Multidisciplinary consensus guideline for the diagnosis and management of spontaneous intracranial hypotension

BACKGROUND

We aimed to create a multidisciplinary consensus clinical guideline for best practice in the diagnosis, investigation and management of spontaneous intracranial hypotension (SIH) due to cerebrospinal fluid leak based on current evidence and consensus from a multidisciplinary specialist interest group (SIG).

METHODS

A 29-member SIG was established, with members from neurology, neuroradiology, anaesthetics, neurosurgery and patient representatives. The scope and purpose of the guideline were agreed by the SIG by consensus. The SIG then developed guideline statements for a series of question topics using a modified Delphi process. This process was supported by a systematic literature review, surveys of patients and healthcare professionals and review by several international experts on SIH.

RESULTS

SIH and its differential diagnoses should be considered in any patient presenting with orthostatic headache. First-line imaging should be MRI of the brain with contrast and the whole spine. First-line treatment is non-targeted epidural blood patch (EBP), which should be performed as early as possible. We provide criteria for performing myelography depending on the spine MRI result and response to EBP, and we outline principles of treatments. Recommendations for conservative management, symptomatic treatment of headache and management of complications of SIH are also provided.

CONCLUSIONS

This multidisciplinary consensus clinical guideline has the potential to increase awareness of SIH among healthcare professionals, produce greater consistency in care, improve diagnostic accuracy, promote effective investigations and treatments and reduce disability attributable to SIH.

Delta power during sleep is modulated by EEG-gated auricular vagal afferent nerve stimulation (EAVANS)

Vagus nerve stimulation (VNS) has many clinical applications under development. In particular, there is a large interest in transcutaneous auricular VNS (taVNS) because it is non-invasive and provides easy access to neuromodulation. The present study proposes a novel approach for electroencephalography (EEG)-gated taVNS, with the ultimate goal of enhancing therapeutic outcomes, including for the treatment of delirium. Delirium arises from an altered state of consciousness and is the most common neuropsychiatric disorder observed in hospitalized patients, especially the elderly. Delirium has been linked to specific disturbances in EEG rhythms. Here, we propose an EEG-gated auricular vagal afferent nerve stimulation (EAVANS) approach to deliver stimulation targeting a specific instantaneous phase of the EEG Delta rhythm to modulate arousal and downstream reduction of neuroinflammation, two of the contributing factors to delirium. We hypothesize that treatment with EAVANS will modulate Delta power, which has been linked with delirium. As dominant Delta power is also a typical feature of non-rapid eye movement (NREM) sleep, we applied a prototype of an EAVANS device on healthy volunteers during sleep to establish preliminary validation. We successfully employed our closed-loop approach to target vagal afference during the rising Delta phase in the range [-π/2 0] radians. We found a significant reduction in Delta wave power for stimulation during the rising Delta phase compared to 1) absence of stimulation, 2) active stimulation during the descending Delta phase, and 3) active stimulation targeting non-vagal territory (i.e. greater auricular nerve) during the rising Delta phase. Further validation of our EEG-gated taVNS approach in the peri-operative period will be needed. As there is presently a lack of effective treatments for delirium, our non-pharmacological and non-invasive approach, if validated, could be easily deployed in clinical settings.Clinical Relevance- Given the serious health consequences and costs associated with delirium, and the absence of effective non-pharmacological treatments, the proposed neuromodulatory approach may be a promising option for reducing delirium and other disorders of consciousness. Our EAVANS prototype system has been tested on healthy volunteers during a NREM sleep state and will require further validation in different patient populations to optimize the proposed technology and gather more evidence to support its clinical utility. This novel non-pharmacological and non-invasive closed-loop neuromodulatory device could be used peri-operatively and in inpatient hospital settings to treat patients at risk of developing delirium. For instance, in a pre-operative setting, this technology may provide an effective preventative "pre-habilitation" approach for patients at high risk of developing delirium. Post-operatively, our technology may help manage patients with delirium more effectively.

CATALYST: challenging antibiotic allergy status

OBJECTIVES

To develop a transferable process, CATALYST (challenging antibiotic allergy  status), to assess and challenge penicillin allergy status of inpatients within an NHS Foundation Hospital.

METHODS

A multidisciplinary team (MDT) steering group reviewed existing literature and protocols enabling penicillin allergy assessment, challenge and de-labelling. Using this, they identified five key steps forming the basis of CATALYST: clinical assessment of the nature of allergy; inclusion/exclusion criteria; consent; direct oral penicillin challenge; and removal of allergy label. A pharmacist-led pilot was conducted to assess the process, during which a continuous PDSA (plan-do-study-act) cycle was observed. This included formally auditing endpoint data such as accuracy of allergy status in medical records post-intervention.

RESULTS

CATALYST was successfully developed with key resources produced to support clinicians. It was piloted in 304 patients, with 172 patients excluded and 132 successful allergy challenges. There was one incident of an adverse event (acute kidney injury) in the 132 successful patients, which occurred as a delayed reaction following 22 days of penicillin therapy. Only 64% of permanent records (held by GP) were appropriately updated when audited at the end of the pilot.

CONCLUSIONS

CATALYST is a transferable process to facilitate safe assessment, challenge and removal of spurious penicillin allergy labels. Handover between care sectors forms a key element of allergy removal to ensure all records are updated and work is needed to ensure this process is done effectively.

1088 A QUALITY IMPROVEMENT PROJECT TO IMPROVE END OF LIFE CARE DOCUMENTATION ON A CARE OF THE ELDERLY WARD

Introduction

The National End of Life Care Strategy highlighted the need for individualised care plans accessible to the multi-disciplinary team. Care planning tools have been shown to improve documentation, with proformas providing a systematic approach to recording EOL discussions. Our initial staff survey highlighted a lack of familiarity with required EOLC documentation. We aimed to increase awareness of existing documentation proformas and to improve EOLC documentation on an elderly care ward.

Methods

A Driver Diagram increased understanding of the principles underlying excellent EOLC and aided development of change ideas. The Model for Improvement allowed identification of measurable aims. 20 patient notes were reviewed fortnightly, including patients who had died since the previous intervention.

Results

Three PDSA cycles were completed, changes were measured by evaluating patient documentation. The first PDSA cycle involved providing training to nursing colleagues. Step-by-step teaching on the use of Cerner EOL documentation demonstrated a 15% increase in completed care plans. The second cycle (placing posters around the ward) - detailing how to access and document care plans resulted in a 5% increase. The third cycle (25% improvement) involved education sessions for ward doctors.

Conclusions

Comprehensive documentation is key to ensuring good EOLC, as it enables continuity of care and improves MDT communication. Withdrawal of the Liverpool Care Pathway resulted in a need for individualised care plans. Active interventions including face-to-face teaching were more effective than passive (posters) in improving documentation. Limitations included small sample sizing, likely due to a lack of engagement with questionnaires and inclusion criteria. Only documentation of deceased patients was analysed, excluding patients discharged home or transferred to hospice. We aim to extend to other elderly care wards and to integrate documentation training into junior doctor induction. A review of existing EOL proformas and their ease of access may also be considered.

Scarring of the Eustachian tube: an unusual presentation following septoplasty and inferior turbinate reduction

Septoplasty and inferior turbinate reduction is a common operation performed by ear, nose and throat surgeons for obstructive nasal symptoms. We present a case of complete unilateral scarring of the Eustachian tube orifice, a previously unreported complication, following septoplasty and inferior turbinate reduction for nasal obstruction. It is important to consider this differential diagnosis in patients presenting with unilateral middle ear effusion postoperatively.

The spinal accessory nerve and its entry point into the posterior triangle of the neck

The course of the spinal accessory nerve in the neck is long and superficial rendering it at high risk of injury during procedures performed in the posterior triangle. The majority of spinal accessory nerve injuries are iatrogenic in nature. This is associated with significant morbidity including reduction in shoulder movements, drooping of the shoulder, winging of the scapula and neuropathic pain. Knowledge of the nerve anatomy reduces the risk of intra-operative nerve injury. Traditional teaching describes the point of entry into the posterior triangle as the intersection between the upper and middle third of the posterior border of sternocleidomastoid. The aim of this study was to determine whether this is in fact the case and if so, whether this landmark can reliably be used to identify the spinal accessory nerve in order to improve patient outcomes. The spinal accessory nerve was identified unilaterally in 26 cadavers. The total length of sternocleidomastoid was measured as well as the length along the posterior border from the inferior aspect of the mastoid process to the point at which the accessory nerve enters the posterior triangle of the neck. These measurements were used to calculate the ratio of the entry point of the nerve into the posterior triangle along the length of the posterior border of sternocleidomastoid from its superior insertion point. The mean ratio was 0.35 with 95% confidence intervals of 0.33 to 0.36. Our findings confirm the traditional description of the entry point of the spinal accessory nerve into the posterior triangle of the neck. We describe a so-called 'safe zone' inferior to the midpoint of the posterior border of sternocleidomastoid within which the spinal accessory nerve is unlikely to be found, thereby reducing the risk of iatrogenic injury.

Seeking celestial positronium with an OH-suppressed diffraction-limited spectrograph

Celestially, positronium (Ps) has been observed only through gamma-ray emission produced by its annihilation. However, in its triplet state, a Ps atom has a mean lifetime long enough for electronic transitions to occur between quantum states. This produces a recombination spectrum observable in principle at near IR wavelengths, where angular resolution greatly exceeding that of the gamma-ray observations is possible. However, the background in the near IR is dominated by extremely bright atmospheric hydroxyl (OH) emission lines. In this paper, we present the design of a diffraction-limited spectroscopic system using novel photonic components-a photonic lantern, OH fiber Bragg grating filters, and a photonic TIGER 2D pseudo-slit-to observe the Ps Balmer alpha line at 1.3122 µm for the first time, to our knowledge.

Potential of commercial SiN MPW platforms for developing mid/high-resolution integrated photonic spectrographs for astronomy

Integrated photonic spectrographs offer an avenue to extreme miniaturization of astronomical instruments, which would greatly benefit extremely large telescopes and future space missions. These devices first require optimization for astronomical applications, which includes design, fabrication, and field testing. Given the high costs of photonic fabrication, multi-project wafer (MPW) silicon nitride (SiN) offerings, where a user purchases a portion of a wafer, provide a convenient and affordable avenue to develop this technology. In this work, we study the potential of two commonly used SiN waveguide geometries by MPW foundries, i.e., square and rectangular profiles, to determine how they affect the performance of mid/high-resolution arrayed waveguide grating (AWG) spectrometers around 1.5 µm. Specifically, we present results from detailed simulations on the mode sizes, shapes, and polarization properties, and on the impact of phase errors on the throughput and cross talk as well as some laboratory results of coupling and propagation losses. From the MPW run tolerances and our phase-error study, we estimate that an AWG with R ∼10,000 can be developed with the MPW runs, and even greater resolving power is achievable with more reliable, dedicated fabrication runs. Depending on the fabrication and design optimizations, it is possible to achieve throughputs ∼60% using the SiN platform. Thus, we show that SiN MPW offerings are highly promising and will play a key role in integrated photonic spectrograph developments for astronomy.

Astrophotonics: introduction to the feature issue

Astrophotonics is an emerging field that focuses on the development of photonic components for astronomical instrumentation. With ongoing advancements, astrophotonic solutions are already becoming an integral part of existing instruments. A recent example is the €60M ESO GRAVITY instrument at the Very Large Telescope Interferometer, Chile, that makes heavy use of photonic components. We envisage far-reaching applications in future astronomical instruments, especially those intended for the new generation of extremely large telescopes and in space. With continued improvements in extreme adaptive optics, the case becomes increasingly compelling. The joint issue of JOSA B and Applied Optics features more than 20 state-of-the-art papers in diverse areas of astrophotonics. This introduction provides a summary of the papers that cover several important topics, such as photonic lanterns, beam combiners and interferometry, spectrographs, OH suppression, and coronagraphy.

Optimizing photonic ring-resonator filters for OH-suppressed near-infrared astronomy

Near-infrared wavelength observations are crucial for understanding numerous fields of astrophysics, such as supernova cosmology and positronium annihilation detection. However, current ground-based observations suffer from an enormous background due to OH emission in the upper atmosphere. One promising way to solve this problem is to use ring-resonator filters to suppress OH emission lines. In this work, we discuss our optimization of ring-resonator filter performance from five perspectives: resonance wavelength matching, polarization-independent operation, low insertion loss, low-loss coupling to astronomical instruments, and broadband operation. In the end, we discuss next steps needed for reliable supernova and positronium observations, thus providing a roadmap for future advances in near-infrared astronomy.

Pneumothorax and Pneumatocoele Formation in a Patient with COVID-19: a Case Report

Coronavirus disease 2019 (COVID-19) causes significant morbidity and mortality for a proportion of infected patients, and our knowledge and understanding of its clinical, radiological and histopathological features are still evolving. An association between COVID-19 and pneumothorax has been described in an increasing number of case reports and series in the literature, which have largely focused on clinical and imaging features. We report the case of a patient who developed COVID-19 complicated by pneumothorax, requiring surgical intervention. We describe the histopathological features seen in the thorascopically resected bullectomy specimen—this is, to our knowledge, the first reported description of the morphological features of pneumothorax in this important clinical setting.

Dysphagia presentation and management following COVID-19: an acute care tertiary centre experience

OBJECTIVES

As the pathophysiology of COVID-19 emerges, this paper describes dysphagia as a sequela of the disease, including its diagnosis and management, hypothesised causes, symptomatology in relation to viral progression, and concurrent variables such as intubation, tracheostomy and delirium, at a tertiary UK hospital.

RESULTS

During the first wave of the COVID-19 pandemic, 208 out of 736 patients (28.9 per cent) admitted to our institution with SARS-CoV-2 were referred for swallow assessment. Of the 208 patients, 102 were admitted to the intensive treatment unit for mechanical ventilation support, of which 82 were tracheostomised. The majority of patients regained near normal swallow function prior to discharge, regardless of intubation duration or tracheostomy status.

CONCLUSION

Dysphagia is prevalent in patients admitted either to the intensive treatment unit or the ward with COVID-19 related respiratory issues. This paper describes the crucial role of intensive swallow rehabilitation to manage dysphagia associated with this disease, including therapeutic respiratory weaning for those with a tracheostomy.

Oral versus intravenous antibiotics for bone and joint infections: the OVIVA non-inferiority RCT

BACKGROUND

Management of bone and joint infection commonly includes 4-6 weeks of intravenous (IV) antibiotics, but there is little evidence to suggest that oral (PO) therapy results in worse outcomes.

OBJECTIVE

To determine whether or not PO antibiotics are non-inferior to IV antibiotics in treating bone and joint infection.

DESIGN

Parallel-group, randomised (1 : 1), open-label, non-inferiority trial. The non-inferiority margin was 7.5%.

SETTING

Twenty-six NHS hospitals.

PARTICIPANTS

Adults with a clinical diagnosis of bone, joint or orthopaedic metalware-associated infection who would ordinarily receive at least 6 weeks of antibiotics, and who had received ≤ 7 days of IV therapy from definitive surgery (or start of planned curative treatment in patients managed non-operatively).

INTERVENTIONS

Participants were centrally computer-randomised to PO or IV antibiotics to complete the first 6 weeks of therapy. Follow-on PO therapy was permitted in either arm.

MAIN OUTCOME MEASURE

The primary outcome was the proportion of participants experiencing treatment failure within 1 year. An associated cost-effectiveness evaluation assessed health resource use and quality-of-life data.

RESULTS

Out of 1054 participants (527 in each arm), end-point data were available for 1015 (96.30%) participants. Treatment failure was identified in 141 out of 1015 (13.89%) participants: 74 out of 506 (14.62%) and 67 out of 509 (13.16%) of those participants randomised to IV and PO therapy, respectively. In the intention-to-treat analysis, using multiple imputation to include all participants, the imputed risk difference between PO and IV therapy for definitive treatment failure was -1.38% (90% confidence interval -4.94% to 2.19%), thus meeting the non-inferiority criterion. A complete-case analysis, a per-protocol analysis and sensitivity analyses for missing data each confirmed this result. With the exception of IV catheter complications [49/523 (9.37%) in the IV arm vs. 5/523 (0.96%) in the PO arm)], there was no significant difference between the two arms in the incidence of serious adverse events. PO therapy was highly cost-effective, yielding a saving of £2740 per patient without any significant difference in quality-adjusted life-years between the two arms of the trial.

LIMITATIONS

The OVIVA (Oral Versus IntraVenous Antibiotics) trial was an open-label trial, but bias was limited by assessing all potential end points by a blinded adjudication committee. The population was heterogenous, which facilitated generalisability but limited the statistical power of subgroup analyses. Participants were only followed up for 1 year so differences in late recurrence cannot be excluded.

CONCLUSIONS

PO antibiotic therapy is non-inferior to IV therapy when used during the first 6 weeks in the treatment for bone and joint infection, as assessed by definitive treatment failure within 1 year of randomisation. These findings challenge the current standard of care and provide an opportunity to realise significant benefits for patients, antimicrobial stewardship and the health economy.

FUTURE WORK

Further work is required to define the optimal total duration of therapy for bone and joint infection in the context of specific surgical interventions. Currently, wide variation in clinical practice suggests significant redundancy that likely contributes to the excess and unnecessary use of antibiotics.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN91566927.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 38. See the NIHR Journals Library website for further project information.

Patient deprivation and perceived scan burden negatively impact the quality of whole-body MRI

AIM

To evaluate the association between the image quality of cancer staging whole-body magnetic resonance imaging (WB-MRI) and patient demographics, distress, and perceived scan burden.

MATERIALS AND METHODS

A sample of patients recruited prospectively to multicentre trials comparing WB-MRI with standard scans for staging lung and colorectal cancer were invited to complete two questionnaires. The baseline questionnaire, administered at recruitment, collated data on demographics, distress and co-morbidity. The follow-up questionnaire, completed after staging investigations, measured perceived WB-MRI scan burden (scored 1 low to 7 high). WB-MRI anatomical coverage, and technical quality was graded by a radiographic technician and grading combined to categorise the scan as "optimal", "sub-optimal" or "degraded". A radiologist categorised 30 scans to test interobserver agreement. Data were analysed using the chi-square, Fisher's exact, t-tests, and multinomial regression.

RESULTS

One hundred and fourteen patients were included in the study (53 lung, 61 colorectal; average age 65.3 years, SD=11.8; 66 men [57.9%]). Overall, 45.6% (n=52), scans were classified as "optimal" quality, 39.5% (n=45) "sub-optimal", and 14.9% (n=17) as "degraded". In adjusted analyses, greater deprivation level and higher patient-reported scan burden were both associated with a higher likelihood of having a sub-optimal versus an optimal scan (odds ratio [OR]: 4.465, 95% confidence interval [CI]: 1.454 to 13.709, p=0.009; OR: 1.987, CI: 1.153 to 3.425, p=0.013, respectively). None of the variables predicted the likelihood of having a degraded scan.

CONCLUSIONS

Deprivation and patients' perceived experience of the WB-MRI are related to image quality. Tailored protocols and individualised patient management before and during WB-MRI may improve image quality.

Applying science to pressing conservation needs for penguins

More than half of the world's 18 penguin species are declining. We, the Steering Committee of the International Union for Conservation of Nature Species Survival Commission Penguin Specialist Group, determined that the penguin species in most critical need of conservation action are African penguin (Spheniscus demersus), Galápagos penguin (Spheniscus mendiculus), and Yellow-eyed penguin (Megadyptes antipodes). Due to small or rapidly declining populations, these species require immediate scientific collaboration and policy intervention. We also used a pairwise-ranking approach to prioritize research and conservation needs for all penguins. Among the 12 cross-taxa research areas we identified, we ranked quantifying population trends, estimating demographic rates, forecasting environmental patterns of change, and improving the knowledge of fisheries interactions as the highest priorities. The highest ranked conservation needs were to enhance marine spatial planning, improve stakeholder engagement, and develop disaster-management and species-specific action plans. We concurred that, to improve the translation of science into effective conservation for penguins, the scientific community and funding bodies must recognize the importance of and support long-term research; research on and conservation of penguins must expand its focus to include the nonbreeding season and juvenile stage; marine reserves must be designed at ecologically appropriate spatial and temporal scales; and communication between scientists and decision makers must be improved with the help of individual scientists and interdisciplinary working groups.

Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline

In systematic reviews that lack data amenable to meta-analysis, alternative synthesis methods are commonly used, but these methods are rarely reported. This lack of transparency in the methods can cast doubt on the validity of the review findings. The Synthesis Without Meta-analysis (SWiM) guideline has been developed to guide clear reporting in reviews of interventions in which alternative synthesis methods to meta-analysis of effect estimates are used. This article describes the development of the SWiM guideline for the synthesis of quantitative data of intervention effects and presents the nine SWiM reporting items with accompanying explanations and examples.

Supporting Cancer Patients Who Are Also Parents: Establishment of a Cross-Sector Service for Families With Adolescent and Young Adult Children

Background and context: Traditionally adult hospitals focus on the patient and less on their family. Adolescent and young adult children of cancer patients (AYA offspring) have significant psychosocial burdens associated with their parent's cancer however they are often invisible within hospitals with no clear referral pathways to community-based support. AYA offspring are 3-6 times more likely than peers to have clinically elevated levels of distress which increases with age. Research shows that 1 of the greatest concerns for parents is how to communicate about cancer with their children, and 1 of the greatest needs for AYA offspring is information about their parent's cancer and talking with their parents about it. Aim: CanTeen, a national AYA cancer community support organization, sought to address these needs by embedding a Parent Support Worker within the social work teams of tertiary hospitals for patients who are parents of AYA children. This service aims to assist with specific parenting challenges that arise due to a cancer diagnosis and establish a referral pathway for AYA offspring to CanTeen for support. Strategy/Tactics: Cofunding with philanthropic organizations was sought and CanTeen executives engaged in advocacy work with senior hospital management, demonstrating the need for the service and a plan to embed it within the existing hospital social work team and services. Program/Policy process: A new Parent Support Worker role was established to provide social work care to parents of AYA children following a parent's cancer diagnosis. The service provides support with parenting issues that arise due to the diagnosis as well as staff education, secondary consultations, and referrals of AYA offspring to CanTeen. A service improvement approach has been established with the collection of monitoring data measuring volume of referrals/sessions, capacity building of other staff, information given to young people and referrals to CanTeen. A service evaluation seeking feedback from patients and relevant hospital staff is also underway. Outcomes: To date, philanthropic funding and hospital support was gained to establish a pilot program placing a Parent Support Worker in 3 hospitals. Early indications are that this novel service is integrating well into established hospital teams and processes, and adding considerable value with the provision of this focused family support. What was learned: This advocacy initiative is highlighting the benefits of a model of care in adult hospitals that centrally considers family and the strength of a well-planned cross-sector service initiative.

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

BACKGROUND

The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications.

METHODS

ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery.

RESULTS

The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784.

CONCLUSIONS

This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.

CLINICAL TRIAL REGISTRATION

NCT03044899.

Mortality risk and social network position in resident killer whales: sex differences and the importance of resource abundance

An individual's ecological environment affects their mortality risk, which in turn has fundamental consequences for life-history evolution. In many species, social relationships are likely to be an important component of an individual's environment, and therefore their mortality risk. Here, we examine the relationship between social position and mortality risk in resident killer whales (Orcinus orca) using over three decades of social and demographic data. We find that the social position of male, but not female, killer whales in their social unit predicts their mortality risk. More socially integrated males have a significantly lower risk of mortality than socially peripheral males, particularly in years of low prey abundance, suggesting that social position mediates access to resources. Male killer whales are larger and require more resources than females, increasing their vulnerability to starvation in years of low salmon abundance. More socially integrated males are likely to have better access to social information and food-sharing opportunities which may enhance their survival in years of low salmon abundance. Our results show that observable variation in the social environment is linked to variation in mortality risk, and highlight how sex differences in social effects on survival may be linked to sex differences in life-history evolution.

Constant Isothiocyanate-Release Potentials across Biofumigant Seeding Rates

Biofumigation is an integrated pest-management method involving the mulching of a glucosinolate-containing cover crop into a field in order to generate toxic isothiocyanates (ITCs), which are effective soil-borne-pest-control compounds. Variation in biofumigation efficacy demonstrates a need to better understand the factors affecting pest-control outcomes and develop best practices for choosing biofumigants, growth conditions, and mulching methods that allow the greatest potential isothiocyanate release. We measured the glucosinolate concentrations of six different commercial varieties of three biofumigant plant species: Brassica juncea (ISCI99, Vitasso, and Scala) Raphanus sativus (Diablo and Bento), and Sinapis alba (Ida Gold). The plants were grown in the range of commercially appropriate seeding rates and sampled at three growth stages (early development, mature, and 50% flowering). Within biofumigant species, the highest ITC-release potentials were achieved with B. juncea cv. ISCI99 and R. sativus cv. Bento. The highest ITC-release potential occurred at the 50% flowering growth stage across the species. The seeding rate had a minor impact on the ITC-release potential of R. sativus but had no significant effects on the ITC-release potentials of the B. juncea or S. alba cultivars.

PRECEPT: an evidence assessment framework for infectious disease epidemiology, prevention and control

Decisions in public health should be based on the best available evidence, reviewed and appraised using a rigorous and transparent methodology. The Project on a Framework for Rating Evidence in Public Health (PRECEPT) defined a methodology for evaluating and grading evidence in infectious disease epidemiology, prevention and control that takes different domains and question types into consideration. The methodology rates evidence in four domains: disease burden, risk factors, diagnostics and intervention. The framework guiding it has four steps going from overarching questions to an evidence statement. In step 1, approaches for identifying relevant key areas and developing specific questions to guide systematic evidence searches are described. In step 2, methodological guidance for conducting systematic reviews is provided; 15 study quality appraisal tools are proposed and an algorithm is given for matching a given study design with a tool. In step 3, a standardised evidence-grading scheme using the Grading of Recommendations Assessment, Development and Evaluation Working Group (GRADE) methodology is provided, whereby findings are documented in evidence profiles. Step 4 consists of preparing a narrative evidence summary. Users of this framework should be able to evaluate and grade scientific evidence from the four domains in a transparent and reproducible way.

Abstract P3-12-07: Pharmacogenetic determinants of aromatase inhibitors pharmacokinetics and side effects: 6-month results of the adjuvant breast cancer longitudinal PHACS study (NCT01127295)

Supported by a PHRC grant (#09-18-005)

Background: Recent literature has suggested that germline genetic variants of drug-metabolizing enzymes or CYP19A1 (coding for aromatase) may be involved in the systemic aromatase inhibitors (AI) concentrations or the occurrence of side effects (Hertz et al. Pharmacogenomics 2017). A prospective multicentre 3-year follow-up study was carried out to investigate the relationships between pharmacogenetics (PG), pharmacokinetics (PK) and toxicity in breast cancer patients treated with adjuvant AI (n=1098) or tamoxifen (n=879). The clinical results and the tamoxifen PG/PK analyses are described elsewhere (abstracts #851544 and #850248).

Methods: SNP genotyping of 95 SNPs was performed on the Biomark (Fluidigm) with Taqman assays and was available for 373, 515 and 151 patients treated with anastrozole (ANA), letrozole (LETRO) and exemestane (EXE) respectively. CYP2A6 metaboliser status (MS) (poor, intermediate or normal) was determined based on alleles function (*1, *9, *2) and number of CYP2A6 copies. Trough plasma concentrations of each drug were determined 6 months after the start of the study by UPLC-MS/MS and were available for 342, 463 and 130 patients of the ANA, LETRO and EXE arms. Patients with AI concentrations below the limit of quantification were excluded for non-compliance (9 patients for ANA, 8 patients for LETRO and 7 patients for EXE). Toxicity was measured as a binary outcome (occurrence or worsening of hot flushes, fatigue, pain, arthralgia, vaginal dryness). All genetic associations were adjusted for multiple testing.

Results: ANA concentration was significantly higher in patients experiencing pain (p=0.025) and was associated with rs28365063 (UGT2B7 g.372A>G).

LETRO concentrations were strongly associated with CYP2A6 metabolizer status (p=0.0001) but did not differ in patients with or without toxicity.

In the EXE arm, patients with hot flushes or arthralgia had a significantly lower level of exemestane (p= 0.0002 and p=0.023 respectively) but since the metabolism of EXE leads to active 17-hydroexemestane, we can hypothesize that the lower EXE concentration is an indirect reflection of the metabolite formation. A SNP (rs2307424) in NR1I3 gene (coding for the constitutive androstane receptor CAR) was associated with EXE concentrations. CAR has been shown to regulate CYP2B6, which is involved in the formation of 6-hydroxy-methyl-exemestane (inactive metabolite).

Regarding the relationships between PG and toxicity, in the ANA arm, 3 SNPs of CYP19A1 gene tended to be associated with hot flushes worsening (rs934635) and arthralgia (rs10046 and rs2304463) but did not remain significant after multiple tests correction. In the EXE arm, several SNPs in NR1I3 gene were associated with fatigue.

In the LETRO arm, patients with a poor CYP2A6 MS had a higher risk of experiencing depression.

Conclusions: Our study confirms the predominant role of CYP2A6 in LETRO PK. To our knowledge, this is the first study to report on the role of UGT2B7 rs28365063 in ANA and NR1I3 in EXE PK and side effects. These relationships need to be re-evaluated with the drug concentrations obtained during the 3-year follow-up.

Citation Format: Thomas F, Marquet P, Pinguet F, White-Koning M, Robert J, Tafzi N, Solassol I, Despax R, Levasseur N, Ellis S, Massoubre A, Mbatchi L, Le Morvan V, Roché H, Chatelut E, Evrard A. Pharmacogenetic determinants of aromatase inhibitors pharmacokinetics and side effects: 6-month results of the adjuvant breast cancer longitudinal PHACS study (NCT01127295) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-12-07.

The Far Ultra-Violet imager on the ICON mission

ICON Far UltraViolet (FUV) imager contributes to the ICON science objectives by providing remote sensing measurements of the daytime and nighttime atmosphere/ionosphere. During sunlit atmospheric conditions, ICON FUV images the limb altitude profile in the shortwave (SW) band at 135.6 nm and the longwave (LW) band at 157 nm perpendicular to the satellite motion to retrieve the atmospheric O/N2 ratio. In conditions of atmospheric darkness, ICON FUV measures the 135.6 nm recombination emission of O+ ions used to compute the nighttime ionospheric altitude distribution. ICON Far UltraViolet (FUV) imager is a CzernyTurner design Spectrographic Imager with two exit slits and corresponding back imager cameras that produce two independent images in separate wavelength bands on two detectors. All observations will be processed as limb altitude profiles. In addition, the ionospheric 135.6 nm data will be processed as longitude and latitude spatial maps to obtain images of ion distributions around regions of equatorial spread F. The ICON FUV optic axis is pointed 20 degrees below local horizontal and has a steering mirror that allows the field of view to be steered up to 30 degrees forward and aft, to keep the local magnetic meridian in the field of view. The detectors are micro channel plate (MCP) intensified FUV tubes with the phosphor fiber-optically coupled to Charge Coupled Devices (CCDs). The dual stack MCP-s amplify the photoelectron signals to dominate the CCD noise and the rapidly scanned frames are co-added to digitally create 12-second integrated images. Digital on-board signal processing is used to compensate for geometric distortion and satellite motion and to achieve data compression. The instrument was originally aligned in visible light by using a special grating and visible cameras. Final alignment, functional and environmental testing and calibration were performed in a large vacuum chamber with a UV source. The test and calibration program showed that ICON FUV meets its design requirements and is ready to be launched on the ICON spacecraft.

Bone density and body composition in newly licenced professional jockeys

The primary objective is the description of bone mineral density (BMD) and body composition in newly licensed jockeys. One in three male, flat jockeys has a very low bone mineral density. Further research is needed to assess the short-term risk of fractures and long-term health implications of these findings.

INTRODUCTION

Describe bone mineral density (BMD) and body composition in entry-level male and female, flat and jump jockeys in Great Britain.

METHODS

Data was collected on jockeys applying for a professional jockey license between 2013 and 2015. Areal BMD at the spine, femoral neck (FN), total hip and body composition were assessed by dual-energy X-ray absorptiometry (DXA) scan. We examined differences between BMD and body composition by gender and race type (flat or jump). Volumetric bone mineral apparent density (BMAD) of the spine and FN was also calculated to account for group differences in bone size.

RESULTS

Seventy-nine male flat jockeys (age 18.5 ± 1.9, BMI 19.0 ± 1.4), 69 male jump (age 20.7 ± 2.0, BMI 20.6 ± 1.3) and 37 female flat jockeys (age 19.3 ± 2.0, BMI 20.8 ± 1.7) took part in this study. Spine BMD Z-scores ≤-2 for male flat, male jump and female flat jockeys were 29, 13 and 2.7%, respectively. Spine BMD was lower in male than female flat jockeys (p<0.001). All BMD scores were lower in male flat compared to male jump jockeys (p<0.001). Body fat percent (BF %) was lower in male flat jockeys compared to male jump and female flat jockeys (p<0.05). Lean mass index (LMI) was lower in male flat compared to male jump jockeys (p<0.001).

CONCLUSIONS

Male flat jockeys had a significantly lower BMD, LMI and BF% compared to jump jockeys and female flat jockeys. Male flat jockeys had lower spine BMD scores than females. Individual bone maturation may influence these findings. Further investigation into the relevance of low BMD and altered body composition on jockey health is required.

Prediction of outcome in newly diagnosed myeloma: a meta-analysis of the molecular profiles of 1905 trial patients

Robust establishment of survival in multiple myeloma (MM) and its relationship to recurrent genetic aberrations is required as outcomes are variable despite apparent similar staging. We assayed copy number alterations (CNA) and translocations in 1036 patients from the NCRI Myeloma XI trial and linked these to overall survival (OS) and progression-free survival. Through a meta-anlysis of these data with data from MRC Myeloma IX trial, totalling 1905 newly diagnosed MM patients (NDMM), we confirm the association of t(4;14), t(14;16), t(14;20), del(17p) and gain(1q21) with poor prognosis with hazard ratios (HRs) for OS of 1.60 (P=4.77 × 10^-7), 1.74 (P=0.0005), 1.90 (P=0.0089), 2.10 (P=8.86 × 10^-14) and 1.68 (P=2.18 × 10^-14), respectively. Patients with 'double-hit' defined by co-occurrence of at least two adverse lesions have an especially poor prognosis with HRs for OS of 2.67 (P=8.13 × 10^-27) for all patients and 3.19 (P=1.23 × 10^-18) for intensively treated patients. Using comprehensive CNA and translocation profiling in Myeloma XI we also demonstrate a strong association between t(4;14) and BIRC2/BIRC3 deletion (P=8.7 × 10^-15), including homozygous deletion. Finally, we define distinct sub-groups of hyperdiploid MM, with either gain(1q21) and CCND2 overexpression (P<0.0001) or gain(11q25) and CCND1 overexpression (P<0.0001). Profiling multiple genetic lesions can identify MM patients likely to relapse early allowing stratification of treatment.

Enhancing titres of therapeutic viral vectors using the transgene repression in vector production (TRiP) system

A key challenge in the field of therapeutic viral vector/vaccine manufacturing is maximizing production. For most vector platforms, the ‘benchmark' vector titres are achieved with inert reporter genes. However, expression of therapeutic transgenes can often adversely affect vector titres due to biological effects on cell metabolism and/or on the vector virion itself. Here, we exemplify the novel ‘Transgene Repression In vector Production' (TRiP) system for the production of both RNA- and DNA-based viral vectors. The TRiP system utilizes a translational block of one or more transgenes by employing the bacterial tryptophan RNA-binding attenuation protein (TRAP), which binds its target RNA sequence close to the transgene initiation codon. We report enhancement of titres of lentiviral vectors expressing Cyclo-oxygenase-2 by 600-fold, and adenoviral vectors expressing the pro-apoptotic gene Bax by >150,000-fold. The TRiP system is transgene-independent and will be a particularly useful platform in the clinical development of viral vectors expressing problematic transgenes.

The maximum titre of therapeutic viral vectors can be adversely affected by the encoded transgene. Here the authors repress transgene expression in producing cells by employing the tryptophan RNA-binding attenuation protein and show that it improves titre of RNA- and DNA-based viral vectors expressing toxic transgenes.

Inferring polydomy: a review of functional, spatial and genetic methods for identifying colony boundaries

Identifying the boundaries of a social insect colony is vital for properly understanding its ecological function and evolution. Many species of ants are polydomous: colonies inhabit multiple, spatially separated, nests. Ascertaining which nests are parts of the same colony is an important consideration when studying polydomous populations. In this paper, we review the methods that are used to identify which nests are parts of the same polydomous colony and to determine the boundaries of colonies. Specifically, we define and discuss three broad categories of approach: identifying nests sharing resources, identifying nests sharing space, and identifying nests sharing genes. For each of these approaches, we review the theoretical basis, the limitations of the approach and the methods that can be used to implement it. We argue that all three broad approaches have merits and weaknesses, and provide a methodological comparison to help researchers select the tool appropriate for the biological question they are investigating.

RNA binding proteins regulate anabolic and catabolic gene expression in chondrocytes

OBJECTIVE

Regulation of anabolic and catabolic factors is considered essential in maintaining the homoeostasis of healthy articular cartilage. In this study we investigated the influence of RNA binding proteins (RNABPs) in this process.

DESIGN

Using small interfering RNA (siRNA), RNABP expression was knocked down in SW1353 chondrosarcoma cells and human articular chondrocytes. Gene expression and messenger RNA (mRNA) decay of anabolic (SOX9, Aggrecan) and catabolic (matrix metalloproteinase (MMP)13) factors were analysed using reverse transcription quantitative polymerase chain reaction (RT-qPCR). RNA-electromobility shift assays (EMSAs) were used to investigate RNABP interactions with the SOX9 mRNA 3' untranslated region (UTR). Immunohistochemical localisation of MMP13 and the RNABP human antigen R (HuR) was performed in E13.5 and E16.5 mouse embryo sections.

RESULTS

SOX9 mRNA, mRNA half-life and protein expression were increased with siRNA targeting the RNABP tristetraprolin (TTP) in both HACs and SW1353s. TTP knockdown also stimulated aggrecan mRNA expression but did not affect its stability. RNA-EMSAs demonstrated that adenine uracil (AU)-rich elements in the SOX9 mRNA 3'UTR interacted with chondrocyte proteins with three specific elements interacting with TTP. HuR knockdown significantly increased MMP13 expression and also regulated the expression of a number of known transcriptional repressors of MMP13. HuR was ubiquitously expressed within mouse embryos yet displayed regional down-regulation within developing skeletal structures.

CONCLUSION

This study demonstrates for the first time how RNABPs are able to affect the balance of anabolic and catabolic gene expression in human chondrocytes. The post-transcriptional mechanisms controlled by RNABPs present novel avenues of regulation and potential points of intervention for controlling the expression of SOX9 and MMP13 in chondrocytes.

Adherence to exercise referral schemes by participants - what do providers and commissioners need to know? A systematic review of barriers and facilitators

Background

Physical inactivity levels are rising worldwide with major implications for the health of the population and the prevalence of non-communicable diseases. Exercise referral schemes (ERS) continue to be a popular intervention utilised by healthcare practitioners to increase physical activity. We undertook a systematic review of views studies in order to inform guidance from the UK National Institute of Health and Care Excellence (NICE) on exercise referral schemes to promote physical activity. This paper reports on the participant views identified, to inform those seeking to refine schemes to increase attendance and adherence.

Methods

Fifteen databases and a wide range of websites and grey literature sources were searched systematically for publications from 1995 to June 2013. In addition, a range of supplementary methods including, a call for evidence by NICE, contacting authors, reference list checking and citation tracking were utilised to identify additional research.

Studies were included where they detailed schemes for adults aged 19 years or older who were ‘inactive’ (i.e. they are not currently meeting UK physical activity guidelines). Study selection was conducted independently in duplicate. Quality assessment was undertaken by one reviewer and checked by a second, with 20 % of papers being considered independently in duplicate. Papers were coded in qualitative data analysis software Atlas.ti. This review was reported in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement).

Results

Evidence from 33 UK-relevant studies identified that support from providers, other attendees and family was an important facilitator of adherence and ‘making exercise a habit’ post programme, as was the variety and personalised nature of sessions offered. Barriers to attendance included the inconvenient timing of sessions, their cost and location. An intimidating gym atmosphere, a dislike of the music and TV and a lack of confidence in operating gym equipment were frequently reported.

Conclusions

These findings provide valuable insights that commissioners and providers should consider. The main themes were consistent across a large number of studies and further research should concentrate on programmes that reflect these findings.

Tamoxifen impairs prepubertal mammary development and alters expression of estrogen receptor α (ESR1) and progesterone receptors (PGR)

Research has shown that prepubertal heifers experience allometric mammary growth that is influenced by the ovaries. Our purpose was to determine the role of estrogen in prepubertal mammary gland development. Sixteen Holstein calves were randomly assigned to 1 of 2 treatment groups: tamoxifen-injected (TAM) or control (CON). Calves were administered the antiestrogen tamoxifen (0.3 mg kg(1) d(1)) or placebo from 28 to 120 d of age. At 120 d, calves were euthanized and udders removed. Weight and DNA content of trimmed parenchymal tissue were halved (P ≤ 0.0001) in TAM compared with CON calves. Parenchymal samples from 3 zones of the left rear mammary gland (lower, middle, and outer regions) were processed for immunohistochemical staining for estrogen receptor α (ESR1) and progesterone receptor (PGR), Ki67-positive cells, and 5-bromo-2'-deoxyuridine label retaining cells (LRCs). Overall, neither the percentage nor location within the epithelial tissue layer of either ESR1- or PGR-positive cells was impacted by TAM treatment. However, image analysis indicated a 6.2-fold lower (P = 0.0001) level of ESR1 protein expression in TAM calves. Similarly, messenger RNA expression of ESR1 was also reduced (P = 0.0001) in TAM heifers. In contrast, expression of PGR protein was greater by 43% (P = 0.03) in TAM calves, but messenger RNA expression did not differ between treatments. Overall, TAM calves had a higher (P ≤ 0.03) percentage and density (cells per tissue area) of Ki67-positive cells. Irrespective of treatment, there were also more Ki67-labeled cells in the outer zones of the mammary gland (P ≤ 0.001). We were able to effectively use multispectral imaging to identify positive cells and quantify the expression of ESR1 and PGR protein. We also identified and counted the proportion of label retaining cells (LCR) (putative epithelial stem cells). We noted an overall 2.9-fold greater number of LRCs in TAM heifers and more LRCs in the outer sampling zones. This suggests that a cohort of LCR cells in TAM remained inactivated in comparison with CON heifers, which exhibited markedly increased growth of the mammary parenchymal tissue over the treatment period. These results suggest that the impacts of ovariectomy are partially explained by loss of ESR1 expression and/or estrogen receptor signaling in the prepubertal bovine mammary gland. The significance of mammary expression of PGR in control of prepubertal bovine mammary development remains unresolved.

Determining the effects and challenges of incorporating genetic testing into primary care management of hypertensive patients with African ancestry

People of African ancestry (Blacks) have increased risk of kidney failure due to numerous socioeconomic, environmental, and clinical factors. Two variants in the APOL1 gene are now thought to account for much of the racial disparity associated with hypertensive kidney failure in Blacks. However, this knowledge has not been translated into clinical care to help improve patient outcomes and address disparities. GUARDD is a randomized trial to evaluate the effects and challenges of incorporating genetic risk information into primary care. Hypertensive, non-diabetic, adults with self-reported African ancestry, without kidney dysfunction, are recruited from diverse clinical settings and randomized to undergo APOL1 genetic testing at baseline (intervention) or at one year (waitlist control). Providers are educated about genomics and APOL1. Guided by a genetic counselor, trained staff return APOL1 results to patients and provide low-literacy educational materials. Real-time clinical decision support tools alert clinicians of their patients' APOL1 results and associated risk status at the point of care. Our academic-community-clinical partnership designed a study to generate information about the impact of genetic risk information on patient care (blood pressure and renal surveillance) and on patient and provider knowledge, attitudes, beliefs, and behaviors. GUARDD will help establish the effective implementation of APOL1 risk-informed management of hypertensive patients at high risk of CKD, and will provide a robust framework for future endeavors to implement genomic medicine in diverse clinical practices. It will also add to the important dialog about factors that contribute to and may help eliminate racial disparities in kidney disease.

Dietary quality and patterns and non-communicable disease risk of an Indian community in KwaZulu-Natal, South Africa

BACKGROUND

Limited data exist on the South African Indian diet despite their high prevalence of non-communicable diseases. This study attempted to determine the dietary quality and patterns of an Indian population in KwaZulu-Natal with reference to the high prevalence of non-communicable disease

METHODS

Two-hundred-and-fifty apparently healthy Indians, aged 35-55 years participated in a cross-sectional study where diet was assessed using a validated quantitative food frequency questionnaire. Mean intakes were compared to the World Health Organization goals. Dietary quality was determined by index construction and dietary patterns by factor analysis.

RESULTS

The mean daily percentage of energy (%E) from n-3 fatty acids (0.24 %E), dietary fibre (18.4 g/day) and fruit and vegetable intakes (229.4 g/day) were below the World Health Organization goals. Total fat (36.1 %E), polyunsaturated fatty acids (11.8 %E), n-6 fatty acids (11 %E) and free sugars (12.5 %E) exceeded the goals. The means for the deficient index reflected a moderate diet quality whereas, the excess index reflected good diet quality. The Pearson partial correlation coefficients between the deficient index and risk markers were weak whilst, the excess index was inversely correlated with waist circumference for the whole sample. Two factors were identified, based on the percentage of fat that contributed to each food group: factor 1 (meat and fish versus legume and cereal pattern), which accounted for added fat through food preparation; and Factor 2 (nuts and seeds versus sugars and visible fat pattern), which accounted for obvious fat. The medians for waist circumference, blood glucose, cholesterol and triglyceride levels showed significant decreasing trends for factor 1 (p < 0.05). The medians for blood glucose and cholesterol showed significant decreasing trends for factor 2 (p < 0.01).

CONCLUSION

A shortfall of fruit and vegetable, fibre and n-3 fatty acid intake in the diet is highlighted. When assessing the diet quality and patterns, guidance on the prudent use of added fats may lead to a healthier lifestyle reducing the prevalence of non-communicable diseases.

Demonstration of uniform multicore fiber Bragg gratings

Fiber Bragg gratings in multicore fibers have significant potential as compact and robust filters for research and commercial applications. With the aid of an innovative, flat-fielded Mach-Zehnder interferometer, we demonstrate deep (>30 dB) narrow (100 pm at 3 dB; 90 pm at 10 dB) notches in the outer 6 cores of a 7-core fiber at a constant wavelength ( ± 15 pm). This is a crucial step in the development of FBGs operating within multimode fibers that carry an arbitrary number of spatial modes.