Oculoplastic Management of an Eyelid Zipper Injury

We present a case of a zipper injury to an upper eyelid in a pediatric patient. The zipper was successfully removed in the operating room by using a double-action bone cutter to cut the median footplate of the zipper and release the entrapped tissue. Zipper injuries are well-described in urology literature, however, limited case reports exist in ophthalmology literature. We review several methods for zipper removal and present special considerations for eyelid injuries.

Multidisciplinary Simulation Training for Surgical Tracheostomy in Patients Mechanically Ventilated Secondary to Severe Acute Respiratory Syndrome Coronavirus 2

OBJECTIVE

A proportion of patients with coronavirus disease (COVID) and severe respiratory manifestations of disease will require admission to intensive care for intubation and ventilation. When anticipating prolonged ventilation, the patient may proceed to surgical tracheostomy to afford safe respiratory wean. As surgical tracheostomy is an aerosol-generating procedure, it poses a high risk of viral transmission and ultimately may prompt anxiety and caution in participating staff members. We aimed to mitigate these risks by providing staff with appropriate training and experience, to improve their confidence as well as practical ability.

METHODS

We developed a multidisciplinary simulation training experience and checklist in order to optimize team performance during the high-stakes procedure. We evaluated staff confidence before and after the training with questionnaires.

RESULTS

Post-simulation, surgeons were more confident with donning the high level personal protective equipment, and nurses were more confident in performing their role.

CONCLUSIONS

Simulation allows the multidisciplinary team an opportunity to practice high-risk procedures and prompts the team to assess staff knowledge base, troubleshoot queries, and teach roles and responsibilities in a safe environment. In the context of COVID-19, simulation encourages staff sense of preparedness and protection for true participation during a high-risk procedure.

A feasibility study of using a high-definition intra-operative exoscope in teaching septorhinoplasty

OBJECTIVE

This pilot study aimed to assess the feasibility of using a high-definition intra-operative exoscope in teaching septorhinoplasty.

METHODS

The exoscope was used in septorhinoplasty cases with different trainers and trainees. A high-definition screen displayed real-time, magnified images. Post-procedure, a questionnaire was completed by trainer and trainees, assessing the feasibility, safety and content validity of the exoscope as a septorhinoplasty training tool.

RESULTS

Trainees and trainers assigned favourable ratings to all aspects of the exoscope as a training tool, particularly with regard to teaching anatomy and improving visualisation.

CONCLUSION

The exoscope is a potentially effective training tool in septorhinoplasty, and is especially useful in improving visualisation, without restricting the operator. Annotatable intra-operative photographs and videos allow trainees to study cases outside of the operating theatre environment. The use of an exoscope for septorhinoplasty in the UK may facilitate increased hands-on involvement earlier in training than is currently typical.

Contrast-enhanced voiding urosonography (CEVUS) as a safe alternate means of assessing vesicoureteral reflux in pediatric kidney transplant patients

BACKGROUND

Although voiding cystourethrogram (VCUG) is currently the gold standard in VUR evaluation, there is ionizing radiation exposure. Contrast-enhanced voiding urosonography (CEVUS) uses ultrasound contrast agents to visualize the urinary tract and has been reported to be safe and effective in VUR evaluation in children. CEVUS application has yet to be specifically described in VUR evaluation in the pediatric kidney transplant population. The purpose of this study was to report the use of CEVUS and VCUG in evaluating and managing VUR in pediatric renal transplant patients.

METHODS

Retrospective review was conducted for pediatric kidney transplant patients (18 years and younger) who underwent VCUG or CEVUS to assess for transplant VUR from July 2019 through June 2021. Demographic information, reason for VUR evaluation, fluoroscopy time, and postimaging complications were evaluated. Costs of imaging modalities were also considered.

RESULTS

Eight patients were evaluated for transplant VUR during the study period. Of the 3 patients who underwent VCUG, all 3 had VUR (median grade 3). Median fluoroscopy time was 18 s and dose-area product was 18.7 uGy*m² . Of the 5 patients who underwent CEVUS, 4 had VUR (median grade 4). There were no complications for either modality. Based on clinical and radiographic findings, patients were recommended no intervention, behavioral modification, or ureteral reimplantation. The total cost of CEVUS was $800 less than that of VCUG.

CONCLUSION

CEVUS can provide an alternate means of safely evaluating VUR in kidney transplant patients with similar outcomes, potentially lower costs, and no exposure to ionizing radiation.

Technology-assisted behavioral intervention to encourage prehabilitation in frail older adults undergoing surgery: Development and design of the BeFitMe™ Apple Watch app

Objective

Increasing the physical activity of frail, older patients before surgery through prehabilitation (prehab) can hasten return to autonomy and reduce complications postoperatively. However, prehab participation is low in the clinical setting. In this study, we re-design an existing prehab smartphone application (BeFitMe™) using a novel standalone Apple Watch platform to increase accessibility and usability for vulnerable patients.

Methods

Design Science Research Methodology was used to (1) develop an approach to clinical research using standalone Apple Watches, (2) re-design BeFitMe™ for the Apple Watch platform, and (3) incorporate user feedback into app design. In phase 3, beta and user testers gave feedback via a follow-up phone call. Exercise data was extracted from the watch after testing. Descriptive statistics were used to summarize accessibility and usability.

Results

BeFitMe™ was redesigned for the Apple Watch with full functionality without requiring patients to have an iPhone or internet connectivity and the ability to passively collect exercise data without patient interaction. Three study staff participated in beta testing over 3 weeks. Six randomly chosen thoracic surgery patients participated in user testing over 12 weeks. Feedback from beta and user testers was addressed with updated software (versions 1.0-1.10), improved interface and notification schemes, and the development of educational materials used during enrollment. The majority of users (5/6, 83%) participated by responding to at least one notification and data was able to be collected for 54/82 (68%) of the days users had the watches. The amount of data collected in BeFitMe™ Watch app increased from 2/11 (16%) days with the first patient tester to 13/13 (100%) days with the final patient tester.

Conclusions

The BeFitMe™ Watch app is accessible and usable. The BeFitMe™ Watch app may help older patients, particularly those from vulnerable backgrounds with fewer resources, participate in prehab prior to surgery.

Description of a Novel Technique to Address Both External Nasal Valve Collapse and the Aesthetic of the Nasal Tip

Severe concavity of the lateral crura can lead to an unsightly aesthetic deformity of the nasal tip and narrowing of the external nasal valve. Concurrently, if the lateral crura are structurally weak, this can lead to a functional issue. We report a previously undescribed technique of combining a lateral crural reversal with a turn-in flap. This achieves dual goals of aesthetic improvement and structural reinforcement, without the need for grafting.

Real world outcomes of minimally invasive epicardial surgical left atrial appendage exclusion in atrial fibrillation patients with high risk of stroke and bleeding

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): AtriCure, Inc

Introduction

The left atrial appendage (LAA) is the site of thrombus formation in patients with atrial fibrillation (AF) and first line therapy for reducing the risk of stroke is oral anticoagulation (OACs). A subset of patients with AF carry a very high risk of stroke and bleeding and are ineligible for OAC and percutaneous LAA occlusion; these patients may be suitable for minimally invasive thoracoscopic epicardial surgical LAA exclusion (LAAE) which can be used with a wide variety of LAA morphologies with a ~98% rate of complete exclusion. While use of LAAE is well studied as a concomitant procedure, there are relatively few data on its use as a stand-alone procedure.

Purpose

To compare real-world outcomes of LAAE versus no-LAAE in AF patients at high risk of stroke and bleeding who are not on OACs.

Methods

We performed an analysis of Medicare beneficiaries with AF who were not on OACs and received LAAE (ICD10-PCS code 02L74CK, Oct 2015 – Dec 31, 2017) in the absence of a concomitant surgical or catheter AF ablation procedure. Patients were propensity-matched (1:4) to otherwise similar patients who did not receive LAAE (control), using age, gender, race, region, AF type, CHA2DS2-VASc, HAS-BLED, and co-morbidities. The primary endpoint was hospital readmission for a thromboembolic event (ischemic stroke, systemic embolism, or transient ischemic attack). Kaplan Meier event rates were calculated and 95% CI were generated via bootstrapping.

Results

A total of 243 patients who underwent LAAE and 1.7M control patients met study criteria. In the matched cohort, the mean age was 75 years, 61% were men, 77% had non-paroxysmal AF, and the mean CHADS2-VASC and HAS-BLED scores were 5.5 and 4.2, respectively. The 1-year rate of thromboembolism in the LAAE and control arms were 7.3% (95% CI 4.3% -10.9%) and 13.6 (95% CI 11.0% -16.4%) (Figure), respectively, with an absolute and relative risk reduction of 6.2% (95% CI 2.0-10.3, p-value=0.001, NNT 17) and 0.54 (95% CI 0.29-0.68, p=0.001).

Conclusion

Among high-risk AF patients who were not on OAC, LAAE was associated with a clinically meaningful and significantly lower risk of TE. Additional studies are needed to confirm these finding.

Risk Prediction Model of 90-Day Mortality After Esophagectomy for Cancer

Importance

Ninety-day mortality rates after esophagectomy are an indicator of the quality of surgical oncologic management. Accurate risk prediction based on large data sets may aid patients and surgeons in making informed decisions.

Objective

To develop and validate a risk prediction model of death within 90 days after esophagectomy for cancer using the International Esodata Study Group (IESG) database, the largest existing prospective, multicenter cohort reporting standardized postoperative outcomes.

Design, Setting, and Participants

In this diagnostic/prognostic study, we performed a retrospective analysis of patients from 39 institutions in 19 countries between January 1, 2015, and December 31, 2019. Patients with esophageal cancer were randomly assigned to development and validation cohorts. A scoring system that predicted death within 90 days based on logistic regression β coefficients was conducted. A final prognostic score was determined and categorized into homogeneous risk groups that predicted death within 90 days. Calibration and discrimination tests were assessed between cohorts.

Exposures

Esophageal resection for cancer of the esophagus and gastroesophageal junction.

Main Outcomes and Measures

All-cause postoperative 90-day mortality.

Results

A total of 8403 patients (mean [SD] age, 63.6 [9.0] years; 6641 [79.0%] male) were included. The 30-day mortality rate was 2.0% (n = 164), and the 90-day mortality rate was 4.2% (n = 353). Development (n = 4172) and validation (n = 4231) cohorts were randomly assigned. The multiple logistic regression model identified 10 weighted point variables factored into the prognostic score: age, sex, body mass index, performance status, myocardial infarction, connective tissue disease, peripheral vascular disease, liver disease, neoadjuvant treatment, and hospital volume. The prognostic scores were categorized into 5 risk groups: very low risk (score, ≥1; 90-day mortality, 1.8%), low risk (score, 0; 90-day mortality, 3.0%), medium risk (score, -1 to -2; 90-day mortality, 5.8%), high risk (score, -3 to -4: 90-day mortality, 8.9%), and very high risk (score, ≤-5; 90-day mortality, 18.2%). The model was supported by nonsignificance in the Hosmer-Lemeshow test. The discrimination (area under the receiver operating characteristic curve) was 0.68 (95% CI, 0.64-0.72) in the development cohort and 0.64 (95% CI, 0.60-0.69) in the validation cohort.

Conclusions and Relevance

In this study, on the basis of preoperative variables, the IESG risk prediction model allowed stratification of an individual patient's risk of death within 90 days after esophagectomy. These data suggest that this model can help in the decision-making process when esophageal cancer surgery is being considered and in informed consent.

Image segmentation for neuroscience: lymphatics

A recent discovery in neuroscience prompts the need for innovation in image analysis. Neuroscientists have discovered the existence of meningeal lymphatic vessels in the brain and have shown their importance in preventing cognitive decline in mouse models of Alzheimer’s disease. With age, lymphatic vessels narrow and poorly drain cerebrospinal fluid, leading to plaque accumulation, a marker for Alzheimer’s disease. The detection of vessel boundaries and width are performed by hand in current practice and thereby suffer from high error rates and potential observer bias. The existing vessel segmentation methods are dependent on user-defined initialization, which is time-consuming and difficult to achieve in practice due to high amounts of background clutter and noise. This work proposes a level set segmentation method featuring hierarchical matting, LyMPhi, to predetermine foreground and background regions. The level set force field is modulated by the foreground information computed by matting, while also constraining the segmentation contour to be smooth. Segmentation output from this method has a higher overall Dice coefficient and boundary F1-score compared to that of competing algorithms. The algorithms are tested on real and synthetic data generated by our novel shape deformation based approach. LyMPhi is also shown to be more stable under different initial conditions as compared to existing level set segmentation methods. Finally, statistical analysis on manual segmentation is performed to prove the variation and disagreement between three annotators.

OVPSYCH2: A randomized controlled trial of psychological support versus standard of care following chemotherapy for ovarian cancer

BACKGROUND

Fear of disease progression (FOP) is a rational concern for women with Ovarian Cancer (OC) and depression is also common. To date there have been no randomized trials assessing the impact of psychological intervention on depression and FOP in this patient group.

PATIENTS AND METHODS

Patients with primary or recurrent OC who had recently completed chemotherapy were eligible if they scored between 5 and 19 on the PHQ-9 depression and were randomized 1:1 to Intervention (3 standardized CBT-based sessions in the 6-12 weeks post-chemotherapy) or Control (standard of care). PHQ-9, FOP-Q-SF, EORTC QLQ C30 and OV28 questionnaires were then completed every 3 months for up to 2 years. The primary endpoint was change in PHQ-9 at 3 months. Secondary endpoints were change in other scores at 3 months and all scores at later timepoints.

RESULTS

182 patients registered; 107 were randomized; 54 to Intervention and 53 to Control; mean age 59 years; 75 (70%) had completed chemotherapy for primary and 32 (30%) for relapsed OC and 67 patients completed both baseline and 3-month questionnaires. Improvement in PHQ-9 was observed for patients in both study arms at three months compared to baseline but there was no significant difference in change between Intervention and Control. A significant improvement on FOP-Q-SF scores was seen in the Intervention arm, whereas for those in the Control arm FOP-Q-SF scores deteriorated at 3 months (intervention effect = -4.4 (-7.57, -1.22), p-value = 0.008).

CONCLUSIONS

CBT-based psychological support provided after chemotherapy did not significantly alter the spontaneously improving trajectory of depression scores at three months but caused a significant improvement in FOP. Our findings call for the routine implementation of FOP support for ovarian cancer patients.

A systematic assessment of the use of opponent variables, data subsetting and hierarchical specification in two-party crash severity analysis

Road crashes impose an important burden on health and the economy. Numerous efforts have been undertaken to understand the factors that affect road collisions in general, and the severity of crashes in particular. In this literature several strategies have been proposed to model interactions between parties in a crash, including the use of variables regarding the other party (or parties) in the collision, data subsetting, and estimating models with hierarchical components. Since no systematic assessment has been conducted of the performance of these strategies, they appear to be used in an ad-hoc fashion in the literature. The objective of this paper is to empirically evaluate ways to model party interactions in the context of crashes involving two parties. To this end, a series of models are estimated using data from Canada's National Collision Database. Three levels of crash severity (no injury/injury/fatality) are analyzed using ordered probit models and covariates for the parties in the crash and the conditions of the crash. The models are assessed using predicted shares and classes of outcomes, and the results highlight the importance of considering opponent effects in crash severity analysis. The study also suggests that hierarchical (i.e., multi-level) specifications and subsetting do not necessarily perform better than a relatively simple single-level model with opponent-related factors. The results of this study provide insights regarding the performance of different modelling strategies, and should be informative to researchers in the field of crash severity.

Transforming food retail for better health: The Healthy Stores 2020 trial

Background

How food is promoted in food retail settings impacts population diet. Foods high in sugar, fat and/or salt are promoted by retailers to attract impulse purchases. To combat the high burden of chronic disease and associated conditions confronting society we examined the impact of restricted retail merchandising (promotion and visibility) of discretionary food and beverages on sales and business outcomes.

Methods

We conducted a pragmatic randomised controlled trial in partnership with a retail organisation operating stores in remote communities of Australia (the Arnhem Land Progress Aboriginal Corporation). Twenty consenting stores were allocated to the 12-week intervention (7-point Healthy Stores 2020 strategy) or to usual retail practice. Four intervention stores with retail competition implemented a modified 6-point strategy. Weekly sales data were used to assess intervention impact on free sugars (g) to energy (MJ) (primary outcome) derived from all purchased food and beverages. Impact on gross profit and sales of targeted food and beverages was also assessed. Managers of intervention stores were interviewed to determine their views on customer response and impact on retail practice.

Results

Free sugars were reduced by a relative 2.8% (95% CI -4.8, -0.7). There were significant reductions in free sugars from targeted beverages (-6.4%; -11.1, -1.5) and soft drinks (-12.5%; -18.1, -6.5). Gross profit was not impacted adversely. Managers mostly viewed the strategy favourably and of benefit to the community.

Conclusions

The public health and business relevant gains demonstrated by this novel trial have resulted in ALPA converting their stores to the Healthy Stores 2020 strategy and integrating the strategy in to their nutrition policy. Retail competition impedes complete implementation of the 7-point strategy. Tackling this will require collective agreement by retailers to implement the full strategy and/or government policy power.

Key messages

Restricting merchandising of unhealthy foods can achieve both public health relevant and business relevant gains. Working in partnership with retailers is critical to testing real-world interventions to impact population diet.

Heritable epigenetic diversity for conservation and utilization of epigenetic germplasm resources of clonal East African Highland banana (EAHB) accessions

KEY MESSAGE

Genetically identical East African Highland banana (EAHB) clones are epigenetically diverse with heritable epialleles that can contribute to morphological diversity. Heritable epigenetic variation can contribute to agronomic traits in crops and should be considered in germplasm conservation. Despite the genetic uniformity arising from a genetic bottleneck of one ancestral clone, followed by subsequent vegetative propagation, East African Highland bananas (EAHBs) display significant phenotypic diversity potentially arising from somatic mutations, heritable epialleles and/or genotype-by-environment interactions. Here, we use DNA methylation profiling across EAHB accessions representing most of the primary EAHB genepool to demonstrate that the genetically uniform EAHB genepool harbours significant epigenetic diversity. By analysing 724 polymorphic DNA methylation sites by methylation-sensitive AFLP across 90 EAHB cultivars, we could differentiate the EAHB varieties according to their regions (Kenya and Uganda). In contrast, there was minimal association of DNA methylation variation with the five morphological groups that are used to classify EAHBs. We further analysed DNA methylation patterns in parent-offspring cohort, which were maintained in offspring generated by sexual (seed) and asexual (vegetative) propagation, with higher levels of altered DNA methylation observed in vegetatively generated offspring. Our results indicate that the phenotypic diversity of near-isogenic EAHBs is mirrored by considerable DNA methylation variation, which is transmitted between generations by both vegetative reproduction and seed reproduction. Genetically uniform vegetatively propagated crops such as EAHBs harbour considerable heritable epigenetic variation, where heritable epialleles could arise in offspring and contribute to functional traits. This study provides a basis for developing strategies for conservation of epigenetic resources and for integration of epimarkers into crop breeding programmes.

Chemotherapy associated dural sinus thrombosis presenting as a cerebrospinal fluid leak

Despite the well documented increased risk of thrombosis in patients with cancer and during chemotherapy, cerebral venous sinus thrombosis (CVT) remains a rare entity. We present a rare case of cerebrospinal fluid (CSF) rhinorrhoea secondary to a left transverse sinus thrombus which occurred 2 years previously during chemotherapy for breast cancer. The patient underwent a three-layer repair using Neuro-Patch, septal cartilage and middle turbinate pedicle flap and was started on acetazolamide. There was no recurrence at 1-year follow-up. Raised intracranial pressure secondary to cerebral venous occlusion can erode the base of skull and predispose to CSF leaks. Despite the theoretical risk, there have been no cases reported where CSF leaks have occurred following chemotherapy induced CVT. We describe the first case and discuss pathophysiology and management.

The role of supply chain integration in strengthening the performance of not-for-profit organizations: evidence from the food banking industry

Purpose

This paper investigates the inter-relationships among supply integration, demand integration and internal integration in the context of food banking.

Design/methodology/approach

This study utilizes survey data from managers at 71 different food banks in the US combined with secondary data gathered from Feeding America's website to provide model controls and an objective measure of food bank performance. The performance metric is the amount of food distributed per food insecure individual in the food bank's service area. Theoretically developed hypotheses were tested using seemingly unrelated regression techniques and a Monte Carlo simulation-based mediation analysis.

Findings

While the previous research on integration relationships on for-profit supply chains has shown that managing internal integration forms the foundation for integrating with suppliers and customers, the findings indicate that, for not-for-profit food banks, external integration should precede internal integration and that demand integration has a stronger influence on performance than supply integration.

Research limitations/implications

The heavy reliance of food banks on external partners necessitates an internal integration structure that supplements and builds upon these external relationships. The basic programs thus developed have a direct impact on the amount of food distributed per food insecure individual.

Originality/value

This paper contributes to the humanitarian supply chain management literature by analyzing supply chain integration and its performance implications in a slow onset disaster setting.

Report from the 20th annual Western Canadian Gastrointestinal Cancer Consensus Conference; Saskatoon, Saskatchewan; 28-29 September 2018

The 20th annual Western Canadian Gastrointestinal Cancer Consensus Conference was held in Saskatoon, Saskatchewan, 28-29 September 2018. This interactive multidisciplinary conference is attended by health care professionals from across Western Canada (British Columbia, Alberta, Saskatchewan, and Manitoba) who are involved in the care of patients with gastrointestinal cancers. In addition, invited speakers from other provinces participate. Surgical, medical, and radiation oncologists, and allied health care professionals participated in presentations and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses current issues in the management of colorectal cancers.

DISTRIBUTION, PREDICTORS, AND CLINICAL RELEVANCE OF 5-YEAR CHANGE IN FRAILTY MEASURES

Implementing frailty assessment into routine clinical practice is a priority. Gait speed and performance on 5 repeated chair stands are two measures of frailty. We face a number of clinical implementation challenges: (1) We lack normative data for U.S. older adults and (2) The clinical relevance of change in frailty measures is unclear. The National Social Life, Health and Aging Project dataset allows an examination of the distribution of 3-meter gait and 5-repeated chair stands times as well as 5-year change in these measures in a nationally-representative, community-dwelling older adult sample. Dr. Huisingh-Scheetz will describe demographic predictors of change in these measures as well as determine whether baseline plus 5-year change in these measures predicts loss of independence in activities of daily living (ADLs).

Cancer league actions against sunbed use for skin cancer prevention

The incidence of non-melanoma and melanoma skin cancer has been rising in Europe. Although the World Health Organization's International Agency for Research on Cancer has since 2009 classified sunbeds as a Group 1 carcinogen, sunbed use, especially by those under the age of 18, continues to be a concern. As the only platform for cancer leagues in Europe, the Association of European Cancer Leagues decided to explore interest and actions by its member leagues at the national level against sunbed use, to share experiences and to provide background information on possible future collective actions at the EU level.

Intratympanic Steroid Use for Sudden Sensorineural Hearing Loss: Current Otolaryngology Practice

OBJECTIVE

To investigate the current practice of intratympanic steroid (ITS) injection for sudden sensorineural hearing loss (SSNHL) in the United Kingdom and link the data with data from the United States and continental Europe.

METHODS

A survey of 21 questions was distributed to members of the British Society of Otology using an online survey platform via ENT UK. Data obtained from UK otolaryngologists (n = 171) were integrated with previously published data from other countries, including the United States (n = 63) and continental Europe (n = 908).

RESULTS

In the United Kingdom, 62% of responding otolaryngologists use ITS injection for SSNHL, while 38% do not. Of those using ITS, 59% use it as first-line treatment, either using it in conjunction with oral steroids (51%) or using it as monotherapy (8%). Of those that use ITS, a majority (83%) use it as salvage therapy when primary treatment with systemic steroids has failed, and similar results are found in the continental Europe and US surveys. The most commonly used preparation is dexamethasone. Responses to questions regarding treatment regimes used are enlightening and show considerable variation in the treatment regimes used within and between countries.

CONCLUSIONS

There is a wide variation in practice with regards to ITS for SSNHL hearing loss in the United Kingdom, United States, and continental Europe. In the absence of protocols or definitive guidance from published literature, knowledge of contemporary practice may help guide or encourage reevaluation of clinical practice and will help guide the design of future clinical trials.

Routine germline BRCA1 and BRCA2 testing in patients with ovarian carcinoma: analysis of the Scottish real-life experience

OBJECTIVE

To determine the rates of germline BRCA1 and BRCA2 mutations in Scottish patients with ovarian cancer, before and after a change in testing policy.

DESIGN

Retrospective cohort study.

SETTING

Four cancer/genetics centres in Scotland.

POPULATION

Patients with ovarian cancer undergoing germline BRCA1 and BRCA2 (gBRCA1/2) sequencing before 2013 (under the 'old criteria', with selection based solely on family history), after 2013 (under the 'new criteria', with sequencing offered to newly presenting patients with non-mucinous ovarian cancer), and in the 'prevalent population' (who presented before 2013, but were not eligible for sequencing under the old criteria but were sequenced under the new criteria).

METHODS

Clinicopathological and sequence data were collected before and for 18 months after this change in selection criteria.

MAIN OUTCOME MEASURES

Frequency of germline BRCA1, BRCA2, RAD51C, and RAD51D mutations.

RESULTS

Of 599 patients sequenced, 205, 236, and 158 were in the 'old criteria', 'new criteria', and 'prevalent' populations, respectively. The frequency of gBRCA1/2 mutations was 30.7, 13.1, and 12.7%, respectively. The annual rate of gBRCA1/2 mutation detection was 4.2 before and 20.7 after the policy change. A total of 48% (15/31) 'new criteria' patients with gBRCA1/2 mutations had a Manchester score of <15 and would not have been offered sequencing based on family history criteria. In addition, 20 patients with gBRCA1/2 were identified in the prevalent population. The prevalence of gBRCA1/2 mutations in patients aged >70 years was 8.2%.

CONCLUSIONS

Sequencing all patients with non-mucinous ovarian cancer gives a much higher annual gBRCA1/2 mutation detection rate, with the frequency of positive tests still exceeding the 10% threshold upon which many family history-based models operate.

TWEETABLE ABSTRACT

BRCA sequencing all non-mucinous cancer patients increases mutation detection five fold.

Diagnostic role of strain imaging in atypical myocarditis by echocardiography and cardiac MRI

BACKGROUND

The diagnosis of myocarditis presenting as isolated acute chest pain with elevated troponins but normal systolic function is challenging with significant drawbacks even for the gold-standard endomyocardial biopsy.

OBJECTIVE

This study aimed to evaluate the diagnostic role of strain imaging by echocardiography and cardiac MRI in these patients.

MATERIALS AND METHODS

This was a retrospective review of children with cardiac MRI for acute chest pain with elevated troponins compared to normal controls. Echocardiographic fractional shortening, ejection fraction, speckle-tracking-derived peak longitudinal, radial, and circumferential strain were compared to cardiac MRI ejection fraction, T2 imaging, late gadolinium enhancement, speckle-tracking-derived peak longitudinal strain, radial strain, and circumferential strain.

RESULTS

Group 1 included 10 subjects diagnosed with myocarditis, 9 (90%) males with a median age of 15.5 years (range: 14-17 years) compared with 10 age-matched controls in group 2. All subjects in group 1 had late gadolinium enhancement consistent with myocarditis and troponin ranged from 2.5 to >30 ng/ml. Electrocardiogram changes included ST segment elevation in 6 and abnormal Q waves in 1. Qualitative echocardiographic function was normal in both groups and mean fractional shortening was similar (35±6% in group 1 vs. 34±4% in group 2, P=0.70). Left ventricle ejection fraction by cardiac MRI, however, was lower in group 1 (52±9%) compared to group 2 at (59±4%) (P=0.03). Cardiac MRI derived strain was lower in group 1 vs. group 2 for speckle-tracking-derived peak longitudinal strain (-12.8±2.8% vs. -17.1±1.5%, P=0.001), circumferential strain (-12.3±3.8% vs. -15.8±1.2%, P=0.020) and radial strain (13.6±3.7% vs. 17.2±3.2%, P=0.040). Echocardiography derived strain was also lower in group 1 vs. group 2 for speckle-tracking-derived peak longitudinal strain (-15.6±3.9% vs. -20.8±2.2%, P<0.002), circumferential strain (-16±3% vs. -19.8±1.9%, P<0.003) and radial strain (17.3±6.1% vs. 24.8±6.3%, P=0.010).

CONCLUSION

In previously asymptomatic children, myocarditis can present with symptoms of acute chest pain suspicious for coronary ischemia. Cardiac MRI and echocardiographic strain imaging are noninvasive, radiation-free tests of immense diagnostic utility in these situations. Long-term studies are needed to assess prognostic significance of these findings.

eHealth readiness of dietitians

BACKGROUND

The present study aimed to determine the eHealth readiness and changes over time of dietitians in Australia.

METHODS

Two cross-sectional analyses of Australian dietitians were conducted in 2013 and 2016, using a survey adapted from one conducted in 2011 by the US Academy of Nutrition and Dietetics. The survey encompassed 30 questions on eHealth readiness across five dimensions: access, standards, attitude, aptitude and advocacy. Descriptive statistics, independent t-tests, chi-squared tests and Z-tests were computed to compare responses from the 2013 and 2016 surveys.

RESULTS

The survey completion rate represented 14.5% (747) of the Dietitians Association of Australia members in 2013 and 8% (417) in 2016. The survey responses in relation to access and standards suggest that dietitians are well positioned for eHealth. For attitude and aptitude, there is a moderate level of preparedness, with minor improvements over time. Although showing significant improvement (P < 0.05), advocacy highlights the area requiring the most development because the majority of dietitians (61%) reported 'no role' in eHealth solutions.

CONCLUSIONS

Dietitians are progressing in relation to access, attitudinal and aptitudinal readiness for eHealth, although they rate poorly with respect to advocacy readiness. It was concluded that dietitians are not yet ready, and also that valuable opportunities to achieve the benefits that eHealth can deliver will be missed, if dietitians do not take the lead in guiding the development, selection and implementation of nutrition-related technologies. Strengthening the dimension of advocacy and ensuring collaboration across the profession, drawing on the varying expertise demonstrated across the practice areas and by the different generations, will be central to improving dietitian eHealth readiness.

More feed efficient sheep produce less methane and carbon dioxide when eating high-quality pellets

The Australian sheep industry aims to increase the efficiency of sheep production by decreasing the amount of feed eaten by sheep. Also, feed intake is related to methane production, and more efficient (low residual feed intake) animals eat less than expected. So we tested the hypothesis that more efficient sheep produce less methane by investigating the genetic correlations between feed intake, residual feed intake, methane, carbon dioxide, and oxygen. Feed intake, methane, oxygen, and carbon dioxide were measured on Merino ewes at postweaning (1,866 at 223 d old), hogget (1,010 sheep at 607 d old), and adult ages (444 sheep at 1,080 d old). Sheep were fed a high-energy grower pellet ad libitum for 35 d. Individual feed intake was measured using automated feeders. Methane was measured using portable accumulation chambers up to 3 times during this feed intake period. Heritabilities and phenotypic and genotypic correlations between traits were estimated using ASReml. Oxygen (range 0.10 to 0.20) and carbon dioxide (range 0.08 to 0.28) were generally more heritable than methane (range 0.11 to 0.14). Selecting to decrease feed intake or residual feed intake will decrease methane (genetic correlation [] range 0.76 to 0.90) and carbon dioxide ( range 0.65 to 0.96). Selecting to decrease intake ( range 0.64 to 0.78) and methane ( range 0.81 to 0.86) in sheep at postweaning age would also decrease intake and methane in hoggets and adults. Furthermore, selecting for lower residual feed intake ( = 0.75) and carbon dioxide ( = 0.90) in hoggets would also decrease these traits in adults. Similarly, selecting for higher oxygen ( = 0.69) in hoggets would also increase this trait in adults. Given these results, the hypothesis that making sheep more feed efficient will decrease their methane production can be accepted. In addition, carbon dioxide is a good indicator trait for feed intake because it has the highest heritability of the gas traits measured; is cheaper, faster, and easier to measure than feed intake and has strong phenotypic and genetic correlations with feed intake. Furthermore, selection for feed intake, feed efficiency, methane, and carbon dioxide can be done early in sheep at postweaning age or hoggets. This early selection reduces the generation interval for breeding, thereby increasing response to selection.

A Data Processing Pipeline for Prediction of Milling Machine Tool Condition from Raw Sensor Data

With recent advances in sensor and computing technology, it is now possible to use real-time machine learning techniques to monitor the state of manufacturing machines. However, making accurate predictions from raw sensor data is still a difficult challenge. In this work, a data processing pipeline is developed to predict the condition of a milling machine tool using raw sensor data. Acceleration and audio time series sensor data is aggregated into blocks that correspond to the individual cutting operations of the Computer Numerical Control (CNC) milling machine. Each block of data is preprocessed using well-known and computationally efficient signal processing techniques. A novel kernel function is proposed to approximate the covariance between preprocessed blocks of time series data. Several Gaussian process regression models are trained to predict tool condition, each with a different covariance kernel function. The model with the novel covariance function outperforms the models that use more common covariance functions. The trained models are expressed using the Predictive Model Markup Language (PMML), where possible, to demonstrate how the predictive model component of the pipeline can be represented in a standardized form. The tool condition model is shown to be accurate, especially when predicting the condition of lightly worn tools.

Spatio-temporal analysis of particulate matter intake fractions for vehicular emissions: Hourly variation by micro-environments in the Greater Toronto and Hamilton Area, Canada

Previous investigations have reported intake fraction (iF) for different environments, which include ambient concentrations (outdoor exposure) and microenvironments (indoor exposure). However, little is known about iF variations due to space-time factors, especially in microenvironments. In this paper, we performed a spatio-temporal analysis of particulate matter (PM_2.5) intake fractions for vehicular emissions. Specifically, we investigated hourly variation (12:00am-11:00pm) by micro-environments (residences and workplaces) in the Greater Toronto and Hamilton Area (GTHA), Canada. We used GIS modeling to estimate air pollution data (ambient concentration, and traffic emission) and population data in each microenvironment. Our estimates showed that the total iF at residences and workplaces accounts for 85% and 15%, respectively. Workplaces presented the highest 24h average iF (1.06ppm), which accounted for 25% higher than residences. Observing the iF by hour at residences, our estimates showed the highest average iF at 2:00am (iF=3.72ppm). These estimates indicate that approximately 4g of PM_2.5 emitted from motor vehicles are inhaled for every million grams of PM_2.5 emitted. For the workplaces, the highest exposure was observed at 10:00am, with average iF equal to 2.04ppm. The period of the day with the lower average iF for residences was at 8:00am (average iF=0.11ppm), while for the workplaces was at 4:00am (average iF=0.47ppm). Our approach provides a new perspective on human exposure to air pollution. Our results showed significant hourly variation in iF across the GTHA. Our findings can be incorporated in future investigations to advance environmental health effects research and human health risk assessment.

Nutritional monitoring of patients post-bariatric surgery: implications for smartphone applications

BACKGROUND

Optimal results from bariatric surgery are contingent on patient commitment to dietary and lifestyle changes and follow-up care. The present study aimed to investigate the attitudes and use of mobile health (mHealth) smartphone applications (apps) as a potential tool for maintaining connectivity between dietitians and patients post-bariatric surgery.

METHODS

A cross-sectional online survey was developed and distributed to a purposeful sample of bariatric dietitians and bariatric patients in Australia. The survey questions explored technology penetration (smartphone and app use), communication preferences, nutrition monitoring methods, professional relationship expectations and reasons for loss to follow-up.

RESULTS

Survey completion rate was 85% (n = 50/59) for dietitians and 80% (n = 39/49) for patients. Smartphone ownership was 98% and 95% for dietitians and patients, respectively. Common reasons given for losing patients to follow-up suggest that a traditional in-clinic practice setting could be a barrier for some. Most dietitians (n = 48; 91%) prefer to see patients face-to-face in their clinic, whereas patient preferences extended to e-mail and mobile messaging. Sixty-eight percent of bariatric patients were receptive to two-way communication with dietitians via an app between clinic visits. Both cohorts recognised the potential for emerging technologies to be used in practice, although there was no single routinely recommended mHealth app.

CONCLUSIONS

The present study provides the first insight into the use of mobile devices and apps by post-bariatric patients and the dietitians who support them. A mixture of traditional methods and smartphone technology is desirable to both dietitians and patients. The utility and effectiveness of such technologies should be confirmed in future intervention studies.

Gaussian Process Regression (GPR) Representation in Predictive Model Markup Language (PMML)

This paper describes Gaussian process regression (GPR) models presented in predictive model markup language (PMML). PMML is an extensible-markup-language (XML) -based standard language used to represent data-mining and predictive analytic models, as well as pre- and post-processed data. The previous PMML version, PMML 4.2, did not provide capabilities for representing probabilistic (stochastic) machine-learning algorithms that are widely used for constructing predictive models taking the associated uncertainties into consideration. The newly released PMML version 4.3, which includes the GPR model, provides new features: confidence bounds and distribution for the predictive estimations. Both features are needed to establish the foundation for uncertainty quantification analysis. Among various probabilistic machine-learning algorithms, GPR has been widely used for approximating a target function because of its capability of representing complex input and output relationships without predefining a set of basis functions, and predicting a target output with uncertainty quantification. GPR is being employed to various manufacturing data-analytics applications, which necessitates representing this model in a standardized form for easy and rapid employment. In this paper, we present a GPR model and its representation in PMML. Furthermore, we demonstrate a prototype using a real data set in the manufacturing domain.

Can preeclampsia be considered a renal compartment syndrome? A hypothesis and analysis of the literature

The morbidity and mortality associated with preeclampsia is staggering. The physiology of the Page kidney, a condition in which increased intrarenal pressure causes hypertension, appears to provide a unifying framework to explain the complex pathophysiology. Page kidney hypertension is renin-mediated acutely and ischemia-mediated chronically. Renal venous outflow obstruction also causes a Page kidney phenomenon, providing a hypothesis for the increased vulnerability of a subset of women who have what we are hypothesizing is a "renal compartment syndrome" due to inadequate ipsilateral collateral renal venous circulation consistent with well-known variation in normal venous anatomy. Dynamic changes in renal venous anatomy and physiology in pregnancy appear to correlate with disease onset, severity, and recurrence. Since maternal recumbent position is well known to affect renal perfusion and since chronic outflow obstruction makes women vulnerable to the ischemic/inflammatory sequelae, heightened awareness of renal compartment syndrome physiology is critical. The anatomic and physiologic insights provide immediate strategies to predict and prevent preeclampsia with straightforward, low-cost interventions that make renewed global advocacy for pregnant women a realistic goal.

The adrenergic-regulated CRTC1 and CRTC2 phosphorylation and cellular distribution is independent of endogenous SIK1 in the male rat pinealocyte

Salt inducible kinase 1 (SIK1) has been reported to repress cAMP-response element binding protein (CREB)-mediated gene transcription by causing the nuclear export of CREB-regulated transcription coactivators (CRTCs) through phosphorylation. Although the repressor role of SIK1 in suppressing the expression of arylalkylamine N-acetyltransferase, the enzyme that controls the daily rhythm in melatonin production in the rat pineal gland, has been established, whether SIK1 regulates the phosphorylation and localization of CRTC1 and CRTC2 in this tissue remains unclear. The present study found that overexpressing SIK1 in NE-stimulated rat pinealocytes could increase the phosphorylation of CRTC1 and CRTC2, reduced selectively the nuclear level of CRTC2 (but not that of CRTC1), and elevated the cytosolic levels of both CRTC1 and CRTC2. In contrast, transient knockdown of endogenous SIK1 had no effect on the phosphorylation or distribution of CRTC1 and CRTC2 in norepinephrine (NE)-stimulated pinealocytes. Our results also showed that adrenergic blockade during NE stimulation led to a rapid rephosphorylation and decline in the nucleus levels of CRTC1 and CRTC2; however SIK1 knockdown had no effect on this rapid rephosphorylation. Moreover, studies with kinase inhibitors revealed that kinase(s) sensitive to KT5823 appeared to be involved in this rapid rephosphorylation. Together, these results indicate that although overexpressing SIK1 can phosphorylate CRTC1 and CRTC2 in the NE-stimulated pinealocyte, the endogenous SIK1, in spite of its induction by NE, does not appear to be the main regulator of the phosphorylation and intracellular localization of these two coactivators.