National multicentered retrospective review of clinical and intraoperative factors associated with the development of cerebellar mutism after pediatric posterior fossa tumor resection

BACKGROUND

Cerebellar mutism (CM) is characterized by a significant loss of speech in children following posterior fossa (PF) surgery. The biological origin of CM remains unclear and is the subject of ongoing debate. Significant recovery from CM is less likely than previously described despite rigorous multidisciplinary neuro-rehabilitational efforts.

METHODS

A national multi-centered retrospective review of all children undergoing PF resection in four midsized Canadian academic pediatric institutions was undertaken. Patient, tumor and surgical factors associated with the post-operative development of CM were reviewed. Retrospective identification of PF surgery patients including those developing and those that did not (internal control).

RESULTS

The study identified 258 patients across the 4 centers between 2010 and 2020 (mean age 6.73 years; 42.2% female). Overall, CM was experienced in 19.5% of patients (N = 50). Amongst children who developed CM histopathology included medulloblastoma (35.7%), pilocytic astrocytoma (32.6%) and ependymoma (17.1%). Intraoperative impression of adherence to the floor of the 4th ventricle was positive in 36.8%. Intraoperative abrupt changes in blood pressure and/or heart rate were identified in 19.4% and 17.8% of cases. The clinical resolution of CM was rated to be complete, significant resolution, slight improvement, no improvement and deterioration in 56.0%, 8.0%, 20.0%, 14.0% and 2.0%, respectively. In the cohort of children who experienced post-operative CM as compared to their no-CM counterpart, proportionally more tumors were felt to be adherent to the floor of the 4th ventricle (56.0% vs 49.5%), intraoperative extent of resection was a GTR (74% vs 68.8%) and changes in heart rate were noted (≥ 20% from baseline) (26.0% vs 15.9%). However, a multiple regression analysis identified only abrupt changes in HR (OR 5.97, CI (1.53, 23.1), p = 0.01) to be significantly associated with the development of post-operative CM.

CONCLUSION

As a devastating surgical complication after posterior fossa tumor surgery with variable clinical course, identifying and understanding the operative cues and revising intraoperative plans that optimizes the child's neurooncological and clinical outcome are essential.

A retrospective cohort study evaluating pregnancy outcomes in women with MIDD

AIMS

The most common pathogenic mitochondrial mutation associated with mitochondrial disease is m.3243A>G. Increased obstetric complications, such as spontaneous abortion, gestational diabetes (GDM), preterm delivery, and preeclampsia, have been reported in women carrying this mutation. We aimed to determine the fetal and maternal outcomes in pregnant women with mitochondrial disease.

METHODS

We retrospectively studied the obstetric and perinatal outcomes in 88 pregnancies of 26 women with genetically confirmed mitochondrial disease (m.3243A>G in the MTTL1 gene (n = 25); m.12258C>A in the MT-TS2 gene (n = 1)). Outcomes included pregnancy related complications, mode of delivery, gestational age at delivery and birthweight.

RESULTS

Mean heteroplasmy rate was 18%. The miscarriage rate was higher than background at 25%. 21 pregnancies (24%) were complicated by GDM; 9 pregnancies (13.6%) had a preterm delivery and 2 of them (3%) an extreme premature delivery < 32 weeks. One woman had preeclampsia and one had a postpartum hemorrhage. The caesarean section (CS) rate was 20%. For every unit increase in maternal heteroplasmy levels there was a 26% increased risk of undergoing an assisted operative vaginal delivery (OR 1.26, 95% CI 1.04-1.53, P = 0.002, Bonferroni corrected P = 0.005) and an 18% increased risk of undergoing a CS (OR 1.18, 95% CI 1.01-1.39, P = 0.01, Bonferroni corrected P = 0.03) compared to a spontaneous vaginal delivery. There was a statistical significant correlation between maternal and offspring heteroplasmy levels. Spearman correlation rho = 0.96, 95% CI 0.78-0.99, P = 0.0002.

CONCLUSION

Women with mitochondrial disease appear to have more frequent obstetric complications including miscarriage and GDM. Pre-pregnancy diagnosis of m.3243A>G will enable the counseling of women and increase awareness of possible obstetric complications.

Post flywheel squat vs. flywheel deadlift potentiation of lower limb isokinetic peak torques in male athletes

The present study investigated the post-activation performance enhancement (PAPE) of isokinetic quadriceps and hamstrings torque after flywheel (FW)-squat vs. FW-deadlift in comparison to a control condition. Fifteen male athletes were enrolled in this randomised, crossover study. Each protocol consisted of 3 sets of 6 repetitions, with an inertial load of 0.029 kg.m2. Isokinetic quadriceps (knee extension) and hamstrings (knee flexion) concentric peak torque (60º/s) and hamstring eccentric peak torque (-60º/s) were measured 5 min after experimental or control conditions. A significant condition (PAPE) effect was reported (f = 4.067, p = 0.008) for isokinetic hamstrings eccentric peak torque following FW-squat and FW-deadlift, but no significant differences were found for quadriceps and hamstrings concentric peak torques. The significant difference averaged 14 Nm between FW-squat vs. control (95% CI: 2, 28; d = 0.75, moderate; p = 0.033), and 13 Nm between FW-deadlift vs. control (95% CI: 1, 25; d = 0.68, moderate; p = 0.038). This study reported that both FW-squat and FW-deadlift exercises are equivalently capable of generating PAPE of isokinetic hamstrings eccentric torque. Practitioners may use these findings to inform strength and power development during complex training sessions consisting of flywheel-based exercises prior to a sport-specific task.

A Comparison of Training and Match Play External Load During a Congested In-Season Period in English League 2 Football

ABSTRACT

Fleming, A, Walker, M, Armitage, M, Connor, M, and Beato, M. A comparison of training and match play external load during a congested in-season period in English League 2 Football. J Strength Cond Res 37(9): e527-e534, 2023-This study aimed to investigate if external training load metrics differ between training days and match day (MD) during a period of fixture congestion and to verify if external load metrics vary based on playing positions. Training and MD data were collected in a part of the competition phase of the 2020-2021 season (6 weeks) in the English Football League 2 ( N = 20 players, mean ± SD s: age = 24.4 ± 4.7 years). Global Navigation Satellite System units (Catapult S7 Vector 10 Hz) were used to monitor external load metrics. The metrics were duration of training, total distance (TD), high-speed running distance (HSR), sprinting distance, relative intensity (m/min), total accelerations (TotAcc) (>3 m·s -2 ), and total decelerations (TotDec) (<-3 m·s -2 ). This study found that duration, TD, relative intensity, HSR distance, sprint distance, TotAcc, and TotDec were different ( p < 0.001, d = small to moderate ) between MD and match day minus two (MD-2) or match day minus one (MD-1); however, during match day minus four (MD-4), only relative intensity was significantly lower ( p < 0.001) compared with MD output. Therefore, MD-4 was the most demanding training session of the week (after the MD), and during MD-2 and MD-1, coaches decreased players' load to favor players' readiness. Moreover, this study found that MD and MD-1 resulted in statistically different values across several metrics between different playing positions (defenders < midfielders and strikers), whereas metrics in MD-4 and MD-2 were not statistically different, which highlights that in these sessions, players have similar external loads independently from their playing positions.

The HSPB1-p62/SQSTM1 functional complex regulates the unconventional secretion and transcellular spreading of the HD-associated mutant huntingtin protein

Conformational diseases, such as Alzheimer, Parkinson and Huntington diseases, are part of a common class of neurological disorders characterized by the aggregation and progressive accumulation of proteins bearing aberrant conformations. Huntington disease (HD) has autosomal dominant inheritance and is caused by mutations leading to an abnormal expansion in the polyglutamine (polyQ) tract of the huntingtin (HTT) protein, leading to the formation of HTT inclusion bodies in neurons of affected patients. Interestingly, recent experimental evidence is challenging the conventional view by which the disease pathogenesis is solely a consequence of the intracellular accumulation of mutant protein aggregates. These studies reveal that transcellular transfer of mutated huntingtin protein is able to seed oligomers involving even the wild-type (WT) forms of the protein. To date, there is still no successful strategy to treat HD. Here, we describe a novel functional role for the HSPB1-p62/SQSTM1 complex, which acts as a cargo loading platform, allowing the unconventional secretion of mutant HTT by extracellular vesicles. HSPB1 interacts preferentially with polyQ-expanded HTT compared with the WT protein and affects its aggregation. Furthermore, HSPB1 levels correlate with the rate of mutant HTT secretion, which is controlled by the activity of the PI3K/AKT/mTOR signalling pathway. Finally, we show that these HTT-containing vesicular structures are biologically active and able to be internalized by recipient cells, therefore providing an additional mechanism to explain the prion-like spreading properties of mutant HTT. These findings might also have implications for the turn-over of other disease-associated, aggregation-prone proteins.

Point prevalence audit surveys of respiratory tract infection consultations and antibiotic prescribing in primary care before and during the COVID-19 pandemic in Ireland

BACKGROUND

Respiratory tract infections (RTIs) are the most common reason for prescribing antibiotics in general practice. The COVID-19 pandemic has impacted on antibiotic prescribing and delivery of primary care in Ireland.

OBJECTIVES

To assess the quality of antibiotic prescribing, the impact of the COVID-19 pandemic and identify opportunities for antimicrobial stewardship (AMS) in Ireland.

METHODS

Point prevalence audit surveys for RTI consultations were conducted as part of a European study at three time periods: January-February 2020, March-May 2020 and March-May 2021. Antibiotic prescribing was assessed and comparisons made between the three time periods.

RESULTS

In total, 765 consultations were recorded, which were mainly face to face before the pandemic, but changed to predominantly remote consultations during the pandemic surveys in 2020 and 2021 (82% and 75%). Antibiotics were prescribed in 54% of RTI consultations before the pandemic. During pandemic surveys, this dropped to 23% in 2020 and 21% in 2021. There was a decrease in prescribing of Red (reserve) agents in 2021. Assessment against indication-specific quality indicators showed a high proportion of consultations for bronchitis and tonsillitis resulting in an antibiotic prescription (67% and 85%). Point-of-care testing (POCT) to aid diagnosis of RTIs were utilized in less than 1% of consultations.

CONCLUSIONS

During the COVID-19 pandemic, there was a reduction in antibiotic prescribing. Opportunities identified to support AMS in primary care in Ireland are targeted initiatives to reduce antibiotic prescribing for bronchitis and tonsillitis and introducing POCT to support appropriate antibiotic prescribing.

External ventricular drainage in the management of pediatric patients with posterior fossa tumors and hydrocephalus: a retrospective cohort study

PURPOSE

To determine whether intraoperative adjunctive EVD placement in patients with a posterior fossa tumor (PFT) led to improved surgical, radiographic, and clinical outcomes compared to those who did not receive an EVD.

METHODS

Patients were grouped as those who underwent routine intraoperative adjunctive EVD insertion and those who did not at time of PFT resection. Patients who pre-operatively required a clinically indicated EVD insertion were excluded. Comparative analyses between both groups were conducted to evaluate clinical, radiological, and pathological outcomes. Odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were computed for post-operative outcomes.

RESULTS

Fifty-five selected patients were included, 15 who had an EVD placed at the time of PFT resection surgery, and 40 who did not. Children without an EVD did not experience a higher rate of complications or poorer post-operative outcomes compared to those with an EVD placed during resection surgery. There was no significant difference in the degree of gross total resection (p = 0.129), post-operative CSF leak (p = 1.000), and post-operative hemorrhage (p = 0.554) between those with an EVD and those without. The frequency of new cranial nerve deficits post-operatively was higher in those with an EVD (40%) compared to those without (3%, p = 0.001). There was a trend towards more frequently observed post-operative hydrocephalus in the EVD group (p = 0.057).

CONCLUSION

The routine use of EVD as an intraoperative adjunct in clinically stable pediatric patients with posterior fossa tumors and hydrocephalus may not be associated with improved radiological or clinical outcomes.

Characterization of an RNA binding protein interactome reveals a context-specific post-transcriptional landscape of MYC-amplified medulloblastoma

Pediatric medulloblastoma (MB) is the most common solid malignant brain neoplasm, with Group 3 (G3) MB representing the most aggressive subgroup. MYC amplification is an independent poor prognostic factor in G3 MB, however, therapeutic targeting of the MYC pathway remains limited and alternative therapies for G3 MB are urgently needed. Here we show that the RNA-binding protein, Musashi-1 (MSI1) is an essential mediator of G3 MB in both MYC-overexpressing mouse models and patient-derived xenografts. MSI1 inhibition abrogates tumor initiation and significantly prolongs survival in both models. We identify binding targets of MSI1 in normal neural and G3 MB stem cells and then cross referenced these data with unbiased large-scale screens at the transcriptomic, translatomic and proteomic levels to systematically dissect its functional role. Comparative integrative multi-omic analyses of these large datasets reveal cancer-selective MSI1-bound targets sharing multiple MYC associated pathways, providing a valuable resource for context-specific therapeutic targeting of G3 MB.

KIdney aNd blooD prESsure ouTcomes in Childhood Cancer Survivors: Description of Clinical Research Protocol of the KINDEST-CCS Study

Background

Approximately 30% of childhood cancer survivors (CCSs) will develop chronic kidney disease (CKD) or hypertension 15 to 20 years after treatment ends. The incidence of CKD and hypertension in the 5-year window after cancer therapy is unknown. Moreover, extent of monitoring of CCS with CKD and associated complications in current practice is underexplored. To inform the development of new and existing care guidelines for CCS, the epidemiology and monitoring of CKD and hypertension in the early period following cancer therapy warrants further investigation.

Objective

To describe the design and methods of the KIdney aNd blooD prESsure ouTcomes in Childhood Cancer Survivors study, which aims to evaluate the burden of late kidney and blood pressure outcomes in the first ~10 years after cancer therapy, the extent of appropriate screening and complications monitoring for CKD and hypertension, and whether patient, disease/treatment, or system factors are associated with these outcomes.

Design

Two distinct, but related studies; a prospective cohort study and a retrospective cohort study.

Setting

Five Ontario pediatric oncology centers.

Patients

The prospective study will involve 500 CCS at high risk for these late effects due to cancer therapy, and the retrospective study involves 5,000 CCS ≤ 18 years old treated for cancer between January 2008 and December 2020.

Measurements

Chronic kidney disease is defined as Estimated glomerular filtration rate <90 mL/min/1.73 m² or albumin-to-creatinine ratio ≥ 3mg/mmol. Hypertension is defined by 2017 American Academy of Pediatrics guidelines.

Methods

Prospective study: we aim to investigate CKD and hypertension prevalence and the extent to which they persist at 3- and 5-year follow-up in CCS after cancer therapy. We will collect detailed biologic and clinical data, calculate CKD and hypertension prevalence, and progression at 3- and 5-years post-therapy. Retrospective study: we aim to investigate CKD and hypertension monitoring using administrative and health record data. We will also investigate the validity of CKD and hypertension administrative definitions in this population and the incidence of CKD and hypertension in the first ~10 years post-cancer therapy. We will investigate whether patient-, disease/treatment-, or system-specific factors modify these associations in both studies.

Limitations

Results from the prospective study may not be generalizable to non-high-risk CCS. The retrospective study is susceptible to surveillance bias.

Conclusions

Our team and knowledge translation plan is engaging patient partners, researchers, knowledge users, and policy group representatives. Our work will address international priorities to improve CCS health, provide the evidence of new disease burden and practice gaps to improve CCS guidelines, implement and test revised guidelines, plan trials to reduce CKD and hypertension, and improve long-term CCS health.

A primary DICER1-sarcoma with KRAS and TP53 mutations in a child with suspected ECCL

A child had been followed since infancy by our multi-disciplinary neuro-oncology clinic with annual magnetic resonance imaging (MRI) under the presumed diagnosis of encephalocraniocutaneous lipomatosis (ECCL), with clinical features including nevus psiloliparus, scalp lipoma, nodular skin tag on and coloboma of the eyelid, cortical atrophy and meningeal angiomatosis. At the age of 4, she was found to have a large temporoparietal lesion causing elevated intracranial pressure requiring surgical resection. Histopathological exam of the tumor was suggestive of an intracranial sarcoma. Sequencing analysis of the tumor revealed mutations in DICER1, KRAS and TP53. Subsequent germline testing confirmed DICER1 syndrome and revealed an insignificant FGFR1 variant at a low frequency. Methylation profile of the tumor showed the tumor clustered most closely with sarcoma (rhabdomyosarcoma-like), confirming this tumor to be a primary DICER1-sarcoma. Compared to the previously reported cases, our unique case of primary DICER1-sarcoma also demonstrated neurofilament and chromogranin positivity, and genomic instability with loss of chromosome 4p, 4q, 8p, 11p, and 19p, as well as gains in chromosome 7p, 9p, 9q, 13q, and 15q on copy variant analysis. The detailed sequencing and methylation information discovered in this unique case of DICER1-sarcoma will hopefully help further our understanding of this rare and emerging entity.

Late effects care for childhood brain Tumor Survivors: A Quality-Improvement Initiative

Childhood and adolescent brain tumor survivors are at risk for long-term consequences of therapy. We reviewed adherence to long-term follow-up (LTFU) guidelines, assessed provider perspectives, and studied the needs, experience and quality of life (QOL) of pediatric malignant brain tumor survivors in the McMaster Children's Hospital Neuro-Oncology clinic. LTFU areas for improvement were evaluated using an anonymous health provider needs assessment questionnaire. The Cancer Care Experience Questionnaire (CCEQ), Cancer Worry Scale (CWS), Self-Management Skills Scale (SMSS), and PedsQL measured parents/patients' needs and QOL. Individual care plans were based on the Children's Oncology Group (COG) LTFU guidelines. Based on 17 responses, staff perceived areas for improvement included: increased multi-disciplinary participation, improved patient education and increased surveillance for therapy-related late effects. Thirty-two families participated, most felt they received high-quality care. Mean cancer worry scores were low (71.8 (± 28.4)). Survivors reported limited self-management skills (58.5 (±18.2)), requiring support with medical needs and activities of daily living. Overall median QOL scores were 'good' (parental report 72.3 (±17.7), survivor 68.2 (±16.6)). Utilizing survivorship guidelines and assessments from patients, caregivers and health providers, we implemented improvements in our provision of neuro-oncology survivorship care. Lessons learned may assist other LTFU programs.

A feasibility study of a pharmacist led proton pump inhibitor deprescribing intervention in older patients in an Irish hospital

Introduction

Proton pump inhibitors (PPIs) are over-prescribed and prescribed inappropriately in the older population and have the potential for long-term adverse effects e.g. increased fracture risk, C. difficile infection, chronic kidney disease and drug interactions (1). Hospitalisation of older patients presents an opportunity for review of the PPI indication and potential for deprescribing.

Aim

The study aimed to assess the feasibility of a pharmacist led intervention to deprescribe inappropriately prescribed PPIs in patients ≥65 years in an Irish teaching hospital.

Methods

A multi-component feasibility intervention consisting of an education session for the medical team, followed by pharmacist-led screening of patients for potential PPI deprescribing, was conducted. The education session was delivered by the pharmacist to a geriatric medical team and the content outlined the prevalence of PPI prescribing, potential long-term effects of PPIs, and implementation of a PPI deprescribing algorithm. Over an eight-week period (May-June 2021), new admissions to the geriatric team were screened daily by the pharmacist and PPI prescribing patterns and indications were recorded. Patients ≥65 years were reviewed for PPI appropriateness based on their medical history and use of a PPI deprescribing algorithm (2). If the PPI was eligible for deprescribing (i.e. dose reduction or discontinuation) this was discussed with the geriatric team and the patient’s primary care general practitioner (GP) and the patient. Patients were counselled and educated on this by the pharmacist. Patients whose PPI was deprescribed were followed up at 4- and 12- weeks post deprescribing to assess their symptoms and satisfaction with deprescribing in the interim period. An online survey was sent to the geriatric team doctors evaluating their views on the study process and implementation of PPI deprescribing in practice; data was analysed descriptively using Microsoft Excel®. Written, informed consent was obtained from all patients and doctors involved.

Results

Of a total of 133 patient charts reviewed over the 8-week period, 94 patients were prescribed a PPI, with esomeprazole 40mg (43/94, 45.7%) being most commonly prescribed PPI, followed by pantoprazole 40mg (17/94, 18.1%). PPIs were inappropriately prescribed as per the indication in 36 cases (36/94, 38.3%). Following GP and Geriatric team discussion, 7/94 (7.4%) of patients were eligible for deprescribing, of which 5 had their PPI dose reduced (5/94, 5.3%). One patient declined the deprescribing, in another case the GP declined the deprescribing recommendation. The 5 patients deprescribed had their esomeprazole 40mg daily dose reduced to 20mg daily. This was sustained at the 12-week follow up and patients reported satisfaction with the change with no negative outcomes reported.

Of the 12 geriatric doctors in the study, 6 completed the online survey. The majority reported barriers to PPI deprescribing being uncertainty regarding the indication (5/6) and being unable to monitor the patient after hospital discharge (5/6). All doctors agreed that pharmacists have a positive role to play in implementing PPI deprescribing.

Conclusion

This study found that esomeprazole 40mg daily was the most commonly prescribing PPI in this hospital cohort, with the majority of PPI prescribing found to be inappropriate according to the indication. The feasibility study resulted in a number of patients having their PPI safely deprescribed with a dose reduction. Despite the limitation of a small sample size and small rates of deprescribing, a strength of the study was that a pharmacist led PPI deprescribing initiative resulted in reducing inappropriate PPI prescribing in older patients, with positive engagement from the geriatric medical team. Further resources and research are required to implement this initiative on a wider scale.

References

(1) Wilsdon TD, Hendrix I, Thynne TR, Mangoni AA. Effectiveness of Interventions to Deprescribe Inappropriate Proton Pump Inhibitors in Older Adults. Drugs Aging. 2017 Apr;34(4):265-287. doi: 10.1007/s40266-017-0442-1. PMID: 28220380.

(2) National Health Service. Proton Pump Inhibitor (PPI): Deprescribing algorithm (adult) [Internet]. [cited 2021 Aug 6]. Available from: https://www.dorsetccg.nhs.uk/Downloads/aboutus/medicines-management/Other Guidelines/prescqipp proton-pump-inhibitor-desprescribing-algorithm.pdf

Exploring the human factors of medication errors in community pharmacy: a mixed methods study

Introduction

Medication errors and near misses in the community pharmacy dispensing process have the potential to adversely impact patient safety. The World Health Organisation has identified the importance of Human factors (HF) in the Patient Safety Curriculum guide (1). However, there is a lack of knowledge on how HF principles have or could be applied in the community pharmacy setting. Adopting a HF approach and using qualitative methods can provide in-depth understanding of factors that contribute to these errors, and contribute to intervention development that may improve patient safety.

Aim

The study aims to investigate the factors contributing to medication dispensing errors and near misses in community pharmacy, and to gather pharmacists’ views of these factors and how these could be mitigated.

Methods

Three Irish community pharmacies were recruited and provided details of the last ten dispensing errors or near misses which occurred. Each error was mapped to the Hierarchical Task Analysis (HTA) steps developed for this study, and mapped to the Systematic Human Error Reduction and Prediction Approach (SHERPA) framework (2). A detailed report was prepared for each pharmacy outlining the error analysis, with recommendations to prevent the errors in future. A qualitative semi-structured interview was conducted with the three pharmacists in the recruited pharmacies to discuss the report, and analysed by thematic analysis.

Results

A total of 30 medication errors/near misses were analysed (10 errors reached the patients and were not administered). The HTA developed outlines 185 subtasks potentially involved in dispensing a prescribed medication. On mapping to the SHERPA framework, selection-based errors were the most frequently reported error category (21/30, 70%); this included incorrect product selection from the shelf (17/30, 56.7%) and incorrect product selection at the point of computer entry (4/30, 13.3%). Of the 75 HTA steps involved across the 30 errors, the most frequent point of error was in the gathering medication steps (47/75, 62.7%), followed by the pharmacist accuracy check steps (16/75, 21.3%) and patient mix up errors (5/30, 16.7%). The pharmacist interview themes found that cognitive burden, fatigue, distraction and staffing deficiencies were reported as increasing the risk of error and near miss. Knowledge gaps and inexperience with certain medications were also reported as contributing to errors. Recommendations to prevent errors included changes to the physical environment (e.g. using product shelf alerts), improved checking processes and taking short mental breaks.

Conclusion

This study found that the most common errors/near misses were at the product selection stage of dispensing, with pharmacy accuracy checks sometimes, but not always, detecting these before they reached the patient. Medication errors occur due to several varying and often interacting factors; cognitive burden and lack of standardised medication checking processes. Despite the small sample size and potential for social desirability bias in the interviews, this study has demonstrated how HF techniques can be applied to the dispensing process as a means of understanding and preventing error occurrence in the community pharmacy.

References

(1) Vosper H, Hignett S. A UK perspective on human factors and patient safety education in pharmacy Curricula. Am J Pharm Educ. 2017;82:6184.

(2) Sutherland A, Ashcroft DM, Phipps DL. Exploring the human factors of prescribing errors in paediatric intensive care units. Arch Dis Child 2019;104:588-595.

P04 An evaluation of antimicrobial stewardship education in the School of Pharmacy of an Irish university—a mixed methods study

Background

Antimicrobial stewardship (AMS) is essential to control the emergence of antimicrobial resistance (AMR) which has become an international health priority. Education of undergraduate students on AMS and AMR is a strategic objective in the WHO Global Action Plan on AMR and Ireland's National Action Plan.^1,2 Research on AMS/AMR education has focused primarily on medical students with less emphasis on those from other healthcare profession including pharmacy students.

Objectives

To investigate AMS and AMR education in the Pharmacy undergraduate programme in the School of Pharmacy of an Irish University.

Methods

A mixed methods study was conducted. Ten semi-structured interviews were conducted in October 2019 with academic staff to capture their views on AMS education. Participants included staff members from different disciplines, those identified as involved in teaching elements of infectious disease, antibiotics, AMS and related topics, and those involved in curriculum design and approval within the School of Pharmacy. Interview transcripts were analysed by thematic analysis. An electronic survey of 17 questions was emailed to all second to fifth year UCC Pharmacy students in October 2019 to gather students’ views and experiences of AMS education. The survey contained four sections which addressed demographics, AMS, resources and education using open-ended, closed-ended or Likert-scale questions. Ethical approval was obtained.

Results

Six key themes were identified from the ten interviews: (i) curriculum priorities and capacity; (ii) housing of the subject, fragmentation and cohesion; (iii) integration; (iv) communication; (v) teaching methods; and (vi) assessment methods. 113 students participated in the survey (32.3% response rate). 96% agree that a strong knowledge of antimicrobials for their future careers is important, and over 89% of students desire more education on AMR and AMS. Only 43% of students found their AMS education provided sufficient preparation for practice. Students felt most prepared to recognize clinical signs of infection and least prepared for IV to oral switching, interpreting biological marker and de-escalation of antimicrobials. Over 50% of students never used or were not familiar with the national primary care antimicrobial guidelines: www.antibioticprescribing.ie.

Conclusions

Pharmacy students and staff agree that AMS and AMR are important and need enhanced educational focus. Students feel there are gaps in their AMS education and expressed a desire for more education in this area. Improved communication and identification of curriculum priorities by staff could help to establish a more cohesive and comprehensive educational approach to this area.

The protected antimicrobial process in a University Teaching Hospital: a qualitative interview study exploring the knowledge, attitudes, and experiences of healthcare professionals

Background The protected or restricted supply of certain antimicrobials such as linezolid, caspofungin, aztreonam, in the acute hospital setting is an important element of Antimicrobial Stewardship (AMS) programmes to address the growing problem of antimicrobial resistance. This process involves submitting an application for use to be reviewed typically by a Consultant Microbiologist, Infectious Disease Consultant or Antimicrobial Pharmacist. Aim To investigate healthcare professionals’ knowledge, experiences, and attitudes towards the protected/restricted antimicrobials process in order to identify possible methods of optimisation and improvement. Method Semi-structured interviews with stakeholders involved in the protected/restricted antimicrobial prescribing, dispensing and administration process were conducted in September–October 2019 in a 350-bed voluntary, general, acute hospital in Ireland. Interviews were analysed by the Framework method and mapped to the Theoretical Domains Framework (TDF). Results Interviews were conducted with 8 Doctors, 4 Pharmacists and 3 Nurses. TDF domains identified included: ‘Knowledge’; ‘Social/professional role and identity’; ‘Social influences’; ‘Memory, attention and decision processes’; ‘Beliefs about consequences’; ‘Environmental contexts and resources’. The relationship between prescribers and the AMS Team was reported as a facilitator of the process, whereas the inconsistency of the filing and versions of forms on the wards were seen as challenges. Conclusion The results of this study have shown that the existing protected/restricted antimicrobial process is a multi-disciplinary effort with barriers that require attention in order to make future improvements. Standardization of the form across all wards, an electronic version of the form, and structured education around AMS were suggested to optimize the process.

Food for all: designing sustainable and secure future seafood systems

Food from the sea can make a larger contribution to healthy and sustainable diets, and to addressing hunger and malnutrition, through improvements in production, distribution and equitable access to wild harvest and mariculture resources and products. The supply and consumption of seafood is influenced by a range of 'drivers' including ecosystem change and ocean regulation, the influence of corporations and evolving consumer demand, as well as the growing focus on the importance of seafood for meeting nutritional needs. These drivers need to be examined in a holistic way to develop an informed understanding of the needs, potential impacts and solutions that align seafood production and consumption with relevant 2030 Sustainable Development Goals (SDGs). This paper uses an evidence-based narrative approach to examine how the anticipated global trends for seafood might be experienced by people in different social, geographical and economic situations over the next ten years. Key drivers influencing seafood within the global food system are identified and used to construct a future scenario based on our current trajectory (Business-as-usual 2030). Descriptive pathways and actions are then presented for a more sustainable future scenario that strives towards achieving the SDGs as far as technically possible (More sustainable 2030). Prioritising actions that not only sustainably produce more seafood, but consider aspects of access and utilisation, particularly for people affected by food insecurity and malnutrition, is an essential part of designing sustainable and secure future seafood systems.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11160-021-09663-x.

Food for all: designing sustainable and secure future seafood systems

Food from the sea can make a larger contribution to healthy and sustainable diets, and to addressing hunger and malnutrition, through improvements in production, distribution and equitable access to wild harvest and mariculture resources and products. The supply and consumption of seafood is influenced by a range of 'drivers' including ecosystem change and ocean regulation, the influence of corporations and evolving consumer demand, as well as the growing focus on the importance of seafood for meeting nutritional needs. These drivers need to be examined in a holistic way to develop an informed understanding of the needs, potential impacts and solutions that align seafood production and consumption with relevant 2030 Sustainable Development Goals (SDGs). This paper uses an evidence-based narrative approach to examine how the anticipated global trends for seafood might be experienced by people in different social, geographical and economic situations over the next ten years. Key drivers influencing seafood within the global food system are identified and used to construct a future scenario based on our current trajectory (Business-as-usual 2030). Descriptive pathways and actions are then presented for a more sustainable future scenario that strives towards achieving the SDGs as far as technically possible (More sustainable 2030). Prioritising actions that not only sustainably produce more seafood, but consider aspects of access and utilisation, particularly for people affected by food insecurity and malnutrition, is an essential part of designing sustainable and secure future seafood systems.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11160-021-09663-x.

Antimicrobial use and antimicrobial resistance in Enterobacterales and Enterococcus faecium: a time series analysis

BACKGROUND

Irish and European antimicrobial resistance (AMR) surveillance data have highlighted increasing AMR in Enterobacterales and vancomycin resistance in Enterococcus faecium (VRE). Antimicrobial consumption (AC) in Irish hospital settings is also increasing.

METHODS

A retrospective time series analysis (TSA) was conducted to evaluate the trends and possible relationship between AC of selected antimicrobials and AMR in Enterobacterales and vancomycin resistance in E. faecium, from January 2017 to December 2020.

RESULTS

Increased AC was seen with ceftriaxone (p= 0.0006), piperacillin/tazobactam (p = 0.03) and meropenem (p = 0.05), while ciprofloxacin and gentamicin use trended downwards. AMR rates in E. coli, K. pneumoniae and other Enterobacterales were largely stable, an increase in ertapenem resistance in the latter from 0.58% in 2017 to 5.19% in 2020 (p= 0.003) being the main concern. The proportion of E. faecium that was VRE did not changed significantly (64% in 2017; 53% in 2020, p = 0.1). TSA identified a correlation between piperacillin/tazobactam use and the decreasing rate of ceftriaxone resistance in E. coli.

CONCLUSION

Our data suggest that hospital antimicrobial stewardship programme is largely containing, but not reducing AMR in key nosocomial pathogens. An increase in AC following the COVID-19 pandemic appears as yet to have had no impact on AMR rates.

Utility of a Cancer Predisposition Screening Tool for Predicting Subsequent Malignant Neoplasms in Childhood Cancer Survivors

PURPOSE

Childhood cancer survivors (CCS) are at risk of developing subsequent malignant neoplasms (SMNs) resulting from exposure to prior therapies. CCS with underlying cancer predisposition syndromes are at additional genetic risk of SMN development. The McGill Interactive Pediatric OncoGenetic Guidelines (MIPOGG) tool identifies children with cancer at increased likelihood of having a cancer predisposition syndrome, guiding clinicians through a series of Yes or No questions that generate a recommendation for or against genetic evaluation. We evaluated MIPOGG's ability to predict SMN development in CCS.

METHODS

Using the provincial cancer registry (Ontario, Canada), and adopting a nested case-control approach, we identified CCS diagnosed and/or treated for a primary malignancy before age 18 years (1986-2015). CCS who developed an SMN (cases) were matched, by primary cancer and year of diagnosis, with CCS who did not develop an SMN (controls) over the same period (1:5 ratio). Potential predictors for SMN development (chemotherapy, radiation, and MIPOGG output) were applied retrospectively using clinical data pertaining to the first malignancy. Conditional logistic regression models estimated hazard ratios and 95% CIs associated with each covariate, alone and in combination, for SMN development.

RESULTS

Of 13,367 children with a primary cancer, 317 (2.4%) developed an SMN and were matched to 1,569 controls. A MIPOGG output recommending evaluation was significantly associated with SMN development (hazard ratio 1.53; 95% CI, 1.06 to 2.19) in a multivariable model that included primary cancer therapy exposures. MIPOGG was predictive of SMN development, showing value in nonhematologic malignancies and in CCS not exposed to radiation.

CONCLUSION

MIPOGG has additional value for SMN prediction beyond treatment exposures and may be beneficial in decision making for enhanced individualized SMN surveillance strategies for CCS.

Quality indicators for hospital antimicrobial stewardship programmes: a systematic review

BACKGROUND

Measuring the quality and effectiveness of antimicrobial stewardship (AMS) programmes with quality indicators (QIs) is an area of increasing interest. We conducted a systematic review to identify QIs of AMS programmes in the hospital setting and critically appraise their methodological quality.

METHODS

We searched the Cochrane Library, PubMed, MEDLINE, EMBASE, CINAHL, Scopus/web of science databases and the grey literature for studies that defined and/or described the development process and characteristics of the QIs developed. The Appraisal of Indicators through Research and Evaluation (AIRE) instrument was used to critically appraise the methodological quality of the QI sets.

RESULTS

We identified 16 studies of QI sets consisting of 229 QIs. The QI sets addressed a broad range of areas of AMS in the hospital setting and consisted of 75% process indicators, 24% structural indicators and 1% outcome indicators. There was a wide variation in the information and level of detail presented describing the methodological characteristics of the QI sets identified.

CONCLUSIONS

The QIs identified in this study focused on process and structural indicators with few outcome indicators developed-a major deficiency in this area. Future research should focus on the development of outcome indicators or the use of process or structural indicators linked to outcomes to assess AMS. Testing of the QIs in practice is an essential methodological element of the QI development process and should be included in the QI development study or as planned validation work.

EPCT-12. NATIONAL MULTICENTERED RETROSPECTIVE REVIEW OF DEMOGRAPHIC, TUMOUR AND INTRAOPERATIVE FEATURES ASSOCIATED WITH THE DEVELOPMENT OF CEREBELLAR MUTISM AFTER PEDIATRIC POSTERIOR FOSSA TUMOUR RESECTION

Background

Cerebellar mutism (CM) is a condition characterized by a significant lack or loss of speech in children following posterior fossa (PF) surgery. The biological origin of CM remains largely unclear and remains the subject of ongoing debate. Despite multidisciplinary rehabilitative interventions, the outcome is less favorable than initially described. Given the treatment refractory nature of CM, central to its management is prevention.

Methods

A national multi-centered retrospective review of all the children undergoing posterior fossa resection at 4 Canadian academic pediatric institutions was undertaken. Patient, tumour, surgical features suggested to be associated with the post-operative development of CM were reviewed to identify pre-operative and intra-operative factors that may predict post-operative CM occurrence.

Results

258 pediatric patients were identified after posterior fossa lesion resection. Mean age at surgery was 6.74 years (SD 4.60) and 42.2% were female. Frozen section was available in 90.3% of cases. The majority of final tumour histology was medulloblastoma (35.7%), pilocytic astrocytoma (32.6%), ependymoma (17.1%) and exophytic glioma (1.2%). Intra-operative impression of adherence to the floor of the 4th ventricle was negative in 47.7%, positive in 36.8% of cases. The extent of resection assessed intraoperatively as gross total resection was 69.8% of cases. Intra-operative abrupt changes in blood pressure and/or heart rate was identified in 19.4% and 17.8% of cases. CM was experienced in 19.5% of patients (N=50), with the majority of cases identified by post-operative day 7. The clinical resolution of CM as mainly assessed by a neurosurgeon (86%) and was complete, significantly resolved, slight improvement, no improvement or deterioration in 56.0%, 8.0%, 20.0%, 14.0%, 2.0% respectively.

Conclusion

As a devastating surgical complication, identifying and understanding the biological origin of CM is the first step to complication avoidance. Maximal safe resection irrespective of intra-operative pathology remains the goal to avoid the devastating complication of CM.

Canadian Pediatric Neuro-Oncology Standards of Practice

Primary CNS tumors are the leading cause of cancer-related death in pediatrics. It is essential to understand treatment trends to interpret national survival data. In Canada, children with CNS tumors are treated at one of 16 tertiary care centers. We surveyed pediatric neuro-oncologists to create a national standard of practice to be used in the absence of a clinical trial for seven of the most prevalent brain tumors in children. This allowed description of practice across the country, along with a consensus. This had a multitude of benefits, including understanding practice patterns, allowing for a basis to compare in future research and informing Health Canada of the current management of patients. This also allows all children in Canada to receive equivalent care, regardless of location.

QOL-46. LATE EFFECTS CARE FOR CHILDHOOD BRAIN TUMOUR SURVIVORS: A QUALITY IMPROVEMENT PROJECT

BACKGROUND

Childhood and adolescent brain tumor survivors are at risk for considerable late morbidity and mortality from their disease and the treatment they receive. Surgery, chemotherapy, radiation therapy and tumor location all have the potential to impact the physical, psychological, functional and social health of these survivors. Comprehensive late effects care may mitigate these risks, but the necessary elements of this care model is unclear. We describe a quality-improvement initiative to improve the long-term follow-up (LTFU) care provided to brain tumour survivors at the McMaster Children’s Hospital.

METHODS

An anonymous needs assessment circulated to health providers was used to evaluate the LTFU practices. Utilizing this feedback as well as the LTFU guidelines from the Children’s Oncology Group a care plan was made for these survivors.

RESULTS

17 of 33 (52%) health care staff responded to the survey, this included 70% physicians or nurse practitioners, and 30% nurses and allied health staff. Improvements suggested included consistent inclusion of additional care providers (i.e. social work, dietitians, endocrinology) reported by 76%, as well as a need for improved patient education and surveillance for late effects of therapy.

CONCLUSION

Treatment summaries with surveillance care plans and LTFU resources were created for all survivors of childhood brain tumours at risk of treatment-related complications. Late effects counselling with distribution of these materials is ongoing as part of this quality improvement initiative. To provide comprehensive management, a neuro-oncology specific late effects programs with multi-disciplinary support is essential for the care of brain tumour survivors.

MBRS-01. DISSECTING REGULATORS OF THE ABERRANT POST-TRANSCRIPTIONAL LANDSCAPE IN MYC-AMPLIFIED GROUP 3 MEDULLOBLASTOMA

Medulloblastoma (MB) is the most common solid malignant pediatric brain neoplasm, with Group 3 (G3) MB representing the most aggressive subgroup. MYC amplification is an independent poor prognostic factor in G3 MB, however, therapeutic targeting of the MYC pathway remains limited and alternative therapies for G3 MB are urgently needed. Here we show that an RNA-binding protein, Musashi-1 (MSI1) is an essential mediator of G3 MB in both MYC-overexpressing mouse models and patient-derived xenografts. Unbiased integrative multi-omics analysis of MSI1 function in human G3 MB suggests a paradigm shift beyond traditional gene-based profiling of oncogenes. Here we identify MSI1 as an oncogene in G3 MB driving stem cell self-renewal through stabilization of HIPK1 mRNA, a downstream context-specific therapeutic target for drug discovery.

QOL-02. PERCEPTIONS OF LATE EFFECTS CARE NEEDS AMONG SURVIVORS OF PEDIATRIC BRAIN TUMOURS

OBJECTIVES

Pediatric brain tumour survivors are at risk of long-term consequences of therapy. Comprehensive late effects care may mitigate these risks, but the best care model is unclear. We sought to describe the care experience and quality of life (QOL) of pediatric brain tumour survivors at the McMaster Children’s Hospital joint adult/pediatric Neuro-Oncology clinic.

METHODS

Cross-sectional survey data were collected. Care needs were assessed with the Cancer Care Experience Questionnaire (CCEQ), Cancer Worry Scale (CWS), and Self-Management Skills Scale (SMSS). Quality of life was measured utilizing the PedsQL Brain Tumor Module. Data were analyzed descriptively.

RESULTS

Thirty-two childhood brain tumor survivors and/or their parents participated. Their malignancies included embryonal tumors (medulloblastoma/ATRT) (62%), ependymoma (22%), and germ cell tumours (16%). Among 77%, therapy included chemotherapy, surgery and radiation. Most respondents reported high quality cancer care, although some could not recall discussions of late effects risks and health promotion. Mean cancer worry scores were low (71.8 (± 28.4)). Survivors reported limited self-management skills (58.5 (±18.2)), with support required in clinic visits, arranging medical appointments, filling prescriptions and tasks of daily living. Overall median QOL scores were in the ‘good’ range (parental report 72.3 (±17.7), survivor 68.2 (±16.6)).

CONCLUSION

In comparison to other childhood cancer survivor cohorts, this group of long-term brain tumour survivors appear to have similar QOL, fewer cancer worries, and increased need for aid with self-management. Given this, along with the positive care experience reported, this clinic model of care appears to meet the needs of this population.

A qualitative process evaluation of the introduction of procalcitonin testing as an antimicrobial stewardship intervention

Background Successful antimicrobial stewardship interventions are imperative in today's environment of antimicrobial resistance. New antimicrobial stewardship interventions should include qualitative analysis such as a process evaluation to determine which elements within an intervention are effective and provide insight into the context in which the intervention is introduced. Objective To assess the implementation process and explore the contextual factors which influenced implementation. Setting An academic teaching hospital in Cork, Ireland. Methods A process evaluation was conducted on completion of a feasibility study of the introduction of a procalcitonin antimicrobial stewardship intervention. The process evaluation consisted of semi-structured face-to-face interviews of key stakeholders including participating (senior) doctors (5), medical laboratory scientists (3) and a hospital administrator. The Consolidated Framework for Implementation Research was used to guide data collection, analysis, and interpretation. Main outcome measures Qualitative assessment of the intervention implementation process, the contextual factors which influenced implementation and identification of improvements to the intervention and its implementation and determine if proceeding to a randomised controlled trial would be appropriate. Results Analysis of the interviews identified three main themes. (1) The procalcitonin intervention and implementation process was viewed positively to support prescribing decisions. Participants identified modifications to procalcitonin processing and availability to improve implementation and allow procalcitonin to be "more of a clinical influence". (2) In the antimicrobial stewardship context the concept of fear of missing an infection and risks of potentially serious outcomes for patients emerged. (3) The hospital context consisted of barriers such as available resources and facilitators including the hospital culture of quality improvement. Conclusion This process evaluation provides a detailed analysis of the implementation of procalcitonin testing as an antimicrobial stewardship intervention. The positive findings of this process evaluation and feasibility study should be built upon and a full randomised controlled trial and economic evaluation should be conducted in a variety of hospital settings to confirm the effectiveness of procalcitonin as an antimicrobial stewardship intervention.

An investigation of the effects of procalcitonin testing on antimicrobial prescribing in respiratory tract infections in an Irish university hospital setting: a feasibility study

BACKGROUND

Diagnostic uncertainty and a high prevalence of viral infections present unique challenges for antimicrobial prescribing for respiratory tract infections (RTIs). Procalcitonin (PCT) has been shown to support prescribing decisions and reduce antimicrobial use safely in patients with RTIs, but recent study results have been variable.

METHODS

We conducted a feasibility study of the introduction of PCT testing in patients admitted to hospital with a lower RTI to determine if PCT testing is an effective and worthwhile intervention to introduce to support the existing antimicrobial stewardship (AMS) programme and safely decrease antimicrobial prescribing in patients admitted with RTIs.

RESULTS

A total of 79 patients were randomized to the intervention PCT-guided treatment group and 40 patients to the standard care respiratory control group. The addition of PCT testing led to a significant decrease in duration of antimicrobial prescriptions (mean 6.8 versus 8.9 days, P = 0.012) and decreased length of hospital stay (median 7 versus 8 days, P = 0.009) between the PCT and respiratory control group. PCT did not demonstrate a significant reduction in antimicrobial consumption when measured as DDDs and days of therapy.

CONCLUSIONS

PCT testing had a positive effect on antimicrobial prescribing during this feasibility study. The successful implementation of PCT testing in a randomized controlled trial requires an ongoing comprehensive education programme, greater integration into the AMS programme and delivery of PCT results in a timely manner. This feasibility study has shown that a larger randomized controlled trial would be beneficial to further explore the positive aspects of these findings.

Pontine gliomas a 10-year population-based study: a report from The Canadian Paediatric Brain Tumour Consortium (CPBTC)

BACKGROUND

Diffuse intrinsic pontine gliomas (DIPG) are midline gliomas that arise from the pons and the majority are lethal within a few months after diagnosis. Due to the lack of histological diagnosis the epidemiology of DIPG is not completely understood. The aim of this report is to provide population-based data to characterize the descriptive epidemiology of this condition in Canadian children.

PATIENTS AND METHODS

A national retrospective study of children and adolescents diagnosed with DIPG between 2000 and 2010 was undertaken. All cases underwent central review to determine clinical and radiological diagnostic characteristics. Crude incidence figures were calculated using age-adjusted (0-17 year) population data from Statistics Canada. Survival analyses were performed using the Kaplan-Meier method.

RESULTS

A total of 163 patients with pontine lesions were identified. Central review determined one-hundred and forty-three patients who met clinical, radiological and/or histological criteria for diagnosis. We estimate an incidence rate of 1.9 DIPG/1,000,000 children/year in the Canadian population over a 10 years period. Median age at diagnosis was 6.8 years and 50.3% of patients were female. Most patients presented with cranial nerve palsies (76%) and ataxia (66%). Despite typical clinical and radiological characteristics, histological confirmation reported three lesions to be low-grade gliomas and three were diagnosed as CNS embryonal tumor not otherwise specified (NOS).

CONCLUSIONS

Our study highlights the challenges associated with epidemiology studies on DIPG and the importance of central review for incidence rate estimations. It emphasizes that tissue biopsies are required for accurate histological and molecular diagnosis in patients presenting with pontine lesions and reinforces the limitations of radiological and clinical diagnosis in DIPG. Likewise, it underscores the urgent need to increase the availability and accessibility to clinical trials.

Advances in the molecular classification of pediatric brain tumors: a guide to the galaxy

Central nervous system (CNS) tumors are the most common solid tumor in pediatrics, accounting for approximately 25% of all childhood cancers, and the second most common pediatric malignancy after leukemia. CNS tumors can be associated with significant morbidity, even those classified as low grade. Mortality from CNS tumors is disproportionately high compared to other childhood malignancies, although surgery, radiation, and chemotherapy have improved outcomes in these patients over the last few decades. Current therapeutic strategies lead to a high risk of side effects, especially in young children. Pediatric brain tumor survivors have unique sequelae compared to age-matched patients who survived other malignancies. They are at greater risk of significant impairment in cognitive, neurological, endocrine, social, and emotional domains, depending on the location and type of the CNS tumor. Next-generation genomics have shed light on the broad molecular heterogeneity of pediatric brain tumors and have identified important genes and signaling pathways that serve to drive tumor proliferation. This insight has impacted the research field by providing potential therapeutic targets for these diseases. In this review, we highlight recent progress in understanding the molecular basis of common pediatric brain tumors, specifically low-grade glioma, high-grade glioma, ependymoma, embryonal tumors, and atypical teratoid/rhabdoid tumor (ATRT). © 2020 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Symposium review: Multiple-trait single-step genomic evaluation for hoof health

Hoof lesions represent an important issue in modern dairy herds, with reported prevalence in different countries ranging from 40 to 70%. This high prevalence of hoof lesions has both economic and social consequences, resulting in increased labor expenses and decreasing animal production, longevity, reproduction, health, and welfare. Therefore, a key goal of dairy herds is to reduce the incidence of hoof lesions, which can be achieved both by improving management practices and through genetic selection. The Canadian dairy industry has recently released a hoof health sub-index. This national genetic evaluation program for hoof health was achieved by creating a centralized data collection system that routinely transfers data recorded by hoof trimmers into a coherent and sustainable national database. The 8 most prevalent lesions (digital dermatitis, interdigital dermatitis, interdigital hyperplasia, heel horn erosion, sole hemorrhage, sole ulcer, toe ulcer, and white line lesion) in Canada are analyzed with a multiple-trait model using a single-step genomic BLUP method. Estimated genomic breeding values for each lesion are combined into a sub-index according to their economic value and prevalence. In addition, data recorded within this system were used to create an interactive management report for dairy producers by Canadian DHI, including the prevalence of lesions on farm, their trends over time, and benchmarks with provincial and national averages.

Short communication: Time-dependent genetic parameters and single-step genome-wide association analyses for predicted milk fatty acid composition in Ayrshire and Jersey dairy cattle

Milk fat content and fatty acid (FA) composition have great economic value to the dairy industry as they are directly associated with taste and chemical-physical characteristics of milk and dairy products. In addition, consumers' choices are not only based on the nutritional aspects of food, but also on products known to promote better health. Milk FA composition is also related to the metabolic status and physiological stages of cows and thus can also be used as indicator for other novel traits of interest (e.g., metabolic diseases and methane yield). Genetic selection is a promising alternative to manipulate milk FA composition. In this study, we aimed to (1) estimate time-dependent genetic parameters for 5 milk FA groups (i.e., short-chain, medium-chain, long-chain, saturated, and unsaturated) predicted based on milk mid-infrared spectroscopy, for Canadian Ayrshire and Jersey breeds, and (2) conduct a time-dependent, single-step genome-wide association study to identify genomic regions, candidate genes, and metabolic pathways associated with milk FA. We analyzed 31,709 test-day records of 9,648 Ayrshire cows from 268 herds, and 34,341 records of 11,479 Jersey cows from 883 herds. The genomic database contained a total of 2,330 Ayrshire and 1,019 Jersey animals. The average daily heritability ranged from 0.18 (long-chain FA) to 0.34 (medium-chain FA) in Ayrshire, and from 0.25 (long-chain and unsaturated FA) to 0.52 (medium-chain and saturated FA) in Jersey. Important genomic regions were identified in Bos taurus autosomes BTA3, BTA5, BTA12, BTA13, BTA14, BTA16, BTA18, BTA20, and BTA21. The proportion of the variance explained by 20 adjacent SNP ranged from 0.71% (saturated FA) to 1.11% (long-chain FA) in Ayrshire, and from 0.70% (unsaturated FA) to 3.09% (medium-chain FA) in Jersey cattle. Important candidate genes and pathways were also identified, such as the PTK2 and TRAPPC9 genes, associated with milk fat percentage, and HMGCS, FGF10, and C6 genes, associated with fertility traits and immune response. Our findings on the genetic parameters and candidate genes contribute to a better understanding of the genetic architecture of milk FA composition in Ayrshire and Jersey dairy cattle.

Once and Again: Intergenerational Transmission of Parenting

Introduction

Animal and human studies suggest that individual differences in maternal parenting behaviour are transmitted from one generation to the next.

Objective

This study aimed to examine potential psychosocial mechanisms underlying an intergenerational transmission of conceptualization of parenting, including affect, cognition, and parental support.

Methods

In a subsample of 201 first-time mothers participating in the Maternal Adversity, Vulnerability and Neurodevelopment (MAVAN) project, we assessed maternal childhood rearing experiences, using the Parental Bonding Instrument and the Childhood Trauma Questionnaire. At 6 months postpartum, mothers completed questionnaires on parenting stress, symptoms of depression, internalization of maternal care regulation and current relationship with mother and father.

Results

We found significant direct associations of maltreatment and rearing by the grandmother with parenting stress at 6 months. These associations were mediated through distinct psychosocial pathways: the association of maltreatment on higher parenting stress was fully mediated through more maternal symptoms of depression (z = 2.297; P = 022). The association between sub-optimal rearing provided by the mother and higher parenting stress was mediated through lower internalization of maternal care regulation (z = -2.155; P = 031) and to a lesser degree through more symptoms of depression (z = -1.842; P = 065). Finally, higher quality rearing by the grandfather was indirectly related to lower parenting stress through positive current relationship with the father (z = -2.617; P = 009).

Conclusions

There are distinct pathways by which early experiences manifest in parenting stress. By understanding the structure of dysregulated parenting, clinicians will have practical information to specifically target maternal motivation, social supports, and depressed mood to disrupt maladaptive parenting cognitions and practices.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Circulating leptin levels are associated with adiposity in survivors of childhood brain tumors

Survivors of Childhood Brain Tumors (SCBT) are at a higher risk of developing cardiovascular disease and type 2 diabetes compared to the general population. Adiposity is an important risk factor for the development of these outcomes, and identifying biomarkers of adiposity may help the stratification of survivors based on their cardiovascular risk or allow for early screening and interventions to improve cardiometabolic outcomes. Leptin is an adipokine that positively correlates with the adipose mass in the general population and is a predictor of adverse cardiometabolic outcomes, yet its association with adiposity in SCBT has not been studied. The aim of this study was to determine if leptin levels are associated with the adipose mass in SCBT, and to define its predictors. This cross-sectional study included 74 SCBT (n = 32 females) with 126 non-cancer controls (n = 59 females). Total adiposity was measured using Bioelectrical Impendence Analysis (BIA) and central adiposity was measured using waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR). We used multivariable linear regression analysis to determine if leptin predicts adiposity in SCBT and adjusted for age, sex, puberty, and cancer status. Leptin correlated strongly with total (p < 0.001) and central (WHR p = 0.001; WHtR p < 0.001) adiposity in SCBT and non-cancer controls. In conclusion, leptin is a potential biomarker for adiposity in SCBT, and further investigation is needed to clarify if leptin is a predictor of future cardiometabolic risk in SCBT.

Does Cellular Metabolism from Primary Fibroblasts and Oxidative Stress in Blood Differ between Mammals and Birds? The (Lack-thereof) Scaling of Oxidative Stress

As part of mitonuclear communication, retrograde and anterograde signaling helps maintain homeostasis under basal conditions. Basal conditions, however, vary across phylogeny. At the cell-level, some mitonuclear retrograde responses can be quantified by measuring the constitutive components of oxidative stress, the balance between reactive oxygen species (ROS) and antioxidants. ROS are metabolic by-products produced by the mitochondria that can damage macromolecules by structurally altering proteins and inducing mutations in DNA, among other processes. To combat accumulating damage, organisms have evolved endogenous antioxidants and can consume exogenous antioxidants to sequester ROS before they cause cellular damage. ROS are also considered to be regulated through a retrograde signaling cascade from the mitochondria to the nucleus. These cellular pathways may have implications at the whole-animal level as well. For example, birds have higher basal metabolic rates, higher blood glucose concentration, and longer lifespans than similar sized mammals, however, the literature is divergent on whether oxidative stress is higher in birds compared with mammals. Herein, we collected literature values for whole-animal metabolism of birds and mammals. Then, we collected cellular metabolic rate data from primary fibroblast cells isolated from birds and mammals and we collected blood from a phylogenetically diverse group of birds and mammals housed at zoos and measured several parameters of oxidative stress. Additionally, we reviewed the literature on basal-level oxidative stress parameters between mammals and birds. We found that mass-specific metabolic rates were higher in birds compared with mammals. Our laboratory results suggest that cellular basal metabolism, total antioxidant capacity, circulating lipid damage, and catalase activity were significantly lower in birds compared with mammals. We found no body-size correlation on cellular metabolism or oxidative stress. We also found that most oxidative stress parameters significantly correlate with increasing age in mammals, but not in birds; and that correlations with reported maximum lifespans show different results compared with correlations with known aged birds. Our literature review revealed that basal levels of oxidative stress measurements for birds were rare, which made it difficult to draw conclusions.

Lipoedema – myths and facts, Part 5

The four previous articles in this series addressed the myths and facts surrounding lipoedema. We have shown that there is no scientific evidence at all for the key statements made about lipoedema – which are published time and time again. The main result of this “misunderstanding” of lipoedema is a therapeutic concept that misses the mark. The patient’s real problems are overlooked.

The national and especially the international response to the series, which can be read in both German and English, has been immense and has exceeded all our expectations. The numerous reactions to our articles make it clear that in other countries, too, the fallacies regarding lipoedema have led to an increasing discrepancy between the experience of healthcare workers and the perspective of patients and self-help groups, based on misinformation mostly generated by the medical profession.

Parts 1 to 4 in this series of articles on the myths surrounding lipoedema have made it clear that we have to radically change the view of lipoedema that has been held for decades. Changing our perspective means getting away from the idea of “oedema in lipoedema” – and hence away from the dogma that decongestion is absolutely necessary – and towards the actual problems faced by our patients with lipoedema. Such a paradigm shift in a disease that has been described in the same way for decades cannot be left to individuals but must be put on a much broader footing. For this reason, the lead author of this series of articles invited renowned lipoedema experts from various European countries to discussions on the subject. Experts from seven different countries took part in the two European Lipoedema Forums, with the goal of establishing a consensus. The consensus reflects the experts’ shared view on the disease, having scrutinized the available literature, and having taken into account the many years of clinical practice with this particular patient group. Appropriate to the clinical complexity of lipoedema, participants from different specialties provided an interdisciplinary approach. Nearly all of the participants in the European Lipoedema Forum had already published work on lipoedema, had been involved in drawing up their national lipoedema guidelines, or were on the executive board of their respective specialty society.

In this fifth and final part of our series on lipoedema, we will summarise the relevant findings of this consensus, emphasising the treatment of lipoedema as we now recommend it. As the next step, the actual consensus paper “European Best Practice of Lipoedema” will be issued as an international publication.

Instead of looking at the treatment of oedema, the consensus paper will focus on treatment of the soft tissue pain, as well as the psychological vulnerability of patients with lipoedema. The relationship between pain perception and the patient’s mental health is recognised and dealt with specifically. The consensus also addresses the problem of self-acceptance, and this plays a prominent role in the new therapeutic concept. The treatment of obesity provides a further pillar of treatment. Obesity is recognised as being the most common comorbid condition by far and an important trigger of lipoedema. Bariatric surgery should therefore also be considered for patients with lipoedema who are morbidly obese. The expert group upgraded the importance of compression therapy and appropriate physical activity, as the demonstrated anti-inflammatory effects directly improve the patients’ symptoms. Patients will be provided with tools for personalised self-management in order to sustain sucessful treatment. Should conservative therapy fail to improve the symptoms, liposuction may be considered in strictly defined circumstances.

The change in the view of lipoedema that we describe here brings the patients’ actual symptoms to the forefront. This approach allows us to focus on more comprehensive treatment that is not only more effective but also more sustainable than focusing on the removal of non-existent oedema.

Nonlinear optical memory effect

Light propagating through random media produces characteristic speckle patterns, directly related to the large multitude of scattering events. These complex dynamics remarkably display robustness to perturbation of the incoming light parameters, maintaining correlation in the scattered wavefront. This behavior is known as the optical memory effect. Here we unveil the properties of the nonlinear optical memory effect, which occurs when an optothermal nonlinearity perturbs the random material. The effect is characterized through a series of pump and probe experiments in silica aerogel, in the visible range. This additional degree of freedom further generalizes the memory effect, opening the road to applications based on the nonlinear response of random media.

A systematic approach to map the adolescent human papillomavirus vaccine decision and identify intervention strategies to address vaccine hesitancy

OBJECTIVES

Unsubstantiated safety concerns with human papillomavirus (HPV) vaccines continue to linger. This study sought to identify factors that influence the adolescent HPV vaccine decision and systematically identify intervention functions and strategies likely to be effective in reducing vaccine hesitancy.

STUDY DESIGN

This is a qualitative focus group study.

METHODS

Focus groups were conducted with female adolescents (aged 14-16 years) in Cork and Kerry. During focus groups, the trained facilitator used a semistructured, Theoretical Domains Framework (TDF)-based topic guide to prompt discussion. Transcripts were thematically analysed using the TDF and Behaviour Change Wheel. Behaviour Change Technique Taxonomy version 1 was used to suggest intervention functions and strategies for addressing HPV vaccine hesitancy.

RESULTS

A total of 50 adolescents (96% vaccinated), participated in 10 focus groups. The key themes were presented by means of the relevant TDF domains. Seven domains were selected as the most relevant: knowledge, social influences, beliefs about capabilities, optimism, beliefs about consequences, emotion and environmental context and resources. Five intervention functions were identified, education, persuasion, enablement, modelling and environmental restructuring, and linked to 11 relevant Behaviour Change Technique (BCTs). Potential intervention strategies were developed.

CONCLUSIONS

This study provided a detailed insight into behavioural factors influencing the vaccine decision-making process. It was identified that awareness and knowledge about HPV and its health sequelae was low. Lack of information is a well-recognised determinant of vaccine hesitancy. Therefore, education was recommended as a key area to address in future intervention studies.

Genome-wide association analysis for β-hydroxybutyrate concentration in Milk in Holstein dairy cattle

BACKGROUND

Ketosis in dairy cattle has been shown to cause a high morbidity in the farm and substantial financial losses to dairy farmers. Ketosis symptoms, however, are difficult to identify, therefore, the amount of ketone bodies (mainly β-hydroxybutyric acid, BHB) is used as an indicator of subclinical ketosis in cows. It has also been shown that milk BHB concentrations have a strong correlation with ketosis in dairy cattle. Mid-infrared spectroscopy (MIR) has recently became a fast, cheap and high-throughput method for analyzing milk components. The aim of this study was to perform a genome-wide association study (GWAS) on the MIR-predicted milk BHB to identify genomic regions, genes and pathways potentially affecting subclinical ketosis in North American Holstein dairy cattle.

RESULTS

Several significant regions were identified associated with MIR-predicted milk BHB concentrations (indicator of subclinical ketosis) in the first lactation (SCK1) and second and later lactations (SCK2) in Holstein dairy cows. The strongest association was located on BTA6 for SCK1 and BTA14 on SCK2. Several SNPs on BTA6 were identified in regions and variants reported previously to be associated with susceptibility to ketosis and clinical mastitis in Jersey and Holstein dairy cattle, respectively. One highly significant SNP on BTA14 was found within the DGAT1 gene with known functions on fat metabolism and inflammatory response in dairy cattle. A region on BTA6 and three SNPs on BTA20 were found to overlap between SCK1 and SCK2. However, a novel region on BTA20 (55-63 Mb) for SCK2 was also identified, which was not reported in previous association studies. Enrichment analysis of the list of candidate genes within the identified regions for MIR-predicted milk BHB concentrations yielded molecular functions and biological processes that may be involved in the inflammatory response and lipid metabolism in dairy cattle.

CONCLUSIONS

The results of this study confirmed several SNPs and genes identified in previous studies as associated with ketosis susceptibility and immune response, and also found a novel region that can be used for further analysis to identify causal variations and key regulatory genes that affect clinical/ subclinical ketosis.

Phenotypic investigation of fine milk components in bovine milk and their prediction using mid-infrared spectroscopy

This study aimed to examine the phenotypic variation observed in fine milk components, the use of mid-infrared (MIR) spectroscopy to predict these components, and the correlations with other milk production traits. A total of 4116 milk samples were collected from 414 dairy cows from 44 Canadian herds. Overall 3117 samples were analyzed for casein micelle size, 986 and 937 for total and soluble calcium, respectively, and 2054 for lactoferrin. Individual milk MIR spectra were obtained. Linear mixed models with repeated records were used to test the effects of herd nested within breed, breed, days in milk class, parity, and season on milk components. Lactoferrin content in milk increased with stage of lactation and parity number. Prediction equations were developed by partial least squares regression to predict each milk component using MIR spectroscopy, with the greatest coefficient of determination achieved for lactoferrin (0.55). Pearson correlation coefficients for lactoferrin with somatic cell score and protein percentage were 0.49% and 0.40%, respectively. The estimated correlation increased to 0.53% for predicted lactoferrin and protein percentage. The examined fine milk components exhibited variation, but low accuracies for their MIR prediction may limit the utility of this technology for their phenotyping.