Screening for lung cancer with computed tomography: protocol for systematic reviews for the Canadian Task Force on Preventive Health Care

PURPOSE

Lung cancer is the leading cause of cancer deaths in Canada, and because early cancers are often asymptomatic screening aims to prevent mortality by detecting cancer earlier when treatment is more likely to be curative. These reviews will inform updated recommendations by the Canadian Task Force on Preventive Health Care on screening for lung cancer.

METHODS

We will update the review on the benefits and harms of screening with CT conducted for the task force in 2015 and perform de novo reviews on the comparative effects between (i) trial-based selection criteria and use of risk prediction models and (ii) trial-based nodule classification and different nodule classification systems and on patients' values and preferences. We will search Medline, Embase, and Cochrane Central (for questions on benefits and harms from 2015; comparative effects from 2012) and Medline, Scopus, and EconLit (for values and preferences from 2012) via peer-reviewed search strategies, clinical trial registries, and the reference lists of included studies and reviews. Two reviewers will screen all citations (including those in the previous review) and base inclusion decisions on consensus or arbitration by another reviewer. For benefits (i.e., all-cause and cancer-specific mortality and health-related quality of life) and harms (i.e., overdiagnosis, false positives, incidental findings, psychosocial harms from screening, and major complications and mortality from invasive procedures as a result of screening), we will include studies of adults in whom lung cancer is not suspected. We will include randomized controlled trials comparing CT screening with no screening or alternative screening modalities (e.g., chest radiography) or strategies (e.g., CT using different screening intervals, classification systems, and/or patient selection via risk models or biomarkers); non-randomized studies, including modeling studies, will be included for the comparative effects between trial-based and other selection criteria or nodule classification methods. For harms (except overdiagnosis) we will also include non-randomized and uncontrolled studies. For values and preferences, the study design may be any quantitative design that either directly or indirectly measures outcome preferences on outcomes pertaining to lung cancer screening. We will only include studies conducted in Very High Human Development Countries and having full texts in English or French. Data will be extracted by one reviewer with verification by another, with the exception of result data on mortality and cancer incidence (for calculating overdiagnosis) where duplicate extraction will occur. If two or more studies report on the same comparison and it is deemed suitable, we will pool continuous data using a mean difference or standardized mean difference, as applicable, and binary data using relative risks and a DerSimonian and Laird model unless events are rare (< 1%) where we will pool odds ratios using Peto's method or (if zero events) the reciprocal of the opposite treatment arm size correction. For pooling proportions, we will apply suitable transformation (logit or arcsine) depending on the proportions of events. If meta-analysis is not undertaken we will synthesize the data descriptively, considering clinical and methodological differences. For each outcome, two reviewers will independently assess within- and across-study risk of bias and rate the certainty of the evidence using GRADE (Grading of Recommendations Assessment, Development, and Evaluation), and reach consensus.

DISCUSSION

Since 2015, additional trials and longer follow-ups or additional data (e.g., harms, specific patient populations) from previously published trials have been published that will improve our understanding of the benefits and harms of screening. The systematic review of values and preferences will allow fulsome insights that will inform the balance of benefits and harms.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022378858.

Association of medication clusters and subsequent labor market marginalization in refugee and Swedish-born young adults with common mental disorders in Sweden

Little is known about the association between common mental disorders (CMD) and labor market integration among refugee and Swedish-born young adults. Socially disadvantaged patients such as refugees are more likely to discontinue their medication use prematurely. This study aimed to identify clusters of individuals with similar psychotropic medication patterns; and examine the relationship between cluster membership with labor market marginalization (LMM) in refugee and Swedish-born young adults with CMD. The study uses a longitudinal matched cohort aged 18-24 years with CMD diagnoses from Swedish registers covering 2006-2016. Dispensed psychotropic medications (antidepressants, antipsychotics, anxiolytics, sedative-hypnotics, mood stabilizers) were collected one year before and after CMD diagnosis. Clusters of patients with similar time courses of prescribed dosages were algorithmically identified. The association of cluster membership with subsequent LMM, (long-term sickness absence, SA, disability pension, DP, or long-term unemployment, UE) was assessed using Cox regression. Among 12,472 young adults with CMD, there were 13.9% with SA, 11.9% with DP, and 13.0% with UE during a mean follow-up of 4.1 years (SD 2.3 years). Six clusters of individuals were identified. A cluster with a sustained increase in all medication types yielded the highest hazard ratio (HR [95% CI]) 1.69 [1.34, 2.13] for SA and 2.63 [2.05, 3.38] for DP. The highest HRs of UE give a cluster with a concentrated peak in antidepressants at CMD diagnosis (HR 1.61[1.18, 2.18]). Refugees and Swedish-born showed similar associations between clusters and LMM. To prevent LMM, targeted support and early assessment of CMD treatment are needed for individuals with a sustained increase in psychotropic medication after CMD diagnosis and for refugees in high-risk clusters for UE characterized by a rapid lowering of treatment dosages, which could be an indicator for premature medication discontinuation.

Phytochemical Analysis and hypoglycemic potential of Filago hurdwarica (Wall. ex DC.) Wagenitz in alloxan induced diabetic mice

Abstract Plants have profound therapeutic benefits, more economical treatments, fewer side effects, and a relatively cheap cost, making them a source of drugs for protective, preventative, curative, or conducive purposes and creating novel phytomedicines. Plant derived medicines are relatively safe compared to synthetic medicines. Many plants have proved to successfully aid in the treatment of diabetes including Filago hurdwarica (Wall. ex DC.) Wagenitz. The current investigations were therefore designed to assess the phytochemical, antioxidant, antidiabetic, and antihyperlipidemic activities of F. hurdwarica. The phytochemical investigations and antioxidant activities of different extracts were carried out using standard chemical tests, DPPH, and H2O2 scavenging assays. F. hurdwarica plant extract in Hydromethanolic solution were prepared by Soxhletation method and stored in refrigerator at 4°C for two days before use. Swiss Albino mice were made diabetic by a single dose of alloxan (150 mg/kg). Hydromethanolic plant extract and fractions of F. hurdwarica were screened for antidiabetic activity and given to the alloxan-induced diabetic mice at a concentration of 150-250 mg/kg of body weight in different groups of 6 diabetic mice each orally once a day for 15 days. Glibenclamide is also given to another group to as a standard drug to support the result at a dose of 10 mg/kg of body weight orally once a day for 15 days. Blood glucose levels and body weights of mice were measured on 0, 4, 7, 11 and 15th days. The study found that the extract was safe up to the dose level of 2000 mg/kg and the dose response effect of chloroform extract (150-250 mg/kg) of F. hurdwarica showed expressive antihyperglycemic effects and also improved other altered biochemical parameters associated with diabetes. The FTIR and XRD spectra demonstrated the occurrence of phenols, alcohols, alkenes, alkyl halides, ketones, and aromatic compounds and confirmed the amorphous nature of the extract. GC-MS spectral analysis showed the tentative presence of 31 phytochemical constituents in the chloroform extract of F. hurdwarica with different retention time. To conclude, the chloroform extract (250 mg/kg) of F. hurdwarica revealed considerable antioxidant, antihyperglycemic, and antihyperlipidemic potential and is safe for treating diabetes and related complications.

Memory support training and lifestyle modifications to promote healthy aging in persons at risk for Alzheimer's disease: a digital application supported intervention (Brain Boosters)

BACKGROUND

Evidence-based interventions to protect against cognitive decline among older adults at risk for Alzheimer's disease and related dementias (ADRD) are urgently needed. Rehabilitation approaches to support memory and behavioral/lifestyle interventions are recognized as promising strategies for preserving or improving cognitive health, although few previous interventions have combined both approaches. This paper describes the protocol of the Brain Boosters intervention, which synergistically combines training in compensatory and healthy lifestyle behaviors and supports implementation and tracking of new behaviors with a digital application.

METHODS

The study utilizes a single-site, single-blinded, randomized controlled design to compare a structured lifestyle and compensatory aid intervention to an education-only self-guided intervention. We plan to enroll 225 community-dwelling adults (25% from underrepresented groups) aged 65 + who endorse subjective cognitive decline (SCD) and low baseline levels of healthy lifestyle behaviors. Both interventions will be administered in group format, consisting of 15 two-hour classes that occur weekly for ten weeks and taper to bi-monthly and monthly, for an intervention duration of 6 months. Participants in both interventions will receive education about a variety of memory support strategies and healthy lifestyle behaviors, focusing on physical and cognitive activity and stress management. The structured intervention will also receive support in adopting new behaviors and tracking set goals aided by the Electronic Memory and Management Aid (EMMA) digital application. Primary outcomes include global cognition (composite of memory, attention, and executive function tests) and everyday function (Everyday Cognition Questionnaire). Data will be collected at baseline and outcome visits, at approximately 6, 12, and 18 months. Qualitative interviews, self-report surveys (e.g., indicators of self-determination, health literacy) and EMMA data metrics will also be used to identify what components of the intervention are most effective and for whom they work.

DISCUSSION

Successful project completion will provide valuable information about how individuals with SCD respond to a compensation and preventative lifestyle intervention assisted by a digital application, including an understanding of factors that may impact outcomes, treatment uptake, and adherence. The work will also inform development, scaling, and personalization of future interventions that can delay disability in individuals at risk for ADRD.

TRIAL REGISTRATION

ClinicalTrials.gov. (NCT05027789, posted 8/30/2021).

The effect of surgical complications on long-term prognosis following oesophagectomy

INTRODUCTION

Complications are frequent after oesophagectomy, and there is evidence these adversely impact long-term prognosis. However, the effect of multiple complications, and the absolute magnitude of effect on survival is unclear. This study aimed to examine these effects in a single high-volume UK unit.

METHODS

Patients undergoing oesophagectomy for cancer and who survived to 90 days post-oesophagectomy were analysed. Complications were graded according to the Clavien-Dindo (CD) classification and the Comprehensive Complication Index (CCI). The effect and magnitude of effect of complications on survival were assessed using multivariable cox regression and the risk-adjusted population attributable fraction.

RESULTS

In total, 380 patients were included. Complications occurred in 251 (66.1%). Suffering ≥3 complications (HR 1.89, 95%CI 1.13-3.16, p = 0.015) or an unplanned escalation in care (HR 2.22, 95%CI 1.43-3.45, p < 0.001) significantly reduced survival whereas pulmonary complications and anastomotic leak did not. Patients with a CCI>30 had worse overall survival (HR 1.91, 95%CI 1.32-2.76, p < 0.001) and CCI>30 due to multiple minor complications gave a worse prognosis compared to CCI>30 due to major complications (HR 2.44, 95%CI 1.14-5.20, p = 0.022). An estimated 9.1% (95%CI 3.4-14.4%) of deaths at 5 years were attributable to a CCI>30.

CONCLUSION

Long-term survival following oesophagectomy for cancer is significantly affected by complications and the cumulative effect of multiple complications. Interestingly, multiple minor complications had a worse effect on survival than major complications. The absolute magnitude of effect is substantial: minimising all types of postoperative complications could have significant benefit to overall outcomes.

Immuno-bioinformatic approach for designing of multi-epitope merozoite surface antigen of Babesia bigemina and evaluation of its immunogenicity in inoculated calves

Babesiosis is a parasitic disease caused by intraerythrocytic parasites of the genus Babesia, which infect both wild and domestic animals. Merozoite surface antigens (MSAs) have been identified as efficient immunogens in Babesia-infected animals. MSAs play a key role in the invasion process and have been proposed as potential targets for vaccine development. Epitope-based vaccines offer several advantages over whole protein vaccines as the immunogenic proteins are small and can induce both Th1 and Th2 immune responses, which are desirable for protection. However, the MSA, particularly gp45, is polymorphic in Babesia bigemina, posing a challenge to vaccine development. The purpose of this study was to develop a recombinant gpME (gp45-multi-epitope) for a vaccine against Babesia bigemina. B-cell, T-cell, and HLA epitope predictions were used to synthesize the gpME sequence from the consensus sequence of gp45. The gpME sequence was synthesized and cloned in the pET28α vector through the commercial biotechnology company to get pET28-gpME. The plasmid cloned with the gpME sequence comprising 1068 bp was expressed in a bacterial expression system. A band of 39 kDa of rec-gpME was obtained via SDS-PAGE and Western blotting. Rec-gpME @200ng was injected in calves 3 times at 2 weeks interval. The humoral response was evaluated through the indirect ELISA method. The ELISA with rec-gp45 protein showed a significant value of optical density. The recombinant protein containing multiple epitopes from the MSA gp45 may represent a promising candidate for a vaccine against Babesia bigemina.

Social demographics determinants for resistome and microbiome variation of a multiethnic community in Southern Malaysia

The prevalence of antibiotic-resistant bacteria in Southeast Asia is a significant concern, yet there is limited research on the gut resistome and its correlation with lifestyle and environmental factors in the region. This study aimed to profile the gut resistome of 200 individuals in Malaysia using shotgun metagenomic sequencing and investigate its association with questionnaire data comprising demographic and lifestyle variables. A total of 1038 antibiotic resistance genes from 26 classes were detected with a mean carriage rate of 1.74 ± 1.18 gene copies per cell per person. Correlation analysis identified 14 environmental factors, including hygiene habits, health parameters, and intestinal colonization, that were significantly associated with the resistome (adjusted multivariate PERMANOVA, p < 0.05). Notably, individuals with positive yeast cultures exhibited a reduced copy number of 15 antibiotic resistance genes. Network analysis highlighted Escherichia coli as a major resistome network hub, with a positive correlation to 36 antibiotic-resistance genes. Our findings suggest that E. coli may play a pivotal role in shaping the resistome dynamics in Segamat, Malaysia, and its abundance is strongly associated with the community's health and lifestyle habits. Furthermore, the presence of yeast appears to be associated with the suppression of antibiotic-resistance genes.

Knowledge, Attitude and Practice of Undergraduate Medical Students of Bangladesh Regarding COVID-19 and its Vaccination

Medical students are one of the socially active, reliable, and persuading population of information, prevention and control, and incentive of vaccination to stop the current pandemic situation. Consequently, knowing the status of medical students' knowledge, about symptoms, and transmission of disease, prevention of COVID-19 and their attitudes towards a vaccine is important. This multi-center cross-sectional descriptive study was one of the first ones in Bangladesh among the undergraduate medical students who completed pathology, microbiology, and pharmacology. The study was conducted from March to April 2021, using a convenience sampling method in twelve government and non-government medical colleges. Among 1132 who completed the questionnaire, and 15 students from different centers were excluded from the pre-testing and face validation. The age of the 1117 respondents were 22 to 23 years, of which the majority of the respondents were female 749 (67.0%), and 368 (33.0%) were male. Almost all participants had correct knowledge (84.1%) about the symptoms of COVID-19. But 59.2% had wrong knowledge about transmission of disease by an afebrile person. Above 60.0 % of the participants have worn a facial mask when contacting people, refrained from shaking hands, washed hands, avoided people with signs and symptoms suggestive of COVID-19, and avoided crowded places as a practice of prevention. 37.6% of medical students showed positive attitudes about the participation of management of a COVID-19 patient. Most of the participants' decided to have a vaccine depending on its availability. But 31.5% had trust in natural immunity rather than vaccination. Most undergraduate Medical college students understood the basic information, possessed a positive attitude, and presented good practice towards the COVID-19 and vaccination. They play a crucial role in motivation and acceptance of vaccines among the general citizen to fight back against the pandemic in the country with limited resources.

Eyes, menstruation and endometriosis

Vicarious menstruation refers to cyclical bleeding outside the uterine cavity during the menstrual cycle. Haemolacria, or blood in tears, is a rare medical phenomenon that can occur with menstruation or in association with endometriosis. Endometriosis, defined by the presence of endometrial-like tissue in extra-uterine sites, affects around 10% of fertile women; the ocular system is one of the rarest sites it can be present in. Endometriosis usually requires a biopsy for diagnosis, and the anatomic difficulty of obtaining a biopsy of the ocular system makes ocular endometriosis diagnosis more obscure. However, few cases have been described in the literature and due to the psychological, physical, and social implications of haemolacria on the patient, treatment is of utmost importance. We reviewed the literature on ocular endometriosis and ocular vicarious menstruation with the aim to discuss the clinical presentation, necessary workup and various treatment modalities, while also shedding light on the connection between the eyes and endometriosis in general. It is hypothesised that uterine endometrial cells can travel lymphatically or haematogenously and deposit extra-uterine endometriotic lesions that bleed in response to hormonal changes in the menstrual cycle. Additionally, the conjunctival vasculature has been found to be responsive to hormonal changes due to the presence of oestrogen and progesterone receptors, causing bleeding at the corresponding sites, even without endometriotic lesions. Clinical correlation of the haemolacria with the menstrual cycle can suffice for a diagnosis of vicarious menstruation, and thus opens the possibility of treatment to provide symptomatic treatment for the patient.

Vulnerable newborn types: analysis of subnational, population-based birth cohorts for 541 285 live births in 23 countries, 2000-2021

OBJECTIVE

To examine prevalence of novel newborn types among 541 285 live births in 23 countries from 2000 to 2021.

DESIGN

Descriptive multi-country secondary data analysis.

SETTING

Subnational, population-based birth cohort studies (n = 45) in 23 low- and middle-income countries (LMICs) spanning 2000-2021.

POPULATION

Liveborn infants.

METHODS

Subnational, population-based studies with high-quality birth outcome data from LMICs were invited to join the Vulnerable Newborn Measurement Collaboration. We defined distinct newborn types using gestational age (preterm [PT], term [T]), birthweight for gestational age using INTERGROWTH-21st standards (small for gestational age [SGA], appropriate for gestational age [AGA] or large for gestational age [LGA]), and birthweight (low birthweight, LBW [<2500 g], nonLBW) as ten types (using all three outcomes), six types (by excluding the birthweight categorisation), and four types (by collapsing the AGA and LGA categories). We defined small types as those with at least one classification of LBW, PT or SGA. We presented study characteristics, participant characteristics, data missingness, and prevalence of newborn types by region and study.

RESULTS

Among 541 285 live births, 476 939 (88.1%) had non-missing and plausible values for gestational age, birthweight and sex required to construct the newborn types. The median prevalences of ten types across studies were T+AGA+nonLBW (58.0%), T+LGA+nonLBW (3.3%), T+AGA+LBW (0.5%), T+SGA+nonLBW (14.2%), T+SGA+LBW (7.1%), PT+LGA+nonLBW (1.6%), PT+LGA+LBW (0.2%), PT+AGA+nonLBW (3.7%), PT+AGA+LBW (3.6%) and PT+SGA+LBW (1.0%). The median prevalence of small types (six types, 37.6%) varied across studies and within regions and was higher in Southern Asia (52.4%) than in Sub-Saharan Africa (34.9%).

CONCLUSIONS

Further investigation is needed to describe the mortality risks associated with newborn types and understand the implications of this framework for local targeting of interventions to prevent adverse pregnancy outcomes in LMICs.

Identification of Variants and Mutational Analyses of Cardiac Myosin-binding Protein C (MYBPC3) Gene of Adult Bangladeshi Patients with Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is the most prevalent genetic hereditary cardiomyopathy characterized by sudden cardiac death. Mutations in the MYBPC3 gene are often the most prevalent genetic abnormality in HCM with a prevalence ranging from 20.0 to 42.0%. The mutation spectrum is available for different countries, but such studies are lacking in the Asian population including Bangladeshi patients. A cross-sectional descriptive study was conducted for mutation analysis of the whole MYBPC3 gene on a cohort of 75 HCM Bengali Bangladeshi probands through Next Generation Sequencing at the Genetic Research Lab of Bangabandhu Sheikh Mujib Medical University from 2016 to 2019. The structural and functional impact of the mutations was further analyzed by in silico process. We analyzed the data and found 103 variants in 102 locations in the MYBPC3 gene. Variants were identified in both the coding region and the non-coding region. We found one possibly novel variant in the MYBPC3 gene. The findings of this research will help to develop a genetic database of HCM which will help in the early diagnosis and proper management of HCM patients in Bangladesh. One pathogenic splice donor variant (47356592 C >T) was found in the intronic region. Among the variants in the coding region, one missense mutation was pathogenic (NP₋000247.2: p.Asp770Asn) which was found in seven patients and another one is of conflicting interpretations of pathogenicity (NP₋000247.2: p.Ser217Gly) which was found in two patients. We have identified one in-frame deletion (NP₋000247.2: p.Ala433del) that is possible a novel variant responsible for the development of HCM.

Corrigendum to 'Point-of-care viscoelastic testing' [BJA Education 22 (2022) 416-423]

[This corrects the article DOI: 10.1016/j.bjae.2022.07.003.].

Percutaneous image-guided thermal ablation of lung cancer: What is the evidence?

Thermal ablation techniques have now been used for more than twenty years in the treatment of primary lung tumours, predominantly non-small cell lung cancer (NSCLC). Although primarily used for the treatment of early-stage disease in non-surgical patients, thermal ablation is now also being used in selected patients with oligometastatic and oligoprogressive disease. This review discusses the techniques available for thermal ablation, the evidence for use of thermal ablation in primary lung tumours in early- and advanced-stage disease and compares thermal ablation to alternative treatment strategies.

1251 FRAILTY PREVALENCE AND RISK OF SARCOPENIA IN OLDER HEART FAILURE (HF) INPATIENTS

Introduction

Both frailty and HF are common in the elderly population. Elderly HF patients have an increased risk of frailty and elderly frail patients are at a higher risk of developing HF. Frailty is an independent predictor of mortality in cardiovascular disease. Sarcopenia (defined as decreased muscle mass and muscle strength and/or performance) is also prevalent in HF patients and may progress to cardiac cachexia. HF may induce sarcopenia and sarcopenia may contribute to the poor prognosis of HF.

Aims

Methods

A cross-sectional, retrospective analysis of consecutive patients, 60 years and over, admitted with HF to a UK hospital. Data was manually extracted from anonymized electronic records. The Rockwood Clinical Frailty Scale (CFS) was used for assessment for frailty and the SARC-F tool was used for screening for sarcopenia. Patients with medical history of HF but did not present with decompensated HF were excluded. Also, patients with incomplete data were excluded. The IBM SPSS 28 statistical package was used for statistical analysis. Descriptive statistics and risk estimates were calculated.

Results

163 patients were analysed; 82 males and 81 females. The mean age was 81.4 years (SD 9.69). 71.5 % of patients were frail while 28.5 % were non-frail. The risk of sarcopenia was 10.9 times greater in the frail than in the non-frail patients (OR = 10.9; 95% C.I 4.85 – 24.67). There was a lower risk of sarcopenia in male patients than in the female patients (OR =0.45; 95% C.I 0.22 – 0.94).

Conclusions

Frailty is prevalent in older heart failure inpatients. It significantly increases the risk of sarcopenia in these patients. Women are at higher risk of sarcopenia than men. More research is needed into frailty and sarcopenia in.

1242 CO-MORBIDITY, FRAILTY AND EJECTION FRACTION IN OLDER HEART FAILURE INPATIENTS

Introduction

Co-morbidities and frailty are common in older heart failure patients. The aim of this study is to explore the relationship between co-morbidity, frailty and ejection fraction (EF) in older heart failure inpatients

Methods

A cross-sectional, observational, retrospective analysis of consecutive patients aged 60 years and over who were admitted with heart failure in a UK hospital. Patients with incomplete data were excluded. The Carlson’s comorbidity index (CCI) was used to compute comorbidity and the Rockwood Clinical Frailty Scale (CFS) was used to measure frailty. The EF was calculated as the midpoint of the ranges measured by echocardiography. IBM SPSS 28 software was used for statistical analysis. Descriptive statistics were used to measure baseline characteristics and Pearson’s correlation coefficient and linear regression were used to calculate correlation.

Results and discussion

101 patients were analysed; 48 males and 53 females. Mean age was 81.2 years(SD 9.98). Mean CCI was 6.97(SD 1.63) and mean CFS was 5.09(SD 1.14). There was statistically significant positive correlation between CCI and CFS (r= 0.232; p= .01). There was statistically significant inverse correlation between CCI and EF (r= -.277; p=. 005). When taking into account the level of frailty the correlation between CCI and EF was much stronger in non-frail than in frail patients (r= -.612; p=. 035 and r= -.216; p= .047 respectively). There was no correlation between CFS and EF (r= .095; p=.26). This was not surprising as HFpEF is the most common type of HF in the elderly. HFpEF patients are more likely to have more comorbidities and to be more frail compared to HFrEF patients.

Conclusion

There was a positive correlation between multi-morbidity and frailty in older inpatients admitted with heart failure. There was statistically significant inverse correlation between CCI and ejection fraction but there was no correlation between frailty and ejection.

Children at risk of anaphylaxis: A mixed-studies systematic review of parents' experiences and information needs

Objective

To explore parents' self-reported experiences and information needs regarding recognition and management of pediatric anaphylaxis.

Methods

We searched Ovid Medline, Ovid PsychInfo, CINAHL Plus, the Cochrane Library, and grey literature to identify primary studies in English or French published since 2000. We used a mixed-method appraisal tool and convergent integrated approach to assess quality and synthesize data, respectively.

Results

43 studies were included (22 quantitative, 19 qualitative, and 2 mixed-method); 77% of studies had high methodological quality. Parents' experiences were categorized as: recognizing an anaphylactic reaction; managing and responding to a reaction; emotional impact of caring for a child at risk of anaphylaxis; and interaction with the health system and healthcare providers. Parents' information needs were categorized into themes relating to: gaps in knowledge and information; type of information desired; information sources; and information delivery format.

Conclusion

Negative emotional experiences and a general lack of information were commonly reported by parents of included studies. Provision of relevant and comprehensible information may help parents to make informed decisions and manage reactions promptly.

Innovation

The findings of this review are guiding the development of an innovative knowledge translation tool (KT) as part of a larger initiative of developing a suite of parent-focused KT tools for acute childhood conditions.

Risk factors and preventive interventions for post Covid-19 condition: systematic review

This systematic review examined pre-existing and clinical risk factors for post Covid-19 condition (≥12 weeks after onset), and interventions during acute and post-acute phases of illness that could potentially prevent post Covid-19 condition. The review focuses on studies collecting data during the early phases of the pandemic and prior to the emergence of variants of concern and widespread vaccination. We searched bibliographic databases and grey literature. Two investigators independently reviewed abstracts and full-text articles, and data extraction and risk of bias assessments were verified. Meta-analysis was performed when suitable and we assessed the certainty of evidence using GRADE. We included 31 studies. We found small-to-moderate associations (e.g. adjusted odds ratios 1.5 to <2.0) between female sex and higher non-recovery, fatigue, and dyspnea (moderate certainty). Severe or critical acute-phase Covid-19 severity (versus not) has probably (moderate certainty) a large association (adjusted ratio ≥2.0) with increased cognitive impairment, a small-to-moderate association with more non-recovery, and a little-to-no association with dyspnea. There may be (low certainty) large associations between hospitalization and increased non-recovery, increased dyspnea, and reduced return to work. Other outcomes had low certainty of small-to-moderate or little-to-no association or very low certainty. Several potential preventive interventions were examined, but effects are very uncertain. Guidelines in relation to surveillance, screening, and other services such as access to sickness and disability benefits, might need to focus on females and those with previously severe Covid-19 illness. Continuous assessment of emerging evidence, especially on whether different variants and vaccination impact outcomes, will be important. PROSPERO registration: CRD42021270354.

Time period effects in work disability due to common mental disorders among young employees

Background

Previous research on period effects in risk for work disability due to common mental disorders across employment sectors and occupational classes in young employees is lacking. Temporal changes in the healthcare system or social insurance policies or other structural/organisational changes could contribute to such time period effects. We aimed to investigate time period effects in the risk of work disability, defined as long-term sickness absence (LTSA) and disability pension (DP) due to common mental disorders (CMDs), among young employees according to their employment sector (private/public) and occupational class (non-manual/manual).

Methods

Three cohorts, including all employed individuals with complete information on employment sector and occupational class, aged 19-29 years and resident in Sweden on the 31-Dec-2004, 2009 and 2014 (n = 573,516, 665,138 and 600,889 individuals in cohort 2004, 2009 and 2014, respectively) were followed for four years. Crude and multivariate-adjusted hazard ratios (HRs and aHRs, respectively) with 95% confidence intervals (CIs) were estimated regarding the risk of LTSA and DP due to CMDs using Cox regression analyses.

Results

In cohort 2004, public sector employees had a higher relative risk for LTSA due to CMDs than private sector employees (aHR, (95%CI): 1.24, 1.16-1.34 and 1.18, 1.11-1.26 among non-manual and manual workers). These associations were similar in the later cohorts. Compared to cohort 2004, the rate of DP due to CMDs was considerably lower in the later cohorts leading to uncertainties in the risk estimates limiting the comparability for time period effects regarding the risk of DP due to CMDs across employment sectors and occupational classes.

Conclusions

Stricter regulation changes regarding the receipt of DP in Sweden, rather than other time period events, may have differentially affected the risk of work disability among young non-manual and manual employees working in the private and public sectors.

Key messages

107 A Rare Presentation of a Giant, Multi-Compartmental Lipoma of the Hand Causing Median Nerve Compression

Lipomas are the commonest benign tumour, made up exclusively of adipose tissue, and can arise anywhere in the body. However, giant lipomas of the hand, defined as greater than 5cm in diameter, are rare. They have the potential to invade and cause a multitude of symptoms due to the compression and proximity of underlying structures.

We describe a case of a 64-year-old woman who presents with a swelling of the left thenar eminence, associated with numbness and tingling in all fingers.

MRI and nerve conduction studies confirmed the diagnosis of a lipoma causing median nerve compression. The patient underwent elective surgical excision using a volar approach, with good postoperative recovery. The excised lesion, measuring 12x7x2.4cm, is the largest giant lipoma of the hand reported in literature, and the first to demonstrate invasion from the mid palmar space into both the dorsal sub-aponeurotic space and carpal tunnel.

Space occupying lesions, such as giant lipomas of the hand, are a rare but important secondary cause of compression neuropathies of the upper extremity and must be suspected when these neuropathies present with atypical symptomatology. Any patient presenting with a soft-tissue lesion of the hand demonstrating rapid growth, pain or large size must be thoroughly investigated to rule out malignancy. MRI forms an essential part of the workup in such cases due to its high diagnostic accuracy. Malignant transformation of giant lipomas of the hand is extremely rare, and such lesions can be removed by en bloc marginal resection with excellent postoperative results.

294 Stem Cell Enriched Fat Grafts Versus Autologous Fat Grafts for Facial Reconstruction: A Systematic Review and Meta-Analysis

Aim

To compare the results of stem cell-enhanced fat grafting to autologous fat grafting for face reconstruction.

Method

A systematic review and meta-analysis were carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines, and an electronic search was carried out to identify all Randomised Controlled Trials (RCTs), case control studies, and cohort studies comparing the outcomes of stem cell-enrichment fat grafting versus routine fat grafting for facial reconstruction. The primary outcome measures were volume retention and infection rate. Secondary outcome measures included post-surgery patient satisfaction, redness and swelling, fat necrosis, cysts, and operation time. For the analysis, fixed and random effects modelling were utilised.

Results

Eight studies with a total of 275 participants were assessed. In terms of mean volume retention, there was a significant difference between the stem cell-enrichment fat grafting and routine grafting groups (standardised Mean Difference [MD] = 2.49, P 0.00001). However, there was no significant difference in infection rates between the two groups (OR = 0.36, P = 0.30). Except for the operation duration, which was shorter in the latter, the intervention group had similar results to the control group for all secondary outcomes.

Conclusions

When compared to conventional fat grafting, stem cell-enriched fat grafting is a better alternative for facial reconstruction surgery since it enhances mean volume retention and does not worsen patient satisfaction or surgical complications.

O086 Genomic analysis of response to neoadjuvant chemotherapy in oesophageal adenocarcinoma

Introduction

Oesophageal adenocarcinoma (OAC) is the ninth most common cancer worldwide with a mortality of over 500,000 deaths yearly. Neoadjuvant chemotherapy (NAC) followed by surgery is the standard of care (SOC) for locally advanced OAC. Although almost all patients receive chemotherapy as SOC, fewer than 20% obtain a clinically meaningful response and benefit before surgery. The OAC genome is complex and heterogeneous between patients, and it is not yet understood whether specific mutational patterns result in chemotherapy sensitivity or resistance.

Methods

To identify associations between genomic events and response to NAC in OAC, a comparative genomic analysis was performed in 65 patients using whole-genome sequencing. We defined response to NAC using Mandard Tumour Regression Grade TRG), with responders classified as TRG1-2 (n=27) and non-responders classified as TRG4- 5 (n=38).

Results

We report a higher non-synonymous mutation burden in responders (median 2.08/Mb vs 1.70/Mb, P=0.036) and elevated copy number variation (CNV) in non-responders (282 vs 136/patient, P&lt;0.001). We identified CNVs unique to each group, with cell cycle (CDKN2A, CCND1), c-Myc (MYC), RTK/PIK3 (KRAS, EGFR) and gastrointestinal differentiation (GATA6) pathway genes being specifically altered in non-responders. Of particular interest was the identification of the Neuron Navigator-3 (NAV3), a known tumour suppressor downstream of EGFR, which was mutated exclusively in 22% of non-responders.

Conclusion

We characterise genetic features and mutations that are uniquely associated with response to NAC. We envision a treatment pipeline that incorporates driver mutation profiling in OAC, combining response prediction with targeted therapies enhancing response to NAC and improving survival outcomes.

Take-home message

Developing a method of determining an OAC patient's response to neoadjuvant chemotherapy before treatment is administered is desperately needed and will improve patient outcome and quality of life. We identified a number of aberrations in the genome that were unique to non-responders to chemotherapy compared to responders, particularly a known tumour suppressor gene namely Neuron Navigator-3, suggesting that these events may contribute to chemoresistance in these patients. Our work characterises pre-existing genomic alterations that have potential as biomarkers for resistance or sensitivity to NAC.

Precision Determination of the Neutral Weak Form Factor of ^{48}Ca

We report a precise measurement of the parity-violating (PV) asymmetry A_{PV} in the elastic scattering of longitudinally polarized electrons from ^{48}Ca. We measure A_{PV}=2668±106(stat)±40(syst) parts per billion, leading to an extraction of the neutral weak form factor F_{W}(q=0.8733  fm^{-1})=0.1304±0.0052(stat)±0.0020(syst) and the charge minus the weak form factor F_{ch}-F_{W}=0.0277±0.0055. The resulting neutron skin thickness R_{n}-R_{p}=0.121±0.026(exp)±0.024(model)  fm is relatively thin yet consistent with many model calculations. The combined CREX and PREX results will have implications for future energy density functional calculations and on the density dependence of the symmetry energy of nuclear matter.

Comparison of the Levels of Blood Homocysteine between Women with Unexplained Infertility and Normal Fertility

Infertility is a common gynaecological problem which remains unexplained in 10-30% cases. This study explores the difference of blood levels of homocysteine between women with unexplained infertility and normal fertility. This was a cross-sectional study conducted from January 2015 to December 2015 in the Department of Gynaecology and Obstetrics of a tertiary care hospital of Bangladesh drawing 30 women with normal fertility as controls and 30 with unexplained infertility as cases. The subjects in both groups were well matched in terms of age (p value 0.875) as well as height, weight and BMI (p value 0.418). There was no statistically significant difference between the two groups in socio-economic status and educational levels. The two groups had similar duration of marriage (7.88±3.5 years in controls vs. 8.15±3.88 years in cases) and coital frequency (3.63±0.76 week in controls vs. 3.33±0.55 week in cases). Based on the institutional cut-off value for normal serum fasting homocysteine level of 15 micromoles/L, the frequency of hyper-homocysteinemia was significantly higher (40%) in unexplained infertility group compared to control group (16.7%, p value 0.044). Fasting serum homocysteine levels were significantly higher in the unexplained infertility group compared to the normal fertility group (13.46±5.05 vs. 9.87±4.84 micromoles/L, p value 0.007). Serum fasting homocysteine levels and frequency of hyper-homocysteinemia were increased in women with unexplained infertility compared to age and BMI matched women with normal fertility.

Deeply Virtual Compton Scattering Cross Section at High Bjorken x_{B}

We report high-precision measurements of the deeply virtual Compton scattering (DVCS) cross section at high values of the Bjorken variable x_{B}. DVCS is sensitive to the generalized parton distributions of the nucleon, which provide a three-dimensional description of its internal constituents. Using the exact analytic expression of the DVCS cross section for all possible polarization states of the initial and final electron and nucleon, and final state photon, we present the first experimental extraction of all four helicity-conserving Compton form factors (CFFs) of the nucleon as a function of x_{B}, while systematically including helicity flip amplitudes. In particular, the high accuracy of the present data demonstrates sensitivity to some very poorly known CFFs.

Reported costs of children with medical complexity-A systematic review

Examining reported costs for Children with Medical Complexity (CMCs) is essential because costing and resource utilization studies influence policy and operational decisions. Our objectives were to (1) examine how authors identified CMCs in administrative databases, (2) compare reported costs for the CMC population in different study settings, and (3) analyze author recommendations related to reported costs. We undertook a systematic search of the following databases: Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library with a focus on CMCs as a heterogeneous group. The most common method used n = 11 (41%) to identify the CMC population in administrative data was the Complex Chronic Conditions methodology. The majority of included studies reported on health care service costs n = 24 (89%). Only n = 3 (11%) of the studies included costs from the family perspective. Author recommendations included standardizing how costs are reported and including the family perspective when making care delivery or policy decisions. Health system administrators and policymakers must consider the limitations of reported costs when assessing local costing studies or comparing costs across jurisdictions.

975 RELATIONSHIP BETWEEN HAND GRIP STRENGTH (HGS) AND 10 YEAR PROBABILITY OF MAJOR OSTEOPOROTIC FRACTURES IN OLDER

Introduction

HGS has been shown to be associated with adverse outcomes in a wide range of conditions. It has also been found to be associated with bone mineral density and is inversely associated with risk of osteoporotic fractures. The aim of this study was to determine the association between HGS and 10 year probability of sustaining a major osteoporotic fractures in older inpatient and to evaluate the effect of gender on this association.

Method

This was a cross-sectional, observational analysis of older patients admitted into hospital between September and November 2021. HGS was measured in these patients using the JAMAR hydraulic hand held dynamometer. The Southampton protocol was used. The FRAX UK tool (without BMD) was used to calculate 10 year probability of major osteoporotic fractures. Patients were included if they were 60 years and above. Younger patients were excluded as were stroke patients. Patients with incomplete data were excluded from analysis. The SPSS 27 package was used for statistical analysis. Baseline characteristics were calculated using descriptive statistics. Pearson’s correlation coefficient and linear regression were used to calculate correlation.

Results

104 patients were analysed—41 males and 63 females. Mean age was 83 years (SD 8.2). Grip strength was inversely correlated with FRAX UK in predicting 10 year probability of major osteoporotic fractures in all patients, male patients and female patients (r = −0.452; p &lt; 0.001, r = −0.351; p = 0.02 and r = −0.271; p = 0.03 respectively).

Conclusion

Grip strength is negatively associated with increased probability of major osteoporotic fractures in older inpatients. Reference(s) Ma Y, Fu L, Jia L, et al. Muscle strength rather than muscle mass is associated with osteoporosis in older Chinese adults. J Formos Med Assoc. 2018;117(2):101–108. doi:10.1016/j.jfma.2017.03.004

New Measurements of the Beam-Normal Single Spin Asymmetry in Elastic Electron Scattering over a Range of Spin-0 Nuclei

We report precision determinations of the beam-normal single spin asymmetries (A_{n}) in the elastic scattering of 0.95 and 2.18 GeV electrons off ^{12}C, ^{40}Ca, ^{48}Ca, and ^{208}Pb at very forward angles where the most detailed theoretical calculations have been performed. The first measurements of A_{n} for ^{40}Ca and ^{48}Ca are found to be similar to that of ^{12}C, consistent with expectations and thus demonstrating the validity of theoretical calculations for nuclei with Z≤20. We also report A_{n} for ^{208}Pb at two new momentum transfers (Q^{2}) extending the previous measurement. Our new data confirm the surprising result previously reported, with all three data points showing significant disagreement with the results from the Z≤20 nuclei. These data confirm our basic understanding of the underlying dynamics that govern A_{n} for nuclei containing ≲50 nucleons, but point to the need for further investigation to understand the unusual A_{n} behavior discovered for scattering off ^{208}Pb.

Form Factors and Two-Photon Exchange in High-Energy Elastic Electron-Proton Scattering

We present new precision measurements of the elastic electron-proton scattering cross section for momentum transfer (Q^{2}) up to 15.75  (GeV/c)^{2}. Combined with existing data, these provide an improved extraction of the proton magnetic form factor at high Q^{2} and double the range over which a longitudinal or transverse separation of the cross section can be performed. The difference between our results and polarization data agrees with that observed at lower Q^{2} and attributed to hard two-photon exchange (TPE) effects, extending to 8  (GeV/c)^{2} the range of Q^{2} for which a discrepancy is established at >95% confidence. We use the discrepancy to quantify the size of TPE contributions needed to explain the cross section at high Q^{2}.

378 Endovascular Stenting vs. Open Surgery in Cerebral AVF Patients

Introduction

Intracranial dural arteriovenous fistulae (dAVF), typically found in the dural leaflets, are vascular malformations defined by a pathological communication between meningeal arteries and dural sinus or cortical veins. Despite many of them spontaneously resolving, they are still at high risk of hemorrhage and mortality if not effectively treated and monitored. Treatment options include endovascular embolization, surgical disconnection, and radiosurgery. With the rise of endovascular treatments now widely available, there is a massive shift towards minimally invasive surgical options while it can still be argued they are not the end of open surgical repairs.

Method

We reviewed 12 cases each of endovascular embolization and microsurgical resection in our Neurosurgical Unit retrospectively and compare between length of hospital stay, hemorrhage, need for open surgery following endovascular technique and wound infection. Cases will be selected at random over a period of 6 months.

Results

We compared surgical outcomes of 12 cases each of dural AvFs that were either managed as surgical repair or endovascular embolization. In cases with associated complication, surgical repair was the preferred method although endovascular repairs had shorter length of hospital stay, lower rates of infections and rarely needed to be followed by surgical repair.

Conclusions

Based on the result we conclude that endovascular repairs have a shorter length of hospital stay, infections and hemorrhage, yet there are instances where surgical disconnection may be the preferred treatment method on a case-by-case basis. Endovascular treatment may not have replaced open surgical procedures just yet, but the future may hold more advances in this field.

353 The Rise of the Exoscope

Introduction

An exoscope is a next generation HD telescope video monitoring system used to perform microsurgeries that is now a formidable rival to the existing operating microscope in neurosurgery. While the microscope revolutionised neurosurgery with its advent in 1957, the exoscope allows surgeons to operate utilising high-definition images enhancing the field of vision and focus. The exoscope opens new avenues with regards to ergonomics, teaching in theatre and enhances the surgeon’s experience.

Method

We will do a literature review on available literature on the use of exoscope in neurosurgery with regards to the operating microscope. Both qualitative and quantitative data will be reviewed. Personal experience of Neurosurgeons in our unit will also be reviewed using questionnaires.

Results

The exoscope has many benefits when compared to the operating microscope where it surpasses its predecessor in many ways. 15 studies were reviewed where the exoscope was compared to the operating microscope which concluded the exoscope equal or superior in many aspects such as teaching, ergonomics, image definition and being user friendly. There were some pitfalls of the exoscope reported such as the image being in 2D which limited the surgeon’s stereoscopic vision and the costs involved.

Conclusions

The exoscope is a revolutionary advent in neurosurgery and may soon make the operating microscope obsolete but there is still room for improvement.

79 Yellow Nail Syndrome Management with Nail Ablation and Reconstruction with a Full-Thickness Skin Graft

Aim

Yellow nail syndrome is a very rare and complex syndrome associated with aberrant nail growth multiple digits, in this case, the report we offer this as a solution to a challenging and rare condition.

Method

A 56-year-old lady underwent nail ablation and reconstruction with a full-thickness skin graft (FTSG).

Results

The patient had good cosmetic results.

Conclusions

Yellow nail syndrome is a rare but complex condition that is not yet fully understood. Nail plate deformity and discoloration are on the way the disease can manifest itself. Although not often encountered by plastic surgeons; The role of surgical excision for patients affected by dystrophic nails in yellow nail syndrome was given more emphasis within the literature. It is an effective technique that can be adapted as a standardized treatment modality

343 Medical Teaching in the Covid Era: The Rise of the Webinar

Background

Since the emergence of COVID-19, virtually the whole world has been forced to into lockdown and adapt to a way of life not seen in living memory. Although pandemics are not new, nor will this likely be the last, the modern era has one major advantage that our ancestors did not have: the internet.

Through the usage of modern technology and the internet, we have been able to continue our professional lives through a virtual medium through programs like Zoom. As part of this virtual shift, medical teaching is also mainly online. A QI study was conducted on webinars.

Aim

To determine whether medical students and junior doctors find online teaching to be an effective medium of learning, as well as to determine the advantages and disadvantages, including mental health impact.

Method

A webinar series was created, entitled back2basics (B2B) surgery, which was run for around 2 months with weekly, 1-hour long webinars on a surgical topic. Feedback was collected following each session specific to that week’s webinar as a general opinion of our participants on webinars.

Results

Both qualitative and quantitative data was collected. The majority (83%) of participants agreed by the 8th week that webinars were an effective mode of medical teaching compared to 48% in the 1st week. Participants pointed out that webinars are ‘low pressure’ and ‘less competitive’ than in person lectures, so good for mental health.

Conclusions

Participants agree that the webinars are effective for medical teaching and that there are mental health benefits.

Evaluation of the Status of Glycated Haemoglobin in Male type 2 Diabetic Patients

The incidence of type 2 diabetes mellitus is increasing in Bangladesh with its attendant complications. Glycated haemoglobin (HbA1c) is broadly used as an index of mean glycaemia. This study was planned to evaluate the status of glycated haemoglobin (HbA1c) in male type 2 diabetic patients. This cross-sectional analytical study was executed in the Department of Physiology, Mymensingh Medical College, Mymensingh, Bangladesh from July 2019 to June 2020. This study included in total 200 male subjects who are above 40 years in age. Among them, one hundred (100) male type 2 diabetic patients were taken as study group (Group I) and one hundred (100) age matched healthy male subjects were taken as control group (Group II). Glycated haemoglobin was assessed by ion-exchange high performance liquid chromatography (HPLC) method. Mean±SD was used to express data and unpaired Student's 't' test was used to calculate the statistical significance of difference amongst the groups. Pearson's correlation coefficient test was done to correlate the relationship between serum fasting glucose and glycated haemoglobin. The mean±SD of fasting serum glucose of Group I and Group II were 9.79±2.88mmol/L and 5.23±0.48mmol/L respectively. The mean±SD of glycated haemoglobin of Group I and Group II were 8.38±1.28mmol/L and 5.19±0.46mmol/L respectively. The mean±SD of glycated haemoglobin is found to be significantly higher in the study group compared to the control group and there is a positive correlation between fasting serum glucose and glycated haemoglobin. So, routine estimation of this parameter (HbA1c) is important for prevention of complications related to type 2 diabetes mellitus for leading healthy life.

Socio-demographic and Clinico-epidemiological Study of Scrub Typhus in A Tertiary Care Hospital of Mymensingh, Bangladesh

Scrub typhus is one of the leading causes of undifferentiated treatable febrile illness in Asia pacific region. It is grossly under diagnosed in many tropical countries of South Asia including Bangladesh, due to wide range of non-specific clinical presentations, low index of suspicion among clinicians, limited awareness and lack of accurate diagnostic facilities. This cross sectional observational study was conducted at department of Microbiology, Mymensingh Medical College, Mymensingh, Bangladesh from March 2019 to February 2020 enrolling 113 diagnosed cases of scrub typhus by Immunochromatographic test (ICT) and / or Nested PCR to characterize the socio-demographic and clinico-epidemiological features of scrub typhus in Mymensingh area. Majority of the scrub typhus cases came from rural areas (63.83%) and there was a slight female predominance (52.21%). The young (32.74%) and the young-adult age group (28.31%) were mostly affected. Most of the scrub typhus cases were housewives (30.98%), followed by farmers (23.89%) and students (21.23%). All the enrolled cases presented with fever. Other findings were myalgia (76.10%), headache (56.63%), cough (30.97%), vomiting (12.38%) and Respiratory distress (9.73%). Typical eschar of scrub typhus was present only in 9(7.96%) cases and 4(3.53%) patients had rashes on their skin. Few cases (3.53%) had jaundice and 15.96% cases were anaemic. Oliguria (7.96%) and neck rigidity (1.76%) were also documented. Most of the Nested PCR positive scrub typhus cases were documented during late rainy season and beginning of winter months. Findings of the study may offer increased awareness about high burden of scrub typhus as well as heightened suspicion among clinicians for early diagnosis, timely treatment and prevention of complications.

Trajectories of antidepressant use and characteristics associated with trajectory groups among young refugees and their Swedish-born peers with diagnosed common mental disorders-findings from the REMAIN study

PURPOSE

This study aimed to (1) identify the trajectories of prescribed antidepressants in refugee youth and matched Swedish-born peers diagnosed with common mental disorder (CMD) and (2) characterize the trajectories according to sociodemographic and medical factors.

METHODS

The study population comprised 2,198 refugees and 12,199 Swedish-born individuals with both Swedish-born parents, aged 16-25 years in 2011, residing in Sweden and treated in specialised healthcare for CMD 2009-11. Group-based trajectory modelling was used to identify different trajectory groups of antidepressant use-based on annual defined daily dosages (DDDs). Multinomial logistic regression was applied to investigate the association of sociodemographic and medical characteristics with the identified trajectories. Nagelkerke pseudo-R² values were estimated to evaluate the strength of these associations.

RESULTS

Four trajectory groups of antidepressant use among young refugees were identified with following proportions and DDD levels in 2011: 'low constant' (88%, < 100), 'low increasing' (2%, ≈710), 'medium decreasing' (8%, ≈170) and 'high increasing' (2%, ≈860). Similar trajectories, however, with different proportions were identified in Swedish-born: 67%, 7%, 21% and 5%, respectively. The most influential factors discriminating the trajectory groups among refugees were 'duration of stay in Sweden' (R² = 0.013), comorbid 'other mental disorders' (R² = 0.009) and 'disability pension' (R² = 0.007), while 'disability pension' (R² = 0.017), comorbid 'other mental disorders' (R² = 0.008) and 'educational level' (R² = 0.008) were the most important determinants discriminating trajectory groups among Swedish-born youth.

CONCLUSION

The lower use of antidepressants in refugees with CMDs compared to their Swedish-born counterparts warrants health literacy programs for refugees and training in transcultural psychiatry for healthcare professionals.

The impact of adolescent nicotine exposure on alcohol use during adulthood: The role of neuropeptides

Nicotine and alcohol abuse and co-dependence represent major public health crises. Indeed, previous research has shown that the prevalence of alcoholism is higher in smokers than in non-smokers. Adolescence is a susceptible period of life for the initiation of nicotine and alcohol use and the development of nicotine-alcohol codependence. However, there is a limited number of pharmacotherapeutic agents to treat addiction to nicotine or alcohol alone. Notably, there is no effective medication to treat this comorbid disorder. This chapter aims to review the early nicotine use and its impact on subsequent alcohol abuse during adolescence and adulthood as well as the role of neuropeptides in this comorbid disorder. The preclinical and clinical findings discussed in this chapter will advance our understanding of this comorbid disorder's neurobiology and lay a foundation for developing novel pharmacotherapies to treat nicotine and alcohol codependence.

Adolescent opioid abuse: Role of glial and neuroimmune mechanisms

Opioids are widely prescribed for pain management, and prescription opioid misuse in adolescents has become a major epidemic in the United States and worldwide. Emerging data indicate that adolescence represents a critical period of brain development, and exposure to opioids during adolescence may increase the risk of addiction in adulthood. There is growing evidence that disruptions in brain glial function may be implicated in numerous chronic neuropathologies. Evidence suggests that glial mechanisms have an important role in the development and maintenance of opioid abuse and the risk for addiction. This review will describe glial and neuroimmune mechanisms involved in opioid use disorders during adolescence, which may increase substance use disorder liability later in life. Moreover, this review will identify some important neuro-glial targets, involved in opioid abuse and addiction, to develop future preventions and treatment strategies.

Early life stress and susceptibility to addiction in adolescence

Early life stress (ELS) is a risk factor for developing a host of psychiatric disorders. Adolescence is a particularly vulnerable period for the onset of these disorders and substance use disorders (SUDs). Here we discuss ELS and its effects in adolescence, especially SUDs, and their correlates with molecular changes to signaling systems in reward and stress neurocircuits. Using a maternal separation (MS) model of neonatal ELS, we studied a range of behaviors that comprise a "drug-seeking" phenotype. We then investigated potential mechanisms underlying the development of this phenotype. Corticotropin releasing factor (CRF) and serotonin (5-HT) are widely believed to be involved in "stress-induced" disorders, including addiction. Here, we show that ELS leads to the development of a drug-seeking phenotype indicative of increased susceptibility to addiction and concomitant sex-dependent upregulation of CRF and 5-HT system components throughout extended brain reward/stress neurocircuits.

Trajectories of labour market marginalisation among young adults with newly diagnosed attention-deficit/hyperactivity disorder (ADHD)

AIMS

Labour market marginalisation (LMM), i.e. severe problems in finding and keeping a job, is common among young adults with attention-deficit/hyperactivity disorder (ADHD). This study aimed to disentangle the extent of LMM as well as the heterogeneity in patterns of LMM among young adults with ADHD and what characterises those belonging to these distinct trajectories of LMM.

METHODS

This population-based register study investigated all 6287 young adults, aged 22-29 years, who had their first primary or secondary diagnosis of ADHD in Sweden between 2006 and 2011. Group-based trajectory (GBT) models were used to estimate trajectories of LMM, conceptualised as both unemployment and work disability, 3 years before and 5 years after the year of an incident diagnosis of ADHD. Odds ratios (ORs) with 95% confidence intervals (CIs) for the association between individual characteristics and the trajectory groups of LMM were estimated by multinomial logistic regression.

RESULTS

Six distinct trajectories of LMM were found: 'increasing high' (21% belonged to this trajectory group) with high levels of LMM throughout the study period, 'rapidly increasing' (19%), 'moderately increasing' (21%), 'constant low' (12%) with low levels of LMM throughout the study period, 'moderately decreasing' (14%) and finally 'fluctuating' (13%), following a reversed u-shaped curve. Individuals with the following characteristics had an increased probability of belonging to trajectory groups of increasing LMM: low educational level (moderately increasing: OR: 1.4; CI: 1.2-1.8, rapidly increasing: OR: 1.7; CI: 1.3-2.1, increasing high: OR: 2.9; CI: 2.3-3.6), single parents (moderately increasing: OR: 1.6; CI: 1.1-2.4, rapidly increasing: OR: 2.0; CI: 1.3-3.0), those born outside the European Union/the Nordic countries (rapidly increasing: OR: 1.7; CI: 1.1-2.5, increasing high: OR: 2.1; CI: 1.4-3.1), persons living in small cities/villages (moderately increasing: OR: 2.4; CI: 1.9-3.0, rapidly increasing: OR: 2.1; CI: 1.6-2.7, increasing high: OR: 2.6; CI: 2.0-3.3) and those with comorbid mental disorders, most pronounced regarding schizophrenia/psychoses (rapidly increasing: OR: 6.7; CI: 2.9-19.5, increasing high: OR: 12.8; CI: 5.5-37.0), autism spectrum disorders (rapidly increasing: OR: 4.6; CI: 3.1-7.1, increasing high: OR: 9.6; CI: 6.5-14.6), anxiety/stress-related disorders (moderately increasing: OR: 1.3; CI: 1.1-1.7, rapidly increasing: OR: 2.0; CI: 1.6-2.5, increasing high: OR: 1.8; CI: 1.5-2.3) and depression/bipolar disorder (moderately increasing: OR: 1.3; CI: 1.0-1.6, rapidly increasing: OR: 1.7; CI: 1.4-2.2, increasing high: OR: 1.5; CI: 1.2-1.9).

CONCLUSIONS

About 61% of young adults were characterised by increasing LMM after a diagnosis of ADHD. To avoid marginalisation, attention should especially be given to young adults diagnosed with ADHD with a low educational level, that are single parents and who are living outside big cities. Also, young adults with comorbid mental disorders should be monitored for LMM early in working life.

Evolution of Structural and Electronic Properties of TiSe2 under High Pressure

A pressure-induced structural phase transition and its intimate link with the superconducting transition was studied for the first time in TiSe₂ up to 40 GPa at room temperature using X-ray diffraction, transport measurement, and first-principles calculations. We demonstrate the occurrence of a first-order structural phase transition at 4 GPa from the standard trigonal structure (S.G.P3̅m1) to another trigonal structure (S-G-P3̅c1). Additionally, at 16 GPa, the P3̅c1 phase spontaneously transforms into a monoclinic C2/m phase, and above 24 GPa, the C2/m phase returns to the initial P3̅m1 phase. Electrical transport results show that metallization occurs above 6 GPa. The charge density wave observed at ambient pressure is suppressed upon compression up to 2 GPa with the emergence of superconductivity at 2.5 GPa, with a critical temperature (T_c) of 2 K. A structural transition accompanies the emergence of superconductivity that persists up to 4 GPa. The results demonstrate that the pressure-induced phase transitions explored by the experiments along with the theoretical predictions may open the door to a new path for searching and controlling the phase diagrams of transition metal dichalcogenides.