A practical evidence-based approach to management of type 2 diabetes in children and young people (CYP): UK consensus

BACKGROUND

Type 2 diabetes in young people is an aggressive disease with a greater risk of complications leading to increased morbidity and mortality during the most productive years of life. Prevalence in the UK and globally is rising yet experience in managing this condition is limited. There are no consensus guidelines in the UK for the assessment and management of paediatric type 2 diabetes.

METHODS

Multidisciplinary professionals from The Association of Children's Diabetes Clinicians (ACDC) and the National Type 2 Diabetes Working Group reviewed the evidence base and made recommendations using the Grading Of Recommendations, Assessment, Development and Evaluation (GRADE) methodology.

RESULTS AND DISCUSSION

Young people with type 2 diabetes should be managed within a paediatric diabetes team with close working with adult diabetes specialists, primary care and other paediatric specialties. Diagnosis of diabetes type can be challenging with many overlapping features. Diabetes antibodies may be needed to aid diagnosis. Co-morbidities and complications are frequently present at diagnosis and should be managed holistically. Lifestyle change and metformin are the mainstay of early treatment, with some needing additional basal insulin. GLP1 agonists should be used as second-line agents once early ketosis and symptoms are controlled. Glycaemic control improves microvascular but not cardiovascular risk. Reduction in excess adiposity, smoking prevention, increased physical activity and reduction of hypertension and dyslipidaemia are essential to reduce major adverse cardiovascular events.

CONCLUSIONS

This evidence-based guideline aims to provide a practical approach in managing this condition in the UK.

Viewpoints of Residency Program Directors Regarding Depressive Symptoms in Pharmacy Residents

Objective: Several publications have highlighted residency-specific factors being associated with depressive symptoms in pharmacy residents, but no studies have investigated the viewpoint of residency program directors (RPDs) regarding this issue. This study's primary objectives were to identify potential contributing factors, determine current resources, and outline possible solutions to decrease depressive symptoms among pharmacy residents from the point of view of RPDs. Methods: RPDs were asked to participate in a 45-60-minute semi-structured interview conducted via phone by the primary investigator, recorded, and transcribed using NVivo. Interviews were manually analyzed by study investigators to identify emerging themes. The investigators discussed findings and discrepancies to agree upon thematic interpretations of the transcripts. Results: Ten interviews were conducted between May 2019 and February 2020. RPD experience ranged from 2-15 years. Pharmacy practice PGY1 programs comprised 60% of interviews, 20% for community practice, and 10% each for managed care and ambulatory care. All RPDs indicated increased workload as a contributing factor to depressive symptoms in residents. The inability to accept and utilize constructive feedback and difficulties transitioning from student to resident were identified as contributing factors by 50% of the RPDs. Nine RPDs reported having employee assistance programs, stating the resource was underutilized, and identified the need for additional education regarding identification and triage, not necessarily management, to help residents. Conclusion: This study highlights consistency among RPDs regarding potential contributors to depressive symptoms in pharmacy residents and emphasizes the need for additional RPD and preceptor training to identify and help residents more effectively with these issues.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Using Emotional Intelligence as a Framework for Students' Professional Identity Formation

Emotional intelligence and professional identity formation (PIF) intersect at various levels. Professional identity formation requires acute observation of others in the profession and the ability to decipher intentionality in behaviors. The developing pharmacist must make a deliberate effort to emulate positive norms and values that coincide with those associated with the profession while deliberately ignoring those that are incongruent. To learn from others in the profession, social skills are required, so one can ask questions, determine the best course of action, set goals, grow, and maintain relationships, and ask for help. The ability to manage one's emotions regardless of external circumstances can be valuable for any profession. Self-regulation and self-assessment of one's emotions and motivations can be useful for reevaluating our perspectives and priorities as pharmacists. Emotional intelligence is a critical component of building, demonstrating, and improving PIF. This commentary will provide strategies to facilitate and solidify the connection between the two.

Genetic and dietary modulators of the inflammatory response in the gastrointestinal tract of the BXD mouse genetic reference population

Inflammatory gut disorders, including inflammatory bowel disease (IBD), can be impacted by dietary, environmental, and genetic factors. While the incidence of IBD is increasing worldwide, we still lack a complete understanding of the gene-by-environment interactions underlying inflammation and IBD. Here, we profiled the colon transcriptome of 52 BXD mouse strains fed with a chow or high-fat diet (HFD) and identified a subset of BXD strains that exhibit an IBD-like transcriptome signature on HFD, indicating that an interplay of genetics and diet can significantly affect intestinal inflammation. Using gene co-expression analyses, we identified modules that are enriched for IBD-dysregulated genes and found that these IBD-related modules share cis-regulatory elements that are responsive to the STAT2, SMAD3, and REL transcription factors. We used module quantitative trait locus analyses to identify genetic loci associated with the expression of these modules. Through a prioritization scheme involving systems genetics in the mouse and integration with external human datasets, we identified Muc4 and Epha6 as the top candidates mediating differences in HFD-driven intestinal inflammation. This work provides insights into the contribution of genetics and diet to IBD risk and identifies two candidate genes, MUC4 and EPHA6, that may mediate IBD susceptibility in humans.

Massive mixed epithelial-stromal tumour of seminal vesicle requiring challenging abdominoperineal resection: a case report and review of literature

Mixed epithelial-stromal tumours (MESTs) are a rare biphasic tumour that frequently arise in women from the renal and urogenital tract. They are also seen in men but are exceptionally uncommon with only few cases reported to originate from the seminal vesicles. Malignant transformation of its epithelial or stromal components is possible; however, by in large, these tumours are benign in nature. We report the case of a 48-year-old man with no remarkable medical or surgical history who presented with a huge expanding pelvic and intra-abdominal mass that required extensive surgical management including a pelvic exenteration. Histopathological analysis concluded the diagnosis of benign MEST originating from the seminal vesicles with no malignant features. No further systemic therapy was recommended for our patient. Given the technical intricacy in the operative resection of this tumour, we aim to present our findings and surgical management of this complex MEST.

Growth with Commensal Streptococci Alters Streptococcus mutans Behaviors

As oral bacteria grow and persist within biofilms attached to the tooth's surface, they interact with other species to form synergistic or antagonistic exchanges that govern homeostasis for the overall population. One example are the interactions between the cariogenic species Streptococcus mutans and oral commensal streptococci. Previously, we showed that the cell-cell signaling pathways of S. mutans were inhibited during coculture with other oral streptococci species, leading us to posit that the S. mutans transcriptome and behaviors are broadly altered during growth with these species. To test this hypothesis, we performed whole transcriptome sequencing (RNA-seq) on cocultures of S. mutans with either Streptococcus gordonii, Streptococcus sanguinis, or Streptococcus oralis and a quadculture containing all 4 species in comparison to S. mutans grown alone. Our results reveal that in addition to species-dependent changes to the S. mutans transcriptome, a conserved response to oral streptococci in general can be observed. We monitored the behavior of S. mutans by both microscopy imaging of biofilms and in a bacteriocin overlay assay and verified that S. mutans acts similarly with each of these species but noted divergences in phenotypes when cocultured with another cariogenic Streptococcus (Streptococcus sobrinus) or with oral nonstreptococci species. RNA-seq with oral nonstreptococci showed lack of a consistent gene expression profile and overlap of differentially expressed genes found with commensal streptococci. Finally, we investigated the role of upregulated S. mutans genes within our data sets to determine if they provided a fitness benefit during interspecies interactions. Eleven total genes were studied, and we found that a majority impacted the fitness of S. mutans in various assays, highlighted by increased biomass of commensal streptococci in mixed-species biofilms. These results confirm a common, species-independent modification of S. mutans behaviors with oral commensal streptococci that emphasizes the need to further evaluate oral bacteria within multispecies settings.

A Transient Printed Soil Decomposition Sensor Based on a Biopolymer Composite Conductor

Soil health is one of the key factors in determining the sustainability of global agricultural systems and the stability of natural ecosystems. Microbial decomposition activity plays an important role in soil health; and gaining spatiotemporal insights into this attribute is critical for understanding soil function as well as for managing soils to ensure agricultural supply, stem biodiversity loss, and mitigate climate change. Here, a novel in situ electronic soil decomposition sensor that relies on the degradation of a printed conductive composite trace utilizing the biopolymer poly(3-hydroxybutyrate-co-3-hydroxyvalerate) as a binder is presented. This material responds selectively to microbially active environments with a continuously varying resistive signal that can be readily instrumented with low-cost electronics to enable wide spatial distribution. In soil, a correlation between sensor response and intensity of microbial decomposition activity is observed and quantified by comparison with respiration rates over 14 days, showing that devices respond predictably to both static conditions and perturbations in general decomposition activity.

Development of a Mobile-First Registry to Recruit Healthy Volunteers and Members of Underrepresented Communities for Alzheimer's Disease Prevention Studies

BACKGROUND

Web-based participant recruitment registries can be useful tools for accelerating enrollment into studies, but existing Alzheimer's disease (AD)-focused recruitment registries have had limited success enrolling individuals from underrepresented racial and ethnic groups. Designing these registries to meet the needs of individuals from these communities, including designing mobile-first, may facilitate improvement in the enrollment of underrepresented groups.

OBJECTIVES

Evaluate the usability of a prototype mobile-first participant recruitment registry for AD prevention studies; assess users' perceptions of and willingness to sign up for the registry.

DESIGN AND SETTING

Quantitative usability testing and an online survey; online setting.

PARTICIPANTS

We recruited 1,358 adults ages 45-75 who self-reported not having a diagnosis of mild cognitive impairment, AD, or other forms of dementia (Study 1: n=589, Study 2: n=769). Black/African American and Hispanic/Latino participants were specifically recruited, including those with lower health literacy.

METHODS AND MEASUREMENTS

Study 1 measures the prototype's usability through observed task success rates, task completion times, and responses to the System Usability Scale. Study 2 uses an online survey to collect data on perceptions of and willingness to sign up for the mobile-first registry.

RESULTS

Study 1 findings show the prototype mobile-first recruitment registry website demonstrates high usability and is equally usable for Black / African American, Hispanic/Latino, and White user groups. Survey results from Study 2 indicate that users from underrepresented communities understand the registry's purpose and content and express willingness to sign up for the registry on a mobile device.

CONCLUSIONS

Designing mobile-first participant recruitment registries based on feedback from underrepresented communities may result in more sign-ups by individuals from minoritized communities.

Evidence and Strategies for Including Emotional Intelligence in Pharmacy Education

Objective. This integrative review summarizes the literature addressing emotional intelligence among health care professionals and students to better define and incorporate it into the pharmacy curricula.Findings. Emotional intelligence is an essential attribute for relationship building, stress management, and self-regulation. Pharmacy students must develop and improve their emotional intelligence to support their development of successful relationships with patients, pharmacy colleagues, and other health care providers. In addition, awareness of one's own biases and emotions can help with behavioral regulation, which can facilitate enhanced communications with others. Increasing evidence suggests that emotional intelligence can influence academic success, the ability to provide compassionate and competent patient care, the ability to lead and influence others, and the ability to manage stress, all of which are important in pharmacy education. Educators can help learners develop emotional intelligence by designing activities that directly identify and target areas of weakness while leveraging areas of strength.Summary. This article discusses key background studies on emotional intelligence in the health professions literature and identifies specific methods and strategies to develop learners' emotional intelligence within the curriculum.

Specialist multidisciplinary input maximises rare disease diagnoses from whole genome sequencing

Diagnostic whole genome sequencing (WGS) is increasingly used in rare diseases. However, standard, semi-automated WGS analysis may overlook diagnoses in complex disorders. Here, we show that specialist multidisciplinary analysis of WGS, following an initial 'no primary findings' (NPF) report, improves diagnostic rates and alters management. We undertook WGS in 102 adults with diagnostically challenging primary mitochondrial disease phenotypes. NPF cases were reviewed by a genomic medicine team, thus enabling bespoke informatic approaches, co-ordinated phenotypic validation, and functional work. We enhanced the diagnostic rate from 16.7% to 31.4%, with management implications for all new diagnoses, and detected strong candidate disease-causing variants in a further 3.9% of patients. This approach presents a standardised model of care that supports mainstream clinicians and enhances diagnostic equity for complex disorders, thereby facilitating access to the potential benefits of genomic healthcare. This research was made possible through access to the data and findings generated by the 100,000 Genomes Project: http://www.genomicsengland.co.uk .

Genome sequencing reveals underdiagnosis of primary ciliary dyskinesia in bronchiectasis

BACKGROUND

Bronchiectasis can result from infectious, genetic, immunological and allergic causes. 60-80% of cases are idiopathic, but a well-recognised genetic cause is the motile ciliopathy, primary ciliary dyskinesia (PCD). Diagnosis of PCD has management implications including addressing comorbidities, implementing genetic and fertility counselling and future access to PCD-specific treatments. Diagnostic testing can be complex; however, PCD genetic testing is moving rapidly from research into clinical diagnostics and would confirm the cause of bronchiectasis.

METHODS

This observational study used genetic data from severe bronchiectasis patients recruited to the UK 100,000 Genomes Project and patients referred for gene panel testing within a tertiary respiratory hospital. Patients referred for genetic testing due to clinical suspicion of PCD were excluded from both analyses. Data were accessed from the British Thoracic Society audit, to investigate whether motile ciliopathies are underdiagnosed in people with bronchiectasis in the UK.

RESULTS

Pathogenic or likely pathogenic variants were identified in motile ciliopathy genes in 17 (12%) out of 142 individuals by whole-genome sequencing. Similarly, in a single centre with access to pathological diagnostic facilities, 5-10% of patients received a PCD diagnosis by gene panel, often linked to normal/inconclusive nasal nitric oxide and cilia functional test results. In 4898 audited patients with bronchiectasis, <2% were tested for PCD and <1% received genetic testing.

CONCLUSIONS

PCD is underdiagnosed as a cause of bronchiectasis. Increased uptake of genetic testing may help to identify bronchiectasis due to motile ciliopathies and ensure appropriate management.

On the adsorption and reactivity of element 114, flerovium

Flerovium (Fl, element 114) is the heaviest element chemically studied so far. To date, its interaction with gold was investigated in two gas-solid chromatography experiments, which reported two different types of interaction, however, each based on the level of a few registered atoms only. Whereas noble-gas-like properties were suggested from the first experiment, the second one pointed at a volatile-metal-like character. Here, we present further experimental data on adsorption studies of Fl on silicon oxide and gold surfaces, accounting for the inhomogeneous nature of the surface, as it was used in the experiment and analyzed as part of the reported studies. We confirm that Fl is highly volatile and the least reactive member of group 14. Our experimental observations suggest that Fl exhibits lower reactivity towards Au than the volatile metal Hg, but higher reactivity than the noble gas Rn.

A Multimodal Sensing Platform for Interdisciplinary Research in Agrarian Environments

Agricultural and environmental monitoring programs often require labor-intensive inputs and substantial costs to manually gather data from remote field locations. Recent advances in the Internet of Things enable the construction of wireless sensor systems to automate these remote monitoring efforts. This paper presents the design of a modular system to serve as a research platform for outdoor sensor development and deployment. The advantages of this system include low power consumption (enabling solar charging), the use of commercially available electronic parts for lower-cost and scaled up deployments, and the flexibility to include internal electronics and external sensors, allowing novel applications. In addition to tracking environmental parameters, the modularity of this system brings the capability to measure other non-traditional elements. This capability is demonstrated with two different agri- and aquacultural field applications: tracking moth phenology and monitoring bivalve gaping. Collection of these signals in conjunction with environmental parameters could provide a holistic and context-aware data analysis. Preliminary experiments generated promising results, demonstrating the reliability of the system. Idle power consumption of 27.2 mW and 16.6 mW for the moth- and bivalve-tracking systems, respectively, coupled with 2.5 W solar cells allows for indefinite deployment in remote locations.

The Impacts of Benefit Sanctions: A Scoping Review of the Quantitative Research Evidence

In recent decades, the use of conditionality backed by benefit sanctions for those claiming unemployment and related benefits has become widespread in the social security systems of high-income countries. Critics argue that sanctions may be ineffective in bringing people back to employment or indeed harmful in a range of ways. Existing reviews largely assess the labour market impacts of sanctions but our understanding of the wider impacts is more limited. We report results from a scoping review of the international quantitative research evidence on both labour market and wider impacts of benefit sanctions. Following systematic search and screening, we extract data for 94 studies reporting on 253 outcome measures. We provide a narrative summary, paying attention to the ability of the studies to support causal inference. Despite variation in the evidence base and study designs, we found that labour market studies, covering two thirds of our sample, consistently reported positive impacts for employment but negative impacts for job quality and stability in the longer term, along with increased transitions to non-employment or economic inactivity. Although largely relying on non-experimental designs, wider-outcome studies reported significant associations with increased material hardship and health problems. There was also some evidence that sanctions were associated with increased child maltreatment and poorer child well-being. Lastly, the review highlights the generally poor quality of the evidence base in this area, with few studies employing research methods designed to identify the causal impact of sanctions, especially in relation to wider impacts.

The mouse metallomic landscape of aging and metabolism

Organic elements make up 99% of an organism but without the remaining inorganic bioessential elements, termed the metallome, no life could be possible. The metallome is involved in all aspects of life, including charge balance and electrolytic activity, structure and conformation, signaling, acid-base buffering, electron and chemical group transfer, redox catalysis energy storage and biomineralization. Here, we report the evolution with age of the metallome and copper and zinc isotope compositions in five mouse organs. The aging metallome shows a conserved and reproducible fingerprint. By analyzing the metallome in tandem with the phenome, metabolome and proteome, we show networks of interactions that are organ-specific, age-dependent, isotopically-typified and that are associated with a wealth of clinical and molecular traits. We report that the copper isotope composition in liver is age-dependent, extending the existence of aging isotopic clocks beyond bulk organic elements. Furthermore, iron concentration and copper isotope composition relate to predictors of metabolic health, such as body fat percentage and maximum running capacity at the physiological level, and adipogenesis and OXPHOS at the biochemical level. Our results shed light on the metallome as an overlooked omic layer and open perspectives for potentially modulating cellular processes using careful and selective metallome manipulation.

The metallome is crucial for normal cell functioning but remains largely overlooked in mammals. Here the authors analyze the metallome and copper and zinc isotope compositions in aging mice and show networks of interactions that are organ-specific, age-dependent, isotopically-typified and associated with a wealth of clinical and molecular traits.

Mass Equilibration and Fluctuations in the Angular Momentum Dependent Dynamics of Heavy Element Synthesis Reactions

Mass and angle distributions for the ^{52}Cr+^{198}Pt and ^{54}Cr+^{196}Pt reactions (both forming ^{250}No) were measured and subtracted, giving new information on fast quasifission mass evolution, and the first direct determination of the dependence of sticking times on angular momentum. TDHF calculations showed good agreement with average experimental values, but experimental mass distributions unexpectedly extended to symmetric splits while the peak yield remained close to the initial masses. This implies a strong role of fluctuations in mass division early in the collision, giving insights into the transition from fast energy dissipative deep-inelastic collisions to quasifission.

P04.09 Frequent inactivating mutations of PBRM1 in meningioma with papillary features

BACKGROUND

Papillary meningiomas (PM) are rare WHO grade III tumors that are associated with frequent recurrences and metastatic disease in spite of surgery and radiation. Due to their low incidence and scarcity of tumor tissues available for genomic analyses, the genetic alterations associated with PM remain unclear.

MATERIAL AND METHODS

We mined data collected as part of our clinical comprehensive genomic profiling (CGP) initiative which has to date analyzed 8 PM (&gt;50% papillary morphology) and 22 meningiomas with focal papillary features (10–50%) amongst over 500 additional meningiomas of other subtypes. The samples were analyzed in a CAP/CLIA-accredited laboratory (Foundation Medicine, Cambridge, MA). GCP was performed on hybridization-captured, adaptor ligation-based libraries to a mean coverage depth of &gt;650x for 236 or 315 genes plus the introns from 19 or 28 genes frequently involved in cancer.

RESULTS

In our cohort of 8 PMs, we identified three cases with inactivation of PBRM1; two cases with a truncating mutation in PBRM1 and one with homozygous deletion of PBRM1. Of the 22 meningiomas with only focal papillary features, 8 cases were PBRM1-mutant. Thus, 11 of 30 cases (36.7%) with at least focal (&gt;10%) papillary morphology had inactivation of PBRM1.In the entire cohort of 562 meningiomas, we identified five additional cases with inactivating alterations in PBRM1 that did not display overt papillary morphology in the H&E sections available for analysis. Thus, 11 of 16 PBRM1-mutant cases (69%) occurred in meningioma with papillary histologic features as opposed to 19 of 546 wild-type cases (3.5%), supporting a significant association between papillary features and PBRM1 mutation (p&lt;0.0001). The majority of PBRM1-mutant meningiomas occurred in female patients (n=10/16, 62.5%), and median age was 51 years. Most cases were located supratentorially (n=10).

CONCLUSION

We identified the tumor suppressor gene PBRM1 as a recurrently altered gene in meningiomas with papillary histomorphology. Further investigational studies are needed to assess outcomes of PBRM1-mutant meningioma and to determine whether mutation is an independent negative prognostic biomarker.

Longitudinal evaluation of laboratory-based serological assays for SARS-CoV-2 antibody detection

Serological assays for SARS-CoV-2 infection are now widely available for use in diagnostic laboratories. Limited data are available on the performance characteristics in different settings, and at time periods remote from the initial infection. Validation of the Abbott (Architect SARS-CoV-2 IgG), DiaSorin (Liaison SARS-CoV-2 S1/S2 IgG) and Roche (Cobas Elecsys Anti-SARS-CoV-2) assays was undertaken utilising 217 serum samples from 131 participants up to 7 months following COVID-19 infection. The Abbott and DiaSorin assays were implemented into routine laboratory workflow, with outcomes reported for 2764 clinical specimens. Sensitivity and specificity were concordant with the range reported by the manufacturers for all assays. Sensitivity across the convalescent period was highest for the Roche at 95.2-100% (95% CI 81.0-100%), then the DiaSorin at 88.1-100% (95% CI 76.0-100%), followed by the Abbott 68.2-100% (95% CI 53.4-100%). Sensitivity of the Abbott assay fell from approximately 5 months; on this assay paired serum samples for 45 participants showed a significant drop in the signal-to-cut-off ratio and 10 sero-reversion events. When used in clinical practice, all samples testing positive by both DiaSorin and Abbott assays were confirmed as true positive results. In this low prevalence setting, despite high laboratory specificity, the positive predictive value of a single positive assay was low. Comprehensive validation of serological assays is necessary to determine the optimal assay for each diagnostic setting. In this low prevalence setting we found implementation of two assays with different antibody targets maximised sensitivity and specificity, with confirmatory testing necessary for any sample which was positive in only one assay.

Comparison of colorectal cancer outcomes in young adults and octogenarians

BACKGROUND

This study aimed to characterise the outcomes associated with colorectal cancer (CRC), comparing young adults (<50 years), patients of screening age (50-79 years), and octogenarians (>80 years).

METHODS

All consecutive CRC resections with curative intent were recruited into this study from a prospectively maintained CRC database at a tertiary academic centre.

RESULTS

A total of 745 eligible cases were identified. Five-year survival in young adults was poorer than that of patients of screening age. Young adults had the highest incidence of rectal cancer resections, and presented with the most advanced tumour stages. Independent associations for poorer survival in young adults were increased nodal stage, the presence of distal metastases, and loss of MLH1/PMS2 staining on immunohistochemistry. Young adults had similar survival to octogenarians, when comparing patients treated with curative intent, regardless of oncological treatment.

The impact of the COVID-19 pandemic on colorectal cancer diagnosis and management: A Binational Colorectal Cancer Audit study

BACKGROUND

The COVID-19 pandemic has resulted in global disruptions to the delivery of healthcare. The national responses of Australia and New Zealand has resulted in unprecedented changes to the care of colorectal cancer patients, amongst others. This paper aims to determine the impact of COVID-19 on colorectal cancer diagnosis and management in Australia and New Zealand.

METHODS

This is a multicentre retrospective cohort study using the prospectively maintained Binational Colorectal Cancer Audit (BCCA) registry. Data is contributed by over 200 surgeons in Australia and New Zealand. Patients receiving colorectal cancer surgery during the pandemic were compared to averages from the same period over the preceding 3 years.

RESULTS

There were fewer operations in 2020 than the historical average. During April to June, patients were younger, more likely to have operations in public hospitals and more likely to have urgent or emergency operations. By October to December, proportionally less patients had Stage I disease, proportionally more had Stage II or III disease and there was no difference in Stage IV disease. Patients were less likely to have rectal cancer, were increasingly likely to have urgent or emergency surgery and more likely to have a stoma created.

CONCLUSION

This study shows that the response to COVID-19 has had measurably negative effects on the diagnosis and management of colorectal cancer in two countries that have had significantly fewer COVID-19 cases than many other countries. The long-term effects on survival and recurrence are yet to be known, but could be significant.

Pharmacological approaches of ADHD

Abstract Body

Adults with ADHD describe self-medicating with cannabis. A small number of psychiatrists in the US prescribe cannabis medication for ADHD, despite there being no evidence from trials. The EMA-C trial (Experimental Medicine in ADHD-Cannabinoids) was a pilot randomised placebo-controlled experimental study of a cannabinoid medication, Sativex Oromucosal Spray, in 30 adults with ADHD. The primary outcome was cognitive performance and activity level using the QbTest. Secondary outcomes included ADHD and emotional lability (EL) symptoms. From 17.07.14-18.06.15, 30 participants were randomly assigned to the active (n=15) or placebo (n=15) group. For the primary outcome, no significant difference was found in the intent-to-treat analysis although the overall pattern of scores was such that the active group usually had scores that were better than the placebo group (Est=-0.17,95%CI-0.40-0.07, p=0.16, n=15/11 active/placebo). For secondary outcomes Sativex was associated with a nominally significant improvement in hyperactivity/impulsivity (p=0.03) and a cognitive measure of inhibition (p=0.05), and a trend towards improvement for inattention (p=0.10) and EL (p=0.11). Per-protocol effects were higher. Results did not meet significance following adjustment for multiple testing. One serious (muscular seizures/spasms) and three mild adverse events occurred in the active group and one serious (cardiovascular problems) adverse event in the placebo group. Adults with ADHD may represent a subgroup of individuals who experience a reduction of symptoms and no cognitive impairments following cannabinoid use. While not definitive, this study provides preliminary evidence supporting the self-medication theory of cannabis use in ADHD and the need for further studies of the endocannabinoid system in ADHD.

Disclosure

During this work-RC was a Ph.D. student funded by a grant to PA from Vifor Pharma. PA received funds (consultancy/sponsored talks/research/education) from Shire, Lilly, Novartis, Janssen, PCMScientific, Vifor Pharma, QBTech. Sativex was free from GW Pharm

Retained fecalith following laparoscopic appendectomy

It is important to identify a retained fecalith and remove that infective nidus to decrease the morbidity in patients undergoing laparoscopic appendectomy for perforated appendicitis.

Utility of intra-operative flexible sigmoidoscopy to assess colorectal anastomosis: a systematic review and meta-analysis

BACKGROUND

Anastomotic leak (AL) after colorectal resection leads to increased oncological and non-oncological, morbidity and mortality. Intra-operative assessment of a colorectal anastomosis with intra-operative flexible sigmoidoscopy (IOFS) has become increasingly prevalent and is an alternative to conventional air leak test. It is thought that intra-operative identification of an AL or anastomotic bleeding (AB) allows for immediate reparative intervention at the time of anastomosis formation itself. We aim to assess the available evidence for the use of IOFS to prevent complications following colorectal resection.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic review of the literature between January 1980 and June 2020 was performed. Comparative studies assessing IOFS versus conventional air leak test were compared, and outcomes were pooled.

RESULTS

A total of 4512 articles were assessed, of which eight were found to meet the inclusion criteria. A total of 1792 patients were compared; 884 in the IOFS arm and 908 in the control arm. IOFS was associated with an increase in the rate of positive leak test (odds ratio (OR) 5.21, P > 0.001), a decrease in AL (OR 0.45, P = 0.006) and a decrease in post-operative AB requiring intervention (OR 0.40, P = 0.037).

CONCLUSION

In a non-randomized meta-analysis, IOFS increases the likelihood of identifying an anastomotic defect or bleeding intra-operatively. This allows for immediate intervention that decreases the rate of AL and AB. This adds impetus for performing routine IOFS after a left-sided colorectal resection with anastomosis and highlights the need for randomized controlled trial to confirm the finding.

How to do safe intracorporeal marking of structures during minimally invasive surgery by simple modification of a skin marking pen

This study describes how to do safe intracorporeal marking of structures during minimally invasive surgery by simple modification of a skin marking pen. We wish to publicize the use of a skin marking pen tip held within laparoscopic graspers as an effective, simple and cheap method to mark intracorporeal structures, avoiding tissue damage.

"I can guess the month … but beyond that, I can't tell" an exploratory qualitative study of health care provider perspectives on gestational age estimation in Rajasthan, India

BACKGROUND

Accurately estimating gestational age is essential to the provision of time-sensitive maternal and neonatal interventions, including lifesaving measures for imminent preterm birth and trimester-specific health messaging.

METHODS

We explored healthcare provider perspectives on gestational age estimation in the state of Rajasthan, India, including the methods they use (last menstrual period [LMP] dating, ultrasound, or fundal height measurement); barriers to making accurate estimates; how gestational age estimates are documented and used for clinical decision-making; and what could help improve the accuracy and use of these estimates. We interviewed 20 frontline healthcare providers and 10 key informants. Thematic network analysis guided our coding and synthesis of findings.

RESULTS

Health care providers reported that they determined gestational age using some combination of LMP, fundal height, and ultrasound. Their description of their practices showed a lack of standard protocol, varying levels of confidence in their capacity to make accurate estimates, and differing strategies for managing inconsistencies between estimates derived from different methods. Many frontline healthcare providers valued gestational age estimation more to help women prepare for childbirth than as a tool for clinical decision making. Feedback on accuracy was rare. The providers sampled could not offer ultrasound directly, and instead could only refer women to ultrasound at higher level facilities, and usually only in the second or third trimesters because of late antenatal care-seeking. Low recall among pregnant women limited the accuracy of LMP. Fundal height was heavily relied upon, despite its lack of precision.

CONCLUSION

The accuracy of gestational age estimates is influenced by factors at four levels: 1. health system (protocols to guide frontline workers, interventions that make use of gestational age, work environment, and equipment); 2. healthcare provider (technical understanding of and capacity to apply the gestational age estimation methods, communication and rapport with clients, and value assessment of gestational age); 3. client (time of first antenatal care, migration status, language, education, cognitive approach to recalling dates, and experience with biomedical services); and, 4. the inherent limitations and ease of application of the methods themselves.

A Smart Collar for Assessment of Activity Levels and Environmental Conditions for Guide Dogs. Annu Int Conf IEEE Eng Med Biol Soc 2020;2020:4628-4631. [PMID: 33019025 DOI: 10.1109/embc44109.2020.9175814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

This paper demonstrates the design and manufacturing of a smart and connected internet-of-things collar system for the collection of behavioral and environmental information from working canines. The environmental factors of ambient light, ambient temperature, ambient noise levels, barometric pressure and relative humidity are recorded by the smart collar system in addition to behavioral information about barking incidences and activity levels. The data are collected from the sensors and transmitted via Bluetooth to the handler's smartphone where the custom app also acquires GPS positioning using the on-board smartphone sensors. The stored data on the smartphone are uploaded to the IBM Cloud once the user is connected to a WiFi network. The low power design of the smart collar system permits it to be used continuously for 27 hours with a 290 mAh lithium polymer battery. The cost of the system is low enough to let the handlers have multiple collars and exchange it if needed or recharge it overnight when not in use. This system is currently being scaled up to be tested on hundreds of canine puppies by a preeminent guide dog school in the US. As a result, the design emphasis here has been on the cost and power reduction, comfortable ergonomics, user friendliness, and robustness of data streaming. We expect the system to provide continuous quantitative data for improving guide dog training programs in addition to contributing the well-being of other working dogs in the future.

The clinical efficacy of PSMA PET/MRI in biochemically recurrent prostate cancer compared with standard of care imaging modalities and confirmatory histopathology: results of a single-centre, prospective clinical trial

Prospective evidence for the clinical role and efficacy of prostate specific membrane antigen (PSMA) positron emission tomography (PET)/magnetic resonance imaging (MRI) combining MRI characterization and localization of lesions with PET avidity in comparison to conventional imaging is limited. In a prospective clinical trial, we aimed to evaluate the diagnostic yield and therapeutic impact of PSMA PET/MRI in men with biochemical recurrence (BCR) following curative therapy. A single-centre, prospective clinical trial at the Princess Alexandra Hospital recruited 30 patients with BCR. Patients underwent PSMA PET/MRI and concurrent conventional CT chest, abdomen, pelvis and whole-body bone scan. Biopsy was performed when safety possible for histological correlation of identified lesions. Clinical efficacy and impact of PSMA PET findings were evaluated. 30 patients with BCR were recruited (median PSA 0.69 ng/ml). PSMA avid lesions were present in 21 patients (70%). 23 patients were previously treated with definitive surgery, 6 patients received external beam radiotherapy and 1 patient had low dose rate brachytherapy. A total of 8 of 9 lesions biopsied were positive (88.9% histological correlation). PSMA PET/MRI detected local recurrence (p = 0.005) and pelvic lesions (p = 0.06) more accurately than conventional imaging. PSMA PET/MRI may be useful in staging men with biochemical recurrence, especially when PSA is low. Our data demonstrates a high detection rate, especially for locally recurrent disease, and highlights the role of this modality when PSA is low. This modality has the potential to significantly improve prostate cancer detection and may have implications for earlier salvage treatment, avoidance of futile local therapy and change patient management to lead to improved outcomes.

De Novo SOX6 Variants Cause a Neurodevelopmental Syndrome Associated with ADHD, Craniosynostosis, and Osteochondromas

SOX6 belongs to a family of 20 SRY-related HMG-box-containing (SOX) genes that encode transcription factors controlling cell fate and differentiation in many developmental and adult processes. For SOX6, these processes include, but are not limited to, neurogenesis and skeletogenesis. Variants in half of the SOX genes have been shown to cause severe developmental and adult syndromes, referred to as SOXopathies. We here provide evidence that SOX6 variants also cause a SOXopathy. Using clinical and genetic data, we identify 19 individuals harboring various types of SOX6 alterations and exhibiting developmental delay and/or intellectual disability; the individuals are from 17 unrelated families. Additional, inconstant features include attention-deficit/hyperactivity disorder (ADHD), autism, mild facial dysmorphism, craniosynostosis, and multiple osteochondromas. All variants are heterozygous. Fourteen are de novo, one is inherited from a mosaic father, and four offspring from two families have a paternally inherited variant. Intragenic microdeletions, balanced structural rearrangements, frameshifts, and nonsense variants are predicted to inactivate the SOX6 variant allele. Four missense variants occur in residues and protein regions highly conserved evolutionarily. These variants are not detected in the gnomAD control cohort, and the amino acid substitutions are predicted to be damaging. Two of these variants are located in the HMG domain and abolish SOX6 transcriptional activity in vitro. No clear genotype-phenotype correlations are found. Taken together, these findings concur that SOX6 haploinsufficiency leads to a neurodevelopmental SOXopathy that often includes ADHD and abnormal skeletal and other features.

Systematic Study of Quasifission in 48Ca-induced reactions

The production of superheavy elements through the fusion of two heavy nuclei is severely hindered by the quasifission process, which results in the fission of heavy systems before an equilibrated compound nucleus (CN) can be formed. The heaviest elements have been synthesised using 48Ca as the projectile nucleus. However, the use of 48Ca in the formation of new superheavy elements has been exhausted, thus a detailed understanding of the properties that made 48Ca so successful is required. Measurements of mass-angle distributions allow fission fragment mass distribution widths to be determined. The effect of the orientation of prolate deformed target nuclei is presented. Closed shells in the entrance channel are also shown to be more important than the stability of the formed CN in reducing the quasifission component, with reduced mass widths for reactions with the closed shell target nuclei 144Sm and 208Pb. Comparison to mass widths for 48Ti-induced reactions show a significant increase in the mass width compared to 48Ca-induced reactions, highlighting the difficulty faced in forming new superheavy elements using projectiles with higher atomic number than 48Ca.