Fatigue-Related Changes of Daily Function: Most Promising Measures for the Digital Age

Background

Fatigue is a prominent symptom in many diseases and is strongly associated with impaired daily function. The measurement of daily function is currently almost always done with questionnaires, which are subjective and imprecise. With the recent advances of digital wearable technologies, novel approaches to evaluate daily function quantitatively and objectively in real-life conditions are increasingly possible. This also creates new possibilities to measure fatigue-related changes of daily function using such technologies.

Summary

This review examines which digitally assessable parameters in immune-mediated inflammatory and neurodegenerative diseases may have the greatest potential to reflect fatigue-related changes of daily function.

Key Messages

Results of a standardized analysis of the literature reporting about perception-, capacity-, and performance-evaluating assessment tools indicate that changes of the following parameters: physical activity, independence of daily living, social participation, working life, mental status, cognitive and aerobic capacity, and supervised and unsupervised mobility performance have the highest potential to reflect fatigue-related changes of daily function. These parameters thus hold the greatest potential for quantitatively measuring fatigue in representative diseases in real-life conditions, e.g., with digital wearable technologies. Furthermore, to the best of our knowledge, this is a new approach to analysing evidence for the design of performance-based digital assessment protocols in human research, which may stimulate further systematic research in this area.

Noninvasive drug adherence monitoring of antipsychotic patients via finger sweat testing

Collection of finger sweat is explored here as a rapid and convenient way of monitoring patient adherence to antipsychotic drugs. Finger sweat samples (n = 426) collected from patients receiving treatment with clozapine, quetiapine and olanzapine were analysed by liquid chromatography mass spectrometry, including a subgroup of patients with paired plasma samples. Finger sweat samples were also analysed from a negative control group and patients who had handled antipsychotic medication only. The finger sweat test (based on the detection of parent drug in one donated sample) was 100% effective in monitoring adherence within commonly prescribed dosing ranges. In comparison to participants who handled the medication only, the test could distinguish between contact and administration through monitoring of the drug metabolite, or the level of parent drug. Additionally, in a subgroup of patients prescribed clozapine, a statistically significant correlation was observed between the mass of parent drug in finger sweat and plasma concentration. The finger sweat technology shows promise as a dignified, noninvasive method to monitor treatment adherence in patients taking antipsychotics.

Diverse Murine Vaccinations Reveal Distinct Antibody Classes to Target Fusion Peptide and Variation in Peptide Length to Improve HIV Neutralization

While neutralizing antibodies that target the HIV-1 fusion peptide have been elicited in mice by vaccination, antibodies reported thus far have been from only a single antibody class that could neutralize ~30% of HIV-1 strains. To explore the ability of the murine immune system to generate cross-clade neutralizing antibodies and to investigate how higher breadth and potency might be achieved, we tested 17 prime-boost regimens that utilized diverse fusion peptide-carrier conjugates and HIV-1 envelope trimers with different fusion peptides. We observed priming in mice with fusion peptide-carrier conjugates of variable peptide length to elicit higher neutralizing responses, a result we confirmed in guinea pigs. From vaccinated mice, we isolated 21 antibodies, belonging to 4 distinct classes of fusion peptide-directed antibodies capable of cross-clade neutralization. Top antibodies from each class collectively neutralized over 50% of a 208-strain panel. Structural analyses - both X-ray and cryo-EM - revealed each antibody class to recognize a distinct conformation of fusion peptide and to have a binding pocket capable of accommodating diverse fusion peptides. Murine vaccinations can thus elicit diverse neutralizing antibodies, and altering peptide length during prime can improve the elicitation of cross-clade responses targeting the fusion peptide site of HIV-1 vulnerability. IMPORTANCE The HIV-1 fusion peptide has been identified as a site for elicitation of broadly neutralizing antibodies, with prior studies demonstrating that priming with fusion peptide-based immunogens and boosting with soluble envelope (Env) trimers can elicit cross-clade HIV-1-neutralizing responses. To improve the neutralizing breadth and potency of fusion peptide-directed responses, we evaluated vaccine regimens that incorporated diverse fusion peptide-conjugates and Env trimers with variation in fusion peptide length and sequence. We found that variation in peptide length during prime elicits enhanced neutralizing responses in mice and guinea pigs. We identified vaccine-elicited murine monoclonal antibodies from distinct classes capable of cross-clade neutralization and of diverse fusion peptide recognition. Our findings lend insight into improved immunogens and regimens for HIV-1 vaccine development.

Efficacy and safety of Felpreva®, a spot-on formulation for cats containing emodepside, praziquantel and tigolaner against experimental infestation with the Australian paralysis tick Ixodes holocyclus

The Australian paralysis tick Ixodes holocyclus continues to be a serious threat to companion animals along Australia's east coast. The tick produces a potent neurotoxin which causes a rapidly ascending flaccid paralysis, which if left untreated, can result in the death of the animal. There is currently only a limited number of products registered in Australia for the treatment and control of paralysis ticks in cats. Felpreva® is an effective spot-on combination containing emodepside, praziquantel and tigolaner. To investigate the therapeutic and long-term persistent efficacy of Felpreva® (2.04% w/v emodepside, 8.14% w/v praziquantel and 9.79% w/v tigolaner) against experimental infestation with I. holocyclus in cats, two studies were undertaken. Fifty cats were included in the studies on study Day -17. These cats were immunized against paralysis tick holocyclotoxin prior to the study commencing. Immunity to holocyclotoxin was confirmed with a tick carrying capacity (TCC) test conducted prior to treatment. Cats were treated once on Day 0. Group 1 cats were treated with the placebo formulation and Group 2 cats were treated with Felpreva®. Cats were infested on Days -14 (tick carrying capacity test), 0, 28, 56, 70, 84 and 91 (weeks 4, 8, 10, 12 and 13). Ticks were counted on cats 24 h, 48 h and 72 ​h post-treatment and infestation, except during the tick carrying capacity test when they were counted approximately 72 ​h post-infestation only. The 24-h and 48-h assessments were conducted without removing the ticks. The ticks were assessed, removed and discarded at the 72-h assessment time-points. Significant differences in total live tick counts at ∼24 h, ∼48 h and ∼72 ​h post-infestation were observed between the treatment and control group. Differences were significant (P ​< ​0.05 to ​< ​0.001) in all instances. Treatment efficacies of 98.1-100% were observed ∼72 ​h post-infestation through to 13 weeks (94 days) post-treatment. These results show that a single application of Felpreva® provides effective treatment and control against induced infestation with paralysis ticks for 13 weeks.

A Trace Mineral Injection before Joining and Lambing Increases Marking Percentages and Lamb Weights on Diverse Farms in Victoria, Australia

This study was conducted on five commercial farms across Victoria, Australia, between September 2018 and November 2019, where the TM status of ewes was within normal ranges before joining. Mix breed ewes (n = 1484) were randomly allocated to receive either nil treatment (Control) or two injections of an ITM product containing zinc (40 mg/mL), manganese (10 mg/mL), selenium (3 mg/mL), and copper (10 mg/mL); 0.2 mL per 10 kg BW (Multimin® plus Copper for Sheep, Virbac (Australia) Pty Ltd., Milperra, NSW, Australia) 30 days before the start of joining and 30 days before the start of lambing. Approximately 90 days after joining, pregnancy status and conception rate were determined by ultrasound. The marking rate was determined approximately four weeks after the end of lambing, and lamb weights were determined at weaning (12 weeks after the end of lambing). In all farms, ITM treatment did not affect the conception rate. The average conception rate was 156 ± 11.0% (p > 0.05). The marking rate of ITM ewes was 9% higher than control ewes (95% Confidence Interval 3−21%). Lambs born to ITM ewes were 2.31 kg heavier at weaning than lambs born to control ewes (p < 0.001). Although not significant, ewe mortality across farms was 1.3% lower in the ITM group than in the control group. On average, ewes treated with ITM pre-joining and pre-lambing produced more and heavier lambs that represent an extra AU$ 2338 per 100 ewes net benefit for the producer. These results help to understand strategic TM supplementation for animal health, performance and farm profitability beyond the treatment of clinical deficiencies.

Value Insider Season 1 Episode 3: How Does Budget Impact and Affordability in Healthcare Work? (BI and Affordability) [Podcast]

How does budget impact and affordability in healthcare work? In this episode of the Value Insider podcast, host Mike Chambers speaks with Prof. Sean Sullivan about affordability and budget impact for the "payers" of healthcare interventions. Prof. Sullivan is Dean of the University of Washington School of Pharmacy. He is past president of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and served as chair of the health technology assessment (HTA) committee of US Health Insurer Premera Blue Cross, was part of the US Governmental Medicare coverage evidence committee and led the ISPOR Task Force on Methods for Conducting and Reporting Budget Impact Assessments. Prof. Sullivan explains how budget impact and affordability are intertwined and how this plays a role in decisions in the US, but also the rest of the world.

Value Insider Season 1 Episode 2: How to Measure Quality of Life and Utility? (QoL) [Podcast]

How do we measure quality of life and utility of interventions? In this episode of the Value Insider podcast, host Mike Chambers speaks with Prof. Nancy Devlin about incorporating quality of life in value assessment. Prof. Devlin is professor of health economics at the University of Melbourne. Her past roles include Director of Research at the Office of Health Economics (OHE) London, Professor of Health Economics at City University of London, and she has been director of the International Society of Pharmacoeconomics and Outcomes Research (ISPOR). She is the Chair of the Board of the EuroQol Research Foundation, the international research organization which has developed and maintains the EQ-5D patient-reported outcome (PRO) instrument. Prof Devlin explains the value of the patient voice and how it can be measured and taken into account when considering the value of healthcare interventions.

Value Insider Season 1 Episode 1: The Importance of Payers and HTA: How Did We End Up Here? (Introduction to Value) [Podcast]

The importance of payers and HTA: How did we end up here? In this episode of the Value Insider podcast, host Mike Chambers speaks with Prof. Mike Drummond about Health Technology Assessment (HTA) and how value is defined. Prof. Drummond is professor of Health Economics of York University, former president of the International Society of Pharmacoeconomics and Outcomes Research (ISPOR), and author of two major textbooks in the field, as well as over 700 publications, and has acted as consultant to the WHO as well as European Union with regards to value assessment. Starting from the very beginning, Prof. Drummond explains in a simple yet engaging way why demonstrating value of new interventions has become so important.

Grazier perceptions and management practices for liver fluke control in north eastern NSW, Australia

A survey of livestock producers (graziers) located in north eastern NSW Australia, collected information on perceptions and management practices for liver fluke control in livestock. The total area farmed by the 161 respondents was 195,600 ha (ranging in size from 4 to 10,522 ha) with cattle and sheep being the dominant livestock enterprises. Overall, 80% of graziers relied exclusively on anthelmintics for liver fluke control and few of these graziers (9%) integrated parasite management (IPM) strategies to reduce disease prevalence. Of those relying on anthelmintic control, triclabendazole (TCBZ) was preferentially chosen by 75% of graziers. Fifty five percent of these graziers used TCBZ in combination with oxfendazole (46%), ivermectin (5%) or abamectin (4%) whilst 45% used TCBZ as a single active ingredient. Thirty eight percent of graziers drenched livestock one or more times per year for liver fluke despite claiming they had no liver fluke or confirmed knowledge of infection. Fifty one percent of graziers based anthelmintic dose on the known weight of the heaviest animal in the herd whilst 43% visually guessed livestock bodyweight to calculate anthelmintic dose. Choice of anthelmintic was predominately based on perceived efficacy (45%) despite very few graziers (2%) having conducted post-treatment fluke egg counts. The majority of graziers (76%) were unsure if they had anthelmintic resistance, 21% claimed they had no resistance whilst 3% of graziers had confirmed resistance. Most graziers (97%) also reported farms were cohabited by kangaroos highlighting additional grazing pressures on-farm. This current survey has revealed that graziers rely on anthelmintics as their primary choice for liver fluke control. Reluctance to adopt IPM strategies and a continued heavy reliance on TCBZ, whilst basing anthelmintic decisions on perception rather than measurement and testing, pose threats for the future control of liver fluke in livestock within this endemic area.

396 Rotator Cuff Assessment Following Traumatic Anterior Shoulder Dislocation

Aim

Glenohumeral joint dislocation is the most common traumatic joint dislocation with a high recurrence rate correlating with age at first dislocation. There is an associated increased incidence in concurrent rotator cuff tears with increasing age affecting 40% aged 40–60. Patient care was assessed against BESS/BOA standard: These patients should have rotator cuff assessment and those aged 40–60 should undergo routine MRI/Ultrasound imaging.

Method

All patients admitted to the emergency departments of the 3 Lanarkshire hospitals undergoing first time traumatic anterior dislocation of the shoulder in February 2021 were included. This was the third cycle of this audit. Previous interventions were presentation at a CPD meeting after cycle one and an NHS Lanarkshire regional meeting after cycle two.

Results

Cycle one (2018)-14 patients. 3/14 underwent rotator cuff assessment. 5/14 aged 40–60. 1/5 underwent rotator cuff imaging.

Cycle two (2020)-11 patients. 0/9 underwent rotator cuff assessment (Two excluded as managed operatively). 4/11 aged 40–60. 0/4 underwent rotator cuff imaging.

Cycle three (2021)-13 patients. 3/11 underwent rotator cuff assessment (Two excluded as managed operatively). 3/13 aged 40–60. 0/3 underwent rotator cuff imaging.

Conclusions

Although a slight improvement has been made over the 3 cycles with rotator cuff assessment the BOA standard is not being met. There has been no improvement in the additional imaging required in traumatic anterior shoulder dislocations in those aged 40–60 over the 3 cycles. These patients may develop pain, reduced function, and rotator cuff arthropathy. There is now an aim to introduce a pathway for these patients across the health board.

Mobility endpoints in marketing authorisation of drugs: what gets the European medicines agency moving?

Background

Mobility is defined as the ability to independently move around the environment and is a key contributor to quality of life, especially in older age. The aim of this study was to evaluate the use of mobility as a decisive outcome for the marketing authorisation of drugs by the European Medicines Agency (EMA).

Methods

Fifteen therapeutic areas which commonly lead to relevant mobility impairments and alter the quantity and/or the quality of walking were selected: two systemic neurological diseases, four conditions primarily affecting exercise capacity, seven musculoskeletal diseases and two conditions representing sensory impairments. European Public Assessment Reports (EPARs) published by the EMA until September 2020 were examined for mobility endpoints included in their ‘main studies’. Clinical study registries and primary scientific publications for these studies were also reviewed.

Results

Four hundred and eighty-four EPARs yielded 186 relevant documents with 402 ‘main studies’. The EPARs reported 153 primary and 584 secondary endpoints which considered mobility; 70 different assessment tools (38 patient-reported outcomes, 13 clinician-reported outcomes, 8 performance outcomes and 13 composite endpoints) were used. Only 15.7% of those tools distinctly informed on patients’ mobility status. Out of 402, 105 (26.1%) of the ‘main studies’ did not have any mobility assessment. Furthermore, none of these studies included a digital mobility outcome.

Conclusions

For conditions with a high impact on mobility, mobility assessment was given little consideration in the marketing authorisation of drugs by the EMA. Where mobility impairment was considered to be a relevant outcome, questionnaires or composite scores susceptible to reporting biases were predominantly used.

Measuring therapeutic engagement in acute mental health inpatient environments: the perspectives of service users and mental health nurses

BACKGROUND

A key component of caring for service users (SUs) in acute mental health inpatient environments is Therapeutic Engagement (TE). To that end, the Therapeutic Engagement Questionnaire (TEQ) was developed and validated. The TEQ measures TE between SUs and registered mental health nurses (RMHNs) from the perspective of both parties and can quantify and recognise how nurses engage with SUs and monitor this activity as well as its enhancement of SU care and recovery. The aim of this study was to explore the views of SUs and RMHNs in relation to the TEQ and how it could be adopted into clinical practice within an acute inpatient environment.

METHODS

As part of the validation stage of the development of the TEQ, the views of 628 SUs and 543 RMHNs were collected using a qualitative approach by way of free text at the end of the questionnaire. Two questions required free text response: - 'what do you think of the TEQ?', and 'how can it be utilised?'

RESULTS

Following thematic analysis, it was found that both sets of participants stated that such a tool could be utilised to improve the service, could help nurses with reflective practice, be utilised as part of clinical supervision and to aid nurses' professional development. The nurse participants also stated that such a tool would help track SU participation and enablement in their care. Furthermore, the nurses noted that the tool would help to reinforce the core 'caring' value of nursing and the overall goal of recovery. The SUs added that the TEQ would recognise the work of mental health nurses and provide them with a clear opportunity to express their views in relation to nursing staff.

CONCLUSIONS

Therapeutic engagement (TE) has been identified as part of the repertoire of mental health nursing and both groups of participants identified how a tool to assess this construct may be utilised in day-to-day clinical practice to the benefit of each group.

Prevalence and gross pathology of liver fluke in macropods cohabiting livestock farms in north eastern NSW, Australia, and diagnosis using cELISA

Liver fluke (Fasciola hepatica) is a parasite of herbivores including wildlife. Macropods, such as Eastern grey kangaroo (Macropus giganteus) and Common wallaroo (Osphranter robustus), are frequently observed sharing grazing sites with domestic livestock. The impact of Macropods, as reservoirs of infection, on livestock production and risks to cross-species transmission are largely unknown. In Phase 1 of this study, liver and faecal samples were collected from 245 Macropods (181 Eastern grey kangaroos, 64 Common wallaroos) cohabiting livestock farms (n = 7) in the Northern Tablelands regions of New South Wales. Total fluke (TFC) and fluke eggs (FEC) were counted in the liver and faeces, respectively, to assess prevalence. Faecal antigens were also measured using the commercial Bio-X Diagnostic Monoscreen AgELISA Fasciola hepatica kit (cELISA) to assess suitability as a diagnostic tool. In Phase 2, Macropod faecal samples were collected from 60 livestock farms to conduct FEC and assess prevalence by region. Liver fluke was prevalent in 22% of Eastern grey kangaroo and 20% of Common wallaroos with prevalence as high as 45% in the Eastern grey kangaroo. Fluke burdens ranged from 1 to 122 flukes (mean = 9 flukes) with a FEC range of 0–195 eggs per gram (epg) of faeces (mean = 18 epg). Evidence of dead and live flukes trapped within fibrotic capsules confirms the ability of Macropods to resolve infections. cELISA proved highly specific (100%) and sensitive (98%) in liver fluke detection however fibrotic capsules observed in the liver may reduce the correlation of coproantigens with fluke burden. Phase 2 revealed that 27% of livestock farms had Macropods infected with liver fluke. Overall, this study confirmed Eastern grey kangaroo and Common wallaroo are susceptible hosts and potential reservoirs for liver fluke and, monitoring infections in Macropods would assist in livestock disease management.

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Eastern grey kangaroo and Common wallaroo harbouring liver fluke in north eastern Australia.

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Macropods with liver fluke may limit effectiveness of integrated parasite management strategies for liver fluke control.

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Monitoring Macropod populations within liver fluke endemic regions may assist livestock disease management.

Kangaroos and liver fluke: The role played in cross-species transmission and drug resistance

Australian livestock are challenged by liver fluke (Fasciola hepatica) in grazing regions endemic to the intermediate snail host. Liver fluke infests a wide range of herbivores including free-roaming wildlife such as kangaroos (Macropods). The role played by Macropods in cross-species transmission and as vectors for anthelmintic resistance is largely unknown. In Phase 1 of this study, liver fluke of Eastern grey kangaroo (Macropus giganteus Shaw, 1790) origin (Kangaroo isolate) were artificially infected in sheep to confirm establishment and cross-species transmission. In Phase 2, the efficacy of triclabendazole (TCBZ) was assessed in vivo against the Kangaroo isolate to identify any drug resistance. Forty (40) merino sheep were housed in pens and allocated to one of 4 groups (Groups 1-4). Groups 1 and 2 were artificially infected with a TCBZ resistant liver fluke isolate (Oberon) originating from sheep whilst Groups 3 and 4 were infected with the Kangaroo isolate (Phase 1). At 9 weeks post infection (wpi), sheep in Groups 2 and 4 were treated with 10 mg/kg TCBZ (Phase 2). Sheep were subsequently euthanased at 11 wpi to conduct total fluke counts (TFC) in the liver. Faecal samples were collected fortnightly to measure fluke egg counts and coproantigens. Individual blood samples were collected, concurrently with faecal sampling, to monitor haematocrit and plasma proteins levels. Liver fluke of kangaroo origin established to patent infections in sheep with similar establishment and pathogenicity to the Oberon isolate. TCBZ achieved an 86 % reduction in TFC (99.8 % - adult fluke, 0 % - immature fluke) in sheep with the Kangaroo isolate and a 28 % reduction in the Oberon isolate (37 % - adult, 0 % - immature fluke). An 89 % reduction in faecal coproantigens was observed in sheep with the Kangaroo isolate and no reduction in sheep with Oberon. This study confirmed cross-species transmission of liver fluke from a kangaroo to sheep. When cohabiting the livestock grazing environment, kangaroos may act as reservoirs for liver fluke and vectors for drug resistance within liver fluke endemic areas.

Immune Monitoring Reveals Fusion Peptide Priming to Imprint Cross-Clade HIV-Neutralizing Responses with a Characteristic Early B Cell Signature

The HIV fusion peptide (FP) is a promising vaccine target. FP-directed monoclonal antibodies from vaccinated macaques have been identified that neutralize up to ∼60% of HIV strains; these vaccinations, however, have involved ∼1 year with an extended neutralization-eclipse phase without measurable serum neutralization. Here, in 32 macaques, we test seven vaccination regimens, each comprising multiple immunizations of FP-carrier conjugates and HIV envelope (Env) trimers. Comparisons of vaccine regimens reveal FP-carrier conjugates to imprint cross-clade neutralizing responses and a cocktail of FP conjugate and Env trimer to elicit the earliest broad responses. We identify a signature, appearing as early as week 6 and involving the frequency of B cells recognizing both FP and Env trimer, predictive of vaccine-elicited breadth ∼1 year later. Immune monitoring of B cells in response to vaccination can thus enable vaccine insights even in the absence of serum neutralization, here identifying FP imprinting, cocktail approach, and early signature as means to improve FP-directed vaccine responses.

Prevalence and pathology of liver fluke (Fasciola hepatica) in fallow deer (Dama dama)

A survey conducted on fallow deer (n = 79) in northern New South Wales Australia, aimed to ascertain the prevalence and gross pathology of liver fluke. In total, three deer populations were assessed (1 farmed and 2 wild) across 2 sites (site A and B) by conducting total fluke counts in the liver and fluke egg counts in faecal samples. At site A, 16 of 19 farmed deer (84.2 %) and 9 of 20 wild deer (45 %) had active or resolved infections. At site B, 16 of 40 wild deer (40 %) had active or resolved infections. Deer with active infections had low fluke burdens (1-11 fluke) which were in the adult development stage, shedding eggs with faeces (0-121.7 eggs per gram). Liver pathology score did not exceed 3.5 out of 5 with gross pathomorphological lesions predominately confined to the peripheral regions of the left lobe. Farmed deer, confined within a fluky habitat, attained the highest group mean pathology score, with dense fibrosis and concomitant atrophy of the left lobe (site A: farmed - 1.8, wild- 0.6; site B: wild - 0.3). Well-defined fibrotic capsules captured and restricted fluke migration beyond the peripheral region of the left lobe of the liver. The presence of live and dead fluke within the fibrotic capsules confirms the inherent ability of fallow deer to resolve infections. This survey has highlighted the susceptibility of fallow deer to liver fluke within an endemic region. Recurrent exposure, as seen in the farmed deer confined within a fluky habitat, appears to strengthen tissue response in terms of gross pathology and may impede the release of fluke eggs from the liver. Low fluke burdens and limited lesions suggest fallow deer have a strong level of resistance to liver fluke. Nevertheless, within this endemic region, fallow deer are widespread and clearly facilitating the liver fluke life cycle. Further research is warranted to ascertain the impact of fallow deer on disease transmission in livestock production when cohabiting the grazing environment.

Measuring therapeutic engagement in finnish adult acute psychiatric in-patient care units using the finnish version of therapeutic engagement questionnaire (TEQ)

Introduction

The Therapeutic Engagement Questionnaire (TEQ) has been developed and validated in partnership with service users (SUs), registered mental health nurses (RMHNs) and nurse academics in the UK in accordance with psychometric theory. The TEQ is highly relevant and useful to clinical practice. The TEQ measures therapeutic engagement (TE) in two contexts - 1-1 interactions between SUs and RMHNs, as well as the overall environment and atmosphere of the units - from the perspective of both SUs and RMHNs. The TEQ has been translated into Finnish by two expert panels and was pre-tested and validated in ten adult acute psychiatric in-patient units in two hospitals in Finland.

Objectives

To measure TE in Finnish adult acute in-patient psychiatric settings from the perspectives of both SUs and RMHNs.

Methods

The Finnish version of the TEQ (Hoidollinen yhteistyö) will be completed by RMHNs and SUs in 15 adult acute psychiatric in-patient units. Nine of the units are within the University Hospital and six in a municipal psychiatric hospital. The data will be collected within a 3-month period (October - December 2020). The coordinating nurse of each unit will organise the operational side of the study including obtaining consent from SUs. The nurses will participate in the survey via Webropol which includes nurses’ consent. Sociodemographic information will be collected from the SUs and nurses.

Results

The results of the measurement study will be reported at the 29th European Congress of Psychiatry.

Conclusions

The conclusions of the measurement study will be reported at the 29th European Congress of Psychiatry.

Conflict of interest

This study is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration South London (NIHR ARC South London).

Topical Application of Lidocaine and Bupivacaine to Disbudding Wounds in Dairy Calves: Safety, Toxicology and Wound Healing

Simple Summary

Disbudding is a common, but painful procedure performed on calves to prevent horn growth. Tri-Solfen^® is a combination local anaesthetic and antiseptic formulation which, applied topically to the disbudding wound, is reported to reduce calf pain. Applied in this manner, the local anaesthetics in Tri-Solfen^®, lidocaine and bupivacaine, are reported to be poorly absorbed, resulting in low risk of neurological or cardiotoxic effects. The potential impacts on other blood, urine and tissue parameters and on wound healing when used in this manner, and/or accidental overdose situations are unknown, however. We performed experiments investigating (i) the safety of Tri-Solfen^® (including overdose situations) and (ii) the impact of Tri-Solfen^® on disbudding wound healing under field conditions. No adverse health effects were observed in Tri-Solfen^®-treated animals, even those receiving 5× the recommended dose, with no clinically significant differences in measured parameters between placebo and Tri-Solfen^® groups. No negative impacts on wound healing were noted. Conversely, lower levels of bacterial wound colonisation were evident, and there was reduced incidence of abnormal wounds at days 11–12 in Tri-Solfen^®-treated animals.

Abstract

Tri-Solfen^® is a combination topical anaesthetic and antiseptic solution containing lidocaine, bupivacaine, adrenaline and cetrimide. Applied to wounds, it is reported to reduce the pain experienced by calves following thermocautery disbudding. While lidocaine and bupivacaine are widely used in medicine, conflicting data exist on the impact of these compounds when applied directly to the surgical wound. To investigate the safety of Tri-Solfen^® applied to thermocautery disbudding wounds of calves, experiments were performed to measure (i) the safety of Tri-Solfen^® (including in overdose situations); and (ii) the impact of Tri-Solfen^® application at recommended doses on disbudding wound healing under field conditions. Haematological, biochemical and urinalysis parameters did not show clinically significant differences between placebo and Tri-Solfen^® groups (1×, 3× and 5× dose). No adverse health impacts were reported. Histopathological analysis of wounds noted a reduction in bacterial colonies in Tri-Solfen^®-treated wounds. Under field conditions, no negative impacts on wound healing were noted. Conversely, there was reduced incidence of abnormal wounds, with an associated trend toward improved average daily gain at days 11–12 in Tri-Solfen^®-treated animals. These data are considered to support the safety of topical anaesthesia, as formulated in Tri-Solfen^®, to the thermocautery disbudding wound in calves.

A pilot study comparing the pharmacokinetics of injectable cyanocobalamin and hydroxocobalamin associated with a trace mineral injection in cattle

Injectable vitamin B₁₂ (cobalamin) is traditionally used to prevent or treat vitamin B₁₂ deficiencies in ruminants. Sheep and human studies have demonstrated the superiority of a single dose of hydroxocobalamin (OHB12) over cyanocobalamin (CNB12) in maintaining high levels of cobalamin in plasma and liver. However, limited data are available for cattle. The purpose of this study was to compare the pharmacokinetics of two forms of cobalamin-OHB12 and CNB12-as a single subcutaneous injection of 28 µg/kg BW at the same time of a trace mineral injection in six non-cobalt/B₁₂ -deficient Holstein-Friesian steers. Plasma and liver samples were obtained to determine cobalamin concentration after treatment. Cyanocobalamin had lower retention in plasma and liver than OHB12 (p < .05). Cobalamin levels peaked in plasma by 8 h after treatment in both groups. However, OHB12 reached a higher peak compared to CNB12. Levels of cobalamin in plasma dropped closer to baseline levels 24 h after CNB12 treatment while OHB12 maintained higher concentrations. Hydroxocobalamin increased significantly hepatic concentration of cobalamin 28 days after treatment, while CNB12 did not increase liver levels relative to pre-treatment (p < .05). These results confirm that a single subcutaneous OHB12 injection increases the level of cobalamin in the blood in the first 24 hours, and this increase is maintained in the liver for at least 28 days.

Topical wound anaesthesia: efficacy to mitigate piglet castration pain

OBJECTIVE

There is a critical need for safe and effective analgesic treatments to address pain resulting from surgical husbandry procedures in livestock. Piglet castration results in acute pain and stress to the animal; however, it is performed globally on millions of piglets annually, often without any analgesia what-so-ever. Tri-Solfen® (Animal Ethics Pty Ltd, Yarra Glen, Victoria, Australia) is a combination local anaesthetic and antiseptic formulation which, applied topically to wounds, has proven effective, and is registered for use to alleviate pain associated with castration (and other wounds) in lambs and calves in Australia and New Zealand. It is also reported to be effective to reduce pain in piglets following castration.

DESIGN

This randomised, blinded, placebo-controlled study examined the safety and efficacy of the formulation, administered via an adapted wound instillation method, to control pain both during and following piglet castration.

METHOD

Piglets received Tri-Solfen or placebo, instilled to the wound immediately following skin incision. A 30 s wait period was then observed prior to completing castration. Pain mitigation was assessed by grading nociceptive resistance movements and piglet vocal response during castration, as well as by grading response to mechanical sensory stimulation of the wound (von Frey and needlestick) following castration.

RESULTS

There was a significant reduction in nociceptive motor and vocal response during castration and in response to mechanical sensory wound stimulation up to and including 2 h following castration. There were no adverse events.

CONCLUSION

Administered via this method, Tri-Solfen is effective to mitigate acute peri-operative castration pain in piglets.

Ex vivo analysis of Plasmodium falciparum-specific B cell responses to natural malaria infection in children and adults

In naturally acquired immunity to malaria, antibodies that reliably protect are only acquired after years of repeated Plasmodium falciparum (Pf) infections. We have shown in Mali that this inefficiency in humoral immunity to malaria is associated with a large expansion of CD21loCD27− ‘atypical’ MBCs. The function of atypical MBCs remains elusive, as they exhibit altered B cell receptor (BCR) signaling and when activated fail to secrete cytokines and antibodies. We set out to study whether atypical or classical B cells are recruited into the immune response to a febrile malaria infection: using Pf antigen probes, we characterized PfAMA1/PfMSP1-specific B cells in Malian children and adults (ages 2 to 36 years), at well-defined time points before, during and after a febrile malaria episode. Our preliminary analysis shows that Pf-specific atypical MBCs display signs of activation after a febrile malaria infection. Using antigen probes to track influenza hemagglutinin-specific B cells in the same individuals, we have gained insight into the relative role of Pf in driving atypical MBC expansion and have also compared the magnitude and kinetics of Pf-and influenza-specific atypical and classical MBC responses. We further show that classical Pf-specific IgG+MBCs are activated and expanded, but interestingly, that a large proportion of activated Pf-specific MBCs are unswitched, expressing surface IgM. Additionally, we have single cell sorted Pf- and influenza-specific MBCs to compare their BCR features (VH gene diversity and somatic hypermutation rates). This analysis provides important new insights into the mechanisms underlying the inefficient acquisition of naturally acquired immunity to malaria in children.

Associating HIV-1 envelope glycoprotein structures with states on the virus observed by smFRET

The HIV-1 envelope glycoprotein (Env) trimer mediates cell entry and is conformationally dynamic^1–8. Imaging by single-molecule fluorescence resonance energy transfer (smFRET) has revealed that, on the surface of intact virions, mature pre-fusion Env transitions from a pre-triggered conformation (state 1) through a default intermediate conformation (state 2) to a conformation in which it is bound to three CD4 receptor molecules (state 3)^8–10. It is currently unclear how these states relate to known structures. Breakthroughs in the structural characterization of the HIV-1 Env trimer have previously been achieved by generating soluble and proteolytically cleaved trimers of gp140 Env that are stabilized by a disulfide bond, an isoleucine-to-proline substitution at residue 559 and a truncation at residue 664 (SOSIP.664 trimers)^5,11–18. Cryo-electron microscopy studies have been performed with C-terminally truncated Env of the HIV-1_JR-FL strain in complex with the antibody PGT15119. Both approaches have revealed similar structures for Env. Although these structures have been presumed to represent the pre-triggered state 1 of HIV-1 Env, this hypothesis has never directly been tested. Here we use smFRET to compare the conformational states of Env trimers used for structural studies with native Env on intact virus. We find that the constructs upon which extant high-resolution structures are based predominantly occupy downstream conformations that represent states 2 and 3. Therefore, the structure of the pretriggered state-1 conformation of viral Env that has been identified by smFRET and that is preferentially stabilized by many broadly neutralizing antibodies—and thus of interest for the design of immunogens—remains unknown.

Epitope-based vaccine design yields fusion peptide-directed antibodies that neutralize diverse strains of HIV-1

A central goal of HIV-1 vaccine research is the elicitation of antibodies capable of neutralizing diverse primary isolates of HIV-1. Here we show that focusing the immune response to exposed N-terminal residues of the fusion peptide, a critical component of the viral entry machinery and the epitope of antibodies elicited by HIV-1 infection, through immunization with fusion peptide-coupled carriers and prefusion stabilized envelope trimers, induces cross-clade neutralizing responses. In mice, these immunogens elicited monoclonal antibodies capable of neutralizing up to 31% of a cross-clade panel of 208 HIV-1 strains. Crystal and cryoelectron microscopy structures of these antibodies revealed fusion peptide conformational diversity as a molecular explanation for the cross-clade neutralization. Immunization of guinea pigs and rhesus macaques induced similarly broad fusion peptide-directed neutralizing responses, suggesting translatability. The N terminus of the HIV-1 fusion peptide is thus a promising target of vaccine efforts aimed at eliciting broadly neutralizing antibodies.

Qualitative and Quantitative Scintigraphic Imaging to Predict Fracture Healing

Purpose: Evaluate the value of 24- hour postoperative quantitative bone scintigraphy to identify devascularized fragments and predict delayed fracture bridging in canine clinical patients; to determine the effect of fracture type, fixation type, age, sex, and weight on fracture bridging and the quantitative scintigraphic ratios; and to evaluate the relationship between qualitative scintigraphic assessment and quantitative scintigraphic ratios. Methods: Forty-two adult dogs, with diaphyseal long bone fractures treated with minimally invasive biological or invasive surgical techniques, were evaluated with 24-hour postoperative bone scintigraphy and six and 12 week postoperative radiographs. Fractured bones were classified as simple, moderately multiple, or severely multiple. Bone scintigrams were qualitatively and quantitatively analyzed. Radiographs were made at six and 12 weeks after the operation and graded as fracture gap(s) bridged or not bridged with bone opacity material. The data was evaluated statistically to determine the relationship between age, sex, and weight of the dogs, fracture type, fixation type, and results of scintigram analysis to fracture bridging at six and 12 weeks. Results: Fourteen of the 42 fractures were bridged at six weeks after the operation and 33 at 12 weeks. Prediction of fracture healing was not possible. There was not any statistical relationship of fracture type, fixation, sex, nor weight to bridged fractures or non-bridged fractures at six and 12 weeks. There was a trend toward more of the fractures with multiple fragments treated with minimally invasive biological techniques to be bridged by 12 weeks when compared to similar fractures treated with invasive techniques. The mean age of dogs with bridged fractures at six and 12 weeks was significantly lower than the mean age of dogs with non-bridged fractures at six and 12 weeks. Qualitative scintigraphic assessment scores were not significantly related to the quantitative scintigraphic ratios or to fracture bridging. Conclusions: Neither qualitative nor quantitative assessment of bone scintigrams 24 hours after the operation could be used to predict fracture bridging at six or 12 weeks postoperatively.

The value of 24-hour postoperative qualitative and quantitative bone scintigraphy to predict fracture bridging by 12 weeks in canine clinical patients with diaphyseal long bone fractures was evaluated. Neither qualitative nor quantitative assessment of bone scintigrams 24 hours after the operation could be used to predict fracture bridging by 12 weeks.

Supported in part by a grant from the AO Vet Centre, Zurich, Switzerland.

Quantification of the Impact of the HIV-1-Glycan Shield on Antibody Elicitation

While the HIV-1-glycan shield is known to shelter Env from the humoral immune response, its quantitative impact on antibody elicitation has been unclear. Here, we use targeted deglycosylation to measure the impact of the glycan shield on elicitation of antibodies against the CD4 supersite. We engineered diverse Env trimers with select glycans removed proximal to the CD4 supersite, characterized their structures and glycosylation, and immunized guinea pigs and rhesus macaques. Immunizations yielded little neutralization against wild-type viruses but potent CD4-supersite neutralization (titers 1: >1,000,000 against four-glycan-deleted autologous viruses with over 90% breadth against four-glycan-deleted heterologous strains exhibiting tier 2 neutralization character). To a first approximation, the immunogenicity of the glycan-shielded protein surface was negligible, with Env-elicited neutralization (ID₅₀) proportional to the exponential of the protein-surface area accessible to antibody. Based on these high titers and exponential relationship, we propose site-selective deglycosylated trimers as priming immunogens to increase the frequency of site-targeting antibodies.

Endosonographer-driven dynamic telecytopathology of pancreatic lesions-a pilot study

INTRODUCTION

Telecytopathology for endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been shown to be an alternative to rapid on-site evaluation (ROSE). Gastroenterologists (endosonographers) performing EUS-FNA can be trained to evaluate a specimen for adequacy. This study examined the ability of an endosonographer with focused cytopathologic training to assess the adequacy of pancreatic FNA specimens and transmit diagnostic images to a remotely located cytopathologist as compared to an experienced cytotechnologist.

MATERIALS AND METHODS

This was a retrospective study of consecutive pancreatic lesions sampled by EUS-FNA reviewed by an endosonographer and a cytotechnologist. The participants were assessed based on their ability to (1) determine adequacy, (2) locate and transmit representative cell groups, (3) provide a preliminary diagnosis, and (4) provide concordance with actual diagnosis.

RESULTS

105 consecutive cases of EUS-FNA of the pancreas were analyzed, including: adenocarcinoma (n = 39), cyst (n = 17), neuroendocrine neoplasia (n = 7), pancreatitis (n = 14), benign pancreas (n = 9), other neoplasms (n = 6), suspicious/atypical (n = 3), and nondiagnostic (n = 10). The cytotechnologist demonstrated superiority in accuracy 92.7% versus 70% (P = 0.003) and subcategorization 95.0% versus 76% (P = 0.007). There was no difference in "broad" categorization (benign/malignant) between the endosonographer and cytotechnologist, 98% and 98.2% (P = 0.946), respectively. Also, there was no difference with regard to adequacy assessment (P = 0.29). A steady learning curve for the endosonographer was demonstrated in their cytologic assessment (P = 0.041). The endosonographer was shown to be able to remotely transmit diagnostic images to a pathologist.

CONCLUSION

An endosonographer with limited training can examine for specimen adequacy, transmit images, and demonstrate representative cell groups. Larger studies are required though preliminary results are encouraging.

Falling under the umbrella cells: A single institutional experience and literature review of urothelial carcinoma presenting as a primary pancreatic mass on endoscopic ultrasound-guided fine-needle aspiration

Metastases to the pancreas are much less common than primary pancreatic lesions, and there are few reports in the literature of metastatic urothelial carcinoma (UC) found in the pancreas. We report two cases of metastatic UC mimicking a primary pancreatic lesion. Two female patients, aged 48 and 83 years, presented with isolated pancreatic lesions causing obstructive jaundice suspicious for pancreatic adenocarcinoma and underwent endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with rapid on-site evaluation (ROSE). On cytopathology, the lesions were found to be UC, confirmed with immunohistochemical (IHC) staining. UC rarely metastasizes to the pancreas, and diagnosis through EUS-FNA can be challenging. However, the utilization of ROSE, dedicated cell block passes, and IHC have proved to be effective in obtaining this unusual pancreatic diagnosis by EUS-FNA.

Mechanisms of Groucho-mediated repression revealed by genome-wide analysis of Groucho binding and activity

Background

The transcriptional corepressor Groucho (Gro) is required for the function of many developmentally regulated DNA binding repressors, thus helping to define the gene expression profile of each cell during development. The ability of Gro to repress transcription at a distance together with its ability to oligomerize and bind to histones has led to the suggestion that Gro may spread along chromatin. However, much is unknown about the mechanism of Gro-mediated repression and about the dynamics of Gro targeting.

Results

Our chromatin immunoprecipitation sequencing analysis of temporally staged Drosophila embryos shows that Gro binds in a highly dynamic manner primarily to clusters of discrete (<1 kb) segments. Consistent with the idea that Gro may facilitate communication between silencers and promoters, Gro binding is enriched at both cis-regulatory modules, as well as within the promotors of potential target genes. While this Gro-recruitment is required for repression, our data show that it is not sufficient for repression. Integration of Gro binding data with transcriptomic analysis suggests that, contrary to what has been observed for another Gro family member, Drosophila Gro is probably a dedicated repressor. This analysis also allows us to define a set of high confidence Gro repression targets. Using publically available data regarding the physical and genetic interactions between these targets, we are able to place them in the regulatory network controlling development. Through analysis of chromatin associated pre-mRNA levels at these targets, we find that genes regulated by Gro in the embryo are enriched for characteristics of promoter proximal paused RNA polymerase II.

Conclusions

Our findings are inconsistent with a one-dimensional spreading model for long-range repression and suggest that Gro-mediated repression must be regulated at a post-recruitment step. They also show that Gro is likely a dedicated repressor that sits at a prominent highly interconnected regulatory hub in the developmental network. Furthermore, our findings suggest a role for RNA polymerase II pausing in Gro-mediated repression.

Electronic supplementary material

The online version of this article (doi:10.1186/s12864-017-3589-6) contains supplementary material, which is available to authorized users.

User acceptance of a multi-media software application to increase preparedness for caring problems

This paper presents verification data for a multimedia software application intended to enhance carers’ ability to respond to everyday difficulties and emergency situations. The program provides educational information about first aid, how to deal with everyday problems and a number of emergency situations such as bleeding, falling and choking. An evaluation plan was developed, including instruments for measuring and assessing usability. These included a questionnaire, scenarios and a pro-forma for user trials; a questionnaire for evaluation of the program; log diaries, field notes and technical diaries. User trials were carried out with both healthcare professionals and family carers. Casual users were encouraged to test the programs at the professional sites. Users’ views on usability were utilized for the development of further prototype of the software application.

The Central Region of the Drosophila Co-repressor Groucho as a Regulatory Hub

Groucho (Gro) is a Drosophila co-repressor that regulates the expression of a large number of genes, many of which are involved in developmental control. Previous studies have shown that its central region is essential for function even though its three domains are poorly conserved and intrinsically disordered. Using these disordered domains as affinity reagents, we have now identified multiple embryonic Gro-interacting proteins. The interactors include protein complexes involved in chromosome organization, mRNA processing, and signaling. Further investigation of the interacting proteins using a reporter assay showed that many of them modulate Gro-mediated repression either positively or negatively. The positive regulators include components of the spliceosomal subcomplex U1 small nuclear ribonucleoprotein (U1 snRNP). A co-immunoprecipitation experiment confirms this finding and suggests that a sizable fraction of nuclear U1 snRNP is associated with Gro. The use of RNA-seq to analyze the gene expression profile of cells subjected to knockdown of Gro or snRNP-U1-C (a component of U1 snRNP) showed a significant overlap between genes regulated by these two factors. Furthermore, comparison of our RNA-seq data with Gro and RNA polymerase II ChIP data led to a number of insights, including the finding that Gro-repressed genes are enriched for promoter-proximal RNA polymerase II. We conclude that the Gro central domains mediate multiple interactions required for repression, thus functioning as a regulatory hub. Furthermore, interactions with the spliceosome may contribute to repression by Gro.