Sickle Cell Health Awareness, Perspectives, and Experiences (SHAPE) survey: Perspectives of adolescent and adult patients, caregivers, and healthcare professionals on the burden of sickle cell disease

OBJECTIVES

Sickle cell disease (SCD) is an inherited disorder that causes lifelong complications, substantially impacting the physical and emotional well-being of patients and their caregivers. Studies investigating the effects of SCD on quality of life (QOL) are often limited to individual countries, lack SCD-specific QOL questionnaires, and exclude the caregiver experience. The SHAPE survey aimed to broaden the understanding of the global burden of SCD on patients and their caregivers and to capture the viewpoint of healthcare providers (HCPs).

METHODS

A total of 919 patients, 207 caregivers, and 219 HCPs from 10, 9, and 8 countries, respectively, answered a series of closed-ended questions about their experiences with SCD.

RESULTS

The symptoms most frequently reported by patients were fatigue/tiredness (84%) and pain/vaso-occlusive crises (71%). Patients' fatigue/tiredness had one of the greatest impacts on both patients' and caregivers' QOL. On average, patients and caregivers reported missing 7.5 days and 5.0 days per month, respectively, of school or work. HCPs reported a need for effective tools to treat fatigue/tiredness and a desire for more support to educate patients on long-term SCD-related health risks.

CONCLUSIONS

The multifaceted challenges identified using the SHAPE survey highlight the global need to improve both patient and caregiver QOL.

The role of contrast-enhanced mammography in the preoperative evaluation of invasive lobular carcinoma of the breast

AIM

To assess the performance of contrast-enhanced mammography (CEM) in the preoperative staging of invasive lobular carcinoma (ILC) of the breast.

MATERIALS AND METHODS

The present study was a multicentre, multivendor, multinational retrospective study of women with a histological diagnosis of ILC who had undergone CEM from December 2013 to December 2021. Index lesion size and multifocality were recorded for two-dimensional (2D) mammography, CEM, and when available magnetic resonance imaging (MRI). Comparison with histological data was undertaken for women treated by primary surgical excision. Pearson correlation coefficients and Bland-Altman's analysis of agreement were used to assess differences with a significance level of 0.05.

RESULTS

One hundred and fifteen ILC lesions were included, 46 (40%) presented symptomatically and 69 were screening detected. CEM demonstrated superior sensitivity when compared to standard mammography. The correlation between the histological size measured on the surgical excision specimen size was greater than with standard mammography (r=0.626 and 0.295 respectively, p=0.001), with 19% of lobular carcinomas not visible without a contrast agent. The sensitivity of CEM for multifocal disease was greater than standard mammography (70% and 20% respectively, p<0.0001). CEM overestimated tumour size by an average of 1.5 times, with the size difference increasing for larger tumour. When MRI was performed (n=22), tumour size was also overestimated by an average of 1.3 times. The degree of size overestimation was similar for both techniques, with the tumour size on CEM being on average 0.5 cm larger than MRI.

CONCLUSION

CEM is a useful tool for the local staging of lobular carcinomas and could be an alternative to breast MRI.

Inactivating negative regulators of cortical branched actin enhances persistence of single cell migration

The Rac1-WAVE-Arp2/3 pathway pushes the plasma membrane by polymerizing branched actin, thereby powering membrane protrusions that mediate cell migration. Here, using knockdown (KD) or knockout (KO), we combine the inactivation of the Arp2/3 inhibitory protein arpin, the Arp2/3 subunit ARPC1A and the WAVE complex subunit CYFIP2, all of which enhance the polymerization of cortical branched actin. Inactivation of the three negative regulators of cortical branched actin increases migration persistence of human breast MCF10A cells and of endodermal cells in the zebrafish embryo, significantly more than any single or double inactivation. In the triple KO cells, but not in triple KD cells, the 'super-migrator' phenotype was associated with a heterogenous downregulation of vimentin (VIM) expression and a lack of coordination in collective behaviors, such as wound healing and acinus morphogenesis. Re-expression of vimentin in triple KO cells largely restored normal persistence of single cell migration, suggesting that vimentin downregulation contributes to the maintenance of the super-migrator phenotype in triple KO cells. Constant excessive production of branched actin at the cell cortex thus commits cells into a motile state through changes in gene expression.

Impact of the COVID-19 pandemic on a post-mortem CT service for adult non-suspicious death

Due to the COVID-19 pandemic, the post-mortem computed tomography (PMCT) service was expanded from three to seven cases per day to help mortuary services and avoid invasive autopsy. Additional targeted angiography and pulmonary ventilation procedures were stopped and triage rules relaxed to allow more indications to be scanned, including those requiring toxicology. A service evaluation was performed for the first 3-months of the COVID-19 pandemic compared to the equivalent period the previous year to study the impact of these changes. It was found that, despite the increase in deaths regionally, coronial referrals remained about 100 per month, a reduction in referral rate. The number undergoing PMCT rose from 28% to 74% of cases. Turnaround time remained the same. For cases triaged to PMCT, the need for subsequent autopsy increased from 7.9% to 15.8%. No significant changes were seen in diagnosis rates, including cardiac or respiratory. There was an increase in patients with coronary death without severe coronary calcification who underwent autopsy after PMCT. These may have been diagnosed by targeted coronary angiography. Fifty-three cases requiring toxicology/biochemistry had PMCT, with 38 having PMCT only. In 8/11 (72.7%) cases with normal PMCT and toxicology as the key diagnostic test, autopsy was performed prior to results. This suggests the pathology team were reluctant to risk an "unascertained" outcome. This study shows that it is possible to increase PMCT services by widening referral criteria and by limiting the use of enhanced imaging techniques, without significantly changing diagnosis rates of key diseases; however, selectively restarting targeted angiography may help avoid autopsy in some cases.

A review of pulmonary neutrophilia and insights into the key role of neutrophils in particle-induced pathogenesis in the lung from animal studies of lunar dusts and other poorly soluble dust particles

The mechanisms of particle-induced pathogenesis in the lung remain poorly understood. Neutrophilic inflammation and oxidative stress in the lung are hallmarks of toxicity. Some investigators have postulated that oxidative stress from particle surface reactive oxygen species (psROS) on the dust produces the toxicopathology in the lungs of dust-exposed animals. This postulate was tested concurrently with the studies to elucidate the toxicity of lunar dust (LD), which is believed to contain psROS due to high-speed micrometeoroid bombardment that fractured and pulverized lunar surface regolith. Results from studies of rats intratracheally instilled (ITI) with three LDs (prepared from an Apollo-14 lunar regolith), which differed 14-fold in levels of psROS, and two toxicity reference dusts (TiO2 and quartz) indicated that psROS had no significant contribution to the dusts' toxicity in the lung. Reported here are results of further investigations by the LD toxicity study team on the toxicological role of oxidants in alveolar neutrophils that were harvested from rats in the 5-dust ITI study and from rats that were exposed to airborne LD for 4 weeks. The oxidants per neutrophils and all neutrophils increased with dose, exposure time and dust's cytotoxicity. The results suggest that alveolar neutrophils play a critical role in particle-induced injury and toxicity in the lung of dust-exposed animals. Based on these results, we propose an adverse outcome pathway (AOP) for particle-associated lung disease that centers on the crucial role of alveolar neutrophil-derived oxidant species. A critical review of the toxicology literature on particle exposure and lung disease further supports a neutrophil-centric mechanism in the pathogenesis of lung disease and may explain previously reported animal species differences in responses to poorly soluble particles. Key findings from the toxicology literature indicate that (1) after exposures to the same dust at the same amount, rats have more alveolar neutrophils than hamsters; hamsters clear more particles from their lungs, consequently contributing to fewer neutrophils and less severe lung lesions; (2) rats exposed to nano-sized TiO2 have more neutrophils and more severe lesions in their lungs than rats exposed to the same mass-concentration of micron-sized TiO2; nano-sized dust has a greater number of particles and a larger total particle-cell contact surface area than the same mass of micron-sized dust, which triggers more alveolar epithelial cells (AECs) to synthesize and release more cytokines that recruit a greater number of neutrophils leading to more severe lesions. Thus, we postulate that, during chronic dust exposure, particle-inflicted AECs persistently release cytokines, which recruit neutrophils and activate them to produce oxidants resulting in a prolonged continuous source of endogenous oxidative stress that leads to lung toxicity. This neutrophil-driven lung pathogenesis explains why dust exposure induces more severe lesions in rats than hamsters; why, on a mass-dose basis, nano-sized dusts are more toxic than the micron-sized dusts; why lung lesions progress with time; and why dose-response curves of particle toxicity exhibit a hockey stick like shape with a threshold. The neutrophil centric AOP for particle-induced lung disease has implications for risk assessment of human exposures to dust particles and environmental particulate matter.

Arfid Genes and Environment (ARFID-GEN): Study Protocol

Background

The Avoidant Restrictive Food Intake Disorder Genes and Environment (ARFID-GEN) study is a study of genetic and environmental factors that contribute to risk for developing ARFID in children and adults.

Methods

A total of 3,000 children and adults with ARFID from the United States will be included. Parents/guardians and their children with ARFID (ages 7 to 17) and adults with ARFID (ages 18+) will complete comprehensive online consent, parent verification of child assent (when applicable), and phenotyping. Enrolled participants with ARFID will submit a saliva sample for genotyping. A genome-wide association study of ARFID will be conducted.

Discussion

ARFID-GEN, a large-scale genetic study of ARFID, is designed to rapidly advance the study of the genetics of eating disorders. We will explicate the genetic architecture of ARFID relative to other eating disorders and to other psychiatric, neurodevelopmental, and metabolic disorders and traits. Our goal is for ARFID to deliver "actionable" findings that can be transformed into clinically meaningful insights.

Trial registration

ARFID-GEN is a registered clinical trial: clinicaltrials.gov NCT05605067.

Long COVID prevalence and associated characteristics among a South Alabama population

OBJECTIVES

Long COVID can significantly impact a patient's quality of life. Defined as persistence or emergence of symptoms 4+ weeks after initial COVID-19 diagnosis, long COVID can result in functional impairments, pulmonary issues, and neuropsychiatric conditions, among others. This study aims to identify long COVID risk factors and prevalence in a south Alabama (US) patient population.

STUDY DESIGN

This was a longitudinal cohort study.

METHODS

Postdiagnosis standardized phone interviews (baseline, 6 months, and 12 months) from April 2020 to July 2021 with patients testing positive through a large healthcare system. Interviews gathered data on sociodemographics, comorbidities, acute illness, and long COVID. Relationships between 1+ ongoing symptoms and variables of interest were assessed using a generalized estimating equation to conduct multivariate analysis.

RESULTS

Of the 516 participants, most were female (65%) and African American (57%, n = 293), with a median (interquartile range) age of 41.1 (25.3-54.6) years. Retention was 70% (n = 359) at 6 months and 58% (n = 301) at 12 months. Participants reporting 1+ persistent symptoms were 20% and 17% at 6 and 12 months, respectively. Illness severity (P < 0.0001) and COVID-related emergency room visit with hospital admission at the time of diagnosis (P = 0.0018) were significantly associated with increased long COVID risk.

CONCLUSIONS

This study found substantial rates of long COVID within our population, with stable rates at 6 and 12 months, indicating illness persistence. Our findings support growing concern for long COVID as a persistent issue within the medical community, with potential to impact patient health for years. Larger, more uniform studies are required to further characterize disease risk factors and clinical course to inform the disease management.

Frequency of Epistaxis and Telangiectasia in patients with Hereditary Hemorrhagic Telangiectasia (HHT) in comparison with the General Population: Curaçao Diagnostic Criteria Revisited

PURPOSE

The Curaçao criteria are well-established diagnostic criteria for HHT but lack details regarding a predictive presentation of epistaxis and telangiectasias. This study collects and compares data in HHT and population cohorts to inform the application of these criteria.

METHODS

In-person interviews regarding epistaxis and targeted examination for telangiectases in a general population cohort (n=204) and an HHT cohort (n=432).

RESULTS

Frequency of epistaxis, rather than intensity or duration, was the best discriminator of HHT. A cut-off of 4 or more nosebleeds per year, alone, yielded a diagnostic sensitivity of 97%, and specificity of 84%. The mean number of telangiectases at the sites investigated was 0.4 in the general population cohort and 26.5 in the HHT cohort. The most distinctive sites for telangiectases in HHT were lips and palmar fingers; whereas telangiectases of the face and dorsum of the hand were comparable in both cohorts.

CONCLUSION

We propose that the Curaçao criteria be modified to include the following cutoffs: 1) epistaxis frequency of 4 or more nosebleeds per year, 2) telangiectasia count of at least 2 in characteristic locations (palmar aspect of fingers, lips and oral cavity); and that cutaneous telangiectases at other sites not be considered relevant for diagnostic purposes.

'Breast Cosmesis After Breast-Conserving Therapy' Who is the Judge, Patient or Surgeon?

INTRODUCTION

More than 80% of newly diagnosed breast cancers are managed with breast-conserving therapy (BCT). Preservation of cosmetically acceptable breasts is an inherent aim of all breast-conserving efforts-this can, however, be difficult to assess objectively. Compounding this is the difference in perception of breast cosmesis between patients and surgeons. This study compares the concordance of a new subscale-based cosmetic score (TCS) with the patient's perception.

METHOD

Eastern Health Breast and Cancer Centre conducted this study on patients who had completed their BCT and radiotherapy. Participation was voluntary and involved permitting an assessor (breast surgery fellow or consultant) to grade cosmetic outcomes to generate a Total Cosmesis Score (TCS). The patients blinded to this assessment were then asked to complete the postoperative segment of the BCT module of the Breast-Q questionnaire. TCS from surgeon assessment was compared against patient assessment (questions BQ1i and BQ1k specifically). Cohen's kappa was calculated to define the strength of the inter-rater agreement.

RESULTS

One hundred twelve patients with a mean age of 59 (range 27-89) participated in the study. TCS was low in 26% and high in 74% of participants. 76% and 69% of participants were satisfied when answering Breast-Q questions 'How your lumpectomy breast looks?' and 'How you look in the mirror unclothed?' respectively (Cohen's k = 0.464, 95% CI 0.337-0.591, p < 0.01). The agreement between the TCS and the patient assessment was poor (Cohen's k = 0.172, 95% CI - 0.020-2.093, p = 0.067).

CONCLUSION

Cosmetic outcomes scored using TCS by surgeons do not match patient's own assessment of the cosmetic result.

393 Communication in Catheter Care: A Closed Loop Audit of Catheter Documentation in Emergency Presentations to a Tertiary Urology Centre

Aim

Estimates suggest that 20% of patients admitted to hospital undergo catheterisation, some of whom will end up discharged with catheters. Clear documentation assists in communication between hospital and community teams. The EAUN has identified key areas for documentation including use of care plans. We audited compliance with documentation pre- and post-intervention in a tertiary urology department

Method

Emergency patients presenting to urology were identified over a 3-week period pre-intervention and 3-weeks post-intervention. Clinical notes were audited for documentation of catheterisation. Domains assessed included indication, type/size of catheter, catheter balloon volume, residual volume, urinalysis, and plan. Use of care plans was also audited. Intervention involved development and deployment of a poster as well as discussion with staff.

Results

In total 274 patients were identified. 47 catheters were inserted pre-intervention, with variable compliance in documentation throughout the domains with similar pattern of compliance noted in the post-intervention group (n=42). Compliance was highest in size of catheter and indication for insertion, with urinalysis the most frequently missed domain (14.9% pre-intervention, 9.5% post-intervention). The only area with significant improvement was documentation of balloon volume (p=0.0019). Use of the care plan showed some minor improvement but was generally poor.

Conclusion

Use of visual cues did not result in approvement in documentation. Discussion with the teams suggested awareness of the domains and care plan however, they didn't necessarily think of them at time of documentation. As such a text prompt for the electronic notes is now in development and further audit to assess impact pending.

Burden of disease, treatment utilization, and the impact on education and employment in patients with sickle cell disease: A comparative analysis of high- and low- to middle-income countries for the international Sickle Cell World Assessment Survey

The international Sickle Cell World Assessment Survey (SWAY) reported a high impact of sickle cell disease (SCD) on patients' daily lives globally. In this study, we analyzed whether the reported burden differed between patients from the USA (n = 384) and other high‐income (HI; n = 820) or low‐ to middle‐income (LMI; n = 941) countries. We assessed symptoms and complications, incidence/management of vaso‐occlusive crises (VOCs), treatment utilization/satisfaction, and the impact of SCD on education/employment. Certain symptoms (bone aches, insomnia, and joint stiffness) and complications (swollen/painful fingers/toes, gallstones, vision problems, blood clots, and asthma) were reported proportionally more by patients in the USA than in the HI/LMI countries. Self‐reported VOCs were more common (mean [SD]: 7.1 [5.7] vs. 5.5 [8.9] and 4.4 [4.6] in the previous 12 months) and were managed more often by hospitalization (52% vs. 24% and 32%) in the USA than the HI and LMI countries. A higher proportion of patients from the USA than the HI/LMI countries reported a negative impact of SCD on their employment/schooling. Although high overall satisfaction with current treatments was reported globally, most patients indicated a strong desire for alternative pain medications. There are likely several reasons for the relatively high patient‐reported burden in the USA group compared with the HI/LMI countries, including an older population and differences in newborn screening programs and pediatric/adult transition of care. It is clear that there is an urgent need for improved understanding and management of SCD globally, not just in the USA.

A lateral protrusion latticework connects neuroepithelial cells and is regulated during neurogenesis

Dynamic contacts between cells within the developing neuroepithelium are poorly understood but play important roles in cell and tissue morphology and cell signalling. Here, using live-cell imaging and electron microscopy we reveal multiple protrusive structures in neuroepithelial apical endfeet of the chick embryonic spinal cord, including sub-apical protrusions that extend laterally within the tissue, and observe similar structures in human neuroepithelium. We characterise the dynamics, shape and cytoskeleton of these lateral protrusions and distinguish them from cytonemes, filopodia and tunnelling nanotubes. We demonstrate that lateral protrusions form a latticework of membrane contacts between non-adjacent cells, depend on actin but not microtubule dynamics, and provide a lamellipodial-like platform for further extending fine actin-dependent filipodia. We find that lateral protrusions depend on the actin-binding protein WAVE1 (also known as WASF1): misexpression of mutant WAVE1 attenuated protrusion and generated a round-ended apical endfoot morphology. However, this did not alter apico-basal cell polarity or tissue integrity. During normal neuronal delamination, lateral protrusions were withdrawn, but precocious protrusion loss induced by mutant WAVE1 was insufficient to trigger neurogenesis. This study uncovers a new form of cell-cell contact within the developing neuroepithelium, regulation of which prefigures neuronal delamination. This article has an associated First Person interview with the first author of the paper.

The Precision Interventions for Severe and/or Exacerbation-Prone (PrecISE) Asthma Network: An overview of Network organization, procedures, and interventions

Asthma is a heterogeneous disease, with multiple underlying inflammatory pathways and structural airway abnormalities that impact disease persistence and severity. Recent progress has been made in developing targeted asthma therapeutics, especially for subjects with eosinophilic asthma. However, there is an unmet need for new approaches to treat patients with severe and exacerbation-prone asthma, who contribute disproportionately to disease burden. Extensive deep phenotyping has revealed the heterogeneous nature of severe asthma and identified distinct disease subtypes. A current challenge in the field is to translate new and emerging knowledge about different pathobiologic mechanisms in asthma into patient-specific therapies, with the ultimate goal of modifying the natural history of disease. Here, we describe the Precision Interventions for Severe and/or Exacerbation-Prone Asthma (PrecISE) Network, a groundbreaking collaborative effort of asthma researchers and biostatisticians from around the United States. The PrecISE Network was designed to conduct phase II/proof-of-concept clinical trials of precision interventions in the population with severe asthma, and is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health. Using an innovative adaptive platform trial design, the PrecISE Network will evaluate up to 6 interventions simultaneously in biomarker-defined subgroups of subjects. We review the development and organizational structure of the PrecISE Network, and choice of interventions being studied. We hope that the PrecISE Network will enhance our understanding of asthma subtypes and accelerate the development of therapeutics for severe asthma.

Levetiracetam-induced gingival hyperplasia

Levetiracetam is a new generation antiseizure medication which binds to synaptic vesicle protein SV2A and inhibits the release of neurotransmitters. Gingival hyperplasia is a common side effect of conventional antiseizure medications like phenytoin, but very rare with the newer ones. A 14-year-old boy was started on levetiracetam 250 mg twice daily after a generalized seizure. Five days later he presented with gingival swelling and painful oral aphthae, without lymphadenopathy or systemic symptoms. Blood investigations were normal. After one-month of stopping the drug, the lesions cleared. This case highlights the importance of maintaining good oral hygiene and periodic dental review in patients on antiseizure medications.

Which lesions with a radiological or core biopsy diagnosis of fibroadenoma should be excised?

INTRODUCTION

A recent Association of Breast Surgery summary statement on fibroadenoma management recommends excision only for cellular fibroepithelial lesions and rapidly growing lesions with a core biopsy diagnosis of fibroadenoma; persistent pain is a relative indication for excision.

METHODS

This retrospective study looked at the impact this approach would have on the diagnosis of phyllodes tumours.

RESULTS

From 2014 to 2018, there were 1,058 core biopsy diagnoses of fibroadenoma; 112 lesions were excised, of which 98 were fibroadenomas, 4 were hamartomas and 10 were phyllodes tumours. In this group, an excision diagnosis of phyllodes tumour was associated with size more than 40 mm, age more than 40 years and radiological suspicion of phyllodes tumour or carcinoma. One hundred and sixty-six excised fibroepithelial lesions with no previous core biopsy included eight phyllodes tumours; in this group, rapid growth was associated with phyllodes tumour diagnosis. Twelve of the 26 fibroepithelial lesions classified as B3 (cellular fibroepithelial lesion or phyllodes tumour) were diagnosed as phyllodes tumours on excision. Using a combination of radiological, clinical and pathological features it was possible to create an excision policy that would recommend excision of 22 of the 31 phyllodes tumours in this period. Eight of the nine 'missed' phyllodes tumours were benign.

CONCLUSION

The Association of Breast Surgery summary statement will reduce the number of fibroadenomas excised, but may also result in delayed diagnosis of some phyllodes tumours. Appropriate safety netting advice should be provided to identify rapidly growing lesions.

1328 A Risk Stratified Post-Nephrectomy Surveillance Protocol – 5-Year Assessment of Performance

Introduction

Recurrence rate of surgically treated localised renal cell carcinoma (RCC) is reported to be approximately 20%. There is lack of consensus on the optimal surveillance regimen. We assess the performance of our surveillance protocol based upon prognostic histological factors. We report the outcome of our first cohort to reach 5 years follow up.

Method

A retrospective analysis was performed of patients who underwent a radical or partial nephrectomy between March 2014 and October 2015. Patients were classified as high, intermediate, or low risk based on pathology; with each group undergoing individualised radiological follow up.

Results

80 patients with pathologically confirmed RCC who underwent partial or radical nephrectomy were identified. Recurrence was noted in 24% (n = 19), and a third of those patients (n = 7) died within the 5-year follow-up period. 79% (n = 15) of patients with recurrence were of intermediate or high-risk group. 90% of recurrences were picked up on surveillance scans, 5% due to symptoms related to the recurrence and 5% incidentally. 70% occurred within the first 2 years post-surgery. 92% (n = 6) of those who died had an ASA of 2 or higher. In the whole cohort, total number of deaths was 13. 38% (n = 5) died of RCC, 54% (n = 7) died of other causes and in 8% (n = 1) cause of death of was unclear.

Conclusions

Our risk stratified surveillance protocol identified 90% of recurrences within the 5-year follow-up. Future refinement of our protocol could include an assessment of performance status which may influence the schedule of radiological surveillance.

Opportunities in cancer imaging: risk-adapted breast imaging in screening

In the UK, women between 50-70 years are invited for 3-yearly mammography screening irrespective of their likelihood of developing breast cancer. The only risk adaption is for women with >30% lifetime risk who are offered annual magnetic resonance imaging (MRI) and mammography, and annual mammography for some moderate-risk women. Using questionnaires, breast density, and polygenic risk scores, it is possible to stratify the population into the lowest 20% risk, who will develop <4% of cancers and the top 4%, who will develop 18% of cancers. Mammography is a good screening test but has low sensitivity of 60% in the 9% of women with the highest category of breast density (BIRADS D) who have a 2.5- to fourfold breast cancer risk. There is evidence that adding ultrasound to the screening mammogram can increase the cancer detection rate and reduce advanced stage interval and next round cancers. Similarly, alternative tests such as contrast-enhanced mammography (CESM) or abbreviated MRI (ABB-MRI) are much more effective in detecting cancer in women with dense breasts. Scintimammography has been shown to be a viable alternative for dense breasts or for follow-up in those with a personal history of breast cancer and scarring as result of treatment. For supplemental screening to be worthwhile in these women, new technologies need to reduce the number of stage II cancers and be cost effective when tested in large scale trials. This article reviews the evidence for supplemental imaging and examines whether a risk-stratified approach is feasible.

Complications of combination intranasal corticosteroids and anti-retroviral therapy

BACKGROUND

Intranasal corticosteroids are widely used for management of many upper airway diseases because of their ability to effectively deliver local relief of inflammation.

CASE REPORT

This paper presents the case of a 51-year-old man with human immunodeficiency virus treated with ritonavir who was started on fluticasone intranasal spray for presumed chronic rhinosinusitis. Months after starting this therapy, he developed symptoms of Cushing's syndrome and avascular necrosis of the shoulder due to the pharmacological interactions between fluticasone and ritonavir.

CONCLUSION

Although intranasal corticosteroids are deemed a low-risk route of drug administration, clinicians need to be vigilant in appropriately prescribing corticosteroids in the setting of drug potentiators, particularly in these high-risk patients. Alternative corticosteroids such as beclomethasone dipropionate should be considered in such cases.

Lime activated flyash-phosphogypsum blend as a low-cost alternative binder

This study investigates the potential of a blended binder formulated from two industrial solid wastes viz. phosphogypsum and fly ash in combination with lime. Three mix proportions of phosphogypsum and fly ash were investigated, and the minimum lime contents required for activation were determined using the Eades and Grim pH test. The lime-fly ash-phosphogypsum blends were then cast into cubes, both in their paste form as well as mortar form, mixed with sand in the ratio of 1:3. They were cured for a period of seven days, and afterwards, their compressive strength was determined. Ordinary Portland cement and lime mortar blocks were also cast as control specimens for comparative evaluation of the strength. The optimal lime-fly ash-phosphogypsum blend was identified and used to construct a masonry prism, and the strengths of the masonry prisms were also evaluated. The optimal lime-fly ash-phosphogypsum blend mortar was also subjected to an X-ray diffraction analysis to determine the reaction products formed during hydration. The study revealed that 5% lime mixed with fly ash:phosphogypsum in the ratio of 3:1 was the optimal proportion which gave the maximum strength to the cubes. The optimal lime-fly ash-phosphogypsum blend mortar developed strength that was higher than conventional Portland cement and lime mortar. The optimal lime-fly ash-phosphogypsum blend mortar masonry prisms developed strength that was comparable to that of Portland cement mortar masonry. The X-ray diffraction analysis revealed the formation of calcium silicate hydrate minerals as well as ettringite and portlandite which were responsible for strength gain.

Impact of sickle cell disease on patients' daily lives, symptoms reported, and disease management strategies: Results from the international Sickle Cell World Assessment Survey (SWAY)

Sickle cell disease (SCD) is a genetic disorder, characterized by hemolytic anemia and vaso‐occlusive crises (VOCs). Data on the global SCD impact on quality of life (QoL) from the patient viewpoint are limited. The international Sickle Cell World Assessment Survey (SWAY) aimed to provide insights into patient‐reported impact of SCD on QoL. This cross‐sectional survey of SCD patients enrolled by healthcare professionals and advocacy groups assessed disease impact on daily life, education and work, symptoms, treatment goals, and disease management. Opinions were captured using a Likert scale of 1‐7 for some questions; 5‐7 indicated “high severity/impact.” Two thousand one hundred and forty five patients (mean age 24.7 years [standard deviation (SD) = 13.1], 39% ≤18 years, 52% female) were surveyed from 16 countries (six geographical regions). A substantial proportion of patients reported that SCD caused a high negative impact on emotions (60%) and school achievement (51%) and a reduction in work hours (53%). A mean of 5.3 VOCs (SD = 6.8) was reported over the 12 months prior to survey (median 3.0 [interquartile range 2.0‐6.0]); 24% were managed at home and 76% required healthcare services. Other than VOCs, fatigue was the most commonly reported symptom in the month before survey (65%), graded “high severity” by 67% of patients. Depression and anxiety were reported by 39% and 38% of patients, respectively. The most common patient treatment goal was improving QoL (55%). Findings from SWAY reaffirm that SCD confers a significant burden on patients, epitomized by the high impact on patientsʼ QoL and emotional wellbeing, and the high prevalence of self‐reported VOCs and other symptoms.

Highly pathogenic avian influenza virus H5N6 (clade 2.3.4.4b) has a preferable host tropism for waterfowl reflected in its inefficient transmission to terrestrial poultry

Highly-pathogenic avian influenza virus (HPAIV) H5N6 (clade 2.3.4.4b) incurred into Europe in late 2017 and was predominantly detected in wild birds, with very few terrestrial poultry cases. Pekin ducks directly-infected with a UK virus (H5N6-2017) were donors of infection to investigate contact transmission to three recipient species: Ducks, chickens and turkeys. H5N6-2017 transmission to ducks was 100% efficient, but transmission to in-contact galliforme species was infrequent and unpredictable, thereby reflecting the European 2017-2018 H5N6 epidemiology. Although only two of 28 (7%) infected ducks died, the six turkeys and one chicken which became infected all died and displayed systemic H5N6-2017 dissemination, while pathogenesis in ducks was generally milder. Analysis of H5N6-2017 progeny in the contacts revealed no emergent polymorphisms in an infected duck, but the galliforme species included changes in the polymerase (PB2 A199T, PA D347A), matrix (M1 T218A) and neuraminidase genes (T88I). H5N6-2017 environmental contamination was associated with duck shedding.

Social Listening in Eastern and Southern Africa, a UNICEF Risk Communication and Community Engagement Strategy to Address the COVID-19 Infodemic

The coronavirus disease 2019 (COVID-19) pandemic has been closely tied with what has been called an infodemic, a “second disease” that occurs when massive information volumes (particularly with a high prevalence of false information) hinder the public health response. In this context, social listening, the process of monitoring and analyzing conversations to inform strategic activities both online and offline, becomes an even more essential component of risk communication and engagement strategies. In the Eastern and Southern Africa region, the United Nations Children's Fund (UNICEF) and partners in the response have activated their capacity to gather insights on the information needs of the populations served to better inform and engage with local communities. We describe the social listening approach taken at the Eastern and Southern Africa regional level to respond to COVID-19 and highlight efforts by the Comoros, Kenya, Madagascar, Malawi, and Zambia UNICEF country offices to implement digital and nondigital social listening to inform risk communication and community engagement. The analysis highlights channels leveraged, types of data monitored, and provides examples of social listening data use, as well as early challenges and lessons learned.

Tyrosine 192 within the SH2 domain of the Src-protein tyrosine kinase p56Lck regulates T-cell activation independently of Lck/CD45 interactions

BACKGROUND

Upon engagement of the T-cell receptor (TCR), the Src-family protein tyrosine kinase p56Lck phosphorylates components of the TCR (e.g. the TCRζ chains), thereby initiating T-cell activation. The enzymatic activity of Lck is primarily regulated via reversible and dynamic phosphorylation of two tyrosine residues, Y394 and Y505. Lck possesses an additional highly conserved tyrosine Y192, located within the SH2 domain, whose role in T-cell activation is not fully understood.

METHODS

Knock-in mice expressing a phospho-mimetic (Y192E) form of Lck were generated. Cellular and biochemical characterization was performed to elucidate the function of Y192 in primary T cells. HEK 293T and Jurkat T cells were used for in vitro studies.

RESULTS

Co-immunoprecipitation studies and biochemical analyses using T cells from Lck^Y192E knock-in mice revealed a diminished binding of Lck^Y192E to CD45 and a concomitant hyperphosphorylation of Y505, thus corroborating previous data obtained in Jurkat T cells. Surprisingly however, in vitro kinase assays showed that Lck^Y192E possesses a normal enzymatic activity in human and murine T cells. FLIM/FRET measurements employing an Lck^Y192E biosensor further indicated that the steady state conformation of the Lck^Y192E mutant is similar to Lck^wt. These data suggest that Y192 might regulate Lck functions also independently from the Lck/CD45-association. Indeed, when Lck^Y192E was expressed in CD45^-/-/Csk^-/- non-T cells (HEK 293T cells), phosphorylation of Y505 was similar to Lck^wt, but Lck^Y192E still failed to optimally phosphorylate and activate the Lck downstream substrate ZAP70. Furthermore, Lck^Y19E was recruited less to CD3 after TCR stimulation.

CONCLUSIONS

Taken together, phosphorylation of Y192 regulates Lck functions in T cells at least twofold, by preventing Lck association to CD45 and by modulating ligand-induced recruitment of Lck to the TCR.

MAJOR FINDINGS

Our data change the current view on the function of Y192 and suggest that Y192 also regulates Lck activity in a manner independent of Y505 phosphorylation. Video Abstract.

Diabetes at the front door. A guideline for dealing with glucose related emergencies at the time of acute hospital admission from the Joint British Diabetes Society (JBDS) for Inpatient Care Group

People with diabetes account for nearly one-fifth of all inpatients in English and Welsh hospitals; of these, up to 90% are admitted as an emergency. Most are admitted for a reason other than diabetes with only 8% requiring admission for a diabetes-specific cause. Healthcare professionals working in emergency departments experience numerous clinical challenges, notwithstanding the need to know whether each individual with diabetes requires urgent admission. This document has been developed and written by experts in the field, and reviewed by the parent organizations of the Joint British Diabetes Societies for Inpatient Care-Diabetes UK, the Diabetes Inpatient Specialist Nurse Group and the Association of British Clinical Diabetologists. The document aims to support staff working in emergency departments and elsewhere by offering practical advice and tools for effective, appropriate and safe triage. Each section relates to the commonest diabetic specific emergencies and algorithms can be printed off to enable ease of access and use.