Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

BACKGROUND

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

METHODS

The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned.

RESULTS

A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31).

CONCLUSION

Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).

Oropharyngeal Teratoma: Five-Month-Old Presenting With Failure to Thrive and Severe Obstructive Sleep Apnea

Oropharyngeal teratomas are an extremely rare congenital tumor. They are often diagnosed prenatally and can cause significant airway obstruction and feeding difficulties at birth. We present a five-month-old female that was diagnosed with a palatal teratoma that presented with failure to thrive, difficulty feeding, and eventually with severe obstructive sleep apnea. We present a five-month-old term, otherwise healthy female who became stridulous after an episode of the respiratory syncytial virus at one month old. At three months old, an otolaryngologist diagnosed mild laryngomalacia with no mass identified, and no surgical intervention was recommended. Due to continued poor weight gain, at four months old, a nasogastric tube was placed. She was subsequently admitted for further workup. She had severe stridor, a failure to thrive, and was in the 0.07th percentile for weight. Workup revealed severe obstructive sleep apnea and a palatal mass obstructing her left oropharynx. A biopsy and debulking of the mass was performed in the operating room. Pathology resulted as a mature teratoma with evidence of glial and intestinal tissue. There are no pathognomonic characteristics found on imaging to diagnose teratomas, and diagnosis is made with pathologic identification of two of the three germ cell layers. Although most teratomas are benign, there is potential for malignant transformation involving any of the represented germ cell layers. Many teratomas are diagnosed prenatally and can be quite large, often requiring Ex Utero Intrapartum Treatment (EXIT) procedure at birth to establish a safe airway. Overall, this case highlights the importance of a thorough head and neck exam, including a bilateral flexible laryngoscopy, when evaluating an infant with airway obstruction. Providers evaluating these patients should consider oropharyngeal masses, such as teratoma, as part of the differential to ensure accurate and timely diagnosis.

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.

Improving Control of Gene Therapy-Based Neurotrophin Delivery for Inner Ear Applications

Background: Survival and integrity of the spiral ganglion is vital for hearing in background noise and for optimal functioning of cochlear implants. Numerous studies have demonstrated that supplementation of supraphysiologic levels of the neurotrophins BDNF and NT-3 by pumps or gene therapy strategies supports spiral ganglion survival. The endogenous physiological levels of growth factors within the inner ear, although difficult to determine, are likely extremely low within the normal inner ear. Thus, novel approaches for the long-term low-level delivery of neurotrophins may be advantageous.

Objectives: This study aimed to evaluate the long-term effects of gene therapy-based low-level neurotrophin supplementation on spiral ganglion survival. Using an adenovirus serotype 28-derived adenovector delivery system, the herpes latency promoter, a weak, long expressing promoter system, has been used to deliver the BDNF or NTF3 genes to the inner ear after neomycin-induced ototoxic injury in mice.

Results: Treatment of the adult mouse inner ear with neomycin resulted in acute and chronic changes in endogenous neurotrophic factor gene expression and led to a degeneration of spiral ganglion cells. Increased survival of spiral ganglion cells after adenoviral delivery of BDNF or NTF3 to the inner ear was observed. Expression of BDNF and NT-3 could be demonstrated in the damaged organ of Corti after gene delivery. Hearing loss due to overexpression of neurotrophins in the normal hearing ear was avoided when using this novel vector–promoter combination.

Conclusion: Combining supporting cell-specific gene delivery via the adenovirus serotype 28 vector with a low-strength long expressing promoter potentially can provide long-term neurotrophin delivery to the damaged inner ear.

AB1205 MEDICAL AND PSYCHOLOGICAL COMORBIDITIES IN FIBROMYALGIA: A CROSS SECTIONAL STUDY

Background

Psychological disorders are commonly observed in fibromyalgia (FMS). Medical comorbidities are less well characterised in FMS. We sought to assess the prevalence of these disorders in an observational cohort of patients in a tertiary hospital in North India.

Objectives

The prevalence of medical and psychological comorbidities in FMS and the prevalence of these disorders in FMS subgroups classified according to different ACR classification criteria were assessed.

Methods

Patients satisfying either the 1990 ACR or the 2016 ACR Fibromyalgia criteria were included in a cross-sectional study between October’19 and December’21. All patients were assessed for prevalence of chronic fatigue syndrome (CFS), post-traumatic stress syndrome (PTSD), restless leg syndrome (RLS) and medical comorbidities including obesity, obstructive sleep apnoea, anemia, diabetes mellitus, hypertension and hypothyroidism.

Results

A total of 98 patients of median age 39 years (34 – 47) were included, of which 9 met only the 1990 ACR criteria (100% females), 30 met only 2016 ACR criteria (86% females) and 59 met both criteria (89% females). Widespread Pain index was significantly higher in the 1990 + 2016 group compared to subgroups which met only either of the criteria. Hypothyroidism (subclinical or clinical) was similarly higher in the 1990 + 2016 subgroup. At least one psychological comorbidity was seen in 41%, with CFS present in 30% and PTSD in 14%. The median systolic blood pressure was in the hypertensive range (146 mm Hg) in the 1990-only group, with hypertension being present in 1/3rd of the total cohort. Obesity was present in 59% and Diabetes in 11%. Iron deficiency anemia was seen in 20%.

Table 1.

Prevalence of comorbidities in different subgroups of Fibromyalgia

Clinical featuresFMS CohortACR 1990ACR 1990 + 2016 (N-59)ACR 2016p-value(N-98)(N-9)(N-30)F:M88:109:053:626:40.6Age (years)39 (34 – 47)38 (32 – 46)38 (34 – 45)44 (35 – 50)0.2Duration of symptoms (months)48 (24 – 84)48 (36 – 84)48 (24 – 78)60 (27 – 84)0.6WPI15 (12 – 17)14 (8 – 15)16 (14 – 18)13 (10 – 16)0.001SSS8 (6 – 10)3 (1 – 4)6 (7 – 10)8 (6 – 9)<0.000TP13 (9-16)13 (12 – 15)15 (13 – 16.5)6 (4 – 8)<0.000BMI (kg/m2)26 (23 – 28)23 (22 – 25)26 (24 – 28)26 (23 – 29)0.2Obese (BMI ≥ 25 kg/m2)58 (59%)3 (33%)37 (62%)18 (60%)0.08Prediabetes (HbA1c 5.7 – 6.5)21 (21%)016 (27%)5 (16%)0.8Diabetes (HbA1C ≥6.5)11 (11%)1(11%)9 (15%)1 (3%)0.2Systolic BP125(115–143)146 (117–148)120(114–137)127(116–143)0.1Diastolic BP80 (76 – 88)80 (76 – 83)82 (75 - 88)79 (76 – 88)0.8Hypertension (≥140/90 cm)37 (37%)6 (66%)20 (33%)11 (36%)0.2Hypothyroidism (TSH > 5 mIU/L)12 (12%)011 (22%)1 (3%)0.04Iron deficiency anemia (Serum Ferritin < 12 ng/ml)14 (20%) (n-67)3 (42%)9 (23%)2 (9%)0.1OSA (intermediate to high risk by STOPBANG questionnaire)32 (32%)1 (11%)17 (28%)140.1CFS30 (30%)1 (11%)22 (37%)7 (23%)0.1PTSD14 (14%)011 (18%)3 (10%)0.2RLS9 (9%)05 (8%)4 (13%)0.4

F female, M male, WPI widespread pain index, SSS symptoms severity score, TP tender points, BMI body mass index, BP blood pressure, OSA obstructive sleep apnoea, CFS chronic fatigue syndrome, PTSD post traumatic stress disorder, RLS restless leg syndrome

Figure 1.

Venn Diagram depicting Fibromyalgia subgroups having psychological comorbidities

Conclusion

There is a high prevalence of comorbidities in patients with fibromyalgia with nearly half having atleast one psychological comorbidity, and obesity, hypertension and iron deficiency anaemia being the common medical comorbidities. Those who met only the 1990 ACR criteria formed less than 10%.

References

[1]Ahmed S, Aggarwal A, Lawrence A. Performance of the American College of Rheumatology 2016 criteria for fibromyalgia in a referral care setting. Rheumatol Int. 2019 Aug;39(8):1397-1403.

[2]Wolfe F, Ablin J, Guymer EK, Littlejohn GO, Rasker JJ. The Relation of Physical Comorbidity and Multimorbidity to Fibromyalgia, Widespread Pain, and Fibromyalgia-related Variables. J Rheumatol. 2020 Apr;47(4):624-631.

Disclosure of Interests

None declared

CARE Score on Chest Radiograph at Diagnosis Predicts Early and Late Outcomes Among Lung Transplant Patients with COVID-19

Purpose

To assess the ability of an objective radiographic scoring system to predict outcomes among lung transplant (LT) patients with Coronavirus disease 2019 (COVID-19).

Methods

We included all LT patients diagnosed with COVID-19 during a one-year period (March 2020 to Feb 2021; n=54; median age: 60, 20-73 years; M:F 37:17) in our program. Patient characteristics and laboratory values during the acute illness were reviewed. Chest radiographs at time of COVID-19 diagnosis were scored by extent of ground-glass opacity and consolidation using the CARE score (0-18 for each lung). The CARE score was calculated using only the allograft in single LT and the average of both lungs in bilateral LT. Primary outcome was six-month survival after COVID-19. Hospital complications and one-month survival were secondary outcomes.

Results

A minority of patients had a clear allograft (CARE=0, n=12, 22.2%) at presentation. The median score was 2 (interquartile range 0.5-4.625), indicating mild abnormalities. Demographics, underlying diagnosis, comorbidities, symptoms, and spirometry changes were not associated with the baseline CARE score. Baseline CARE score >5 was strongly associated with development of respiratory failure (91.7% vs 35.7%; OR, 95% CI: 19.8, 2.3-168.7; p=0.001), ICU admission (p<0.001), need for ventilator support (p<0.001), and one-month mortality (41.7% vs 2.4%; OR, 95% CI: 29.4, 2.96-333.3; p=0.001). Overall six-month survival was 81.5%. The CARE score was significantly higher among non-survivors (7.7±4.1 vs 2.2±2.7; p=0.002). Patients with a CARE score>5 at diagnosis were significantly less likely to survive at six-month follow-up (41.7%.vs 92.3%; p<0.001). The CARE score had an excellent area under the curve (86.8%, 74.4%-99.2%; p<0.001) on the Receiver operating characteristic curve for predicting six-month survival after COVID-19.

Conclusion

The CARE score at time of COVID-19 diagnosis provides useful prognostic information among patients with LT.

Assessing the Risks to Bats from Plant Protection Products: A Review of the Recent European Food Safety Authority Statement Regarding Toxicity and Exposure Routes

Wild birds and mammals that feed in agricultural habitats are potentially exposed to pesticides through various routes. Until recently, it has been implicitly assumed that the existing European Union risk assessment scheme for birds and mammals also covered bats (Chiroptera). However, recent publications raised concerns and, in 2019, a scientific statement was published by the European Food Safety Authority (EFSA) that concluded that bats were not adequately covered by the current risk assessment scheme. We review the evidence presented and assumptions made in the EFSA bat statement relating to toxicity, bioaccumulation, and exposure pathways (oral, dermal, and inhalation), in terms of their relevance for bats potentially foraging in agricultural areas in the European Union; we highlight where uncertainties remain and how these could be addressed. Based on our review, it is clear that there is still much uncertainty with regard to the appropriateness of the assumptions made in the EFSA bat statement. Significantly more information needs to be gathered to answer fundamental questions regarding bat behavior in agricultural landscapes, together with the relative sensitivity of bats to pesticide exposure. Given the current critical information gaps, it is recommended that quantitative risk assessments for bats not be performed for pesticides until more robust, reliable, and relevant data are available. The risk to bats can then be compared with that for birds and ground-dwelling mammals, to determine the protectiveness of the existing scheme and thus whether a bat scenario is indeed required and under what circumstances. Environ Toxicol Chem 2021;40:2978-2989. © 2021 Cambridge Environmental Assessments, part of RSK ADAS Ltd. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

Transcutaneous Electrical Stimulation for Neurogenic Bladder Dysfunction Following Spinal Cord Injury: Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

To assess the efficacy of transcutaneous electrical nerve stimulation (TENS) for neurogenic bladder dysfunction secondary to spinal cord injury (SCI).

MATERIALS AND METHODS

A systematic search of MEDLINE, EMBASE, Web of Science, Scopus, and Cochrane libraries up to February 2021 was performed using PRISMA methodology. All randomized controlled trials (RCTs) that studied TENS for neurogenic bladder in a SCI population were included. The primary outcomes of interest were maximum cystometric capacity (MCC) and maximum detrusor pressure (Pdet). Meta-analysis was conducted with RevMan v5.3.

RESULTS

Six RCTs involving 353 participants were included. Meta-analysis showed that TENS significantly increased MCC (standardized mean difference 1.11, 95% confidence interval [CI] 0.08-2.14, p = 0.03, I²  = 54%) in acute SCI. No benefits were seen for maximum Pdet. TENS was associated with no major adverse events.

CONCLUSIONS

TENS may be an effective, safe intervention for neurogenic bladder dysfunction following SCI. Further studies are essential to confirm these results and more work is required to determine optimal stimulation parameters and duration of the treatment.

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.

Forests in common: Learning from diversity of community forest arrangements in Europe

Europe has a wealth of community forest arrangements. This paper aims to transcend the diversity of locally specific terms and forms, to highlight the value of considering them inclusively. Building on methods to make sense of diversity, we use reflexive grounded inquiry in fifteen cases in Italy, Scotland, Slovenia and Sweden. Within four dimensions (forest, community, relationships between them, and relationships with wider society), we identify 43 subdimensions to describe them collectively. Our approach shows how European arrangements contribute to wider discourses of collective natural resource management. Both tradition and innovation in Europe inform options for environmental governance. Arrangements challenge the distinction between 'communities of place' and 'communities of interest', with implications for social and environmental justice. They exemplify multilevel environmental governance through both vertical and horizontal connections. Emerging from long histories of political and environmental pressures, they have a role in enhancing society's connection with nature and adaptive capacity.

Fetal lung interstitial tumor: Prenatal presentation of a rare fetal malignancy

Fetal lung interstitial tumor (FLIT) is a rare fetal malignancy that is typically diagnosed in the postnatal period, or, if recognized prenatally can mimic a benign lesion such as congenital pulmonary airway malformation. We present the earliest case of a FLIT tumor described by ultrasound and MRI at 26 weeks of gestation. Our case highlights features suggestive of FLIT including presentation later in gestation in combination with findings on fetal MRI such as a solid appearance with radiating curved bands of high signal within and along the periphery of the lesion (not as intensely high signal as the typical CPAM), possibly detailing a radiographic signature for these tumors. The role of betamethasone for these tumors is not known.

AB0581 HIGH PREVALENCE OF TUBERCULOSIS IN ADULTS AND CHILDREN WITH IIM AS COMPARED WITH SLE: RETROSPECTIVE DATA REVIEW FROM A LARGE COHORT AT A TERTIARY CARE CENTER IN INDIA

Background:

Infections are the most common cause of morbidity and mortality in idiopathic inflammatory myositis (IIM). India is endemic for Tuberculosis (TB) with a prevalence of 2.3 cases per thousand population.

Objectives:

Thus, we studied the prevalence of TB in our cohort of IIM patients and compared with that in systemic lupus erythematosus (SLE).

Methods:

Medical records from paper charts and electronic medical records were reviewed for adults and juvenile patients with SLE (ACR criteria 1997) and IIM (Bohan and Peter criteria 1975) first presented at a tertiary care hospital in India from 1989 to 2016. Clinical variables including disease characteristics variables, the frequency, site, duration and complication of active TB as well as dose of corticosteroids and other immunosuppressive drugs were extracted retrospectively from the medical records. Descriptive statistics were used to describe the cohort and TB characteristics. Chi-square and t-test were used to evaluate association of TB with clinical diagnosis as well as medication data.

Results:

There were 167 (132 adults and 35 juvenile) IIM and 280 (131 adults and 149 juvenile) SLE in our cohort. Active TB occurred in 24 (14.4%) of all IIM cases (18, 13.6% adults; 6, 17.1% juvenile) as compared to 18 (6.4%) of all SLE cases (8, 6.1% adults; 10, 6.7% juvenile, p value < 0.01). Of all the TB in myositis, most often it was seen in Dermatomyositis (n=11, 45.8%) followed by Polymyositis (5, 20.8%), and occasionally in Overlap myositis (3, 12.5) and juvenile dermatomyositis (1,4.1%).

Considering an annual TB rate of 211 per 100,000 of the general population, the risk of developing active TB was 62-fold higher in patients with IIM and 27-fold higher in those with lupus. Patients with IIM had higher odds of developing TB as compared with Lupus [odds ratio 2.86 (CI 1.5-5.47), p=0.007).

Amongst 24 IIM patients with TB, 10 had pulmonary TB and 14 had extra-pulmonary TB. The median glucocorticoid dose at the diagnosis of TB was 0.25 (0-1.5) mg/kg/day. Half the cases of active TB occurred during inactive myositis. Seventeen patients with active TB were followed up over 27 months (8-184), with remission of TB in all cases but required prolonged courses of Anti-Tuberculous Therapy (ATT) in 25% cases with 10 ATT related adverse events in 8 patients and 5 patients with relapse of myositis due to lowering of immunosuppression.

Conclusion:

Patients with IIM have higher prevalence of active TB as compared with SLE patients. The risk is highest in patients with Dermatomyositis possibly related to high doses of steroids. Extra-pulmonary forms of TB are more common, and patients commonly require prolonged course of ATT and may suffer relapses of myositis during ATT. Screening for latent TB may be useful in IIM patients before prescribing steroids and other immunosuppressive drugs.

References:

[1]TB Statistics India | National, treatment outcome & state statistics [Internet]. TB Facts | TB, tests, drugs, statistics. [cited 2019 Jun 13]. Available from:https://www.tbfacts.org/tb-statistics-india/

[2]Muhammed H, Gupta L, Zanwar A, Misra DP, Lawrence A, Agarwal V, Aggarwal A, Misra R;OPC0243: Infections are leading cause of in-hospital mortality in patients with inflammatory myositis; Indian J Rheumatol 2018;13, Suppl S2:93-241

[3]Gaitonde S, Pathan E, Sule A, Mittal G, Joshi VR. Efficacy of isoniazid prophylaxis in patients with systemic lupus erythematosus receiving long term steroid treatment. Ann Rheum Dis. 2002 Mar;61(3):251–3.

[18]He D, Bai F, Zhang S, Jiang T, Shen J, Zhu Q, et al. High incidence of tuberculosis infection in rheumatic diseases and impact for chemoprophylactic prevention of tuberculosis activation during biologics therapy. Clin Vaccine Immunol CVI. 2013 Jun;20(6):842–7.

Figure 1.

(A) Prevalence and (B) sites of tuberculosis

Table 1.

Table 2.

Clinical profile of patients with Tuberculosis

Disclosure of Interests:

Latika Gupta: None declared, Abhishek Zanwar: None declared, Rohit Aggarwal Grant/research support from: Pfizer, Genentech, BMS, Mallinckrodt, Consultant of: Pfizer, Genentech, BMS, Mallinckrodt, Bristol Myers-Squibb, octapharma, CSL Behring, AstraZeneca, Corbus, Kezar, Abbvie, Able Lawrence: None declared, Durga Misra: None declared, Vikas Agarwal: None declared, Ramnath Misra: None declared, Amita Aggarwal: None declared

SAT0230 MACROPHAGE ACTIVATION SYNDROME IN SLE AND SYSTEMIC ONSET JIA: SIMILAR OR DISSIMILAR

Background:

Macrophage activation syndrome (MAS) is a serious complication in rheumatic disease. Fever and hyperferritinemia are common in systemic onset JIA and cytopenias are common in SLE thus recognising MAS in them is a challenge.

Objectives:

We compared clinical, laboratory parameters, various classification criteria for MAS, and its outcome in SLE and sJIA.

Methods:

Clinical and laboratory data were extracted from clinician diagnosed cases of MAS with SLE/sJIA who were admitted between 2004-2018 at a tertiary care hospital. Percentage of patients satisfying Ravelli, International consensus, HLH 2004 and criteria proposed by Parodi et al1were calculated.

Results:

Among 33 patients (18 females) with MAS 19 had SLE and 14 had sJIA. MAS was more likely to be the presenting manifestation of disease in SLE as compared to sJIA (p<0.05). There were no differences in the clinical features among these two diseases. EBV and CMV were identified in 2 patients each as the trigger for MAS.

Patients with SLE had lower baseline TLC and platelet whereas patients with sJIA-MAS had significantly higher median CRP (p = 0.002), fall in TLC (p=0.012) and delta ESR/CRP ratio (p=0.02) and lower fibrinogen level (p=0.006). Neutrophil to lymphocyte ratio, Ferritin/CRP ratio and number of patients with Ferritin/ESR >80 were similar. Bone Marrow hemophagocytosis was seen in only in 21% of patients.

Only 6/33 fulfilled HLH criteria but criteria meant for sJIA or SLE performed well for both diseases and majority of patients could be diagnosed using them. Treatment included steroids(100%), cyclosporine(30%), Tacrolimus(21%), cyclophosphamide(21%), etoposide(3%) and thalidomide(12%). Mortality was similar in both groups.

Table 1.

Agreement amongst MAS/HLH criteria in SLE and sJIA MAS

SLE-MASHLHRavelli et alConsensusParodi et alHLH4444Ravelli et al4191918Consensus4191918Parodi et al4181818sJIA-MASHLHRavelli et alConsensusParodi et alHLH2222Ravelli et al2121112Consensus2111212Parodi et al2121214Table 2.

Comparison with various other cohorts

Minoia et alsJIAn (%)Our studysJIA, n (%)Our Study SLE, n (%)SLE, n (%) Ai-Chun Liu et alJuvenile SLE n (%)Parodi et alNumber36214193238MAS as presenting feature (%)80 (22)4 (28)12 (63)NA24 (63)Most common manifestation (%)Fever (96)Fever (100)Fever (89)Fever (96)Fever (89)Most common triggerDisease activityDisease activityDisease activityDisease activityDisease activityBM done251 (72.3)8 (57)12 (63)32 (96)38 (100)BM hemophagocytosis150 (60.7)2 (25)5 (41)32 (100)20 (52)Mortality28 (8)2 (14)2 (10.5)4 (12.5)4 (11.4)Patients meeting JIA criteria %NA-100NA100Patients meeting HLH criteria %NA1419NA66

Conclusion:

MAS is more likely to be presenting manifestation in SLE compared to sJIA. Though lab parameters are significantly different in MAS associated with SLE & sJIA, criteria meant for MAS in sJIA or SLE MAS performed equally well in both diseases.

References:

[1]Parodi A et al, Macrophage activation syndrome in juvenile systemic lupus erythematosus: a multinational multicenter study of thirty-eight patients. Arthritis Rheum. 2009 Nov;60(11):3388-99.

Disclosure of Interests:

None declared

Reaching out to reduce health inequities for Māori youth

AIM

This paper describes an initiative facilitating comprehensive assessment and delivery of brief interventions for Māori youth in Northland, New Zealand.

BACKGROUND

The population in Northland is predominantly Māori and is one of New Zealand's most deprived populations. Māori youth have the highest youth suicide rate in the developed world and elevated numbers of youth displaying mental health issues and/or risk behaviours are of grave national concern. Like Indigenous peoples worldwide, inequities persist for Māori youth accessing and engaging with healthcare services.

DESCRIPTION

Taking services out to Māori youth in remote and isolated areas, Northland's youth specialist nurses are reducing some barriers to accessing health care. The youth version of the Case-finding and Help Assessment Tool is a New Zealand-developed, e-screening tool for youth psychosocial issues, facilitating comprehensive assessment and brief intervention delivery.

DISCUSSION

Early detection of, and timely intervention for, mental health and risk behaviours can significantly improve health outcomes in youth. However, for this to happen barriers preventing youth from accessing appropriate care need to be overcome.

CONCLUSION

Youth specialist nurses could improve access to care for youth from ethnic minorities, rural and isolated regions, and areas of high deprivation without overwhelming the medical profession.

IMPLICATIONS FOR NURSING POLICY

Specialist nurses are trained and empowered to practice at the top of their scope. With general practitioner oversight and standing order sign off specialist nurses can work autonomously to improve access to health services, without increasing the workload of doctors.

IMPLICATIONS FOR NURSING PRACTICE

Encouraging continuous self-reflection of the nurse's effectiveness in meeting patient needs, holistically and culturally, facilitates the provision of accessible care that is patient-centred and culturally safe.

Outcomes in juvenile onset lupus: single center cohort from a developing country

Introduction

About 10–20% of systemic lupus erythematosus (SLE) patients have onset in childhood and have more severe organ involvement. Survival of juvenile SLE patients is improving worldwide. Long-term data of childhood onset SLE from developing countries is scarce.

Methods

Clinical and laboratory data at initial presentation and follow-up visits were retrieved from clinic files, hospital information system and personal interviews. Treatment received, complications, flares, outcomes and death were recorded. Survival was calculated using Kaplan–Meier survival curves and regression analysis was done for predictors of mortality.

Results

Children with SLE ( n = 273, 250 girls) had a median age at onset of 14 years and duration of illness prior to diagnosis at our hospital of 1 year. Fever and arthritis were the most common presenting manifestations. Renal disease was seen in 60.5% and central nervous system (CNS) disease in 29%. The median follow-up period in 248 patients was 3.5 years. Fourteen children died, and 10 of these had active disease at the time of death. The mean actuarial survival was 24.5 years and survival rates at 1, 5 and 10 years were 97.9%, 95% and 89% respectively. Fever, CNS disease, anti-dsDNA levels and serious infections predicted death on univariate and multivariate analysis. Infections were seen in 72 children (26.3%), and 38 of these infections were serious. One-third of the patients had damage on the last follow-up. Flares were seen in 120 children, the majority being major flares.

Conclusion

Outcomes of pediatric SLE in North Indian children are similar to those seen in developed countries. Infections pose a major challenge in these patients.

Citizen science networks in natural history and the collective validation of biodiversity data

Biodiversity data are in increasing demand to inform policy and management. A substantial portion of these data is generated in citizen science networks. To ensure the quality of biodiversity data, standards and criteria for validation have been put in place. We used interviews and document analysis from the United Kingdom and The Netherlands to examine how data validation serves as a point of connection between the diverse people and practices in natural history citizen science networks. We found that rather than a unidirectional imposition of standards, validation was performed collectively. Specifically, it was enacted in ongoing circulations of biodiversity records between recorders and validators as they jointly negotiated the biodiversity that was observed and the validity of the records. These collective validation practices contributed to the citizen science character or natural history networks and tied these networks together. However, when biodiversity records were included in biodiversity-information initiatives on different policy levels and scales, the circulation of records diminished. These initiatives took on a more extractive mode of data use. Validation ceased to be collective with important consequences for the natural history networks involved and citizen science more generally.

Outcome of lupus nephritis in childhood onset SLE in North and Central India: single-centre experience over 25 years

INTRODUCTION

Childhood SLE (cSLE) has a higher prevalence of lupus nephritis (LN), and there are ethnic variations in response to treatment as well as outcome of LN. There are limited data on long-term outcome of LN in cSLE from the Indian subcontinent.

METHODS

Retrospective analysis of case records of patients with cSLE (satisfying revised American College of Rheumatology (ACR) 1997 criteria for diagnosis) and age of onset <18 years was conducted from 1989 to 2013. Data on clinical features, renal involvement and biopsy findings, treatment, renal outcome, damage accrual and mortality were collected. End-stage renal disease (ESRD) was defined as the need for renal replacement therapy. Actuarial ESRD-free survival was studied as the primary outcome measure using Kaplan-Meier analysis.

RESULTS

Among 205 children with cSLE, 134 (121 girls) had evidence of LN. The mean age at disease onset was 13.7 ± 3.5 years and the mean disease duration at presentation was 1.9 ± 2.5 years. Kidney biopsy was available for 92 patients, and histology included: 13 (14.2%) Class II, 24 (26%) Class III, 43 (46.7%) Class IV and 12 (13.1%) Class V LN. The mean follow-up period was 6.75 ± 5.7 years. At last visit, 81 (60.4%) children were in complete remission, 28 (20.9%) were in partial remission, 15 (11.2%) still had active nephritis and 10 (7.4%) had progressed to ESRD. Almost two-thirds (62.9%) of patients experienced lupus flares, and mean flare rate was 0.09 flares/patient follow-up year. Fifty-six (43.8%) children accrued damage and the mean Systemic Lupus International Collaborating Clinics (SLICC)/ACR damage score was 0.79 ± 1.13. Actuarial ESRD-free survival at five, 10 and 15 years was 91.1%, 79% and 76.2%, and five-, 10- and 15-year renal survival was 93.8%, 87.1% and 84%, respectively. Although multiple factors individually predicted poor outcome (death/ESRD), only raised serum creatinine at onset (R square = 0.65, p ≤ 0.0001) and damage accrual (R square = 0.62, p ≤ 0.0001) remained significant on multivariate analysis. Eleven (8.2%) children died during the follow-up period, and infections were the leading cause of mortality.

CONCLUSIONS

Long-term outcome of LN in cSLE in our cohort was better than previous reports from India. However, a high rate of major infection still remains the leading cause of mortality.

First Report of Kudzu (Pueraria montana) Infections by Tobacco ringspot virus in Mississippi

Virus-like symptoms were observed in several kudzu patches in Mississippi during a survey of viruses infecting soybean carried out in late summer/fall of 2013 as a part of a project funded by the Mississippi Soybean Promotion Board. Symptomatology consisted of chlorotic mottle and ringspots, vein-associated feathering, necrosis, and leaf deformation, which were often observed in combination on the same plant. In order to identify the virus(es) involved in the disease, young leaves from a symptomatic kudzu sample collected in Kemper County were crushed in 10 volumes of 0.1 M phosphate buffer (pH 7.2) and mechanically inoculated onto celite-dusted leaves of two soybean varieties (Asgrow AG4605 and AG4730), each represented by 10 plants. Sap from an asymptomatic kudzu sample from Oktibbeha County was used as a control. Both varieties reacted by systemic mottle, stunting, and apical leaf necrosis approximately 2 weeks after inoculation, while no symptoms could be observed in controls. Partially purified preparations from both symptomatic soybean cultivars exhibited the presence of putative intact and empty spherical virus particles ~30 nm in diameter. ELISA tests with antisera to several soybean viruses were performed on the original kudzu sample and inoculated AG4605 and AG4730 soybean plants. These tests revealed the presence of Tobacco ringspot virus (TRSV) in all symptomatic samples. In order to better understand the incidence of this virus in kudzu in Mississippi, a total of 127 samples from 28 counties were collected during October 2013 and tested using ELISA. A total of 11 samples collected in 8 different counties were positive for TRSV. To further confirm these results, one step RT-PCR test was performed on total nucleic extracts from all ELISA-positive and four negative kudzu samples using TRSV-specific primers (3). A specific PCR product of 766 bp was present in all ELISA-positive samples and positive controls, whereas no visible bands were present in negative samples. PCR products generated from samples, collected in Kemper, Tippah, and Jefferson Davis counties, were cloned and custom sequenced. Pair-wise comparisons indicated conserved nucleotide (95 to 98%) and amino acid (98 to 99%) contents among sequenced products. Kudzu isolates from Mississippi shared 91 to 96% and 98 to 99% conserved nucleotides and amino acids, with TRSV sequences currently available in the NCBI/GenBank database. This is the first report of TRSV infection of kudzu in Mississippi. The possible implications to the soybean industry are yet to be determined since kudzu occupies approximately 202,000 ha in Mississippi and TRSV has historically been reported associated with bud blight in soybean (1). Nonetheless, results of our study, along with the recent report from Louisiana (2), strongly suggest that kudzu, due to its widespread distribution in the region, may represent a major reservoir of TRSV in the southeastern United States. References: (1) G. L. Hartman et al. Compendium of Soybean Diseases. American Phytopathological Society, St. Paul, MN, 1999. (2) Khankhum et al. Plant Dis. 97:561, 2013. (3) S. Sabanadzovic et al. Plant Dis. 94:126, 2010.

Effectiveness of community forestry in Prey Long forest, Cambodia

Cambodia has 57% forest cover, the second highest in the Greater Mekong region, and a high deforestation rate (1.2%/year, 2005-2010). Community forestry (CF) has been proposed as a way to reduce deforestation and support livelihoods through local management of forests. CF is expanding rapidly in Cambodia. The National Forests Program aims to designate one million hectares of forest to CF by 2030. However, the effectiveness of CF in conservation is not clear due to a global lack of controlled comparisons, multiple meanings of CF, and the context-specific nature of CF implementation. We assessed the effectiveness of CF by comparing 9 CF sites with paired controls in state production forest in the area of Prey Long forest, Cambodia. We assessed forest condition in 18-20 randomly placed variable-radius plots and fixed-area regeneration plots. We surveyed 10% of households in each of the 9 CF villages to determine the proportion that used forest products, as a measure of household dependence on the forest. CF sites had fewer signs of anthropogenic damage (cut stems, stumps, and burned trees), higher aboveground biomass, more regenerating stems, and reduced canopy openness than control areas. Abundance of economically valuable species, however, was higher in control sites. We used survey results and geographic parameters to model factors affecting CF outcomes. Interaction between management type, CF or control, and forest dependence indicated that CF was more effective in cases where the community relied on forest products for subsistence use and income.

Pyocystis after urinary diversion for incontinence--is a concomitant cystectomy necessary?

OBJECTIVE

To review the incidence of defunctionalized bladder-related complications in patients who have had a supravesical urinary diversion for intractable urinary incontinence without concomitant cystectomy.

MATERIALS AND METHODS

We retrospectively analyzed the records of patients requiring urinary diversion for intractable urinary incontinence from 1996 to 2011 at our institution. Patients were excluded from the cohort if they had evidence of bladder outlet obstruction or a cystectomy at time of diversion, or had been diverted for active malignancy. Sixty patients underwent a supravesical urinary diversion without concomitant cystectomy for intractable urinary incontinence. The etiology of the urinary incontinence was overtly neurogenic in 28 patients and non-neurogenic in 32 patients. Patients had an average follow-up of 45 months (range, 9-96). The indications for surgery, previous surgical interventions, complications of surgery, and long-term outcomes, including the incidence of pyocystis and the need for secondary cystectomy in the postoperative period were reviewed.

RESULTS

Four of 60 patients (7%) experienced complications relating to the defunctionalized bladder; this included pelvic pain and pyocystis. Only 1 patient required admission to hospital for treatment of pyocystis, the remaining 3 patients were successfully managed as outpatients with oral antibiotics or analgesics. No patient required a secondary surgical procedure for the defunctionalized bladder.

CONCLUSION

Pyocystis and the need for a secondary cystectomy were rare complications in this cohort; we therefore believe that a concomitant cystectomy is unnecessary in patients undergoing supravesical urinary diversion for intractable urinary incontinence.

FOOT CARE EDUCATION IN RENAL PATIENTS WITH DIABETES

Foot complications are said to be the primary cause of hospitalization for patients with diabetes, resulting in enormous personal and financial costs. It is reported that end-stage renal disease (ESRD) diabetic patients with peripheral vascular disease have a much higher incidence of foot complications and increased risk for amputation. However, despite the serious financial burden caused by diabetic foot ulcers and their complications, the importance of diabetic foot care is still not fully recognised or supported. There is increasing evidence to suggest that education on foot care is essential for patients with diabetes. Studies have shown that simple techniques such as identifying those at risk of developing foot ulcers, educating patients about foot care that is tailored to meet the requirements of individual patient needs, educational background and learning ability can be of obvious benefit to people with diabetes and is cost-effective.

Exploring visuomotor priming following biological and non-biological stimuli

Observation of human actions influences the observer's own motor system, termed visuomotor priming, and is believed to be caused by automatic activation of mirror neurons. Evidence suggests that priming effects are larger for biological (human) as opposed to non-biological (object) stimuli and enhanced when viewing stimuli in mirror compared to anatomical orientation. However, there is conflicting evidence concerning the extent of differences between biological and non-biological stimuli, which may be due to stimulus related confounds. Over three experiments, we compared how visuomotor priming for biological and non-biological stimuli was affected over views, over time and when attention to the moving stimulus was manipulated. The results indicated that the strength of priming for the two stimulus types was dependent on attentional location and load. This highlights that visuomotor priming is not an automatic process and provides a possible explanation for conflicting evidence regarding the differential effects of biological and non-biological stimuli.