Classifying early infant feeding status from clinical notes using natural language processing and machine learning

The objective of this study is to develop and evaluate natural language processing (NLP) and machine learning models to predict infant feeding status from clinical notes in the Epic electronic health records system. The primary outcome was the classification of infant feeding status from clinical notes using Medical Subject Headings (MeSH) terms. Annotation of notes was completed using TeamTat to uniquely classify clinical notes according to infant feeding status. We trained 6 machine learning models to classify infant feeding status: logistic regression, random forest, XGBoost gradient descent, k-nearest neighbors, and support-vector classifier. Model comparison was evaluated based on overall accuracy, precision, recall, and F1 score. Our modeling corpus included an even number of clinical notes that was a balanced sample across each class. We manually reviewed 999 notes that represented 746 mother-infant dyads with a mean gestational age of 38.9 weeks and a mean maternal age of 26.6 years. The most frequent feeding status classification present for this study was exclusive breastfeeding [n = 183 (18.3%)], followed by exclusive formula bottle feeding [n = 146 (14.6%)], and exclusive feeding of expressed mother's milk [n = 102 (10.2%)], with mixed feeding being the least frequent [n = 23 (2.3%)]. Our final analysis evaluated the classification of clinical notes as breast, formula/bottle, and missing. The machine learning models were trained on these three classes after performing balancing and down sampling. The XGBoost model outperformed all others by achieving an accuracy of 90.1%, a macro-averaged precision of 90.3%, a macro-averaged recall of 90.1%, and a macro-averaged F1 score of 90.1%. Our results demonstrate that natural language processing can be applied to clinical notes stored in the electronic health records to classify infant feeding status. Early identification of breastfeeding status using NLP on unstructured electronic health records data can be used to inform precision public health interventions focused on improving lactation support for postpartum patients.

COVID-19 booster enhances IgG mediated viral neutralization by human milk in vitro

Background

Facilitated by the inability to vaccinate, and an immature immune system, COVID-19 remains a leading cause of death among children. Vaccinated lactating mothers produce specific SARS-CoV-2 antibodies in their milk, capable of neutralizing the virus in vitro. Our objective for this study is to assess the effect of COVID-19 booster dose on SARS-CoV-2 antibody concentration and viral neutralization in milk, plasma, and infant stool.

Methods

Thirty-nine mothers and 25 infants were enrolled from December 2020 to May 2022. Milk, maternal plasma, and infants' stool were collected at various time-points up to 12 months following mRNA COVID-19 vaccination. A subgroup of 14 mothers received a booster dose. SARS-CoV-2 antibody levels and their neutralization capacities were assessed.

Results

Booster vaccination led to significantly higher IgG levels within human milk and breastfed infants' stool. In vitro neutralization of VSV-gfp-SARS-CoV-2-S-gp, a laboratory safe SARS-CoV-2 like pseudovirus, improved following the booster, with a 90% increase in plasma neutralization and a 60% increase in milk neutralization. We found that post-booster neutralization by human milk was highly correlated to SARS-CoV-2 IgG level. In support of our correlation result, Protein G column depletion of IgG in milk yielded a significant reduction in viral neutralization (p = 0.04).

Discussion

The substantial increase in neutralizing IgG levels in milk and breastfed infants' stool post-booster, coupled with the decrease in milk neutralization capabilities upon IgG depletion, underscores the efficacy of booster doses in augmenting the immune response against SARS-CoV-2 in human milk.

Detection of SARS-CoV-2 IgA and IgG in human milk and breastfeeding infant stool 6 months after maternal COVID-19 vaccination

OBJECTIVE

Assess presence, durability, and neutralization capacity of SARS-CoV-2-specific antibodies in breastfeeding infants' stool, mother's plasma and milk following maternal vaccination.

DESIGN

Thirty-seven mothers and 25 infants were enrolled between December 2020 and November 2021 for this prospective observational study. All mothers were vaccinated during lactation except three, which were vaccinated during pregnancy. Milk, maternal plasma, and infants' stool was collected pre-vaccination and at periods up to 6 months following COVID-19 vaccine series initiation/completion. SARS-CoV-2 antibody levels and their neutralization capacities were assessed.

RESULTS

SARS-CoV-2-specific IgA and IgG levels were higher in infant stool post-maternal vaccination amongst milk-fed compared to controls. Maternal SARS-CoV-2-specific IgA and IgG concentrations decreased over 6 months post-vaccination but remained higher than pre-vaccination levels. We observed improved neutralization capacity in milk and plasma after COVID-19 vaccination.

CONCLUSIONS

The presence of SARS-CoV-2-specific antibodies in infant stool following maternal vaccination offers further evidence of the lasting transfer of these antibodies through breastfeeding.

Skin microbiome sampling in the preterm neonate

Despite advances in our understanding of the human microbiome, there exist significant knowledge gaps in our understanding of the skin microbiome of the preterm neonate. Herein, we describe skin microbiome sampling of six preterm neonates at multiple timepoints, and compare the skin microbiome samples to environmental (crib/isolette swabs) and negative controls. Samples of the same type (skin, crib, control) were more similar than when compared by week or by patient.

Detection of SARS-CoV-2 IgA and IgG in human milk and breastfeeding infant stool 6 months after maternal COVID-19 vaccination

Objective Assess the presence, durability, and neutralization capacity of SARS-CoV-2-specific antibodies in breastfeeding infants' stools, mother's plasma, and human milk following maternal vaccination. Design Thirty-seven mothers and 25 infants were enrolled between December 2020 and November 2021 for this prospective observational study. Human milk, maternal plasma, and infants' stools were collected pre-vaccination and at periods up to 6 months following COVID-19 vaccine series initiation/completion. SARS-CoV-2 antibody levels and their neutralization capacities were assessed in collected samples. Results SARS-CoV-2-specific IgA and IgG levels were higher in infant stool post-maternal vaccination amongst milk-fed compared to pre-COVID controls. Human milk and plasma SARS-CoV-2-specific IgA and IgG concentrations decreased over 6 months post-vaccination but remained higher than pre-vaccination levels. We observed improved neutralization capacity in milk antibodies over time. Conclusions The presence of neutralizing SARS-CoV-2-specific antibodies in infant stool following maternal vaccination offers further evidence of the lasting transfer of these antibodies through breastfeeding and their protective effect.

POS0690 SYSTEMATIC LITERATURE REVIEW: WHICH ROUTE AND DOSE OF CORTICOSTEROID IS MOST EFFECTIVE IN INDUCING REMISSION IN EARLY RHEUMATOID ARTHRITIS?

Background

Current NICE guidance for rheumatoid arthritis (RA) states that glucocorticoids may be used for bridging therapy and to rapidly decrease inflammation in acute flares1. However, a recommended route and dosage is not specified, and variation has been observed between individual departments as to whether or not steroids are administered2. Glucocorticoids are associated with adverse events that can be severe, leading to a strong recommendation by the American College of Rheumatology to avoid long term use3. It is therefore important to ascertain the efficacy of available routes and dosages of glucocorticoids to weigh against these risks.

Objectives

This review aimed to ascertain the optimum route and dose of corticosteroid for adults with early RA.

Methods

Papers included were full text, English language, randomised controlled trials that fulfilled the PICO criteria. The population was defined as adults with early RA with onset <2 years, the intervention corticosteroids of any route or dose, the comparator conventional DMARDs or placebo, and the primary outcome remission. Functional improvement and X ray progression were considered as secondary outcomes. MEDLINE, Embase, Web of Science and Cochrane Central were searched. Screening of results and extracted data was carried out by both reviewers. During data extraction, outcomes were rounded to timepoints of 3, 6 and 12 months, and steroid doses were stratified into low (up to 10mg/day prednisolone or equivalent), medium (15-30mg) and high (>30mg). Meta-analyses were carried out in RevMan 5.4 when 3 or more studies measured the same outcome at the same dose and route. A funnel plot was generated to check for publication bias.

Results

Three papers measured DAS28 remission rate at 1 year, comparing DMARDs only to DMARDs plus low dose oral steroids. The Forest plot for this meta-analysis is shown in Figure 1. As I2 = 0%, a fixed effect method was used. This shows an odds ratio (OR) of 1.73 (95% CI 1.25, 2.39) favouring low dose steroids in addition to DMARDs. Meta-analyses were also possible for HAQ at 1 year, and mean DAS28 at 1 year, comparing DMARDs alone to DMARDs plus low dose steroids. Both analyses favoured steroids; for HAQ scores the standardised mean difference (SMD) was -0.69 (95% CI -1.66, 0.29), and for DAS28 the SMD was -0.36 (95% CI -0.58, -0.15). At 3 and 6 months there was a lack of available data for meta-analyses.

Figure 1.

Forest plot showing the OR of DAS28 remission with low dose steroids and conventional DMARDs vs DMARDs only

Conclusion

At 1 year, remission and improvement in function appear more likely if low dose steroids are used. Due to a lack of available data, non-oral routes, higher doses and X ray progression could not be analysed. Studies were not designed to detect differences in adverse events. This highlights the need for further clinical research into steroid efficacy in early RA, as the meta-analyses suggest that glucocorticoids may be more effective in inducing remission in early disease than conventional DMARDs alone.

References

[1]National Institute for Health and Care Excellence. Rheumatoid arthritis in adults: management. https://www.nice.org.uk/guidance/ng100/chapter/Recommendations

[2]Yates et al. Rheumatology. 2020;59: 2035-42.

[3]Fraenkel et al. Arthritis Care & Research. 2021;73: 924-39.

Disclosure of Interests

None declared

Detection of SARS-CoV-2 specific antibodies in breastfeeding infant stool following mother’s COVID-19 vaccination

In December 2020, efficacious COVID-19 vaccines were approved for use and since, millions have been immunized against SARS-CoV-2, the virus responsible for COVID-19. It is known that administration of the COVID-19 vaccine leads to increased SARS-CoV-2 specific antibodies in plasma and human milk. While this increase has been studied, the durability, longevity, and efficacy of these antibodies remains unknown. Historically, human milk serves a vital role in providing protection and nutrients to infants, and with COVID-19 vaccines not approved for children under five, immunity and protection from vaccinated mothers is likely a crucial barrier for infant safety. This study aimed at determining how long these antibodies remain in plasma and milk after COVID-19 vaccination, how effective these antibodies are at neutralizing SARS-CoV-2, and if antibodies are detectable in breastfeeding infant stool after mother has been vaccinated. This study found that concentrations of SARS-CoV-2 specific IgA and IgG decrease over 6 months post vaccine, but remain higher than pre-vaccination levels in plasma and milk. Although post-neutralization efficacy decreased over a 6-month period in plasma, using a pseudo-type vaccine neutralization assay, neutralization efficacy in human milk became more robust over the same period. Notably, we found elevated levels of SARS-CoV-2 specific IgA and IgG and neutralization within the stool of breastfeeding infants, post COVID vaccination compared to pre-COVID stool. Although further studies will be needed to determine the full extent of this passive immunity, these studies implicate the maternal/infant transfer of neutralizing SARS-CoV-2 specific antibodies through human milk subsequent to vaccination.

Supported by Children's Miracle Network

Detection of SARS-CoV-2-Specific IgA in the Human Milk of COVID-19 Vaccinated Lactating Health Care Workers

Background: In 2019, a deadly virus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), responsible for coronavirus disease 2019 (COVID-19), emerged. In December 2020, two mRNA-based COVID-19 vaccines were approved for use in the United States, which provide immunity to those receiving the vaccine. Maternally derived antibodies are a key element of infants' immunity. Certain vaccines given to pregnant and lactating mothers provide immunity to infants through transmission across the placenta, umbilical cord (IgG), and human milk (IgA). Human milk produced by mothers with a history of COVID-19 infection contains SARS-CoV-2 IgA and IgG. The purpose of this study is to determine whether SARS-CoV-2-specific immunoglobulins are found in human milk after the COVID-19 vaccination, and to characterize the types of immunoglobulins present. Methods: This is a prospective observational study conducted at Shands Hospital, University of Florida, from December 2020 to March 2021. Twenty-two lactating health care workers who received the SARS-CoV-2 mRNA vaccine (Pfizer/BioNTech or Moderna) made up the sample group. Plasma and human milk were collected at three time points (prevaccination, post-first vaccine dose, and post-second vaccine dose). SARS-CoV-2-specific IgA and IgG in human milk and in plasma were measured by enzyme-linked immunosorbent assay (ELISA). Maternal demographics were compiled. Results: We found significant secretion of SARS-CoV-2-specific IgA and IgG in human milk and plasma after SARS-CoV-2 vaccination. Conclusions: Our results show that the mRNA-based COVID-19 vaccines induce SARS-CoV-2-specific IgA and IgG secretion in human milk. Further studies are needed to determine the duration of this immune response, its capacity to neutralize the COVID-19 virus, the transfer of passive immunity to breastfeeding infants, and the potential therapeutic use of human milk IgA to combat SARS-CoV-2 infections and COVID-19.

The public health community's use of social media for policy advocacy: a scoping review and suggestions to advance the field

OBJECTIVES

This study aimed to investigate the extent and key characteristics of academic research and scholarship on the public health community's use of social media for policy advocacy purposes. This will enable an evaluation of extant research and provide insight into directions for future research.

STUDY DESIGN

This study was a scoping review of academic literature.

METHODS

A scoping review of academic literature published between 1 January 2011 and 31 December 2020 was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Boolean searches were conducted using a university library platform, which included databases, such as EBSCO host, Informit, Scopus, and ScienceDirect. Data were extracted using an a priori code frame, and publication, content, and disciplinary characteristics were analysed. The results of coding and screening comparison checks were within acceptable limits.

RESULTS

In total, 2672 works from around the world were identified and screened for inclusion. Twenty-two English language articles were included in the final analysis. The public health community's use of social media for policy advocacy purposes has largely been approached from a health perspective, despite research and scholarship about social media in communication and policy disciplines (among others). Reported research aims or questions emphasised functional rather than theoretical contributions. Most analysed works used empirical or case study-based methods and were produced by authors in Western geographies. Among the health issues discussed, tobacco and tobacco control were discussed most frequently. While recognising issues with social media, most publications framed social media as more of an opportunity than a problem.

CONCLUSIONS

The public health community's use of social media for policy advocacy purposes is an emerging field. There is considerable potential to expand scholarship and research in this field internationally, especially by integrating transdisciplinary knowledge and perspectives and by applying social media to foster policy change around identified global health challenges. Greater representation of authors from institutions in the Global South is also encouraged, as are applied and theoretical contributions.

AB0298 PREGNANCY IN RHEUMATIC DISEASE: A REGION WIDE SURVEY OF CURRENT PRACTICE AMONGST CLINICIANS IN THE WESSEX MULTI-DISCIPLINARY CONNECTIVE TISSUE DISEASE NETWORK

Background:

Rheumatic diseases frequently affect females of child-bearing age, with implications for foetal and maternal outcomes.

Two-thirds (66%) of the women who died in the 2016-18 MBRRACE report were known to have pre-existing medical problems1. The NHS long-term plan supports creation of Maternal Medicine Networks to facilitate access to specialist care and advice in pregnancy.

Guidelines exist for use of disease modifying anti-rheumatic drugs (DMARDs) during pregnancy but other aspects of pregnancy related care in rheumatic disease remain less well defined. The Wessex wide connective tissue disease (CTD) network provides a multi-disciplinary forum to discuss cases, to obtain approval for high cost drugs, to compare practice in multiple hospitals but does not specifically discuss pregnancy related uncertainties.

Objectives:

To survey variations in clinical practice relating to rheumatic disease in pregnancy

Methods:

Following careful project planning with the tertiary referral centre obstetric lead consultant for maternal medicine, several areas of care were identified which were prone to local and individual variation. An anonymous online survey relating to these specific areas of pregnancy related care was circulated amongst members of the CTD network, including rheumatology consultants, rheumatology practitioners and specialist trainees.

Results:

16 responses were obtained across 7 hospital sites; 56% were from rheumatology consultants. 12/16 (75%) reported routinely offering contraceptive advice when prescribing DMARDs. Only 4/16 (25%) were aware of a specific pre-natal obstetric clinic available in their hospital. There was major variation in planned frequency of clinical review. 10/16 would increase frequency of review during pregnancy if a patient’s disease became active or unstable; 6/16 would aim to review patients approximately 3 monthly; 3/16 would not routinely increase frequency of review during pregnancy. Planned post-natal care was equally varied. 3/16 would routinely prescribe aspirin to all lupus women during pregnancy despite this being recommended for all women with SLE for prevention of pre-eclampsia2. Prescription of low molecular weight heparin was variable, and several responses were at odds with the current RCOG guidance on the subject3. 8/16 (50%) would prescribe corticosteroids judiciously in case of an acute disease flare.

Conclusion:

This survey has revealed significant variation in practice relating to rheumatic disease in pregnancy. Integrated care with colleagues from the regional referral centre for maternal medicine is required, in keeping with the recently published NICE guidance on the subject4. Adopting a hub and spoke model, with local centres working closely alongside a tertiary centre, will help optimise peri-partum care and outcome for patients with long-term rheumatic conditions.

References:

[1]Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) Saving Lives, Improving Mothers’ Care Maternal Report (December 2020). Available at https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2020/MBRRACE-UK_Maternal_Report_Dec_2020_v10.pdf [Accessed 28 January 2021]

[2]National Institute for Health and Care Excellence (2019) Hypertension in pregnancy: diagnosis and management (NICE guideline 133) Available at https://www.nice.org.uk/guidance/ng133 [Accessed 28 January 2021]

[3]Royal College of Obstetricians and Gynaecologists (2015) Reducing the risk of venous thromboembolism during pregnancy and the puerperium (Green-top Guideline Number 37a) Available at https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-37a.pdf [Accessed 5 January 2021]

[4]National Institute for Health and Care Excellence (2019) Intrapartum care for women with existing medical conditions or obstetric complications and their babies (NICE guideline 121) Available at https://www.nice.org.uk/guidance/ng121 [Accessed 5 January 2021]

Disclosure of Interests:

None declared

AB0903-HPR DURATION OF TELEPHONE CONSULTATIONS AMONGST RHEUMATOLOGY PRACTITIONERS IN A DISTRICT GENERAL HOSPITAL - ADAPTING TO REMOTE CONSULTATION IN A COVID-19 PANDEMIC

Background:

The Covid-19 pandemic has resulted in a rapid adoption of remote consultations in order to limit face to face clinical contact wherever appropriate, as recommended by the British Society for Rheumatology. The same clinic templates which existed for face-to-face encounters have been retrospectively adapted, without consideration of any potential difference in duration of consultations. Rheumatology practitioners from a variety of clinical backgrounds work alongside the rheumatology consultants, providing clinical care to patients with both inflammatory arthritis and connective tissue disease.

Objectives:

To record the duration of all scheduled telephone consultations carried out by advances rheumatology practitioners in a 4-week period.

Methods:

All scheduled telephone clinic encounters over a 4-week period were timed and the duration recorded in a spreadsheet. Data was collected in real time by all 8 rheumatology advanced practitioners working within the rheumatology department of a district general hospital, following each clinic episode.

Results:

Data was recorded from a total of 337 clinic appointments. Of these, 317 (94%) were booked as routine, 3 (0.9%) as urgent, 4 (1.2%) were expedited following an advice line contact, and 13 (3.9%) no data was recorded. 28 (8%) of the patients did not answer when contacted. 80 (24%) clinic appointments lasted 15 minutes or less, 186 (55%) lasted 16 - 30 minutes, 37 (11%) lasted 31 - 45 minutes, and 6 (2%) lasted 46 - 60 minutes. The average duration was 22 minutes.

Conclusion:

Within this department, remote consultations appear to have a similar duration when compared against the traditional clinic template for a fully face-to-face clinic, with some encounters lasting significantly longer than the planned duration. This would appear to differ to telephone consultations used in other settings, such as general practice where the duration is reportedly shorter1. This may be representative of the additional complexity and co-morbidity of a typical rheumatology patient, or due to the multi-faceted nature of a rheumatology follow-up appointment2. Although remote consultations are effective in limiting risk of exposure to Covid-19, they may not offer a quicker or more efficient service compared with the face-to-face model. Further study in this field is required to evaluate this widely adopted new pattern of working.

References:

[1]Pinnock H, Bawden R, Proctor S, Wolfe S, Scullion J, Price D, Sheikh A. Accessibility, acceptability, and effectiveness in primary care of routine telephone review of asthma: pragmatic, randomised controlled trial. BMJ. 2003 Mar 1;326(7387):477-9. doi: 10.1136/bmj.326.7387.477. PMID: 12609944; PMCID: PMC150181.

[2]National Institute for Health and Care Excellence (NICE) (2018) rheumatoid arthritis in adults: management (NICE Guideline NG100). Available at https://www.nice.org.uk/guidance/ng100 [Accessed 05 January 2021].

Disclosure of Interests:

None declared

AB0421 MANAGEMENT OF ULCERATION IN SYSTEMIC SCLEROSIS BY A SPECIALIST PODIATRY SERVICE; A CASE SERIES

Background:

Systemic sclerosis is a chronic disorder characterised by diffuse fibrosis and vascular abnormalities in the skin and major organs. Digital ulceration is a common complication, often resulting in patient disability. These ulcers can form through a variety of processes and management should be tailored according to aetiology. In Dorset, the specialist podiatry service has created a unique facility for optimal wound care in the setting of digital ulceration.

Objectives:

In this case series, we outline podiatric management of 4 common causes of digital ulceration in systemic sclerosis.

Methods:

Tissue ischaemia, infection, micro-trauma and calcinosis were identified as four major contributory factors resulting in ulceration or delayed wound healing. Four cases exemplifying management of each different contributory factor were identified and their case notes reviewed in order to extract clinically relevant data and images.

Results:

Case 1 illustrates treatment of ischaemic tissue injury to promote earlier healing, using careful wound care, debridement under local anaesthetic and low-level laser therapy.

Case 2 illustrates the importance of identifying repeated micro-trauma as a contributing factor to non-healing ulceration.

Case 3 demonstrates how surgical debridement or removal of the subcutaneous calcinosis in an outpatient setting can be a useful adjunct in encouraging ulcer healing.

Case 4 illustrates the complexity of correctly identifying infection in the setting of ulceration, with prompt management promoting wound healing.

Conclusion:

The pathophysiology of ischaemic tissue damage in scleroderma is complex and can reflect a broad range of vascular pathologies, often occurring concurrently1 including vasospasm, macrovascular disease and microvascular vasculopathy, leading to digital ulceration. Rapid identification of which processes are driving the ischaemia is critical in targeting therapy to the affected individual. A local podiatry service with expertise in management of tissue -related complications of systemic sclerosis is invaluable in promoting wound healing and preventing further complications.

References:

[1]Hughes M, Herrick A L. Digital ulcers in systemic sclerosis. Rheumatology 2017; 56(1):14-25.

Disclosure of Interests:

None declared

AB0409 INTRAVENOUS ILOPROST: A REGION WIDE SURVEY OF CURRENT PRESCRIBING AMONGST HOSPITALS IN THE WESSEX MULTI-DISCIPLINARY CONNECTIVE TISSUE DISEASE NETWORK

Background:

Digital ulceration in systemic sclerosis is a severe and disabling aspect of this complex, multi-system disease. Traditionally, intravenous (IV) iloprost has been prescribed to treat the problem. Alternative oral medications including sildenafil and bosentan are now readily available, although NHS clinical commissioning policy is yet to be updated to reflect changes in drug costs. Use of IV iloprost across Wessex was audited to review current practice across the region.

Objectives:

To compare use of IV iloprost across 7 different hospital rheumatology departments

Methods:

Data was collected across 7 different NHS hospital sites using rheumatology specific pharmacy records for high cost drug prescribing and a single uniform data collection proforma, which was then analysed by 1 person to ensure uniformity of results. Case notes were reviewed retrospectively to determine diagnosis, frequency and duration of iloprost treatment, if patients had been considered for sildenafil treatment (including if sildenafil was prescribed, any cautions or contra-indications to treatment, dose and any reason for discontinuation of treatment) and if patients had been considered for bosentan treatment and if it was prescribed.

Results:

45 patients were identified currently receiving IV iloprost. 32/45 (71%) had a diagnosis of systemic sclerosis, mixed connective tissue disease (CTD) or undifferentiated CTD (to be called scleroderma group). 13/45 had other miscellaneous diagnoses which had resulted in digital ulceration. These 13 patients were excluded from further analysis relating to sildenafil or bosentan prescribing as these medications were not indicated for other causes of digital ulceration. In the scleroderma group, 27/32 (84%) had been considered for sildenafil treatment. Of these, 8/27 started and discontinued due to intolerance and 17/27 remained on sildenafil. In the scleroderma group, 9/32 had been considered for bosentan treatment, and of these 7/9 remained on bosentan.

Conclusion:

The authors have identified that IV iloprost is still widely used for management of digital ulceration in rheumatology departments across seven different hospitals in Wessex. Most of this group of patients would likely be eligible for treatment with sildenafil or bosentan. Sildenafil intolerance is a challenge to management. Consideration of bosentan as a treatment option was limited in this group, and may be a cost-effective alternative to IV iloprost which would also eliminate the risk of infection associated with IV access in a potentially immunosuppressed group of patients.

Disclosure of Interests:

None declared

Effect of SARS-CoV-2 vaccine on the breastmilk antibody response among lactating healthcare workers

In 2019, a deadly virus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), responsible for COVID-19, emerged. Two mRNA-based COVID-19 vaccines were approved for use in December 2020 in the US and have begun providing immunity to those receiving the vaccination. Certain vaccines given to pregnant and lactating mothers provide immunity to infants through transmission across the placenta and umbilical cord (IgG) and breast milk (IgA). Breastmilk produced by mothers with a history of COVID-19 infection has found to be a source of anti-SARS-CoV-2 IgA and IgG. This study aimed to determine the presence of specific SARS-CoV-2 IgA in the breastmilk of lactating women after the COVID-19 vaccine administration. As such, lactating healthcare workers who received the SARS-CoV-2 mRNA vaccine (Pfizer-BioNtech or Moderna) made up a sample group. Plasma and breast milk were collected at three time points (pre-vaccination, 14–28 days post first dose of vaccine, and 7 days post second dose of vaccine). SARS-CoV-2 specific IgA (breastmilk) and IgG (plasma) concentration were then measured by ELISA. We found consistent secretion of SARS-CoV-2 specific IgA in breast milk after COVID-19 vaccination. The second dose of the SARS-CoV-2 vaccine was necessary to elicit IgA response in breastmilk detectable by ELISA. There is a correlation of the level of SARS-CoV-2 specific IgG in blood with SARS-CoV-2 specific IgA in breastmilk. Our results show that the mRNA-based COVID-19 vaccines from Pfizer-BioNTech and Moderna induce SARS-CoV-2 specific IgA secretion in breastmilk. Further studies are needed to determine the duration of this immune response and a possible passive immunity transfer of SARS-CoV-2 specific IgA to breastfeeding infants.

Industry funding of patient groups: a systematic review

Background

Patient groups play an important role in health care and policy. Concerns have been raised about the financial ties between the pharmaceutical industry and patient groups, because of potential threats to the groups' independence. We conducted a systematic review to synthesise studies that explored pharmaceutical or medical device industry funding of patient groups.

Methods

We searched Medline, Embase, Web of Science, Scopus and Google Scholar (from inception to January 2018). We included observational studies reporting at least one of the following outcomes: prevalence of industry funding; proportion of industry funded patient groups which disclosed information about this funding; association between industry funding and organisational positions on health and policy issues. We carried out duplicate independent data extraction and assessed study quality.

Results

26 cross-sectional studies were included. Fifteen studies assessed the prevalence of industry funding, which ranged from 20% (12/61) to 83% (86/104). The proportion of patient groups which disclosed funding information on their websites was low (27% [95% CI: 24%-31%]). Few patient groups had formal policies governing corporate sponsorship (range from 2% (2/125) to 64% (175/274)). Among the few studies examining funding status versus organisational position, industry sponsored groups tend to hold positions consistent with sponsors' interests.

Conclusions

We found widespread indications of industry funding of patient groups. Transparency of funding is inadequate and the prevalence of policies governing corporate sponsorship is low. Research on policy impact is still limited. Considering the important role that patient groups play in health, strategies to prevent biases that may favour commercial interests above those of patients need to be implemented.

Key messages

Industry funding of patient groups is common in high income countries. Transparency of funding is inadequate and the prevalence of policies governing corporate sponsorship is low. Considering the important role that patient groups play in health care and policy, strategies to prevent biases that may favour commercial interests above those of patients need to be implemented.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Untargeted Metabolomic Analysis of Gestationally Matched Human and Bovine Milk Samples at 2-Weeks Postnatal

Objectives

Human breast milk is the ideal nutrition source for infant development during the first year of life. Epidemiological data demonstrates that bovine whole milk is often substituted for human milk during the first 12-months of life and may be associated with adverse infant outcomes. The goal of this project is to interrogate the human and bovine milk metabolome at 2-weeks postnatal to identify unique and overlapping metabolites that may impact infant health outcomes.

Methods

Human milk (n = 10) was collected at 2-weeks postpartum from normal weight mothers (pre-pregnant BMI &lt;25 kg/m2) that vaginally delivered term infants and planned to exclusively breastfeed for at least 2-months. Similarly, bovine milk (n = 10) was collected 2-weeks postpartum from normal weight primiparous Holstein dairy cows. Dairy cattle were housed in sand-bedded, shaded barns with access to fans and water soakers and fed a common transition cow total mixed ration. Untargeted metabolomics was completed on all milk samples using high-resolution mass spectrometry. Metabolomic analysis was implemented using an open-source containerized metabolomics pipeline. Data processing was completed using MZmine, mummichog and Python were used for statistical analysis.

Results

We detected 716 metabolomic features in human and bovine milk samples after quality control. Our analysis also revealed that 43% (312) of metabolomics features were present in both human and bovine milk, 23% (167) of metabolomics features were unique to human milk and 33% (237) of metabolomics features existed only in bovine milk samples. Pathway analysis revealed that sialic acid and glycosphingolipid metabolism (P &lt; 0.0009) were common to human and bovine milk samples. We also found that amino acid (tryptophan, tyrosine, purine) metabolism (P &lt; 0.005) was unique to bovine samples and vitamin B3 pathways (P = 0.03) was unique to human samples.

Conclusions

Our analysis revealed a core milk metabolome shared between human and bovine samples. Collectively, these results highlight untargeted metabolomics as a potential strategy to identify unique and overlapping metabolites in bovine and human milk that may impact infant health outcomes.

Funding Sources

Research was supported by NIDDK/K01; SECIM P&F; CTSI Pilot Award; Robin Hood Foundation; NIH Loan Repayment Program.

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

References:

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

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

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

Disclosure of Interests:

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

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

Current concepts in the management of ankle arthritis

Ankle arthritis is a common condition. It causes a significant socioeconomic burden, and is associated with significant morbidity. Patients with ankle arthritis are either elderly with significant co-morbidities, or young adults who have previously suffered with ankle injuries, resulting in post-traumatic arthritis. There is a wide variation in the management of these patients with ankle arthritis. We therefore present an overview of the current evidence based management of patients with symptomatic ankle arthritis.

Determination of the Efficacy of Preservation of Non-Eye Area Water-Miscible Cosmetic and Toiletry Formulations: Collaborative Study

A collaborative study was conducted to test a method developed to distinguish between adequately and inadequately preserved cosmetic formulations. Nineteen laboratories participated in the study. Samples tested included shampoos, hair conditioners, oil-in-water emulsions, and water-in-oil-emulsions. Triplicate samples of 4 adequately preserved and 4 inadequately preserved cosmetic products were tested by each collaborative laboratory. Results showed that all inadequately preserved shampoo and conditioner samples failed to meet the acceptance criteria for adequately preserved formulations. Of the 51 preserved samples, 49 shampoos and 48 conditioners met the criteria for adequate preservation. All samples of inadequately preserved water-in-oil emulsions and oil-in-water emulsions failed to meet the acceptance criteria, whereas all adequately preserved emulsion formulations met the acceptance criteria.

Intra-Operative 3-Dimensional Imaging (O-arm) in Foot and Ankle Trauma Surgery: Report of 2 Cases and Review of the Literature

Background:

Intraoperative two-dimensional (2D) fluoroscopy is the standard imaging modality available to orthopaedic surgeons worldwide. It is well-accepted, however, multiplanar 3 dimensional (3D) CT scanning is superior to 2D imaging for visualising joint surfaces and is now a fundamental feature of the pre-operative planning of intra-articular fractures.

Objective:

We present two cases in which the use of 3D intraoperative imaging and the O-arm® (Medtronic, Minneapolis, USA) led to immediate intraoperative revision to optimise fixation and articular congruity. A review of the current literature is also provided.

Methods:

During the trial period of the O-arm at our major trauma centre, intra-operative imaging was used in the lower limb trauma setting. The O-arm was used intra-operatively in a comminuted pilon fracture and a displaced talus fracture. We recorded all the intra-operative events, including quality of reduction, implant positioning and operation time. Each patient was followed-up for 12 months post-operation and was finally assessed with x-rays and the AOFAS score.

Results:

In both the cases, either fracture reduction or the implant position/usage that was observed with 2D fluoroscopy was revised following a 3D intra-operative scan. No postoperative complications were noted and the healing process was uneventful. X-rays at the final follow-up were excellent and acceptable for the talus and pilon fracture, respectively, with corresponding clinical results and AOFAS score.

Conclusion:

Although frequently used in spinal surgery, to the best of our knowledge, the use of intra-operative 3D techniques in lower limb trauma is sparse and sporadically reported. We present our cases in which the most current innovative imaging techniques influenced intra-operative outcomes without compromising patient safety. We feel that this is a real example of how innovation can positively influence patient care.

Acute continuous moderate-intensity exercise, but not low-volume high-intensity interval exercise, attenuates postprandial suppression of circulating osteocalcin in young overweight and obese adults

Bone remodeling markers (BRMs) are suppressed following the consumption of a meal. Our findings indicate that a single session of continuous moderate-intensity exercise, but not low-volume high-intensity interval exercise, performed 1 h after a meal attenuates the postprandial suppression of BRMs.

INTRODUCTION

Acute exercise transiently increases BRMs including osteocalcin (tOC) and the undercarboxylated form of osteocalcin (ucOC), a hormone that is implicated in glucose regulation. The effects of acute exercise and exercise-intensity on postprandial levels of tOC and ucOC are unknown.

METHODS

Twenty-seven adults that were overweight or obese (age 30 ± 1 years; BMI 30 ± 1 kg∙m^-2; mean ± SEM) were randomly allocated to perform a single session of low-volume high-intensity interval exercise (LV-HIIE; nine females, five males) or continuous moderate-intensity exercise (CMIE; eightfemales, five males) 1 h after consumption of a standard breakfast. Serum tOC, ucOC, and ucOC/tOC were measured at baseline, 1 h, and 3 h after breakfast consumption on a rest day (no exercise) and the exercise day (exercise 1 h after breakfast).

RESULTS

Compared to baseline, serum tOC and ucOC were suppressed 3 h after breakfast on the rest day (- 10 ± 1% and - 6 ± 2%, respectively; p < 0.05), whereas ucOC/tOC was elevated (2.5 ± 1%; p = 0.08). Compared to the rest day, CMIE attenuated the postprandial-induced suppression of tOC (rest day - 10 ± 2% versus CMIE - 5 ± 2%, p < 0.05) and ucOC (rest day - 6 ± 4% versus CMIE 11 ± 2%, p < 0.05), and increased postprandial ucOC/tOC (rest day 3 ± 2% versus CMIE 15 ± 1%, p < 0.05). In contrast, LV-HIIE did not alter postprandial tOC, ucOC, or ucOC/tOC (all p > 0.1).

CONCLUSIONS

Acute CMIE, but not LV-HIIE, attenuates the postprandial-induced suppression of tOC and ucOC. CMIE may be an effective tool to control the circulating levels of BRMs following meal consumption in overweight/obese adults.

Initial microbial community of the neonatal stomach immediately after birth

The purpose of this prospective cross-sectional cohort pilot study is to explore the initial microbial community of gastric aspirate fluid as collected immediately after birth and its relationships with mode of delivery and preterm birth. Twenty-nine gastric aspirate samples collected immediately after birth from infants born between 24-40 weeks gestation were analyzed for microbial composition. Total microbial content was low in many samples, with a substantial number sharing taxonomic composition with negative controls. qPCR targeting the 16S rRNA gene showed that infants delivered vaginally had a higher microbial load than infants delivered by C-section. Some pre-term samples showed high relative abundance of genus Ureaplasma, consistent with previous literature that has implicated infections with this taxon as a potential cause of pre-term birth. Vaginally born term infant samples, by contrast, had significantly higher levels of genus Lactobacillus with Lactobacillus crispatus the most dominant species. Microbial evaluation showed that vaginally born term infant gastric aspirate samples had higher levels of lactobacilli than pre-terms. Samples from many infants had low microbial load near the edge of the detection limit.

Atopic dermatitis and risk of hypertension, type 2 diabetes, myocardial infarction and stroke in a cross-sectional analysis from the Canadian Partnership for Tomorrow Project

BACKGROUND

Atopic dermatitis (AD) has been associated with cardiovascular risk factors and diseases, but epidemiological studies to date have found conflicting results.

OBJECTIVES

To determine the associations of AD with hypertension, type 2 diabetes (T2D), myocardial infarction (MI) and stroke.

METHODS

We conducted a cross-sectional analysis of baseline data from the Canadian Partnership for Tomorrow Project, which includes Canadian residents aged 30-74 years living in British Columbia, Alberta, Ontario, Quebec and the Atlantic Provinces. We excluded participants with incomplete data on AD, hypertension, T2D, MI or stroke, who had type 1 or gestational diabetes or who developed any of the outcomes at an age prior to a diagnosis of AD. This left 259 119 participants in our analysis. We used logistic regression to calculate age- and sex-, and multivariable-adjusted odds ratios (ORs) and 95% confidence intervals (CIs) between AD and subsequent hypertension, T2D, MI and stroke.

RESULTS

AD was reported by 21 379 (8·4%) participants. In total, 52 787 cases of hypertension, 12 739 cases of T2D, 4390 cases of MI and 2235 cases of stroke were reported by participants at enrolment. In the multivariable-adjusted model, AD was associated with decreased odds of hypertension (OR 0·87, 95% CI 0·83-0·90), T2D (OR 0·78, 95% CI 0·71-0·84), MI (OR 0·87, 95% CI 0·75-1·00) and stroke (OR 0·79, 95% CI 0·66-0·95).

CONCLUSIONS

We did not find evidence of a positive association between AD and subsequent hypertension, T2D, MI or stroke; AD was inversely associated with these outcomes in our study. Given our findings and the conflicting literature, AD is likely not a major risk factor for cardiovascular disease.

Multifaceted interaction of bone, muscle, lifestyle interventions and metabolic and cardiovascular disease: role of osteocalcin

Undercarboxylated osteocalcin (ucOC) may play a role in glucose homeostasis and cardiometabolic health. This review examines the epidemiological and interventional evidence associating osteocalcin (OC) and ucOC with metabolic risk and cardiovascular disease. The complexity in assessing such correlations, due to the observational nature of human studies, is discussed. Several studies have reported that higher levels of ucOC and OC are correlated with lower fat mass and HbA1c. In addition, improved measures of glycaemic control via pharmacological and non-pharmacological (e.g. exercise or diet) interventions are often associated with increased circulating levels of OC and/or ucOC. There is also a relationship between lower circulating OC and ucOC and increased measures of vascular calcification and cardiovascular disease. However, not all studies have reported such relationship, some with contradictory findings. Equivocal findings may arise because of the observational nature of the studies and the inability to directly assess the relationship between OC and ucOC on glycaemic control and cardiovascular health in humans. Studying OC and ucOC in humans is further complicated due to numerous confounding factors such as sex differences, menopausal status, vitamin K status, physical activity level, body mass index, insulin sensitivity (normal/insulin resistance/T2DM), tissue-specific effects and renal function among others. Current observational and indirect interventional evidence appears to support a relationship between ucOC with metabolic and cardiovascular disease. There is also emerging evidence to suggest a direct role of ucOC in human metabolism. Further mechanistic studies are required to (a) clarify causality, (b) explore mechanisms involved and

Geostatistical modelling of arsenic in drinking water wells and related toenail arsenic concentrations across Nova Scotia, Canada

Arsenic is a naturally occurring class 1 human carcinogen that is widespread in private drinking water wells throughout the province of Nova Scotia in Canada. In this paper we explore the spatial variation in toenail arsenic concentrations (arsenic body burden) in Nova Scotia. We describe the regional distribution of arsenic concentrations in private well water supplies in the province, and evaluate the geological and environmental features associated with higher levels of arsenic in well water. We develop geostatistical process models to predict high toenail arsenic concentrations and high well water arsenic concentrations, which have utility for studies where no direct measurements of arsenic body burden or arsenic exposure are available. 892 men and women who participated in the Atlantic Partnership for Tomorrow's Health Project provided both drinking water and toenail clipping samples. Information on socio-demographic, lifestyle and health factors was obtained with a set of standardized questionnaires. Anthropometric indices and arsenic concentrations in drinking water and toenails were measured. In addition, data on arsenic concentrations in 10,498 private wells were provided by the Nova Scotia Department of Environment. We utilised stepwise multivariable logistic regression modelling to develop separate statistical models to: a) predict high toenail arsenic concentrations (defined as toenail arsenic levels ≥0.12 μg g(-1)) and b) predict high well water arsenic concentrations (defined as well water arsenic levels ≥5.0 μg L(-1)). We found that the geological and environmental information that predicted well water arsenic concentrations can also be used to accurately predict toenail arsenic concentrations. We conclude that geological and environmental factors contributing to arsenic contamination in well water are the major contributing influences on arsenic body burden among Nova Scotia residents. Further studies are warranted to assess appropriate intervention strategies for reducing arsenic body burden among human populations.

Updated investigations of cancer excesses in individuals born or resident in the vicinity of Sellafield and Dounreay

BACKGROUND

Earlier studies have shown raised risks of leukaemia and non-Hodgkin lymphoma in children, teenagers and young adults resident either at birth or diagnosis in Seascale. Some increases in cancer risk in these age groups have also been noted among those living around Dounreay. We aimed to update previous analyses relating to areas close to these nuclear installations by considering data from an additional 16 years of follow-up.

METHODS

Cross-sectional analyses compared cancer incidence rates for 1963-2006 among those aged 0-24 years at diagnosis living in geographically specified areas around either Sellafield or Dounreay with general population rates. Cancer incidence for the period 1971-2006 among the cohort of Cumbrian births between 1950 and 2006 was compared to national incidence for 1971-2006 using person-years analysis. Cancer among those born in the postcode sector closest to Dounreay was compared with that among those born in the three adjoining postcode sectors. Analyses considered both cancer overall and ICD-O-3 defined diagnostic subgroups including leukaemia, central nervous system tumours and other malignancies.

RESULTS

Apart from previously reported raised risks, no new significantly increased risks for cancer overall or any diagnostic subgroup were found among children or teenagers and young adults living around either nuclear installation. Individuals born close to the installations from 1950 to 2006 were not shown to be at any increased risk of cancer during the period 1971 to date.

CONCLUSIONS

Analysis of recent data suggests that children, teenagers and young adults currently living close to Sellafield and Dounreay are not at an increased risk of developing cancer. Equally, there is no evidence of any increased cancer risk later in life among those resident in these areas at birth.

Gastric residual evaluation in preterm neonates: a useful monitoring technique or a hindrance?

It is routine practice in most neonatal intensive care units to measure the volume and color of gastric residuals (GRs) prior to enteral bolus feedings in preterm very low birth weight infants. However, there is paucity of evidence supporting the routine use of this technique. Moreover, owing to the lack of uniform standards in the management of GRs, wide variations exist as to what constitutes significant GR volume, the importance of GR color and frequency of GR evaluation, and the color or volume standards that dictate discarding or returning GRs. The presence of large GR volumes or green-colored residuals prior to feeding often prompts subsequent feedings to be withheld or reduced because of possible necrotizing enterocolitis resulting in delays in enteral feeding. Cessation or delays in enteral feeding may result in extrauterine growth restriction, a known risk factor for poor neurodevelopmental and growth outcomes in preterm very low birth weight infants. Although some neonatal intensive care units are abandoning the practice of routine GR evaluation, little evidence exists to support the discontinuation or continuation of this practice. This review summarizes the current state of GR evaluation and underlines the need for a scientific basis to either support or refute the routine evaluation of GRs.

Screw fixation of medial malleolar fractures: a cadaveric biomechanical study challenging the current AO philosophy

The AO Foundation advocates the use of partially threaded lag screws in the fixation of fractures of the medial malleolus. However, their threads often bypass the radiodense physeal scar of the distal tibia, possibly failing to obtain more secure purchase and better compression of the fracture. We therefore hypothesised that the partially threaded screws commonly used to fix a medial malleolar fracture often provide suboptimal compression as a result of bypassing the physeal scar, and proposed that better compression of the fracture may be achieved with shorter partially threaded screws or fully threaded screws whose threads engage the physeal scar. We analysed compression at the fracture site in human cadaver medial malleoli treated with either 30 mm or 45 mm long partially threaded screws or 45 mm fully threaded screws. The median compression at the fracture site achieved with 30 mm partially threaded screws (0.95 kg/cm(2) (interquartile range (IQR) 0.8 to 1.2) and 45 mm fully threaded screws (1.0 kg/cm(2) (IQR 0.7 to 2.8)) was significantly higher than that achieved with 45 mm partially threaded screws (0.6 kg/cm(2) (IQR 0.2 to 0.9)) (p = 0.04 and p < 0.001, respectively). The fully threaded screws and the 30mm partially threaded screws were seen to engage the physeal scar under an image intensifier in each case. The results support the use of 30 mm partially threaded or 45 mm fully threaded screws that engage the physeal scar rather than longer partially threaded screws that do not. A 45 mm fully threaded screw may in practice offer additional benefit over 30 mm partially threaded screws in increasing the thread count in the denser paraphyseal region.

Hydrogen peroxide production and free radical-mediated cell stress in Mycoplasma bovis pneumonia

Mycoplasma bovis causes chronic pneumonia and polyarthritis in feedlot cattle. M. bovis infects the lungs of most feedlot cattle, but the majority of calves never develop disease. Competing explanations are that some strains of M. bovis are more virulent than others or, alternatively, that calves require some other abnormality to be present in order for M. bovis to cause disease. We hypothesize that H2O2 production is an important virulence factor of M. bovis, causing oxidative injury to lung tissue. A second hypothesis is that isolates associated with caseonecrotic bronchopneumonia have an increased capacity for H2O2 production. Immunohistochemical markers of oxidative stress (4-hydroxynonenal, HN) and nitrative stress (3-nitrotyrosine, NT) were compared in lungs of calves with caseonecrotic bronchopneumonia characteristic of M. bovis infection, with other forms of bronchopneumonia or with non-inflamed lungs. HN and NT were identified in M. bovis pneumonia, mainly in foci of caseous necrosis. HN was not observed in inflamed non-necrotic tissue in lesions typical of pneumonic pasteurellosis. H2O2 production by M. bovis was identified, but the levels did not differ in isolates from calves with caseonecrotic bronchopneumonia compared with those with non-inflamed lungs or other forms of pneumonia. These findings provide evidence that oxidative and nitrative injury contribute to the formation of the caseonecrotic lesions that are characteristic of M. bovis pneumonia and that production of H2O2 by M. bovis may contribute to this oxidative injury.