Development of a translatable gene augmentation therapy for CNGB1-retinitis pigmentosa

In this study, we investigate a gene augmentation therapy candidate for the treatment of retinitis pigmentosa (RP) due to cyclic nucleotide-gated channel beta 1 (CNGB1) mutations. We use an adeno-associated virus serotype 5 with transgene under control of a novel short human rhodopsin promoter. The promoter/capsid combination drives efficient expression of a reporter gene (AAV5-RHO-eGFP) exclusively in rod photoreceptors in primate, dog, and mouse following subretinal delivery. The therapeutic vector (AAV5-RHO-CNGB1) delivered to the subretinal space of CNGB1 mutant dogs restores rod-mediated retinal function (electroretinographic responses and vision) for at least 12 months post treatment. Immunohistochemistry shows human CNGB1 is expressed in rod photoreceptors in the treated regions as well as restoration of expression and trafficking of the endogenous alpha subunit of the rod CNG channel required for normal channel formation. The treatment reverses abnormal accumulation of the second messenger, cyclic guanosine monophosphate, which occurs in rod photoreceptors of CNGB1 mutant dogs, confirming formation of a functional CNG channel. In vivo imaging shows long-term preservation of retinal structure. In conclusion, this study establishes the long-term efficacy of subretinal delivery of AAV5-RHO-CNGB1 to rescue the disease phenotype in a canine model of CNGB1-RP, confirming its suitability for future clinical development.

Randomized Phase 2b Study of Brimonidine Drug Delivery System Generation 2 for Geographic Atrophy in Age-related Macular Degeneration

PURPOSE

To evaluate the safety and efficacy of repeat injections of Brimonidine Drug Delivery System (Brimo DDS) Generation 2 (Gen 2) containing 400 μg brimonidine in patients with geographic atrophy (GA) secondary to age-related macular degeneration (AMD).

DESIGN

Phase 2b, randomized, multicenter, double-masked, sham-controlled, 30-month study (BEACON).

PARTICIPANTS

Patients diagnosed with GA secondary to AMD and multifocal lesions with total area >1.25 mm² and ≤18 mm² in the study eye.

METHODS

Enrolled patients were randomized to treatment with intravitreal injections of 400-μg Brimo DDS (n=154) or sham procedure (n=156) in the study eye every 3 months from day 1 through month 21.

MAIN OUTCOME MEASURES

The primary efficacy endpoint was change from baseline in the GA lesion area in the study eye, assessed with fundus autofluorescence imaging, at month 24. Safety measures included treatment-emergent adverse events (AEs).

RESULTS

The study was terminated early, at the time of the planned interim analysis, because of a slow GA progression rate (∼1.6 mm²/year) in the enrolled population. Least-squares mean (standard error) GA area change from baseline at month 24 (primary endpoint) was 3.24 (0.13) mm² with Brimo DDS (n=84) versus 3.48 (0.13) mm² with sham (n=91); the reduction in GA area change from baseline in the Brimo DDS group compared with the sham group was 0.25 mm² (7%) (P = 0.150). At month 30, the GA area change from baseline was 4.09 (0.15) mm² with Brimo DDS (n=49) versus 4.52 (0.15) mm² with sham (n=46), a reduction of 0.43 mm² (10%) with Brimo DDS compared with sham (P=0.033). Exploratory analysis showed numerically smaller loss over time in retinal sensitivity assessed with scotopic microperimetry with Brimo DDS compared with sham (P=0.053 at month 24). Treatment-related AEs were usually related to the injection procedure. No implant accumulation was observed.

CONCLUSIONS

Multiple intravitreal administrations of Brimo DDS (Gen 2) were well tolerated. The primary efficacy endpoint at 24 months was not met, but there was a numerical trend for reduction in GA progression at 24 months compared with sham treatment. The study was terminated early because of the lower-than-expected GA progression rate in the sham/control group.

MO917: Self-Reported Perceptions of Haemodialysis Patients´ Cognitive State––The Goodrenal Project

BACKGROUND AND AIMS

Patients with chronic kidney disease have an increased risk of developing cognitive impairment and neurocognitive disorders including Alzheimer's disease that affect their quality of life. Changes involve deterioration of domains such as learning and memory, language, attention, executive function, perceptual motor or social cognition. We explored the subjective perception that the patients have regarding their cognitive state.

METHOD

This study is part of the GoodRENAL project, which is funded by the European Community Erasmus + and involves four countries: Belgium, Greece, Spain and Sweden. Exploratory questionnaires regarding patients’ cognitive state were answered by 38 patients (mean age 58 ± 0.5 years; 50% women) randomly allocated to this study from the dialysis shifts. The questionnaire had 10 questions with answers rated as 1 (never), 2 (sometimes), 3 (half of the time), 4 (more than half of the time) and 5 (almost all the time), plus 1 open question about main barriers, difficulties or needs related to their cognitive state.

RESULTS

To analyse the descriptive data, the response frequency was grouped into items based on the frequency of the occurrence (almost all the time and all the time). The table below summarizes answers received from patients.

CONCLUSION

The patients’ perception of their attention capacity, memory function and learning capacity was in general positive. However, further studies using validated questionnaires regarding different aspects such as attention, memory or learning functionality are needed to confirm these findings.

MO925: Psychological Wellbeing in Haemodialysis Patients: Comparing Perspectives From Patients, Caregivers and Healthcare Professionals––The Goodrenal Project

BACKGROUND AND AIMS

The start of dialysis therapy can contribute to the development of depression, stress and anxiety, which, in turn, has an impact on the patient´s quality of life, the disease process and the associated social and health care costs. This underlines the importance of studies that analyse the psychological profiles of patients on maintenance dialysis to establish relationships between risk factors, prevention steps and intervention strategies aimed at improving their quality of life. Therefore, we explored the perceptions regarding the patient's psychological wellbeing, seen from three different perspectives: patients’ own, their caregivers’ and that of their healthcare professionals (HCPs).

METHOD

This study is part of the GoodRENAL Project, which is funded by the European Community Erasmus + and involves four countries: Belgium, Greece, Spain and Sweden. Exploratory questionnaires regarding patients’ psychological wellbeing were developed by the team, and responses were obtained from three groups of stakeholders: 38 patients, who were randomly allocated to this study from the first dialysis shift of the week (mean age 58 ± 0.51 years; 50% women); 34 caregivers (mean age 54 ± 13 years; 80% women); and 39 healthcare professionals (HCPs mean age 42 ± 10 years; 79% women).

The exploratory questionnaires comprised different parts, exploring the psychological state of patients through closed questions, open questions and questions about barriers, needs and facilitators regarding psychological wellbeing. The patients’ and caregivers’ questionnaires had 10 items scored from 1 (‘never’) to 5 (‘almost all the time’). The HCPs questionnaire included 10 items rated as 1 (‘totally disagree’) to 5 (‘totally agree’).

RESULTS

To analyse the descriptive data, the response frequency was grouped into items based on the level of agreement or the frequency of the occurrence (almost all the time and all the time). The table below shows answers received from patients, caregivers and HCPs.

CONCLUSION

Patients consistently reported a much more positive subjective perception of their psychological state, compared with that assumed by HCPs, while the perceived perception of patients’ states reported by their caregivers was in general closer to that reported by the patients. The extent by which patients’ positive responses are related to adaptations such as social desirability, distorted subjective perception, minimization or normalization of symptomatology should be explored in further studies.

MO560: Adherence to Nutritional Recommendations as Expressed by Patients on Hemodialysis, Their Informal Carers and Healthcare Professionals—the Goodrenal Project

BACKGROUND AND AIMS

Low adherence to nutritional recommendations is common in patients on hemodialysis (HD), but the reasons are not well known. We explored the main needs, barriers and facilitators affecting nutritional adherence as experienced by patients on HD, their informal carers and their healthcare professionals (HCPs) at the dialysis centre.  

METHOD

This study is part of the GoodRENal project—funded by the European Community, Erasmus + program that comprises four countries: Spain, Sweden, Belgium and Greece. As part of this project, exploratory questionnaires were constructed and answered by the patients, their carers and their HCPs. The questionnaire comprised three sections consisting of statements exploring the needs, barriers and facilitators affecting adherence to nutritional recommendations for patients on HD. Each statement could be rated from 1 (strongly disagree), 2 (disagree), 3 (neither agree or disagree), 4 (agree) to 5 (strongly agree). In addition, there was a section for free text. To avoid bias in patient selection, 10 patients were randomized from the first dialysis shift of the week in the four participating countries. 

RESULTS

In total, 40 patients, 40 informal carers and 40 HCPs HealthCP accepted to participate, out of whom 38 patients (68% male, 62 ± 15 years), 33 informal carers (21% male, age 54 ± 12 years, of whom 68% were spouses) and 37 HCPs (22% male, age 42 ± 10 years, 60% were nurses) answered the questionnaires. Two of the four centres had a dedicated dietitian at the dialysis unit, who worked there on average 18 ± 8 hours per week. At the dialysis units without a dietitian, the nurses and doctors were responsible for nutritional care. To simplify the analysis, answers rated as 4 and 5 were grouped as agree. The main findings are presented below:

CONCLUSION

These descriptive findings show that patients, informal carers and HCPs identified different needs, barriers, and facilitators to increase adherence to nutritional recommendations. These results can be used to build and tailor strategies aimed at patients, informal carers and HCPs.

Three-Year Safety Results of SAR422459 (EIAV-ABCA4) Gene Therapy in Patients With ABCA4-Associated Stargardt Disease: An Open-Label Dose-Escalation Phase I/IIa Clinical Trial, Cohorts 1-5

PURPOSE

To report on the safety of the first 5 cohorts of a gene therapy trial using recombinant equine infectious anemia virus expressing ABCA4 (EIAV-ABCA4) in adults with Stargardt dystrophy due to mutations in ABCA4.

DESIGN

Nonrandomized multicenter phase I/IIa clinical trial.

METHODS

Patients received a subretinal injection of EIAVABCA4 in the worse-seeing eye at 3 dose levels and were followed for 3 years after treatment.

MAIN OUTCOME MEASURES

The primary end point was ocular and systemic adverse events. The secondary end points were best-corrected visual acuity, static perimetry, kinetic perimetry, total field hill of vision, full field electroretinogram, multifocal ERG, color fundus photography, short-wavelength fundus autofluorescence, and spectral domain optical coherence tomography.

RESULTS

The subretinal injections were well tolerated by all 22 patients across 3 dose levels. There was 1 case of a treatment-related ophthalmic serious adverse event in the form of chronic ocular hypertension. The most common adverse events were associated with the surgical procedure. In 1 patient treated with the highest dose, there was a significant decline in the number of macular flecks as compared with the untreated eye. However, in 6 patients, hypoautofluorescent changes were worse in the treated eye than in the untreated eye. Of these, 1 patient had retinal pigment epithelium atrophy that was characteristic of tissue damage likely associated with bleb induction. No patients had any clinically significant changes in best-corrected visual acuity, static perimetry, kinetic perimetry, total field hill of vision, full field electroretinogram, or multifocal ERG attributable to the treatment.

CONCLUSIONS

Subretinal treatment with EIAV-ABCA4 was well tolerated with only 1 case of ocular hypertension. No clinically significant changes in visual function tests were found to be attributable to the treatment. However, 27% of treated eyes showed exacerbation of retinal pigment epithelium atrophy on fundus autofluorescence. There was a significant reduction in macular flecks in 1 treated eye from the highest dose cohort. Additional follow-up and continued investigation in more patients will be required to fully characterize the safety and efficacy of EIAV-ABCA4.

MO619GOODRENAL: HOLISTIC PATIENT CARE INTRADIALYSIS PROGRAM IN HEMODIALYSIS THROUGH A VIRTUAL HEALTH PLATFORM

Background and Aims

There is wide evidence that weak points of the care of end-stage Chronic kidney disease (CKD) patients in hemodialysis include three aspects that are suitable for intervention: exercise, nutrition and psychological support. Evidence shows that exercise for patients on hemodialysis results in increased functional capacity and strength and improved health-related quality of life and survival. Additionally, earlier studies have shown the benefits of psychological interventions and the positive effect of educational programs on nutritional status for patients on hemodialysis. Despite the well-known benefits of exercise, these programs are not being implemented in the routine clinical care of hemodialysis patients. Thus, the GoodRENal project aims to promote a healthy lifestyle among hemodialysis patients using a holistic pedagogical approach that, addressing adult learners, combines exercise, nutrition and psychological well-being as well as cognitive functioning.

Method

GoodRENal is a project funded by the European Community, Erasmus + program (336.327 euros). The project will last 3 years, from September 2020 to August 2023 and the Partners of the consortium include institutions from five European countries: Spain (Universidad CEU Cardenal Herrera, Hospital de Manises, Univesitat de Valéncia, Universitat Politécnica de Valéncia), Sweden (Skane University Hospital and Karolinska Institutet), Greece (Aristotles University of Thessaloniki) and Belgium (Katholieke Universiteit Leuven). Other supporting institutions are located in the UK, Chile and Brazil.

Results

The project will develop a virtual platform comprising three aspects of care: physical activity/exercise, nutrition, psychological well-being/cognition. In summary, the project outputs will be: 1. A didactic content on a modular platform with an educational program for integrated treatment in patients on hemodialysis; 2. A guideline to promote a healthy lifestyle among patients on hemodialysis for healthcare providers; 3. A guideline to promote a healthy lifestyle among patients on hemodialysis for patients, and their formal- and non-formal carers. At the present stage exploratory questionnaires regarding physical activity/exercise-nutrition-psychological well-being/cognition have been developed in consensus with all the partners. Data from this first exploratory study regarding needs and barriers of the stakeholders (patients, health professionals, carers) will be presented at the ERA-EDTA congress.

Conclusion

GoodRENal aims at improving the overall health, and thus the health-related quality of life, of patients on hemodialysis through a holistic and pedagogical approach that will target especially improvements of patient reported outcomes including quality of life.

Validation of a new in vitro Sun Protection Factor method to include a wide range of sunscreen product emulsion types

In 2017, Cosmetics Europe performed a double‐blinded ring test of 24 emulsion‐type sunscreen products, across 3 in vivo test laboratories and 3 in vitro test laboratories, using a new candidate in vitro SPF test method. Based on the results of this work, an article was published showing how data derived from a new lead candidate method conform to new International Standards (ISO) acceptance criteria for alternative SPF test methods (Any alternative method should consider the matrix effect and if required, specify the matrix applicability of the method; Criterion 1a: Systematic differences between methods should be negligible: 95% of all individual results of an alternative method are within the range of ±2× reproducibility standard deviation of the in vivo method, that is overall bias must be below 0.5× reproducibility standard deviation of the in vivo method; Criterion 1b: Measurement uncertainty of an alternative method should be below the measurement uncertainty of the in vivo method. Candidate method predicted values must fall within the full ‘funnel’ (SPF 6‐50+) limits proposed by Cosmetics Europe (derived from the same minimum test design, that is using the ISO24444 Method to measure at least 24 products across at least 3 laboratories using at least 5 test subjects/laboratory, in a blinded fashion).). Of the 24 sunscreen products tested, the majority of emulsions were of the oil‐in‐water (O/W) type, whereas only one was water‐in‐oil (W/O) and there were no products with a mineral‐only sun filter system. In order to confirm the scope of this method, therefore, a new study was conducted that included 73 W/O (12 mineral + organic, 44 mineral only and 17 organic only) and 3 O/W mineral‐only, emulsion‐type sunscreen products (a total of 76 new sunscreen products). When combined with the previous 24 products (tested in 3 different laboratories), this yielded a new data set comprising a total of 100 emulsion‐type sunscreen products, with SPF values ranging from 6 to 50+ (with a total of 148 data points). These products were tested using the double‐plate in vitro SPF test method and compared with the ISO TC217/WG7 acceptance criteria for alternative SPF test methods. Over 95% of paired in vitro: in vivo SPF values lay within the upper and lower limits of the ISO acceptance criteria funnel, with no bias. This new in vitro SPF test method, therefore, meets the minimum requirements for an alternative SPF test method to ISO24444:2010, for emulsion‐type sunscreen products (which make up the majority of marketed sunscreen products).

Classification of Choroidal Neovascularization Using Projection-Resolved Optical Coherence Tomographic Angiography

Purpose

To evaluate if projection-resolved optical coherence tomographic angiography (PR-OCTA) reduces projection artifact with less attenuation of choroidal neovascularization (CNV) flow signal compared to conventional OCTA with slab subtraction.

Methods

In this retrospective cross-sectional study, participants with subfoveal treatment-naïve CNV secondary to age-related macular degeneration underwent OCTA. Scans were exported for custom processing including manual segmentation as necessary, application of slab subtraction and PR-OCTA algorithm, and calculation of CNV vascular area and connectivity. CNV was classified as type 1, minimally type 2, or predominantly type 2 based on fluorescein angiography (FA) and OCT. Two masked retina specialists independently classified CNV using cross-sectional conventional OCTA and PR-OCTA.

Results

A total of 17 eyes were enrolled in this study. Mean CNV vessel area (mm2) was 0.67 ± 0.51 for PR-OCTA and 0.53 ± 0.41 for slab subtraction (P = 0.018). Mean vascular connectivity was 96.80 ± 1.28 for PR-OCTA and 90.90 ± 4.42 (P = 0.018) for slab subtraction. Within-visit repeatability (coefficient of variation) of PR-OCTA was 0.044 for CNV vessel area and 0.012 for vascular connectivity, compared to 0.093 and 0.028 by slab subtraction. PR-OCTA classification agreement with FA/OCT was 88.2% and 76.5% for the two graders, while conventional OCTA agreement was 58.8% and 70.6% (grader 1, P = 0.025; grader 2, P = 0.56). Moreover, PR-OCTA enabled the individual quantification of type 1 and type 2 components of a CNV.

Conclusions

PR-OCTA had greater CNV vessel area and vascular connectivity, as well as better repeatability, compared to slab subtraction, suggesting PR-OCTA is a superior technique for imaging CNV. Furthermore, PR-OCTA removes projection artifact on cross-sectional OCTA, improving the ability to classify and quantify CNV components.

A Novel Pathogenic Variant in NDP Gene With Incomplete Penetrance Manifests as X-Linked Familial Exudative Vitreoretinopathy

Familial exudative vitreoretinopathy (FEVR) is a rare hereditary ocular disorder characterized by incomplete or abnormal development of peripheral retinal vasculature. The genes responsible for this disorder are associated with the wingless-related integration site (Wnt) signaling pathway, a critical pathway for the development of normal retinal vasculature. A pathogenic variant in any one of these genes may disrupt retinal vasculogenesis. Furthermore, the type and number of pathogenic variants may influence the severity of disease and clinical course. Here, the authors identify a novel pathogenic variant in the NDP gene, not previously described in the literature. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:120-124.].

Allogeneic iPSC-Derived RPE Cell Graft Failure Following Transplantation Into the Subretinal Space in Nonhuman Primates

Purpose

To characterize the intraocular immune response following transplantation of iPS-derived allogeneic RPE cells into the subretinal space of non–immune-suppressed rhesus macaques.

Methods

GFP-labeled allogeneic iPS-derived RPE cells were transplanted into the subretinal space of one eye (n = 6), and into the contralateral eye 1 day to 4 weeks later, using a two-stage transretinal and transscleral approach. Retinas were examined pre- and post-surgery by color fundus photography, fundus autofluorescence, and optical coherence tomography (OCT) imaging. Animals were euthanized between 2 hours and 7 weeks following transplantation. T-cell (CD3), B-cell (CD20), and microglial (Iba1) responses were assessed immunohistochemically.

Results

Cells were delivered into the subretinal space in all eyes without leakage into the vitreous. Transplanted RPE cells were clearly visible at 4 days after surgery but were no longer detectable by 3 weeks. In localized areas within the bleb containing transplanted cells, T- and B-cell infiltrates and microglia were observed in the subretinal space and underlying choroid. A T-cell response predominated at 4 days, but converted to a B-cell response at 3 weeks. By 7 weeks, few infiltrates or microglia remained. Host RPE and choroid were disrupted in the immediate vicinity of the graft, with fibrosis in the subretinal space.

Conclusions

Engraftment of allogeneic RPE cells failed following transplantation into the subretinal space of rhesus macaques, likely due to rejection by the immune system. These data underscore the need for autologous cell sources and/or confirmation of adequate immune suppression to ensure survival of transplanted RPE cells.

Molecular diagnosis and ocular imaging of varicella zoster virus associated neuroretinitis

Purpose

To report a case of varicella zoster virus associated neuroretinitis confirmed via polymerase chain reaction analysis of ocular fluid.

Observations

A 30-year-old man presented with a 1-week history of decreased vision in his left eye and ulcerative skin lesions above his left eyebrow. On exam, he had clinical findings consistent with neuroretinitis characterized by optic disc edema and formation of a macular star. Polymerase chain reaction analysis of aqueous fluid was positive for varicella zoster virus. He was treated with oral valacyclovir with excellent resolution of his symptoms and clinical findings.

Conclusions and importance

Varicella zoster virus is a rare cause of neuroretinitis. We report for the first time a case of varicella zoster virus associated neuroretinitis confirmed by polymerase chain reaction analysis of ocular fluid. Molecular testing of ocular tissue may lead to a definitive diagnosis.

Extent of Microstructural Tissue Damage Correlates with Hemodynamic Failure in High-Grade Carotid Occlusive Disease: An MRI Study Using Quantitative T2 and DSC Perfusion

BACKGROUND AND PURPOSE

Chronic hemodynamic impairment in high-grade carotid occlusive disease is thought to cause microstructural abnormalities that might be subclinical or lead to subtle symptoms including cognitive impairment. Quantitative MR imaging allows assessing pathologic structural changes beyond macroscopically visible tissue damage. In this study, high-resolution quantitative T2 mapping combined with DSC-based PWI was used to investigate quantitative T2 changes as a potential marker of microstructural damage in relation to hemodynamic impairment in patients with unilateral high-grade carotid occlusive disease.

MATERIALS AND METHODS

Eighteen patients with unilateral high-grade ICA or MCA stenosis/occlusion were included in the study. T2 values and deconvolved perfusion parameters, including relative CBF, relative CBV, and the relative CBF/relative CBV ratio as a potential indicator of local cerebral perfusion pressure, were determined within areas with delayed TTP and compared with values from contralateral unaffected areas after segmentation of normal-appearing hypoperfused WM and cortical regions. Hemispheric asymmetry indices were calculated for all parameters.

RESULTS

Quantitative T2 was significantly prolonged (P < .01) in hypoperfused tissue and correlated significantly (P < .01) with TTP delay and relative CBF/relative CBV reduction in WM. Significant correlations (P < .001) between TTP delay and the relative CBF/relative CBV ratio were found both in WM and in cortical areas.

CONCLUSIONS

Quantitative T2 can be used as a marker of microstructural tissue damage even in normal-appearing GM and WM within a vascular territory affected by high-grade carotid occlusive disease. Furthermore, the extent of damage correlates with the degree of hemodynamic failure measured by DSC perfusion parameters.

Validation of an in vitro sun protection factor (SPF) method in blinded ring-testing

OBJECTIVE

The objective of this work was to investigate the utility of a new in vitro SPF test method in blinded ring-testing, against new ISO acceptance criteria.

METHODS

Twenty four blinded, commercial, emulsion-type, primary sunscreen products, covering the full range of labelled SPF in Europe (SPF6 - 50+), were tested by three test institutes using the current ISO24444:2010 In Vivo SPF Test Method and simultaneously by three separate test laboratories using a new candidate in vitro SPF test method, developed under the leadership of Cosmetics Europe (CE). The resulting relationship between in vitro SPF and in vivo SPF values was then compared with acceptance criteria developed recently by the International Standards (ISO) TC217/WG7 Sun Protection Test Methods Working Group.

RESULTS

Analysis of the mean inter-laboratory in vitro and mean inter-institute in vivo SPF values revealed a strong correlation between in vitro and in vivo values, with a Pearson correlation coefficient of r2  = 0.88 (P < 0.0001), a slope of 1.01 and a non-significant intercept (-1.48; P = 0.62). When these data were compared to the new ISO WG7 acceptance criteria, method bias was found to be extremely low and over 95% of the coupled data lay within the model 'funnel' (defined by upper and lower confidence intervals).

CONCLUSION

In conclusion, the results of blinded ring testing and comparison to new ISO WG7 acceptance criteria indicate that a new in vitro SPF test method meets (and exceeds) these minimum criteria and is an interesting candidate for possible deployment as an industry test methodology.

Probing the Single-Particle Character of Rotational States in ^{19}F Using a Short-Lived Isomeric Beam

A beam containing a substantial component of both the J^{π}=5^{+}, T_{1/2}=162  ns isomeric state of ^{18}F and its 1^{+}, 109.77-min ground state is utilized to study members of the ground-state rotational band in ^{19}F through the neutron transfer reaction (d,p) in inverse kinematics. The resulting spectroscopic strengths confirm the single-particle nature of the 13/2^{+} band-terminating state. The agreement between shell-model calculations using an interaction constructed within the sd shell, and our experimental results reinforces the idea of a single-particle-collective duality in the descriptions of the structure of atomic nuclei.

[Traumatic hip dislocation in a 6-year-old male child: Seldom but demanding]

Traumatic hip dislocations in children are not frequent but constitute true emergencies. They require urgent reduction because of the risk of consecutive avascular necrosis of the femoral head. We report a 6-year-old boy with traumatic posterior hip dislocation on a vacation abroad. After closed reduction the day of the accident, a hip spica cast was applied and the patient was transferred home. Once home, X‑ray and CT diagnostics were completed by MRI. In future, long-term clinical and radiological investigations for avascular necrosis and growth disorders, as well as thoroughly informing the parents, should be mandatory.

Three-dimensional imaging of carbonyl sulfide and ethyl iodide photodissociation using the pixel imaging mass spectrometry camera

The Pixel Imaging Mass Spectrometry (PImMS) camera is used in proof-of-principle three-dimensional imaging experiments on the photodissociation of carbonyl sulfide and ethyl iodide at wavelengths around 230 nm and 245 nm, respectively. Coupling the PImMS camera with DC-sliced velocity-map imaging allows the complete three-dimensional Newton sphere of photofragment ions to be recorded on each laser pump-probe cycle with a timing precision of 12.5 ns, yielding velocity resolutions along the time-of-flight axis of around 6%-9% in the applications presented.

Mitigating the health impacts of pollution from oceangoing shipping: an assessment of low-sulfur fuel mandates

Concerns about health effects due to emissions from ships have magnified international policy debate regarding low-sulfur fuel mandates for marine fuel. Policy discussions center on setting sulfur content levels and the geographic specification of low-sulfur fuel use. We quantify changes in premature mortality due to emissions from ships under several sulfur emissions control scenarios. We compare a 2012 No Control scenario (assuming 2.7% or 27 000 ppm S) with three emissions control scenarios. Two control scenarios represent cases where marine fuel is limited to 0.5% S (5000 ppm) and 0.1% S (1000 ppm) content, respectively, within 200 nautical miles of coastal areas. The third control scenario represents a global limit of 0.5% S. We apply the global climate model ECHAMSSy-MESSy1-MADE to geospatial emissions inventories to determine worldwide concentrations of particular matter (PM2.5) from ocean going vessels. Using those PM2.5 concentrations in cardiopulmonary and lung cancer concentration-risk functions and population models, we estimate annual premature mortality. Without control, our central estimate is approximately 87 000 premature deaths annually in 2012. Coastal area control scenarios reduce premature deaths by approximately 33 500 for the 0.5% case and approximately 43 500 for the 0.1% case. Where fuel sulfur content is reduced globally to 0.5% S, premature deaths are reduced by approximately 41 200. These results provide important support that global health benefits are associated with low-sulfur marine fuels, and allow for relative comparison of the benefits of alternative control strategies.

Relative importance of predators and parasitoids for cereal aphid control

Field experiments with manipulations of natural enemies of plant-feeding insects may show how a diverse enemy group ensures an important ecosystem function such as naturally occurring biological pest control. We studied cereal aphid populations in winter wheat under experimentally reduced densities of: (i) ground-dwelling generalist predators (mostly spiders, carabid and staphylinid beetles); (ii) flying predators (coccinellid beetles, syrphid flies, gall midges, etc.) and parasitoids (aphidiid wasps), and a combination of (i) and (ii), compared with open controls. Aphid populations were 18% higher at reduced densities of ground-dwelling predators, 70% higher when flying predators and parasitoids were removed, and 172% higher on the removal of both enemy groups. Parasitoid wasps probably had the strongest effect, as flying predators occurred only in negligible densities. The great importance of parasitism is a new finding for aphid control in cereal fields. In conclusion, a more detailed knowledge of the mechanisms of natural pest control would help to develop environmentally sound crop management with reduced pesticide applications.

Pain management in children with and without cognitive impairment following spine fusion surgery

BACKGROUND

We compared pain assessment and management practices in children with and without cognitive impairment (CI) undergoing spine fusion surgery.

METHODS

The medical records of 42 children (19 with CI and 23 without) were reviewed and data related to demographics, surgery, pain assessment and management, and side-effects were recorded.

RESULTS

Fewer children with CI were assessed for pain on postoperative days (POD) 0-4 compared to those without CI (P < 0.002). Self-report was used for 81% of pain assessments in children without CI, while a behavioural tool was used for 75% of assessments in cognitively impaired children. Children with CI received smaller total opioid doses on POD 1-3 compared to those without CI (P < or = 0.02). Furthermore, children without CI received patient/nurse-controlled analgesia for more postoperative days than children with CI (P=0.02).

CONCLUSION

Our data demonstrate a discrepancy in pain management practices in children with and without CI following spine fusion.

Prediction of outcome after rectus femoris surgery in cerebral palsy: the role of cocontraction of the rectus femoris and vastus lateralis

Rectus femoris surgery was performed on 70 patients with cerebral palsy and stiff-knee gait. Fifty-three patients underwent distal rectus transfer, and 17 patients had distal rectus release with complete muscle mobilization. Gait analysis was performed preoperatively and postoperatively at a minimum of 1 year. Swing-phase peak knee flexion (PKF) was improved in the transfer group, allowing improved foot clearance and more efficient gait (p = 0.04). PKF in swing deteriorated slightly in the release group (p = 0.04). The presence of abnormal swing-phase electromyogram (EMG) activity in the rectus alone or abnormal combined rectus and vastus lateralis activity did not influence the PKF results in either surgery (p < 0.05). The Ely test had no predictive value in identifying patients with abnormal EMG activity (p > 0.05). Preoperative knee range of motion was not a significant variable in determining relative success of rectus surgery. No deleterious effects were observed in stance phase in either group (p > 0.05).

Hemodynamic consequences of continuous arteriovenous hemofiltration

Continuous arteriovenous hemofiltration (CAVH) is an extracorporeal treatment in which fluid, electrolytes, and low and middle molecular weight solutes are removed from the blood by ultrafiltration. It is efficacious in the management of acute or chronic renal failure complicated by fluid overload, and following surgery. In this study, cardiac filling pressures, cardiac indices, and BP were monitored in nine patients. A mean of 7 kg of fluid was removed in ten treatments without the induction of hypotension. In nine of ten treatments, cardiac index increased following fluid removal. An increment in myocardial pump function was noted even in patients with low output heart failure. This treatment differs from dialysis in its ability to remove large fluid volumes without compromising cardiac hemodynamics. In addition, CAVH may have a role in treating volume overload patients with renal insufficiency and heart failure resistant to pharmacologic intervention.

Sodium fluxes during hemodialysis

Three sets of experiments were performed to determine the effect of the dialysate sodium concentration on the sodium balance of patients undergoing maintenance hemodialysis. First, patients were treated with three different dialysate bath sodium concentrations: 125-132 mEq/l (n = 7), 135-140 mEq/l (n = 11) and 145-150 mEq/l (n = 6). We demonstrated that the pretreatment plasma sodium concentration was independent of the sodium concentration of the dialysate used. Second, the plasma sodium concentration available for diffusion during the treatment was calculated from the plasma sodium concentration and the plasma proteins. The accuracy of this calculation was demonstrated by comparing the predicted value with the concentration of sodium measured in an ultrafiltrate obtained at minimal filtration fraction. Third, the sodium fluxes using a hypernatremic or hyponatremic dialysate were calculated for 100 ml of plasma going through the dialyzer. At steady state, no significant differences in net sodium fluxes were demonstrated between hyper- and hyponatremic dialysis.

Renal hemodynamic changes in humans. Response to protein loading in normal and diseased kidneys

This study was undertaken to define the renal hemodynamic changes that mediate the acute response to an oral protein load. Three groups of subjects were studied: (1) disease-free subjects; (2) patients with chronic renal disease of various causes, except for diabetes mellitus, documented by history and/or renal biopsy; and (3) patients with diabetes mellitus, that is, a history of hyperglycemia requiring antihyperglycemic therapy. All subjects were studied before (baseline) and after (test) ingestion of a protein load. Glomerular filtration rate and effective renal plasma flow were evaluated by inulin and para-amino-hippurate, respectively. In the disease-free subjects, the mean baseline glomerular filtration rate and renal plasma flow were 122 +/- 10 ml/minute/1.73 m2 and 644 +/- 64 ml/minute/1.73 m2, whereas test glomerular filtration rate and renal plasma flow were 151 +/- 15 ml/minute/1.73 m2 and 791 +/- 111 ml/minute/1.73 m2, respectively. In patients with chronic renal disease, the test glomerular filtration rate and renal plasma flow were related to the severity of the disease. The more severe the disease, the lower the absolute test values and the smaller the increment from baseline to test values. Patients with diabetes mellitus had a paradoxic response to ingestion of a protein load. Glomerular filtration rate fell while renal plasma flow remained unchanged. This response was observed in all diabetic patients regardless of the type of diabetes or whether clinical evidence of diabetic nephropathy was absent, minimal, or severe.

Short-term protein loading in assessment of patients with renal disease

The effect of short-term protein loading on the glomerular filtration rate in normal persons and patients with renal disease was evaluated. Previous studies have demonstrated that in healthy subjects, protein loading results in an increased glomerular filtration rate. By determining the glomerular filtration rate preceding (baseline glomerular filtration rate) and following (test glomerular filtration rate) oral protein loading, it was possible to define (1) the filtration capacity (test glomerular filtration rate) and (2) the renal reserve (test glomerular filtration rate - baseline glomerular filtration rate) of the kidney. In normal persons, filtration capacity averaged 157 +/- 13 ml per minute and renal reserve 34 ml per minute. The test glomerular filtration rate was reproducible and independent of protein intake, whereas baseline glomerular filtration rate was significantly influenced by diet. Patients with renal disease were found to have a reduced renal reserve and/or a diminished filtration capacity. The reduction in filtration capacity appears to correlate with the damage sustained by the organ. It is suggested that an abnormal response to protein loading in renal disease may herald the fall in the baseline glomerular filtration rate and the rise in plasma creatinine level.

Renal functional reserve in humans. Effect of protein intake on glomerular filtration rate

This study was designed to investigate the effect of protein intake on glomerular filtration rate, and to demonstrate and evaluate the functional reserve of the kidney. Normal subjects ingesting a protein diet had a significantly higher creatinine clearance than a comparable group of normal subjects ingesting a vegetarian diet. A progressive increment in protein intake in normal volunteers resulted in a significant increase in creatinine clearance. Diurnal variations in creatinine clearance were found. These daily variations correlated well with the periods of food intake. The capacity of the kidney to increase its level of function with protein intake suggests a renal function reserve. In short-term studies, the effect of a protein load on glomerular filtration rate was evaluated. Normal subjects showed an increase in glomerular filtration rate two and a half hours after protein load to a maximal glomerular filtration rate of 171.0 +/- 7.7 ml per minute. In patients with a reduced number of nephrons, renal functional reserve may be diminished or absent.

Continuous arteriovenous hemofiltration in the critically ill patient. Clinical use and operational characteristics

Continuous arteriovenous hemofiltration is an extracorporeal technique for the treatment of fluid overload and electrolyte disturbances and for the removal of urea nitrogen. This technique is especially applicable in critically ill patients with hemodynamic instability. A special filter and modified hemodialysis blood lines can easily and rapidly be attached to a patient. No special blood access is needed. Fluids and solutes are removed from the patient by ultrafiltration. A net filtration pressure inside the filter causes an ultrafiltrate to form. The extracorporeal circuit can be kept in place for hours or days.