The Genetic Origin of the Indo-Europeans

The Yamnaya archaeological complex appeared around 3300BCE across the steppes north of the Black and Caspian Seas, and by 3000BCE reached its maximal extent from Hungary in the west to Kazakhstan in the east. To localize the ancestral and geographical origins of the Yamnaya among the diverse Eneolithic people that preceded them, we studied ancient DNA data from 428 individuals of which 299 are reported for the first time, demonstrating three previously unknown Eneolithic genetic clines. First, a "Caucasus-Lower Volga" (CLV) Cline suffused with Caucasus hunter-gatherer (CHG) ancestry extended between a Caucasus Neolithic southern end in Neolithic Armenia, and a steppe northern end in Berezhnovka in the Lower Volga. Bidirectional gene flow across the CLV cline created admixed intermediate populations in both the north Caucasus, such as the Maikop people, and on the steppe, such as those at the site of Remontnoye north of the Manych depression. CLV people also helped form two major riverine clines by admixing with distinct groups of European hunter-gatherers. A "Volga Cline" was formed as Lower Volga people mixed with upriver populations that had more Eastern hunter-gatherer (EHG) ancestry, creating genetically hyper-variable populations as at Khvalynsk in the Middle Volga. A "Dnipro Cline" was formed as CLV people bearing both Caucasus Neolithic and Lower Volga ancestry moved west and acquired Ukraine Neolithic hunter-gatherer (UNHG) ancestry to establish the population of the Serednii Stih culture from which the direct ancestors of the Yamnaya themselves were formed around 4000BCE. This population grew rapidly after 3750-3350BCE, precipitating the expansion of people of the Yamnaya culture who totally displaced previous groups on the Volga and further east, while admixing with more sedentary groups in the west. CLV cline people with Lower Volga ancestry contributed four fifths of the ancestry of the Yamnaya, but also, entering Anatolia from the east, contributed at least a tenth of the ancestry of Bronze Age Central Anatolians, where the Hittite language, related to the Indo-European languages spread by the Yamnaya, was spoken. We thus propose that the final unity of the speakers of the "Proto-Indo-Anatolian" ancestral language of both Anatolian and Indo-European languages can be traced to CLV cline people sometime between 4400-4000 BCE.

Abstract Figure

Medieval DNA from Soqotra points to Eurasian origins of an isolated population at the crossroads of Africa and Arabia

Soqotra, an island situated at the mouth of the Gulf of Aden in the northwest Indian Ocean between Africa and Arabia, is home to ~60,000 people subsisting through fishing and semi-nomadic pastoralism who speak a Modern South Arabian language. Most of what is known about Soqotri history derives from writings of foreign travellers who provided little detail about local people, and the geographic origins and genetic affinities of early Soqotri people has not yet been investigated directly. Here we report genome-wide data from 39 individuals who lived between ~650 and 1750 CE at six locations across the island and document strong genetic connections between Soqotra and the similarly isolated Hadramawt region of coastal South Arabia that likely reflects a source for the peopling of Soqotra. Medieval Soqotri can be modelled as deriving ~86% of their ancestry from a population such as that found in the Hadramawt today, with the remaining ~14% best proxied by an Iranian-related source with up to 2% ancestry from the Indian sub-continent, possibly reflecting genetic exchanges that occurred along with archaeologically documented trade from these regions. In contrast to all other genotyped populations of the Arabian Peninsula, genome-level analysis of the medieval Soqotri is consistent with no sub-Saharan African admixture dating to the Holocene. The deep ancestry of people from medieval Soqotra and the Hadramawt is also unique in deriving less from early Holocene Levantine farmers and more from groups such as Late Pleistocene hunter-gatherers from the Levant (Natufians) than other mainland Arabians. This attests to migrations by early farmers having less impact in southernmost Arabia and Soqotra and provides compelling evidence that there has not been complete population replacement between the Pleistocene and Holocene throughout the Arabian Peninsula. Medieval Soqotra harboured a small population that showed qualitatively different marriage practices from modern Soqotri, with first-cousin unions occurring significantly less frequently than today.

Evolution and prognostic value of left ventricular deformation and myocardial work parameters in transthyretin amyloid cardiomyopathy

AIMS

Wild-type transthyretin amyloid cardiomyopathy (ATTR-CM) is an increasingly recognized condition. It remains challenging to estimate the extent of disease and the prognosis for most patients. Myocardial work is a sensitive echocardiographic approach that improves the characterization of myocardial damage. We investigate the parameters of myocardial deformation and work in ATTR-CM patients and their changes over time.

METHODS AND RESULTS

We analysed clinical, electrocardiographic, biological, and echocardiographic characteristics in 113 patients [median age 82 (77-85), 90.4% male] diagnosed with wild-type ATTR-CM based on international consensus at a single centre. We compared the data at baseline and 18-month follow-up. Thirty-four patients died and 12 were hospitalized for heart failure at a median follow-up of 935 days (interquartile range 691-1159 days). Left ventricular end-diastolic diameter, left atrial strain during reservoir phase (LASRES), left ventricular longitudinal strain, global work index (GWI), global constructive work significantly decreased from baseline to 18 months, while left ventricular wall thickness increased. Left ventricular ejection fraction, right ventricular free wall strain (FWS), global wasted work (GWW), and global work efficiency did not alter significantly. Strain parameters were identified as prognostic on baseline evaluation using a multivariate analysis: GWI, GWW, FWS, and LASRES. They were significantly associated with the risk of death and hospitalization for heart failure.

CONCLUSION

Multi-chamber strain assessment may improve the surveillance of patients with ATTR-CM, and myocardial work parameters may improve clinical risk stratification in this population.

Primary mitral regurgitation: Toward a better quantification on left ventricular consequences

BACKGROUND

Left ventricular end-systolic diameter (LVESD) and ejection fraction (LVEF) are the parameters to look for when discussing repair in asymptomatic patients with a primary mitral regurgitation (PMR). Loading conditions are altering LV-function quantification. LV-myocardial work (LVMW) is a method based on pressure-strain loops.

HYPOTHESIS

We sought to evaluate the additive value of the LVMW for predicting clinical events in patients with PMR.

METHODS

103 patients (66% men, median age 57 years) with asymptomatic severe PMR were explored at rest and during an exercise stress echocardiography. LV myocardial global work index (GWI), constructive work (GCW), wasted work (GWW), and work efficiency (GWE) were measured with speckle-tracking echocardiography at rest and low workload. The indication for surgery was based on the heart teams' decision. The median follow-up was 670 days.

RESULTS

Clinical events occurred for 50 patients (48.5%) with a median of event-free survival distribution of 289 days. Systolic pulmonary artery pressure (sPAP) at rest was 32.61 ± 8.56 mmHg and did not predict the risk of event like LVEF and LVESD. Changes in, GLS (hazard ratio [HR] 0.55; 95% confidence interval (Cl): 0.36-0.83; p = .005), GWI (HR 1.01; 95% Cl: 1.00-1.02; p = .002) and GCW (HR 1.85; 95% Cl: 1.28-2.68; p = .001) in addition to Left Atrial Volume Index (HR 1.73; 95% CI: 1.28 - 2.33; p < 0,001) were independent predictors of events.

CONCLUSION

Changes in myocardial work indices related to low-dose exercise are relevant to best predict PMR patient prognosis It might help to better select patient's candidate for "early-surgery."

Transcatheter aortic valve implantation impact on left ventricular myocardial damage: long term follow-up

INTRODUCTION

Aortic stenosis (AS) is causing myocardial damages and replacement is mainly indicated based on symptoms. Non-invasive estimation of myocardial work (MW) provide a less afterload dependent tool that, we sought to look at the impact of transcatheter aortic valve implantation (TAVI) on the myocardium at long-term follow-up and according to current indications.

METHODS

We conducted an observational, cross-sectional, single-center study. Patients were selected based on the validated indication for a TAVI. Standardized echocardiographies were repeated.

RESULTS

102 patients were included. Mean age was 85-year-old, 45% were female, 68% get high-blood pressure and 52% had a coronary disease. One fifth was suffering from low-flow low-gradient aortic stenosis. Follow-up was performed at 22 ± 9.5 months after the TAVI. No TAVI-dysfunction was observed. LVEF was stable (62 ± 8%), and global longitudinal strain get improved (-14.0% ± 3.7 vs -16.0% ± 3.6, p-value <0.0001). No improvement of the MW-parameters was noticed (Global Work Index (LV GWI) 2099 ± 692mmHg% vs 2066 ± 706mmHg%, p=0.8, Global Constructive (LV GCW) 2463 ± 736mmHg% vs 2463 ± 676mmHg%, p=0.8). Global Wasted Work increased (214 [149; 357] mmHg% vs 247 [177; 394] mmHg%, p= 0.0008).

CONCLUSION

In a population of severe symptomatic AS-patients who had undergone a TAVI, the non-invasive myocardial indices that assess the LV performance at long term follow-up did not improve. These results are questioning the timing of the intervention and the need for a more attention in the pharmacological management of these AS-patients.

Phenotyping of heart failure with preserved ejection faction using electronic health records and echocardiography

Aims

Patients presenting symptoms of heart failure with preserved ejection fraction (HFpEF) are not a homogenous population. Different phenotypes can differ in prognosis and optimal management strategies. We sought to identify phenotypes of HFpEF by using the medical information database from a large university hospital centre using machine learning.

Methods and results

We explored the use of clinical variables from electronic health records in addition to echocardiography to identify different phenotypes of patients with HFpEF. The proposed methodology identifies four phenotypic clusters based on both clinical and echocardiographic characteristics, which have differing prognoses (death and cardiovascular hospitalization).

Conclusion

This work demonstrated that artificial intelligence-derived phenotypes could be used as a tool for physicians to assess risk and to target therapies that may improve outcomes.

Genetic continuity and change among the Indigenous peoples of California

Before the colonial period, California harboured more language variation than all of Europe, and linguistic and archaeological analyses have led to many hypotheses to explain this diversity1. We report genome-wide data from 79 ancient individuals from California and 40 ancient individuals from Northern Mexico dating to 7,400-200 years before present (BP). Our analyses document long-term genetic continuity between people living on the Northern Channel Islands of California and the adjacent Santa Barbara mainland coast from 7,400 years BP to modern Chumash groups represented by individuals who lived around 200 years BP. The distinctive genetic lineages that characterize present-day and ancient people from Northwest Mexico increased in frequency in Southern and Central California by 5,200 years BP, providing evidence for northward migrations that are candidates for spreading Uto-Aztecan languages before the dispersal of maize agriculture from Mexico2-4. Individuals from Baja California share more alleles with the earliest individual from Central California in the dataset than with later individuals from Central California, potentially reflecting an earlier linguistic substrate, whose impact on local ancestry was diluted by later migrations from inland regions1,5. After 1,600 years BP, ancient individuals from the Channel Islands lived in communities with effective sizes similar to those in pre-agricultural Caribbean and Patagonia, and smaller than those on the California mainland and in sampled regions of Mexico.

Increasing awareness of bullying through small-scale initiatives in higher education

Employees are entitled to work in an environment that upholds their dignity and respect, but bullying still exists in many disciplines, including in nurse education and nursing practice. Researchers have suggested that to address bullying employers need to intervene at team and/or organisational level rather than focusing solely on the individuals involved. To reduce the incidence of bullying and other adverse social behaviours in the workplace, many higher education institutions and healthcare organisations have developed dignity and respect (D&R) policies. In this article, the authors describe the development and implementation of several small-scale initiatives designed to increase awareness of bullying and D&R policy among staff and students at the School of Nursing and Midwifery at Trinity College Dublin. The interventions were informed by the concepts of distributed leadership and implementation science.

Nursing students' attitudes, behaviour, and knowledge toward smoking cessation: Results from a descriptive survey at a regional university

BACKGROUND

Smoking is the largest single cause of lifestyle-related preventable morbidity and mortality. Nurses form the largest cohort of health professionals and are strategically placed to implement smoking cessation interventions. However their capacity is underutilised, particularly in rural and remote areas in countries such as Australia where the incidence of smoking in is higher than average and access to healthcare is limited. One strategy to address the underutilisation of nurses in smoking cessation interventions is to include training in the university/college nursing curriculum. To effectively implement this training, it is vital to have an in-depth knowledge of student nurses' attitudes towards smoking including the role of healthcare professionals in smoking cessation, their smoking behaviour and that of their peers, and knowledge regarding smoking cessation techniques and resources.

OBJECTIVES

Investigate nursing students' attitudes, behaviour, and knowledge towards smoking cessation, determine the impact of demographics and educational experienced on these, and develop recommendations for future research and educational practice.

DESIGN

Descriptive survey.

PARTICIPANTS

Non-probability sample of undergraduate nursing students (n = 247) from a regional Australian university.

RESULTS

Significantly more participants had tried smoking cigarettes than had not (p = 0.026). There were no significant relationships between gender and smoking (p = 0.169) or e-cigarette use (p = 0.200), but a significant relationship was found between age and smoking status where older participants (48-57 years) were more likely to smoke (p < 0.001). Most participants (70 %) were supportive of public health measures to reduce cigarette smoking but felt that they lacked specific knowledge to assist their patients to cease smoking.

CONCLUSIONS

Within education there needs to be an emphasis on the central role that nurses play in smoking cessation with a greater focus on training nursing students about smoking cessation strategies and resources. There is also a need to ensure that students know it falls within their duty of care to address smoking cessation with patients.

Entwined African and Asian genetic roots of medieval peoples of the Swahili coast

The urban peoples of the Swahili coast traded across eastern Africa and the Indian Ocean and were among the first practitioners of Islam among sub-Saharan people1,2. The extent to which these early interactions between Africans and non-Africans were accompanied by genetic exchange remains unknown. Here we report ancient DNA data for 80 individuals from 6 medieval and early modern (AD 1250-1800) coastal towns and an inland town after AD 1650. More than half of the DNA of many of the individuals from coastal towns originates from primarily female ancestors from Africa, with a large proportion-and occasionally more than half-of the DNA coming from Asian ancestors. The Asian ancestry includes components associated with Persia and India, with 80-90% of the Asian DNA originating from Persian men. Peoples of African and Asian origins began to mix by about AD 1000, coinciding with the large-scale adoption of Islam. Before about AD 1500, the Southwest Asian ancestry was mainly Persian-related, consistent with the narrative of the Kilwa Chronicle, the oldest history told by people of the Swahili coast3. After this time, the sources of DNA became increasingly Arabian, consistent with evidence of growing interactions with southern Arabia4. Subsequent interactions with Asian and African people further changed the ancestry of present-day people of the Swahili coast in relation to the medieval individuals whose DNA we sequenced.

Clinical predictors and management for radial artery spasm: an Australian cross-sectional study

INTRODUCTION

The transradial approach for coronary artery catheterisation has increased in popularity compared to the transfemoral approach for patients undergoing percutaneous coronary interventions. However, radial artery spasm continues to be a major complication of the procedure. Current management strategies vary concerning radial artery spasm and there is limited evidence of practice in the Australian context.

AIM

To identify the predictors of radial artery spasm and the medications used for its prevention and management.

METHODS

A descriptive cross-sectional study was carried out over a three-month period in two tertiary hospitals in NSW, Australia. A self-administered pre-procedural survey was completed by patients undergoing coronary artery catheterisation. This survey collected socio-demographic data and assessed anxiety using the Spielberger State-Trait Anxiety Inventory. Procedural data, including length of procedure, equipment used, occurrence of radial artery spasm, and medications given, were collected post-procedure by the interventionalist.

RESULTS

Of the 169 participants, over half were male (59.8%) and aged 66 years or older (56.8%). Radial artery spasm was reported in 24 (14.2%) participants. Rates of spasm were significantly higher among females (66.6%, p = 0.004), those aged under 65 years (62.5%, p = 0.001) and those who reported a medical history of anxiety (33.3%, p = 0.0004). There were no significant differences in State and Trait anxiety scores among those who had RAS and those who did not. Logistic regression identified younger age as the only statistically significant predictor of RAS (OR 0.536; 95% CI 0.171-1.684; p = 0.005). To prevent radial artery spasm most patients received midazolam (n = 158; 93.5%), nitrates (n = 133; 78.7%) and/or fentanyl (n = 124; 73.4%) prophylactically. Nitrates were the most frequently administered medication to treat radial artery spasm (78.7%).

CONCLUSION

This study highlights that there is a need to develop a clearer understanding of the predictors of RAS, as identifying patients at risk can ensure prophylactic measures are implemented. This study identified nitrates as the preferred vasodilator as a preventative measure along with the use of sedation.

Ancient DNA from Mesopotamia suggests distinct Pre-Pottery and Pottery Neolithic migrations into Anatolia

We present the first ancient DNA data from the Pre-Pottery Neolithic of Mesopotamia (Southeastern Turkey and Northern Iraq), Cyprus, and the Northwestern Zagros, along with the first data from Neolithic Armenia. We show that these and neighboring populations were formed through admixture of pre-Neolithic sources related to Anatolian, Caucasus, and Levantine hunter-gatherers, forming a Neolithic continuum of ancestry mirroring the geography of West Asia. By analyzing Pre-Pottery and Pottery Neolithic populations of Anatolia, we show that the former were derived from admixture between Mesopotamian-related and local Epipaleolithic-related sources, but the latter experienced additional Levantine-related gene flow, thus documenting at least two pulses of migration from the Fertile Crescent heartland to the early farmers of Anatolia.

The genetic history of the Southern Arc: A bridge between West Asia and Europe

By sequencing 727 ancient individuals from the Southern Arc (Anatolia and its neighbors in Southeastern Europe and West Asia) over 10,000 years, we contextualize its Chalcolithic period and Bronze Age (about 5000 to 1000 BCE), when extensive gene flow entangled it with the Eurasian steppe. Two streams of migration transmitted Caucasus and Anatolian/Levantine ancestry northward, and the Yamnaya pastoralists, formed on the steppe, then spread southward into the Balkans and across the Caucasus into Armenia, where they left numerous patrilineal descendants. Anatolia was transformed by intra-West Asian gene flow, with negligible impact of the later Yamnaya migrations. This contrasts with all other regions where Indo-European languages were spoken, suggesting that the homeland of the Indo-Anatolian language family was in West Asia, with only secondary dispersals of non-Anatolian Indo-Europeans from the steppe.

A genetic probe into the ancient and medieval history of Southern Europe and West Asia

Literary and archaeological sources have preserved a rich history of Southern Europe and West Asia since the Bronze Age that can be complemented by genetics. Mycenaean period elites in Greece did not differ from the general population and included both people with some steppe ancestry and others, like the Griffin Warrior, without it. Similarly, people in the central area of the Urartian Kingdom around Lake Van lacked the steppe ancestry characteristic of the kingdom's northern provinces. Anatolia exhibited extraordinary continuity down to the Roman and Byzantine periods, with its people serving as the demographic core of much of the Roman Empire, including the city of Rome itself. During medieval times, migrations associated with Slavic and Turkic speakers profoundly affected the region.

Pregnancy Outcomes and Risk Evaluation in a Contemporary Adult Congenital Heart Disease Cohort

BACKGROUND

More women with congenital heart disease (CHD) are surviving to childbearing age. In this population, pregnancy results in a higher rate of adverse events for the mother and offspring. We sought to evaluate outcomes in our cohort and relate these to previously developed risk classifications.

METHOD

We retrospectively reviewed all pregnancies occurring in our tertiary referral centre CHD cohort between 2007 and 2019 resulting in data from 128 pregnancies in 89 women. The mean age was 29±6 years. Underlying cardiac diagnoses were grouped according to the ESC Registry of Pregnancy and Cardiac disease (ROPAC) classification and baseline risk assessed as per the modified WHO classification.

RESULTS

There were a wide range of underlying diagnoses and large number of moderate to high risk pregnancies with 57 (44.5%) classified as mWHO III or IV. There were no maternal deaths. The mean gestation at delivery was 37 weeks. The majority delivered vaginally. Adverse events occurred in 80 pregnancies (63%). Cardiovascular events in 21 (16%), obstetric 54 (42%) and neonatal 52 (41%). Common events included premature labour and delivery in 21 pregnancies (16%); post-partum haemorrhage in 33 (26%), small for gestational age infants in 38 (30%) and admission to the NICU in 23 (18%). Event rates increased in women classified as higher risk by mWHO group.

CONCLUSION

Women with CHD have increased rates of adverse cardiovascular, obstetric and neonatal events in pregnancy. As expected, adverse outcomes occur more frequently in higher risk mWHO groups.

Widening access to veterinary education: descriptive analysis of ethnicity, societal representation and educational background of applicants to veterinary education in Aotearoa New Zealand

AIMS

To describe the ethnicity of domestic applicants for selection into the professional phase of veterinary education in Aotearoa New Zealand from 2003 to 2019, and to compare this with the ethnic composition of New Zealand society. This study also aims to explore whether there are differences in the demographic features and educational background of Māori applicants compared to non-Māori applicants that may be relevant to widening access to veterinary education.

METHODS

This study was conducted with a Kaupapa Māori research methodology. Data for all applicants to the Bachelor of Veterinary Science programme at Massey University (Palmerston North, NZ) from 2003 to 2019 were retrieved from the university's Student Management System and the School of Veterinary Science selection application databases. Self-identified ethnicity was analysed in four time periods (2003-2006, 2007-2012, 2013-2016, 2017-2019) defined by factors that might influence whether an individual chose to apply for selection into the veterinary programme. Gender, age, previous university experience, decile and type of high school, and being first in family to attend university were compared between Māori and non-Māori.

RESULTS

From 2003 to 2019, 3,819 individuals submitted 4,802 applications for selection into the veterinary programme. Across all time periods, applicants who identified as Māori (274/4,802; 5.7%) or Pacific (56/4,802; 1.2%) were underrepresented compared to the New Zealand population (Māori 16.5%; Pacific 8.1%), while applicants who identified as European (4,035/4,802; 84%) were over-represented (70.2% of the New Zealand population). The proportion of Māori (p = 0.82) and Pacific (p = 0.31) applicants did not change over time, while the proportion of European applicants decreased from 853/968 (88.1%) to 823/977 (84.2%; p < 0.001). Compared to non-Māori, Māori applicants were more likely to have attended a lower decile school (p < 0.001), have attended a state rather than private or overseas school (p = 0.003) and to have been the first in their family to attend university (p = 0.001).

CONCLUSIONS

Māori are underrepresented in the veterinary applicant pool and veterinary profession in comparison to the New Zealand population. Additionally, Māori applicants differed from non-Māori applicants in pre-university factors that are barriers to university attendance. Implementing activities and processes aimed at widening veterinary programme access with the eventual goal of improving the ethnic representation of the veterinary workforce needs to be a priority for the university and profession.

Poor Bone Quality is Associated With Greater Arterial Stiffness: Insights From the UK Biobank

Osteoporosis and ischemic heart disease (IHD) represent important public health problems. Existing research suggests an association between the two conditions beyond that attributable to shared risk factors, with a potentially causal relationship. In this study, we tested the association of bone speed of sound (SOS) from quantitative heel ultrasound with (i) measures of arterial compliance from cardiovascular magnetic resonance (aortic distensibility [AD]); (ii) finger photoplethysmography (arterial stiffness index [ASI]); and (iii) incident myocardial infarction and IHD mortality in the UK Biobank cohort. We considered the potential mediating effect of a range of blood biomarkers and cardiometabolic morbidities and evaluated differential relationships by sex, menopause status, smoking, diabetes, and obesity. Furthermore, we considered whether associations with arterial compliance explained association of SOS with ischemic cardiovascular outcomes. Higher SOS was associated with lower arterial compliance by both ASI and AD for both men and women. The relationship was most consistent with ASI, likely relating to larger sample size available for this variable (n = 159,542 versus n = 18,229). There was no clear evidence of differential relationship by menopause, smoking, diabetes, or body mass index (BMI). Blood biomarkers appeared important in mediating the association for both men and women, but with different directions of effect and did not fully explain the observed effects. In fully adjusted models, higher SOS was associated with significantly lower IHD mortality in men, but less robustly in women. The association of SOS with ASI did not explain this observation. In conclusion, our findings support a positive association between bone and vascular health with consistent patterns of association in men and women. The underlying mechanisms are complex and appear to vary by sex. © 2020 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Ultrastructure of cell trafficking pathways and coronavirus: how to recognise the wolf amongst the sheep

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has resulted in an urgent need to understand the pathophysiology of SARS-CoV-2 infection, to assist in the identification of treatment strategies. Viral tissue tropism is an active area of investigation, one approach to which is identification of virus within tissues by electron microscopy of post-mortem and surgical specimens. Most diagnostic histopathologists have limited understanding of the ultrastructural features of normal cell trafficking pathways, which can resemble intra- and extracellular coronavirus; in addition, viral replication pathways make use of these trafficking pathways. Herein, we review these pathways and their ultrastructural appearances, with emphasis on structures which may be confused with coronavirus. In particular, we draw attention to the fact that, when using routine fixation and processing, the typical 'crown' that characterises a coronavirus is not readily identified on intracellular virions, which are located in membrane-bound vacuoles. In addition, the viral nucleocapsid is seen as black dots within the virion and is more discriminatory in differentiating virions from other cellular structures. The identification of the viral replication organelle, a collection of membranous structures (convoluted membranes) seen at a relatively low scanning power, may help to draw attention to infected cells, which can be sparse. © 2020 The Authors. The Journal of Pathology published by John Wiley & Sons, Ltd. on behalf of The Pathological Society of Great Britain and Ireland.

Examining emergency department inequities between Māori and non-Māori: do they exist?

Despite Māori (Indigenous population of New Zealand, NZ) having high Emergency Department (ED) use, few studies have explored for ethnic inequities in ED within NZ. ED healthcare can be time-pressured, complex and demanding. Clinical decision-making in this context may facilitate provider prejudice, stereotyping and bias.

The Examining Emergency Department Inequities (EEDI) is a retrospective observational study, designed from a Kaupapa Māori Research position, examining ED admissions in NZ between 2006 and 2012 using the existing Shorter Stays in Emergency Department National Research Project dataset combined with clinical information extracted from NZ’s National Minimum Dataset. The key predictor variable is patient ethnicity with covariates: sex, age-group, area deprivation, mode of presentation, referral method, Australasian Triage Scale and the Multimorbidity Measure (M3 Index) for co-morbidities. Generalised linear regression models investigated the associations between pre-admission variables and the measures of ED care, and mortality.

There were a total of 5,972,102 ED events (1,168,944 Māori, 4,803,158 non-Māori). We found an increasing proportion of ED events/year, a higher proportion of Māori ED events from younger age groups and areas of high deprivation compared to non-Māori. Māori had a higher proportion of self-referral and were triaged to be seen within a longer timeframe compared to non-Māori. After controlling for year of ED event, gender, triage category, age at presentation, NZ Deprivation decile and M3 Comorbidity score: Māori had shorter ED arrival to assessment time; shorter ED Length of Stay and less Access Block (&gt;8 hour ED LOS before ward admission). Despite this, Māori mortality within ED or within 10 days of discharge was higher than non-Māori.

These findings suggest different patterns in ED usage between Māori and non-Māori. Of concern, inequities in mortality exist despite positive indicators of ED care.

Key messages

There is evidence of different patterns in emergency department use between Māori and non-Māori in New Zealand. Māori:non-Māori inequities in mortality exist despite positive indicators of emergency department care.

The New Strategy for the Treatment of Cerebrospinal Fluid Leak Following Lumbar Surgery

Introduction

Cerebrospinal fluid (CSF) leak is a common complication of surgery involving the lumbar spine. However, although there are various therapeutic options for CSF leak, there is currently no optimal technique, and the choice of therapy often depends on the surgeon's cumulative experience. The aim of this study was to describe the successful treatment of CSF leakage using blood injection therapy along the drain removal tract.

Technical Note

We enrolled 7 consecutive patients who underwent lumbar surgery at our institute. The surgeries performed included decompression in two patients (one microendoscopic surgery), fusion in four, and an epidural cyst resection in one. After finding a CSF leak, we injected about 10 ml of blood from the patient into the drain tract. CSF leak did not recur after the blood injection in any of the seven patients. Following just one day of bed rest, the symptoms of intracranial hypotension disappeared with no instances of worsened symptoms of back pain, lower limb pain or fever.

Conclusions

We propose this route of blood injection therapy as a novel method for the treatment of CSF leak after lumbar surgery.

Acute papillary muscle infarction and rupture in the puerperium complicating Libman-Sacks endocarditis in a patient with systemic lupus erythematosus and antiphospholipid syndrome: a case report

BACKGROUND

Acute heart failure caused by severe mitral regurgitation (MR) due to papillary muscle rupture has been described in the puerperium by case reports; however, the majority of cases of papillary muscle rupture are caused by myocardial infarction. We describe papillary muscle rupture occurring in the postpartum period in a patient with systemic lupus erythematosus (SLE), antiphospholipid syndrome (APLS), and chronic Libman-Sacks endocarditis and explore the multifactorial nature of the papillary muscle infarction and rupture in the setting of postpartum fluid shifts, chronic myocardial injury from Libman-Sacks, and high thrombotic risk.

CASE SUMMARY

A 29-year-old woman presented with acute heart failure 2 weeks' postpartum and was found to have acute MR due to a flail leaflet caused by papillary muscle rupture. She proceeded to emergency surgery with mitral valve (MV) replacement and the histology revealed evidence of chronic Libman-Sacks endocarditis and papillary muscle infarction with thrombi in the intramyocardial arteries.

DISCUSSION

This is the second case report of papillary muscle rupture in the puerperium in a patient with SLE in the literature, the other case was caused by catastrophic APLS. However, in this case, the cause of the rupture is likely to be multifactorial; as a consequence of thrombosis in the microvasculature causing isolated papillary muscle ischaemia, and fibrosis of the muscle due to chronic Libman-Sacks endocarditis resulting in limited pliability which caused rupture of the papillary muscle when faced with the added stress of increased volume that occurs in the puerperium.

The effect of topical medications on radial artery spasm in patients undergoing transradial coronary procedures: a systematic review

OBJECTIVE

The objective of this review was to identify the effectiveness of topical medications on radial artery spasm (RAS) in patients undergoing transradial percutaneous coronary procedures.

INTRODUCTION

Percutaneous coronary procedures were traditionally carried out via the femoral artery; however, over the last 20 years there has been a global increase in the number of proceduralists carrying out percutaneous coronary procedures via the transradial approach. Radial artery spasm remains an issue for the transradial approach, potentially leading to procedural failure. Topical medications have been suggested to reduce the occurrence of RAS during transradial percutaneous coronary procedures.

INCLUSION CRITERIA

This review considered papers that included participants aged 18 years and over undergoing non-emergency transradial percutaneous coronary procedures. This review considered papers on the utilization of topical medications prior to commencing the transradial approach for percutaneous coronary procedures to reduce RAS. Topical medications were compared to other medications. The primary outcome was the incidence of RAS as assessed by angiography or ultrasound or resistance felt by the operator while manipulating the catheter. Other outcomes of interest included change in radial artery diameter, measured by angiography or ultrasound, change in radial artery patency and side effects of medications administered. Randomized and quasi-randomized controlled trials were considered.

METHODS

A three-step search strategy was utilized in this review. A search of various databases was carried out followed by a search for unpublished literature between 1989 to January 2017. Only papers published in English were included in the review. Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instrument from the Joanna Briggs Institute (JBI). There was no need for a third reviewer. Quantitative data was extracted from papers included in the review using the JBI data extraction instrument and entered in to RevMan5 (Copenhagen: The Nordic Cochrane Centre, Cochrane). All results were subject to double data entry. Effect sizes were expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals were calculated for analysis.

RESULTS

Only three studies involving 697 participants met the inclusion criteria. There was a statistically significant reduction in the incidence of RAS in patients treated with a eutectic mixture of local anesthetics compared to subcutaneous lidocaine (OR 0.26; 95%CI 0.07,0.96). However there were no significant differences in RAS in studies that compared eutectic mixture of local anesthetics and placebo or a combinations of lidocaine with nitroglycerine compared to placebo.

CONCLUSIONS

It is difficult to draw a valid conclusion, given the low number of studies, small sample sizes and heterogeneity between the studies.

Precipitation of de novo atrial fibrillation during Shockwave Intravascular Lithotripsy® after pacing capture during the treatment of proximal right coronary artery disease: a case report

Background

Shockwave Intravascular Lithotripsy^® has been recently translated to the treatment of coronary artery disease with a long history of use for ureteric stones where it has been observed to have caused cardiac arrhythmias. The risk of arrhythmia with the use of this method in coronary artery disease is currently unknown.

Case summary

A 72-year-old man undergoing planned percutaneous intervention to a heavily calcified proximal right coronary artery (RCA) lesion using S-IVL developed pacing capture from the device and subsequently new atrial fibrillation (AF) during the procedure. The technique resulted in successful treatment of the coronary lesion and he spontaneously reverted within an hour of the procedure before discharge.

Discussion

We postulate the pulsed energy delivered to break apart the calcium has the capacity to cause depolarization, and therefore, affect cardiac rhythm as seen in treatment of renal stones in the past before the introduction of routine electrocardiogram (ECG) gating. In this case, the proximity of the RCA to the right atrium caused short circuiting and development of AF in a susceptible patient. Both the pacing implications and the risk of arrhythmia needs to be investigated further and the potential for ECG gating of the pulsed energy to mitigate this effect needs to be explored to enhance the safety of this technique.

Safety of Cyclooxygenase-2 Inhibitors in Osteoarthritis: Outcomes of a Systematic Review and Meta-Analysis

Objective

Our aim was to assess the safety of cyclooxygenase-2 (COX-2) inhibitors in the management of osteoarthritis (OA) in a systematic review and meta-analysis of randomized, placebo-controlled trials.

Methods

A comprehensive literature search was undertaken in the databases MEDLINE, Cochrane Central Register of Controlled Trials (Ovid CENTRAL) and Scopus. Randomized, double-blind, placebo-controlled, parallel-group trials that assessed adverse events (AEs) with COX-2 inhibitors in patients with OA were eligible for inclusion. Two authors appraised titles, abstracts and full-text papers for suitability and then assessed the studies for random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data and selective outcomes reporting. The primary outcomes of interest were gastrointestinal disorders, cardiac disorders, vascular disorders, nervous system disorders, skin and subcutaneous tissue disorders, hepatobiliary disorders, renal and urinary disorders, as well as overall severe and serious AEs, drug-related AEs and mortality. Secondary outcomes were withdrawals due to AEs (i.e. the number of participants who stopped the treatment due to an AE) and total number of AEs (i.e. the number of patients who experienced any AE at least once).

Results

Database searches identified 2149 records from which, after exclusions, 40 trials were included in the meta-analysis. The use of COX-2 inhibitors in OA was associated with a significant increased risk of drug-related AEs compared with placebo (relative risk (RR) 1.26, 95% CI 1.09–1.46; I² = 24%). The risk of upper gastrointestinal complications (including dyspepsia, gastritis and heartburn) was significantly increased with COX-2 inhibitors versus placebo (RR 1.19, 95% CI 1.03–1.38; I² = 0%), particularly for abdominal pain, which increased by 40% with COX-2 inhibitors (RR 1.40, 95% CI 1.08–1.80; I² = 0%). The risk of hypertension increased by 45% overall (RR 1.45, 95% CI 1.01–2.10; I² = 25%); however, when rofecoxib was removed from the analysis the risk of hypertension in the COX-2 inhibitor group was no longer significant (RR 1.21, 95% CI 0.80–1.83; I² = 20%). The overall risk of heart failure and edema was increased by nearly 70% with COX-2 inhibitors versus placebo (RR 1.68, 95% CI 1.22–2.31; 0%) and this level of risk did not change appreciably when rofecoxib was excluded (RR 1.67, 95% CI 1.21–2.29; 0%).

Conclusions

In our analysis, COX-2 inhibitors were associated with an increased risk of upper gastrointestinal AEs, especially abdominal pain. We also found an increased risk of cardiovascular AEs with COX-2 inhibitors, namely hypertension, heart failure and edema.

Electronic supplementary material

The online version of this article (10.1007/s40266-019-00664-x) contains supplementary material, which is available to authorized users.

Slowly progressive distal muscle weakness: neuropathy or myopathy?

Nonaka myopathy is an autosomal recessive and slowly progressive distal myopathy. It is part of a rare group of myopathies predominantly affecting the distal limb musculature. Over 150 cases have been reported across the Middle East, Japan and Europe. We report the case of a 33-year-old woman presenting with symmetrical upper and lower limb weakness, most severely affecting the distal muscle groups. After extensive neurological investigation including neurophysiology, muscle biopsy and genetic analysis, she was finally diagnosed with Nonaka myopathy and treated conservatively with physiotherapy.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

The Impact of Lumbar Spinal Stenosis, Knee Osteoarthritis, and Loss of Lumbar Lordosis on the Quality of Life: Findings from the Katsuragi Low Back Pain Study

Introduction

Musculoskeletal diseases and spinal malalignment are associated with poorer quality of life (QOL) in the elderly. However, to date, few general population cohort studies have focused on these conditions together. Our objectives were to clarify the associations between musculoskeletal degenerative diseases and/or spinal malalignment with QOL measures in a group of Japanese older adults.

Methods

In this cross-sectional study, we analyzed data from 334 individuals recruited from the local population (120 men, 214 women; mean age 62.7 years; range 40-75). Low back pain (LBP) was assessed by questionnaire, and lumbar spinal stenosis (LSS) was diagnosed using a validated lumbar spinal stenosis support tool. Knee osteoarthritis (KOA) was diagnosed by the presence of clinical knee pain plus radiographic KOA. Spinal radiographs were used to assess the degree of lumbar lordosis (LL) and sagittal vertical alignment (SVA). QOL assessment was performed using the Oswestry Disability Index (ODI). A score of 12 was used as a cut-off point for poor QOL.

Results

Overall, 107 (32.0%) participants had an ODI > 12 (cases), and the remaining 227 individuals were designated controls. LBP, LSS, KOA, and LL were associated with poorer QOL, both in basic models and models adjusted for age, sex, and BMI. Associations persisted after adjustment for other musculoskeletal outcomes.

Conclusions

In a free-living Japanese population, the poor QOL odds are increased by LBP, LSS, KOA, and certain spinal radiographic features, loss of LL, and increased SVA. Poor QOL odds were greatest in those diagnosed with LSS or KOA. From spinal radiographs, decreased LL and increased SVA were also predictors of poor QOL.

Neurologic impairments from pediatric low-grade glioma by tumor location and timing of diagnosis

BACKGROUND

The neurologic outcomes of low-grade gliomas (LGGs) according to tumor location and duration of presenting symptoms remain poorly characterized in children.

PROCEDURE

We retrospectively reviewed neurologic impairments in 246 pediatric patients with LGGs (88 with optic pathway and midline tumors, 56 with posterior fossa tumors, 52 with cerebral hemisphere tumors, 35 with brainstem tumors, and 15 with spinal cord tumors) who were treated at St. Jude Children's Research Hospital between 1995 and 2005. We compared neurologic impairments (defined by Common Terminology Criteria for Adverse Events, version 4.03) by tumor location and prediagnosis symptom interval (PSI) (≥ 3 months or < 3 months) at first and last patient visits.

RESULTS

The median age of diagnosis was 7.1 years; median PSI was 2.1 months; and median time to last follow-up was 11.6 years. LGGs in the cerebral hemispheres resulted in significantly fewer neurologic impairments, compared with that of other locations at baseline (P < 0.001) and at last follow-up (P < 0.001). In all patients, PSIs greater than 3 months resulted in a significantly higher incidence of ataxia and dysmetria at last follow-up (42%, P = 0.003). Greater PSI was also significantly associated with worsening lower extremity motor weakness from cerebral hemisphere tumors; dysmetria from optic pathway and midline tumors; eye and visual dysfunction from posterior fossa tumors; and ear and vestibular disturbances from brainstem tumors (P ≤ 0.05).

CONCLUSION

Neurologic impairment in pediatric LGGs varies by tumor location, and PSIs greater than 3 months affect some functionally important neurologic outcomes.

The price of journeying towards the prize-Commencing nursing students' experiences of working and studying: A qualitative study

AIMS AND OBJECTIVES

To explore the experiences of commencing first-year undergraduate nursing students who were studying full time while engaging in 20 or more hours of paid work each week.

METHOD

Using a qualitative exploratory design, commencing full-time nursing students who were employed in paid work for at least 20 hr per week were interviewed between May-June 2016. Data were thematically analysed using the following approach: data familiarisation, generating initial codes independently, searching and reviewing themes and subthemes, and defining and naming these themes and subthemes.

RESULTS

Four main themes were identified which illustrated students' experiences of working and studying: (a) "Work is a necessity…not a choice" identified how students relied heavily on the financial income from paid work to support themselves and others during their studies, (b) "Something's got to give" highlighted the sacrifices that needed to be made to avoid negative effects on their studies, (c) "It's a balancing act!" demonstrated how students studied strategically and balanced their workload despite challenges, and lastly (d) "Being supported to work and study" described the overwhelming support from others for students to succeed academically.

CONCLUSIONS

Despite support, working 20 hr or more per week while studying full time often overwhelmed students' personal resources and negatively impacted on course grades. Inflexible University timetables compounded the challenges experienced by students who struggled to balance work and study commitments.

RELEVANCE TO CLINICAL PRACTICE

Nursing employers play a pivotal role in enabling students to juggle effectively their work-study commitments, through providing work flexibility. Students may also benefit if the nursing workforce advocates that they be awarded exclusion from selected clinical placement requirements, particularly if the clinical placement focus is closely related to their current nursing employment.

Critical preparation and readiness to support future change

The challenging nature of change is well documented and adequate preparation before implementing a change initiative is critical to reducing resistance and increasing its chances of success. This article describes a service review conducted in preparation for possible change and improvement at an internationally ranked school of nursing and midwifery in an Irish tertiary education institution. The purpose of the review was to examine organisational structures and work activities, including pressures facing the administrative team that supports the school, and to establish whether operations were fit for purpose and capable of continuing to support the international ranking. The article outlines the importance of change to maintain a competitive edge and the critical role of leadership during change. The background and rationale for the service review are discussed along with the methods used to prepare staff. The article also reports outcomes of the surveys and focus groups undertaken and discusses the main recommendations and changes implemented so far. It also suggests how the outcomes are relevant to clinical practice.

Safety and efficacy of ulnar artery approach for percutaneous cardiac catheterization: Systematic review and meta-analysis

BACKGROUND

Trans-radial access has rapidly become the standard for percutaneous coronary procedures in the last decade. As proceduralists overcome the learning curve and become more competent in trans-radial access, alternative safe access sites such as the ulnar artery have been increasingly used for emergent and elective procedures. The aim of this study was to synthesize the best available evidence of the impact on major adverse cardiac events (MACE) of ulnar artery compared to radial artery cardiac catheterization.

METHODS

This review considered randomized controlled trials that included adult patients who had a percutaneous coronary procedure via the radial or ulnar artery. The intervention of interest was the use of ulnar compared to radial artery for cardiac catheterization. An extensive search was undertaken for published and unpublished trials up to May 2017. Methodological quality was assessed independently by two reviewers using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) checklist. Data were analyzed using Review Manager.

RESULTS

A total of six trials were included in the review. There was no statistically significant difference in the incidence of MACE between patients who underwent trans-ulnar or trans-radial artery catheterization (OR 0.90; 95% CI 0.65-1.25). Complications associated with access including hematoma formation, (n = 6 trials) pseudo-aneurysm, and arterio-venous fistulae formation (n = 5 trials), were investigated in a total of 5,276 patients, with no difference in these complications noted between the two groups. There were no differences in arterial access time, fluoroscopy time, and contrast load between the two groups.

CONCLUSIONS

There is evidence to support safe use of the ulnar artery as an alternative to the radial artery for access for cardiac catheterization.