Vivaria housing conditions expose sex differences in brain oxidation, microglial activation, and immune system states in aged hAPOE4 mice

Apolipoprotein E ε4 allele (APOE4) is the predominant genetic risk factor for late-onset Alzheimer's disease (AD). APOE4 mouse models have provided advances in the understanding of disease pathogenesis, but unaccounted variables like rodent housing status may hinder translational outcomes. Non-sterile aspects like food and bedding can be major sources of changes in rodent microflora. Alterations in intestinal microbial ecology can cause mucosal barrier impairment and increase pro-inflammatory signals. The present study examined the role of sterile and non-sterile food and housing on redox indicators and the immune status of humanized-APOE4 knock-in mice (hAPOe4). hAPOE4 mice were housed under sterile conditions until 22 months of age, followed by the transfer of a cohort of mice to non-sterile housing for 2 months. At 24 months of age, the redox/immunologic status was evaluated by flow cytometry/ELISA. hAPOE4 females housed under non-sterile conditions exhibited: (1) higher neuronal and microglial oxygen radical production and (2) lower CD68+ microglia (brain) and CD8+ T cells (periphery) compared to sterile-housed mice. In contrast, hAPOE4 males in non-sterile housing exhibited: (1) higher MHCII+ microglia and CD11b+CD4+ T cells (brain) and (2) higher CD11b+CD4+ T cells and levels of lipopolysaccharide-binding protein and inflammatory cytokines in the periphery relative to sterile-housed mice. This study demonstrated that sterile vs. non-sterile housing conditions are associated with the activation of redox and immune responses in the brain and periphery in a sex-dependent manner. Therefore, housing status may contribute to variable outcomes in both the brain and periphery.

LIV Well when Life Is Limited: Technology to Support Independence at Home

There has been significant growth in technologies and services creating 'care at home' ecosystems for people with life-limiting conditions such as dementia. Dementia is one of the leading causes of disability and loss of independence that causes a heavy burden for families and caregivers. There is a clear need to support independent living of people living with dementia and their caregivers. Health technologies can help to foster supported living and social connection. The LIV app, developed by Miroma Project Factory and piloted in collaboration with CSIRO, was designed to achieve these aims. Here we describe the development and functionality of the app and present the preliminary findings from the pilot trial.

A New Role for Chatbots: Automation of a Sleep-Dependent Memory Task

Sleep is known to contribute to memory consolidation. Sleep-dependent memory is not often studied in patients with mild cognitive impairment (MCI), however, due to the need to attend sleep laboratories which are typically expensive, time-consuming and lacking in trained task administrators. We developed a conversation agent able to deliver a sleep-dependent memory task at home. Utility of the chatbot was confirmed through in-house testing and focus groups. The chatbot promises consistent task delivery and improved access for people with MCI.

Sensing Swelling: Towards Remote Monitoring of Craniectomy Patients

Decompressive craniectomy (DC) is a surgical procedure where a portion of the skull is removed to relieve potentially fatal brain swelling. As the swelling can take months to subside, the patient is discharged from an acute care facility to recover prior to cranioplasty (reconstruction surgery). Cranioplasty is associated with complications due to infection, seizure, haematoma and death. The interval between these surgeries is potentially a modifiable risk factor to reduce the rate of complication. We aim to allow clinicians to remotely monitor patients to facilitate an optimal pre-operative review. We have developed a platform technology encompassing a 'smart' device fitted into a skullcap to measure physiological parameters, such as changes in brain swelling, and a clinician portal that allows remote viewing of the patients' physiological data. The use of patient generated data during the transition between craniectomy and cranioplasty has the potential to significantly improve neurorehabilitation outcomes for patients.

Early brain morphometrics from neonatal MRI predict motor and cognitive outcomes at 2-years corrected age in very preterm infants

Infants born very preterm face a range of neurodevelopmental challenges in cognitive, language, behavioural and/or motor domains. Early accurate identification of those at risk of adverse neurodevelopmental outcomes, through clinical assessment and Magnetic Resonance Imaging (MRI), enables prognostication of outcomes and the initiation of targeted early interventions. This study utilises a prospective cohort of 181 infants born <31 weeks gestation, who had 3T MRIs acquired at 29-35 weeks postmenstrual age and a comprehensive neurodevelopmental evaluation at 2 years corrected age (CA). Cognitive, language and motor outcomes were assessed using the Bayley Scales of Infant and Toddler Development - Third Edition and functional motor outcomes using the Neuro-sensory Motor Developmental Assessment. By leveraging advanced structural MRI pre-processing steps to standardise the data, and the state-of-the-art developing Human Connectome Pipeline, early MRI biomarkers of neurodevelopmental outcomes were identified. Using Least Absolute Shrinkage and Selection Operator (LASSO) regression, significant associations between brain structure on early MRIs with 2-year outcomes were obtained (r = 0.51 and 0.48 for motor and cognitive outcomes respectively) on an independent 25% of the data. Additionally, important brain biomarkers from early MRIs were identified, including cortical grey matter volumes, as well as cortical thickness and sulcal depth across the entire cortex. Adverse outcome on the Bayley-III motor and cognitive composite scores were accurately predicted, with an Area Under the Curve of 0.86 for both scores. These associations between 2-year outcomes and patient prognosis and early neonatal MRI measures demonstrate the utility of imaging prior to term equivalent age for providing earlier commencement of targeted interventions for infants born preterm.

Spread of stinging ants to oceanic islands, and the need to raise awareness of prevention and treatment of ant stings

OBJECTIVE

Venomous invasive ants are rapidly dispersing throughout oceanic islands. Medics unfamiliar with envenomation or venom-induced anaphylaxis may be unprepared for the range of possible reactions and corresponding treatments. We detail the suboptimal treatment of a patient suffering anaphylaxis from an ant sting on a remote island and describe what treatment should have been provided.

METHODS

The patient experienced stings on his feet from an ant later identified as tropical fire ant, Solenopsis geminata. Clinical examination revealed throat swelling without obstruction of the airway or pharynx.

RESULTS

The patient was provided the following suboptimal treatment: intravenously-administered antihistamine and saline perfusion. Injected epinephrine should be the standard first line of treatment for anaphylaxis, even when not all symptoms are present.

CONCLUSION

A rise in invasive hymenopteran stings on oceanic islands is inevitable, and proactively improving public awareness and medical training could save lives.

Socially-Assistive Robots to Support Learning in Students on the Autism Spectrum: Investigating Educator Perspectives and a Pilot Trial of a Mobile Platform to Remove Barriers to Implementation

Technology offers educators tools that can tailor learning to students' learning styles and interests. Research into the use of socially-assistive robots as a learning support for children on the autism spectrum are showing promising results. However, to date, few schools have introduced these robots to support learning in students on the autism spectrum. This paper reports on a research project that investigated the barriers to implementing socially-assistive robot supported learning, and the expectations, perceived benefits and concerns of school teachers and therapists of students on the autism spectrum and adults on the autism spectrum. First, three focus groups were conducted with six adults on the autism spectrum, and 13 teachers and therapists of students from two autism-specific schools. During the focus groups, there was cautious optimism from participants about the value of socially-assistive robots for teaching support. While the data showed that participants were in favour of trialling socially-assistive robots in the classroom, they also raised several concerns and potential barriers to implementation, including the need for teacher training. In response to their concerns, the second part of the project focussed on developing a software platform and mobile application (app) to support the introduction of robots into autism-specific classrooms. The software platform and app were then trialled in two schools (n = 7 teachers and therapists). Results from focus groups indicated that participants believe socially-assistive robots could be useful for learning support, as the mobile app provides an easy to use tool to support preparing and conducting lessons that would motivate them to trial robots in the classroom.

Impaired spatial memory in adult vitamin D deficient BALB/c mice is associated with reductions in spine density, nitric oxide, and neural nitric oxide synthase in the hippocampus

Vitamin D deficiency is prevalent in adults and is associated with cognitive impairment. However, the mechanism by which adult vitamin D (AVD) deficiency affects cognitive function remains unclear. We examined spatial memory impairment in AVD-deficient BALB/c mice and its underlying mechanism by measuring spine density, long term potentiation (LTP), nitric oxide (NO), neuronal nitric oxide synthase (nNOS), and endothelial NOS (eNOS) in the hippocampus. Adult male BALB/c mice were fed a control or vitamin D deficient diet for 20 weeks. Spatial memory performance was measured using an active place avoidance (APA) task, where AVD-deficient mice had reduced latency entering the shock zone compared to controls. We characterised hippocampal spine morphology in the CA1 and dentate gyrus (DG) and made electrophysiological recordings in the hippocampus of behaviourally naïve mice to measure LTP. We next measured NO, as well as glutathione, lipid peroxidation and oxidation of protein products and quantified hippocampal immunoreactivity for nNOS and eNOS. Spine morphology analysis revealed a significant reduction in the number of mushroom spines in the CA1 dendrites but not in the DG. There was no effect of diet on LTP. However, hippocampal NO levels were depleted whereas other oxidation markers were unaltered by AVD deficiency. We also showed a reduced nNOS, but not eNOS, immunoreactivity. Finally, vitamin D supplementation for 10 weeks to AVD-deficient mice restored nNOS immunoreactivity to that seen in in control mice. Our results suggest that lower levels of NO and reduced nNOS immunostaining contribute to hippocampal-dependent spatial learning deficits in AVD-deficient mice.

A validation study of a ballistocardiograph sleep tracker EMFIT QS against polysomnography

STUDY OBJECTIVES

Consumer home sleep trackers provide a great opportunity for longitudinal objective sleep monitoring. Non-wearable sleep devices cause little to no disruption in the daily life routine and need little maintenance. However, their validity needs further investigation. This study aims to evaluate the accuracy of sleep outcomes of EMFIT Quantified Sleep (QS), an unobtrusive non-wearable sleep tracker based on ballistocardiography, against polysomnography (PSG).

METHODS

62 sleep-lab patients underwent a single clinical PSG with measures simultaneously collected through PSG and EMFIT QS. Resting heart rate (HR), Total Sleep Time (TST), Wake After Sleep Onset (WASO), Sleep Onset Latency (SOL) and duration in sleep stages, collected from the two devices, compared using paired t-tests and their agreement analyzed using Bland-Altman plots. Additionally, continuous HR and sleep stages in 30-seconds epochs were evaluated.

RESULTS

EMFIT QS data loss occurred in 47% of participants. In the remaining 33 participants (15 females, with mean age of 53.7±16.5), EMFIT QS overestimated TST by 177.5±119.4 minutes (p<0.001) and underestimated WASO by 44.74±68.81 minutes (p<0.001). It accurately measured average resting HR and was able to distinguish SOL with some accuracy. However, the agreement between EMFIT QS and PSG on sleep-wake detection was very low (kappa=0.13, p<0.001), EMFIT QS failed to distinguish sleep stages.

CONCLUSIONS

A consensus between PSG and EMFIT QS was found in SOL and average HR. There was significant discrepancy and lack of consensus in other sleep outcomes. These findings indicated that further development is necessary before using EMFIT QS in clinical and research settings.

CLINICAL TRIAL REGISTRATION

Registry: Australian New Zealand Clinical Trials Registry; Name: Sleep parameter validation of a consumer home sleep monitoring device, EMFIT Quantified Sleep (QS), against Polysomnography; Identifier: ACTRN12621000600842; URL: https://www.anzctr.org.au/ACTRN12621000600842.aspx.

Automating Quantitative Measures of an Established Conventional MRI Scoring System for Preterm-Born Infants Scanned between 29 and 47 Weeks' Postmenstrual Age

BACKGROUND AND PURPOSE

Conventional MR imaging scoring is a valuable tool for risk stratification and prognostication of outcomes, but manual scoring is time-consuming, operator-dependent, and requires high-level expertise. This study aimed to automate the regional measurements of an established brain MR imaging scoring system for preterm neonates scanned between 29 and 47 weeks' postmenstrual age.

MATERIALS AND METHODS

This study used T2WI from the longitudinal Prediction of PREterm Motor Outcomes cohort study and the developing Human Connectome Project. Measures of biparietal width, interhemispheric distance, callosal thickness, transcerebellar diameter, lateral ventricular diameter, and deep gray matter area were extracted manually (Prediction of PREterm Motor Outcomes study only) and automatically. Scans with poor quality, failure of automated analysis, or severe pathology were excluded. Agreement, reliability, and associations between manual and automated measures were assessed and compared against statistics for manual measures. Associations between measures with postmenstrual age, gestational age at birth, and birth weight were examined (Pearson correlation) in both cohorts.

RESULTS

A total of 652 MRIs (86%) were suitable for analysis. Automated measures showed good-to-excellent agreement and good reliability with manual measures, except for interhemispheric distance at early MR imaging (scanned between 29 and 35 weeks, postmenstrual age; in line with poor manual reliability) and callosal thickness measures. All measures were positively associated with postmenstrual age (r = 0.11-0.94; R² = 0.01-0.89). Negative and positive associations were found with gestational age at birth (r = -0.26-0.71; R² = 0.05-0.52) and birth weight (r = -0.25-0.75; R² = 0.06-0.56). Automated measures were successfully extracted for 80%-99% of suitable scans.

CONCLUSIONS

Measures of brain injury and impaired brain growth can be automatically extracted from neonatal MR imaging, which could assist with clinical reporting.

Enabling Nurse-Patient Communication With a Mobile App: Controlled Pretest-Posttest Study With Nurses and Non-English-Speaking Patients

BACKGROUND

There is growing concern regarding the implications of miscommunication in health care settings, the results of which can have serious detrimental impacts on patient safety and health outcomes. Effective communication between nurses and patients is integral in the delivery of timely, competent, and safe care. In a hospital environment where care is delivered 24 hours a day, interpreters are not always available. In 2014, we developed a communication app to support patients' interactions with allied health clinicians when interpreters are not present. In 2017, we expanded this app to meet the needs of the nursing workforce. The app contains a fixed set of phrases translated into common languages, and communication is supported by text, images, audio content, and video content.

OBJECTIVE

This study aims to evaluate the efficacy of the communication app to support nursing staff during the provision of standard care to patients from non-English-speaking backgrounds when an interpreter is not available.

METHODS

This study used a one-group pretest-posttest sequential explanatory mixed methods research design, with quantitative data analyzed using inferential statistics and qualitative data analyzed via thematic content analysis. A total of 134 observation sessions (82 pretest and 52 posttest) of everyday nurse-patient interactions and 396 app use sessions were recorded. In addition, a total of 134 surveys (82 pretest and 52 posttest) with nursing staff, 7 interviews with patients, and 3 focus groups with a total of 9 nursing staff participants were held between January and November 2017.

RESULTS

In the absence of the app, baseline interactions with patients from English-speaking backgrounds were rated as more successful (t₈₀=5.69; P<.001) than interactions with patients from non-English-speaking backgrounds. When staff used the app during the live trial, interactions with patients from non-English-speaking backgrounds were rated as more successful than interactions without the app (F_2,119=8.17; P<.001; η²=0.37). In addition, the level of staff frustration was rated lower when the app was used to communicate (t₈₀=2.71; P=.008; r=0.29). Most participants indicated that the app assisted them in communicating.

CONCLUSIONS

Through the use of the app, a number of patients from non-English-speaking backgrounds experienced better provision of standard care, similar to their English-speaking peers. Thus, the app can be seen as contributing to the delivery of equitable health care.

Introducing Edna: A trainee chatbot designed to support communication about additional (secondary) genomic findings

OBJECTIVE

To support informed decision-making about reanalysis of clinical genomic data for risk of preventable conditions ('additional findings') by developing a chatbot (electronic genetic resource, 'eDNA').

METHODS

Interactions in pre-test genetic counseling sessions (13.5 h) about additional findings were characterized using proponent, thematic and semantic analyses of transcripts. We then wrote interfaces to draw supplementary data from external genetics applications. To create Edna, this content was programmed using a chatbot framework which interacts with patients via speech-to-text.

RESULTS

Conditions, terms, explanations of concepts, and key factors to consider in decision making were all encoded into chatbot conversations emulating counseling session flows. Patient agency can be enhanced by prompted consideration of the personal and familial implications of testing. Similarly, health literacy can be broadened through explanation of genetic conditions and terminology. Novel aspects include sentiment analysis and collection of family history. Medical advice and the impact of existing genetic conditions were deemed inappropriate for inclusion.

CONCLUSION

Edna's successful development represents a movement towards accessible, acceptable and well-supported digital health processes for patients to make informed decisions for additional findings.

PRACTICE IMPLICATIONS

Edna complements genetic counseling by collecting and providing genomic information before or after pre-test consultations.

Predicting motor outcome in preterm infants from very early brain diffusion MRI using a deep learning convolutional neural network (CNN) model

BACKGROUND AND AIMS

Preterm birth imposes a high risk for developing neuromotor delay. Earlier prediction of adverse outcome in preterm infants is crucial for referral to earlier intervention. This study aimed to predict abnormal motor outcome at 2 years from early brain diffusion magnetic resonance imaging (MRI) acquired between 29 and 35 weeks postmenstrual age (PMA) using a deep learning convolutional neural network (CNN) model.

METHODS

Seventy-seven very preterm infants (born <31 weeks gestational age (GA)) in a prospective longitudinal cohort underwent diffusion MR imaging (3T Siemens Trio; 64 directions, b ​= ​2000 ​s/mm²). Motor outcome at 2 years corrected age (CA) was measured by Neuro-Sensory Motor Developmental Assessment (NSMDA). Scores were dichotomised into normal (functional score: 0, normal; n ​= ​48) and abnormal scores (functional score: 1-5, mild-profound; n ​= ​29). MRIs were pre-processed to reduce artefacts, upsampled to 1.25 ​mm isotropic resolution and maps of fractional anisotropy (FA) were estimated. Patches extracted from each image were used as inputs to train a CNN, wherein each image patch predicted either normal or abnormal outcome. In a postprocessing step, an image was classified as predicting abnormal outcome if at least 27% (determined by a grid search to maximise the model performance) of its patches predicted abnormal outcome. Otherwise, it was considered as normal. Ten-fold cross-validation was used to estimate performance. Finally, heatmaps of model predictions for patches in abnormal scans were generated to explore the locations associated with abnormal outcome.

RESULTS

For the identification of infants with abnormal motor outcome based on the FA data from early MRI, we achieved mean sensitivity 70% (standard deviation SD 19%), mean specificity 74% (SD 39%), mean AUC (area under the receiver operating characteristic curve) 72% (SD 14%), mean F1 score of 68% (SD 13%) and mean accuracy 73% (SD 19%) on an unseen test data set. Patch-based prediction heatmaps showed that the patches around the motor cortex and somatosensory regions were most frequently identified by the model with high precision (74%) as a location associated with abnormal outcome. Part of the cerebellum, and occipital and frontal lobes were also highly associated with abnormal NSMDA/motor outcome.

DISCUSSION/CONCLUSION

This study established the potential of an early brain MRI-based deep learning CNN model to identify preterm infants at risk of a later motor impairment and to identify brain regions predictive of adverse outcome. Results suggest that predictions can be made from FA maps of diffusion MRIs well before term equivalent age (TEA) without any prior knowledge of which MRI features to extract and associated feature extraction steps. This method, therefore, is suitable for any case of brain condition/abnormality. Future studies should be conducted on a larger cohort to re-validate the robustness and effectiveness of these models.

Vitamin D deficiency is associated with reduced hippocampal volume and disrupted structural connectivity in patients with mild cognitive impairment

Vitamin D deficiency may exacerbate adverse neurocognitive outcomes in the progression of diseases such as Parkinson's, Alzheimer's, and other dementias. Mild cognitive impairment (MCI) is prodromal for these neurocognitive disorders and neuroimaging studies suggest that, in the elderly, this cognitive impairment is associated with a reduction in hippocampal volume and white matter structural integrity. To test whether vitamin D is associated with neuroanatomical correlates of MCI, we analyzed an existing structural and diffusion MRI dataset of elderly patients with MCI. Based on serum 25-OHD levels, patients were categorized into serum 25-OHD deficient (<12 ng/mL, n = 27) or not-deficient (>12 ng/mL, n = 29). Freesurfer 6.0 was used to parcellate the whole brain into 164 structures and segment the hippocampal subfields. Whole-brain structural connectomes were generated using probabilistic tractography with MRtrix. The network-based statistic (NBS) was used to identify subnetworks of connections that significantly differed between the groups. We found a significant reduction in total hippocampal volume in the serum 25-OHD deficient group especially in the CA1, molecular layer, dentate gyrus, and fimbria. We observed a connection deficit in 13 regions with the right hippocampus at the center of the disrupted network. Our results demonstrate that low vitamin D is associated with reduced volumes of hippocampal subfields and connection deficits in elderly people with MCI, which may exacerbate neurocognitive outcomes. Longitudinal studies are now required to determine if vitamin D can serve as a biomarker for Alzheimer's disease and if intervention can prevent the progression from MCI to major cognitive disorders.

CALD Assist-Nursing: Improving communication in the absence of interpreters

AIMS AND OBJECTIVES

To develop a communication app to support nursing staff during the provision of standard care of patients from non-English-speaking backgrounds (NESBs), when an interpreter is not available. This paper reports on the user needs analysis phase that informed the development, content and functionality of the app.

BACKGROUND

In 2014 we developed CALD Assist, a communication app to support patient interactions with allied health clinicians when interpreters are not present. It includes 95 commonly used phrases professionally interpreted into 10 languages and grouped by discipline. This work expands upon our previous app to meet the needs of the nursing workforce.

DESIGN

Qualitative through focus groups, observations and interviews, with a quantitative component from observational data and staff surveys.

METHODS

Four focus groups with hospital staff, ten interviews with patients from NESBs and 85 observation sessions of everyday patient-staff interactions followed by staff surveys (n = 85) were held between January and June 2017.

RESULTS

Baseline data prior to app development revealed that staff confidence of the patients' level of understanding and the success of the interaction were significantly greater for English-speaking (ES) patients, than for non-English-speaking patients. A total of 143 phrases were identified and subdivided into 16 categories for inclusion in the new app.

CONCLUSION

Staff participants highlighted that patients from NESBs are a challenging patient group to interact with. Patient and staff participants identified a range of areas where the nursing app could benefit, including pain management, mobility, hygiene and nutrition.

RELEVANCE TO CLINICAL PRACTICE

The proposed app can be used to reduce variances in practice and provide a timely and positive patient experience for patients from NESBs who are unable to communicate in English during hospital admissions.

Behavioural Effects of Adult Vitamin D Deficiency in BALB/c Mice Are not Associated with Proliferation or Survival of Neurons in the Adult Hippocampus

Epidemiological studies have shown that up to one third of adults have insufficient levels of vitamin D and there is an association between low vitamin D concentrations and adverse brain outcomes, such as depression. Vitamin D has been shown to be involved in processes associated with neurogenesis during development. Therefore, the aim of this study was to test the hypothesis that adult vitamin D (AVD) deficiency in BALB/c mice was associated with (a) adult hippocampal neurogenesis at baseline, b) following 6 weeks of voluntary wheel running and (c) a depressive-like phenotype on the forced swim test (FST), which may be linked to alterations in hippocampal neurogenesis. We assessed proliferation and survival of adult born hippocampal neurons by counting the number of cells positive for Ki67 and doublecortin (DCX), and incorporation of 5-Bromo-2’-Deoxyuridine (BrdU) within newly born mature neurons using immunohistochemistry. There were no significant effects of diet on number of Ki67⁺, DCX⁺ or BrdU⁺ cells in the dentate gyrus. All mice showed significantly increased number of Ki67⁺ cells and BrdU incorporation, and decreased immobility time in the FST, after voluntary wheel running. A significant correlation was found in control mice between immobility time in the FST and level of hippocampal neurogenesis, however, no such correlation was found for AVD-deficient mice. We conclude that AVD deficiency was not associated with impaired proliferation or survival of adult born neurons in BALB/c mice and that the impact on rodent behaviour may not be due to altered neurogenesis per se, but to altered function of new hippocampal neurons or processes independent of adult neurogenesis.

Making an APPropriate Care Program for Indigenous Cardiac Disease: Customization of an Existing Cardiac Rehabilitation Program

Cardiovascular disease is a major health problem for all Australians and is the leading cause of death in Aboriginal and Torres Strait Islanders. In 2010, more then 50% of all heart attack deaths were due to repeated events. Cardiac rehabilitation programs have been proven to be effective in preventing the recurrence of cardiac events and readmission to hospitals. There are however, many barriers to the use of these programs. To address these barriers, CSIRO developed an IT enabled cardiac rehabilitation program delivered by mobile phone through a smartphone app and succesfully trialed it in an urban general population. If these results can be replicated in Indigenous populations, the program has the potential to significantly improve life expectancy and help close the gap in health outcomes. The challenge described in this paper is customizing the existing cardiac health program to make it culturally relevant and suitable for Indigenous Australians living in urban and remote communities.

Detecting degeneration: monitoring cognitive health in independent elders

Australia has an ever increasing ageing population due to advances in healthcare and post-war booms in fertility. Estimations that over 22% of the population will be aged 65+ in 2050 provide a strong incentive to develop innovative assistive technologies to support elderly people to live safely at home longer. Extended independent living can improve quality of life for elders and their families and reduce costs associated with health and aged care. There is however, the need to monitor the elderly resident's safety, physical health and brain function. The Smarter Safer Homes project aims to develop a platform to facilitate independent living. The platform will aggregate sensor information at environmental, cognitive, physical, and physiological levels, allowing changes and trends in activities of daily living to be monitored. Such monitoring could potentially predict decline of brain function. Here we present how data derived from a sensor-based in-home monitoring system may be able to be used to provide a measure of neurological health. This measure could then facilitate tailoring of the home to meet the resident's changing needs, or to determine when a move to residential care is required.

Randomized phase II clinical trial comparing tremelimumab (CP-675,206) with best supportive care (BSC) following first-line platinum-based therapy in patients (pts) with advanced non-small cell lung cancer (NSCLC)

8071

Background: Pts diagnosed with advanced NSCLC with good performance status typically receive platinum-based chemotherapy; however, no approved maintenance therapy exists. Tremelimumab, a fully human anti-CTLA4 mAb, is associated with durable responses in some pts with metastatic melanoma. Methods: This open-label, randomized, multicenter, phase II clinical trial evaluating efficacy and safety of tremelimumab as maintenance therapy was conducted in pts with locally advanced or metastatic NSCLC with ECOG performance status ≤1. Pts treated with ≥4 cycles of first-line platinum-based therapy resulting in either stable disease (SD) or response per RECIST were eligible and were randomized 3–6 weeks after prior therapy. Pts received 15 mg/kg IV tremelimumab Q90D or BSC until disease progression. Primary endpoint was progression-free survival (PFS) at 3 months. Secondary endpoints included safety, objective response rate, and 1-year survival. Results: Eighty-seven pts received tremelimumab (n=44) or BSC (n=43). Nine (20.9%; 90% CI: 11.4%, 33.7%) pts receiving tremelimumab and 6 (14.3%; 90% CI: 6.4%, 26.3%) pts receiving BSC were progression free at 3 months. Among pts receiving tremelimumab, there were 2 (4.8%) partial responses and 7 (16.6%) SDs, compared with 0 and 6 (14.3%) pts receiving BSC, respectively. Treatment-related adverse events (AEs) were observed in 27 (61.4%) pts receiving tremelimumab and 3 (7.0%) receiving BSC. Nine pts (20.5%) receiving tremelimumab reported grade 3 or 4 AEs compared with 0 patients receiving BSC. The most common grade 3 or 4 AEs attributed to tremelimumab were diarrhea and colitis (n=4, 9.1%). Conclusions: In pts with advanced NSCLC and good performance status receiving platinum-based first-line therapy, single-agent tremelimumab was tolerable, with safety consistent with prior studies. Although PFS analysis did not demonstrate superiority of tremelimumab over BSC, the 4.8% objective response rate seen only in the investigational arm may support future combination studies. Analysis of 1-year survival is forthcoming.

[Table: see text]

Randomized, double blind, multicenter, phase II study of pemetrexed (PEM), carboplatin (CARBO), bevacizumab (BEV) with enzastaurin (ENZ) or placebo (PBO) in chemotherapy-naive patients with stage IIIB/IV non-small cell lung cancer (NSCLC): Hoosier Oncology Group (HOG) LUN06–116

8035^

Background: Pre-clinical data suggests that ENZ and BEV may have complementary effects in inhibiting angiogenesis. This study compared ENZ vs PBO in combination with PEM+CARBO+ BEV. Methods: Pts ≥18 years of age, non-squamous NSCLC, no prior systemic therapy, disease measurable by RECIST, and ECOG PS 0–1 were randomized. Pts received either PBO or 500 mg ENZ daily after loading dose of 375 mg orally, TID, on day 1, cycle 1. Starting on day 8, cycle 1, patients received PEM 500mg/m2, CARBO AUC 6 and BEV 15mg/kg, intravenously, every 21 days. After 4 cycles, pts continued on BEV+ENZ or BEV+PBO. Pts were stratified by ECOG status, disease stage and site with a planned sample size of 90 pts. Primary end point was progression-free survival (PFS). Secondary end points included objective response rate (ORR) and toxicity. Results: Study was terminated after a planned interim analysis for safety and efficacy. From October 2007 to July 2008, 40 pts were enrolled: 20 in each arm. Median age was 60.5 years (range: 44 to 78); M 52.5%, F 47.5%; ECOG PS 0/1 52.5% and 47.5%; stage IIIB/IV 15% and 85%. Baseline characteristics were well matched. The PEM+CARBO+BEV+ENZ arm received a median of 3 cycles of therapy and the PEM+CARBO+BEV+PBO arm 4 cycles. Median PFS was 4.3 mo and 4.2 mo for ENZ and PBO, respectively (unadjusted HR: 0.94, 95% CI [0.39, 2.33]). ORR for ENZ and PBO was 20% and 25%, respectively. Overall, grade 3/4 toxicities were similar in both arms. One patient in ENZ arm experienced a grade 3/4 hemorrhage (vs. none in the PBO arm). Two patients experienced a GI perforation (1 on each arm): 1 resulted in death on the PBO arm. Both patients had a history of diverticulosis. Conclusions: Based upon the results of this interim efficacy analysis, addition of ENZ to PEM+CARBO+BEV will not significantly prolong PFS in patients with stage IIIB/IV NSCLC. This combination does not warrant further study in NSCLC.

[Table: see text]

ASCO Conflict of Interest Policy and Exceptions

In compliance with the guidelines established by the ASCO Conflict of Interest Policy (J Clin Oncol. 2006 Jan 20;24[3]:519–521) and the Accreditation Council for Continuing Medical Education (ACCME), ASCO strives to promote balance, independence, objectivity, and scientific rigor through disclosure of financial and other interests, and identification and management of potential conflicts. According to the ASCO Conflict of Interest Policy, the following financial and other relationships must be disclosed: employment or leadership position, consultant or advisory role, stock ownership, honoraria, research funding, expert testimony, and other remuneration (J Clin Oncol. 2006 Jan 20;24[3]:520). The ASCO Conflict of Interest Policy disclosure requirements apply to all authors who submit abstracts to the Annual Meeting.

For clinical trials that began accrual on or after April 29, 2004, ASCO's Policy places some restrictions on the financial relationships of principal investigators (J Clin Oncol. 2006 Jan 20;24[3]:521). If a principal investigator holds any restricted relationships, his or her abstract will be ineligible for placement in the 2009 Annual Meeting unless the ASCO Ethics Committee grants an exception. Among the circumstances that might justify an exception are that the principal investigator (1) is a widely acknowledged expert in a particular therapeutic area; (2) is the inventor of a unique technology or treatment being evaluated in the clinical trial; or (3) is involved in international clinical oncology research and has acted consistently with recognized international standards of ethics in the conduct of clinical research. NIH-sponsored trials are exempt from the Policy restrictions. Abstracts for which authors requested and have been granted an exception in accordance with ASCO's Policy are designated with a caret symbol (^) in the Annual Meeting Proceedings.

For more information about the ASCO Conflict of Interest Policy and the exceptions process, please visit www.asco.org/conflictofinterest .

Netrin-1: diversity in development

In 1990, the discovery of three Caenorhabditis elegans genes (unc5, unc6, unc40) involved in pioneer axon guidance and cell migration marked a significant advancement in neuroscience research [Hedgecock EM, Culotti JG, Hall DH. The unc-5, unc-6, and unc-40 genes guide circumferential migrations of pioneer axons and mesodermal cells on the epidermis in C. elegans. Neuron 1990;4:61-85]. The importance of this molecular guidance system was exemplified in 1994, when the vertebrate orthologue of Unc6, Netrin-1, was discovered to be a key guidance cue for commissural axons projecting toward the ventral midline in the rodent embryonic spinal cord [Serafini T, Kennedy TE, Galko MJ, Mirzayan C, Jessell TM, Tessier-Lavigne M. The netrins define a family of axon outgrowth-promoting proteins homologous to C. elegans UNC-6. Cell 1994;78:409-424]. Since then, Netrin-1 has been found to be a critical component of embryonic development with functions in axon guidance, cell migration, morphogenesis and angiogenesis. Netrin-1 also plays a role in the adult brain, suggesting that manipulating netrin signals may have novel therapeutic applications.

Neogenin is expressed on neurogenic and gliogenic progenitors in the embryonic and adult central nervous system

The Netrin/RGMa receptor, Neogenin, has recently been identified on neuronal and gliogenic progenitors, including radial glia in the embryonic mouse cortex and ganglionic eminences, respectively [Fitzgerald, D.P., Cole, S.J., Hammond, A., Seaman, C., Cooper, H.M., 2006a. Characterization of Neogenin-expressing neural progenitor populations and migrating neuroblasts in the embryonic mouse forebrain. Neuroscience 142, 703-716]. Here we have undertaken a detailed analysis of Neogenin expression in the embryonic mouse central nervous system at key developmental time points. We demonstrate that Neogenin protein is present on actively dividing neurogenic precursors during peak phases of neurogenesis (embryonic days 12.5-14.5) in the forebrain, midbrain and hindbrain. Furthermore, we show that Neogenin protein is localized to the cell bodies and glial processes of neurogenic radial glial populations in all these regions. We have also observed Neogenin on gliogenic precursors within the subventricular zones of the forebrain late in development (embryonic day 17.5). Adult neural stem cells found in the subventricular zone of the lateral ventricle of the rodent forebrain are direct descendants of the embryonic striatal radial glial population. Here we show that Neogenin expression is maintained in the neural stem cell population of the adult mouse forebrain. In summary, this study demonstrates that Neogenin expression is a hallmark of many neural precursor populations (neurogenic and gliogenic) in both the embryonic and adult mammalian central nervous system.

Antiretroviral therapy for HIV-infected people in Papua New Guinea: challenges and opportunities

Antiretroviral treatment services for Papua New Guineans infected with HIV (human immunodeficiency virus) have been severely limited because of the expense and difficulty in gaining access to antiretroviral drugs and the tests that are required to monitor the response of patients to them. Because some Papua New Guineans are beginning to seek out these services in Australia, clinicians are being challenged to manage the condition properly across an international border. Several case histories presented here highlight such difficulties. Progress is being made to reduce drug prices and simplify tablet-taking regimens, which has made the use of antiretroviral therapy more feasible. We briefly discuss infrastructure requirements for the more widespread provision of antiretroviral treatment services within Papua New Guinea.

The effect of education on patients' willingness to participate in a telemedicine study

We assessed the effect of previous education on patients' willingness to participate in a clinical study of telemedicine for hypertensive patients. The design was a cross-sectional study of adult patients arriving for appointments in a hypertension clinic. Of the 259 patients approached, 86% completed a baseline survey and were subsequently asked if they would be willing to participate in a one-year telemedicine study. One hundred and fifty patients (58%) agreed to participate. A stepwise logistic regression analysis was performed to assess the effect of level of education on willingness to participate, while controlling for potentially confounding variables. In the final model, only education remained significant. The odds ratio for non-participation of patients with high-school education or less was 3.6 (95% confidence interval 1.9-7.0). Educational status should be carefully considered when designing, implementing and interpreting telemedicine studies.

Patient and physician satisfaction in a clinical study of telemedicine in a hypertensive patient population

We studied patient and physician satisfaction with telemedicine for the care of a hypertensive population. Once recruited, participants were seen both in person and via telemedicine (in random order) on the same day. After each meeting, patient and physician satisfaction surveys were completed. In the 12-month study, there were 107 pairs of visits. The physicians reported a small but significant increase in workload, mental effort, technical skills and visit duration for telemedicine when compared with face-to-face consultations. They noted that the telemedicine system worked well in the majority of cases and could reduce the need for future treatment. Patients reported slightly but significantly higher satisfaction scores for the following for in-person than for telemedicine meetings: technical quality, interpersonal care and time spent. Patients reported high satisfaction scores for both telemedicine and in-person visits.

A method to report utilization for quality initiatives in medical facilities

OBJECTIVE

We undertook this project to outline a methodology for quantifying aggregate health care utilization of medical "technologies" that could be rank ordered by volume. The identification of specific high-volume technologies could guide future efforts for quality initiatives such as program planning, preventive services implementation, quality improvement activities, and innovative and cost-effective technology development.

DESIGN

This study utilized a retrospective cross-sectional study design.

METHODS

We generated combined ranks for the top 200 high-volume procedures from three data sources that incorporated in- and outpatient procedures. Data were collected using primarily ICD-9 and CPT-4 codes; all codes were translated into CPT-4 codes and collapsed into categories using truncated three-digit CPT-4 codes. Frequencies for each collapsed code were determined with each dataset; procedures were reranked based on the mean rank of the three sources.

MAIN OUTCOME MEASURES

We itemized the individual procedure codes making up each of the top 20 categories and reported the unique codes making up at least 80% of the procedure code category.

RESULTS

The top five procedure categories identified in this study were patient visits (inpatient and outpatient), chest x-rays, mammograms, ophthalmological services, and electrocardiograms.

CONCLUSION

The methodology described provides a new way to combine and concisely report on utilization of procedures that is relevant to data obtained from different sources. This methodology may be of potential benefit to health care administrators, technology developers, and other planners as they contemplate ways to identify quality and technology development initiatives that can have a broad impact on populations served by health care organizations.

High rates of multiple antibiotic resistance in Streptococcus pneumoniae from healthy children living in isolated rural communities: association with cephalosporin use and intrafamilial transmission

OBJECTIVE

Streptococcus pneumoniae is one of the most clinically significant pathogens with emerging antibiotic resistance. We performed a surveillance study in isolated rural populations of healthy children to estimate the prevalence of pneumococcal resistance and to contrast factors that predict pneumococcal carriage with those that specifically predict resistant pneumococcal carriage.

METHODS

The study was conducted in 1998 in 2 rural communities in Utah. Families were recruited directly for participation through community canvassing. Surveillance nasopharyngeal cultures were obtained from children who were younger than 8 years. Antibiotic usage and information on other potential risk factors were obtained from questionnaires and local pharmacy records. Resistance was determined by testing isolates for susceptibility to penicillin, cefaclor, trimethoprim-sulfamethoxazole, erythromycin, ceftriaxone, and trovafloxacin. Selected resistant isolates were characterized further by serotyping, pulsed field gel electrophoresis, and Southern blot with DNA probes specific for the pneumococcal lytA gene and for antibiotic resistance genes.

RESULTS

In April 1998, surveillance nasopharyngeal cultures were obtained from 368 children aged </=8 years in community A and 369 children in community B. The number of antibiotic courses per child within 1 year before culture was higher in community B than A (mean: 2.2 vs 1.7). Conversely, oral cephalosporins were more frequently used in community A than B (community A: 22% received cephalosporins within 4 months; community B: 12%). Colonization with S pneumoniae was detected in 24% of children in community A and 14% in community B; 36% of isolates from community A and 28% of isolates from community B were resistant or intermediately susceptible to at least 1 antibiotic tested. Reduced susceptibility was most common to trimethoprim-sulfamethoxazole and cefaclor (28% and 26%, respectively). Pneumococcal carriage (susceptible or resistant) was independently associated with age <5 years (odds ratio [OR]: 2.2), child care exposure (OR: 2.4), presence of a sibling with a positive culture (OR: 3.3), and residence in community A (OR: 1.7). Among carriers, age <2 years (OR: 2.6), use of cephalosporins within the preceding 4 months (OR: 2.7), and having a sibling colonized with resistant S pneumoniae (OR: 5.5) were independent predictors of reduced susceptibility or resistance. Each pair of resistant isolates from siblings was indistinguishable by pulsed field gel electrophoresis and other molecular typing techniques. Several pneumococcal isolates from these isolated rural areas had the molecular characteristics of international clones of multiple-drug-resistant pneumococci that have been associated with worldwide spread.

CONCLUSIONS

Young age and intrafamilial transmission were important risk factors for carriage of both susceptible and resistant S pneumoniae. In contrast, previous cephalosporin use was linked specifically to resistant pneumococcal carriage, which suggests that modifications in antibiotic usage patterns may have salutary effects on antimicrobial resistance. These results extend previous observations in large cities regarding the penetration of multiple-drug-resistant clones of pneumococci into community populations.

Effectiveness of second-generation antipsychotics in patients with treatment-resistant schizophrenia: a review and meta-analysis of randomized trials

OBJECTIVE

The authors conducted a review and meta-analysis of studies that compared the efficacy and tolerability of typical and second-generation antipsychotics for patients with treatment-resistant schizophrenia.

METHOD

A systematic search revealed 12 controlled studies (involving 1,916 independent patients), which were included in the review. For the seven studies that compared clozapine to a typical antipsychotic, a meta-analysis was performed to examine clozapine's effects on overall psychopathology, response rate, extrapyramidal symptoms, and tardive dyskinesia.

RESULTS

The meta-analysis confirmed that treatment-resistant schizophrenic patients have more favorable outcomes when treated with clozapine rather than a typical antipsychotic, as reflected by Brief Psychiatric Rating Scale total score, categorical response rate, Scale for the Assessment of Negative Symptoms score, Simpson-Angus Rating Scale score, and compliance rate. Clozapine also conferred benefits on the sickest treatment-resistant schizophrenic patients. Patients treated with olanzapine also had more favorable outcomes with regard to categorical response and compliance rates.

CONCLUSIONS

In the aggregate, the results of a meta-analysis indicated that clozapine exhibits superiority over typical antipsychotics in terms of both efficacy (as measured by improvement in overall psychopathology) and safety (in terms of reduced extrapyramidal side effects). However, the magnitude of the clozapine treatment effect was not consistently robust. Efficacy data for other second-generation antipsychotics in the treatment of patients with refractory schizophrenia were inconclusive. There is, therefore, a growing need to consider new and different treatment strategies, whether they be adjunctive or monotherapeutic, for schizophrenia that continues to be resistant or only partially responsive to treatment.

Effects of gender, body composition and birth size on IGF-I in 7- and 8-year-old children

We investigated the relationship between IGF-I, gender, height, weight, body composition and birth size in 260 healthy 7- and 8-year-old children (139 females). All children were born term at Nepean Hospital, Western Sydney. Body composition was measured using dual energy X-ray absorptiometry. IGF-I levels were determined by radioimmunoassay. Girls had higher IGF-I levels than boys (20.2 +/- 6.5 nmol/l compared to 15.9 +/- 6.1 nmol/l, p < 0.001) but there was no correlation between age and IGF-I. IGF-I was positively correlated with height SDS (R(2) = 0.12), weight SDS (R(2) = 0.19), BMI SDS (R(2) = 0.18), total body fat (%) (R(2) = 0.14), and fat-free tissue/cm (R(2) = 0.03). After adjusting for gender and current weight, IGF-I-levels were inversely related to birth size - children with the lowest birth size and heaviest current weight had the highest IGF-I levels. This correlation between birth weight and IGF-I supports the hypothesis that the IGF-I axis is altered in babies who are small for gestational age.

'Candidatus Nostocoida limicola', a filamentous bacterium from activated sludge

Five strains of 'Candidatus Nostocoida limicola' were isolated by micromanipulation from two activated sludge plants. Two (Ben17 and Ben18) were from Sunbury, Victoria, Australia, and three (Ben67, Ver1 and Ver2) were from Verona, Italy. The near complete 16S rDNA sequences were determined for five strains and the phylogenetic location of this important bulking filament in the actinomycete subphylum is reported for the first time. Phylogenetically, the Ben strains formed one group with 99.4% 16S rDNA similarity, and the Ver strains formed another with 99.9% 16S rDNA similarity. The mean similarity between the two groups was 97.4%. By 16S rDNA comparison, the closest relative to all strains was Terrabacter sp. strain DPO1361 (95.0-95.5% identical). On R2A medium, all strains generally grew as short filaments or clumps of cocci, whereas on glucose sulfide (GS) medium, all grew as irregular twisting filaments comprising Gram-positive and Gram-negative cells, which is close to their in situ morphology. Polyphosphate was stored either as granules (R2A) or throughout the trichomes (GS). None of the strains could grow without added nitrogen, reduce nitrate to nitrogen gas or grow anaerobically, whereas all could grow at 15-30 degrees C, produce catalase and reduce nitrate to nitrite. All were inactive in the Hugh & Leifson test. This paper describes 'Candidatus Nostocoida limicola'.

CCU patient survey tool: all-out recovery

Studies show that patients' recall of their CCU stays is extremely limited due to various factors. To monitor patient satisfaction in this area, a team of CCU managers developed a survey and began an "All-Out Recovery Program."

Recruitment of African Americans into prostate cancer screening

PURPOSE

Both incidence and mortality rates for prostate cancer are significantly higher in African American men than in white men. This report identifies community sites for the optimal recruitment of African American men into prostate cancer screening.

DESCRIPTION OF STUDY

A descriptive study was conducted, providing an educational program to 1369 African American men, 1264 of whom completed a survey on demographic data, prostate cancer knowledge, and prostate cancer screening history. The programs were offered at six different types of community sites, including various work sites, churches, housing projects, National Association for Advancement of Colored Persons (NAACP) sites, barber shops, and a state fairground. Free prostate cancer screening was offered to all participants.

RESULTS

The advertised mass screening site (state fairground), the most common method used nationally to recruit African American men for cancer screening, was the least effective site, with only 16 men completing the survey. Of the 1264 men completing the survey at all community sites, 597 men (47%) did so at work sites and 438 (35%) did so at churches. Per site, the largest percentage of men who had never been screened was at work sites (n = 276, 46%) and NAACP sites (n = 22, 33.8%). The highest percentage of men who obtained free screening were at the state fairground (14 of 16), churches (256 of 438), and work sites (336 of 597). The most prostate cancers were detected at the housing projects, where 3 of 38 (7.9%) men who were screened received diagnoses of prostate cancer.

CLINICAL IMPLICATIONS

To reduce prostate mortality rates in African American men, healthcare providers need to make a concerted effort to increase prostate cancer education and screening in this population. To be effective, recruitment of African American men must move from a provider/health site orientation to a consumer/community orientation. These findings indicate that recruitment strategies are more successful if efforts are based in the community or where a large number of African American men live and/or work. Because a history of screening has been shown to be a predictor for current participation, programs need to target men who have not had previous screening ever or within the last year. In addition, the large percentage of men recruited at work sites who had not been screened previously indicates an opportunity for collaboration with healthcare professionals in employee health programs. Efforts to increase participation in prostate cancer screening will be enhanced significantly by eliciting the active involvement of community leaders.

Update on issues for HIV management

During the past 12 months, there have been major advances in knowledge about HIV. With this new knowledge comes better management. In a very short period of time, both doctors and patients have swung from a mood of deep despondency to optimism and hopefulness. There have been several factors in this changed outlook: the availability of viral load testing; the licensing of new more potent anti retroviral drugs (particularly the protease inhibitors), and the demonstration (for the first time) that combination anti retroviral therapy offers benefit, not only in controlled clinical trials, but in the everyday lives of people living with HIV/AIDS.

The filamentous morphotype Eikelboom type 1863 is not a single genetic entity

Five isolates of a filamentous bacterial morphotype with the distinctive diagnostic microscopic features of Eikelboom Type 1863 were obtained from activated sludge sewage treatment plants in Victoria, Australia. On the basis of phenotypic evidence and 16S rDNA sequence data, these isolates proved to be polyphyletic. Two (Ben 06 and Ben 06C) are from the Chryseobacterium subgroup which is in the Cytophaga group, subdivision I of the Flexibacter-Cytophaga-Bacteroides phylum. Two (Ben 56 and Ben 59) belong to the genus Acinetobacter, and one (Ben 58) is a Moraxella sp., closest to Mor. osloensis. The significance of these findings to the reliance on microscopic features for identification of these filamentous bacteria in activated sludge is discussed.

A comparison of fluvoxamine and fluoxetine in the treatment of major depression

This randomized, double-blind, parallel-group design study of 100 outpatients with major depressive disorder is the first study in the United States to compare the efficacy and tolerability of fluvoxamine (100-150 mg/day) and fluoxetine (20-80 mg/day). After a variable, single-blind, washout period, patients were randomized to receive either fluvoxamine (51 patients) of fluoxetine (49 patients) for 7 weeks. Efficacy was assessed with the 21-item Hamilton Rating Scale for Depression (HAM-D), and Clinical Global Impressions scale for severity and improvement. Eighty-four percent of each treatment group completed the study with each group having a mean score at end point of less than 10. Both groups demonstrated a 60% improvement in HAM-D scores over the 7-week trial. There were no statistically significant differences observed between the two groups on any efficacy parameter. The medications were well tolerated, with only two patients in each group who were terminated because of side effects. There were differences in the side-effect profiles, with fluvoxamine being associated with less nausea than fluoxetine. In summary, fluvoxamine and fluoxetine were equally effective in reducing depressive symptoms, but the two drugs displayed slightly different side-effect profiles.

Managing HIV. Part 8: Controlling an epidemic. 8.2 HIV prevention in the community: sexual transmission

Preventing sexual transmission is the key to containing the HIV epidemic, and the key to prevention is in the positive promotion of safer sexual behaviours: using condoms and avoiding unprotected penetrative sex. Doctors can play a vital public health role by providing frank advice.

"Candidatus Microthrix parvicella", a filamentous bacterium from activated sludge sewage treatment plants

"Candidatus Microthrix parvicella" is a filamentous bacterium that grows with great difficulty in cultures from the mixed liquor of activated sludge sewage treatment plants. It is gram positive, and the ultrastructure of its cell walls has been determined to be of the gram-positive type by electron microscopical examination. Phylogenetically, it is a deep-branching member of the subphylum actinomycetes within the gram-positive phylum of the domain Bacteria. As for phenotypic features, it is known that the organism contains a polyphosphate inclusions and that it is catalase positive. In mixed cultures in activated sludge plants and in pure culture in the laboratory, it has a characteristic and distinctive winding filamentous morphology, with filaments hundreds of micrometers long.

An open study of oral flesinoxan, a 5-HT1A receptor agonist, in treatment-resistant depression

Flesinoxan, a full 5-HT1A receptor agonist, was administered (4-8 mg) to treatment-resistant depressed patients in an open study. Safety and tolerance of the substance appeared satisfactory. Headache, dizziness and nausea were the most frequently reported side effects. The observations suggested that flesinoxan is an antidepressant agent and that it may be of particular value in some difficult, treatment-resistant depressions. Based on these observations, a double-blind, placebo-controlled evaluation of flesinoxan's efficacy appears warranted.

The Cotrel-Dubousset system--results in spinal reconstruction. Early experience in 47 patients

Forty-seven patients were treated with spinal fusion and Cotrel-Dubousset instrumentation and were followed for an average of 28 months. Spinal procedures included: 1) posterior spinal fusion for idiopathic scoliosis (26 patients); 2) posterior pseudarthrosis repair (5 patients); 3) combined anterior/posterior fusion to the sacrum (6 patients); and 4) combined anterior/posterior osteotomies (10 patients). Group 1: Partial derotational correction was achieved for adolescent idiopathic scoliosis. Group 2: Successful pseudarthrosis repair was achieved in four patients. Group 3: A solid arthrodesis was obtained in two patients, whereas the other three patients underwent revision of sacral screw fixation for pseudarthrosis. One patient died postoperatively. Group 4: Pain relief and a balanced correction was achieved in all patients. The Cotrel-Dubousset system appears to be a versatile system and provides a wide range of possibilities for a variety of spinal problems.

Endogenous Listeria monocytogenes endophthalmitis presenting as keratouveitis

We report a case of Listeria monocytogenes endophthalmitis that presented as a recalcitrant keratouveitis in a nonimmunocompromized patient. L. monocytogenes was recovered from the patient's aqueous, vitreous, and two of three blood cultures. He was treated with topical, subconjunctival, and systemic antibiotics, but the visual outcome was poor, possibly because of late diagnosis. A review of previous cases of L. monocytogenes endophthalmitis demonstrates unique features of this infection: (a) presentation as an anterior uveitis or keratouveitis with elevated intraocular pressure, (b) endogenous origin, and (c) frequent occurrence in nonimmunocompromized patients.