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.

Prevention of allergic reactions during oxaliplatin desensitization through inhibition of Bruton tyrosine kinase

BACKGROUND

Acute infusion reactions to oxaliplatin, a chemotherapeutic used to treat gastrointestinal cancers, are observed in about 20% of patients. Rapid drug desensitization (RDD) protocols often allow the continuation of oxaliplatin in patients with no alternative options. Breakthrough symptoms, including anaphylaxis, can still occur during RDD.

OBJECTIVE

Our aim was to evaluate whether pretreatment with acalabrutinib, a Bruton tyrosine kinase inhibitor, can prevent anaphylaxis during RDD in a patient sensitized to oxaliplatin.

METHODS

A 52-year-old male with locally advanced gastric carcinoma developed anaphylaxis during his fifth cycle of oxaliplatin. As he required 6 additional cycles to complete his curative-intent treatment regimen, he underwent RDD to oxaliplatin but still developed severe acute reactions. The risks and benefits of adding acalabrutinib before and during RDD were reviewed, and the patient elected to proceed.

RESULTS

With acalabrutinib taken before and during the RDD, the patient was able to tolerate oxaliplatin RDD without complication. Consistent with its mechanism of action, acalabrutinib completely blocked the patient's positive skin prick response to oxaliplatin. Acalabrutinib did not alter the percentage of circulating basophils (1.24% vs 0.98%) before the RDD but did protect against basopenia (0.74% vs 0.09%) after the RDD. Acalabrutinib was associated with a drastic reduction in the ability of basophils to upregulate CD63 in vitro following incubation with oxaliplatin (0.11% vs 2.38%) or polyclonal anti-human IgE antibody (0.08% vs 44.2%).

CONCLUSIONS

Five doses of acalabrutinib, 100 mg, orally twice daily starting during the evening 2 days before and continuing through RDD allowed a sensitized patient to receive oxaliplatin successfully and safely.

Safety and feasibility of establishing an adjuvant hepatic artery infusion program

BACKGROUND

Hepatic artery infusion (HAI) is less frequently used in the adjuvant setting for resectable colorectal liver metastasis (CRLM) due to concerns regarding toxicity. Our objective was to evaluate the safety and feasibility of establishing an adjuvant HAI program.

METHODS

Patients who underwent HAI pump placement between January 2019 and February 2023 for CRLM were identified. Complications and HAI delivery were compared between patients who received HAI in the unresectable and adjuvant settings.

RESULTS

Of 51 patients, 23 received HAI for unresectable CRLM and 28 in the adjuvant setting. Patients with unresectable CRLM more commonly had bilobar disease (n = 23/23 vs n = 18/28, p < 0.01) and more preoperative liver metastases (median 10 [IQR 6-15] vs 4 [IQR 3-7], p < 0.01). Biliary sclerosis was the most common complication (n = 2/23 vs n = 4/28); however, there were no differences in postoperative or HAI-specific complications. In the most recent two years, 0 patients in the unresectable group vs 2 patients in the adjuvant group developed biliary sclerosis. All patients were initiated on HAI with no difference in treatment times or dose reductions.

CONCLUSION

Adjuvant HAI is safe and feasible for patients with resectable CRLM. HAI programs can carefully consider including patients with resectable CRLM if managed by an experienced multidisciplinary team with quality assurance controls in place.

Pharmacological Relief of Acute Urinary Retention in a Remote Environment

BACKGROUND: In spaceflight, acute urinary retention (AUR) could develop as a sequela of medication use, urinary tract infection, urolithiasis, or intentional urine holding. While AUR is generally treated with bladder decompression, urinary catheterization could be difficult operationally in terms of training and proficiency, supplies, and lack of space or privacy. This report discusses a case in which tamsulosin and lorazepam were used successfully on an offshore ship while awaiting medical evacuation, a situation that could arise in remote locations where aerospace operations are conducted.CASE REPORT: A 52-yr-old man with hypertension and obstructive sleep apnea but no formal diagnosis of benign prostatic hyperplasia was unable to urinate for over 16 h while on a deep-sea fishing vessel approximately 200 nmi offshore. By phone, the physician providing remote medical direction diagnosed AUR in the setting of possible infection and prescribed acetaminophen, ciprofloxacin, and a trial of tamsulosin as the ship did not have any medical personnel trained to perform urinary catheterization and there were no catheter supplies available. Lorazepam was later added for anxiolysis and potential smooth muscle relaxation. Within 1 h of initial medication administration, the patient successfully voided a large quantity of urine, which tested positive for infection by urine dipstick. The patient was continued on antibiotics and evacuated to a medical facility onshore for further management.DISCUSSION: Pharmacological treatment could be considered as a temporizing measure where operational constraints limit the ability to perform urinary catheterization to relieve acute urinary retention.Law J, Cardy V. Pharmacological relief of acute urinary retention in a remote environment. Aerosp Med Hum Perform. 2023; 94(2):90-93.

Periplasmic stress contributes to a tradeoff between protein secretion and cell growth in E. Coli Nissile

Maximizing protein secretion is an important target in the design of engineered living systems. In this paper, we characterize a tradeoff between cell growth and per cell protein secretion in the curli biofilm secretion system of E Coli Nissile 1917. Initial characterization using 24-hour continuous growth and protein production monitoring confirms decreased growth rates at high induction leading to a local maximum in total protein production at intermediate induction. Propidium iodide staining at the endpoint indicates that cellular death is a dominant cause of growth reduction. Assaying variants with combinatorial constructs of inner and outer membrane secretion tags, we find that diminished growth at high production is specific to secretory variants associated with accumulation of protein containing the outer membrane transport tag in the periplasmic space. RNA sequencing experiments indicate upregulation of known periplasmic stress response genes in the highly secreting variant, further implicating periplasmic stress in the growth-secretion tradeoff. Overall, these results motivate additional strategies for optimizing total protein production and longevity of secretory engineered living systems.

Implantable Collamer Lens Use in a Spaceflight Participant During Short Duration Spaceflight

BACKGROUND: The purpose of this report is to document the first use of a single piece, posterior chamber phakic implantable collamer lens (ICL) with a central port in the right eye (OD) of a spaceflight participant (SFP) during a 12-d Soyuz mission to the International Space Station (ISS). We also briefly document the stability of a pre-existing pachychoroid pigment epitheliopathy (PPE) in the macula of his left eye (OS) during this mission.CASE REPORT: Ocular examination, including refraction, slit lamp examination, macular examination by optical coherence tomography (OCT), and tonometry were performed before and after his mission and he was questioned regarding visual changes during each portion of his flight.DISCUSSION: We documented no change in ICL position during his spaceflight. He reported stable vision during liftoff, entry into microgravity, 12 d on the ISS, descent, and landing. Our results suggest that the modern ICL with a central port is stable, effective, and well tolerated during short duration spaceflight. His PPE also remained stable during this mission as documented by OCT.Gibson CR, Mader TH, Lipsky W, Brown DM, Jennings R, Law J, Sargsyan A, Brunstetter T, Danilichev SN, Maezawa Y. Implantable collamer lens use in a spaceflight participant during short duration spaceflight. Aerosp Med Hum Perform. 2023; 94(1):48-50.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

PMON190 Characterization Of Lymphedema With Respect To Phenotype and Karyotype in Patients With Turner Syndrome

We characterize karyotypic and phenotypic features of a cohort of patients with Turner syndrome (TS) and lymphedema (LD).

Medical records from two large TS specialized pediatric clinics were reviewed retrospectively. Seventy-one patients with TS and history of LD were identified, mean age 15.9 ± 7.71 years. Reported LD onset was in infancy in 72% of patients, with 56% (40/71) reporting LD present at birth. LD affected hands in 29% of patients, feet in 57%, and both hands and feet in 25%. 46% reported LD was a current problem, with 11% stating it was present but not a problem. 73% (52/71) of children in this cohort had the 45,X karyotype. The remainder had mosaic/complex karyotypes. 55% of children had congenital heart disease and 10% had renal anomalies. 76% were on growth hormone treatment, 52% had a history of estrogen replacement.

Lymphedema is a frequently under-documented comorbidity in Turner syndrome, with limited data currently available. Analysis of a larger cohort comparing patients with TS with and without LD is underway including the role of growth hormone and estrogen replacement in LD. Given that new therapies are being developed for LD in other genetic conditions, a better understanding of LD in Turner syndrome is important for management considerations.

Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Postoperative Packing of Perianal Abscess Cavities (PPAC2): randomized clinical trial

BACKGROUND

Perianal abscess is common. Traditionally, postoperative perianal abscess cavities are managed with internal wound packing, a practice not supported by evidence. The aim of this randomized clinical trial (RCT) was to assess if non-packing is less painful and if it is associated with adverse outcomes.

METHODS

The Postoperative Packing of Perianal Abscess Cavities (PPAC2) trial was a multicentre, RCT (two-group parallel design) of adult participants admitted to an NHS hospital for incision and drainage of a primary perianal abscess. Participants were randomized 1:1 (via an online system) to receive continued postoperative wound packing or non-packing. Blinded data were collected via symptom diaries, telephone, and clinics over 6 months. The objective was to determine whether non-packing of perianal abscess cavities is less painful than packing, without an increase in perianal fistula or abscess recurrence. The primary outcome was pain (mean maximum pain score on a 100-point visual analogue scale).

RESULTS

Between February 2018 and March 2020, 433 participants (mean age 42 years) were randomized across 50 sites. Two hundred and thirteen participants allocated to packing reported higher pain scores than 220 allocated to non-packing (38.2 versus 28.2, mean difference 9.9; P < 0.0001). The occurrence of fistula-in-ano was low in both groups: 32/213 (15 per cent) in the packing group and 24/220 (11 per cent) in the non-packing group (OR 0.69, 95 per cent c.i. 0.39 to 1.22; P = 0.20). The proportion of patients with abscess recurrence was also low: 13/223 (6 per cent) in the non-packing group and 7/213 (3 per cent) in the packing group (OR 1.85, 95 per cent c.i. 0.72 to 4.73; P = 0.20).

CONCLUSION

Avoiding abscess cavity packing is less painful without a negative morbidity risk.

REGISTRATION NUMBER

ISRCTN93273484 (https://www.isrctn.com/ISRCTN93273484).

REGISTRATION NUMBER

NCT03315169 (http://clinicaltrials.gov).

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

POS1217 ANTI-TNF THERAPY FOR IMMUNE MEDIATED INFLAMMATORY DISEASES MAY BE ASSOCIATED WITH LOWER ANTIBODY LEVELS AND VIRUS NEUTRALIZATION EFFICACY FOLLOWING SARS-CoV-2 mRNA VACCINATION

Background

The impact of immunosuppressants on COVID-19 vaccination response and durability in patients with immune-mediated inflammatory diseases (IMID) is yet to be fully characterized. Humoral response may be attenuated in these patients especially those on B cell depleting therapy and higher doses of corticosteroids, but data regarding other immunosuppressants are scarce.

Objectives

We aimed to investigate antibody and T cell responses and durability to SARS-CoV-2 mRNA vaccines (BNT162b and/or mRNA 1273) in IMID patients on immunomodulatory maintenance therapy other than B-cell depleting therapy and corticosteroids.

Methods

This prospective observational cohort study examined the immunogenicity of SARS-CoV-2 mRNA vaccines in adult patients with IMIDs (psoriatic arthritis, psoriasis, inflammatory bowel disease and rheumatoid arthritis) with or without maintenance immunosuppressive therapies (anti-TNF, methotrexate/azathioprine [MTX/AZA], anti-TNF + MTX/AZA, anti IL12/23, anti-IL-17, anti-IL23) compared to healthy controls. Automated ELISA for IgGs to spike trimer, spike receptor binding domain (RBD) and the nucleocapsid (NP) and T-cell release of 9 cytokines (IFNg, IL2, IL4, IL17A, TNF) and cytotoxic molecules (sFasL, GzmA, GzmB, Perforinin) in cell culture supernatants following stimulation with spike or NP peptide arrays were conducted at 4 time points: T1=pre vaccination, T2=median 26 days after dose 1, T3=median 16 days after dose 2 and T4=median 106 days after dose 2. Neutralization assays against four SARS-CoV-2 variants (wild type, delta, beta and gamma) were conducted at T3.

Results

We followed 150 subjects: 26 healthy controls and 124 IMID patients: 9 untreated, 44 on anti-TNF, 16 on anti-TNF with MTX/AZA, 10 on anti-IL23, 28 on anti-IL12/23, 9 on anti-IL17, 8 on MTX/AZA (Table 1). Most patients mounted antibody and T cell responses with increases from dose 1 to dose 2 (100% seroconversion at T3) and some decline by T4, with variability within groups. Antibody levels and neutralization efficacy was lower in anti-TNFgroups (anti-TNF, anti-TNF + MTX/AZA) compared to controls and waned by T4 (Figure 1). T cell responses were not consistently different between groups. Pooled data showed a higher antibody response to mRNA-1273 compared to BNT162b.

Table 1.

Baseline characteristics of study participants

Controluntreated IMIDAnti- TNFAnti- TNF +MTX/AZAAnti-IL-23Anti -IL-12/23Anti -IL-17MTX/AZAn=26n=9n=44n=16n=10n=28n=9n=8p-valueIMID*N/A IBD9301002704 Psoriasis1318122 PA0732172 AS0830010 RA1100011Age median years [IQR]36 [26-46]33 [27-41]38 [30-51]53 [44-59]48 [45-61]34 [28-47]49 [46-61]42 [31-55]<0.001^Sex male (%)16 (62)5 (56)18 (41)8 (50)5 (50)13 (46)6 (67)4 (50)0.772~BMImedian kg/m2 [IQR]25 [23-28]26 [22-27]22 [24-26]26 [24-28]27 [24-35]22 [21-24]32 [26-34]26[25-33]0.001^Vaccine interval median days [IQR]74 [35-84]54 [31-64]60 [45-69]64 [50-72]74 [35-84]62 [49-69]65 [52-75]58 [21-97]0.372^

*multiple IMIDs per patient possible

Figure 1.

Antibody responses (A) Anti spike and anti RBD IgG levels at indicated time points. Blue line represents median ratio in convalescent patients. The red line is the seropositivity threshold: the median antibody level of those that pass both a 1% false positive rate and show ≥3SD from the log means of the negative controls. (B) Relative ratio of RBD, spike and NP across time. Black and gray lines indicate median and mean values, respectively. *p≤0.05, **p≤0.01, ***p≤0.001, ****p≤0.0001

Conclusion

Following 2 doses of mRNA vaccination there is 100% seroconversion in IMID patients on maintenance therapy. Antibody levels and neutralization efficacy in anti-TNF group are lower than controls, and wane substantially by 3 months after dose 2. These findings highlight the need for third dose in patients undergoing treatment with anti-TNF therapy and continued monitoring of immunity in these patient groups, taking into consideration newer variants and additional vaccine doses.

Acknowledgements

This work was funded by a donation from Juan and Stefania Speck and by grants VR-1 172711, VS1-175545, FDN-143250, GA1- 177703 and GA2- 177716, from Canadian Institutes of Health Research and COVID Immunity task force and by Sinai Health Foundation

Disclosure of Interests

Naomi Finkelstein: None declared, Roya M. Dayam: None declared, Jaclyn Law: None declared, Rogier Goetgebuer: None declared, Gary Chao: None declared, Kento T. Abe: None declared, Mitchell Sutton: None declared, Joanne M. Stempak: None declared, Daniel Pereira: None declared, David Croitoru: None declared, Lily Acheampong: None declared, Saima Rizwan: None declared, Klaudia Rymaszewski: None declared, Raquel Milgrom: None declared, Darshini Ganatra: None declared, Nathalia V. Batista: None declared, Melanie Girard: None declared, Irene Lau: None declared, Ryan Law: None declared, Michelle Cheung: None declared, Bhavisha Rathod: None declared, Julia Kitaygorodsky: None declared, Reuben Samson: None declared, Queenie Hu: None declared, Nigil Haroon: None declared, Robert Inman Consultant of: AbbVie, Janssen, Lilly, Novartis., Grant/research support from: AbbVie, Novartis, Vincent Piguet Consultant of: AbbVie, Almirall, Celgene, Janssen, Kyowa Kirin Co. Ltd, LEO Pharma,

Novartis, Pfizer, Sanofi, UCB, and Union Therapeutic, Grant/research support from: Unrestricted educational grants from AbbVie, Bausch Health, Celgene, Janssen, LEO Pharma, Lilly, L’Oréal, NAOS, Novartis, Pfizer, Pierre-Fabre, Sandoz, and Sanofi, Mark Silverberg Speakers bureau: AbbVie, Janssen, Takeda, Pfizer, Gilead and Amgen, Consultant of: AbbVie, Janssen, Takeda, Pfizer, Gilead and Amgen, Grant/research support from: AbbVie, Janssen, Takeda, Pfizer, Gilead and Amgen, Anne-Claude Grigras: None declared, Tania H. Watts: None declared, Vinod Chandran Consultant of: AbbVie, Amgen, BMS, Eli Lilly, Janssen, Novartis, Pfizer and UCB, Grant/research support from: AbbVie, Amgen, Eli-Lilly.

Impact on blood loss and transfusion rates following administration of tranexamic acid in major oncological abdominal and pelvic surgery: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Major bleeding and receiving blood products in cancer surgery are associated with increased postoperative complications and worse outcomes. Tranexamic acid (TXA) reduces blood loss and improves outcomes in various surgical specialities. We performed a systematic review and meta-analysis to investigate TXA use on blood loss in elective abdominal and pelvic cancer surgery.

METHODS

A literature search was performed for studies comparing intravenous TXA versus placebo/no TXA in patients undergoing major elective abdominal or pelvic cancer surgery.

RESULTS

Twelve articles met the inclusion criteria, consisting of 723 patients who received TXA and 659 controls. Patients receiving TXA were less likely to receive a red blood cell (RBC) transfusion (p < 0.001, OR 0.4 95% CI [0.25, 0.63]) and experienced less blood loss (p < 0.001, MD -197.8 ml, 95% CI [-275.69, -119.84]). The TXA group experienced a smaller reduction in haemoglobin (p = 0.001, MD -0.45 mmol/L, 95% CI [-0.73, -0.18]). There was no difference in venous thromboembolism (VTE) rates (p = 0.95, OR 0.98, 95% CI [0.46, 2.08]).

CONCLUSIONS

TXA use reduced blood loss and RBC transfusion requirements perioperatively, with no significant increased risk of VTE. However, further studies are required to assess its benefit for cancer surgery in some sub-specialities.

Cambridge hybrid closed-loop algorithm in children and adolescents with type 1 diabetes: a multicentre 6-month randomised controlled trial

BACKGROUND

Closed-loop insulin delivery systems have the potential to address suboptimal glucose control in children and adolescents with type 1 diabetes. We compared safety and efficacy of the Cambridge hybrid closed-loop algorithm with usual care over 6 months in this population.

METHODS

In a multicentre, multinational, parallel randomised controlled trial, participants aged 6-18 years using insulin pump therapy were recruited at seven UK and five US paediatric diabetes centres. Key inclusion criteria were diagnosis of type 1 diabetes for at least 12 months, insulin pump therapy for at least 3 months, and screening HbA1c levels between 53 and 86 mmol/mol (7·0-10·0%). Using block randomisation and central randomisation software, we randomly assigned participants to either closed-loop insulin delivery (closed-loop group) or to usual care with insulin pump therapy (control group) for 6 months. Randomisation was stratified at each centre by local baseline HbA1c. The Cambridge closed-loop algorithm running on a smartphone was used with either (1) a modified Medtronic 640G pump, Medtronic Guardian 3 sensor, and Medtronic prototype phone enclosure (FlorenceM configuration), or (2) a Sooil Dana RS pump and Dexcom G6 sensor (CamAPS FX configuration). The primary endpoint was change in HbA1c at 6 months combining data from both configurations. The primary analysis was done in all randomised patients (intention to treat). Trial registration ClinicalTrials.gov, NCT02925299.

FINDINGS

Of 147 people initially screened, 133 participants (mean age 13·0 years [SD 2·8]; 57% female, 43% male) were randomly assigned to either the closed-loop group (n=65) or the control group (n=68). Mean baseline HbA1c was 8·2% (SD 0·7) in the closed-loop group and 8·3% (0·7) in the control group. At 6 months, HbA1c was lower in the closed-loop group than in the control group (between-group difference -3·5 mmol/mol (95% CI -6·5 to -0·5 [-0·32 percentage points, -0·59 to -0·04]; p=0·023). Closed-loop usage was low with FlorenceM due to failing phone enclosures (median 40% [IQR 26-53]), but consistently high with CamAPS FX (93% [88-96]), impacting efficacy. A total of 155 adverse events occurred after randomisation (67 in the closed-loop group, 88 in the control group), including seven severe hypoglycaemia events (four in the closed-loop group, three in the control group), two diabetic ketoacidosis events (both in the closed-loop group), and two non-treatment-related serious adverse events. There were 23 reportable hyperglycaemia events (11 in the closed-loop group, 12 in the control group), which did not meet criteria for diabetic ketoacidosis.

INTERPRETATION

The Cambridge hybrid closed-loop algorithm had an acceptable safety profile, and improved glycaemic control in children and adolescents with type 1 diabetes. To ensure optimal efficacy of the closed-loop system, usage needs to be consistently high, as demonstrated with CamAPS FX.

FUNDING

National Institute of Diabetes and Digestive and Kidney Diseases.

A Modular Digital Twinning Framework for Safety Assurance of Collaborative Robotics

Digital twins offer a unique opportunity to design, test, deploy, monitor, and control real-world robotic processes. In this paper we present a novel, modular digital twinning framework developed for the investigation of safety within collaborative robotic manufacturing processes. The modular architecture supports scalable representations of user-defined cyber-physical environments, and tools for safety analysis and control. This versatile research tool facilitates the creation of mixed environments of Digital Models, Digital Shadows, and Digital Twins, whilst standardising communication and physical system representation across different hardware platforms. The framework is demonstrated as applied to an industrial case-study focused on the safety assurance of a collaborative robotic manufacturing process. We describe the creation of a digital twin scenario, consisting of individual digital twins of entities in the manufacturing case study, and the application of a synthesised safety controller from our wider work. We show how the framework is able to provide adequate evidence to virtually assess safety claims made against the safety controller using a supporting validation module and testing strategy. The implementation, evidence and safety investigation is presented and discussed, raising exciting possibilities for the use of digital twins in robotic safety assurance.

Frailty in Older Patients Undergoing Emergency Laparotomy: Results From the UK Observational Emergency Laparotomy and Frailty (ELF) Study

OBJECTIVE

This study aimed to document the prevalence of frailty in older adults undergoing emergency laparotomy and to explore relationships between frailty and postoperative morbidity and mortality.

SUMMARY BACKGROUND DATA

The majority of adults undergoing emergency laparotomy are older adults (≥65 y) that carry the highest mortality. Improved understanding is urgently needed to allow development of targeted interventions.

METHODS

An observational multicenter (n=49) UK study was performed (March-June 2017). All older adults undergoing emergency laparotomy were included. Preoperative frailty score was calculated using the progressive Clinical Frailty Score (CFS): 1 (very fit) to 7 (severely frail). Primary outcome measures were the prevalence of frailty (CFS 5-7) and its association to mortality at 90 days postoperative. Secondary outcomes included 30-day mortality and morbidity, length of critical care, and overall hospital stay.

RESULTS

A total of 937 older adults underwent emergency laparotomy: frailty was present in 20%. Ninety-day mortality was 19.5%. After age and sex adjustment, the risk of 90-day mortality was directly associated with frailty: CFS 5 adjusted odds ratio (aOR) 3.18 [95% confidence interval (CI), 1.24-8.14] and CFS 6/7 aOR 6·10 (95% CI, 2.26-16.45) compared with CFS 1. Similar associations were found for 30-day mortality. Increasing frailty was also associated with increased risk of complications, length of Intensive Care Unit, and overall hospital stay.

CONCLUSIONS

A fifth of older adults undergoing emergency laparotomy are frail. The presence of frailty is associated with greater risks of postoperative mortality and morbidity and is independent of age. Frailty scoring should be integrated into acute surgical assessment practice to aid decision-making and development of novel postoperative strategies.

Decision-making for older patients undergoing emergency laparotomy: defining patient and clinician values and priorities

AIM

There remains limited knowledge on what patients value and prioritize in their decision to undergo emergency laparotomy (ELap) and during their subsequent recovery. The aim of this study was to explore factors in decision-making and to reach a consensus amongst patients on the 10 most important priorities in decision-making in ELap.

METHODS

Patients aged over 65 years who had required an ELap decision within the preceding 12 months (regardless of management) were identified and invited to attend a modified Delphi process focus group.

RESULTS

A total of 20 participants attended: eight patients, four relatives and eight perioperative specialists. The perioperative specialists group defined 12 important factors for perioperative decision-making. The patient group agreed that only six (50%) of these factors were important: independence, postoperative complications, readmission to hospital, requirement for stoma formation, delirium (including long-term cognition) and presence of an advocate (such as a friend or family member). Open discussion refined multiple themes. Agreement was reached by patients and relatives about 10 factors that they valued as most important in their ELap patient journey: return to independence, realistic expectations, postoperative complications, what to expect postoperatively, readmission to hospital, nutrition, postoperative communication, stoma, follow-up and delirium.

CONCLUSION

Patients and clinicians have different values and priorities when discussing the risks and implications of undergoing ELap. Patients value quality of life outcomes, in particular, the formation of a stoma, returning to their own home and remaining independent. This work is the first to combine both perspectives to guide future ELap research outcomes.

Ultrasound: From Earth to Space

Ultrasonography is a versatile imaging modality that offers many ad- vantages over radiography, computed tomography, and magnetic resonance imag- ing. on Earth, the use of ultrasound has become standard in many areas of medi- cine including diagnosis of medical and surgical diseases, management of obstetric  and gynecologic conditions, assessment of critically ill patients, and procedural  guidance. Advances in telecommunications have enabled remotely-guided ultraso- nography for both geographically isolated populations and astronauts aboard the  International Space Station. while ultrasound has traditionally been used in space- fight to study anatomical and physiological adaptations to microgravity and evalu- ate countermeasures, recent years have seen a growth of applications adapted from  terrestrial techniques. Terrestrial, remote, and space applications for ultrasound are reviewed in this paper.

The influence of social media on recruitment to surgical trials

BACKGROUND

Social media has changed the way surgeons communicate worldwide, particularly in dissemination of trial results. However, it is unclear if social media could be used in recruitment to surgical trials. This study aimed to investigate the influence of Twitter in promoting surgical recruitment in The Emergency Laparotomy and Frailty (ELF) Study.

METHODS

The ELF Study was a UK-based, prospective, observational cohort that aimed to assess the influence of frailty on 90-day mortality in older adults undergoing emergency surgery. A power calculation required 500 patients to be recruited to detect a 10% change in mortality associated with frailty. A 12-week recruitment period was selected, calculated from information submitted by participating hospitals and the numbers of emergency surgeries performed in adults aged > 65 years. A Twitter handle was designed (@ELFStudy) with eye-catching logos to encourage enrolment and inform the public and clinicians involved in the study. Twitter Analytics and Twitonomy (Digonomy Pty Ltd) were used to analyse user engagement in relation to patient recruitment.

RESULTS

After 90 days of data collection, 49 sites from Scotland, England and Wales recruited 952 consecutive patients undergoing emergency laparotomy, with data logged into a database created on REDCap. Target recruitment (n = 500) was achieved by week 11. A total of 591 tweets were published by @ELFStudy since its conception, making 218,136 impressions at time of writing. The number of impressions (number of times users see a particular tweet) prior to March 20th 2017 (study commencement date) was 23,335 (343.2 per tweet), compared to the recruitment period with 114,314 impressions (256.3 per tweet), ending June 20th 2017. Each additional tweet was associated with an increase in recruitment of 1.66 (95%CI 1.36 to 1.97; p < 0.001).

CONCLUSION

The ELF Study over-recruited by nearly 100%, reaching over 200,000 people across the U.K. Branding enhanced tweet aesthetics and helped increase tweet engagement to stimulate discussion and healthy competition amongst clinicians to aid trial recruitment. Other studies may draw from the social media experiences of the ELF Study to optimise collaboration amongst researchers.

TRIAL REGISTRATION

This study is registered online at www.clinicaltrials.gov (registration number NCT02952430 ) and has been approved by the National Health Service Research Ethics Committee.

Postflight Rash and Skin Sensitivity Following a Year-Long Spaceflight Mission

BACKGROUND: While skin conditions are commonly reported in flight on the International Space Station (ISS), postflight skin complaints have generally been limited to foot sole sensitivity upon reloading after landing. In this case report, we describe the postflight skin findings in NASA's first year-long crewmember.CASE REPORT: The crewmember was a 51-yr-old astronaut who spent 340 d in space on this mission. His in-flight course was unremarkable except for medication use for congestion, likely secondary to microgravity-induced fluid shift and elevated CO₂ levels on the ISS, and an episode of contact dermatitis from electrodes for an experiment. He had a nominal landing in Kazakhstan. During his direct return to Houston, approximately 10 h after the Soyuz landing, he developed erythema and skin sensitivity in gravity-dependent areas. The skin findings persisted for 6 d and were successfully treated with nonsteroidal anti-inflammatory drugs, gabapentin, hydrotherapy, and massage.DISCUSSION: While vascular, allergic, and immunologic causes cannot be ruled out, we hypothesize that a prolonged lack of skin stimulation over the course of the year-long mission led to the crewmember's postflight rash and skin sensitivity. Previous studies have demonstrated alterations in cutaneous receptor feedback in the sole of the foot in spaceflight and, therefore, it is plausible that skin in other parts of the body can undergo similar changes if they are not stimulated as they normally would be on Earth. More work will be needed to better understand this phenomenon and test potential mitigations.Law J, Gilmore S, Kelly S. Postflight rash and skin sensitivity following a year-long spaceflight mission. Aerosp Med Hum Perform. 2020; 91(7):604-607.

THU0276 HIGH HYDROXYCHLOROQUINE EXPOSURE IS ASSOCIATED WITH ABNORMAL STRAIN IMAGING IN LUPUS PATIENTS WITH END-STAGE RENAL DISEASE

Background:

Hydroxychloroquine (HCQ) cardiotoxicity remains an underrecognized condition. Diagnosis ultimately relies on invasive endomyocardial biopsy (EMB) and non-invasive screening methods are warranted. Strain imaging is a novel tool to detect early subclinical left ventricular (LV) dysfunction and may have a role in screening for HCQ cardiotoxicity (1). Strain measures systolic deformation indices that when decreased can predict cardiovascular outcomes more accurately than LV ejection fraction (2).

Objectives:

We assessed whether high HCQ cardiotoxicity risk is associated with a specific strain pattern in a group of patients with SLE and end-stage renal disease (ESRD).

Methods:

This was a retrospective study in a tertiary care center in New York on a group of patients with an established diagnosis of SLE, ESRD and cardiomyopathy on the index echocardiogram followed between years 2003 and 2019. The patients were stratified into two groups: high risk HCQ toxicity group was defined as either cumulative HCQ dose ≥1000g and/or an endomyocardial biopsy confirming HCQ toxicity. Low/moderate risk group was defined as a cumulative dose of HCQ <1000g. Clinical, demographic, electrocardiographic and echocardiographic strain parameters were compared between the groups.

Results:

A total of 16 patients were included. Two patients had EMB consistent with HCQ induced toxicity and 3 patients had cumulative HCQ doses ≥1000g. There were no significant differences in the baseline demographic characteristics between the two groups. Compared to patients with low/moderate risk, patients in the high risk group had a lower heart rate at the time of the echocardiogram (69 vs 87 beats per minute, p=0.08) and a higher frequency of LV hypertrophy (40% vs 9.1%, p=0.2). Strain analysis showed that both groups had compromised LV global longitudinal strain (GLS) and global cross-sectional strain (GCS). However, compared to the low/moderate risk group, the high risk group had a weaker LV GLS (-12.3% vs -14.9%, p=0.27).

Characteristics overall and stratified by HCQ risk group

CharacteristicOverall (n=16)Low/Moderate HCQ Risk(n=11)High HCQ Risk and/or Positive EMB (n=5)P valueDemographicsAge, years47.5 (36.5,60.7)50.0 (33.9,60.5)42.5 (42.7,61.0)0.95Female, n(%)14 (87.5)9 (90)5 (83.3)0.99Clinical FeaturesSLE duration, years7.4 (4.3,17.5)5.5 (3.5,13.2)15.6 (11.6,19.3)0.15HCQ cumulative dose, g422.8 (224.2,422.8)285.4 (110.8,523.6)1140 (1006,1625.4)0.005HCQ therapy duration, years3.4 (2.5, 8.9)3.2 (1.5,5.1)7.8 (6.8,11.6)0.06HCQ daily dose, mg/d226 (200,394.9)200 (179.4,253.7)400 (389.8,400)0.007Hypertension, n (%)14 (87.5)10 (90.9)4 (80.0)0.99Diabetes, n (%)3 (18.8)2 (18.8)1 (20.0)0.99CAD, n (%)3 (18.8)2 (18.8)1 (20)0.99EchocardiogramEF, %55 (42.5,60)55 (40,60)55 (55,70)0.45LA size, cm3.8 (3.4,4.3)3.8 (3.4,4.2)4.3 (3.4,4.9)0.30LVEDD, cm4.9 (4.4, 5.5)4.8 (4.2,5.5)5.0 (4.9,5.4)0.43E/E’12.3 (8.8,16.3)12 (8.8,14.9)16.9 (4.9,21.8)0.43Moderate-severe LV hypertrophy, n(%)3 (18.7)1 (9.1)2 (40.0)0.20Strain echocardiographyGLS, %-13.9 (-16.7,-12.3)-14.9 (-16.7,-12.9)-12.3 (-15.4,-12.2)0.27Base/Apex Ratio0.8 (0.7,0.9)0.76 (0.68,0.86)0.76 (0.66,0.83)0.95GCS, %-20.2 (-21.7,-17)-19.7 (-20.5,18.0)-21.7 (-23.9,-20.9)0.16RV GLS, %-20.19 (-22.1,-17.5)-20.2 (-22.3,-17.1)-19.8 (-22.1,-17.5)0.99

Conclusion:

We report an association of higher HCQ cardiotoxicity risk and impaired strain in a set of SLE ESRD patients. Standard echo measures did not differentiate between high and low/moderate risk patients. Although the findings did not reach statistical significance, given the small sample size, results are still suggestive of a possible utility of strain echocardiography for detection of early HCQ toxicity.

References:

[1]Buss SJ, et al. J Rheumatol. 2010;37(1):79-86

[2]Kalam K, et al. Heart. 2014;100(21):1673-80

Disclosure of Interests: None declared

Association between preadmission frailty and care level at discharge in older adults undergoing emergency laparotomy

Background

Older adults undergoing emergency abdominal surgery have significantly poorer outcomes than younger adults. For those who survive, the level of care required on discharge from hospital is unknown and such information could guide decision-making. The ELF (Emergency Laparotomy and Frailty) study aimed to determine whether preoperative frailty in older adults was associated with increased dependence at the time of discharge.

Methods

The ELF study was a UK-wide multicentre prospective cohort study of older patients (65 years or more) undergoing emergency laparotomy during March and June 2017. The objective was to establish whether preoperative frailty was associated with increased care level at discharge compared with preoperative care level. The analysis used a multilevel logistic regression adjusted for preadmission frailty, patient age, sex and care level.

Results

A total of 934 patients were included from 49 hospitals. Mean(s.d.) age was 76·2(6·8) years, with 57·6 per cent women; 20·2 per cent were frail. Some 37·4 per cent of older adults had an increased care level at discharge. Increasing frailty was associated with increased discharge care level, with greater predictive power than age. The adjusted odds ratio for an increase in care level was 4·48 (95 per cent c.i. 2·03 to 9·91) for apparently vulnerable patients (Clinical Frailty Score (CFS) 4), 5·94 (2·54 to 13·90) for those mildly frail (CFS 5) and 7·88 (2·97 to 20·79) for those moderately or severely frail (CFS 6 or 7), compared with patients who were fit.

Conclusion

Over 37 per cent of older adults undergoing emergency laparotomy required increased care at discharge. Frailty scoring was a significant predictor, and should be integrated into all acute surgical units to aid shared decision-making and discharge planning.

Serious Altitude Illness at the South Pole

BACKGROUND: Gradual ascent is impractical for personnel deploying to the South Pole due to logistical challenges. Prevention of altitude illness relies on prophylactic medications such as acetazolamide and behavioral modifications including hydration and avoidance of overexertion. We present three recent cases of altitude illness that occurred in previously healthy individuals at the South Pole.CASE REPORTS: 1) A 52-yr-old woman not on prophylactics presented with headache and intractable vomiting 7 h after arriving and hiking around the station. She was treated with acetazolamide, dexamethasone, oxygen, and supportive care. Her symptoms resolved during the evacuation flight. 2) A 23-yr-old man presented with dyspnea at rest 3 d after arriving without prophylactic treatments. He had a S_ao₂ of 49%, wheezes and crackles on lung exam, and interstitial infiltrates on chest X-ray. His treatment included oxygen, nifedipine, acetazolamide, and dexamethasone. His symptoms resolved during the evacuation flight. 3) A 40-yr-old man presented with dyspnea after a series of strenuous workouts since his arrival 5 d prior. He had a S_ao₂ of 41%, and his chest X-ray was consistent with high altitude pulmonary edema. He was treated with oxygen, nifedipine, and fluids before descent to sea level, where his symptoms fully resolved 4 d later.DISCUSSION: These patients illustrate that altitude illness may develop despite medical screening, participant education, and availability of prophylactic medications based on published guidelines. These cases could be attributed to noncompliance and misinformation, bringing to light some of the challenges with managing more diverse populations that deploy to remote environments.Rose JS, Law J, Scheuring R, Ramage MH, McKeith JJ. Serious altitude illness at the South Pole. Aerosp Med Hum Perform. 2020; 91(1):46-50.

Socio-economic, demographic, and clinical correlates of poor glycaemic control within insulin regimens among children with Type 1 diabetes: the SEARCH for Diabetes in Youth Study

AIM

To examine the distribution and association of sociodemographic, adherence, and barriers-to-care factors in relation to glycaemic control within insulin regimens in US children with Type 1 diabetes in the SEARCH for Diabetes in Youth Study.

METHODS

Self- or parent-reported data from 1095 children with Type 1 diabetes aged 10-17 years were collected on insulin regimen, sociodemographics, diabetes self-management, diabetes-related family conflict and barriers to care. Multivariable logistic regression analysis identified poor glycaemic control correlates within each insulin regimen.

RESULTS

Participants included 694 children on insulin pump therapy, 188 receiving basal-bolus injections, and 213 on a mixed insulin regimen. Of these, 28.5%, 45.2% and 51.2%, respectively, had poor glycaemic control [HbA_1c ≥ 80 mmol/mol (9.5%)]. Family conflict between parent and child regarding diabetes management was the only factor significantly associated with poor glycaemic control in all insulin regimens (insulin pump, P≤ 0.0001; basal-bolus injections, P=0.0002; mixed insulin regimen, P=0.0103). For children on insulin pump, poor control was significantly associated with non-white race (P=0.0008), living in multiple households (P=0.0331), having Medicaid insurance (P=0.0090), and decreased insulin adherence (P<0.0001). For children on a mixed insulin regimen, living in multiple households (P=0.0256) and not spending enough time with healthcare provider (P=0.0058) correlated with poor control.

CONCLUSIONS

A high percentage of US children with Type 1 diabetes had poor glycaemic control, especially those not using an insulin pump. Early identification of children with risk factors associated with poor glycaemic control within insulin regimens and addressing diabetes-related family conflict may allow interventions to improve diabetes management.

Physician-Led EHR Customization Tracking Assessments for Pediatric Patients with Turner Syndrome

In 2015, a pediatric endocrinologist designed a progress note in an electronic health record (EHR) system to improve adherence to clinical practice guidelines for pediatric patients with Turner Syndrome. In 2018, to improve upon the note template, a flowsheet containing embedded decision support content from an international guideline was designed and implemented with help from a general pediatrician who was also an Epic Physician Builder. The flowsheet allowed for the creation of discrete data elements for improved consistency and enhanced reporting. The design process may be useful in other EHR customizations.

Liquid Nitrogen Spray Cryotherapy in Treatment of Barrett's Esophagus, where do we stand? A Systematic Review and Meta-Analysis

Radiofrequency ablation (RFA) is the preferred treatment option for Barrett's esophagus (BE) to achieve complete eradication (CE) of dysplasia (D), and intestinal metaplasia (IM). Cryotherapy, using liquid nitrogen (LNC), is a cold-induced tissue-injury technique option for the ablation of BE. We conducted a systematic review and meta-analysis to assess the overall efficacy and safety of LNC in the treatment of BE. We conducted a search of multiple electronic databases and conference proceedings from inception through June 2018. The primary outcome was to estimate the pooled rates of CE-IM, CE-D, and CE-HGD. The secondary outcome was to estimate the risk of adverse events and recurrence of disease after LNC. Nine studies reported 386 patients who were treated with LNC. The pooled rate of CE-IM was 56.5% (95% CI 48.5-64.2, I2 = 47), pooled rate of CE-D was 83.5% (95% CI 78.3-87.7, I2 = 22.8), and pooled rate of CE-HGD was 86.5% (95% CI 64.4-95.8, I2 = 88.1). Rate of adverse events was 4.7%, and the risk of BE recurrence was 12.7%. On subgroup analysis, the pooled rate of CE-IM with LNC in patients who failed RFA was 58.4% (95% CI 47.2-68.8, I2 = 32.5), and the pooled rate of CE-D in the same population was 81.9% (95% CI 72.5-88.6, I2 = 5.9). CE-D rates with LNC are comparable to RFA while CE-IM rates appear to be lower than the rates achievable with RFA. CE-IM rate in RFA failed patients is 58.4% and thus LNC is a rescue option to consider in this population.

Frailty predicts mortality in all emergency surgical admissions regardless of age. An observational study

BACKGROUND

frail patients in any age group are more likely to die than those that are not frail. We aimed to evaluate the impact of frailty on clinical mortality, readmission rate and length of stay for emergency surgical patients of all ages.

METHODS

a multi-centre prospective cohort study was conducted on adult admissions to acute surgical units. Every patient presenting as a surgical emergency to secondary care, regardless of whether they ultimately underwent a surgical procedure was included. The study was carried out during 2015 and 2016.Frailty was defined using the 7-point Clinical Frailty Scale. The primary outcome was mortality at Day 90. Secondary outcomes included: mortality at Day 30, length of stay and readmission within a Day 30 period.

RESULTS

the cohort included 2,279 patients (median age 54 years [IQR 36-72]; 56% female). Frailty was documented in patients of all ages: 1% in the under 40's to 45% of those aged 80+. We found that each incremental step of worsening frailty was associated with an 80% increase in mortality at Day 90 (OR 1.80, 95% CI: 1.61-2.01) supporting a linear dose-response relationship. In addition, the most frail patients were increasingly likely to stay in hospital longer, be readmitted within 30 days, and die within 30 days.

CONCLUSIONS

worsening frailty at any age is associated with significantly poorer patient outcomes, including mortality in unselected acute surgical admissions. Assessment of frailty should be integrated into emergency surgical practice to allow prognostication and implementation of strategies to improve outcomes.

SUN-219 Human Congenital Arhinia Is Associated with GnRH Deficiency and Primary Testicular Defects

Congenital arhinia (absent external nose) is an extremely rare mendelian disorder (<100 case reports in the past century) caused by heterozygous missense mutations in the gene SMCHD1. Arhinia is frequently accompanied by ocular and reproductive defects, a clinical triad which defines the Bosma arhinia microphthalmia syndrome (BAMS). The etiology and spectrum of reproductive defects in BAMS is unknown. We studied eleven subjects with arhinia or nasal hypoplasia (aged 18-53 yrs; 5 males) to assess endogenous luteinizing hormone (LH) secretion (n=11), a validated marker of GnRH, responsiveness to pulsatile GnRH (n=2), and non-reproductive phenotypes (n=11). Clinical data abstracted from questionnaires were analyzed in 33 additional international patients. Nearly every male demonstrated clinical and biochemical signs of severe congenital GnRH deficiency (CGD) including a history of microphallus and/or cryptorchidism, testicular volumes < 3 ml, hypogonadotropic hypogonadism (HH), low inhibin B levels, and apulsatile LH profiles; two young boys (studied from afar) had normal genitals but an absent mini-puberty of infancy was confirmed biochemically in one case. Pulsatile GnRH administered to one adult male and hCG to two others also revealed testicular resistance. Several females reported spontaneous breast bud development, but all had primary amenorrhea, small ovaries on pelvic ultrasound, HH, and apulsatile LH profiles. Pulsatile GnRH administered to one female induced ovulation on treatment day 21. Two females (studied from afar) reported normal thelarche and menstrual cycles. The 11 subjects studied in detail were completely anosmic with absent internal olfactory structures on brain MRI but normal hypothalamic-pituitary anatomy. Subjects with arhinia demonstrated some, but not all, non-reproductive phenotypes characteristic of Kallmann syndrome (KS) and/or CHARGE syndrome including dental agenesis (56%) and congenital mirror movements (CMMs; 50%); none had renal agenesis, severe congenital heart defects, or deafness. This study demonstrates for the first time that the hypogonadotropism observed in BAMS is indeed secondary to GnRH deficiency. In contrast to the male predominance (3-5:1) in KS, there is no sex bias in the incidence of BAMS. However, females may demonstrate partial or complete pubertal development whereas males are severely affected with some showing both hypothalamic and testicular defects. The combination of defects in the nasal skeleton, olfactory structures, and GnRH ontogeny point to aberrant development of the nasal placode in BAMS, yet the high prevalence of CMMs, a sign of misrouted commissural axons, suggests insults may occur even earlier in neurogenesis, at the neural plate border.

Intracellular manipulation and measurement with multipole magnetic tweezers

The capability to directly interrogate intracellular structures inside a single cell for measurement and manipulation is important for understanding subcellular and suborganelle activities, diagnosing diseases, and developing new therapeutic approaches. Compared with measurements of single cells, physical measurement and manipulation of subcellular structures and organelles remain underexplored. To improve intracellular physical measurement and manipulation, we have developed a multipole magnetic tweezers system for micromanipulation involving submicrometer position control and piconewton force control of a submicrometer magnetic bead inside a single cell for measurement in different locations (spatial) and different time points (temporal). The bead was three-dimensionally positioned in the cell using a generalized predictive controller that addresses the control challenge caused by the low bandwidth of visual feedback from high-resolution confocal imaging. The average positioning error was quantified to be 0.4 μm, slightly larger than the Brownian motion–imposed constraint (0.31 μm). The system is also capable of applying a force up to 60 pN with a resolution of 4 pN for a period of time longer than 30 min. The measurement results revealed that significantly higher stiffness exists in the nucleus’ major axis than in the minor axis. This stiffness polarity is likely attributed to the aligned actin filament. We also showed that the nucleus stiffens upon the application of an intracellularly applied force, which can be attributed to the response of structural protein lamin A/C and the intracellular stress fiber actin filaments.

Plasmid DNA contaminant in molecular reagents

Background noise in metagenomic studies is often of high importance and its removal requires extensive post-analytic, bioinformatics filtering. This is relevant as significant signals may be lost due to a low signal-to-noise ratio. The presence of plasmid residues, that are frequently present in reagents as contaminants, has not been investigated so far, but may pose a substantial bias. Here we show that plasmid sequences from different sources are omnipresent in molecular biology reagents. Using a metagenomic approach, we identified the presence of the (pol) of equine infectious anemia virus in human samples and traced it back to the expression plasmid used for generation of a commercial reverse transcriptase. We found fragments of multiple other expression plasmids in human samples as well as commercial polymerase preparations. Plasmid contamination sources included production chain of molecular biology reagents as well as contamination of reagents from environment or human handling of samples and reagents. Retrospective analyses of published metagenomic studies revealed an inaccurate signal-to-noise differentiation. Hence, the plasmid sequences that seem to be omnipresent in molecular biology reagents may misguide conclusions derived from genomic/metagenomics datasets and thus also clinical interpretations. Critical appraisal of metagenomic data sets for the possibility of plasmid background noise is required to identify reliable and significant signals.

Using non-nutritive sucking to support feeding development for premature infants: A commentary on approaches and current practice

Non-nutritive sucking is often used with premature infants by either using a pacifier or an expressed breast nipple to support the introduction and development of early oral feeding. The pattern of non-nutritive sucking is distinct in that it involves two sucks per second in contrast to nutritive sucking which is one suck per second. Although some literature has identified that non-nutritive sucking has some benefit for the premature infant's feeding development, it is not entirely clear why such an approach is helpful as neurologically, activation of non-nutritive and nutritive skills are different. A summary is presented of the main approaches that use non-nutritive sucking with reference to the literature. This paper also considers other factors and beneficial approaches to managing the introduction of infant feeding. These are: the infant's toleration of enteral feeds pre oral trials, overall development and gestational age when introducing oral experiences, developing swallowing skills before sucking, physiological stability, health status, as well as the development and interpretation of infant oral readiness signs and early communication.

Superior immunogenicity of HCV envelope glycoproteins when adjuvanted with cyclic-di-AMP, a STING activator or archaeosomes

Three decades after the discovery, hepatitis C virus (HCV) is still the leading cause of liver transplantation and poses a major threat to global health. In spite of recent advances in the development of direct acting antivirals, there is still a need for a prophylactic vaccine to limit the virus spread and protect at-risk populations, especially in developing countries, where the cost of the new treatments may severely limit access. The use of recombinant HCV glycoproteins E1E2 (rE1E2) in combination with the MF59, an oil-in-water emulsion-based adjuvant, has previously been shown to reduce the rate of chronicity in chimpanzees and to induce production of cross-neutralizing antibodies and cellular immune responses in human volunteers. To further improve neutralizing antibody responses in recipients along with robust T cell responses, we have explored the immunogenicity of different adjuvants when formulated with the HCV rE1E2 vaccine in mice. Our data show that cyclic di-adenosine monophosphate (c-di-AMP) and archaeosomes elicit strong neutralizing antibodies similar to those elicited using aluminum hydroxide/monophosphoryl lipid A (Alum/monophos. /MPLA) and MF59. However, both c-di-AMP and archaeosomes induced a more robust cellular immune response, which was confirmed by the detection of vaccine-specific poly-functional CD4⁺ T cells. We conclude that these adjuvants may substantially boost the immunogenicity of our E1E2 vaccine. In addition, our data also indicates that use of a partial or exclusive intranasal immunization regimen may also be feasible using c-di-AMP as adjuvant.

Carbon Dioxide Physiological Training at NASA

INTRODUCTION

Astronauts undergo CO2 exposure training to recognize their symptoms that can arise acutely both on the ground and in spaceflight. This article describes acute CO2 exposure training at NASA and examines the symptoms reported by astronauts during training.

METHODS

In a controlled training environment, astronauts are exposed to up to 8% CO2 (60 mmHg) by a rebreathing apparatus. Symptoms are reported using a standard form.

RESULTS

Symptom documentation forms between April 1994 and February 2012 were obtained for 130 astronauts. The number of symptoms reported per session out of the possible 24 was related to age and sex, with those older slightly more likely to report symptoms. Women reported more symptoms on average than men (men: 3.7, women: 4.7). Respiratory symptoms (90%), flushing sensation/sweating (56%), and dizziness/feeling faint/lightheadedness (43%) were the top symptoms. Only headache reached statistical significance in differences between men (13%) and women (37%) after adjustment for multiple testing. Among those with multiple training sessions, respiratory symptoms were the most consistently reported.

DISCUSSION

CO2 exposure training is an important tool to educate astronauts about their potential acute CO2 symptoms. Wide interindividual and temporal variations were observed in symptoms reported during astronaut CO2 exposure training. Headache could not be relied on as a marker of acute exposure during testing since fewer than half the subjects reported it. Our results support periodic refresher training since symptoms may change over time. Further study is needed to determine the optimal interval of training to maximize symptom recognition and inform operational decisions.Law J, Young M, Alexander D, Mason SS, Wear ML, Méndez CM, Stanley D, Meyers Ryder V, Van Baalen M. Carbon dioxide physiological training at NASA. Aerosp Med Hum Perform. 2017; 88(10):897-902.