Strategies for Developing a Nurturing Environment for the next Generation of Nurses

With the introduction of more complex health conditions and the changing landscape of the healthcare infrastructure, burnout is increasingly becoming a crisis for the nursing profession and for the public. Recruitment in nursing must consider the concept of a nurturing environment as a key driver of sustainability within the profession. Human beings cannot flourish in hostile and unwelcoming environments. Failure to thrive in nursing is a real phenomenon that is driven by multiple factors, including incivility, workplace bullying, and lack of support. Mitigation requires intentional, strategic interventions toward building nurturing environments in education and practice for the next generation of nurses.

Enhancing Spatial Transcriptomics Analysis by Integrating Image-Aware Deep Learning Methods

Spatial transcriptomics (ST) represents a pivotal advancement in biomedical research, enabling the transcriptional profiling of cells within their morphological context and providing a pivotal tool for understanding spatial heterogeneity in cancer tissues. However, current analytical approaches, akin to single-cell analysis, largely depend on gene expression, underutilizing the rich morphological information inherent in the tissue. We present a novel method integrating spatial transcriptomics and histopathological image data to better capture biologically meaningful patterns in patient data, focusing on aggressive cancer types such as glioblastoma and triple-negative breast cancer. We used a ResNet-based deep learning model to extract key morphological features from high-resolution whole-slide histology images. Spot-level PCA-reduced vectors of both the ResNet-50 analysis of the histological image and the spatial gene expression data were used in Louvain clustering to enable image-aware feature discovery. Assessment of features from image-aware clustering successfully pinpointed key biological features identified by manual histopathology, such as for regions of fibrosis and necrosis, as well as improved edge definition in EGFR-rich areas. Importantly, our combinatorial approach revealed crucial characteristics seen in histopathology that gene-expression-only analysis had missed.Supplemental Material: https://github.com/davcraig75/song_psb2014/blob/main/SupplementaryData.pdf.

To Tube or Not to Tube ... That Continues to Be the Question

In the prehospital setting, "to tube, or not to tube" will persist as a probing question - long after this article is published. It is the hope of the authors simply to position a compilation of thoughts to consider in regards to alternate airways vs. endotracheal intubation. Ultimately, it's all about the right care, for the right patient, at the right time!

Debakarn Koorliny Wangkiny: steady walking and talking using first nations-led participatory action research methodologies to build relationships

Aboriginal participatory action research (APAR) has an ethical focus that corrects the imbalances of colonisation through participation and shared decision-making to position people, place, and intention at the centre of research. APAR supports researchers to respond to the community's local rhythms and culture. APAR supports researchers to respond to the community's local rhythms and culture. First Nations scholars and their allies do this in a way that decolonises mainstream approaches in research to disrupt its cherished ideals and endeavours. How these knowledges are co-created and translated is also critically scrutinised. We are a team of intercultural researchers working with community and mainstream health service providers to improve service access, responsiveness, and Aboriginal client outcomes. Our article begins with an overview of the APAR literature and pays homage to the decolonising scholarship that champions Aboriginal ways of knowing, being, and doing. We present a research program where Aboriginal Elders, as cultural guides, hold the research through storying and cultural experiences that have deepened relationships between services and the local Aboriginal community. We conclude with implications of a community-led engagement framework underpinned by a relational methodology that reflects the nuances of knowledge translation through a co-creation of new knowledge and knowledge exchange.

Public-Private Partnerships to Lower the Risk of Diabetes Among Black Women Using Cooperative Agreements: The National Diabetes Prevention Program and the Black Women's Health Imperative

The National Diabetes Prevention Program (National DPP) is a partnership of public and private organizations working to build a nationwide delivery system for a lifestyle change program (LCP), which is proved to prevent or delay onset of type 2 diabetes in adults with prediabetes. Through this program, the Centers for Disease Control and Prevention (CDC) establishes partnerships with organizations to prevent or delay the onset of type 2 diabetes by using the evidence-based and audience-tailored LCP. The DP17-1705 cooperative agreement aims to expand the reach of the program in underserved areas and to populations currently underrepresented in the program relative to their risk. This article highlights a successful adaptation of the National DPP PreventT2 curriculum to address the needs of women who are Black funded by this cooperative agreement. The Change your Lifestyle, Change your Life (CYL²) program resulted from a partnership between CDC and the Black Women's Health Imperative. Successes and challenges associated with this program are highlighted. Lessons learned from these efforts can be used by practitioners to inform future type 2 diabetes prevention initiatives.

High prevalence of deleterious mutations in concomitant nonsyndromic cleft and outflow tract heart defects

Our previous work demonstrating enrichment of outflow tract (OFT) congenital heart disease (CHD) in children with cleft lip and/or palate (CL/P) suggests derangements in common underlying developmental pathways. The current pilot study examines the underlying genetics of concomitant nonsyndromic CL/P and OFT CHD phenotype. Of 575 patients who underwent CL/P surgery at Children's Hospital Los Angeles, seven with OFT CHD, negative chromosomal microarray analysis, and no recognizable syndromic association were recruited with their parents (as available). Whole genome sequencing of blood samples paired with whole‐blood‐based RNA sequencing for probands was performed. A pathogenic or potentially pathogenic variant was identified in 6/7 (85.7%) probands. A total of seven candidate genes were mutated (CHD7, SMARCA4, MED12, APOB, RNF213, SETX, and JAG1). Gene ontology analysis of variants predicted involvement in binding (100%), regulation of transcription (42.9%), and helicase activity (42.9%). Four patients (57.1%) expressed gene variants (CHD7, SMARCA4, MED12, and RNF213) previously involved in the Wnt signaling pathway. Our pilot analysis of a small cohort of patients with combined CL/P and OFT CHD phenotype suggests a potentially significant prevalence of deleterious mutations. In our cohort, an overrepresentation of mutations in molecules associated with Wnt‐signaling was found. These variants may represent an expanded phenotypic heterogeneity within known monogenic disease genes or provide novel evidence of shared developmental pathways. The mechanistic implications of these mutations and subsequent developmental derangements resulting in the CL/P and OFT CHD phenotype require further analysis in a larger cohort of patients.

A syndemic effect: Interrelationships between systemic racism, health disparities, and COVID-19

ABSTRACT

This article discusses the interconnection between the syndemic effect of racial inequities and disparities as well as the impact of the COVID-19 pandemic on Black Americans. It also highlights meaningful reforms and priorities to achieve health equity in Black communities.

Best Practices for Using Telehealth in Hospice and Palliative Care

Hospice and palliative care providers throughout the United States have continued to provide compassionate patient- and family-centered care during the COVID-19 (coronavirus disease 2019) pandemic while adapting to the need for scrupulous infection control measures and the accelerated use of telehealth. Prior to the pandemic, hospice and palliative care adopted telehealth slowly compared with other specialties, but its rapidly increasing utilization during the COVID-19 pandemic has long-term implications for access to primary and specialty palliative care, particularly for patients in rural communities and populations experiencing inequitable access to services. Telehealth also shows great promise for leveraging technology to provide care more effectively and efficiently. As more provider organizations become equipped with telehealth infrastructure, and as advocacy for broader reimbursement of these services grows, telehealth services for hospice and palliative care are expected to continue. This article highlights the work of expert clinicians from multiple hospice and palliative care organizations to develop best practices for conducting telehealth visits in inpatient and community settings. The authors propose that best practices be compiled and considered to ensure quality-driven, evidence-based clinical practice guidelines with interprofessional applicability.

Our journey, our story: a study protocol for the evaluation of a co-design framework to improve services for Aboriginal youth mental health and well-being

INTRODUCTION

Mainstream Australian mental health services are failing Aboriginal young people. Despite investing resources, improvements in well-being have not materialised. Culturally and age appropriate ways of working are needed to improve service access and responsiveness. This Aboriginal-led study brings Aboriginal Elders, young people and youth mental health service staff together to build relationships to co-design service models and evaluation tools. Currently, three Western Australian youth mental health services in the Perth metropolitan area and two regional services are working with local Elders and young people to improve their capacity for culturally and age appropriate services. Further Western Australian sites will be engaged as part of research translation.

METHODS AND ANALYSIS

Relationships ground the study, which utilises Indigenous methodologies and participatory action research. This involves Elders, young people and service staff as co-researchers and the application of a decolonising, strengths-based framework to create the conditions for engagement. It foregrounds experiential learning and Aboriginal ways of working to establish relationships and deepen non-Aboriginal co-researchers' knowledge and understanding of local, place-based cultural practices. Once relationships are developed, co-design workshops occur at each site directed by local Elders and young people. Co-designed evaluation tools will assess any changes to community perceptions of youth mental health services and the enablers and barriers to service engagement.

ETHICS AND DISSEMINATION

The study has approval from the Kimberley Aboriginal Health Planning Forum Kimberley Research Subcommittee, the Western Australian Aboriginal Health Ethics Committee, and the Curtin University Human Research Ethics Committee. Transferability of the outcomes across the youth mental health sector will be directed by the co-researchers and is supported through Aboriginal and non-Aboriginal organisations including youth mental health services, peak mental health bodies and consumer groups. Community reports and events, peer-reviewed journal articles, conference presentations and social and mainstream media will aid dissemination.

Abstract IA41: Novel Approaches for Accessing Molecular Heterogeneity

Ovarian cancer is the fifth leading cause of cancer-related deaths in women and is the deadliest gynecological malignancy in the United States. The standard treatment of ovarian cancer is based on debulking surgery followed by platinum- and taxane-based chemotherapy, and has remained the same over the past three decades. Over those years, molecular targeted and combination therapies have been developed and clinically approved, however the overall survival rate has not improved significantly due to chemo-resistance. Further, the majority of patients experience recurrence of treatment-resistant tumors. The genomic diversity within a tumor and the varying cell types within its microenvironment has placed significant importance on heterogeneity and its clinical implications. Intra-tumor heterogeneity has often been blamed for treatment failure in ovarian carcinoma. Consequently, intra-tumor heterogeneity is a key factor driving drug resistance, therapeutic failure, and poor outcomes and poses a significant challenge to personalized cancer medicine. Intra-tumor heterogeneity is a hallmark of cancer where the molecular and cellular interactions within the tumor microenvironment can dictate a cancer’s fate. Molecular profiling of bulk tissue specimens using methods such as whole-transcriptome sequencing are limited in their ability to resolve fine grain molecular signatures and hinder our utility to dissect the underlying biology of individual tumors. Although informatics approaches are available that attempt to disentangle tissue heterogeneity from bulk tumor data, emerging spatial whole transcriptome sequencing technologies allow a more precise delineation of cellular and molecular substructure in a comprehensive unbiased approach. Spatial Transcriptomics (ST) enables high-throughput whole transcriptomic sequencing within a single intact tissue by using a glass slide arrayed with barcoded cDNA primers at a resolution of 100um (3-30 cells). This workflow requires no tissue dissociation keeping fragile cell types intact. Resulting data from this workflow is overlaid on the tissue, displayed as a “cluster reference map”, providing comprehensive unbiased transcriptional substructure and unique possibilities for subsequent in situ analysis. The overall goal of this study is to utilize ST to unveil the unexplored landscape of intra-tumor heterogeneity in ovarian cancer and determine its translational relevance. Here, we applied ST to profile gene expression in fresh frozen OCT embedded sections from nine high grade ovarian patients. Three serial 5-micron frozen sections were placed on proprietary 10x Genomics Spatial Transcriptomics (ST) slides and processed using manufacturer specifications. Libraries were sequenced on the Illumina NovaSeq 6000 system and data was processed using 10X Genomics analytical tools. Next, we aggregated the transcriptional profiles of serial sections from each case increasing our power to cluster similar regions and identify differentially expressed genes within these tissues. Using serial sections of solid tumors from each subject we were not only able to profile each section at 100um resolution but also spatially resolve gene expression signatures and cluster regions of tissue based on these signatures. This ST workflow reliably quantitated an average spatial distribution of 19,285 genes per section in our ovarian cancer cohort. Interestingly, within our cohort we have extreme outliers that include primary tumors that did not have any response to standard adjuvant chemotherapy, paclitaxel and carboplatin, and patients that sustained a durable response to standard adjuvant chemotherapy and diagnosed as disease free ≥3 years and then presented with recurrent disease. We identified tumor heterogeneity as unique spatially-resolved gene expression clusters across each tissue section defined by individual gene sets associated with tumorigenic molecular processes, immune cell quantity and localization. These approaches highlight the power of spatial whole-transcriptomic sequencing in solid tumor studies to help unravel the complexity of heterogeneous cancers and provide a comprehensive characterization of transcriptional substructure within a single tissue section.

Citation Format: Lee D. Gibbs, Lynda Roman, Michelle Webb, Rania Bassiouni, Stephen R Williams, Neil I. Weisenfeld, Nigel F. Delaney, Yifeng Yin, Solomon Rotimi, Jennifer Chew, Meghan Frey, Jing Qian, Heather Miller, Laila Murderspach, Diane Da Silva, Troy McEachron, David W. Craig, John D. Carpten. Novel Approaches for Accessing Molecular Heterogeneity [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr IA41.

Falling short of a culture of health: Planning alcohol-permitted events at a U.S. university

The Healthy Campus movement in the United States aims to infuse health promotion into higher education operations. We examined the extent to which event planners employ a culture-of-health approach related to alcohol consumption when planning alcohol-permitted events in a large, public university in California. We interviewed 31 event planners to assess their strategies for ensuring health and safety at the events and accommodating people in recovery from substance use disorders. We focused on events that involved faculty, staff, and graduate students. Event planners were most concerned about avoiding legal liabilities at the events, were less concerned about promoting responsible drinking among drinkers, and often failed to consider the needs of non-drinkers at the events. Their actions were informed by problematic beliefs about alcohol (e.g., people need alcohol to relax), drinkers (e.g., only undergraduate students engage in risky consumption), and people in recovery (e.g., they lack self-control). Planners over-relied on informal control to shape attendees' behavior, failing to acknowledge how contextual factors can shape individual behavior. Planners need to be educated about how to shape the event context to promote healthy behaviors, avoid exclusively focusing on preventing unhealthy behaviors and informal control, and promote better inclusion of people who don't drink.

Key messages

There is fertile ground for infusing a culture of health into events in higher education. Event planners need expanded perspectives that consider context, inclusivity, and health promotion.

Abstract NG03: Spatial RNA-seq reveals intratumor heterogeneity and transcriptional substructure in high-grade ovarian cancers

Ovarian cancer is the fifth leading cause of cancer-related deaths in women and is the deadliest gynecological malignancy in the United States. The standard treatment of ovarian cancer is based on debulking surgery followed by platinum- and taxane-based chemotherapy, and has remained the same over the past three decades. Over those years, molecular targeted and combination therapies have been developed and clinically approved, however the overall survival rate has not improved significantly due to chemo-resistance. Further, the majority of patients experience recurrence of treatment-resistant tumors. The genomic diversity within a tumor and the varying cell types within its microenvironment has placed significant importance on heterogeneity and its clinical implications. Intra-tumor heterogeneity has often been blamed for treatment failure in ovarian carcinoma. Consequently, intra-tumor heterogeneity is a key factor driving drug resistance, therapeutic failure, and poor outcomes and poses a significant challenge to personalized cancer medicine.

Intra-tumor heterogeneity is a hallmark of cancer where the molecular and cellular interactions within the tumor microenvironment can dictate a cancer's fate. Molecular profiling of bulk tissue specimens using methods such as whole-transcriptome sequencing are limited in their ability to resolve fine grain molecular signatures and hinder our utility to dissect the underlying biology of individual tumors. Although informatics approaches are available that attempt to disentangle tissue heterogeneity from bulk tumor data, emerging spatial whole transcriptome sequencing technologies allow a more precise delineation of cellular and molecular substructure in a comprehensive unbiased approach. Spatial Transcriptomics (ST) enables high-throughput whole transcriptomic sequencing within a single intact tissue by using a glass slide arrayed with barcoded cDNA primers at a resolution of 100um (3-30 cells). This workflow requires no tissue dissociation keeping fragile cell types intact. Resulting data from this workflow is overlaid on the tissue, displayed as a “cluster reference map”, providing comprehensive unbiased transcriptional substructure and unique possibilities for subsequent in situ analysis.

The overall goal of this study is to utilize ST to unveil the unexplored landscape of intra-tumor heterogeneity in ovarian cancer and determine its translational relevance. Here, we applied ST to profile gene expression in fresh frozen OCT embedded sections from nine high grade ovarian patients. Three serial 5-micron frozen sections were placed on proprietary 10x Genomics Spatial Transcriptomics (ST) slides and processed using manufacturer specifications. Libraries were sequenced on the Illumina NovaSeq 6000 system and data was processed using 10X Genomics analytical tools. Next, we aggregated the transcriptional profiles of serial sections from each case increasing our power to cluster similar regions and identify differentially expressed genes within these tissues. Using serial sections of solid tumors from each subject we were not only able to profile each section at 100um resolution but also spatially resolve gene expression signatures and cluster regions of tissue based on these signatures. This ST workflow reliably quantitated an average spatial distribution of 19,285 genes per section in our ovarian cancer cohort. Interestingly, within our cohort we have extreme outliers that include primary tumors that did not have any response to standard adjuvant chemotherapy, paclitaxel and carboplatin, and patients that sustained a durable response to standard adjuvant chemotherapy and diagnosed as disease free ≥3 years and then presented with recurrent disease.

ST revealed cellular heterogeneity across the entirety of the tumor microenvironment in an anatomically resolved manner. Bioinformatic tools and molecular pathway enrichment were used to annotate tumor, stromal, and immune tissue regions. Our analyses blindly recapitulate specific histopathological annotations spatially through unsupervised gene expression clustering. These data also revealed clear transcriptional substructure, where we identified transcriptionally diverse tumor clones that have unique gene sets associated with distinct molecular processes that relate to oncogenesis (BRCA1, P53, and PTEN Pathway). and potential targetable pathways (EGFR, HER2, PI3K/AKT/MAPK signaling pathways). Additionally, we were able to create spatial heat maps of the inflammatory microenvironment at the single gene level and for gene profiles that define specific inflammatory signals and immune cell profiles. Using this approach, we went on to conduct a refined analysis of key inflammatory genes that have been previously known to play an important role in the immune response of ovarian cancer and developed a spatially resolved inflammation score for each section from each subject. Not only did we observe statistically significant regionalized inflammation scores within each subject, we also found inter-subject differences which may give clinical insight into response to treatment. Surprisingly, this technology also enabled the ability to analyze conventional and emerging immune checkpoint gene expression while accessing the cells and regions of the tissue where they are expressed. Further, our analysis of spatial maps and immune cell quantitation within a primary and recurrent tumor from the same individual revealed dynamic longitudinal changes in inflammation scores and immune infiltration between tumors and spatially within each tumor.

These approaches highlight the power of spatial whole-transcriptomic sequencing in solid tumor studies to help unravel the complexity of heterogeneous cancers and provide a comprehensive characterization of transcriptional substructure within a single tissue section.

Citation Format: Lee D. Gibbs, Stephen R. Williams, Neil I. Weisenfeld, David W. Craig, Rania Bassiouni, Nigel F. Delaney, Diane Da Silva, Yifeng Yin, Solomon Rotimi, Jennifer Chew, Meghan Frey, Michelle Webb, Jing Qian, Heather Miller, Laila Murderspach, Troy McEachron, Lynda Roman, John D. Carpten. Spatial RNA-seq reveals intratumor heterogeneity and transcriptional substructure in high-grade ovarian cancers [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr NG03.

Chlortetracycline, Oxytetracycline, and Tetracycline in Edible Animal Tissues, Liquid Chromatographic Method: Collaborative Study

Thirteen laboratories analyzed samples of edible animal tissues for tetracycline residues. The method included extraction of analytes into buffer, elution from a C18 solid-phase extraction (SPE) cartridge, and reversed-phase liquid chromatographic (LC) analysis, including use of a confirmation column. An additional laboratory, using an alternative LC assay based on a different sample cleanup, also analyzed the samples. Results showed the 2 methods are comparable. The LC method for determination of cholortetracycline, oxytetracycline, and tetracycline in edible animal tissues has been adopted by AOAC INTERNATIONAL. Results from 13 laboratories indicate that the method under study provides generally better results at the higher concentrations tested than at concentrations near the detection limit and that there is less problem with interferences in muscle tissue than in kidney. The method can achieve reliable results for analytes and matrixes studied at concentrations from 0.1 to 0.6 ppm and above, depending on the analyte-matrix combination, with generally better performance to be expected with muscle than with kidney. The poorer performance for fortified samples, particularly kidney, was attributed to additional homogenization steps required to prepare these samples. Recovery of analytes from different

Ultrasonic cement removal in cement-in-cement revision total hip arthroplasty: What is the effect on the final cement-in-cement bond?

Objectives

Previous studies have evidenced cement-in-cement techniques as reliable in revision arthroplasty. Commonly, the original cement mantle is reshaped, aiding accurate placement of the new stem. Ultrasonic devices selectively remove cement, preserve host bone, and have lower cortical perforation rates than other techniques. As far as the authors are aware, the impact of ultrasonic devices on final cement-in-cement bonds has not been investigated. This study assessed the impact of cement removal using the Orthosonics System for Cemented Arthroplasty Revision (OSCAR; Orthosonics) on final cement-in-cement bonds.

Methods

A total of 24 specimens were manufactured by pouring cement (Simplex P Bone Cement; Stryker) into stainless steel moulds, with a central rod polished to Stryker Exeter V40 specifications. After cement curing, the rods were removed and eight specimens were allocated to each of three internal surface preparation groups: 1) burr; 2) OSCAR; and 3) no treatment. Internal holes were recemented, and each specimen was cut into 5 mm discs. Shear testing of discs was completed by a technician blinded to the original grouping, recording ultimate shear strengths. Scanning electron microscopy (SEM) was completed, inspecting surfaces of shear-tested specimens.

Results

The mean shear strength for OSCAR-prepared specimens (33.6 MPa) was significantly lower than for the control (46.3 MPa) and burr (45.8 MPa) groups (p < 0.001; one-way analysis of variance (ANOVA) with Tukey’s post hoc analysis). There was no significant difference in shear strengths between control and burr groups (p = 0.57). Scanning electron microscopy of OSCAR specimens revealed evidence of porosity undiscovered in previous studies.

Conclusion

Results show that the cement removal technique impacts on final cement-in-cement bonds. This in vitro study demonstrates significantly weaker bonds when using OSCAR prior to recementation into an old cement mantle compared with cement prepared with a burr or no treatment. This infers that care must be taken in surgical decision-making regarding cement removal techniques used during cement-in-cement revision arthroplasty, suggesting that the risks and benefits of ultrasonic cement removal need consideration.

Cite this article: A. Liddle, M. Webb, N. Clement, S. Green, J. Liddle, M. German, J. Holland. Ultrasonic cement removal in cement-in-cement revision total hip arthroplasty: What is the effect on the final cement-in-cement bond? Bone Joint Res 2019;8:246–252. DOI: 10.1302/2046-3758.86.BJR-2018-0313.R1.

A Team-Based Approach to Delivering Person-Centered Care at the End of Life

The use of team-based models of care is widely regarded as a mechanism for enhancing the delivery of high-quality care, especially at the end of life. Active collaboration to promote effective coordination and delivery of person-centered care is an integral part of the team-based model that is the focus of this article.

Decision making on timing of surgery for hip fracture patients on clopidogrel

Patients taking clopidogrel who sustain a fractured neck of femur pose a challenge to orthopaedic surgeons. The aim of this study was to determine whether delay to theatre for these patients affects drop in haemoglobin levels, need for blood transfusion, length of hospital stay and 30-day mortality. A retrospective review of all neck of femur patients admitted at two centres in the North East of England over 3 years revealed 85 patients. Patients were divided into two groups depending on whether they were taking clopidogrel alone (C) or with aspirin (CA). Haemoglobin drop was significantly different in the CA group that was operated on early (CA1) versus the group for which surgery was delayed by over 48 hours (CA2): 3.3g/dl and 1.9g/dl respectively (p=0.01). The mean inpatient stay in group C was 35.9 days while in group CA it was 19.9 days (p=0.002). The mean length of stay in group CA2 (26.7 days) was significantly longer than for CA1 patients (14.1 days) (p=0.01). There were no significant differences in mortality or wound complications. Hip fracture patients on clopidogrel can be safely operated on early provided they are medically stable. Bleeding risk should be borne in mind in those patients on dual therapy with aspirin.

RISUS study: Rugby Injury Surveillance in Ulster Schools

OBJECTIVE

To examine injury patterns in adolescent rugby players and determine factors associated with injury risk.

DESIGN

Prospective injury surveillance study.

SETTING

N=28 Grammar Schools in Ulster, Ireland (2014-2015 playing season).

PARTICIPANTS

825 adolescent rugby players, across in 28 school first XV rugby squads; mean age 16.9 years.

MAIN OUTCOME MEASURES

Injuries were classified by body part and diagnosis, and injury incidence using injuries per 1000 match hours of exposure. HRs for injury were calculated through Cox proportional hazard regression after correction for influential covariates.

RESULTS

A total of n=426 injuries were reported across the playing season. Over 50% of injuries occurred in the tackle situation or during collisions (270/426), with few reported during set plays. The 3 most common injury sites were head/face (n=102, 23.9%), clavicle/shoulder (n=65, 15.3%) and the knee (n=56, 13.1%). Sprain (n=133, 31.2%), concussion (n=81, 19%) and muscle injury (n=65, 15.3%) were the most common diagnoses. Injury incidence is calculated at 29.06 injuries per 1000 match hours. There were no catastrophic injuries. A large percentage of injuries (208/424) resulted in absence from play for more than 28 days. Concussion carried the most significant time out from play (n=33; 15.9%), followed by dislocations of the shoulder (n=22; 10.6%), knee sprains (n=19, 9.1%), ankle sprains (n=14, 6.7%), hand/finger/thumb (n=11; 5.3%). 36.8% of participants in the study (304/825) suffered at least one injury during the playing season. Multivariate models found higher risk of injury (adjusted HR (AHR); 95% CI) with: higher age (AHR 1.45; 1.14 to 1.83), heavier weight (AHR 1.32; 1.04 to 1.69), playing representative rugby (AHR 1.42; 1.06 to 1.90) and undertaking regular strength training (AHR 1.65; 1.11 to 2.46). Playing for a lower ranked team (AHR 0.67; 0.49 to 0.90) and wearing a mouthguard (AHR 0.70; 0.54 to 0.92) were associated with lower risk of injury.

CONCLUSIONS

There was a high incidence of severe injuries, with concussion, ankle and knee ligament injuries and upper limb fractures/dislocations causing greatest time loss. Players were compliant with current graduated return-to-play regulations following concussion. Physical stature and levels of competition were important risk factors and there was limited evidence for protective equipment.

Phospho-dependent Regulation of SAMHD1 Oligomerisation Couples Catalysis and Restriction

SAMHD1 restricts HIV-1 infection of myeloid-lineage and resting CD4⁺ T-cells. Most likely this occurs through deoxynucleoside triphosphate triphosphohydrolase activity that reduces cellular dNTP to a level where reverse transcriptase cannot function, although alternative mechanisms have been proposed recently. Here, we present combined structural and virological data demonstrating that in addition to allosteric activation and triphosphohydrolase activity, restriction correlates with the capacity of SAMHD1 to form “long-lived” enzymatically competent tetramers. Tetramer disruption invariably abolishes restriction but has varied effects on in vitro triphosphohydrolase activity. SAMHD1 phosphorylation also ablates restriction and tetramer formation but without affecting triphosphohydrolase steady-state kinetics. However phospho-SAMHD1 is unable to catalyse dNTP turnover under conditions of nucleotide depletion. Based on our findings we propose a model for phosphorylation-dependent regulation of SAMHD1 activity where dephosphorylation switches housekeeping SAMHD1 found in cycling cells to a high-activity stable tetrameric form that depletes and maintains low levels of dNTPs in differentiated cells.

SAMHD1 is a restriction factor that blocks infection of certain immune cells by HIV-1. It was discovered to be an enzyme that catalyses the breakdown of dNTPs, suggesting that it inhibits HIV-1 replication by reducing cellular dNTP pools to such low levels that reverse transcriptase cannot function. However, recently, alternative mechanisms have been proposed. SAMHD1 is also regulated by phosphorylation, although the effects of phosphorylation on protein function are unclear. In order to address these issues, we carried out combined structural and virological studies and have demonstrated that in addition to allosteric activation and triphosphohydrolase activity, restriction correlates with the capacity of SAMHD1 to form “long-lived” enzymatically competent tetramers. Disrupting the tetramer in various ways always abolished restriction but had differing effects on enzyme activity in vitro. SAMHD1 phosphorylation also prevented restriction and tetramer formation but without affecting enzyme catalysis under steady-state dNTP conditions. However phosphorylated SAMHD1 was unable to catalyse dNTP turnover at very low nucleotide levels that more accurately represent conditions in the cells in which restriction takes place. Based on our findings we propose a model for phosphorylation-dependent regulation of SAMHD1 activity and substantiate that degradation of dNTPs by SAMHD1 is sufficient to restrict HIV-1.

A review of the classification of Dupuytren's disease

Although much has been published about the treatment of Dupuytren's disease, there is no clear consensus regarding the most effective form of treatment. Part of this uncertainty may result from the absence of a universal method of assessing this condition. We undertook a review of the literature in order to summarize the various methods by which Dupuytren's disease has been measured and quantified. We included all articles that offered a classification or assessment system for the disease. We excluded articles that dealt solely with surgical technique (although inevitably there was some overlap). We conclude that there are many methods of assessment, but that none of them is perfect and that further work is needed in the field.

Directing specialist care through email admission alerting

Unscheduled care is complex, particularly because many patients have multiple long term medical conditions. It is difficult to ensure the appropriate care is delivered by specialist services to patients in a timely manner. Lack of specialist input may impact on patient safety and adversely affect outcomes. We describe an automated email alerting system which was developed as result of a clinical incident. Using free software and minimal computing resources an automated email alerting system was developed. The system identified patient admissions, compared them against patient cohorts and created alerts. It used only around 1,000 lines of Java7 code combined with free software and secure NHS mail accounts. The system currently sends alerts to many different teams at our hospital. The patient population includes 6,047 patients on one of our 10 monitored lists or special registers. From May to June 2013 the system alerted to 863 monitored patient admissions in 2,158 separate messages. This system has been adopted across multiple specialties, has been well received and has had a direct impact on patient care. Not only is this system efficient and effective, but importantly can be implemented with low cost and complexity and is hence easily reproducible across the NHS.

Interactive hazards education program for youth in a low SES community: a quasi-experimental pilot study

A pilot study of an interactive hazards education program was carried out in Canberra (Australia), with direct input from youth participants. Effects were evaluated in relation to youths' interest in disasters, motivation to prepare, risk awareness, knowledge indicators, perceived preparedness levels, planning and practice for emergencies, and fear and anxiety indicators. Parents also provided ratings, including of actual home-based preparedness activities. Using a single group pretest-posttest with benchmarking design, a sample of 20 youths and their parents from a low SES community participated. Findings indicated beneficial changes on a number of indicators. Preparedness indicators increased significantly from pre- to posttest on both youth (p < 0.01) and parent ratings (p < 0.01). Parent ratings reflected an increase of just under six home-based preparedness activities. Youth knowledge about disaster mitigation also was seen to increase significantly (p < 0.001), increasing 39% from pretest levels. While personalized risk perceptions significantly increased (p < 0.01), anxiety and worry levels were seen either not to change (generalized anxiety, p > 0.05) or to reduce between pre- and posttest (hazards-specific fears, worry, and distress, ps ranged from p < 0.05 to < 0.001). In terms of predictors of preparedness, a number of variables were found to predict posttest preparedness levels, including information searching done by participants between education sessions. These pilot findings are the first to reflect quasi-experimental outcomes for a youth hazards education program carried out in a setting other than a school that focused on a sample of youth from a low SES community.

The quickest way to A&E may be via the Segway

The Segway, the two-wheeled, motorised self-transport device is becoming increasingly popular across the globe with the trend of Segway tours now starting to hit cities across the UK. However, Segways have been shown to be potentially extremely dangerous. Stumbling from a moving Segway places pressure on the knee joint while it is being medially or laterally stressed. This is the mechanism associated with tibial plateau fractures; complex fractures often associated with other soft tissue injuries, which are easily missed, are challenging to manage and can be very disabling. This is the case of a young, otherwise healthy woman, who tripped from a moving Segway and sustained a lateral depressed tibial plateau fracture. She was managed with a knee brace, physiotherapy and serial check radiographs. The fracture healed well and she has returned to an almost normal level of function with intensive physiotherapy.

A guide for functional analysis of BRCA1 variants of uncertain significance

Germline mutations in the tumor suppressor gene BRCA1 confer an estimated lifetime risk of 56-80% for breast cancer and 15-60% for ovarian cancer. Since the mid 1990s when BRCA1 was identified, genetic testing has revealed over 1,500 unique germline variants. However, for a significant number of these variants, the effect on protein function is unknown making it difficult to infer the consequences on risks of breast and ovarian cancers. Thus, many individuals undergoing genetic testing for BRCA1 mutations receive test results reporting a variant of uncertain clinical significance (VUS), leading to issues in risk assessment, counseling, and preventive care. Here, we describe functional assays for BRCA1 to directly or indirectly assess the impact of a variant on protein conformation or function and how these results can be used to complement genetic data to classify a VUS as to its clinical significance. Importantly, these methods may provide a framework for genome-wide pathogenicity assignment.