Utilisation of specialist epilepsy services and antiseizure medication adherence rates in a cohort of people with epilepsy (PWE) accessing emergency care

BACKGROUND

An epilepsy-related attendance at A&E is associated an increased risk of subsequent death within 6 months. Although further work is required to provide a definitive explanation to account for these findings, in the interim it would seem reasonable that services are designed to ensure timely access and provide support at a time of greatest risk. We aim to determine the frequency of patients accessing specialist neurology services following an epilepsy-related admission/unscheduled care episode and consider ASM adherence at the point of attendance.

METHODS

Patients were identified retrospectively via the NHS Greater Glasgow and Clyde live integrated epilepsy Dashboard following an unscheduled epilepsy-related admission or A&E attendance between 1st January 2022 and 30th June 2022. We calculated adherence to anti-seizure medication for a period of 6 months prior to admission and defined poor medication adherence as a medication possession ratio of less than 80 %. We evaluated the rate of any outpatient neurology clinic attendance in the subsequent 3, 6 and 12 months following an epilepsy-related unscheduled care episode. Additional clinical information was identified via the electronic patient records.

RESULTS

Between 1st Jan 2022 and 30th June 2022, there were 266 emergency care seizure-related attendances. The mean age at attendance was 46 years (range: 16-91). Most of PWE were males (63 %) and 37 % were females. Epilepsy classification-29.3 % had GGE, 41.7% had focal epilepsy, and in 29 % of cases the epilepsy was unclassified. Of the admissions, 107/ 266 (40.2 %) generated follow-up within 6 months of attendance. Poor medication adherence was noted in 54/266 (20.3 %). 28.2 % of cases had input from on-call neurology service during admission/ED attendance, and of those 60 % had ASM adjusted. 18 % of attendances had a background diagnosis of learning disability. One-third of attendances of PWE had a history of mental health disorder 35 % (93/266). 25 % of ED attendances noted an active history of alcohol consumption misuse or/and recreational drug use. 14 (5.5 %) of PWE died during the period of interest (12 months following the last ED visit). In 6/14 (42.3 %) death was associated with poor medication adherence.

CONCLUSION

This study demonstrates that a significant proportion of patients who experienced seizure-related admissions/ attendance did not access specialist neurology services in a timely manner. In addition, poor medication adherence remains a problem for a substantial number of people living with epilepsy. Early access to specialist services may go some way to improving care and reducing excessive mortality in PWE by allowing anti-seizure medication to be titrated and poor medication adherence to be addressed in those at greatest risk.

The Role of Lipid-Lowering Therapy in Post-Stroke Patients: Update and Recommendations

PURPOSE OF REVIEW

Stroke is the second leading cause of death and disability-adjusted life years worldwide, and the global lifetime risk of stroke is rising. Moreover, patients with a prior stroke are at high risk of recurrent events. We aimed at reviewing the evidence supporting aggressive secondary prevention strategies for lipid-lowering treatment in this population.

RECENT FINDINGS

Statins are the key players in such aggressive management; however, stroke survivors remain at significant residual risk suggesting the need for both better implementation of statin use as well as additional lipid lowering therapies. Newer drugs have become available and represent important tools in the management of patients with prior ischemic stroke. The role of lipid lowering treatment in hemorrhagic stroke is more controversial, given epidemiological data linking low lipid levels with increased risk of first and recurrent events. Aggressive secondary prevention strategies, including lipid lowering treatments, have proven to mitigate the risk of recurrent events in post-stroke patients. The tools available for treating such high-risk population have expanded beyond statins, and clinicians should familiarize themselves with them.

P–105 Clinical validation of mojo AISA, an artificial intelligence robotic CASA system

Study question

Can a CASA system based on Artificial Intelligence perform as well as manual semen assessment, within the WHO error margins?

Summary answer

The AI-based CASA systems that mimic high quality assessments show great potential for reducing clinical workloads while increasing treatment efficacy.

What is known already

The field of male-factor fertility investigation is still lacking an automated semen analysis system that can be widely clinically adopted. By leveraging state-of-the-art robotics and Artificial Intelligence (AI), it was possible to build mojo AISA which is an AI and robotic platform designed according to WHO recommendation for semen analysis. This system is based on AI software with a unique convolutional neural network (CNN) that detects and measures sperm concentration and motility while ruling out unwanted cells and debris in raw samples.

Study design, size, duration

This study presents and validates the mojo AISA device. A total of 60 patient samples at ANOVA Karolinska University Hospital were collected and results from manual assessment were compared to mojo AISA for concentration and motility. Semen samples were assessed manually (WHO 2010) and concurrently with Mojo AISA. Manual measurements ranged from 1–206M/ml. This study lasted from May 2020 to December 2020 following informed consent and ethics committee practices of ANOVA.

Participants/materials, setting, methods

Sample preparation protocol for mojo AISA consisted of placing two 10ul drops and covering with two 22x22mm coverslip. Manual assessment followed ANOVA EQA procedures akin to the WHO. A CNN was trained using videos captured with mojo AISA as input data. Images were annotated to form a validation set by which the AI was trained. To account for sampling error, videos of Hamilton Thorne Accubeads+ were captured using mojo AISA and the mojo counting chambers.

Main results and the role of chance

Comparing the concentration measured by mojo AISA with the known value for each microbead, results are in agreement of 86%, within the confidence interval of the microbeads. The mean relative error was 6.7% and maximum error was 11%. Therefore, Accubeads+ validation proved no observational error regarding the use of mojo AISA microscope. As for comparing mojo AISA to manual assessment for concentration, Pearson (Spearman) correlation was 0.95 (0.97). The mean relative error was 24.8% and maximum relative error was 71.1%, where 90% of samples were below 50% error. By looking at the concentration range between 10 and 20 M/ml, mojo AISA displayed a mean error of 18.5%. For motility, as comparing mojo AISA to manual assessment, a result of 35.4% mean relative error was obtained. To conclude, mojo’s robotic solution shows promise for clinical practice as the AI continues to improve. In 6 months, sperm concentration correlation improved by 3-fold. Next, the AI will be further clinically trained for low concentration.

Limitations, reasons for caution

mojo AISA requires further development, especially for very low concentration ranges, below 5M/ml, due to high sensibility to false positive detections. The same applies to post-vasectomy samples. Additionally, the necessity to compute the motility of each sperm scales poorly with high concentration generating a poor experience for high volume clinics.

Wider implications of the findings: Automation is crucial in several industries. It enables fertility clinics & andrologists to standardize male factor infertility measurements (if paired with widespread standardization of protocols for automation) while enabling them to put more focus on demanding activities of their profession and removes human biases of inter-laboratory performance.

Trial registration number

Not applicable

P–123 How to develop accurate Computer Assisted Sperm Analysis (CASA) AI in the absence of protocol standardization and abundance of human error when performing semen analyses?

Study question

How can an automation & artificial intelligent tools be developed to perform according to WHO recommendations?

Summary answer

Developing CASA performs at < 20% error margin requires AI trained with high quality datasets and a robotic system adheres to WHO guidelines.

What is known already

A survey of 40 andrology laboratories, in 22 countries, revealed that > 90% had nonconformities in correct use of equipment, standardisation of protocols and quality control, leading to a lack of compliance to WHO protocols. Conventional CASA systems can standardize analysis, but controversy has occurred due to differences between manual and automated analyses stemming from: 1) all cells in a semen sample are detected including debris; 2) protocol variation when compared to top-notch manual analysis. The first point can be addressed by AI. The second point can be addressed by robotics designed to adhere to WHO guidelines.

Study design, size, duration

A mojo AISA (AI-powered semen analysis) system was placed in four clinical laboratories mentioned above capturing images of over 300 samples, one million images were generated over a course of 2 years. Mojo AISA’s AI was trained on data collected from the four clinics using robotic system is developed according to WHO guidelines.

Participants/materials, setting, methods

For an AI to detect sperm accurately, sperm samples were captured using mojo AISA smart microscopy and then the extracted sperm images expertly annotated. To evaluate the system-ability for semen analysis, fresh sample were analysed for concentration and motility by a manual operator and compared to a mojo AISA test.

Main results and the role of chance

To train the sperm detection AI, representative sperm images were carefully captured using mojo AISA and processed according to the following criteria: the number of images and videos to train and to test the model: 50,000 spermatozoon head and tails with various variations the variety of images: data used to train the AI has to be representative of the population that will undergo the analysis: 1) wide concentration ranges from 0 to 300 M/ml, 2) high and low density of debris and cells, 3) Presence of slight aggregations careful and precise annotation: expert andrology scientists annotated sperm images and identify objects to exclude, such as debris in seminal plasma, Mojo AISA is an attempt strictly build CASA AI system to WHO-guidelines. The marriage of AI and robotics automation has shown a promising results to mimic humans when measuring a semen sample and attempt to obtain results comparable to the manual analysis.

mojo AISA’s performance improved three-fold (from 0,85 to 0,95 Pearson sperm count correlation and from >100% means relative error to 25% mean relative error).

Limitations, reasons for caution

Lack of standardization for semen analysis laboratory process globally is a bottleneck towards building a robust multi-center study, on-site CASA testing and generating an actionable data pool for studying the causes behind male fertility declineWider implications of the findings: Key learnings for parties advancing developing AI based on images and videos for application in the fertility space.

Trial registration number

Not applicable

Digging out insights and behavioral correlates of false and true femininity in borderline personality disorder patients attending four-step integrative model group psychotherapy

Introduction

The four-step integrative model of psychotherapy is concerned with individual's needs, wants, rights and decisions in that order. It may carry a promise for deep and changing vision for patients with borderline personality disorder (BPD).

Objectives

The study of the illuminating and changing effect of dealing with BPD patients in view of their needs, wants, rights and decisions.

Aims

To evaluate the effect of group work through the hierarchy of the four-step integrative model with BPD patients and to help them explore false and true elements of their femininity.

Methods

Forty-three female patients (age range: 19-37) diagnosed according to DSM-IV diagnostic criteria for BPD were enrolled in a dynamic psychotherapy group. Their progress was evaluated using Borderline evaluation of severity over time (BEST) and they wrote down detailed comments about their experience quarterly.

Results

Results of regular attendants for 2 years were included (35 = 81.4%). The results of BEST showed a significant reduction of BPD severity at the end of 1 and 2 years. During psychotherapy sessions and within their quarterly comments, patients expressed their change in terms of moving from a state of cunning, manipulation, aggression, arrogance, envy and rejection (as stemming from their false femininity) into wisdom, confrontation, patience, pride, healthy competition and containment respectively (as stemming from their true femininity).

Conclusions

Patients with BPD may gain a better insight and genuine change as they realize what is false and what is true about their femininity in the context of attending four-step integrative model group psychotherapy.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Efficiency of riboflavin and ultraviolet light treatment against high levels of biofilm-derived Staphylococcus epidermidis in buffy coat platelet concentrates

BACKGROUND AND OBJECTIVES

Staphylococcus epidermidis forms surface-attached aggregates (biofilms) in platelet concentrates (PCs), which are linked to missed detection during PC screening. This study was aimed at evaluating the efficacy of riboflavin-UV treatment to inactivate S. epidermidis biofilms in buffy coat (BC) PCs.

MATERIALS AND METHODS

Biofilm and non-biofilm cells from S. epidermidis ST-10002 and S. epidermidis AZ-66 were individually inoculated into whole blood (WB) units (~10⁶ colony-forming units (CFU)/ml) (N = 4-5). One spiked and three unspiked WB units were processed to produce a BC-PC pool. Riboflavin was added to the pool which was then split into two bags: one for UV treatment and the second was untreated. Bacterial counts were determined before and after treatment. In vitro PC quality was assessed by flow cytometry and dynamic light scattering.

RESULTS

Bacterial counts were reduced during BC-PC production from ~10⁶ CFU/ml in WB to 10³ -10⁴ CFU/ml in PCs (P < 0·0001). Riboflavin-UV treatment resulted in significantly higher reduction of S. epidermidis AZ-66 than strain ST-10002 (≥3·5 log reduction and 2·6-2·8 log reduction, respectively, P < 0·0001). Remaining bacteria post-treatment were able to proliferate in PCs. No differences in S. epidermidis inactivation were observed in PCs produced from WB inoculated with biofilm or non-biofilm cells (P > 0·05). Platelet activation was enhanced in PCs produced with WB inoculated with biofilms compared to non-biofilm cells (P < 0·05).

CONCLUSION

Riboflavin-UV treatment was similarly efficacious in PCs produced from WB inoculated with S. epidermidis biofilm or non-biofilm cells. Levels of biofilm-derived S. epidermidis ≥10³ CFU/ml were not completely inactivated; however, further testing is necessary with lower (real-life) bacterial levels.

Preliminary characterization of human skin microbiome in healthy Egyptian individuals

Human skin is a large, complex ecosystem that harbors diverse microbial communities. The rapid advances in molecular techniques facilitate the exploration of skin associated bacterial populations. The objective of this study was to perform a preliminary characterization of skin associated bacterial populations in Egyptian individuals. Samples were collected from five healthy subjects from two skin sites; Antecubital Fossa (AF) and Popliteal Fossa (PF). Genomic DNA was extracted and used to amplify bacterial 16S rRNA genes which were sequenced on Illumina MiSeq platform. The two sites showed distinct diversity where PF was more diverse than AF. Taxonomic analysis of sequences revealed four main phyla Proteobacteria, Firmicutes, Actinobacteria and Deinococcus-Thermus, with Proteobacteria presenting the highest diversity. Klebsiella, Bacillus, Pseudomonas and Escherichia were the most predominant genera. Our data suggest that environmental factors can shape the composition of the skin microbiome in certain geographical regions. This study presents a new insight for subsequent analyses of human microbiome in Egypt.

Bacterial survival and distribution during buffy coat platelet production

BACKGROUND AND OBJECTIVES

At Canadian Blood Services, buffy coat (BC) platelet concentrates (BC-PCs) show a generally lower bacterial contamination rate than apheresis PCs. This study investigated whether the PC production method contributes to this observation.

MATERIALS AND METHODS

Whole blood (WB) inoculated with eight bacterial strains was processed using the BC method. Bacteria were enumerated throughout BC-PC production and subsequent PC storage. Endotoxin production and bacterial adhesion to PC bags were evaluated during PC storage. PC quality was monitored by CD62P expression (flow cytometry) and changes in dynamic light scattering (ThromboLUX^® ).

RESULTS

During overnight WB hold, Staphylococcus epidermidis titres remained unchanged, commercial Escherichia coli and Klebsiella pneumoniae were eliminated and the remaining organisms proliferated to high concentrations. Through BC-PC production, bacteria segregated preferentially towards the cellular fractions compared to plasma (P < 0·05). During PC storage, most bacteria adhered to the PC bags and Gram negatives produced clinically significant endotoxin levels. Changes in CD62P expression or ThromboLUX scoring did not consistently reflect bacterial contamination in BC-PCs.

CONCLUSION

WB hold during BC-PC production does not have a broad-spectrum bactericidal effect, and therefore, other factors contribute to low rates of contamination in BC-PCs.

The present and future disease burden of hepatitis C virus infections with today's treatment paradigm - volume 3

The total number, morbidity and mortality attributed to viraemic hepatitis C virus (HCV) infections change over time making it difficult to compare reported estimates from different years. Models were developed for 15 countries to quantify and characterize the viraemic population and forecast the changes in the infected population and the corresponding disease burden from 2014 to 2030. With the exception of Iceland, Iran, Latvia and Pakistan, the total number of viraemic HCV infections is expected to decline from 2014 to 2030, but the associated morbidity and mortality are expected to increase in all countries except for Japan and South Korea. In the latter two countries, mortality due to an ageing population will drive down prevalence, morbidity and mortality. On the other hand, both countries have already experienced a rapid increase in HCV-related mortality and morbidity. HCV-related morbidity and mortality are projected to increase between 2014 and 2030 in all other countries as result of an ageing HCV-infected population. Thus, although the total number of HCV countries is expected to decline in most countries studied, the associated disease burden is expected to increase. The current treatment paradigm is inadequate if large reductions in HCV-related morbidity and mortality are to be achieved.

Strategies to manage hepatitis C virus infection disease burden - volume 3

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 15 countries in Europe, the Middle East and Asia, and the relative impact of two scenarios was considered: increased treatment efficacy while holding the annual number of treated patients constant and increased treatment efficacy and an increased annual number of treated patients. Increasing levels of diagnosis and treatment, in combination with improved treatment efficacy, were critical for achieving substantial reductions in disease burden. A 90% reduction in total HCV infections within 15 years is feasible in most countries studied, but it required a coordinated effort to introduce harm reduction programmes to reduce new infections, screening to identify those already infected and treatment with high cure rate therapies. This suggests that increased capacity for screening and treatment will be critical in many countries. Birth cohort screening is a helpful tool for maximizing resources. Among European countries, the majority of patients were born between 1940 and 1985. A wider range of birth cohorts was seen in the Middle East and Asia (between 1925 and 1995).

Historical epidemiology of hepatitis C virus (HCV) in select countries - volume 3

Detailed, country-specific epidemiological data are needed to characterize the burden of chronic hepatitis C virus (HCV) infection around the world. With new treatment options available, policy makers and public health officials must reconsider national strategies for infection control. In this study of 15 countries, published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates were gathered from the literature and validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Iran and Lebanon to 4.2% in Pakistan. The largest viraemic populations were in Pakistan (7 001 000 cases) and Indonesia (3 187 000 cases). Injection drug use (IDU) and a historically unsafe blood supply were major risk factors in most countries. Diagnosis, treatment and liver transplant rates varied widely between countries. However, comparison across countries was difficult as the number of cases changes over time. Access to reliable data on measures such as these is critical for the development of future strategies to manage the disease burden.

Quantifying the co-solvent effects on trypsin from the digestive system of carp Catla catla by biophysical techniques and molecular dynamics simulations

Urea molecules locate within 0.5 nm of the surface of trypsin.

6-Nitrobenzimidazole derivatives: potential phosphodiesterase inhibitors: synthesis and structure-activity relationship

6-Nitrobenzimidazole derivatives (1-30) synthesized and their phosphodiesterase inhibitory activities determined. Out of thirty tested compounds, ten showed a varying degrees of phosphodiesterase inhibition with IC(50) values between 1.5±0.043 and 294.0±16.7 μM. Compounds 30 (IC(50)=1.5±0.043 μM), 1 (IC(50)=2.4±0.049 μM), 11 (IC(50)=5.7±0.113 μM), 13 (IC(50)=6.4±0.148 μM), 14 (IC(50)=10.5±0.51 μM), 9 (IC(50)=11.49±0.08 μM), 3 (IC(50)=63.1±1.48 μM), 10 (IC(50)=120.0±4.47 μM), and 6 (IC(50)=153.2±5.6 μM) showed excellent phosphodiesterase inhibitory activity, much superior to the standard EDTA (IC(50)=274±0.007 μM), and thus are potential molecules for the development of a new class of phosphodiesterase inhibitors. A structure-activity relationship is evaluated. All compounds are characterized by spectroscopic parameters.

Antigenic and genetic diversity of highly pathogenic avian influenza A (H5N1) viruses isolated in Egypt

Highly pathogenic avian influenza A virus (H5N1) has diverged antigenically and genetically since its initial detection in Asia in 1997. Viruses belonging to clade 2.2 in particular have been reported in numerous countries with the majority occurring in Egypt. Previous reports identified antigenic similarities between viruses belonging to clade 2.2. However, poultry and human viruses isolated in northern Egypt during 2007 and 2008 were found to be antigenically distinct from other clade 2.2 viruses from this country. Genetic analysis of the hemagglutinin revealed a high degree of nucleotide and amino acid divergence. The antigenic changes in Egyptian viruses isolated during 2007-08 necessitated that two of these strains be considered as potential H5N1 pre-pandemic vaccine candidates.

The Plate cage Benezech implant as an alternative to autologous bone graft in the treatment of cervical spondylosis: clinical and functional outcome

Plate cage Benezech (PCB) is a titanium-made implant introduced recently in spinal surgery as a new substitute for autograft in cervical spine interbody fusion. It has a plate attached to the anterior surface of the cage to prevent any displacement of the cage, and to provide additional support in patients with dynamic instability. A small number of studies have shown the PCB cage is safe and efficient. We conducted a retrospective study on 54 consecutive patients with cervical spondylosis who underwent anterior cervical discectomy and interbody fusion (ACDF) with a PCB cage between the year 2001 and 2005 with a mean follow up of 24 months (9-62 months). The mean age was 51 years, 27 patients presented with radiculopathy, 15 patients with myelopathy, and eight patients with both. Clinical and functional outcomes were assessed by using Prolo scale, Japanese orthopaedic association (JOA) score, and Visual analogue scale (VAS). Prolo results were documented good to excellent in 43 (86%) of cases and poor in 7 (14%) of cases. Mean preoperative Prolo scale of 4.7 (SD 1.63) improved postoperatively to 8.22 (SD 2.12.) The average preoperative JOA score was 11.7 (SD 2.51) compared with 15.42 (SD 2.20) postoperatively with a mean recovery rate of 76.3%. VAS score improved from 6.65 (SD 1.77) to 1.76 (SD 2.40). All the results were statistically significant (p-value <0.0001).This study suggests that Plate cage Benezech implant is a safe and effective device for anterior cervical discectomy and interbody fusion.

Result of neck clipping and coil embolization as a treatment for unruptured aneurysm

SUMMARY

The report of the International Subarachnoid Aneurysm Trial (ISAT) study showed that coil embolization was superior to neck clipping as a treatment for subarachnoid hemorrhage (SAH) (1). Recently, some results of treatments for unruptured aneurysm via coil embolization and neck clipping have been reported (2,3).We compared the results of coil embolization and neck clipping in our institute. Generally better outcomes were obtained by endovascular surgery than by neck clipping. Postoperative ischemic strokes occurred in one case (1.8%) as a major stroke and in three cases (5.6% ) as a minor stroke among coil-treated cases, and in two cases(2.6%) as a major stroke, and in seven cases(9.0%) as a minor stroke among neck clipping cases. Other complications after these treatments were six cases of subdural effusion/hematoma, four cases of infection, two cases of epidural hematoma, one abducens nerve palsy, one hydrocephalus, and one acute myocardial infarction among 78 neck clipping cases, and two subcutaneous hematoma, one pseudoaneurysm at the puncture points, one direct carotid-cavernous fistula among 54 coil-treated cases. Four coil-treated cases, in which introduction of microcatheters to the aneurysm was impossible, were treated completely by neck clipping after endovascular treatments. In terms of modified Rankin Scale(mRS) three months after treatments, while mRS 3 was noted in only one case in the endovascular treatment group, there were one case of mRS 3, two cases of mRS 4, and two cases of mRS 5 in the neck clipping group. Duration of hospitalization averaged 11.9 days in the endovascular group and 24.1 days in the neck clipping group. The results of endosaccular enbolizations as treatment of the unruptured aneurysm seems to be better than neck clipping. However, not all cases of unruptured aneurysms can be treated by coil embolization due to the width of aneurysmal neck and relation of the aneurysm to parent arteries. Therefore, surgeons should also be able to perform neck clipping as an alternative modality.