Description of a clinical intervention among patients admitted to the medium secure forensic psychiatric services in Central Denmark Region

Introduction

Patients with schizophrenia suffer from increased mortality rates equivalent to 15-20 years shorter life expectancy. Up to 60% of this excess mortality can be explained by preventable, somatic conditions like cardiovascular, metabolic, and respiratory comorbidities. As forensic psychiatric (FP) patients often experience the triple stigmatization of mental illness, substance misuse and criminal conviction, the risk of suboptimal diagnosis and treatment may be high. Although benefits from the addition of general practitioner (GP) services to non-FP wards have been shown elsewhere, this cross-sectoral approach has never been attempted in a Danish FP ward.

Objectives

One purpose of this project is to evaluate the associations between self-reported quality of life and objective measures of somatic health.

Methods

A clinical intervention in which a GP consults patients in all medium secure wards in the Central Denmark Region (N=72). The consultation includes a physical examination, medication review, and evaluation of blood samples. Data is collected from: electronic patient files and questionnaires regarding quality of life (SF-12), lifestyle, and attitude towards GP services.

Results

The population will be described in regards to socio-demographic, clinical, and forensic characteristics. Associations will be made between quality of life (SF-12), metabolic syndrome, blood markers, and heart-SCORE risk. Risk profiles for endocrinologic and coronary illness will be examined.

Conclusions

Results may guide future health interventions and will be used as a basis for adjustments to the current project.

Disclosure

No significant relationships.

Quality of Life, Risk and Recovery in a National Forensic Mental Health Service: A D-FOREST study from DUNDRUM Hospital

Introduction

Secure forensic mental health services have a dual role, to treat mental disorder and reduce violent recidivism. Quality of life is a method of assessing an individual patients’ perception of their own life and is linked to personal recovery. Placement in secure forensic hospital settings should not be a barrier to achieving meaningful quality of life. The WHO-QuOL measure is a self-rated tool, internationally validated used to measure patients own perception of their quality of life.

Objectives

This aim of this study was to assess self-reported quality of life in a complete National cohort of forensic in-patients, and ascertain the associations between quality of life and measures of violence risk, recovery and functioning.

Methods

This is a cross sectional study, set in Dundrum Hospital, the site of Ireland’s National Forensic Mental Health Service. It therefore includes a complete national cohort of forensic in-patients. The WHO-QuOL was offered to all 95 in-patients in Dundrum Hospital during December 2020 – January 2021, as was PANSS (Positive and Negative Symptoms for Schizophrenia Scale). During the study period the researchers collated the scores from HCR-20 (violence risk), therapeutic programme completion (DUNDRUM-3) and recovery (DUNDRUM-4). Data was gathered as part of the Dundrum Forensic Redevelopment Evaluation Study (D-FOREST).

Results

Lower scores on dynamic violence risk, better recovery and functioning scores were associated with higher self-rated quality of life.

Conclusions

The quality of life scale was meaningful in a secure forensic hospital setting. Further analysis will test relationships between symptoms, risk and protective factors and global function.

Disclosure

No significant relationships.

Sedentary Behaviour in the Secure Forensic Hospital Setting: A Study from Dundrum Hospital Ireland

Introduction

Secure forensic mental health services offer care and treatment to mentally disordered offenders, with high rates of schizophrenia and major mental illness in these groups. Much of the excess morbidity and mortality seen among patients with schizophrenia is due to cardiovascular disease and obesity. Sedentary behaviour is associated with negative symptoms of schizophrenia and obesity.

Objectives

The aim of this study was to ascertain the level of sedentary behaviour among inpatients in a secure forensic psychiatric hospital, Dundrum, Ireland, using a structured self-report measure of sedentary behaviours, the SIT-Q tool.

Methods

A cross sectional study of self-reported sedentary behaviour was completed amongst the secure forensic inpatient population of Dundrum Hospital (N=94). Demographic details, details pertaining to diagnoses, ward level of dependency and length of stay were collated.

Results

The majority of patients in the sample were male (89%) and the most common diagnosis was schizophrenia (71.7%). Mean age was 44.7 years (SD 11.42). 58.2% met criteria for obesity. We found high rates of self-reported sedentary behaviour across all wards of the service, with significantly high rates of sedentary behaviour being associated with screen time use in the hospital, including both personal screen time and therapeutic sessions based on screen time.

Conclusions

Sedentary behaviour among in-patients in secure forensic hospitals is a significant issue. Measuring sedentary behaviour in a systematic manner is possible and identifies a potentially modifiable target to reduce co-morbidity and pre-mature mortality independent of other risk factors in this vulnerable patient group.

Disclosure

No significant relationships.

Frailty in Secure Forensic Mental Health Settings: A Study from Dundrum Hospital, Ireland

Introduction

Frailty is defined as a clinical syndrome that encompasses a combination of decreased physiological reserve and low resistance to stressors. There is an association between mental illness and frailty among elderly cohorts. Frailty is also associated with obesity and smoking. There are high rates of treatment resistant schizophrenia among patients in secure forensic services. Patients with schizophrenia have high rates of morbidity and early mortality.

Objectives

The primary aim of this study was to examine the rates of frailty present in a complete cohort of forensic in-patients.

Methods

An assessment using Fried Frailty criteria was offered to all in-patients (n=95) in Ireland’s National Forensic Service, which included measures of walking speed, grip strength, low physical activity and exhaustion. Demographic details and details pertaining to diagnoses and medications were also gathered.

Results

Of the 95 in-patients, 92 patients agreed to participate. The majority were male (89%). The most common diagnosis was schizophrenia (71.7%). Mean age was 44.7 years (SD 11.42), and 58.2% met criteria for obesity. Of the total group, 47 patients met criteria for ‘pre-frail’ and 10 met criteria for ‘frail’ using Fried criteria.

Conclusions

This is the first study examining frailty in a cohort of patients in secure forensic settings. We found high rates of patients meeting frailty criteria at very young ages. Rates of frailty in this group were comparable to those found amongst elders in community settings. We consider this demonstrates significant medical vulnerability in this patient group.

Disclosure

No significant relationships.

Decision-making capacity regarding healthcare, welfare and finances in a secure forensic setting

Introduction

Impairment in decision-making capacity is a serious consequence of executive dysfunction secondary to serious mental disorders like schizophrenia. Functional mental capacity (FMC) refers to an individual’s ability to make and communicate legally competent decisions autonomously. Studies have shown that FMC is dependent on severity of psychosis and can improve with treatment.

Objectives

To ascertain the correlation between the scores on a structured judgement tool, namely the Dundrum Capacity Ladders (DCL) with level of acuity of treatment setting and length of stay in a secure forensic hospital.

Methods

Sixty-two patients were interviewed using the DCL across three domains – healthcare, welfare and finances. Correlation between DCL scores, length of hospital stay and level of acuity of treatment setting was assessed.

Results

As patients moved from higher to lower dependency wards, mean DCL score increased, indicating a higher level of capacity. Patients in high dependency wards were most impaired while those in the low dependency wards performed significantly better (r_s=0.472, p<0.001). The longer the patients stayed in the hospital, up until five years, the higher the mean welfare domain score (r_s=0.402, p=0.011) and mean DCL score (r_s=0.376, p=0.018). Beyond five years of hospital stay, those who had lower DCL scores and did not improve had longer length of stay.

Conclusions

Patients’ FMC improve as they progress from high to low level of acuity of treatment setting. However, this is dependent on the length of hospital stay. FMC may be a measure of recovery in the forensic setting.

Disclosure

No significant relationships.

Zero violence or zero seclusion. Which is more acceptable in our hospitals?

Introduction

There is an established association between serious mental illness and violence. Secure forensic psychiatric services provide care and treatment to mentally disordered offenders. The majority of patients in forensic services suffer from severe mental illnesses such as schizophrenia, with co-morbid polysubstance abuse and maladaptive personality traits. Psychiatric services are under significant pressure to reduce the use of seclusion and restrictive practices, whilst mandated to provide safe environments for patients and staff.

Objectives

To determine the number and characteristics of violent incidents in a secure forensic hospital in Ireland.

Methods

A retrospective review of all incidents in Central Mental Hospital, Ireland between 1^st March 2019 and 31^st August 2021 was completed. Incidents were categorised into physical assaults and other violent incidents. Demographic measures and measures of violence risk (HCR-20), functioning (GAF), programme completion and recovery (DUNDRUM tool) were collated.

Results

A total of 321 incidents took place during the period examined, of which 47 (14.6%) involved physical assaults perpetrated by patients. Between March 2020 and August 2021, numbers of assaults increased by 50% and 78% compared to the preceding six-month period respectively. The majority of assaults were committed by a relatively small group of patients. Victims of assaults were more likely to be patients (n=27, 57.4%) and more likely to be males (n=43, 91.9%).

Conclusions

Physical assaults and other violent incidents happen in forensic and general psychiatric units. Restrictive practices, used in accordance with the law, are necessary at times to prevent serious harm to patients and staff in psychiatric hospitals.

Disclosure

No significant relationships.

A national service for delivering CD19 CAR-Tin large B-cell lymphoma - The UK real-world experience

CD19 CAR-T have emerged as a new standard treatment for relapsed/refractory (r/r) large B-cell lymphoma (LBCL). CAR-T real-world (RW) outcomes published to date suggest significant variability across countries. We provide results of a large national cohort of patients intended to be treated with CAR-T in the UK. Consecutive patients with r/r LBCL approved for CAR-T by the National CAR-T Clinical Panel between December 2018 and November 2020 across all UK CAR-T centres were included. 404/432 patients were approved [292 axicabtagene ciloleucel (axi-cel), 112 tisagenlecleucel (tisa-cel)], 300 (74%) received the cells. 110/300 (38.3%) patients achieved complete remission (CR) at 6 months (m). The overall response rate was 77% (52% CR) for axi-cel, 57% (44% CR) for tisa-cel. The 12-month progression-free survival was 41.8% (axi-cel) and 27.4% (tisa-cel). Median overall survival for the intention-to-treat population was 10.5 m, 16.2 m for infused patients. The incidence of grade ≥3 cytokine release syndrome and neurotoxicity were 7.6%/19.6% for axi-cel and 7.9%/3.9% for tisa-cel. This prospective RW population of CAR-T eligible patients offers important insights into the clinical benefit of CD19 CAR-T in LBCL in daily practice. Our results confirm long-term efficacy in patients receiving treatment similar to the pivotal trials, but highlight the significance of early CAR-T failure.

The characteristics of homicide perpetrators in a medium secure forensic hospital: A study from dundrum hospital

Introduction

The majority of homicides in society are not associated with mental illness, however there is an established association between homicide and schizophrenia. Homicide perpetrated by mentally disordered offenders is a leading reason for admission to secure forensic psychiatric hospitals.

Objectives

To investigate the clinical characteristics of those with a history of completed homicide in the CMH Dundrum.

Methods

This study was a cross sectional study of a cohort of patients in the Central Mental Hospital who had completed homicide (n=63).

Results

A total of 136 patients were included, 46.3% (n=63) of whom had committed homicide. Mean age of homicide perpetrators at admission was 34.6 years old (median 33.4, s.d. = 9.72). The most common diagnosis was schizophrenia (n=40, 63.5%). 73.0% (n=46) had a history of substance misuse. 36.5% (n=23) had a diagnosis of a personality disorder, including traits only. The most common victim type was a family member (n=32, 50.8%). Patients with a history of homicide had better scores on dynamic risk of violence (F=8.553, p=0.004), programme completion (F=8.258, p=0.005) and recovery (F=3.666, p=0.058) compared to non-homicide offenders, however they also had significantly longer mean length of stay, 12.7 years v 7.5 years (F=9.634,p=0.002).

Conclusions

Homicide perpetrators with a mental illness constitute a significant portion of the forensic mental health population and a high number of these offences were against family members. A history of homicide among forensic in-patients is associated with a longer length of stay which has implications for service development into the future.

Improvement in pain interference and function by an allied health pain management program: Results of a randomized trial

BACKGROUND

Chronic pain is a significant health problem worldwide and requires a biopsychosocial treatment approach. Access to traditional pain medicine specialist services is limited and innovative treatment models are required to support patients in tertiary care. The study evaluated the clinical effectiveness and safety of the Treatment Access Pathway (TAP), an allied health expanded scope model of care which included innovative group assessment and collaboration with patients to create individualized treatment plans.

METHODS

One hundred and eighty-one patients referred to a tertiary level chronic pain service were randomly allocated to either the TAP or the waitlist study groups. Primary (pain interference) and secondary outcome measures were collected at recruitment and again at 6 months. Per-protocol analyses were utilized due to high participant attrition (46% across groups).

RESULTS

The TAP group reported greater reductions in pain interference at 6 months than waitlist group (0.9, 95% CI: 0.2-1.6), with more than half of the TAP group (52%) reporting clinically significant improvement. In addition, statistically significant differences between the TAP and waitlist groups were observed for objective measurements of walking endurance (5.4 m, 95% CI: 1.7-9.1); and global impressions of change (1.4 unit decrease, 95% CI: 1-1.9). Nil adverse events were recorded.

CONCLUSIONS

The study suggests that an expanded scope allied health model of care prioritizing patient choice and group-based interventions provides modest benefits for tertiary-referral chronic pain patients. TAP warrants further investigation as a potentially viable alternative for tertiary healthcare where traditional pain services are unavailable or have long waiting lists.

SIGNIFICANCE

The study tests effectiveness and safety of an expanded scope allied health-led chronic pain program. Despite a high attrition rate, the study showed reduced pain interference and increased physical function in those who completed the protocol. The results are promising and support introduction of this model as an adjunct to existing traditional chronic pain models of care, with a particular focus on improving participant retention in the program. Additionally, the model of care can be used as a standalone chronic pain model of care where no other pain management resources are available. The study was registered on ANZCTR (Trial ID: ACTRN12617001284358).

The Eating Disorders Genetics Initiative (EDGI): study protocol

BACKGROUND

The Eating Disorders Genetics Initiative (EDGI) is an international investigation exploring the role of genes and environment in anorexia nervosa, bulimia nervosa, and binge-eating disorder.

METHODS

A total of 14,500 individuals with eating disorders and 1500 controls will be included from the United States (US), Australia (AU), New Zealand (NZ), and Denmark (DK). In the US, AU, and NZ, participants will complete comprehensive online phenotyping and will submit a saliva sample for genotyping. In DK, individuals with eating disorders will be identified by the National Patient Register, and genotyping will occur using bloodspots archived from birth. A genome-wide association study will be conducted within EDGI and via meta-analysis with other data from the Eating Disorders Working Group of the Psychiatric Genomics Consortium (PGC-ED).

DISCUSSION

EDGI represents the largest genetic study of eating disorders ever to be conducted and is designed to rapidly advance the study of the genetics of the three major eating disorders (anorexia nervosa, bulimia nervosa, and binge-eating disorder). We will explicate the genetic architecture of eating disorders relative to each other and to other psychiatric and metabolic disorders and traits. Our goal is for EDGI to deliver "actionable" findings that can be transformed into clinically meaningful insights.

TRIAL REGISTRATION

EDGI is a registered clinical trial: clinicaltrials.gov NCT04378101 .

Care & custody: E-sport and patient-professional power-relations in forensic psychiatry. A qualitative study

Introduction

Recovery orientated care emphasizes equality in relations. Forensic psychiatric professionals need to engage in care-relationships with patients in ways where power is symmetrically distributed among them. However, professionals also need to focus on security at the ward. This promotes patient-professional power-relations that are asymmetrically skewed towards professionals. New practical ways of balancing between the power-relations defined by a care and custody dichotomy in forensic care need to be developed and studied to guide clinical practice.

Objectives

To study how power-relations are articulated between patient-professional within a social gaming activity (E – sport) in a Danish medium secure forensic psychiatric ward.

Methods

Three months of observational data, collected via anthropological fieldwork Interviews with 3 professionals and 6 patients Data was analyzed using sociologist Pierre Bourdieu’s notions of field, capital and power

Results

The E-sport intervention consists of two fields “in-game” and “over-game” In-game concerns the practice of gaming Over-game concerns the interventions organization Power in each field is driven by specific values and access to certain competencies Power in-game was equally open to patients and professionals leading to symmetric power relations Power over-game was open to professionals only leading to asymmetrical power relations Professionals may allow power distribution to patients during gameplay, while still retaining the overall power over the intervention

Conclusions

It is possible to balance between care-and-custody in forensic psychiatry. This study provides important insights to guide further practice.

Tidier. e-sport; a recovery oriented intervention in forensic psychiatry

Introduction

Recently video gaming, have attracted considerable attention for its possible beneficial therapeutic effects, the possibility for testing behavior in safe artificial environments and as a tool for professionals and patients to build specific competencies for the everyday life. Also, a substantial amount of research suggests that videogaming might improve the participants social and cognitive skills and emotional regulation. There is little or no evidence that videogaming increases long term aggression or leads to physical aggression. At a medium secure forensic psychiatric in-patient ward, the patients and staff engage in weekly E – Sport sessions (primarily counterstrike) to further the recovery process.

Objectives

To provide a standardized description of how E-sport is organized and used in the recovery process among forensic psychiatric patients.

Methods

The Template for Intervention Description and Replication (TIDieR) checklist and guide is widely used to in health research to describe interventions in clinical trials and other health research contexts. By use of TIDieR we describe a newly developed E-sport intervention, in which staff members and patients in a medium secure forensic psychiatric ward engage in weekly E-Sport sessions (primarily counterstrike) to improve patient–staff relationship.

Results

The E-sport intervention is detailed by use of the 12 TIDieR items and practical experiences and insights will be described.

Conclusions

This standardized and detailed description of how is used in a recovery-oriented process in forensic psychiatry can be used for future studies that wishes to implement the intervention or for research studies replicating the treatment.

Conflict of interest

No significant relationships.

Modernized architecture may reduce coercion

Introduction

Prevention and treatment of aggression in psychiatric hospitals is achieved through appropriate medical treatment, professional skills, and optimized physical environment and architecture. Coercive measures are used as a last resort. In 2018 Aarhus University Hospital Psychiatry moved from 19th-century asylum buildings to a newly built modern psychiatric hospital. Advances within psychiatric care have rendered the old psychiatric asylum hospitals inadequate for modern treatment of mental disorders.

Objectives

To examine if relocating from a psychiatric hospital, dating from 19th century to a new, modern psychiatric hospital decreased the use of coercive measures.

Methods

This is a retrospective longitudinal study, with a follow-up from 2017 to 2019. We use two designs; 1) a pre-post analysis of the use of coercive measures at Aarhus University Hospital Psychiatry before and after the relocation and 2) a case-control analysis of Aarhus University Hospital Psychiatry and the other psychiatric hospitals in the Central Region. Data will be analyzed in STATA using an interrupted time-series analysis or similar method. Additionally case-mix and sensitivity analysis will be performed.

Results

Preliminary results show a 45% decrease in the total number of coercive measures and a 52% decrease in the use of mechanical restraint. The reduction that may reasonably be attributed to the relocation is still to be determined and will be presented at the congress.

Conclusions

The study may illuminate how future development and planning of psychiatric facilities might improve psychiatric treatment and increase the understanding of how structural changes might contribute the prevention of the use of coercive measures.

Disclosure

No significant relationships.

Stratification of a medium secure forensic care pathway according to risk and need: A study from dundrum hospital

Introduction

Secure forensic mental health services have a dual role, to treat mental illness and reduce violent recidivism. Those admitted to secure forensic services have a significant history of violence and treatment needs in multiple domains including psychiatric illness, violence and other areas such as substance misuse and physical health.

Objectives

The aim of this study was to ascertain if the units in a medium secure forensic hospital are stratified according to individual risks and needs. We also aimed to clarify if there were differences in the symptom level, risks and needs of those with and without community leave and to clarify the risks and needs of the female patients and ID patients.

Methods

This is a cross sectional study a cohort of patients (n=138) in a secure forensic hospital.

Results

There was a total of 138 patients, the majority of whom were male (n=123, 89.1%). The most common diagnosis was schizophrenia (n=99, 71.7%). Placements in the care pathway of the medium secure forensic hospital were associated with level of symptomatology (PANSS positive), dynamic violence risk (F=26.880,P<0.001), DUNDRUM-3 therapeutic programme completion (F=44.067,P<0.001), and DUNDRUM 4 recovery (F=59.629,P<0.001). Patients with community leave had better scores than those without leave on violence risk (F=77.099, P<0.001), therapeutic programme completion (F=116.072, P<0.001) and recovery (F=172.211, P<0.001).

Conclusions

Stratifying secure forensic psychiatric hospitals according to individual risks and needs provides in-patient care in the least restrictive setting appropriate for individuals, however niche groups such as female forensic patients and ID patients may need special consideration.

COVID-19 in forensic psychiatry settings: The unique vulnerability of patients in secure services

Introduction

Secure forensic mental health services treat patient with high rates of treatment resistant psychoses, typically schizophrenia. These groups have high rates of obesity and medical co-morbidities. Population based studies have identified high risk groups in the event of SARS-CoV-2 infection, including those with long term medical conditions.

Objectives

The aim of this study was to compare the vulnerability to serious adverse outcome in the event of COVID-19 infection in a forensic psychiatric patient population.

Methods

All patients of a complete National Forensic Mental Health Service (n=141) were rated for risk of adverse outcome in the event of SARS-CoV-2 infection, using two structured tools, the COVID-AGE tool and the COVID-Risk tool.

Results

Eighty-two patients (58.2%) met criteria for obesity, 32 had type II diabetes and 28 were hypertensive. Mean chronological age was 45.5 years (SD 11.4, median 44.1), while mean COVID-AGE was 59.1 years (SD 19.4, median 58.0), mean difference 13.6 years (SD 15.6) paired t=10.9, df=140, p=0.000. Three patients (2.1%) were chronologically over 70 years compared to 40 (28.4%) with a COVID-AGE over 70 (X2=6.99, df=1, p=0.008, Fishers exact test p=0.027).

Conclusions

These risk assessments may identify the extent of increased risk among a uniquely medically vulnerable patient group. Patients in secure forensic psychiatric services represent a high-risk group for adverse outcomes in the event of SARS-COV-2 infection. Population based cocooning and self-isolating guidance based on chronological age may not be sufficient. There is an urgent need for better physical health research and treatment in this group.

Changes in BMI and blood pressure after implementing a complete smoking ban in a medium secure forensic setting: A study from dundrum hospital dublin

Introduction

In February 2020, the Central Mental Hospital Dundrum moved to a complete ban on cigarette smoking. Concerns were raised that this might represent a ‘restrictive practice’ and that patients might gain weight or see changes in their blood pressure if they were not permitted to smoke.

Objectives

The aim of the study was to ascertain if there were changes in the blood pressure readings or body mass index of a group of patients in a secure forensic hospital after the implementation of a complete campus-wide smoking ban

Methods

All patients (n=20) working with one medium cluster team were included in the study. Demographic details and data pertaining to legal status, diagnosis and length of stay in the hospital were obtained. BMI, blood pressure and medications were reviewed at the time of introduction of the smoking ban, 1^st February 2020 and again 5 months later.

Results

All those included in the study were male. The median age was 35 years, most common diagnosis was schizophrenia and mean length of stay was 4.23 years. 20% of patients were prescribed anti-hypertensives at the time of introduction of the smoking ban. All of the patients on anti-hypertensives were overweight. At follow up there was no increase in BMI noted in the patient group. Two patients had dose reductions in anti-hypertensives, three had discontinuation of bronchodilators.

Conclusions

Introducing a campus wide smoking ban in a secure forensic psychiatric hospital is both clinically positive and practically possible. There was no noted increase in incidents in the hospital during this period.

Surprise Diagnosis of COVID-19 following Neuroimaging Evaluation for Unrelated Reasons during the Pandemic in Hot Spots

During the height of the recent outbreak of coronavirus 19 (COVID-19) in New York City, almost all the hospital emergency departments were inundated with patients with COVID-19, who presented with typical fever, cough, and dyspnea. A small number of patients also presented with either unrelated conditions (such as trauma) or other emergencies, and some of which are now known to be associated with COVID-19 (such as stroke). We report such a scenario in 17 patients who were admitted and investigated with CT spine imaging and CT angiography for nonpulmonary reasons (trauma = 13, stroke = 4). Their initial work-up did not suggest COVID-19 as a diagnosis but showed unsuspected/incidental lung findings, which led to further investigations and a diagnosis of COVID-19.

Molecular High-Grade B-Cell Lymphoma: Defining a Poor-Risk Group That Requires Different Approaches to Therapy

PURPOSE

Biologic heterogeneity is a feature of diffuse large B-cell lymphoma (DLBCL), and the existence of a subgroup with poor prognosis and phenotypic proximity to Burkitt lymphoma is well known. Conventional cytogenetics identifies some patients with rearrangements of MYC and BCL2 and/or BCL6 (double-hit lymphomas) who are increasingly treated with more intensive chemotherapy, but a more biologically coherent and clinically useful definition of this group is required.

PATIENTS AND METHODS

We defined a molecular high-grade (MHG) group by applying a gene expression-based classifier to 928 patients with DLBCL from a clinical trial that investigated the addition of bortezomib to standard rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) therapy. The prognostic significance of MHG was compared with existing biomarkers. We performed targeted sequencing of 70 genes in 400 patients and explored molecular pathology using gene expression signature databases. Findings were validated in an independent data set.

RESULTS

The MHG group comprised 83 patients (9%), with 75 in the cell-of-origin germinal center B-cell-like group. MYC rearranged and double-hit groups were strongly over-represented in MHG but comprised only one half of the total. Gene expression analysis revealed a proliferative phenotype with a relationship to centroblasts. Progression-free survival rate at 36 months after R-CHOP in the MHG group was 37% (95% CI, 24% to 55%) compared with 72% (95% CI, 68% to 77%) for others, and an analysis of treatment effects suggested a possible positive effect of bortezomib. Double-hit lymphomas lacking the MHG signature showed no evidence of worse outcome than other germinal center B-cell-like cases.

CONCLUSION

MHG defines a biologically coherent high-grade B-cell lymphoma group with distinct molecular features and clinical outcomes that effectively doubles the size of the poor-prognosis, double-hit group. Patients with MHG may benefit from intensified chemotherapy or novel targeted therapies.

Mutation screening using formalin-fixed paraffin-embedded tissues: a stratified approach according to DNA quality

DNA samples from formalin-fixed paraffin-embedded tissues are highly degraded with variable quality, and this imposes a big challenge for targeted sequencing due to false positives, largely caused by PCR errors and cytosine deamination. To eliminate false positives, a common practice is to validate the detected variants by Sanger sequencing or perform targeted sequencing in duplicate. Technically, PCR errors could be removed by molecular barcoding of template DNA prior to amplification as in the HaloPlexHS design. Nonetheless, it is uncertain to what extent variants detected using this approach should be further validated. Here, we addressed this question by correlating variant reproducibility with DNA quality using HaloPlexHS target enrichment and Illumina HiSeq4000, together with an in-house validated variant calling algorithm. The overall sequencing coverage, as shown by analyses of 70 genes in 266 cases of large B-cell lymphoma, was excellent (98%) in DNA samples amenable for PCR of ≥400 bp, but suboptimal (92%) and poor (80%) in those amenable for PCR of 300 bp and 200 bp respectively. By mutation analysis in duplicate in 93 cases, we demonstrated that 20 alternative allele depth (AAD) was an optimal cut-off value for separating reproducible from non-reproducible variants in DNA samples amenable for PCR of ≥300 bp, with 97% sensitivity and 100% specificity. By cross validation with a previously established targeted sequencing protocol by Fluidigm-PCR and Illumina MiSeq, the HaloPlexHS protocol was shown to be highly sensitive and specific in mutation screening. To conclude, we proposed a stratified approach for mutation screening by HaloplexHS and Illumina HiSeq4000 according to DNA quality. DNA samples with good quality (≥400 bp) are amenable for mutation analysis with a single replicate, with only variants at 15-20 AAD requiring for further validation, while those with suboptimal quality (300 bp) are better analysed in duplicate with reproducible variants at >15 AAD regarded as true genetic changes.

Hepatitis and HIV in Northern Ireland prisons: a cross-sectional study

A study was undertaken in Northern Ireland (NI) prisons to (i) determine prevalence of bloodborne viruses among inmates, (ii) estimate the extent of self-reported risk behaviours. All three prisons in NI were included in the study. Outcome measures included (i) antibodies to hepatitis C (HCV), hepatitis B (HBV) core antigen, HIV, (ii) self-reported risk behaviour. Five prisoners (0.75%) tested positive for HBV, seven (1.1%) for HCV and none for HIV. Eleven per cent reported ever having injected drugs. Of these, 20% had started injecting while in prison, and 12% shared injecting equipment in prison. Two per cent had completed HBV immunisation. Injecting drugs was associated with HCV (adjusted prevalence ratio=5.2; 95% CI 0.9-16) and HBV infection (adjusted prevalence ratio=4.1; 95% CI 0.7-23). The low prevalence of bloodborne viruses within NI prisons is not consistent with findings of studies in other countries, possibly reflecting the unique sociopolitical situation in NI. In spite of knowledge of the risks of transmission of bloodborne viruses in prison, high-risk practices are occurring. Preventing risk behaviours and transmission of infection in prisons now poses a challenge for health services in the United Kingdom.