Cognitive performance and mortality among patients receiving autologous hematopoietic stem cell transplant

OBJECTIVES

Patients undergoing autologous hematopoietic stem cell transplant (HCT) are at risk for death and remain understudied relative to those undergoing allogeneic HCT. Cognitive functioning may be a useful indicator of mortality risk. We examined cognition among patients who underwent autologous HCT and its relationship to mortality.

METHODS

Participants (N = 51; 11 patients deceased) completed tasks of processing speed, working memory, executive-mediated learning, and visual recall using the computerized CogState battery prior to HCT, 30 days post-autologous HCT, and 100 days post-autologous HCT.

RESULTS

Slower processing speed (HR = 3.00) and more errors on an executive-mediated visual learning task (HR = 2.78) prior to HCT were associated with an increased risk of death following HCT. Our sample size limited longitudinal analyses of whether cognitive change predicted survival, however descriptive cognitive data of the deceased versus living patient's performances over time suggested different patterns of performance across groups.

CONCLUSIONS

Pre-HCT cognition may have utility as an indicator of mortality risk following autologous HCT. More research is needed to examine whether cognitive changes after HCT could also predict mortality.

Neurocognitive change over the course of a multiday external lumbar drain trial in patients with suspected normal pressure hydrocephalus

Objective: To characterize neurocognitive response to cerebrospinal fluid (CSF) diversion during a multiday external lumbar drainage (ELD) trial in patients with suspected normal pressure hydrocephalus (NPH). Methods: Inpatients (N = 70) undergoing an ELD trial as part of NPH evaluation participated. Cognition and balance were assessed using standardized measures before and after a three-day ELD trial. Cognitive change pre- to post-ELD trial was assessed in relation to change in balance, baseline neuroimaging findings, NPH symptoms, demographics, and other disease-relevant clinical parameters. Results: Multiday ELD resulted in significant cognitive improvement (particularly on measures of memory and language). This improvement was independent of demographics, test-retest interval, number of medical and psychiatric comorbidities, NPH symptom duration, estimated premorbid intelligence, baseline level of cognitive impairment, cerebrovascular disease burden, degree of ventriculomegaly, or other NPH-related morphological brain alterations. Balance scores evidenced a greater magnitude of improvement than cognitive scores and were weakly, but positively correlated with cognitive change scores. Conclusions: Findings suggest that cognitive improvement associated with a multiday ELD trial can be sufficiently captured with bedside neurocognitive testing. These findings support the utility of neuropsychological consultation, along with balance assessment, in informing clinical decision-making regarding responsiveness to temporary CSF diversion for patients undergoing elective NPH evaluation. Implications for the understanding of neuroanatomical and cognitive underpinnings of NPH are discussed.

POS1224 RHEUMATOID ARTHRITIS DISEASE ACTIVITY ASSESSED BY PATIENT-REPORTED OUTCOMES AND FLOW CYTOMETRY BEFORE AND AFTER AN ADDITIONAL DOSE OF COVID-19 VACCINE

Background

The Centers for Disease Control and Prevention recommends an additional dose (AddDose) of COVID-19 vaccine for moderately/severely immunosuppressed individuals following an initial vaccine series. The American College of Rheumatology suggests that patients interrupt use (hold) certain DMARDs around the time of COVID-19 vaccination to improve immunogenicity. Whether holding DMARDs around an AddDose of COVID-19 vaccine affects RA disease activity or affects frequencies of lymphocyte populations that may be associated with RA disease activity remains unknown.

Objectives

To test whether RA disease activity and frequencies of lymphocyte populations change pre- vs. post-AddDose of COVID-19 vaccine, overall and stratified by holding vs. continuation of DMARDs around the AddDose.

Methods

Prospective observational cohort study of patients with RA who had completed an initial COVID-19 vaccine series (2 doses of mRNA vaccine or 1 dose of adenovirus vector vaccine). Subjects enrolled July-November 2021, prior to receiving an AddDose. Subjects held or continued DMARDs around the AddDose based on discussion with their rheumatologist and/or personal decision-making. RA disease activity was assessed weekly using the validated patient-reported RA Disease Activity Index-5 (RADAI-5) from enrollment through 4 weeks post-AddDose. We compared mean RADAI-5 pre- vs. post-AddDose using generalized estimating equations to account for correlated data among individual subjects. We aimed to enroll 60 subjects to achieve 91% power to detect a 15% non-inferiority margin in mean RADAI-5 post- vs. pre-AddDose. A subset of subjects with seropositive RA provided blood for flow cytometry at enrollment and week 4 post-AddDose. Frequencies of lymphocyte populations (T peripheral helper [Tph] cells, T follicular helper [Tfh] cells, age-associated B cells [ABC], and plasmablasts) were compared pre- vs. post-AddDose using Wilcoxon paired tests with Bonferroni correction.

Results

Among 71 subjects, mean age was 62 (SD 12) years, 85% were female, and 87% had seropositive RA. Methotrexate (42%) and TNF inhibitors (38%) were the most common DMARDs; 21% were taking prednisone. One subject reported COVID-19 infection prior to the AddDose. The mean RADAI-5 was 3.20 (SD 0.23) pre-AddDose compared to 3.25 (SD 0.23) after (difference of 1.6%, p=0.51). Figure 1 displays mean RADAI-5 in 35 (49%) subjects that held at least 1 DMARD and 36 (51%) subjects that continued all DMARDs around the AddDose. Mean change in RADAI-5 between pre- vs. post-AddDose did not significantly differ based on whether subjects held vs. continued DMARDs (p for interaction = 0.16). Frequencies of Tph, Tfh, ABC, and plasmablast populations did not significantly differ between the pre- and post-AddDose timepoints in subjects that held at least 1 DMARD (n=16) or subjects that continued all DMARD (n=11) (Figure 1).

Conclusion

RA disease activity, measured weekly with a validated patient-reported outcome, is stable around the time of an AddDose of COVID-19 vaccine. Lymphocyte subsets of interest in RA were also similar before and after the AddDose, supporting the observation of stable patient-reported RA disease activity. Holding DMARDs was not associated with greater RA disease activity following the AddDose.

Disclosure of Interests

Sara Tedeschi Consultant of: NGM Biopharmaceuticals: payment to Dr. Tedeschi, Grant/research support from: Moderna: research support to institution, Jacklyn Stratton: None declared, Jack Ellrodt: None declared, Mary Grace Whelan: None declared, Keigo Hayashi: None declared, Kazuki Yoshida Consultant of: OM1, Inc: consulting fees paid to Dr. Yoshida, Lin Chen: None declared, Ifeoluwakiisi Adejoorin: None declared, Kathryne E. Marks: None declared, A. Helena Jonsson Grant/research support from: Moderna: research support to institution

Amgen: payment to institution for unrelated project, Deepak Rao Speakers bureau: Merck: honoraria lecture paid to Dr. Rao, Consultant of: Janssen: consulting fees paid to Dr. Rao

Bristol Myers Squibb: participation on scientific advisory board with compensation paid to Dr. Rao, Grant/research support from: Moderna: research funding paid to institution

Janssen: research funding paid to institution

Merck: research funding paid to institution, Daniel Solomon Grant/research support from: Moderna: payment made to institution

Amgen: payment to institution

Abbvie: payment to institution

CorEvitas: payment to institution

Implementation of OIE international standards: challenges and opportunities for monitoring

The World Organisation for Animal Health (OIE) is a major actor in international cooperation to improve animal health and welfare throughout the world. The OIE sets international standards to support Member Countries in their efforts to prevent and control animal diseases, strengthen Veterinary Services and Aquatic Animal Health Services, and facilitate safe international trade. Member Countries face many challenges in the implementation of OIE standards. Poor governance and a lack of resources and technical capacity are often major constraints. Trade concerns raised at the World Trade Organization (WTO) can also be a signal that countries are experiencing difficulties in implementing international standards. In May 2018, the World Assembly of OIE Delegates adopted a resolution recommending the establishment of an observatory to monitor the implementation of OIE standards. This monitoring mechanism will help the OIE to improve its international standard-setting process and identify the capacity-building needs of Member Countries. Monitoring implementation will be challenging as the OIE does not prescribe a specific procedure for implementing OIE standards. World Organisation for Animal Health Member Countries use a range of approaches to implement OIE standards, because of differences in animal health situations, legal frameworks and procedures, trade profiles, and acceptable levels of risk. Given this complexity, this article proposes a 'cross-over' approach to monitoring implementation that would require the collection of information from various trusted sources, such as the World Animal Health Information System (WAHIS), the OIE Performance of Veterinary Services (PVS) Pathway mission reports and the WTO Sanitary and Phytosanitary Information Management System database. This approach aims to document what is currently happening and to identify potential patterns in Member Country practices when implementing OIE standards.

The utility of cognitive changes in identifying those with acute graft vs. host disease following allogeneic hematopoietic cell transplant

Objectives: Acute graft versus host disease (aGVHD) is a common complication of allogeneic hematopoietic cell transplant (HCT) and is associated with morbidity and mortality. Identifying those at risk for developing aGVHD is crucial for early intervention. The current study assessed whether scores on a brief cognitive screening measure could identify those that develop aGVHD by 100 days post-HCT.Methods: Participants were 37 patients undergoing allogeneic HCT, assessed prior to transplant, and at 30- and 100-days post-HCT. Of those completing all evaluations, patients were divided into those who did (n = 14) and did not (n = 16) develop aGVHD by day 100 post-HCT. At 100 days post-transplant, groups did not differ on relevant demographic factors, disease, conditioning regimen, relatedness of donor, stem cell source, steroid use, total body irradiation use, human leukocyte antigens (HLA) match, or frequency of infection.Results: At 100 days post-HCT, those with aGVHD performed significantly worse on a working memory measure than those without aGvHD. The presence of aGVHD at day 100 increased significantly with every one standard deviation decrease in working memory from baseline to 30 days post-HCT (odds ratio = 3.08; 95% CI: 1.00-9.36). These findings were observed despite a small sample size and statistically controlling for multiple analyses.Conclusions: While this study is exploratory in nature, and has a small sample size, findings suggest that early detection of working memory declines could coincide with, or signal the development of, aGVHD. Potential etiologies are discussed. Implementing early cognitive screening within the first 30 days post-HCT may be useful in identifying patients at risk for aGVHD.

Performance of Veterinary Services Pathway evolution and One Health aspects

Animals, and the health systems which ensure their protection, play a vital role in the security and economic and social well-being of humanity, and are therefore a key component of the One Health concept. For global and national health security, prevention is better than cure, and targeting 'risk at source' in animal populations is a vital strategy in safeguarding the planet from risks of emerging zoonoses and antimicrobial resistance (AMR). Neglected zoonoses - such as rabies and brucellosis - continue to have a significant global impact on human health and are also best managed at their animal source. The World Organisation for Animal Health (OIE) has built international consensus on the principles of good governance and the quality of Veterinary Services, which are incorporated within its international standards. The OIE has a proven track record in the provision of Member Country support based on these standards, especially since the advent of its flagship Performance of Veterinary Services (PVS) Pathway programme in 2006-2007. To date, approximately 140 countries have benefited from the structured and sustainable process of animal health systems evaluation and planning afforded by the PVS Pathway. The PVS Tool, the basic methodology upon which the PVS Pathway is based, addresses One Health by evaluating the Veterinary Authority's ability to coordinate with other Competent Authorities that have a role to play in One Health, most notably public health, food safety, and environmental authorities. Despite the undoubted success of the PVS Pathway, the OIE felt that it was time to consider how the programme might be developed to adapt to new challenges. Consequently, during 2017-2018, the OIE embarked on a process of PVS evolution, during which it carried out extensive consultation and further tailored the PVS Pathway to a changing global context. These improvements, which include both fundamental adaptations to the PVS Pathway methods and the development of new PVS Pathway activities targeting topics such as multisectoral collaboration, rabies and AMR, have further strengthened and embedded the One Health approach within the PVS Pathway.

One Health operations: a critical component in the International Health Regulations Monitoring and Evaluation Framework

Under the International Health Regulations (IHR, 2005), a legally binding document adopted by 196 States Parties, countries are required to develop their capacity to rapidly detect, assess, notify and respond to unusual health events of potential international concern. To support countries in monitoring and enhancing their capacities and complying with the IHR (2005), the World Health Organization (WHO) developed the IHR Monitoring and Evaluation Framework (IHR MEF). This framework comprises four complementary components: the State Party Annual Report, the Joint External Evaluation, after-action reviews and simulation exercises. The first two are used to review capacities and the second two to help to explore their functionality. The contribution of different disciplines, sectors, and areas of work, joining forces through a One Health approach, is essential for the implementation of the IHR (2005). Therefore, WHO, in partnership with the Food and Agriculture Organization of the United Nations (FAO), the World Organisation for Animal Health (OIE), and other international and national partners, has actively worked on facilitating the inclusion of the relevant sectors, in particular the animal health sector, in each of the four components of the IHR MEF. Other tools complement the IHR MEF, such as the WHO/OIE IHR-PVS [Performance of Veterinary Services] National Bridging Workshops, which facilitate the optimal use of the results of the IHR MEF and the OIE Performance of Veterinary Services Pathway and create an opportunity for stakeholders from animal health and human health services to work on the coordination of their efforts. The results of these various tools are used in countries' planning processes and are incorporated in their National Action Plan for Health Security to accelerate the implementation of IHR core capacities. The present article describes how One Health is incorporated in all components of the IHR MEF.

Institutionalizing One Health: From Assessment to Action

A One Health approach is critical to strengthening health security at country, regional, and global levels. However, operationally its uptake remains limited. Recent momentum in assessing capacity to effectively prevent, detect, and respond to disease threats has resulted in identification of gaps that require dedicated action. This article highlights relevant tools, standards, and guidance to assist countries and institutions in meeting the collective vision articulated at the 2018 Prince Mahidol Award Conference on "Making the World Safe from the Threats of Emerging Infectious Diseases." Taking stock of assessment findings, resources, priorities, and implementation initiatives across human and animal health, environment and disaster risk reduction sectors can help expand participation in global health security, target risk drivers, and form synergies for collective action and shared gains for both emerging and endemic disease challenges. In addition to health security gains, a multisectoral, One Health approach can drive benefits for wider health sector and global development goals.

Differences in Neuropsychological Functioning Between Homicidal and Nonviolent Schizophrenia Samples

Few studies have compared performance on neurocognitive measures between violent and nonviolent schizophrenia samples. A better understanding of neurocognitive dysfunction in violent individuals with schizophrenia could increase the efficacy of violence reduction strategies and aid in risk assessment and adjudication processes. This study aimed to compare neuropsychological performance between 25 homicide offenders with schizophrenia and 25 nonviolent schizophrenia controls. The groups were matched for age, race, sex, and handedness. Independent t-tests and Mann-Whitney U-tests were used to compare the schizophrenia groups' performance on measures of cognition, including composite scores assessing domain level functioning and individual neuropsychological tests. Results indicated the violent schizophrenia group performed worse on measures of memory and executive functioning, and the Intellectual Functioning composite score, when compared to the nonviolent schizophrenia sample. These findings replicate previous research documenting neuropsychological deficits specific to violent individuals with schizophrenia and support research implicating fronto-limbic dysfunction among violent offenders with schizophrenia.

Murder and psychosis: Neuropsychological profiles of homicide offenders with schizophrenia

BACKGROUND

Neurocognitive dysfunction, a core feature of schizophrenia, is thought to contribute to the impulsive violent aggression manifested by some individuals with schizophrenia, but not enough is known about how homicidal individuals with schizophrenia perform on neuropsychological measures.

AIMS

The primary aim of our study was to describe the neuropsychological profiles of homicide offenders with schizophrenia. Supplementary analyses compared the criminal, psychiatric and neuropsychological features of schizophrenic homicide offenders with and without God/Satan/demon-themed psychotic symptoms.

METHODS

Twenty-five men and women diagnosed with schizophrenia who had killed another person - 21 convicted of first-degree murder and 4 found not guilty by reason of insanity - completed neuropsychological testing during forensic evaluations.

RESULTS

The sample was characterised by extensive neurocognitive impairments, involving executive dysfunction (60%), memory dysfunction (68%) and attentional dysfunction (50%), although those with God/Satan/demon-themed psychotic symptoms performed better than those with nonreligious psychotic content.

CONCLUSIONS

Our findings indicate that impaired cognition may play an important role in the commission of homicide by individuals with schizophrenia. A subgroup with God/Satan/demon delusions seem sufficiently less impaired that they might be able to engage in metacognitive treatment approaches, aimed at changing their relationship to their psychotic symptoms, thus reducing the perception of power and omnipotence of hallucinated voices and increasing their safety. Copyright © 2016 John Wiley & Sons, Ltd.

Abstract P6-11-03: A cost effectiveness analysis of baseline left ventricular function assessment for breast cancer patients undergoing anthracycline chemotherapy

Background: It is unclear if all breast cancer (BC) patients require baseline left ventricular function (LVEF) assessment prior to anthracycline based chemotherapy (ABC), and the approach is variable in clinical practice. Our objective is to determine the cost effectiveness of obtaining a baseline LVEF assessment prior to (neo) adjuvant ABC in clinical practice.

Methods: We performed a retrospective analysis of the Yale Equilibrium Radionuclide Angiography (ERNA) database for 701 breast cancer patients who had a baseline ERNA scan prior to systemic therapy for an initial diagnosis of stages I-IV BC between July 2003 and May 2013. We found that 14 of 701 (2%) patients had a baseline LVEF < 50%. Age, pre-existing cardiac risk factors and coronary artery disease did not predict an abnormal baseline LVEF <50 %. To evaluate the benefit of obtaining a baseline echocardiogram or ERNA before ABC, we considered the screening scenario in which BC patients with a baseline LVEF < 50% on screening echocardiogram are treated with a second (2nd) generation non-ABC and those with baseline LVEF ≥ 50% receive a third (3rd) generation ABC, and compared this with a non-screening scenario with uniform 3rd generation ABC treatment for all patients who do not have a baseline echocardiogram. We used Adjuvant Online to obtain estimates of the disease free (DFS) and overall survival (OS) for a 3rd generation ABC regimen vs a 2nd generation non-ABC regimen for 50 year old patients with a T2N1 hormone receptor positive BC. We implemented these oncologic clinical outcomes (in addition to cardiotoxicity-related clinical outcomes, costs of screening echocardiogram and treatment of congestive heart failure (CHF), quality of life metrics, as reported in the literature) into a simplified decision-analytic cost-effectiveness analysis that accounts for the different disease states and their associated costs and quality of life outcomes.

Results: Assuming that 20% of the unscreened patients with a LVEF < 50% will develop CHF if treated with ABC regimen without management of baseline cardiac dysfunction, the base case incremental cost effectiveness ratio (ICER) was determined to be 18,520 $USD/QALY. Sensitivity analysis suggested that the cost-effectiveness of baseline LVEF assessment is primarily driven by the prevalence of patients with LVEF < 50%, the incidence of CHF in this high-risk patient group if treated with ABC regimen, and time to CHF development. While our analysis did not reveal risk factors predictive of low baseline LVEF, our model's dependence on prevalence of LVEF < 50% demonstrates the importance of risk factor stratification. A hypothetical predictive marker which enriches the prevalence of an abnormal baseline LVEF 5-fold to 10% would result in a cost-effectiveness of 10,990 $USD/QALY. The model is less sensitive to the cost of baseline echocardiogram testing.

Conclusion: Baseline LVEF assessment was found to be cost-effective under a willingness-to-pay threshold of $50,000/QALY. Our sensitivity analysis suggests that risk factor-guided LVEF baseline LVEF screening may increase the number of high-risk patients in the treatment population, thus further increasing the cost-effectiveness of baseline LVEF assessment.

Citation Format: Safonov A, Hatzis C, Stratton J, Gross CP, Russell R, Pusztai L, Abu-Khalaf MM. A cost effectiveness analysis of baseline left ventricular function assessment for breast cancer patients undergoing anthracycline chemotherapy. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-11-03.

Income disparities in life expectancy in the City of Toronto and Region of Peel, Ontario

INTRODUCTION

To understand the lack of a gradient in mortality by neighbourhood income in a previous study, we used individual-level data from the 1991-2001 Canadian census mortality follow-up study to examine income-related disparities in life expectancy and probability of survival to age 75 years in the City of Toronto and Region of Peel.

METHODS

We calculated period life tables for each sex and income adequacy quintile, overall and separately for immigrants and non-immigrants.

RESULTS

For all cohort members of both sexes, including both immigrants and non-immigrants, there was a clear gradient across the income quintiles, with higher life expectancy in each successively richer quintile. However, the disparities by income were much greater when the analysis was restricted to non-immigrants. The lesser gradient for immigrants appeared to reflect the higher proportion of recent immigrants in the lower income quintiles.

CONCLUSION

These findings highlight the importance of using individual-level ascertainment of income whenever possible, and of including immigrant status and period of immigration in assessments of health outcomes, especially for areas with a high proportion of immigrants.

Survey of raw milk cheeses for microbiological quality and prevalence of foodborne pathogens

Cheese may be manufactured in the United States using raw milk, provided the cheese is aged for at least 60 days at temperatures not less than 35°F (1.7°C). There is now increased concern among regulators regarding the safety of raw milk cheese due to the potential ability of foodborne pathogens to survive the manufacturing and aging processes. In this study, 41 raw milk cheeses were obtained from retail specialty shops, farmers' markets, and on-line sources. The cheeses were then analyzed for the presence of Listeria monocytogenes, Salmonella, Escherichia coli O157:H7, Staphylococcus aureus, and Campylobacter. Aerobic plate counts (APC), coliform and yeast/mold counts were also performed. The results revealed that none of the enteric pathogens were detected in any of the samples tested. Five samples contained coliforms; two of those contained E. coli at less than 10(2) cfu/g. Three other cheese samples contained S. aureus. The APC and yeast-mold counts were within expected ranges. Based on the results obtained from these 41 raw milk cheeses, the 60-day aging rule for unpasteurized milk cheeses appears adequate for producing microbiologically safe products.

Polymorphisms in DNA repair genes and epithelial ovarian cancer risk

DNA repair gene polymorphisms and mutations are known to influence cancer risk. We studied whether polymorphisms in DNA double strand break (DSB) repair genes are associated with epithelial ovarian cancer (EOC) risk. Up to 1,600 cases and 4,241 controls from 4 separate genetic association studies from 3 countries were genotyped for 13 single nucleotide polymorphisms (SNP) in 6 genes (BRCA1, NBS1, RAD51, RAD52, XRCC2 and XRCC3) involved in homologous recombination of DNA double strand breaks. Genotype specific risks were estimated as odds ratios (OR) by unconditional logistic regression. No association was detected between EOC risk and BRCA1 Q356R, BRCA1 P871L, RAD51 g135c, RAD51 g172t, RAD52 c2259t, NBS1 L34L, NBS1 E185Q, NBS1 A399A, NBS1 P672P, XRCC2 g4324c, XRCC2 c41657t and XRCC3 T241M. The XRCC2 R188H polymorphism was associated with a modest reduction in EOC risk: OR for heterozygotes was 0.8 (95% confidence interval [CI] = 0.7-1.0) and for rare homozygotes 0.3 (0.1-0.9). The XRCC3 a4541g polymorphism, situated in the 5'UTR, and the intronic XRCC3 a17893g polymorphism were not associated with EOC risk in general, but when the serous EOC subset only was analysed, the OR for heterozygotes for a4541g was 1.0 (0.9-1.2) and for the rare homozygotes 0.5 (0.3-0.9). For the XRCC3 a17893g polymorphism, the OR for the heterozygotes and the rare homozygotes were 0.8 (0.7-0.9) and 0.9 (0.7-1.2), respectively. In our study, some polymorphisms in XRCC2 and XRCC3 genes were associated with EOC risk. Further research on the role of these genes on epithelial ovarian cancer is warranted.

Photocatalytic coatings for environmental applications

A series of nano- and micronparticle-grade anatase and rutile titanium dioxide pigments have been prepared with various densities of surface treatments, particle size and surface area. Their photocatalytic activites have been determined in a series of paint films by FTIR, chalking, color, gloss change and weight loss after artifical weathering. The pigments have also been examined by rapid assessment methodologies using photodielectric microwave spectroscopy, 2-propanol oxidation and hydroxyl analysis. The microwave response under light and dark cycles provides an extended timescale probe of charge-carrier dynamics in the pigments. Pigment particle size, surface area and properties clearly play an important role in dispersion and any polymer-pigment interactions. Photooxidation studies on several types of paint films show a clear demarcation between nanoparticle- and pigmentary-grade titanium dioxide, with the former being more active because of their greater degree of catalytic surface activity. The photosensitivity of titanium dioxide is considered to arise from localized sites on the crystal surface (i.e. acidic OH), and occupation of these sites by surface treatments inhibits photoreduction of the pigment by ultraviolet radiation; hence, the destructive oxidation of the binder is inhibited. Coatings containing 2-5% by weight alumina or alumina and silica are satisfactory for general-purpose paints. If greater resistance to weathering is desired, the pigments are coated more heavily to about 7-10% weight. The coating can consist of a combination of several materials, e.g. alumina, silica, zirconia, aluminum phosphates of other metals. For example, the presence of hydrous alumina particles lowers van der Waals forces between pigments particles by several orders of magnitude, decreasing particle-particle attractions. Hydrous aluminum oxide phases appear to improve dispersibility more effectively than most of the other hydroxides and oxides. Coated nanoparticles are shown to exhibit effective light stabilization in various water- and oil-based paint media in comparison with conventional organic stabilizers. Hindered piperidine stabilizers are shown to provide no additional benefits in this regard, often exhibiting strong antagonism. The use of photocatalytic titania nanoparticles in the development of self-cleaning paints and microbiological surfaces is also demonstrated in this study. In the former case, surface erosion is shown to be controlled by varying the ratio of admixture of durable pigmentary-grade rutile (heavily coated) and a catalytic-grade anatase nanoparticle. For environmental applications in the development of coatings for destroying atmospheric pollutants such as nitrogen oxide gases (NO(X)), stable substrates are developed with photocatalytic nanoparticle-grade anatase. In this study, porosity of the coatings through calcium carbonate doping is shown to be crucial in the control of the effective destruction of atmospheric NO(X) gases. For the development of microbiological substrates for the destruction of harmful bacteria, effective nanoparticle anatase titania is shown to be important, with hydrated high surface area particles giving the greatest activity.

Investigation of the performance of safety systems for protection of the elderly

This study investigates injury occurrence for belted occupants as a function of age. An analysis of NASS/CDS 1997-2003 data was conducted to determine crash involvement rates and injury rates for front seat occupants versus mean occupant age. In frontal and near-side crashes, the average age of MAIS 3+ belted front seat occupants injured in crashes less severe than 15 mph is of the order of 50 years. The average age of the population exposed to crashes less severe than 15 mph is under 40 years old. The crash exposure and frequency if injuries to the elderly were both found to be the highest in low severity crashes. The chest is the most frequent body region injured for the elderly. These findings suggest the need for more benign safety systems to protect the elderly in low severity crashes. Design of safety systems for the elderly should give priority to reducing the chest loading in low severity frontal and near-side crashes.

Validation of the urgency algorithm for near-side crashes

The URGENCY algorithm uses vehicle crash sensor data in Automatic Crash Notification (ACN) systems to assist in instantly identifying crashes that are most likely to have time critical injuries. The algorithm also provides the capability of improving injury identification, using data obtained from the scene. The prime purpose of the algorithm is to automatically provide emergency medical responders with objective information on crash severity to assist in detecting the approximately 1% of crashes with serious injuries needing the most urgent medical care. The algorithm calculates the risk of a MAIS 3+ injury being present in the crashed vehicle, instantly at the time of the crash. The prediction can be subsequently updated as more information becomes available. The algorithm was based on a multiple regression analysis using data from the National Accident Sampling System/Crashworthiness Data System, (NASS/CDS) years 1988-95. In this paper, the accuracy of the algorithm was evaluated for near side crashes by applying it retrospectively to the population of injured occupants in NASS 1997-2000. URGENCY was applied to the population of injured occupants in near side crashes. Using an injury risk criterion of 50%, URGENCY identified 69% of the crashes with MAIS 3+ injuries. By lowering injury risk criterion to 40%, URGENCY identified 78% of the crashes with MAIS 3+ injuries. Vehicle side intrusion was found to be a highly influential variable. By changing side intrusion from a binary to a continuous variable, the correctly identified crashes increased from 69% to 81%. Examination of the consequence of missing variables found that unknown values of occupant height and weight had a negligible effect on the ability to capture the MAIS 3+ injured. However, lack of knowledge of these variables did increase the magnitude of the false positives.

A descriptive analysis of giardiasis cases reported in Ontario, 1990-1998

Cases of giardiasis in Ontario were described using notifiable disease data from the Ontario Ministry of Health for the years 1990-1998 inclusive. The mean annual age- and sex-adjusted incidence rate was 25.77 cases per 100,000 population for the 25,289 cases reported. Children under five years of age had the highest incidence of disease. Males had a higher mean annual incidence in all age groups. Four deaths occurred among cases. The most frequently reported symptoms were loose stools or watery diarrhea (50.1%). A seasonal pattern was noted, peaking in late summer and early autumn. The most frequently reported probable risk settings were the home (40.1%) and travel (39.1%). The study findings suggest that a high proportion of cases occur in urban areas and spatial analysis showed the highest incidence around Lake Huron and Georgian Bay. Unfiltered water and person-to-person contact are believed to be important sources of infection.

Cytogenetic-clinicopathologic correlations in rhabdomyosarcoma: a report of five cases

Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children younger than the age of 15 years. Histologically, RMS can be subdivided into two major subtypes; embryonal (E-RMS) and alveolar (A-RMS) rhabdomyosarcoma, with E-RMS being the more common. Although cytogenetic and molecular genetic findings have been reported extensively for RMS, clinicopathologic-genetic correlations among these tumors have not been reported in detail. In this report, we correlate the cytogenetic findings, including fluorescence in situ hybridization and spectral karyotyping, with pathologic findings and outcome for five RMS, including two A-RMS, one E-RMS, one botryoid RMS, and one anaplastic nonclassified RMS (N-RMS). The findings in A-RMS and E-RMS generally were consistent with previous reports; however, gain of chromosome 7 in A-RMS and gain of chromosome 9 segments in E-RMS observed here have seldom been reported in the literature. Importantly, the botryoid RMS had a cytogenetic profile similar to other types of E-RMS. An add(11)(q21) observed in this tumor, together with a t(8;11)(q12 approximately 13;q21) reported previously, indicates that 11q21 rearrangements may be nonrandomly related to botryoid RMS. In addition, the N-RMS expressed a cytogenetic pattern similar to that observed in E-RMS, thus providing genetic evidence that anaplastic N-RMS is a variant of E-RMS. Finally, these cases provide cogent evidence for the diagnostic and prognostic significance of the pathologic-genetic classification of RMS.

Validation of methods used to recover Escherichia coli O157:H7 and Salmonella spp. subjected to stress conditionst

Escherichia coli O157:H7, Salmonella spp., and Salmonella Typhimurium DT104 were stressed with lactic acid and cell-free supernatants from lactic acid bacteria and plated on three different media to determine if injured cells were recovered. A comparison of the susceptibility and recovery of antibiotic-resistant strains of the pathogens and nonresistant strains was also made. Acid stress conditions were created by adjusting the pH of a cocktail mixture (two to four strains) of the pathogen to 3.50 with lactic acid and holding for 18 h. The pathogen cocktail was also stressed with a cell-free supernatant of Lactobacillus lactis (pH 3.90) in a 4:6 ratio. Both nonstressed and stressed cocktail cultures were plated on Trypticase soy agar (TSA) and violet red bile agar (VRBA) for E. coli and xylose lysine tergitol4 (XLT4) for Salmonella. Repair of injured cells was evaluated by pour plating the stressed cells on a 5-ml thin layer of TSA and allowing a 2-h room temperature incubation followed by overlaying with VRBA or XLT4. There were significant reductions in the populations of both pathogens under both stress conditions when plating was done on nonselective media. Injured E. coli O157:H7 was not recovered on recovery or selective media compared with TSA. Numbers of cells of supernatant-stressed Salmonella spp. plated on selective and recovery media were similar to those on TSA. Acid-stressed cells for all Salmonella spp. were not recovered on TSA, selective, or recovery media at levels comparable to recovery on TSA. Antibiotic-resistant strains showed similar recovery patterns on all media evaluated. However, the antibiotic-resistant strains were less sensitive to both stress conditions. The use of antibiotic-resistant strains resulted in a greater recovery of stressed pathogens than the use of recovery media.

Injuries to restrained occupants in far-side crashes

Occupants exposed to far-side crashes are those seated on the side of the vehicle opposite the struck side. This study uses the NASS/CDS 1988-98 to determine distributions of AIS 3+ injuries among occupants exposed to far-side crashes and the sources of the injuries. The William Lehman Injury Research Center (WLIRC) data from 1994-98 is used to assess injury mechanisms among seriously injured crash exposed far-side occupants. The NASS/CDS indicated that injury patterns for far-side restrained drivers were different from far-side restrained front passengers. For the driver, the head accounted for 40% of the AIS 3+ injuries in far-side collisions and the chest/abdomen accounted for 45.5%. For the right front passengers, head injuries contributed 27.2%, while chest and abdominal injuries accounted for 64.5%. The opposite-side interior was the most frequent contact associated with driver AIS 3+ injuries (30.5%). The seat belt was second, accounting for 22.6%. Among thirteen WLIRC cases of far-side belted occupants with MAIS 3+ injuries, five of the most serious injuries were attributed to the seat belt. The liver or the spleen was the most seriously injured body organ in all five cases. The seat was the most frequent source of passenger AIS 3+ injuries for the NASS/CDS weighted cases. However, non-contacts, contacts with other occupants, and the seat belt contacts were more frequent sources when considering the raw number of injuries. Overall, contacts with the opposite side of the car interior and with safety belts were the most frequent causes of AIS 3+ injuries in far-side crashes. The presence of an occupant on the near-side changed the injury pattern of the far-side occupant, mitigating injuries from contacts with the opposite side interior of the vehicle.

Dummy measurement of chest injuries induced by two-point shoulder belts

The University of Miami's William Lehman Injury Research Center at the Jackson Memorial Medical Center conducts interdisciplinary investigations to study seriously injured restrained occupants in frontal automobile collisions. Engineering analysis of these crashes is conducted in conjunction with the National Crash Analysis Center at the George Washington University. The multidisciplinary research team includes expertise in crash investigation, crash reconstruction, computer graphics, biomechanics of injuries, crash data analysis, trauma care, and all of the medical specialties associated with the Ryder Trauma Center at Jackson Memorial Hospital. More than 350 injured occupants and their crashes have been studied in depth. The purpose of this paper is to report on an observed pattern of liver lacerations suffered by drivers wearing shoulder belts, without the lap belt fastened and to assess the ability of existing crash test dummies to measure the potential for these injuries. During the initial years of the study, 48 cases of drivers protected by shoulder belts but without the lap belt fastened met the criteria for the study. Fifty percent of these drivers suffered liver lacerations. Further study showed that 22 of the crashes involved damage to the right front of the vehicle. Among the drivers in vehicles with right front damage, 92% sustained injuries to the liver. This observation indicated that 2-point belts were most likely to produce liver injuries in low severity frontal collisions when the crash direction is 1 to 2 o'clock. An analysis of the National Accident Sampling System for the years 1988-95 indicated that liver injuries constitute about 0.5% of the injuries suffered by drivers who are in tow-away crashes. NASS data showed that the risk of chest injury is more likely among drivers with automatic shoulder belts than drivers with 3-point manual belts. The crash test dummies showed no difference in chest injury measures. Finite element computer modeling demonstrated that the high deflection of the right lower rib on the Hybrid III dummy predicts the liver injuries in the 1 o'clock crashes. These higher deflections were less apparent at the location of the center chest deflection measurement device on the Hybrid III.

Transthoracic contrast echocardiographic detection of ascending aortic dissection

BACKGROUND

Ascending aortic dissection is highly lethal if left untreated. Therefore rapid accurate diagnosis is necessary. Diagnosis can be made with imaging modalities that use contrast agents to delineate anatomy reliably. Transthoracic echocardiography has not routinely been diagnostically useful because of the inability in clearly visualizing the ascending aorta.

METHOD AND RESULTS

We describe a case in which transthoracic echocardiography with an echocardiographic contrast agent provided diagnostic information regarding an acute ascending aortic dissection, delineating both the true and false lumens.

CONCLUSIONS

Transthoracic echocardiography combined with an echocardiographic contrast agent can be useful in detecting an ascending aortic dissection.

High cell-density fermentation

The purpose of this chapter is to educate the reader about the basic equipment and strategies used in fermentations of P. pastoris in both bench-top and pilot-scale operations. A key element in expression of foreign proteins in this yeast is the need for sufficient aeration, which is achieved by proper mixing of the media and by blending gases to control dissolved oxygen content. Automatic pH control is essential for growth and expression in P. pastoris. Finally, fed-batch fermentations require the use of peristaltic pumps and tubing capable of low rates of delivery for the feeding of nutrients and base. Teflon tubing and peristaltic pump adapters are recommended for fed-batch operations. The information in this chapter should enable a reader with little or no experience to perform a high-cell density fermentation of a P. pastoris expression strain. Although most procedures described here are specifically for the BioFlo III (NBS), it should be possible to achieve high expression levels with almost any good-quality fermentor, modified to accommodate this organism.

A new approach to substance abuse treatment. Adolescents and adults with ADHD

Adolescents and young adults with Attention Deficit Hyperactivity Disorder (ADHD) are not only at risk for drug and alcohol dependence, but are also difficult to maintain in a chemical dependency facility due to disruptive behaviors. Such patients may be "hyperaroused," a term coined by the field of occupational therapy, but oppositional behaviors hide their physical and emotional overreactivity. Thirty years ago, occupational therapist Dr. Jean Ayres developed Sensory Integration (SI) techniques that are traditionally used with children under 12 years of age who are diagnosed with learning disabilities, autism, and ADHD. Many of the chemically dependent adolescent and young adult patients with ADHD who are in treatment display characteristics similar to those of children traditionally targeted for this therapy. Techniques used by occupational therapists trained in SI were adapted to treat hyperarousal and overreactivity to the environment in chemically dependent adolescents and young adults, in order to maintain them in the treatment environment until they were ready to graduate. The techniques were successful in maintaining and educating patients about ADHD and chemical dependency.

Rectal prolapse associated with bulimia nervosa: report of seven cases

PURPOSE

Rectal prolapse is a condition in which, when complete, the full thickness of the rectal wall protrudes through the anus. Bulimia nervosa is an eating disorder characterized by periodic food binges, which are followed by purging. Purging usually takes the form of self-induced vomiting, laxative abuse, and/or diuretic abuse. We report seven cases of rectal prolapse associated with bulimia nervosa.

METHODS

The case histories of seven women with rectal prolapse and bulimia nervosa, average age 29 (range 21-42) years, seen over a period of 11 years (1987-1997) were reviewed. An analysis of the clinical data, including history, presenting physical examination, surgical treatment, and outcome was performed.

RESULTS

All seven patients had a diagnosis of bulimia nervosa, made either before or with a diagnosis of rectal prolapse. Rectal prolapse was confirmed in each patient at anorectal examination. Five patients underwent sigmoid resection with proctopexy, one died before operative therapy, and one awaits further treatment. One of the five surgical patients had a recurrence that was managed by a perineal rectosigmoidectomy.

CONCLUSION

To our knowledge, despite extensive review of both bulimia nervosa and rectal prolapse as seen in the medical literature, an association between the two has not been described previously. Several aspects of bulimia nervosa, including constipation, laxative use, overzealous exercise, and increased intra-abdominal pressure from forced vomiting are likely causes for the probable relationship with rectal prolapse. The possibility that an atypically young female presenting with rectal prolapse may also have bulimia nervosa should be taken into account by clinicians. This may assist the diagnosis of bulimia nervosa, a disease with multiple morbidities. Conversely, a patient being treated for bulimia nervosa who develops anorectal symptoms may come to earlier diagnosis and treatment for rectal prolapse.

The influence of age on the assessment of motor unit activation in a human hand muscle

Two indices of motor unit recruitment, the ramp-force and repetitive-discharge thresholds, were compared in the first dorsal interosseus muscle of ten young and twelve elderly subjects. The purpose was to determine the effect of age on the relationship between the two recruitment thresholds and the spike-triggered average force of motor units. Each subject performed three tasks requiring isometric abduction of the left index finger: a maximum voluntary contraction (MVC), a ramp-and-hold contraction, and a repetitive-discharge task. The elderly subjects used coactivation of the antagonist muscle (second palmar interosseus) more frequently than the young subjects during the ramp-and-hold contraction. Many elderly subjects expressed difficulty with the controlled ramp-down phase of the ramp-and-hold contraction and preferred a coactivation strategy to a derecruitment strategy for this task. There were no differences due to age or gender in the ramp-force thresholds between the various groups. However, the normalized repetitive-discharge threshold was significantly less for the younger subjects and for the male subjects. Nonetheless, the two recruitment thresholds were able to predict the spike-triggered average force with similar success for both the young and the elderly subjects. These data suggest that the recruitment threshold of a motor unit in first dorsal interosseus was characterized equally well by either the ramp-force or repetitive-discharge measurement for both young and elderly subjects but that coactivation was used more frequently by the elderly subjects during the ramp-and-hold task.

Which formula should be used in Ireland to estimate fetal weight?

In order to determine which formula most accurately predicts weight in Irish infants we performed a prospective study on 162 mothers within one week of delivery. Actual weights were compared with estimated weights derived from the formulae of Shepard; Hadlock; Birnholtz; Deter and Campbell. Overall the Deter formula gave the closest approximation of birth weight. All the formulae became increasingly inaccurate in the larger infants i.e. > 4 kg. However in infants of average weight the Campbell formula, which is based on a single measurement (A.C), is as good as any.