An Ontario Health (Cancer Care Ontario) Clinical Practice Guideline: Surveillance Strategies in Patients with Stage I, II, III or Resectable IV Melanoma Who Were Treated with Curative Intent

AIMS

To make recommendations on managing the surveillance of patients with stage I, II, III or resectable IV melanoma who are clinically free of disease following treatment with curative intent.

MATERIALS AND METHODS

This guideline was developed by Ontario Health's (Cancer Care Ontario's) Program in Evidence-Based Care and the Melanoma Disease Site Group (including seven medical oncologists, four surgical oncologists, three dermatologists, one radiation oncologist and one patient representative). The MEDLINE, EMBASE, Cochrane Library, PROSPERO databases and the main relevant guideline websites were searched. Internal and external reviews were conducted, with final approval by the Program in Evidence-Based Care and the Melanoma Disease Site Group. The Grading of Recommendations, Assessment, Development and Evaluation approach was followed, and the Modified Delphi method was used.

RESULTS

Based on the current evidence (eight eligible original study papers and four relevant guidelines) and the clinical opinions of the authors of this guideline, the initial recommendations were made. To reach 75% agreement for each recommendation, the Melanoma Disease Site Group (16 members) voted twice and one recommendation was voted on three times. After a comprehensive internal and external review process (including national and international reviewers), 12 recommendations, three weak recommendations and six qualified statements were ultimately made.

CONCLUSIONS

After a systematic review, a comprehensive internal and external review process and a consensus process, the current guideline has been created. The guideline authors believe that this guideline will help clinicians, patients and policymakers make well-informed healthcare decisions that will guide them in clinical melanoma surveillance and ultimately assist in improving patient outcomes.

Mini review: Breast cancer care in individuals with differences of sexual development

Disorders or differences of sexual development encompasses an important group of conditions that affects up to 1 in 5,000 live births. Many individuals living in the female gender includes Turner syndrome, congenital adrenal hyperplasia and conditions with 46XY karyotype such as gonadal dysgenesis (Swyer syndrome). Individuals are commenced on high dose oestrogen to initiate and maintain development of secondary sexual characteristics such as breasts which is paramount in them identifying in the female gender. We highlight the first case of a patient with Swyer syndrome who was treated with long term oestrogen therapy and later developed breast cancer. In individuals with gonadal dysgenesis, testicular malignancy is a recognised risk and is screened for. Prolonged exposure to exogenous and endogenous hormones can increase the risk of breast cancer however how much this risk increases in those taking high dose hormones is not documented in the literature. We aim to highlight the importance of breast cancer treatment and surgical reconstruction in this group and whether they should be considered for early breast cancer screening. CONCLUSION: It is imperative that triple assessment is undertaken in every patient with a breast lump, regardless of gender identification. Clinicians must not delay investigations in this patient group due to a misunderstanding of their condition. Those on long term hormone supplementation should be entered into the breast screening program at an earlier age with Magnetic Resonance Imaging surveillance. Careful consideration of post treatment endocrine therapy is required and under the care of the multi-disciplinary team.

An Efficient Watermarking Based Matrix Manipulation and Optimization Based Cryptographic Method for Privacy Preservation in Biomedical Data

The biomedical processing of images is an important aspect of the modern medicine field and has an immense influence on the modern world. Automatic device assisted systems are immensely useful in order to diagnose biomedical images easily, accurately and effectively. Remote health care systems allow medical professionals and patients to work from different locations. In addition, expert advice on a patient can be received within a prescribed period of time from a specialist in a foreign country or in a remote area. Digital biomedical images must be transmitted over the network in remote healthcare systems. But the delivery of the biomedical goods entails many security challenges. Patient privacy must be protected by ensuring that images are secure from unwanted access. Furthermore, it must be effectively maintained so that nothing will affect the content of biomedical images. In certain instances, data manipulation can yield dramatic effects. A biomedical image safety method was suggested in this work. The suggested method will initially be used to construct a binary pixel encoding matrix and then to adjust matrix with the use of decimation mutation DNA watermarking principle. Afterwards to defend the sub keys couple privacy which was considered over the logical uplift utilization of tent maps and purpose. As acknowledged by chaotic (C-function) development, the security was investigated similar to transmission in addition to uncertainty. Depending on the preliminary circumstances, various numbers of random were generated intended for every map as of chaotic maps. An algorithm of Multi scale grasshopper optimization resource with correlation coefficient fitness function and PSNR was projected for choosing the optimal public key and secret key of system over random numbers. For choosing the validation process of optimization is to formulate novel model more relative stable to the conventional approach. In conclusion, the considered suggested findings were contrasted with current approaches protection that was appear to be successful extremely.

Systemic adjuvant therapy for adult patients at high risk for recurrent cutaneous or mucosal melanoma: an Ontario Health (Cancer Care Ontario) clinical practice guideline

Background

Previous versions of the guideline from the Program in Evidence-Based Care (pebc) at Ontario Health (Cancer Care Ontario) recommended that the use of high-dose interferon alfa 2b therapy be discussed and offered to patients with resected cutaneous melanoma with a high risk of recurrence. Subsequently, several clinical trials in patients with resected or metastatic melanoma found that immune checkpoint inhibitors and targeted therapies have a benefit greater than that with interferon. It was therefore considered timely for an update to the guideline about adjuvant systemic therapy in melanoma.

Methods

The present guideline was developed by the pebc and the Melanoma Disease Site Group (dsg). Based on a systematic review from a literature search conducted using medline, embase, and the Evidence Based Medicine Reviews databases for the period 1996 to 28 May 2019, the Working Group drafted recommendations. The systematic review and recommendations were then circulated to the Melanoma dsg and the pebc Report Approval Panel for internal review; the revised document underwent external review.

Recommendations

For patients with completely resected cutaneous or mucosal melanoma with a high risk of recurrence, the recommended adjuvant therapies are nivolumab, pembrolizumab, or dabrafenib-trametinib for patients with BRAF V600E or V600K mutations; nivolumab or pembrolizumab are recommend for patients with BRAF wild-type disease. Use of ipilimumab is not recommended. Molecular testing should be conducted to help guide treatment decisions. Interferon alfa, chemotherapy regimens, vaccines, levamisole, bevacizumab, bacillus Calmette-Guérin, and isolated limb perfusion are not recommended for adjuvant treatment of cutaneous melanoma except as part of a clinical trial.

Isolated diastolic hypertension and its risk factors in semi-rural population of South India

Background

Isolated diastolic hypertension (IDH) has been actively discussed for the last two decades because of its prevalence in a younger population and its association with cardiovascular disease. Furthermore, the association of IDH is significant in South Asian Countries such as India because relatively younger populations are known to have a higher risk of cardiovascular events.

Objective

The objective of this study is to find prevalence of IDH and its risk correlates in a semiurban population of South Indian state of Andhra Pradesh.

Methods

Data were collected using the modified World Health Organization - STEPwise approach to Surveillance (WHO STEPS) questionnaire for 16,636 individuals from a group of villages under Thavanampalle Mandal. Collated data were analyzed for prevalence and risk factors of IDH.

Results

Prevalence of IDH was found to be 4.0% with mean age of 46.0 (±SD 13.6) years and a relatively higher prevalence in men (5.3%) as compared with women (3.2%). The prevalence of IDH peaked in the fifth decade of life (40–49 years of age) and declined thereafter. Among various risk factors that were analyzed for their association with IDH, only age, body weight, and body mass index retained their significance in multivariate binary logistic regression analysis.

Conclusion

There is a significant prevalence of IDH below 50 years of age in the semiurban population of South India. As IDH in young and middle age is known to be associated with increased risk of cardiovascular events and end organ involvement, it highlights need for study and development of effective IDH management strategies to reduce associated morbidity and mortality.

P91 Post-operative pain in neurosurgery

Objectives

Are the analgesic guidelines for those neurosurgical operations associated with major and complex major pain consistently followed? Is there a correlation between adherence and post-operative pain?

Design

Patients undergoing spinal surgery and foramen magnum decompressions were visited on the first post-operative day (D1). They provided their pain score subjectively (0=nil; 10=worst ever experienced); objectively we recorded whether they could move in/out of bed without pain limitation.

Subjects

n=57 consecutive patients undergoing elective major and complex major pain neurosurgery between April and June 2018 at the NHNN, Queen Square.

Methods

A proforma was completed on D1. The patients consented to take part and answered three questions. We examined what (if any) analgesics they were admitted on, and what had been prescribed to cover the post-operative period. This was compared against the appropriate guideline for that category of operation.

Results

Guidelines were only followed in 16/57 (28.1%) cases; not followed in 41/57 (71.9%). On an unpaired T-test: 2-tailed P value=0.0195. Where guidelines were followed, the mean pain score reported was: 3.75 (SD 2.72) Where not followed, the mean pain score was 5.46 (SD 2.29). So with a 95% confidence interval −3.41 to −0.29, there is a significant difference between the pain in those prescribed according to the guidelines and those that were not.

Conclusions

The pain guidelines are not routinely followed. Most commonly this was due to no prescription for a non-steroidal anti-inflammatory agent. We suggest regular sessions of education of the guidelines. Cycle 2 closed the loop of the audit. We re-reviewed adherence and pain scores and found guidelines were followed in 34% of cases, which represented a 6% improvement. On a paired two-tailed P value=0.0794. The mean pain score where guidelines were followed=3.42 (SD1.62) against a mean=4.74 (SD 1.89) where guidelines were not followed.

Diagnostic yield in the evaluation of dysphagia: experience at a single tertiary care center

Evaluation of dysphagia typically starts with esophagogastroduodenoscopy (EGD); further testing is pursued if this is negative. When no mucosal, structural, or motor esophageal disorders are identified with persisting symptoms, functional dysphagia is considered. We evaluated outcomes in patients undergoing EGD for dysphagia, and estimated prevalence of functional dysphagia. The endoscopy database at single tertiary care center was interrogated to identify EGDs performed for an indication of 'dysphagia' over a 12-month period (2008-09). Electronic medical records were reviewed over the next 8 years to assess if an etiology was identified. Data were analyzed to assess the diagnostic yield of endoscopy and subsequent tests in the evaluation of dysphagia. Of 5486 EGDs, 822 (15.0%) were performed for dysphagia in 694 patients (58.4 ± 0.6 year, range: 18-95 year, 55.8% female). Of these, 529 (76.2%) had EGD findings that explained dysphagia; another 22 (3.2%) had findings on histopathology. Of the remainder 143 patients (20.6%) with normal index EGD, 38 (26.6%) patients underwent barium esophagram with 15 (39.5%) having abnormal studies. 19 patients (13.3%) underwent esophageal high resolution manometry with 12 (63.2%) being abnormal, and 7 had a mechanism for dysphagia on alternate testing. A repeat EGD was abnormal in 6 patients, while 45 patients were lost to follow-up. 42 patients had complete resolution of symptoms despite normal endoscopy, of which 30 were treated empirically with a proton pump inhibitor (PPI). Only 16 patients had no findings on evaluation, and had continued dysphagia symptoms, representing true functional dysphagia in 2.3% of all dysphagia patients and 11.2% of patients with normal EGD. Endoscopy remains the test with the highest yield (over 75%) for a diagnosis in patients presenting with dysphagia; secondary tests are useful when endoscopy does not provide a diagnosis. Benign strictures and GERD-related etiologies are leading causes; PPI therapy is useful even when testing is negative. Functional dysphagia is extremely rare, accounting for <2.5% of all dysphagia.

Immuno-detection of cleaved SNAP-25 from differentiated mouse embryonic stem cells provides a sensitive assay for determination of botulinum A toxin and antitoxin potency

Botulinum toxin type A is a causative agent of human botulism. Due to high toxicity and ease of production it is classified by the Centres for Disease Control and Prevention as a category A bioterrorism agent. The same serotype, BoNT/A, is also the most widely used in pharmaceutical preparations for treatment of a diverse range of neuromuscular disorders. Traditionally, animals are used to confirm the presence and activity of toxin and to establish neutralizing capabilities of countermeasures in toxin neutralization tests. Cell based assays for BoNT/A have been reported as the most viable alternative to animal models, since they are capable of reflecting all key steps (binding, translocation, internalization and cleavage of intracellular substrate) involved in toxin activity. In this paper we report preliminary development of a simple immunochemical method for specifically detecting BoNT/A cleaved intracellular substrate, SNAP-25, in cell lysates of neurons derived from mouse embryonic stem cells. The assay offers sensitivity of better than 0.1LD50/ml (3fM) which is not matched by other functional assays, including the mouse bioassay, and provides serotype specificity for quantitative detection of BoNT/A and anti-BoNT/A antitoxin. Subject to formal validation, the method described here could potentially be used as a substitute for the mouse bioassay to measure potency and consistency of therapeutic products.

Clinical presentation, management, and outcomes in the Indian Heart Rhythm Society-Atrial Fibrillation (IHRS-AF) registry

Aim

A national atrial fibrillation (AF) registry was conducted under the aegis of the Indian Heart Rhythm Society (IHRS), to capture epidemiological data-type of AF, clinical presentation and comorbidities, current treatment practices, and 1-year follow-up outcomes.

Methods

A total of 1537 patients were enrolled from 24 sites in India in the IHRS-AF registry from July 2011 to August 2012. Their baseline characteristics and follow-up data were recorded in case report forms and subsequently analyzed.

Results

The average age of Indian AF patients was 54.7 years. There was a marginal female preponderance – 51.5% females and 48.5% males. At baseline, 20.4% had paroxysmal AF; 33% had persistent AF; 35.1% had permanent AF and 11% had first AF episode. At one-year follow-up, 45.6% patients had permanent AF.

Rheumatic valvular heart disease (RHD) was present in 47.6% of patients. Hypertension, heart failure, coronary artery disease, and diabetes were seen in 31.4%, 18.7%, 16.2%, and 16.1%, respectively.

Rate control was the strategy used in 75.2% patients, digoxin and beta-blockers being the most frequently prescribed rate-control drugs. Oral anticoagulation (OAC) drugs were used in 70% of patients. The annual mortality was 6.5%, hospitalization 8%, and incidence of stroke 1%.

Conclusions

In India, AF patients are younger and RHD is still the most frequent etiology. Almost two-third of the patients have persistent/permanent AF. At one-year follow-up, there is a significant mortality and morbidity in AF patients in India.

Systematic synthesis and analysis of change in morphology, electronic structure and photoluminescence properties of 2,2′-dipyridyl intercalated MoO3 hybrid nanostructures and investigation of their photocatalytic activity

An organic–inorganic hybrid was synthesized using 2,2′-dipyridyl and MoO₃ nanorods via simple hydrothermal method. Here, dipyridyl has acted as stretching molecule and bonded the MoO₃ nanorods together along the length to form hybrid micro crystals.

Scale Matters: A Cost-Outcome Analysis of an m-Health Intervention in Malawi

BACKGROUND

The primary objectives of this study are to determine cost per user and cost per contact with users of a mobile health (m-health) intervention. The secondary objectives are to map costs to changes in maternal, newborn, and child health (MNCH) and to estimate costs of alternate implementation and usage scenarios.

MATERIALS AND METHODS

A base cost model, constructed from recurrent costs and selected capital costs, was used to estimate average cost per user and per contact of an m-health intervention. This model was mapped to statistically significant changes in MNCH intermediate outcomes to determine the cost of improvements in MNCH indicators. Sensitivity analyses were conducted to estimate costs in alternate scenarios.

RESULTS

The m-health intervention cost $29.33 per user and $4.33 per successful contact. The average cost for each user experiencing a change in an MNCH indicator ranged from $67 to $355. The sensitivity analyses showed that cost per user could be reduced by 48% if the service were to operate at full capacity.

CONCLUSIONS

We believe that the intervention, operating at scale, has potential to be a cost-effective method for improving maternal and child health indicators.

Oral and Vaginal Tenofovir for Genital Herpes Simplex Virus Type 2 Shedding in Immunocompetent Women: A Double-Blind, Randomized, Cross-over Trial

BACKGROUND

Tenofovir is a potent anti-human immunodeficiency virus (HIV) agent that decreased risk of herpes simplex virus type 2 (HSV-2) acquisition in HIV pre-exposure prophylaxis trials. Whether tenofovir has utility in established HSV-2 disease is unclear.

METHODS

We randomized immunocompetent women with symptomatic HSV-2 infection to oral tenofovir disoproxil fumarate (TDF)/placebo vaginal gel, oral placebo/tenofovir (TFV) vaginal gel, or double placebo (ratio 2:2:1) in a one-way cross-over trial. Women collected genital swabs twice daily for HSV PCR during 4-week lead-in and 5-week treatment phases. The primary intent-to-treat end point was within-person comparison of genital HSV shedding and lesion rates.

RESULTS

64 women completed the lead-in phase and were randomized. Neither TDF nor TFV gel decreased overall shedding or lesion rate in the primary analysis; TFV gel decreased quantity of HSV DNA by -0.50 (-0.86-0.13) log10 copies/mL. In the per-protocol analysis, TDF reduced shedding (relative risk [RR] = 0.74, P = .006) and lesion rates (RR = 0.75, P = .032); quantity of virus shed decreased by 0.41 log10 copies/mL.

CONCLUSIONS

Oral TDF modestly decreased HSV shedding and lesion rate, and quantity of virus shed when used consistently. Vaginal TFV gel decreased quantity of virus shed by 60%. In contrast to effects on HSV-2 acquisition, tenofovir is unlikely to provide clinically meaningful reductions in the frequency of HSV shedding or genital lesions.

CLINICAL TRIALS REGISTRATION

NCT01448616.

Rapid diagnostic test supply chain and consumption study in Cabo Delgado, Mozambique: estimating stock shortages and identifying drivers of stock-outs

Background

Malaria rapid diagnostic tests (RDTs) are particularly useful in low-resource settings where follow-through on traditional laboratory diagnosis is challenging or lacking. The availability of these tests depends on supply chain processes within the distribution system. In Mozambique, stock-outs of malaria RDTs are fairly common at health facilities. A longitudinal cross-sectional study was conducted to evaluate drivers of stock shortages in the Cabo Delgado province.

Methods

Data were collected from purposively sampled health facilities, using monthly cross-sectional surveys between October 2011 and May 2012. Estimates of lost consumption (consumption not met due to stock-outs) served as the primary quantitative indicator of stock shortages. This is a better measure of the magnitude of stock-outs than binary indicators that only measure frequency of stock-outs at a given facility. Using a case study based methodology, distribution system characteristics were qualitatively analysed to examine causes of stock-outs at the provincial, district and health centre levels.

Results

15 health facilities were surveyed over 120 time points. Stock-out patterns varied by data source; average monthly proportions of 59%, 17% and 17% of health centres reported a stock-out on stock cards, laboratory and pharmacy forms, respectively. Estimates of lost consumption percentage were significantly high; ranging from 0% to 149%; with a weighted average of 78%. Each ten-unit increase in monthly-observed consumption was associated with a nine-unit increase in lost consumption percentage indicating that higher rates of stock-outs occurred at higher levels of observed consumption. Causes of stock-outs included inaccurate tracking of lost consumption, insufficient sophistication in inventory management and replenishment, and poor process compliance by facility workers, all arguably stemming from inadequate attention to the design and implementation of the distribution system.

Conclusions

Substantially high levels of RDT stock-outs were found in Cabo Delgado. Study findings point to a supply chain with a commendable degree of sophistication. However, insufficient attention paid to system design and implementation resulted in deteriorating performance in areas of increased need. In such settings fast moving commodities like malaria RDTs can call attention to supply chain vulnerabilities, the findings from which can be used to address other slower moving health commodities.

Incidence of herpes simplex virus type 2 infections in Africa: a systematic review

The burden of HSV type 2 varies substantially by region, with the highest incidence and prevalence in sub-Saharan Africa. We undertook a systematic review to identify studies reporting prospective data on incidence rates in men and women in Africa. Of 18 eligible studies, 7 were conducted in high-risk populations. Among women, incidence rates appeared to be higher in those with high-risk sexual behavior, with rates ranging from 3 to 23 per 100 person-years. In contrast, incidence rates in men appeared to be lower, ranging from 1 to 12 per 100 person-years. Risk factors for HSV-2 in women included prevalent human immunodeficiency virus (HIV) infection, younger age at sexual initiation, and sexual activity. Among men, condom use and circumcision had a protective effect, whereas prevalent HIV increased the risk of HSV-2 acquisition. This review draws attention to the high HSV-2 acquisition rates reported in Africa, thereby identifying an efficient setting for preventative HSV-2 vaccine trials.

Aptamer-based label-free detection of PDGF using ruthenium(II) complex as luminescent probe

We report a simple, cost-effective, and label-free detection method, consisting of a platelet-derived growth factor (PDGF) binding aptamer and hydrophobic Ru(II) complex as a sensor system for PDGF. The binding of PDGF with the aptamer results in the weakening of the aptamer-Ru(II) complex, monitored by luminescence signal. A substantial enhancement in the luminescence intensity of Ru(II) complex is observed in the presence of aptamer due to the hydrophobic interaction. Upon addition of PDGF, the luminescence intensity is decreased, due to the stronger interaction between the aptamer and PDGF resulting in the displacement of Ru(II) complex to the aqueous solution. Our assay can detect a target specifically in a complex medium such as the mixture of proteins, at a concentration of 0.8 pM.

The role of fibroblast Tiam1 in tumor cell invasion and metastasis

The co-evolution of tumors and their microenvironment involves bidirectional communication between tumor cells and tumor-associated stroma. Various cell types are present in tumor-associated stroma, of which fibroblasts are the most abundant. The Rac exchange factor Tiam1 is implicated in multiple signaling pathways in epithelial tumor cells and lack of Tiam1 in tumor cells retards tumor growth in Tiam1 knock-out mouse models. Conversely, tumors arising in Tiam1 knock-out mice have increased invasiveness. We have investigated the role of Tiam1 in tumor-associated fibroblasts as a modulator of tumor cell invasion and metastasis, using retroviral delivery of short hairpin RNA to suppress Tiam1 levels in three different experimental models. In spheroid co-culture of mammary epithelial cells and fibroblasts, Tiam1 silencing in fibroblasts led to increased epithelial cell outgrowth into matrix. In tissue-engineered human skin, Tiam1 silencing in dermal fibroblasts led to increased invasiveness of epidermal keratinocytes with premalignant features. In a model of human breast cancer in mice, co-implantation of mammary fibroblasts inhibited tumor invasion and metastasis, which was reversed by Tiam1 silencing in co-injected fibroblasts. These results suggest that stromal Tiam1 may play a role in modulating the effects of the tumor microenvironment on malignant cell invasion and metastasis. This suggests a set of pathways for further investigation, with implications for future therapeutic targets.

Chemotherapy Induced Febrile Neutropenia of Docetaxel with Cyclophosphamide (TC) for Adjuvant Therapy of Breast Cancer in the Community – Reality Check

Following the publication of the paper utilising docetaxel and cyclophosphamide as adjuvant therapy for breast cancer Jones et al JCO 24:5381-5387/2006, we elected to use this program for low to intermediate risk breast cancer patients at the Carlo Fidani Cancer Centre in Mississauga Ontario. From January 2008 until June 2009 we have treated 86 patients. After treating our first 16 patients 6 had developed febrile neutropenia requiring admission to hospital. These patients were subsequently treated with either dose reduction or filgastrim/pegfilgastrim was added. For all 70 subsequently treated patients with this program, either dose reduction or primary prophylaxis with filgatrim or pegfilgastrim was used,prophylactic antibiotics were not used. In this cohort 2 patients required admission to hospital with infection and only 1 was neutropenic (2/70=3%). Details of all patients will be presented. The likelihood of this difference occurring from chance was small p&lt; .0005. (Fischer exact test) Within the paper the quoted febrile neutropenia rate was 5% for the TC group. In the first publication JCO 24:5381-5387, 2006 it is stated that neither prophylactic antibiotics nor growth factors were routinely used whereas in the second paper JCO 27:1177-1183,2009 it is stated that prophylactic quinoline antibiotics were recommended but not required. It is important in a landmark study like this one that details regarding anciliary treatments be detailed so that it may be used safely in the community. Our rate of febrile neutropenia without filgastrim/pegfilgastrim was 6/16=37.5%. The causes of the differences between our rate of fne and that seen in the paper will be discusseed. In addition the differences we saw in the fne rate when either filgastrim/pegfilgatrim were added were markedly improved. In conclusion the TC program given a fne rate &gt; 30 % would mandate the usage of filgastrim or pegfilgastrim for primary prophylaxis. The addition of figastrim/pegfilgastrim markedly reduced our fne rate.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2092.

A random phased array device for delivery of high intensity focused ultrasound

Randomized phased arrays can offer electronic steering of a single focus and simultaneous multiple foci concomitant with low levels of secondary maxima and are potentially useful as sources of high intensity focused ultrasound (HIFU). This work describes laboratory testing of a 1 MHz random phased array consisting of 254 elements on a spherical shell of radius of curvature 130 mm and diameter 170 mm. Acoustic output power and efficiency are measured for a range of input electrical powers, and field distributions for various single- and multiple-focus conditions are evaluated by a novel technique using an infrared camera to provide rapid imaging of temperature changes on the surface of an absorbing target. Experimental results show that the array can steer a single focus laterally to at least +/-15 mm off axis and axially to more than +/-15 mm from the centre of curvature of the array and patterns of four and five simultaneous foci +/-10 mm laterally and axially whilst maintaining low intensity levels in secondary maxima away from the targeted area in good agreement with linear theoretical predictions. Experiments in which pork meat was thermally ablated indicate that contiguous lesions several cm(3) in volume can be produced using the patterns of multiple foci.

Controlled Growth of WO(3) Nanostructures with Three Different Morphologies and Their Structural, Optical, and Photodecomposition Studies

Tungsten trioxide (WO(3)) nanostructures were synthesized by hydrothermal method using sodium tungstate (Na(2)WO(4).2H(2)O) alone as starting material, and sodium tungstate in presence of ferrous ammonium sulfate [(NH(4))(2)Fe(SO(4))(2).6H(2)O] or cobalt chloride (CoCl(2).6H(2)O) as structure-directing agents. Orthorhombic WO(3) having a rectangular slab-like morphology was obtained when Na(2)WO(4).2H(2)O was used alone. When ferrous ammonium sulfate and cobalt chloride were added to sodium tungstate, hexagonal WO(3) nanowire clusters and hexagonal WO(3) nanorods were obtained, respectively. The crystal structure and orientation of the synthesized products were studied by X-ray diffraction (XRD), micro-Raman spectroscopy, and high-resolution transmission electron microscopy (HRTEM), and their chemical composition was analyzed by X-ray photoelectron spectroscopy (XPS). The optical properties of the synthesized products were verified by UV-Vis and photoluminescence studies. A photodegradation study on Procion Red MX 5B was also carried out, showing that the hexagonal WO(3) nanowire clusters had the highest photodegradation efficiency.

Sediment features, macrozoobenthic assemblages and trophic relationships (delta13C and delta15N analysis) following a dystrophic event with anoxia and sulphide development in the Santa Giusta lagoon (western Sardinia, Italy)

Macrozoobenthic assemblages and stable carbon (delta(13)C) and nitrogen (delta(15)N) isotope values of various primary producers (macroalgae and angiosperms) and consumers (macroinvertebrate filter/suspension feeders, deposit feeders, detritivores/omnivores and carnivores and fishes) were studied in the Santa Giusta lagoon (Sardinia, Italy) before (spring) and after (autumn) a dystrophic event which occurred in the summer of 2004. A few days after the dystrophy, the physico-chemical characteristics of sediments and macrozoobenthic assemblages were also investigated. In the latter occasion, high total organic carbon (3.9%) and organic matter (15.9%) contents of surface sediments went together with peaks in acid-volatile sulphide concentrations. Certain immediate effects were quite extreme, such as the drastic reduction in macrozoobenthos and the massive fish kill in August 2004. Among the macrozoobenthos, there were few individuals of chironomid larvae and Capitella cf. capitata left. However, by October, chironomid larvae were numerous, indicating a lack of predators (e.g. fish) and competitors. In addition, some bivalve species and polychaetes which were absent, or present in small numbers before the event, became relatively numerous. The results are discussed based on a knowledge of the sulphide tolerance of these species. Stable isotope analysis clearly showed that the basal level of the food web for most consumers consisted mainly of macroalgae and sedimentary organic matter, and that the values before and after the dystrophic event were not significantly different from one another. This indicates that the relations among different trophic levels were quickly restored following the dystrophic event.

Selective serotonin re-uptake inhibitors (SSRIs) versus placebo for obsessive compulsive disorder (OCD)

BACKGROUND

Obsessive compulsive disorder is a common and disabling disorder. A significant proportion of patients manifest a chronic course. Individual randomised controlled trials (RCTs) have shown that selective serotonin re-uptake inhibitors (SSRIs) are effective in this condition. Previous systematic reviews or meta-analyses summarising the evidence are methodologically problematic or limited in the scope of their analysis.

OBJECTIVES

To examine the efficacy and adverse effects of serotonin re-uptake inhibitors (SSRIs) versus placebo for obsessive compulsive disorder (OCD) in adults.

SEARCH STRATEGY

CCDANCTR-Studies and CCDANCTR-References were searched on 12/11/2007. Reference lists were checked. Experts in the field were contacted.

SELECTION CRITERIA

All RCTs and quasi-RCTs examining the efficacy of SSRIs compared with placebo for OCD in adults were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Selection of studies and data extraction were carried out by two review authors independently, and quality assessment of studies was undertaken. Data analysis was conducted using Review Manager software. Summary measures were produced using the weighted mean difference (WMD) for continuous data and relative risk (RR) for dichotomous data, with 95% confidence intervals (CI). SSRIs were examined as an overall group of drugs, and as individual drugs.

MAIN RESULTS

Seventeen studies were included in the review, involving 3097 participants. Based on all 17 studies, SSRIs as a group were more effective than placebo in reducing the symptoms of OCD between 6 and 13 weeks post-treatment, measured using the Yale-Brown Obsessive Compulsive Scale (YBOCS) (WMD -3.21, 95% CI -3.84 to -2.57). The WMD for individual SSRI drugs were similar and not statistically different. Based on 13 studies (2697 participants), SSRIs were more effective than placebo in achieving clinical response at post-treatment (RR 1.84, 95% CI 1.56 to 2.17). The pooled RR was shown to be similar between individual SSRI drugs. Although reported adverse effects data were more limited, with few exceptions, the overall and individual adverse effects for the different SSRIs were always worse than for placebo and, in the majority of cases, the difference was statistically significant. Nausea, headache and insomnia were always reported amongst the most common adverse effects in trials of each of the drugs.

AUTHORS' CONCLUSIONS

SSRIs are more effective than placebo for OCD, at least in the short-term, although there are differences between the adverse effects of individual SSRI drugs. The longer term efficacy and tolerability of different SSRI drugs for OCD has yet to be established.

Photoluminescence Electron-Transfer Quenching of Rhenium(I) Rectangles with Amines

Electron-transfer (ET) reactions from aromatic amines to excited states of rhenium(I)-based molecular rectangles [{Re(CO)3(mu-bpy)Br}{Re(CO)3(mu-L)Br}]2 (bpy = 4,4'-bipyridine, L = 4,4'-dipyridylacetylene (dpa), I; L = 4,4'-dipyridylbutadiyne (dpb), II; and L = 1,4-bis(4'-pyridylethynyl)benzene (bpeb), III) were investigated in a dichloromethane solution using luminescence quenching techniques. Direct evidence for the ET reaction was obtained from the detection of the amine cation radical in this system using time-resolved transient absorption spectroscopy. The values of the luminescence quenching rate constants, kq, of the 3MLCT excited state of Re(I) rectangles with amines were found to be higher than those for the monomeric Re(I) complexes and other Re(I)-based metallacyclophanes. The observed kq values were correlated well with the driving force (Delta G degrees) for the ET reactions. In addition, a semiclassical theory of ET was successfully applied to the photoluminescence quenching of Re(I) rectangles with amines.

Control of modiolid mussels in cooling water systems by continuous chlorination

Modiolid mussels such as Modiolus philippinarum and Modiolus metcalfei constitute a numerically significant group in fouling communities, especially in tropical and subtropical industrial cooling water systems. Nevertheless, there are hardly any published reports on the tolerance of these species to chlorination or biofouling control measures, This article provides data on the mortality pattern (LT(50) and LT(100)) and physiological activities (oxygen consumption, filtration rate, foot activity, and byssus thread production) of different size groups of M. philippinarum (7- to 30-mm shell lengths) and M. metcalfei (6- to 26-mm shell lengths) exposed to different concentrations of residual chlorine (0.25, 0.50, 0.75, and 1.00 mg/L for sublethal responses; 1, 2, 3, and 5 mg/L for mortality). It is shown that exposure time for 100% mortality of M. philippinarum and M. metcalfei significantly decreased with increasing residual chlorine concentration. For example, 30-mm size group M. philippinarum exposed to 1 mg/L chlorine residual took 402 h to reach 100% mortality, whereas those exposed to 5 mg/L chlorine took 108 h. Among the two mussels, M. philippinarum showed slightly higher tolerance (9-20%) to chlorine when compared to M. metcalfei. The effect of mussel size on mortality of M. philippinarum was significant, with the larger size group mussels showing greater resistance than smaller ones. However, in M. metcalfei, size of the mussel does not seem to be a determinant of its chlorine tolerance. All size groups of M. philippinarum and M. metcalfei showed progressive reduction in physiological activities (oxygen consumption, filtration rate, foot activity index, and byssus thread production) when chlorine residuals gradually increased from 0 to 1 mg/L. Reduction in physiological activities was strongly correlated with chlorine concentration. A comparison of present data with data available for other coexisting mussel species suggests that M. philippinarum and M. metcalfei are relatively less tolerant to chlorine than Perna viridis, Perna perna, and Brachidontes striatulus, which also cause fouling problems in tropical coastal waters.

Mussel colonization of a high flow artificial benthic habitat: byssogenesis holds the key

Water flow is an important characteristic determining the settlement and growth of macro-invertebrates in the marine environment. Intake systems of coastal power stations offer a unique opportunity to study the effect of water flow on benthic organisms under field conditions. The cooling water intake system of a tropical coastal power station is used as an experimental facility to study the effect of flow on the recruitment and growth of three mussel species, viz, Brachidontes variabilis, B. striatulus, and Modiolus philippinarum. The study was prompted by earlier observation that these mussels were numerically abundant in the biofouling community present inside the seawater intake tunnel of the power station, even though their occurrence in the benthic community in the coastal waters outside was only nominal. Recruitment data showed that the three mussel species very successfully colonised surfaces exposed to the intake mouth (characterised by relatively high flow) of the power station. Significant difference was observed in the recruitment recorded at the intake point and the ambient environment outside. Under high flow condition, the growth rates of all the three mussel species were uniformly enhanced. It is argued that recruitment of the different species is related to the number of byssus threads produced by each mussel and the strength of the byssus threads. The results indicate that byssus number and byssus strength of the mussels are important criteria that decide successful colonization and establishment in high flow environments.

Schwannoma of the nasal septum

Schwannomas of the nasal cavity and paranasal sinuses are very rare. We report the case of a 54-year-old woman with a schwannoma arising from the nasal septum. We discuss the clinical presentation, differential diagnosis, imaging characteristics and treatment of this rarely encountered lesion.