.

Effects of in ovo Administration of Zinc Oxide Nanoparticles and Vitamin C on Hatchability Performance and Redox Status in Day Old Kadaknath Hatchlings

Background: In poultry industry, hatcheries play a vital role in connecting the poultry production chain and are expected in the productive performance, with an impact on company profits. The use of in ovo feeding support poultry embryonic development and offers the production efficiency and welfare of commercial poultry. Methods: This study investigated the impact of in ovo administration of normal saline, Zinc oxide nanoparticles and Vitamin C on hatchability, chick growth and redox status in Kadaknath hatchlings. Zinc oxide nanostructures were synthesized by chemical method and characterized for size determination. A total of 150 fertile eggs of the Kadaknath poultry breed were divided into five groups (T0 to T4) and treated with in ovo administration of 200 μl each of normal saline, zinc oxide nanoparticles (5 and 10 ppm) and Vitamin C respectively on the 18th day of incubation through air sac into amniotic fluid. Result: Rod shaped nanostructures ranging from 45 to 98 nm were synthesized and showed sharp peak positioned at 436.59 cm-1. Zinc nano composite 5 ppm and vitamin C administration had significantly (p less than 0.05) improved hatchability, hatch weight, chick weight and egg weight ratio and antioxidant status.

Precorneal retention time of ocular lubricants measured with fluorophotometry in healthy dogs

OBJECTIVE

Determine the precorneal retention time of five different ocular lubricants commonly used in dogs.

ANIMALS STUDIED

Six healthy Beagle dogs (n = 12 eyes).

PROCEDURES

Five ocular lubricants were studied: Artificial Tears Solution® (1.4% polyvinyl alcohol), I-Drop® Vet Plus (0.25% hyaluronate), Optixcare® Eye Lube Plus (0.25% hyaluronate), Systane® Ultra (0.4% polyethylene glycol 400 and 0.3% propylene glycol), and Artificial Tears Ointment® (mineral oil/white petrolatum). Each lubricant was mixed with 10% sodium fluorescein to achieve 1% fluorescein formulations. Following topical administration of 35 mg in each eye, tear fluid was collected with capillary tubes at selected times (0, 1, 5, 10, 20, 30, 40, 50, 60, 90, 120, 180 min) and fluorescein concentrations were measured with a computerized scanning ocular fluorophotometer.

RESULTS

Tear fluorescence was significantly greater with Artificial Tears Ointment® compared with other lubricant formulations from 1 to 20 min post-administration. Median (range) precorneal retention times were significantly different among the 5 lubricants, ranging from 40 minutes (20-90 min) for Artificial Tears Ointment®, 35 min (20-90 min) for Systane® Ultra, 30 min (10-60 min) for I-Drop® Vet Plus, 25 min (10-60 min) for Optixcare® Eye Lube Plus, and 10 min (10-20 min) for Artificial Tears Solution®. Precorneal retention time was significantly lower for Artificial Tears Solution® compared with the other 4 formulations.

CONCLUSIONS

This study established normative data for the retention time of common lubricants on the ocular surface of dogs, which may be used to guide clinicians with their choice of lubricant and frequency of administration.

A membrane-based green and low-cost system for ensuring safe drinking water in a selenium-affected region

Towards an efficient, low-cost solution to the problem of contamination of groundwater by selenium leached out from earth's mineral crust, a new system is developed using a novel graphene-based nanocomposite membrane. The system not only purified selenium-contaminated groundwater with high degree but also ensured safe disposal of the rejected selenium through algorithmic chemical stabilization in a mineral matrix. All experiments were conducted with live contaminated water from selenium affected area rather than using synthetic solution in a semi-pilot unit involving a largely fouling-free flat sheet cross-flow membrane module. Pure water flux of up to 190 Lm^-2h^-1(LMH) with 96-97% selenium rejection at an optimum operating pressure of only 14 bar could be achieved. Rejected selenium was stabilized in mineral matrix through chemical coagulation-precipitation using suitable coagulants following prior optimization of the critical operating parameters by Model-based calibration toolbox (MATLAB R2020a). A high degree of stabilization efficiency (99.8%) could be achieved as reflected in an error-index of only 1.13%. For selenium-affected region, the membrane-integrated hybrid treatment system proved to be a potential candidate technology offering safe drinking water at an approximate cost of only 1.77 $/m³ which was found to be affordable to the consumers in subsequent willingness to pay survey.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Physical function and physical activity in adults with X-linked hypophosphatemia

We described physical function and activity in UK adults with X-linked hypophosphatemia (XLH). Our data indicate that low physical activity and impaired mobility are common in adults with XLH. Deficits in lower limbs muscle power and functional capacity contribute to the loss of physical function in adults with XLH.

INTRODUCTION

There is a dearth of literature on physical function and physical activity in adults with X-linked hypophosphatemia (XLH). We described muscle strength and power, functional capacity, mobility and physical activity level and explored the relationships among these variables in adults with XLH.

METHODS

Participants were recruited as part of a UK-based prospective cohort study, the RUDY Study. They underwent a clinical visit and physical examination, including assessment of handgrip strength, jump power (mechanography), six-minute walk test (6MWT) and short physical performance battery (SPPB), and completed the International Physical Activity Questionnaire (IPAQ). Performance data were analysed using parametric and non-parametric tests, whereas correlations were assessed by univariate analysis.

RESULTS

Twenty-six adults with XLH (50% males) with a mean age of 44 ± 16.1 years were recruited. Jump power and 6MWT distances (p < 0.0001) were 54.4% and 38.6% lower respectively in individuals with XLH compared with normative values. These deficits were not associated with age or sex. Handgrip strength values were similar to expected values. Deficits in muscle power were more pronounced than those reported at 6MWT (p < 0.0001). Univariate analysis revealed only a correlation between total physical activity and muscle power (r = 0.545, p = 0.019).

CONCLUSIONS

Adults with XLH have a marked deficit in lower limb muscle power and a reduced functional capacity, with a high incidence of impaired mobility and inactivity. In addition to metabolic effects of XLH, low physical activity may contribute to deficits in lower limb power. Further studies are required to develop novel treatment approaches to improve physical function and mobility.

Tractostorm 2: Optimizing tractography dissection reproducibility with segmentation protocol dissemination

The segmentation of brain structures is a key component of many neuroimaging studies. Consistent anatomical definitions are crucial to ensure consensus on the position and shape of brain structures, but segmentations are prone to variation in their interpretation and execution. White-matter (WM) pathways are global structures of the brain defined by local landmarks, which leads to anatomical definitions being difficult to convey, learn, or teach. Moreover, the complex shape of WM pathways and their representation using tractography (streamlines) make the design and evaluation of dissection protocols difficult and time-consuming. The first iteration of Tractostorm quantified the variability of a pyramidal tract dissection protocol and compared results between experts in neuroanatomy and nonexperts. Despite virtual dissection being used for decades, in-depth investigations of how learning or practicing such protocols impact dissection results are nonexistent. To begin to fill the gap, we evaluate an online educational tractography course and investigate the impact learning and practicing a dissection protocol has on interrater (groupwise) reproducibility. To generate the required data to quantify reproducibility across raters and time, 20 independent raters performed dissections of three bundles of interest on five Human Connectome Project subjects, each with four timepoints. Our investigation shows that the dissection protocol in conjunction with an online course achieves a high level of reproducibility (between 0.85 and 0.90 for the voxel-based Dice score) for the three bundles of interest and remains stable over time (repetition of the protocol). Suggesting that once raters are familiar with the software and tasks at hand, their interpretation and execution at the group level do not drastically vary. When compared to previous work that used a different method of communication for the protocol, our results show that incorporating a virtual educational session increased reproducibility. Insights from this work may be used to improve the future design of WM pathway dissection protocols and to further inform neuroanatomical definitions.

Glomus tumour of the nipple in a male patient

A glomus tumour is a benign mesenchymal tumour. It is extremely rare in the breast. We report a case of glomus tumour of the nipple in a 54-year-old man. To the best of the authors' knowledge, this is the first case report of a glomus tumour of the nipple. We describe the different presenting symptoms, method of diagnosis and treatment.

A ketogenic supplement improves white matter energy supply and processing speed in mild cognitive impairment

INTRODUCTION

White matter (WM) energy supply is crucial for axonal function and myelin maintenance. An exogenous source of ketones, the brain's alternative fuel to glucose, bypasses the brain's glucose-specific energy deficit and improves cognitive outcomes in mild cognitive impairment (MCI). How an additional supply of ketones affects glucose or ketone uptake in specific WM fascicles in MCI has not previously been reported.

METHODS

This 6-month interventional study included MCI participants randomized to a placebo (n = 16) or ketogenic medium chain triglyceride (kMCT; n = 17) drink. A neurocognitive battery and brain imaging were performed pre- and post-intervention. WM fascicle uptake of ketone and glucose and structural properties were assessed using positron emission tomography and diffusion imaging, respectively.

RESULTS

Ketone uptake was increased in the kMCT group by 2.5- to 3.2-fold in all nine WM fascicles of interest (P < .001), an effect seen both in deep WM and in fascicle cortical endpoints. Improvement in processing speed was positively associated with WM ketone uptake globally and in individual fascicles, most importantly the fornix (r = +0.61; P = .014).

DISCUSSION

A 6-month kMCT supplement improved WM energy supply in MCI by increasing ketone uptake in WM fascicles. The significant positive association with processing speed suggests that ketones may have a role in myelin integrity in MCI.

Metastatic melanoma to the ovary in pregnancy: A case report

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Metastatic melanoma to the ovary is uncommon and can occur years after initial diagnosis.

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Ovarian metastatic melanoma can mimic various benign lesions on imaging and clinical history is key.

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If any suspicion in pregnancy, placenta should be evaluated due to possibility of transplacental transmission.

Metastatic melanoma to the ovary is an uncommon presentation. We report a case of metastatic melanoma to the ovary that presented as a growing left adnexal mass during pregnancy and was thought to be benign by imaging and frozen section pathology. Here we discuss the challenges in radiologic and pathologic diagnosis, as well as considerations for the mother and newborn.

Mosquito Identification From Bulk Samples Using DNA Metabarcoding: a Protocol to Support Mosquito-Borne Disease Surveillance in Canada

Approximately 80 species of mosquitoes (Diptera: Culicidae) have been documented in Canada. Exotic species such as Aedes albopictus (Skuse) (Diptera: Culicidae) are becoming established. Recently occurring endemic mosquito-borne diseases (MBD) in Canada including West-Nile virus (WNV) and Eastern Equine Encephalitis (EEE) are having significant public health impacts. Here we explore the use of DNA metabarcoding to identify mosquitoes from CDC light-trap collections from two locations in eastern Canada. Two primer pairs (BF2-BR2 and F230) were used to amplify regions of the cytochrome c oxidase subunit I (CO1) gene. High throughput sequencing was conducted using an Illumina MiSeq platform and GenBank-based species identification was applied using a QIIME 1.9 bioinformatics pipeline. From a site in southeastern Ontario, Canada, 26 CDC light trap collections of 72 to >300 individual mosquitoes were used to explore the capacity of DNA metabarcoding to identify and quantify captured mosquitoes. The DNA metabarcoding method identified 33 species overall while 24 species were identified by key. Using replicates from each trap, the dried biomass needed to identify the majority of species was determined to be 76 mg (equivalent to approximately 72 mosquitoes), and at least two replicates from the dried biomass would be needed to reliably detect the majority of species in collections of 144-215 mosquitoes and three replicates would be advised for collections with >215 mosquitoes. This study supports the use of DNA metabarcoding as a mosquito surveillance tool in Canada which can help identify the emergence of new mosquito-borne disease potential threats.

Effect of boiling and roasting on physicochemical and antioxidant properties of dark red kidney bean (Phaseolus vulgaris)

The effects of two processing methods (boiling and roasting) on physicochemical qualities of dark red kidney bean (Phaseolus vulgaris) were investigated. Changes in total polyphenol content (TPC) and antioxidant activity due to processing were also analyzed by using Folin–Ciocaltue method and 1,1 diphenyl-2-picrylhydrazyl (DPPH) assay, respectively. Analysis of physicochemical properties exhibited substantial variations (p<0.05) in the levels of moisture, ash, protein, fat, carbohydrate, gross energy and pH of raw and processed beans. Meanwhile, there was no considerable difference (p<0.05) in the fibre content of fresh and processed beans. Investigation of total phenolic content showed the significant (p<0.05) reduction of phenolic compounds in boiled (5.53±0.74 mg GAE/ g) and roasted (8.15±1.60 mg GAE/g) beans than raw samples (12.55±1.42 mg GAE/g). DPPH radical scavenging activity was also decreased significantly (p<0.05) in boiled and roasted samples with IC50 value of 0.0608±0.0765 mg/mL and 0.0523±0.0026 mg/mL, respectively. In the case of household cooking, keeping boiling water would be advised for the preservation of minerals, vitamins and phenolic compounds. The roasting process may be used to develop high-quality health-promoting dark red kidney bean products.

Fascicle- and Glucose-Specific Deterioration in White Matter Energy Supply in Alzheimer's Disease

BACKGROUND

White matter energy supply to oligodendrocytes and the axonal compartment is crucial for normal axonal function. Although gray matter glucose hypometabolism is extensively reported in Alzheimer's disease (AD), glucose and ketones, the brain's two main fuels, are rarely quantified in white matter in AD.

OBJECTIVE

Using a dual-tracer PET method combined with a fascicle-specific diffusion MRI approach, robust to white matter hyper intensities and crossing fibers, we aimed to quantify both glucose and ketone metabolism in specific white matter fascicles associated with mild cognitive impairment (MCI; n = 51) and AD (n = 13) compared to cognitively healthy age-matched controls (Controls; n = 14).

METHODS

Eight white matter fascicles of the limbic lobe and corpus callosum were extracted and analyzed into fascicle profiles of five sections. Glucose (18F-fluorodeoxyglucose) and ketone (11C-acetoacetate) uptake rates, corrected for partial volume effect, were calculated along each fascicle.

RESULTS

The only fascicle with significantly lower glucose uptake in AD compared to Controls was the left posterior cingulate segment of the cingulum (-22%; p = 0.016). Non-significantly lower glucose uptake in this fascicle was also observed in MCI. In contrast to glucose, ketone uptake was either unchanged or higher in sections of the fornix and parahippocampal segment of the cingulum in AD.

CONCLUSION

To our knowledge, this is the first report of brain fuel uptake calculated along white matter fascicles in humans. Energetic deterioration in white matter in AD appears to be specific to glucose and occurs first in the posterior cingulum.

Bioactive compounds and antioxidant activity of black and green tea available in Bangladesh

People in Bangladesh are traditionally used to consume mainly black tea. However, some tea manufacturing companies are now producing green tea, though in a small scale. To create new knowledge as well as awareness about the consumption of green tea, the present study was carried out to compare the black and green tea available in Bangladesh based on their bioactive compounds and antioxidant activity. A total of eight brands of black tea and two brands of green tea were bought from the supermarkets. Total phenolics, total tannin, total flavonoids, and caffeine content were measured as bioactive compounds, and antioxidant activity was evaluated by using two different methods such as DPPH (1,1- diphenyl-2-picrylhydrazyl) radical-scavenging activity and ABTS+ radical scavenging activity of methanol extracts of black and green tea. Every bioactive compound in black and green tea was found to be significantly different (P < 0.05). The total phenolic content, on average, was measured at 242.46 mg GAE/g dry extract and 763.41 mg GAE/ g dry extract in black and green tea, respectively. Black tea contained 6.47 mg TAE/g dry extract tannin, whereas green tea had much more tannin content, 14.51 mg TAE/g dry extract, which is more than double in amount. On the other hand, the total flavonoid content was almost double in black tea (61.82 mg QE/g dry extract) compared to green tea (31.85 mg QE/g dry extract). Antioxidant activities were determined at different concentrations of tea samples. At every concentration, green tea presented higher ABTS+ and DPPH radical scavenging activity than black tea. The highest percentage of inhibition was observed at 20 ppm both in black and green tea, finding 98.50 % and 99.07 % inhibition, respectively. Overall, significantly (P < 0.05) higher amount of phenolic compounds as well as antioxidant activity were observed in green tea.

Bundle-specific associations between white matter microstructure and Aβ and tau pathology in preclinical Alzheimer's disease

Beta-amyloid (Aβ) and tau proteins, the pathological hallmarks of Alzheimer's disease (AD), are believed to spread through connected regions of the brain. Combining diffusion imaging and positron emission tomography, we investigated associations between white matter microstructure specifically in bundles connecting regions where Aβ or tau accumulates and pathology. We focused on free-water-corrected diffusion measures in the anterior cingulum, posterior cingulum, and uncinate fasciculus in cognitively normal older adults at risk of sporadic AD and presymptomatic mutation carriers of autosomal dominant AD. In Aβ-positive or tau-positive groups, lower tissue fractional anisotropy and higher mean diffusivity related to greater Aβ and tau burden in both cohorts. Associations were found in the posterior cingulum and uncinate fasciculus in preclinical sporadic AD, and in the anterior and posterior cingulum in presymptomatic mutation carriers. These results suggest that microstructural alterations accompany pathological accumulation as early as the preclinical stage of both sporadic and autosomal dominant AD.

Impact of blanching pretreatment on physicochemical properties, and drying characteristics of cabbage (Brassica oleracea)

Cabbage (Brassica oleracea) is popular winter vegetables cultivated all over Bangladesh and contains essential nutrients. This study aimed to evaluate the efficacy of pre-blanching on the preservation of cabbage by drying. In this research work, cabbage was blanched at 80°C, 90°C, and 100°C temperature for 12, 8, and 2 mins, respectively. Then the samples were dried at 60°C maintaining 60% relative humidity. The moisture and ash content of untreated and treated dried samples was in the range of 16.07±0.04 to 10.80±0.01% and 5.71±0.06 to 3.81±0.02%, respectively. The total phenolic content in cabbage was 74.47±0.63 mg GAE/100g at 100°C blanching temperature for a short time of 2 mins, which was higher compared to 61.91±0.48 mg GAE/100g at 80°C for 12 mins. It was observed that the antioxidant activity and two water-soluble vitamins-ascorbic acid and beta carotene decreased in pre-blanched dried samples in contrast with fresh ones. Blanching at higher water temperature and a short period was found useful for the retention of total phenolic content and greenness of cabbage. Blanching pre-treatments were also found to have better color retention capacity than untreated dried cabbage. A proper combination of drying time and temperature, along with the incorporation of blanching pretreatment, might be useful to preserve cabbage for a long time.

Future directions for the concept of salutogenesis: a position article

Aaron Antonovsky advanced the concept of salutogenesis almost four decades ago (Antonovsky, Health, Stress and Coping. Jossey-Bass, San Francisco, CA, 1979; Unravelling the Mystery of Health. Jossey-Bass, San Francisco, CA, 1987). Salutogenesis posits that life experiences shape the sense of coherence (SOC) that helps to mobilize resources to cope with stressors and manage tension successfully (determining one's movement on the health Ease/Dis-ease continuum). Antonovsky considered the three-dimensional SOC (i.e. comprehensibility, manageability, meaningfulness) as the key answer to his question about the origin of health. The field of health promotion has adopted the concept of salutogenesis as reflected in the international Handbook of Salutogenesis (Mittelmark et al., The Handbook of Salutogenesis. Springer, New York, 2016). However, health promotion mostly builds on the more vague, general salutogenic orientation that implies the need to foster resources and capacities to promote health and wellbeing. To strengthen the knowledge base of salutogenesis, the Global Working Group on Salutogenesis (GWG-Sal) of the International Union of Health Promotion and Education produced the Handbook of Salutogenesis. During the creation of the handbook and the regular meetings of the GWG-Sal, the working group identified four key conceptual issues to be advanced: (i) the overall salutogenic model of health; (ii) the SOC concept; (iii) the design of salutogenic interventions and change processes in complex systems; (iv) the application of salutogenesis beyond health sector. For each of these areas, we first highlight Antonovsky's original contribution and then present suggestions for future development. These ideas will help guide GWG-Sal's work to strengthen salutogenesis as a theory base for health promotion.

A ketogenic drink improves cognition in mild cognitive impairment: Results of a 6-month RCT

Introduction

Counteracting impaired brain glucose metabolism with ketones may improve cognition in mild cognitive impairment (MCI).

Methods

Cognition, plasma ketone response, and metabolic profile were assessed before and 6 months after supplementation with a ketogenic drink containing medium chain triglyceride (ketogenic medium chain triglyceride [kMCT]; 15 g twice/day; n = 39) or placebo (n = 44).

Results

Free and cued recall (Trial 1; P = .047), verbal fluency (categories; P = .024), Boston Naming Test (total correct answers; P = .033), and the Trail‐Making Test (total errors; P = .017) improved significantly in the kMCT group compared to placebo (analysis of covariance; pre‐intervention score, sex, age, education, and apolipoprotein E4 as covariates). Some cognitive outcomes also correlated positively with plasma ketones. Plasma metabolic profile and ketone response were unchanged.

Conclusions

This kMCT drink improved cognitive outcomes in MCI, at least in part by increasing blood ketone level. These data support further assessment of MCI progression to Alzheimer's disease.

Community outreach workers: Perceived practices and impacts on families and young children

Background

Community outreach workers support individuals accessing healthcare and other services that could be useful to respond to their needs. Even though community outreach workers have been working in the province of Quebec (Canada) for the past 40 years, their practice is poorly documented and evaluated, especially with respect to young children aged 0 to 5 years. This study aimed to document the practice of community outreach workers and its perceived impacts among children and families.

Methods

A qualitative methodology with a descriptive research design was used. We performed a content analysis on 55 scientific and grey literature documents, 24 individual interviews, and 3 focus groups with stakeholders including parents, community outreach workers, healthcare employees, and inter-sectoral partners.

Results

Our analysis reveals three main themes: 1) characteristics of the population served, 2) concrete actions performed by community outreach workers, and 3) perceived impacts of community outreach on families and children. Community outreach workers were perceived as essential to reach families with vulnerable circumstances and children with special needs. With respect to concrete actions, community outreach workers were reported to tailor their interventions to respond in different but complementary ways to the healthcare system. Perceived impacts included increased access for children and families to appropriate services, decreased social isolation, increased empowerment (especially with respect to parental abilities), increased social capital of families, and confidence towards the healthcare system. Results showed that community outreach workers helped to reduce inequalities in health

Conclusions

Community outreach work help the healthcare system to fulfill its legal mandate to protect citizen and increase health and well-being. It is crucial that such type of proximity approaches be not only encouraged but also sustained.

Key messages

Community outreach workers adapt their practices to act in a complementary way to the healthcare system. Community outreach workers help to reduce inequalities in health.

Free Water in White Matter Differentiates MCI and AD From Control Subjects

Recent evidence shows that neuroinflammation plays a role in many neurological diseases including mild cognitive impairment (MCI) and Alzheimer's disease (AD), and that free water (FW) modeling from clinically acquired diffusion MRI (DTI-like acquisitions) can be sensitive to this phenomenon. This FW index measures the fraction of the diffusion signal explained by isotropically unconstrained water, as estimated from a bi-tensor model. In this study, we developed a simple but powerful whole-brain FW measure designed for easy translation to clinical settings and potential use as a priori outcome measure in clinical trials. These simple FW measures use a "safe" white matter (WM) mask without gray matter (GM)/CSF partial volume contamination (WM safe) near ventricles and sulci. We investigated if FW inside the WM safe mask, including and excluding areas of white matter damage such as white matter hyperintensities (WMHs) as shown on T2 FLAIR, computed across the whole white matter could be indicative of diagnostic grouping along the AD continuum. After careful quality control, 81 cognitively normal controls (NC), 103 subjects with MCI and 42 with AD were selected from the ADNIGO and ADNI2 databases. We show that MCI and AD have significantly higher FW measures even after removing all partial volume contamination. We also show, for the first time, that when WMHs are removed from the masks, the significant results are maintained, which demonstrates that the FW measures are not just a byproduct of WMHs. Our new and simple FW measures can be used to increase our understanding of the role of inflammation-associated edema in AD and may aid in the differentiation of healthy subjects from MCI and AD patients.

The aza-Michael reaction: towards semi-crystalline polymers from renewable itaconic acid and diamines

This paper reports, for the first time, semi-crystalline polymers based on bis-pyrrolidone dicarboxylic acids (BPDA) obtained from the aza-Michael reaction between renewable itaconic acid and various diamines.

Differential interference contrast microscopy for cells using hard x-ray holography

We propose a differential interference contrast method for cells using hard x-ray Gabor holography and knife-edge filtering in the spatial frequency domain, without relying on beam shearing. A phase object is holographically recorded and reconstructed by computer. Interference between the wavefronts of zeroth order weighted by e^jπ/2 in the positive frequency region produces a dark image. Similarly, interference between the wavefronts of the zeroth order weighted by e^j3π/2 in the negative frequency region produces a bright image. By adding these two intensity distributions, good quality phase-contrast images of 8-μm-diameter polystyrene beads and human HeLa cells were obtained.

Self-monitoring has no adverse effect on disordered eating in adults seeking treatment for obesity

OBJECTIVES

Although monitoring is considered a key component of effective behaviour change, the development of apps has allowed consumers to constantly evaluate their own diet, with little examination of what this might mean for eating behaviour. The aim of this study was to investigate whether self-monitoring of diet using the app MyFitnessPal or daily self-weighing increases the reported occurrence of eating disorders in adults with overweight/obesity following a weight loss programme.

METHODS

Two hundred fifty adults with body mass index ≥ 27 kg/m2 received diet and exercise advice and were randomized to one of four monitoring strategies (daily self-weighing, MyFitnessPal, brief monthly consults or self-monitoring hunger) or control for 12 months. The Eating Disorder Examination Questionnaire 6.0 was used to assess eating disorder symptoms and behaviours for the previous 28 d at 0 and 12 months.

RESULTS

There were no significant differences in the global Eating Disorder Examination Questionnaire score or the subscales between those in the four monitoring groups and the control at 12 months (all p ≥ 0.164), nor were there differences in binge eating, self-induced vomiting, laxative misuse or excessive exercise at 12 months (p ≥ 0.202). The overall prevalence of one or more episodes of binge eating was 53.6% at baseline and 50.6% at 12 months, with no change over time (p = 0.662).

CONCLUSIONS

There was no evidence that self-monitoring, including using diet apps like MyFitnessPal or daily self-weighing, increases the reported occurrence of eating disorder behaviours in adults with overweight/obesity who are trying to lose weight.

Community based kangaroo mother care for low birth weight babies: A pilot study

Background & objectives:

Kangaroo mother care (KMC - early continuous skin-to-skin contact between mother and infants) has been recommended as an alternative care for low birth weight infants. There is limited evidence in our country on KMC initiated at home. The present study was undertaken to study acceptability of KMC in different community settings.

Methods:

A community-based pilot study was carried out at three sites in the States of Odisha, Gujarat and Maharashtra covering rural, urban and rural tribal population, respectively. Trained health workers provided IEC (information, education and communication) on KMC during antenatal period along with essential newborn care messages. These messages were reinforced during the postnatal period. Outcome measures were the proportion of women accepting KMC, duration of KMC/day and total number of days continuing KMC. Focus group discussions and in-depth interviews were also carried out.

Results:

KMC was provided to 101 infants weighing 1500-2000 g; 57.4 per cent were preterm. Overall, 80.2 per cent mothers received health education on KMC during antenatal period, family members (68.3%) also attended KMC sessions along with pregnant women and 55.4 per cent of the women initiated KMC within 72 h of birth. KMC was provided on an average for five hours per day. Qualitative survey data indicated that the method was acceptable to mothers and family members; living in nuclear family, household work, twin pregnancy, hot weather, etc., were cited as reasons for not being able to practice KMC for a longer duration.

Interpretation & conclusions:

It was feasible to provide KMC using existing infrastructure, and the method was acceptable to most mothers of low birth infants.

Atlantoaxial Instability in down Syndrome-Guidelines for Screening and Detection

A community survey was conducted in all adults with Down syndrome living in three health districts to see if there was any correlation between radiological and neurological abnormalities which could indicate the presence of atlantoaxial instability. There was no difference in the proportion of individuals with neurological abnormalities in the group with radiological abnormalities suggestive of atlantoaxial instability (6/14) compared with individuals with normal X-rays (50/123) as determined by the chi square test (0.01463: not significant). The clinical and ethical implications for screening of people with Down syndrome living in the community are discussed in view of these findings.

A community survey establishing the prevalence rate of autistic disorder in adults with learning disability

AIMS AND METHOD

Most studies into autistic disorder have concentrated on children. This study aims to establish a prevalence rate of autistic disorders in an adult population with learning disabilities. Adults accessing learning disability services were diagnosed as having an autistic disorder by a two-stage process. The first stage was screening using the Pervasive Developmental Disorder – Mental Retardation Scale and then those identified by screening were diagnosed clinically.

RESULTS

An overall population rate of 7.7/10 000 for autistic disorder was obtained, which is a prevalence rate of 30% in those with learning disability. The prevalence rate was higher in intensive service settings.

CLINICAL IMPLICATIONS

Specific funding and interventions need to be targeted for the treatment of autistic disorders.