Volumetric changes in post hemiglossectomy reconstruction with anterolateral thigh free flap versus radial forearm free flap

The volume of the reconstructed tongue is considered a critical factor for tongue function. Studies investigating the difference in volume loss between the anterolateral thigh free flap (ALTF) and radial forearm free flap (RFFF) used in reconstruction of the tongue after hemiglossectomy are lacking. The aim of this study was to determine whether there is a significant difference in shrinkage between these two flaps. This was a retrospective study of all patients treated for tongue cancer by hemiglossectomy who underwent either ALTF or RFFF reconstruction at the University of Florida College of Medicine between January 2018 and April 2022. Computed tomography scans were used to measure the volumetric changes in the ALTF and RFFF at two time points over a 6-month period. Of the 85 patients assessed, 10 fulfilled the inclusion criteria: five were reconstructed with an ALTF and five with a RFFF. All underwent adjuvant radiotherapy. The mean ALTF percentage shrinkage was 39.6% ± 3.9%, while for the RFFF it was 51.1% ± 6.2% (P = 0.008). Therefore, it is recommended that the difference in volume loss between the two flaps is taken into consideration. It is suggested that in hemiglossectomy cases, the ALTF is made 1.4 times larger than the defect, while the RFFF is made 1.5 times larger.

Prevalence of Antimicrobial Resistance in Escherichia coli and Salmonella Species Isolates from Chickens in Live Bird Markets and Boot Swabs from Layer Farms in Timor-Leste

The rapid emergence of antimicrobial resistance is a global concern, and high levels of resistance have been detected in chicken populations worldwide. The purpose of this study was to determine the prevalence of antimicrobial resistance in Escherichia coli and Salmonella spp. isolated from healthy chickens in Timor-Leste. Through a cross-sectional study, cloacal swabs and boot swabs were collected from 25 live bird markets and two layer farms respectively. E. coli and Salmonella spp. from these samples were tested for susceptibility to six antimicrobials using a disk diffusion test, and a subset was tested for susceptibility to 27 antimicrobials using broth-based microdilution. E. coli and Salmonella spp. isolates showed the highest resistance towards either tetracycline or ampicillin on the disk diffusion test. E. coli from layer farms (odds ratio:5.2; 95%CI 2.0-13.1) and broilers (odds ratio:18.1; 95%CI 5.3-61.2) were more likely to be multi-drug resistant than those from local chickens. Based on the broth-based microdilution test, resistance to antimicrobials in the Timor-Leste Antimicrobial Guidelines for humans were low, except for resistance to ciprofloxacin in Salmonella spp. (47.1%). Colistin resistance in E. coli was 6.6%. Although this study shows that antimicrobial resistance in chickens was generally low in Timor-Leste, there should be ongoing monitoring in commercial chickens as industry growth might be accompanied with increased antimicrobial use.

Identification of candidate novel production variants on the Bos taurus chromosome X

Chromosome X is often excluded from bovine genetic studies due to complications caused by the sex specific nature of the chromosome. As chromosome X is the second largest cattle chromosome and makes up approximately 6% of the female genome, finding ways to include chromosome X in dairy genetic studies is important. Using female animals and treating chromosome X as an autosome, we performed X chromosome inclusive genome-wide association studies in the selective breeding environment of the New Zealand dairy industry, aiming to identify chromosome X variants associated with milk production traits. We report on the findings of these genome-wide association studies and their potential effect within the dairy industry. We identify missense mutations in the MOSPD1 and CCDC160 genes that are associated with decreased milk volume and protein production and increased fat production. Both of these mutations are exonic SNP that are more prevalent in the Jersey breed than in Holstein-Friesians. Of the 2 candidates proposed it is likely that only one is causal, though we have not been able to identify which is more likely.

Extended postoperative venous thromboembolism prophylaxis after bariatric surgery: a comparison of existing risk-stratification tools and 5-year MBSAQIP analysis

BACKGROUND

Venous thromboembolism (VTE) is a leading cause of 30-day mortality after metabolic and bariatric surgery (MBS). Multiple predictive tools exist for VTE risk assessment and extended VTE chemoprophylaxis determination.

OBJECTIVE

To review existing risk-stratification tools and compare their predictive abilities.

SETTING

MBSAQIP database.

METHODS

Retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was performed (2015-2019) for primary minimally invasive MBS cases. VTE clinical factors and risk-assessment tools were evaluated: body mass index threshold of 50 kg/m2, Caprini risk-assessment model, and 3 bariatric-specific tools: the Cleveland Clinic VTE risk tool, the Michigan Bariatric Surgery Collaborative tool, and BariClot. MBS patients were deemed high risk based on criteria from each tool and further assessed for sensitivity, specificity, and positive predictive value.

RESULTS

Overall, 709,304 patients were identified with a .37% VTE rate. Bariatric-specific tools included multiple predictors: procedure, age, race, gender, operative time, length of stay, heart failure, and dyspnea at rest; operative time was the only variable common to all. The body mass index cutoff and Caprini risk-assessment model had higher sensitivity but lower specificity when compared with the Michigan Bariatric Surgery Collaborative and BariClot tools. While the sensitivity of the tools varied widely and was overall low, the Cleveland Clinic tool had the highest sensitivity. The bariatric-specific tools would have recommended extended prophylaxis for 1.1%-15.6% of patients.

CONCLUSIONS

Existing MBS VTE risk-assessment tools differ widely for inclusion variables, high-risk definition, and predictive performance. Further research and registry inclusion of all significant risk factors are needed to determine the optimal risk-stratified approach for predicting VTE events and determining the need for extended prophylaxis.

Approach to anisocoria in the emergency department; A case report and literature review

Anisocoria describes asymmetric pupillary diameter, which can result from traumatic, pharmacologic, inflammatory, or ischemic effects on the eye. In many cases, anisocoria represents a normal physiologic variant. Morbidity associated with anisocoria is directly related to the inciting cause and can vary from benign to life-threatening. A thorough understanding by emergency physicians of normal ocular neuroanatomy, and of common causes of pathologic anisocoria, including medication-induced anisocoria, can facilitate appropriate resource utilization and timely subspecialty consultation, and can help prevent irreversible ocular injury and patient morbidity. We describe a patient who presented to the emergency department with acute onset of blurry vision with anisocoria.

Angiotensin II-Mediated Neuroinflammation in the Hippocampus Contributes to Neuronal Deficits and Cognitive Impairment in Heart Failure Rats

BACKGROUND

Heart failure (HF) is a debilitating disease affecting >64 million people worldwide. In addition to impaired cardiovascular performance and associated systemic complications, most patients with HF suffer from depression and substantial cognitive decline. Although neuroinflammation and brain hypoperfusion occur in humans and rodents with HF, the underlying neuronal substrates, mechanisms, and their relative contribution to cognitive deficits in HF remains unknown.

METHODS

To address this critical gap in our knowledge, we used a well-established HF rat model that mimics clinical outcomes observed in the human population, along with a multidisciplinary approach combining behavioral, electrophysiological, neuroanatomical, molecular and systemic physiological approaches.

RESULTS

Our studies support neuroinflammation, hypoperfusion/hypoxia, and neuronal deficits in the hippocampus of HF rats, which correlated with the progression and severity of the disease. An increased expression of AT1aRs (Ang [angiotensin] II receptor type 1a) in hippocampal microglia preceded the onset of neuroinflammation. Importantly, blockade of AT1Rs with a clinically used therapeutic drug (Losartan), and delivered in a clinically relevant manner, efficiently reversed neuroinflammatory end points (but not hypoxia ones), resulting in turn in improved cognitive performance in HF rats. Finally, we show than circulating Ang II can leak and access the hippocampal parenchyma in HF rats, constituting a possible source of Ang II initiating the neuroinflammatory signaling cascade in HF.

CONCLUSIONS

In this study, we identified a neuronal substrate (hippocampus), a mechanism (Ang II-driven neuroinflammation) and a potential neuroprotective therapeutic target (AT1aRs) for the treatment of cognitive deficits in HF.

Fossil diversity in ‘dawn’ hexapods (Diplura: Projapygoidea), with direct evidence for being chemically predaceous in the Cretaceous

Diplurans are among the earliest hexapods in the geological record. These primitively wingless relatives of insects are infrequently encountered despite being pervasive in soil habitats. Two groups have disparate adaptations for hunting, one mechanical and the other chemical, in Japygoidea and Projapygoidea, respectively. Here, we report three genera (two new) and four species of fossil Projapygidae preserved in Mesozoic and Cenozoic ambers: Electroprojapyx alchemicus gen. et sp. nov. in mid-Cretaceous Myanmar amber, and Symphylurinopsis punctatus gen. et sp. nov. and two species (unnamed) of Symphylurinus in Miocene Dominican amber. The exceptionally preserved specimens possess cerci that are morphologically specialized for expelling a glandular substance on prey. The new Cretaceous E. alchemicus is a stem group to all living species of the family and provides conclusive Mesozoic evidence for a rare type of predation involving offensive (vs. defensive) secretions. The specimen was fossilized in a preying-and-spraying position with its presumptive meal, a Symphypleona springtail (Collembola), reflecting the behavioural predatory repertoire of modern relatives. Apart from one Cenozoic species, these rare specimens represent the only fossil record of the family Projapygidae. Our findings demonstrate that these basal hexapods were predators of small arthropods of ancient forest soils and enrich our understanding of palaeoecological associations and behavioural strategies paramount for the survival of species.

Statistical inference for unreliable grading using the maximum entropy principle

Quantitatively assessing the level of confidence on a test score can be a challenging problem, especially when the available information is based on multiple criteria. A concrete example beyond the usual grading of tests occurs with recommendation letters, where a recommender assigns a score to a candidate, but the reliability of the recommender must be assessed as well. Here, we present a statistical procedure, based on Bayesian inference and Jaynes' maximum entropy principle, that can be used to estimate the most probable and expected score given the available information in the form of a credible interval. Our results may provide insights on how to properly state and analyze problems related to the uncertain evaluation of performance in learning applied to several contexts, beyond the case study of the recommendation letters presented here.

Knowledge, attitudes and practices of government animal health workers on antibiotic use and antibiotic resistance in Timor-Leste

Introduction

Antibiotic resistance is a global health threat, and there is growing concern on the inappropriate use of antibiotics in the livestock sector especially in low and middle income countries. The purpose of the study was to understand the knowledge, attitudes and practices on antibiotic use and antibiotic resistance of government animal health workers in Timor-Leste.

Method

A cross-sectional survey using a census approach was conducted between August 2021 and January 2022 focusing on government animal health workers involved in field work and access to antibiotics. Interviews were face-to-face in the local Tetun language. Descriptive and regression analysis informed by causal diagrams were performed.

Result

The study found poor knowledge of antibiotics among participants, with only 8.0% (13/162) able to correctly answer questions on how antibiotics worked. Knowledge of antibiotic resistance was poor as only 29.0% (47/162) of participants had heard of antibiotic resistance and were able to accurately identify that it made antibiotics less effective. Knowledge of antibiotics and knowledge of antibiotic resistance were crudely associated with being a veterinary technician and having university education. Attitude scores were positively influenced by knowledge of antibiotics and antibiotic resistance. Antibiotics were most commonly used in pigs, cattle and buffalo, with oxytetracycline being the most commonly used antibiotics in pigs and chicken. However, most participants reported a lack in supply of this antibiotic (137/162, 78.4%) and other antibiotics. Empiric use of antibiotics in sick animals was common, and some participants used antibiotics for parasitic diseases. Less than a fifth of participants reported ever using human antibiotics, and use of antibiotics for growth promotion was uncommon.

Conclusion

There is a need to develop Timor-Leste specific treatment guidelines, strengthen veterinary diagnostic support, improve antibiotic procurement, and develop training programs to address knowledge gaps and poor practices found in this study.

QTc interval in anorexia nervosa: a systematic review and meta-analysis

Background

Patients with anorexia nervosa (AN) are at higher risk of sudden cardiac death. Although the underlying aetiology for this association remains unclear. It may be related to prolongation of the QT interval, which can degenerate into fatal ventricular arrhythmias. However, the presence of prolonged heart rate-corrected QT interval (QTc) in AN remains controversial, and two previous meta-analyses on AN and QTc showed contradictory findings [1,2].

Purpose

In this systematic review and meta-analysis, we aimed to evaluate if AN was associated with changes in the QTc interval and dispersion.

Methods

MEDLINE, EMBASE and COCHRANE databases were systematically searched from inception to January 2021. Random-effects meta-analysis and meta-regression were used. The inclusion criteria were (i) confirmed diagnosis of AN, (ii) measurement of QTc on electrocardiogram and (iii) peer-reviewed articles. The primary endpoint of the study was the duration of the QTc interval calculated using the Bazett (QTcB), Hodges (QTcH), Fridericia (QTcF) and Framingham (QTcFr) formulae. The secondary endpoints were QT dispersion (QTd) and QTc dispersion (QTcd).

Results

The 25 eligible studies included 5687 patients (1862 AN, 3825 control) (Figure 1: PRISMA diagram). The majority of patients were female (96.3%) with a mean age between 14.3 to 31.0 years and mean duration of disease ranging from 9.1 to 129.6 months. The mean BMI ranged from 13.7 to 18.5 kg/m2. Pooled analysis did not show significant prolongation between AN versus control in QTcB (mean difference (MD) MD 4.9ms, 95% CI −3.2, 13.1ms, p=0.23; I2=95%; n=24/25 studies; Figure 2A), QTcH (MD 1.3ms, 95% CI −8.5, 11.2ms, p=0.79; I2=71%; n=3/25 studies), and QTcF (MD 3.1ms, 95% CI −21.6, 27.7ms, p=0.81; I2=97%; n=3/25 studies). Only two studies reporting QTcFr showed a significant prolongation between AN and control (MD 15.9ms, 95% CI 0.0, 31.8ms, p=0.05, I2=65%; n=2/25 studies; Figure 2B). However, QTd and QTcd were significantly greater in AN than control (MD 21.3ms, 95% CI 10.4, 32.3ms, p=0.0001, I2=94%; Figure 2C and MD 16.9ms, 95% CI 4.5, 29.3ms, p=0.007 I2=93%; Figure 2D, respectively).

Conclusion

To the best of our knowledge, this is the largest meta-analysis of QTc in AN and the first meta-analysis exploring the significance of QTd and QTcd in AN. AN was not found to be associated with prolongation of QTc calculated using the Bazett, Fridericia and Hodges formulae. However, an association of AN with prolonged QTc was observed in the studies using the Framingham formula. More pronounced dispersion (QTd and QTcd) was also observed in patients with AN.

Funding Acknowledgement

Type of funding sources: None.

Multi-center matched cohort study of convalescent plasma for hospitalized patients with COVID-19

Background

Although frequently used in the early pandemic, data on the effectiveness of COVID-19 convalescent plasma (CCP) remain mixed. We investigated the effectiveness and safety of CCP in hospitalized COVID-19 patients in real-world practices during the first two waves of the pandemic in a multi-hospital healthcare system in Texas.

Methods and findings

Among 11,322 hospitalized patients with confirmed COVID-19 infection from July 1, 2020 to April 15, 2021, we included patients who received CCP and matched them with those who did not receive CCP within ±2 days of the transfusion date across sites within strata of sex, age groups, days and use of dexamethasone from hospital admission to the match date, and oxygen requirements 4–12 hours prior to the match date. Cox proportional hazards model estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for effectiveness outcomes in a propensity score 1:1 matched cohort. Pre-defined safety outcomes were described. We included 1,245 patients each in the CCP treated and untreated groups. Oxygen support was required by 93% of patients at the baseline. The pre-defined primary effectiveness outcome of 28-day in-hospital all-cause mortality (HR = 0.85; 95%CI: 0.66,1.10) were similar between treatment groups. Sensitivity and stratified analyses found similar null results. CCP-treated patients were less likely to be discharged alive (HR = 0.82; 95%CI: 0.74, 0.91), and more likely to receive mechanical ventilation (HR = 1.48; 95%CI: 1.12, 1.96). Safety outcomes were rare and similar between treatment groups.

Conclusion

The findings in this large, matched cohort of patients hospitalized with COVID-19 and mostly requiring oxygen support at the time of treatment, do not support a clinical benefit in 28-day in-hospital all-cause mortality for CCP. Future studies should assess the potential benefits with specifically high-titer units in perhaps certain subgroups of patients (e.g. those with early disease or immunocompromised).

Genetic variation within the human papillomavirus type 16 genome is associated with oropharyngeal cancer prognosis

PURPOSE

A significant barrier to adoption of de-escalated treatment protocols for human papillomavirus-driven oropharyngeal cancer (HPV-OPC) is that few predictors of poor prognosis exist. We conducted the first large whole-genome sequencing (WGS) study to characterize the genetic variation of the HPV type 16 (HPV16) genome and to evaluate its association with HPV-OPC patient survival.

PATIENTS AND METHODS

A total of 460 OPC tumor specimens from two large United States medical centers (1980-2017) underwent HPV16 whole-genome sequencing. Site-specific variable positions [single nucleotide polymorphisms (SNPs)] across the HPV16 genome were identified. Cox proportional hazards model estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for overall survival by HPV16 SNPs. Harrell C-index and time-dependent positive predictive value (PPV) curves and areas under the PPV curves were used to evaluate the predictive accuracy of HPV16 SNPs for overall survival.

RESULTS

A total of 384 OPC tumor specimens (83.48%) passed quality control filters with sufficient depth and coverage of HPV16 genome sequencing to be analyzed. Some 284 HPV16 SNPs with a minor allele frequency ≥1% were identified. Eight HPV16 SNPs were significantly associated with worse survival after false discovery rate correction (individual prevalence: 1.0%-5.5%; combined prevalence: 15.10%); E1 gene position 1053 [HR for overall survival (HRos): 3.75, 95% CI 1.77-7.95; Pfdr = 0.0099]; L2 gene positions 4410 (HRos: 5.32, 95% CI 1.91-14.81; Pfdr = 0.0120), 4539 (HRos: 6.54, 95% CI 2.03-21.08; Pfdr = 0.0117); 5050 (HRos: 6.53, 95% CI 2.34-18.24; Pfdr = 0.0030), and 5254 (HRos: 7.76, 95% CI 2.41-24.98; Pfdr = 0.0030); and L1 gene positions 5962 (HRos: 4.40, 95% CI 1.88-10.31; Pfdr = 0.0110) and 6025 (HRos: 5.71, 95% CI 2.43-13.41; Pfdr = 0.0008) and position 7173 within the upstream regulatory region (HRos: 9.90, 95% CI 3.05-32.12; Pfdr = 0.0007). Median survival time for patients with ≥1 high-risk HPV16 SNPs was 3.96 years compared with 18.67 years for patients without a high-risk SNP; log-rank test P < 0.001. HPV16 SNPs significantly improved the predictive accuracy for overall survival above traditional factors (age, smoking, stage, treatment); increase in C-index was 0.069 (95% CI 0.019-0.119, P < 0.001); increase in area under the PPV curve for predicting 5-year survival was 0.068 (95% CI 0.015-0.111, P = 0.008).

CONCLUSIONS

HPV16 genetic variation is associated with HPV-OPC prognosis and can improve prognostic accuracy.

Comparing medication adherence in patients receiving bisphosphonates for preventing fragility fractures: a comprehensive systematic review and network meta-analysis

BACKGROUND

Bisphosphonates are effective in preventing fragility fractures; however, high rates of adherence are needed to preserve clinical benefits.

OBJECTIVE

To investigate persistence and compliance to oral and intravenous bisphosphonates (alendronate, ibandronate, risedronate, and zoledronate).

METHODS

Searches of 12 databases, unpublished sources, and trial registries were conducted, covering the period from 2000 to April 2021. Screening, data extraction, and risk of bias assessment (Cochrane Collaboration risk-of-bias tool 1.0 & ROBINS-I) were independently undertaken by two study authors. Randomised controlled trials (RCTs) and observational studies that used prescription claim databases or hospital medical records to examine patients' adherence were included. Network meta-analyses (NMA) embedded within a Bayesian framework were conducted, investigating users' likelihood in discontinuing bisphosphonate treatment. Where meta-analysis was not possible, data were synthesised using the vote-counting synthesis method.

RESULTS

Fifty-nine RCTs and 43 observational studies were identified, resulting in a total population of 2,656,659 participants. Data from 59 RCTs and 24 observational studies were used to populate NMAs. Zoledronate users were the least likely to discontinue their treatment HR = 0.73 (95%CrI: 0.61, 0.88). Higher rates of compliance were observed in those receiving intravenous treatments. The paucity of data and the heterogeneity in the reported medication possession ratio thresholds precluded a NMA of compliance data.

CONCLUSIONS

Users of intravenously administered bisphosphonates were found to be the most adherent to treatment among bisphosphonates' users. Patterns of adherence will permit the more precise estimation of clinical and cost-effectiveness of bisphosphonates.

TRIAL REGISTRATION

PROSPERO 2020 CRD42020177166.

Utility of PINP to monitor osteoporosis treatment in primary care, the POSE study (PINP and Osteoporosis in Sheffield Evaluation)

PURPOSE

In Sheffield (UK), we introduced the PINP monitoring algorithm for the management of osteoporosis treatment delivered in primary care. Our aims were to evaluate whether this algorithm was associated with better osteoporosis outcomes and was cost-effective compared to standard care.

METHODS

Inclusion criteria were referral from Sheffield GPs, BMD scans performed between 2012 and 2013 and a report advising initiation of oral bisphosphonate and PINP monitoring. 906 patients were identified and retrospectively divided into Group A (intention to monitor, with baseline PINP, n = 588) and Group B (no intention to monitor, without baseline PINP, n = 318). The model described by Davis and colleagues was used to extrapolate life-time costs and quality-adjusted life-years (QALYs).

RESULTS

No differences were found in baseline characteristics between groups (age, gender, BMI, BMD and major risk factors for fractures). More patients in Group A started oral treatment (77.4% vs 49.1%; p < 0.001), but there were no differences between groups in the presence of a gap in treatment >3 months or in treatment duration. Patients in Group A were more likely to have follow-up DXA scan at 4-6 years from baseline (46.9% vs 29.2%; p < 0.000) and had a greater increase in total hip BMD (+2.74% vs + 0.42%; p value = 0.003). Fewer new fractures occurred in Group A but this was not statistically significant, but the numbers of fractures were small. Patients in Group A were more likely to change management (p = 0.005) including switching to zoledronate (p = 0.03). The PINP measurement and increased prescribing in Group A resulted in increases in both costs (£30.19) and QALYs (0.0039) relative to Group B, giving an incremental cost effectiveness ratio (ICER) of £7660 in the probabilistic sensitivity analysis.

CONCLUSIONS

Patients monitored with PINP are more likely to start oral bisphosphonate treatment, switch to zoledronate, have follow-up DXA scans and a greater increase of hip BMD. PINP monitoring has the potential to be cost-effective in a UK NHS setting given that interventions with an ICER under £20,000 are generally considered to be cost-effective.

Latent profiles of autism symptoms in children and adolescents with Down syndrome

BACKGROUND

Down syndrome (DS) is associated with elevated rates of autism spectrum disorder (ASD) and autism symptomatology. To better characterise heterogeneity in ASD symptomatology in DS, profiles of caregiver-reported ASD symptoms were modelled for children and adolescents with DS.

METHODS

Participants (n = 125) were recruited through several multi-site research studies on cognition and language in DS. Using the Social Responsiveness Scale-2 (SRS-2; Constantino and Gruber 2012), two latent profile analyses (LPA) were performed, one on the broad composite scores of social communication and interaction and restricted interests and repetitive behaviour, and a second on the four social dimensions of social communication, social motivation, social awareness, and social cognition.

RESULTS

A three-profile model was the best fit for both analyses, with each analysis yielding a low ASD symptom profile, an elevated or mixed ASD symptom profile and a high ASD symptom profile. Associations were observed between profile probability scores and IQ, the number of co-occurring biomedical conditions reported, sex, and SRS-2 form.

CONCLUSIONS

Characterising heterogeneity in ASD symptom profiles can inform more personalised supports in this population, and implications for potential therapeutic approaches for individuals with DS are discussed.

Knowledge and Practices on Antibiotic Use and Antibiotic Resistance Among Smallholder Pig Farmers in Timor-Leste

Antibiotic resistance is an emerging global health threat which is linked to the overuse and misuse of antibiotics. This study was conducted to understand the knowledge and practices of smallholder pig farmers on antibiotic use and resistance in Timor-Leste. A cross-sectional study using a structured face-to-face interview was conducted in three municipalities. The interview was piloted and implemented in the local Tetun language. This study found that knowledge of antibiotics was very poor as only 12.7% (95% CI: 6.3–23.9) of farmers reported knowing what antibiotics were, and of these only one was able to correctly explain how an antibiotic worked. None of the farmers knew about antibiotic resistance and were able to explain the concept correctly. After the definition of antibiotic was explained to the farmer, only 3.6% (95% CI: 0.8–14.9) reported that their pigs had ever received antibiotics, and the majority of farmers whose pigs had not received antibiotics reported the lack of access to veterinary services. When used, antibiotics were only used for treatment with no reported use for disease prevention or growth promotion. None of the commonly used antibiotics were critically important antimicrobials. Compliance with withdrawal periods was not routinely followed. There is a need to improve access to government veterinary services for farmers in Timor-Leste, while addressing identified knowledge gaps on antibiotics and promoting prudent use practices. The findings from this study serve as baseline information to inform future interventions.

Integration of energy systems

ABSTRACT

This article in MRS Bulletin and the framework set out in the introductory article articulate a scenario of renewable electrons and electrification of end use appliances and industrial processes as a plausible paradigm to realize a carbon-free energy economy. The subsequent articles cover specific sectoral or chemical applications of those renewable electrons (e.g., for hydrogen, transportation, building use, electrochemical storage, and within the chemical industry). This article addresses the intersections among and across those sectors. We describe the importance of considering integrated systems and systems of systems as we consider pathways to a decarbonized energy economy. Further, we review and summarize key insights into the innovation challenges that reside at the particular integration interfaces among sectors, and highlight the opportunity for advances in materials and processes that will be critical to successful achievement of economy-wide, low-carbon energy systems.

Acute respiratory infection symptoms and COVID-19 testing behaviour: results based on South Australian health surveys

Background

Effective syndromic surveillance alongside COVID-19 testing behaviours in the population including in higher risk and hard to reach subgroups is vital to detect re-emergence of COVID-19 transmission in the community. The aim of this paper was to identify the prevalence of acute respiratory infection symptoms and coronavirus testing behaviour among South Australians using data from a population based survey.

Methods

We used cross-sectional data from the 2020 state-wide population level health survey on 6857 respondents aged 18 years and above. Descriptive statistics were used to explore the risk factors and multivariable logistic regression models were used to assess the factors associated with the acute respiratory infection symptoms and coronavirus testing behaviour after adjusting for gender, age, household size, household income, Aboriginal and/or Torres Strait Islander status, SEIFA, Country of birth, number of chronic diseases, wellbeing, psychological distress, and mental health.

Results

We found that 19.3% of respondents reported having symptoms of acute respiratory infection and the most commonly reported symptoms were a runny nose (11.2%), coughing (9.9%) and sore throat (6.2%). Fever and cough were reported by 0.8% of participants. Of the symptomatic respondents, 32.6% reported seeking health advice from a nurse, doctor or healthcare provider. Around 18% (n = 130) of symptomatic respondents had sought testing and a further 4.3% (n = 31) reported they intended to get tested. The regression results suggest that older age, larger household size, a higher number of chronic disease, mental health condition, poor wellbeing, and psychological distress were associated with higher odds of ARI symptoms. Higher household income was associated with lower odds of being tested or intending to be tested for coronavirus after adjusting for other explanatory variables.

Conclusions

There were relatively high rates of self-reported acute respiratory infection during a period of very low COVID-19 prevalence and low rate of coronavirus testing among symptomatic respondents. Ongoing monitoring of testing uptake, including in higher-risk groups, and possible interventions to improve testing uptake is key to early detection of disease.

1087 Establishing Guidelines for VTE Prophylaxis for Acute ENT Admissions

Aim

VTE prophylaxis is a vital aspect of patient safety. The decision whether to offer pharmacological thromboprophylaxis is a balance of risk versus benefit. There is a low incidence of VTE in ENT patients, admissions are often short and active bleeding on admission is not uncommon (epistaxis patients, already on anticoagulation are particularly difficult to manage}. There are no clear, specialty specific guidelines to assist in these frequently encountered endeavours.

Method

The number of emergency ENT admissions who had a documented VTE during admission or in the 28 days following was used to calculate the incidence of VTE in acute admissions. An audit of VTE prophylaxis and documentation was also conducted using 20 admissions over 24 hours.

Results

Incidence was 0.12%. 75% had a documented VTE risk assessment. Only 50% patients were prescribed chemical and mechanical thromboprophylaxis. 0% had appropriately documented that the patient did not require thromboprophylaxis on the drug chart (as per trust guidelines).

Conclusions

The results showed that both documentation and prescribing related to VTE prevention were poor. By highlighting the low incidence amongst this patient group, we were able to establish clearer guidance for VTE prophylaxis in acute ENT admissions and a protocol to standardise the management of anticoagulation in actively bleeding epistaxis patients.

Differences in obstetrical care and outcomes associated with the proportion of the obstetrician's shift completed

BACKGROUND

Understanding and improving obstetrical quality and safety is an important goal of professional societies, and many interventions such as checklists, safety bundles, educational interventions, or other culture changes have been implemented to improve the quality of care provided to obstetrical patients. Although many factors contribute to delivery decisions, a reduced workload has addressed how provider issues such as fatigue or behaviors surrounding impending shift changes may influence the delivery mode and outcomes.

OBJECTIVE

The objective was to assess whether intrapartum obstetrical interventions and adverse outcomes differ based on the temporal proximity of the delivery to the attending's shift change.

STUDY DESIGN

This was a secondary analysis from a multicenter obstetrical cohort in which all patients with cephalic, singleton gestations who attempted vaginal birth were eligible for inclusion. The primary exposure used to quantify the relationship between the proximity of the provider to their shift change and a delivery intervention was the ratio of time from the most recent attending shift change to vaginal delivery or decision for cesarean delivery to the total length of the shift. Ratios were used to represent the proportion of time completed in the shift by normalizing for varying shift lengths. A sensitivity analysis restricted to patients who were delivered by physicians working 12-hour shifts was performed. Outcomes chosen included cesarean delivery, episiotomy, third- or fourth-degree perineal laceration, 5-minute Apgar score of <4, and neonatal intensive care unit admission. Chi-squared tests were used to evaluate outcomes based on the proportion of the attending's shift completed. Adjusted and unadjusted logistic models fitting a cubic spline (when indicated) were used to determine whether the frequency of outcomes throughout the shift occurred in a statistically significant, nonlinear pattern RESULTS: Of the 82,851 patients eligible for inclusion, 47,262 (57%) had ratio data available and constituted the analyzable sample. Deliveries were evenly distributed throughout shifts, with 50.6% taking place in the first half of shifts. There were no statistically significant differences in the frequency of cesarean delivery, episiotomy, third- or fourth-degree perineal lacerations, or 5-minute Apgar scores of <4 based on the proportion of the shift completed. The findings were unchanged when evaluated with a cubic spline in unadjusted and adjusted logistic models. Sensitivity analyses performed on the 22.2% of patients who were delivered by a physician completing a 12-hour shift showed similar findings. There was a small increase in the frequency of neonatal intensive care unit admissions with a greater proportion of the shift completed (adjusted P=.009), but the findings did not persist in the sensitivity analysis.

CONCLUSION

Clinically significant differences in obstetrical interventions and outcomes do not seem to exist based on the temporal proximity to the attending physician's shift change. Future work should attempt to directly study unit culture and provider fatigue to further investigate opportunities to improve obstetrical quality of care, and additional studies are needed to corroborate these findings in community settings.

Antimicrobial Use in Animals in Timor-Leste Based on Veterinary Antimicrobial Imports between 2016 and 2019

Monitoring veterinary antimicrobial use is part of the global strategy to tackle antimicrobial resistance. The purpose of this study was to quantify veterinary antimicrobials imported into Timor-Leste between 2016 and 2019 and describe the antimicrobial import profile of importers. Data were obtained from import applications received by the Ministry of Agriculture and Fisheries (MAF) of Timor-Leste. Import quantities were analysed by antimicrobial class, importance for human medicine, recommended route of administration and type of importer. An average of 57.4 kg (s.d. 31.0 kg) and 0.55 mg/kg (s.d. 0.27 mg/kg) animal biomass of antimicrobials was imported per year. Tetracyclines (35.5%), penicillins (23.7%), and macrolides (15.9%) were the commonly imported antimicrobial classes. Antimicrobials imported for parenteral administration were most common (60.1%). MAF was the largest importer (52.4%). Most of the critically important antimicrobials for human medicine were imported by poultry farms for oral administration and use for growth promotion could not be ruled out. In conclusion, the use of antimicrobials in animals in Timor-Leste is very low, in keeping with its predominantly subsistence agriculture system. Farmer education, development of treatment guidelines, and strengthening of the veterinary service is important for addressing the potential future misuse of antimicrobials especially in the commercial poultry industry.

Aquatic contaminants in Solomon Islands and Vanuatu: Evidence from passive samplers and Microtox toxicity assessment

Water Quality issues in many Pacific countries are rising, with the increase in coastal populations and associated urban runoff but management requires contamination issues in the aquatic environment to be identified and prioritised. In Vanuatu and Solomon Islands there are few laboratories and resources to assess for the presence or impact of complex chemical contaminants. The extent and impact of chemical contamination of the marine and coastal environment is poorly described. Passive chemical samplers were used to measure a range of aquatic pollutants around the capital cities, Honiara (Solomon Islands) and Port Vila (Vanuatu). We detected a range of chemicals indicative of agricultural and industrial contamination and a few sites had concerning concentrations of specific hydrocarbons and pesticides. The rapid ecotoxicology test, Microtox, indicated toxic impacts in rivers, coastal sites and urban drains This work provides new data on chemical contamination and possible impacts of that contamination for both countries. The techniques could be applied widely across the region to generate critical data for environmental management, guide monitoring efforts and measure the impact of policy or land-use changes.

Examining online postings on a russian internet self-harm message board: Further evidence of addiction to self-harm?

Introduction

There has been an increasing amount of research examining the addictive nature of self-harm (non-suicidal self-injury). One such area of research has examined if themes related to addiction are present in self-harm board postings on imessages. Recent research from the UK suggests that such themes are evident.

Objectives

The present aim was to build on previous research to examine if themes of addiction are present in other cultural contexts.

Methods

A sample of 254 online postings from a self-harm discussion forum on a Russian Internet message board were translated, extracted, read, and re-read before being coded using inductive content analysis to identify themes.

Results

Five themes were extracted and labelled: “Relationships with Family and Friends”, “Self-Blame and Hatred”, “Ongoing Battle”, “Positive affect”, “Other Mental Health Problems Difficulties”. These themes are somewhat similar to those found within messages in a UK based self-harm forum.

Conclusions

The present findings, obtained from Russian respondents, provide further evidence demonstrating that repetitive self-harming seems to have addictive aspects.

Exit strategies: optimising feasible surveillance for detection, elimination, and ongoing prevention of COVID-19 community transmission

BACKGROUND

Following implementation of strong containment measures, several countries and regions have low detectable community transmission of COVID-19. We developed an efficient, rapid, and scalable surveillance strategy to detect remaining COVID-19 community cases through exhaustive identification of every active transmission chain. We identified measures to enable early detection and effective management of any reintroduction of transmission once containment measures are lifted to ensure strong containment measures do not require reinstatement.

METHODS

We compared efficiency and sensitivity to detect community transmission chains through testing of the following: hospital cases; fever, cough and/or ARI testing at community/primary care; and asymptomatic testing; using surveillance evaluation methods and mathematical modelling, varying testing capacities, reproductive number (R) and weekly cumulative incidence of COVID-19 and non-COVID-19 respiratory symptoms using data from Australia. We assessed system requirements to identify all transmission chains and follow up all cases and primary contacts within each chain, per million population.

RESULTS

Assuming 20% of cases are asymptomatic and 30% of symptomatic COVID-19 cases present for testing, with R = 2.2, a median of 14 unrecognised community cases (8 infectious) occur when a transmission chain is identified through hospital surveillance versus 7 unrecognised cases (4 infectious) through community-based surveillance. The 7 unrecognised community upstream cases are estimated to generate a further 55-77 primary contacts requiring follow-up. The unrecognised community cases rise to 10 if 50% of cases are asymptomatic. Screening asymptomatic community members cannot exhaustively identify all cases under any of the scenarios assessed. The most important determinant of testing requirements for symptomatic screening is levels of non-COVID-19 respiratory illness. If 4% of the community have respiratory symptoms, and 1% of those with symptoms have COVID-19, exhaustive symptomatic screening requires approximately 11,600 tests/million population using 1/4 pooling, with 98% of cases detected (2% missed), given 99.9% sensitivity. Even with a drop in sensitivity to 70%, pooling was more effective at detecting cases than individual testing under all scenarios examined.

CONCLUSIONS

Screening all acute respiratory disease in the community, in combination with exhaustive and meticulous case and contact identification and management, enables appropriate early detection and elimination of COVID-19 community transmission. An important component is identification, testing, and management of all contacts, including upstream contacts (i.e. potential sources of infection for identified cases, and their related transmission chains). Pooling allows increased case detection when testing capacity is limited, even given reduced test sensitivity. Critical to the effectiveness of all aspects of surveillance is appropriate community engagement, messaging to optimise testing uptake and compliance with other measures.

Exit strategies: optimising feasible surveillance for detection, elimination, and ongoing prevention of COVID-19 community transmission

BACKGROUND

Following implementation of strong containment measures, several countries and regions have low detectable community transmission of COVID-19. We developed an efficient, rapid, and scalable surveillance strategy to detect remaining COVID-19 community cases through exhaustive identification of every active transmission chain. We identified measures to enable early detection and effective management of any reintroduction of transmission once containment measures are lifted to ensure strong containment measures do not require reinstatement.

METHODS

We compared efficiency and sensitivity to detect community transmission chains through testing of the following: hospital cases; fever, cough and/or ARI testing at community/primary care; and asymptomatic testing; using surveillance evaluation methods and mathematical modelling, varying testing capacities, reproductive number (R) and weekly cumulative incidence of COVID-19 and non-COVID-19 respiratory symptoms using data from Australia. We assessed system requirements to identify all transmission chains and follow up all cases and primary contacts within each chain, per million population.

RESULTS

Assuming 20% of cases are asymptomatic and 30% of symptomatic COVID-19 cases present for testing, with R = 2.2, a median of 14 unrecognised community cases (8 infectious) occur when a transmission chain is identified through hospital surveillance versus 7 unrecognised cases (4 infectious) through community-based surveillance. The 7 unrecognised community upstream cases are estimated to generate a further 55-77 primary contacts requiring follow-up. The unrecognised community cases rise to 10 if 50% of cases are asymptomatic. Screening asymptomatic community members cannot exhaustively identify all cases under any of the scenarios assessed. The most important determinant of testing requirements for symptomatic screening is levels of non-COVID-19 respiratory illness. If 4% of the community have respiratory symptoms, and 1% of those with symptoms have COVID-19, exhaustive symptomatic screening requires approximately 11,600 tests/million population using 1/4 pooling, with 98% of cases detected (2% missed), given 99.9% sensitivity. Even with a drop in sensitivity to 70%, pooling was more effective at detecting cases than individual testing under all scenarios examined.

CONCLUSIONS

Screening all acute respiratory disease in the community, in combination with exhaustive and meticulous case and contact identification and management, enables appropriate early detection and elimination of COVID-19 community transmission. An important component is identification, testing, and management of all contacts, including upstream contacts (i.e. potential sources of infection for identified cases, and their related transmission chains). Pooling allows increased case detection when testing capacity is limited, even given reduced test sensitivity. Critical to the effectiveness of all aspects of surveillance is appropriate community engagement, messaging to optimise testing uptake and compliance with other measures.

Leveraging nurse practitioner capacities to achieve global health for all: COVID-19 and beyond

Aim

To argue that nurse practitioners have been under‐utilized generally in the current global health environment, creating barriers to achieving universal health coverage and the Sustainable Development Goals.

Background

Nurse practitioners are advanced practice nurses possessing expert knowledge and leadership skills that can be optimized to narrow disparities and ensure access to high‐quality health care globally. Nurses worldwide have been challenged to meet global public health needs in the context of COVID‐19 (SARS‐CoV‐2 virus), and there are early indications that nurse practitioners are being called upon to the full extent of their capabilities in the current pandemic.

Sources of evidence

PubMed; Google Scholar; the International Council of Nurses; World Health Organization; United Nations; and the experiences of the authors.

Discussion

Several international reports, nursing and health organizations have called for continued investment in and development of nursing to improve mechanisms that promote cost‐effective and universally accessible care. Expanding nurse practitioner scopes of practice across nations will leverage their clinical capacities, policy and advocacy skills, and talents to lead at all levels.

Conclusion

Ongoing empirical data and policy change is needed to enable the full scope and strategic utilization of nurse practitioners across healthcare systems and contexts.

Implications for nursing practice, and nursing and health policy

Widespread education regarding nurse practitioner capacities for interdisciplinary partners, policymakers and the public is needed. Policies that safely expand their roles are critical. Role titles and remuneration reflective of their scope and service are required to lead, sustain and grow the workforce internationally.

Examining the impact of students’ attendance, sketching, visualization, and tutors experience on students’ performance: a case of building structures course in construction management

The aim of this paper is to examine students’ performance in a computation-based course by evaluating the effects of key factors including sketching, visualization resources provided to them during the lectures, their attendance and tutors’ experience. A systematic review was conducted including 192 articles published during January 2010 to December 2019. Further, a case study has been conducted in which 633 students from non-engineering backgrounds were taught a core course of construction over three-yearly sessions from 2017 to 2019. The performance has been assessed through two quizzes of 10% weight each, assignment of 40% weight and a final exam with 30% weight in 2017-18 and 40% weight in 2019 were utilized with an attendance criterion of below 75% as low attendance. The statistical result highlights that a clear difference of 14% overall marks exist between the students with less than 75% attendance and the ones with 75% and above in 2017 and a 10% gap in 2018. Students with high marks in sketching secured higher overall marks as compared to others highlighting that the sketching skill is useful to construction students. The findings contribute to the body of education knowledge by evaluating key influential factors and provide a useful benchmark to other educators in the field. 

A phase 1 trial of the safety, tolerability and biological effects of intravenous Enadenotucirev, a novel oncolytic virus, in combination with chemoradiotherapy in locally advanced rectal cancer (CEDAR)

BACKGROUND

Chemoradiotherapy remains the standard of care for locally advanced rectal cancer. Efforts to intensify treatment and increase response rates have yet to yield practice changing results due to increased toxicity and/or absence of increased radiosensitization. Enadenotucirev (EnAd) is a tumour selective, oncolytic adenovirus which can be given intravenously. Pre-clinical evidence of synergy with radiation warrants further clinical testing and assessment of safety with radiation.

METHODS

Eligibility include histology confirmed locally advanced rectal cancer that require chemoradiation. The trial will use a Time-to-Event Continual Reassessment Model-based (TiTE-CRM) approach using toxicity and efficacy as co-primary endpoints to recommend the optimal dose and treatment schedule 30 patients will be recruited. Secondary endpoints include pathological complete response the neoadjuvant rectal score. A translational program will be based on a mandatory biopsy during the second week of treatment for 'proof-of-concept' and exploration of mechanism. The trial opened to recruitment in July 2019, at an expected rate of 1 per month for up to 4 years.

DISCUSSION

Chemoradiation with Enadenotucirev as a radiosensitiser in locally Advanced Rectal cancer (CEDAR) is a prospective multicentre study testing a new paradigm in radiosensitization in rectal cancer. The unique ability of EnAd to selectively infect tumour cells following intravenous delivery is an exciting opportunity with a clear translational goal. The novel statistical design will make efficient use of both toxicity and efficacy data to inform subsequent studies.

TRIAL REGISTRATION

ClinicalTrial.gov, NCT03916510. Registered 16th April 2019.

Computed tomography imaging in ventral hernia repair: can we predict the need for myofascial release?

INTRODUCTION

Currently, the need for additional myofascial release (AMR) in addition to retromuscular dissection during open Rives-Stoppa hernia repair is determined intraoperatively based on the discretion of the surgeon. We developed a novel method to objectively predict the need for AMR preoperatively using computed tomography (CT)-measured rectus width to hernia width ratio (RDR).

METHODS

A retrospective chart review of all patients who underwent open retro-muscular mesh repair of midline ventral hernia between August 1, 2007 and February 1, 2018, who had a preoperative CT scan within 1 year prior to their operation. The primary endpoint was the ability of the defect ratio to predict the need for AMR in pursuit of fascial closure. The secondary endpoint was the ability of Component Separation Index (CSI) to predict the need for AMR to obtain fascial closure.

RESULTS

Of 342 patients, 208 repaired with rectus abdominis release alone (RM group), while 134 required AMR (RM + group). An RDR of > 1.34 on area under the curve analysis predicted the need for AMR with 77.6% accuracy. There was a linear decrease in the need for AMR with increasing RDR: RDR < 1 required AMR in 78.8% of cases, RDR 1.1-1.49 in 52%, RDR 1.5-1.99 in 32.1%, and RDR > 2 in just 10.8%. Similarly, CSI > 0.146 predicted the need for AMR with 76.3% accuracy on area under the curve analysis.

CONCLUSION

The RDR is a practical and reliable tool to predict the ability to close the defect during open Rives-Stoppa ventral hernia repair without AMR. An RDR of > 2 portends fascial closure with rectus abdominis myofascial release alone in 90% of cases.

NS4/5 mutations enhance flavivirus Bamaga virus infectivity and pathogenicity in vitro and in vivo

Flaviviruses such as yellow fever, dengue or Zika viruses are responsible for significant human and veterinary diseases worldwide. These viruses contain an RNA genome, prone to mutations, which enhances their potential to emerge as pathogens. Bamaga virus (BgV) is a mosquito-borne flavivirus in the yellow fever virus group that we have previously shown to be host-restricted in vertebrates and horizontally transmissible by Culex mosquitoes. Here, we aimed to characterise BgV host-restriction and to investigate the mechanisms involved. We showed that BgV could not replicate in a wide range of vertebrate cell lines and animal species. We determined that the mechanisms involved in BgV host-restriction were independent of the type-1 interferon response and RNAse L activity. Using a BgV infectious clone and two chimeric viruses generated as hybrids between BgV and West Nile virus, we demonstrated that BgV host-restriction occurred post-cell entry. Notably, BgV host-restriction was shown to be temperature-dependent, as BgV replicated in all vertebrate cell lines at 34°C but only in a subset at 37°C. Serial passaging of BgV in Vero cells resulted in adaptive mutants capable of efficient replication at 37°C. The identified mutations resulted in amino acid substitutions in NS4A-S124F, NS4B-N244K and NS5-G2C, all occurring close to a viral protease cleavage site (NS4A/2K and NS4B/NS5). These mutations were reverse engineered into infectious clones of BgV, which revealed that NS4B-N244K and NS5-G2C were sufficient to restore BgV replication in vertebrate cells at 37°C, while NS4A-S124F further increased replication efficiency. When these mutant viruses were injected into immunocompetent mice, alongside BgV and West Nile virus chimeras, infection and neurovirulence were enhanced as determined by clinical scores, seroconversion, micro-neutralisation, viremia, histopathology and immunohistochemistry, confirming the involvement of these residues in the attenuation of BgV. Our studies identify a new mechanism of host-restriction and attenuation of a mosquito-borne flavivirus.

The Role of Tranexamic Acid in the Management of an Acutely Hemorrhaging Patient

Background: Acute hemorrhage, both traumatic and nontraumatic, leads to significant morbidity and mortality, both in the United States and globally. Traditional treatment of acute hemorrhage is focused on hemostasis and blood product replacement. Tranexamic acid is an antifibrinolytic agent that may reduce acute hemorrhage through inhibition of plasminogen. Newer research suggests that coagulopathy, specifically fibrinolysis, may contribute significantly to the pathology of acute hemorrhage. Methods: We searched the PubMed database for relevant articles from 2000 to 2018 for the terms "tranexamic acid," "TXA," "antifibrinolytic," "hyperfibrinolysis," and "coagulopathy." Our search was limited to studies published in the English language. Results: A total of 53 studies were included in this review. These articles suggest a potential role for tranexamic acid in the management of acute intracranial hemorrhage, epistaxis, hematuria, postpartum hemorrhage, gastrointestinal hemorrhage, and trauma-related hemorrhage. A theoretical risk of thrombotic events following tranexamic acid use exists, though large clinical trials suggest this risk remains exceedingly small. Conclusions: Recent studies suggest a mortality benefit with tranexamic acid following acute hemorrhage. First responders such as emergency medical technicians and emergency department clinicians should consider tranexamic acid as an adjunct therapy in the management of acute, severe traumatic and nontraumatic hemorrhage.

P6546Canadian Registry of Electronic Device Outcomes (CREDO): remote monitoring outcomes in the abbott battery performance alert, a multicentre cohort

Background

Cardiac implantable electronic devices have been known to have lead and device malfunctions leading to advisories. Increased use of remote monitoring of devices has been suggested to allow the identification of abnormal device performance and allow early intervention. We sought to describe the outcomes of patients with and without remote monitoring of in devices in the Abbott Premature Battery Depletion advisory with data from a Canadian registry

Methods

Patients with an Abbott device subject to the Battery Performance Alert Advisory from nine ICD implanting centres in Canada were included in the registry. The use of remote monitoring was identified from baseline and followup data in the registry. The primary outcome was detection of premature battery depletion and all cause mortality.

Results

2679 patents were identified with a device subject to the advisory. Devices were implanted between 2010 and 2017. 1716 patients (64%) had remote monitoring at baseline with this increasing to 83.7% at followup at 12 months. Premature battery depletion occurred in 43 patients (1.6%). Discovery of premature battery depletion was detected by remote monitoring in 70% of patients. There were 492 deaths during the follow up. Mortality was higher in those without a remote monitor compared to those with a remote monitor at follow-up and remote monitor at baseline and follow-up (11.3%, 2.6% versus 6.1% respectively; p=0.0186). There were no deaths attributed to premature battery depletion

Conclusion

The use of remote monitoring in patients with ICD and CRT under advisory reliably detected device failure and was associated with a reduction in all-cause mortality.

Diagnosis of Traumatic Eye Injuries With Point-of-Care Ocular Ultrasonography in the Emergency Department

STUDY OBJECTIVE

Traumatic eye injuries are common emergency department presentations worldwide, and diagnosis may be delayed because of concurrent injuries and lack of guidelines in regard to the utility of clinical examination, computed tomography (CT), and point-of-care ultrasonography. In this study, we compare point-of-care ultrasonography with ophthalmologist clinical examination and CT for 6 types of traumatic eye injury.

METHODS

We conducted a prospective cohort study evaluating patients with suspected traumatic eye injury who were recruited at an academic medical center in Tabriz, Iran. Each patient was evaluated by an emergency physician with point-of-care ultrasonography using a 7- to 15-MHz linear transducer, by a radiologist with orbital CT imaging, and by an ophthalmologist with a complete bedside ocular examination. Obtained results were tabulated. Sensitivity, specificity, and likelihood ratios were subsequently calculated. Cohen's κ was assessed to evaluate the agreement between ocular point-of-care ultrasonography with orbital CT and point-of-care ultrasonography with complete bedside ocular examination.

RESULTS

Two hundred thirty-two patients (351 eyes) with suspected traumatic eye injury were included. In all measures of accuracy, diagnosis by point-of-care ultrasonography compared favorably with CT and a complete bedside ocular examination by an ophthalmologist in the 6 ocular injury patterns included in this study. Compared with CT imaging, point-of-care ultrasonography provided a specificity of 99.4% (95% confidence interval [CI] 97.8% to 99.9%) and a sensitivity of 96.8% (95% CI 83.3% to 99.9%) in the diagnosis of lens dislocation, and a specificity of 99.7% (95% CI 98.3% to 100.0%) and sensitivity of 95.7% (95% CI 78.1% to 99.9%) in the diagnosis of retrobulbar hematoma. Compared with complete bedside ocular examination by an ophthalmologist, point-of-care ultrasonography provided a specificity of 98.7% (95% CI 96.7% to 99.6%) and sensitivity of 97.8% (95% CI 88.2% to 99.9%) in the diagnosis of vitreous hemorrhage. In all injury types, positive likelihood ratios were high and negative ones were low.

CONCLUSION

Point-of-care ultrasonography demonstrates high sensitivity and specificity in the diagnosis of traumatic eye injury, and represents a valuable diagnostic tool in addition to orbital CT and complete beside ocular examination by an ophthalmologist in the diagnosis of traumatic eye injury.

Abstract P3-08-07: Distinct biological signatures describe differences in BRCA mutated subgroups

Background: BRCA mutated (BRCA+) breast cancers are expected to have increased activation of Homologous Recombination Deficiency (HRD) and altered DNA damage repair pathways when compared to BRCA wildtype (BRCA-). To better understand differences in these populations, biological patterns and immune responses to BRCA+ breast cancers were evaluated. The primary aim of our study was to use novel gene expression tools to assess early stage breast cancers with and without germline BRCA mutations, and within distinct BRCA+ subgroups.

Methods: We identified 124 early stage untreated breast cancers with and without BRCA mutations (n = 62 and 62, respectively). Our BRCA- group was matched by hormone receptor (HR) status, age, and stage to the BRCA+ group. The NanoString Breast Cancer 360 panel was applied to RNA isolated from 80 breast tumors (BRCA+ = 39; BRCA- = 41). The BRCA+ group had a BRCA1+ subgroup (n=17) and a BRCA2+ subgroup (n=22).

Results: There was a significant increase in two BC360 signatures in both the BRCA1+ and BRCA2+ tumors compared with the BRCA- population: Prosigna™Risk of Recurrence (ROR) score [BRCA1+: HR: 1.142 (95% CI 1.019, 1.279), p=0.02; BRCA2+: HR: 1.321 (95% CI 1.190, 1.466), p&lt;0.001] and HRD [BRCA1+: HR: 3.576 (95% CI 2.174, 5.880), p=0.02; BRCA2+: HR: 1.801 (95% CI 1.142, 2.840), p&lt;0.001]. BRCA1+ tumors had lower expression of ESR1 [p=0.03], PGR [p=0.02], ER signaling [p&lt;0.001], and differentiation [p=0.005]; while BRCA2+ tumors had lower expression of stroma markers [p=0.02] and inflammatory chemokines [p=0.001]. The two BRCA+ subgroups had distinct molecular subtype correlation trends that were highly significant. BRCA1+ tumors were positively associated with a basal subtype [p&lt;0.001], whereas this association was not significant for BRCA2+ tumors. BRCA2+ tumors were associated with an increase in luminal B subtype [p=0.05]. All BRCA+ tumors had a decrease in luminal A subtype correlation [BRCA1+: p&lt;0.001; BRCA2+: p=0.002]. In addition to the BC360 signatures, a differential analysis of all genes in the BC360 panel revealed more single gene differences in BRCA2+ than BRCA1+ tumors when compared to BRCA- tumors.

Conclusions: In early stage BRCA+ breast cancer, tumors have higher ROR and increased HRD signature scores compared to BRCA- tumors. Furthermore, BRCA1+ and BRCA2+ tumors have both signature and single gene expression differences when compared to BRCA- tumors, indicating distinct subgroup-related biology. The greater correlation of BRCA1+ tumors with basal-like biology and BRCA2+ tumors with aggressive hormonal biology confirms these trends. Distinctions in hormone receptor signaling, DNA-damage pathways, and microenvironment/inflammatory features between BRCA1 and BRCA2 associated cancers suggest a need for different prevention and therapeutic strategies for each of these breast cancer subtypes. The unique biological patterns identified here should be further evaluated as predictive or prognostic tools that could be translated into clinical care for early stage BRCA+ patients.

Citation Format: Force J, Plichta J, Stashko I, Kimmick G, Westbrook K, Sammons S, Hwang S, Hyslop T, Kauff N, Castellar E, Nair S, Weinhold K, Davis S, Mashadi-Hossein A, Brauer HA, Marcom PK. Distinct biological signatures describe differences in BRCA mutated subgroups [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-08-07.

An observational cohort study to produce and evaluate an improved tool to screen older women with back pain for osteoporotic vertebral fractures (Vfrac): study protocol

The aim of this study is to produce an easy to use checklist for general practitioners to complete whenever a woman aged over 65 years with back pain seeks healthcare. This checklist will produce a binary output to determine if the patient should have a radiograph to diagnose vertebral fracture.

PURPOSE

People with osteoporotic vertebral fractures are important to be identified as they are at relatively high risk of further fractures. Despite this, less than a third of people with osteoporotic vertebral fractures come to clinical attention due to various reasons including lack of clear triggers to identify who should have diagnostic spinal radiographs. This study aims to produce and evaluate a novel screening tool (Vfrac) for use in older women presenting with back pain in primary care based on clinical triggers and predictors identified previously. This tool will generate a binary output to determine if a radiograph is required.

METHODS

The Vfrac study is a two-site, pragmatic, observational cohort study recruiting 1633 women aged over 65 years with self-reported back pain. Participants will be recruited from primary care in two sites. The Vfrac study will use data from two self-completed questionnaires, a simple physical examination, a lateral thoracic and lateral lumbar radiograph and information contained in medical records.

RESULTS

The primary objective is to develop an easy-to-use clinical screening tool for identifying older women who are likely to have vertebral fractures.

CONCLUSIONS

This article describes the protocol of the Vfrac study; ISRCTN16550671.