Stability Comparison Between Microglassification and Lyophilization Using a Monoclonal Antibody

Producing solid-state formulations of biologics remains a daunting task despite the prevalent use of lyophilization and spray drying technologies in the biopharmaceutical industry. The challenges include protein stability (temperature stresses), high capital costs, particle design/controllability, shortened processing times and manufacturing considerations (scalability, yield improvements, aseptic operation, etc.). Thus, scientists/engineers are constantly working to improve existing methodologies and exploring novel dehydration/powder-forming technologies. Microglassification™ is a dehydration technology that uses solvent extraction to rapidly dehydrate protein formulations at ambient temperatures, eliminating the temperature stress experienced by biologics in traditional lyophilization and spray drying methods. The process results in microparticles that are spherical, dense, and chemically stable. In this study, we compared the molecular stability of a monoclonal antibody formulation processed by lyophilization to the same formulation processed using Microglassification™. Both powders were placed on stability for 3 months at 40 °C and 6 months at 25 °C. Both dehydration methods showed similar chemical stability, including percent monomer, charge variants, and antigen binding. These results show that Microglassification™ is viable for the production of stable solid-state monoclonal antibody formulations.

Assessing management practices for variants of uncertain significance among genetic counselors in pediatrics

Increased utilization of genomic sequencing in pediatric medicine has increased the detection of variants of uncertain significance (VUS). Periodic VUS reinterpretation can clarify clinical significance and increase diagnostic yield, highlighting the importance of systematic VUS tracking and reinterpretation. There are currently no standardized guidelines or established best practices for VUS management, and our understanding of how genetic counselors (GCs) track and manage VUS results for pediatric patients is limited. In this exploratory study, GCs in pediatric clinics in North America were surveyed about their VUS management practices. A total of 124 responses were included in the analysis. The majority (n = 115, 92.7%) of GCs reported that VUS management workflows were at the discretion of each individual provider in their workplace. Approximately half (n = 65, 52%) kept track of patient VUS results over time, and GCs with lower patient volumes were more likely to do so (p = 0.04). While 95% (n = 114) of GCs had requested VUS reinterpretation at least once, only 5% (n = 6) requested it routinely. Most (n = 80, 86%) GCs notified patients when a VUS was reclassified, although methods of recontact differed when the reclassification was an upgrade versus a downgrade. GCs who asked patients to stay in touch through periodic recontact or follow-up appointments were more likely to request VUS reinterpretation (p = 0.01). The most frequently reported barriers to requesting reinterpretation regularly were patients being lost to follow-up (n = 39, 33.1%), insufficient bandwidth (n = 27, 22.9%), and lack of standardized guidelines (n = 25, 21.2%). GCs had consistent overall practices around VUS management around investigation, disclosure, reinterpretation, and recontact, but specific methods used differed and were at the discretion of each provider. These results showcase the current landscape of VUS management workflows in pediatrics and the challenges associated with adopting more uniform practices. The study findings can help inform future strategies to develop standardized guidelines surrounding VUS management.

High-grade renal trauma in children and adolescents can be successfully managed non-operatively

BACKGROUND

This paper reviews our experience with management of renal injuries in children and adolescents with a focus on the outcome of non-operative management (NOM).

METHODS

Retrospective review of the clinical characteristics, injury grade (I-III, low grade and IV and V high grade), management and outcomes of children ≤ 18 years old with renal trauma presenting to a major trauma centre in South Africa between December 2012 and October 2020.

RESULTS

Sixty-one children with a renal injury were identified with a median age of 13 (range 0-18) years. Forty-five were boys; blunt and penetrating mechanisms of trauma were sustained by 55 (90%) and six (10%) children, respectively. The median American Association for the Surgery of Trauma (AAST) grade of renal injury was 3 (range 1-5): this included eight (13%) with grade I, six (10%) with grade II, 17 (28%) with grade III, 20 (46%) with grade IV and 10 (16%) with grade V injuries. Forty children (66%) were successfully managed non-operatively and 21 required a laparotomy; of these six (28%) required nephrectomy. The overall renal salvage rate was 55/61 (90%). Children who required laparotomy were significantly more likely to have sustained a penetrating mechanism of injury (24% vs 2%) and have greater length of hospital stay (median 9 vs 3 days) compared to children managed non-operatively (p < 0.05). Children who underwent a nephrectomy had a significantly greater length of hospital stay (median 9 vs 4 days, p = 0.03); however, their demographics, outcomes developed complications. Two children (3%) died; one managed non-operatively and one with a laparotomy.

CONCLUSION

Paediatric renal trauma can be successfully managed non-operatively in over two-thirds of cases in this middle-income country. High grade of renal injury does not absolutely predict need for surgery or nephrectomy and can be managed non-operatively.

The neglected epidemic of trauma from interpersonal violence against the elderly in South Africa

BACKGROUND

Geriatric injuries comprise a significant burden in the developed world but much less are known in the developing world setting. This study aims to review our experience of geriatric injuries with a focus on interpersonal violence (IPV) managed at a major trauma centre in South Africa.

METHODS

This was a retrospective study on all patients who were aged > 65 years admitted to our trauma centre from January 2013 to December 2020, based in Pietermaritzburg, South Africa.

RESULTS

Over the 8-year study period, 323 cases were included (62% male, mean age 72 years). Mechanism of injury: 80% blunt, 16% penetrating and 4% others. The median injury severity score (ISS) was 9. The median Charlson comorbidity index (CCI) for all 323 cases was 3. Diabetes (n = 53) was the most prevalent comorbidity which was followed by pulmonary disease (n = 23), cerebral vascular accidents (n = 16) and myocardial infarction (n = 15). Fifteen patients were on antiretroviral therapy (5%). Twenty-four per cent required surgical intervention. Eight per cent of cases experienced one or more complications. Twenty-five per cent (80/323) were related to IPV, 61% (49/80) of these were penetrating injuries and the remaining 31 cases were blunt injuries. Of the 49 cases of penetrating injuries, 33 were gunshot wounds (GSWs) and 16 were stab wounds (SWs) (1 GSW and 2 SWs were self-inflicted and were not included in IPV). Those cases that resulted from IPV were significantly more likely to require operative intervention, experience complications and longer lengths of hospital stay. Geriatric patients had poorer outcomes than non-geriatric patients and rural geriatric patients had worse outcomes than urban geriatric patients.

CONCLUSION

Although the burden of geriatric trauma in South Africa appears to be relatively low, it is associated with significant morbidity and mortality. Trauma from interpersonal violence is especially common and is associated with significantly worse outcomes than that of non-interpersonal violence-related trauma. Elderly rural trauma victims have worse outcomes than their urban counterparts.

LBODP093 Evaluation Of The Impact Of Covid-19 Vaccines On Thyroid Function And Autoimmunity And The Potential Influence Of Pre-existing Thyroid Autoimmunity On Neutralizing Antibody Responses

Objectives

There are concerns for COVID-19 vaccination in causing thyroid dysfunction and triggering thyroid autoimmunity. Also, data on the impact of pre-existing thyroid autoimmunity on COVID-19 vaccination efficacy are limited. We evaluated the impact of COVID-19 vaccination on thyroid function and antibodies, and the influence of pre-existing thyroid autoimmunity on neutralizing antibody (NAb) responses.

Methods

Adults without history of COVID-19 or thyroid disorders who received COVID-19 vaccination between 14 June 2021 and 8 August 2021 at three vaccination centers were recruited. All participants received two doses of vaccines. Thyroid-stimulating hormone (TSH), free thyroxine (fT4), free triiodothyronine (fT3), anti-thyroid peroxidase (anti-TPO) and anti-thyroglobulin (anti-Tg) antibodies were measured at baseline and 8 weeks after the first dose of vaccination. Post-vaccination NAb against SARS-CoV-2 receptor-binding domain was measured.

Results

In total, 215 individuals were included (129 BNT162b2 [60%] and 86 CoronaVac [40%] recipients): mean age 49.6 years, 37.2% men, and 12.1% positive for anti-TPO/anti-Tg at baseline. After vaccination, TSH levels did not change (p=0.225), but fT4 slightly increased (from 12. 0±1.1 to 12.2±1.2 pmol/L, p&lt;0. 001) and fT3 slightly decreased (from 4.1±0.4 to 4. 0±0.4 pmol/L, p&lt;0. 001). Only 3 patients (1.4%) had abnormal thyroid function after vaccination: two occurred among BNT162b2 recipients - both were subclinical thyrotoxicosis (TSH 0.32mIU/L, fT4 11.51pmol/L and fT3 4.40pmol/L; TSH 0.34mIU/L, fT4 12.67pmol/L and fT3 4.22pmol/L; both were anti-TPO and anti-Tg negative before and after vaccination); one occurred among CoronaVac recipients - isolated mild low fT3 (TSH 0.90mIU/L, fT4 9.94pmol/L and fT3 2.33pmol/L; anti-TPO/Tg negative before and after vaccination). All three recipients were asymptomatic. Both anti-TPO and anti-Tg titers increased modestly after vaccination (anti-TPO: from 7.50 [IQR: 5.90-11.2] to 9.80 IU/mL [IQR: 7.80-13.1], p&lt;0. 001; anti-Tg: from 12.4 [IQR: 11.1-14.9] to 15.7 IU/mL [IQR: 14.2-18.2], p&lt;0. 001), without significant changes in anti-TPO/Tg positivity. Changes in thyroid function and anti-thyroid antibodies were generally consistent between BNT162b2 and CoronaVac recipients, although anti-TPO titer rise was greater after BNT162b2 (p&lt;0. 001). NAb responses were similar between individuals with and without pre-existing thyroid autoimmunity (p=0.855).

Conclusion

COVID-19 vaccination was associated with a modest increase in anti-thyroid antibody titers. Anti-TPO increase was greater among BNT162b2 recipients. However, there was no clinically significant thyroid dysfunction 8 weeks post-vaccination. NAb responses were not influenced by pre-existing thyroid autoimmunity. Our results provided important reassurance to people to proceed to COVID-19 vaccination.

Presentation: No date and time listed

An audit of trauma laparotomy in children and adolescents highlights the role of damage control surgery and the need for a trauma systems approach to injury in this vulnerable population

BACKGROUND

This study reviews the indications and outcome of emergency laparotomy for paediatric trauma in a South African trauma centre.

METHODS

This was a retrospective study of all children less than 18 years of age who underwent an emergency laparotomy for trauma between December 2012 and October 2020 at Grey's Hospital in Pietermaritzburg.

RESULTS

During the eight-year period under review, a total of 136 children of which 107 were male underwent a laparotomy for trauma. The median age was 14 years. There were 80 (57.1%) blunt mechanisms, and the rest were penetrating mechanisms. A total of 46 (33%) patients required ICU admission. Thirty-four patients developed a complication. These included nine cases of pneumonia, one case of renal failure, two patients developed abdominal collections, three woundrelated complications, three neurological complications and one miscellaneous complication. There were seven (5%) deaths. The penetrating cohort were older than the blunt cohort. Solid viscera were more likely to be injured in the blunt cohort and hollow viscera more likely in the penetrating cohort. A total of 16 (11%) patients underwent damage control surgery (DCS). Of this cohort, there were three female children. Six sustained blunt trauma and ten penetrating trauma. A total of six (37%) of these children died.

CONCLUSION

Emergency laparotomy for trauma in children is not infrequent in Pietermaritzburg and there is a high incidence of penetrating trauma in this cohort. The response to increased degrees of physiological derangement is the application of DCS. Ongoing efforts to develop and strengthen a paediatric trauma service appear to be justified.

Abdominal stab wounds with retained knife: 15 years of experience from a major trauma centre in South Africa

Introduction

This study reviews our cumulative experience with the management of patients presenting with a retained knife following an abdominal stab wound (SW).

Methods

A retrospective study was conducted at a major trauma centre in South Africa over a 15-year period from July 2006 to December 2020 including all patients who presented with a retained knife in the abdomen following a SW.

Results

A total of 42 cases were included: 37 males (93%) with a mean age of 26 years. A total of 18 knives (43%) were in the anterior abdomen and 24 were posterior abdomen. Plain radiography was performed in 88% (37/42) of cases and computed tomography was performed in 81% (34/42); 90% (38/42) underwent extraction in the operating theatre. Laparotomy was performed in 62% (26/42). Of all the laparotomies performed, 77% (20/26) were positive for intra-abdominal organ or visceral injury. Overall morbidity was 31%. There were two mortalities (5%). Laparotomy was less commonly required for the posterior abdomen (33% (8/24) vs 100% (18/18), p<0.001). For retained knives in the anterior abdomen, 72% (13/18) of the laparotomies were positive for intra-abdominal organ or visceral injury. For the posterior abdomen, 7 of the 8 (88%) were positive for intra-abdominal organ or visceral injury. There were no differences in the need for intensive care unit admission, length of hospital stay, morbidities or mortalities.

Conclusions

Uncontrolled extraction of a retained knife in the abdomen outside of the operating theatre must be avoided. Retained knives in the anterior abdomen usually require formal laparotomy, but this is generally not required for posterior abdomen.

An audit of trauma laparotomy in children and adolescents highlights the role of damage control surgery and the need for a trauma systems approach to injury in this vulnerable population

BACKGROUND: This study reviews the indications and outcome of emergency laparotomy for paediatric trauma in a South African trauma centre. METHODS: This was a retrospective study of all children less than 18 years of age who underwent an emergency laparotomy for trauma between December 2012 and October 2020 at Grey's Hospital in Pietermaritzburg. RESULTS: During the eight-year period under review, a total of136 children of which 107 were male underwent a laparotomy for trauma. The median age was 14 years. There were 80 (57.1%) blunt mechanisms, and the rest were penetrating mechanisms. A total of 46 (33%) patients required ICU admission. Thirty-four patients developed a complication. These included nine cases of pneumonia, one case of renal failure, two patients developed abdominal collections, three wound-related complications, three neurological complications and one miscellaneous complication. There were seven (5%) deaths. The penetrating cohort were older than the blunt cohort. Solid viscera were more likely to be injured in the blunt cohort and hollow viscera more likely in the penetrating cohort. A total of 16 (11%) patients underwent damage control surgery (DCS). Of this cohort, there were three female children. Six sustained blunt trauma and ten penetrating trauma. A total of six (37%) of these children died. CONCLUSION: Emergency laparotomy for trauma in children is not infrequent in Pietermaritzburg and there is a high incidence of penetrating trauma in this cohort. The response to increased degrees of physiological derangement is the application of DCS. Ongoing efforts to develop and strengthen a paediatric trauma service appear to be justified.

Management of penetrating thoracic trauma with retained knife blade: 15-year experience from a major trauma centre in South Africa

INTRODUCTION

This study reviews our experience with the management a retained knife in the setting of thoracic stab wounds.

METHODS

A retrospective study was conducted at a major trauma in South Africa over a 15-year period from January 2004 to December 2018.

RESULTS

There were 40 patients, of whom 37 were males (93%). Median age was 24 years; 78% of cases (31 of 40) were a retained knife and 23% (9 of 40) were a retained blade. The locations of the stab wounds were 19 (48%) anterior and 21 (53%) posterior. Plain x-ray was performed in 85% (34) of patients and computed tomography angiography was performed in 85% (34). Six patients had haemodynamic instability and were expedited to the operating room without further imaging. Three of these had cardiac tamponade and three a massive haemothorax. Simple extraction and wound exploration were performed in 58% (23 of 40) of cases and the remaining 43% (17 of 40) required operative exploration and extraction. The operative approach was anterolateral thoracotomy in nine cases, posterolateral thoracotomy in four and median sternotomy in three cases. One patient required extraction and concurrent vertebral laminectomy due to cord compression. Twelve patients (30%) experienced complications (nine wound sepsis and three hospital-acquired pneumonia). There was one mortality (3%). The median length of hospital stay was 6 days.

CONCLUSION

Uncontrolled extraction of a retained thoracic knife outside the operating room must be avoided. An unstable patient should proceed directly for operative exploration. For stable patients, cross-sectional imaging will allow for planned extraction in operating room.

Endothelial-T cell crosstalk contributes to vascular injury in fatty liver disease

 

Cardiovascular complications are often the fundamental causes of death in non-alcoholic fatty liver disease (NAFLD) patients. While there are known systemic mediators in NAFLD that may induce vascular inflammation, the mechanism of endothelial dysfunction remain understudied. In this work, we harnessed the replicative potential of blood outgrowth endothelial cells (BOECs) to develop personalized cell lines from NAFLD patients and healthy controls. Our transcriptomic analysis showed that the top interactome network enriched in NAFLD BOECs comprised of several C-C and C-X-C chemokine ligands involved in immune cell chemotaxis. We previously reported T cell infiltration in mouse model of non-alcoholic steatohepatitis, and here, we confirmed enhanced endothelial chemokine signatures in arterial histological sections. To elucidate endothelial-immune crosstalk, we performed single-cell analysis on human peripheral blood mononuclear cells and found T cell intensification in NAFLD patients compared to healthy controls. Our immunoprofiling by flow cytometry further revealed that NAFLD patients possessed higher levels CD8+ memory cells. Functionally, T cells, instead of monocytes, adhered more pronouncedly to NAFLD BOECs. In evaluating the CXCL12-CXCR4 axis in chemotaxis, CXCR4 antagonist (AMD3100) substantially modulated the migration of patient-derived CD8+ T cells towards NAFLD BOECs, which was not observed in healthy endothelial-T cell chemotaxis coculture. Finally, we validated NAFLD-associated endothelial dysfunction by enumerating two folds more circulating endothelial cells, a biomarker of vascular injury, in the blood samples of NAFLD patients than healthy controls. Our work provides insights for translation to restore blood vessel health and potentially mitigate adverse vascular events in NAFLD.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Industrial Alignment Fund Pre-Positioning grant from the Agency for Science, Technology and Research, Singapore Endothelial-T cell crosstalk in NAFLD

Observation of an Electric Quadrupole Transition in a Negative Ion: Experiment and Theory

The first direct experimental observation of an electric quadrupole (E2) absorption transition between bound states of an atomic negative ion has been made. The transition was observed in the negative ion of bismuth by resonant (1+1) photon detachment from Bi^{-} via ^{3}P_{2}→^{3}P_{0} excitation. The E2 transition properties were completely independently calculated using a hybrid theoretical approach to account for the strong multilevel electron interactions and relativistic effects. The experimental and ab initio theoretical results are in excellent agreement, providing valuable new insight into this complex system and forbidden transitions in negative ions more generally.

Accurate Prediction of Clock Transitions in a Highly Charged Ion with Complex Electronic Structure

We develop a broadly applicable approach that drastically increases the ability to predict the properties of complex atoms accurately. We apply it to the case of Ir^{17+}, which is of particular interest for the development of novel atomic clocks with a high sensitivity to the variation of the fine-structure constant and to dark matter searches. In general, clock transitions are weak and very difficult to identify without accurate theoretical predictions. In the case of Ir^{17+}, even stronger electric-dipole (E1) transitions have eluded observation despite years of effort, raising the possibility that the theoretical predictions are grossly wrong. In this work, we provide accurate predictions of the transition wavelengths and E1 transition rates for Ir^{17+}. Our results explain the lack of observations of the E1 transitions and provide a pathway toward the detection of clock transitions. The computational advances we demonstrate in this work are widely applicable to most elements in the periodic table and will allow us to solve numerous problems in atomic physics, astrophysics, and plasma physics.

Evaluating RANKL and OPG levels in patients with Duchenne muscular dystrophy

RANKL-OPG should be explored in DMD patients to potentially provide targeted therapy. We quantified RANKL and OPG levels in DMD patients compared with controls. RANKL, OPG, and RANKL:OPG significantly declined with age in DMD patients suggesting some bone turnover markers are difficult to assess or use as therapeutic indicators.

INTRODUCTION

Osteoporosis in Duchenne muscular dystrophy (DMD) is multi-factorial in nature with high prevalence of fractures. RANKL-OPG should be explored to potentially provide targeted therapy for these patients. We quantified RANKL, OPG, and RANKL:OPG levels in DMD patients compared with controls and analyzed the influence of age, glucocorticoid use, ambulatory status, bone density, and fracture history.

METHODS

DMD patients were enrolled at CHLA. Controls were recruited from general pediatric clinic and in collaboration with samples from a previously completed study. Free soluble RANKL and OPG levels were quantified using a sandwich ELISA.

RESULTS

Fifty DMD patients and 50 controls were enrolled. DMD patients had a significant decline in RANKL, OPG, and RANKL:OPG with age (p = < 0.0001, p = 0.026, and p = 0.002, respectively) while healthy controls showed no significant change. RANKL trended lower in patients on glucocorticoids (p = 0.05), attributed to the significantly older age in the treatment group. RANKL and RANKL:OPG levels were significantly lower in the non-ambulatory group compared with the ambulatory group (p = 0.010 and 0.036 respectively), again likely due to their older age. There was no correlation of RANKL, OPG, or RANKL:OPG with DXA Z-score or presence of vertebral fractures.

CONCLUSION

There was significant decline in RANKL, OPG, and RANKL:OPG with age in DMD patients compared with controls, potentially due to disease severity or worsening osteoblastic function. This suggests some bone turnover markers may be difficult to assess or use as therapeutic indicators in DMD patients. Larger studies are needed to evaluate the role of RANKL-OPG in DMD patients to provide better targeted therapy.

Computational cytometer based on magnetically modulated coherent imaging and deep learning

Detecting rare cells within blood has numerous applications in disease diagnostics. Existing rare cell detection techniques are typically hindered by their high cost and low throughput. Here, we present a computational cytometer based on magnetically modulated lensless speckle imaging, which introduces oscillatory motion to the magnetic-bead-conjugated rare cells of interest through a periodic magnetic force and uses lensless time-resolved holographic speckle imaging to rapidly detect the target cells in three dimensions (3D). In addition to using cell-specific antibodies to magnetically label target cells, detection specificity is further enhanced through a deep-learning-based classifier that is based on a densely connected pseudo-3D convolutional neural network (P3D CNN), which automatically detects rare cells of interest based on their spatio-temporal features under a controlled magnetic force. To demonstrate the performance of this technique, we built a high-throughput, compact and cost-effective prototype for detecting MCF7 cancer cells spiked in whole blood samples. Through serial dilution experiments, we quantified the limit of detection (LoD) as 10 cells per millilitre of whole blood, which could be further improved through multiplexing parallel imaging channels within the same instrument. This compact, cost-effective and high-throughput computational cytometer can potentially be used for rare cell detection and quantification in bodily fluids for a variety of biomedical applications.

Association of preterm birth with ADHD-like cognitive impairments and additional subtle impairments in attention and arousal malleability

BACKGROUND

Whilst preterm-born individuals have an increased risk of developing attention-deficit/hyperactivity disorder (ADHD), and are reported to have ADHD-like attention and arousal impairments, direct group comparisons are scarce.

METHODS

We directly compared preterm-born adolescents (n = 186) to term-born adolescents with ADHD (n = 69), and term-born controls (n = 135), aged 11-23, on cognitive-performance, event-related potential and skin conductance level (SCL) measures associated with attention and arousal. The measures are from baseline and fast-incentive conditions of a four-choice reaction time task, previously shown to discriminate between the individuals with ADHD and controls. We aimed to establish whether preterm-born adolescents show: (a) identical cognitive-neurophysiological impairments to term-born adolescents with ADHD (b) possible additional impairments, and whether (c) the observed impairments correlate with ADHD symptom scores.

RESULTS

The preterm group, like the term-born ADHD group, showed increased mean reaction time (MRT) and reaction time variability (RTV) in the baseline condition, and attenuated contingent negative variation (CNV) amplitude (response preparation) in the fast-incentive condition. The preterm group, only, did not show significant within-group adjustments in P3 amplitude (attention allocation) and SCL (peripheral arousal). Dimensional analyses showed that ADHD symptoms scores correlated significantly with MRT, RTV and CNV amplitude only.

CONCLUSIONS

We find impairments in cognition and brain function in preterm-born adolescents that are linked to increased ADHD symptoms, as well as further impairments, in lack of malleability in neurophysiological processes. Our findings indicate that such impairments extend at least to adolescence. Future studies should extend these investigations into adulthood.

Admission Gatekeeping and Safe Discharge for the Elderly: Referral by the Emergency Department to the Community Nursing Service for Home Visits

Objective

To assess the gatekeeping effect and discharge safety in elderly referrals to the community nursing service (CNS) in a major accident & emergency department (AED).

Methods

Descriptive review analysis of the referrals in 2002–2004.

Results

Altogether 333 patients were accepted, comprising 5% of the total CNS referrals in the hospital: 323 were aged ≥65 (median age 81), 13.8% were living alone, 21.6% had unscheduled return to the AED within 14 days, and 11.7% in 15–28 days. The ≤14 days and 15–28 days admission to hospital was 15.0% and 6.0%, with 4.8% and 0.6% patients admitted with the same or related diagnosis as the first visit respectively, including missed fractures and stroke. One patient died 17 days after discharge. Eight of the 162 falls returned within 28 days with a second fall. Overall, 317 admissions were avoided with 1,978 bed-days saved. Living alone was strongly associated with unscheduled return and admission ≤14 and ≤28 days, while age was not. The six categories of community nursing care were fall-related, tube care, skin and soft tissue care, pain control, medical and diabetic care. Injections were given for cellulitis, pain, and diabetics. Forty-nine patients had phone follow-ups.

Conclusion

The gatekeeping effect of AED referrals to CNS remained small. The commonest referrals were falls with head injury. It was safe to discharge the elderly for CNS care. A wide range of home nursing care was feasible. CNS referral could decrease elderly return visits with falls. Living alone was strongly associated with return visit and admission.

Thrombocytosis in 715 Dogs (2011-2015)

BACKGROUND

Thrombocytosis is a hematologic abnormality in dogs that has been associated with various neoplastic, metabolic, and inflammatory conditions.

OBJECTIVE

To classify thrombocytosis in dogs based on severity and evaluate whether there are associations between severity and underlying disease processes.

ANIMALS

Seven hundred and fifteen dogs with thrombocytosis and 1,430 dogs with normal numbers of platelets.

METHODS

Retrospective study. Medical records of dogs with increased (>500 × 10³ /μL; thrombocytosis group) and normal (300-500 × 10³ /μL; control group) platelet counts between 2011 and 2015 were reviewed. Dogs were characterized by severity of platelet increase and diagnosis. Diagnostic categories included neoplasia, endocrine disease, inflammatory disease, or miscellaneous.

RESULTS

A total of 1,254 complete blood counts with thrombocytosis from 715 dogs were included in the study. Median platelet count in this population was 582 × 10³ /μL (500-1,810 × 10³ /μL). No correlation between severity of thrombocytosis and diagnosis was identified. Causes of secondary thrombocytosis included neoplasia (55.7%), endocrine disease (12.0%), and inflammatory disease (46.6%). Immune-mediated disease was common (22.2%), associated with frequent glucocorticoid administration, and had a significantly higher median platelet count (636 × 10³ /μL [500-1,262 × 10³ /μL] versus 565 × 10³ /μL [500-1,810 × 10³ /μL]) when compared to the other inflammatory processes (P < 0.001). The diagnoses in the thrombocytosis dogs differed significantly from the control population (P < 0.001).

CONCLUSIONS AND CLINICAL IMPORTANCE

Thrombocytosis is commonly associated with carcinoma and immune-mediated disease in dogs.

Six-year follow-up study of combined type ADHD from childhood to young adulthood: Predictors of functional impairment and comorbid symptoms

BACKGROUND

ADHD in childhood is associated with development of negative psychosocial and behavioural outcomes in adults. Yet, relatively little is known about which childhood and adulthood factors are predictive of these outcomes and could be targets for effective interventions. To date follow-up studies have largely used clinical samples from the United States with children ascertained at baseline using broad criteria for ADHD including all clinical subtypes or the use of DSM III criteria.

AIMS

To identify child and adult predictors of comorbid and psychosocial comorbid outcomes in ADHD in a UK sample of children with DSM-IV combined type ADHD.

METHOD

One hundred and eighteen adolescents and young adults diagnosed with DSM-IV combined type ADHD in childhood were followed for an average of 6years. Comorbid mental health problems, drug and alcohol use and police contact were compared for those with persistent ADHD, sub-threshold ADHD and population norms taken from the Adult Psychiatric Morbidity Study 2007. Predictors included ADHD symptomology and gender.

RESULTS

Persistent ADHD was associated with greater levels of anger, fatigue, sleep problems and anxiety compared to sub-threshold ADHD. Comorbid mental health problems were predicted by current symptoms of hyperactivity-impulsivity, but not by childhood ADHD severity. Both persistent and sub-threshold ADHD was associated with higher levels of drug use and police contact compared to population norms.

CONCLUSIONS

Young adults with a childhood diagnosis of ADHD showed increased rates of comorbid mental health problems, which were predicted by current levels of ADHD symptoms. This suggests the importance of the continuing treatment of ADHD throughout the transitional years and into adulthood. Drug use and police contact were more common in ADHD but were not predicted by ADHD severity in this sample.

Does an enhanced recovery integrated care pathway (ICP) encourage adherence to prescribing guidelines, accelerate postoperative recovery and reduce the length of stay for gynaecological oncology patients?

A new integrated care pathway (ICP) proforma for gynaecological oncology patients was developed and introduced in early 2010. The ICP is a goal-defined and time-specified documentation by gynaecological oncology doctors and nurses, guided by certain parameters to be achieved in pre and postoperative days. All patients were admitted to the same unit and underwent a major abdominal/pelvic procedure for confirmed or suspected gynaecological malignancy, including hysterectomy and oophorectomy. The control group included 58 randomly selected patients from May 2008 to March 2009 and the intervention group comprised 52 patients, after the introduction of the ICP. The effectiveness was assessed with a variety of measurements: the duration of intraperitoneal drains, urethral catheters and intravenous fluids postoperatively; time taken for the patient to eat and drink; time taken to mobilisation; and the total length of stay in hospital. We also assessed whether the implementation of the care pathway was associated with an increase in adherence to prescribing guidelines for thromboprophylaxis and postoperative antibiotics and sodium docusate. The new ICP encouraged clearer documentation and regular review of fluids, drains and catheters. There was a modest reduction in the length of stay and an increase in prescribed thromboprophylaxis and sodium docusate ( Cheung et al. 2011 ).

Should money follow the patient: Financial implication for being the National Centre for the Treatment and Management of Pelvic and Acetabular Fractures in Ireland

BACKGROUND

Pelvic and acetabular fractures are complex injuries requiring specialist treatment. Our institution is the National Centre for Treatment and Management of these injuries.

AIM

To audit all referrals to our institution over a 6-month period and calculate the cost incurred by being the national referral centre.

METHODS

Retrospective review of database, and subsequent allocation of Casemix points to assess total cost of treatment for each patient referred to our institution.

RESULTS

103 patients referred with pelvic or acetabular fracture for operative management. The furthest referral distance was 181miles. Over-all, the length of stay was 15.4 days. The average inclusive cost for a referral to our unit for operative management was €16,302.

CONCLUSION

Pelvic and acetabular fractures are complex injuries that require specialist referral unit management. However for these units to remain sustainable money needs to "follow the patient".

White-matter microstructure in previously drug-naive patients with schizophrenia after 6 weeks of treatment

BACKGROUND

It is not clear whether the progressive changes in brain microstructural deficits documented in previous longitudinal magnetic resonance imaging (MRI) studies might be due to the disease process or to other factors such as medication. It is important to explore the longitudinal alterations in white-matter (WM) microstructure in antipsychotic-naive patients with first-episode schizophrenia during the very early phase of treatment when relatively 'free' from chronicity.

METHOD

Thirty-five patients with first-episode schizophrenia and 22 healthy volunteers were recruited. High-resolution diffusion tensor imaging (DTI) was obtained from participants at baseline and after 6 weeks of treatment. A 'difference map' for each individual was calculated from the 6-week follow-up fractional anisotropy (FA) of DTI minus the baseline FA. Differences in Positive and Negative Syndrome Scale (PANSS) scores and Global Assessment of Functioning (GAF) scores between baseline and 6 weeks were also evaluated and expressed as a 6-week/baseline ratio.

RESULTS

Compared to healthy controls, there was a significant decrease in absolute FA of WM around the bilateral anterior cingulate gyrus and the right anterior corona radiata of the frontal lobe in first-episode drug-naive patients with schizophrenia following 6 weeks of treatment. Clinical symptoms improved during this period but the change in FA did not correlate with the changes in clinical symptoms or the dose of antipsychotic medication.

CONCLUSIONS

During the early phase of treatment, there is an acute reduction in WM FA that may be due to the effects of antipsychotic medications. However, it is not possible to entirely exclude the effects of underlying progression of illness.

Fronto-parietal white matter microstructural deficits are linked to performance IQ in a first-episode schizophrenia Han Chinese sample

BACKGROUND

Evidence shows that cognitive deficits and white matter (WM) dysconnectivity can independently be associated with clinical manifestations in schizophrenia. It is important to explore this triadic relationship in order to investigate whether the triplet could serve as potential extended endophenotypes of schizophrenia.

METHOD

Diffusion tensor images and clinical performances were evaluated in 122 individuals with first-episode schizophrenia and 122 age- and gender-matched controls. In addition, 65 of 122 of the patient group and 40 of 122 controls were measured using intelligence quotient (IQ) testing.

RESULTS

The schizophrenia group showed lower fractional anisotropy (FA) values than controls in the right cerebral frontal lobar sub-gyral (RFSG) WM. The schizophrenia group also showed a significant positive correlation between FA in the RFSG and performance IQ (PIQ) ; in turn, their PIQ score showed a significant negative correlation with negative syndromes.

CONCLUSIONS

Overall, these findings support the hypothesis that WM deficits may be a core deficit that contributes to cognitive deficits as well as to negative symptoms.

Restoring proximal caries lesions conservatively with tunnel restorations

The tunnel restoration has been suggested as a conservative alternative to the conventional box preparation for treating proximal caries. The main advantage of tunnel restoration over the conventional box or slot preparation includes being more conservative and increasing tooth integrity and strength by preserving the marginal ridge. However, tunnel restoration is technique-sensitive and can be particularly challenging for inexperienced restorative dentists. Recent advances in technology, such as the contemporary design of dental handpieces with advanced light-emitting diode (LED) and handheld comfort, offer operative dentists better vision, illumination, and maneuverability. The use of magnifying loupes also enhances the visibility of the preparation. The advent of digital radiographic imaging has improved dental imaging and reduced radiation. The new generation of restorative materials has improved mechanical properties. Tunnel restoration can be an option to restore proximal caries if the dentist performs proper case selection and pays attention to the details of the restorative procedures. This paper describes the clinical technique of tunnel restoration and reviews the studies of tunnel restorations.