Functional connectivity changes in neurodegenerative biomarker-positive athletes with repeated concussions

Multimodal biomarkers may identify former contact sports athletes with repeated concussions and at risk for dementia. Our study aims to investigate whether biomarker evidence of neurodegeneration in former professional athletes with repetitive concussions (ExPro) is associated with worse cognition and mood/behavior, brain atrophy, and altered functional connectivity. Forty-one contact sports athletes with repeated concussions were divided into neurodegenerative biomarker-positive (n = 16) and biomarker-negative (n = 25) groups based on positivity of serum neurofilament light-chain. Six healthy controls (negative for biomarkers) with no history of concussions were also analyzed. We calculated cognitive and mood/behavior composite scores from neuropsychological assessments. Gray matter volume maps and functional connectivity of the default mode, salience, and frontoparietal networks were compared between groups using ANCOVAs, controlling for age, and total intracranial volume. The association between the connectivity networks and sports characteristics was analyzed by multiple regression analysis in all ExPro. Participants presented normal-range mean performance in executive function, memory, and mood/behavior tests. The ExPro groups did not differ in professional years played, age at first participation in contact sports, and number of concussions. There were no differences in gray matter volume between groups. The neurodegenerative biomarker-positive group had lower connectivity in the default mode network (DMN) compared to the healthy controls and the neurodegenerative biomarker-negative group. DMN disconnection was associated with increased number of concussions in all ExPro. Biomarkers of neurodegeneration may be useful to detect athletes that are still cognitively normal, but with functional connectivity alterations after concussions and at risk of dementia.

Self-managing symptoms of Long COVID: an education and strategies research protocol

Post-acute sequelae of SARS-COV-2 (PASC) is growing in prevalence, and involves symptoms originating from the central neurological, cardiovascular, respiratory, gastrointestinal, autonomic nervous, or immune systems. There are non-specific symptoms such as fatigue, headaches, and brain fog, which cannot be ascribed to a single system. PASC places a notable strain on our healthcare system, which is already laden with a large number of acute-COVID-19 patients. Furthermore, it impedes social, academic and vocational functioning, and impacts family life, relationships, and work/financial life. The treatment for PASC needs to target this non-specific etiology and wide-ranging sequelae. In conditions similar to PASC, such as "chemo brain," and prolonged symptoms of concussion, the non-specific symptoms have shown to be effectively managed through education and strategies for self-management and Mindfulness interventions. However, such interventions have yet to be empirically evaluated in PASC to our knowledge. In response to this gap, we have developed a virtual education intervention synthesized by psychiatrists and clinical psychologists for the current study. We will undertake a two-phase randomized controlled trial to determine the feasibility (Phase 1; N = 90) and efficacy (Phase 2; sample sized based on phase 1 results) of the novel 8 week Education and Self-Management Strategies group compared to a mindfulness skills program, both delivered virtually. Main outcomes include confidence/ability to self-manage symptoms, quality of life, and healthcare utilization. This study stands to mitigate the deleterious intrusiveness of symptoms on everyday life in patients with PASC, and may also help to reduce the impact of PASC on the healthcare system. Clinical trial registration:https://classic.clinicaltrials.gov/ct2/show/NCT05268523; identifier NCT05268523.

Serum S100A8/A9 and MMP-9 levels are elevated in systemic lupus erythematosus patients with cognitive impairment

Objective

Cognitive impairment (CI) is one of the most common manifestations of Neuropsychiatric Systemic Lupus Erythematosus (NPSLE). Despite its frequency, we have a limited understanding of the underlying immune mechanisms, resulting in a lack of pathways to target. This study aims to bridge this gap by investigating differences in serum analyte levels in SLE patients based on their cognitive performance, independently from the attribution to SLE, and exploring the potential for various serum analytes to differentiate between SLE patients with and without CI.

Methods

Two hundred ninety individuals aged 18-65 years who met the 2019-EULAR/ACR classification criteria for SLE were included. Cognitive function was measured utilizing the adapted ACR-Neuropsychological Battery (ACR-NB). CI was defined as a z-score of ≤-1.5 in two or more domains. The serum levels of nine analytes were measured using ELISA. The data were randomly partitioned into a training (70%) and a test (30%) sets. Differences in the analyte levels between patients with and without CI were determined; and their ability to discriminate CI from non-CI was evaluated.

Results

Of 290 patients, 40% (n=116) had CI. Serum levels of S100A8/A9 and MMP-9, were significantly higher in patients with CI (p=0.006 and p=0.036, respectively). For most domains of the ACR-NB, patients with CI had higher S100A8/A9 serum levels than those without. Similarly, S100A8/A9 had a negative relationship with multiple CI tests and the highest AUC (0.74, 95%CI: 0.66-0.88) to differentiate between patients with and without CI.

Conclusion

In this large cohort of well-characterized SLE patients, serum S100A8/A9 and MMP-9 were elevated in patients with CI. S100A8/A9 had the greatest discriminatory ability in differentiating between patients with and without CI.

Filling in the Gaps. Making Sense of Living with Temporomandibular Disorders: A Reflexive Thematic Analysis

INTRODUCTION

Persistent, painful temporomandibular disorders (TMDs) are challenging to manage and usually require the active engagement of patients. To achieve this, it is necessary to understand the complex and multifactorial nature of persistent pain. Many dental professionals have little education about persistent pain and may prefer to offer structural management and advice. This research aims to explore how people understand their persistent TMD and how this understanding has been influenced by their treatment providers.

METHODS

Twenty-one people were recruited to represent a diversity of experience with persistent TMD. Interviews followed a semistructured topic guide. Themes were constructed through reflexive thematic analysis to represent how people made sense of their symptoms and the messages that they had picked up through their treatment journey.

RESULTS

Participants described examples of conflicting opinions and inconsistent management recommendations. They rarely recalled collaborative discussions about the nature and complexity of their symptoms and different options for treatment. This experience is represented by a single theme, "a medical merry-go-round." Subthemes of "a medical journey to nowhere-participants' frustrated attempts to find medical management that will end their pain" and "is it me?-participants' questioning their role in persisting pain" kept participants on the merry-go-round, while symptom resolution and participants' emerging development of a holistic understanding of their TMD pain provided exit points. Understanding pain holistically tended to be helpful and typically occurred despite rather than because of the advice given in routine treatment settings.

CONCLUSION

Participants in this study had not typically found their pain management within dental and medical settings to have helped them to construct meaning and understand their experiences of painful TMD. However, understanding symptoms holistically was experienced as beneficial. This study suggests that improved communication and signposting within services for persistent TMD may be beneficial to patients with TMD pain.

KNOWLEDGE TRANSFER STATEMENT

Results of this study confirm that being offered a series of anatomically based, singular-cause explanations for persisting pain symptoms had been experienced as unhelpful by the participants who had sought help for their TMD. Participants highlighted the importance of accurate and collaborative communication and of dental professionals explicitly adopting and communicating a biopsychosocial understanding of pain to their patients who have TMD. Results highlight that some people can struggle to manage persisting pain with minimal support. Signposting patients to appropriate services and resources may help them to understand more about the nature of persistent pain and methods of managing it.

Systemic lupus erythematosus phenotypes formed from machine learning with a specific focus on cognitive impairment

OBJECTIVE

To phenotype SLE based on symptom burden (disease damage, system involvement and patient reported outcomes), with a specific focus on objective and subjective cognitive function.

METHODS

SLE patients ages 18-65 years underwent objective cognitive assessment using the ACR Neuropsychological Battery (ACR-NB) and data were collected on demographic and clinical variables, disease burden/activity, health-related quality of life (HRQoL), depression, anxiety, fatigue and perceived cognitive deficits. Similarity network fusion (SNF) was used to identify patient subtypes. Differences between the subtypes were evaluated using Kruskal-Wallis and χ2 tests.

RESULTS

Of the 238 patients, 90% were female, with a mean age of 41 years (s.d. 12) and a disease duration of 14 years (s.d. 10) at the study visit. The SNF analysis defined two subtypes (A and B) with distinct patterns in objective and subjective cognitive function, disease burden/damage, HRQoL, anxiety and depression. Subtype A performed worst on all significantly different tests of objective cognitive function (P < 0.03) compared with subtype B. Subtype A also had greater levels of subjective cognitive function (P < 0.001), disease burden/damage (P < 0.04), HRQoL (P < 0.001) and psychiatric measures (P < 0.001) compared with subtype B.

CONCLUSION

This study demonstrates the complexity of cognitive impairment (CI) in SLE and that individual, multifactorial phenotypes exist. Those with greater disease burden, from SLE-specific factors or other factors associated with chronic conditions, report poorer cognitive functioning and perform worse on objective cognitive measures. By exploring different ways of phenotyping SLE we may better define CI in SLE. Ultimately this will aid our understanding of personalized CI trajectories and identification of appropriate treatments.

Misfolded α-Synuclein in Cerebrospinal Fluid of Contact Sport Athletes

BACKGROUND

Misfolded α-synuclein in Parkinson's disease (PD) and dementia with Lewy bodies (DLB) can be detected using the real-time quaking-induced conversion (RT-QuIC) technique in cerebrospinal fluid (CSF).

OBJECTIVES

The objectives are (1) to examine misfolded CSF α-synuclein incidence, and (2) to compare clinical presentation, sports history, brain volumes, and RT-QuIC α-synuclein positivity in former athletes.

METHODS

Thirty former athletes with magnetic resonance imaging, neuropsychological testing, and CSF analyzed for phosphorylated tau 181 (p-tau), total tau (t-tau), amyloid-β 42 (Aβ42), and neurofilament light chain (NfL). CSF α-synuclein was detected using RT-QuIC.

RESULTS

Six (20%) former athletes were α-synuclein positive. α-Synuclein positive athletes were similar to α-synuclein negative athletes on demographics, sports history, clinical features, CSF p-tau, t-tau, Aβ42, and NfL; however, had lower grey matter volumes in the right inferior orbitofrontal, right anterior insula and right olfactory cortices.

CONCLUSIONS

α-Synuclein RT-QuIC analysis of CSF may be useful as a prodromal biofluid marker of PD and DLB. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Illuminating protein space with a programmable generative model

Three billion years of evolution has produced a tremendous diversity of protein molecules1, but the full potential of proteins is likely to be much greater. Accessing this potential has been challenging for both computation and experiments because the space of possible protein molecules is much larger than the space of those likely to have functions. Here we introduce Chroma, a generative model for proteins and protein complexes that can directly sample novel protein structures and sequences, and that can be conditioned to steer the generative process towards desired properties and functions. To enable this, we introduce a diffusion process that respects the conformational statistics of polymer ensembles, an efficient neural architecture for molecular systems that enables long-range reasoning with sub-quadratic scaling, layers for efficiently synthesizing three-dimensional structures of proteins from predicted inter-residue geometries and a general low-temperature sampling algorithm for diffusion models. Chroma achieves protein design as Bayesian inference under external constraints, which can involve symmetries, substructure, shape, semantics and even natural-language prompts. The experimental characterization of 310 proteins shows that sampling from Chroma results in proteins that are highly expressed, fold and have favourable biophysical properties. The crystal structures of two designed proteins exhibit atomistic agreement with Chroma samples (a backbone root-mean-square deviation of around 1.0 Å). With this unified approach to protein design, we hope to accelerate the programming of protein matter to benefit human health, materials science and synthetic biology.

A - 169 Efficacy, Retention and Predictors of Response to Treatment of Group Based Remotely Delivered Goal Management Training for Acquired Brain Injury

OBJECTIVE

Given the gap in group-based, remotely delivered executive interventions, and the ubiquitousness of executive impairment in acquired brain injury (ABI), we examined: (1) pre-to-post-to-follow-up efficacy of remotely-delivered, group-based Goal Management Training (GMT; a metacognitive, executive intervention) in individuals with neurological disorders in the chronic stages of illness (2) predictors of response to treatment.

METHODS

Participants and Protocol. N = 160 adults with ABI >6 months post-diagnosis, participated in this single-group study at the Telerehab Centre for ABI @KITE, University Health Network, Toronto, Canada. GMT - which enhances self-awareness, task engagement and task follow-through - was delivered remotely and in group format to allow scalability, peer-to-peer support, cost-effectiveness, and geographical reach. Primary outcomes. Cognitive Failures Questionnaire (CFQ); Dysexecutive Questionnaire (DEX). Predictors of response to treatment. Demographics (age, education); time since injury; and symptom burden (i.e., cognitive, somatic, and emotional). Linear mixed effects models measured efficacy and predictors of change.

RESULTS

Significant pre/post and pre/follow-up improvements on the CFQ total and "forget", "false", and "distract" subscales (95% CI; p = 0.000 all comparisons). Significant pre/post improvements observed for the DEX (95% CI; p = 0.000), but not significant retention. No effects of age, education or time since injury found, indicating generalizability. High symptom burden negatively associated with pre/post and pre/ follow-up improvements on CFQ.

CONCLUSIONS

Encouragingly, this group-based, remotely delivered GMT offers promise of efficacy and retention regardless of age, time since injury or educational attainment of patients, and can reach patients regardless of geographic location. Lower response with heavy symptom burden suggests collateral treatment of symptoms may improve treatment response.

Long-Term Outcomes of De-Intensified Chemoradiotherapy for Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma

PURPOSE/OBJECTIVE(S)

To report long-term oncologic outcomes among patients with human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) treated with definitive de-intensified chemoradiotherapy.

MATERIALS/METHODS

Major criteria for de-intensification were (1) AJCC 7th edition T0-T3, N0-N2c, M0 (AJCC 8th edition T0-T3, N0-N2, M0), (2) pathologically confirmed p16 positive, and (3) no or minimal/remote smoking history (non-mutated p53 if ≥30 pack-years). Treatment was 60 Gy intensity-modulated radiotherapy with first-choice concurrent cisplatin 30 mg/m2 once per week (alternative regimens permissible for cisplatin ineligible patients). Patients with T0-T2 N0-1 (AJCC 7th edition) were recommended 60 Gy radiation alone. Systemic therapy received included: cisplatin 30 mg/m2 (n = 122), cetuximab (n = 15), cisplatin 40 mg/m2 (n = 12), carboplatin/paclitaxel (n = 2), and radiation alone (n = 25). Kaplan Meier estimates for overall survival (OS), progression-free survival (PFS), locoregional control (LRC), and freedom from distant metastasis (FFDM) were calculated. Cox regression models were used for comparisons among subgroups.

RESULTS

A total 176 patients received de-intensified treatment (n = 153 prospective protocol, n = 23 off-protocol). Median follow-up was 52.6 months (range 5.3 - 102.0, 90.8% with minimum 2-year follow-up); 56.8% (n = 100) were never smokers and 43.2% (n = 76) former smokers; former smokers had median 9 pack-years smoking history (range 0.25 - 50) with 46% ≥10 pack-years. Outcomes were as follows: 2-year OS 99.4% and 5-year OS 91.8%; 2-year PFS 94.1% and 5-year PFS 84.3%; 2-year LRC 98.3% and 5-year LRC 95.8%; 2-year FFDM 95.8% and 5-year FFDM 93.2%. Median time to progression events were 21.1 months (range, 7.2 - 54.1) with 37.5% (6 of 16) of recurrences occurring after 24 months. Six total locoregional events occurred (five recurrences and one site of persistent disease), within the 60 Gy planning target volume. Twenty-three patients with T0-T2 N0-1 disease received radiation alone with 2-year PFS 92.9% (5-year 83.8%) and 2-year LRC 100% (5-year 95.2%). Outcomes for former smokers with ≥10 pack-years were comparable to patients with less or no smoking history (2-year PFS 94.1% vs 94.1%; 5-year PFS 90.6% vs 82.7%; HR 0.58, p = 0.38). Early results suggest similar oncologic outcomes among those treated off-protocol (median follow-up 25.6 months) with 1 of 23 patients experiencing locoregional recurrence.

CONCLUSION

Dose de-intensification of 60 Gy radiotherapy with weekly cisplatin results in favorable long-term tumor control in patients with HPV-associated OPSCC. De-intensified 60 Gy alone may be efficacious in carefully selected patients with T0-T2 N0-1 (AJCC 7th edition) disease. Inclusion of biologically favorable patients with more extensive former smoking history in de-intensification clinical trials may be warranted.

Preliminary efficacy and predictors of response to a remotely-delivered symptom self-management program for persistent symptoms after concussion

BACKGROUND

More than a quarter of adults with concussion endure prolonged symptoms of >3 months. We developed the Concussion Education Self-Management program to help people manage persisting symptoms. Here, we assess feasibility, preliminary efficacy, and correlates of response.

METHODS

N = 80 adults participated in the program; ages ranged from 18 to 65 years and time post-injury ranged from 6 months to 18 years. Weekly sessions, delivered remotely and in groups, comprised education and strategies for management of cognitive, emotional, and physical symptoms. Primary outcome: Confidence to self-manage symptoms. Secondary outcomes: Quality of life; mood/anxiety/stress. Predictors of response: Self-reported cognitive, emotional and physical symptoms at intake.

RESULTS

Pre- to post-program improvements were observed in confidence to self-manage, p < 0.03; quality of life, p < 0.001; depression, p < 0.001; anxiety, p < 0.001; and stress, p < 0.001. Considering confidence to self-manage, those with fewer cognitive and physical symptoms benefitted more (p's < 0.0005 and p < 0.01, respectively).

DISCUSSION

This program shows promise for improving self-management of prolonged symptoms. Those with high symptom burden may need extra sessions to benefit. This is a cost-effective and scalable program that can reach people regardless of geographic location or impediments to travel.

Feasibility of a Home-Based Cognitive-Physical Exercise Program in Patients With Chronic Obstructive Pulmonary Disease: Protocol for a Feasibility and Pilot Randomized Controlled Trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a progressive condition associated with physical and cognitive impairments contributing to difficulty in performing activities of daily living (ADLs) that require dual tasking (eg, walking and talking). Despite evidence showing that cognitive decline occurs among patients with COPD and may contribute to functional limitations and decreased health-related quality of life (HRQL), pulmonary rehabilitation continues to focus mainly on physical training (ie, aerobic and strength exercises). An integrated cognitive and physical training program compared to physical training alone may be more effective in increasing dual-tasking ability among people living with COPD, leading to greater improvements in performance of ADLs and HRQL.

OBJECTIVE

The aims of this study are to evaluate the feasibility of an 8-week randomized controlled trial of home-based, cognitive-physical training versus physical training for patients with moderate to severe COPD and derive preliminary estimates of cognitive-physical training intervention efficacy on measures of physical and cognitive function, dual task performance, ADLs, and HRQL.

METHODS

A total of 24 participants with moderate to severe COPD will be recruited and randomized into cognitive-physical training or physical training. All participants will be prescribed an individualized home physical exercise program comprising 5 days of moderate-intensity aerobic exercise (30-50 minutes/session) and 2 days of whole-body strength training per week. The cognitive-physical training group will also perform cognitive training for approximately 60 minutes, 5 days per week via the BrainHQ platform (Posit Science Corporation). Participants will meet once weekly with an exercise professional (via videoconference) who will provide support by reviewing the progression of their training and addressing any queries. Feasibility will be assessed through the recruitment rate, program adherence, satisfaction, attrition, and safety. The intervention efficacy regarding dual task performance, physical function, ADLs, and HRQL will be evaluated at baseline and at 4 and 8 weeks. Descriptive statistics will be used to summarize intervention feasibility. Paired 2-tailed t tests and 2-tailed t tests will be used to compare the changes in the outcome measures over the 8-week study period within and between the 2 randomized groups, respectively.

RESULTS

Enrollment started in January 2022. It is estimated that the enrollment period will be 24 months long, with data collection to be completed by December 2023.

CONCLUSIONS

A supervised home-based cognitive-physical training program may be an accessible intervention to improve dual-tasking ability in people living with COPD. Evaluating the feasibility and effect estimates is a critical first step to inform future clinical trials evaluating this approach and its effects on physical and cognitive function, ADL performance, and HRQL.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05140226; https://clinicaltrials.gov/ct2/show/NCT05140226.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48666.

Centrally acting ACE inhibitor (cACEi) and angiotensin receptor blocker (cARB) use and cognitive dysfunction in patients with SLE

OBJECTIVE

Cognitive dysfunction (CD) is detectable in approximately 40% of patients with SLE. Despite this high prevalence, there are no approved pharmacological treatment options for this detrimental condition. Preliminary murine studies show potential for targeting microglial activation as a treatment of SLE-CD, which may be ameliorated with centrally acting ACE inhibitor (cACEi) and angiotensin receptor blocker (cARB) use. The aim of this study is to determine if there is an association of cACEi/cARB use with cognitive function in a human SLE cohort.

METHODS

The American College of Rheumatology neuropsychological battery was administered to patients with consecutive SLE at a single academic health centre at baseline, 6 and 12 months. Scores were compared with sex-matched and age-matched control subjects. Clinical and demographic data were gathered at each visit. The primary outcome was CD defined as dysfunction in two or more cognitive domains. The primary predictor was a total cumulative dose of cACEi/cARB in milligrams per kilogram, recorded as an equivalent ramipril dose. Odds of CD with respect to cACEi/cARB use were determined through generalised linear mixed modelling.

RESULTS

A total of 300 patients, representing 676 visits, completed this study. One hundred sixteen (39%) met the criteria for CD. Fifty-three participants (18%) were treated with a cACEi or cARB. Mean cumulative dose was 236 mg/kg (calculated as equivalent ramipril dose). Cumulative cACEi/cARB dose was not protective against SLE-CD. Caucasian ethnicity, current employment status and azathioprine cumulative dose were each associated with reduced odds of SLE-CD. Increasing Fatigue Severity Scale score was associated with increased odds of CD.

CONCLUSIONS

In a single-centre SLE cohort, cACEi/cARB use was not associated with absence of CD. Many important confounders may have influenced the results of this retrospective study. A randomised trial is required to accurately determine if cACEi/cARB is a potential treatment for SLE-CD.

Association of mycophenolate and azathioprine use with cognitive function in systemic lupus

OBJECTIVES

Cognitive dysfunction (CD) is a common manifestation of SLE that can have detrimental consequences for those affected. To date, no treatments have been approved for SLE-CD. This study aims to assess the association of azathioprine (AZA) and mycophenolate (MMF) use with SLE-CD, given that these medications have demonstrated neuroprotective qualities in prior studies.

METHODS

Consecutive adult SLE patients presenting to a single healthcare center were considered for participation. The ACR neuropsychological battery for SLE was administered to consenting patients at 0, 6 and 12 months. Scores were compared with age- and sex-matched controls. Primary outcome was CD, defined as a z-score ≤-1.5 in two or more cognitive domains. Mixed-effects logistic regression models were constructed to estimate the odds of CD with respect to AZA and MMF use.

RESULTS

A total of 300 participants representing 676 patient visits completed the study; 114 (38%) met criteria for CD at baseline. The cumulative AZA dose (g/kg) was associated with reduced odds of CD [odds ratio (OR) 0.76 (95% CI 0.58, 0.98), P = 0.04]. Years of AZA treatment was also associated with reduced odds of CD [OR 0.72 (95% CI 0.54, 0.97), P = 0.03]. MMF use was not associated with CD.

CONCLUSION

AZA use was associated with significantly lower odds of SLE-CD, while MMF use was not. Additional studies are warranted to further investigate the relationship of AZA and SLE-CD.

In-person versus virtual administration of the American College of Radiology gold standard cognitive battery in systemic lupus erythematosus: Are they interchangeable?

OBJECTIVE

During the COVID-19 pandemic, many research studies were adapted, including our longitudinal study examining cognitive impairment (CI) in systemic lupus erythematosus (SLE). Cognitive testing was switched from in-person to virtual. This analysis aimed to determine if the administration method (in-person vs. virtual) of the ACR-neuropsychological battery (ACR-NB) affected participant cognitive performance and classification.

METHODS

Data from our multi-visit, SLE CI study included demographic, clinical, and psychiatric characteristics, and the modified ACR-NB. Three analyses were undertaken for cognitive performance: (1) all visits, (2) non-CI group visits only and (3) intra-individual comparisons. A retrospective preferences questionnaire was given to participants who completed the ACR-NB both in-person and virtually.

RESULTS

We analysed 328 SLE participants who had 801 visits (696 in-person and 105 virtual). Demographic, clinical, and psychiatric characteristics were comparable except for ethnicity, anxiety and disease-related damage. Across all three comparisons, six tests were consistently statistically significantly different. CI classification changed in 11/71 (15%) participants. 45% of participants preferred the virtual administration method and 33% preferred in-person.

CONCLUSIONS

Of the 19 tests in the ACR-NB, we identified one or more problems with eight (42%) tests when moving from in-person to virtual administration. As the use of virtual cognitive testing will likely increase, these issues need to be addressed - potentially by validating a virtual version of the ACR-NB. Until then, caution must be taken when directly comparing virtual to in-person test results. If future studies use a mixed administration approach, this should be accounted for during analysis.

Effects of High-Intensity Interval Training Protocols on Blood Lactate Levels and Cognition in Healthy Adults: Systematic Review and Meta-Regression

BACKGROUND

Some health benefits from high-intensity interval training (HIIT) are facilitated by peripheral blood lactate levels. However, the lactate response from HIIT is variable and dependent on protocol parameters.

OBJECTIVES

We aimed to determine the HIIT protocol parameters that elicited peak lactate levels, and how these levels are associated with post-HIIT cognitive performance.

STUDY DESIGN

We conducted a systematic review with meta-regression.

METHODS

MEDLINE, Embase, CENTRAL, SPORTDiscus, and CINAHL + were searched from database inception to 8 April, 2022. Peer-reviewed primary research in healthy adults that determined lactate (mmol/L) and cognitive performance after one HIIT session was included. Mixed-effects meta-regressions determined the protocol parameters that elicited peak lactate levels, and linear regressions modelled the relationship between lactate levels and cognitive performance.

RESULTS

Study entries (n = 226) involving 2560 participants (mean age 24.1 ± 4.7 years) were included in the meta-regression. A low total work-interval volume (~ 5 min), recovery intervals that are about five times longer than work intervals, and a medium session volume (~ 15 min), elicited peak lactate levels, even when controlling for intensity, fitness (peak oxygen consumption) and blood measurement methods. Lactate levels immediately post-HIIT explained 14-17% of variance in Stroop interference condition at 30 min post-HIIT.

CONCLUSIONS

A HIIT protocol that uses the above parameters (e.g., 8 × 30-s maximal intensity with 90-s recovery) can elicit peak lactate, a molecule that is known to benefit the central nervous system and be involved in exercise training adaptations. This review reports the state of the science in regard to the lactate response following HIIT, which is relevant to those in the sports medicine field designing HIIT training programs.

TRIAL REGISTRY

Clinical Trial Registration: PROSPERO (CRD42020204400).

Assessing the Utility of the Montreal Cognitive Assessment in Screening for Cognitive Impairment in Patients With Systemic Lupus Erythematosus

OBJECTIVE

Screening for cognitive impairment (CI) in systemic lupus erythematosus (SLE) relies on the American College of Rheumatology (ACR) neuropsychological battery (NB). By studying the concurrent criterion validity, our goal was to assess the Montreal Cognitive Assessment (MoCA) as a screening tool for CI compared to the ACR-NB and to evaluate the added value of the MoCA to the Automated Neuropsychological Assessment Metrics (ANAM).

METHODS

A total of 285 adult SLE patients were administered the ACR-NB, MoCA, and ANAM. For the ACR-NB, patients were classified as having CI if there was a Z score of ≤-1.5 in ≥2 domains. The area under the curve (AUC) and sensitivities/specificities were determined. A discriminant function analysis was applied to assess the ability of the MoCA to differentiate between CI, undetermined CI, and non-CI patients.

RESULTS

CI was not accurately identified by the MoCA compared to the ACR-NB (AUC of 0.66). Sensitivity and specificity were poor at 50% and 69%, respectively, for the cutoff of 26, and 80% and 45%, respectively, for the cutoff of 28. The MoCA had a low ability to identify CI status. The addition of the MoCA to the ANAM led to improvement on the AUC by only 2.5%.

CONCLUSION

The MoCA does not have adequate concurrent criterion validity to accurately identify CI in patients with SLE. The low specificity of the MoCA may lead to overdiagnosis and concern among patients. Adding the MoCA to the ANAM does not substantially improve the accuracy of the ANAM. These results do not support using the MoCA as a screening tool for CI in patients with SLE.

Psychosocial impacts of the COVID-19 pandemic on women with trauma histories: Study of Women's Health Across the Nation (SWAN)

Older adults, particularly those with trauma histories, may be vulnerable to adverse psychosocial outcomes during the COVID-19 pandemic. We tested associations between prepandemic childhood abuse or intimate partner violence (IPV) and elevated depressive, anxiety, conflict, and sleep symptoms during the pandemic among aging women. Women (N = 582, age: 65-77 years) from three U.S. sites (Pittsburgh, Boston, Newark) of the longitudinal Study of Women's Health Across the Nation (SWAN) reported pandemic-related psychosocial impacts from June 2020-March 2021. Prepandemic childhood abuse; physical/emotional IPV; social functioning; physical comorbidities; and depressive, anxiety, and sleep symptoms were drawn from SWAN assessments between 2009 and 2017. There were no measures of prepandemic conflict. In total, 47.7% and 35.3% of women, respectively, reported childhood abuse or IPV. Using logistic regression models adjusted for age; race/ethnicity; education; site; prepandemic social functioning and physical comorbidities; and, in respective models, prepandemic depressive, anxiety, or sleep symptoms, childhood abuse predicted elevated anxiety symptoms, OR = 1.67, 95% CI [1.10, 2.54]; household conflict, OR = 2.19, 95% CI [1.32, 3.61]; and nonhousehold family conflict, OR = 2.14, 95% CI [1.29, 3.55]. IPV predicted elevated sleep problems, OR = 1.63, 95% CI [1.07, 2.46], and household conflict, OR = 1.96, 95% CI [1.20, 3.21]. No associations emerged for depressive symptoms after adjusting for prepandemic depression. Aging women with interpersonal trauma histories reported worse anxiety, sleep, and conflict during the COVID-19 pandemic than those without. Women's trauma histories and prepandemic symptoms are critical to understanding the psychosocial impacts of the pandemic.

Criterion validity of the brief test of adult cognition by telephone (BTACT) for mild traumatic brain injury

OBJECTIVES

There is a growing demand for remote assessment options for measuring cognition after mild traumatic brain injury (mTBI). The current study evaluated the criterion validity of the Brief Test of Adult Cognition by Telephone (BTACT) in distinguishing between adults with mTBI and trauma controls (TC) who sustained injuries not involving the head or neck.

METHODS

The BTACT was administered to the mTBI (n = 46) and TC (n = 35) groups at 1-2 weeks post-injury. Participants also completed the Rivermead Post Concussion Symptoms Questionnaire.

RESULTS

The BTACT global composite score did not significantly differ between the groups (t(79) = -1.04, p = 0.30); the effect size was small (d = 0.23). In receiver operating characteristic curve analyses, the BTACT demonstrated poor accuracy in differentiating between the groups (AUC = 0.567, SE = 0.065, 95% CI [0.44, 0.69]). The BTACT's ability to discriminate between mTBI and TCs did not improve after excluding mTBI participants (n = 15) who denied ongoing cognitive symptoms (AUC = 0.567, SE = 0.072, 95% CI [0.43, 0.71]).

CONCLUSIONS

The BTACT may lack sensitivity to subacute cognitive impairment attributable to mTBI (i.e., not explained by bodily pain, post-traumatic stress, and other nonspecific effects of injury).

Search for Subsolar-Mass Binaries in the First Half of Advanced LIGO's and Advanced Virgo's Third Observing Run

We report on a search for compact binary coalescences where at least one binary component has a mass between 0.2  M_{⊙} and 1.0  M_{⊙} in Advanced LIGO and Advanced Virgo data collected between 1 April 2019 1500 UTC and 1 October 2019 1500 UTC. We extend our previous analyses in two main ways: we include data from the Virgo detector and we allow for more unequal mass systems, with mass ratio q≥0.1. We do not report any gravitational-wave candidates. The most significant trigger has a false alarm rate of 0.14  yr^{-1}. This implies an upper limit on the merger rate of subsolar binaries in the range [220-24200]  Gpc^{-3} yr^{-1}, depending on the chirp mass of the binary. We use this upper limit to derive astrophysical constraints on two phenomenological models that could produce subsolar-mass compact objects. One is an isotropic distribution of equal-mass primordial black holes. Using this model, we find that the fraction of dark matter in primordial black holes in the mass range 0.2  M_{⊙}<m_{PBH}<1.0  M_{⊙} is f_{PBH}≡Ω_{PBH}/Ω_{DM}≲6%. This improves existing constraints on primordial black hole abundance by a factor of ∼3. The other is a dissipative dark matter model, in which fermionic dark matter can collapse and form black holes. The upper limit on the fraction of dark matter black holes depends on the minimum mass of the black holes that can be formed: the most constraining result is obtained at M_{min}=1  M_{⊙}, where f_{DBH}≡Ω_{DBH}/Ω_{DM}≲0.003%. These are the first constraints placed on dissipative dark models by subsolar-mass analyses.

POS1222 FOLIC ACID AND METHOTREXATE USE AND THEIR ASSOCIATION WITH COVID-19 DIAGNOSIS AND MORTALITY: AN ANALYSIS FROM THE UK BIOBANK

Background

Folate metabolism is implicated in SARS-CoV-2 infectivity (Ref).

Objectives

To determine if methotrexate (an antifolate) or folic acid prescription were associated with a lowered and increased risk, respectively, for COVID-19 diagnosis or mortality in a large population-based cohort (UK Biobank).

Methods

Data from 380,380 UK Biobank participants with general practice prescription data were used. Criteria for COVID-19 diagnosis were 1) a positive SARS-CoV-2 test and / or 2) ICD-10 code for confirmed COVID-19 (U07.1) or probable COVID-19 (U07.2) in hospital records, or death records. This definition identified 26,003 individuals diagnosed with COVID-19 of whom 820 were known to have died from COVID-19. Logistic regression statistical models were adjusted for age group (4 categories), sex, ethnicity, Townsend deprivation index, BMI, smoking status, presence of rheumatoid arthritis, sickle cell disease, use of anticonvulsants, statins and iron supplements.

Results

Compared with people prescribed neither folic acid nor methotrexate, people prescribed folic acid supplementation had increased risk of diagnosis of COVID-19 (OR 1.51 [1.42; 1.61]). The prescription of methotrexate with or without folic acid was not associated with COVID-19 diagnosis (P≥0.18). Compared with people prescribed neither folic acid nor methotrexate, people prescribed folic acid supplementation had an increased risk of death after a diagnosis of COVID-19 (OR 2.64 [2.15; 3.24]) in a fully adjusted model. The prescription of methotrexate in combination with folic acid was not associated with an increased risk for death after a diagnosis of COVID-19 (1.07 [0.57; 1.98]). (Table 1)

Table 1.

COVID-19 diagnosis and associated death in people prescribed methotrexate and / or folic acid in the UKBB, compared to people not prescribed methotrexate or folic acid. Model 1 adjusted for age group, sex, ethnicity, Townsend deprivation index, BMI, smoking status Model 2 is model 1 plus adjustment by the presence of rheumatoid arthritis, sickle cell disease, use of statins, anticonvulsants and iron supplementation.

UnadjustedModel 1Model 2OR[95% CI]POR[95% CI]POR[95% CI]PNeither Folic acid nor Methotrexate1.0-1.0-1.0-COVID-19 diagnosisFolic acid only1.58[1.49; 1.68]<0.0011.60[1.50; 1.70]<0.0011.51[1.42; 1.61]<0.001Methotrexate and Folic acid1.09[0.96; 1.23]0.181.15[1.02; 1.30]0.0211.09[0.96; 1.23]0.18COVID-19 associated deathFolic acid only5.14 [4.23; 6.24]<0.0012.91 [2.38; 3.55]<0.0012.64[2.15; 3.24]<0.001Methotrexate and folic acid1.47 [0.81; 2.67]0.211.26 [0.70; 2.30]0.441.07 [0.57; 1.98]0.84

Conclusion

We report increased risk for COVID-19 diagnosis and COVID-19-related death for people prescribed folic acid supplementation. The prescription and use of supplemental folic acid may confer risk of infection with the SARS-CoV-2 virus as well as the risk of death resulting from COVID-19. Our results also suggest that methotrexate might attenuate an increased risk for COVID-19 diagnosis and death conferred by folic acid.

References

[1]Zhang Y, Guo R, Kim SH, et al. SARS-CoV-2 hijacks folate and one-carbon metabolism for viral replication. Nature Communications 2021;12(1):1676. doi: 10.1038/s41467-021-21903-z

Disclosure of Interests

Ruth Topless: None declared, Ralph Green: None declared, Sarah Morgan: None declared, Philip Robinson Consultant of: Abbvie, Atom Biosciences, Eli Lilly, Gilead, Janssen, Novartis, UCB, Roche, Pfizer, Grant/research support from: Janssen, Novartis, Pfizer and UCB Pharma, Tony Merriman: None declared, Angelo Gaffo Consultant of: SOBI, Selecta

Osimertinib and anti-HER3 combination therapy engages immune dependent tumor toxicity via STING activation in trans

Over the past decade, immunotherapy delivered novel treatments for many cancer types. However, lung cancer still leads cancer mortality, and non-small-cell lung carcinoma patients with mutant EGFR cannot benefit from checkpoint inhibitors due to toxicity, relying only on palliative chemotherapy and the third-generation tyrosine kinase inhibitor (TKI) osimertinib. This new drug extends lifespan by 9-months vs. second-generation TKIs, but unfortunately, cancers relapse due to resistance mechanisms and the lack of antitumor immune responses. Here we explored the combination of osimertinib with anti-HER3 monoclonal antibodies and observed that the immune system contributed to eliminate tumor cells in mice and co-culture experiments using bone marrow-derived macrophages and human PBMCs. Osimertinib led to apoptosis of tumors but simultaneously, it triggered inositol-requiring-enzyme (IRE1α)-dependent HER3 upregulation, increased macrophage infiltration, and activated cGAS in cancer cells to produce cGAMP (detected by a lentivirally transduced STING activity biosensor), transactivating STING in macrophages. We sought to target osimertinib-induced HER3 upregulation with monoclonal antibodies, which engaged Fc receptor-dependent tumor elimination by macrophages, and STING agonists enhanced macrophage-mediated tumor elimination further. Thus, by engaging a tumor non-autonomous mechanism involving cGAS-STING and innate immunity, the combination of osimertinib and anti-HER3 antibodies could improve the limited therapeutic and stratification options for advanced stage lung cancer patients with mutant EGFR.

Effects of high-intensity interval training on blood lactate levels and cognition in healthy adults: protocol for systematic review and network meta-analyses

BACKGROUND

High-intensity interval training (HIIT) has shown to confer cognitive benefits in healthy adults, via a mechanism purportedly driven by the exercise metabolite lactate. However, our understanding of the exercise parameters (e.g., work interval duration, session volume, work-to-rest ratio) that evoke a peak blood lactate response in healthy adults is limited. Moreover, evidence relating HIIT-induced blood lactate and cognitive performance has yet to be reviewed and analyzed. The primary objective of this systematic review is to use network meta-analyses to compare the relative impact of different HIIT work-interval durations, session volumes, and work-to-rest ratios on post-exercise blood lactate response in healthy adults. The secondary objective is to determine the relationship between HIIT-induced blood lactate and acute post-HIIT cognitive performance.

METHODS

A systematic review is being conducted to identify studies measuring blood lactate response following one session of HIIT in healthy adults. The search was carried out in (1) MEDLINE, (2) EMBASE, (3) Cochrane Central Register of Controlled Trials, (4) Sport Discus, and (5) Cumulative Index to Nursing and Allied Health Literature Plus with Full Text (CINAHL+). After abstract and full-text screening, two reviewers will independently extract data on key outcomes variables and complete risk of bias assessment using the Cochrane Risk of Bias Tool and the Risk of Bias in Non-Randomized Studies of Interventions tool. Network meta-analyses will be used to generate estimates of the comparative effectiveness of blood lactate on cognitive outcomes using corresponding rankings for each work-interval duration, session volume, and work-to-rest ratio category. Where applicable, meta-regressions analyses will be performed to test the relationship between changes in the blood lactate and changes in cognitive performance. Analyses will be conducted using MetaInsight Software.

DISCUSSION

This study will provide evidence on how to structure a HIIT protocol to elicit peak blood lactate response in healthy adults and will increase our understanding of the relationship between HIIT-induced blood lactate response and associated cognitive benefits.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020204400.

Functional brain activity constrained by structural connectivity reveals cohort-specific features for serum neurofilament light chain

Background

Neuro-axonal brain damage releases neurofilament light chain (NfL) proteins, which enter the blood. Serum NfL has recently emerged as a promising biomarker for grading axonal damage, monitoring treatment responses, and prognosis in neurological diseases. Importantly, serum NfL levels also increase with aging, and the interpretation of serum NfL levels in neurological diseases is incomplete due to lack of a reliable model for age-related variation in serum NfL levels in healthy subjects.

Methods

Graph signal processing (GSP) provides analytical tools, such as graph Fourier transform (GFT), to produce measures from functional dynamics of brain activity constrained by white matter anatomy. Here, we leveraged a set of features using GFT that quantified the coupling between blood oxygen level dependent signals and structural connectome to investigate their associations with serum NfL levels collected from healthy subjects and former athletes with history of concussions.

Results

Here we show that GSP feature from isthmus cingulate in the right hemisphere (r-iCg) is strongly linked with serum NfL in healthy controls. In contrast, GSP features from temporal lobe and lingual areas in the left hemisphere and posterior cingulate in the right hemisphere are the most associated with serum NfL in former athletes. Additional analysis reveals that the GSP feature from r-iCg is associated with behavioral and structural measures that predict aggressive behavior in healthy controls and former athletes.

Conclusions

Our results suggest that GSP-derived brain features may be included in models of baseline variance when evaluating NfL as a biomarker of neurological diseases and studying their impact on personality traits.

Neurofilament light chain (NfL) is a marker released into the blood as a result of central nervous system damage or neurodegeneration. However, we know little about how NfL levels relate to brain structure and activity. Here, we use imaging data and advanced statistical methods to look at the relationship between brain activity and structure in healthy people and former athletes with a history of multiple concussions, and determine whether these can predict NfL levels in the blood. We find the relationship between brain activity and structure and NfL levels is different between the two groups. Our findings help us to understand how brain injury might impact NfL levels and their relationship with brain activity, and could guide how NfL and imaging data are used as tools in research and in the clinic.

Sihag et al. analyse brain imaging data, circulating neurofilament light chain levels and personality scores in a cohort of former athletes with a history of concussions. The authors use graph signal processing to identify brain structural and connectivity features associated with neurofilament levels and with aggressive behaviour.

Comparison of T-cell immune responses to SARS-CoV-2 spike (S) and nucleocapsid (N) protein using an in-house flow-cytometric assay in laboratory employees with and without previously confirmed COVID-19 in South Africa: nationwide cross-sectional study

AIMS

To compare specific T-cell responses between laboratory employees in South Africa with and without previously diagnosed SARS-CoV-2 infection.

METHODS

Employees at a private pathology laboratory in South Africa were invited to participate in a nationwide cross-sectional study. T-cell proliferation to SARS-CoV-2 nucleocapsid (N)-proteins and spike (S)-proteins was measured by flow cytometry and compared between participants.

RESULTS

Based on classification according to SARS-CoV-2 reverse transcription (RT)-PCR results, a total of 81% (42/52) of positive participants demonstrated T-cell proliferation to SARS-CoV-2 N-proteins or S-proteins (95% CI 67.5% to 90.4%), while 62% (68/110) of negative participants also had detectable T-cell responses to SARS-CoV-2 proteins (95% CI 52.1% to 70.9%). When classified according to SARS-CoV-2 serology results, 92.6% (50/54) of positive participants demonstrated T-cell proliferation to SARS-CoV-2 proteins (95% CI 82.1 to 97,9 %), while 56% (60/108) of negative participants demonstrated T-cell proliferation (95% CI 45.7% to 65.1%). The magnitude of the T-cell responses as determined by a stimulation index, was significantly higher in the group previously infected by SARS-CoV-2 than in the negative group. A statistically significant difference in T-cell proliferation was noted between high risk and low risk groups for exposure to SARS-CoV-2 within the negative group, but no significant difference in magnitude of the response.

CONCLUSIONS

A significant proportion of South African laboratory employees who were not previously diagnosed with COVID-19 demonstrated T-cell reactivity to SARS-CoV-2 N-proteins and S-proteins. The pre-existing T-cell proliferation responses may be attributable to cross-reactive immune responses to other human coronaviruses, or possibly asymptomatic infection.

Brain Connectivity Changes in Post-Concussion Syndrome as the Neural Substrate of a Heterogeneous Syndrome

BACKGROUND

Post-concussion syndrome (PCS) or persistent symptoms of concussion refers to a constellation of symptoms that persist for weeks and months after a concussion. To better capture the heterogeneity of the symptoms of patients with post-concussion syndrome, we aimed to separate patients into clinical subtypes based on brain connectivity changes.

METHODS

Subject-specific structural and functional connectomes were created based on Diffusion Weighted and Resting State Functional Magnetic Resonance Imaging, respectively. Following an informed dimensionality reduction, a gaussian mixture model was used on patient specific structural and functional connectivity matrices to find potential patient clusters. For validation, the resulting patient subtypes were compared in terms of cognitive, neuropsychiatric, and post-concussive symptom differences.

RESULTS

Multimodal analyses of brain connectivity were predictive of behavioural outcomes. Our modelling revealed 2 patient subtypes; mild and severe. The severe group showed significantly higher levels of depression, anxiety, aggression, and a greater number of symptoms than the mild patient subgroup.

CONCLUSION

This study suggests that structural and functional connectivity changes together can help us better understand the symptom severity and neuropsychiatric profiles of patients with post-concussion syndrome. This work allows us to move towards precision medicine in concussions and provides a novel machine learning approach that can be applicable to other heterogeneous conditions.

Validation of the automated neuropsychological assessment metrics for assessing cognitive impairment in systemic lupus erythematosus

OBJECTIVE

We previously demonstrated the utility of the Automated Neuropsychological Assessment Metrics (ANAM) for screening cognitive impairment (CI) in patients with systemic lupus erythematosus (SLE) and developed composite indices for interpreting ANAM results. Our objectives here were to provide further support for the ANAM's concurrent criterion validity against the American College of Rheumatology neuropsychological battery (ACR-NB), identify the most discriminatory subtests and scores of the ANAM for predicting CI, and provide a new approach to interpret ANAM results using Classification and Regression Tree (CART) analysis.

METHODS

300 adult SLE patients completed an adapted ACR-NB and ANAM on the same day. As per objectives, six models were built using combinations of ANAM subtests and scores and submitted to CART analysis. Area under the curve (AUC) was calculated to evaluate the ANAM's criterion validity compared to the adapted ACR-NB; the most discriminatory ANAM subtests and scores in each model were selected, and performance of models with the highest AUCs were compared to our previous composite indices; decision trees were generated for models with the highest AUCs.

RESULTS

Two models had excellent AUCs of 86 and 89%. Eight most discriminatory ANAM subtests and scores were identified. Both models demonstrated higher AUCs against our previous composite indices. An adapted decision tree was created to simplify the interpretation of ANAM results.

CONCLUSION

We provide further validity evidence for the ANAM as a valid CI screening tool in SLE. The decision tree improves interpretation of ANAM results, enhancing clinical utility.

EPOS 4 Patients

EPOS2020 is the 4th and most recent version of the European Position Paper on Rhinosinusitis and Nasal Polyps which was first published in 2005. It aims to provide the most up to date scientifically robust information on the topic published in the literature which has been critically analysed by an international group of clinicians drawn from all disciplines dealing with these problems together with patients. The guidelines offer evidence-based recommendations and care pathways for acute and chronic rhinosinusitis in both adults and children. Management of these diseases from the patients' perspective is an important part of EPOS2020. Not only is this included in the main document but, for the first time, we have produced a separate supplement dedicated to and in collaboration with patients, EPOS4Patients, which aims to provide information in an accessible format, to answer frequently asked questions about these diseases and their treatment options as well as including useful patient resources and websites. It has never been more important for patients to be actively involved in their care. Being well informed helps you to make the best decisions together with your doctor.

Defining variant-resistant epitopes targeted by SARS-CoV-2 antibodies: A global consortium study

Antibody-based therapeutics and vaccines are essential to combat COVID-19 morbidity and mortality after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Multiple mutations in SARS-CoV-2 that could impair antibody defenses propagated in human-to-human transmission and spillover or spillback events between humans and animals. To develop prevention and therapeutic strategies, we formed an international consortium to map the epitope landscape on the SARS-CoV-2 spike protein, defining and structurally illustrating seven receptor binding domain (RBD)–directed antibody communities with distinct footprints and competition profiles. Pseudovirion-based neutralization assays reveal spike mutations, individually and clustered together in variants, that affect antibody function among the communities. Key classes of RBD-targeted antibodies maintain neutralization activity against these emerging SARS-CoV-2 variants. These results provide a framework for selecting antibody treatment cocktails and understanding how viral variants might affect antibody therapeutic efficacy.

Dimensions of fruit and vegetable access in the retail food environment; a systematic review

 

The consumption of fruit and vegetable (F&V) is important for human health to protect against non-communicable disease and micronutrient deficiency. Increasing consumption of F&V may also benefit planetary health if these foods are substituted for foods with higher environmental footprints such as red meat or dairy. The retail food environment (RFE) is an influential junction between the food system and individual diets as it drives access to F&V through external (physical access) and personal (availability, affordability, acceptability) domains. We performed a systematic search of six literature databases (January 2021) for studies assessing access to F&V in the RFE and its association with F&V consumption in adults in high- and upper-middle income countries. 36 studies were identified and categorised by dimensions of food access - accessibility, affordability, acceptability, availability and accommodation. More than half of the studies (n = 20) were based in the USA. F&V accessibility was the most commonly reported dimension (n = 29); no study reported on accommodation. 6 studies were rated to be high quality. A positive association of increased availability of F&V options in the RFE with intake was identified in 9 of 15 studies. Associations in both acceptability and accessibility dimensions were inconsistent. No association was observed between F&V affordability and consumption although available data were limited. Many challenges exist to building a robust evidence base within food environment research including conceptual, definitional and methodological heterogeneity and measurement standardisation. Future food policies should consider multi-dimensional interventions to promote access to F&V in the RFE across all domains.

Key messages

First systematic review of dimensions of access in the retail food environment (RFE) and fruit and vegetable (F&V) intake suggesting importance of access to available healthy options for F&V intake. The retail food environment is complex but likely predictor of F&V consumption.

Insight into intraindividual variability across neuropsychological tests and its association with cognitive dysfunction in patients with lupus

Objective

Dispersion, or variability in an individual’s performance across multiple tasks at a single assessment visit, has been associated with cognitive dysfunction (CD) in many neurodegenerative and neurodevelopmental disorders. We aimed to compute a dispersion score using neuropsychological battery (NB) tests and determine its association with CD in patients with SLE.

Methods

CD was defined as a z-score of ≤−1.5 on ≥2 domains of the NB. To compute a type of dispersion score known as the intraindividual SD (ISD), the SD of age-adjusted and sex-adjusted z-scores was calculated for each visit in each patient. To estimate the association between ISD and cognitive status (CD and non-CD), we used multilevel logistic regression, adjusting for clinically important covariates.

Results

A total of 301 adult patients with SLE completed the NB at baseline, 187 of whom were reassessed at 6 months and 189 at 12 months. CD was observed in 35.2% of patients at baseline, 27.8% at 6 months and 28.0% at 12 months. Prior to covariate adjustment, the mean ISD for non-CD was 1.10±0.31 compared with 1.50±0.70 for CD. After adjusting for ethnicity, education, employment, socioeconomic status and anxiety/depression, there was a statistically significant association between ISD and CD (OR for one-unit increase in ISD: 13.56, 95% CI 4.80 to 38.31; OR for 1/10th-unit increase in ISD: 1.30, 95% CI 1.17 to 1.44). Findings were valid across multiple sensitivity analyses.

Conclusion

This is the first study to show that patients with SLE who were classified as having CD by the NB had more variability across the NB tests (ie, higher ISD score) compared with those who were not classified as having CD.

Ecological Momentary Assessment of Depression in People With Advanced Dementia: Longitudinal Pilot Study

Background

Barriers to assessing depression in advanced dementia include the presence of informant and patient recall biases. Ecological momentary assessment provides an improved approach for mood assessment by collecting observations in intervals throughout the day, decreasing recall bias, and increasing ecological validity.

Objective

This study aims to evaluate the feasibility, reliability, and validity of the modified 4-item Cornell Scale for Depression in Dementia for Momentary Assessment (mCSDD4-MA) tool to assess depression in patients with advanced dementia.

Methods

A intensive longitudinal pilot study design was used. A total of 12 participants with advanced dementia were enrolled from an inpatient psychogeriatric unit. Participants were assessed using clinical depression assessments at admission and discharge. Research staff recorded observations four times a day for 6 weeks on phones with access to the mCSDD4-MA tool. Descriptive data related to feasibility were reported (ie, completion rates). Statistical models were used to examine the interrater reliability and construct and predictive validity of the data.

Results

Overall, 1923 observations were completed, representing 55.06% (1923/3496) of all rating opportunities with 2 raters and 66.01% (1923/2913) with at least one rater. Moderate interrater reliability was demonstrated for all items, except for lack of interest. Moderate correlations were observed between observers and patient-reported outcomes, where observers reported fewer symptoms relative to participants’ self-reports. Several items were associated with and able to predict depression.

Conclusions

The mCSDD4-MA tool was feasible to use, and most items in the tool showed moderate reliability and validity for assessing depression in dementia. Repeated and real-time depression assessment in advanced dementia holds promise for the identification of clinical depression and depressive symptoms.

Prognostic value of heart rate reserve in patients with suspected coronary artery disease undergoing stress myocardial perfusion imaging

Funding Acknowledgements

Type of funding sources: None.

Background. The prognostic value of stress myocardial perfusion single-photon emission computed tomography (MPS) has been widely demonstrated. Also, chronotropic incompetence, evaluated by heart rate reserve (HRR) is associated with increased risk of adverse events. Yet, the incremental prognostic value of HRR over stress MPS data has not been fully investigated.

Purpose. To assess the incremental prognostic value of HRR over stress MPS finding in patients with suspected coronary artery disease (CAD) undergoing exercise stress MPS.

Methods. The study population consisted of 866 consecutive patients with suspected CAD undergoing exercise stress-MPS at University of Naples Federico II, between May 2002 and January 2014 as part of their diagnostic program. The primary study endpoint was all-cause mortality. All patients were followed for at least 60 months. HRR was calculated as the difference between peak exercise and resting HR, divided by the difference of age-predicted maximal and resting HR and expressed as percent. The summed difference score (SDS) was considered an index of ischemic burden. Patients were considered to have mild ischemia with a SDS of 2 to 6, and moderate-severe ischemia with a SDS ≥6. During follow-up, the occurrence of all-cause of deaths was noted and considered as event. Follow-up was censored at 84 months.

Results. During follow-up, 61 deaths occurred, with a 7% cumulative event rate. Patients experiencing death were older (56.2 ± 10.7 years vs. 66.4 ± 8.6 years), with a higher prevalence of male gender (56% vs. 87 %, P &lt; 0.05) and diabetes mellitus (23% vs. 36%, P &lt; 0.05). At stress-MPS, patients with event had lower mean values of HRR (53.2 ± 21.3% vs. 61.5 ± 16.4%, P &lt; 0.0001) and higher prevalence of moderate-severe ischemia (24% vs. 8%, P &lt; 0.0001). The best trade-off between sensitivity and specificity for identifying chronotropic incompetence was a HRR &lt;67% with an area under the receiver operating characteristic curve of 0.62. The event free survival was lower in patients with HRR &lt;67% compared to those with HRR ≥67% (log-rank 9.75, P &lt; 0.005). Accordingly, the annualized event rate was 0.006 in patients with HRR &lt;67% and 0.014 in those with HRR ≥67% (P &lt; 0.001). At Cox regression analysis, univariable predictors of all-cause mortality were age, male gender, diabetes mellitus, HRR and moderate-severe ischemia (all P &lt; 0.05). At multivariable analysis age, male gender, HRR and moderate-severe ischemia were independent predictors of all-cause mortality (all P &lt; 0.05). HRR improved the prognostic power of a model including clinical data and MPS findings for the prediction of all-cause mortality, increasing the global chi-square from 76.16 to 82.68 (P &lt; 0.005).

Conclusion. Chronotropic incompetence assessed by HRR evaluation, has independent and incremental prognostic value in predicting all cause of death in patients with suspected CAD undergoing exercise stress-MPS.

External carotid artery pseudoaneurysm following upper respiratory infection masquerading as a pharyngeal abscess in an 8-month-old

Pseudoaneurysms are very rare with an incidence of less than 0.1% in the pediatric population. Approximately 30 cases of carotid artery aneurysms in children have been published in the literature, usually affecting children over one year of age. We present one of the youngest cases in the literature; the patient is an 8-month old female with a strep throat infection complicated by pseudoaneurysm development of the external carotid artery. Because of the rarity of these lesions, there is little known regarding the types of clinical presentation and management. They are commonly the result of direct arterial trauma; however, they can also occur secondary to infection, connective tissue disease or arteritis. We are presenting a case with a highly atypical presentation. When present, pseudoaneurysms harbor the potential risk of life-threatening hemorrhage and warrant immediate management. It is important to be aware of cases and the treatment modalities used to guide future diagnosis and planning.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

532 CARING FOR AND CARING ABOUT OLDER PEOPLE LIVING WITH SEVERE FRAILTY DURING COVID-19

Introduction

An ongoing study collected survey and interview data from older people with frailty living in the community near end-of-life during the Covid-19 pandemic.

Methods

Unstructured interviews with older people with frailty living in the community (N = 10), which included accounts from unpaid carers (N = 5), were video and audio recorded between October–November 2021. Six of these older people have died since fieldwork completion. A face-to-face survey collected data from a further 10 older people. Participants ages ranged from 70–99, 11, men, and 9 women, living in owned, rented, or sheltered accommodation, with Clinical Frailty Scores of 6 (N = 8), 7 (N = 9), and 8 (N = 3).

Results

Topics raised in relation to the pandemic included loss of social contact and increased loneliness, concern about not physically getting out, and losing physical function. Older people struggled to gain access to health and social care for support and previously received services were withdrawn. Most participants did not have access to internet and relied heavily on families to facilitate virtual contact with health professionals. Families and friends were the main anchor in facilitating social and health care including chasing up medications, liaising with social care to ensure quality and consistency of care provided, and monitoring older people’s health. Where older people’s conditions worsened family provided intense support, though family carers described the strain and unsustainability of this provision. Older people and their families felt they had been forgotten.

Conclusions

These are insights from hard-to-reach population that are frequently invisible. Greater examination of the impact of using communication technologies in care provision on those with poor access to and capabilities with using these technologies is required. Unpaid carers need more information and resources to support the care they provide and to facilitate access to appropriate social and health care services for those they care for.

Metrics and definitions used in the assessment of cognitive impairment in systemic lupus erythematosus: A systematic review

OBJECTIVE

To review: 1) degree of conformity to the American College of Rheumatology neuropsychological battery (ACR-NB) among studies that used a NB, 2) review definitions of cognitive impairment (CI) from studies that used a NB, and 3) characterize measurement tools used to assess CI in systemic lupus erythematosus (SLE).

METHODS

The literature search was conducted in Ovid Medline, Embase, and PsycINFO for articles on CI in adult SLE patients. We reviewed studies that used a NB and compared their tests to the ACR-NB to assess the degree of conformity. Definitions of CI from studies that used a NB were reviewed when sufficient information was available. We reviewed and categorized CI measurement tools into four broad categories: NB, screening, incomplete/mixed batteries, and computerized batteries.

RESULTS

Of 8727 references, 118 were selected for detailed review and 97 were included in the final analysis. Of 43 studies that used a NB, none of the studies used the ACR-NB exactly as published. Many studies supplemented with other tests. Overall, there was inconsistent use of ACR-NB tests. Definitions for CI varied, with cut-offs ranging from 1 to 3 standard deviations below normative values on domains/tests varying in type and number. The most frequently used measurement tool for assessing CI in SLE was a NB. Use of screening tests and computerized batteries have also increased over the last decade.

CONCLUSION

The assessment and definition of CI in SLE remains heterogeneous. A consensus meeting to address existing inconsistencies should be considered to harmonize the field of CI in SLE.

The psychological burden of waiting for procedures and patient-centred strategies that could support the mental health of wait-listed patients and caregivers during the COVID-19 pandemic: A scoping review

BACKGROUND

Waiting for procedures delayed by COVID-19 may cause anxiety and related adverse consequences.

OBJECTIVE

To synthesize research on the mental health impact of waiting and patient-centred mitigation strategies that could be applied in the COVID-19 context.

METHODS

Using a scoping review approach, we searched 9 databases for studies on waiting lists and mental health and reported study characteristics, impacts and intervention attributes and outcomes.

RESULTS

We included 51 studies that focussed on organ transplant (60.8%), surgery (21.6%) or cancer management (13.7%). Most patients and caregivers reported anxiety, depression and poor quality of life, which deteriorated with increasing wait time. The impact of waiting on mental health was greater among women and new immigrants, and those of younger age, lower socio-economic status, or with less-positive coping ability. Six studies evaluated educational strategies to develop coping skills: 2 reduced depression (2 did not), 1 reduced anxiety (2 did not) and 2 improved quality of life (2 did not). In contrast, patients desired acknowledgement of concerns, peer support, and periodic communication about wait-list position, prioritization criteria and anticipated procedure date.

CONCLUSIONS

Findings revealed patient-centred strategies to alleviate the mental health impact of waiting for procedures. Ongoing research should explore how to optimize the impact of those strategies for diverse patients and caregivers, particularly in the COVID-19 context.

PATIENT OR PUBLIC CONTRIBUTION

Six patients and four caregivers waiting for COVID-19-delayed procedures helped to establish eligibility criteria, plan data extraction and review a draft and final report.

Management of acute fever in children: Consensus recommendations for community and primary healthcare providers in sub-Saharan Africa

Fever is one of the most common reasons for unwell children presenting to pharmacists and primary healthcare practitioners. Currently there are no guidelines for assessment and management of fever specifically for community and primary healthcare workers in the sub-Saharan Africa region. This multidisciplinary consensus guide was developed to assist pharmacists and primary healthcare workers in sub-Saharan Africa to risk stratify and manage children who present with fever, decide when to refer, and how to advise parents and caregivers. Fever is defined as body temperature ≥ 37.5 °C and is a normal physiological response to illness that facilitates and accelerates recovery. Although it is often associated with self-limiting illness, it causes significant concern to both parents and attending healthcare workers. Clinical signs may be used by pharmacy staff and primary healthcare workers to determine level of distress and to distinguish between a child with fever who is at high risk of serious illness and who requires specific treatment, hospitalisation or specialist care, and those at low risk who could be managed conservatively at home. In children with warning signs, serious causes of fever that may need to be excluded include infections (including malaria), non-infective inflammatory conditions and malignancy. Simple febrile convulsions are not in themselves harmful, and are not necessarily indicative of serious infection. In the absence of illness requiring specific treatment, relief from distress is the primary indication for prescribing pharmacotherapy, and antipyretics should not be administered with the sole intention of reducing body temperature. Care must be taken not to overdose medications and clear instructions should be given to parents/caregivers on managing the child at home and when to seek further medical care.

Remotely delivered environmental enrichment intervention for traumatic brain injury: Study protocol for a randomised controlled trial

INTRODUCTION

Individuals with moderate-severe traumatic brain injury (m-sTBI) experience progressive brain and behavioural declines in the chronic stages of injury. Longitudinal studies found that a majority of patients with m-sTBI exhibit significant hippocampal atrophy from 5 to 12 months post-injury, associated with decreased cognitive environmental enrichment (EE). Encouragingly, engaging in EE has been shown to lead to neural improvements, suggesting it is a promising avenue for offsetting hippocampal neurodegeneration in m-sTBI. Allocentric spatial navigation (ie, flexible, bird's eye view approach), is a good candidate for EE in m-sTBI because it is associated with hippocampal activation and reduced ageing-related volume loss. Efficacy of EE requires intensive daily training, prohibitive within most current health delivery systems. The present protocol is a novel, remotely delivered and self-administered intervention designed to harness principles from EE and allocentric spatial navigation to offset hippocampal atrophy and potentially improve hippocampal functions such as navigation and memory for patients with m-sTBI.

METHODS AND ANALYSIS

Eighty-four participants with chronic m-sTBI are being recruited from an urban rehabilitation hospital and randomised into a 16-week intervention (5 hours/week; total: 80 hours) of either targeted spatial navigation or an active control group. The spatial navigation group engages in structured exploration of different cities using Google Street View that includes daily navigation challenges. The active control group watches and answers subjective questions about educational videos. Following a brief orientation, participants remotely self-administer the intervention on their home computer. In addition to feasibility and compliance measures, clinical and experimental cognitive measures as well as MRI scan data are collected pre-intervention and post-intervention to determine behavioural and neural efficacy.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from ethics boards at the University Health Network and University of Toronto. Findings will be presented at academic conferences and submitted to peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Version 3, ClinicalTrials.gov Registry (NCT04331392).

COVID-19 testing in outbreak-free care homes: what are the public health benefits?

BACKGROUND

COVID-19 care home outbreaks represent a significant proportion of COVID-19 morbidity and mortality in the UK. National testing initially focused on symptomatic care home residents, before extending to asymptomatic cohorts.

AIM

The aim was to describe the epidemiology and transmission of COVID-19 in outbreak free care homes.

METHODS

A two-point prevalence survey of COVID-19, in 34 Liverpool care homes, was performed in April and May 2020. Changes in prevalence were analysed. Associations between care home characteristics, reported infection, prevention and control interventions, and COVID-19 status were described and analysed.

FINDINGS

No resident developed COVID-19 symptoms during the study. There was no significant difference between: the number of care homes containing at least one test positive resident between the first (17.6%, 95% confidence interval (CI) 6.8-34.5) and second round (14.7%, 95% CI 5.0-31.1) of testing (p>0.99); and the number of residents testing positive between the first (2.1%, 95% CI 1.2-3.4) and second round (1.0%, 95% CI 0.5-2.1) of testing (P=0.11). Care homes providing nursing care (risk ratio (RR) 7.99, 95% CI 1.1-57.3) and employing agency staff (RR 8.4, 95% CI 1.2-60.8) were more likely to contain test positive residents. Closing residents shared space was not associated with residents testing positive (RR 2.63, 95% CI 0.4-18.5).

CONCLUSIONS

Asymptomatic COVID-19 care homes showed no evidence of disease transmission or development of outbreaks; suggesting that current infection prevention and control measures are effective in preventing transmission. Repeat testing at two to three weeks had limited or no public health benefits over regular daily monitoring of staff and residents for symptoms. These results should inform policies calling for regular testing of asymptomatic residents.