Social workers and acquired brain injury: A systematic review of the current evidence-base

Social work plays an important role in the assessment and treatment of people with acquired brain injury. Acquired brain injury is a complex and highly prevalent condition which can impact on cognitive, emotional and social domains. As acquired brain injury is a hidden disability it can be misdiagnosed or classified as another condition entirely. We sought to systematically explore the evidence base to examine how social workers have been prepared to work with their clients with brain injury. Employing six electronic databases (Social Policy & Practice, Web of Science, Scopus, PubMed, PsycINFO, CINAHL Plus) we reviewed 1071 papers. After applying eligibility criteria 17 papers were included in this review. We utilised standardised data extraction and quality appraisal tools to assess all included papers. Following appraisal, 9 papers were judged as possessing high methodological quality whilst 8 were judged as medium. Employing narrative synthesis, we identified four themes which captured the key findings of these papers. Themes were named as (i) advocacy and social work (ii) training and multidisciplinary team working (iii) inclusion of social networks and (iv) societal barriers. In order to meet their statutory responsibilities to practice safely, social workers must receive training in how to identify ABI and develop understanding of its consequences and subsequent need for provision. Social workers are also in a unique position to advocate for their clients and should make every effort to ensure their needs are met.

Coping with fibromyalgia during the COVID-19 pandemic: adjustment and wellbeing

OBJECTIVE

Fibromyalgia syndrome (FMS) is a chronic condition with symptoms known to be exacerbated by stress. Individuals with FMS may be experiencing particular distress under Covid-19 pandemic-related lifestyle restrictions. The present study examined wellbeing, perceived symptom change and coping in individuals with and without FMS during pandemic-related social lockdown in the UK.

DESIGN

Participants with a diagnosis of FMS (N = 390) and a general public sample with no FMS (N = 151) completed questionnaires at three time points.

MAIN OUTCOME MEASURES

BBC Wellbeing Scale, Cognitive-Emotional Regulation Questionnaire measure of coping, perception of extent to which symptoms have worsened or improved over time.

RESULTS

Contrary to expectations, FMS participants reported no worsening of symptoms and an increase in wellbeing over the study period. Non-FMS participants experienced worsening health symptoms and no change in wellbeing. Coping strategies involving positive reappraisal, refocussing and planning were positively associated with wellbeing in the FMS group.

CONCLUSION

The unpredictable symptom profile in FMS, and the regular readjustment this necessitates, may support a form of resilience which has been adaptive during the pandemic. The results have implications for supporting people with FMS, and potentially other chronic conditions, especially at times of stress.

Oxford cognitive screen: A critical review and independent psychometric evaluation

The Oxford cognitive screen (OCS) is a stroke-specific cognitive screening assessment. Although the test developers have provided psychometric information for the assessment, the OCS has received minimal external scrutiny, with which to triangulate the underpinning psychometrics. The purpose of this study is to provide a critical review and independent validation of the OCS. This study analysed data from an anonymised clinical database, which consisted of 316 patients who were assessed using the OCS on an Acute Stroke Unit. The rates of impairment on tests of memory and receptive communication were lower than expectation, suggesting that these subtests may be relatively insensitive. Patients with aphasia were more likely to be unable to categorised as impaired on non-language tests, suggesting that they remain sensitive to language processing or non-dominant hand usage. Some of the subtests of the OCS achieve high retest reliability, which makes them good candidates for measuring cognitive change over time. Although the OCS has many advantages, it is also important to adequately consider its limitations, that is insensitivity to memory problems, the potential confounding impact of non-dominant hand usage, and the potential that some tests may sample overall cognitive ability instead of domain-specific functioning.

Measurement of the ν_{e}-Nucleus Charged-Current Double-Differential Cross Section at ⟨E_{ν}⟩=2.4 GeV Using NOvA

The inclusive electron neutrino charged-current cross section is measured in the NOvA near detector using 8.02×10^{20} protons-on-target in the NuMI beam. The sample of GeV electron neutrino interactions is the largest analyzed to date and is limited by ≃17% systematic rather than the ≃7.4% statistical uncertainties. The double-differential cross section in final-state electron energy and angle is presented for the first time, together with the single-differential dependence on Q^{2} (squared four-momentum transfer) and energy, in the range 1  GeV≤E_{ν}<6  GeV. Detailed comparisons are made to the predictions of the GENIE, GiBUU, NEUT, and NuWro neutrino event generators. The data do not strongly favor a model over the others consistently across all three cross sections measured, though some models have especially good or poor agreement in the single differential cross section vs Q^{2}.

Experiences of individuals with acquired brain injury and their families interacting with community services: a systematic scoping review

PURPOSE

This scoping review aims to (1) synthesise the research findings on the experiences of individuals with acquired brain injuries, and their families, when interacting with, or accessing, community-based services and (2) identify where gaps in service provision may exist and their cause.

METHODS

A systematic search strategy was employed across multiple databases to identify all studies relating to the experiences of individuals with acquired brain injuries and their families when interacting with, or accessing, community-based services. Inclusion was assessed by at least two reviewers at each stage and data extraction was completed by one researcher and validity checked by another. A narrative synthesis was employed.

RESULTS

A total of 101 papers met the inclusion criteria with the narrative synthesis identifying three main themes of (1) unmet needs, (2) types of access, and (3) barriers to access.

CONCLUSIONS

The results identify that those with acquired brain injuries, and their families, experience significant difficulties interacting with community-based services and often do not receive appropriate access. Many barriers to access were identified including a lack of knowledge of the long-term effects of acquired brain injury amongst professionals working in health and social care services.Implications for rehabilitationBrain injury is a leading cause of disability worldwide with a range of physical, cognitive, emotional, and behavioural difficulties.It is important that service users and families are given appropriate information about the long-term difficulties associated with ABI so they are better informed about the types of support they may need upon discharge from hospital.Rehabilitation professionals need to ensure they have good level of knowledge of the difficulties associated with ABI to ensure appropriate access to services for individuals and their families.Understanding more about unmet needs allows community rehabilitation services to be tailored and person-centred.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

Hidden disability: a study of the psychosocial impact of living with pituitary conditions

BACKGROUND

Pituitary patients often experience psychosocial symptoms associated with their condition.

AIMS

To explore the condition management experiences of pituitary patients and their psychosocial symptoms and to explore the impact of these on quality of life.

METHODS

A sample of 748 individuals aged 18 to more than 65 years) completed a questionnaire relating to quality of life and the psychosocial impact of pituitary conditions.

FINDINGS

Analysis of the qualitative sections using content analysis identified four themes: social isolation, emotional and behavioural issues, appearance distress and physical and cognitive effects including fatigue and pain. An overarching theme of hidden disability emerged.

CONCLUSION

The study identified multiple biopsychosocial factors that impact quality of life, with symptoms not visible to others most likely to impact negatively. Nurses are well placed to provide support and information to patients about the possible psychosocial impact of pituitary conditions to enable positive adjustment.

Service evaluation of the efficiency of moving discharge medicine request screening from the dispensary to hospital wards over a two-year period

Introduction

It is a common patient perception that their discharge from hospital is delayed by waiting for medicines (1). However, it is important to consider the entire discharge process when addressing this problem (2). In our large tertiary referral hospital, clinical pharmacy services were moved from wards to the dispensary following a staffing crisis during 2018. Ward-based services were reintroduced in 2020, but doubts remained over the practicality and benefits of doing this.

Aim

To compare the efficiency of ward and dispensary based clinical pharmacy services in our hospital in terms of interventions made and time taken.

Methods

We completed an observational service evaluation. Data on the time taken to process discharge medication requests with the dispensary-based service were collected retrospectively from the hospital electronic discharge system for 12 months (2018) for five medical wards. Equivalent data for the ward-based service were collected prospectively over three days (2020) by pharmacists delivering the service to seven medical wards, as this was considered more accurate, and several process steps did not exist in the ward-based model. For example, prescriber sending request to pharmacy and pharmacy acknowledging receipt of a request. The prospective data collection period was curtailed by Covid-19. Descriptive statistics were produced using Excel.

Results

Using the dispensary-based service (2018), 4459 medicine requests were processed from 5 medical wards, during a 12-month period. The mean time between prescribing and reaching the screening pharmacist was 175 minutes [95%CI ± 25.4]. It took an estimated time of 62 minutes [95%CI ± 2.99] to screen and resolve an intervention, with a mean of 3 interventions/ward/day. In 2020, using the ward-based approach to clinical pharmacy which screened medicine requests on the ward, 142 requests were screened over three days from seven wards, with no delay between prescribing and clinical screening. It took a mean of 17 minutes [95%CI ± 10.63] to screen and resolve an intervention, with a mean of 15 interventions/ward/day.

Conclusion

Ward based pharmacy yielded five times more interventions, took an average of 45 minutes less to screen and resolve issues per request and removed 175 minutes of process time. The additional time required to resolve issues identified in the dispensary-based screening process was thought to be the delay in contacting either the appropriate member of the ward staff referencing a particular patient for information or identifying and contacting the prescriber, or a combination of both. This study is limited by the long delay between data collection periods and the small sample size in 2020, but the differences between the two systems were large and there had been few other changes to hospital systems. Other limitations include changes related to Covid-19 and the lack of a control group, so it is not possible to establish a causal relationship between the type of pharmacy service and study outcomes.

References

(1) Wright S, Morecroft CW, Mullen R, Ewing AB. UK hospital patient discharge: the patient perspective. Eur J Hosp Pharm. 2017 Nov;24(6):338-342.

(2) Green CF, Hunter L, Jones L, Morris K. The TTO Journey: How much of it is actually in pharmacy? Pharm Man. 2015 Oct;31(4):16-20.

Search for Active-Sterile Antineutrino Mixing Using Neutral-Current Interactions with the NOvA Experiment

This Letter reports results from the first long-baseline search for sterile antineutrinos mixing in an accelerator-based antineutrino-dominated beam. The rate of neutral-current interactions in the two NOvA detectors, at distances of 1 and 810 km from the beam source, is analyzed using an exposure of 12.51×10^{20} protons-on-target from the NuMI beam at Fermilab running in antineutrino mode. A total of 121 of neutral-current candidates are observed at the far detector, compared to a prediction of 122±11(stat.)±15(syst.) assuming mixing only between three active flavors. No evidence for ν[over ¯]_{μ}→ν[over ¯]_{s} oscillation is observed. Interpreting this result within a 3+1 model, constraints are placed on the mixing angles θ_{24}<25° and θ_{34}<32° at the 90% C.L. for 0.05  eV^{2}≤Δm_{41}^{2}≤0.5  eV^{2}, the range of mass splittings that produces no significant oscillations at the near detector. These are the first 3+1 confidence limits set using long-baseline accelerator antineutrinos.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

Accepting what we do not know: A need to improve professional understanding of brain Injury in the UK

Acquired brain injury (ABI) can lead to life-long changes and disability. The complex and extensive nature of behavioural, cognitive, executive, physical and psychological difficulties mean ABI survivors and their families may come into contact with a range of health and social care services as part of their long-term care. This study aimed to understand the ABI knowledge base of professionals across a range of organisations within the UK, and to identify areas for improvement. This was achieved through a mixed methods approach using a mixed methods questionnaire (117 participants) and qualitative semi-structured interviews about service experiences (31 participants) of professionals and service users (families and individuals with ABI). Participants included UK health and social care professionals, ABI specialists, ABI survivors and family members. Data were collected from February 2017 to April 2018. The results of the study identified a lack of knowledge and understanding of ABI among health and social care professionals in the UK, from those involved in acute care through to long-term community services. Poor knowledge was associated with a lack of understanding of "hidden" disabilities associated with ABI, a lack of empathy and a lack of knowledge regarding specific safeguarding. Health and social care professionals across a range of services could benefit in ABI-specific training to improve their knowledge and improve the service currently being provided to individuals with ABI and their families.

Comparison of electric hand dryers and paper towels for hand hygiene: a critical review of the literature

Numerous studies are published on the benefits of electric hand dryers vs paper towels (PT) for drying hands after washing. Data are conflicting and lacking key variables needed to assess infection risks. We provide a rapid scoping review on hand-drying methods relative to hygiene and health risks. Controlled vocabulary terms and keywords were used to search PubMed (1946-2018) and Embase (1947-2018). Multiple researchers independently screened abstracts for relevance using predetermined criteria and created a quality assessment scoring system for relative study comparisons. Of 293 papers, 23 were included in the final analysis. Five studies did not compare multiple methods; however, 2 generally favoured electric dryers (ED); 7 preferred PT; and 9 had mixed or statistically insignificant results (among these, 3 contained scenarios favourable to ED, 4 had results supporting PT, and the remaining studies had broadly conflicting results). Results were mixed among and within studies and many lacked consistent design or statistical analysis. The breadth of data does not favour one method as being more hygienic. However, some authors extended generalizable recommendations without sufficient scientific evidence. The use of tools in quantitative microbial risk assessment is suggested to evaluate health exposure potentials and risks relative to hand-drying methods. We found no data to support any human health claims associated with hand-drying methods. Inconclusive and conflicting results represent data gaps preventing the advancement of hand-drying policy or practice recommendations.

Living with suicidality following traumatic brain injury: a qualitative study

PURPOSE

Numbers of traumatic brain injury (TBI) are increasing, and with suicidality post-injury presenting at 3-4 times higher than in the general population, understanding this is crucial in reducing a devastating outcome. Given the lack of literature, this study investigated the experiences of living with suicidality after TBI.

METHODS

Interview data from nineteen participants with TBI from a Brain Injury Rehabilitation Unit (BIRU) in New South Wales (NSW), Australia were collected and thematically analyzed.

FINDINGS

The participants (predominantly male) sustained extremely severe injuries (median PTA 60 [IQR 81.0] days) and were in the chronic phase post-injury (median 8.0 [IQR 9.0] years). Six main themes were identified; Loss of sense of self, TBI as a hidden disability, Chronic but transient suicidality, Reliance, Protective factors, and Hope. Tentative relationships between themes and subthemes were identified.

CONCLUSION

Chronic suicidality after TBI was demonstrated consistently regardless of receiving long-term support. However, their engagement with protective factors such as social support, spirituality and positive personal qualities was identified. Implementing these as coping strategies during long-term rehabilitation may reduce the levels of suicidal distress. Implications, methodological considerations and future research were discussed, with the aim of improving experiences of individuals with TBI to reduce suicidality.

The inter-relationship between acquired brain injury, substance use and homelessness; the impact of adverse childhood experiences: an interpretative phenomenological analysis study

PURPOSE

Acquired Brain Injuries, caused by a range of illnesses and injuries, can lead to long-term difficulties for individuals; mental health problems, cognitive and executive impairment and psychosocial problems including relationship breakdown, substance abuse and potentially homelessness. The study aimed to seek and gain a more definitive understanding of the inter-relationship of Acquired Brain Injury, substance abuse and homelessness by identifying key themes associated with the inter-relationship between these variables.

MATERIALS AND METHODS

The study recruited eight participants through homeless organisations and treatment centres. Participants were screened for suitability (Brain Injury Screening Index; Drug Abuse Screening Tool; Alcohol Use Disorders Identification Test and then participated in recorded semi-structured interviews, transcribed and analysed using Interpretative Phenomenological Analysis.

RESULTS

The study identified five master themes: Adverse Childhood Experiences and Trauma; Mental Health; Cognitive Decline and Executive Function; Services; Relationships.

CONCLUSION

Healthcare professionals need to engage with children, their families, and adults, who have been exposed to adverse childhood experiences and should employ routine screening tools for brain injury to ensure their presence is factored into developing appropriate models of intervention.IMPLICATIONS FOR REHABILITATIONNeed person-centred approaches to intervention for those with acquired brain injury who are homeless and have substance abuse issues.Need to screen for the presence of acquired brain injury when engaging with individuals who are homeless or have substance abuse.Need screening of acquired brain injury and adverse childhood experiences to improve access to services post-brain injury.

First measurement of neutrino oscillation parameters using neutrinos and antineutrinos by NOvA

The NOvA experiment has seen a 4.4σ signal of ν[over ¯]_{e} appearance in a 2 GeV ν[over ¯]_{μ} beam at a distance of 810 km. Using 12.33×10^{20} protons on target delivered to the Fermilab NuMI neutrino beamline, the experiment recorded 27 ν[over ¯]_{μ}→ν[over ¯]_{e} candidates with a background of 10.3 and 102 ν[over ¯]_{μ}→ν[over ¯]_{μ} candidates. This new antineutrino data are combined with neutrino data to measure the parameters |Δm_{32}^{2}|=2.48_{-0.06}^{+0.11}×10^{-3}  eV^{2}/c^{4} and sin^{2}θ_{23} in the ranges from (0.53-0.60) and (0.45-0.48) in the normal neutrino mass hierarchy. The data exclude most values near δ_{CP}=π/2 for the inverted mass hierarchy by more than 3σ and favor the normal neutrino mass hierarchy by 1.9σ and θ_{23} values in the upper octant by 1.6σ.

Pituitary conditions: importance of geography and the Pituitary Foundation in patient support

Quality of life is significantly impacted for those with pituitary conditions, and patients need support to meet ongoing physical and psychological needs. This study aimed to explore the support needs and experiences of patients with pituitary conditions in the community. Ten self-selected members of the Pituitary Foundation were interviewed about their conditions, needs and experiences. Data were analysed using thematic analysis. Secondary thematic analysis was conducted on data from a sample of 748 members of the Pituitary Foundation. Four themes were revealed, under one over-arching theme of geography: (1) life-changing diagnosis, (2) the Foundation as a source of support, (3) access to the Foundation and (4) attendance at support groups. On the basis of the findings of this study, the authors concluded that better training is required for health professionals about pituitary conditions, their long-term consequences and the need to signpost patients to wider services offering essential support.

Treatment Choice in Adolescents With Cleft Lip and/or Palate: The Importance of Shared Decision-Making

OBJECTIVE

Limited research has studied the involvement of children in medical decision-making. The aim of the study was to understand the involvement of adolescents with cleft lip and/or palate (CL/P) in decisions about elective surgeries and treatments.

DESIGN

Parents and professionals completed mixed-methods questionnaires about the degree to which children had been involved in choices about elective treatments. Data were analyzed using content analysis. Young people aged 12 to 25 years were asked to take part in semistructured interviews. The data were analyzed using inductive thematic analysis.

SETTING

Questionnaire data collection took place online, and interview data were collected via messenger or telephone-based interviews.

PARTICIPANTS

The study employed 30 participants; 11 young people (3 male, 8 female), 17 parents (13 mothers, 4 fathers), and 5 professionals (2 surgeons, 2 speech and language therapists, and 1 pediatric dentist).

RESULTS

Five main themes were identified. These reflected participants feeling that with increasing age should come increased involvement in decision-making and that it was important for adolescents to "have a voice" during decision-making. Parents, peers, and health professionals were identified as influencing decisions. Most adolescents reported overall satisfaction with their involvement in decision-making but sometimes felt "left in the dark" by professionals or under pressure from parents. A desire to improve speech and/or appearance was as an area where adolescents wanted to be more involved in decision-making.

CONCLUSIONS

Shared decision-making is an important factor for psychological well-being by promoting autonomy and self-esteem among adolescents with CL/P.

Abstract P1-12-10: Regimen-specific rates of chemotherapy-related amenorrhea in breast cancer survivors

Background: Chemotherapy can damage the ovaries and cause amenorrhea, a surrogate for infertility. Young women often wish to understand and minimize their risk of chemotherapy-related amenorrhea (CRA). However, the incidence of CRA with regimens that do not include either an anthracycline or cyclophosphamide is poorly studied. For patients with HER-2 positive disease, these anthracycline and cyclophosphamide-sparing regimens (e.g., docetaxel-carboplatin) are common (in combination with Her-2 directed therapy) in both the neoadjuvant and adjuvant settings.

Methods: Women diagnosed with breast cancer under age 50 and within the past 10 years were recruited through a Dr. Susan Love Research Foundation Army of Women e-mail blast. Those who provided their contact information were mailed a consent form and medical record authorization form. Participants then received a web-based survey that inquired about receipt of and type of chemotherapy (including date of last dose) and date of last menstrual period (LMP). Patient-reported LMP was compared to date of final chemotherapy dose to determine if the LMP occurred before (defined as “CRA”) or after the last chemotherapy dose. When available, medical record data was used in place of survey data regarding type of chemotherapy used. Exclusion criteria included: LMP prior to diagnosis date, receipt of multiple chemotherapy regimens or no chemotherapy regimens, receipt of ovarian suppression medications (which interfere with interpretation of menstrual data), surgical menopause prior to or at the same time as diagnosis, a cancer diagnosis more than 10 years prior, incomplete menstrual data on the survey, report of an unknown chemotherapy regimen, and no date available for the last chemotherapy dose without an LMP within a month prior to survey completion. Fisher Exact test was used to compare CRA rates between regimens. Rates after two anthracycline-sparing regimens (taxane/cyclophosphamide; taxane/carboplatin) were compared to rates after anthracycline/cyclophosphamide/taxane.

Results: 273 women consented to participate in this study, 258 of whom filled out the web survey. 151 of them were eligible for this analysis with a median age at diagnosis of 41 (range 24-49) and a median time from last chemotherapy dose to survey of 62.5 months (range 2-138). CRA occurred in 51.2% of the 86 participants who received an anthracycline, cyclophosphamide, and a taxane, in 41.9% of the 43 participants who received only a taxane and cyclophosphamide (p=0.35), and in 13.3% of the 15 participants who received carboplatin with a taxane (p=0.01). When the 11 patients who were &lt;12 months since last chemotherapy were excluded, CRA rates changed minimally. Age did not differ by regimen, but median time since chemotherapy was shorter in the taxane/carboplatin group (35 months vs. 68 months). Trastuzumab with or without pertuzumab was administered in 100% of patients who received carboplatin/taxane, in 23.3% of patients who received taxane and cyclophosphamide, and in 22.1% of patients who received anthracycline/cyclophosphamide/taxane.

Conclusions: This study suggests that carboplatin/taxane may be substantially less gonadotoxic than cyclophosphamide-based (neo)adjuvant regimens. Further research is necessary to confirm these findings.

Citation Format: Gast KC, Cathcart-Rake EJ, Norman A, Eshragi L, Obidegwu N, Yost K, Nichols HB, Rosenberg S, Su HI, Stewart E, Couch F, Vachon C, Ruddy KJ. Regimen-specific rates of chemotherapy-related amenorrhea in breast cancer survivors [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-12-10.

MOLECULAR TYPING OF MYCOBACTERIUM KANSASII — A GLOBAL PERSPECTIVE

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Phenotype of CNTNAP1: a study of patients demonstrating a specific severe congenital hypomyelinating neuropathy with survival beyond infancy

CHN is genetically heterogeneous and its genetic basis is difficult to determine on features alone. CNTNAP1 encodes CASPR, integral in the paranodal junction high molecular mass complex. Nineteen individuals with biallelic variants have been described in association with severe congenital hypomyelinating neuropathy, respiratory compromise, profound intellectual disability and death within the first year. We report 7 additional patients ascertained through exome sequencing. We identified 9 novel CNTNAP1 variants in 6 families: three missense variants, four nonsense variants, one frameshift variant and one splice site variant. Significant polyhydramnios occurred in 6/7 pregnancies. Severe respiratory compromise was seen in 6/7 (tracheostomy in 5). A complex neurological phenotype was seen in all patients who had marked brain hypomyelination/demyelination and profound developmental delay. Additional neurological findings included cranial nerve compromise: orobulbar dysfunction in 5/7, facial nerve weakness in 4/7 and vocal cord paresis in 5/7. Dystonia occurred in 2/7 patients and limb contractures in 5/7. All had severe gastroesophageal reflux, and a gastrostomy was required in 5/7. In contrast to most previous reports, only one patient died in the first year of life. Protein modelling was performed for all detected CNTNAP1 variants. We propose a genotype-phenotype correlation, whereby hypomorphic missense variants partially ameliorate the phenotype, prolonging survival. This study suggests that biallelic variants in CNTNAP1 cause a distinct recognisable syndrome, which is not caused by other genes associated with CHN. Neonates presenting with this phenotype will benefit from early genetic definition to inform clinical management and enable essential genetic counselling for their families.

Novel 9 amino acid in-frame deletion in the NTRK1 tyrosine kinase domain in a patient with congenital insensitivity to pain with anhydrosis

Schematic presentation of NTRK1 protein structure. Variants identified in this study are shown in red and previously reported variants associated with CIPA are shown in black (LRM, leucine rich motif; Ig, immunoglobulin-like domain; TM, transmembrane domain; TK, tyrosine kinase domain).

Serum ionic dysequilibria in clinical opioid dependence: Cross-sectional and longitudinal studies

INTRODUCTION

Despite an increasing awareness that the activity of excitable membranes is determined by the underlying ionic gradients across them, and their importance in drug dependency, we were not able to identify any reports of comparing the electrolyte composition of opioid-dependent and non-addicted controls.

METHODS

Linear regression was used to compare clinical pathology blood results taken from 2699 opioid-dependent patients (ODP) and 5307 medical control (MC) patients on a total of 21,734 occasions for the period 1995-2015. The presence of a hepatitis C antibody test was used to separate OPD and MC patients.

RESULTS

The mean age among ODP and MC was 33.51 ± 0.16 and 37.99 ± 0.23 years, respectively ( p < 0.0001). The groups were 71.5% and 54.2% male ( p < 0.0001). Drug use in this cohort has been reported previously. Analysis of sodium, haemoglobin and albumin were used to exclude marked effects of haemodilution/haemoconcentration. Repeated measures linear regression against age and time showed depressed levels of bicarbonate ( p < 0.0001) and potassium ( p < 0.05) and elevated levels of chloride ( p < 0.025) and anions ( p < 0.01) in ODP in both sexes. Multiple regression in mixed-effects models showed that these effects were all worse in females ( p = 0.0001).

CONCLUSION

This data shows that opioid dependence is associated with significant changes in chloride, potassium, bicarbonate and anions in both sexes, and worse in females. This likely has implications for the electrophysiological properties of excitable membranes. It is consistent with the reported impairment of potassium-chloride exchangers in opioid dependence. Explication of the mechanisms responsible must await further studies.

Treatment and outcomes for glioblastoma in elderly compared with non-elderly patients: a population-based study

PURPOSE

Elderly patients make up a large percentage of the individuals newly diagnosed with glioblastoma (gbm), but they face particular challenges in tolerating standard therapy, and compared with younger patients, they experience significantly shorter survival. We set out to compare clinical characteristics, treatment patterns, and outcomes in a non-elderly group (<65 years) and an elderly group (≥65 years) of patients diagnosed with gbm.

METHODS

This retrospective population-based study used a province-wide cancer registry to identify patients with a new diagnosis of gbm within a 6-year period (2006-2012). Of the 138 patients identified, 56 (40.6%) were 65 years of age or older. Demographic characteristics, treatment patterns, and overall survival (os) in the elderly and non-elderly groups were compared. Predictors of os were determined using multivariate analysis.

RESULTS

Elderly patients were more likely to present with a poor performance status (Eastern Cooperative Oncology Group ≥ 2), to undergo biopsy without resection, and to receive whole-brain or hypofractionated radiotherapy. Compared with non-elderly patients, the elderly patients were less likely to receive adjuvant temozolomide. Survival time was significantly shorter in the elderly than in the non-elderly patients (7.2 months vs. 11.2 months). In multivariate analysis, surgical resection, hypofractionated radiotherapy (compared with whole-brain or conventional radiotherapy), and chemotherapy were predictive of os in older patients. Among elderly patients receiving radiation, survival was improved with the use of combined therapy compared with the use of radiation only (11.3 months vs. 4.6 months).

CONCLUSIONS

Overall survival was shorter for elderly patients with gbm than for non-elderly patients; the elderly patients were also less likely to receive intensive surgical or adjuvant therapy. Our population-based analysis demonstrated improved os with surgical resection, hypofractionated radiotherapy, and temozolomide, and supports the results of recent clinical trials demonstrating a benefit for combination chemoradiotherapy in older patients.

Measurement of the Neutrino Mixing Angle θ_{23} in NOvA

This Letter reports new results on muon neutrino disappearance from NOvA, using a 14 kton detector equivalent exposure of 6.05×10^{20} protons on target from the NuMI beam at the Fermi National Accelerator Laboratory. The measurement probes the muon-tau symmetry hypothesis that requires maximal θ_{23} mixing (θ_{23}=π/4). Assuming the normal mass hierarchy, we find Δm_{32}^{2}=(2.67±0.11)×10^{-3}  eV^{2} and sin^{2}θ_{23} at the two statistically degenerate values 0.404_{-0.022}^{+0.030} and 0.624_{-0.030}^{+0.022}, both at the 68% confidence level. Our data disfavor the maximal mixing scenario with 2.6σ significance.

First Measurement of Electron Neutrino Appearance in NOvA

We report results from the first search for ν_{μ}→ν_{e} transitions by the NOvA experiment. In an exposure equivalent to 2.74×10^{20} protons on target in the upgraded NuMI beam at Fermilab, we observe 6 events in the Far Detector, compared to a background expectation of 0.99±0.11(syst) events based on the Near Detector measurement. A secondary analysis observes 11 events with a background of 1.07±0.14(syst). The 3.3σ excess of events observed in the primary analysis disfavors 0.1π<δ_{CP}<0.5π in the inverted mass hierarchy at the 90% C.L.

Adverse childhood experience and asthma onset: a systematic review

Adverse childhood experiences such as abuse and neglect are associated with subsequent immune dysregulation. Some studies show an association between adverse childhood experiences and asthma onset, although significant disparity in results exists in the published literature.

We aimed to review available studies employing a prospective design that investigates associations between adverse childhood experience and asthma. A search protocol was developed and studies were drawn from four electronic journal databases. Studies were selected in accordance with pre-set inclusion criteria and relevant data were extracted.

12 studies, assessing data from a total of 31 524 individuals, were identified that investigate the impact of a range of adverse childhood experiences on the likelihood of developing asthma. Evidence suggests that chronic stress exposure and maternal distress in pregnancy operate synergistically with known triggers such as traffic-related air pollution to increase asthma risk.

Chronic stress in early life is associated with an increased risk of asthma onset. There is evidence that adverse childhood experience increases the impact of traffic-related air pollution and inconsistent evidence that adverse childhood experience has an independent effect on asthma onset.

The Effectiveness of Psychosocial Intervention for Individuals with Cleft Lip and/or Palate

Objective

The aim of this review was to assess the effectiveness of different psychological interventions for children and adults with cleft lip and/or palate and their parents.

Design

We searched six databases including MEDLINE and EMBASE to June 2013 and checked bibliographies. We included research that evaluated any psychological intervention in studies in which at least 90% of the participants had cleft lip and/or palate or were parents of those with cleft lip and/or palate. Studies containing less than 90% were excluded unless they reported results separately for those with cleft lip and/or palate, or raw data were available upon request from the authors. Inclusion assessment, data extraction, and risk of bias assessment were carried out independently by two reviewers.

Results

Seven studies were identified as inclusions, with only two studies being included in the full data analysis (one of which failed to meet the full inclusion criteria). The five remaining studies were included only in a narrative synthesis because data were available for people or parents of those with cleft lip and/or palate only. This highlights a distinct dearth of research into psychological intervention within the field of cleft lip and/or palate.

Conclusions

The review found no evidence to support any specific intervention. Key uncertainties need to be identified and addressed. Adequately powered, methodologically rigorous randomized controlled trials are needed to provide a secure evidence base for psychological intervention techniques in participants with cleft lip and/or palate and their parents.

Psychosocial interventions for adults with visible differences: a systematic review

Background. Some individuals with visible differences have been found to experience psychosocial adjustment problems that can lead to social anxiety and isolation. Various models of psychosocial intervention have been used to reduce social anxiety and appearance related distress in this population. The objective of this review was to update a previous systematic review assessing the efficacy of psychosocial intervention programs for adults with visible differences. The original review (Bessell & Moss, 2007) identified 12 papers for inclusion. Methods. A search protocol identified studies from 13 electronic journal databases.

METHODS

Studies were selected in accordance with pre-set inclusion criteria and relevant data were extracted. Results. This update identified an additional four papers that met the inclusion criteria. Two papers provided very limited evidence for the efficacy of a combined cognitive-behavioural and social skills training approach. None of the papers provided sufficient evidence for the optimal duration, intensity or setting of psychosocial interventions for this population. Discussion. The review concluded that a greater number of Randomised Controlled Trials and experimental studies were required to increase the methodological validity of intervention studies.

Large-scale discovery of novel genetic causes of developmental disorders

Despite three decades of successful, predominantly phenotype-driven discovery of the genetic causes of monogenic disorders, up to half of children with severe developmental disorders of probable genetic origin remain without a genetic diagnosis. Particularly challenging are those disorders rare enough to have eluded recognition as a discrete clinical entity, those with highly variable clinical manifestations, and those that are difficult to distinguish from other, very similar, disorders. Here we demonstrate the power of using an unbiased genotype-driven approach to identify subsets of patients with similar disorders. By studying 1,133 children with severe, undiagnosed developmental disorders, and their parents, using a combination of exome sequencing and array-based detection of chromosomal rearrangements, we discovered 12 novel genes associated with developmental disorders. These newly implicated genes increase by 10% (from 28% to 31%) the proportion of children that could be diagnosed. Clustering of missense mutations in six of these newly implicated genes suggests that normal development is being perturbed by an activating or dominant-negative mechanism. Our findings demonstrate the value of adopting a comprehensive strategy, both genome-wide and nationwide, to elucidate the underlying causes of rare genetic disorders.

Psychosocial interventions for patients with head and neck cancer

BACKGROUND

A diagnosis of head and neck cancer, like many other cancers, can lead to significant psychosocial distress. Patients with head and neck cancer can have very specific needs, due to both the location of their disease and the impact of treatment, which can interfere with basic day-to-day activities such as eating, speaking and breathing. There is a lack of clarity on the effectiveness of the interventions developed to address the psychosocial distress experienced by patients living with head and neck cancer.

OBJECTIVES

To assess the effectiveness of psychosocial interventions to improve quality of life and psychosocial well-being for patients with head and neck cancer.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 17 December 2012.

SELECTION CRITERIA

We selected randomised controlled trials and quasi-randomised controlled trials of psychosocial interventions for adults with head and neck cancer. For trials to be included the psychosocial intervention had to involve a supportive relationship between a trained helper and individuals diagnosed with head and neck cancer. Outcomes had to be assessed using a validated quality of life or psychological distress measure, or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data and assessed the risk of bias, with mediation from a third author where required. Where possible, we extracted outcome measures for combining in meta-analyses. We compared continuous outcomes using either mean differences (MD) or standardised mean differences (SMD) and 95% confidence intervals (CI), with a random-effects model. We conducted meta-analyses for the primary outcome measure of quality of life and secondary outcome measures of psychological distress, including anxiety and depression. We subjected the remaining outcome measures (self esteem, coping, adjustment to cancer, body image) to a narrative synthesis, due to the limited number of studies evaluating these specific outcomes and the wide divergence of assessment tools used.

MAIN RESULTS

Seven trials, totaling 542 participants, met the eligibility criteria. Studies varied widely on risk of bias, interventions used and outcome measures reported. From these studies, there was no evidence to suggest that psychosocial intervention promotes global quality of life for patients with head and neck cancer at end of intervention (MD 1.23, 95% CI -5.82 to 8.27) as measured by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30). This quality of life tool includes five functional scales, namely cognitive, physical, emotional, social and role. There was no evidence to demonstrate that psychosocial intervention provides an immediate or medium-term improvement on any of these five functional scales. From the data available, there was no significant change in levels of anxiety (SMD -0.09, 95% CI -0.40 to 0.23) or depression following intervention (SMD -0.03, 95% CI -0.24 to 0.19). At present, there is insufficient evidence to refute or support the effectiveness of psychosocial intervention for patients with head and neck cancer.

AUTHORS' CONCLUSIONS

The evidence for psychosocial intervention is limited by the small number of studies, methodological shortcomings such as lack of power, difficulties with comparability between types of interventions and a wide divergence in outcome measures used. Future research should be targeted at patients who screen positive for distress and use validated outcome measures, such as the EORTC scale, as a measure of quality of life. These studies should implement interventions that are theoretically derived. Other shortcomings should be addressed in future studies, including using power calculations that may encourage multi-centred collaboration to ensure adequate sample sizes are recruited.

Endoscopic evaluation of the gastro-duodenal tolerance of short-term analgesic treatment with 25 mg diclofenac-K liquid capsules

BACKGROUND

Diclofenac-potassium (diclofenac--K) 25 mg liquid capsule is absorbed more quickly than the tablet formulation. It offers potential for rapid pain relief, but may alter gastro-duodenal tolerability.

AIM

To evaluate the gastro-duodenal tolerance of diclofenac-K 25 mg liquid capsules vs. diclofenac-K 12.5 mg tablets, acetylsalicylic acid (ASA) 500 mg tablets and ibuprofen 200 mg liquid capsules.

METHODS

In an endoscopist-blinded, randomised, parallel-group study, volunteers received 15 doses of diclofenac-K 25 mg liquid capsules (n = 36), diclofenac-K 2 × 12.5 mg tablets (n = 36), ibuprofen 2 × 200 mg liquid capsules (n = 24) or ASA 2 × 500 mg tablets (n = 36) over 5 days. The primary outcome was the incidence of erosive gastro-duodenal lesions at Day 6. Secondary outcomes included modified Lanza score and change in gastric mucosal prostaglandin synthesis.

RESULTS

The lowest incidence of erosive gastro-duodenal lesions was with diclofenac-K liquid capsules (53%), compared to 61% with diclofenac-K tablets (P = 0.52), 75% with ibuprofen (P = 0.08) and 94% with ASA (P = 0.001). Results were similar for the Lanza scores, although diclofenac-K liquid capsules were significantly superior to ibuprofen liquid capsules (P = 0.04). Diclofenac-K liquid capsules inhibited prostaglandin synthesis by 52% compared to 64% for diclofenac-K tablets (P = 0.10), 50% for ibuprofen (P = 0.85) and 79% for ASA (P = 0.002). With respect to safety, adverse events were most frequent in the ASA group, predominantly gastrointestinal events.

CONCLUSIONS

Mucosal injury with diclofenac-K liquid 25 mg liquid capsules was similar to diclofenac-K 25 mg tablets, significantly lower than ASA 1 g tablets and showed some superiority over ibuprofen 400 mg liquid capsules (EudraCT Number 2009-011278-14).

Promoter mutation is a common variant in GJC2-associated Pelizaeus-Merzbacher-like disease

Pelizaeus-Merzbacher-like disease (PMLD) is a clinically and genetically heterogeneous neurological disorder of cerebral hypomyelination. It is clinically characterised by early onset (usually infantile) nystagmus, impaired motor development, ataxia, choreoathetoid movements, dysarthria and progressive limb spasticity. We undertook autozygosity mapping studies in a large consanguineous family of Pakistani origin in which affected children had progressive lower limb spasticity and features of cerebral hypomyelination on MR brain imaging. SNP microarray and microsatellite marker analysis demonstrated linkage to chromosome 1q42.13-1q42.2. Direct sequencing of the gap junction protein gamma-2 gene, GJC2, identified a promoter region mutation (c.-167A>G) in the non-coding exon 1. The c.-167A>G promoter mutation was identified in a further 4 individuals from two families (who were also of Pakistani origin) with clinical and radiological features of PMLD in whom previous routine diagnostic screening of GJC2 had been reported as negative. A common haplotype was identified at the GJC2 locus in the three mutation-positive families, consistent with a common origin for the mutation and likely founder effect. This promoter mutation has only recently been reported in GJC2-PMLD but it has been postulated to affect the binding of the transcription factor SOX10 and appears to be a prevalent mutation, accounting for ~29% of reported patients with GJC2-PMLD. We propose that diagnostic screening of GJC2 should include sequence analysis of the non-coding exon 1, as well as the coding regions to avoid misdiagnosis or diagnostic delay in suspected PMLD.

What you need to know when you prescribe a proton pump inhibitor

Ever since they were launched, proton pump inhibitors (PPIs) have been regarded as profligate prescription interventions and have become a favourite target for pharmacy advisers. Now that they are cheap, with generic omeprazole 20 mg daily costing £1.88 per month (£24.51 per annum) in the UK, it is time to ask whether this status should be reviewed, whether there are areas where the message should be reversed and whether there are any circumstances in which the extra cost of branded PPIs or combined preparations is justified. Equally, with the recognition of an extended toxicity profile, is prescribing profligacy not an economic but a safety issue?

Screening and cell-based assessment of mutations in the Aristaless-related homeobox (ARX) gene

ARX mutations cause a diverse spectrum of human disorders, ranging from severe brain and genital malformations to non-syndromic intellectual disability (ID). ARX is a transcription factor with multiple domains that include four polyalanine (pA) tracts, the first two of which are frequently expanded by mutations. We progressively screened DNA samples from 613 individuals with ID initially for the most frequent ARX mutations (c.304ins(GCG)(7)'expansion' of pA1 and c.429_452dup 'dup24bp' of pA2). Five hundred samples without pA1 or pA2 mutations had the entire ARX ORF screened by single stranded polymorphism conformation (SSCP) and/or denaturing high pressure liquid chromatography (dHPLC) analysis. Overall, eight families with six mutations in ARX were identified (1.31%): five duplication mutations in pA2 (0.82%) with three new clinical reports of families with the dup24bp and two duplications larger than the dup24bp mutation discovered (dup27bp, dup33bp); and three point mutations (0.6%), including one novel mutation in the homeodomain (c.1074G>T). Four ultraconserved regions distal to ARX (uc466-469) were also screened in a subset of 94 patients, with three unique nucleotide changes identified in two (uc466, uc467). The subcellular localization of full length ARX proteins was assessed for 11 variants. Protein mislocalization increased as a function of pA2 tract length and phenotypic severity, as has been previously suggested for pA1. Similarly, protein mislocalization of the homeodomain mutations also correlated with clinical severity, suggesting an emerging genotype vs cellular phenotype correlation.