Impaired vision in children prenatally exposed to methadone: an observational cohort study

BACKGROUND/OBJECTIVES

To examine prevalence of failed visual assessment at 8-10 years in children born to methadone-maintained opioid dependent (MMOD) mothers and relate this to known in utero substance exposure.

SUBJECTS/METHODS

Follow up of observational cohort study of methadone-exposed and comparison children matched for birthweight, gestation and postcode of residence at birth. Participants were 144 children (98 exposed, 46 comparison). Prenatal drug exposure was previously established via comprehensive maternal and neonatal toxicology. Children were invited to attend for visual assessment and casenotes were reviewed. Presence of acuity poorer than 0.2 logMAR, strabismus, nystagmus and/or impaired stereovision constituted a 'fail'. Fail rates were compared between methadone-exposed and comparison children after adjusting for known confounding variables.

RESULTS

33 children attended in person: data were also derived from casenote review for all children. After controlling for maternal reported tobacco use, methadone-exposed children were more likely to have a visual 'fail' outcome, adjusted odds ratio 2.6, 95% CI 1.1-6.2; adjusted relative risk 1.8 (95% CI 1.1-3.4). Visual 'fail' outcome rates did not differ between methadone-exposed children who had (n = 47) or had not (n = 51) received pharmacological treatment for neonatal abstinence/opioid withdrawal syndrome (NAS/NOWS); fail rate 62% vs 53% (95% CI of difference-11-27%).

CONCLUSIONS

Children born to MMOD mothers are almost twice as likely as unexposed peers to have significant visual abnormalities at primary school age. Prenatal methadone exposure should be considered in the differential diagnosis of nystagmus. Findings support visual assessment prior to school entry for children with any history of prenatal opioid exposure.

TRIAL REGISTRATION

The study was prospectively registered on ClinicalTrials.gov (NCT03603301), https://clinicaltrials.gov/ct2/show/NCT03603301 .

Assessment of Patient Satisfaction Among Cancer Patients Undergoing Radiotherapy

The patient-provider relationship is a key driver of patient satisfaction as it relates to overall healthcare experience. We surveyed patients undergoing radiation therapy to determine what they consider to be the most valued qualities in their interactions with the healthcare team. An ethics-approved 35-item patient satisfaction survey was developed in-house to gain insights on patients' perception of their relationship with the healthcare team throughout their cancer journey. There were 199 completed survey, median age 68 years, 54% women and 45% men. Almost all (95%) "agreed" or "strongly agreed" that their physicians had been sensitive and compassionate. Over 90% felt that they received adequate explanations about their treatment, and had their questions answered. The vast majority (93%) felt included in the decision-making process. Patients reported the 5 most highly rated qualities among their healthcare providers (HCPs) as knowledge, kindness, honesty, good communication, and a cheerful attitude. Overall satisfaction was high but areas for improvement were identified including being offered future appointments for further discussion, more information about clinical trials, other treatments, and community resources. Patients noted their HCPs tended to focus on the physical and emotional needs of patients, but spiritual and cultural needs were rarely addressed. Patients receiving radiotherapy reported high rates of satisfaction across many aspects of their care. These findings also reinforce the different aspects of holistic care that can be improved, and serve as a reminder to clinicians that patients perceive their role as more than just that of a medical expert.

562 Biopsy of Localised Renal Masses Offers High Diagnostic Yield and Low Complication Rate in Patients with Suspicious Renal Masses

Aim

Biopsy of localised renal masses is generally accurate at detecting benign or malignant histology but can cause complications. The aim of this study was to determine the detection rate and complication rate of renal mass biopsies.

Method

Patients undergoing a renal mass biopsy at a single tertiary centre between January 2015 and December 2019 were identified electronically using a prospective database. Details about their biopsies were recorded including tumour size, radiological guidance, number of cores, longest margin of biopsy, accuracy of biopsy, histology type, and complications.

Results

This study included 334 biopsies (Median age 68 years (IQR 60-72); 61.4% (n = 204) male). Median size of tumour was 30mm (IQR 25-50) and 79.9% (n = 267) were solid masses. The biopsies were done under ultrasound (78.4%) or computed tomography (21.6%) guidance. 91.9% had core biopsies (n = 307) with median biopsy margin of 14mm (IQR 9-21). Benign histology was observed in 18.9% (n = 63), malignant in 72.1% (n = 241) while biopsy was non-diagnostic in 9.0% (n = 30). 62.6% (n = 209) of the cases were renal cell carcinoma with clear cell subtype more commonly seen (72.2%, n = 151). Complications following biopsy included haematoma (n = 7, 2.1%), haemorrhage (n = 3, 0.9%), pneumothorax (n = 1, 0.3%) and vasovagal episode (n = 1, 0.3%), resulting in an overall complication rate of 3.6%.

Conclusions

Biopsy of localised renal masses in this study showed a detection rate of 91% and complication rate of 3.6%. This study suggests renal mass biopsies have high diagnostic yield and low complication rate.

The importance of humour in oncology: a survey of patients undergoing radiotherapy

Background

Humour has long been considered an important coping tool for patients with cancer, but published quantitative data about its significance are limited. The purpose of our study was to survey patients with cancer undergoing radiotherapy regarding their opinions about the use of humour in their care.

Methods

An anonymous 35-item questionnaire evaluating the patient experience, including the value of humour, was developed by an interdisciplinary team of health care providers (hcps) working within the Radiation Medicine program. This anonymous, voluntary, paper-based survey for self-completion required approximately 10 minutes to finish and was administered during the fall of 2018 and the spring of 2019.

Results

For the 199 patients who completed the survey [108 women, 89 men (2 respondents did not specify)], median age was 68 years. That group represents approximately 30%-35% of the patients on treatment during the study period. Almost all respondents (86%) indicated that, during their visits to the cancer centre, it was "somewhat important" or "very important" for health care providers (hcps) to use appropriate humour, and 61% of respondents indicated using humour "frequently" or "always" when dealing with their individual cancers. Most respondents (79%) said that humour decreased anxiety, and 86% indicated that laughing was considered "somewhat important" or "very important." Approximately 4% of respondents even listed "sense of humour" as being the most important quality that they looked for in their interactions with their hcps.

Conclusions

Cancer patients undergoing radiotherapy clearly view humour as being important for coping and dealing with their disease, and oncology hcps should routinely consider incorporating the use of appropriate humour into the care that they provide.

Prevalence and characteristics of adults with fetal alcohol spectrum disorder in corrections: a Canadian case ascertainment study

BACKGROUND

Individuals with fetal alcohol spectrum disorder (FASD) experience a range of cognitive, affective, and physical deficits following prenatal alcohol exposure. They are thought to be overrepresented in criminal justice settings. However, limited evidence is available to inform prevalence. We sought to estimate the prevalence of FASD in a Northern Canadian correctional population.

METHODS

Using an active case ascertainment approach we recruited a representative sample of 80 justice-involved adults (ages 18-40, 85% male) over an 18-month period from 2013 to 2015. Participants completed interdisciplinary clinical assessments comprising medical and psychological evaluations that adhered to the 2005 Canadian FASD Diagnostic Guidelines.

RESULTS

We identified a high rate of FASD (17.5, 95% CI [9.2, 25.8%]) in this sample, and this rate could have been as high as 31.2% with confirmation of prenatal alcohol exposure. Most participants in this study presented with significant neurodevelopmental and cognitive deficits in at least two domains of functioning, irrespective of diagnosis, with only five of 80 participants (6.3%) demonstrating no cognitive impairment.

CONCLUSIONS

Findings showed disproportionately high estimated FASD prevalence in this representative sample compared to general population estimates in both Canada and the U.S. (2-5%), underscoring the need for improved FASD screening and diagnosis in correctional settings, and education for clinicians working in the justice context. Strengthened health prevention and intervention efforts to support the needs of individuals with FASD outside the criminal justice context are needed.

Monitoring of stimulated cycles in assisted reproduction (IVF and ICSI)

BACKGROUND

Traditional monitoring of ovarian hyperstimulation during in vitro fertilisation (IVF) treatment has included ultrasonography plus serum estradiol concentration to ensure safe practice by reducing the incidence and severity of ovarian hyperstimulation syndrome (OHSS). The need for intensive monitoring during ovarian stimulation in IVF is controversial. It has been suggested that close monitoring is time consuming, expensive and inconvenient for the woman and simplification of IVF therapy by using ultrasound only should be considered. This systematic review assessed the effects of ovarian monitoring by ultrasound only versus ultrasound plus serum estradiol measurement on IVF outcomes and the occurrence of OHSS in women undergoing stimulated cycles in IVF and intra-cytoplasmic sperm injection (ICSI) treatment.

OBJECTIVES

To quantify the effect of monitoring controlled ovarian stimulation in IVF and ICSI cycles with ultrasound plus serum estradiol concentration versus ultrasound only in terms of live birth rates, pregnancy rates and the incidence of OHSS.

SEARCH STRATEGY

We searched the Menstrual Disorders and Subfertility Group Specialised Register of controlled trials, Cochrane Central Register of Controlled Trials (CENTRAL) on the latest issue of The Cochrane Library, MEDLINE (1966 to May 2007), EMBASE (1980 to May 2007), CINAHL (1982 to May 2007), the National Research Register, and web-based trial databases such as Current Controlled Trials. There was no language restriction. Additionally all references in the identified trials and background papers were checked and authors were contacted to identify relevant published and unpublished data.

SELECTION CRITERIA

Only randomised controlled trials that compared monitoring with ultrasound plus serum estradiol concentration versus ultrasound only in women undergoing ovarian hyperstimulation for IVF and ICSI treatment were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently examined the electronic search results for relevant trials, extracted data and assessed trial quality. They resolved disagreements by discussion with two other authors. Outcomes data were pooled when appropriate and summary statistics presented when limited data did not allow meta-analysis.

MAIN RESULTS

Our search strategy identified 1119 potentially eligible reports, of which two met our inclusion criteria. These involved 411 women who underwent controlled ovarian stimulation monitoring. Our primary outcome of live birth rate was not reported in either study. One trial reported clinical pregnancy rate per woman (33% versus 31%; RR 1.07, 95% CI 0.77 to 1.49), the second trial reported clinical pregnancy rate per oocyte retrieval (22% versus 25%). There was no significant difference between the ultrasound plus estradiol group and the ultrasound alone group in the mean number of oocytes retrieved (WMD -0.55, 95% CI -1.79 to 0.69) and the incidence of ovarian hyperstimulation (RR 0.73, 95% CI 0.30 to 1.78) for the two studies.

AUTHORS' CONCLUSIONS

There is no evidence from randomised trials to support cycle monitoring by ultrasound plus serum estradiol as more efficacious than cycle monitoring by ultrasound only on outcomes of live birth and pregnancy rates. A large well-designed randomised controlled trial is needed that reports on live birth rates and pregnancy, with economic evaluation of the costs involved and the views of the women undergoing cycle monitoring. A randomised trial with sufficiently large sample size to test the effects of different monitoring protocols on OHSS, a rare outcome, will pose a great challenge. Until such a trial is considered feasible, cycle monitoring by transvaginal ultrasound plus serum estradiol may need to be retained as a precautionary good practice point.

Clinical and immunologic effects of a HER2/neu (E75) peptide vaccine booster in previously vaccinated breast cancer patients

3014

Background: We are conducting clinical trials of the HER2/neu E75-peptide vaccine in clinically disease-free breast cancer (BCa) patients. Our Phase I/II trials have shown that the E75+GM-CSF vaccine is safe and effective in stimulating clonal expansion of E75-specific CD8+ T-cells. Since peptide vaccines may not lead to long term immunity, we have assessed the need for and response to a vaccine booster for patients after completion of their primary vaccination series. Methods: BCa patients enrolled in our E75 vaccine trials who were >6 months from the completion of their primary vaccination series were offered a single 1000 mcg dose of E75 peptide with 250 mcg of GM-CSF. Patients were monitored for local and systemic toxicity. E75-specific CD8+ T-cells were quantified using the HLA-A2:IgG dimer before and after booster administration. Results: 19 patients have received the vaccine booster. Median time from primary vaccine series was 12 months (range 6–25) and median residual E75-specific immunity was 0.61% (range 0- 3.43%). Significant residual immunity (SRI=CD8+ E75-specific T-cells >0.5%) was seen in 71% of patients <12 months from primary vaccination vs. 33% of patients ≥12 months. Graded local toxicities were as follows: 18/19 (94.7%) grade 1; 1/19 (5.3%) grade 2. Only 6/19 (31.6%) experienced even grade 1 systemic toxicity. Local reactions were more robust in patients receiving the booster <12 months from primary vaccine compared to those ≥12 months (99±2.8 mm vs. 75±1 mm, p=0.01). In patients lacking SRI, 80% showed increased specific immunity post-vaccination. In these patients, the average CD8+ E75-specific T-cells pre-booster vs. post-booster was 0.37±0.03% vs. 1.06 ± 0.14% (p=0.07). Conclusions: The HER2/neu peptide vaccine E75 stimulates specific immunity in disease-free BCa patients. However, only about half of patients show SRI at median follow-up of 12 months. A vaccine booster is safe and highly effective in stimulating E75-specific immunity especially in those patients without SRI. Initial results suggest that the booster should be given within a year of completion of the initial vaccine series.

No significant financial relationships to disclose.

Conscious sedation and analgesia for oocyte retrieval during in vitro fertilisation procedures

BACKGROUND

Various methods of sedation and analgesia have been used for pain relief during oocyte recovery in IVF/ICSI procedures. The choice of agents has also been influenced by quality of analgesia as well as by concern about possible detrimental effects on reproductive outcome.

OBJECTIVES

To assess the efficacy of conscious sedation and analgesia versus alternative methods on pregnancy outcomes and pain relief in patients undergoing transvaginal oocyte retrieval.

SEARCH STRATEGY

We searched the Specialised Register of the Menstrual Disorders and Subfertility Group, The Central Register of Controlled Trials (CENTRAL) , MEDLINE (1966 to present), EMBASE (1980 to present), CINAHL (1982 to present), the National Research Register, and Current Controlled Trials. There was no language restriction. All references in the identified trials and background papers were checked and authors contacted to identify relevant published and unpublished data.

SELECTION CRITERIA

Only randomised controlled trials comparing conscious sedation and analgesia versus alternative methods for pain relief during oocyte recovery were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently scanned abstracts of the reports identified by electronic searching to identify relevant papers, extracted data and assessed trial quality. Interventions were classified and analysed under broad categories/strategies of pain relief comparing conscious sedation/analgesia with alternative methods and administration protocols.

MAIN RESULTS

Our search strategy identified 390 potentially eligible reports and 12 papers met our inclusion criteria. There were no significant differences in clinical pregnancy rates per woman and patient satisfaction between the methods compared. Women's perception of pain showed conflicting results. Due to considerable heterogeneity, in terms of types and dosages of sedation or analgesia used, and tools used to assess the principal outcomes of pain and satisfaction, a meta-analysis of all the studies was not attempted. Of the three trials which compared the effect of conventional medical analgesia plus paracervical block versus electro-acupuncture plus paracervical block, there was no significant difference in clinical pregnancy rates per woman in the two groups (OR 1.01; 95% CI 0.73 to 1.4). For intra-operative pain score as measured by visual analogue scale (VAS), there was a significant difference (WMD -4.95; 95% CI -7.84 to -2.07), favouring conventional medical analgesia plus paracervical block . There was also a significant difference in intra-operative pain by VAS between patient-controlled sedation and physician-administered sedation (WMD 5.98; 95% CI 1.63 to 10.33), favouring physician -administered sedation. However, as different types and dosages of sedative and analgesic agents were used in these trials, these data should be interpreted with caution. For the rest of the trials, a descriptive summary of the outcomes was presented.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the effect of different methods of pain relief when compared with conscious sedation and analgesia used during oocyte recovery. In this review, no one particular pain relief method or delivery system appeared to be better than the other. In future, greater consensus is needed to determine both the tools used to evaluate pain and the timing of pain evaluation during and after the procedure. Pain assessment using both subjective and objective measures may merit consideration. In addition, future trials should include intra- and post-operative adverse respiratory and cardiovascular events as outcomes.

Agreement between troponin T levels from plain and heparinized tubes

OBJECTIVE

To determine whether there was a clinically significant effect on troponin T measurement when the sample was collected in a heparinized (plasma) blood collection tube compared with a serum tube.

METHODS

Prospective cohort study using a convenience sample of 198 patients with undifferentiated illness presenting to an Emergency Department who required troponin T measurement. Samples were collected in both plain (serum) tubes and plasma tubes for comparison. All samples were measured using an Elecsys 2010 Immunoassay system (Roche-Boehringer Mannheim, Germany).

RESULTS

There were 35 troponin T measurements > or = 0.03 microg/L (the limit of reproducibility of the test). The negative predictive value for troponin T performed in heparinized tubes compared with plain tubes was 100% (95% confidence interval 96.4-100) at the > or = 0.03 microg/L level and 100% (95% confidence interval 97-100%) at the > or = 0.1 microg/L level. At a cut-off point for risk stratification in acute coronary syndromes (> or = 0.1 microg/L), there was 100% concordance between the two measurements for each sample.

CONCLUSION

The use of plasma (heparinized) tubes for the collection of troponin T samples is unlikely to produce clinically significant false-negative results compared with collection of troponin T samples in serum (plain) tubes.

Unexpected electrolyte changes in a vomiting man

A 27 year old man presented with 24 hours of unexplained vomiting. His past health was unremarkable except for a deep vein thrombosis one year earlier. At that time his serum electrolytes were normal. The results of repeat electrolyte measurement are shown in Table 1.

The uncoupling of Shc activation from distal intracellular signalling in a cell line which expresses a truncated human epidermal growth factor receptor

We have examined epidermal growth factor (EGF) signalling in a CHO cell line (CHO11) which expresses a human EGF receptor truncated at amino acid 990. Previous studies showed that EGF treatment of these cells failed to increase prostaglandin production or phospholipase A2 activity. In the current study EGF increased the tyrosine phosphorylation of the intracellular signalling protein Shc in CHO11 cells but did not activate either of the downstream signalling enzymes raf or mitogen activated protein kinase (MAPK). The uncoupling of Shc activation from distal signalling in CHO11 cells contrasts with other cells which express similar mutant EGF receptors. The failure of She to activate distal signalling may reflect qualitative differences in the way that this protein is activated or could result from the activation of an inhibitory signalling pathway.

Salmonella typhimurium displays normal invasion of mice with defective epidermal growth factor receptors

The role of the epidermal growth factor (EGF) receptor in cell invasion by Salmonella typhimurium was examined in vitro and in vivo by using waved-2 mice which express an EGF receptor with reduced kinase activity. S. typhimurium invaded fibroblasts from waved-2 mice as efficiently as fibroblasts from wild-type control animals. In vivo, S. typhimurium both invaded the gastrointestinal tract and penetrated through to the spleen of waved-2 mice. Our studies suggest that the EGF receptor has only a limited role, if any, in cell invasion by S. typhimurium.

Effect of biofeedback-assisted relaxation on migraine headache and changes in cerebral blood flow velocity in the middle cerebral artery

Twenty-three patients with diagnosed migraine headaches were randomly assigned to a biofeedback-assisted relaxation therapy group or to a group who relaxed on their own. The biofeedback trained group decreased pain and medication more than the self relax group. Cerebral blood flow velocity was measured in the middle cerebral artery with transcranial doppler (TCD). The trained group significantly reduced systolic and mean cerebral blood flow velocity on the side with the highest velocity.

Outpatient medical care of injection drug use related HIV

By the end of March 1990 470 HIV positive patients, 77% injection drug use (IDU) related, had attended the outpatient department of the Regional Infectious Disease Unit with a cumulative loss to follow-up of only 20%. Coincident with the prescribing of oral methadone and a specific all-day IDU-related HIV medical clinic the total number of appointments increased from 28/month in May 1986 to 300/month in May 1989 (P less than 0.001) and the number of defaulted appointments decreased from a maximum of 60% (17/28) to 16% (48/294, P less than 0.001) in these months. There was a significant initial increase in the number of defaulted appointments for the infectious disease (ID) clinics from 11% (77/726) to 16% (124/797, P less than 0.01) which returned to previous levels once a specific IDU-related HIV clinic was established. There was also a significant decline in the number of new patients referred which was greater for the urinary tract infection clinics (108 to 56 per 6 months, P less than 0.0001) than for the ID clinics (119 to 88 per 6 months, P less than 0.05).

Role of physiotherapy auxiliary personnel in Nova Scotia: a descriptive survey

This study was designed to gather information and opinion on the impact and role of auxiliary personnel in physiotherapy, in Nova Scotia (NS). The physiotherapist/auxiliary ratio and present and future levels of education, supervision, and activities of auxiliary personnel were investigated. All NS physiotherapists registered with the Nova Scotia College of Physiotherapists (NSCP) were surveyed by mailed questionnaire; one follow-up was sent. Two questionnaires were developed. Potential levels of the terms assistant and technician were defined to facilitate interpretation of the opinion statements. Questionnaire A was mailed to all registered physiotherapists (n = 279, response rate 83%). Questionnaire B was mailed with Questionnaire A to directors and clinic owners (n = 73, 79% response rate). Results showed a physiotherapist/auxiliary personnel ratio (excluding clerical) of 3.75:1. The majority of personnel were trained in-house. There was a trend toward less frequent supervision with more extensively trained auxiliary personnel. More respondents considered that formally trained assistants would best serve the profession of physiotherapy in the future. To conclude, this study adds to the body of knowledge of the Canadian Physiotherapy Association and the NSCP. It should assist the NS Department of Health and Fitness in analyzing needs for training of auxiliary personnel in Physiotherapy, and provide data for future studies.

Cerebral arteriovenous malformation in a neonate: treatment by embolisation

A neonate with an aneurysm of the vein of Galen was treated by embolisation using Giant-urco coils. Doppler ultrasound examination showed that blood flow in the internal carotid artery decreased while that in the pericallosal artery increased after occlusion, suggesting a 'steal phenomenon' with blood directed preferentially towards the aneurysm.