Longitudinal associations between digital media use and ADHD symptoms in children and adolescents: a systematic literature review

Previous reviews have often shown a link between digital media ADHD symptom levels. However, longitudinal studies are needed to find stronger evidence of a causal effect as well as to determine the direction of effects. The aim of the present review (PROSPERO CRD42021262695) was therefore to provide a systematic review of studies meeting the following inclusion criteria: (1) include longitudinal data investigating associations between digital media (i.e., gaming and social media) and later ADHD symptoms or vice versa, (2) be published within the past 10 years (i.e., 2011 until June 2021), (3) be published in a peer-reviewed journal in English, and (4) include children or adolescents (age 0-17 years). After a systematic search in the Web of Science and PsycInfo databases, we included 28 studies, all with adequate or high quality. Results showed support for reciprocal associations between digital media and ADHD symptoms, with associations being more consistent for problematic use of digital media than for screen time. Thus, children with ADHD symptoms appear more vulnerable to developing high or problematic use of digital media (i.e., selection effects), and digital media also have effects on later ADHD symptom levels, either because of specific characteristics of digital media or because of indirect effects on, for example, sleep and social relations (i.e., media effects). However, it should be emphasized that further studies investigating potential moderators and mediators are needed if we are to better understand the complex associations between digital media and ADHD symptom levels.

ODP381 Changes in Perceptions of Pediatric Endocrinologists (PE) and Urologists (PU) to Infants and Children regarding care of individuals with 46,XY DSD

Introduction

Over recent decades, controversy regarding standards of care has contributed to questioning past management recommendations for infants and children with a 46,XY DSD. Surveys conducted in 3 waves (2003, 2010, 2020) provide evidence of changes in recommendations for care have changed over this period.

Methods

Online surveys of the members of the Pediatric Endocrine Society (PE) and Societies for Pediatric Urology (PU) included case vignettes representing partial androgen insensitivity syndrome (PAIS), micropenis resulting from primary testicular failure, and penile ablation (non-DSD). Survey items included questions regarding recommended gender of rearing (GoR), genital surgery (and timing), and disclosure of diagnostic details to patient.

Results

The newborn PAIS vignette included elevated LH and FSH and a 1.2 cm. phallus that increased to 1.7 after exogenous testosterone. Male GoR was chosen by 47, 55 & 55% PE and 81, 83 & 69% of PU in waves 1 to 3, respectively; 27 PE and 28% PU chose an added "non-binary" option in 2020. The recommendation that parents, rather than patients, should decide about perineal hypospadias repair was chosen by 70, 60 & 50% of PE and 93, 90 & 79% of PU. Recommending against surgery were 25, 22 & 10% PE and 23, 13 & 8% PU. Recommending surgery be completed at <1 year of age: 56, 59, 66% PE and 69, 78, 84% PU. Recommendation against disclosure of the underlying condition to the patient 12, 17 & 28% PE and 17, 19 & 22% PU, while 35, 28 to 32% PE and 34, 43 & 30% PU recommended that disclosure occur by 11 years of age. For the penile ablation vignette, 78, 92 & 92% PE and 98, 95 & 97% PU recommended male GoR. The 2020 non-binary option was chosen by 4 and 2% PE and PU. The majority of both groups recommended male GoR for the micropenis vignette with testicular failure; 94, 94 & 89% PE and 96, 97 & 88% PU. The decline in 2020 resulted from the recommendation of the non-binary option by 9% PE and 8% PU.

Conclusions

It seems clear that a female GoR recommendation is currently rare across 46,XY vignettes with evidence of testicular function during at least some of fetal life. It is also apparent that the current emphasis/controversy regarding GoR has resulted in confusion as to how to apply this poorly understood concept. The resulting shift of delaying decisions regarding surgery until the patient can decide is inconsistent with the recommendation that hypospadias repair occur before age 1 year. Finally, lack of or delayed disclosure is inconsistent with patient centered care recommendations.

Presentation: No date and time listed

RONC-06. Stereotactic radiosurgery and stereotactic radiotherapy for pediatric brain metastases or recurrences

BACKGROUND/PURPOSE: Stereotactic radiosurgery (SRS) and stereotactic radiotherapy (SRT) deliver highly conformal, ablative doses of radiation over 1–5 treatments, while minimizing dose to surrounding normal tissues. To document toxicities and outcomes of these treatments in children, our updated institutional experience with SRS or SRT for intracranial targets in pediatric patients was reviewed. METHODS: On an IRB approved study, institutional databases were reviewed to identify pediatric patients with intracranial lesions treated with SRS or SRT from October 2009 to July 2021. Medical records were retrospectively reviewed for patient and treatment characteristics. Outcomes were analyzed for symptomatic radionecrosis and CNS progression. RESULTS: Thirty SRS or SRT treatment courses in 26 patients age 3.2 to 17.8y (median, 15.6y) at the time of SRS or SRT were identified. Twenty-two patients had one treatment and four had two treatments. Sixteen patients had brain metastases from extracranial primary disease; 10 had recurrence of a primary CNS tumor. Fifteen patients had prior fractionated radiation to the brain. Nineteen treatments used Gamma Knife (GK) with Leksell frame, three used GK ICON with mask, and eight used linear accelerator with volumetric modulated arc therapy with thermoplastic mask. All patients (10 treatments in nine patients) treated since July 2016 received mask-based radiation. Twelve of 26 (46%) patients were treated with anesthesia. With 9.6-month median follow up (range, 0.1-96.2m), five patients had progression of treated lesions, eight had distant CNS failure, and one had both local and distant failure, for a crude local failure rate of 6/26 (23%) and a crude distant failure rate of 9/26 (35%). There were no skull fractures or other complications from Leksell frame placement. One patient developed symptomatic radionecrosis requiring surgery. CONCLUSION: SRS and SRT can be safely performed in pediatric patients with intracranial lesions. Mask-based immobilization provides an alternative to frame-based treatments.

RADT-09. ROLE OF RADIOTHERAPY IN MANAGEMENT OF PRIMARY SPINAL HIGH GRADE GLIOMA: A SINGLE INSTITUTION RETROSPECTIVE ANALYSIS

BACKGROUND

Primary spinal high-grade gliomas(S-HGG) are rare, aggressive tumors and radiation therapy(RT) plays a dominant role in the management given their infiltrative nature. We conducted a single-institution retrospective review to study the clinicopathological features and management of S-HGGs.

METHODS

Patients with biopsy-proven S-HGG who received RT from 2001-2020 were analyzed for patient, tumor, and treatment characteristics. Kaplan-Meier estimate and Cox proportional hazard regression method were used for survival analyses.

RESULTS

Twenty-nine patients were identified with a median age of 25.9 years (range 1-74y). Four patients had gross total resection(GTR) while 25 underwent subtotal resection or biopsy. Nineteen patients had WHO grade 4 tumor. IDH1 mutation and MGMT promoter methylation were analyzed in 14 and four patients respectively; all were IDH wildtype and MGMT-promoter unmethylated. H3K27M mutation was present in five out of 10 patients tested. Twenty-two patients received photon-based radiation and 7 received proton therapy. Median RT dose was 50.4 Gy (range 39.6-54Gy) with 79% receiving >45Gy. 65% patients received concurrent chemotherapy, most commonly temozolomide. Twenty-three (79%) patients had documented recurrence. Overall, 16 patients relapsed locally, 10 relapsed in the brain and 8 developed leptomeningeal disease; only 8(35%) had isolated local relapse. Median OS from diagnosis was 21.3 months and median PFS after RT was 9.7 months. On univariate analysis, age, sex, GTR, grade, RT modality, RT dose and concurrent chemotherapy did not predict for survival. Patients with H3K27M mutation had a poorer median PFS after RT compared to those without the mutation but the difference did not reach statistical significance (p = 0.26).

CONCLUSIONS

Although 86% of patients had gross disease at RT and received a lower median RT dose than typically used in cerebral high-grade gliomas, only 55% of patients failed locally. H3K27M mutation may portend worse survival; future studies to improve the therapeutic approach in these patients are warranted.

Gaming and Social Media Addiction in University Students: Sex Differences, Suitability of Symptoms, and Association With Psychosocial Difficulties

Background: Previous research has shown that addictions to digital media can have negative impact on psychosocial health. Although Internet Gaming Disorder (IGD) has received most scholarly recognition, the potential negative consequences of Social Media Disorder (SMD) have also been found. However, few studies have assessed the symptoms of these two digital media addictions in the same way, making comparisons difficult. The present study aims to fill this gap by investigating differences and similarities regarding how common the symptoms are, sex differences, the suitability of the symptoms, and their association with psychosocial difficulties. Method: A total of 688 university students (63.2% women, Mean age = 25.98) completed a questionnaire measuring symptoms of IGD and SMD, as well as psychosocial difficulties (i.e., psychosomatic symptoms, low self-concept, and social problems). Results: Results showed that 1.2% of the men and 0.9% of the women met the symptom criteria for IGD (non-significant difference), whereas 3.2% men and 2.8% women met the symptom criteria for SMD (non-significant difference). Dimensional analyses indicated that men had higher IGD scores compared to women, whereas the opposite was found for SMD. Symptoms of heavy involvement in digital media (i.e., Preoccupation, Tolerance, Withdrawal, Unsuccessful attempts to control, and Escape) had high sensitivity, but low positive predictive value (PPV). However, symptoms associated with negative consequences of digital media use (i.e., Loss of interest, Continued excessive use, Deception, and Jeopardizing career/relationships) had low sensitivity, but high PPV. These symptom patterns were similar for IGD and SMD. Meeting the criteria for IGD or SMD as well as being at risk of these disorders were significantly associated with psychosocial difficulties. Symptoms of SMD generally had stronger associations with psychosomatic symptoms compared to symptoms of IGD. Conclusions: We conclude that heavy involvement in digital media seems common among individuals with IGD or SMD, but also among those not meeting the symptom criteria, whereas negative consequences are less common but highly predictive of digital media addictions once present. Further attention to SMD is warranted, as it seems more common than IGD and also seems to be equally or more strongly associated with psychosocial difficulties.

IMG-15. PEDIATRIC GLIOBLASTOMAS CONTRAST ENHANCEMENT PATTERN IS PREDICTIVE OF SURVIVAL

BACKGROUND

Pediatric GBMs are rare, accounting for 3% of all pediatric CNS tumors. Despite advances in treatment, the outcomes for pediatric glioblastomas (GBM) have not significantly improved. Research suggests a link between enhancement patterns and survival in adult patients with glial tumors. We sought to study this relationship in a cohort of pediatric GBMs.

METHODS

A radiology database was searched for cases < 22 years, pathology proven brain glioblastoma, and pre-surgical MR imaging available for review. Based on pre-treatment, T1-contrast enhanced MR images, size, and contrast enhancement patterns were characterized as focal, diffuse, or ring-like. The extent of resection was assessed by comparing pre- and post-surgery T2 hyperintensity and contrast enhancement.

RESULTS

64 eligible patients (age 2-21y, 14.6 + 5.4) were identified. The majority of lesions demonstrated enhancement on gadolinium-enhanced T1 imaging. (n=58/64; 90%). The lesions were categorized into six (9.4%) cases with focal enhancement, 37 (57.8%) cases with diffuse enhancement, and 15 (23.4%) with ring-like enhancement. Patients who received GTR/subtotal resection (STR) and had focal-enhanced GBMs had a significantly longer progression-free survival (PFS) – 14.1 months (p = 0.0308), comparing to diffuse and ring-like enhancing glioblastomas which had respectively 13.9 and 5.5 months of PFS.

DISCUSSION

Our data suggests that the contrast enhancement pattern is a significant prognostic factor for survival in pediatric GBM. Patients with GTR/STR who had focal-enhancing GBMs had a significantly longer progression-free survival (p=0.03) comparing to other enhancement patterns.

RARE-19. PEDIATRIC HIGH GRADE GLIOMA WITH DNA REPAIR PATHWAY ABERRATIONS, CLINICAL CHARACTERISTICS AND OUTCOME

DNA mismatch repair machinery is an integral part of the human genome and its defect has been involved in tumorigenesis and treatment resistance. Heterozygous monoallelic germline loss of function in MLH-1, MSH-2, MSH-6 or PMS-2 is involved in Lynch syndrome, whereas biallelic mutations cause constitutional mismatch repair deficiency (CMMRD) which is associated with hematologic malignancies and glioblastoma. We report here the clinical characterization and molecular analyses of 7 patients who presented with gliomas and MMR machinery aberrations. Two patients had a clinical diagnosis of NF-1 with dermatologic stigmata, of whom one patient has CMMRD and the other has Lynch syndrome. Two patients had a known family history of Lynch syndrome upon their diagnosis of glioma. Three patients with high-grade glioma and negative family history, 2 had germline mutations in MMR genes, and one had numerous mutations including MMR genes with microsatellite instability. Patients were initially treated with chemotherapy and radiation for high-grade gliomas (HGG); 5/7 had progression. Median time to progression was 12 months (range: 5–52), and median time from progression to death was 7 months (range: 2–25). One patient had low-grade glioma initially but progressed to HGG and is currently on therapy. Another patient treated with temozolomide and radiation is currently receiving maintenance therapy without any disease recurrence. Although the literature data on brain tumors with MMR deficiency is limited, these consistently show that MMRD-associated gliomas are treatment-resistant and have a dismal outcome. Collaborative efforts are needed to better understand this subgroup of pediatric HGG and to define optimal treatment strategy.

ETMR-04. EMBRYONAL TUMOR WITH MULTILAYERED ROSETTES: THE MD ANDERSON CANCER CENTER EXPERIENCE

BACKGROUND

Embryonal Tumor with Multilayered Rosettes (ETMR) are rare tumors that are molecularly diagnosed by C19MC amplification. Rarity of this tumor has precluded profiling uniform therapeutic strategy.

METHODS

Retrospective review after institutional approval, identified 10 pediatric case of ETMR, treated at MD Anderson Cancer Center during the period of 2005 to 2019.

RESULTS

Median age of at diagnosis was 4.6 years. Tumor sites include frontal or parietal lobes (3), spine (3) and posterior fossa involving the brainstem (4). All patients received a combination of chemotherapy and radiation. 4 patients had metastasis at the presentation. 9 patients received focal radiation but only 6 of them received Craniospinal irradiation (CSI). Average dose of radiation was 50 Gy. Surgical resection was performed in all cases except the brainstem tumors. 7 children had recurrence including all the patients with metastasis at diagnosis (median time: 9.4 months), 1 passed away secondary to hemorrhage in brainstem and data was not available for 2 patients. 5/6 patients who received CSI had recurrence.

CONCLUSIONS

To-date no well-defined treatment regimens exists for these neoplasms, resulting in poor overall survival. Preclinical drug screen have shown the efficacy of topotecan, actinomycin D, and volasertib as potential new therapeutic candidates, though this has not translated successfully into the clinical arena. Given the limited success with current conventional therapeutic methods, molecular interrogation in addition to histopathological diagnosis are essential upfront, as it could provide clues to targeted therapy. Defining molecularly-based treatment with less toxicities and increased survival are warranted.

PDCT-16. A PHASE I STUDY OF SUBEROYLANILIDE HYDROXAMIC ACID (SAHA) WITH TEMSIROLIMUS IN CHILDREN WITH NEWLY DIAGNOSED OR PROGRESSIVE DIFFUSE INTRINSIC PONTINE GLIOMA (DIPG)

Diffuse intrinsic pontine glioma (DIPG) in children remains essentially incurable with a median survival of 12 months. Radiation therapy is currently the standard treatment modality. To date chemotherapy or biologic agents have had no meaningful increase in survival. Data from biopsied DIPG showed the PI3K/AKT/mTOR pathway as a major oncogenic player. Thus targeting these pathways with mTOR inhibitors could hold promise. Genomic and epigenetic insights have shown the role of histone deacetylase (HDAC) in these tumors. Both temsirolimus (mTOR inhibitor) and SAHA (HDAC inhibitor) are well described in pediatric clinical trials with an established maximum tolerated dose (MTD) for phase II studies. This is the first ongoing phase I multi-targeted therapeutic study, in pediatric DIPG, using SAHA and temsirolimus in a combinatorial approach, targeting the key oncogenic pathway and molecules (NCT02420613 currently recruiting). Patients with a performance score of 50 or greater, with newly diagnosed (Stratum I), or progressive (stratum II) DIPG will be eligible. Biopsy is not mandatory. A standard 3 + 3 design is being used for this study. 1 dose escalation and 2 dose de-escalations are permitted beyond the starting dose level. In stratum I patients receive radiation therapy concurrently with vorinostat on the days of radiation, followed by adjuvant therapy with vorinostat and temsirolimus for 10 cycles if they do not have progressive disease. In stratum II patients receive vorinostat and temsirolimus for 12 cycles (28 day cycle), if they do not have progressive disease. Correlative studies evaluating histone acetylation, phosphorylated 70S6K and Akt are being performed. Currently 5 patients have been enrolled, and the study is at the dose escalation level with no dose limiting toxicity (DLT) seen so far. Safety, adverse effects, biological correlatives, and clinical outcomes will be reported once study is completed.

Abstract CT216: Phase I study of intraventricular infusions of autologous ex vivo expanded NK cells in children with recurrent/refractory malignant posterior fossa tumors of the central nervous system

Scientific background/rationale: The prognosis of recurrent/refractory medulloblastoma (MB), ependymoma (EP) and atypical teratoid/rhabdoid neoplasms (AT/RT) which constitutes the majority of malignant posterior fossa tumors (MPFT) in children, remains dismal with no defined effective therapy. Current treatment strategies have significant toxicities, thus profiling newer trials with clinical efficacy and minimal side-effects are imperative. Advantages of direct infusion of Natural Killer (NK) cells into the ventricles could enhance therapeutic efficacy by maximally concentrating them in the brain in close proximity to the tumor area, bypassing the blood brain barrier and alleviating toxicity often seen with systemic chemotherapy. We have shown efficacy of activated and propagated NK cells to lyse and kill the MPFT in vitro and tumor explants in mice models. We demonstrated in a pilot study for the first time in humans, the feasibility of infusions of biologic agents into the fourth ventricle. Infusing biologic agents into the lateral ventricles are well established in neurooncology. The current ongoing study is the first-in-human, loco-regional infusion of NK cells directly into the brain evaluating safety and efficacy in the context of a phase I trial with an intent to avoid the significant side-effects of systemic therapy. This novel trial, will hopefully be able to provide therapeutic efficacy and a meaningful increase in the survival of these children.

Correlative studies: Cerebrospinal fluid (CSF) withdrawn during infusions of NK cells will be evaluated for the immunophenotype, function, persistence of NK cells and influx or presence of any other immune cells.

Methods: NK cells are directly infused into the lateral or fourth ventricles, after placement of a catheter at that location. Recurrent or refractory MB, AT/RT and EP involving the brain and/or spine at original diagnosis or relapse with histological verification are eligible. Three to six evaluable patients, are entered at a dose level in this study for determination of maximum tolerated dose (MTD). A minimum of 9 patients and a maximum of 24 patients are planned to be enrolled. After autologous expanded NK cell product have been manufactured as per good manufacturing guidelines (GMP) and released, patients receive 3 cycles of NK cell infusions over 12 weeks. Each cycle consists of 1 infusion per week for 3 weeks followed by a rest week (week 4). Dosing is based on recipient body surface area (BSA) and 3 dose levels will be evaluated. Currently the trial is at the final cohort (third dose level), with no dose limiting toxicity (DLT) noted with the previous dose levels. 80% of the initial minimal accrual have been met. Also as a secondary aim we will evaluate the anti-tumor activity of the NK cell infusions within the confines of a phase I study. Trial (NCT02271711-recruiting)

Citation Format: Soumen Khatua, Dean Lee, Laurence Cooper, Judy Moyes, David Sandberg, Zsila Sadighi, Heather Meador, Leena Ketonen, Michael E. Rytting, Jason M. Johnson, Dristhi Raagonanan, Diane D. Liu, Vidya Gopalakrishnan, Wafik Zaky. Phase I study of intraventricular infusions of autologous ex vivo expanded NK cells in children with recurrent/refractory malignant posterior fossa tumors of the central nervous system [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT216.

SAT-LB050 Congenital Adrenal Hyperplasia Newborn Screening Protocols Differ Widely in the US: A Survey by the Differences/Disorders of Sex Development Translational Research Network (DSD-TRN)

All 50 United States and the District of Columbia incorporate newborn screening for congenital adrenal hyperplasia (CAH) caused by 21-hydroxylase deficiency. Filter paper blood specimens are typically collected in full-term infants on day two of life for 17-hydroxyprogesterone (17OHP) fluoroimmunoassay (DELFIA). Prematurity, low birth weight, or critical illness are known to cause falsely elevated results. Protocols differ for each state laboratory as to assay cut-points by birthweight or gestational age, which are key in determining the positive predictive value. As a preliminary step to quality improvement, we investigated the diversity of approaches to CAH screening nationally among the states representing members of the DSD-Translational Research Network. Ten data sets were returned from a survey circulated to state laboratory directors with qualitative and quantitative information about individual screening programs. Disease incidence generally correlated with published worldwide data, ranging from 1:10,000 to 1: 28,500 live births. Screening results are typically reported by direct phone call to the designated healthcare provider and/or coordinator at each referral center, followed by a faxed written report. Specialists are notified of unequivocally high 17OHP results; however, borderline results are not usually referred to a pediatric endocrinologist. Only one state laboratory required a mandatory second screen for healthy term infants regardless of initial screen result; most did for infants in intensive care units. Nine of 10 programs utilized birthweight cut-points, but cutoffs for normal results varied widely - from 17OHP values of 25 to 75 ng/mL for birthweights >2250-2500 grams. One program used gestational age cut-points. The positive predictive values for term or normal birthweight infants varied from 1.2 to 9.6%, implying differences in sensitivity and/or specificity of screening between states. There was no apparent correlation between the total number of infants each state screened annually, assay cut-point and positive predictive value. Data were unavailable for negative predictive values. Conclusion: There is a need for standardization of newborn screening protocols for CAH to improve the positive predictive value. Future efforts will be directed to expanding this survey and determining best practices. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Abstract B80: NK therapy for pediatric brain tumors of the posterior fossa

Brain tumors are the second most common childhood malignancies and the leading cause of childhood cancer mortality. Medulloblastomas (MBs) account for approximately 20% of pediatric brain tumors. They develop in the cerebellum and frequently metastasize. Current treatment has increased overall survival to 70-80%, however the prognosis for patients with recurrent disease, metastases or diagnosis at &lt;3 years old is still poor. Atypical teratoid/rhabdoid tumors (ATRTs) represent yet another pediatric brain malignancy with poor prognosis. ATRTs generally occur in children &lt;3 years old and the overall survival rate for children &lt;3 is only 17%. In addition, therapy related toxicities including impaired neurological development and function are a critical problem associated with the treatment of both diseases. Thus, there is an urgent need to discover new therapies for these tumors. Immunotherapy is an alternative to traditional therapies that may circumvent the potential toxicities associated with chemotherapy and radiation. Many therapeutics that harness the power of the immune system to combat cancer rely on the presence of tumor associated antigens (TAAs) and/or antigen processing and class I human leukocyte antigen (HLA I) expression. However, the identification of well-defined TAAs for MB or ATRT has remained elusive and neuronal tissues have very low HLA I expression. Therefore an agent that does not require the presence of TAAs, such as natural killer (NK) cells, might be useful for the treatment of these diseases. The current barriers to clinical application of NK therapy for brain tumors are both quantitative and qualitative. We have overcome the former problem by developing a platform technology wherein large numbers of NK cells can be generated ex vivo through co-culture of peripheral blood mononuclear cells with artificial antigen presenting cells expressing membrane-bound IL-21 (mbIL21). This method results in an average 48,000-fold expansion of donor NK cells from a small volume of blood. The qualitative barriers of NK lifespan, persistence and cytolytic activity have also been addressed by our approach. We demonstrate significantly increased life-span characterized by continued ex vivo proliferation for at least 6 weeks using mbIL21 as compared to only 3 weeks of ex vivo proliferation with IL-15. Furthermore, these NK cells have the ability to persist for up to 3 weeks post-infusion in the murine brain as determined by fluorescence imaging. These cells also express high levels of immune stimulatory and anti-tumor cytokines Ifnγ and TNFα following activation. Finally we demonstrate NK cytolytic activity in vitro against a panel of primary and established ATRT and MB cells and in vivo following locoregional delivery in a mouse orthotopic model of MB. Successful tumor infiltration of mbIL21 expanded NK cells was demonstrated by immunohistochemistry. Our data provide the first pre-clinical evidence supporting the use of mbIL21 expanded NK cells to target pediatric brain tumors. Based on this data our group has begun the first pediatric phase I clinical trial to assess the safety and efficacy of locoregional delivery of mbIL21 expanded NK cells for the treatment of posterior fossa brain tumors.

Citation Format: William Benjamin Brugmann, Alvaro Laureano, Cecele Denman, Harjeet Singh, Helen Huls, Zaky Wafik, David Sandberg, Soumen Khatua, Dean Lee, Laurence Cooper, Vidya Gopalakrishnan. NK therapy for pediatric brain tumors of the posterior fossa. [abstract]. In: Proceedings of the AACR Special Conference on Pediatric Cancer at the Crossroads: Translating Discovery into Improved Outcomes; Nov 3-6, 2013; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2013;74(20 Suppl):Abstract nr B80.

Abstract P4-01-17: Molecular imaging and quantification of HER-2 status in metastatic breast cancer by using 68Ga-ABY-025/PET-CT

Background: Molecular imaging, in particular, positron emission tomography (PET) provides unique possibility to non-invasively quantify the biomarkers. A small peptide, ABY-025, is targeting a unique epitope of the HER2-receptor and can be labeled with 111In or 68Ga. It is non-competitive with current antibody-targeted epitopes and is approximately 25 times smaller than an antibody and posses superior pharmacokinetics as imaging agent. We have earlier reported promising results of lesion visualization and determination of HER2 status by 111In-ABY-025/SPECT-CT in seven patients with metastatic breast cancer (MBC). As PET-CT provides superior possibilities for quantification and allows for imaging with shorter time frames, we now investigate 68Ga-ABY-025 in HER2-positive and HER2-negative MBC patients in a prospective study. The influence of the administered amount of ABY-025 on the discrimination between HER2-positive and HER2-negative metastases as well as detection rate and image contrast is investigated. The HER2 status changes will be followed at disease progression. We report here promising data on the first three patients.

Patients and methods: The study considers twenty patients in two cohorts. Of the first 10 patients, 4 should have HER2-negative MBC and 6 patients HER2-positive disease. Metastases were localized by 18F-FDG/PET-CT prior HER2 imaging. Each patient (two HER2-positive and one HER-negative) underwent two subsequent examinations. First, 68Ga-ABY-025 PET/CT (ABY-025: 75±14 μg) was performed with dynamic acquisition during 0-45 minutes and static images after 1, 2 and 4 hours. The procedure was repeated after one week with a higher dose of 68Ga-ABY-025 (ABY-025: 445±10 μg) to identify the optimal dosage for the discrimination between HER2-positive and HER2-negative metastases. Blood levels of radioactivity, anti-ABY-025-antibodies, shed serum HER2 and toxicity markers were evaluated. Biopsies were taken to verify the HER2 status of the lesions. The second cohort of 10 patients (all with HER2-positive disease), will have their primary PET-CT with the optimal dose of 68Ga-ABY-025 and will, as the HER-positive from the first cohort, have a follow-up 68Ga-ABY-025 PET/CT after disease progression or, at latest, after 9 months.

Results: The imaging agent was well tolerated by the patients without adverse events. The rapid blood clearance and normal tissue wash out allowed high contrast HER2 images within a few hours. The HER2 status was confirmed by histological analysis of biopsies. In one patient with HER2-negative primary tumor, imaging suggested a HER2-positive liver metastasis. The change of HER2 expression was verified with analysis of the corresponding biopsy. This finding resulted in the change of the treatment management. Preliminary validation suggests the preference of high dose ABY-025 in terms of image contrast and detection. The study is ongoing and more patients will be reported

Conclusion: Preliminary results indicate strong potential of 68Ga-ABY-025 PET/CT for discriminating HER2-positive versus HER2-negative metastatic breast cancer, regardless of ongoing HER2-targeted antibody treatment. The method introduces rapid whole-body receptor mapping of primary tumor and metastases in a single examination.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-01-17.

The characteristics of sleepiness during real driving at night--a study of driving performance, physiology and subjective experience

STUDY OBJECTIVES

Most studies of sleepy driving have been carried out in driving simulators. A few studies of real driving are available, but these have used only a few sleepiness indicators. The purpose of the present study was to characterize sleepiness in several indicators during real driving at night, compared with daytime driving.

DESIGN

Participants drove 55 km (at 90 km/h) on a 9-m-wide rural highway in southern Sweden. Daytime driving started at 09:00 or 11:00 (2 groups) and night driving at 01:00 or 03:00 (balanced design).

SETTING

Instrumented car on a real road in normal traffic.

PARTICIPANTS

Eighteen participants drawn from the local driving license register.

INTERVENTIONS

Daytime and nighttime drives.

MEASUREMENT AND RESULTS

The vehicle was an instrumented car with video monitoring of the edge of the road and recording of the lateral position and speed. Electroencephalography and electrooculography were recorded, together with ratings of sleepiness every 5 minutes. Pronounced effects of night driving were seen for subjective sleepiness, electroencephalographic indicators of sleepiness, blink duration, and speed. Also, time on task showed significant effects for subjective sleepiness, blink duration, lane position, and speed. Sleepiness was highest toward the end of the nighttime drive. Night driving caused a leftward shift in lateral position and a reduction of speed. The latter two findings, as well as the overall pattern of sleepiness indicators, provide new insights into the effects of night driving.

CONCLUSION

Night driving is associated with high levels of subjective, electrophysiologic, and behavioral sleepiness.

Sleepiness and prediction of driver impairment in simulator studies using a Cox proportional hazard approach

Cox proportional hazard models were used to study relationships between the event that a driver is leaving the lane caused by sleepiness and different indicators of sleepiness. In order to elucidate different indicators' performance, five different models developed by Cox proportional hazard on a data set from a simulator study were used. The models consisted of physiological indicators and indicators from driving data both as stand alone and in combination. The different models were compared on two different data sets by means of sensitivity and specificity and the models' ability to predict lane departure was studied. In conclusion, a combination of blink indicators based on the ratio between blink amplitude and peak closing velocity of eyelid (A/PCV) (or blink amplitude and peak opening velocity of eyelid (A/POV)), standard deviation of lateral position and standard deviation of lateral acceleration relative road (ddy) was the most sensitive approach with sensitivity 0.80. This is also supported by the fact that driving data only shows the impairment of driving performance while blink data have a closer relation to sleepiness. Thus, an effective sleepiness warning system may be based on a combination of lane variability measures and variables related to eye movements (particularly slow eye closure) in order to have both high sensitivity (many correct warnings) and acceptable specificity (few false alarms).

Reaction of sleepiness indicators to partial sleep deprivation, time of day and time on task in a driving simulator--the DROWSI project

Studies of driving and sleepiness indicators have mainly focused on prior sleep reduction. The present study sought to identify sleepiness indicators responsive to several potential regulators of sleepiness: sleep loss, time of day (TOD) and time on task (TOT) during simulator driving. Thirteen subjects drove a high-fidelity moving base simulator in six 1-h sessions across a 24-h period, after normal sleep duration (8 h) and after partial sleep deprivation (PSD; 4 h). The results showed clear main effects of TOD (night) and TOT but not for PSD, although the latter strongly interacted with TOD. The most sensitive variable was subjective sleepiness, the standard deviation of lateral position (SDLAT) and measures of eye closure [duration, speed (slow), amplitude (low)]. Measures of electroencephalography and line crossings (LCs) showed only modest responses. For most variables individual differences vastly exceeded those of the fixed effects, except for subjective sleepiness and SDLAT. In a multiple regression analysis, SDLAT, amplitude/peak eye-lid closing velocity and blink duration predicted subjective sleepiness bouts with a sensitivity and specificity of about 70%, but were mutually redundant. The prediction of LCs gave considerably weaker, but similar results. In summary, SDLAT and eye closure variables could be candidates for use in sleepiness-monitoring devices. However, individual differences are considerable and there is need for research on how to identify and predict individual differences in susceptibility to sleepiness.

Health-related quality of life of children and adolescents with growth hormone deficiency or idiopathic short stature - part 2: available results and future directions

Research on the health-related quality of life (HrQoL) impact of short stature and its treatment in children and adolescents has developed recently. Based on a PubMed literature search, studies addressing this issue were identified and considerable methodological problems mainly related to the HrQoL instruments used and conflicting results are discussed in this mini review. Additionally, this mini review identifies a need for further research and indicates potential directions.

Charged meson rapidity distributions in central Au+Au collisions at square root(sNN) = 200 GeV

We have measured rapidity densities dN/dy of pi+/- and K+/- over a broad rapidity range (-0.1 < y < 3.5) for central Au + Au collisions at square root(sNN) = 200 GeV. These data have significant implications for the chemistry and dynamics of the dense system that is initially created in the collisions. The full phase-space yields are 1660 +/- 15 +/- 133 (pi+), 1683 +/- 16 +/- 135 (pi-), 286 +/- 5 +/- 23 (K+), and 242 +/- 4 +/- 19 (K-). The systematics of the strange to nonstrange meson ratios are found to track the variation of the baryochemical potential with rapidity and energy. Landau-Carruthers hydrodynamics is found to describe the bulk transport of the pions in the longitudinal direction.

Centrality dependence of charged-particle pseudorapidity distributions from d + Au collisions at sqrt[sNN] = 200 GeV

Charged-particle pseudorapidity densities are presented for the d + Au reaction at sqrt[s(NN)] = 200 GeV with -4.2 < or = eta < or = 4.2. The results, from the BRAHMS experiment at BNL Relativistic Heavy-Ion Collider, are shown for minimum-bias events and 0%-30%, 30%-60%, and 60%-80% centrality classes. Models incorporating both soft physics and hard, perturbative QCD-based scattering physics agree well with the experimental results. The data do not support predictions based on strong-coupling, semiclassical QCD. In the deuteron-fragmentation region the central 200 GeV data show behavior similar to full-overlap d+Au results at sqrt[s(NN)] = 19.4 GeV.

Evolution of the nuclear modification factors with rapidity and centrality in d + Au collisions at (sqrt)[N(S)N]=200 GeV

We report on a study of the transverse momentum dependence of nuclear modification factors R(dAu) for charged hadrons produced in deuteron + gold collisions at sqrt[s(NN)]=200 GeV, as a function of collision centrality and of the pseudorapidity (eta=0, 1, 2.2, 3.2) of the produced hadrons. We find a significant and systematic decrease of R(dAu) with increasing rapidity. The midrapidity enhancement and the forward rapidity suppression are more pronounced in central collisions relative to peripheral collisions. These results are relevant to the study of the possible onset of gluon saturation at energies reached at BNL RHIC.

Nuclear stopping in Au+Au collisions at square root of S(NN)=200 GeV

Transverse momentum spectra and rapidity densities, dN/dy, of protons, antiprotons, and net protons (p-p) from central (0%-5%) Au+Au collisions at square root of S(NN)=200 GeV were measured with the BRAHMS experiment within the rapidity range 0</=y</=3. The proton and antiproton dN/dy decrease from midrapidity to y=3. The net-proton yield is roughly constant for y<1 at dN/dy approximately 7, and increases to dN/dy approximately 12 at y approximately 3. The data show that collisions at this energy exhibit a high degree of transparency and that the linear scaling of rapidity loss with rapidity observed at lower energies is broken. The energy loss per participant nucleon is estimated to be 73+/-6 GeV.

Transverse-momentum spectra in Au+Au and d+Au collisions at sqrt[s(NN)]=200 GeV and the pseudorapidity dependence of high-p(T) suppression

We present spectra of charged hadrons from Au+Au and d+Au collisions at sqrt[s(NN)]=200 GeV measured with the BRAHMS experiment at RHIC. The spectra for different collision centralities are compared to spectra from p+(-)p collisions at the same energy scaled by the number of binary collisions. The resulting ratios (nuclear modification factors) for central Au+Au collisions at eta=0 and eta=2.2 evidence a strong suppression in the high p(T) region (>2 GeV/c). In contrast, the d+Au nuclear modification factor (at eta=0) exhibits an enhancement of the high p(T) yields. These measurements indicate a high energy loss of the high p(T) particles in the medium created in the central Au+Au collisions. The lack of suppression in d+Au collisions makes it unlikely that initial state effects can explain the suppression in the central Au+Au collisions.

Rapidity dependence of charged antihadron to hadron ratios in Au+Au collisions at sqrt[s(NN)]=200 GeV

We present ratios of the numbers of charged antihadrons to hadrons (pions, kaons, and protons) in Au+Au collisions at sqrt[s(NN)]=200 GeV as a function of rapidity in the range y=0-3. While the ratios at midrapidity are approaching unity, the K(-)/K(+) and p;/p ratios decrease significantly at forward rapidities. An interpretation of the results within the statistical model indicates a reduction of the baryon chemical potential from mu(B) approximately 130 MeV at y=3 to mu(B) approximately 25 MeV at y=0.

Pseudorapidity distributions of charged particles from Au + Au collisions at the maximum RHIC energy, square root[s(NN)] = 200 GeV

We present charged-particle multiplicities as a function of pseudorapidity and collision centrality for the 197Au+197Au reaction at square root[s(NN)] = 200 GeV. For the 5% most central events we obtain dN(ch)/deta/(eta = 0) = 625+/-55 and N(ch)/(-4.7< or =eta < or =4.7) = 4630 +/- 370, i.e., 14% and 21% increases, respectively, relative to square root[s(NN)] = 130 GeV collisions. Charged-particle production per pair of participant nucleons is found to increase from peripheral to central collisions around midrapidity. These results constrain current models of particle production at the highest RHIC energy.

Perception of family functioning and depressive symptomatology in individuals with anorexia nervosa or bulimia nervosa

This study investigated the relationship between the perception of family functioning and depressive symptomatology in individuals with eating disorders (EDs). Subjects were evaluated by diagnostic clinical interview using DSM-III-R criteria for EDs, the Schedule for Affective Disorders and Schizophrenia-Lifetime Version (SADS-L), and two self-report measures, the Beck Depression Inventory (BDI) and the Family Assessment Device (FAD). A significant association was found between self-reported depressive symptomatology and perceived poor family functioning. Subjects with bulimia nervosa (BN) reported a significantly more dysfunctional family background than subjects with anorexia nervosa (AN). In our sample, the presence of self-reported depressive symptomatology was a more powerful predictive variable for perceived family dysfunction than the diagnosis of affective disorder. Also, the diagnosis of BN was a more consistent predictor of dysfunctional family interaction than the diagnosis of affective disorder. Depressive symptoms and EDs seem to play different roles in the way in which they contribute to dysfunctional family patterns.

Peer relationships and quality of life

Measures of peer relationships during childhood have been shown to be reliable predictors of several indicators of functioning during adulthood. Within each of these areas of functioning, children who have troubled peer relationships are more likely to show signs of distress than are other children. In addition, experiences with peers appear to provide a context for the development of many fundamental human capacities (e.g., moral judgment, conflict resolution skills, emotional regulation, etc.). Three interrelated levels of analysis can be used to assess a child's experiences with peers: the level of the individual (i.e., what the child is like); the level of the dyad (e.g., experiences with friends); and the level of the group (e.g., experiences with the set of individuals with whom the child typically associates). By determining a child's functioning at these three levels of analysis (using assessments from teachers, parents, and peers), it is possible to obtain a good assessment of a central portion of the quality of a child's life. Such measures have been used to assess the quality of life of children across the height spectrum and preliminary findings show that the peer experiences of children who are substantially shorter than their peers are remarkably similar to those of other children.

Sodium lactate infusion in late luteal phase dysphoric disorder

The effects of sodium lactate infusion were compared in 13 women who sought treatment for marked premenstrual dysphoric changes that met criteria for late luteal phase dysphoric disorder and 7 control women. No subject had a lifetime history of panic disorder. The rate of blindly rated panic to sodium lactate was 7 (58%) in patients and 0% in controls. Nonpanicking patients also had higher Modified Acute Panic Inventory scores than control subjects. The differences cannot be fully explained on the basis of a history of panic attacks. Further study is warranted.

The pharmacotherapy of moral or religious scrupulosity

Moral or religious scrupulosity is a disabling condition which is sometimes seen in patients with obsessive compulsive disorder (OCD). The authors described 10 patients with moral or religious scrupulosity who were treated with fluoxetine or clomipramine. Seven of the 10 patients completed open treatment of at least 8 weeks without requiring adjunctive medication; 5 of those 7 patients were rated as much improved. Among the 3 patients who required adjunctive medication, 1 was rated as much improved. Of the 4 nonresponders at 3 months, 2 responded after longer treatment trials. These results suggest that extreme moral or religious concerns and behaviors might be a form of OCD and that the scrupulosity can be effectively treated with serotonin reuptake blockers.

Fluoxetine treatment of obsessive-compulsive disorder: an open clinical trial

The selective serotonin reuptake blocker fluoxetine was administered to 49 patients with obsessive-compulsive disorder in a 12-week open clinical trial. A minimum adequate trial of at least 8 weeks of treatment was completed by 39 patients. Response rates were 62% (24/39) of adequately treated patients and 49% (24/49) of the whole sample. These uncontrolled findings suggest that fluoxetine is of significant benefit for a substantial proportion of obsessive-compulsive disorder patients. However, controlled trials comparing fluoxetine with placebo and other active agents are needed to confirm this, as are studies aimed to delineate fluoxetine's full dose range, optimal length of treatment and relapse rate following discontinuation.

A comparison of sodium bicarbonate and sodium lactate infusion in the induction of panic attacks

Infusion of sodium lactate has been shown by a number of investigators to induce panic in patients with panic disorder, but the pathophysiology underlying this phenomenon is unknown. One theory to explain lactate's anxiety-producing effects involves its ability to induce alkalosis because of metabolic conversion to bicarbonate. To test this hypothesis, we administered both sodium lactate and sodium bicarbonate infusions in counterbalanced order to patients with panic disorder. Thirteen of 22 subjects panicked in response to lactate and nine of 20 subjects panicked in response to bicarbonate. Although the rate of panic between the two infusion responses was not significantly different, several aspects of response to the two infusions indicated that lactate may be a more potent producer of anxiety than bicarbonate. An unexpected finding was that bicarbonate panickers had a reduction in arterial carbon dioxide pressure during the infusion, while bicarbonate nonpanickers had an increase in arterial carbon dioxide pressure during the infusion. Induction of hyperventilation and subsequent hypocapnia appears to be a common denominator between lactate- and bicarbonate-induced panic.

Provocation of panic with carbon dioxide inhalation in patients with premenstrual dysphoria

The effects of double breath inhalation of a 35% CO2 mixture in oxygen and placebo air inhalation were compared in 14 women seeking treatment for marked premenstrual dysphoric changes who did not have panic disorder and 12 control women. The first exposure to CO2 inhalation induced a panic attack reaction (severe subjective anxiety with autonomic symptoms) in 9 of 14 women with premenstrual dysphoria but none of the controls. Neither patients nor controls panicked in response to the air inhalation. Control subjects experienced mild anxiety and/or somatic symptoms after CO2 inhalation, but these did not resemble panic attacks and were clearly different from the response of the patient group.

Effects of clonidine on alprazolam discontinuation in panic patients: a pilot study

Effects of adjunctive clonidine (0.15 to 0.7 mg/day) on symptoms experienced during and for 4 weeks after gradual alprazolam discontinuation were observed in panic disorder patients after 6 weeks of successful treatment. Twelve of 14 entered patients were considered to have had a sufficient period of discontinuation (2 weeks) and clonidine administration (1 week) for effects to be assessed adequately. Nine of these 12 patients reached zero dose of alprazolam in 3 to 4 weeks. However, 10 of 12 patients experienced new withdrawal symptoms and 11 of 12 experienced recurrent panic attacks during tapering. Although a greater proportion of patients were successfully discontinued in a shorter time than in a previous nonclonidine trial, clonidine did not appear to have a specific effect on relapse or withdrawal. A placebo-controlled trial is needed to discriminate between possible contributions of clonidine and other factors (e.g., physician attitude, placebo effect of pill taking) to this improved outcome.

Pharmacotherapy of social phobia: an interim report of a placebo-controlled comparison of phenelzine and atenolol

Forty-one patients meeting DSM-III criteria for social phobia completed a randomized comparative trial of the monoamine oxidase inhibitor phenelzine, the cardioselective beta-adrenergic blocker atenolol, and placebo. No significant differences were seen after 4 weeks of treatment in this preliminary trial. At the end of 8 weeks, however, phenelzine demonstrated greater efficacy than atenolol or placebo on dimensional ratings of overall severity of social phobia. No atenolol-placebo differences were observed. The authors shall present maintenance and discontinuation findings in a final report. Phenelzine may act in patients with social phobia by directly reducing interpersonal hypersensitivity.