Predictors of favorable outcome after pyloroplasty for gastroparesis: should response to pyloric dilation or Botox injection be used as a marker of surgical outcome?

INTRODUCTION

Pyloroplasty and gastric peroral endoscopic myotomy (G-POEM) are effective surgeries for gastroparesis. The primary aim of this study was to evaluate outcomes of pyloroplasty and G-POEM in patients with gastroparesis and determine factors associated with favorable outcome. The secondary aim was to assess the utility of clinical response to preoperative pyloric dilation or botulinum toxin injection (Botox) on surgical outcome, a factor conventionally used as a favorable marker.

METHODS

There were 204 patients who underwent pyloroplasty (n = 177) or G-POEM (n = 27) for gastroparesis at our institution from 2014 to 2021. Demographic and clinical parameters were analyzed to assess their impact on surgical outcome. A subgroup of patients who had pyloric dilation or Botox injection were assessed separately. Favorable outcome was defined as patient reported complete resolution of the predominant gastroparesis symptom.

RESULTS

Favorable outcome was achieved in 78.4% of patients (pyloroplasty: 79.7% and G-POEM: 70.4%, p = 0.274). Among 61 patients where pre- and postoperative gastric emptying studies (GES) were available, mean 4-hour retention significantly improved from 33.5 to 15.0% (p < 0.001) and 77.0% of patients achieved normalization. Favorable outcome was not significantly impacted by etiology of gastroparesis (p = 0.120), GERD (p = 0.518), or primary gastroparesis symptom (p = 0.244). Age ≥ 40 was a significant predictor of favorable surgical outcome on multivariate analysis [OR: 2.476 (1.224-5.008), p = 0.012]. Among the patients who had preoperative dilation (n = 82) or Botox injection (n = 46), response to these interventions was not a predictor of favorable surgical outcome (p = 0.192 and 0.979, respectively). However, preoperative Botox injection, regardless of response to injection, was associated with favorable surgical outcome [OR: 3.205 (CI 1.105-9.299), p = 0.032].

CONCLUSION

Symptomatic improvement after pyloroplasty or G-POEM is independent of etiology of gastroparesis, GERD, and primary symptom. Response to dilation or Botox are not markers of response to surgery. However, patients who receive Botox are 3.2 times more likely to improve postoperatively.

Experimental testing of a prototype cantilevered liquid-nitrogen-cooled silicon mirror

This report presents testing of a prototype cantilevered liquid-nitrogen-cooled silicon mirror. This mirror was designed to be the first mirror for the new soft X-ray beamlines to be built as part of the Advanced Light Source Upgrade. Test activities focused on fracture, heat transfer, modal response and distortion, and indicated that the mirror functions as intended.

POS1189 THE IMPACT OF TELEMEDICINE AND COVID-19 ON A TERTIARY RHEUMATOLOGY SERVICE: A RETROSPECTIVE AUDIT

Background:

Telemedicine was widely utilised to complement face-to-face (F2F) care in 2020 during the COVID-19 pandemic, but the impact of this on patient care is poorly understood.

Objectives:

To investigate the impact of telemedicine during COVID-19 on outpatient rheumatology services.

Methods:

We retrospectively audited patient electronic medical records from rheumatology outpatient clinics in an urban tertiary rheumatology centre between April-May 2020 (telemedicine cohort) and April-May 2019 (comparator cohort). Differences in age, sex, primary diagnosis, medications, and proportion of new/review appointments were assessed using Mann-Whitney U and Chi-square tests. Univariate analysis was used to estimate associations between telemedicine usage and the ability to assign a diagnosis in patients without a prior rheumatological diagnosis, the frequency of changes to immunosuppression, subsequent F2F review, planned admissions or procedures, follow-up phone calls, and time to next appointment.

Results:

3,040 outpatient appointments were audited: 1,443 from 2019 and 1,597 from 2020. There was no statistically significant difference in the age, sex, proportion of new/review appointments, or frequency of immunosuppression use between the cohorts. Inflammatory arthritis (IA) was a more common diagnosis in the 2020 cohort (35.1% vs 31%, p=0.024). 96.7% (n=1,444) of patients seen in the 2020 cohort were reviewed via telemedicine. In patients without an existing rheumatological diagnosis, the odds of making a diagnosis at the appointment were significantly lower in 2020 (28.6% vs 57.4%; OR 0.30 [95% CI 0.16-0.53]; p<0.001). Clinicians were also less likely to change immunosuppressive therapy in 2020 (22.6% vs 27.4%; OR 0.78 [95% CI 0.65-0.92]; p=0.004). This was mostly driven by less de-escalation in therapy (10% vs 12.6%; OR 0.75 [95% CI 0.59-0.95]; p=0.019) as there was no statistically significant difference in the escalation or switching of immunosuppressive therapies. There was no significant difference in frequency of follow-up phone calls, however, patients seen in 2020 required earlier follow-up appointments (p<0.001). There was also no difference in unplanned rheumatological presentations but significantly fewer planned admissions and procedures in 2020 (1% vs 2.6%, p=0.002). Appointment non-attendance reduced in 2020 to 6.5% from 10.9% in 2019 (OR 0.57 [95% CI 0.44-0.74]; p<0.001), however the odds of discharging a patient from care were significantly lower in 2020 (3.9% vs 6%; OR 0.64 [95% CI 0.46-0.89]; p=0.008), although there was no significance when patients who failed to attend were excluded. Amongst patients seen via telemedicine in 2020, a subsequent F2F appointment was required in 9.4%. The predictors of needing a F2F review were being a new patient (OR 6.28 [95% CI 4.10-9.64]; p<0.001), not having a prior rheumatological diagnosis (OR 18.43 [95% CI: 2.35-144.63]; p=0.006), or having a diagnosis of IA (OR 2.85 [95% CI: 1.40-5.80]; p=0.004) or connective tissue disease (OR 3.22 [95% CI: 1.11-9.32]; p=0.031).

Conclusion:

Most patients in the 2020 cohort were seen via telemedicine. Telemedicine use during the COVID-19 pandemic was associated with reduced clinic non-attendance, but with diagnostic delay, reduced likelihood of changing existing immunosuppressive therapy, earlier requirement for review, and lower likelihood of discharge. While the effects of telemedicine cannot be differentiated from changes in practice related to other aspects of the pandemic, they suggest that telemedicine may have a negative impact on the timeliness of management of rheumatology patients.

Disclosure of Interests:

None declared.

Multifactorial dysphagia: Azygos vein aneurysm (AVA) and esophagogastric junction outflow obstruction (EGJOO)

Introduction

Vascular impingement of the esophagus is a rare cause of dysphagia, and is most commonly due to aortic arch anomalies such as arterial lusoria. Dysphagia resultant from venous compression is even further less likely.

Presentation of case

We present a highly unusual case of dysphagia secondary to a large aneurysm of the azygous vein near its confluence with the superior vena cava, which was managed with endovascular modalities. Despite initial treatment success, patient reported some intermittent solid food dysphagia, and was also found to have esophagogastric junction outflow obstruction (EGJOO) on high resolution impedance manometry (HRIM) which was successfully managed with surgical myotomy and partial fundoplication.

Discussion

The azygos vein has an intimate anatomic relationship with the esophagus as it traverses the posterior mediastinum. Because of this anatomic association, the azygos vein may present a point of esophageal obstruction in the setting of significant pathology.

Conclusion

This case highlights the possibility of multifactorial causes of dysphagia, and that HRIM is a key aspect of this workup. Additionally we discuss the pertinent anatomy, diagnosis, and treatments for azygos vein aneurysm and EGJOO.

•

Vascular impingement of the esophagus is a rare cause of dysphagia.

•

This type of dysphagia is most commonly due to aortic arch anomalies such as arterial lusoria.

•

The azygos vein may present a point of esophageal obstruction in the setting of significant pathology.

•

Endovascular therapy in selected patients can provide resolution of dysphagia in patients with azygos vein aneurysm.

•

There is possibility of multifactorial causes of dysphagia, and high resolution manometry is a key aspect of this workup.

SAT0067 SEVERE INFECTIONS REMAIN COMMON IN A REAL-WORLD RHEUMATOID ARTHRITIS COHORT: A SIMPLE CLINICAL MODEL TO PREDICT INFECTION RISK

Background:

Patients with rheumatoid arthritis (RA) have a higher risk of infection due to immunological dysfunction, immunosuppressive use, and coexisting comorbidities1. An understanding of these risk factors has helped develop infection risk calculators2. However, there are currently no screening tools available torapidlyidentify patients with high infection risk.

Objectives:

To investigate the incidence of severe infection in a real-world RA cohort, identify associated risk factors, and propose a simple infection risk screening tool.

Methods:

Between January and July 2019, patients were recruited consecutively from an Australian tertiary hospital’s RA clinic. We included all adult patients with RA. The primary outcome was a severe infection (any infection requiring hospital admission) between January 2018 and July 2019. We collected data using hospital notes, medical records and pathology results. We used validated scores such as the disease activity score of 28 joints (DAS28) and the Charlson comorbidity index to assess disease activity and comorbidity burden. Multivariable regression was used for statistical analysis.

Results:

We recruited 263 eligible patients. 45 severe infections occurred in 34 patients (13%), corresponding to 10.8 infections per 100 patient years. Respiratory (53%) and urinary tract infections (13%) were the most common. On multivariable analysis, the most significant risk factors for severe infection included low lymphocyte counts (odds ratio (OR) 4.08), a previous infection within the last three years (OR 3.58), a Charlson comorbidity index of two or more (OR 2.69) and higher disease activity (OR 1.35 per 0.5-increase in DAS-28). The multivariable model incorporating these factors had a large area under receiver operating characteristic (ROC) curve of 0.82. Glucocorticoid and biologic use were not significantly associated with infection.

Conclusion:

To our knowledge, this was one of the first Australian studies to evaluate severe infection rates in a real-world RA cohort. Rates remained high and comparable with older studies3. Lymphopenia, high disease activity, comorbidity burden and a previous infection were independent risk factors for infection. Our multivariable model is a composite of easily assessible clinical and biological parameters, with excellent predictive potential for infection. Once validated, it may be developed into a screening tool to help clinicians rapidly identify high risk patients and inform tailored clinical decision making.

References:

[1] Listing J, Gerhold K, Zink A. The risk of infections associated with rheumatoid arthritis, with its comorbidity and treatment. Rheumatology. 2012;52(1):53-61.

[2] Strangfeld A, Eveslage M, Schneider M, Bergerhausen HJ, Klopsch T, Zink A, et al. Treatment benefit or survival of the fittest: What drives the time-dependent decrease in serious infection rates under TNF inhibition and what does this imply for the individual patient? Ann Rheum Dis. 2011;70(11):1914-20.

[3] Doran MF, Crowson CS, Pond GR, O’Fallon WM, Gabriel SE. Frequency of infection in patients with rheumatoid arthritis compared with controls: A population-based study. Arthritis Rheum. 2002;46(9):2287-93.

Table 1.

Cohort Demographics

CharacteristicMedian (Interquartile Range) or Number (%)Age (years)62 (50-70)Sex (female)191 (73)Length of diagnosis (years)9 (5-18)Biologic use over study period106 (40)Steroid use over study period77 (29)Charlson comorbidity index (excluding age)0 (0-1)Table 2.

multivariable logistic regression model for severe infection

VariablesOdds RatiopvalueAge ≥50*0.600.368Charlson comorbidity index (≥2)2.690.043Previous severe infection in last 3 years3.580.015Disease activity score of 28 joints (per 0.5 increase)1.350.005Low lymphocyte counts (<1)4.080.028

*Age was included despite insignificance due to ana prioridecision about its clinical relevance

Figure 1.

Receiver operating characteristic curve (ROC) of the multivariable model for infection

Disclosure of Interests:

None declared

The sustainable development goals provide an important framework for addressing dangerous climate change and achieving wider public health benefits

OBJECTIVES

To suggest how public health systems and the health sector can utilise the United Nation (UN) sustainable development goals (SDGs) to address climate change and other threats to future health and deliver immediate public health benefits.

STUDY DESIGN AND METHODS

We examined UN and World Health Organisation guidance on SDGs and other published texts on systems thinking, integration, universality and co-benefits.

RESULTS AND CONCLUSIONS

The UN SDGs are a set of globally agreed objectives to end poverty, protect all that makes the planet habitable and ensure that all people enjoy peace and prosperity. The SDGs integrate the three dimensions of sustainable development (economic, environmental and social), they apply to high-income countries as well as developing countries and there are mechanisms to hold countries to account. There are three crucial issues for public health. First, a systems approach to future proof health and social justice. Second, an evidence-based approach to aid communication, framing and engagement. And, third, the importance of interventions that deliver health co-benefits (i.e. both immediate and long-term benefits to health, equity and prosperity). The SDGs present public health professionals with an important opportunity to create the right conditions for a better future through the organised efforts of society.

Public health outcome of Tuberculosis Cluster Investigations, England 2010-2013

OBJECTIVES

Tuberculosis (TB) is a serious re-emergent public health problem in the UK. In response to rising case incidence a National TB Strain-Typing Service based on molecular strain-typing was established. This facilitates early detection and investigation of clusters, targeted public health action, and prevention of further transmission. We review the added public health value of investigating molecular TB strain-typed (ST) clusters.

METHODS

A structured questionnaire for each ST cluster investigated in England between 1 January 2010 and 30 June 2013 was completed. Questions related to epidemiological links and public health action and the perceived benefits of ST cluster investigation.

RESULTS

There were 278 ST cluster investigations (CIs) involving 1882 TB cases. Cluster size ranged from 2 to 92. CIs identified new epidemiological links in 36% of clusters; in 18% STs were discordant refuting transmission thought to have occurred. Additional public health action was taken following 23% of CI.

CONCLUSIONS

We found positive benefits of TB molecular ST and CI, in identifying new epidemiological links between cases and taking public health action and in refuting transmission and saving resources. This needs to be translated to a decrease in transmission to provide evidence of public health value in this low prevalence high resource setting.

Provision of cellular blood components to CMV-seronegative patients undergoing allogeneic stem cell transplantation in the UK: survey of UK transplant centres

OBJECTIVES

To identify current UK practice with regards to provision of blood components for cytomegalovirus (CMV)-seronegative, potential, allogeneic stem cell recipients of seronegative grafts.

BACKGROUND

Infection with CMV remains a major cause of morbidity and mortality after allogeneic stem cell transplantation (aSCT). CMV transmission has been a risk associated with the transfusion of blood components from previously exposed donors, but leucocyte reduction has been demonstrated to minimise this risk. In 2012, the UK Advisory Committee for the Safety of Tissues and Organs (SaBTO) recommended that CMV-unselected components could be safely transfused without increased risk of CMV transmission.

METHODS

We surveyed UK aSCT centres to establish current practice.

RESULTS

Fifteen adult and seven paediatric centres (75%) responded; 22·7% continue to provide components from CMV-seronegative donors. Reasons cited include the continued perceived risk of CMV transmission by blood transfusion, its associated morbidity and concerns regarding potential for ambiguous CMV serostatus in seronegative potential transplant recipients due to passive antibody transfer from CMV-seropositive blood donors, leading to erroneous donor/recipient CMV matching at transplant.

CONCLUSIONS

The survey demonstrated a surprisingly high rate (22.7%) of centres continuing to provide blood components from CMV-seronegative donors despite SaBTO guidance.

Discordance of patient and physician health status concerns in systemic lupus erythematosus

Objectives To compare the health status concerns of patients with systemic lupus erythematosus (SLE) and of their physicians. Methods Cross-sectional questionnaire study of SLE patients and their treating physicians at a tertiary disease-specific outpatient clinic. Patients and physicians completed a questionnaire regarding their concern about specific disease manifestations and impact on quality of life. For each item, degree of concern was rated on a five-point Likert scale and summarized as median (interquartile range). Ratings between patients and physicians were compared using Mann-Whitney U tests. Results A total of 84 patients and 21 physicians participated. Patients' predominant concerns centred on function and fatigue, whereas physicians' concerns focused on SLE-related organ complications. Of the 10 highest ranked patient concerns, only two were common to the 10 highest ranked physician concerns, while physicians rated seven significantly differently; all 10 highest ranked physician concerns were rated significantly lower by patients. The three highest ranked patient concerns (fatigue, pain and feeling worn out) were routinely assessed by 47.6%, 42.9% and 9.5% of physicians, respectively. Conclusion There was significant discordance between SLE patient and physician health status concerns. Items which were ranked highly by patients were not assessed consistently by physicians, highlighting a significant gap in healthcare communication.

Abstract P3-10-09: Predictors of social support among newly diagnosed breast cancer patients seeking care at an urban safety net academic medical center

Background:

Disparities in breast cancer care are a worsening problem, requiring effective interventions that seek to address the delivery of high quality cancer care. Evidence from interventions designed to improve timeliness of care routinely identify lack of social support as one of the biggest barriers to care. And, social support is associated with adherence to treatment and survival. This study explores predictors of social support in a diverse population of cancer patients.

Patients and Methods:

This is a secondary analysis of baseline preliminary data from participants enrolled in Project SUPPORT, a randomized controlled comparative effectiveness trial designed to evaluate the impact of patient navigation with or without legal support and services, among women diagnosed with Stages 0-4 breast cancer between 2014-2016. Upon enrollment (within one month of a cancer diagnosis) we administered the Medical Outcomes Survey (MOS) of social support to all participants. This validated survey tool addresses functional support, including an overall score (range 0-95) and 4 distinct domains: Emotional/Informational, Tangible, Affectionate and Positive Social Interaction. Using chi-squared and t-tests we compared MOS scores across socio-demographic variables: age, race, language, insurance, health literacy and marital status.

Results:

Of the 103 participants, mean age is 54.5 (SD = 10.6); 56% Hispanic, 19% Black, and 22% White and 2% identified as other; the majority had public insurance 76%; 66% speak English, 21% Spanish and 13% Haitian Creole. Only 36% have adequate health literacy as measured by the BRIEF. Only 32% are currently partnered. The overall mean total score for social support is 75.8 (+/- 23.6), median of 78.9 (range 60.5 – 98.7). Participants scored lowest in tangible support (mean score 67.7 +/- 33.1) and highest in affective support (83.5 +/- 25.8). Non-White participants scored significantly lower across all domains (mean overall MOS score 73.3 +/- 2.6) when compared with Whites (mean overall MOS score 84.5 +/- 4.8, p value = 0.04). There were no differences in MOS scores by language, insurance, literacy or marital status.

Conclusion:

This is the first study to describe social support scores (overall and specific domains) from the validated MOS survey tool among a racially diverse, urban cancer patient population. We found significant differences by race. Studies to identify risks for low social support can help inform future targeted interventions.

Citation Format: Ko NY, Festa K, Gunn C, Bak S, Wang N, Nelson K, Flacks J, Morton S, Battaglia TA. Predictors of social support among newly diagnosed breast cancer patients seeking care at an urban safety net academic medical center [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-10-09.

Does attending general practice prior to the emergency department change patient outcomes? A descriptive, observational study of one central London general practice

BACKGROUND

The challenge of keeping Emergency Department (ED) attendances down continues and timely access to general practice (GP) is often portrayed as a potential solution.

SETTING

One London general practice (registered population = 4900).

QUESTION

Does seeing a GP before attending the ED affect the outcome of a patient's ED care?

METHODS

Routine clinical data were extracted using SystmOne primary care computer system for all registered patients with an ED attendance between 1 October 2014 and 31 September 2015. The scanned discharge summaries from the ED and GP notes were reviewed and outcome measures extracted.

RESULTS

227 patients (121 female; 104 male) attended the ED. The most common presentation was abdominal pain (n = 11). 25% of patients had seen (n = 50), or contacted by phone (n = 6), a GP about the same presenting complaint before attending the ED. Of those, 73% (n = 41/56) were referred to the ED and 49% (n = 20/41) were admitted versus 33% (n = 60/184) who self-presented (statistically significant, p = 0.05). An additional 32% of those who saw the GP first (n = 13/41) received specialist ED treatment.

DISCUSSION/CONCLUSION

Only 25% of patients see their GP prior to attending the ED. The majority of patients who were referred by their GP required admission or specialised ED treatment. It remains unclear why the majority of patients did not choose to contact their GP prior to attending the ED, despite urgent appointments being offered; research into patients' health beliefs in this group is required for greater understanding.

Healthcare use among preschool children attending GP-led urgent care centres: a descriptive, observational study

OBJECTIVE

Urgent care centres' (UCCs) hours were developed with the aim of reducing inappropriate emergency department (ED) attendances in England. We aimed to examine the presenting complaint and outcomes of care in 2 general practitioner (GP)-led UCCs with extended opening times.

DESIGN

Retrospective observational epidemiological study using routinely collected data.

SETTING

2 GP-led UCCs in London, colocated with a hospital ED.

PARTICIPANTS

All children aged under 5 years, attending 2 GP-led UCCs over a 3-year period.

OUTCOMES

Outcomes of care for the children including: primary diagnosis; registration status with a GP; destination following review within the UCC; and any medication prescribed. Comparison between GP-led UCC visit rates and routine general practices was also made.

RESULTS

3% (n=7747/282 947) of all attenders at the GP-led UCCs were children aged under 5 years. The most common reason for attendance was a respiratory illness (27%), followed by infectious illness (17%). 18% (n=1428) were either upper respiratory tract infections or viral infections. The majority (91%) of children attending were registered with a GP, and over two-thirds of attendances were 'out of hours'. Overall 79% were seen and discharged home. Preschool children were more likely to attend their GP (47.0 per 100) than a GP-led UCC (9.4 per 100; 95% CI 8.9 to 10.0).

CONCLUSIONS

Two-thirds of preschool children attending GP-led UCCs do so out of hours, despite the majority being registered with a GP. The case mix is comparable with those presenting to an ED setting, with the majority managed exclusively by the GPs in the UCC before discharge home. Further work is required to understand the benefits of a GP-led urgent system in influencing future use of services especially emergency care.

What do patients really know? An evaluation of patients' physical activity guideline knowledge within general practice

Background

Physical inactivity is well recognised as one of the leading causes of preventable death. However, little is known about the general public’s knowledge surrounding national physical activity guidelines, particularly within general practice (GP).

Setting

Two GPs (York and Maidenhead, UK).

Question

Are GP patients aware of the national physical guidelines? Also, are health care professionals routinely raising the issue of physical inactivity and would patients welcome support from health care professionals regarding inactivity?

Methodology

A questionnaire was distributed in two GPs over a one-week period to evaluate patients knowledge of the national physical activity guidelines.

Results

Ninety-four participants completed the questionnaire over one week (60 female; 34 male), with an average age of 54.2 (standard deviation: 19.9 years). 14% (95% Confidence Interval (CI): 8–22%) of the total participants correctly knew the recommended national guidelines for physical activity. 52% (95% CI: 42–63%) recalled being asked by a health care professional about their activity levels. 46% (95% CI: 35–56%) would welcome support from a health care professional around improving their activity levels.

Discussion/Conclusion

Only 14% of responders correctly knew the current national minimum activity guidelines. Encouragingly 46% of participants in our study were interested in physical activity advice from a health care professional. Health care professionals need to be aware that many patients do not know the current physical activity guidelines and recognise that primary care may be an underutilised opportunity to educate and promote physical activity.

Wheelchair-mounted robotic arm to hold and move a communication device - final design

At the 51st Rocky Mountain Bioengineering Symposium we presented a preliminary design for a robotic arm to assist an individual living within an assistive technology smart home. The individual controls much of their environment with a Dynavox Maestro communication device. However, the device obstructs the individual’s line of site when navigating about the smart home. A robotic arm was developed to move the communication device in and out of the user’s field of view as desired. The robotic arm is controlled by a conveniently mounted jelly switch. The jelly switch sends control signals to a four state (up, off, down, off) single-axis robotic arm interfaced to a DC motor by high power electronic relays. This paper describes the system, control circuitry, and multiple safety features. The arm will be delivered for use later in 2015.

Presentation of a benign fibroepithelial polyp with frank haematuria: an unusual diagnosis

INTRODUCTION

Fibroepithelial polyps are rare benign lesions which can mimic malignant disease symptomatically and radiologically. They should form part of the differential diagnosis in patients presenting with frank haematuria but they can present a diagnostic dilemma for clinicians.

CASE PRESENTATION

This is a case of a 30-year-old female who initially presented with a small palpable urethral lump, thought to be a urethral caruncle by her general practitioner, obstructive voiding and intermittent frank painless haematuria. A rigid cystoscopy identified a polypoid lesion protruding out of the left ureteric orifice. This was resected and pathology showed it to be a fibroepithelial polyp. A post-operative computerized tomography scan showed no hydronephrosis on either side and no lymphadenopathy was identified but the distal left ureter could not be visualised. Further resection with a flexible ureteroscopy confirmed the presence of a benign fibroepithelial polyp and the stalk remnant was ablated with a laser.

CONCLUSION

Fibroepithelial polyps mimic malignant disease symptomatically and radiologically and need to be considered in the differential diagnosis of frank haematuria.

Wheelchair-mounted robotic arm to hold and move communication device

Some individuals with disabilities who use wheelchairs utilize communication devices to control their environment. Such devices are typically mounted on a fixed arm in a manner that obstructs the line of sight of a user when navigating the wheelchair. Some individuals with disabilities who utilize wheelchairs have limited or no control of arm or head movement. Design of a user-controlled robotic arm which moves the communication device in and out of the user’s line of sight would enable navigation of the wheelchair without removal of the communication device. Such a robotic device will be controlled by a push-button jelly switch. Positioning of this activation device will be located behind the user’s left elbow. Design of a single-axis, rotary robotic arm to be installed on a Quantum Q6 Edge wheelchair is ongoing, and will be completed by February 2014. A working prototype will be completed before April 2014. It is expected that upon completion of the robotic arm, the device will successfully move an 8 lb. Dynavox Maestro communication device in and out of a user’s line of sight by single-switch activation initiated by a user. The design presented in this report is patent pending.

Wrist/Arm support to assist in fine motor control for essential tremor patients

Steady-state hand tremors tend to exhibit simple harmonic motion associated with frequencies of 2-11 Hz, and maximum amplitudes of 7.8 inches. Tremors often present difficulties in applications dependent on fine motor control. A wrist/arm constraint is being designed to minimize the difficulty of performing fine motor functions via amplitude and frequency reduction of the hand tremor. Tremor amplitude and frequency reduction can be achieved by utilizing mechanical dampers as well as viscoelastic materials to cradle the wrist and hand. The goal of this project is to design a mechanical, table-mounted wrist cradle with a damped natural frequency lower than the tremor frequency. This project is being designed for a specific person with tremor frequency of 5-6 Hz and peak-to-peak amplitude of 2.5 inches. These specifications will enable the user to touch a 1 inch by 1 inch icon on a touchscreen tablet device. The design team for this project consisted of senior Mechanical Engineering students from the University of Wyoming. Funding for this project is provided by NSF-BME-RAPD Grant 0962380.

Alpidem and Lorazepam in the Treatment of Patients with Anxiety Disorders: Comparison of Physiological and Psychological Effects

The physiologcal and psychological effects of the novel imidazo-pyridine alpidem were compared with those of the benzodiazepine lorazepam in the context of a clinical trial. Twenty-three psychiatric out-patients with generalised anxiety disorder received alpidem (mean dose 112.5 mg daily) or lorazepam (mean 3.5 mg daily) in doses adjusted to clinical need under double-blind conditions. A battery of tests was performed before and after four weeks treatment. Anxiety scores improved very significantly in both groups with no subjective sedation nor other particular side-effects noted in either group. However, lorazepam reduced the EEG averaged evoked response and produced significant impairment in the reaction time and memory tests whereas alpidem had no such effects. Alpidem therefore shows promise as an effective anxiolytic devoid of the adverse psychomotor and cognitive effects often associated with the benzodiazepines.

Electromigration of microspheres in ferroelectric smectic liquid crystals

When an electric field is applied to microspheres which are dispersed in a ferroelectric smectic liquid crystal, particle translation along the smectic layer plane, i.e., in a direction nearly perpendicular to that of the director, can be observed. Under certain electric field conditions the translation is shown to be linear in time. We have determined the stability regime of linear particle displacement in the parameter space of amplitude and frequency for various applied wave forms. This regime enlarges for increasing electric field amplitude and frequency, with a threshold behavior observed for small parameters. The upper stability boundary is related to the reciprocal ferroelectric switching time. The microspheres translational velocity is independent of the applied electric field amplitude, but increases linearly with applied frequency. The microsphere velocity also increases with increasing temperature, which is indicative of the respective decrease in liquid crystal viscosity. Possible mechanisms of electric-field-induced particle motion are discussed.

Paediatricians' attitudes about discussing maternal depression during a paediatric primary care visit

OBJECTIVES

To assess paediatricians' beliefs about discussing maternal depressive symptoms during a paediatric visit, and methods paediatricians use to identify mothers with depressive symptoms.

METHODS

In-depth telephone interviews were conducted with 23 primary care paediatricians from a practice-based research network. We asked a series of previously developed questions about discussing maternal depressive symptoms during a paediatric visit; methods used to identify mothers at risk; barriers encountered, and potential strategies to improve recognition and treatment of maternal depression. Interviews were audiotaped and transcribed. Data were codified and analysed using standard qualitative data techniques.

RESULTS

All paediatricians agreed that it is appropriate to ask mothers about their own health during a well-child visit, because a mother's well-being affects her children. Paediatricians relied on observational cues to identify a mother with depressive symptoms, especially mother-child interactions. Few used direct questions or a checklist. Almost all paediatricians felt that lack of time was the barrier most often faced in addressing maternal depression. Lack of training, inadequate knowledge of resources and distractions encountered in the primary care setting were additional barriers cited. One-third of paediatricians acknowledged the fear of judgement and stigma that a mother may face when discussing maternal stresses. Paediatricians desired better ability to refer mothers to social workers for help.

CONCLUSIONS

Observational cues are used more often than direct questions or screening tools to identify mothers at risk of depression. This may under-identify mothers at risk. Paediatricians prefer to rely on other professionals, particularly social services, to address maternal depression, yet mothers may be hesitant or ambivalent about such assistance because of fear of judgement. Paediatricians, in fact, may be the professional mothers most want to communicate with. Thus, appreciation of mothers' perspectives, empathetic communication skills and knowledge of community resources can enhance paediatricians' abilities to assist mothers at risk for depression.

Regulatory Roles of Leptin at the Hypothalamic-Hypophyseal Axis Before and after Sexual Maturation in Cattle1

Studies assessed, either directly or indirectly, the role of GnRH in leptin-mediated stimulation of LH release in cattle before and after sexual maturation. In experiment 1, the objectives were to determine whether leptin could acutely accelerate the frequency of LH pulses, and putatively GnRH pulses, in prepubertal heifers at different stages of development. In experiment 2, we determined directly whether acute, leptin-mediated increases in LH secretion in the fasted, mature female are accompanied by an increase in GnRH secretion. Ten-month-old prepubertal heifers (experiment 1) fed normal- (n = 5) and restricted-growth (n = 5) diets received three injections of saline or recombinant ovine leptin (oleptin; 0.2 microg/kg body weight, i.v.) at hourly intervals during 5-h experiments conducted every 5 wk until all normal-growth heifers were pubertal. Leptin increased mean concentrations of circulating LH regardless of diet, but pulse characteristics were not altered at any age. In experiment 2, ovariectomized, estradiol-implanted cows (n = 5) were fasted twice for 72 h and treated with either saline or oleptin i.v. (as in experiment 1) on Day 3 of each fast. Leptin increased plasma concentrations of LH and third ventricle cerebrospinal fluid concentrations of GnRH, and increased the amplitude of LH and the size of GnRH pulses, respectively, on Day 3 of fasting compared to saline. Overall, results indicate that leptin is unable to accelerate the pulse generator in heifers at any developmental stage. However, leptin-mediated augmentation of LH concentrations and pulse amplitude in the nutritionally stressed, mature female are associated with modifications in GnRH secretory dynamics.

Effects of leptin on basal and GHRH-stimulated GH secretion from the bovine adenohypophysis are dependent upon nutritional status

We have shown recently that leptin modulates at least two aspects of anterior pituitary LH release in ruminants: basal and GnRH-mediated release. To test the hypothesis that leptin directly affects basal and GHRH-mediated GH secretion from the adenohypophysis, we examined the effects of various doses of recombinant ovine leptin (oleptin) on perifused adenohypophyseal (AP) explants and compared responses of tIssues from control and fasted cows. Ten mature, ovariectomized and estradiol-implanted cows were assigned to one of two dietary groups: (1) normal-fed (n=5) and (2) fasted for 72 h (n=5). At the end of the fasting period, cows were euthanized and pituitaries were collected. Adenohypophyseal explants were perifused for a total of 6.5 h, including a 2-h treatment at 2.5 h with Krebs-Ringer bicarbonate buffer containing 0, 5, 10, 50, or 100 ng/ml oleptin, and a challenge with GHRH at 4.5 h. All doses of oleptin greater than 5 ng/ml decreased (P<0.01) basal GH secretion compared with controls in tIssues collected from normal-fed cows. In contrast, GH release from AP explants from fasted cows treated with the lowest dose of oleptin was 28% (P<0.002) higher than control explants, but larger doses had no effect. Leptin caused an inversely related, dose-dependent increase in GHRH-mediated GH release in tIssues from normal-fed cows. Marked increases (P<0.01-P<0.001) in GH release were observed for the 5 and 10 ng/ml oleptin, with lesser (P<0.08) and no effects observed at the 50 and 100 ng/ml doses respectively. In fasted cows, oleptin had no stimulatory effect on GHRH-induced GH release. Results show that leptin can act directly at the anterior pituitary level to modulate GH release, and this effect is dependent upon nutritional history.