t-EER: Parameter-Free Tandem Evaluation of Countermeasures and Biometric Comparators

Presentation attack (spoofing) detection (PAD) typically operates alongside biometric verification to improve reliablity in the face of spoofing attacks. Even though the two sub-systems operate in tandem to solve the single task of reliable biometric verification, they address different detection tasks and are hence typically evaluated separately. Evidence shows that this approach is suboptimal. We introduce a new metric for the joint evaluation of PAD solutions operating in situ with biometric verification. In contrast to the tandem detection cost function proposed recently, the new tandem equal error rate (t-EER) is parameter free. The combination of two classifiers nonetheless leads to a set of operating points at which false alarm and miss rates are equal and also dependent upon the prevalence of attacks. We therefore introduce the concurrent t-EER, a unique operating point which is invariable to the prevalence of attacks. Using both modality (and even application) agnostic simulated scores, as well as real scores for a voice biometrics application, we demonstrate application of the t-EER to a wide range of biometric system evaluations under attack. The proposed approach is a strong candidate metric for the tandem evaluation of PAD systems and biometric comparators.

Positive selection in the genomes of two Papua New Guinean populations at distinct altitude levels

Highlanders and lowlanders of Papua New Guinea have faced distinct environmental stress, such as hypoxia and environment-specific pathogen exposure, respectively. In this study, we explored the top genomics regions and the candidate driver SNPs for selection in these two populations using newly sequenced whole-genomes of 54 highlanders and 74 lowlanders. We identified two candidate SNPs under selection - one in highlanders, associated with red blood cell traits and another in lowlanders, which is associated with white blood cell count - both potentially influencing the heart rate of Papua New Guineans in opposite directions. We also observed four candidate driver SNPs that exhibit linkage disequilibrium with an introgressed haplotype, highlighting the need to explore the possibility of adaptive introgression within these populations. This study reveals that the signatures of positive selection in highlanders and lowlanders of Papua New Guinea align closely with the challenges they face, which are specific to their environments.

The SelfSTarT intervention for low back pain patients presenting to first contact physiotherapists: A mixed methods service evaluation

INTRODUCTION

Globally, back pain is the leading cause of years of disability. In the United Kingdom, over 20 million people live with musculoskeletal (MSK) pain, with low back pain being one of the most common causes. National strategies promote self-management and the use of digital technologies to empower populations.

AIMS

To evaluate the uptake and impact of providing the SelfSTart approach (STarT Back and SelfBACK App) when delivered by a First Contact Physiotherapist (FCP) to people presenting with low back pain in primary care.

METHODS

Patients presenting with a new episode of low back pain underwent routine assessment and completion of a STarT Back questionnaire. Patients with low/medium scores were offered the SelfBACK App. A control population was provided by the MIDAS-GP study. Patient Experience, outcome measures, healthcare utilisation and retention were captured through the app and clinical systems (EMIS). Interviews with five FCPs explored the experiences of using the SelfSTart approach.

RESULTS

SelfSTarT was taken up by almost half (48%) of those to whom it was offered. Compared to MIDAS-GP, users were more likely to be younger, male, in work, and with higher health literacy. SelfSTarT users reported significant improved experiences relating to receiving an agreed care plan and receiving sufficient information. There were no significant differences in treatments offered. FCPs were positive about the app and felt it had value but wanted feedback on patient progress. They recognised that a digital solution would not be suitable for all.

CONCLUSION

This approach offers an opportunity to empower and support self-management, using robustly evaluated digital technology.

Early experience of thalidomide therapy for high-grade peripheral and facial arteriovenous malformations

BACKGROUND

Arteriovenous malformations (AVMs) are developmental defects in the vascular system with abnormal connections between arteries and veins. A minority of AVMs are characterized by aggressive growth and continue to proliferate despite maximal surgical and interventional therapy. We report our outcomes with the use of thalidomide as the only UK specialist center adopting this novel approach for the management of AVMs refractory to conventional therapy.

METHODS

This was a retrospective case series which included only complex and proliferative AVM lesions (Schobinger grade III and IV). All patients prescribed thalidomide on a compassionate basis between September 2006 and August 2022 after attempts at embolosclerotherapy without satisfactory response were reviewed.

RESULTS

Eleven patients were included in our study. The median total duration of thalidomide use was 10 months. Two thirds of patients with pain (six of nine) reported an improvement, three quarters reported a reduction in swelling (six of eight) and all who presented with bleeding reported improvement in overall volume or frequency (four of four). Over the study period, 45% achieved a non-proliferative state with no further target vessel demonstrable on angiography. Mild, tolerable side effects such as fatigue were common (73%). There was only one major adverse reaction (neutropenia) necessitating cessation of therapy.

CONCLUSIONS

We can conclude that thalidomide is able to reduce the symptom burden for patients with complex and proliferative AVMs that were refractory to established treatment modalities. Adverse effects are common, but the benefit achieved from taking thalidomide in otherwise treatment resistant cases outweighs the risks, most of which are manageable.

Kinbank: A global database of kinship terminology

For a single species, human kinship organization is both remarkably diverse and strikingly organized. Kinship terminology is the structured vocabulary used to classify, refer to, and address relatives and family. Diversity in kinship terminology has been analyzed by anthropologists for over 150 years, although recurrent patterning across cultures remains incompletely explained. Despite the wealth of kinship data in the anthropological record, comparative studies of kinship terminology are hindered by data accessibility. Here we present Kinbank, a new database of 210,903 kinterms from a global sample of 1,229 spoken languages. Using open-access and transparent data provenance, Kinbank offers an extensible resource for kinship terminology, enabling researchers to explore the rich diversity of human family organization and to test longstanding hypotheses about the origins and drivers of recurrent patterns. We illustrate our contribution with two examples. We demonstrate strong gender bias in the phonological structure of parent terms across 1,022 languages, and we show that there is no evidence for a coevolutionary relationship between cross-cousin marriage and bifurcate-merging terminology in Bantu languages. Analysing kinship data is notoriously challenging; Kinbank aims to eliminate data accessibility issues from that challenge and provide a platform to build an interdisciplinary understanding of kinship.

Grambank reveals the importance of genealogical constraints on linguistic diversity and highlights the impact of language loss

While global patterns of human genetic diversity are increasingly well characterized, the diversity of human languages remains less systematically described. Here, we outline the Grambank database. With over 400,000 data points and 2400 languages, Grambank is the largest comparative grammatical database available. The comprehensiveness of Grambank allows us to quantify the relative effects of genealogical inheritance and geographic proximity on the structural diversity of the world's languages, evaluate constraints on linguistic diversity, and identify the world's most unusual languages. An analysis of the consequences of language loss reveals that the reduction in diversity will be strikingly uneven across the major linguistic regions of the world. Without sustained efforts to document and revitalize endangered languages, our linguistic window into human history, cognition, and culture will be seriously fragmented.

Efficacy and safety of embolo-sclerotherapy of arteriovenous malformations with foam sodium tetradecyl sulphate

BACKGROUND

To evaluate the efficacy and safety of embolo-sclerotherapy (EST) particularly with foamed sclerotherapy in the treatment of arteriovenous malformations (AVMs).

METHODS

All patients with AVM who underwent interventional therapy i.e. EST from January 1^st, 2015 - December 31^st, 2019 were identified through a prospective database. Types of AVM were classified according to Schobinger's classification. The outcome measures assessed efficacy and complications. The former was divided into four groups: no response, mild response, moderate response, and complete response.. Complications were defined as any tissue or functional damage, distal embolization or tissue reaction. Continuous variables were compared using analysis of variance (ANOVA) F test and discrete variables were analysed using χ² tests. P<0.05 was considered significant.

RESULTS

A total of 65 patients were included. There was no statistical difference amongst the volume of foam STS 3% or alcohol used across all types of AVM. Overall, majority of patients (86.2%) reported some degree of improvement following interventional therapy. Six (9.2%) patients experienced complications including necrosis and amputation. The proportions of complication were significantly different across the categories (P=0.009). Patients with type III AVM seemed to report more complications than others.

CONCLUSIONS

Foam sclerotherapy was clinically effective and safe for patients with AVM. This study showed that foam sclerotherapy with STS 3% provided a safe and efficacious alternative sclerosant to ethanol despite it was not often reported to be used to treat AVM. However, a combination of embolic agents is likely required to treat type IV AVMs.

Efficacy and safety of foam sclerotherapy with sodium tetradecyl sulfate as preferred sclerosant of venous malformations based on experience from a single specialist center

OBJECTIVE

We have assessed the efficacy and safety of interventional therapy for venous malformations (VMs), with foam sclerotherapy as the treatment of choice according to our experience at a single specialist center.

METHODS

All the patients with VMs who had undergone interventional therapy (ie, embolo-sclerotherapy and/or open surgery) from January 1, 2015 to December 31, 2019 were identified through a prospective database. The VM types were classified according to the Puig classification. The outcome measures assessed included the efficacy and complications. The former was divided into four groups: no response, mild response, moderate response, and complete response. The complications were defined as any tissue or functional damage, distal embolization, or tissue reaction. The continuous variables were compared using the analysis of variance F test, and discrete variables were analyzed using the χ² tests. P values < .05 were considered statistically significant.

RESULTS

A total of 207 patients were included. Puig type I lesions were significantly less likely to have received foam sclerotherapy using sodium tetradecyl sulfate (STS) 3% (P ≤ .001) and more likely to have been surgically excised (P ≤ .001). At the patient's first procedure during the study period, the volumes of foam STS 3% were significantly different across all types of VM (P ≤ .001). The patients with type I VMs had received a lower volume of STS 3% compared with those with type II and III VMs. The efficacy outcome categories were significantly different across all types of VMs (P ≤ .001). Overall, only 14 patients (6.8%) had reported no improvement in efficacy, and 38 patients (18%) had not attended follow-up. Therefore, 154 patients (74.8%) had experienced some form of efficacious outcome. Ten patients (4.8%) had developed complications such as hematoma, thrombophlebitis, and ulceration. The incidence of complications differed significantly across the categories (P = .030), with more complications reported for those with type I VMs.

CONCLUSIONS

We found that intervention with foam sclerotherapy using STS 3% is clinically effective and safe for patients with VMs and was most successful for those with Puig type I and II VMs.

Early follow-up quality of life and mental health of patients with congenital vascular malformations cared for in a multi-disciplinary specialist centre

OBJECTIVE

The study aimed to evaluate the early follow-up quality of life (QoL), pain and mental health of patients with congenital vascular malformation (CVM) from a variety of treatment options.

METHODS

All patients with CVM who received care and had follow-up between February 1st 2018 and January 31st 2020 were included. The health-related QoL, pain, and mental health were assessed with RAND Health Care 36-Item Short Form Survey (SF-36), visual analogue score for pain (VAS-P) and Hospital Anxiety and Depression Scale (HADS). Paired t-test was used for all analyses. p < .05 were considered significant.

RESULTS

In total, 110 patients with a mean age of 36.9 years were included in this study. In all patients following care, significant improvement was found in the bodily pain domain of SF-36 and VAS-P (both p = .01). This was largely driven by high-flow vascular malformation patients who responded better to embolo-sclerotherapy, which revealed significant improvement in the bodily pain domain of SF-36 (p = .002) and VAS-P (p = .02). Patients who received supportive treatment only reported significant improvement in mental health (p = .004) and social functioning (p = .03) domains of SF-36. Meanwhile, patients treated with embolo-sclerotherapy reported significant improvement only in VAS-P (p = .02).

CONCLUSIONS

This study concluded that the effects of care on early follow-up QoL, pain and mental health of patients with CVM were heterogenous. Future research should therefore, include larger sample size and longer term follow-up to understand the various factors that affect the QoL and mental health of these patients, as well as the holistic approaches to manage them.

522 Early Follow-Up Quality of Life and Mental Health of Patients with Congenital Vascular Malformations Cared for in a Multi-Disciplinary Specialist Center

Aim

To evaluate the early follow-up quality of life (QoL), pain and mental health of patients with congenital vascular malformation (CVM) receiving care by a single multi-disciplinary specialist center

Method

This was a prospective observational study. All patients with CVM who received care (supportive treatment only, open surgery, targeted pharmacological therapy, embolosclerotherapy), and had follow-up, between February 1st 2018 and January 31st 2020 were included. The health-related QoL, pain, and mental health were assessed with validated questionnaires: SF-36, VAS-P and HADS. The CVM were categorized into types – low-flow (LFVM) and high-flow (HFVM), and anatomical locations. Paired t-test was used for all analyses. P&lt;0.05 were considered significant.

Results

110 patients (85 LFVM and 25 HFVM) with a mean age of 36.9 years were included. Significant improvement was found in the bodily pain domain of SF-36 and VAS-P (both P = 0.01) in all patients. However, only patients with HFVM reported significant improvement in the bodily pain domain of SF-36 (P=0.002) and VAS-P (P = 0.02). Patients who received supportive treatment only reported significant improvement in mental health (P=0.004) and social functioning (P=0.03) domains of SF-36. Meanwhile, patients treated with embolo-sclerotherapy reported significant improvement only in VAS-P (P=0.02). Patients who received targeted pharmacological therapy reported no significant early changes.

Conclusions

The effects of care on early follow-up QoL, pain and mental health of patients with CVM were heterogenous. Future research is required to understand the various factors that affect the QoL and mental health of these patients, as well as the holistic approaches to manage them.

518 Efficacy and Safety of Embolo-Sclerotherapy of Low-Flow Vascular Malformations Based on the Experience from a Single Specialist Centre

Aim

To evaluate the efficacy and safety of embolo-sclerotherapy (EST) of low-flow vascular malformations (LFVM) in a specialist vascular anomalies centre.

Method

All patients with LFVM who underwent EST from 01 January 2015–31 December 2019 were retrospectively reviewed. All ESTs were performed with foam STS 3%, ethanol, coils and/or other substances e.g., triamcinolone. LFVMs were grouped according to Puig's classification. The outcome measures were treatment effects and complications. Continuous variables were compared using analysis of variance (ANOVA) F test. Other discrete variables were compared using Chi-squared tests. P&lt;0.05 were considered significant.

Results

A total of 207 patients, with a mean age of 32 years (range 1–71 years) were included. The use of EST with foam STS was significantly lower for type I LFVM (61.8%) compared to others (p&lt;0.001). However, significantly higher type I LFVM (26.5%) were treated with surgery than EST (p&lt;0.001). Overall, outcome categories were significantly different across all types of LFVM (p&lt;0.001), with more discharges for Type I (52.9%) LFVMs but more failure to follow-up in patients with Type II (24.5%) LFVM. EST complications was significantly higher with type I (14.7%) LFVMs (p=0.030). The doses of STS in the first procedure were significantly different across all types of LFVM (p&lt;0.001) with most type I LFVM patients receiving ≤2ml.

Conclusions

EST particularly with foam sclerotherapy is clinically effective and safe for patients with LFVM especially in those with Puig's type I and II lesions. This classification may provide an important guide to volume of sclerosant required and the potential success rate.

O064 Early follow-up quality of life and mental health of patients with congenital vascular malformations cared for in a multi-disciplinary specialist center

Introduction

To evaluate the early follow-up quality of life (QoL), pain and mental health of patients with congenital vascular malformation (CVM) receiving care by a single multi-disciplinary specialist centre

Methods

All patients with CVM who received care (supportive treatment only, open surgery, targeted pharmacological therapy, embolosclerotherapy), and had follow-up, between 1 February 2018 and 31 January 2020 were included. The health-related QoL, pain, and mental health were assessed with validated questionnaires: SF-36, VAS-P and HADS. The CVM were categorized into types – low-flow (LFVM) and high-flow (HFVM), and anatomical locations. Paired t-test was used for all analyses. Differences were considered significant at P&lt;0.05.

Results

110 patients (85 LFVM and 25 HFVM) with a mean age of 36.9 years were included. Significant improvement was found in the bodily pain domain of SF-36 and VAS-P (both P = 0.01) in all patients. However, only patients with HFVM reported significant improvement in the bodily pain domain of SF-36 (P=0.002) and VAS-P (P = 0.02). Patients who received supportive treatment only reported significant improvement in mental health (P=0.004) and social functioning (P=0.03) domains of SF-36. Meanwhile, patients treated with embolosclerotherapy reported significant improvement only in VAS-P (P=0.02). Patients who received targeted pharmacological therapy reported no significant early changes.

Conclusion

The effects of care on early follow-up QoL, pain and mental health of patients with CVM were heterogenous. Future research is required to understand the various factors that affect the QoL and mental health of these patients, as well as the holistic approaches to manage them.

Take-home message

The effects of care on early follow-up QoL, pain and mental health of patients with CVM were heterogenous. Future research is required to understand the various factors that affect the QoL and mental health of these patients, as well as the holistic approaches to manage them.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

A reassessment of TBT action levels for determining the fate of dredged sediments in the United Kingdom

As part of reviewing the United Kingdom (UK) action levels (ALs) of contaminants for managing the disposal of dredged marine sediment material, tributyl tin (TBT) has been reassessed. TBT is a banned biocide capable of causing severe harm to the marine environment. Its presence is routinely screened for prior to marine disposal of dredged sediment material. Dredged sediment TBT concentrations have been studied using UK monitoring data obtained between 2000 and 2018. The changes in these TBT concentrations have guided the reassessment of ALs. Recent toxicity studies have also guided the reassessment of TBT ALs. This study, which itself forms part of a larger review by the Department for Environment, Food and Rural Affairs, has concluded that current UK TBT ALs may no longer be fit for purpose. A more environmentally protective approach for controlling release of TBT into the marine environment is recommended.

Physician Assisted Death for Psychiatric Suffering: Experiences in the Netherlands

Physician assisted death (PAD) for patients with a psychiatric disorder is a controversial topic of increasing relevance, since a growing number of countries are allowing it. General requirements for PAD include that patients possess decision-making capacity to decide on PAD and that their suffering is unbearable and irremediable. In the Netherlands PAD has been eligible for patients with psychiatric disorders since the 1990s, making it one of the few countries that can offer insights on the practice from real life experience. Much of the literature describing these experiences is only available in Dutch. This article aims to make this knowledge more widely available and provide a comprehensive overview of the experience with PAD for psychiatric suffering in the Netherlands. First, the history of PAD for patients suffering from a psychiatric disorder is described. Second, an overview of relevant rules and regulations governing the practice is given. Third, an overview is provided of the scarce epidemiological data. Finally, we will discuss two major clinical challenges; establishing irremediability and decision-making capacity.

875 Using Stress Testing to Identify Vulnerabilities in Artificial Intelligence Models for the Identification of Culprit Carotid Lesions in Cerebrovascular Events

Introduction

Carotid atherosclerosis is a major risk factor for ischaemic stroke, a leading cause of death. Carotid CT angiography (CTA) is commonly performed following a stroke or transient ischaemic attack (TIA) to help guide patient management in secondary prevention of stroke. Deep learning algorithms can help extract greater information from scans.

Method

The dataset comprised CTA scans from 40 culprit and 40 non-culprit carotid arteries of patients with recent stroke/TIA, and 40 carotid arteries of asymptomatic patients without previous stroke/TIA. A 3D convolutional neural network was trained to classify carotid artery type. Each input comprised 14 axial CTA carotid patches (centred around the carotid artery) concatenated together to form a 3D volume (capturing ∼3cm of artery). 75% of the dataset was used for training and 25% for internal validation. Following training, computer vision operations were applied to input images to assess their impact on the model’s classification decisions.

Results

The model achieved 100% accuracy on the training set and 67% on the internal validation set. However, after subjecting input images to image operations, vulnerabilities in the deep learning model were revealed, even when using input images from the training set. For example, using a Gaussian blur filter with sigma 1.0 was sufficient to change classification decisions, as was horizontally flipping the image.

Conclusions

Deep learning has exceptional capabilities for learning, however the risk with such high-capacity models is failure to learn relevant features from the data. Stress testing provides a viable method to further evaluate deep learning models before clinical deployment.

Initiating compression therapy for those living with heart failure

Compression therapy is used to treat leg symptoms arising from chronic venous disease and lymphoedema. Heart failure, which is traditionally regarded as a contraindication for compression therapy, is prevalent among patients with such leg symptoms. This article aims to assess the evidence on the safety and effectiveness of compression therapy, as well as recommending the assessment and measures required when initiating compression therapy in patients with heart failure. Recent evidence suggests that initiating compression therapy in patients with stable and compensated heart failure is safe if appropriate precautionary measures are undertaken. However, there is still insufficient evidence to support the safety of compression therapy in patients with severe and decompensated heart failure. A standardised, evidence-based guideline on compression therapy in patients with heart failure will help medical and nursing professionals and improve informed consent for the patients.

The experience of using prompting technology from the perspective of people with Dementia and their primary carers

OBJECTIVES

People who are living with dementia typically experience difficulties in completing multi-step, everyday tasks. However, digital technology such as touchscreen tablets provide a means of delivering concise personalised prompts that combine audio, text and pictures. This study was one component of a broader, mixed methods study that tested how an application (app) -based prompter running on a touchscreen tablet computer could support everyday activities in individuals with mild to moderate dementia. In this study we set out to understand the experiences of people living with dementia and their primary carer in using the prompter over a four-week period.

METHOD

We collected qualitative data using semi-structured interviews from 26 dyads, composed of a person living with dementia and their carer. Dyads were interviewed at the start and end of this period. Transcripts were then analysed using thematic analysis.

RESULTS

The study identified three overarching themes related to: participants' attitudes towards the technology; their judgements about how useful the prompter would be; and the emotional impact of using it.

CONCLUSION

Consistent with the Technology Acceptance Model, carers and participants were influenced by their approaches to technology and determined the usefulness of the prompter according to whether it worked for them and fitted into their routines. In addition, participants' decisions about using the prompter were also determined by the extent to which doing so would impact on their self-identity.

Incidence of major complications from embolo-sclerotherapy of head and neck vascular malformations in a single specialist centre

OBJECTIVE

Current data on the nature and rate of major complications for embolo-sclerotherapy (EST) of vascular malformations are scarce. However, even fewer studies focus on vascular malformations specific to the head and neck, which confer an increased specific risk of airway compromise, neurologic and ophthalmologic injury. More understanding is required surrounding the type and incidence of complications to improve treatment planning and informed consent. Therefore, this study aimed to review major complications secondary to EST of head and neck vascular malformations over a 5-year period in a single specialized multidisciplinary centre for vascular anomalies.

METHODS

All interventions were decided by the multidisciplinary team. Demographic, procedural and complication data between 1st January 2013 and 31st December 2017 were prospectively documented in a dedicated database and analysed. EST of high-flow vascular malformations (HFVMs) was performed by selective catheter angiography or direct injection, and by direct injection only for low-flow vascular malformations (LFVMs). Major complications were defined as any tissue or functional damage caused by direct injection, distal embolization or tissue reaction and were decided by the multidisciplinary team.

RESULTS

Forty-eight patients (median age of 35 years; range of 14-70 years; 18 men and 30 women) had 100 EST procedures for head and neck vascular malformation. Of these, 14 patients had EST for HFVM and 34 patients for LFVM, total 43 and 57 procedures, respectively. Overall, five patients with HFVM developed major complications from EST when compared with two patients with LFVM (p = 0.0167). Two patients required pre-emptive tracheostomy due to risk of post-operative airway compromise. Overall, seven (14.6%) patients experienced major complication from EST. In the HFVM group, major complications from EST occurred in five patients; four cases of tissue ulceration and necrosis (two needed debridement, one healed with resultant fibrosis that impeded speech and one resolved spontaneously) and one post-procedural airway compromise requiring tracheostomy. Meanwhile, in the LFVM group, major complications occurred in two patients; one case of severe necrosis involving the alar cartilage, lip and cheek requiring debridement and reconstruction under plastics and one simple cellulitis. No patients sustained stroke or vision impairment.

CONCLUSIONS

EST is relatively safe for head and neck vascular malformations in a high-volume experienced centre. Our major complication rate of 14.6% per patient (35.7% for HFVM; 5.9% for LFVM) or 7% per procedure (11.6% for HFVM; 3.5% LFVM) compares favourably with published data from other centres. These data will improve treatment planning and informed consent for EST for both HFVM and LFVM of the head and neck.

“Lung Time No See”: SARS‐Cov‐2 Spike Protein Changes Genetic Expression in Human Primary Bronchial Epithelial Cells After Recovery

Background

Current reports show that people infected with SARS‐CoV‐2 do not recover completely, and even asymptomatic COVID‐19 patients may experience slight changes in their overall health, which is the basis of the new area of study termed “Long‐Haul COVID”. Our hypothesis is that even in the asymptomatic infection, exposures to the viral spike protein are enough to induce long‐lasting changes in baseline genetic expression.

Objective

This study sought to survey what type of cell biological processes would be affected in human primary bronchial epithelial cells (HBECs) post‐exposure to spike protein and whether they would persist post‐recovery.

Methods

Herein, we advanced an Air Liquid Interface (ALI) cell culture technique to simulate the physiological conditions in the lung airway in vitro. Briefly, HBECs were grown and differentiated, before treatment with either a low (50 ng/mL) or high (5 ug/mL) concentration of recombinant SARS‐CoV‐2 spike protein for 4 hours. After a 48‐hour recovery, cells were processed for RNA extractions and qPCR to screen genes using Qiagen RT² Profiler PCR Arrays; data were analyzed in GeneGlobe.

Results

We used the (2^ (‐Delta Delta CT)) method to analyze the gene expression data, using both ACTB and RPLP0 as reference genes for normalization. Our survey included genes related to oxidative stress, hypoxia, osmotic stress, cell death, inflammatory response, DNA damage and unfolded protein response. We found that the genes CCL2, IL1A, IL1B, and MMP9 showed fold changes greater than 2.00 in the low and high concentration treatments after recovery.

Conclusions

Our preliminary results suggest that the SARS‐CoV‐2 spike protein is enough to change the baseline protein expression in primary HBECs. After recovery, genes related to immune response retained changes in gene expression, and these may indicate relevant long‐term effects in asymptomatic patients. Additionally, the interplay between immune response and other pathways after SARS‐CoV‐2 spike protein exposure should be investigated in the future.

O75: SINGLE CENTRE EXPERIENCE OF SIROLIMUS THERAPY IN HEAD AND NECK VASCULAR MALFORMATIONS

Introduction

To assess the efficacy and safety of Sirolimus in the treatment of low-flow head and neck (H&N) vascular malformations

Method

Patients who presented to our tertiary referral clinic were assessed for eligibility. Suitable patients were commenced on Sirolimus at 0.8 mg/m2, administered orally twice daily, which was approved by our trust Drug and Therapeutic Committee. Patients were reviewed on a monthly basis for a total of six months with an additional one-month review to check for effects upon ceasing treatment. Efficacy and safety were measured through functional and radiological response, laboratory investigations and quality of life questionnaire (36-Item Short Form Health Survey (SF-36), Hospital Anxiety and Depression Scale (HADS) and Visual Analogue Score for Pain (VAS-P)).

Result

Seven patients (mean age 39 years, range 23-65 years) were recruited. One patient did not complete treatment due to intolerable side effects. All patients had a partial response with no patients showing disease progression or complete response. All post-treatment MRI scans showed stable disease with five patients demonstrating a decrease in lesion volume. Five patients reported return of symptoms at one-month post review upon discontinuation of treatment. No statistical significance (P&gt;0.05) in all eight domains of SF-36, HADS, VAS-P and radiological vascular lesion volume between pre- and post-treatment. Most common reported side effects were mouth ulcers (n=2) and metabolic/laboratory abnormality (n=2)

Conclusion

Sirolimus is an effective and safe treatment for patients with complicated low-flow H&N vascular malformations. This provides an alternative treatment where interventional therapy is considered to be limited or challenging.

Take-home message

Sirolimus is an effective and safe treatment option for patients with complicated low-flow head and neck vascular malformations where interventional therapy is limited or challenging.

Single Center Experience of Sirolimus Therapy in Head and Neck Low-flow Vascular Malformations

OBJECTIVE

Recently, studies have shown that sirolimus is clinically efficacious in the treatment of some low-flow vascular malformations (LFVM). This study aimed to assess the efficacy and safety of sirolimus in treating complex head and neck (H&N) LFVM that were challenging and/or refractory to standard treatment.

METHODS

Each patient had baseline and 6-months assessments consisting of clinical history and examination, quality of life (QoL) questionnaires, laboratory investigations, MRI and medical photography. Patients were followed up 1-week and then 1-monthly for 6-months. Wilcoxon signed-rank test was used to compare pre-and 6-months treatment in all 8 domains of RAND 36-Item Short Form Health Survey (SF-36), hospital anxiety and depression scale (HADS), and visual analog score for pain (VAS-P). P < 0.05 was considered significant.

RESULTS

Seven patients (median age 43 years, range 23-65 years) were recruited. Six patients completed the six-months course of therapy with 1 patient withdrawing due to intolerable side effects. All six patients reported reduction of swelling with and without other symptom improvement related to the vascular malformations while on treatment. However, at 1-month review after discontinuation of sirolimus, 5 patients reported return of initial symptoms. Overall, patients demonstrated an improvement in QoL six-months treatment but there was no statistical significance (P > 0.05) in all 8 domains of SF-36, HADS and VAS-P. Five patients demonstrated a minimum 10% decrease in lesion size six-months treatment (median 21%, range 13-40%). A Wilcoxon signed-rank test showed that sirolimus treatment did elicit a statistically significant change in lesion size in either direction (Z = -1.992, P = 0.046). The most common side effects found were dyslipidaemia (n-4) and mouth ulcers (n = 2).

CONCLUSION

In our preliminary experience, sirolimus is effective and safe in treating patients with complex H&N LFVM. This provides an alternative treatment where standard treatment is challenging and/or refractory.

Quality of life and mental health of patients with vascular malformations in a single specialist center in the United Kingdom

OBJECTIVE

Patients with vascular malformations suffer from chronic debilitating symptoms that have been shown to contribute negatively to their quality of life (QoL) and mental health. Despite this, the current literature evaluating the QoL and mental health of patients with vascular malformations remains scarce. Our aim was to evaluate the QoL and mental health of patients with vascular malformations.

METHODS

We prospectively analyzed the validated health-related QoL (HRQoL) questionnaires: the RAND Health Care 36-Item Short Form Survey (SF-36), Hospital Anxiety and Depression Scale (HADS), and visual analogue score for pain reported by 253 patients with vascular malformations in a specialist center of vascular anomalies in the UK over two years.

RESULTS

Patients with vascular malformations reported significantly poorer SF-36 scores in all domains compared with the UK general population. Patients with low-flow vascular malformations and arteriovenous malformations reported little variations in SF-36, HADS, and visual analogue score for pain scores. No significant association was found between age and any of the health-related QoL scores, other than the physical functioning in SF-36. Female patients reported significantly lower physical and social functioning of SF-36 and worse HADS-Depression than their male counterparts. Patients with syndromic vascular malformations reported significantly lower SF-36 scores in role-physical, role-emotional and bodily pain than nonsyndromic vascular malformations.

CONCLUSIONS

This study concluded that patients with vascular malformations reported worse QoL than the UK general population. Therefore, the assessment and management of QoL and mental health should be incorporated into the overall treatment strategies of patients with vascular malformations.

SARS-CoV-2 and Human Immunodeficiency Virus: Pathogen Pincer Attack

Paramount efforts worldwide are seeking to increase understanding of the basic virology of SARS-CoV-2, characterize the spectrum of complications associated with COVID-19, and develop vaccines that can protect from new and recurrent infections with SARS-CoV-2. While we continue learning about this new virus, it is clear that 1) the virus is spread via the respiratory route, primarily by droplets and contact with contaminated surfaces and fomites, as well as by aerosol formation during invasive respiratory procedures; 2) the airborne route is still controversial; and 3) that those infected can spread the virus without necessarily developing COVID-19 (ie, asymptomatic). With the number of SARS-CoV-2 infections increasing globally, the possibility of co-infections and/or co-morbidities is becoming more concerning. Co-infection with Human Immunodeficiency Virus (HIV) is one such example of polyparasitism of interest. This military-themed comparative review of SARS-CoV-2 and HIV details their virology and describes them figuratively as separate enemy armies. HIV, an old enemy dug into trenches in individuals already infected, and SARS-CoV-2 the new army, attempting to attack and capture territories, tissues and organs, in order to provide resources for their expansion. This analogy serves to aid in discussion of three main areas of focus and draw attention to how these viruses may cooperate to gain the upper hand in securing a host. Here we compare their target, the key receptors found on those tissues, viral lifecycles and tactics for immune response surveillance. The last focus is on the immune response to infection, addressing similarities in cytokines released. While the majority of HIV cases can be successfully managed with antiretroviral therapy nowadays, treatments for SARS-CoV-2 are still undergoing research given the novelty of this army.

Understanding the Treatment Algorithm of Patients with Metastatic Pancreatic Neuroendocrine Neoplasms: A Single-Institution Retrospective Analysis Comparing Outcomes of Chemotherapy, Molecular Targeted Therapy, and Peptide Receptor Radionuclide Therapy in 255 Patients

BACKGROUND

The number of therapeutic options for patients with pancreatic neuroendocrine neoplasms (PNEN) has increased, but the optimal therapeutic algorithm has not been defined due to lack of randomised trials comparing different modalities.

METHODS

We performed a retrospective study in patients with metastatic PNEN treated with ≥1 line of systemic therapy. The relationship between baseline characteristics, treatment type, and time to treatment failure (TTF), time to progression (TTP), and overall survival (OS) was analysed using the Kaplan-Meier method. Univariate and multivariate analyses were performed using the Cox proportional hazards model.

RESULTS

Two hundred and fifty-five patients with metastatic PNEN had 491 evaluable lines of therapy. Independent predictors of TTF included treatment type, Ki-67, tumour grade, and chromogranin A. To reduce selection bias, a subgroup of 114 patients with grade 2 (G2) metastatic pancreatic neuroendocrine tumours (PNET) was analysed separately. These patients had received 234 lines of treatment (105 chemotherapy, 82 molecular targeted therapy, and 47 peptide receptor radionuclide therapy [PRRT]). In the G2 cohort, TTF and TTP were superior for PRRT compared with both chemotherapy and molecular targeted therapy. OS in the G2 cohort was also superior for those that had received PRRT compared with those that had not (median 84 vs. 56 months; HR 0.55, 95% CI: 0.31-0.98, p = 0.04).

CONCLUSIONS

This study suggests that PRRT is associated with superior clinical outcomes relative to other systemic therapies for G2 metastatic PNET. Prospective studies are required to confirm these observations.

Patient radiation exposure from embolo-sclerotherapy of peripheral vascular malformations

OBJECTIVE

Embolo-sclerotherapy (EST) is the mainstay therapy for peripheral vascular malformations that involves the exposure of patients to ionizing radiation. We analyzed the radiation exposure to patients from EST of peripheral vascular malformations during a 5-year period in a single specialist center.

METHODS

All patients who had undergone EST at a single specialist center for peripheral vascular malformations from January 1, 2013 to January 8, 2018 were identified from a prospectively collected database. Data collection included basic demographics, procedure date, anatomic site, type of vascular malformations, and procedural details. Radiation exposure, measured as the dose-area product (DAP) and fluoroscopy time, of all patients who had undergone EST during the study period were retrospectively reviewed. Statistical analysis was performed using the Mann-Whitney U and Kruskal-Wallis tests for comparison between subgroups. P < .05 was considered statistically significant.

RESULTS

A total of 237 patients (median age, 30 years; range, 1-73 years) had undergone 419 EST sessions during the study period. Of the 237 patients, 61 (25.7%) had had arteriovenous malformations (AVMs) and had undergone 140 EST sessions (33.4%) and 176 (74.3%) had had venous and lymphatic malformations and had undergone 279 EST sessions (66.6%). Patients with AVMs had undergone a median of 2 procedures (range, 1-13) compared with a median of 1 (range, 1-6) for venous and lymphatic malformations within the study period. The median DAP for the single and cumulative EST for peripheral vascular malformations was 1.26 Gycm² (range, 0.00-698.36 Gycm²) and 1.91 Gycm² (range, 0.00-1300.24 Gycm²), respectively. The median fluoroscopy time for single and cumulative EST was 19 seconds (range, 1-3846 seconds) and 30 seconds (range, 1-5843 seconds), respectively. Significantly greater patient radiation exposure, in DAP and fluoroscopy time, was measured for single and cumulative EST for AVMs compared with venous and lymphatic malformations (P < .01 for both; Mann-Whitney U test). A significant difference in DAP but not fluoroscopy time was found when the anatomic areas of vascular malformations were compared.

CONCLUSIONS

Patient radiation exposure for EST for peripheral vascular malformations, measured in DAP and fluoroscopy time, appeared to be generally less than that reported for endovascular arterial and deep venous interventions. However, some patients with peripheral vascular malformations received relatively high radiation doses. Further studies to investigate the risk factors and long-term side effects of radiation exposure in these patients and strategies to reduce these are required.

The transcription factor scleraxis differentially regulates gene expression in tenocytes isolated at different developmental stages

The transcription factor scleraxis (SCX) is expressed throughout tendon development and plays a key role in directing tendon wound healing. However, little is known regarding its role in fetal or young postnatal tendons, stages in development that are known for their enhanced regenerative capabilities. Here we used RNA-sequencing to compare the transcriptome of adult and fetal tenocytes following SCX knockdown. SCX knockdown had a larger effect on gene expression in fetal tenocytes, affecting 477 genes in comparison to the 183 genes affected in adult tenocytes, indicating that scleraxis-dependent processes may differ in these two developmental stages. Gene ontology, network and pathway analysis revealed an overrepresentation of extracellular matrix (ECM) remodelling processes within both comparisons. These included several matrix metalloproteinases, proteoglycans and collagens, some of which were also investigated in SCX knockdown tenocytes from young postnatal foals. Using chromatin immunoprecipitation, we also identified novel genes that SCX differentially interacts with in adult and fetal tenocytes. These results indicate a role for SCX in modulating ECM synthesis and breakdown and provide a useful dataset for further study into SCX gene regulation.

Incidence of major complication following embolo-sclerotherapy for upper and lower extremity vascular malformations

OBJECTIVE

The current literature on the major complications of embolo-sclerotherapy of upper and lower extremity vascular malformations is scarce. Evaluating and understanding the rates and types of potential major complications of embolo-sclerotherapy of vascular malformations help treatment planning and informed consent. Therefore, this study reviewed major complications following embolo-sclerotherapy of all upper and lower extremity vascular malformations in a single specialized multidisciplinary vascular malformation center over a 5-year period.

METHODS

All patients with vascular malformations underwent multidisciplinary directed intervention. Demographic, procedural, follow-up, and complication data were collected prospectively in a dedicated database, and reviewed retrospectively. Major complications for upper and lower extremity vascular malformations from 1 January 2013 to 31 December 2017 were analyzed. All embolo-sclerotherapies of high-flow vascular malformations (HFVMs) were performed under selective catheter angiography and direct injection, but low-flow vascular malformations (LFVM) with direct injection only. Major complications were defined as any tissue or functional damage caused by direct injection, distal embolization, or tissue reaction.

RESULTS

Seventy patients (median age of 25 years; 44 males and 26 females) had 150 embolo-sclerotherapy procedures for upper extremity vascular malformation. Of these, 28 patients had embolo-sclerotherapy for HFVM and 42 patients for LFVM; total 78 and 72 procedures, respectively. A total of 107 patients (median age of 26 years; 42 males and 65 females) had 160 embolo-sclerotherapy interventions for lower extremity vascular malformations. Of these, 18 patients had embolo-sclerotherapy for HFVM and 89 patients for LFVM; total of 30 and 130 procedures, respectively. The overall major complication rates following embolo-sclerotherapy of upper and lower extremity vascular malformations were 14.3% and 4.7%, respectively (P = 0.030). In the upper extremity HFVM group, major complications from embolo-sclerotherapy occurred in five patients; three ischemic fingers requiring amputation and two skin ulcerations. Meanwhile, in the upper extremity LFVM group, major complications occurred in five patients; one median nerve injury requiring nerve grafting and hand therapy, one hand contracture requiring tendon release, and three skin ulcerations. There was only one major complication, which was cellulitis in the lower extremity HFVM group. In the lower extremity LFVM group, major complications occurred in four patients; two skin ulcerations, one cellulitis, and one deep vein thrombosis.

CONCLUSIONS

Embolo-sclerotherapy is relatively safe for upper and lower extremity vascular malformations in a high-volume experienced center where our major complication rates were 14.3% and 4.7%, respectively, which compare favorably or similar to those reported in most recent literature. These outcomes will direct treatment strategies to avoid local and systemic toxic complications in the upper and lower extremity, for both HFVM and LFVM, and to improve informed consent.

PARE0018 WEBSITE FOR PARENTS OF CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS REDUCES PARENTING STRESS

Background:

Having a child with JIA presents many challenges. Many parents experience considerable stress. Parental distress and functioning have been found to be related to child outcomes (Cousino, 2013), therefore interventions that help parents to manage their child’s illness are important for both parents and child. We developed a website for parents of children with newly diagnosed JIA to help increase parental confidence in managing their child’s arthritis and reduce parenting stress.

Objectives:

To evaluate the efficacy of a web-based tool ‘WebParC’ for parents of children with JIA.

Methods:

Design:Multi-centre randomised controlled trial conducted in 16 tertiary paediatric rheumatology centres in England.

Participants:Parent(s) of children aged ≤12 years, diagnosed with JIA within the previous six months.

Procedures:Parents were enrolled when they attended the rheumatology service and were randomised by household to either the intervention arm (I) who were given access to the website in addition to their child’s standard care or the control arm (C) who received standard care alone.

The primary outcome was parenting stress, measured with the Pediatric Inventory for Parents (PIP) (Streisand, 2001), which parents completed prior to randomisation and at 4-months and 12-months post randomisation.

Website content was developed by a multidisciplinary team including rheumatology, physiotherapy, ophthalmology, social work, podiatry, occupational therapy, clinical and health psychology along with parents of children with JIA. It includes information about JIA and its treatment plus a ‘toolkit’ for parents. The toolkit is based on cognitive-behavioural principles to develop skills for managing JIA-related issues.

Analysis:We conducted linear mixed models to examine the main effect of trial arm (I vs C), main effect of time (between 4M and 12M scores), and interaction between trial arm and time on PIP scores, after controlling for baseline scores.

Results:

A total of 220 parents (183 mothers, 37 fathers) of 203 children were randomised, 106 intervention and 114 controls. Parents mean (SD) age was 36.5 (6.5). Their children with JIA were mostly female (137/203, 67.5%), mean (SD) age of 6.1 (3.4) years. There were 107 (52.7%) with oligoarthritis, 65 (32%) polyarthritis, 8 (3.9%) systemic and 23 (11.3%) other JIA subtypes. Seventy (34.5%) were prescribed methotrexate.

Trial arms did not differ significantly at baseline except for parent education, which was higher in the intervention group and was controlled for in the analysis.

Follow-up assessments were completed by 133 (I60, C73) at 4M and 124 (I58, C66) at 12M.

We found significant main effects of trial arm on PIP Difficulty (p=0.022, Control (Mean=93.62, SE=2.717) > Intervention (Mean=84.23, SE=3.025)) and PIP Frequency (p= 0.008, Control (Mean=95.78, SE=2.400) > Intervention (Mean=86.23, SE=2.622), with Controls reporting significantly greater frequency and difficulty of stressful events than the Intervention group (Fig 1).

Conclusion:

This trial found that a website for parents of children with JIA can help to reduce parenting stress.

References:

[1]Cousino MK, Hazen RA. J Pediatr Psychol 2013; 38(8):809-28

[2]Streisand R, Braniecki S, Tercyak KP, Kazak AE. J Pediatr Psychol 2001; 26(3):155-62.

Acknowledgments:

We thank all parent participants, the health professionals and parents who developed website content and the clinical teams who supported recruitment.

Funded by NIHR RfPB.

Disclosure of Interests:

Kathleen Mulligan: None declared, Shashivadan Hirani: None declared, Sally Clarke: None declared, Neil Evans: None declared, Chris Flood: None declared, Jo Taylor: None declared, Lucy Wedderburn Speakers bureau: Pfizer, Stanton Newman Grant/research support from: Yes Baxter Healthcare Educational Grants not in relation to rheumatology, Speakers bureau: Yes Baxter Healthcare and Merke Sharp and Dome

Quantitative Signal Intensity in Fluid-Attenuated Inversion Recovery and Treatment Effect in the WAKE-UP Trial

Background and Purpose—

Relative signal intensity of acute ischemic stroke lesions in fluid-attenuated inversion recovery (fluid-attenuated inversion recovery relative signal intensity [FLAIR-rSI]) magnetic resonance imaging is associated with time elapsed since stroke onset with higher intensities signifying longer time intervals. In the randomized controlled WAKE-UP trial (Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke Trial), intravenous alteplase was effective in patients with unknown onset stroke selected by visual assessment of diffusion weighted imaging fluid-attenuated inversion recovery mismatch, that is, in those with no marked fluid-attenuated inversion recovery hyperintensity in the region of the acute diffusion weighted imaging lesion. In this post hoc analysis, we investigated whether quantitatively measured FLAIR-rSI modifies treatment effect of intravenous alteplase.

Methods—

FLAIR-rSI of stroke lesions was measured relative to signal intensity in a mirrored region in the contralesional hemisphere. The relationship between FLAIR-rSI and treatment effect on functional outcome assessed by the modified Rankin Scale (mRS) after 90 days was analyzed by binary logistic regression using different end points, that is, favorable outcome defined as mRS score of 0 to 1, independent outcome defined as mRS score of 0 to 2, ordinal analysis of mRS scores (shift analysis). All models were adjusted for National Institutes of Health Stroke Scale at symptom onset and stroke lesion volume.

Results—

FLAIR-rSI was successfully quantified in stroke lesions in 433 patients (86% of 503 patients included in WAKE-UP). Mean FLAIR-rSI was 1.06 (SD, 0.09). Interaction of FLAIR-rSI and treatment effect was not significant for mRS score of 0 to 1 ( P =0.169) and shift analysis ( P =0.086) but reached significance for mRS score of 0 to 2 ( P =0.004). We observed a smooth continuing trend of decreasing treatment effects in relation to clinical end points with increasing FLAIR-rSI.

Conclusions—

In patients in whom no marked parenchymal fluid-attenuated inversion recovery hyperintensity was detected by visual judgement in the WAKE-UP trial, higher FLAIR-rSI of diffusion weighted imaging lesions was associated with decreased treatment effects of intravenous thrombolysis. This parallels the known association of treatment effect and elapsing time of stroke onset.

Survival of bovine digital dermatitis treponemes on hoof knife blades and the effects of various disinfectants

Background

Bovine digital dermatitis (BDD) is a painful infectious foot disease of cattle, and much evidence implicates a pathogenic role for treponemes. This study measured the survival of BDD treponemes on hoof knife blades and tested the efficacy of relevant disinfectants under laboratory conditions.

Methods

Two strains of BDD treponemes were applied to hoof knife blades under aerobic conditions. Swabs were taken at different time points (10 minutes, one hour, two hours, four hours and 18 hours) and again after 20-second disinfection time with one of five disinfectants. Swabs were used directly for nested PCR to detect treponemes or inoculated for anaerobic growth, and subsequently examined using phase contrast microscopy and PCR.

Results

BDD treponeme DNA was detectable by nested PCR at all survival time points, and these organisms were culturable from hoof knives for two hours after exposure under aerobic conditions in the laboratory. Three of the five disinfectants—1 per cent volume per volume (v/v) FAM30^®, 2 per cent weight per volume (w/v) Virkon^® or 2 per cent (v/v) sodium hypochlorite—were effective at preventing visible growth of treponemes following 20-seconds contact, and 1 per cent (v/v) FAM30^® also prevented detection of treponemes by PCR.

Conclusion

Treponeme viability of two hours under aerobic conditions suggests BDD treponemes could be transmitted between cows on hoof knives. It is therefore important to apply a disinfection protocol during foot-trimming; the authors have identified three common disinfectants that may be suitable.

Drivers of geographical patterns of North American language diversity

Although many hypotheses have been proposed to explain why humans speak so many languages and why languages are unevenly distributed across the globe, the factors that shape geographical patterns of cultural and linguistic diversity remain poorly understood. Prior research has tended to focus on identifying universal predictors of language diversity, without accounting for how local factors and multiple predictors interact. Here, we use a unique combination of path analysis, mechanistic simulation modelling, and geographically weighted regression to investigate the broadly described, but poorly understood, spatial pattern of language diversity in North America. We show that the ecological drivers of language diversity are not universal or entirely direct. The strongest associations imply a role for previously developed hypothesized drivers such as population density, resource diversity, and carrying capacity with group size limits. The predictive power of this web of factors varies over space from regions where our model predicts approximately 86% of the variation in diversity, to areas where less than 40% is explained.

Challenging the Current Risk Factors of Appendiceal Neuroendocrine Neoplasms: Can They Accurately Predict Local Lymph Nodal Invasion? Results from a Large Case Series

BACKGROUND

Appendiceal neuroendocrine neoplasms (ANEN) are uncommon entities, which run mostly an indolent course. Appendicectomy alone is usually curative, except for in a selected group of patients that are deemed to be at risk of loco-regional metastases, in whom a completion right hemicolectomy (RHC) is recommended. The current "Guidelines" criteria for the latter have been controversial, and may result in overtreatment, which is concerning for a young patient population.

OBJECTIVE

The aim of this study is to evaluate the prognostic value of the current criteria in identifying more accurately those at-risk patients.

METHODS

This was a retrospective study of the 263 cases of ANEN referred for advice or management to a tertiary referral unit over a 10-year period. Seventy-two patients underwent RHC, based on criteria, suggested by International Guidelines. Each one of those was assessed to identify whether it correlated with lymph node invasion (LNI) at the RHC surgical specimen.

RESULTS

Tumour grade (p < 0.001), vascular (p = 0.044) and lymph vessel invasion (p < 0.001) were all found to be statistically significant independent risk factors for LNI identified following RHC, whilst tumour size (p = 0.375) and mesoappendiceal invasion (MAI) (p = 0.317) were not statistically significant. However, deep MAI and tumour size >2 cm showed a correlation with each other on LNI positive subgroup analysis. Location in appendiceal base made LNI more likely but again was not significant (p = 0.133).

CONCLUSIONS

Higher tumour grade and lymphovascular invasion should be considered as the most important risk prognosticators. Surprisingly, tumour size was not found to be significant in our cohort. Further international multicentre studies with large numbers of patients are needed to fully validate those data.

Effect of Delayed Cord Clamping on Cerebral Oxygenation in Very Preterm Infants

BACKGROUND AND OBJECTIVE

The mechanism of reported benefits of delayed cord clamping (DCC) are unclear. We aimed to determine whether DCC compared to immediate cord clamping (ICC) in very preterm infants improves cerebral oxygenation in the first 24 h.

STUDY DESIGN

This is a prospective study of a subset of infants at < 30 weeks of gestation who were randomised to DCC (≥60 s) or ICC (< 10 s) and required an indwelling arterial catheter. Regional cerebral oxygenation (rScO2), blood pressure, PI, and peripheral saturation were measured and cerebral fractional tissue oxygen extraction (cFTOE) calculated for the following 3 time intervals: 3-6, 6-12, and 12-28 h of age. Functional ultrasound measures including superior vena cava flow, right ventricular output, ductus arteriosus size and shunt and anterior cerebral artery resistive index were determined.

RESULTS

The mean (±SD) gestation and birth weight of the 51 study infants were 27 ± 1 weeks and 1,046 ± 241 g respectively. Twenty infants received DCC and 31 received ICC. Baseline demographics were similar between the 2 groups. Comparing DCC and ICC infants, there was no difference in rScO2 or cFTOE at any time point. Three out of 20 infants did not receive DCC due to clinical concerns. A sensitivity analysis revealed that cord clamping ≥30 s was significantly associated with increased rScO2 and decreased cFTOE at all 3 time points after adjusting for gestation.

CONCLUSION

Although DCC was not associated with changes in cerebral oxygenation overall, sensitivity analysis suggested a possible effect of an increased rScO2 and a decreased cFTOE with ≥30 s of DCC.