Impaired communication ability in SOX11 syndrome

BACKGROUND

Speech and language skills are important for social interaction and learning. This study characterised the communication abilities of verbal individuals with SOX11 syndrome using a standardised parent/carer questionnaire, the Children's Communication Checklist (CCC-2).

METHOD

Thirteen parent/carers of verbal individuals (aged 5-19 years) diagnosed with SOX11 syndrome completed the CCC-2. In order to contextualise findings, responses were compared to norms and to data from Noonan syndrome, a relatively well-known genetic diagnosis associated with communication impairment.

RESULTS

For all individuals, the CCC-2 composite score indicated significant communication difficulties. Language structure (speech, syntax, semantics and coherence), pragmatic language (inappropriate initiation, stereotyped language use of context and non-verbal communication) and autistic features (social relations and interests) scores were lower than typically developing norms. Subscale comparisons revealed relative difference in use of context compared to other pragmatic domains (stereotyped language and inappropriate initiation). Individual scores showed substantial variation, particularly in regard to language structure profile. Differences were more pronounced than for Noonan syndrome, specifically in domains of speech, syntax, non-verbal communication and social relations.

CONCLUSIONS

SOX11 syndrome is associated with communication impairment. It is important to assess communication abilities as part of the management of individuals with SOX11 syndrome and understand individual strengths and difficulties in order to provide targeted support.

Fabrication, defect chemistry and microstructure of Mn-doped UO2

Mn-doped UO2 is under consideration for use as an accident tolerant nuclear fuel. We detail the synthesis of Mn-doped UO2 prepared via a wet co-precipitation method, which was refined to improve the yield of incorporated Mn. To verify the Mn-doped UO2 defect chemistry, X-ray absorption spectroscopy at the Mn K-edge was performed, in addition to X-ray diffraction, Raman spectroscopy and high-energy resolved fluorescence detection X-ray absorption near edge spectroscopy at the U M4-edge. It was established that Mn2+ directly substitutes for U4+ in the UO2 lattice, accompanied by oxygen vacancy (Ov) charge compensation. In contrast to other divalent-element doped UO2 materials, compelling evidence for U5+ in a charge compensating role was not found. This work furthers understanding of the structure and crystal chemistry of Mn-doped UO2, which could show potential advantages as a novel efficient advanced nuclear fuel.

Diamond-Like Carbon: A Surface for Extreme, High-Wear Environments

In this study, we present an in-depth characterization of a diamond-like carbon (DLC) film, using a range of techniques to understand the structure and chemistry of the film both in the interior and particularly at the DLC/air surface and DLC/liquid interface. The DLC film is found to be a combination of sp2 and sp3 carbon, with significant oxygen present at the surface. The oxygen seems to be present as OH groups, making the DLC somewhat hydrophilic. Quartz-Crystal Microbalance (QCM) isotherms and complementary neutron reflectivity data indicate significant adsorption of a model additive, bis(2-ethylhexyl) sulfosuccinate sodium salt (AOT) surfactant, onto the DLC from water solutions and indicate the adsorbed film is a bilayer. This initial study of the structure and composition of a model surfactant is intended to give a clearer insight into how DLC and additives function as antiwear systems.

'The dark before the dawn': the 2021 British Thoracic Society Audit of the treatment of tobacco dependency in acute trusts

Smoking remains the single largest cause of preventable death, disability and health inequality. Smoking tobacco directly contributes to over 500 000 hospital admissions each year, making hospitals an important location to optimise treatment for tobacco dependency. The third British Thoracic Society Tobacco Dependency Audit was undertaken to determine how effectively national standards for treating tobacco-dependent smokers have been implemented and assess if any progress has been made from previous audits. Data on 14579 patients from 119 hospitals revealed 21% of patients were current smokers, 45% were offered very brief advice and 5% prescribed combination nicotine replacement therapy or varenicline. Only 9% completed a consultation with a specialist tobacco dependency practitioner during their inpatient stay and fewer than 1% of smokers were abstinent at 4 weeks following discharge. Clinical leadership of tobacco dependency services was deficient, and staff were ill equipped in supporting current smokers in their efforts to quit with only 50% of trusts offering regular smoking cessation training. There has been little meaningful improvement from previous audits and there remains woefully inadequate provision of tobacco dependency treatment for patients who smoke. The National Health Service (NHS) Long Term Plan has committed substantial, new funding to the NHS to ensure every patient that smokes admitted to hospital will be offered evidence-based support and treatment for tobacco dependency. The findings of this audit highlight the urgency with which this programme must be implemented to tackle the greatest cause of premature death in the UK and to achieve the wider well-recognised benefits for the healthcare system.

Prediction on X-ray output of free electron laser based on artificial neural networks

Knowledge of x-ray free electron lasers' (XFELs) pulse characteristics delivered to a sample is crucial for ensuring high-quality x-rays for scientific experiments. XFELs' self-amplified spontaneous emission process causes spatial and spectral variations in x-ray pulses entering a sample, which leads to measurement uncertainties for experiments relying on multiple XFEL pulses. Accurate in-situ measurements of x-ray wavefront and energy spectrum incident upon a sample poses challenges. Here we address this by developing a virtual diagnostics framework using an artificial neural network (ANN) to predict x-ray photon beam properties from electron beam properties. We recorded XFEL electron parameters while adjusting the accelerator's configurations and measured the resulting x-ray wavefront and energy spectrum shot-to-shot. Training the ANN with this data enables effective prediction of single-shot or average x-ray beam output based on XFEL undulator and electron parameters. This demonstrates the potential of utilizing ANNs for virtual diagnostics linking XFEL electron and photon beam properties.

Investigating the Role of MK2 in Head and Neck Squamous Cell Carcinoma Growth, Metastasis and STING Pathway Activation

PURPOSE/OBJECTIVE(S)

Our prior work demonstrated that inhibition of MAPKAPK2 (MK2) can enhance radiation (RT)-mediated in vivo head and neck squamous cell carcinoma (HNSCC) tumor control and survival in preclinical immune incompetent models. The cytosolic DNA sensor cyclic GMP-AMP synthetase (cGAS) and its downstream adaptor protein, stimulator of interferon genes (STING), are conserved proteins within the innate immune signaling pathways and are important for mediating host defense against microbial infection and can play a role in anti-cancer immunity. We hypothesized that loss of MK2 enhances radiation-induced cGAS-STING pathway activation leading to improved tumor control and survival.

MATERIALS/METHODS

MK2 shRNA knockdown human (Tu167, CAL27) and MK2 Cas9/CRISPR knockout (KO) syngeneic murine (Ly2, MLM3) HNSCC cell lines were treated with 10 Gy irradiation. Micronuclei were quantitated by DAPI-immunofluorescence (IF). Protein changes in cGAS-STING were evaluated by immunoblot. Inflammatory cytokine production including Type I IFNβ1 were evaluated by RT-qPCR. Ly2 and MLM3 cells were orthotopically or flank engrafted into immune competent mice (Balb/c, C57Bl/6, respectively) for animal tumor control-survival studies. Tumor immune cell infiltrate was examined using FACS and immunohistochemistry. Selected drug studies using the MK2 inhibitor, ATI-450, were performed with RT.

RESULTS

Loss of MK2 in HNSCC (Tu167, CAL27, Ly2, MLM3) treated with RT led to a significant increase in micronuclei formation compared to control cells. MK2-enhanced micronuclei generation following RT could be inhibited with the actin filament polymerization inhibitor, cytochalasin B. RT treatment of MK2 shRNA cells led to increased cGAS and phospho-STING levels compared to either treatment alone. IFNβ1 levels were significantly higher in HNSCC cell lines treated with RT and with MK2 inhibited by an MK2 inhibitor (ATI-450) or genetic reduction compared to either treatment alone. In-vivo implantation of MLM3 cells into C57Bl/6 comparing control vs MK2 KO tumors treated with ±8 Gy RT demonstrated improved mouse survival favoring RT+MK2 KO over RT, MK2 KO or parental (63, 58, 58.5, 35 days, respectively). FACS analysis of MLM3 WT v KO tumors 3 days post RT showed an overall increase in the number of CD3/CD8 T-cells infiltrating into the tumor in all groups except for parental tumors. Further analysis demonstrated that loss of MK2 reversed CD8 T-cell exhaustion and when combined with radiotherapy led to increased CD8 T-cell activation. Furthermore, activated CD4 and CD8 T cells were reduced in WT+RT cells compared to WT tumors whereas no reduction was seen in the KO or KO+RT.

CONCLUSION

HNSCC tumor MK2 inhibition enhances RT-mediated micronuclei formation and subsequent cGAS-STING-IFNβ1 levels. Loss of HNSCC MK2 leads to increased CD4-CD8 T-cell infiltration into the tumor and this effect is enhanced following RT. Targeting tumor MK2 may facilitate improved tumor control.

Online prediction tools for melanoma survival: A comparison

BACKGROUND

Breslow thickness, patient age and ulceration are the three most valuable clinical and pathological predictors of melanoma survival. A readily available reliable online tool that accurately considers these and other predictors could be valuable for clinicians managing melanoma patients.

OBJECTIVE

To compare online melanoma survival prediction tools that request user input on clinical and pathological features.

METHODS

Search engines were used to identify available predictive nomograms. For each, clinical and pathological predictors were compared.

RESULTS

Three tools were identified. The American Joint Committee on Cancer tool inappropriately rated thin tumours as higher risk than intermediate tumours. The University of Louisville tool was found to have six shortcomings: a requirement for sentinel node biopsy, unavailable input of thin melanoma or patients over 70 years of age and less reliable hazard ratio calculations for age, ulceration and tumour thickness. The LifeMath.net tool was found to appropriately consider tumour thickness, ulceration, age, sex, site and tumour subtype in predicting survival.

LIMITATIONS

The authors did not have access to the base data used to compile various prediction tools.

CONCLUSION

The LifeMath.net prediction tool is the most reliable for clinicians in counselling patients with newly diagnosed primary cutaneous melanoma regarding their survival prospects.

Successful live birth following a short course of glucocorticoid suppression in a patient with autoimmune polyglandular syndrome type 2 and premature ovarian insufficiency: A case report

A 32-year-old nulliparous woman with premature ovarian insufficiency POI and autoimmune polyglandular syndrome type 2 (APS-2), presented to our fertility center with a 2.5-year history of amenorrhoea. Controlled ovarian hyperstimulation (COH), with high dose gonadotropins, failed to promote antral follicle growth. The patient was given a short, 4-week course of 2 mg dexamethasone prior to a repeat COH cycle, which resulted in the retrieval of good oocyte numbers and eventual live birth from a thawed embryo transfer.

The barriers and facilitators to research in practice: the experiences of a medicines optimisation team within a clinical commissioning group

Introduction

Research active healthcare organisations and staff have been shown to significantly improve performance and patient outcomes1. Undertaking research is a core element of the pharmacist role, however many pharmacists report not having the skills, knowledge and/or resources to take part2. There are many opportunities for the delivery of transformational research within primary care, however pharmacy team engagement is lacking.

Aim

To explore the barriers and facilitators to research engagement within a Clinical Commissioning Group (CCG) Medicines Optimisation team.

Methods

Twelve focus groups, guided by a semi-structured topic guide, were held over MS Teams between October 2021 and February 2022. 37 participants (pharmacists, pharmacy technicians and administrative support roles) attended and discussed topics relating to their experiences of engaging with research, as well as what helped or hindered them. Detailed notes were taken and analysed using Thematic Analysis. Following this inductive analysis, which aimed to capture all themes arising from the data, the Consolidated Framework for Implementation Research (CFIR)3 was applied. This helped to categorise the barriers and facilitators into domains which influence to what extent research is undertaken. The analysis was validated by the CCG team. This study was deemed to be service evaluation and therefore no ethical approval was needed.

Results

Three core themes emerged: People, Place and Practicalities. Individuals felt they had limited knowledge and capabilities in the field of research, despite having an internal motivation to engage in research activity. The perception of research was often linked in peoples’ thoughts to academia or secondary care/ acute Trusts or lab-based, and therefore not really something they would engage with in their current role. A lack of research culture, leadership and visibility of projects were all thought to hinder the team. A clear need for training and education in research (what it is, how it can be done, and available tools) was expressed, as well as appropriate resource allocation. Mapping to the CFIR illustrated that most barriers fell within the inner setting (i.e. the organisation itself) and with the process of conducting research, such as limited time, lack of encouragement from champions and poor feedback from projects. Enablers were also identified which included advice offered by external organisations, dissemination about work conducted in other primary care organisations and beliefs about the benefits of being research active.

Discussion/Conclusion

Participants perceived there to be many more barriers to research engagement than enablers, and these ranged from challenges with the individual projects, the process of conducting research within the organisation, things about the person themselves, their organisation or the wider setting of primary care. Areas for improvement were identified, mainly through increased training, visibility of projects and interested people, development of champions and role models, and stronger links with academia. This study was conducted with only one CCG and therefore further work needs to explore the experience within other integrated care boards and across secondary and community practice.

References

1. Hanney, S., Boaz, A., Soper, B. and Jones, T. Engagement in research: an innovative three-stage review of the benefits for health-care performance. Health Services and Delivery Research, 2013;1(8). ISSN (print) 2050-4349

2. Crilly P, Patel N, Ogunrinde A, Berko D, Kayyali R. Community Pharmacists’ Involvement in Research in the United Kingdom. Pharmacy. 2017;5(3):48. https://doi.org/10.3390/pharmacy5030048

3. Damschroder, L.J., Aron, D.C., Keith, R.E. et al. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Sci 2009;4:50. https://doi.org/10.1186/1748-5908-4-50

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Intracardiac device associated interference with tricuspid valve apparatus on echocardiography: What can we learn from pathology?

Funding Acknowledgements

Type of funding sources: None.

Background

 New or worsening tricuspid regurgitation (TR) is associated with right-sided heart failure and worsened outcomes. Cardiac Implantable Electronic Devices (CIEDs), which are being implanted at growing rates worldwide, are increasingly being recognized as associated with TR occurrence related to interference with the tricuspid valve (TV) apparatus. Purpose: We sought to identify echocardiographic features in the right ventricle and TV that differentiate patients who have anatomically demonstrated interference with the TV on direct pathology inspection. 

Methods

 Explanted hearts from 44 consecutive patients undergoing orthotopic heart transplant (55 ±13 yrs, 68% men) with known implanted CIEDs were dissected to assess the presence (n = 18) or absence (n = 26) of CIED interference with the TV (Figure). Echocardiographic measurements performed prior to transplantation, including left and right ventricular (LV, RV) size and performance metrics as well as TR severity, were compared between both groups using non-parametric testing. 

Results

 Echocardiographic features of patients with and without anatomically demonstrated TV interference are shown in the Table. Although overall LV dimensions and volumes were not different between the two groups and LV ejection fraction was severely reduced in both groups, patients demonstrating CIED interference trended towards larger right atrial volumes (Table) and also larger RV and tricuspid annular sizes. Importantly, however, they were more than 4 times likely to have abnormal right ventricular function. Lastly, patients with tricuspid apparatus interference tended to have more significant TR, although these differences have not reached statistical significance (Table). 

Conclusion

 CIED interreference with tricuspid valve apparatus occurs frequently (41%) among patients with CIEDs, who undergo orthotopic heart transplantation. This may be associated with worsening TV function with subsequent changes in right atrial and ventricular geometry and function. In light of prior data showing poor outcomes with CIED associated TR, this study emphasizes the importance of non-invasive assessment of CIED interference with the tricuspid valve, in order to improve device placement and patient outcomes. Abstract Figure  Abstract Table

Delivery of TB preventive therapy to incarcerated people living with HIV in southern African correctional facilities

TB preventive treatment (TPT) is recommended for high-risk and hard-to-reach populations such as incarcerated people living with HIV (PLHIV). To assess implementation of TPT delivery in correctional settings, we conducted an exploratory analysis of data from a multisite cohort study in South Africa and Zambia. From 975 participants, 648 were screened for TB, and 409 initiated TPT mostly within a month after initiation of antiretroviral therapy (190/409, 46.5%). We observed a median gap of one month (IQR 0.6-4.7) in TPT delivery to incarcerated PLHIV. Future research should examine standardised quality improvement tools and new strategies such as short-course regimens to improve TPT initiation in this population.

Retrospective cohort study on preparation regimens for frozen embryo transfer

The objective of this study was to examine the pregnancy outcomes from frozen embryo transfer (FET) cycles using different endometrial preparation regimens, compared to ovulation induction with letrozole (letrozole OI). A retrospective cohort study was conducted at a fertility centre in Sydney, Australia, on 6060 FET cycles. The cycles were stratified into one of four ways to achieve endometrial preparation. These were either a natural, letrozole OI, OI with follicle-stimulating hormone (FSH OI) or a programmed cycle. The primary outcome was live birth rate (LBR) per embryo transfer. Secondary outcomes included clinical pregnancy and biochemical pregnancy rates, adverse events including miscarriage, ectopic pregnancy, stillbirth, neonatal death and multiple births. Ovarian stimulation parameters were also analysed including the time taken to reach the luteal phase and the number of blood or urine tests required for monitoring the cycle. The results of the study showed that the LBR following letrozole OI cycles was higher when compared to natural cycles (odds ratio (OR): 1.27 (1.07–1.49)) and programmed cycles (OR: 2.36 (1.67–3.34)). There was no significant difference between letrozole OI and FSH OI LBR (OR: 0.99 (0.76–1.28)). An improved LBR with letrozole OI compared to natural cycles was maintained when only women with a normal length cycle were considered (OR: 1.44 (1.10–1.89)). There was a significant reduction in miscarriage rates when letrozole OI was compared to programmed cycles (OR: 0.46 (0.26–0.83)). It was therefore concluded that the use of letrozole OI for endometrial preparation in an FET cycle may be associated with higher LBR and lower miscarriage rate, compared to using a programmed cycle.

Prioritisation of colonoscopy services in colorectal cancer screening programmes to minimise impact of COVID-19 pandemic on predicted cancer burden: A comparative modelling study

Objectives

Colorectal cancer (CRC) screening with a faecal immunochemical test (FIT) has been disrupted in many countries during the COVID-19 pandemic. Performing catch-up of missed screens while maintaining regular screening services requires additional colonoscopy capacity that may not be available. This study aimed to compare strategies that clear the screening backlog using limited colonoscopy resources.

Methods

A range of strategies were simulated using four country-specific CRC natural-history models: Adenoma and Serrated pathway to Colorectal CAncer (ASCCA) and MIcrosimulation SCreening ANalysis for CRC (MISCAN-Colon) (both in the Netherlands), Policy1-Bowel (Australia) and OncoSim (Canada). Strategies assumed a 3-month screening disruption with varying recovery period lengths (6, 12, and 24 months) and varying FIT thresholds for diagnostic colonoscopy. Increasing the FIT threshold reduces the number of referrals to diagnostic colonoscopy. Outcomes for each strategy were colonoscopy demand and excess CRC-related deaths due to the disruption.

Results

Performing catch-up using the regular FIT threshold in 6, 12 and 24 months could prevent most excess CRC-related deaths, but required 50%, 25% and 12.5% additional colonoscopy demand, respectively. Without exceeding usual colonoscopy demand, up to 60% of excess CRC-related deaths can be prevented by increasing the FIT threshold for 12 or 24 months. Large increases in FIT threshold could lead to additional deaths rather than preventing them.

Conclusions

Clearing the screening backlog in 24 months could avert most excess CRC-related deaths due to a 3-month disruption but would require a small increase in colonoscopy demand. Increasing the FIT threshold slightly over 24 months could ease the pressure on colonoscopy resources.

Understanding the anatomy of a malpractice suit. In the United States this is a doctor's best defence

In the United States, the majority of physicians have been sued and those who have not, will be. Defendants share the notion that the lawsuit is totally fallacious. To be fallacious, the outcome of a medical intervention must be an unpreventable random maloccurrence. This is the only alternative to a medical error. The conflict over outcomes that are random and outcomes that are medical errors results in 46,000 malpractice suits every year in the USA. The burden of proof is a preponderance of evidence, but this is insufficient to do more than just infer, not prove, a relationship between the medical intervention and the outcome. Plaintiffs, generally, prove a malpractice case using inductive reasoning. Inductive reasoning leaves much to intuition. They use inductive reasoning because, by definition, preponderance of evidence, also, leaves much to intuition. Deductive reasoning is objective and there is no place for intuition. With deductive reasoning, the burden of proof is now sufficient to distinguish whether or not the cause relates to the effect with 95% confidence. A model for deductive reasoning in malpractice which is completely consistent with the scientific method is presented. This should and would derail frivolous lawsuits.

477 Surgical Solutions and Problems in An Adult Patient with VACTERL Association

Background

We report an adult patient with features of VACTERL - oesophageal and anal atresia, with cardiac malformation. In infancy he underwent colonic interposition for oesophageal atresia using the transverse colon as a conduit. As a teenager he underwent formation of a Koch continent ileostomy after previous stoma formation for anal atresia. Eventual failure of the Koch pouch nipple valve necessitated a laparotomy for attempted refashioning. Unfortunately, this operation was beset by life-threatening complications and a protracted post-operative course. He presented to our hospital with a laparostomy, high output enterocutaneous fistulae (ECF) necessitating home total parenteral nutrition (TPN), severe cachexia and deconditioning.

Method

Conservative therapy was utilised to improve the nutritional and physiological status of the patient. Simultaneously, attempts were made to define the anatomy of his abdomen in relation to previous surgery. However, operation notes for the original procedures (oesophageal reconstruction and Koch pouch formation) were lost due to closure of the hospital which he attended at the time.

A laparotomy was subsequently performed to manage the ECFs. Most of the small intestine was unsalvageable due to multiple fistulae and adhesions, leaving 35cm of small bowel terminating in an end ileostomy. A cholecystectomy was performed to mitigate gallstone formation.

Conclusions

Efficient communication is imperative in the management of complex patients. The loss of original operation notes made interpretation of subsequent imaging and planning of surgery troublesome. In contrast, efficient communication between teams involved in his peri-operative care, particularly the respiratory and intensive care teams facilitated a smooth post-operative course and successful discharge from hospital.

Dapsone as an Effective Treatment for Arthritis Secondary to Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a disorder of the terminal follicular epithelium in the apocrine sweat glands. Chronic relapsing inflammation, mucopurulent discharge, and progressive scarring frequently involving the axillary and inguinoperineal area characterize HS. Reactive arthritis is associated with chronic infections, such as HS, although joint involvement is uncommon. Treatment is based on the eradication of the underling infection. Whereas skin lesions may improve with antibiotic therapy, the arthritis of HS is often unresponsive to therapy. Various therapies have been tried in HS, including nonsteroidal antiinflammatory drugs, colchicine, mesalamine, dapsone, and TNF inhibitors. A case of severe, debilitating arthritis associated with HS that responded to dapsone is reported. This case demonstrates the difficulty of successful treatment of HS as well as of the associated arthritis.

Identifying behaviour change techniques to support medicines management for older people at care transitions

Introduction

Older patients are at significant risk of medicines-related harm following a hospital to home transition [1]. Strategies, such as information transfer and medicines reconciliation, have been suggested to promote successful transitions through better medicines management [2]. These interventions, however, are not often underpinned by patient experience or grounded in theory, and therefore have variable effects in real-world contexts.

Aim

To identify which behaviour change techniques (BCTs) could be combined within a complex intervention to support post-discharge medicines management.

Methods

Barriers and facilitators to post-discharge medicines management behaviours were identified from an analysis of interviews with twenty-seven older people (aged 75 years plus) and mapped to the Theoretical Domains Framework (TDF). These participants were recruited during a stay in two large hospitals in the North of England. All potential BCTs targeting the identified TDF domains were found using validated mapping exercises and refined by panel consensus. The panel consisted of two pharmacists, two health services researchers, a social work academic and a patient representative. Next, a convenience sample of key stakeholders (n=40; patients and family carers, healthcare professionals and researchers) were invited to take part in an online survey to prioritise remaining techniques. A total score for each BCT was calculated based on its potential i) effectiveness, ii) acceptability and iii) ability to cause unintended consequences. The BCTs were ranked from lowest to highest scores. As validation, the final selection of BCTs was assessed using the APEASE criteria and mapped back to the behavioural determinants to check the components would enhance facilitators and overcome barriers (Figure 1).

Results

Forty-six behavioural determinants were identified within interviews and classified as barriers (n=19), facilitators (n=10), or both (n=17). These were deductively mapped onto 11 domains of the TDF. Following the mapping, 50 discrete BCTs were identified, which were reduced to 35 after subsequent consensus discussions between panel members to remove any deemed inappropriate. The survey resulted in 25 responses (62.5% response rate). Following visual inspection of the ranking, a natural cut-off was identified by panel consensus at 88% of the total score. This, and further assessment using the APEASE criteria, prioritised eight BCTs that were highly rated to be effective in promoting post-discharge medicines management when combined within a complex intervention. These were: practical social support, goal/ target specified, prompts, triggers or cues, social processes of encouragement, motivational interviewing, rehearsal, review goals, and comparative imagining of future outcomes.

Conclusion

This study has identified eight BCTs that could be valuable when combined within a complex intervention to support post-discharge medicines management for older people. Consensus allowed prioritisation of BCTs that were likely to be effective, acceptable to older people, practical and cost-effective to deliver within current healthcare organisations. Limitations included challenges of coding complex behavioural determinants to the TDF, defining the BCTs within the medicines management context and modest survey sample size. To overcome these limitations, input was sought from a health psychologist with expertise and consensus involved all relevant stakeholders.

References

1. Parekh, N., Ali, K., Stevenson, J. M., et al. Incidence and cost of medication harm in older adults following hospital discharge: a multicentre prospective study in the UK. British journal of clinical pharmacology 2018;84(8):1789–1797.

2. Tomlinson, J., Cheong, V., Fylan, B., et al. Successful care transitions for older people: a systematic review and meta-analysis of the effects of interventions that support medication continuity. Age and Ageing 2020;00:1–12.

22 Coping with Medicines After Hospital Discharge; the Invisible Work of Older Patients and Their Care-Givers

Introduction

Older patients often experience medication-related problems following discharge from hospital. These can be categorised as issues with obtaining medication, taking medication, medication effects or problems with communication or care co-ordination (Nicosia et al., Journal of General Internal Medicine, 2019, https://doi.org/10.1007/s11606-019-05463-z). The aim of this study was to explore older adults’ experiences of post-discharge medicines management, including the strategies they use to safely manage their changed medicines.

Methods

Following ethical approval, patients aged 75 and above, with a change in their long term medicines, were recruited during admission to one of two hospitals in Yorkshire. Semi-structured interviews took place with the participants in their own homes, approximately two weeks after discharge. Interviews were audio recorded and transcribed. Data were analysed using the Framework method.

Results

Twenty-seven patients (mean age 85 years; 6 males) consented to be interviewed. They described multiple self-management and safety strategies used to support medicines management in the early post-discharge phase. The work done included adaptations (to routines, the home environment and action plans), scaffolding (where patients and their care-givers support the primary care system by providing additional documentation or prompts to ensure medicines were supplied on time and were correct) and error avoidance (seeking information, performing checks and balances).

Conclusion

Older patients experience gaps in their post-discharge medicines-related care which they had to bridge through implementing their own strategies or by enlisting support from others. This study shines a spotlight on to the invisible work that patients have to do in order to make post-discharge medicines management fit for purpose. Further work should consider those patients who are not able to carry out these tasks or who do not have any care-givers available for support and how this potential gap in care can be addressed.

The use of echocardiography as a health assessment tool in green sea turtles (Chelonia mydas)

There are limited techniques available to assess the health of sea turtles as physical examination has little correlation to clinical findings, and blood reference intervals are broad and provide limited prognostic significance. Advances in the portability of ultrasound machines allow echocardiography to be increasingly used in the health assessments of wild animals. This study performed blood analysis and echocardiograms on 11 green sea turtles upon admission to a rehabilitation clinic and six animals before release. Significant differences were seen between groups, with admission animals having significantly smaller diameters of the cavum arteriosum at systole and diastole, smaller E-waves and an increased fractional shortening. Pre-release animals displayed significant increases in the maximum blood velocities of both the pulmonary artery and the left aorta. Significant negative correlations were seen between fractional shortening and uric acid and between the velocity time integral of the pulmonary artery and urea. The pulmonary artery velocity time integral was also significantly correlated to the E wave. Furthermore, there was asynchrony between the cavum arteriosum and the cavum pulmonale and the detection of a parasitic granuloma in the ventricular outflow tract of one animal. Overall, the results suggest that cardiac function in stranded green sea turtles is significantly impaired and that echocardiography has applications in the health assessments of green sea turtles.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

AB1357-HPR DESIGNING THE ROYAL COLLEGE OF NURSING COMPETENCY FRAMEWORK FOR RHEUMATOLOGY NURSES

Background:

The 1st Edition of the RCN Competency Framework for Rheumatology Nurse Specialists (RNS) will be published in March 2020. The role of the RNS is complex, and can include caring for children and young people. The importance of RNS’s was highlighted by the National Rheumatoid Arthritis Society (NRAS 2017). The British Society for Rheumatology (BSR) outlined the need for education, training supervision and work force development. Education for RNS isn’t currently centralized but is key to improving skills and developing workforce for the future. RNS are in short supply resulting in problems of access to services and delays in care (BSR 2019). In all 4 UK nations the titles of RNS and proficiency vary greatly (Titrate trial 2019) This is likely to have an impact on patient experience and outcomes. The European League Against Rheumatism (EULAR) developed recommendations for the role of the RNS which were recently updated (Beech et al, 2019). This framework maps all of these requirements.

Objectives:

This work supports the development of roles, improve access for patients and reduce. This document will act as a foundation for building sustainability and a more robust education and role development strategy. This work will strengthen rheumatology nursing and support all 4 UK nation’s issues regarding recruitment, retention, sustainability, succession planning and benchmarking. Dissemination is key and we will work hard with stakeholders to ensure centralization of a nationally adopted framework. This abstract submission will increase dissemination opportunities.

Methods:

Online data sources were searched for the most relevant and current evidence. Where research evidence wasn’t available, existing and new knowledge was utilised from a consensus of clinical expert and patient opinions, several rounds of discussions took place virtually and face to face. RCN Rheumatology Nurse Forum Workshop attendees in June 2019 also answered a questionnaire to elicit views and demographic information regarding roles.

Results:

The questionnaire results demonstrated 100% (n37) agreement with the development of the framework and that only 2 respondents had completed a competency process. 60% were RNS. Of these 52% (n13) were band 6, 47% (n9) were band 7, and 1% were band 8 consultant nurses. The questionnaire highlighted the need to develop the framework. Results were fed back to the working party to inform the domains to be included.

Conclusion:

Document will be at BSR 2020 having successfully submitted a session proposal and abstract. Evaluation will begin later in the year 6 to 12 months from launch. We will measure impact using a variety of methods including membership Facebook pages and the questionnaire at point of download request. We will measure where and how the competency is being used and adoption of the framework throughout the UK.

References:

[1]Beech B, Primdahl J, van Tubergen A, et al., (2019) 2019 update of the EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis. Ann Rheum Dis.http://dx.doi.org/10.1136/annrheumdis-2019-215458 (accessed 13 December 2019). Benner, P (1984) From novice to expert, excellence

[2]British Society of Rheumatology (2019) State of Play, London: BSR. Available at: www. rheumatology.org.uk/Portals/0/Documents/ Policy/BSR_State_Of_Play_Scotland2018. pdf?ver=2019-03-11-094117-440 (accessed 13 December 2019).

[3]Martin N, Ibrahim F, Tom B, et al., (2017) Does intensive management improve remission rates in patients with intermediate rheumatoid arthritis? (the TITRATE trial): study protocol for a randomized controlled trial. Trials. 2017;18:591. doi.org/10.1186/s13063-017-2330-8.

Disclosure of Interests:

Polly Livermore: None declared, Diana Finney Speakers bureau: Nordic

Abbvie, Julie Begum: None declared, Ruth Wyllie: None declared, Trish Cornell Employee of: Consultant Nurse for Abbvie, Helen Smith: None declared, Lisa Howie: None declared, Louise Parker: None declared

Optimal surface estimation and thresholding of confocal microscope images of biofilms using Beer's Law

Beer's Law explains how light attenuates into thick specimens, including thick biofilms. We use a Bayesian optimality criterion, the maximum of the posterior probability distribution, and computationally efficiently fit Beer's Law to the 3D intensity data collected from thick living biofilms by a confocal scanning laser microscope. Using this approach the top surface of the biofilm and an optimal image threshold can be estimated. Biofilm characteristics, such as bio-volumes, can be calculated from this surface. Results from the Bayesian approach are compared to other approaches including the method of maximum likelihood or simply counting bright pixels. Uncertainty quantification (i.e., error bars) can be provided for the parameters of interest. This approach is applied to confocal images of stained biofilms of a common lab strain of Pseudomonas aeruginosa, stained biofilms of Janthinobacterium isolated from the Antarctic, and biofilms of Staphylococcusaureus that have been genetically modified to fluoresce green.

Risk Factors for Respiratory Syncytial Virus Bronchiolitis Admissions

Aim Determine the seasonal incidence of hospital Respiratory Syncytial Virus (RSV) bronchiolitis and explore the variables associated with admission to ward versus the Paediatric Intensive Care Unit (PICU). Method Retrospective case-control study. Children, aged ≤2 years, between November and March, over a 3 year period with a positive RSV nasopharyngeal aspirate test. Results A total of 557 children were included; 19% (n=106) required PICU admission. Children admitted to the PICU were younger in age, median (IQR) 6.93 (3.96, 11.89) weeks compared to children who remained on the wards 11.00 (5.86, 24.14) weeks. Being underweight at the point of admission (adjusted odds ratio 3.15, 95% 1.46, 6.70, p=0.003) was associated with a PICU admission. Conclusion Number of RSV bronchiolitis hospitalisations are increasing each year. Age, weight and the use of HFNC were independent predictors for PICU admission.

Validation of Three Rapid Screening Methods for Detection of Verotoxin-Producing Escherichia coli in Foods: Interlaboratory Study

An interlaboratory study was conducted for the validation of 3 methods for the detection of all verotoxin-producing Escherichia coli (VTEC) in foods. The methods were a multi-analyte 1-step lateral flow immunoassay (LFIA) for detection of E. coli O157 and verotoxin (VT); an enzyme-linked immunosorbent assay targeted against VT1, VT2, and VT2c (VT-ELISA); and a polymerase chain reaction (PCR) method for detection of VT genes (VT-PCR). Aliquots (25 g or 25 mL) of 4 food types (raw minced [ground] beef, unpasteurized milk, unpasteurized apple juice [cider], and salami) were individually inoculated with low numbers (<9 to 375 cells/25 g) of 6 test strains of E. coli (serogroups O26, O103, O111, O145, and O157) with differing VT-producing capabilities. Five replicates for each test strain and 5 uninoculated samples were prepared for each food type. Fourteen participating laboratories analyzed samples using the LFIA, 9 analyzed the samples by ELISA, and 9 by PCR. The LFIA for O157 and VT had a specificity (correct identification of negative samples) of 92 and 94%, respectively, and a sensitivity (correct identification of positive samples) of 94 and 55%, respectively. The VT-ELISA and VT-PCR

Intercontinental collaborative experience with abdominal, retroperitoneal and pelvic schwannomas

Background

Schwannomas are rare tumours that pose a significant management challenge in the abdomen, retroperitoneum and pelvis. No data are available to inform management strategy.

Methods

A collaborative international cohort study, across specialist sarcoma units, was conducted to include adults presenting between 2000 and 2017 with histopathologically confirmed schwannomas within the abdomen, retroperitoneum or pelvis.

Results

Of 485 patients across 12 centres, 38 (7·8 per cent) were discharged without follow-up, 199 (41·0 per cent) underwent early resection and 248 (51·1 per cent) had radiological monitoring. Of these 248 patients, 96 (38·7 per cent) eventually had surgery, giving an overall resection rate of 60·8 per cent (295 of 485). At baseline, median tumour volume was 90·1 (i.q.r. 26·5–262·0) cm3. The estimated growth rate was 10·5 (95 per cent c.i. 9·4 to 11·6) per cent per year, and was consistent in the short term (within 2 years of diagnosis) and long term (beyond 2 years) (ρ = 0·405, P = 0·021). A decision to operate was more common in symptomatic patients (P < 0·001) and for rapidly growing tumours (growth rate more than 20 per cent per year) (P = 0·025). R0/R1 resection was achieved in 91·6 per cent of patients (263 of 287). Kaplan–Meier long-term recurrence rates after R0/R1 resection were 2·3 and 6·7 per cent at 3 and 5 years respectively.

Conclusion

Specific recommendations include: indications for early surgery, prediction of growth from radiological monitoring, promotion of selective submacroscopic resection and cessation of postoperative imaging surveillance.

National audit on the management of bullous pemphigoid

BACKGROUND

Bullous pemphigoid (BP) is an autoimmune, subepidermal, blistering condition that typically affects elderly people.

AIM

To undertake a national clinical audit based on standards derived from the British Association of Dermatologists (BAD) clinical guidelines on the management of BP.

METHODS

In 2018, BAD members were invited to submit data for five consecutive adults with BP per centre, who had been under hospital supervision for at least 12 months, in a national audit over an 11-week period.

RESULTS

In total, 123 responders from 120 hospitals provided data for 524 cases. Diagnosis was made either clinically (10.7%; 56 of 524) or through histology with direct immunofluorescence (41.6%; 218 of 524), indirect immunofluorescence (10.3%; 54 of 524) or both (37.4%; 196 of 524). Most patients had very mild baseline disease (63.9%; 225 of 352) with 21.9% (77 of 352) considered mild, 9.8% (31 of 352) moderate and 5.4% (19 of 352) severe. Documentation of diabetes, glycated haemoglobin (HbA1c), blood pressure and hypertension was available for 54.1% (283 of 523), 51% (267 of 524), 44.2% (231 of 522) and 61.5% (321 of 522) of cases, respectively. Oral corticosteroids were commenced in 85.5% (448 of 524) of patients, with 38.4% (172 of 448) of these having documented risk of osteoporosis; data regarding prescription of bone-protection therapies were available for 99.7% (447 of 448) of cases, with 75.6% (338 of 447) of these having a bone-protection prescription. Patient satisfaction was documented in 59.3% (310 of 523) of cases. Systemic treatment was commenced in 95.9% (502 of 524) of cases during the 12-month assessment period, with baseline blood test and follow-up data available for 96.6% (485 of 502) and 95.6% (480 of 502), respectively. Documentation of baseline blood tests was available for 87.4% (424 of 485) of cases, with follow-up tests recorded in 69.8% (335 of 480).

CONCLUSION

Overall, compliance with elements of documentation was moderate or low, whereas standards pertaining to direct care were high.

BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017; First edition 2007)

This is an updated guideline for the diagnosis and management of allergic and non-allergic rhinitis, first published in 2007. It was produced by the Standards of Care Committee of the British Society of Allergy and Clinical Immunology, using accredited methods. Allergic rhinitis is common and affects 10-15% of children and 26% of adults in the UK, it affects quality of life, school and work attendance, and is a risk factor for development of asthma. Allergic rhinitis is diagnosed by history and examination, supported by specific allergy tests. Topical nasal corticosteroids are the treatment of choice for moderate to severe disease. Combination therapy with intranasal corticosteroid plus intranasal antihistamine is more effective than either alone and provides second line treatment for those with rhinitis poorly controlled on monotherapy. Immunotherapy is highly effective when the specific allergen is the responsible driver for the symptoms. Treatment of rhinitis is associated with benefits for asthma. Non-allergic rhinitis also is a risk factor for the development of asthma and may be eosinophilic and steroid-responsive or neurogenic and non- inflammatory. Non-allergic rhinitis may be a presenting complaint for systemic disorders such as granulomatous or eosinophilic polyangiitis, and sarcoidoisis. Infective rhinitis can be caused by viruses, and less commonly by bacteria, fungi and protozoa.

A multi-variable analysis of four factors affecting caries levels among five-year-old children; deprivation, ethnicity, exposure to fluoridated water and geographic region

OBJECTIVE

To assess the role of factors posited to affect population caries levels across England.

BASIC RESEARCH DESIGN

Multivariable regression analysis assessing four potential determinants of caries severity and prevalence: deprivation, exposure to fluoridated water, ethnicity and geographic region Participants: Random sample of 121,875 five-year-old children in England in the 2014/15 academic year.

MAIN OUTCOME MEASURES

Decayed, missing and filled teeth, with decay measured at the dentinal level, (d₃mft), presented as prevalence (dmft⟩0) and extent of decay among children who have any (d₃mft if d₃mft>0).

INDEPENDENT VARIABLES

Parental reported ethnicity from school records, index of multiple deprivation (IMD) scores, region and exposure to water fluoridation calculated utilising home postcodes.

RESULTS

The data support wider literature displaying associations between caries and deprivation across a social gradient. The important, new findings are deprivation, some ethnic groups and lack of exposure to water fluoridation are all associated with increased prevalence and severity of caries when considered together and independently. New evidence supports the impact of water fluoridation on health inequalities in that the greatest impact of exposure to fluoridated water was seen in the most deprived children and those from an Asian / Asian British ethnic group.

CONCLUSIONS

Five-year-old children who were from the most deprived areas, not exposed to fluoridated water, of an Eastern European ethnic group and living in the North West demonstrated the highest prevalence and severity of caries in the survey under scrutiny. This is of public health importance, providing evidence for population groups to target with health improvement activities.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.