CAnceR IN PreGnancy (CARING) - a retrospective study of cancer diagnosed during pregnancy in the United Kingdom

BACKGROUND

The incidence of cancer diagnosed during pregnancy is increasing. Data relating to investigation and management, as well as maternal and foetal outcomes is lacking in a United Kingdom (UK) population.

METHODS

In this retrospective study we report data from 119 patients diagnosed with cancer during pregnancy from 14 cancer centres in the UK across a five-year period (2016-2020).

RESULTS

Median age at diagnosis was 33 years, with breast, skin and haematological the most common primary sites. The majority of cases were new diagnoses (109 patients, 91.6%). Most patients were treated with radical intent (96 patients, 80.7%), however, gastrointestinal cancers were associated with a high rate of palliative intent treatment (63.6%). Intervention was commenced during pregnancy in 68 (57.1%) patients; 44 (37%) had surgery and 31 (26.1%) received chemotherapy. Live births occurred in 98 (81.7%) of the cases, with 54 (55.1%) of these delivered by caesarean section. Maternal mortality during the study period was 20.2%.

CONCLUSIONS

This is the first pan-tumour report of diagnosis, management and outcomes of cancer diagnosed during pregnancy in the UK. Our findings demonstrate proof of concept that data collection is feasible and highlight the need for further research in this cohort of patients.

Multifocal lesions in a kidney allograft

BACKGROUND

Common complications following kidney transplant include infection, rejection, and malignancy. Multiple masses in a transplanted kidney raise suspicion for malignancy.

CASE PRESENTATION

A 20-year-old female with chronic kidney disease stage 3 T presented with graft tenderness, acute kidney injury, and heterogeneous masses in her transplanted kidney visualized via ultrasound. She was inadequately treated for chlamydia 1 month prior and retested positive upon admission. Initial workup revealed anemia, hyperglycemia, hyperuricemia, and elevated lactate dehydrogenase. Magnetic resonance imaging revealed complex masses of varying sizes in the transplanted kidney. Biopsy grew Streptococcus agalactiae, informing the diagnosis of multiple perinephric abscesses. Additional evaluations for infectious etiology were unremarkable. Her perinephric abscesses resolved with several months of antibiotics.

CONCLUSIONS

Even without a clear source, serious infections may develop in kidney transplant patients who otherwise have concern for malignancy. Chlamydial infections may lead to serious intra-abdominal infections in immunocompromised patients. The inadequately treated chlamydia likely led to polymicrobial ascension of the genitourinary tract that seeded the transplanted kidney. A high index of suspicion for infection is essential in immunosuppressed patients. Biopsy is crucial for a timely diagnosis.

Music therapy for supporting informal carers of adults with life-threatening illness pre- and post-bereavement; a mixed-methods systematic review

BACKGROUND

Music therapy interventions with informal carers of individuals with life-threatening illness at pre- and post-bereavement is an increasingly important clinical area. This systematic review is the first to synthesise and critically evaluate the international evidence associated with music therapy with adult informal carers pre- and post-bereavement. Specifically, the objectives were: i) to describe the characteristics and effectiveness of music therapy interventions which aim to improve health-related outcomes for adult informal carers of adults with life-threatening illness (pre- and post-bereavement), and ii) to describe the experience of music therapy for adult informal carers of adults with life-threatening illness (pre- and post-bereavement).

METHODS

Eligibility: adult informal carers of adults at end of life or bereaved; music therapy interventions for improving health-related outcomes; qualitative; mixed-method; and quantitative studies including comparators of any other intervention; published in English from 1998 onwards. Six databases were searched up to July 2022. A JBI mixed-methods systematic review approach was followed throughout, including quality appraisal, data extraction and a convergent segregated approach to synthesis and integration.

RESULTS

A total of 34 studies were included, published between 2003 and 2022. Most were conducted in North America (n = 13), Australia (n = 10), or Europe (n = 8). No studies were conducted in low- and middle-income countries or in the UK. The majority were qualitative (n = 17), followed by quasi-experimental (n = 8), mixed-methods (n = 7) and two RCTs. The majority focused on carers of individuals with dementia (n = 21) or advanced cancer (n = 7). Seventeen studies were purely quantitative or included a quantitative component. During meta-synthesis, findings were aligned to core outcomes for evaluating bereavement interventions in palliative care and previously identified risk factors for complicated grief. Commonly targeted outcomes in quantitative studies included quality of life and mental wellbeing, showing equivocal effectiveness of music therapy with significant and non-significant results. Twenty-two studies either purely qualitative or with a qualitative component underwent meta synthesis and suggested a diverse range of improved pre- and post-bereavement outcomes for informal carers across all core outcomes, and across all risk and protective factors, including psychological, spiritual, emotional, and social outcomes.

CONCLUSIONS

Qualitative studies provide moderate to strong evidence for improved health-related outcomes for adult informal carers of adults with life-threatening illness pre-bereavement. Limited studies including those bereaved negates conclusions for the bereavement phase. Comparisons and explanations for effectiveness across quantitative and qualitative studies are equivocal, with a high risk of bias and small samples in the limited number of quantitative studies, demonstrating a need for high-quality RCTs.

SYSTEMATIC REVIEW PRE-REGISTRATION

PROSPERO [CRD42021244859].

Evaluation of a virtual interprofessional oral-systemic health simulation experience in nursing, dentistry, medicine, and pharmacy education

PURPOSE

The annual teaching oral-systemic health (TOSH) virtual clinical simulation and case study activity exposes interprofessional teams of nurse practitioner, nurse midwifery, dental, medical, and pharmacy students to a virtual clinical simulation experience that uses oral-systemic health as a clinical exemplar for promoting interprofessional core competencies. The present study examines changes in participating students' self-reported interprofessional competencies following participation in virtual TOSH from 2020 to 2022. These findings are also compared to those from in-person TOSH (2019) to examine the equivalence of student outcomes of both the in-person and virtual programs.

METHODS

A pre- and post-test evaluation design was used to examine the effectiveness of exposure to the TOSH program on self-reported attainment of interprofessional competencies for participating students using the interprofessional collaborative competency attainment scale.

RESULTS

Analysis of pre- and post-surveys demonstrated statistically significant improvement in students' self-rated interprofessional experience competencies following the virtual TOSH program, which aligns with results from the in-person cohorts. Similar findings between the in-person and virtual cohorts indicated no statistically significant difference between the two formats.

CONCLUSION

These findings demonstrate the success of TOSH in promoting attainment of interprofessional competencies among future health professionals. We encourage administrators and faculty who lead health professional programs to take advantage of using virtual simulations as an integral component of interprofessional oral health clinical experiences where students from different health professions learn from and about each other in assessing and treating patients across the lifespan.

National increase in the community supply of take-home naloxone associated with a mass media campaign in Scotland: a segmented time series analysis

BACKGROUND

Take-home naloxone (THN) programmes have been associated with reductions in opioid-related mortality. In response to high rates of drug-related deaths in Scotland, the Scottish Government commissioned the 'How to save a life' (HTSAL) mass media campaign to: (1) increase awareness of drug-related deaths and how to respond to an overdose, and (2) increase the supply of THN. The aim of this study was to assess the effect of the campaign on the supply of THN.

METHODS

We used an interrupted time series design to assess the effect of the HTSAL mass media campaign on the national community supply of THN. The study time period was August 2020-December 2021. We modelled two key dates: the start of the campaign (week beginning (w/b) 30th of August 2021) and after the end of the main campaign (w/b 25th of October 2021).

RESULTS

The total number of THN kits distributed in the community in Scotland during the study period was 27,064. The mean number of THN kits distributed per week (relative to the pre-campaign period), increased by 126% during the campaign and 57% post-campaign. In segmented regression analyses, the pre-campaign trend in the number of THN kits supplied was increasing by an average of 1% each week (RR=1.01, 95% CI 1.01 to 1.01, p<0.001). Once the campaign started, a significant change in level was observed, and the number of kits increased by 75% (RR=1.75, 95% CI 1.29 to 2.40, p<0.001). The trend during the campaign was stable (i.e. not increasing or decreasing) but a significant change in level was observed when the campaign ended, and the number of THN kits supplied decreased by 32% (RR=0.68, 95% CI 0.46 to 0.98, p = 0.042). The trend during the post-campaign period was stable.

CONCLUSIONS

The HTSAL campaign had a short term, but large and significant impact, on the community supply of THN in Scotland. Mass media campaigns could be combined with other interventions and strategies to maintain the increased uptake of THN outside of campaign periods.

Energetic Electron Precipitation Driven by Electromagnetic Ion Cyclotron Waves from ELFIN's Low Altitude Perspective

We review comprehensive observations of electromagnetic ion cyclotron (EMIC) wave-driven energetic electron precipitation using data collected by the energetic electron detector on the Electron Losses and Fields InvestigatioN (ELFIN) mission, two polar-orbiting low-altitude spinning CubeSats, measuring 50-5000 keV electrons with good pitch-angle and energy resolution. EMIC wave-driven precipitation exhibits a distinct signature in energy-spectrograms of the precipitating-to-trapped flux ratio: peaks at >0.5 MeV which are abrupt (bursty) (lasting ∼17 s, or Δ L ∼ 0.56 ) with significant substructure (occasionally down to sub-second timescale). We attribute the bursty nature of the precipitation to the spatial extent and structuredness of the wave field at the equator. Multiple ELFIN passes over the same MLT sector allow us to study the spatial and temporal evolution of the EMIC wave - electron interaction region. Case studies employing conjugate ground-based or equatorial observations of the EMIC waves reveal that the energy of moderate and strong precipitation at ELFIN approximately agrees with theoretical expectations for cyclotron resonant interactions in a cold plasma. Using multiple years of ELFIN data uniformly distributed in local time, we assemble a statistical database of ∼50 events of strong EMIC wave-driven precipitation. Most reside at L ∼ 5 - 7 at dusk, while a smaller subset exists at L ∼ 8 - 12 at post-midnight. The energies of the peak-precipitation ratio and of the half-peak precipitation ratio (our proxy for the minimum resonance energy) exhibit an L -shell dependence in good agreement with theoretical estimates based on prior statistical observations of EMIC wave power spectra. The precipitation ratio's spectral shape for the most intense events has an exponential falloff away from the peak (i.e., on either side of ∼ 1.45 MeV). It too agrees well with quasi-linear diffusion theory based on prior statistics of wave spectra. It should be noted though that this diffusive treatment likely includes effects from nonlinear resonant interactions (especially at high energies) and nonresonant effects from sharp wave packet edges (at low energies). Sub-MeV electron precipitation observed concurrently with strong EMIC wave-driven >1 MeV precipitation has a spectral shape that is consistent with efficient pitch-angle scattering down to ∼ 200-300 keV by much less intense higher frequency EMIC waves at dusk (where such waves are most frequent). At ∼100 keV, whistler-mode chorus may be implicated in concurrent precipitation. These results confirm the critical role of EMIC waves in driving relativistic electron losses. Nonlinear effects may abound and require further investigation.

How to save a life: Public awareness of a national mass media take home naloxone campaign, and effects of exposure to campaign components on overdose knowledge and responses

BACKGROUND

Take home naloxone (THN) programmes are effective at reducing opioid related mortality, but require high levels of distribution, including to the general public. Mass media campaigns can be effective in improving public understanding of a topic and encouraging behavior change. Whilst mass media campaigns focusing on naloxone have been developed internationally, there is a lack of research on their potential impact. We investigated the effects of components of a recent national mass media campaign (Scotland, UK) designed to improve public awareness of drug related deaths, and readiness to intervene.

METHODS

We undertook a cross-sectional online experimental study with a randomized design, conducted with a nationally representative sample. Participants (N = 1551; 52.6% female; age 46.1±16.5 years) were assessed on overdose knowledge and readiness to intervene after presentation of eight combinations of campaign components.

RESULTS

Compared to a basic campaign description, exposure to all types of campaign component were associated with higher overdose knowledge (p < .001), but not knowledge of what to do in response to an overdose (p = .374), or readiness to intervene (p= .286). The greatest effects were associated with a media rich audio-visual resource (animated video with a popular song on the soundtrack, and narrated by a well-known actor).

CONCLUSION

Our data suggest that harm reduction is an appropriate topic for large-scale mass media campaigns. However, effects may be limited to knowledge and awareness raising in the general public, and may be related to the types of media used. Audience segmentation is important and more general messaging about drug related deaths may be more appropriate for the majority of audiences.

Adverse childhood experiences and clustering of high-risk behaviors among high school students: a cross-sectional study

OBJECTIVES

This study assessed the association between adverse childhood experiences (ACEs) and clustering of high-risk behaviors in a sample of high school students.

STUDY DESIGN

This was a cross-sectional study.

METHODS

A sample of students who attended randomly selected classes in 99 high schools completed the 2019 Nevada Youth Risk Behavior Survey (N = 4959). The survey included six ACE measures: (1) physical abuse, (2) sexual abuse, (3) verbal abuse, (4) household physical abuse, (5) household mental illness, and (6) household substance abuse. Students were assigned a cumulative ACE score (range = 0-6). A count of high-risk behavior domains was created using multiple questions across the following domains: (1) violence behaviors, (2) suicidal indicators, (3) non-suicidal self-injury, (4) substance use, (5) high-risk sexual behaviors, (6) poor diet, (7) physical inactivity, and (8) high screen time (range = 0-8). The relationship between ACEs and the count of high-risk behavior domains was assessed using weighted negative binomial regression; incidence rate ratios (IRRs) were calculated adjusting for sociodemographic characteristics.

RESULTS

More than 40% of the sampled students reported high-risk behaviors across two or more domains. There was a strong, graded relationship between cumulative ACE score and the count of high-risk behavior domains. Compared with students who experienced zero ACEs, there was an increase in the count of high-risk behavior domains among students who experienced one ACE (adjusted IRR [aIRR] = 1.22, 95% confidence interval [CI] = 1.12-1.33), two ACEs (aIRR = 1.57, 95% CI = 1.42-1.73), three ACEs (aIRR = 1.73, 95% CI = 1.54-1.94), four ACEs (aIRR = 2.07, 95% CI = 1.84-2.33), five ACEs (aIRR = 2.69, 95% CI = 2.34-3.10), and six ACEs (aIRR = 2.91, 95% CI = 2.34-3.62).

CONCLUSION

Trauma-informed prevention efforts may be an efficient way to address multiple adolescent risk behaviors that cluster.

Post-processed data and graphical tools for a CONUS-wide eddy flux evapotranspiration dataset

Large sample datasets of in situ evapotranspiration (ET) measurements with well documented data provenance and quality assurance are critical for water management and many fields of earth science research. We present a post-processed ET oriented dataset at daily and monthly timesteps, from 161 stations, including 148 eddy covariance flux towers, that were chosen based on their data quality from nearly 350 stations across the contiguous United States. In addition to ET, the data includes energy and heat fluxes, meteorological measurements, and reference ET downloaded from gridMET for each flux station. Data processing techniques were conducted in a reproducible manner using open-source software. Most data initially came from the public AmeriFlux network, however, several different networks (e.g., the USDA-Agricultural Research Service) and university partners provided data that was not yet public. Initial half-hourly energy balance data were gap-filled and aggregated to daily frequency, and turbulent fluxes were corrected for energy balance closure error using the FLUXNET2015/ONEFlux energy balance ratio approach. Metadata, diagnostics of energy balance, and interactive graphs of time series data are included for each station. Although the dataset was developed primarily to benchmark satellite-based remote sensing ET models of the OpenET initiative, there are many other potential uses, such as validation for a range of regional hydrologic and atmospheric models.

Cost of illness of HER2-positive and metastatic and recurrent HER2-positive breast cancer – a Danish register-based study from 2005 to 2016

Background

Information and knowledge about cost of illness and labour productivity in patients with HER2-positive early-stage and metastatic breast cancer treated with trastuzumab is limited. The aim of this study was to estimate the direct and indirect costs associated with treatment of HER2-positive breast cancer among patients with early-stage and metastatic breast cancer, treated with trastuzumab, in a 10-year period after diagnosis.

Materials and methods

This study included all Danish HER2-positive breast cancer patients (≥ 18 years) treated with trastuzumab between 2005 and 2016 identified in The Danish Patient Register and the Danish Cancer Register. Furthermore, we identified patients experiencing metastatic or recurrent breast cancer. For the study populations, we estimated total direct costs and indirect costs for one year prior to the breast cancer diagnosis and up to 10 years after diagnosis compared with a group of matched controls free of breast cancer. In addition to The Danish Patient Register and Cancer Register, we applied patient level data from The Civil Registration System, The National Pathology Register, National Health Service Register for Primary Care, Register of Medicinal Product Statistics, Register of Municipal Services, The DREAM database, and Population’s Education Register.

Results

We identified 4,153 HER2-positive breast cancer patients, whereof 27% were identified with metastatic or recurrent breast cancer. During the follow-up period of 10 years, we estimated excess direct costs of EUR 115,000 among the total study population compared to controls; EUR 211,000 among patients with metastases or recurrence; and EUR 89,000 among patients without metastases or recurrence. Direct costs were found to be highest in the first year after diagnosis and also peaked in the year after recurrence. Labour productivity was significantly lower among patients with recurrence 10 years after breast cancer diagnosis compared with controls.

Conclusions

In this study, we estimated the direct and indirect cost associated with HER2-positive breast cancer. The costs were significantly higher during the 10 years after diagnosis compared to the control group, specifically among patients experiencing metastases or recurrence of breast cancer.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08143-7.

Accurate Determination of Hubble Attenuation and Amplification in Expanding and Contracting Cold-Atom Universes

In the expanding universe, relativistic scalar fields are thought to be attenuated by "Hubble friction," which results from the dilation of the underlying spacetime metric. By contrast, in a contracting universe this pseudofriction would lead to amplification. Here, we experimentally measure, with fivefold better accuracy, both Hubble attenuation and amplification in expanding and contracting toroidally shaped Bose-Einstein condensates, in which phonons are analogous to cosmological scalar fields. We find that the observed attenuation or amplification depends on the temporal phase of the phonon field, which is only possible for nonadiabatic dynamics. The measured strength of the Hubble friction disagrees with recent theory [Gomez Llorente et al., Phys. Rev. A 100, 043613 (2019)PLRAAN2469-992610.1103/PhysRevA.100.043613 and Eckel et al., SciPost Phys. 10, 64 (2021)SPCHCW2542-465310.21468/SciPostPhys.10.3.064].

Galactic Star Formation with NIKA2 (GASTON): Evidence of mass accretion onto dense clumps

High-mass stars (m* ≳ 8 M⊙) play a crucial role in the evolution of galaxies, and so it is imperative that we understand how they are formed. We have used the New IRAM KIDs Array 2 (NIKA2) camera on the Institut de Radio Astronomie Millimétrique (IRAM) 30-m telescope to conduct high-sensitivity continuum mapping of ~ 2 deg2 of the Galactic plane (GP) as part of the Galactic Star Formation with NIKA2 (GASTON) large program. We have identified a total of 1467 clumps within our deep 1.15 mm continuum maps and, by using overlapping continuum, molecular line, and maser parallax data, we have determined their distances and physical properties. By placing them upon an approximate evolutionary sequence based upon 8 μm Spitzer imaging, we find evidence that the most massive dense clumps accrete material from their surrounding environment during their early evolution, before dispersing as star formation advances, supporting clump-fed models of high-mass star formation.

Site Readiness Framework to Improve Health System Preparedness for a Potential New Alzheimer’s Disease Treatment Paradigm

New therapies that address the underlying pathophysiology of Alzheimer’s Disease (AD), coupled with the growth of the AD population, will transform the AD care pathway and present significant challenges to health systems. We explored real-world challenges health systems may face in delivering potential new AD therapies with diverse stakeholders. Key challenges in care included integrating primary care providers into assessment and management, availability of memory care specialists, understanding payment and coverage issues and training mid-level providers to help coordinate care and serve as a shared resource across the system. This input informed a novel Site Readiness Framework for AD, comprising self-assessment exercises to identify health system capabilities and gaps and a framework of core strategies and responsive tools to help prepare to integrate new AD therapies. These resources may help health systems improve readiness to modify care pathways to integrate new therapies for AD.

Erratum: Azimuthal Anisotropy of K_{S}^{0} and Λ+Λ[over ¯] Production at Midrapidity from Au+Au Collisions at sqrt[s]_{NN}=130 GeV [Phys. Rev. Lett. 89, 132301 (2002)]

This corrects the article DOI: 10.1103/PhysRevLett.89.132301.

Erratum: Azimuthal Anisotropy at the Relativistic Heavy Ion Collider: The First and Fourth Harmonics [Phys. Rev. Lett. 92, 062301 (2004)]

This corrects the article DOI: 10.1103/PhysRevLett.92.062301.

Development of dental caries and risk factors between 1 and 7 years of age in areas of high risk for dental caries in Stockholm, Sweden

Purpose

To explore caries predictors at age 1 year and caries development at ages 5 and 7 years in two groups of children following different fluoride-based preventive programs.

Methods

We conducted a prospective cluster-randomized controlled intervention trial with two parallel arms comparing two prevention programs: one program included fluoride varnish applications every 6 months, the other did not; otherwise, the programs were the same. Participants were 1- and 3-year-old children enrolled at 23 dental clinics in high-risk areas in Stockholm, Sweden. The baseline examination included structured interviews. Caries data were extracted from dental records. The primary outcome measures were ICDAS 1–6 > 0 at baseline (age 1 year) and defs > 0 at ages 2, 3, 5, and 7 years. The secondary outcome measure at age 7 was DFS > 0.

Results

Continuous caries development occurred: defs > 0 in 23% at 5 years and in 42% at 7 years. We found no difference in caries development between children who had or had not received fluoride varnish as toddlers. At age 1-year, significant predictors for dental caries in later preschool years were immigrant background, family income, and sweets consumption. Fluoride toothpaste > once a day at 1 year had an OR < 1 for defs > 0 at 5- and 7 years.

Conclusions

For toddlers, fluoride varnish does not seem to be an adequate prevention tool. Brushing with fluoride toothpaste from 1 year of age could not arrest caries development. Immigrant background was the strongest predictor. A new toolbox as well as collaborative upstream actions for reducing free-sugar intake are needed.

Why predict climate hazards if we need to understand impacts? Putting humans back into the drought equation

Virtually all climate monitoring and forecasting efforts concentrate on hazards rather than on impacts, while the latter are a priority for planning emergency activities and for the evaluation of mitigation strategies. Effective disaster risk management strategies need to consider the prevailing "human terrain" to predict who is at risk and how communities will be affected. There has been little effort to align the spatiotemporal granularity of socioeconomic assessments with the granularity of weather or climate monitoring. The lack of a high-resolution socioeconomic baseline leaves methodical approaches like machine learning virtually untapped for pattern recognition of extreme climate impacts on livelihood conditions. While the request for "better" socioeconomic data is not new, we highlight the need to collect and analyze environmental and socioeconomic data together and discuss novel strategies for coordinated data collection via mobile technologies from a drought risk management perspective. A better temporal, spatial, and contextual understanding of socioeconomic impacts of extreme climate conditions will help to establish complex causal pathways and quantitative proof about climate-attributable livelihood impacts. Such considerations are particularly important in the context of the latest big data-driven initiatives, such as the World Bank's Famine Action Mechanism (FAM).

Strengthening implementation of antimicrobial resistance national action plans

Antimicrobial resistance is one of the major challenges of our time. Countries use national action plans as a mechanism to build engagement among stakeholders and coordinate a range of actions across human, animal, and environmental health. However, implementation of recommended policies such as stewardship of antimicrobials, infection prevention and control, and stimulating research and development of novel antimicrobials and alternatives remains inconsistent. Improving the quality of governance within antimicrobial resistance national action plans is an essential step to improving implementation. To date, no systematic approach to governance of national action plans on AMR exists. To address this issue, we aimed to develop the first governance framework to offer guidance for both the development and assessment of national action plans on AMR. We reviewed health system governance framework reviews to inform the basic structure of our framework, international guidance documents from WHO, the Food and Agriculture Organization, the World Organisation for Animal Health, and the European Commission, and sought the input of 25 experts from international organisations, government ministries, policy institutes, and academic institutions to develop and refine our framework. The framework consists of 18 domains with 52 indicators that are contained within three governance areas: policy design, implementation tools, and monitoring and evaluation. Countries must engage with a cyclical process of continuous design, implementation, monitoring and evaluation to achieve these aims.

The ELFIN Mission

The Electron Loss and Fields Investigation with a Spatio-Temporal Ambiguity-Resolving option (ELFIN-STAR, or heretoforth simply: ELFIN) mission comprises two identical 3-Unit (3U) CubeSats on a polar (∼93^∘ inclination), nearly circular, low-Earth (∼450 km altitude) orbit. Launched on September 15, 2018, ELFIN is expected to have a >2.5 year lifetime. Its primary science objective is to resolve the mechanism of storm-time relativistic electron precipitation, for which electromagnetic ion cyclotron (EMIC) waves are a prime candidate. From its ionospheric vantage point, ELFIN uses its unique pitch-angle-resolving capability to determine whether measured relativistic electron pitch-angle and energy spectra within the loss cone bear the characteristic signatures of scattering by EMIC waves or whether such scattering may be due to other processes. Pairing identical ELFIN satellites with slowly-variable along-track separation allows disambiguation of spatial and temporal evolution of the precipitation over minutes-to-tens-of-minutes timescales, faster than the orbit period of a single low-altitude satellite (T_orbit ∼ 90 min). Each satellite carries an energetic particle detector for electrons (EPDE) that measures 50 keV to 5 MeV electrons with Δ E/E < 40% and a fluxgate magnetometer (FGM) on a ∼72 cm boom that measures magnetic field waves (e.g., EMIC waves) in the range from DC to 5 Hz Nyquist (nominally) with <0.3 nT/sqrt(Hz) noise at 1 Hz. The spinning satellites (T_spin ∼ 3 s) are equipped with magnetorquers (air coils) that permit spin-up or -down and reorientation maneuvers. Using those, the spin axis is placed normal to the orbit plane (nominally), allowing full pitch-angle resolution twice per spin. An energetic particle detector for ions (EPDI) measures 250 keV - 5 MeV ions, addressing secondary science. Funded initially by CalSpace and the University Nanosat Program, ELFIN was selected for flight with joint support from NSF and NASA between 2014 and 2018 and launched by the ELaNa XVIII program on a Delta II rocket (with IceSatII as the primary). Mission operations are currently funded by NASA. Working under experienced UCLA mentors, with advice from The Aerospace Corporation and NASA personnel, more than 250 undergraduates have matured the ELFIN implementation strategy; developed the instruments, satellite, and ground systems and operate the two satellites. ELFIN's already high potential for cutting-edge science return is compounded by concurrent equatorial Heliophysics missions (THEMIS, Arase, Van Allen Probes, MMS) and ground stations. ELFIN's integrated data analysis approach, rapid dissemination strategies via the SPace Environment Data Analysis System (SPEDAS), and data coordination with the Heliophysics/Geospace System Observatory (H/GSO) optimize science yield, enabling the widest community benefits. Several storm-time events have already been captured and are presented herein to demonstrate ELFIN's data analysis methods and potential. These form the basis of on-going studies to resolve the primary mission science objective. Broad energy precipitation events, precipitation bands, and microbursts, clearly seen both at dawn and dusk, extend from tens of keV to >1 MeV. This broad energy range of precipitation indicates that multiple waves are providing scattering concurrently. Many observed events show significant backscattered fluxes, which in the past were hard to resolve by equatorial spacecraft or non-pitch-angle-resolving ionospheric missions. These observations suggest that the ionosphere plays a significant role in modifying magnetospheric electron fluxes and wave-particle interactions. Routine data captures starting in February 2020 and lasting for at least another year, approximately the remainder of the mission lifetime, are expected to provide a very rich dataset to address questions even beyond the primary mission science objective.

A-31 Association Between Cognitive Activity and Recovery Outcomes in College Students Following Concussion

Objective

To evaluate the relationship between self-reported cognitive activity and recovery outcomes (symptom reporting, recovery time) in college students following concussion.

Method

Cognitive activity was defined as self-reported minutes spent in class and studying during the first 5 days following concussion. Self-reported symptoms were reported at day 5 post-injury using the Post-Concussion Symptom Scale (PCSS). The PCSS evaluates 22 symptoms on a 7-point Likert Scale from 0 (none) to 6 (severe). Recovery time was defined as total days from injury to unrestricted medical clearance. Separate Spearman’s rank correlations assessed the relationship between total cognitive activity (minutes in class and studying) and recovery outcomes (symptom total (22), symptom severity (132), and recovery time). Alpha level set a priori at 0.05.

Results

Twenty-one participants (14 female, 7 male, 19.5 ± 1.3 years) averaged a total of 653[IQR = 348] minutes of cognitive activity during the first 5 days after concussion (334[IQR = 149] minutes in class, 273[IQR = 313] minutes studying). Five days after injury, participants self-reported 3[IQR = 8] total symptoms yielding a severity of 4[IQR = 12]. Participants took 15 [IQR = 8] days to reach unrestricted medical clearance. No associations were found between total cognitive load and any post-concussion recovery outcomes (symptom total: Rs = −.299, p = .19; symptom severity: Rs = −.230, p = .32; recovery time: Rs = −.041, p = .86).

Conclusions

Preliminary analyses suggest that concussed college students can be encouraged to gradually return to normal levels of cognitive activity, as it may not be associated with future symptom reporting or recovery time. Future research is needed to assess specific cognitive activities immediately influence on post-concussion symptom reporting.

A-49 To Nap or Not to Nap? The Influence of Napping on Recovery Outcomes Following Concussion

Objective

To determine the influence of nap frequency on daily symptom severity and recovery time following concussion in college students.

Method

A prospective study of college students within 72 hours of a diagnosed concussion was performed. Participants reported nap occurrence (yes/no) and daily concussion symptoms using the Post-Concussion Symptom Scale (PCSS) for six days. Participants were categorized into frequent (&gt;2 naps) and infrequent (&lt;3 naps) nap groups. Recovery time was defined as total days from injury to unrestricted medical clearance. A mixed between-within ANOVA evaluated changes in daily symptom severity between nap groups, while Spearman’s Rank Correlation assessed the relationship between the number of days napping and recovery time.

Results

Thirty-four participants (23 female, 11 male; age = 19.91 ± 1.38 years) were included, with 22 in the infrequent nap group and 12 in the frequent nap group. Average recovery time for the infrequent nap group was 13.85 days compared to 18.8 days in the frequent nap group. There was no significant group x time interaction for daily symptom severity (Wilks’ λ = 0.85, F(5,24) = 0.85, p = 0.53, η2 = 0.15). There was a significant main effect for time, with daily symptom severity improving following concussion (Wilks’ λ = 0.31, F(5,24) = 10.66, p &lt; 0.001, η2 = 0.69), but there was no significant group effect (F(1,28) = 0.79, p = 0.38, η2 = 0.03). Overall, the more naps taken, the longer the recovery time (Rs = 0.46, p = 0.01).

Conclusions

Findings from the present study suggest that frequent napping does not affect symptom severity following concussion. Further research is needed to elucidate the association between the number of naps and recovery time.

A-01 Comparing State Anxiety Between Concussed Athletes with and without a History of Sport Related Concussion

Objective

To compare state anxiety between concussed athletes with and without a history of sport related concussion (SRC).

Method

This study utilized a cross-sectional design. The State Trait Anxiety Inventory (STAI) was administered to athletes within 72 hours of SRC diagnosis. The STAI is a subjective, 40-item inventory that assesses state and trait anxiety; however, this study only examined the state anxiety component. Participants reported how they were feeling at the moment of testing on a 4-point Likert scale ranging from 1 (not at all) to 4 (very much so). State anxiety scores range from 20–80, with higher scores indicating higher levels of state anxiety. An independent samples t-test was used to compare state anxiety between concussed athletes with and without a history of SRC. Statistical significance was set at p &lt; .05.

Results

A total of 104 (18.12 ± 2.5 years; male = 65, female = 39) high school (n = 36) and collegiate (n = 68) athletes completed the STAI within 72 hours of SRC. Fifty-nine (56.7%) concussed athletes had no history of SRC and 45 (43.3%) athletes had a history of one or more SRCs. There was no significant difference in state anxiety between concussed athletes with (37.64 ± 9.22) and without (38.47 ± 9.44) a history of SRC (p = .65).

Conclusions

This study suggests that concussion history does not affect state anxiety after SRC. However, clinicians should continue to assess emotional changes after SRC in order to best manage and treat SRC.

Development and Evaluation of a Prediction Model for Ascertaining Rheumatic Heart Disease Status in Administrative Data

Background

Previous research has raised substantial concerns regarding the validity of the International Statistical Classification of Diseases and Related Health Problems (ICD) codes (ICD-10 I05-I09) for rheumatic heart disease (RHD) due to likely misclassification of non-rheumatic valvular disease (non-rheumatic VHD) as RHD. There is currently no validated, quantitative approach for reliable case ascertainment of RHD in administrative hospital data.

Methods

A comprehensive dataset of validated Australian RHD cases was compiled and linked to inpatient hospital records with an RHD ICD code (2000-2018, n=7555). A prediction model was developed based on a generalized linear mixed model structure considering an extensive range of demographic and clinical variables. It was validated internally using randomly selected cross-validation samples and externally. Conditional optimal probability cutpoints were calculated, maximising discrimination separately for high-risk versus low-risk populations.

Results

The proposed model reduced the false-positive rate (FPR) from acute rheumatic fever (ARF) cases misclassified as RHD from 0.59 to 0.27; similarly for non-rheumatic VHD from 0.77 to 0.22. Overall, the model achieved strong discriminant capacity (AUC: 0.93) and maintained a similar robust performance during external validation (AUC: 0.88). It can also be used when only basic demographic and diagnosis data are available.

Conclusion

This paper is the first to show that not only misclassification of non-rheumatic VHD but also of ARF as RHD yields substantial FPRs. Both sources of bias can be successfully addressed with the proposed model which provides an effective solution for reliable RHD case ascertainment from hospital data for epidemiological disease monitoring and policy evaluation.

Immune checkpoint inhibitor diabetes mellitus: a novel form of autoimmune diabetes

Autoimmune diabetes mellitus is a rare but significant side effect of treatment with immune checkpoint inhibitors. Immune checkpoint inhibitor-induced diabetes mellitus (CPI-DM) is characterized by acute onset of dramatic hyperglycemia with severe insulin deficiency and occurrence following exposure to programmed cell death-1/programmed cell death ligand-1 (PD-1/PD-L1) inhibitors rather than cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) inhibitors. As a growing number of patients undergo immunotherapy, further understanding of the characteristics of CPI-DM patients is needed for improved prognostic and diagnostic application in order to reduce overall morbidity for this already at-risk population. Additionally, understanding of the features and mechanisms of CPI-DM may contribute to understanding mechanisms of spontaneous type I diabetes mellitus (T1DM). Here, we summarize the clinical features of CPI-DM and interrogate the genetic and cellular mechanisms that may contribute to the disease, as well as the clinical challenges for predicting and treating these patients as increasing cancer immunotherapies reach clinical utility.

International league of associations for rheumatology recommendations for the management of psoriatic arthritis in resource-poor settings

Background

Psoriatic arthritis (PsA) is a challenging heterogeneous disease. The European League Against Rheumatism (EULAR) and the Group for Research and Assessment of Psoriasis and PsA (GRAPPA) last published their respective recommendations for the management of PsA in 2015. However, these guidelines are primarily based on studies conducted in resource replete countries and may not be applicable in countries in the Americas (except Canada and USA) and Africa. We sought to adapt the existing recommendations for these regions under the auspices of the International League of Associations for Rheumatology (ILAR).

Process

The ADAPTE Collaboration (2009) process for guideline adaptation was followed to adapt the EULAR and GRAPPA PsA treatment recommendations for the Americas and Africa. The process was conducted in three recommended phases: set-up phase; adaptation phase (defining health questions, assessing source recommendations, drafting report), and finalization phase (external review, aftercare planning, and final production).

Result

ILAR recommendations have been derived principally by adapting the GRAPPA recommendations, additionally, EULAR recommendations where appropriate and supplemented by expert opinion and literature from these regions. A paucity of data relevant to resource-poor settings was found in PsA management literature.

Conclusion

The ILAR Treatment Recommendations for PsA intends to serve as reference for the management of PsA in the Americas and Africa. This paper illustrates the experience of an international working group in adapting existing recommendations to a resource-poor setting. It highlights the need to conduct research on the management of PsA in these regions as data are currently lacking.

Key Points • The paper presents adapted recommendations for the management of psoriatic arthritis in resource-poor settings. • The ADAPTE process was used to adapt existing GRAPPA and EULAR recommendations by collaboration with practicing clinicians from the Americas and Africa. • The evidence from resource-poor settings to answer clinically relevant questions was scant or non-existent; hence, a research agenda is proposed.

Electronic supplementary material

The online version of this article (10.1007/s10067-020-04934-7) contains supplementary material, which is available to authorized users.

"How am I gonna cope?": Caregivers of adolescents with diabetes in Jamaica

Objective

To determine the challenges, coping strategies and needs of urban and rural Jamaican caregivers of adolescents with diabetes, and suggest ways to assist coping.

Methods

This qualitative study comprised four focus groups (two urban and two rural) with a total of nineteen caregivers of adolescents with diabetes. Thematic analysis was conducted on the data.

Results

The main challenges caregivers faced were keeping their children healthy, managing conflict with their children, and financial concerns. They met these challenges with problem-focused and emotion-focused coping strategies. Caregivers used the problem-focused strategies of vigilance, advocacy, minimising their children’s negative emotions, coercion, education, and seeking support, and the emotion-focused strategies of relying on their identity as parents and turning to their faith. Caregivers wanted assistance acquiring medication and equipment, increased diabetes education, and support groups.

Discussion

More resources should be channelled toward provision of diabetes supplies. Diabetes education is necessary in schools and for the general public. Healthcare practitioners should explore issues beyond diabetes management, such as caregivers’ coping and the caregiver-child relationship. Support groups are needed to facilitate learning. Special attention must be paid to rural areas: rural residents appeared to be in greater need than their urban counterparts.

A25 Impact of polymorphism in the hepatitis B surface gene on human leukocyte antigen (HLA) class II

There is still no cure for chronic hepatitis B virus infection (CHBV), a major cause of liver cancers and related malignancies. Elucidating the role of CD4+ T-helper cells in activating immunological responses that clear antigenic peptides during primary HBV infection holds a potential strategy for developing potent vaccines. Since the strength of CD4+ T cell responses is dictated by binding of viral epitopes to class-II human leukocyte antigens (HLAs), we hypothesize that the quality of immunological responses in CHBV patients is influenced by host genetics and HBV genotypes. Here, ninety-two non-recombinant complete HBV surface-gene proteins (PreS1/S) from Botswana were sequenced (genotype A 44(47.8%); D 48(52.2%)) and 15-mer binding epitopes restricted to nine HLA-class II molecules (DRB5/1) were mapped in silico. The HLAs used have high population coverage in Botswana. The total predicted epitopes per HLA were 94-(genotype A) and 105-(genotype D) for PreS1, 42 (A and D) for PreS2, and 105 (A and D) for S. Epitope densities (binding peptides to total epitopes) were 3 per cent and 6 per cent (PreS1A&D), 4 per cent and 2 per cent (PreS2A&D), and 23 per cent and 22 per cent (S1A&D). SA&D proteins had most polytopes: CPGYRWMCLRRFII66-81, PGYRWMCLRRFIIF67-82, GYRWMCLRRFIIFL68-83, and YRWMCLRRFIIFLF69-84 binding to 5 (55.6%) HLAs (DRB1*0101/0701/1101/1501 and DRB5*0101) used. HLA-DRB*0101 bound the most epitopes, and the least were bound by HLA-DRB*0302/0701/0401 for both genotypes. PreS1D polytope: PAFRANTANPDWDFN32-46 binds to DRB1*0101/0401/1302 and PreS2 polytopes: TAFHQALQDPRVRG6-19 and AFHQALQDPRVRGL7-20 bind to DRB1*010/1501 alleles. Non-synonymous mutations impair peptide-HLA binding when assessed as combinations of > 2. The least active HLAs may be associated with CHBV and vice-versa for HBV clearance, thus the algorithm may be used to predict HBV prognosis for different haplotypes. The results favor the use of epitopes from S protein as broad genotype vaccine. This study highlights the need to explore further the mechanisms of PreS1 and its effect on the immune system.

Sources of Acquired Concussion Information Reported by Parents of Youth Athletes

Purpose

Examining the relationships between demographics (sex, geographic location) and sources of acquired concussion information, and where parents would take their child for concussion evaluation.

Methods

A cross-sectional survey collecting demographics and concussion knowledge of parents (male: n=136/359, 38%; female: n=22/359, 62%) of youth athletes (i.e., football, ice hockey, lacrosse, soccer) in Michigan (n=131/359, 36.5%) and Pennsylvania (n=228/359, 62%). Separate Chi-square tests for independence examined the relationship between demographics (sex, geographic location) and sources of acquired concussion information, and where parents would take their child for concussion evaluation.

Results

Overall, parents recognized common concussion signs and symptoms and had general knowledge of concussion. There was a significant association between sex and acquiring information from sports medicine physicians (male: 31.6%, female: 18.9%; χ2 (1, n=358)=6.83, p=.009), and sports news outlets (male: 32.4%, female: 18.9%; χ2 (1, n=358)=7.62, p=.006). There was a significant association between geographic location and acquiring information from a coach (Michigan: 72.5%, Pennsylvania: 40.4%; χ2 (1, n=359)=32.22, p<.001), recreational league officials/league mandated paperwork (Michigan: 50.4%, Pennsylvania: 26.3%; χ2 (1, n=359)=20.11, p<.001), and youth sport state concussion laws (Michigan: 38.2%, Pennsylvania: 10.5%; χ2 (1, n=359)=37.18, p<.001). There was a significant association between geographic location and where parents would take their child for concussion evaluation (χ2 (3, n=338)=19.76, p<.001).

Conclusion

Sex and geographic location may influence where parents of youth athletes acquire concussion information and where they may seek medical attention.

Examining Changes in Sleep Between Concussed and Healthy Individuals Across Recovery

Purpose

To examine changes and the relationship between Pittsburgh Sleep Quality Index (PSQI) scores and the Sport Concussion Assessment Tool–5th Edition (SCAT5) sleep symptom across recovery between concussed and healthy individuals.

Methods

Sixty-eight (18.12±2.6 years; male:n=47, female:n=21; concussed:n=38, healthy:n=30) individuals completed the PSQI and SCAT5 at three times across recovery (≤72 hours of injury, return-to-play (RTP), >one-month after RTP). Two mixed between-within subjects analysis of variance (ANOVAs) evaluated changes in PSQI scores and SCAT5 sleep symptom across recovery between concussed and healthy individuals. Spearman’s rho correlations were used to examine the relationships between the two sleep measures. Significance was set at p≤.05.

Results

There was no significant groupXtime interaction for PSQI scores (Wilks λ=.96, F(2,65)=1.50, p=.23, η2=.04) or SCAT5 sleep symptom (Wilks λ=.93, F(2,65)=2.42, p=.10, η2=.07). There was a significant main effect for time for PSQI scores (Wilks λ=.65, F(2,65)=17.2, p<.001, η2=.35) and SCAT5 sleep symptom (Wilks λ=.88, F(2,65)=4.25, p=.02, η2=.12) with PSQI scores and SCAT5 sleep symptom improving over time. For the SCAT5 sleep symptom there was a significant main effect for group (F(1,66)=13.41, p<.001, η2=.17), with concussed individuals reporting higher SCAT5 sleep symptom (M=0.59, SE=0.1) than healthy controls (M=0.09, SE=0.1). There was no significant correlation between PSQI scores and SCAT5 sleep symptom ≤72 hours (r=.15, p=.36), but there were significant correlations at RTP (r=.38, p=.02) and >one-month (r=.43, p=.01).

Conclusion

Global sleep quality changes throughout recovery and may influence post-concussion outcomes. Utilizing a specialized sleep measure along with sleep-related symptoms may be beneficial to healthcare professionals, specifically during acute concussion management.