A study protocol for implementing Canadian Practice Guidelines for Treating Children and Adolescents with Eating Disorders

BACKGROUND

Eating disorders have one of the highest mortality rates among psychiatric illnesses. Timely intervention is crucial for effective treatment, as eating disorders tend to be chronic and difficult to manage if left untreated. Clinical practice guidelines play a vital role in improving healthcare delivery, aiming to minimize variations in care and bridge the gap between research and practice. However, research indicates an active guideline implementation approach is crucial to effective uptake.

METHODS

Mixed methods will be used to inform and evaluate our guideline implementation approach. Semi-structured focus groups will be conducted in each of the eight provinces in Canada. Each focus group will comprise 8-10 key stakeholders, including clinicians, program administrators, and individuals with lived experience or caregivers. Qualitative data will be analyzed using conventional content analysis and the constant comparison technique and the results will be used to inform our implementation strategy. The study will then evaluate the effectiveness of our implementation approach through pre- and post-surveys, comparing changes in awareness, use, and impact of the guidelines in various stakeholder groups.

DISCUSSION

Through a multifaceted implementation strategy, involving the co-creation of educational materials, tailored training, and context-specific strategies, this study intends to enhance guideline uptake and promote adherence to evidence-based practices. Our study will also contribute valuable information on the impact of our implementation strategies.

[Transition, fertility and options for preservation of fertility]

Oftentimes ignored or infrequently expressed, some transgender persons harbor a desire for parenthood. Given the evolution of medical techniques and the enacting of legislative reforms, it is henceforth possible to propose fertility preservation strategies in the overall context of gender transidentity. During the "female to male" (FtM) transition pathway, androgen therapy has an impact on gonadic function, generally inducing blockage of the ovarian function, with amenorrhea. Even though these events may be reversed on cessation of treatment, the possible long-term effects on future fertility and on the health of children yet to be born are little known. Moreover, transition surgeries definitively compromise the possibility of pregnancy insofar as they involve bilateral adnexectomy and/or hysterectomy. Options for fertility preservation in the framework of FtM transition are premised on cryopreservation of oocytes and/or ovarian tissue. In a comparable manner, even though relevant documentation is lacking, hormonal treatments for persons transitioning from male to female (MtF) can have an impact on future fertility. In the event of surgery involving bilateral orchidectomy in which spermatozoid cryopreservation has not been carried out, fertility is definitively impossible. In both cases and under present-day legislation, numerous legal and regulatory barriers render highly problematic the reutilization of cryopreserved gametes. Given these different constraints, it is indispensable to closely supervise these types of treatment by proposing psychological support.

Significant vomiting and weight loss in a pediatric epilepsy patient secondary to vagus nerve stimulation: A case report and review of the literature

Vagus nerve stimulation is a neuromodulatory treatment option for individuals with drug resistant epilepsy who are not resective surgical candidates. As the vagus nerve has widespread neural connections, stimulation can lead to an array of adverse effects. While vomiting and weight loss are known side effects of vagus nerve stimulation, these are typically transient, mild, and do not limit the ability to continue treatment. We describe a 17-year-old female with drug resistant focal epilepsy secondary to tuberous sclerosis complex, who began to experience daily emesis and significant weight loss approximately 2.5 years after VNS device insertion. Her body mass index progressively fell from between the 75th-85th percentiles to less than the first percentile. She underwent extensive workup by neurology, gastroenterology, and adolescent medicine services with no obvious cause identified. Prior to the insertion of an enteral tube for feeding support and urgent weight restoration, her vagus nerve stimulator was switched off, resulting in immediate cessation of her vomiting and a dramatically rapid recovery of weight over the ensuing few months. This case emphasizes the need to consider adverse effects of vagus nerve stimulation in the differential diagnosis of patients with otherwise unexplained new medical sequelae, and provides evidence potentially linking vagal stimulation to significant malnutrition-related complications. Outside of GI-related effects, few studies have shown late-onset adverse effects from VNS, including laryngeal and facial pain as well as bradyarrhythmia. Further research is needed to elucidate the exact mechanisms of vagus nerve stimulation to better anticipate and mitigate adverse effects, and to understand the pathophysiology of late-onset adverse effects in previously tolerant VNS patients.

Barriers and enablers of vigorous intermittent lifestyle physical activity (VILPA) in physically inactive adults: a focus group study

BACKGROUND

Vigorous Intermittent Lifestyle Physical Activity (VILPA) refers to brief bouts of vigorous intensity physical activity performed as part of daily living. VILPA has been proposed as a novel concept to expand physical activity options among the least active. As a nascent area of research, factors which impede or encourage VILPA in physically inactive adults are yet to be explored. Such information is pertinent in the design of future interventions. We examined the barriers and enablers of VILPA among physically inactive adults using the Capability, Opportunity, Motivation, Behavior (COM-B) model as a conceptual framework.

METHODS

We recruited a sample of self-identified physically inactive middle-aged and older adults (N = 78) based in Australia to take part in 19 online focus groups across three age groups: young-middle (age 35-44), middle (age 45-59) and old (age 60-76). We analyzed interviews using a critical realist approach to thematic analysis. Identified barriers and enablers were subsequently mapped onto the COM-B model components.

RESULTS

The data generated 6 barriers and 10 enablers of VILPA that corresponded to COM-B concepts. Barriers included physical limitations (physical capability), perceptions of aging, need for knowledge (psychological capability), environmental constraints (physical opportunity), perceptions of effort and energy, and fear (automatic motivation). Enablers included convenience, reframing physical activity as purposeful movement, use of prompts and reminders (physical opportunity), normalization of taking the active option, gamification (social opportunity), sense of achievement, health improvements, personally salient rewards (reflective motivation), identity fit, and changing from effortful deliberation to habitual action (automatic motivation).

CONCLUSION

The barriers and enablers of VILPA span capability, opportunity, and motivation beliefs. Promoting the time-efficient nature and simplicity of VILPA requiring no equipment or special gym sessions, the use of prompts and reminders at opportune times, and habit formation strategies could capitalize on the enablers. Addressing the suitability of the small bouts, the development of specific guidelines, addressing safety concerns, and explicating the potential benefits of, and opportunities to do, VILPA could ameliorate some of the barriers identified. Future VILPA interventions may require limited age customization, speaking to the potential for such interventions to be delivered at scale.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Rural healthy people 2030: New decade, new challenges

Rural Healthy People is a companion piece to the federal Healthy People initiative released once a decade to identify the most important Healthy People priorities for rural America, as identified by rural stakeholders, for the current decade. This study reports on the findings of Rural Healthy People 2030. The study relied on a survey of rural health stakeholders collected from July 12, 2021, to February 14, 2022, and: 1) identified the 20 Healthy People priorities most frequently selected as priorities for rural America, 2) studied the priorities that were most frequently selected as a "top 3" priority within each Healthy People 2030 category, and 3) investigated Healthy People 2030 priorities in terms of ranked importance for rural Americans. The analysis finds that for the first time across 3 decades of Rural Healthy People, a greater proportion of respondents selected "Mental Health and Mental Disorders" and "Addiction" as Healthy People priorities for rural America, than did "Health Care Access and Quality". Even still, respondents ranked "Health Care Access and Quality" as the single-most important rural priority. "Economic Stability," a new priority within the Social Determinant of Health category, debuted within the 10 most frequently selected priorities for rural America for the coming decade. As public health practitioners, researchers, and policymakers work toward closing the urban-rural divide, the most important rural priorities to address in the coming decade are mental health and substance use disorders, access to high quality health care services, and social determinants of health, such as economic stability.

Dihydroartemisinin-induced ferroptosis in acute myeloid leukemia: links to iron metabolism and metallothionein

Artemisinin is an anti-malarial drug that has shown anticancer properties. Recently, ferroptosis was reported to be induced by dihydroartemisinin (DHA) and linked to iron increase. In the current study, we determined the effect of DHA in leukemic cell lines on ferroptosis induction and iron metabolism and the cytoprotective effect triggered in leukemic cells. We found that treatment of DHA induces early ferroptosis by promoting ferritinophagy and subsequent iron increase. Furthermore, our study demonstrated that DHA activated zinc metabolism signaling, especially the upregulation of metallothionein (MT). Supportingly, we showed that inhibition MT2A and MT1M isoforms enhanced DHA-induced ferroptosis. Finally, we demonstrated that DHA-induced ferroptosis alters glutathione pool, which is highly dependent on MTs-driven antioxidant response. Taken together, our study indicated that DHA activates ferritinophagy and subsequent ferroptosis in AML and that MTs are involved in glutathione regenerating and antioxidant response.

Health State Utility Values in Patients Undergoing Chest Masculinization Surgery

BACKGROUND

Chest masculinization surgery is the most common gender-affirming procedure performed in transgender and gender-diverse individuals. While evidence on the health-related quality of life (HRQL) impact of chest masculinization is starting to emerge, data on health state utility values (HSUVs) associated with the surgery is largely missing. The objectives of this study were to estimate the HSUVs using EQ-5D for patients seeking chest masculinization surgery and assess the determinants of EQ-5D score at 6 months postoperatively.

METHODS

Patients seeking chest masculinization at a single community plastic surgery clinic by 2 surgeons completed 3 patient-reported outcome measures - EQ-5D-3L, Patient Health Questionnaire (PHQ)-9, and BODY-Q Chest module - preoperatively and postoperatively at 6 weeks and 6-months. Friedman test was used to assess the differences in PROM scores at the 3 timepoints. Simple and backward stepwise regression analyses of 6-month postoperative EQ-5D scores were performed.

RESULTS

A total of 113 patients (mean [SD] age, 25.7 [6.9] years) were included. The mean [SD] EQ-5D scores at preoperative, postoperative 6 weeks and 6 months were 0.81 [0.15], 0.84 [0.15] and 0.87 [0.12], respectively. Postoperatively, problems were most frequently reported in the dimensions "pain/discomfort" and "anxiety/depression". Preoperative PHQ-9 score was a predictor of 6-month postoperative EQ-5D scores following simple (p < 0.01) and backward stepwise linear regression analysis (p < 0.01).

CONCLUSION

Chest masculinization was associated with an improvement in overall HRL at 6 months postoperatively; however, this did not achieve statistical significance. Preoperative depression severity was a significant determinant of postoperative HRL. Consequently, additional support must be offered to patients who have a higher level of preoperative depression.

Examining the feasibility of a parental self-help intervention for families awaiting pediatric eating disorder services

OBJECTIVE

Waitlists for eating disorder (ED) services grew immensely during the COVID-19 pandemic. To address this, we studied the feasibility of a novel parental self-help waitlist intervention.

METHOD

Parents of a child/adolescent (7-17 years) awaiting pediatric ED services were provided with our intervention, adapted from the family-based treatment model, and consisting of videos and reading material with no therapist involvement. Parent-reported child/adolescent weight was collected weekly 6 weeks pre-intervention, 2 weeks during the intervention, and 6-week post-intervention. Recruitment and retention rates were calculated. Regression-based interrupted time series analyses were completed to measure changes in the rate of weight gain.

RESULTS

Ninety-seven parents were approached, and 30 agreed to participate (31% recruitment rate). All but one completed end-of-study measures (97% retention rate). The average rate of weight gain was 0.24 lbs/week pre-intervention, which increased significantly to 0.78 lbs/week post-intervention (p < .034).

DISCUSSION

Our findings provide preliminary evidence that this intervention is feasible. Future research is needed to confirm the efficacy of this intervention on a larger scale.

PUBLIC SIGNIFICANCE

The COVID-19 pandemic has resulted in several challenges in providing care for children and adolescents with eating disorders, including long waiting lists and delays in treatment. This study suggests that providing parents on a waitlist with educational videos and reading material is acceptable to parents, and may even help in improving the child's symptoms of an eating disorder.

[Fertility preservation for transmen]

The evolution of medical techniques as well as legislative changes currently allow to propose fertility preservation strategies in the context of transidentity. During "female to male" transition, androgen therapy has an impact on gonadal function since it usually induces a blockage of ovulation with amenorrhea. Although this effect is reversible when treatment is stopped, the possible long-term effects of testosterone treatment on future fertility or health of future children are poorly known. In addition, transitional surgeries definitely compromise fecundity when they include bilateral ovariectomy and/or hysterectomy. Yet, although long ignored or poorly expressed, the desire for parenthood is a reality in transgender men. Fertility preservation options in FtM transition rely on oocyte or ovarian tissue cryopreservation. The purpose of this review is to provide an overview of the literature regarding fertility preservation in transgender men. Although series remain limited, the increase in the number of recently published articles reflects the interest in improving the management of fertility issues in transgender men.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Predicting Success on ASCP-BOC by Using Existing Data

Introduction/Objective

The MLS Program at tUAMS is housed within the College of Health Professions. Our graduates take the ASCP BOC certification exam as a graduation requirement and the vast majority of students will take the exam.

Methods/Case Report

For this study, we examined online MLT to MLS students who took their ASCP BOC certification exam in late 2019 thru April of 2020 and used this data to build a multiple regression model to predict ASCP scores . This model was used to predict ASCP MLS scores of students graduating in the next cohort in December of 2021.

Results (if a Case Study enter NA)

103 students took the ASCP MLS certification exam in early 2022. In early 2018, the MLS program created a database to store pre-admission information that was routinely collected. In addition, we also gathered academic information as the student progressed thru the program and post-graduation. There were a total of over 50 variables included in the database. The goal of this database was to provide insight to help both faculty and students succeed. We used a simple multiple regression model to determine which variables were correlated with the ASCP BOC score. We also used this data to develop a simple predictive model to prospectively estimate a student’s ASCP BOC score. 6 variables were identified as potentially useful in a simple model. For the initial student ASCP score prediction, a blended model using the average predicted score of the six models in Table 2 was used. The performance of the model is shown in Table 3. At the individual level, the model was accurate 82% of the time.

Conclusion

Based on our initial findings, we believe that this model may be useful to help gauge student readiness for passing the ASCP BOC exam. Several students expressed their gratitude, including one who stated that this information spurred them to study harder. There was one interesting finding. 8 of the 12 students (67%) who were predicted to fail passed the exam on the first attempt. However, only 64% of students (11/17) predicted to pass, but with a predicted score of &lt;430, passed. Subsequently, 2 of these 6 failures passed on their second attempt. We may need to investigate a more powerful way to communicate the results of the model for all of those in the “danger area”. 98% of students with a predicted score of 470 or above passed on their first attempt. The model is currently being refined to include 2021-2 certification scores which should improve the academic utility of the model.

Using Early Exam Results to Predict Online MLS Program Success

Introduction/Objective

The objective of this effort is to demonstrate the impact of early didactic exam results for potential early intervention for students in an online medical laboratory science bridge program.

Methods/Case Report

For this study, we took retrospective data of 299 students from 2018 to 2021 who took MLSC 4312, Hematology, in their first semester. We then analyzed their first exam score and then used this data to evaluate its potential use as an early predictor of overall student success in both this course and the program. Specifically, the exam one score in the course was used to evaluate progression to the second semester, graduation, UAMS GPA, and ASCP Board of Certification total score and Hematology sub-score. Descriptive statistics and 2-sample T-tests were calculated using Number Cruncher Statistical System. Fisher’s exact test was performed using Graphpad software.

Results (if a Case Study enter NA)

Of the 296 students whose records were examined, 49 scored below a 76% on Hematology exam 1. 247 students scored above 75%.35 students who scored below 76% progressed to the second semester and of those, 33 (94.2%) graduated on time. 14 students were dismissed from the program after the first semester. The overall graduation rate of students who started the program and scored less than 76% on the first hematology exam was 67%. Of the 247 students who scored above 76% on exam 1, 229 (93%) progressed to the second semester and of those, 214 graduated on time (93.4%). 18 of these students were dismissed from the program. The overall graduation rate of students who started the program and scored greater than 76% on the first hematology exam was 86.70%. The overall ASCP Board of Certification pass rate was almost 19 percent higher, 81.7% vs. 62.9% in those who scored greater than 76% on the first hematology exam. Each of the comparisons was statistically significant (P=&lt;0.05) using a 2-sample T-test or Fisher’s exact test as appropriate.

Conclusion

This study revealed the importance of doing well on the first major didactic exam in the Medical Laboratory Sciences program. Students who score &lt; 76% on their first exam fail to progress to the second semester at four times the rate of those who score &gt;76%. In addition, those who score &lt;76% and progress fail the ASCP Board of Certification Exam at almost double the rate of those who score &gt;76% on the first hematology exam. In the future, we will reach out earlier and offer targeted help to these students.

221 BEFRIENDING SERVICES ARE ASSOCIATED WITH LESS DECLINE IN HEALTH-RELATED QUALITY OF LIFE, BUT NOT COGNITIVE FUNCTION, OVER TIME

Background

Befriending services are commonly deployed in the support of older people living alone, but lack an established evidence base, particularly in relation to their association with health outcomes.

Methods

To explore the potentially therapeutic impact of befriending on Health-Related Quality-of-Life (HR-QoL) and cognitive function, we used a single case experimental design. Data were collected from 85 new users of ALONE’s befriending service between 2019 and 2021 in an AB multiple baseline design. Generalised additive modelling was then used to assess trajectories of HR-QoL and cognitive function (semantic fluency) over the course of six months, and its association with the onset of the befriending service intervention

Results

The befriending service was associated with less decline over time in HR-QoL, and with a mitigated impact of loneliness on HR-QoL too. No such effects were observed for cognitive function as an outcome, which did not change over time.

Conclusion

Befriending may exert a positive effect on health-related quality of life, and reduce the negative impact that loneliness has on this outcome.

O-305 SPIRIT long-term extension study: two-year efficacy and safety of relugolix combination therapy in women with endometriosis-associated pain

Study question

To assess the long-term efficacy and safety of once-daily Relugolix combination therapy (Relugolix-CT) in the treatment of endometriosis-associated pain over two years.

Summary answer

Relugolix-CT previously demonstrated sustained improvement of endometriosis-associated pain and was generally well tolerated over 52 weeks. Research is ongoing: two-year results will be reported.

What is known already

SPIRIT 1&2 were international, Phase 3, replicate, randomized, double-blind, placebo-controlled studies of Relugolix-CT (relugolix 40mg, estradiol 1mg, norethisterone acetate 0.5mg) in premenopausal women with moderate-to-severe endometriosis-associated pain, which were followed by the open-label, 80-week, long-term extension. 52-week results showed sustained improvement in dysmenorrhea and non-menstrual pelvic pain (NMPP) with 84.8% and 73.3% of responders, respectively. Efficacy was evidenced by reductions in dysmenorrhea (82.8%,) NMPP (62.9%,) proportion of women using opioids, and improvements in function. Relugolix-CT was generally well tolerated. Bone mineral density (BMD) assessment showed minimal initial decline (&lt;1%) from baseline followed by stabilization from Week 24 to 52.

Study design, size, duration

Women who completed the 24-week pivotal studies (SPIRIT 1&2) were eligible to enroll in an 80-week open-label, single-arm, long-term extension study of safety and efficacy, representing up to 104 weeks of treatment in total. All women enrolled in the long-term extension study received once-daily oral Relugolix-CT. Analyses were performed based on the initial randomized treatment groups in pivotal studies: Relugolix-CT, delayed Relugolix-CT (relugolix 40mg alone for 12 weeks, then Relugolix-CT for 12 weeks), or placebo.

Participants/materials, setting, methods

Primary endpoints are proportion of dysmenorrhea and NMPP responders at Weeks 52 and 104 based on daily Numerical Rating Scale (NRS) scores (0=no pain, 10=worst pain imaginable) and analgesic use. Responders are women who achieved a predefined, clinically meaningful reduction from baseline in NRS score and no increase in analgesic use. Secondary efficacy endpoints include change in Endometriosis Health Profile-30 pain domain scores, use of opioids/analgesics. Safety endpoints include adverse events and BMD (percent change).

Main results and the role of chance

Of 1251 randomized patients in SPIRIT 1&2, 1044 (83.4%) completed the pivotal studies; 802 (76.8%) enrolled in the long-term extension, and 681 (84.9%) completed 52 weeks of treatment. Baseline demographics and clinical characteristics of the long-term extension population were consistent with those of the pivotal study population. The study remains ongoing at the time of writing. Efficacy and safety data with Relugolix-CT for up to Week 104, will be presented at the scientific session of the 2022 congress.

Limitations, reasons for caution

The study was conducted as an open-label study without a control group over the 80 weeks of the extension period.

Wider implications of the findings

Through 52 weeks of treatment, Relugolix-CT demonstrated sustained improvement of dysmenorrhea, NMPP, function, and reduced need for opiates in women with endometriosis-associated pain. No new safety concerns were identified, and treatment was associated with BMD loss &lt;1%. Data from 104 weeks of treatment will be presented at the 2022 congress.

Trial registration number

NCT03654274

POS1257 READING THE WAVES: IDENTIFYING DISTINCT PHENOTYPES OF MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN IN A SINGLE CANADIAN CENTER DURING THE 2020-2021 COVID-19 PANDEMIC

Background

The COVID-19-associated multisystem inflammatory syndrome in children (MIS-C) is characterized by Kawasaki disease (KD)-like features and circulatory shock [1]. The genesis of SARS-CoV-2 variants triggered successive waves of mass infections followed by MIS-C outbreaks.

Objectives

To compare MIS-C phenotypes across the waves of the COVID-19 pandemic. To identify predictors of pediatric intensive care unit (PICU) admission and treatment with biologic agents.

Methods

Youth aged 0-18 years, fulfilling the WHO case definition of MIS-C, and admitted to the Alberta Children’s Hospital during the COVID-19 pandemic (May 2020-December 2021) were included. Clinical, laboratory, imaging, and treatment data were captured (KD-like manifestations, signs of shock and/or hypotension, peak C-reactive protein (CRP) and ferritin, platelet count nadir, peak NT-proBNP and troponin, liver enzyme abnormalities, sodium and albumin nadir, echocardiogram findings, biologic agents).

Results

57 consecutive MIS-C patients (median age 6 years, IQR 4-6; 72% males) were included. 31 patients (54%) required PICU admission. All received immunoglobulins, 44 (77%) received corticosteroids, 8 patients (14%) were treated with biologic agents. Patients presenting during the third (mainly driven by Alpha variant) or fourth wave (mainly driven by Delta variant) presented with higher ferritin and NT-proBNP levels, and more liver enzyme abnormalities, hypoalbuminemia and thrombocytopenia compared to those presenting during the first or second wave (Table 1, Figure 1). PICU admission was associated with the presence of shock/hypotension, higher CRP, ferritin, and NT-proBNP levels, lower albumin levels, and the presence of ventricular dysfunction on echocardiogram (Table 1). A logistic regression model combining peak NT-proBNP, troponin and ferritin levels explained 70% (Nagelkerke R2) of the variance in PICU admission and correctly classified 91% of the cases. NT-proBNP was the sole significant contributor (p=0.017). Treatment with biologic agents was associated with higher CRP (mean 148.8 mg/l versus 251.7 mg/l; p=0.024) and ferritin (797 μg/l versus 1280 μg/l; p=0.049) levels.

Table 1.

Upper panel: Differences in MIS-C features of patients presenting during the first phase of the COVID-19 pandemic (first + second wave) compared to those presenting during the second phase (third + fourth wave) (*one missing value). Lower panel: Differences regarding MIS-C features between patients admitted to PICU compared to those managed on the general ward.

Phase 1(n = 31)Phase 2(n = 26)P-valuePeak ferritin, μg/l (mean, SD)548 (529)1129 (724)<0.001Liver enzyme abnormalities (n, %)10 (32)18 (69)0.008Peak NT-proBNP, ng/l (mean, SD)5250 (4721)13366 (11211)0.012Hypoalbuminemia (n, %)24 (80)*25 (100)*0.027Thrombocytopenia (n, %)11 (35)18 (69)0.017PICUNo(n = 26)Yes(n = 31)P-valueShock/hypotension (n, %)19 (73)31 (100)0.002Peak CRP, mg/l (mean, SD)140.7 (92)203.8 (84)0.008Peak ferritin, μg/l (mean, SD)612 (676)1183 (627)0.002Peak NT-proBNP, ng/l (mean, SD)3772 (5074)15584 (9662)<0.001Albumin nadir, g/l (mean, SD)24 (4)19 (3)0.014Ventricular dysfunction (n, %)2 (8)18 (58)<0.001Figure 1.

Violin plots depicting differences in key laboratory MIS-C features between the waves (A) and both phases (phase 1 = wave 1 + 2, phase 2 = wave 3 + 4; B) of the COVID-19 pandemic.

Conclusion

A shift in MIS-C phenotype was identified across the successive COVID-19 waves, including the predominance of features associated with macrophage activation syndrome in later stages. These findings may reflect the impact of distinct SARS-CoV-2 variants. NT-proBNP emerged as the most important MIS-C feature predicting PICU admission, underscoring the importance of monitoring.

References

[1]Riphagen S, Gomez X, Gonzalez-Martinez C, et al. Hyperinflammatory shock in children during COVID-19 pandemic. Lancet 2020;395(10237):1607–8

Disclosure of Interests

None declared

Insights about Cannabis and Psychosis Using Video Games for Young People with a First Episode of Psychosis, particularly those from Black Racialized Backgrounds: Study Design

Background

Cannabis use disorder among young people with a first episode of psychosis contributes to relapse, hospitalization, and impaired functioning. However, few studies have examined what young people with early phase psychosis, particularly those from Black racialized communities, understand or appreciate about this relationship, even though they may be at risk. There are no formally tested knowledge translation strategies that disseminate these research findings for young people with emerging psychosis from Black racialized communities.

Objective

This study aims to conceptualize what young people with early phase psychosis/cannabis use disorder understand about the relationship between cannabis and psychosis, focusing on people from racialized backgrounds. This study also aims to assess whether the knowledge translation product, the “Back to Reality Series,” increases awareness of the impact of cannabis use on psychosis from the perspectives of young people with emerging psychosis and cannabis use disorder from Black African and Caribbean communities.

Methods

Qualitative analysis will reveal themes from qualitative interviews about cannabis and psychosis from the perspectives of young people with emerging psychosis and cannabis use disorder from Black African and Caribbean communities. Perceptions before and after exposure to the Back to Reality Series will be qualitatively analyzed. A control game will be used for comparison, and scores on a quiz after playing the Back to Reality Series will be quantitatively analyzed to establish whether the Back to Reality Series raises awareness of the effects of cannabis on psychosis. An advisory council involving young people from Black communities, family members, and clinicians will bring community perspectives to this research.

Results

We began recruiting participants for this study in September 2021. We will complete data collection on demographic and clinical factors, qualitative interviews, and quantitative assessments of the Back to Reality Series.

Conclusions

The voices of young people from racialized backgrounds will generate preliminary data to inform early psychosis programs, addressing cannabis use in this population. The findings may advance the use of a new knowledge translation product that deals with gaps in knowledge about cannabis use for people experiencing early phase psychosis, particularly those from racialized communities.

International Registered Report Identifier (IRRID)

DERR1-10.2196/36758

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Is there a unique cardiac deformation behaviour in COVID-patients? The SARS-2-DEFORM Study

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

SARS-2-DEFORM

Myocardial dysfunction is common and associated with worse outcomes in patients with ARDS, pulmonary embolism or severe sepsis due to pulmonary hypoxic vasoconstriction. Thrombotic events, myocarditis and endothelial dysfunction may contribute to these effects in COVID-19 infection. The evaluation of myocardial function can provide prognostic information regarding the severity of a current COVID-19 infection, but scarce data available on the role of Deformation Indices obtained by Speckle Tracking Analysis to describe unique features of myocardial dysfunction in COVID-19 pneumonitis. AIMS: to evaluate the value of ventricular and atrial Deformation Imaging in patients with COVID-19 infection and hypoxia who had preserved systolic function in comparison with age-, gender-, BSA, hypoxia-matched control subjects with respiratory disease on oxygen therapy, thus excluding the effects of pulmonary vasoconstriction. We also assessed the impact of biochemical and inflammatory markers on the Echo-Indices. METHODS: 21 patients with PCR-confirmed COVID-pneumonitis (15 males, age:60.1 ± 16.1yrs, range:43-89) and 31 control, PCR-negative subjects (age:62.8 ± 15.5yrs, range:22-92) on oxygen with matched biometric data were compared. 2 examiners, blinded to the clinical data performed off-line standard Echocardiographic assessment and Deformation Imaging by 2D-Speckle Tracking Analysis with the TomTec Arena software package (Unterschleissheim, Germany) in both ventricles and atria. Plasma chemistry data were compared between the groups. RESULTS: No differences found in the biometric data and the cardiac chamber sizes between the groups. The global systolic strain indices were reduced in the COVID-group in the LV, but not the EF (LV-GLS -13.6 ± 2.9 vs -16 ± 1.1%, LV-GCS -24.8 ± 2.4 vs -28.9 ± 2.8%, p = 0.001, LVEF 61 ± 3.7 vs 60.7 ± 4.9%, p = NS), and these were reduced in the RV and RA, but not the TAPSE and TDI-S` when compared to the controls (RV-FWS -12.3 ± 2.9 vs -16.2 ± 1.5%, RV-GLS -14.6 ± 3.4 vs -17.1 ± 1.7%, RASr 18.5 ± 6 vs 22.3 ± 4.8% p = 0.005. Interestingly, the dispersion of contraction was increased in the COVID-patients in both the LV (LV-SD 416.2 ± 81.8 vs 309.8 ± 69.8ms, p &lt; 0.001) and the RV and the RA (RV-SD 414.9 ± 117 vs 303.8 ± 61ms, RA-SD 33.5 ± 6.7 vs 26.1 ± 4.7ms, p &lt; 0.001). The right heart indices correlated well with the biochemical data (RV-FWS and RV-SD with Ferritin r = 0.54 and -0.46, p = 0.003, RASr with GLS r = 0.64, p = 0.002, RA-SD with Troponin, p = 0.01 and with the RV-coupling Index r = 0.72, p = 0.02). CONCLUSIONS: Myocardial dysfunction is common among severely ill and hypoxic COVID-19 patients. The conventional Echo-parameters of systolic function or pulmonary pressures do not appear being specific but the Deformation Indices can provide tools to detect unique changes of the myocardial function and dys-synchrony imposed by the COVID-19 infection, independently from the impact of hypoxia or raised pulmonary pressures, hence they can predict outcome more accurately.

Genetic epidemiology of SARS-CoV-2 transmission in renal dialysis units - A high risk community-hospital interface

OBJECTIVES

Patients requiring haemodialysis are at increased risk of serious illness with SARS-CoV-2 infection. To improve the understanding of transmission risks in six Scottish renal dialysis units, we utilised the rapid whole-genome sequencing data generated by the COG-UK consortium.

METHODS

We combined geographical, temporal and genomic sequence data from the community and hospital to estimate the probability of infection originating from within the dialysis unit, the hospital or the community using Bayesian statistical modelling and compared these results to the details of epidemiological investigations.

RESULTS

Of 671 patients, 60 (8.9%) became infected with SARS-CoV-2, of whom 16 (27%) died. Within-unit and community transmission were both evident and an instance of transmission from the wider hospital setting was also demonstrated.

CONCLUSIONS

Near-real-time SARS-CoV-2 sequencing data can facilitate tailored infection prevention and control measures, which can be targeted at reducing risk in these settings.

Global analysis of protein-RNA interactions in SARS-CoV-2-infected cells reveals key regulators of infection

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19). SARS-CoV-2 relies on cellular RNA-binding proteins (RBPs) to replicate and spread, although which RBPs control its life cycle remains largely unknown. Here, we employ a multi-omic approach to identify systematically and comprehensively the cellular and viral RBPs that are involved in SARS-CoV-2 infection. We reveal that SARS-CoV-2 infection profoundly remodels the cellular RNA-bound proteome, which includes wide-ranging effects on RNA metabolic pathways, non-canonical RBPs, and antiviral factors. Moreover, we apply a new method to identify the proteins that directly interact with viral RNA, uncovering dozens of cellular RBPs and six viral proteins. Among them are several components of the tRNA ligase complex, which we show regulate SARS-CoV-2 infection. Furthermore, we discover that available drugs targeting host RBPs that interact with SARS-CoV-2 RNA inhibit infection. Collectively, our results uncover a new universe of host-virus interactions with potential for new antiviral therapies against COVID-19.

Global analysis of protein-RNA interactions in SARS-CoV-2-infected cells reveals key regulators of infection

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19). SARS-CoV-2 relies on cellular RNA-binding proteins (RBPs) to replicate and spread, although which RBPs control its life cycle remains largely unknown. Here, we employ a multi-omic approach to identify systematically and comprehensively the cellular and viral RBPs that are involved in SARS-CoV-2 infection. We reveal that SARS-CoV-2 infection profoundly remodels the cellular RNA-bound proteome, which includes wide-ranging effects on RNA metabolic pathways, non-canonical RBPs, and antiviral factors. Moreover, we apply a new method to identify the proteins that directly interact with viral RNA, uncovering dozens of cellular RBPs and six viral proteins. Among them are several components of the tRNA ligase complex, which we show regulate SARS-CoV-2 infection. Furthermore, we discover that available drugs targeting host RBPs that interact with SARS-CoV-2 RNA inhibit infection. Collectively, our results uncover a new universe of host-virus interactions with potential for new antiviral therapies against COVID-19.

1001 Intra-Articular Distal Radius Fracture Surgical Intervention Threshold Origins and Development

Background

Treatment of intra-articular distal radius fractures is guided by the displacement of the articular fragments. Symptomatic post-traumatic arthritis is expected to occur if step displacement is &gt; 2mm; this value is often used as an indication for surgery if closed reduction is not possible.

Method

A systematic review was performed to establish the origin and adaptations of the threshold, with papers screened and relevant citations reviewed. Orthopaedic textbooks were reviewed to ensure no earlier mention of the threshold was present.

Results

Knirk and Jupiter, 1986, are the first to quantify a threshold, with all their patients developing arthritis with &gt;2mm displacement. Some papers have discussed using 1mm, although 2mm is most widely reported. Current guidance from the British Society for Surgery of the Hand supports 2mm. Although this paper is still widely cited, the authors published a re-examination of the data showing methodological flaws which is not as widely reported. They claim their conclusions are still relevant today; however, the radiological arthritis does not correlate with the clinical presentation.

Conclusions

Knirk and Jupiter originated the threshold value of 2mm. The lack of correlation between the radiological and clinical presentations warrants further investigation. The principle of treatment remains restoration of normal anatomical position.

The COVID-19 pandemic and eating disorders in children, adolescents, and emerging adults: virtual care recommendations from the Canadian consensus panel during COVID-19 and beyond

OBJECTIVE

The COVID-19 pandemic has had detrimental effects on mental health. Literature on the impact on individuals with eating disorders is slowly emerging. While outpatient eating disorder services in Canada have attempted to transition to virtual care, guidelines related to optimal virtual care in this field are lacking. As such, the objective of our Canadian Consensus Panel was to develop clinical practice guidelines related to the provision of virtual care for children, adolescents, and emerging adults living with an eating disorder, as well as their caregivers, during the COVID-19 pandemic and beyond.

METHODS

Using scoping review methodology (with literature in databases from 2000 to 2020 and grey literature from 2010 to 2020), the Grading of Recommendations, Assessment, Development, and Evaluation system, the Appraisal of Guidelines, Research and Evaluation tool, and a panel of diverse stakeholders from across Canada, we developed high quality treatment guidelines that are focused on virtual interventions for children, adolescents, and emerging adults with eating disorders, and their caregivers.

RESULTS

Strong recommendations were supported specifically in favour of in-person medical evaluation when necessary for children, adolescents, and emerging adults, and that equity-seeking groups and marginalized youth should be provided equal access to treatment. For children and adolescents, weak recommendations were supported for telehealth family-based treatment (FBT) and online guided parental self-help FBT. For emerging adults, internet cognitive-behavioural therapy (CBT)-based guided self-help was strongly recommended. Weak recommendations for emerging adults included CBT-based group internet interventions as treatment adjuncts, internet-based relapse prevention Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) guided self-help, telehealth relapse prevention using MANTRA, and guided CBT-based smartphone apps as treatment adjuncts. For caregivers of children and adolescents, weak recommendations were supported for virtual parent meal support training, and moderated online caregiver forums and support groups. For caregivers of emerging adults, guided parental self-help CBT was strongly recommended, and unguided caregiver psychoeducation self-help was weakly recommended.

CONCLUSIONS

Several gaps for future work were identified including the impact of sex, gender, race, and socioeconomic status on virtual care among children, adolescents, and emerging adults with eating disorders, as well as research on more intensive services, such as virtual day hospitals.

The BODY-Q Chest Module: Further Validation in a Canadian Chest Masculinization Surgery Sample

BACKGROUND

The BODY-Q Chest module is a patient-reported outcome (PRO) instrument that measures satisfaction with how the chest (10 items) and nipples (5 items) look. This PRO instrument was previously field tested in an international sample of people seeking treatment for gynecomastia (n = 174), weight loss (n = 224), and chest masculinization (n = 341).

OBJECTIVES

The aim of this study was to examine the psychometric performance of the BODY-Q Chest module in a new chest masculinization surgery sample.

METHODS

Data were collected from patients attending a private plastic surgery outpatient clinic in Canada between January 2018 and June 2019. Rasch measurement theory analysis was used to examine how the scales performed psychometrically.

RESULTS

The sample provided 266 assessments (115 preoperative, 151 postoperative). All items had ordered thresholds, providing evidence that the 4 response options for each scale worked as expected. Item fit was within ±2.5 for all items, with all Bonferroni adjusted chi-square values nonsignificant. The data for the chest (χ2(20) = 18.72, P = 0.54) and nipples (χ 2(10) = 12.28, P = 0.27) scales fit the requirements of the Rasch model. Reliability was high with person separation index and Cronbach's α values of ≥0.95 for the chest and ≥0.87 for the nipple scales, respectively. More depressive symptoms on the Patient Health Questionnaire-9 and lower health-related quality of life scales were weakly correlated with worse scores on the chest and nipple scales (P < 0.001).

CONCLUSIONS

The BODY-Q Chest module was shown to be scientifically sound in an independent sample of patients seeking chest masculinization surgery.

Detection of SARS-CoV-2 in respiratory samples from cats in the UK associated with human-to-cat transmission

OBJECTIVES

The aim of the study was to find evidence of SARS-CoV-2 infection in UK cats.

DESIGN

Tissue samples were tested for SARS-CoV-2 antigen using immunofluorescence and for viral RNA by in situ hybridisation. A set of 387 oropharyngeal swabs that had been submitted for routine respiratory pathogen testing was tested for SARS-CoV-2 RNA using reverse transcriptase quantitative PCR.

RESULTS

Lung tissue collected post-mortem from cat 1 tested positive for both SARS-CoV-2 nucleocapsid antigen and RNA. SARS-CoV-2 RNA was detected in an oropharyngeal swab collected from cat 2 that presented with rhinitis and conjunctivitis. High throughput sequencing of the viral genome revealed five single nucleotide polymorphisms (SNPs) compared to the nearest UK human SARS-CoV-2 sequence, and this human virus contained eight SNPs compared to the original Wuhan-Hu-1 reference sequence. An analysis of the viral genome of cat 2 together with nine other feline-derived SARS-CoV-2 sequences from around the world revealed no shared cat-specific mutations.

CONCLUSIONS

These findings indicate that human-to-cat transmission of SARS-CoV-2 occurred during the COVID-19 pandemic in the UK, with the infected cats developing mild or severe respiratory disease. Given the ability of the new coronavirus to infect different species, it will be important to monitor for human-to-cat, cat-to-cat and cat-to-human transmission.

Circulating SARS-CoV-2 spike N439K variants maintain fitness while evading antibody-mediated immunity

SARS-CoV-2 can mutate and evade immunity, with consequences for efficacy of emerging vaccines and antibody therapeutics. Here, we demonstrate that the immunodominant SARS-CoV-2 spike (S) receptor binding motif (RBM) is a highly variable region of S and provide epidemiological, clinical, and molecular characterization of a prevalent, sentinel RBM mutation, N439K. We demonstrate N439K S protein has enhanced binding affinity to the hACE2 receptor, and N439K viruses have similar in vitro replication fitness and cause infections with similar clinical outcomes as compared to wild type. We show the N439K mutation confers resistance against several neutralizing monoclonal antibodies, including one authorized for emergency use by the US Food and Drug Administration (FDA), and reduces the activity of some polyclonal sera from persons recovered from infection. Immune evasion mutations that maintain virulence and fitness such as N439K can emerge within SARS-CoV-2 S, highlighting the need for ongoing molecular surveillance to guide development and usage of vaccines and therapeutics.

Circulating SARS-CoV-2 spike N439K variants maintain fitness while evading antibody-mediated immunity

SARS-CoV-2 can mutate and evade immunity, with consequences for efficacy of emerging vaccines and antibody therapeutics. Here, we demonstrate that the immunodominant SARS-CoV-2 spike (S) receptor binding motif (RBM) is a highly variable region of S and provide epidemiological, clinical, and molecular characterization of a prevalent, sentinel RBM mutation, N439K. We demonstrate N439K S protein has enhanced binding affinity to the hACE2 receptor, and N439K viruses have similar in vitro replication fitness and cause infections with similar clinical outcomes as compared to wild type. We show the N439K mutation confers resistance against several neutralizing monoclonal antibodies, including one authorized for emergency use by the US Food and Drug Administration (FDA), and reduces the activity of some polyclonal sera from persons recovered from infection. Immune evasion mutations that maintain virulence and fitness such as N439K can emerge within SARS-CoV-2 S, highlighting the need for ongoing molecular surveillance to guide development and usage of vaccines and therapeutics.

A plasmid DNA-launched SARS-CoV-2 reverse genetics system and coronavirus toolkit for COVID-19 research

The recent emergence of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), the underlying cause of Coronavirus Disease 2019 (COVID-19), has led to a worldwide pandemic causing substantial morbidity, mortality, and economic devastation. In response, many laboratories have redirected attention to SARS-CoV-2, meaning there is an urgent need for tools that can be used in laboratories unaccustomed to working with coronaviruses. Here we report a range of tools for SARS-CoV-2 research. First, we describe a facile single plasmid SARS-CoV-2 reverse genetics system that is simple to genetically manipulate and can be used to rescue infectious virus through transient transfection (without in vitro transcription or additional expression plasmids). The rescue system is accompanied by our panel of SARS-CoV-2 antibodies (against nearly every viral protein), SARS-CoV-2 clinical isolates, and SARS-CoV-2 permissive cell lines, which are all openly available to the scientific community. Using these tools, we demonstrate here that the controversial ORF10 protein is expressed in infected cells. Furthermore, we show that the promising repurposed antiviral activity of apilimod is dependent on TMPRSS2 expression. Altogether, our SARS-CoV-2 toolkit, which can be directly accessed via our website at https://mrcppu-covid.bio/, constitutes a resource with considerable potential to advance COVID-19 vaccine design, drug testing, and discovery science.

[Fertility preservation for transwomen]

The evolution of medical care for transgender people currently makes it possible to propose fertility preservation. Fertility preservation should be initiated before the start of hormonal treatments and/or surgical procedures. The "reproductive" aspect and the desire for parenthood among transgender people have long been ignored. However, these aspects are important to consider and fertility preservation should be discussed before the start of the physical transition. The aim of this review is to assess the literature on fertility preservation for transgender women ("male to female"). Many uncertainties remain regarding the impact of hormonal treatments on the reproductive functions of transgender women and their reversibility. However, the significant increase in the number of recently published articles is evidence of the improvement in the conditions of access to these procedures for women starting a transition process. Nevertheless, there are still a number of barriers that can prevent or delay this process.

Genomic epidemiology reveals multiple introductions of SARS-CoV-2 from mainland Europe into Scotland

Coronavirus disease 2019 (COVID-19) was first diagnosed in Scotland on 1 March 2020. During the first month of the outbreak, 2,641 cases of COVID-19 led to 1,832 hospital admissions, 207 intensive care admissions and 126 deaths. We aimed to identify the source and number of introductions of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) into Scotland using a combined phylogenetic and epidemiological approach. Sequencing of 1,314 SARS-CoV-2 viral genomes from available patient samples enabled us to estimate that SARS-CoV-2 was introduced to Scotland on at least 283 occasions during February and March 2020. Epidemiological analysis confirmed that early introductions of SARS-CoV-2 originated from mainland Europe (the majority from Italy and Spain). We identified subsequent early outbreaks in the community, within healthcare facilities and at an international conference. Community transmission occurred after 2 March, 3 weeks before control measures were introduced. Earlier travel restrictions or quarantine measures, both locally and internationally, would have reduced the number of COVID-19 cases in Scotland. The risk of multiple reintroduction events in future waves of infection remains high in the absence of population immunity.

L’évaluation complète de la santé sexuelle à l’ adolescence

L’activité et l’expérimentation sexuelles sont des aspects normaux du développement des adolescents, mais peuvent toutefois avoir des effets défavorables sur la santé, y compris sous forme d’infections transmises sexuellement, de grossesse non planifiée et de violence dans les fréquentations. Les conseils préventifs aux adolescents sur la santé sexuelle et reproductive doivent inclure les questions relatives au développement sexuel normal, telles que l’identité et l’attirance, les relations sécuritaires, les activités sexuelles mieux protégées et la contraception. Les professionnels de la santé peuvent améliorer l’éducation sexuelle des jeunes qu’ils rencontrent en cabinet et contribuer à atténuer les effets négatifs de leur sexualité sur la santé. Le présent point de pratique propose l’approche des 7 P pour aider les professionnels de la santé à obtenir une évaluation complète de la santé sexuelle des adolescents. Des enjeux liés à l’adolescence sont abordés, comme l’identité, la confidentialité, le consentement et la violence dans les fréquentations, et des ressources de la Société canadienne de pédiatrie sont proposées pour fournir des cheminements cliniques plus détaillés sur des enjeux connexes : la contraception, la grossesse et les infections transmises sexuellement.

Comprehensive sexual health assessments for adolescents

Sexual activity and experimentation are normative parts of adolescent development that may, at the same time, be associated with adverse health outcomes, including the acquisition of sexually transmitted infections, unplanned pregnancy, and teen dating violence. Anticipatory guidance regarding sexual and reproductive health for teens should address normal sexual development issues, such as identity and attractions, safe relationships, safer sex, and contraception. Health care providers can enhance the sexual education of the youth they see and help mitigate negative health outcomes. This practice point offers a '7-P' approach to ensure that health care providers obtain comprehensive sexual health assessments for adolescents. Teen issues such as identity, confidentiality, and consent, and dating violence are discussed, and Canadian Paediatric Society resources are cited to provide more detailed care pathways on related issues: contraception, pregnancy, and sexually transmitted infections.

Revascularization decisions in patients with stable angina and intermediate lesions: results of the second International Survey on Interventional Strategy (ISIS-2)

Background

ISIS-1 survey (conducted in 2012–2013) demonstrated a significant disconnect between guideline recommendations on invasive functional and imaging assessment of coronary stenosis severity and effective intention to adoption in patients with chronic coronary syndromes (CCS). Ever since, more evidences and new indexes/tools have become available, supposedly resulting into a simplified adoption. Therefore, six years later the second survey was repeated (ISIS-2) with the aim to evaluate a possible evolution in the intended adoption of invasive diagnostic tools.

Methods

ISIS-2 was conducted via a web-based platform from June to December 2019. Here, five complete angiograms were provided, presenting only focal intermediate stenoses. FFR and quantitative coronary angiography (QCA) values were known and kept concealed to the participants. Estimation of stenosis significance was asked for each lesion. In case of uncertainty, the most appropriate adjunctive invasive diagnostic method among QCA, intravascular ultrasound, optical coherence tomography, or invasive functional test (i.e. with FFR or a non-hyperemic index) was to be selected. Primary endpoint of the study was the rate of requested adjunctive functional or imaging assessment, as indicated by guideline recommendations. Secondary endpoint was the rate and accuracy of purely angiography-based decisions.

Results

A total of 411 participants performed 3749 lesion evaluations in ISIS-2: 2237 (60%) decisions were taken solely on angiogram and expressed no need for further evaluation with adjunctive tools. This rate of angiographic reliance was significantly reduced in ISIS-2 as compared with ISIS-1 (3139 [71%]; p&lt;0.001). Here the decision (significant or non-significant) was discordant with the known functional significance in 870 (39%) cases, markedly less as in ISIS-1 (1459, 46%; p&lt;0.001). In ISIS-2, participants expressed the need for either invasive functional assessment or intravascular imaging in 1110 (29%) and 379 (11%) cases, respectively. These rates were significantly higher as compared with ISIS-1 (928 [21%]; p&lt;0.001 and 354 [8%]; p&lt;0.001, respectively).

Conclusions

ISIS-2 survey suggests an evolving pattern over 6 years in the intention to integrate coronary angiography with invasive coronary physiology and imaging testing in patients with CCS.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Unrestricted grant from Abbott Medical

Brca1 mutations in the coiled-coil domain impede Rad51 loading on DNA and mouse development

We recently developed a Brca1 coiled-coil mutant mouse model (Brca1^CC). Brca1^CC/CC results in embryonic lethality, with a fraction of mice reaching birth but with defects that parallel Fanconi anemia. Brca1^CC/CC cells lacked Rad51 foci and were PARP inhibitor sensitive. Strikingly, inter-crossing with Brca1^Δ11 generated Brca1^CC/Δ11 mice that were developmentally normal.

103 Pediatric resident knowledge and comfort in providing care to transgender youth: A single centre needs assessment

Background

Transgender youth experience high rates of health disparities and inequities. There is currently no formal curriculum for transgender health within our centre’s pediatric residency program. This gap in training is similar to other programs across the country. With the drastic rise in trans youth patients seeking care, general pediatricians will be the first point of contact for many. Pediatricians therefore need to be equipped with the proper knowledge and skill to provide care to these patients.

Objectives

We conducted a needs assessment to assess pediatric residents’ comfort with the health care needs of transgender patients, and to assess knowledge about the medical management of transgender youth. The goal was to identify learning gaps within our centre’s residency program to guide future curriculum.

Design/Methods

A survey with Likert scale and case-based questions, based on literature review, identified key components of trans care. The study was granted an exemption from ethics review.

Results

We achieved a 50% response rate (24/58) from pediatric residents, and 50% of these residents were in their senior years (PGY3 and PGY4). All residents felt it was important to have trans specific training during residency. While the majority of senior residents received training during their residency, the total duration was estimated to be ≤ 5 hours. Despite the training received, only 50% [95% CI: 30, 70] of residents felt comfortable asking patients about their gender identity, and only 8% [0, 19] and 33% [14, 52] of residents were comfortable diagnosing gender dysphoria in children and teens, respectively. Most residents felt uncomfortable addressing trans specific health care needs, and 83% [62, 100] of senior residents were uncomfortable counselling patients on available gender affirming pharmacologic agents. Similarly, 92% [77, 100] of senior residents felt uncomfortable prescribing either GnRH analogs or hormonal therapy for trans youth. Lastly, only 58% [30, 86] of senior residents felt comfortable performing Tanner staging in trans patients.

Conclusion

In order to help narrow the gap in care for trans patients, we need to better educate pediatric residents on trans specific health care. Future curriculum should focus on discussing gender identity, identifying gender dysphoria, performing Tanner staging, and counselling patients on gender affirming pharmacologic therapies. These skills are critical for general pediatricians to adequately provide care to trans youth.

Genetic diversity and population structure of Culex modestus across Europe: does recent appearance in the United Kingdom reveal a tendency for geographical spread?

In mainland Europe, the mosquito species Culex modestus Ficalbi (1890) is a bridge vector for West Nile virus (WNV) from its natural bird-mosquito cycle to mammals. The present study assessed the genetic diversity of Cx. modestus, as well as related Culex species, using the mitochondrial COI DNA barcoding region and compared this with the population structure across Europe. A haplotype network was mapped to determine genealogical relationships among specimens. The intraspecific genetic diversity within individual Culex species was below 2%, whereas the interspecific genetic divergence varied from 2.99% to 13.74%. In total, 76 haplotypes were identified among 198 sequences. A median-joining network determined from 198 COI sequences identified two major lineages that were separated by at least four mutation steps. A high level of intraspecific genetic diversity was not detected in Cx. modestus in samples submitted from different European populations, which indicates that morphologically identified specimens represent a single species and not a species complex. Therefore, it is deduced that different populations of Cx. modestus will show a similar potential to transmit WNV, lending support to concerns that the population present in southeast England represents a risk of transmission to humans.