Palliative care integration and end-of-life care intensity for patients with NSCLC

BACKGROUND

Non-small cell lung cancer (NSCLC) without oncogenic driver mutations is considered to have a poor prognosis, although recent therapeutic progress. This study aims to assess the real-life integration of palliative care (PC) and the intensity of end-of-life (EOL) care for this population.

METHODS

This was an observational cohort study of decedent patients from metastatic NSCLC without oncogenic driver mutations over the period 01/2018 to 12/2022, treated in first line with immunotherapy +/- chemotherapy. We analysed PC integration and aggressiveness criteria of EOL care in the last month before death: systemic anti-cancer treatment administration, emergency room visits, intensive care unit admission, hospitalization, hospitalization duration > 14 days, and hospital death.

RESULTS

Among 149 patients, 75 (50 %) met the PC team at least once, and the median time from the first encounter to death was 2.3 months. In the last month before death, at least one criterion of aggressive EOL care was present for 97 patients (70 %). For patients with PC use < 30 days and for patients with PC use < 90 days before death, there were significant changes: increase in the frequency of systemic anti-cancer treatment (respectively 51.1 % vs 20 %; p < 0.001 and 58.7 % vs 6.2 %; p < 0.001); decrease in hospitalization lasting > 14 days (respectively 30 % vs 7 %; p = 0.001 and 36 % vs 6.2 %; p = 0.018) and in death hospitalisation (respectively 66 % and 18 %; p < 0.001 and 58.7 % and 10.3 %; p < 0.001). After adjusting for the factors tested, patients with no PC or late PC use in the last month before death or in the last three month before death, the odds ratio (OR) remained significantly greater than 1 (respectively OR = 3.97 [1.70; 9.98]; p = 0.001 and OR = 23.1 [5.21-177.0], p < 0.0001).

CONCLUSION

PC is still insufficiently integrated for patients with NSCL cancer. Cancer centres should monitor key indicators such as PC use and aggressiveness criteria of EOL care.

Global spread, genetic differentiation and selection of barley spot form of net blotch isolates

Spot form of net blotch, caused by Pyrenophora teres f. maculata, is a significant necrotrophic disease of barley that spread world-wide in the 20th century. Genetic relationships were analysed to determine the diversity, survival and dispersal of a diverse collection of 346 isolates from Australia, Southern Africa, North America, Asia Minor and Europe. The results, based on genome-wide DArTseq data, indicated isolates from Turkey were the most differentiated with regional sub-structuring, together with individuals closely related to geographically distant genotypes. Elsewhere, population subdivision related to country of origin was evident, although low levels of admixturing was found that may represent rare genotypes or migration from unsampled populations. Canadian isolates were the next most diverged and Australian and South African the most closely related. With the exception of Turkish isolates, multiple independent Cyp51A mutation events (which confer insensitivity to demethylation inhibitor fungicides) between countries and within regions was evident, with strong selection for a transposable element insertion at the 3' end of the promoter and counter-selection elsewhere. Individuals from Western Australia shared genomic regions and Cyp51A haplotypes with South African isolates, suggesting a recent common origin.

Trans-radial cerebral angiography for stereotactic radiosurgery treatment of arteriovenous malformations

OBJECTIVES

The popularity of trans-radial access (TRA) for cerebral angiography is growing. Potential benefits of TRA over traditional trans-femoral access (TFA) are multitude. This study aimed to evaluate discharge outcomes and patient opinion of TRA compared to TFA in patients undergoing cerebral angiography prior to stereotactic radiosurgery (SRS) treatment for cerebral arteriovenous malformations.

METHODS

Consecutive patients treated at the National Centre for Stereotactic Radiosurgery (Sheffield, United Kingdom) over a 22-month period were included. All patients underwent cerebral angiography with either TRA or TFA as part of treatment planning prior to SRS. TRA patients who had previously undergone TFA in other centres were surveyed for their experience of cerebral angiography using a questionnaire. SRS staff at our centre was approached for their opinion.

RESULTS

492 patients were included (median age = 43 years, 57.5% male, median lesions treated = 1). More patients underwent angiography with TFA (75.2%) than TRA (24.8%). No difference was found in accumulated dose for angiography between the groups (p>0.05). There was 17.6% reduction in overnight stay between TRA and TRF, the proportion of patients requiring overnight admission was higher for the TFA (35.2%) than TRA (17.6%, p<0.05). 101 patients were surveyed, with a response rate of 47%. Most respondents (79%) indicated preference for TRA over TFA.

CONCLUSIONS

Use of TRA in pre-SRS cerebral angiography is feasible and improves both patient and staff experience. The adoption of TRA could have important implications for department resources and costs by reducing the proportion of overnight admissions.

Mobile treatment for opioid use disorder: Implementation of community-based, same-day medication access interventions

BACKGROUND

Medications for Opioid Use Disorder (MOUD) are lifesaving, but <20 % of individuals in the US who could benefit receive them. As part of the NIH-supported HEALing Communities Study (HCS), coalitions in several communities in Massachusetts and Ohio implemented mobile MOUD programs to overcome barriers to MOUD receipt. We defined mobile MOUD programs as units that provide same-day access to MOUD at remote sites. We aimed to (1) document the design and organizational structure of mobile programs providing same-day or next-day MOUD, and (2) explore the barriers and facilitators to implementation as well as the successes and challenges of ongoing operation.

METHODS

Program staff from five programs in two states (n = 11) participated in semi-structured interviews. Two authors conducted thematic analysis of the transcripts based on the domains of the social-ecological model and the semi-structured interview guide.

RESULTS

Mobile MOUD units sought to improve immediate access to MOUD ("Our answer is pretty much always, 'Yes, we'll get you started right here, right now,'"), advance equity ("making sure that we have staff who speak other languages, who are on the unit and have some resources that are in different languages,"), and decrease opioid overdose deaths. Salient program characteristics included diverse staff, including staff with lived experience of substance use ("She just had that personal knowledge of where we should be going"). Mobile units offered harm reduction services, broad medical services (in particular, wound care), and connection to transportation programs and incorporated consistency in service provision and telemedicine access. Implementation facilitators included trusting relationships with partner organizations (particularly pharmacies and correctional facilities), nuanced understanding of local politics, advertising, protocol flexibility, and on-unit prescriber hours. Barriers included unclear licensing requirements, staffing shortages and competing priorities for staff, funding challenges due to inconsistency in grant funding and low reimbursement ("It's not really possible that billing in and of itself is going to be able to sustain it"), and community stigma toward addiction services generally.

CONCLUSIONS

Despite organizational, community, and policy barriers, participants described mobile MOUD units as an innovative way to expand access to life-saving medications, promote equity in MOUD treatment, and overcome stigma.

Impact of the COVID-19 pandemic on employment and inequalities: a systematic review of international evidence and critical appraisal of statistical methods

AIMS

To assess the impact of the COVID-19 pandemic on individual labour market outcomes and how these vary over time and between different groups of individuals.

METHODS

Searches were conducted using Medline, Scopus and EconLit. Grey literature searches used Google Scholar and Econpapers. Study quality was assessed using the risk of bias in non-randomised studies of exposure tool (ROBINS-E), accompanied by a directed acyclic graph (DAG) to identify relevant mediators, moderators and confounders.

RESULTS

A total of 85 studies (77 peer-reviewed articles, 8 working papers) were included. The ROBINS-E showed that the overall risk of bias varied between studies from low (n = 14), moderate (n = 56) to serious (n = 15). Studies also varied in terms of outcome measures, study designs and the academic disciplines of researchers. Generally, studies using data collected before and during the pandemic showed large negative effects on employment, working hours and income. Studies that assessed moderators (e.g. by industry, occupation, age, gender, race and country of birth) indicated the pandemic has likely worsened pre-existing disparities in health and work. Generally, women, less educated, non-whites and young workers were affected the most, perhaps due to their jobs involving high levels of personal contact (e.g. hospitality, sales and entertainment) and being less amenable to remote working. The DAG highlighted methodological challenges in drawing robust inferences about COVID-19's impact on employment, including the lack of an unexposed control group.

CONCLUSIONS

The COVID-19 health crisis caused unanticipated and unprecedented changes to employment opportunities around the world, with potential long-term health consequences. Further research should investigate the longer-term impact of COVID-19, with greater attention given to low- and middle-income countries. Our study provides guidance on the design and critical appraisal of future studies.

Learning curve of achieving competency in emergency endoscopy in upper gastrointestinal bleeding: how much experience is necessary?

OBJECTIVES

The management of upper gastrointestinal bleeding (UGIB) has seen rapid advancements with revolutionising innovations. However, insufficient data exist on the necessary number of emergency endoscopies needed to achieve competency in haemostatic interventions.

DESIGN

We retrospectively analysed all oesophagogastroduodenoscopies with signs of recent haemorrhage performed between 2015 and 2022 at our university hospital. A learning curve was created by plotting the number of previously performed oesophagogastroduodenoscopies with signs of recent haemorrhage against the treatment failure rate, defined as failed haemostasis, rebleeding and necessary surgical or radiological intervention.

RESULTS

The study population included 787 cases with a median age of 66 years. Active bleeding was detected in 576 cases (73.2%). Treatment failure occurred in 225 (28.6%) cases. The learning curve showed a marked decline in treatment failure rates after nine oesophagogastroduodenoscopies had been performed by the respective endoscopists followed by a first plateau between 20 and 50 procedures. A second decline was observed after 51 emergency procedures followed by a second plateau. Endoscopists with experience of <10 emergency procedures had higher treatment failure rates compared with endoscopists with >51 emergency oesophagogastroduodenoscopies performed (p=0.039) or consultants (p=0.041).

CONCLUSIONS

Our data suggest that a minimum number of 20 oesophagogastroduodenoscopies with signs of recent haemorrhage is necessary before endoscopists should be considered proficient to perform emergency procedures independently. Endoscopists might be considered as advanced-qualified experts in managing UGIB after a minimum of 50 haemostatic procedure performed. Implementing recommendations on minimum numbers of emergency endoscopies in education programmes of endoscopy trainees could improve their confidence and competency in managing acute UGIB.

It Looks Like a Spinal Cord Tumor but It Is Not

Differentiating neoplastic from non-neoplastic spinal cord pathologies may be challenging due to overlapping clinical and radiological features. Spinal cord tumors, which comprise only 2-4% of central nervous system tumors, are rarer than non-tumoral myelopathies of inflammatory, vascular, or infectious origins. The risk of neurological deterioration and the high rate of false negatives or misdiagnoses associated with spinal cord biopsies require a cautious approach. Facing a spinal cord lesion, prioritizing more common non-surgical myelopathies in differential diagnoses is essential. A comprehensive radiological diagnostic approach is mandatory to identify spinal cord tumor mimics. The diagnostic process involves a multi-step approach: detecting lesions primarily using MRI techniques, precise localization of lesions, assessing lesion signal intensity characteristics, and searching for potentially associated anomalies at spinal cord and cerebral MRI. This review aims to delineate the radiological diagnostic approach for spinal cord lesions that may mimic tumors and briefly highlight the primary pathologies behind these lesions.

Evaluation of a flexible assertive community treatment (FACT) program for patients with severe mental illness: an observational study in Salzburg, Austria

BACKGROUND

Inpatient treatment of severe mentally ill patients binds substantial resources and creates the dilemma of "revolving-door hospitalizations". Evidence suggests that these patients benefit more from an assertive outreach community psychiatric treatment. This descriptive study evaluates the implementation of a new treatment program for severe mentally ill patients provided by a flexible assertive community treatment (FACT) team.

METHODS

An uncontrolled design with routine data was used to measure the total length of stays, readmission rates and number of contacts one year prior to the implementation of the FACT program and the following first three years of treatment.

RESULTS

A continuous decrease of hospitalization among patients with severe mental illness was observed with the implementation of the FACT program with declines in total length of stays and readmission rates and accompanied with a decreasing number of contacts per year.

CONCLUSION

Our findings indicate that this program may create effects in stabilizing patients with severe mental illness and may be highly relevant also for other patient groups.

Accurate Diagnosis of Cortical and Infratentorial Lesions in Multiple Sclerosis Using Accelerated Fluid and White Matter Suppression Imaging

OBJECTIVES

The precise location of multiple sclerosis (MS) cortical lesions can be very challenging at 3 T, yet distinguishing them from subcortical lesions is essential for the diagnosis and prognosis of the disease. Compressed sensing-accelerated fluid and white matter suppression imaging (CS-FLAWS) is a new magnetic resonance imaging sequence derived from magnetization-prepared 2 rapid acquisition gradient echo with promising features for the detection and classification of MS lesions. The objective of this study was to compare the diagnostic performances of CS-FLAWS (evaluated imaging) and phase sensitive inversion recovery (PSIR; reference imaging) for classification of cortical lesions (primary objective) and infratentorial lesions (secondary objective) in MS, in combination with 3-dimensional (3D) double inversion recovery (DIR).

MATERIALS AND METHODS

Prospective 3 T scans (MS first diagnosis or follow-up) acquired between March and August 2021 were retrospectively analyzed. All underwent 3D CS-FLAWS, axial 2D PSIR, and 3D DIR. Double-blinded reading sessions exclusively in axial plane and final consensual reading were performed to assess the number of cortical and infratentorial lesions. Wilcoxon test was used to compare the 2 imaging datasets (FLAWS + DIR and PSIR + DIR), and intraobserver and interobserver agreement was assessed using the intraclass correlation coefficient.

RESULTS

Forty-two patients were analyzed (38 with relapsing-remitting MS, 29 women, 42.7 ± 12.6 years old). Compressed sensing-accelerated FLAWS allowed the identification of 263 cortical lesions versus 251 with PSIR ( P = 0.74) and 123 infratentorial lesions versus 109 with PSIR ( P = 0.63), corresponding to a nonsignificant difference between the 2 sequences. Compressed sensing-accelerated FLAWS exhibited fewer false-negative findings than PSIR either for cortical lesions (1 vs 13; P < 0.01) or infratentorial lesions (1 vs 15; P < 0.01). No false-positive findings were found with any of the 2 sequences. Diagnostic confidence was high for each contrast.

CONCLUSION

Three-dimensional CS-FLAWS is as accurate as 2D PSIR imaging for classification of cortical and infratentorial MS lesions, with fewer false-negative findings, opening the way to a reliable full brain MS exploration in a clinically acceptable duration (5 minutes 15 seconds).

'Nesting networks': Women's experiences of social network support in high-risk pregnancy

OBJECTIVE

Social support, an individual's social relationships (both online and offline), may provide protection against adverse mental health outcomes, such as anxiety and depression, which are high in women who have been hospitalised with high-risk pregnancy. This study explored the social support available to women at higher risk of preeclampsia during pregnancy by examining personal social networks.

DESIGN

Semi-structured interviews were accompanied by social network mapping using the web-based social networking tool GENIE.

SETTING

England.

PARTICIPANTS

Twenty-one women were recruited, of whom 18 were interviewed both during pregnancy and postnatally between April 2019 and April 2020. Nineteen women completed maps pre-natally, 17 women completed maps pre-natally and post-natally. Women were taking part in the BUMP study, a randomised clinical trial that included 2441 pregnant individuals at higher risk of preeclampsia and recruited at a mean of 20 weeks' gestation from 15 hospital maternity units in England between November 2018 and October 2019.

RESULTS

Women's social networks tightened during pregnancy. The inner network changed most dramatically postnatally with women reporting fewer network members. Interviews revealed networks were primarily 'real-life' rather than online social networks, with members providing emotional, informational, and practical support. Women with a high-risk pregnancy valued the relationships they developed with health professionals during pregnancy, and would like their midwife to have a more central role in their networks by providing informational and, where needed, emotional support. The social network mapping data supported the qualitative accounts of changing networks across high-risk pregnancy.

CONCLUSION

Women with a high-risk pregnancy seek to build "nesting networks" to support them through pregnancy into motherhood. Different types of support are sought from trusted sources. Midwives can play a key role.

PRACTICE IMPLICATIONS

As well as highlighting other potential needs during pregnancy and the ways in which they can be met, support from midwives has a key role. Through talking to women early in their pregnancy, signposting information and explaining ways to contact health professionals regarding informational or emotional support would fill a gap that currently is met by other aspects of their network.

Mosaic results after preimplantation genetic testing for aneuploidy may be accompanied by changes in global gene expression

Aneuploidy in preimplantation embryos is a major cause of human reproductive failure. Unlike uniformly aneuploid embryos, embryos diagnosed as diploid-aneuploid mosaics after preimplantation genetic testing for aneuploidy (PGT-A) can develop into healthy infants. However, the reason why these embryos achieve full reproductive competence needs further research. Current RNA sequencing techniques allow for the investigation of the human preimplantation transcriptome, providing new insights into the molecular mechanisms of embryo development. In this prospective study, using euploid embryo gene expression as a control, we compared the transcriptome profiles of inner cell mass and trophectoderm samples from blastocysts with different levels of chromosomal mosaicism. A total of 25 samples were analyzed from 14 blastocysts with previous PGT-A diagnosis, including five low-level mosaic embryos and four high-level mosaic embryos. Global gene expression profiles visualized in cluster heatmaps were correlated with the original PGT-A diagnosis. In addition, gene expression distance based on the number of differentially expressed genes increased with the mosaic level, compared to euploid controls. Pathways involving apoptosis, mitosis, protein degradation, metabolism, and mitochondrial energy production were among the most deregulated within mosaic embryos. Retrospective analysis of the duration of blastomere cell cycles in mosaic embryos revealed several mitotic delays compared to euploid controls, providing additional evidence of the mosaic status. Overall, these findings suggest that embryos with mosaic results are not simply a misdiagnosis by-product, but may also have a genuine molecular identity that is compatible with their reproductive potential.

Aroma-active volatiles and rheological characteristics of the plastic mass during conching of dark chocolate

Chocolate conching is a highly complex, thermomechanical process that transforms the aroma and flow properties of a dry starting material. Different conched plastic masses of dark chocolate were characterized. Rheological characterization of plastic masses was performed for the first time using a closed cavity rheometer (CCR¹). In free cocoa butter derived from the plastic masses, acetic acid, benzaldehyde, (R,S)-(±)-linalool, 2,3,5,6-tetramethylpyrazine, and 2-phenylethanol were quantified by stable isotope dilution analysis (SIDA²) and gas chromatography-mass spectrometry. During the conching process, the amount of free cocoa butter increased possibly due to de-agglomeration. The complex viscosity of the plastic mass decreased as a function of conching time. Regarding aroma refinement, the concentrations of all five aroma-active volatiles decreased with increasing conching duration, albeit to varying degrees. The level of acetic acid showed the most pronounced decrease of about 60%, whereas linalool exhibited the lowest decrease in concentration, up to 26%. Overall, a lower polarity or boiling point of the aroma-active volatiles was linked to a stronger decrease in concentration during conching. These data illustrate the influence of conching on texture and the respective aroma changes, which deepens understanding of the conching effect on the sensory quality of dark chocolate.

Dietary omega-6/omega-3 ratio is not associated with gut microbiota composition and disease severity in patients with nonalcoholic fatty liver disease

In this cross-sectional study, we hypothesized that a high dietary ratio of omega-6 (n-6) to omega-3 (n-3) fatty acids could be associated with an altered gut bacterial composition and with the disease severity in patients with nonalcoholic fatty liver disease (NAFLD). A total of 101 NAFLD patients were included in the study, of which 63 underwent a liver biopsy. All 101 patients completed a 14-day food and activity record. Ebispro 2016 professional software was used to calculate individual macronutrients and micronutrients consumed. Patients were grouped into 3 quantiles (Q) according to a low (Q1: <6.1, n = 34), moderate (Q2: 6.1-7.8, n = 33), or high (Q3: >7.8, n = 34) dietary n-6/n-3 ratio. Stool samples were analyzed using 16S rRNA gene sequencing. Spearman correlation coefficients and principal coordinate analysis were used to detect differences in the bacterial composition of the gut microbiota. The median dietary n-6/n-3 ratio of all patients was 6.7 (range, 3.1-14.9). No significant associations between the dietary n-6/n-3 ratio and the gut microbiota composition or disease severity were observed. However, the abundance of specific bacteria such as Catenibacterium or Lactobacillus ruminis were found to be positively correlated and the abundance of Clostridium were negatively correlated with dietary n-6 fatty acid intake. The results indicate that a high dietary n-6/n-3 ratio is probably not a highly relevant factor in the pathogenesis of human NAFLD. Further studies are needed to clarify the importance of interactions between gut bacterial taxa and n-6 fatty acids in the pathophysiology of NAFLD.

167 ASSISTED DECISION-MAKING (CAPACITY) ACT 2015: KNOWLEDGE AND ATTITUDES AMONG HOSPITAL DOCTORS

Background

Assessing capacity is part of our daily practice, and an important pillar of patient centred care. Assisted Decision-Making (Capacity) Act 2015, which is due to commence in June 2022, is an act to provide reform of the law to assist patients who require help in making decisions in a manner that will ensure their autonomy, dignity, and best interests. This study aimed to investigate the knowledge, attitudes, and confidence of hospital doctors regarding this act.

Methods

This study was conducted using an anonymous online survey completed by hospital doctors from all levels and specialties in a tertiary hospital. The survey contained two sections, the first asked questions on confidence and attitudes about capacity assessment. The second section contained practical scenarios to test knowledge around the new framework for decision support under the Act.

Results

Of the 670 consultants and non-consultant hospital doctors (NCHD) surveyed, an 11% response rate was achieved (75 respondents), 44% were consultants 56% were NCHD. 43% reported to lack confidence in assessing capacity. 92% felt that they needed more training regarding the act. Also, 80% agreed the act will have an impact on our practice. 80% thought capacity was carried out by a certain specialty (mostly Psychiatry and Geriatrics). In the decision support scenarios 18-27% of responders felt they did not know what the appropriate level of decision support was. In each scenario, with the exception of one, the most frequent response was the correct one but responses were widely distributed on most questions.

Conclusion

Despite the lack of a representative sample, doctors’ knowledge about capacity seems to have improved compared to previously carried out studies. However, our study appears to indicate a significant knowledge gap and further training is needed regarding the Assisted Decision-Making (Capacity) Act 2015 proposed to commence next month. Mandatory training on the act should be considered by HSE and the professional training bodies.

The impact of inhaler technique on clinical outcomes in adolescents and adults with asthma: A systematic review

BACKGROUND

Many patients with asthma use their inhalers incorrectly, which can lead to sub-optimal asthma control and an increased risk of exacerbations. The Accuhaler/Diskus and Turbuhaler are arguably two of the most commonly used dry powder inhalers worldwide.

METHODS

A systematic literature review (SLR) was conducted to assess the impact of inhalation errors with these dry powder inhalers on clinical outcomes in asthma. Database searches were conducted in MEDLINE, Embase and proceedings from scientific conferences. Observational studies in adults and adolescents with asthma, reporting data for Accuhaler/Diskus and Turbuhaler devices and at least one outcome of interest, were included. Dual-independent screening and validation of studies was performed.

RESULTS

The search identified 35 studies. A range of inhaler errors was observed across studies and devices. In 8 out of the 9 studies that involved the two devices, the percentage of overall inhaler error rates was numerically (7 studies) or significantly (1 study) higher for Turbuhaler than Diskus, ranging from 3.7% to 71.9% for Diskus and 1.2%-83% for Turbuhaler. Critical errors, reported in three studies using similar definitions, ranged from 20% to 43% for Diskus and 32%-100% for Turbuhaler. Five studies reported a significant association between inhaler errors and worse asthma control, while one showed no difference.

CONCLUSIONS

This SLR identified a large range of inhaler errors with both devices. Across devices, a better inhalation technique was associated with better asthma outcomes. This systematic review confirms the importance of patients using their inhalers correctly as an integral part of achieving optimal asthma outcomes.

Texture, sensory properties and functionality of extruded snacks from pulses and pseudocereal proteins

BACKGROUND

The protein-rich fractions of pulses and pseudocereals exhibit a well-balanced amino acid profile, particularly when combined in different portions, and are therefore high-value ingredients for the production of extruded snacks. However, the impact of a combination of pulses and pseudocereals on the physical and sensory qualities of extruded snacks has not been investigated up to now. Native or preconditioned protein isolates and concentrates from pulses - as single ingredients or in combination with protein-rich flours of pseudocereals - were analyzed regarding their thermal and functional properties in relation to extrusion characteristics. Low moisture extrusion cooking was used to investigate the impact of protein source (lentil, lupin, faba bean), pseudocereal source (quinoa, amaranth, buckwheat) and protein content (30%, 50%, 70%) on sectional expansion, specific hardness, density and sensory properties of the snacks.

RESULTS

With increasing protein content from 30% to 50%, the sectional expansion decreased and the density and specific hardness of the extrudates increased, which could be counteracted by preconditioning of the protein-rich ingredients. Lupin protein-based extrudates exhibited satisfactory texture and sensory properties. Extruded mixtures of pulses and pseudocereals (70% protein) exhibited a smaller sectional expansion compared to pulses as single ingredients (30%, 50%), regardless of pseudocereal type. However, the texture and sensory properties of the extruded blends were satisfactory.

CONCLUSIONS

We show for the first time that protein-rich fractions of pulses and pseudocereals can be processed into expanded snacks with favorable texture and nutritional properties such as increased protein contents (70%) and balanced amino acid profiles. © 2020 The Authors. Journal of The Science of Food and Agriculture published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry.

P-082 Microfluidic-based device selects sperm with less DNA damage and higher motility, what else?

Study question

Does the microfluidic-based sperm selection device ZyMōt improve sperm parameters and other laboratory key performance indicator (KPI) values compared to the conventional swim-up method?

Summary answer

The microfluidic-based sperm selection device ZyMōt selects sperm with lower DNA fragmentation and higher motility than conventional swim-up method in intracytoplasmic sperm injection (ICSI) cycles.

What is known already

Elevated levels of sperm DNA fragmentation (SDF) in semen samples have been associated with poor embryo development and low pregnancy rates. SDF refers to breaks in the sperm's genetic material, mainly due to defects during spermatogenesis and other factors such as reactive oxygen species that are favored by centrifugation. Conventional sperm selection methods, by integrating centrifugation into their protocols, have become ineffective in selecting sperm with low SDF. In order to solve this problem and improve reproductive outcomes, microfluidic-based devices such as ZyMōt have been designed to avoid centrifugation and select spermatozoa with low SDF.

Study design, size, duration

Prospective, experimental, single-center study conducted from June to December 2021. A total of 14 couples with ≥ 10 retrieved oocytes were recruited for an intra-patient comparison. Semen sample was split and processed for ICSI by the conventional swim-up method or by the microfluidic-based device ZyMōt. Each fraction was used to fertilize half of the total number of oocytes retrieved. SDF index, semen parameters, useful blastocyst rate, fertilization rate and morphokinetic variables were observed.

Participants/materials, setting, methods

Oocytes retrieved were from own (n = 96) and donation cycles (n = 93). From each patient, the cohort of oocytes was divided into two groups: 1) inseminated with spermatozoa selected by swim-up and 2) inseminated with spermatozoa selected by ZyMōt 850 µL device. Embryo evaluation and development were then followed by time-lapse monitoring using EmbryoScope. Sperm chromatin dispersion (SCD) assay was used to measure SDF, analyzed by ImageJ. Each treatment followed routine protocol established in the clinical practice.

Main results and the role of chance

SDF index was significantly lower in ZyMōt group in comparison with swim-up group (10% vs 20%), indicating a better selection by the ZyMōt of sperm with less DNA breaks. Additionally, ZyMōt group also presented a significantly greater number of spermatozoa with progressive motility (96.9% vs 95.4%). In contrast, useful blastocyst rate showed a slightly, but not significantly, increment in ZyMōt group compared to swim-up group (53.2% vs 46.6%). No significant differences in fertilization rate or sperm recovery rate were observed between groups. Regarding morphokinetic parameters, timing variables from first cell division to blastocyst stage (t2-tB) showed no significant correlation with ZyMōt group contrasted with swim-up. Blastocysts were evaluated and a value was assigned with respect to their quality (A to D). There was a higher number of embryos with A grade in ZyMōt group and a higher number of embryos with D grade in swim-up group. The annotated variables were assessed using paired t-test and P value &lt;0.05 was considered statistically significant.

Limitations, reasons for caution

The impact on reproductive outcomes may vary depending on whether the breakage is single- or double-stranded, however, SCD is not able to distinguish between them. These, together with the oocyte's ability to repair sperm damage, lead us to the explanation for the non-significance on embryo quality.

Wider implications of the findings

This study provides further insights into the use of ZyMōt for the selection of low SDF spermatozoa in a simple manner. Its use could be indicated in patients with a high SDF value in their semen samples. Benefits on reproductive outcome will be confirmed with larger sample size.

Trial registration number

2102-VLC-007-MD

O-145 Limitations of designing carrier screening panels based on estimated frequencies. Concordance between recommendations and observed frequencies

Study question

Are recommended carrier screening (CS) panels suitable worldwide or should they be designed taking into account observed carrier frequencies (CF)?

Summary answer

Limitations of carrier screening panel recommendations based on estimated frequencies could be avoided with a worldwide-database of observed carrier frequencies.

What is known already

Currently, there is no consensus for specific gene panel for CS, but some scientific societies, based on estimated carrier frequencies, recommend to analyze a narrow panel rather than exome. The American College of Medical Genetics and Genomics (ACMG) recently recommended a 4-tiered system, encouraging to analyze genes in tier 3, genes with less carrier frequency (tier 4) are only recommended to be analyzed on specific cases. Similarly, Sociedad Española de Fertilidad (SEF) recommends in absence of genetic matching (GM) a 6 gene basic panel for donor screening and in a GM context suggests a 50-diseases panel.

Study design, size, duration

This study includes 8542 patients analyzed with an expanded carrier screening panel of 300 genes, including autosomal recessive (AR) and X-linked (XL) disorders by next-generation sequencing (NGS). ACMG guidelines were followed for variant interpretation and only pathogenic and likely pathogenic variants were reported. The study has been conducted between August 2018 and December 2021.

Participants/materials, setting, methods

DNA was extracted and sequenced. Obtained data was processed by bioinformatic tools. CF for diseases analyzed was stablished. Genes were categorized according to tier-3 of the ACMG recommendations (112 genes, only 80 included on this study) and also by 50-disease panel of SEF recommendations (49 genes, 40 included on this study). Likewise, analyzed diseases were divided in two groups according to the obtained CF: A (CF ≤ 1/200 - 56 genes); B (CF &gt; 1/200 - 244 genes).

Main results and the role of chance

The analysis of the 8542 patients showed that 2582 (30.23%) of them were not carriers of any disease analyzed, 2205 (25.81%) of them were only carriers of one or more of the diseases included in the ACMG tier3 panel and 3755 (43.96%) were carriers of at least one disease not included this category. 

When diseases analyzed were categorized by SEF 50-disease panel, 2280 (26.69%) patients were only carriers of one or more of the diseases included in this panel and 3680 (43.08%) were carriers of at least one disease that would not be analyzed by this panel.  

On the other hand, when diseases were divided by observed carrier frequency, a total of 3476 patients (40.69%) were carriers only of a disease(s) included in A group. With this panel, only 2484 (29.08%) of the 8542 patients would not have been correctly diagnosed. Moreover, the variants undetected would affect less frequent diseases (B group).

It is important to notice that group A has been created regarding the data of a 300 gene panel. If another panel would have been analyzed, the group of genes may have changed, but the data collected highlights the importance of observed CF on panel design.

Limitations, reasons for caution

Not all Tier3 ACMG and 50-disease SEF genes are included due to original panel limitations. Observed CF may vary depending on the population analyzed. NGS panel design does not cover variants in regulatory or deep intronic regions. Pseudogenes can interfere. Not all structural variants can be detected by NGS.

Wider implications of the findings

These data highlight the importance of reviewing the genes included in carrier screening panels by their frequency. Furthermore, it points out the need to have updated databases with observed CF available so an universal panel can be designed or adapted to patient’s needs.

Trial registration number

Not applicable

Mother and father depression symptoms and child emotional difficulties: a network model

Introduction

Enhancing understanding of depression symptom interactions between parents and associations with subsequent child emotional difficulties will inform targeted treatment of depression to prevent transmission within families.

Objectives

To use a network approach to identify ‘bridge’ symptoms that reinforce mother and father depression, and whether bridge symptoms, as well as other symptoms, impact subsequent child emotional difficulties.

Methods

Symptoms were examined using two unregularized partial correlation network models. The study included 4,492 mother-father-child trios from a prospective, population-based cohort in the United Kingdom. Mother and father reports of depression symptoms were assessed when the child was twenty-one months old. Child emotional difficulties were reported by the mother at ages nine, eleven and thirteen years.

Results

Bridge symptoms mutually reinforcing mother and father depression symptoms were feelings of guilt and self-harm ideation, whereas anhedonia acted as a bridge from the father to the mother, but not vice-versa (fig.1, network 1). The symptom of feelings of guilt in mothers was the only bridge symptom which directly associated with child emotional difficulties. Other symptoms that directly associated with child emotional difficulties were feeling overwhelmed for fathers and anhedonia, sadness, and panic in mothers (fig.1, network 2).

Conclusions

Specific symptom interactions are central to the co-occurrence of depression symptoms between parents. Of interest, only one of the bridge symptoms associated with later child emotional difficulties. In addition, specific symptom-to-child outcomes were identified, suggesting that different symptoms in mothers and fathers are central for increased vulnerability in children.

Disclosure

No significant relationships.

Nature-Based Early Childhood Education and Children's Physical Activity, Sedentary Behavior, Motor Competence, and Other Physical Health Outcomes: A Mixed-Methods Systematic Review

BACKGROUND

The purpose was to synthesize evidence on the association between nature-based Early Childhood Education (ECE) and children's physical activity (PA) and motor competence (MC).

METHODS

A literature search of 9 databases was concluded in August 2020. Studies were eligible if (1) children were aged 2-7 years old and attending ECE, (2) ECE settings integrated nature, and (3) assessed physical outcomes. Two reviewers independently screened full-text articles and assessed study quality. Synthesis was conducted using effect direction (quantitative), thematic analysis (qualitative), and combined using a results-based convergent synthesis.

RESULTS

1370 full-text articles were screened and 39 (31 quantitative and 8 qualitative) studies were eligible; 20 quantitative studies assessed PA and 6 assessed MC. Findings indicated inconsistent associations between nature-based ECE and increased moderate to vigorous PA, and improved speed/agility and object control skills. There were positive associations between nature-based ECE and reduced sedentary time and improved balance. From the qualitative analysis, nature-based ECE affords higher intensity PA and risky play, which could improve some MC domains. The quality of 28/31 studies was weak.

CONCLUSIONS

More controlled experimental designs that describe the dose and quality of nature are needed to better inform the effectiveness of nature-based ECE on PA and MC.

Fetoscopic Laser Ablation for Twin-to-Twin Transfusion Syndrome: A 15-year Review of Perinatal Survival

Objective Twin to twin transfusion syndrome (TTTS) complicates 5-15% of monochorionic twin pregnancies and untreated is associated with a 90% mortality rate. The aim was to present the perinatal survival of patients with TTTS treated with laser ablation, by a national fetal medicine team. Methods This was a review of all cases of TTTS treated with fetoscopic laser ablation performed from March 2006 through to December 2020. All patients treated with fetoscopic laser were identified from the hospital database. The perinatal outcomes for the overall cohort and the individual Quintero stages were determined. Results A total of 155 cases of TTTS underwent fetoscopic laser ablation during the study period. The median gestational age at diagnosis was 19+1 weeks, with a mean growth discordance of 23.6%. The Quintero stage at diagnosis was: Stage 1 6.5% (10/155), Stage 2 49% (76/155), Stage 3 38.7% (60/155), Stage 4 5.8% (9/155). There was at least one survivor in 83.2% (129/155) of pregnancies, with dual survival in 52.9% (82/155). An increase in the rate of any survivor was observed from 75% (2006-2014) to 94% (2014-2020) (p<0.05). Dual survival decreased with increasing Quintero Stage (p<0.05). 80.6% (125/155) of pregnancies delivered prior to 34+6 weeks gestation. Conclusion Fetoscopic laser ablation is the recommended first line treatment for severe TTTS. We observed a survival rate of at least one twin in 83.2% pregnancies which is comparable to internationally published data on single-centre outcomes.

Comparative analysis of lateral maxillary sinus augmentation with a xenogeneic bone substitute material in combination with piezosurgical preparation and bony wall repositioning or rotary instrumentation and membrane coverage: a prospective randomized clinical and histological study

OBJECTIVES

The present randomized controlled clinical study aimed to investigate if, in lateral maxillary sinus augmentation, the repositioned bony wall or the application of a collagen membrane results in more preferable new hard tissue formation.

MATERIALS AND METHODS

Forty patients were divided into two study groups. Both groups received a xenogeneic bone substitute material (BSM) during lateral sinus augmentation. In the bony wall group (BW), following piezosurgery, the retrieved bony wall was repositioned. In the collagen membrane group (CM), following rotary instrument preparation, collagen membrane coverage was applied. After 6 months, biopsies were taken to histologically analyze the percentage of BSM, connective tissue (CT), and newly formed bone (NFB) following both approaches.

RESULTS

Forty implants were placed and 29 harvested biopsies could be evaluated. Duration of surgery, membrane perforations, and VAS were detected. Histomorphometrical analysis revealed comparable amounts of all analyzed parameters in both groups in descending order: CT (BW: 39.2 ± 9%, CM: 37,9 ± 8.5%) > BSM (BW: 32.9 ± 6.3%, CM: 31.8 ± 8.8%) > NB (BW: 27.8 ± 11.2%, CM: 30.3 ± 4.5%).

CONCLUSIONS

The results of the present study show that the closure of the access window by means of the retrieved bony wall or a native collagen membrane led to comparable bone augmentation results.

CLINICAL TRIAL

clinicaltrials.gov NCT04811768.

CLINICAL RELEVANCE

Lateral maxillary sinus augmentation with the application of a xenogeneic BSM in combination with a native collagen membrane for bony window coverage represents a reliable method for surgical reconstruction of the posterior maxilla. Piezosurgery with bony window repositioning delivers comparable outcomes without membrane coverage.

A taxonomy of occupational and organisational stressors and protectors of mental health reported by veterinary professionals in Australasia

AIM

To develop a taxonomy of positive and negative occupational and organisational factors reported that impact the mental health of veterinary professionals.

METHODS

Veterinary professionals working in Australasia were surveyed between February and June of 2021. The survey comprised two questions related to participants' perceptions of the positive and negative aspects of their job role that impact their mental health and wellbeing. Reflexive thematic analysis was employed to analyse the responses and generate two taxonomies of occupational and organisation stressors and protectors reported by participants.

RESULTS

Fifty-three responses from veterinary professionals were analysed. The final stressor taxonomy generated contained 9 overarching themes and 36 subthemes. The most common of these were negative work conditions, challenging relationships with clients, and adverse events and patient outcomes. The taxonomy of protectors contained 11 overarching themes and 32 subthemes, with the most common including fulfillment and satisfaction, positive work conditions, and relationships with colleagues.

CONCLUSION

This study is the first to examine both positive and negative factors in the veterinary industry reported by veterinary professionals in Australasia. The results highlighted stressors that can be addressed on both an individual and organisational level to promote the mental and health well-being of professionals working in the animal care industry.

The fecal mycobiome in non-alcoholic fatty liver disease

BACKGROUND & AIMS

Studies investigating the gut-liver axis have largely focused on bacteria, whereas little is known about commensal fungi. We characterized fecal fungi in patients with non-alcoholic fatty liver disease (NAFLD) and investigated their role in a fecal microbiome-humanized mouse model of Western diet-induced steatohepatitis.

METHODS

We performed fungal internal transcribed spacer 2 sequencing using fecal samples from 78 patients with NAFLD, 16 controls and 73 patients with alcohol use disorder. Anti-Candida albicans (C. albicans) IgG was measured in blood samples from 17 controls and 79 patients with NAFLD. Songbird, a novel multinominal regression tool, was used to investigate mycobiome changes. Germ-free mice were colonized with feces from patients with non-alcoholic steatohepatitis (NASH), fed a Western diet for 20 weeks and treated with the antifungal amphotericin B.

RESULTS

The presence of non-obese NASH or F2-F4 fibrosis was associated with a distinct fecal mycobiome signature. Changes were characterized by an increased log-ratio for Mucor sp./Saccharomyces cerevisiae (S. cerevisiae) in patients with NASH and F2-F4 fibrosis. The C. albicans/S. cerevisiae log-ratio was significantly higher in non-obese patients with NASH when compared with non-obese patients with NAFL or controls. We observed a different fecal mycobiome composition in patients with NAFLD and advanced fibrosis compared to those with alcohol use disorder and advanced fibrosis. Plasma anti-C. albicans IgG was increased in patients with NAFLD and advanced fibrosis. Gnotobiotic mice, colonized with human NASH feces and treated with amphotericin B were protected from Western diet-induced steatohepatitis.

CONCLUSIONS

Non-obese patients with NAFLD and more advanced disease have a different fecal mycobiome composition to those with mild disease. Antifungal treatment ameliorates diet-induced steatohepatitis in mice. Intestinal fungi could be an attractive target to attenuate NASH.

LAY SUMMARY

Non-alcoholic fatty liver disease is one of the most common chronic liver diseases and is associated with changes in the fecal bacterial microbiome. We show that patients with non-alcoholic fatty liver disease and more severe disease stages have a specific composition of fecal fungi and an increased systemic immune response to Candida albicans. In a fecal microbiome-humanized mouse model of Western diet-induced steatohepatitis, we show that treatment with antifungals reduces liver damage.

HCV cure: an appropriate moment to reduce cannabis use in people living with HIV? (ANRS CO13 HEPAVIH data)

BACKGROUND

Thanks to direct-acting antivirals, hepatitis C virus (HCV) infection can be cured, with similar rates in HCV-infected and HIV-HCV co-infected patients. HCV cure is likely to foster behavioral changes in psychoactive substance use, which is highly prevalent in people living with HIV (PLWH). Cannabis is one substance that is very commonly used by PLWH, sometimes for therapeutic purposes. We aimed to identify correlates of cannabis use reduction following HCV cure in HIV-HCV co-infected cannabis users and to characterize persons who reduced their use.

METHODS

We used data collected on HCV-cured cannabis users in a cross-sectional survey nested in the ANRS CO13 HEPAVIH cohort of HIV-HCV co-infected patients, to perform logistic regression, with post-HCV cure cannabis reduction as the outcome, and socio-behavioral characteristics as potential correlates. We also characterized the study sample by comparing post-cure substance use behaviors between those who reduced their cannabis use and those who did not.

RESULTS

Among 140 HIV-infected cannabis users, 50 and 5 had reduced and increased their use, respectively, while 85 had not changed their use since HCV cure. Cannabis use reduction was significantly associated with tobacco use reduction, a decrease in fatigue level, paying more attention to one's dietary habits since HCV cure, and pre-HCV cure alcohol abstinence (p = 0.063 for alcohol use reduction).

CONCLUSIONS

Among PLWH using cannabis, post-HCV cure cannabis reduction was associated with tobacco use reduction, improved well-being, and adoption of healthy behaviors. The management of addictive behaviors should therefore be encouraged during HCV treatment.

744 3 YEAR FOLLOW-UP OF SEDATIVE PRESCRIBING FOR RESPONSIVE BEHAVIOURS IN NURSING HOME RESIDENTS, AN IRISH STUDY

Introduction

Sedative medications are commonly prescribed for older adults; these include neuroleptics, benzodiazepines, opioids, ‘z’ drugs and trazadone. The prevalence of sedative drug prescriptions is increasing (1). Nursing home residents are three times more likely to be prescribed benzodiazepines (2). Regular medication review and education have been shown to reduce rates of sedative use in nursing homes (3). We previously demonstrated a significant reduction in prescription of these target medications at an Irish nursing home with specific focus, within scheduled medication reviews, on reduction or discontinuation of the target drugs in combination with education on management of Behavioural and Psychological symptoms (BPSD). This audit examines the prescribing patterns 3 years on from the initial audit.

Methods

Point prevalence study of sedative prescriptions and BPSD of all 95 nursing home residents on 6/5/21. Comparison with data from two previous audits in the same unit. All data was anonymised. Data analysed with SPSS statistical software.

Results

Sustained significant drop in quetiapine use from 30% of residents to 14% post-intervention in 2018 and three-year follow-up (p = 0.06). Borderline significant reduction in overall neuroleptics (from 39% to 25%, p = 0.06). Significant rise in ‘z’ drug prescription (from 8% to 17%, p = 0.03). BPSD reported in 33%, compared to 49% pre-intervention.

Conclusion

Regularly scheduled medication reviews can effectively rationalise sedative prescription rates in nursing home residents. Increasing ‘z’ drug prescription likely represents the appropriate replacement of neuroleptics. Reduced BPSD may be due to reporting bias of staff since regular education has been introduced or changing cohort of residents. References numbered above not included given limited word count.

A121 QUANTIFYING INTER-OBSERVER VARIABILITY IN THE SEGMENTATION OF RECTAL TUMORS IN ENDOSCOPY IMAGES AND ITS EFFECTS ON DEEP LEARNING

Background

Tumor delineation in endoscopy images is a crucial part of clinical diagnoses and treatment planning for rectal cancer patients. However, it is challenging to detect and adequately determine the size of tumors in these images, especially for inexperienced clinicians. This motivates the need for a standardized, automated segmentation method. While deep learning has proven to be a powerful tool for medical image segmentation, it requires a large quantity of high-quality annotated training data. Since the annotation of endoscopy images is prone to high inter-observer variability, creating a robust unbiased deep learning model for this task is challenging.

Aims

To quantify the inter-observer variability in the manual segmentation of tumors in endoscopy images of rectal cancer patients and investigate an automated approach using deep learning.

Methods

Three gastrointestinal physicians and radiation oncologists (G1, G2, and G3) segmented 2833 endoscopy images into tumor and non-tumor regions. The whole image classifications and the pixelwise classifications into tumor and non-tumor were compared to quantify the inter-observer variability. Each manual annotator is from a different institution.

Three different deep learning architectures (FCN32, U-Net, and SegNet) were trained on the binary contours created by G2. This naive approach investigates the effectiveness of neglecting any information about the uncertainty associated with the task of tumor delineation.

Finally, segmentations from G2 and the deep learning models’ predictions were compared against ground truth labels from G1 and G3, and accuracy, sensitivity, specificity, precision, and F1 scores were computed for images where both segmentations contained tumors.

Results

The deep-learning segmentation took less than 1 second, while manual segmentation took approximately 10 seconds per image. There was significant inter-observer variability for the whole-image classifications made by the manual annotators (Figure 1A). The segmentation scores achieved by the deep learning models (SegNet F1:0.80±0.08) were comparable to the inter-observer variability for the pixel-wise image classification (Figure 1B).

Conclusions

The large inter-observer variability observed in this study indicates a need for an automated segmentation tool for tumors in endoscopy images of rectal cancer patients. While deep learning models trained on a single observer’s labels can segment tumors with an accuracy similar to the inter-observer variability, these models do not accurately reflect the intrinsic uncertainty associated with tumor delineation. In our ongoing studies, we investigate training a model with all observers’ contours to reflect the uncertainty associated with the tumor segmentations.

Funding Agencies

CIHRNSERC