A Randomized Phase 2 Study to Evaluate Efficacy and Safety of AR36 for Prevention of Acute Mountain Sickness

INTRODUCTION

AR36 is a pharmaceutical-grade plant extract used to support cardiovascular health in traditional Chinese medicine. Studies suggest that AR36 may prevent acute mountain sickness (AMS) during gradual ascent to high altitude. This randomized, placebo-controlled Phase 2 trial aimed to evaluate dosing regimens and assess efficacy and safety of AR36 for AMS prevention during rapid ascent.

METHODS

Participants received placebo, low-dose AR36 (225 mg twice daily for 14 d prior and 5 d at altitude), or high-dose AR36 (12 d placebo, 300 mg twice daily for 2 d prior and 5 d at altitude). The primary efficacy outcome was 1993 Lake Louise Scoring System (LLSS) score on the morning after ascent. Safety was assessed through the proportion of treatment-emergent adverse events (TEAEs).

RESULTS

One hundred thirty-two participants were randomized. Mean±SD age was 31.4±8.6 (range, 19-54) y. Baseline characteristics did not differ across groups. Lake Louise Scoring System scores on Day 16 in the placebo, low-dose, and high-dose groups were 4.03 (2.88), 4.42 (3.17), and 3.5 (2.31), respectively (placebo versus low-dose, P=0.462; placebo versus high-dose, P=0.574; n=110). The incidence of AMS on Day 16 was 66.7% in the placebo, 61.1% in the low-dose, and 55.3% in the high-dose group (P=0.66). The proportion of TEAEs in the placebo, low-dose, and high-dose groups was 38.4% (81), 28.4% (60), and 33.2% (70), respectively (P=0.205; n=127). There was no statistical difference between groups in LLSS, incidence of AMS, or TEAEs.

CONCLUSIONS

AR36 did not improve LLSS or AMS incidence using the current regimens. AR36 was well tolerated.

Electronic Patient Symptom Management Program to Support Patients Receiving Cancer Treatment at Home During the COVID-19 Pandemic

OBJECTIVES

Remote patient monitoring became critical for patients receiving cancer treatment during the COVID-19 pandemic. We sought to test feasibility of an electronic patient symptom management program implemented during a pandemic. We collected and analyzed the real-world data to inform practice quality improvement and understand the patient experience.

METHODS

Eligible patients had breast, lung, or ovarian cancers, multiple myeloma, or acute myeloid leukemia and 12 weeks of planned chemotherapy. Patients were notified that a symptom survey with common symptoms derived from the National Cancer Institute's Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events was available to complete using a smart phone, tablet, or computer. Patients recorded their symptoms and results were sent to the provider. Patients received care guidelines for mild/moderate severity symptoms and a phone call from the provider for severe reports.

RESULTS

A total of 282 patients generated > 119 088 data points. Patients completed 2860 of 3248 assigned surveys (88%), and 152 of 282 patients (54%) had symptom reports that generated an immediate notification to the provider. Longitudinal data were analyzed to determine whether previous reports predicted a notification alert and whether symptoms resolved after the alert was addressed.

CONCLUSIONS

An electronic patient symptom management program was implemented in the midst of the COVID-19 pandemic. Enrollment of 282 patients and a high survey completion (88%) demonstrated feasibility/acceptance. Patients reported symptoms at severe levels of 54% of the time and received self-management instructions and provider phone calls that resolved or decreased the severity of the symptom. A standard approach and validated instrument provide opportunities for improving and benchmarking outcomes.

Integrating touchscreen-based geriatric assessment and frailty screening for adults with acute myelogenous leukemia to drive personalized treatment decisions

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Background: AML is a disease of older adults, with median age of 68 years at presentation. NCCN guidelines suggest comprehensive geriatric assessments (GA) be included in clinical practice to guide treatment decisions. Utility of GA in older AML patients in a real-world environment is not yet established. We tested the feasibility of using a modified GA (mGA), administered by patient self-report on a touchscreen computer, real-time use and utility by clinicians and the correlation of mGA results on treatment decision-making. Methods: Sixty-two patients were recruited from three sites to complete a tablet-based mGA screening at a treatment decision-making time point. The mGA consists of the Frailty Index (FI) that includes four domains: age, activities of daily living, instrumental ADLs, and comorbidities. Falls within the past 6 months and patient reported health interference with function are also assessed. Results are displayed for the clinician to inform the treatment discussion. Results: Participants were mean age 73 years (range 61-88), 63% male, and 90% white. Frailty Index result was 32% fit, 40% intermediate, and 28% frail. Providers were asked the fit/frailty status prior to seeing the results of the mGA. Of 53 provider responses, there was 57% (n=30) provider concordance with the mGA result; 9% (n=5) said fit when mGA said intermediate and 17% (n=9) said intermediate when mGA said frail. When asked their goals of care, nearly all (n=60, 97%) patients agreed with the statement “my cancer is curable”, yet 30% (n=19) disagreed the treatment goal was to get rid of all the cancer. Nearly half (n=30) indicated they want to make treatment decisions together with the provider rather than provider or patient making decision alone. 73% (45/62) of patients were satisfied with the ease of using the survey and took an average 16.3 minutes to complete. Patient self-reported presence/severity of eight symptoms at baseline (see Table). Conclusions: A simple electronic tool may provide valuable insight into patient understanding of disease to better tailor patient-provider discussion and treatment decision-making. Providers overestimated fitness 26% of the time. Final results will be presented to include the outcome at 3 months by Frailty Index. [Table: see text]

Use of a patient-preferences shared-decision-making encounter tool in clinical practice for patients with non-Hodgkin’s lymphoma

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Background: Non-Hodgkin lymphoma (NHL) is the fourth leading cause of cancer in the United States with 77,240 new cases and 19,940 deaths annually. Treatment options are numerous and driven by patient’s molecular profile, risk, preferences/goals, and ability to tolerate treatment. Aligning physician-patient goals of care and integrating patient preferences into a shared-decision making (SDM) model allows patients and providers to select treatment consistent with medical science and personalized to each patient. This project evaluates feasibility of a patient preferences (PP) SDM encounter tool using technology to facilitate SDM at treatment decision (TD) for patients with NHL. Methods: To date, 45 patients with NHL at a TD making point were recruited from two sites to complete a tablet-based PPSDM encounter tool. The tool includes questions about needs, decision making preferences, values and goals of care. Results are reviewed by the provider and used to facilitate SDM in treatment selection during the clinical encounter. Patients also completed measures to assess satisfaction with the TD, patient activation, and perceived achievement of desired role in SDM at 3 weeks and 3 months post TD. Results: Participants are mean age 66 years (range 23-86), 53% male, and 98% white. 47% (n = 45) preferred that their doctor share responsibility with them when deciding which treatment was best for them. 69% said they would like to make the TD together with family and close friends and 69% agreed that their spouse was the most important person in helping make a TD. 51% said spirituality did not play a part in their TD. When asked how they liked to get medical information, 67% said they wanted all the facts, but not the prognosis. 87% said they had identified a medical surrogate to make decisions, yet 31% had an advanced directive on file. 64% agreed their cancer was curable and 84% agreed that a treatment goal was to get rid of all cancer. 73% of providers used the PPSDM results in conversation with the patient and 53% indicated their patient management changed based on the PPSDM results. There was 24% concordance between patient and provider perception of how TD were made. Conclusions: Collecting patient preferences, values, and care goals prior to the clinical visit using technology is feasible in busy clinics. Although most providers used the PPSDM results and over half changed their management plan, there was low concordance between patient and provider perceptions. Final analysis will include 3 week and 3 month measures of patient activation and satisfaction.

Veliparib (V) monotherapy (monoTx) following combination therapy with V + carboplatin/paclitaxel (CP) in patients with gBRCA-associated advanced breast cancer: Exploratory results from BROCADE3

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Background: In BROCADE3 (NCT02163694), addition of PARP inhibitor V to CP resulted in improved progression-free survival (PFS) (HR 0.71 [95% CI 0.57−0.88], p=0.002) in patients (pts) with advanced HER2-negative breast cancer and g BRCA1/2 mutation. A subset of pts transitioned to V/placebo (PL) monoTx at an intensified dose/schedule after CP discontinuation prior to progression (investigator discretion). Here, we evaluate the impact of this transition on efficacy and safety. Methods: Pts were randomized 2:1 to CP with V (n=337) or PL (n=172). V (120 mg po BID) or PL was given on Days (D) −2 to 5, C (AUC 6) on D1, and P (80 mg/m2) on D1, 8, and 15 (21-day cycles). Pts who transitioned to monoTx received V/PL 300-400mg BID daily until progression. A Cox model with a time varying covariate indicating transition from V/PL with CP to V/PL monoTx was fit to estimate treatment effect during combination and monoTx phases. PFS by cycles of CP prior to monoTx and AEs during monoTx are summarized. Results: A subgroup of 136 (40%) and 58 (34%) pts on the V and PL arms, respectively, received monoTx. When a Cox model with a time-varying covariate was fit for PFS (per investigator), the nominal P-value for treatment by covariate interaction was 0.038. The HRs (95% CI) for V vs PL during combination therapy and monoTx were 0.81 (0.62–1.06) and 0.49 (0.33–0.73). The Table summarizes PFS by cycles of C and/or P prior to monoTx. Common AEs (>20% of pts) during V or PL monoTx were nausea (52%/10%), fatigue (23%/12%), headache (21%/17%), and diarrhea (21%/9%). Seizures (2.2%/0%) were reported during monoTx. Rates of cytopenias for V or PL monoTx were: anemia 12%/14%; neutropenia 13%/12%; and thrombocytopenia 10%/5%. Conclusions: These analyses suggest that pts treated with V + CP derive benefit from both combination therapy as well as V monoTx after CP discontinuation. Pts receiving V monoTx after ≤ 6 cycles of VCP experienced a similar benefit to those who transitioned to monoTx after 7–12 cycles of VCP, suggesting that V maintenance therapy may be suitable following a limited duration of combination therapy. Clinical trial information: NCT02163694 . [Table: see text]

Abstract PD4-01: First-line veliparib plus carboplatin/paclitaxel in patients with HER2-negative advanced/metastatic gBRCA-associated breast cancer: Planned subgroup analysis from the phase 3 BROCADE3 trial

Background: BROCADE3 (NCT02163694) evaluated the PARP inhibitor veliparib in combination with carboplatin/paclitaxel (C/P) vs placebo + C/P in patients with HER2-negative locally advanced/metastatic breast cancer and a germline BRCA1/2 mutation. In the intent-to-treat (ITT) population, investigator-assessed median progression-free survival (PFS) was 14.5 months for veliparib vs 12.6 months for placebo (hazard ratio=0.71 [95% CI 0.57-0.88], p=0.002); 75th percentile PFS was 39.9 months for veliparib vs 20.7 months for placebo. In this preplanned analysis, we evaluated efficacy and safety of veliparib plus C/P in patients with no previous cytotoxic chemotherapy for metastatic disease.

Methods: Patients with ≤2 prior lines of cytotoxic chemotherapy for metastatic breast cancer were randomized 2:1 to C/P with veliparib or C/P with placebo. Veliparib (120 mg p.o. BID) or placebo was given on Days −2 to 5, C (AUC 6 mg/mL/min IV) on Day 1, and P (80 mg/m2 IV) on Days 1, 8, and 15 (21-day cycles). Patients who discontinued both C and P for toxicity or reasons other than disease progression could continue veliparib/placebo monotherapy until progression. Monotherapy dose was 300 mg BID, increasing to 400 mg BID if tolerated. Although randomization was not stratified by lines of prior cytotoxic chemotherapy, the treatment arms were well-balanced with respect to this baseline characteristic. The primary endpoint was PFS as assessed by investigator. Secondary endpoints included overall survival (OS), clinical benefit rate (CBR), and objective response rate (ORR). Adverse events were monitored throughout the study. Analysis of PFS in patients with no prior cytotoxic therapy for metastatic disease was pre-planned.

Results: In the ITT population, 337 patients (81% of the entire cohort) received treatment as first line and were randomized to veliparib plus C/P and 172 patients to placebo plus C/P. Most patients received prior cytotoxic chemotherapy in the neo-adjuvant/adjuvant setting (66%, placebo plus C/P; 70%, veliparib plus C/P). Among the 81% of patients in each arm who had no prior cytotoxic chemotherapy in the metastatic setting, median PFS was longer in patients receiving veliparib plus C/P compared to placebo plus C/P (16.6 mo vs 13.1 mo), and median PFS for both arms was over 1 year (Table). Proportion of patients with a serious AE was 30.9% for placebo plus C/P and 33.1% for veliparib plus C/P; proportion with an AE leading to study drug discontinuation was 10.8% for placebo plus C/P and 15.6% for veliparib plus C/P. Additional safety data will be presented.

Conclusions: In patients with HER2-negative advanced/metastatic breast cancer and a germline BRCA1/2 mutation who had no prior cytotoxic chemotherapy for metastatic disease, veliparib with C/P demonstrated an improvement in median PFS over C/P alone. This benefit was durable with 25% of patients alive and progression free at nearly 4 years.

Table. Efficacy in patients with no prior cytotoxic chemotherapy for metastatic disease.Veliparib + C/P, n=274Placebo + C/P, n=139mPFS per INV (mo, 95% CI)16.6 (13.4, 18.7)13.1 (11.4, 14.5)PFS HR (95% CI)0.69 (0.54, 0.88)PFS 75th percentile (mo, 95% CI)46.3 (29.3, NR)22.6 (16.5, 27.2)mPFS per ICR (mo, 95% CI)21.5 (18.7, 29.2)14.0 (12.5, 16.5)PFS HR (95% CI)0.63 (0.47, 0.84)PFS 75th percentile (mo, 95% CI)NR33.3 (19.7, NR)mOS (mo, 95% CI) [interim]36.0 (32.0, 43.1)29.9 (26.0, 39.3)OS HR (95% CI)0.92 (0.68, 1.2)CBR at 24 weeks (% [95% CI])92.8 (90.0, 94.9)93.4 (89.1, 96.0)ORR (% [95% CI])79.7 (74.0, 84.7)76.3 (67.4, 83.8)

C/P, carboplatin and paclitaxel; CBR, clinical benefit rate; HR, hazard ratio; m, median; mo, months; NR, not reached; ORR, objective response rate; OS, overall survival; PFS, progression-free survival; INV, investigator; ICR, independent central review.

Citation Format: Banu K. Arun, Hyo S. Han, Bella Kaufman, Hans Wildiers, Michael Friedlander, Jean-Pierre Ayoub, Shannon L. Puhalla, Bruce A. Bach, Matthew Dudley, Christine K. Ratajczak, David Maag, Véronique Diéras. First-line veliparib plus carboplatin/paclitaxel in patients with HER2-negative advanced/metastatic gBRCA-associated breast cancer: Planned subgroup analysis from the phase 3 BROCADE3 trial [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr PD4-01.

53BP1 as a potential predictor of response in PARP inhibitor-treated homologous recombination-deficient ovarian cancer

OBJECTIVE

Poly(ADP-ribose) polymerase (PARP) inhibitors have shown substantial activity in homologous recombination- (HR-) deficient ovarian cancer and are undergoing testing in other HR-deficient tumors. For reasons that are incompletely understood, not all patients with HR-deficient cancers respond to these agents. Preclinical studies have demonstrated that changes in alternative DNA repair pathways affect PARP inhibitor (PARPi) sensitivity in ovarian cancer models. This has not previously been assessed in the clinical setting.

METHODS

Clonogenic and plasmid-based HR repair assays were performed to compare BRCA1-mutant COV362 ovarian cancer cells with or without 53BP1 gene deletion. Archival biopsies from ovarian cancer patients in the phase I, open-label clinical trial of PARPi ABT-767 were stained for PARP1, RAD51, 53BP1 and multiple components of the nonhomologous end-joining (NHEJ) DNA repair pathway. Modified histochemistry- (H-) scores were determined for each repair protein in each sample. HRD score was determined from tumor DNA.

RESULTS

53BP1 deletion increased HR in BRCA1-mutant COV362 cells and decreased PARPi sensitivity in vitro. In 36 women with relapsed ovarian cancer, responses to the PARPi ABT-767 were observed exclusively in cancers with HR deficiency. In this subset, 7 of 18 patients (39%) had objective responses. The actual HRD score did not further correlate with change from baseline tumor volume (r = 0.050; p = 0.87). However, in the HR-deficient subset, decreased 53BP1 H-score was associated with decreased antitumor efficacy of ABT-767 (r = -0.69, p = 0.004).

CONCLUSION

Differences in complementary repair pathways, particularly 53BP1, correlate with PARPi response of HR-deficient ovarian cancers.

A phase 1 study of PARP-inhibitor ABT-767 in advanced solid tumors with BRCA1/2 mutations and high-grade serous ovarian, fallopian tube, or primary peritoneal cancer

Purpose This phase 1 study examined safety, pharmacokinetics (PK), and efficacy of the poly(ADP-ribose) polymerase (PARP) inhibitor ABT-767 in patients with advanced solid tumors and BRCA1/2 mutations or with high-grade serous ovarian, fallopian tube, or primary peritoneal cancer. Methods Patients received ABT-767 monotherapy orally until disease progression or unacceptable toxicity. Dose was escalated from 20 mg once daily to 500 mg twice daily (BID). Dose-limiting toxicities, recommended phase 2 dose (RP2D), food effect, objective response rate, and biomarkers predicting response were determined. Results Ninety-three patients were treated with ABT-767; 80 had a primary diagnosis of ovarian cancer. ABT-767 demonstrated dose-proportional PK up to 500 mg BID and half-life of ~2 h. Food had no effect on ABT-767 bioavailability. Most common grade 3/4 treatment-related adverse events were nausea, fatigue, decreased appetite, and anemia. Anemia showed dose-dependent increase. RP2D was 400 mg BID. Objective response rate by RECIST 1.1 was 21% (17/80) in all evaluable patients and 20% (14/71) in evaluable patients with ovarian cancer. Response rate by RECIST 1.1 and/or CA-125 was 30% (24/80) in patients with ovarian cancer. Mutations in BRCA1 or BRCA2, homologous recombination deficiency (HRD), and platinum sensitivity were associated with tumor response. Median progression-free survival was longer for HRD positive (6.7 months) versus HRD negative patients (1.8 months) with ovarian cancer. Conclusions ABT-767 had an acceptable safety profile up to the established RP2D of 400 mg BID and dose-proportional PK. Patients with BRCA1 or BRCA2 mutation, HRD positivity, and platinum sensitivity were more sensitive to ABT-767.

Phase 1 trial of linifanib (ABT-869) in patients with refractory or relapsed acute myeloid leukemia

Linifanib, a potent oral inhibitor of fms-like tyrosine kinase 3 (FLT3) and vascular endothelial growth factor receptor tyrosine kinases, has demonstrated promising preclinical single-agent and synergistic anti-leukemic activity in combination with cytarabine. In this phase 1, multicenter, open-label, dose-escalation study, 45 adults with relapsed/refractory acute myeloid leukemia (AML) received linifanib alone in arm A (n = 29) and linifanib plus intermediate-dose cytarabine in arm B (n = 16). Median treatment duration was 21 days (range 5-110). Linifanib was well tolerated overall. The most common grade 3/4 events were fatigue (arm A) and febrile neutropenia (arm B). The recommended phase 2 dose was 15 mg (alone), and 10 mg (with cytarabine). Evidence of on-target kinase inhibition in patients with FLT3-mutant and wild-type AML was seen. Decreased phosphorylated FLT3 was seen in 3/3 patients with FLT3-internal tandem duplication (ITD) with peripheral blast reductions and in 8/24 (33%) patients with wild-type, D835 or unknown FLT3 mutation. Eight/29 (28%) patients had decreased phosphorylated extracellular signal-regulated kinase (ERK).

Progress in the Preparation of Aluminum Nitride Substrates from Bulk Crystals

Large (11-mm diameter) single-crystal AlN boules have been prepared using sublimationrecondensation growth. X-ray topography shows that substrates prepared from those boules have a dislocation density of less than 500 cm-2, while the central region of these substrates was nearly dislocation-free. Rocking curves of less than 10 arcsecs have been obtained indicating the high quality of these crystals. The AlN substrates have been used to growth an AlGaN/AlN multiquantum well structure with excellent crystalline quality and with photoluminescence peaked at around 260nm. In addition, a UV LED with emission wavelength at 360nm has been fabricated. This is the first operating opto-electronic device demonstrated on an AlN substrate.

Electronic excitations in B12As2 and their temperature dependence by vacuum ultraviolet ellipsometry

The dielectric response function of epitaxial B(12)As(2) films on 4H-SiC was determined at room temperature and at 10 K in the spectral region of 3.6-9.8 eV, i.e., in the vacuum ultraviolet (VUV) spectral region, by synchrotron ellipsometry. The experimental dielectric function was simulated with the critical point parabolic band model. The parameters of the dispersive structures were derived by numerical fitting of the experimental data to the proposed model. New high energy optical transitions are resolved at 5.95, 7.8 and 8.82 eV and their lineshape and origin are discussed. The temperature dependence of the critical point energies and transition strengths was determined, and the excitonic effect is considered.

Step-controlled strain relaxation in the vicinal surface epitaxy of nitrides

On-axis and vicinal GaN/AlN/6H-SiC structures grown under identical conditions have been studied by x-ray diffraction and transmission electron microscopy to demonstrate the distinctive features of vicinal surface epitaxy (VSE) of nitrides on SiC. In VSE, the epilayers are tilted from the substrate due to the out-of-plane lattice mismatch (Nagai tilts), and the in-plane mismatch strains are more relaxed. The majority of misfit dislocations (MDs) at the vicinal AlN/6H-SiC interface are found to be unpaired partial MDs that are geometrically necessary to correct the stacking sequences from 6H to 2H. This mechanism indicates that it is possible to develop "step-controlled-epitaxy" strategies to control strain relaxation by adjusting the substrate offcut angles.

Simulation of threading dislocation images in X-ray topographs of silicon carbide homo-epilayers

Three types of dislocation are seen in homo-epilayers of SiC grown on 4H-SiC wafers with an 8° surface offcut: axial screw dislocations, basal plane dislocations propagated into the epilayer at an 8° inclination and threading edge dislocations. These types may be imaged by monochromatic synchrotron X-ray topography in the grazing-incidence reflection geometry using the 11\overline 28 reflection. Equations needed to apply the ray-tracing method of computer simulating X-ray topographic defect images in this experimental geometry were derived and used to simulate images of all three. Simulations for axial screw dislocations appear as white circles surrounded by narrow dark rings, and those for basal plane dislocations as linear white streaks, both consistent with experimental topographs. Simulations of the threading edge dislocations showed 4 µm wide white ovals with narrow arcs of dark contrast at their ends, inclined relative to the g vector of the topograph according to the sign of their Burgers vector. These images resembled the experimental topographs inasmuch as was possible at the maximum resolution of X-ray topographs.

Periorbital swelling: the important distinction between allergy and infection

Orbital cellulitis and abscess formation are rare complications of sinusitis, however acute orbital inflammation is secondary to sinusitis in about 70% of cases. Delay in diagnosis must not occur to avoid serious complications such as blindness and life threatening intracranial sepsis. A case is reported in which despite late referral, emergency surgical intervention was sight saving.

Secretory proteins in the reproductive tract of the snapping turtle, Chelhydra serpentina

SDS-polyacrylamide gel electrophoresis was used to separate the secretory proteins produced by the epithelial and endometrial glands of the uterine tube and uterus in the snapping turtle Chelydra serpentina. The proteins were analyzed throughout the phases of the reproductive cycle from May to August, including preovulatory, ovulatory, postovulatory or luteal, and vitellogenic phases. The pattern of secretory proteins is quite uniform along the length of the uterine tube, and the same is true of the uterus, but the patterns for uterine tube and uterus are clearly different. We identify 13 major proteins in C. serpentina egg albumen. Bands co-migrating with 11 of these are found in the uterine tube, but at most 4 are found in the uterus, suggesting that the majority of the albumen proteins are most likely secreted in the uterine tube, not in the uterus. Although some of the egg albumen proteins are present in the uterine tube only at the time of ovulation, most of the bands corresponding to albumen proteins are present throughout the breeding season even though the snapping turtle is a monoclutch species. These results suggest that the glandular secretory phase in the uterine tube is active and quite homogeneous in function regardless of location or phase of the reproductive cycle.

The contrast of inclusions compared with that of micropipes in back-reflection synchrotron white-beam topographs of SiC

Images of inclusions in synchrotron white-beam back-reflection X-ray topographs appear as spots of light contrast surrounded by darker rings, resembling images of micropipes, which appear as distinct white circles surrounded by dark rings. Section topographs taken across the centers of micropipes gave vertically displaced two-tailed images, arising from the helical tilt of the reflecting planes about the micropipes' screw dislocation axes. Section topographs taken across the inclusions showed no vertical displacement, only dark bars bracketing a region of depleted contrast, arising from the convex bulge of the reflecting planes lying above the inclusion. The features of the inclusion images could be reproduced in computer simulations based on the elastic displacement function of a spherical inclusion in a semi-infinite solid, and compared with others based on the displacement function of a screw dislocation in an infinite solid.

Surface-relaxation contributions to axial screw dislocation contrast in synchrotron white-beam X-ray topographs of SiC

Micropipe images appeared in synchrotron white-beam X-ray topographs of thin basal-cut SiC wafers taken using prismatic reflections whereg · b= 0. They consisted of white ovals inclined along the direction of the topographs'gvector that were terminated with dark spikes at either end. The thin wafers tended to curl; the appearance of a defect's image varied depending on the sign of the curvature relative to the side serving as the diffracted beam's exit surface. The micropipe images were computer simulated using the ray-tracing method. The calculation assumed that they arose from the surface-relaxation strain component of a closed-core screw dislocation perpendicular to the surface of a thin foil. The qualitative features of the micropipe images were reproduced in their simulations, but the magnitude of the lattice misorientations predicted by the model was not large enough to account for the size of the experimentally observed dislocation images.

Synchrotron white-beam X-ray topography of ribonuclease S crystals

With careful experimental design, indexed synchrotron white-beam X-ray topographs of ribonuclease S crystals at ambient temperature could be recorded with a definition and contrast comparable to that of monochromatic beam topographs of other proteins reported in the literature. By excluding wavelengths longer than 1 A from the white beam with a filter, a radiation dose equivalent to that required to record about 18 topographs could be tolerated without appreciable radiation damage to the samples. Bragg angles of 0.5 degrees or less were required to select low-index harmonically pure reflections with high intensities and extinction lengths only several times the sample's thickness. The resulting X-ray topographs in some cases showed topographic detail and in others showed the even featureless background that has been considered characteristic of a protein crystal of low mosaicity. The ribonuclease S crystals were well ordered single crystals of a quality comparable to other protein crystals that have been studied by X-ray topography.

Popped eye (blunt trauma leading to penetrating eye injury and lens displacement in the pseudophakic eye)

Blunt trauma to the eye of patients with an artificial intraocular lens may cause globe rupture with all the accompanying sequelae. It must be recognised promptly and dealt with appropriately before urgent referral to ophthalmology.

From efficacy to effectiveness: managing organisational change to improve health services for young people with deliberate self harm behaviour

Repeat Deliberate Self Harm is a recognised risk factor for completed suicide and therefore reduction by effective health service response represents a valid contribution to suicide prevention. However, only a small fraction of people with deliberate self harm presentations to general health settings actually reach specialist mental health follow-up appointments. Therefore, even if responses at that point are known to be effective they do not make a significant contribution to reducing repeat self-harm overall. We describe health system organisational change strategies to improve health service engagement for the target group, and present data demonstrating the effectiveness of these strategies.

X-ray topographic dislocation contrast visible in reflections orthogonal to the Burgers vectors of axial screw dislocations in hexagonal silicon carbide

Contrast is associated with micropipes in X-ray topographs of SiC crystals obtained with prismatic reflections, representing an apparent violation of theg·b= 0 invisibility criterion. This is explained as a population of basal-plane dislocations with Burgers vectors of the setb= {\textstyle{1 \over 3}}〈11{\bar{2}}0〉 that occur in a high density within a few micrometers of the micropipes, below the resolution of X-ray topography. These basal-plane dislocations could be observed under an electron microscope. The presence of the surfaces of the micropipes influences the dislocation images in the topographs taken with prismatic reflections, often resulting in a band of light contrast along the axes of the micropipes.

Forbidden X-ray wavefields of three-beam Bragg reflections from thick crystals

A detailed analysis of a three-beam diffraction dispersion surface is performed to study the forbidden wavefields of thick-crystal Bragg reflections. From the asymptotic transition between two- and three-beam diffraction, it is found that the excitation state of each wavefield can be accurately determined with the two-beam criterion. Consequently, Bragg-case three-beam diffraction from thick crystals is either a four-mode diffraction process for the Bragg-Laue geometry or a two-mode process for the Bragg-Bragg geometry, and the amplitudes of the excited wavefields can be completely determined by the entrance boundary conditions. Based on this picture, the intrinsic mechanisms underlying three-beam Bragg reflections are clearly illustrated.

Systematic process and outcome evaluation of brief staff training in psychosocial interventions for severe mental illness

This study evaluated systematically the integrity and effectiveness of a topical staff training programme. The integrity of the training was evaluated in terms of its adherence to the trainer's protocol, using an observational instrument. To assess effectiveness, multiple measures of learner satisfaction, learning, generalisation and impact were administered longitudinally to N = 45 multi-disciplinary mental health professionals in the UK. The integrity evaluation indicated that the training had been delivered appropriately. Significant effects of the training were obtained on the learning assessments (knowledge gain and skill enhancement) and on the generalisation measure. No adverse effects were found, and learner satisfaction was very favourable. The findings indicate that a brief in-service training programme can be delivered consistently and can foster good practice amongst mental health staff, leading to benefits for their clients.

Superscrew dislocation contrast on synchrotron white-beam topographs: an accurate description of the direct dislocation image

A kinematic (geometrical) diffraction simulation model has been developed to provide understanding of direct dislocation images on synchrotron white-beam X-ray topographs, and has been successfully applied to illustrate the contrast formation mechanisms involved in images of micropipe-related superscrew dislocations in silicon carbide crystals. The coincidence of the simulations with the contrast features of the superscrew dislocation images, recorded using a series of synchrotron topography techniques, shows that this model is capable of revealing the detailed diffraction behavior of the highly distorted region around the dislocation core and determining the quantitative characteristics of the dislocations. The simulation technique is thus demonstrated to be a simple but efficient method for interpretation of synchrotron topographs, and may be applied to explain the topographic contrast characters of general crystal defects.

Craniofacial trauma presenting at an adult accident and emergency department with an emphasis on soft tissue injuries

We have retrospectively compiled data on 1000 consecutive adult patients presenting at an accident and emergency department (AED) with a total of 1048 soft tissue injuries and 151 fractures to the craniofacial region, with an emphasis on soft tissue injuries. Facial injuries were common in the AED, forming 7% of all attenders. The main cause of facial fractures was assaults (56%), whereas the largest proportion of soft tissue injuries was caused by falls/ accidents (44%). There was a left sided dominance in soft tissue injuries arising from assaults. However, when subdivided into type of soft tissue injuries, the left sided dominance was significant in contusions only, with virtually equal side distribution in open wounds. Almost half of the 458 open wounds which required treatment were in the upper third of the face. Most lacerations in the upper face can be managed by steristrips or glue but most lacerations in the lower third required suturing. 90% of these injuries were treated by AED personnel. Tertiary referrals were made in only 10% of these cases.

Fish oil supplementation does not impair the gut immune response to Trichinella spiralis infection in rats

BACKGROUND

Fish oil has been recommended as a source of omega-3 fatty acids for preterm infants and for therapy of some inflammatory diseases.

METHODS

Because fish oil supplementation could downregulate the host's immune response, we studied the gut inflammatory response to an enteric infection in 72 rats assigned to three dietary groups with differing fatty acid profile: 1) fish oil, rich in eicosapentaenoic and docosahexaenoic acid; 2) olive oil, containing 71% monounsaturated fat; and 3) rat chow, containing 57% saturated fat. One half (n = 36) of the rats were infected with Trichinella spiralis larvae; the other half served as controls. The inflammatory response to initial infection (study 1), and type I hypersensitivity response to a subsequent parasite-derived antigenic challenge (study 2) were assessed. Jejunal inflammatory cell infiltrate, mean villus height, disaccharidase levels, changes in short-circuit current in response to glucose absorption, and chloride secretagogues (study 1) were measured 9 days after infection. Short-circuit current changes induced by chloride secretion were measured when the proximal jejunum was challenged with T. spiralis-derived antigen 40 days after infection (study 2).

RESULTS

In study 1, jejunal tissue from infected animals had more eosinophilic infiltrate, lower disaccharidase levels, and less glucose absorptive and chloride secretory capacity than tissue from noninfected animals. In study 2, the jejunum of infected animals showed an antigen-induced chloride secretory response, whereas no response was obtained from jejunal tissue from noninfected animals. Type of diet did not affect the response in either study.

CONCLUSION

Under the conditions of this experiment, fish oil supplementation did not interfere with the local intestinal inflammatory response after T. spiralis infection.

Harmonic composition of synchrotron white-beam X-ray topographic back-reflection images of basal-cut silicon carbide single-crystal wafers

Superscrew dislocations are visible in back-reflection synchrotron white-beam X-ray topographs of basal-cut SiC wafers in striking contrast as black rings surrounding white circles, even though such topographs suffer from extensive harmonic contamination. The contributions to the synchrotron white-beam topograph of each member of its series of harmonic reflections, {\bf g}=(0006n), where n=3 to 16, were calculated. Through intensity considerations and comparison with a {\bf g}=00018 topograph taken with Cu Kα1radiation, the {\bf g}=00024 harmonic was determined to be the most important contributor. The contrast of features lying deep beneath the crystal's surface was attributed to higher harmonics with larger penetration depths.

Coroners' records of rural and non-rural cases of youth suicide in New South Wales

OBJECTIVE

The aim of this study is to compare the frequency of certain putative risk factors for youth suicide in New South Wales (especially use of alcohol, social class, unemployment, and internal migration) in metropolitan and rural settings.

METHOD

A review of 137 files for 10-19-year-old subjects judged by the Coroner to have committed suicide in 1988-1990 was carried out.

RESULTS

One hundred and fifteen males and 21 females were identified (one subjects sex was unavailable). The male-female ratio was higher in rural (13.0) areas than non-rural (4.9 chi 2 = 12.14, p < 0.01). Of 27 subjects migrating within Australia, most migrated in a rural direction, and most to rural shires. Unemployment was somewhat more common among rural (38.5%) than non-rural (28.9%) subjects (chi 2 = 0.75, p = 0.39). Eleven of 50 non-rural parents of the deceased, but none of the 11 rural parents, were ranked as being in social classes 2 or 3. Alcohol consumption appeared more common in rural shires (44%) than metropolitan areas (32.9%), but this was not statistically significant. Medical services were less utilised prior to death in rural (15%) than non-rural (25%) areas (chi 2 = 1.69, p = 0.19), and a psychiatric diagnosis was recorded more commonly in non-rural areas.

CONCLUSIONS

Incomplete coronial file data and relatively small numbers limit this study's conclusions. Male suicides, principally by firearms, predominated in rural areas. Youth firearm access remains highly relevant to rural communities. Possible trends among rural subjects toward rural migration, higher unemployment, lower social class and lower medical attendance may point to resource deprivation among this group; these matters require further investigation.

Open reduction and bone plate stabilization, compared with closed reduction and external fixation, for treatment of comminuted tibial fractures: 47 cases (1980-1995) in dogs

OBJECTIVE

To compare open reduction and bone plate fixation with closed reduction and external skeletal fixation as treatment for severely comminuted fractures of the tibia. Limb alignment, fracture reduction, operating time, hospitalization time, postoperative care, time to unrestricted activity, bone healing, complications, and number of surgical procedures were considered.

DESIGN

Retrospective case series.

ANIMALS

47 dogs with severely comminuted fractures of the tibia treated with open reduction and bone plate application (22 dogs) or closed reduction and external fixation (25 dogs).

PROCEDURE

Medical records of all dogs included in this study were reviewed. Postoperative and follow-up radiographs were evaluated by 2 independent observers.

RESULTS

Differences were not found in hospitalization time, time to unrestricted activity, or time to earliest radiographic evidence of bone healing between dogs with fractures treated with a bone plate and dogs with fractures treated with an external fixator. Fractures treated with an external fixator had more caudal malalignment, and fractures treated with a bone plate had more valgus malalignment. Malalignments were determined not to be related to clinical problems. Dogs with fractures treated with an external fixator had shorter surgery times and more recheck examinations. Dogs with fractures treated with a bone plate had more complications.

CLINICAL IMPLICATIONS

Open reduction with bone plate fixation and closed reduction with external fixation were both effective for treatment of comminuted tibial fractures. External fixation was associated with shorter surgery time, but dogs required more extensive postoperative care. Bone plate fixation was associated with more complications.

Assessment of the value of technician reporting of electrocardiographs in an accident and emergency department

OBJECTIVE

To assess the value of a cardiac technicians' report on electrocardiographs (ECGs) in reducing serious errors of interpretation by senior house officers.

METHODS

A parallel study of interpretation of ECGs by senior house officers from 238 cases seen in an accident and emergency (A&E) department in a teaching hospital. 129 ECGs were reported by a cardiac technician at the time of recording and before the senior house officer wrote a report, and 109 were reported only by the senior house officers. Misinterpretations by doctors and technicians were graded by a consultant cardiologist on a four point scale and compared in the two groups. Serious errors (grade 4) were defined as those which potentially affected immediate management.

RESULTS

The number of grade 4 errors of interpretation of ECGs by A&E senior house officers was reduced by 59% when there was a prior technical report (mean (SD), 18(17)% v 6 (7%); Fisher's exact test P < 0.05).

CONCLUSIONS

When cardiac technicians provide a report on an ECG at the time of its recording, serious errors of interpretation by senior house officers are reduced.

Suicide among young rural Australians 1964-1993: a comparison with metropolitan trends

The study tested hypotheses that from 1964 to 1993: (1) suicide rates among Australian 15- to 24-year-old males rose more sharply in rural than metropolitan areas; (2) firearm suicide rates among 15- to 24-year-old males, declining throughout Australia recently, rose continuously in rural areas; (3) suicide rates among 15- to 24-year-old females did not change significantly in either metropolitan or rural areas. Suicides of those aged 10-24 years recorded by the Australian Bureau of Statistics (ABS) were classified according to the subject's residential grouping. Rates were calculated using ABS population data corresponding to these groupings. Results were analysed using log-linear analysis and chi-square statistics. The results supported the first two hypotheses, but not the third. Suicide rates for 15- to 24-year-old males rose by a factor of 2.2 in metropolitan areas, by 4-fold in towns with populations between 4,000 and 25,000, and by 12-fold in towns with populations less than 4,000. Male firearm suicide rates continued to rise in rural areas, and the greatest proportion of deaths in those locations were by firearms, though male hanging rates increased most in recent years in all locations. Female youth suicide rates did not change overall, but in towns with populations less than 4,000, they increased 4.5-fold. Possible explanations for this epidemic, which are mostly speculative and require confirmation, are discussed.

IV. An account of insects in the barks of decaying elms and ashes

About 5 or 6 years since, l removed divers Elms, more than six inches Diameter, which for the first two or three years all thrived very well; but two or three years ago there happening a very dry time in <italic>July</italic> or <italic>August</italic>, I observed one of those Elms, which stood very shallow, and on pretty high ground, looked very sick; the Leaves turned yellow, and began to fall off; which made me with a Knife examine the Bark.

Jumping the gun: firearms and the mental health of Australians

OBJECTIVES

The aims of this study were to (i) survey mental health-related correlates of firearms ownership and availability in Australia, and (ii) assess possible causal relationships between civilian gun deaths, gun availability and mental disorders.

METHOD

Available data regarding firearms ownership, injuries and deaths were reviewed as well as studies of (i) gun ownership, suicide and homicide, and (ii) gun control laws and suicide.

RESULTS

Findings indicated that 85% of firearm deaths are triggered by distress, as opposed to crime. Most firearm homicides are intrafamilial or involve familiar persons. Firearm suicide rates, although tapering off in recent years, continue to rise among certain groups. It was also found that: (1) Beyond reasonable doubt, a causal relationship exists between gun ownership and firearm suicides and homicides. The role of method substitution is controversial, but is probably less important among the young. (2) Outside the United States, legislation may be useful in reducing firearm and possibly overall suicide rates. (3) If firearm owners are representative of the community, then 15-20% suffer from a psychiatric disorder at any time. While a modest increase in risk of firearms misuse exists for this group, especially those with a history of substance abuse or violence, concern also arises regarding those with mental disorders who access firearms because owners have not secured them. No uniform definition or way of verifying self-reports exists for gun licence applicants regarding these issues.

CONCLUSIONS

Further regulation of firearm safety and availability is warranted. Public health measures include improved surveillance regarding firearm events, advocacy for appropriate firearm legislation, and better education and communication about firearms.

Bacterial resistance mechanisms to beta-lactam antibiotics: assessment of management strategies

Several mechanisms render antimicrobials inactive; one of these, beta-lactamase hydrolysis of beta-lactam antimicrobials, is a common and serious problem resulting in loss of antimicrobial activity. Resistance in gram-negative organisms may be caused by chromosomally or plasmid-mediated beta-lactamases. Chromosomally mediated resistance may result from exposure to inducer compounds (induction) or by selection of stably derepressed mutants. Plasmids are extrachromosomal elements of DNA that can transfer resistance between bacteria. Common plasmid-encoded beta-lactamases are the TEM- and SHV-type enzymes, which include the newer extended-spectrum beta-lactamases. Infections caused by resistant bacteria frequently result in longer hospital stays, higher mortality, and increased cost of treatment. When bacteria develop resistance during antimicrobial therapy, therapeutic failure ensues in approximately 50% of patients. Clinical studies demonstrate that resistance mediated by beta-lactamases is a critical issue. Strategies for overcoming it include use of beta-lactam-beta-lactamase inhibitor combinations, development of new antimicrobial compounds, and use of regimens that optimize in vivo exposure to drug.