A Prospective Phase II Dose Escalation Study Using IMRT for High Risk N0M0 Prostate Cancer

PURPOSE/OBJECTIVE(S)

Published data supports the use of very high dose intensity modulated radiotherapy (IMRT) in achieving high efficacy and low toxicity for high-risk prostate cancer (HRPCa). This phase II multi-institutional non-randomized prospective dose escalation study using intensity modulated radiotherapy (IMRT) for high risk N0M0 prostate cancer was designed to investigate dose escalation using 1.8 Gy increments from baseline 75.6 Gy up to maximum 81 Gy, once dose volume constraints were adhered to.

MATERIALS/METHODS

Inclusion criteria were patients undergoing a radical course of RT for high and very high-risk disease, defined as one or more of the criteria ≥ T3*, ≥ Gleason 8, Prostate specific antigen (PSA) > 20ng/ml. All patients received Androgen Deprivation Therapy (ADT) and none had radiological evidence of distant metastatic disease. The primary objective was to determine if dose escalated IMRT for high risk localized prostate cancer could provide freedom from biochemical relapse (BR; PSA rising > nadir +2ng/mL or initiation of salvage hormone therapy) similar to that reported in the literature. The Kaplan-Meier method was used to estimate survival times. Secondary objectives included OS, Disease Free Survival (DFS), and the incidence and severity of Genito-urinary (GU), Gastro-intestinal (GI) and erectile dysfunction (ED) toxicities (CTCAE v.3). Toxicities and performance status were collected and graded weekly during RT, 2 months after completing RT, 8 months' post RT, and 6 monthly thereafter to year five and annually thereafter to year nine.

RESULTS

A total of 230 evaluable patients were enrolled between April 2009 and June 2016. The median follow-up was 7.3 years. The cumulative proportion of patients surviving without BR at 5 years was 91% (95% Confidence Interval (CI): 86% to 94%). Overall survival at 5 and 7 years was 92% (88% to 95%) and 89% (83% to 92%) respectively, while the cumulative proportion of patients free from disease was 89% (84% to 93%) at 5 years and 81% (75% to 86%) at 7 years. The incidence of acute G2 and G3 toxicities were; GU; 57.8% G2, 12.6% G3, GI; 15.2% G2, 0.4% G3, ED; 30.0% G2 and 61.7% G3. The incidence of late G2, G3 and G4 toxicities were; GU; 40.9% G2, 8.7% G3, GI; 36.5% G2, 2.2% G3, 0.4% G4, ED; 11.7% G2 and 86.1% G3. The percentage of patients receiving each dose level was; 3.5% received 75.6Gy in 42 fractions, 2.2% received 77.4Gy in 43 fractions, 93% received 81Gy in 45 fractions.

CONCLUSION

The findings indicate that high-dose IMRT is well tolerated and is associated with excellent long-term tumor-control outcomes in patients with localized high and very high-risk prostate cancer, with 91% of patients surviving at 5 years without biochemical relapse. The rates of long term G3 GU and GI toxicity were low at 8.7% and 0.4% respectively.

Enhancing Specialist Training in Radiation Oncology through the Implementation of Structured Radiotherapy Contouring Workshops

PURPOSE/OBJECTIVE(S)

Contouring tumor volumes and organs at risk is a key component of Radiation Oncology specialist training. As trainees rotate through different tumor sites, they are expected to develop proficiency in contouring skills relevant to their year of training. These skills have historically been acquired in an unstructured manner during supervised clinical work. However, trainees often struggle to learn these skills due to variability in practice and approach amongst senior colleagues. Research has shown that contouring workshops improve the standardization of contouring and can be an effective way of enhancing the learning experience through interaction, instant feedback and reflection. We present our experience of implementing structured contouring workshops and the feedback received from the trainees.

MATERIALS/METHODS

Eight contouring workshops were held in our institution over a period of 3 years between 2019 and 2022. These included Head & Neck (3), Prostate (1), SABR Lung (2), Breast (1), and Esophagus (1). Six were held in-person pre-COVID and two in a virtual format during the pandemic. Each workshop was 2 hours long and attended by trainees with varying levels of contouring experience. All the workshops were facilitated by a consultant radiation oncologist and a clinical tutor and followed a similar format consisting of a brief tutorial on the tumor site, followed by a contouring demonstration on an anonymized case on an Eclipse planning platform referencing published contouring atlases. Each of the trainees had access to a copy of the same case throughout the workshop and their contours were then reviewed both individually and collectively. A key component of the workshops was instant feedback, as trainees could compare their contours to that of the tutors and discuss any differences. Feedback on the contouring workshop was then collected through a post workshop questionnaire.

RESULTS

The workshops were attended by an average of 12 trainees (range 10 to 14). Regardless of their year of training, all trainees rated the content and format of the workshops highly and stated they were relevant to their daily practice. Their subjective level of confidence in contouring in that specific tumor site improved significantly, going from an average of 5.6 out of 10 (range of 4 to 7) before the workshop to 8.7 (range of 8 to 9) after the 8 workshops. All the workshops were conducted at no extra cost as they were held using our existing planning software.

CONCLUSION

The trainees indicated that the workshops were of definite educational benefit and strongly supported incorporating this approach to teaching contouring skills into the curriculum. Based on this feedback, these contouring workshops have been integrated into the recently revised higher specialist training curriculum on a more structured basis. This will ensure that trainees will continue to develop progressive expertise in contouring skills in keeping with best international practice as they advance through their training scheme.

Endoscopic Botulinum toxin as a treatment for delayed gastric emptying following oesophagogastrectomy

INTRODUCTION

The incidence of delayed gastric emptying (DGE) following oesophagogastrectomy with gastric conduit reconstruction is reported to be between 1.7% and 50%. This variation is due to differing practices of intraoperative pylorus drainage procedures, which increase the risk of postoperative biliary reflux and dumping syndrome, resulting in significant morbidity. The aim of our study was to establish rates of DGE in people undergoing oesophagogastrectomy without routine intraoperative drainage procedures, and to evaluate outcomes of postoperative endoscopically administered Botulinum toxin into the pylorus (EBP) for people with DGE resistant to systemic pharmacological treatment.

METHODS

All patients undergoing oesophagogastrectomy between 1 January 2016 and 31 March 2018 at our unit were included. No intraoperative pyloric drainage procedures were performed, and DGE resistant to systemic pharmacotherapy was managed with EBP.

RESULTS

Ninety-seven patients were included. Postoperatively, 29 patients (30%) were diagnosed with DGE resistant to pharmacotherapy. Of these, 16 (16.5%) were diagnosed within 30 days of surgery. The median pre-procedure nasogastric tube aspirate was 780ml; following EBP, this fell to 125ml (p<0.001). Median delay from surgery to EBP in this cohort was 13 days (IQR 7-16 days). Six patients required a second course of EBP, with 100% successful resolution of DGE before discharge. There were no procedural complications.

CONCLUSIONS

This is the largest series of patients without routine intraoperative drainage procedures. Only 30% of patients developed DGE resistant to pharmacotherapy, which was managed safely with EBP in the postoperative period, thus minimising the risk of biliary reflux in people who would otherwise be at risk following prophylactic pylorus drainage procedures.

Gingival health status in individuals using different types of toothpaste

OBJECTIVES

To examine the relationship between the medium term use (>1 year) of a toothpaste containing natural enzymes and proteins (Zendium™) upon gingival index, plaque index and bleeding index compared to medium term use of toothpastes without antimicrobial/antiinflammatory ingredients.

METHODS

A total of 305 participants eligible for inclusion were grouped according to their toothpaste use and matched with regard to gender and age (18-30, 31-55 and 56+ years of age). A total of 161 persons were using a toothpaste which contained enzymes and proteins (Zendium™, test group), and 144 persons were using a toothpaste without these ingredients (control group). The amount of dental plaque and the gingival condition were assessed at six sites of each tooth using the modified gingival index (MGI), plaque index (Modified Quigley and Hein plaque index, PI), and bleeding index (BI). Mean values of MGI, PI and BI were compared using analysis of covariance.

RESULTS

The test group had significantly less gingival inflammation than the control group (adjusted mean scores (SD); 1.80 (0.65) vs. 2.27 (0.63),p < 0.0001), as well as lower levels of plaque (2.03 (0.33) vs. 2.12 (0.33), p = 0.0168) and gingival bleeding (0.74 (0.45) vs. 1.08 (0.45), p < 0.0001). Females had significantly less gingival inflammation (p < 0.0001), plaque (p = 0.0005) and bleeding (p = 0.0118) than males. Participants aged 18-30 years had significantly higher levels of inflammation and bleeding than the older age groups (p < 0.001), and also higher plaque levels compared to participants aged 31-55 years (p = 0.0069). Potential confounding factors including oral hygiene practices and consistency of dental visits did not differ between groups.

CONCLUSIONS

Our findings indicate that medium term use of fluoride toothpaste containing enzymes and proteins (Zendium™) is associated with a better gingival health than the use of other types of fluoride toothpastes without antimicrobial active ingredients.

CLINICAL SIGNIFICANCE

Medium term (> 1 year) use of toothpaste containing naturally occurring enzymes and proteins (Zendium™) in an unsupervised home setting is associated with better gingival health compared to the unsupervised use of other commercially available toothpastes without antimicrobial/antiinflammatory active ingredients.

Pan-cancer analysis of whole genomes

Cancer is driven by genetic change, and the advent of massively parallel sequencing has enabled systematic documentation of this variation at the whole-genome scale1-3. Here we report the integrative analysis of 2,658 whole-cancer genomes and their matching normal tissues across 38 tumour types from the Pan-Cancer Analysis of Whole Genomes (PCAWG) Consortium of the International Cancer Genome Consortium (ICGC) and The Cancer Genome Atlas (TCGA). We describe the generation of the PCAWG resource, facilitated by international data sharing using compute clouds. On average, cancer genomes contained 4-5 driver mutations when combining coding and non-coding genomic elements; however, in around 5% of cases no drivers were identified, suggesting that cancer driver discovery is not yet complete. Chromothripsis, in which many clustered structural variants arise in a single catastrophic event, is frequently an early event in tumour evolution; in acral melanoma, for example, these events precede most somatic point mutations and affect several cancer-associated genes simultaneously. Cancers with abnormal telomere maintenance often originate from tissues with low replicative activity and show several mechanisms of preventing telomere attrition to critical levels. Common and rare germline variants affect patterns of somatic mutation, including point mutations, structural variants and somatic retrotransposition. A collection of papers from the PCAWG Consortium describes non-coding mutations that drive cancer beyond those in the TERT promoter4; identifies new signatures of mutational processes that cause base substitutions, small insertions and deletions and structural variation5,6; analyses timings and patterns of tumour evolution7; describes the diverse transcriptional consequences of somatic mutation on splicing, expression levels, fusion genes and promoter activity8,9; and evaluates a range of more-specialized features of cancer genomes8,10-18.

Measurements of Fission Products Yields with the LOHENGRIN mass spectrometer at ILL

The CEA in collaboration with ILL and LPSC has developed a measurement program on symmetric and heavy mass fission product distributions. The combination of measurements with ionisation chamber and Ge detectors is necessary to describe precisely the heavy fission product region in mass and charge. Recently, new measurements of fission yields and kinetic energy distributions, for different fissioning systems (233,235 U(nth, f),241 Am(2nth, f) and 239,241 Pu(nth, f), were performed with recoil spectrometer LOHENGRIN. The focus has been done on the self-normalization of the data to provide new absolute measurements, independently of any libraries along with the experimental covariance matrix. To reach precise measurements, a new experimental procedure was developed along with a new analysis method.

Fission fragments observables measured at the LOHENGRIN spectrometer

Nuclear fission yields are key data for reactor studies, such as spent fuel inventory or decay heat, and for understanding fission process. Despite a significant effort allocated to measure fission yields during the last decades, the recent evaluated libraries still need improvements in particular in the reduction of the uncertainties. Moreover, some discrepancies between these libraries must be explained.

Additional measurements provide complementary information and estimations of experimental correlations, and new kinds of measurements enable to test the models used during the nuclear data evaluation process. A common effort by the CEA, the LPSC and the ILL aims at tackling these issues by providing precise measurements of isotopic and isobaric fission yields with the related variance-covariance matrices. Additionally, the experimental program involves a large range of observables requested by the evaluations, such as kinetic energy dependency of isotopic yields and odd-even effect in order to test the sharing of total excitation energy and the spin generation mechanism. Another example is the complete range of isotopic distribution per mass that allows the determination of the charge polarization, which has to be consistent for complementary masses (pre-neutron emission). For instance, this information is the key observable for the evaluation of isotopic yields. Finally, ionic charge distributions are indirect measurements of nanosecond isomeric ratios as a probe of the nuclear de-excitation path in the (E*, J, π) representation.

Measurements for thermal neutron induced fission of 241 Pu have been carried out at the ILL in Grenoble, using the LOHENGRIN mass spectrometer. Methods, results and comparison to models calculations will be presented corresponding to a status on fission fragments observables reachable with this facility.

Status of fission fragment observables measured with the LOHENGRIN spectrometer

Nuclear fission yields are key parameters to evaluate reactor physics observables, such as fuel inventory, decay heat, spent fuel radiotoxicity, criticality but also for understanding the fission process. Despite a significant effort allocated to measure fission yields during the last decades, the recent evaluated libraries still need improvements in particular in the description of the uncertainties with the associated correlations. Additional kinds of measurements provide complementary information in order to test the models used in the nuclear data evaluation. Moreover, some discrepancies between these libraries must be explained. A common effort by the CEA, the LPSC and the ILL aims at tackling these issues by providing precise measurement of isotopic and isobaric fission yields with the related variance-covariance matrices. Nevertheless, the experimental program represents itself a large range of observables requested by the evaluations: isotopic yields, nuclear charge polarization, odd-even effect, isomeric ratio and their dependency with fission fragment kinetic energy as a probe of the nuclear de-excitation path in the (E*, Jπ) representation. Measurements for thermal neutron induced fission of 241Pu have been carried out at the Institut Laue Langevin using the LOHENGRIN mass spectrometer. Experimental program, observables reachable, results and comparison to model calculations are shown.

Therapies and outcomes of congenital hyperinsulinism-induced hypoglycaemia

Congenital hyperinsulinism is a rare disease, but is the most frequent cause of persistent and severe hypoglycaemia in early childhood. Hypoglycaemia caused by excessive and dysregulated insulin secretion (hyperinsulinism) from disordered pancreatic β cells can often lead to irreversible brain damage with lifelong neurodisability. Although congenital hyperinsulinism has a genetic cause in a significant proportion (40%) of children, often being the result of mutations in the genes encoding the K_ATP channel (ABCC8 and KCNJ11), not all children have severe and persistent forms of the disease. In approximately half of those without a genetic mutation, hyperinsulinism may resolve, although timescales are unpredictable. From a histopathology perspective, congenital hyperinsulinism is broadly grouped into diffuse and focal forms, with surgical lesionectomy being the preferred choice of treatment in the latter. In contrast, in diffuse congenital hyperinsulinism, medical treatment is the best option if conservative management is safe and effective. In such cases, children receiving treatment with drugs, such as diazoxide and octreotide, should be monitored for side effects and for signs of reduction in disease severity. If hypoglycaemia is not safely managed by medical therapy, subtotal pancreatectomy may be required; however, persistent hypoglycaemia may continue after surgery and diabetes is an inevitable consequence in later life. It is important to recognize the negative cognitive impact of early-life hypoglycaemia which affects half of all children with congenital hyperinsulinism. Treatment options should be individualized to the child/young person with congenital hyperinsulinism, with full discussion regarding efficacy, side effects, outcomes and later life impact.

Contemporary Approaches to Perioperative IV Fluid Therapy

BACKGROUND

Intravenous fluid therapy is required for most surgical patients, but inappropriate regimens are commonly prescribed. The aim of this narrative review was to provide evidence-based guidance on appropriate perioperative fluid management.

METHOD

We did a systematic literature search of the literature to identify relevant studies and meta-analyses to develop recommendations.

RESULTS

Of 275 retrieved articles, we identified 25 articles to inform this review. "Normal" saline (0.9% sodium chloride) is not physiological and can result in sodium overload and hyperchloremic acidosis. Starch colloid solutions are not recommended in surgical patients at-risk of sepsis or renal failure. Most surgical patients can have clear fluids and/or administration of carbohydrate-rich drinks up to 2 h before surgery. An intraoperative goal-directed fluid strategy may reduce postoperative complications and reduce hospital length of stay. Regular postoperative assessment of the patient's fluid status and requirements should include looking for physical signs of dehydration or hypovolemia, or fluid overload. Both hypovolemia and salt and water overload lead to adverse events, complications and prolonged hospital stay. Urine output can be an unreliable indicator of hydration status in the postoperative surgical patient. Excess fluid administration has been linked to acute kidney injury, gastrointestinal dysfunction, and cardiac and pulmonary complications.

CONCLUSION

There is good evidence supporting the avoidance of unnecessary fasting and the value of an individualized perioperative IV fluid regimen, with transition to oral fluids as soon as possible, to help patients recover from major surgery.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Development and evaluation of an online educational resource about cancer survivorship for cancer nurses: a mixed-methods sequential study

Cancer survivorship is recognised globally as a key issue. In spite of the key role played by nurses in survivorship care, there is an identified gap in nurse's knowledge in this area. This study reports on the development and evaluation of an educational resource for nurses working with people affected by cancer. The resource was designed using adult learning principles and includes a variety of learning materials and point of care resources. A mixed-methods sequential exploratory design was used to undertake an evaluation of the programme. This included the use of online surveys and semi-structured interviews with pilot participants. A total of 21 participants completed an online survey and 11 participants completed a telephone interview. Overall, the participants found the Cancer Survivorship resource to be engaging, practical and intuitive. A major theme emerging from the survey and interview data was that the resource was applicable to practice and useful in developing survivorship care plans. Respondents requested additional information be included on the role of various health professionals working in survivorship as well as guidelines on when to make referrals. This study provides evidence that the Cancer Survivorship tool may be a promising vehicle for delivering evidence-based education on survivorship care.

Strategies for parenting by mothers and fathers with a mental illness

WHAT IS KNOWN ON THE SUBJECT?: The combination of coping with their mental health problems and caring for children makes parents vulnerable. Family-centred practice can help to maintain and strengthen important family relationships, and to identify and enhance the strengths of a parent with a mental illness, all contributing to the recovery of the person with the mental illness. WHAT THIS PAPER ADDS TO THE EXISTING KNOWLEDGE?: Taking the strength and the opportunities formulated by parents themselves as a starting point is fairly new. Parents with severe mental illness find strength for parenting in several ways. They feel responsible, and this helps them to stay alert while parenting, whereas parenthood also offers a basis for social participation through school contacts and the child's friendships. Dedication to the parent role provides a focus; parents develop strengths and skills as they find a balance between attending to their own lives and caring for their children; and parenting prompts them to find adequate sources of social support. In this study these strategies were found to be the fundamentals of recovery related to parenting. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses can support and coach patients who are identified as parents, and self-chosen parenting related goals are set and addressed. A family-focused approach by nurses can be used to prevent problems for children and their families, identify their strengths as well as vulnerabilities, and address the challenges to build resilience.

INTRODUCTION

Understanding of the problems of parents with mental illness is growing. Gaining insight into strategies for parenting, while taking the opportunities formulated by these parents themselves as a starting point is fairly new.

QUESTION

What are the strategies of parents with a mental illness to be successful?

METHOD

Experiences of 19 mothers and eight fathers with a mental illness were explored with in-depth interviews. Data were content analysed, using qualitative methods.

RESULTS

Next to feelings of inadequacy, interviewees also describe how children enrich and structure their lives and are not only a burden but serve as distraction from problems. Developing activities that interest both child and parent provides avenues for emerging strength. Mental illness constrains fathers, but also gives opportunities to develop a meaningful relation with their children.

DISCUSSION

Strategies like being fully dedicated to the parental role, finding a balance between attention for one's own life and parenting and finding adequate sources of support are found to be fundamental for recovery in the parent role. Implications for practice Peer groups can be of valuable help and mental health workers can support parents to set self-chosen parenting related goals.

Effects of Cohabitation on the Population Performance and Survivorship of the Invasive Mosquito Aedes albopictus and the Resident Mosquito Aedes notoscriptus (Diptera: Culicidae) in Australia

The presence of Aedes albopictus (Skuse) in the Torres Strait of northern Australia increases the potential for colonization and establishment on the mainland. However, there is a possibility that native species that occupy the same habitats may influence the population performance of Ae. albopictus, potentially affecting the establishment of this species in Australia. Cohabitation experiments were performed with the endemic Aedes notoscriptus (Skuse), which has been found occupying the same larval habitats as Ae. albopictus in the Torres Strait and is the most widespread container-inhabiting Aedes species in Australia. The influence of environmental factors and cohabitation between the two species was examined using different climates, food resource levels, food resource types, and species densities. Survivorship proportions and a population performance index (λ') were calculated and compared. The consequences of increased Ae. notoscriptus densities were reduced survivorship and λ' for Ae. albopictus. Despite this, the mean λ' of Ae. albopictus and Ae. notoscriptus was consistently ≥ 1.06, indicating both species could increase under all conditions, potentially due to increasing conspecific densities negatively affecting Ae. notoscriptus. The outcomes from this study suggest that the preexisting presence of Ae. notoscriptus may not prevent the establishment of Ae. albopictus in Australia.

Aerosol steroids for the treatment of peristomal mucocutaneous breakdown due to severe eczema

INTRODUCTION

We describe a novel treatment of mucocutaneous peristomal junction breakdown in a patient with severe eczema using aerosol steroids, where conventional methods failed to achieve healing.

PRESENTATION OF CASE

Observation and photographic evidence showing resolution of severe peristomal eczema in a patient, in whom systemic steroids were contraindicated, using a topical aerosol steroid. We found complete resolution of peristomal eczema and symptoms within four weeks.

DISCUSSION

Topical aerosol steroids are better tolerated than alcohol based steroid preparations, achieve improved stoma appliance adherence in comparison to oil based steroid preparations and reduce systemic side effects in comparison to systemic oral steroids.

CONCLUSION

Aerosol steroids appear to be a safe and effective way to treat refractory peristomal eczema and may be of use in other peristomal inflammatory conditions including contact dermatitis.

Ability for Aedes albopictus (Diptera: Culicidae) to survive at the climatic limits of its potential range in eastern Australia

Aedes albopictus (Skuse) is one of the most invasive mosquito species in the world and has infested islands in the Torres Strait, off the northern coast of Australia since at least 2004. This has led to fears that it may establish on the Australian mainland, including highly populated cities in southern temperate regions. To supplement theoretical projections addressing the range expansion of Ae. albopictus into Australia, laboratory-based trials were conducted to assess the performance of a Torres Strait Ae. albopictus population under a range of Australian conditions. First-instar larvae were placed in individual microcosms and maintained on a natural food resource, under average climatic conditions representing different regions of Australia's east coast. Larvae could not survive winter conditions in southern Australia. As the population performance index was >1.0 for tropical winter and summer conditions, and temperate summer conditions, populations would likely increase during these times. To test whether Ae. albopictus could overwinter during adverse conditions as eggs, we exposed cohorts to four different temperature (7, 17, 27, and 33 degrees C) and relative humidity (35, 55, and 80%) combinations for up to 3 mo. High temperatures and low humidity were most detrimental to egg survival. However, those eggs maintained under cooler climates remained viable after 3 mo, including 17% of eggs kept at 7 degrees C. Overall, this study suggests that a Torres Strait Ae. albopictus strain could proliferate all year round under northern tropical conditions and could overwinter in the egg stage before proliferating in the summer in southern temperate regions.

The economic status of parents with serious mental illness in the United States

OBJECTIVE

Parents with serious mental illness may be vulnerable to financial insecurity, making successful parenting especially difficult. We explored relationships among parenting, serious mental illness, and economic status in a nationally representative sample.

METHOD

The sample included all working-age participants from the 2009 and 2010 National Survey on Drug Use and Health (n = 77,326). Two well-established scales of mental health distinguished participants with none, mild, moderate, and serious mental illness. We compared economic status by parenthood status and mental illness severity.

RESULTS

Rates of employment were low for parents with serious mental illness (38% full time and 17% part time among mothers; 60% full time and 9% part time among fathers) compared with parents with no mental illness (50% full time and 19% part time among mothers; 85% full time and 5% part time among fathers). Mothers and fathers with serious mental illness were twice as likely to fall below the U.S. Census poverty threshold as their peers without mental illness.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Parents with serious mental illness are less likely to be employed than those without mental illnesses, and are highly likely to be living in poverty. Reducing poverty by helping parents with serious mental illness achieve better jobs and education is likely to translate into family stability and better outcomes.

Aedes albopictus (Diptera: Culicidae) as a potential vector of endemic and exotic arboviruses in Australia

In 2005, established populations of Aedes albopictus (Skuse) were discovered in the Torres Strait, the region that separates Papua New Guinea from northern Australia. This increased the potential for this species to be introduced to mainland Australia. Because it is an arbovirus vector elsewhere, we undertook laboratory-based infection and transmission experiments to determine the potential for Ae. albopictus from the Torres Strait to become infected with and transmit the four major Australian endemic arboviruses--Murray Valley encephalitis virus, West Nile virus Kunjin strain (WNV(KUN)), Ross River virus (RRV), and Barmah Forest virus--as well as the exotic Japanese encephalitis virus. Ae. albopictus is susceptible to infection with all viruses, with infection rates ranging between 8% for WNV(KUN) and 71% for RRV. Transmission rates of approximately 25% were observed for RRV and Barmah Forest virus, but these were < 17% for Murray Valley encephalitis virus, WNV(KUN), and Japanese encephalitis virus. Given its relative vector competence for alphaviruses, we also examined the replication kinetics and extrinsic incubation periods required for transmission of RRV and chikungunya virus. Despite lower body titers, more mosquitoes reared and maintained at 28 degrees C became infected with and transmitted the virus than those reared and maintained at 22 degrees C. The minimum time between Ae. albopictus consuming an infected bloodmeal and transmitting chikungunya virus was 2 d at 28 degrees C and 4 d at 22 degrees C, and for RRV, it was 4 d, irrespective of the temperature. Given its opportunistic feeding habits and aggressive biting behavior, the establishment of Ae. albopictus on the Australian mainland could have a considerable impact on alphavirus transmission.

Automated coaching to help parents increase their children's brushing frequency: an exploratory trial

Advances in digital communication, such as the internet, now provide a cost effective channel to reach and help families struggling to establish good oral hygiene in their homes. This paper describes a novel internet based oral hygiene intervention whose design draws from advances in social cognitive models of behaviour change. Intervention components included role-modelling cartoons for children, a guide for parents on using rewards, a personalised plan with clear steps, tips to follow and a weekly 10-minute review of progress.

OBJECTIVE

To evaluate the efficacy of the online coaching programme; specifically we expected that those in the intervention group would brush their teeth more frequently during the intervention period than those in the control group.

BASIC RESEARCH DESIGN

An exploratory trial using a randomised controlled parallel approach.

PARTICIPANTS

Children aged 5 to 9 years from 44 families (23 control and 21 intervention).

MAIN OUTCOME MEASURE

An objective monitoring of tooth brushing.

RESULTS

In the 3-week intervention period, children from families assigned to the coaching programme brushed their teeth 38% more often than those in the control group.

CONCLUSIONS

The programme was effective in a number of respects. Opportunities for further research are discussed, including the need to create a more engaging system and so increase compliance.

Oral vs intravenous paracetamol for lower third molar extractions under general anaesthesia: is oral administration inferior?

BACKGROUND

Paracetamol formulations provide effective analgesia after surgery [Duggan ST, Scott LJ. Intravenous paracetamol (acetominophen). Drugs 2009; 69: 101-13; Toms L, McQuay HJ, Derry S, Moore RA. Single dose oral paracetamol (acetaminophen) for postoperative pain in adults. Cochrane Database Syst Rev 2008: CD004602]. I.V. paracetamol is superior to oral for pain rescue (Jarde O, Boccard E. Parenteral versus oral route increases paracetamol efficacy. Clin Drug Invest 1997; 14: 474-81). By randomized, double-blinded trial, we aimed to determine whether preoperative oral paracetamol provides inferior postoperative analgesia to preoperative i.v. paracetamol.

METHODS

One hundred and thirty participants received either oral paracetamol and i.v. placebo (Group OP), or oral placebo and i.v. paracetamol (Perfalgan™) (Group IP). Oral preparations were given at least 45 min before surgery; i.v. preparations after induction of anaesthesia. Pain was assessed by a 100 mm visual analogue scale (VAS) 1 h from the end of surgery. Rescue analgesia was given on request.

RESULTS

A total of 128 patients completed the study. There were no significant differences in baseline characteristics or intraoperative variables between the groups. The study was designed to reveal whether OP is inferior to IP, with an inferiority margin of 20%. The number of patients reporting satisfactory analgesia at 1 h with VAS ≤ 30 mm were 15 (OP) and 17 (IP), respectively. The secondary outcome measure of the mean (standard deviation) VAS (mm) for the whole of each group was 52 (22) for OP and 47 (22) for IP. Analysis of confidence intervals indicates that oral paracetamol is not inferior to i.v. paracetamol. The median survival (90% CI) to rescue analgesia request was 54.3 (51.2-57.4) min in Group OP and 57.3 (55.4-59.2) min in Group IP; there was no significant difference in this measure.

CONCLUSIONS

In this study of lower third molar extraction, oral paracetamol is not inferior to i.v. for postoperative analgesia. ISRCTN Registration http://www.controlled-trials.com/ISRCTN77607163.

Single incision laparoscopic surgery in general surgery: a review

Single incision laparoscopic surgery (SILS) is a rapidly developing field that may represent the future of laparoscopic surgery. The major advantage of SILS over standard laparoscopic surgery is in cosmesis, with surgery becoming essentially scarless if the incision is hidden within the umbilicus. Only one incision is required so the risk of potential complications like port site hernias, haematomas and wound infection is reduced. The trade-off for this is a technically more challenging procedure with different underlying principles to that of traditional laparoscopic surgery. A wide variety of new equipment has been developed to support SILS and the range of procedures that are amenable to the technique is increasing. To date most of the published data relating to SILS are in the form of case series, with the first large randomised controlled trials due to be completed by the end of 2012. The existing evidence suggests that SILS is similar to standard laparoscopic surgery in terms of complication rates, completion rates and post-operative pain scores. However, the duration of SILS is longer than equivalent laparoscopic procedures. This article discusses SILS with regard to its applications in general surgery and reviews the evidence currently available.

Intermanual temporal differences in bimanual simple isometric coupling by instructions

To study intermanual temporal and force differences during contractions of adductor thumb muscles, the force-time history during isometric contraction of both hands was recorded and analysed for temporal phases including initiation of force, moments of maximum acceleration and velocity of force development, and period to peak force. 36 strongly right-handed young participants (18 women, 18 men) were instructed to use their thumbs to push buttons bimanually in response to 20 separate 35-db sound signals in each of four sessions. Sessions 1 and 2 were preceded with a "strong" instruction to "react as strongly as possible" (Strong Reaction task). Sessions 3 and 4 were preceded with a "speed" instruction to "react as quickly as possible" (Speed Reaction task). Lateral differences between magnitudes of forces developed by left and right thumbs and asynchrony between defined temporal parameters in bilateral force-time histories were significantly greater for Strong Reaction tasks. This departure from bilateral correlation observed between identical phases of isometric pushing action may suggest that participants' thumbs operate more independently under instructions that focus attention on force. Thus, specific instructions given to participants may have a profound effect on performance. It was also found that intermanual temporal differences for women were significantly smaller than for men, especially on Strong Reaction tasks. This phenomenon may be partly explained by a lower lateralization in women.