The Fragility of Scientific Rigour and Integrity in "Sped up Science": Research Misconduct, Bias, and Hype and in the COVID-19 Pandemic

During the early years of the COVID-19 pandemic, preclinical and clinical research were sped up and scaled up in both the public and private sectors and in partnerships between them. This resulted in some extraordinary advances, but it also raised a range of issues regarding the ethics, rigour, and integrity of scientific research, academic publication, and public communication. Many of the failures of scientific rigour and integrity that occurred during the pandemic were exacerbated by the rush to generate, disseminate, and implement research findings, which not only created opportunities for unscrupulous actors but also compromised the methodological, peer review, and advisory processes that would usually identify sub-standard research and prevent compromised clinical or policy-level decisions. While it would be tempting to attribute these failures of science and its translation solely to the "unprecedented" circumstances of the COVID-19 pandemic, the reality is that they preceded the pandemic and will continue to arise once it is over. Existing strategies for promoting scientific rigour and integrity need to be made more rigorous, better integrated into research training and institutional cultures, and made more sophisticated. They might also need to be modified or supplemented with other strategies that are fit for purpose not only in public health emergencies but in any research that is sped-up and scaled up to address urgent unmet medical needs.

Retraction speed and chronic poststernotomy pain: A randomized controlled trial

OBJECTIVES

Approximately 30% of patients develop chronic poststernotomy pain (CPSP) following cardiac surgery with sternal retraction. Risk factors have been described but no causal determinants identified. Investigators hypothesized that opening the sternum slowly would impart less force (and thereby less nerve/tissue damage) and translate to a reduced incidence of CPSP. The main objectives were to determine whether or not slower sternal retraction would reduce the incidence of CPSP and improve health-related quality of life.

METHODS

Patients undergoing coronary artery bypass graft surgery were recruited to this randomized controlled trial. Patients were randomized to slow or standard retraction (ie, sternum opened over 15 minutes vs 30 seconds, respectively). Although the anesthesiologist and surgeon were aware of the randomization, the patients, assessors, and postoperative nursing staff remained blinded. Sternotomy pain and analgesics were measured in hospital. At 3, 6, and 12 months postoperatively, all patients completed the Medical Outcomes Survey Short Form and reported on CPSP and complications requiring rehospitalization. Thirty-day rehospitalizations and mortality were recorded.

RESULTS

In total, 326 patients consented to participate and 313 were randomized to slow (n = 159) versus standard retraction (n = 154). No clinically relevant differences were detected in acute pain, analgesic consumption, or the incidence of CPSP or health-related quality of life. Although the slow group had significantly more hospitalizations at 3 and 12 months postoperatively, the reasons were unrelated to retraction speed. No differences were observed in 30-day rehospitalizations or mortality.

CONCLUSIONS

All outcomes were consistent with previous reports, but no clinically significant differences were observed with retraction speed.

Gamma knife capsulotomy for intractable OCD: Neuroimage analysis of lesion size, location, and clinical response

Obsessive-compulsive disorder (OCD) affects 2-3% of the population. One-third of patients are poorly responsive to conventional therapies, and for a subgroup, gamma knife capsulotomy (GKC) is an option. We examined lesion characteristics in patients previously treated with GKC through well-established programs in Providence, RI (Butler Hospital/Rhode Island Hospital/Alpert Medical School of Brown University) and São Paulo, Brazil (University of São Paolo). Lesions were traced on T1 images from 26 patients who had received GKC targeting the ventral half of the anterior limb of the internal capsule (ALIC), and the masks were transformed into MNI space. Voxel-wise lesion-symptom mapping was performed to assess the influence of lesion location on Y-BOCS ratings. General linear models were built to compare the relationship between lesion size/location along different axes of the ALIC and above or below-average change in Y-BOCS ratings. Sixty-nine percent of this sample were full responders (≥35% improvement in OCD). Lesion occurrence anywhere within the targeted region was associated with clinical improvement, but modeling results demonstrated that lesions occurring posteriorly (closer to the anterior commissure) and dorsally (closer to the mid-ALIC) were associated with the greatest Y-BOCS reduction. No association was found between Y-BOCS reduction and overall lesion volume. GKC remains an effective treatment for refractory OCD. Our data suggest that continuing to target the bottom half of the ALIC in the coronal plane is likely to provide the dorsal-ventral height required to achieve optimal outcomes, as it will cover the white matter pathways relevant to change. Further analysis of individual variability will be essential for improving targeting and clinical outcomes, and potentially further reducing the lesion size necessary for beneficial outcomes.

Crevasse refreezing and signatures of retreat observed at Kamb Ice Stream grounding zone

Ice streams flowing into Ross Ice Shelf are presently responsible for around 10% of the mass flux from West Antarctica, with the noteworthy exception of Kamb Ice Stream, which stagnated in the late 1800s. The subsequent reduction in ice supply led to grounding-line retreat at the coastal margin where Kamb transitions into the floating Ross Ice Shelf. Grounding-line migration is linked to broader changes in ice-sheet mass balance and sea level, but our understanding of related ice, ocean and seafloor interactions is limited by the difficulty in accessing these remote regions. Here we report in situ observations from an underwater vehicle deployed at Kamb that show how fine-scale variability in ice and ocean structure combine to influence a diversity of ice-ocean interactions. We found a stratified water column within a tenth of a degree of freezing at the ice base and mapped basal crevasses with supercooled water and active marine ice formation. At the seafloor, we interpret parallel ridges as crevasse impressions left as the ice lifted off during grounding-line retreat. These observations from a recently ungrounded sub-shelf environment illuminate both the geomorphological signatures of past grounding-line retreat and the fine-scale sensitivity of ongoing ice-ocean interactions to ice topography.

Molecular and clinical diversity in primary central nervous system lymphoma

BACKGROUND

Primary central nervous system lymphoma (PCNSL) is a rare and distinct entity within diffuse large B-cell lymphoma presenting with variable response rates probably to underlying molecular heterogeneity.

PATIENTS AND METHODS

To identify and characterize PCNSL heterogeneity and facilitate clinical translation, we carried out a comprehensive multi-omic analysis [whole-exome sequencing, RNA sequencing (RNA-seq), methylation sequencing, and clinical features] in a discovery cohort of 147 fresh-frozen (FF) immunocompetent PCNSLs and a validation cohort of formalin-fixed, paraffin-embedded (FFPE) 93 PCNSLs with RNA-seq and clinico-radiological data.

RESULTS

Consensus clustering of multi-omic data uncovered concordant classification of four robust, non-overlapping, prognostically significant clusters (CS). The CS1 and CS2 groups presented an immune-cold hypermethylated profile but a distinct clinical behavior. The 'immune-hot' CS4 group, enriched with mutations increasing the Janus kinase (JAK)-signal transducer and activator of transcription (STAT) and nuclear factor-κB activity, had the most favorable clinical outcome, while the heterogeneous-immune CS3 group had the worse prognosis probably due to its association with meningeal infiltration and enriched HIST1H1E mutations. CS1 was characterized by high Polycomb repressive complex 2 activity and CDKN2A/B loss leading to higher proliferation activity. Integrated analysis on proposed targets suggests potential use of immune checkpoint inhibitors/JAK1 inhibitors for CS4, cyclin D-Cdk4,6 plus phosphoinositide 3-kinase (PI3K) inhibitors for CS1, lenalidomide/demethylating drugs for CS2, and enhancer of zeste 2 polycomb repressive complex 2 subunit (EZH2) inhibitors for CS3. We developed an algorithm to identify the PCNSL subtypes using RNA-seq data from either FFPE or FF tissue.

CONCLUSIONS

The integration of genome-wide data from multi-omic data revealed four molecular patterns in PCNSL with a distinctive prognostic impact that provides a basis for future clinical stratification and subtype-based targeted interventions.

Nature-positive goals for an organization's food consumption

Organizations are increasingly committing to biodiversity protection targets with focus on 'nature-positive' outcomes, yet examples of how to feasibly achieve these targets are needed. Here we propose an approach to achieve nature-positive targets with respect to the embodied biodiversity impacts of an organization's food consumption. We quantify these impacts using a comprehensive database of life-cycle environmental impacts from food, and map exploratory strategies to meet defined targets structured according to a mitigation and conservation hierarchy. By considering the varying needs and values across the organization's internal community, we identify a range of targeted approaches towards mitigating impacts, which balance top-down and bottom-up actions to different degrees. Delivering ambitious nature-positive targets within current constraints will be challenging, particularly given the need to mitigate cumulative impacts. Our results evidence that however committed an organization is to being nature positive in its food provision, this is unachievable in the absence of systems change.

NB housing study protocol: investigating the relationship between subsidized housing, mental health, physical health and healthcare use in New Brunswick, Canada

BACKGROUND

Income and housing are pervasive social determinants of health. Subsidized housing is a prominent affordability mechanism in Canada; however, waitlists are lengthy. Subsidized rents should provide greater access to residual income, which may theoretically improve health outcomes. However, little is known about the health of tenants who wait for and receive subsidized housing. This is especially problematic for New Brunswick, a Canadian province with low population density, whose inhabitants experience income inequality, social exclusion, and challenges with healthcare access.  METHODS: This study will use a longitudinal, prospective matched cohort design. All 4,750 households on New Brunswick's subsidized housing wait list will be approached to participate. The survey measures various demographic, social and health indicators at six-month intervals for up to 18 months as they wait for subsidized housing. Those who receive housing will join an intervention group and receive surveys for an additional 18 months post-move date. With consent, participants will have their data linked to a provincial administrative database of medical records.  DISCUSSION: Knowledge of housing and health is sparse in Canada. This study will provide stakeholders with a wealth of health information on a population that is historically under-researched and underserved.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimising pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Rapid synthesis of drug-encapsulated films by evaporation-induced self-assembly for highly-controlled drug release from biomaterial surfaces

Infection at the surgical site for dental implants results in failed procedures, patient pain, burdensome economic impact, and the over-prescription of prophylactic antibiotics. Mesoporous silica films as coatings for implants may provide an ideal antimicrobial drug storage and local release vector to the site of infection, however traditional drug loading techniques result in insufficient drug load and short-term release kinetics. In this work, we have applied a method to use a surfactant-antimicrobial drug octenidine dihydrochloride (OCT) as a template for mesostructured silica, to demonstrate silica-OCT composite films. The films are synthesized by evaporation induced self-assembly (EISA) and we explore the effects of synthesis parameters on porous film structure, OCT incorporation, and OCT drug release rates. Drug micelle incorporation into the silica mesostructure was highly dependent on silica precursor pre-reaction to form silica oligomers before film spin-casting. The OCT drug concentration of the synthesis solution dictated the time required for effective incorporation (without phase separation), with total loading in the film of up to 90% by mass. The OCT content in the films was found to directly determine the timescale of drug release, from 2 to 8 h for a single layer film. The total release timescale was increased by the addition of multiple layers of OCT-silica films to nearly 2 weeks. Drug release from films completely inhibited Streptococcus mutans (UA159) growth, while drug-free porous silica films showed no increase in bacterial growth over non-porous control. These OCT-silica films have a significant potential to store and release antimicrobial drugs from dental implant surfaces.

Remote Assessment of Disease and Relapse in Major Depressive Disorder (RADAR-MDD): Recruitment, retention, and data availability in a longitudinal remote measurement study

Introduction

Major Depressive Disorder (MDD) is prevalent, often chronic, and requires ongoing monitoring of symptoms to track response to treatment and identify early indicators of relapse. Remote Measurement Technologies (RMT) provide an exciting opportunity to transform the measurement and management of MDD, via data collected from inbuilt smartphone sensors and wearable devices alongside app-based questionnaires and tasks.

Objectives

To describe the amount of data collected during a multimodal longitudinal RMT study, in an MDD population.

Methods

RADAR-MDD is a multi-centre, prospective observational cohort study. People with a history of MDD were provided with a wrist-worn wearable, and several apps designed to: a) collect data from smartphone sensors; and b) deliver questionnaires, speech tasks and cognitive assessments and followed-up for a maximum of 2 years.

Results

A total of 623 individuals with a history of MDD were enrolled in the study with 80% completion rates for primary outcome assessments across all timepoints. 79.8% of people participated for the maximum amount of time available and 20.2% withdrew prematurely. Data availability across all RMT data types varied depending on the source of data and the participant-burden for each data type. We found no evidence of an association between the severity of depression symptoms at baseline and the availability of data. 110 participants had > 50% data available across all data types, and thus able to contribute to multiparametric analyses.

Conclusions

RADAR-MDD is the largest multimodal RMT study in the field of mental health. Here, we have shown that collecting RMT data from a clinical population is feasible.

Disclosure

No significant relationships.

Face-to-face versus online clinically integrated EBM teaching in an undergraduate medical school: a pilot study

OBJECTIVES

The aim of this study was to test the feasibility and effectiveness of two models (face-to-face vs online teaching) of clinically integrating evidence-based medicine (EBM) teaching in an undergraduate medical school.

DESIGN AND SETTING

A pilot study of face-to-face versus online EBM teaching.

PARTICIPANTS

This study focused on undergraduate medical students who entered the University of Buckingham Medical School MBChB course in 2016 (n=65). Of the 65 students, 45 received face-to-face teaching, while 20 received online teaching.

MAIN OUTCOME MEASURES

Feasibility was assessed by the ability to deliver the content, students' engagement during teaching and their completion rates in formative assessments-Assessing Competency in EBM (ACE) tool, and educational prescriptions (EPs). Effectiveness of teaching for the two models was compared by evaluating students' performance in the formative assessments and in the summative final professional examination and final year EBM objective structured clinical examination (OSCE).

RESULTS

We had similar students' engagement and completion rates in formative assessments in both models. Students receiving face-to-face teaching performed better in EPs (mean difference=-2.28, 95% CI: -4.31 to -0.26). There was no significant difference in performances in the ACE tool (mean difference=-1.02, 95% CI: -2.20 to 0.16); the written final professional exams (mean difference=-0.11, 95% CI: -0.65 to 0.44) and the EBM OSCE station (mean difference=-0.81, 95% CI: -2.38 to 0.74).

CONCLUSIONS

It was feasible to deliver both models of clinically integrated EBM teaching. While students in the face-to-face model scored higher in EPs; there was no significant difference between the two models of teaching as measured by performances in the ACE tool or the summative assessments.

61 Use of Ketamine Sedation for the Treatment of Minor Plastic Surgery Procedures in the Paediatric Emergency Department

Aim

To determine if ketamine sedation is a safe and cost-effective way of treating paediatric patients presenting with minor injuries, requiring plastic surgery procedures, in the emergency department.

Method

A retrospective cohort study was carried out over a 9-month period in children between ages 18 months and 16 years old, presenting to the paediatric emergency department at Chelsea and Westminster Hospital with minor injuries requiring plastic surgery input. The data collected included previously validated co-primary outcome measures of surgical site infection at 7 days and cosmetic appearance summary score at a minimum of 4 months. Parental satisfaction surveys were completed at 4 months to assess perceived quality of treatment. A cost analysis comparison against procedures completed under general anaesthetic was also undertaken.

Results

During the 9-month period of study, 24 minor procedures were performed under ketamine in the paediatric emergency department. There were no serious adverse events recorded. Three cases exceeded the recommended 20-minute maximum procedure duration, but there was no associated adverse outcome. No cases required further procedures under general anaesthesia and there were no cases of surgical site infections at 7 days. Parents reported extremely favourable outcomes using this technique, with an average overall satisfaction score of 9.2 (assessed over a number of parameters, where 10 is complete satisfaction).

Conclusions

Ketamine procedural sedation in the paediatric population is a safe and cost-effective method for the treatment of minor plastic surgery procedures, with low risk for surgical site infection post-operatively, and high parent satisfaction rates

Clinical effects of hypertonic saline boluses in children with severe traumatic brain injury

AIM

To quantify the effects of 3% hypertonic saline (HTS) boluses on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in children.

METHODS

A retrospective study of patients admitted to a regional neurosurgical children's intensive care unit.

RESULTS

A total of 156 HTS boluses were given to children with traumatic brain injury. ICP decreased 6 mmHg (P < 0.01) and CPP increased 4 mmHg (P = 0.003) 1-h post-bolus. Effects persisted for 3 h post-dose ICP was 5 mmHg lower) and 4 h post-bolus CPP was 3 mmHg higher. ICP change was not associated with pre-bolus serum sodium concentration.

CONCLUSIONS

Hypertonic saline 3% at 5 mL/kg is an effective osmolar therapy for reducing ICP and increasing CPP in children for up to 3 h. '53-53' is a suitable guide - 5 mL/kg of 3% HTS will on average decrease ICP by at least 5 mmHg for 3 h. Pre-bolus serum sodium concentration is not correlated with effect size.

Distressing psychotic-like experiences, cognitive functioning and early developmental markers in clinically referred young people aged 8-18 years

PURPOSE

Neurocognitive difficulties and early childhood speech/motor delays are well documented amongst older adolescents and young adults considered at risk for psychosis-spectrum diagnoses. We aimed to test associations between unusual or psychotic-like experiences (PLEs), co-occurring distress/emotional symptoms, current cognitive functioning and developmental delays/difficulties in young people (aged 8-18 years) referred to Child and Adolescent Mental Health Services in South London, UK.

METHODS

Study 1 examined receptive language, verbal learning and caregiver-reported speech and motor delays/difficulties in a sample of 101 clinically-referred children aged 8-14 years, comparing those reporting no PLEs (n = 19), PLEs without distress (n = 16), and PLEs with distress (n = 66). Study 2 tested associations of severity of distressing PLEs with vocabulary, perceptual reasoning, word reading and developmental delays/difficulties in a second sample of 122 adolescents aged 12-18 years with distressing PLEs.

RESULTS

In Study 1, children with distressing PLEs had lower receptive language and delayed recall and higher rates of developmental delays/difficulties than the no-PLE and non-distressing PLE groups (F values: 2.3-2.8; p values: < 0.005). Receptive language (β = 0.24, p = 0.03) and delayed recall (β = - 0.17, p = 0.02) predicted PLE distress severity. In Study 2, the cognitive-developmental variables did not significantly predict PLE distress severity (β values = 0.01-0.22, p values: > 0.05).

CONCLUSION

Findings may be consistent with a cognitive-developmental model relating distressing PLEs in youth with difficulties in cognitive functioning. This highlights the potential utility of adjunctive cognitive strategies which target mechanisms associated with PLE distress. These could be included in cognitive-behavioural interventions offered prior to the development of an at-risk mental state in mental health, educational or public health settings.

Increased air temperature decreases high-speed, but not total distance, in international field hockey

This study investigated the effect of heat stress on locomotor activity within international field hockey at team, positional and playing-quarter levels. Analysis was conducted on 71 matches played by the Malaysia national men’s team against 24 opponents. Fixtures were assigned to match conditions, based on air temperature [COOL (14 ± 3°C), WARM (24 ± 1°C), HOT (27 ± 1°C), or VHOT (32 ± 2°C), p < 0.001]. Relationships between locomotor metrics and air temperature (AIR), absolute and relative humidity, and wet bulb globe temperature (WBGT) were investigated further using correlation and regression analyses. Increased AIR and WBGT revealed similar correlations (p < 0.01) with intensity metrics; high-speed running (AIR r = −0.51, WBGT r = −0.45), average speed (AIR r = −0.48, WBGT r = −0.46), decelerations (AIR r = −0.41, WBGT r = −0.41), sprinting efforts (AIR r = −0.40, WBGT r = −0.36), and sprinting distance (AIR r = −0.37, WBGT r = −0.29). In comparison to COOL, HOT, and VHOT matches demonstrated reduced high-speed running intensity (−14–17%; p < 0.001), average speed (−5-6%; p < 0.001), sprinting efforts (−17%; p = 0.010) and decelerations per min (−12%; p = 0.008). Interactions were found between match conditions and playing quarter for average speed (+4-7%; p = 0.002) and sprinting distance (+16-36%; p < 0.001), both of which were higher in the fourth quarter in COOL versus WARM, HOT and VHOT. There was an interaction for “low-speed” (p < 0.001), but not for “high-speed” running (p = 0.076) demonstrating the modulating effect of air temperature (particularly >25°C) on pacing within international hockey. These are the first data demonstrating the effect of air temperature on locomotor activity within international men’s hockey, notably that increased air temperature impairs high-intensity activities by 5–15%. Higher air temperatures compromise high-speed running distances between matches in hockey.

1111 Shifting the Paradigm of Abscess Treatment – From Theatre to Clinic

Aim

Treatment of skin and soft tissue abscesses forms a substantial part of the emergency general surgery workload. Abscesses account for approximately 2% of presentations to Accident and Emergency, with 0.9% of patients requiring surgical intervention. Incision and drainage is often performed in theatre and may necessitate admission to hospital, impacting bed space and theatre availability. This study aims to identify if the introduction of a clinic-based abscess service could reduce the number of abscess drainages in theatre without compromise to clinical outcomes.

Method

Retrospective data was collected for patients undergoing abscess treatment at Musgrove Park Hospital (Taunton) in September 2019. Subsequently, a Nurse-led abscess drainage pathway was initiated in Emergency Surgery Ambulatory Clinic (ESAC) encompassing initial assessment and drainage at the bedside. Prospective data was then collected for abscesses drained in theatre and ESAC during September 2020 and compared with data from 2019.

Result

22 abscess drainages were performed in September 2019 vs 25 in September 2020. 8 cases were carried out in theatre during September 2020, with the rest being treated in ESAC. Of those who were treated in clinic (n = 17), admission was prevented in 16 patients. Readmission rates were similar between ESAC (16%) and theatre (18.1%).

Conclusions

A clinic-based abscess service is achievable and prevents unnecessary use of theatres and hospital admissions, with comparable re-presentation rates. A nurse led approach also relieves pressure on Doctors during busy surgical on calls. Nonetheless, a larger data set would be needed to consolidate the findings from this study.

Evaluation of carbonic anhydrase IX as a potential therapeutic target in urothelial carcinoma

OBJECTIVE

Carbonic anhydrase IX (CA9) is important in the regulation of intra- and extracellular pH in solid tumors, contributing to cell growth and invasion. In urothelial carcinoma (UC), CA9 has been identified as a urinary marker for disease detection, but its biologic role is unknown. To date, differential gene expression patterns of CA9 in various molecular subtypes and potential effects of CA9 inhibition in UC cells are unknown. We aimed to investigate the function of CA9 and the effects of CA9 inhibition in invasive UC.

METHODS

Immunohistochemistry was used to assess CA9 expression in a cohort of 153 patients undergoing radical cystectomy. CA9 expression was correlated with molecular subtype by analysis of the TCGA data and of our own cohort of 223 patients with invasive UC receiving neoadjuvant chemotherapy. CA9 expression was assessed in a panel of 12 UC cell lines by Western Blot and qPCR, and multiple siRNAs were used to silence CA9 in 2 cell lines. Effects of CA9 silencing on cell growth, migration, and invasion were assessed. We also used the small molecule inhibitor U-104 to inhibit CA9 in vitro and in an orthotopic xenograft model.

RESULTS

CA9 expression was higher in cancer tissue compared to benign urothelium and was particularly highly expressed in luminal papillary and basal squamous tumors. CA9 expression did not correlate with outcome after neoadjuvant chemotherapy and/or radical cystectomy. Silencing of CA9 by siRNA diminished invasion but did not induce a consistent change of cell growth and migration. Treatment with U-104 led to cell growth reduction only at high concentrations in vitro and failed to have a significant effect on tumor growth in vivo.

CONCLUSIONS

The present study confirms over-expression of CA9 in UC and for the first time shows a correlation with molecular subtypes. However, CA9 expression showed no association with the outcome of patients with muscle invasive bladder cancer and inhibition of CA9 did not lead to a consistent inhibition of tumor growth. Based on these data, CA9 exhibits a role neither as a predictive or prognostic marker nor as a therapeutic target in invasive UC.

The effect of lower airway inflammation on inflammatory cytokine gene expression in bronchoalveolar lavage fluid and whole blood in racing Thoroughbreds

BACKGROUND

Immunological mechanisms involved in the pathogenesis of mild to moderate equine asthma (MEA) are not completely understood. There are limited data on bronchoalveolar lavage fluid (BALF) and blood inflammatory cytokine profiles in racehorses with MEA, and the effect of racing on inflammatory cytokines is unknown.

HYPOTHESIS/OBJECTIVES

We hypothesized that inflammatory cytokine gene expression in BALF and resting blood would be higher in racehorses with lower airway inflammation compared to healthy controls, and that gene expression in blood collected immediately post-race would be increased compared to resting blood in racehorses with lower airway inflammation.

ANIMALS

38 racing Thoroughbreds (samples: 30 resting blood, 22 post-race BALF, 41 post-race blood).

METHODS

Prospective observational study. Inflammatory cytokine gene expression was determined in resting blood, post-race BALF and post-race blood from racehorses with lower airway inflammation and controls.

RESULTS

Lower airway inflammation was diagnosed in 79 % of racehorses (23 % neutrophilic, 67 % mastocytic, and 10 % mixed). There was no difference in gene expression in BALF or resting blood between racehorses with lower airway inflammation and controls. IL-8 gene expression was higher in post-race blood compared to resting peripheral blood, regardless of disease (p = 0052). BALF neutrophil proportions increased with increasing IL-1β gene expression in all sample types (p = 0.0025). BALF mast cell proportions increased with increasing TNF-α gene expression in post-race blood (p = 0.015).

CONCLUSIONS AND CLINICAL IMPORTANCE

Lower airway inflammation was common in a population of racehorses without respiratory signs or exercise intolerance. Exercise alone increased peripheral blood IL-8 gene expression. Inflammatory cytokine gene expression was not increased in BALF or resting blood in horses with subclinical lower airway inflammation, precluding its diagnostic utility in clinical practice.

815 The Impact and Implications for The Workload for Vascular Surgery as A Result of the COVID-19 Lockdown

Introduction

The emergence of the coronavirus pandemic and subsequent UK lockdown resulted in a significant reduction in elective vascular surgery to increase critical care capacity. We aimed to ascertain the impact of lockdown on the workload of a busy vascular surgical unit.

Method

Data on all major vascular procedures performed between March 2020 and June 2020 were collected prospectively. Comparison to the same time period over the last 6 years was performed using a prospectively maintained database.

Results

92 major cases were performed, a reduction of 30% compared with cases performed during similar periods (803 cases total, mean 133), with an increased proportion of unplanned & emergency cases(35.9% & 31.5% vs 31.4% & 20.5%).

There was a significant reduction in aortic procedures (19 vs mean 36). Despite the reduction in cases there was a similar number of amputations performed (9 vs mean 10).

Conclusions

The lockdown period resulted in a 30% reduction in cases performed with far fewer aortic procedure performed and a similar number of amputations. These pending cases will need consideration, especially with critical care capacity to ensure they are completed within a timely period. Considerations for capacity are also pertinent given the approach of winter and the possibility of a second wave.

Development and evaluation of a spiral model of assessing EBM competency using OSCEs in undergraduate medical education

BACKGROUND

Medical students often struggle to understand the relevance of Evidence Based Medicine (EBM) to their clinical practice, yet it is a competence that all students must develop prior to graduation. Objective structured clinical examinations (OSCEs) are a valued assessment tool to assess critical components of EBM competency, particularly different levels of mastery as they progress through the course. This study developed and evaluated EBM based OSCE stations with an aim to establish a spiral approach for EBM OSCE stations for undergraduate medical students.

METHODS

OSCE stations were developed with increasingly complex EBM tasks. OSCE stations were classified according to the classification rubric for EBP assessment tools (CREATE) framework and mapped against the recently published core competencies for evidence-based practice (EBP). Performance data evaluation was undertaken using Classical Test Theory analysing mean scores, pass rates, and station item total correlation (ITC) using SPSS.

RESULTS

Six EBM based OSCE stations assessing various stages of EBM were created for use in high stakes summative OSCEs for different year groups across the undergraduate medical degree. All OSCE stations, except for one, had excellent correlation coefficients and hence a high reliability, ranging from 0.21-0.49. The domain mean score ranged from 13.33 to 16.83 out of 20. High reliability was demonstrated for the each of the summative OSCE circuits (Cronbach's alpha = 0.67-0.85). In the CREATE framework these stations assessed knowledge, skills, and behaviour of medical students in asking, searching, appraising, and integrating evidence in practice. The OSCE stations were useful in assessing six core evidence-based practice competencies, which are meant to be practiced with exercises. A spiral model of OSCEs of increasing complexity was proposed to assess EBM competency as students progressed through the MBChB course.

CONCLUSIONS

The use of the OSCEs is a feasible method of authentically assessing leaner EBM performance and behaviour in a high stakes assessment setting. Use of valid and reliable EBM-based OSCE stations provide evidence for continued development of a hierarchy of assessing scaffolded learning and mastery of EBM competency. Further work is needed to assess their predictive validity.

Clinico-radiological findings of neuroendocrine tumour metastases to the orbit

Purpose: We present the clinico-radiological findings of neuroendocrine tumour metastases to the orbit.Methods: This was a multicentre, retrospective study of patients with neuroendocrine tumour metastases to the orbit. Data was collected from medical records across five different sites within Australia and the United Kingdom.Results: Nine patients (eleven lesions) were identified. The most common presenting complaint was diplopia (5/9, 56%). Disease occurred bilaterally in two patients. Seven patients (78%) had extraocular muscle involvement. The lateral recti (4/9, 44%) and superior recti (2/9, 22%) were the most commonly affected. Ocular presentation preceded primary tumour diagnosis in three patients (33%). On orbital imaging, metastases were most commonly reported as well circumscribed, ovoid or round, heterogeneous, contrast-enhancing masses. Features of intralesional haemorrhage and bony invasion are uncommonly reported.Conclusions: Neuroendocrine tumour metastasis to the orbit is uncommon. Metastases have a propensity for the extraocular muscles, commonly presenting as heterogeneous, well circumscribed, contrast-enhancing lesions on neuroimaging. New ocular symptoms, a history of neuroendocrine tumours, and these radiological findings, should lead to high clinical suspicion of metastatic disease. Atypical findings warrant biopsy to exclude other causes of orbital lesions.

Ten years of enzyme replacement therapy in paediatric onset mucopolysaccharidosis II in England

The outcome of 110 patients with paediatric onset mucopolysaccharidosis II (MPS II) since the commercial introduction of enzyme replacement therapy (ERT) in England in 2007 is reported. Median length of follow up was 10 years 3 months (range = 1 y 2 m to 18 years 6 month). 78 patients were treated with ERT, 18 had no ERT or disease modifying treatment 7 had haematopoietic stem cell transplant, 4 experimental intrathecal therapy and 3 were lost to follow up. There is clear evidence of improved survival (median age of death of ERT treated (n = 16) = 15.13 years (range = 9.53 to 20.58 y), and untreated (n = 17) = 11.43 y (0.5 to 19.13 y) p = .0005). Early introduction of ERT improved respiratory outcome at 16 years, the median FVC (% predicted) of those in whom ERT initiated <8 years = 69% (range = 34-86%) and 48% (25-108) (p = .045) in those started >8 years. However, ERT appears to have minimal impact on hearing, carpal tunnel syndrome or progression of cardiac valvular disease. Cardiac valvular disease occurred in 18/46 (40%), with progression occurring most frequently in the aortic valve 13/46 (28%). The lack of requirement for neurosurgical intervention in the first 8 years of life suggests that targeted imaging based on clinical symptomology would be safe in this age group after baseline assessments. There is also emerging evidence that the neurological phenotype is more nuanced than the previously recognized dichotomy of severe and attenuated phenotypes in patients presenting in early childhood.

Pain in older adults with dementia : A survey across Europe on current practices, use of assessment tools, guidelines and policies

BACKGROUND

We aimed to explore the existing use of pain assessment tools and guidelines, and develop understanding of the practical considerations required to facilitate their use within the nursing home, hospital and community settings.

METHODS

A self-administered web-based survey was conducted with nurses, health and social care workers with an interest in the assessment of pain in older adults with cognitive impairment. The survey was distributed to participants in Austria, Belgium, Denmark, Germany, The Netherlands, Switzerland and United Kingdom.

RESULTS

Only a minority of staff reported use of (inter-)national or local standards or specific pain assessment tools in daily practice. A range of tools were reported as being used, which varied across country. While participants generally reported that these pain assessment tools were easy/very easy to use, many participants reported that they were difficult to interpret. Assessment is generally performed whilst providing nursing care. This was highlighted in 70-80% of all participating countries. While many of these tools rely on facial expression of pain, facial expressions were considered to be the least useful in comparison to other items. Furthermore findings showed that nurses employed in long-term care settings did not feel that they were educated enough in pain assessment and management.

CONCLUSION

Our findings suggest that pain education is required across all countries surveyed. This should include a focus on guidelines and standards for assessment and subsequent management of pain. Findings suggest that clinical staff find interpreting facial expressions in relation to pain more difficult.

A review of the law of consent in dentistry

The development of the law of consent has led to much discussion within the dental literature as to how these changes might impact practice. The move from a practitioner-focused standard of consent to a patient-focused standard has altered the nature of the framework required to support a patient's decision-making to avoid an allegation or finding of a negligent consent process. Contrastingly, there has been little in the way of exploration as to how the law of battery (in civil matters) and assault (in criminal cases), where consent is entirely absent, might apply to dentistry and the practice of the profession. This article considers the law of consent, using several key examples from dentistry, as well as providing an update of recent case law of relevance to dental practice.

Mucosal lactoferrin response to genital tract infections is associated with iron and nutritional biomarkers in young Burkinabé women

BACKGROUND/OBJECTIVES

The iron-binding affinity of vaginal lactoferrin (Lf) reduces iron available to genital pathogens. We describe host reproductive, nutritional, infection and iron biomarker profiles affecting vaginal Lf concentration in young nulliparous and primigravid women in Burkina Faso.

SUBJECTS/METHODS

Vaginal eluates from women who had participated in a randomized, controlled periconceptional iron supplementation trial were used to measure Lf using a competitive double-sandwich ELISA. For this analysis samples from both trial arms were combined and pregnant and non-pregnant cohorts compared. Following randomization Lf was measured after 18 months (end assessment) for women remaining non-pregnant, and at two antenatal visits for those becoming pregnant. Associations between log Lf levels and demographic, anthropometric, infection and iron biomarker variables were assessed using linear mixed models.

RESULTS

Lf samples were available for 712 non-pregnant women at end assessment and for 303 women seen at an antenatal visit. Lf concentrations of pregnant women were comparable to those of non-pregnant, sexually active women. Lf concentration increased with mid-upper-arm circumference, (P = 0.047), body mass index (P = 0.018), Trichomonas vaginalis (P < 0.001) infection, bacterial vaginosis (P < 0.001), serum C-reactive protein (P = 0.048) and microbiota community state types III/IV. Adjusted Lf concentration was positively associated with serum hepcidin (P = 0.047), serum ferritin (P = 0.018) and total body iron stores (P = 0.042). There was evidence that some women maintained persistently high or low Lf concentrations from before, and through, pregnancy.

CONCLUSION

Lf concentrations increased with genital infection, higher BMI, MUAC, body iron stores and hepcidin, suggesting nutritional and iron status influence homeostatic mechanisms controlling vaginal Lf responses.

Decisions on repositioning of intruded permanent incisors; a review and case presentation

Traumatic intrusion is a luxation type of injury where the tooth is displaced along the axis of the tooth, into the alveolus. This injury is regarded as serious because of the tissue damage that it causes. The traumatic movement is associated with severe damage to the periodontal ligament, pulpal tissue, root and alveolar socket. Despite its severity, the rare occurrence of this injury in permanent teeth has resulted in limited studies of immature and mature permanent incisors. The purpose of this paper is to review this luxation injury of permanent immature incisors, and to describe its diagnosis, treatment and management. In particular, we describe the repositioning strategies used in cases of intrusion injury. These include (i) monitoring spontaneous re-eruption, (ii) active orthodontic repositioning and (iii) surgical repositioning. Firstly, monitoring spontaneous re-eruption is observing and waiting for the intruded tooth to return to its original position. This process is not a normal developmental eruption and the outcome is not always predictable, nor is the time needed for this to happen. Secondly, active orthodontic repositioning is used to describe the process of rapidly moving the intruded tooth to its original position with the aid of an orthodontic appliance. Active orthodontic repositioning is often misunderstood as normal orthodontic movement. Orthodontic movement allows for periodontal ligament remodelling, using light intermittent forces. In contrast the active orthodontic repositioning used to move intruded incisors is rapid, and the primary aim is to achieve correct tooth position as rapidly as possible. Thirdly, surgical repositioning uses surgical intervention to bring the tooth back to its original position. A case of an intruded immature permanent incisor is presented, with a particular emphasis on these critical decisions on repositioning and showing the use of the three modalities of treatment in sequence, in order to achieve an outcome.

Evaluating the implementation of confusion assessment method-intensive care unit using a quality improvement approach

Quality improvement (QI) is a way through which health care delivery can be made safer and more effective. Various models of quality improvement methods exist in health care today. These models can help guide and manage the process of introducing changes into clinical practice. The aim of this project was to implement the use of a delirium assessment tool into three adult critical care units within the same hospital using a QI approach. The objective was to improve the identification and management of delirium. Using the Model for Improvement framework, a multidisciplinary working group was established. A delirium assessment tool was introduced via a series of educational initiatives. New local guidelines regarding the use of delirium assessment and management for the multidisciplinary team were also produced. Audit data were collected at 6 weeks and 5 months post-implementation to evaluate compliance with the use of the tool across three critical care units within a single hospital in London. At 6 weeks, in 134 assessment points out of a possible 202, the tool was deemed to be used appropriately, meaning that 60% of patients received timely assessment; 18% of patients were identified as delirious in audit one. Five months later, only 95 assessment points out of a possible 199 were being appropriately assessed (47%); however, a greater number (32%) were identified as delirious. This project emphasizes the complexity of changing practice in a large busy critical care centre. Despite an initial increase in delirium assessment, this was not sustained over time. The use of a QI model highlights the continuous process of embedding changes into clinical practice and the need to use a QI method that can address the challenging nature of modern health care. QI models guide changes in practice. Consideration should be given to the type of QI model used.

PTPα is required for laminin-2-induced Fyn-Akt signaling to drive oligodendrocyte differentiation

Extrinsic signals that regulate oligodendrocyte maturation and subsequent myelination are essential for central nervous system development and regeneration. Deficiency in the extracellular factor laminin-2 (Lm2), as occurs in congenital muscular dystrophy, can lead to impaired oligodendroglial development and aberrant myelination, but many aspects of Lm2-regulated oligodendroglial signaling and differentiation remain undefined. We show that receptor-like protein tyrosine phosphatase alpha (PTPα) is essential for myelin basic protein expression and cell spreading during Lm2-induced oligodendrocyte differentiation. PTPα complexes with the Lm2 receptors α6β1 integrin and dystroglycan to transduce Fyn activation upon Lm2 engagement. In this way, PTPα mediates a subset of Lm2-induced signals required for differentiation that includes mTOR-dependent Akt activation but not Erk activation. We identify N-myc downstream regulated gene-1 (NDRG1) as a PTPα-regulated molecule during oligodendrocyte differentiation and distinguish Lm2 receptor-specific modes of Fyn-Akt-dependent and -independent NDRG1 phosphorylation. Altogether, this reveals a Lm2-regulated PTPα-Fyn-Akt signaling axis that is critical for key aspects of the gene expression and morphological changes that mark oligodendrocyte maturation.

The risk of depression, suicidal ideation and suicide attempt in patients with psoriasis, psoriatic arthritis or ankylosing spondylitis

BACKGROUND

Sparse information is available concerning mental health issues in psoriasis, psoriatic arthritis (PsA) and ankylosing spondylitis (AS) patients.

OBJECTIVE

To estimate risk of depression, suicidal ideation and suicide attempt in patients with psoriasis, PsA and AS, respectively, compared with the general population.

METHODS

This population-based cohort study analysed 36 214 psoriasis patients, 5138 PsA patients and 1878 AS patients who were frequency-matched with a general population cohort. Annual incidence rate of depression, suicidal ideation and suicide attempt was calculated separately for psoriasis, PsA and AS.

RESULTS

There was an increased risk of depression in the three cohorts; adjusted IRR: psoriasis, 1.14 (95% CI, 1.11, 1.17); PsA, 1.22 (95% CI, 1.16, 1.29); AS, 1.34 (95% CI, 1.23, 1.47). There was no significantly increased risk for suicidal ideations or suicide attempt among psoriasis, PsA or AS patients.

LIMITATIONS

Patients were not excluded if previously diagnosed with depression, suicidal ideation or suicide attempt. Suicide attempt and completed suicide analyses were not adjusted for presence of depression. Use of systemic psoriasis treatment to measure severe psoriasis could lead to psoriasis severity misclassification.

CONCLUSION

The risk of depression, but not suicidal ideation or suicide attempt, was significantly increased in patients with psoriasis, PsA and AS.

Evaluation of hepatitis C testing in men who have sex with men, and associated risk behaviours, in Manchester, UK

OBJECTIVE

To determine the prevalence of newly diagnosed hepatitis C virus (HCV) and associated risk behaviours among men who have sex with men (MSM) in Manchester.

METHOD

A survey among MSM attending four genitourinary medicine clinics in Manchester was carried out over 9 months in 2013. Participants were asked about recent sexual behaviour, recreational drug use and HIV status. All men were offered an HCV test.

RESULTS

Overall, 2030 MSM completed a questionnaire and accepted an HCV test. Of whom, 0.9% (18) were newly diagnosed with HCV, including 1.8% (13/735) of HIV-positive MSM, 0.7% (3/440) of MSM of unknown HIV status and 0.2% (2/855) of HIV-negative MSM. HCV positivity was significantly associated with HIV status (p<0.001). When compared with HIV-negative MSM, HIV-positive MSM had higher rates of sharing snorting drug equipment, injecting drugs/'slamming' and using recreational drugs (all p<0.05) but lower rates of five or more sexual partners and insertive unprotected anal intercourse (p<0.05). MSM newly diagnosed with HCV had significantly higher prevalence of unprotected sex, sex with someone HCV positive, fisting, group sex, ever injecting drugs/'slamming' and recreational drug use (p<0.002).

CONCLUSIONS

In this survey, HIV-positive MSM had significantly different drug use behaviour which may explain the higher HCV burden. However, HCV was also associated with HIV-negative MSM engaging in high-risk sexual practices. All MSM attending sexual health clinics must have a risk assessment and HCV screening should be offered based on the risk. Further studies are warranted to explore the interplay between HCV and HIV risk associated with drug use versus sexual practices.