Opioid tapering in older cancer survivors does not increase psychiatric or drug hospitalization rates

BACKGROUND

Opioid tapering in the general population is linked to increases in hospitalizations or emergency department visits related to psychiatric or drug-related diagnoses. Cancer survivors represent a unique population with different opioid indications, prescription patterns, and more frequent follow-up care. This study sought to describe patterns of opioid tapering among older cancer survivors and to test the hypothesis of whether older cancer survivors face increased risks of adverse events with opioid tapering.

METHODS

Using the Surveillance, Epidemiology and End Results Medicare-linked database, we identified 15 002 Medicare-beneficiary cancer survivors diagnosed between 2010 and 2017 prescribed opioids consistently for at least 6 months after their cancer diagnosis. Tapering was defined as a binary time-varying event occurring with any monthly oral morphine equivalent reduction of 15% or more from the previous month. Primary diagnostic billing codes associated with emergency room or hospital admissions were used for the composite endpoint of psychiatric- or drug-related event(s).

RESULTS

There were 3.86 events per 100 patient-months, with 97.8% events being mental health emergencies, 1.91% events being overdose emergencies, and 0.25% involving both. Using a generalized estimating equation for repeated measure time-based analysis, opioid tapering was not statistically associated with acute events in the 3-month posttaper period (odds ratio [OR] = 1.02; P = .62) or at any point in the future (OR = 0.96; P = .46).

CONCLUSIONS

Opioid tapering in older cancer survivors does not appear to be linked to a higher risk of acute psychiatric- or drug-related events, in contrast to prior research in the general population.

The Role of Radical Cystectomy in Clinically Node Positive Bladder Cancer: A US Veterans Health Administration Study

INTRODUCTION

The role of local definitive therapy in addition to systemic treatment in clinically positive regional lymph node (cN+) bladder cancer is yet to be determined. Herein, we sought to investigate the role of radical cystectomy (RC) in management of patients with cN+ bladder cancer at US Veterans Health Administration Facilities.

METHODS

We identified patients diagnosed with cN+ bladder cancer between 2000-2017 using the Department of Veterans Affairs (VA) Informatics and Computing Infrastructure (VINCI). We employed a combination of database/registry coded values and chart review for data collection. To minimize mortality bias, we excluded patients who died within 90 days of diagnosis. We divided the patients into cystectomy (C) versus "no cystectomy" (NOC) cohorts. Propensity score matching was performed based on predictors of undergoing RC. Multivariable Cox models and Kaplan-Meier survival curves were used to estimate overall survival (OS) and cancer specific survival (CCS).

RESULT

After matching, 158 patients were included in the C and NOC groups. In the C-group, 85(54%) patients received pre-cystectomy chemotherapy, and 73(46%) patients underwent post-cystectomy chemotherapy. In the C-group, 65(41%) patients and in the NOC-group, 66(42%) patients had clinical N1 disease (P = .77). In multivariable Cox model, undergoing RC was associated with improved OS (HR0.62; 95%CI 0.47-0.81), P < .001) and CSS (HR0.58; 95%CI 0.42-0.80; P < .001).

CONCLUSION

As part of multimodal treatment, undergoing RC was associated with improved OS and CSS in subset of patients with cN+ bladder cancer. Prospective randomized trials are warranted to further investigate the role of local definitive therapy in this specific patient population.

Health System Practices and Perspectives of Social Risk Screening in Oncology

PURPOSE/OBJECTIVE(S)

Social risks (e.g., food insecurity) are adverse social/economic conditions associated with poor health outcomes. Among patients with cancer, presence of social risks is associated with increased late-stage diagnoses, care delays, and mortality. The purpose of this project was to assess the perspectives and practices regarding social risk screening within a large NCI-designated cancer center.

MATERIALS/METHODS

Email invitations to complete a secure, online survey were distributed to oncology healthcare staff (e.g., oncologists, nurses, pharmacists, medical assistants, social workers, and patient navigators) at Moores Cancer Center between June 1, 2022 and July 31, 2022. The 6-item survey collected information on clinical role, current practices and perceived barriers to screening for social risks as part of routine care. Respondents were categorized as MD-trained providers versus non-MD clinical staff. Descriptive statistics were used, including Fisher's exact test to compare responses by respondent type (MD vs non-MD). All analyses were conducted using data management and decision management software. This project was approved by the UCSD Institutional Review Board.

RESULTS

A total of 59 respondents completed the survey, including 20 MDs (34%) and 39 non-MD staff (66%). Overall, most respondents reported asking patients about their social risks (75%) and communicating information about patients' social risks with other healthcare staff when clinically relevant (84%). MDs were significantly more likely to agree that they ask patients about social risks when clinically relevant than non-MDs (95% vs 64%, p = 0.024). MDs were also more likely to communicate, review and use social risk information than their non-MD colleagues. The most reported barriers to integrating social risk information into clinical care, overall, included insufficient time (73%), uncertainty about who is responsible (70%), and lack of knowledge about existing tools (75%) for asking patients about social risks, as well as lack of resources to address social risks (76%). Non-MDs were more likely to cite concern that patients and families will feel uncomfortable answering questions about social risks (67% vs 20% of MDs, p = 0.003) as a barrier. Only 30% of MDs and 46% of non-MDs agreed that "asking about social risks is outside of the scope of my role" was a barrier.

CONCLUSION

Most oncology providers and staff agree that obtaining social risk information is important for patient care. Developing clinic-based solutions that integrate social risk screening and referral workflows within the oncology setting is imperative to reduce cancer health disparities. Future efforts that leverage the use of electronic health records to conduct social risk screening and streamline referrals to community-based resources in oncology may improve cancer health equity.

Association of Transgender or Gender Non-Binary Identity on Disease Characteristics and Survival Outcomes in Prostate Cancer

PURPOSE/OBJECTIVE(S)

While it is becoming increasingly common for people to identify as transgender or gender-non-binary, our understanding of the influence of gender identity on disease severity of hormone-sensitive malignancies, including prostate cancer (PC) is limited. The goal of this study is to compare the aggressiveness of disease and survival outcomes between transgender or gender non-binary (TG) and cis-gender (CG) patients with PC.

MATERIALS/METHODS

The cohort included patients diagnosed with PC between 1999 and 2022 within the Veterans Health Administration (VHA) Database. TG patients were identified with an ICD 9 or 10 diagnosis code that occurred prior to PC diagnosis. Treatment information and baseline disease characteristics were ascertained through the VHA electronic health records. Multivariable logistic regressions were performed to estimate the association between TG status and presenting with Gleason > = 8, PSA > 20 ng/mL, and metastatic disease at diagnosis. Covariates in these models included age at diagnosis, race, ethnicity, marital status, and smoking status. Metastases were identified through natural language processing from cancer or radiology documents. Time to metastases was defined as the time from PC diagnosis to metastases, with other causes of death considered as competing risks. The association between TG identity status and metastatic disease was calculated with a Cox regression model. The difference in overall survival was assessed with the Kaplan-Meier method and log-rank test.

RESULTS

The final cohort was composed of 282,264 individuals, 219 (0.08%) of which were identified as TG. TG patients have similar odds of presenting with presenting with Gleason Score ≥8 (Odds Ratio (OR) 1.18, p = 0.31), PSA >20 ng/mL (OR 0.78, p = 0.59), and metastasis at diagnosis (OR 0.47, p = 0.29). There were 34,918 patients who develop metastatic disease at any time, 24 of which were TG. The 10-year cumulative incidence of metastases for TG and CG individuals was 11.5% (95% Confidence Interval (CI): 6.6-16.1%) and 13.9% (CI: 13.7-14.0%), respectively. There was no significant difference between TG status and risk of developing metastases (Hazard Ratio (HR) 0.93, p = 0.71). The 10-year overall survival for TG and CG was 73.4% (CI: 66.5-80.9%) and 65.0% (CI: 64.8-65.2%), respectively. There was no significant difference between TG status and overall survival (Hazard Ratio (HR) 0.83, p = 0.13).

CONCLUSION

TG individuals do not appear to have a difference in disease characteristics at diagnosis or survival compared to CG individuals. Future research should be done to determine the effect of gender affirming treatment on these outcomes. Furthermore, it is unclear if diagnosis codes are accurately identifying TG individuals.

Psychiatric or Drug Hospitalizations in Older Cancer Survivors on Long-Term Opioids

PURPOSE/OBJECTIVE(S)

Non-cancer patients prescribed chronic courses of opioids are at high risk of psychiatric or drug overdose particularly during the post-tapering period, but data are limited on this effect in cancer survivors. This study quantified emergency room visits or hospital admissions for psychiatric or drug/alcohol overdose/withdrawal (henceforth "events") in cancer survivors prescribed opioids related to their cancer diagnoses.

MATERIALS/METHODS

We identified 15,002 cancer survivors in SEER-Medicare diagnosed between 2010 and 2017 with bladder, breast, colon/rectal, kidney, lung, head/neck, or prostate cancer who were prescribed at least 6 months of stable opioids following their cancer diagnosis. The post-tapering interval was defined as a 3-month period following monthly oral morphine equivalent (OME) reduction of at least 15%. Outcomes were studied with logistic regression and time-dependent analysis was performed using a generalized estimating equation (GEE) using an auto-regressive correlation matrix; all reported p-values are two-sided.

RESULTS

The study had a median follow up of 24 months; in this time, 8,311 patients (55%) initiated a taper at some point. The mean daily OME in non-tapering patients was 33.4 mg compared to 47.4 mg in tapering patients (p < 0.001); both groups had a low rate of any prior events in the baseline period (7.5% versus 8%, respectively p = 0.686). Patients attempting a taper also tended to be younger (40.3% versus 35.2% age 66-70, p <0.001). There was no difference by race. Opioid tapering was not associated with a higher rate of events in the 3-month post-taper period (p = 0.81) when correcting for sex, primary care site, baseline event rate, comorbidity, and age.

CONCLUSION

Many older cancer survivors who are prescribed chronic opioids remain on high doses of opioids after completing therapy. These patients are at risk of acute psychiatric and drug-related emergencies. Unlike the general population, this risk does not appear to be exacerbated in the months following opioid tapering. Oncologists should be mindful of psychiatric and drug-related events in long-term cancer survivors prescribed chronic opioids, and these data should reassure physicians deciding whether or not to initiate an opioid taper. Future research should explore risk mitigation in these patients.

Association between National Area Deprivation Index Rank on Disease Characteristics in Prostate Cancer

PURPOSE/OBJECTIVE(S)

Social determinants of health (SDH) play a large role in an individual's health; in recent years, there has been a push to examine the impact of one's neighborhood or "place." Previous studies have showed that living in a disadvantage neighborhood is associated with worth health outcomes. We hypothesize that equal access care will diminish the effects of living in a disadvantaged neighborhood.

MATERIALS/METHODS

We identified non-Hispanic African American (AA) and White (NHW) men diagnosed with PC between 2012 and 2015 in the Veterans Health Administration (VHA). Patient SDH was measured using census tract level 2015 Area Deprivation Index (ADI) information. The ADI is a composite measure that includes factor such as housing quality, income, health care access etc. We measured both National and State ADI rank as a continuous variable from 1 to 10 with 10 being highest deprivation. Patient information was gathered at the census tract level while ADI is assigned at the census block group. In order to get all information on the same geographic level, we averaged the ADI to its corresponding census tract. Associations between ADI and disease characteristics at diagnosis were measured using multivariable logistic regression models including age, race, and marital status as covariates.

RESULTS

The final cohort was composed of 25,222 men (8,384 AA and 16,838 NHW.) At the national level, there was no significant association between ADI and Gleason Score ≥8 (Odds Rations (OR) 0.99 [95% Confidence Interval (CI):0.98 - 1.00]), PSA >20 ng/mL (OR 0.99 [95% CI: 0.98 - 1.01]), and metastasis at diagnosis (OR 1.01 [CI: 0.98-1.04]).

CONCLUSION

Our results are consistent with our hypothesis that equal access care diminishes the impacts of living within a disadvantaged neighborhood. Future research should investigate the interaction between health care access and social and demographic factors.

Proof-of-Principle Experiment for Testing Strong-Field Quantum Electrodynamics with Exotic Atoms: High Precision X-Ray Spectroscopy of Muonic Neon

To test bound-state quantum electrodynamics (BSQED) in the strong-field regime, we have performed high precision x-ray spectroscopy of the 5g-4f and 5f- 4d transitions (BSQED contribution of 2.4 and 5.2 eV, respectively) of muonic neon atoms in the low-pressure gas phase without bound electrons. Muonic atoms have been recently proposed as an alternative to few-electron high-Z ions for BSQED tests by focusing on circular Rydberg states where nuclear contributions are negligibly small. We determined the 5g_{9/2}- 4f_{7/2} transition energy to be 6297.08±0.04(stat)±0.13(syst)  eV using superconducting transition-edge sensor microcalorimeters (5.2-5.5 eV FWHM resolution), which agrees well with the most advanced BSQED theoretical prediction of 6297.26 eV.

Impact of chemotherapy on anxiety, depression, and suicidality amongst testicular cancer survivors

418

Background: Chemotherapy for testicular cancer (TC) is highly effective yet associated with significant consequences on long-term health-related quality of life. We evaluate the impact of chemotherapy on anxiety, depression, and suicidality amongst TC survivors. Methods: We conducted a retrospective cohort study of US veterans diagnosed with TC in the Veterans Health Affairs database from 1990-2016. Patients with non-primary germ cell tumor histologies were excluded. Baseline disease characteristics and treatment received were ascertained from the VA Central Cancer Registry. Anxiety or depression was a composite endpoint comprised of diagnosis codes for anxiety, depression, or administration of medications used to treat these diagnoses. Incident suicidality was defined as a diagnosis code for suicidal ideation. Time to event was defined as time from diagnosis to event or censor at the time of last follow-up. Rates of outcomes were reported through cumulative incidences. Associations with outcomes and receipt of chemotherapy were assessed through multivariable Cox regression models. Results: In total, 1684 patients (1174 seminoma, 510 nonseminoma) were included in the cohort. Median age at diagnosis in the cohort was 40 years old. Median follow up time was 7.67 years for surviving patients. 1506 (89.4%) patients were white, 114 (6.8%) were African American, and 64 (3.8%) were another or unknown race. There were 1066 (63.3%) stage I patients, 191 (11.3%) stage II, 198 (11.8%) stage III, and 229 (13.6%) unknown stage patients. 579 (34.4%) patients received chemotherapy. At the time of diagnosis, 104 (6.2%) patients already experienced anxiety or depression. At 10 years, cumulative incidence of the diagnosis of anxiety or depression as 44.1% in the entire cohort. At 10 years, cumulative incidence of the diagnosis of suicidality was 5.5%. On multivariable Cox regression, factors associated with a higher risk of anxiety or depression were older age at diagnosis (Hazard Ratio (HR): 1.11 per standard deviation increase, p=0.01), being unemployed (HR: 1.25, p=0.01), and receipt of chemotherapy (HR: 1.43, p<0.001). Race, stage, alcohol or tobacco use and seminoma type were nonsignificant. Factors associated with increased risks of suicidality were being unemployed (HR: 2.00, p=0.01) and not being married (HR: 2.50, p=0.001). Stage, age, race, alcohol and tobacco use, seminoma type, and receipt of chemotherapy were not significantly associated with suicidality. Conclusions: Psychosocial morbidity is high among TC survivors. Despite being effective and necessary for maintaining excellent oncologic outcomes, chemotherapy appears to increase the rates of psychosocial morbidity. Socioeconomic risk factors, including employment and marriage, may also impact psychosocial health. Clinicians should be proactive in identifying support systems for TC survivors.

Association of exposure of Camp Lejeune contaminated water and prostate cancer outcomes

265

Background: There is evidence that exposure to contaminated water while serving at Camp Lejeune is associated with the development of genitourinary cancers including kidney and bladder; however, there is a lack of literature regarding prostate cancer (PC). We investigated disease severity at diagnosis, overall survival, and cumulative incidence of metastases for PC patients within the Veterans Health Administration (VHA) who served at Camp Lejeune. Methods: The cohort included men diagnosed with PC between 1999 and 2022 within the VHA Database. Patients who were housed at or had one or more Military Service Episodes between August 1, 1953 and December 31, 1987 at Camp Lejeune were considered to have exposure. Camp Lejeune exposure status and baseline characteristics were ascertained through the VHA electronic health records. Logistic regressions were used to analyze associations between Camp Lejeune exposure and adverse diagnostic characteristics, adjusted for demographic covariates. The outcome of metastases was identified through natural language processing from cancer or radiology documents. Time to metastases was defined as the time from PC diagnosis to metastases, with other causes of death considered as competing risks. The hazard ratio for the association between Camp Lejeune exposure and metastatic disease was calculated with a Cox regression model, controlling for covariates. The difference in overall survival was assessed with the Kaplan-Meier method and log-rank test. Results: The cohort included 6,918 men with PC, 1,635 (23.6%) of which had Camp Lejeune exposure and 5,283 (76.4%) without. Median age at diagnosis was 65 years. Logistic regression models indicated patients with Camp Lejeune exposure have similar odds of having Gleason Score ≥8 at diagnosis (odds ratio (OR) 0.97, p=0.62) and metastasis at diagnosis (OR 1.00, p=0.997), and slightly lower odds of PSA >20 ng/mL at diagnosis (OR 0.78, p=0.02).There were 803 patients with metastatic disease, 159 of which had Camp Lejeune exposure in comparison to the 644 that did not. The 10-year cumulative incidence of metastases for those with Camp Lejeune exposure was 11.9% (CI: 9.9-13.9%), while for those without exposure it was 14.0% (CI: 12.8-15.1%). The Cox proportional hazards model indicated that those with Camp Lejeune exposure had a similar risk of developing metastases (hazard tatio (HR) 0.93, p=0.43) compared to those without exposure. The 10-year overall survival was similar for those with Camp Lejeune exposure (83.3% [CI: 80.7-85.9%]) compared to those without exposure (82.5% [CI: 81.1-83.9%]) (p=0.2). Conclusions: In contrast to kidney and bladder cancers, Camp Lejeune exposure is not associated with worse outcomes for PC. Further research should be conducted to test whether Camp Lejeune exposure affects the risk of developing PC. However, these data do not support Camp Lejeune exposure playing a large role in PC outcomes.

Deexcitation Dynamics of Muonic Atoms Revealed by High-Precision Spectroscopy of Electronic K X Rays

We observed electronic K x rays emitted from muonic iron atoms using superconducting transition-edge sensor microcalorimeters. The energy resolution of 5.2 eV in FWHM allowed us to observe the asymmetric broad profile of the electronic characteristic Kα and Kβ x rays together with the hypersatellite K^{h}α x rays around 6 keV. This signature reflects the time-dependent screening of the nuclear charge by the negative muon and the L-shell electrons, accompanied by electron side feeding. Assisted by a simulation, these data clearly reveal the electronic K- and L-shell hole production and their temporal evolution on the 10-20 fs scale during the muon cascade process.

Absolute energies and emission line shapes of the L x-ray transitions of lanthanide metals

We use an array of transition-edge sensors, cryogenic microcalorimeters with 4 eV energy resolution, to measure L x-ray emission-line profiles of four elements of the lanthanide series: praseodymium, neodymium, terbium, and holmium. The spectrometer also surveys numerous x-ray standards in order to establish an absolute-energy calibration traceable to the international system of units for the energy range 4 keV to 10 keV. The new results include emission line profiles for 97 lines, each expressed as a sum of one or more Voigt functions; improved absolute energy uncertainty on 71 of these lines relative to existing reference data; a median uncertainty on the peak energy of 0.24 eV, four to ten times better than the median of prior work; and six lines that lack any measured values in existing reference tables. The 97 lines comprise nearly all of the most intense L lines from these elements under broad-band x-ray excitation. The work improves on previous measurements made with a similar cryogenic spectrometer by the use of sensors with better linearity in the absorbed energy and a gold x-ray absorbing layer that has a Gaussian energy-response function. It also employs a novel sample holder that enables rapid switching between science targets and calibration targets with excellent gain balancing. Most of the results for peak energy values shown here should be considered as replacements for the currently tabulated standard reference values, while the line shapes given here represent a significant expansion of the scope of available reference data.

Demonstration of Athena X-IFU Compatible 40-Row Time-Division-Multiplexed Readout

Time-division multiplexing (TDM) is the backup readout technology for the X-ray Integral Field Unit (X-IFU), a 3,168-pixel X-ray transition-edge sensor (TES) array that will provide imaging spectroscopy for ESA's Athena satellite mission. X-0IFU design studies are considering readout with a multiplexing factor of up to 40. We present data showing 40-row TDM readout (32 TES rows + 8 repeats of the last row) of TESs that are of the same type as those being planned for X-IFU, using measurement and analysis parameters within the ranges specified for X-IFU. Singlecolumn TDM measurements have best-fit energy resolution of (1.91 ± 0.01) eV for the Al Kα complex (1.5 keV), (2.10 ± 0.02) eV for Ti Kα (4.5 keV), (2.23 ± 0.02) eV for Mn Kα (5.9 keV), (2.40 ± 0.02) eV for Co Kα (6.9 keV), and (3.44 ± 0.04) eV for Br Kα (11.9 keV). Three-column measurements have best-fit resolution of (2.03 ± 0.01) eV for Ti Kα and (2.40 ± 0.01) eV for Co Kα. The degradation due to the multiplexed readout ranges from 0.1 eV at the lower end of the energy range to 0.5 eV at the higher end. The demonstrated performance meets X-IFU's energy-resolution and energy-range requirements. True 40-row TDM readout, without repeated rows, of kilopixel scale arrays of X-IFU-like TESs is now under development.

Energy calibration of high-resolution X-Ray TES microcalorimeters with 3 eV optical photons

With the improving energy resolution of transitionedge sensor (TES) based microcalorimeters, performance verification and calibration of these detectors has become increasingly challenging, especially in the energy range below 1 keV where fluorescent atomic X-ray lines have linewidths that are wider than the detector energy resolution and require impractically high statistics to determine the gain and deconvolve the instrumental profile. Better behaved calibration sources such as grating monochromators are too cumbersome for space missions and are difficult to use in the lab. As an alternative, we are exploring the use of pulses of 3 eV optical photons delivered by an optical fiber to generate combs of known energies with known arrival times. Here, we discuss initial results of this technique obtained with 2 eV and 0.7 eV resolution X-ray microcalorimeters. With the 2 eV detector, we have achieved photon number resolution for pulses with mean photon number up to 133 (corresponding to 0.4 keV).

Optimization of Time- and Code-Division-Multiplexed Readout for Athena X-IFU

Readout of a large, spacecraft-based array of superconducting transition-edge sensors (TESs) requires careful management of the layout area and power dissipation of the cryogenic-circuit components. We present three optimizations of our time- (TDM) and code-division-multiplexing (CDM) systems for the X-ray Integral Field Unit (X-IFU), a several-thousand-pixel-TES array for the planned Athena-satellite mission. The first optimization is a new readout scheme that is a hybrid of CDM and TDM. This C/TDM architecture balances CDM's noise advantage with TDM's layout compactness. The second is a redesign of a component: the shunt resistor that provides a dc-voltage bias to the TESs. A new layout and a thicker Pd-Au resistive layer combine to reduce this resistor's area by more than a factor of 5. Third, we have studied the power dissipated by the first-stage SQUIDs (superconducting quantum-interference devices) and the readout noise versus the critical current of the first-stage SqUIDs. As a result, the X-IFU TDM and C/TDM SQUIDs will have a specified junction critical current of 5 μA. Based on these design optimizations and TDM experiments described by Durkin, et al. (these proceedings), TDM meets all requirements to be X-IFU's backup-readout option. Hybrid C/TDM is another viable option that could save spacecraft resources.

Mapping TES Temperature Sensitivity and Current Sensitivity as a Function of Temperature, Current, and Magnetic Field with IV curve and Complex Admittance Measurements

We have specialized astronomical applications for X-ray microcalorimeters with superconducting transition edge sensors (TESs) that require exceptionally good TES performance, but which operate in the small-signal regime. We have therefore begun a program to carefully characterize the entire transition surface of TESs with and without the usual zebra stripes to see if there are reproducible local "sweet spots" where the performance is much better than average. These measurements require precise knowledge of the circuit parameters. Here, we show how the Shapiro effect can be used to precisely calibrate the value of the shunt-resistor. We are also investigating the effects of stress and external magnetic fields to better understand reproducibility problems.

A practical superconducting-microcalorimeter X-ray spectrometer for beamline and laboratory science

We describe a series of microcalorimeter X-ray spectrometers designed for a broad suite of measurement applications. The chief advantage of this type of spectrometer is that it can be orders of magnitude more efficient at collecting X-rays than more traditional high-resolution spectrometers that rely on wavelength-dispersive techniques. This advantage is most useful in applications that are traditionally photon-starved and/or involve radiation-sensitive samples. Each energy-dispersive spectrometer is built around an array of several hundred transition-edge sensors (TESs). TESs are superconducting thin films that are biased into their superconducting-to-normal-metal transitions. The spectrometers share a common readout architecture and many design elements, such as a compact, 65 mK detector package, 8-column time-division-multiplexed superconducting quantum-interference device readout, and a liquid-cryogen-free cryogenic system that is a two-stage adiabatic-demagnetization refrigerator backed by a pulse-tube cryocooler. We have adapted this flexible architecture to mate to a variety of sample chambers and measurement systems that encompass a range of observing geometries. There are two different types of TES pixels employed. The first, designed for X-ray energies below 10 keV, has a best demonstrated energy resolution of 2.1 eV (full-width-at-half-maximum or FWHM) at 5.9 keV. The second, designed for X-ray energies below 2 keV, has a best demonstrated resolution of 1.0 eV (FWHM) at 500 eV. Our team has now deployed seven of these X-ray spectrometers to a variety of light sources, accelerator facilities, and laboratory-scale experiments; these seven spectrometers have already performed measurements related to their applications. Another five of these spectrometers will come online in the near future. We have applied our TES spectrometers to the following measurement applications: synchrotron-based absorption and emission spectroscopy and energy-resolved scattering; accelerator-based spectroscopy of hadronic atoms and particle-induced-emission spectroscopy; laboratory-based time-resolved absorption and emission spectroscopy with a tabletop, broadband source; and laboratory-based metrology of X-ray-emission lines. Here, we discuss the design, construction, and operation of our TES spectrometers and show first-light measurements from the various systems. Finally, because X-ray-TES technology continues to mature, we discuss improvements to array size, energy resolution, and counting speed that we anticipate in our next generation of TES-X-ray spectrometers and beyond.

Bleaching drives collapse in reef carbonate budgets and reef growth potential on southern Maldives reefs

Sea-surface temperature (SST) warming events, which are projected to increase in frequency and intensity with climate change, represent major threats to coral reefs. How these events impact reef carbonate budgets, and thus the capacity of reefs to sustain vertical growth under rising sea levels, remains poorly quantified. Here we quantify the magnitude of changes that followed the ENSO-induced SST warming that affected the Indian Ocean region in mid-2016. Resultant coral bleaching caused an average 75% reduction in coral cover (present mean 6.2%). Most critically we report major declines in shallow fore-reef carbonate budgets, these shifting from strongly net positive (mean 5.92 G, where G = kg CaCO₃ m⁻² yr⁻¹) to strongly net negative (mean −2.96 G). These changes have driven major reductions in reef growth potential, which have declined from an average 4.2 to −0.4 mm yr⁻¹. Thus these shallow fore-reef habitats are now in a phase of net erosion. Based on past bleaching recovery trajectories, and predicted increases in bleaching frequency, we predict a prolonged period of suppressed budget and reef growth states. This will limit reef capacity to track IPCC projections of sea-level rise, thus limiting the natural breakwater capacity of these reefs and threatening reef island stability.

Technique for Recovering Pile-up Events from Microcalorimeter Data

We report here a technique for processing microcalorimeter data that offers improved live-time over conventional optimal filtering techniques without loss of spectral resolution. Separate filters optimized for pulse amplitude and pulse arrival time (constructed in the usual way from the averaged signal and noise spectral densities) are applied to the entire pixel data stream. Pulses in the resulting filtered streams are then simultaneously fit as the sum of scaled and shifted copies of an isolated filtered pulse template. Analysis using calibration data from the University of Wisconsin/Goddard Space Flight Center X-ray Quantum Calorimeter (XQC) sounding rocket payload demonstrates the ability of this technique to recover pulses separated by as little as the rise-time of the detectors without observable spectral broadening.

Diving behaviour of wildlife impacted by an oil spill: A clean-up and rehabilitation success?

The value of rehabilitating oiled wildlife is an on-going global debate. On October 5, 2011, the cargo vessel C/V Rena grounded on Astrolabe Reef, New Zealand (NZ), spilling over 300 tonnes of heavy fuel oil. As part of the Rena oil spill response, 383 little blue penguins (LBP, Eudyptula minor) were captured, cleaned, rehabilitated and released back into a cleaned environment. This research investigates foraging behaviour changes due either to the oil spill or by the rehabilitation process by comparing the diving behaviour of rehabilitated (n=8) and non-rehabilitated (n=6) LBPs and with LBP populations throughout NZ. Stabile isotope analysis of feathers was also used to investigate diet. There were no foraging behaviour differences between rehabilitated and non-rehabilitated LBPs and the overall diving behaviour of these LBPs have similar, if not less energetic, foraging behaviour than other LBPs in NZ. This suggests the rehabilitation process and clean-up undertaken after the Rena appears effective and helps justify the rehabilitation of oiled wildlife across the world.

Skeletal extension and calcification of reef-building corals in the central Indian Ocean

Skeletal extension, density and calcification rate of 12 scleractinian coral species comprising 7 morphological groups were examined on the reef crest of Vabbinfaru platform, Maldives. Growth rates of coral specimens were measured over the period of February 2010-March 2011 using alizarin staining and direct measurements. Skeletal extension rate was highly variable between coral species. Colony morphology was a major control on the skeletal extension and calcification of coral specimens. Growth rates of Acropora and Porites corals were comparable to existing data recorded for Caribbean and Indo-Pacific reef provinces. Skeletal density was less variable between species and was typically consistent among morphological groups. Findings represent the first estimates of coral growth in the central Indian Ocean region and add to the limited growth studies available that have examined a broad range of coral growth morphologies in other reef-building regions.

A deliberative method for ranking risks (I): Overview and test bed development

Risk ranking offers a potentially powerful means for gathering public input to help set risk-management priorities. In most rankings conducted to date, the categories and attributes used to describe the risks have varied widely, the materials and procedures have not been designed to facilitate comparisons among risks on all important attributes, and the validity and reproducibility of the resulting rankings have not been assessed. To address these needs, a risk-ranking method was developed in which risk experts define and categorize the risks to be ranked, identify the relevant risk attributes, and characterize the risks in a set of standardized risk summary sheets, which are then used by lay or other groups in structured ranking exercises. To evaluate this method, a test bed involving 22 health and safety risks in a fictitious middle school was created. This article provides an overview of the risk-ranking method and describes the challenges faced in designing the middle school test bed. A companion article in this issue reports on the validity of the ranking procedures and the level of agreement among risk managers regarding ranking of risks and attributes.

A deliberative method for ranking risks (II): Evaluation of validity and agreement among risk managers

A deliberative method for ranking risks was evaluated in a study involving 218 risk managers. Both holistic and multiattribute procedures were used to assess individual and group rankings of health and safety risks facing students at a fictitious middle school. Consistency between the rankings that emerged from these two procedures was reasonably high for individuals and for groups, suggesting that these procedures capture an underlying construct of riskiness. Participants reported high levels of satisfaction with their groups' decision-making processes and the resulting rankings, and these reports were corroborated by regression analyses. Risk rankings were similar across individuals and groups, even though individuals and groups did not always agree on the relative importance of risk attributes. Lower consistency between the risk rankings from the holistic and multiattribute procedures and lower agreement among individuals and groups regarding these rankings were observed for a set of high-variance risks. Nonetheless, the generally high levels of consistency, satisfaction, and agreement suggest that this deliberative method is capable of producing risk rankings that can serve as informative inputs to public risk-management decision making.

An experimental and computational study of 1,2-hydrogen migrations in 2-hydroxycyclopentylidene and its conjugate base

Thermal decomposition of alpha-hydroxydiazirine 2 gives primarily cyclopentanone and some allylic alcohol, in similar amounts as the known cyclohexyl analogue 1. Calculations (B3LYP/6-31+G) also show cyclopentanone to be the major product of this carbene rearrangement. Diazirine 2 and the lithium salt of the corresponding conjugate base 3 were decomposed by photolysis. The proportion of ketone formed increases with deprotonation, a trend also found computationally. In comparison, the base-induced isomerization of cyclopentene oxide, which proceeds via alpha-elimination to a carbenoid intermediate similar to that obtained from 3, yields primarily allylic alcohol rather than ketone; neither ring size nor charge thus accounts for the unusual product distribution observed. Interestingly, the calculations reveal that in the gas phase with no counterion, the singlet, oxyanionic carbene, and the alpha-deprotonated epoxide are the same, rather than discrete structures. This intramolecular complexation stablilizes the oxyanionic carbene by 20-25 kcal/mol.

Modified amino acids and peptides as substrates for the intestinal peptide transporter PepT1

The binding affinities of a number of amino-acid and peptide derivatives by the mammalian intestinal peptide transporter PepT1 were investigated, using the Xenopus laevis expression system. A series of blocked amino acids, namely N-acetyl-Phe (Ac-Phe), phe-amide (Phe-NH2), N-acetyl-Phe-amide (Ac-Phe-NH2) and the parent compound Phe, was compared for efficacy in inhibiting the uptake of the peptide [3H]-D-Phe-L-Gln. In an equivalent set of experiments, the blocked peptides Ac-Phe-Tyr, Phe-Tyr-NH2 and Ac-Phe-Tyr-NH2 were compared with the parent compound Phe-Tyr. Comparing amino acids and derivatives, only Ac-Phe was an effective inhibitor of peptide uptake (Ki = 1.81+/- 0.37 mM). Ac-Phe-NH2 had a very weak interaction with PepT1 (Ki = 16.8+/-5.64 mM); neither Phe nor Phe-NH2 interacted with PepT1 with measurable affinity. With the dipeptide and derivatives, unsurprisingly the highest affinity interaction was with Phe-Tyr (Ki = 0.10+/-0.04 mM). The blocked C-terminal peptide Phe-Tyr-NH2 also interacted with PepT1 with a relatively high affinity (Ki = 0.94+/-0.38 mM). Both Ac-Phe-Tyr and Ac-Phe-Tyr-NH2 interacted weakly with PepT1 (Ki = 8.41+/-0.11 and 9.97+/-4.01 mM, respectively). The results suggest that the N-terminus is the primary binding site for both dipeptides and tripeptides. Additional experiments with four stereoisomers of Ala-Ala-Ala support this conclusion, and lead us to propose that a histidine residue is involved in binding the C-terminus of dipeptides. In addition, a substrate binding model for PepT1 is proposed.

How to Make Drugs Orally Active: A Substrate Template for Peptide Transporter PepT1

By building key structural features into hydrophilic drugs, they can be recognized by the PepT1 transporter system of the small intestine and rendered orally active. The model shown provides, for the first time, a 3D template for all known substrates of PepT1.

Retrospective analysis of an implant system

The reliability of dental implants results from a combination of design, placement, and reconstructive techniques. Retrospective analysis is one vehicle for evaluating implant success. This article presents the reliability of these techniques in Bicon dental implants. The survivability of this implant was evaluated retrospectively using life table survival analysis over a 10-year period in 13 practices. The parameters used for success included no implant loss, no mobility, no continuing bone loss that did not stabilize after 1 year, no discomfort, and no purulence.

4-aminomethylbenzoic acid is a non-translocated competitive inhibitor of the epithelial peptide transporter PepT1

1. 4-Aminomethylbenzoic acid, a molecule which mimics the special configuration of a dipeptide, competitively inhibits peptide influx in both Xenopus Laevis oocytes expressing rabbit PepT1 and through PepT1 in rat renal brush border membrane vesicles. 2. This molecule is not translocated through PepT1 as measured both by direct HPLC analysis in PepT1-exp ressing oocytes and indirectly by its failure to trans-stimulate labelle d peptide efflux through PepT1 in oocytes and in renal membrane vessicle s. 3. However 4-aminiomethylbenzoic acid does reverse trans-stimulation through expressed PepT1 of labelled peptid efflux induced by unlabelled peptide. Quantitatively this reversal is compatible with 4-aminomethyl benzoic acid competitively binding to the external surface of PepT1. 4. 4-Aminomethylbenzoic acid (the first molecule discovered to be a non-translocated competitive inhibitor of proton-coupled oligopeptide transport) and its derivatives may thus be particularly useful as experimental tools.

Peptide mimics as substrates for the intestinal peptide transporter

4-Aminophenylacetic acid (4-APAA), a peptide mimic lacking a peptide bond, has been shown to interact with a proton-coupled oligopeptide transporter using a number of different experimental approaches. In addition to inhibiting transport of labeled peptides, these studies show that 4-APAA is itself translocated. 4-APAA transport across the rat intact intestine was stimulated 18-fold by luminal acidification (to pH 6.8) as determined by high performance liquid chromatography (HPLC); in enterocytes isolated from mouse small intestine the intracellular pH was reduced on application of 4-APAA, as shown fluorimetrically with the pH indicator carboxy-SNARF; 4-APAA trans-stimulated radiolabeled peptide transport in brush-border membrane vesicles isolated from rat renal cortex; and in Xenopus oocytes expressing PepT1, 4-APAA produced trans-stimulation of radiolabeled peptide efflux, and as determined by HPLC, was a substrate for translocation by this transporter. These results with 4-APAA show for the first time that the presence of a peptide bond is not a requirement for rapid translocation through the proton-linked oligopeptide transporter (PepT1). Further investigation will be needed to determine the minimal structural requirements for a molecule to be a substrate for this transporter.

African-American homeless and low-income housed mothers: comparison of parenting practices

The child-rearing practices of homeless and low-income housed mothers of preschool children in Head Start were compared. Overall, homeless mothers provided less learning and academic stimulation, less variety in social and cultural experiences, less warmth and affection, and a less positive physical environment for their children than did housed mothers. Mothers in both living arrangements provided more language stimulation to daughters than to sons. Implications of the findings for working with homeless families are discussed.

Candidal endophthalmitis after lithotripsy of renal calculi

Candidal endophthalmitis is most commonly due to hematogenous seeding of the eye by Candida albicans. Although it is most often seen as a manifestation of disseminated candidiasis in patients who are seriously ill, other patients may have candidal endophthalmitis as the only evidence of fungal infection. We have presented a case of endophthalmitis due to C albicans in a patient who had bilateral renal calculi and who had received multiple antibiotics and extracorporeal shock wave lithotripsy.

A nursing approach to the management of type IIA hyperlipidemia: case study of a young adult

This case study illustrates the chronic nature of hyperlipidemia type IIa and the important contribution of the nurse in helping the client adjust life style, manage complex health regimes, and cope with the uncertainty of disease progression and its associated risks.

Spontaneous involution of subfoveal neovascularization

We studied five patients who maintained or spontaneously regained significant central vision despite the presence of a subfoveal neovascular membrane. Sequential photographs and fluorescein angiograms showed a pattern of development common to these patients and not observed in patients who lose all central vision. The pattern involves formation of a pigmented ring around the subfoveal neovascular membrane followed by alteration of the membrane from one that leaks fluorescein to one that stains but does not leak. This pattern is associated with gradual resorption of subretinal fluid and apparent limitation of subretinal hemorrhage and fibrosis. This course suggests the occurrence of spontaneous involution of some subfoveal neovascular membranes and implicates the retinal pigment epithelium in this process.

A donor-age-dependent change in the activity of alpha-mannosidase in human cultured RPE cells

Six acidic glycosidase activities in cultured human retinal pigment epithelium (RPE) cells from donors of different ages (19 to 80 years) were studied with regard to pH optimum, Km, Vmax and specific activity. For alpha-mannosidase we found significant age-dependent decreases in specific activity and Vmax but not in Km. The other glycosidases and acid phosphatase, lactate dehydrogenase (LDH) and citrate synthase showed no change in these parameters with donor age. The alpha mannosidase activity of older donor cells could be activated almost 2-fold by the addition of zinc. This is the first report of age-dependent change in a human RPE lysosomal enzyme. Since alpha-mannosidase is probably required for the degradation of rhodopsin in the phagolysosomal system of the RPE, decrease in this enzyme activity may lead to accumulation of undigested rod outer segments (ROS) and drusen, both of which are associated with age-related macular degeneration (AMD).

Comparison of corneal storage in K-Sol and chondroitin sulfate corneal storage medium in human corneal transplantation

Fifty-one pairs of corneas, stored in either K-Sol or CSM (chondroitin sulfate corneal storage medium) from 8 to 97 hours (mean +/- standard deviation, 58 +/- 21 and 57 +/- 21 hours, respectively), were transplanted in a prospective, randomized manner into 99 patients (n = 102 eyes), paired by diagnostic group and procedure. Ninety-six percent of K-Sol grafts (n = 51) and 94% of the CSM grafts (n = 51) were clear at 6 months; 92% of both the K-Sol (n = 38) and CSM (n = 35) grafts were clear at 12 months. One primary donor failure occurred, a K-Sol cornea stored for 76 hours. The CSM group experienced a greater number of persistent epithelial defects beyond 2 weeks (7 versus 4 defects) and graft reaction episodes (7 versus 3 episodes) than the K-Sol group; however, an equal number of late graft failures (3) occurred in both groups. No significant differences by paired t test analyses were found in endothelial cell density, area, coefficient of variation, or figure coefficient at 3 (n = 37 pairs), 6 (n = 36 pairs), and 12 (n = 26 pairs) months between the two groups. Mean endothelial cell density significantly decreased by 11% +/- 22 by 3 months in the K-Sol group, whereas the 7% +/- 24 decrease in the CSM group was insignificant. By 12 months, both groups experienced a significant decrease: K-Sol, 27% +/- 22; CSM, 17% +/- 26. A significant decrease in the mean coefficient of variation (polymegathism) was noted after 3 months in the K-Sol group which returned to the preoperative mean by 1 year, whereas this parameter remained unchanged in the CSM group. Both chondroitin sulfate-based media result in successful corneal transplantation with storage up to 4 days; however, endothelial survival with both media are comparable with previous studies with McCarey-Kaufman (M-K) medium.

Sustained release of 5-fluorouracil from ethylene acetate copolymer

Pharmacologic inhibition of fibroblast proliferation and scar formation remains an important consideration in many ophthalmologic surgical procedures. Such inhibition is particularly important in glaucoma filtration surgery. A sustained release system for 5-fluorouracil (5-FU) using ethylene vinyl acetate copolymer (Elvax) was characterized in vitro. 5-FU was incorporated into Elvax discs of 4 mm diameter. Discs were coated to allow sustained and predictable release over a 14 day period. Alteration of coatings, which act as rate-controlling membranes, allowed variation in the pattern of 5-FU release from the core which acts as the drug reservoir. This system for the sustained release of 5-FU may prove valuable in glaucoma surgery where the suppression of cellular proliferation is desired. The non-inflammatory nature of Elvax suggests this compound may provide an alternative means of 5-FU delivery.

Lysosomal enzyme levels in corneal storage media. K-Sol versus McCarey-Kaufman

Evidence indicates that lysosomal enzymes can carry out corneal autolysis during corneal storage and that they are damaging to the corneal endothelium. The authors investigated the release of lysosomal enzymes into two corneal storage media (K-Sol and McCarey-Kaufman [M-K]) by paired human donor corneas during 4 degrees C storage. The authors also studied the interaction of these media with lysosomal enzymes from human cornea. K-Sol and M-K stimulated (P less than 0.01) both beta-glucuronidase and alpha-galactosidase about equally. beta-N-Acetyl-glucosaminidase, a major catabolic enzyme of the cornea, was inhibited by the chondroitin sulfate in K-Sol by over 90% (P less than 0.01). Corneas stored in M-K released more lysosomal enzymes than corneas stored in K-Sol. At 4 days, the values approached significance (P less than 0.06) and by day 10 significantly higher values were found in the M-K media (P less than 0.01). Both storage methods showed a linear release. Individual corneas were found to vary in their release rates. Whether corneas that release more enzyme will show higher endothelial cell loss or produce less successful penetrating keratoplasty grafts deserves further study.

Beta-N-acetyl-glucosaminidase: possible role in ocular neovascularization

The possibility that lysosomal enzymes might be involved as angiogenic factors in ocular neovascularization (NV) was investigated. Beta-N-acetyl-glucosaminidase (NAGase) activity, and that of two other glycosidases, were present in the retinal derived protein fraction (RDPF) reported by others to be angiogenic. NAGase, but not the other glycosidases, was inhibited by vitreous. NAGase exhibited the same stability characteristics as RDPF. In diabetic rats there was a significant rise in vitreous but a fall in retinal NAGase activity. The sera of these animals, however, showed elevation in the activities of all five glycosidases. Preliminary experiments indicate that only the intermediate isoenzyme of NAGase, putatively insulin dependent, is elevated in the eyes of these diabetic rats. NAGase was also specifically elevated in the intraocular fluid from monkey eyes with retinal vein occlusion (RVO), and markedly so if NV was present. These results suggest the involvement of NAGase in the neovascular process in the eye.

The glucose uptake kinetics of some marine bacteria

The kinetics of glucose uptake by marine microbial populations have been investigated. Pure cultures were used in an attempt to define the conditions affecting uptake kinetics. The use of routine marine microbiological media did not isolate microorganisms capable of responding to the substrate levels that one might expect to find in the ocean, but a chemostat approach was successful in the isolation of such forms. Some factors affecting the uptake of glucose at very low levels were investigated. The kinetic approach with pure cultures has possible application as a bioassay method for substrates in low concentrations in seawater. The ecological significance of the investigation is discussed.