The accuracy of prehospital triage decisions in English trauma networks - a case-cohort study

BACKGROUND

Care for injured patients in England is provided by inclusive regional trauma networks. Ambulance services use triage tools to identify patients with major trauma who would benefit from expedited Major Trauma Centre (MTC) care. However, there has been no investigation of triage performance, despite its role in ensuring effective and efficient MTC care. This study aimed to investigate the accuracy of prehospital major trauma triage in representative English trauma networks.

METHODS

A diagnostic case-cohort study was performed between November 2019 and February 2020 in 4 English regional trauma networks as part of the Major Trauma Triage Study (MATTS). Consecutive patients with acute injury presenting to participating ambulance services were included, together with all reference standard positive cases, and matched to data from the English national major trauma database. The index test was prehospital provider triage decision making, with a positive result defined as patient transport with a pre-alert call to the MTC. The primary reference standard was a consensus definition of serious injury that would benefit from expedited major trauma centre care. Secondary analyses explored different reference standards and compared theoretical triage tool accuracy to real-life triage decisions.

RESULTS

The complete-case case-cohort sample consisted of 2,757 patients, including 959 primary reference standard positive patients. The prevalence of major trauma meeting the primary reference standard definition was 3.1% (n=54/1,722, 95% CI 2.3 - 4.0). Observed prehospital provider triage decisions demonstrated overall sensitivity of 46.7% (n=446/959, 95% CI 43.5-49.9) and specificity of 94.5% (n=1,703/1,798, 95% CI 93.4-95.6) for the primary reference standard. There was a clear trend of decreasing sensitivity and increasing specificity from younger to older age groups. Prehospital provider triage decisions commonly differed from the theoretical triage tool result, with ambulance service clinician judgement resulting in higher specificity.

CONCLUSIONS

Prehospital decision making for injured patients in English trauma networks demonstrated high specificity and low sensitivity, consistent with the targets for cost-effective triage defined in previous economic evaluations. Actual triage decisions differed from theoretical triage tool results, with a decreasing sensitivity and increasing specificity from younger to older ages.

Is a randomised controlled trial of take home naloxone distributed in emergency settings likely to be feasible and acceptable? Findings from a UK qualitative study exploring perspectives of people who use opioids and emergency services staff

OBJECTIVE

Distribution of take-home naloxone (THN) by emergency services may increase access to THN and reduce deaths and morbidity from opioid overdose. As part of a feasibility study for a randomised controlled trial (RCT) of distribution of THN kits and education within ambulance services and Emergency Departments (EDs), we used qualitative methods to explore key stakeholders' perceptions of feasibility and acceptability of delivering the trial.

METHODS

We undertook semi-structured interviews and focus groups with 26 people who use opioids and with 20 paramedics and ED staff from two intervention sites between 2019 and 2021. Interviews and focus groups were recorded, transcribed verbatim and analysed using Framework Analysis.

RESULTS

People using opioids reported high awareness of overdose management, including personal experience of THN use. Staff perceived emergency service provision of THN as a low-cost, low-risk intervention with potential to reduce mortality, morbidity and health service use. Staff understood the trial aims and considered it compatible with their work. All participants supported widening access to THN but reported limited trial recruitment opportunities partly due to difficulties in consenting patients during overdose. Procedural problems, restrictive recruitment protocols, limited staff buy-in and patients already owning THN limited trial recruitment. Determining trial effectiveness was challenging due to high levels of alternative community provision of THN.

CONCLUSIONS

Distribution of THN in emergency settings was considered feasible and acceptable for stakeholders but an RCT to establish the effectiveness of THN delivery is unlikely to generate further useful evidence due to difficulties in recruiting patients and assessing benefits.

The Value of Adding Scribe Services to 2 Distinct Pediatric Subspecialties in the Era of the Electronic Medical Record

To evaluate the impact of adding medical scribes to 2 distinct outpatient pediatric subspecialty clinics on provider burnout, visit length, and patient satisfaction. A total of 2 pediatric endocrinologists and 2 developmental-behavioral pediatrics/pediatrician (DBP) were randomly assigned based on days of the week to see patients aged 0 to 21 years in their clinics with and without in-person medical scribes from February 2019 to February 2020. Parent satisfaction rates were examined through pre- and postappointment surveys. Provider burnout rates were assessed through the Maslach Burnout Inventory-Human Services Survey. A retrospective comparative analysis of average appointment duration was undertaken considering the scribe/no scribe random allocation in the examination room. Funding for this pilot provided by the department of pediatrics budgeted funds. Over 2923 appointments during the project dates, 829 appointments were seen with a scribe. The average appointment time for a new DBP appointment was 61 minutes with scribes and 71 minutes without (P < .001). Return patient appointments in DBP averaged 31 minutes with scribes and 43 minutes without (P < .001). There was no significant difference in appointment duration for endocrinology with and without scribes. The average time for chart completion was reduced with the presence of scribes in DBP but not in endocrinology. Out of the 209 families surveyed, patient satisfaction rates with and without a scribe did not differ in that between 96% and 97% of respondents rated the appointment overall as "excellent" for each measure of provider communication with scribes present. Finally, from the Maslach Burnout Inventory-Human Services Survey, the average score across all 4 providers for Emotional Exhaustion and Depersonalization decreased during the project period, whereas Personal Accomplishment scores increased over the project period. Scribes might be more advantageous for some subspecialties that utilize prolonged narratives in clinic notes, like DBP, and an important avenue to consider in reducing provider burnout in busy ambulatory settings.

Analysis of fibrinolytic shutdown in trauma patients with traumatic brain injury

BACKGROUND

Coagulation profiles following major trauma vary depending on injury pattern and degree of shock. The physiologic mechanisms involved in coagulation function at any given time are varied and remain poorly understood. Thromboelastography (TEG) has been used evaluate coagulation profiles in the trauma population with some reports demonstrating a spectrum of fibrinolysis to fibrinolytic shutdown on initial presentation. The objective of this study was to evaluate the fibrinolytic profile of patients with TBI using thromboelastography (TEG). We hypothesized that patients with TBI would demonstrate low fibrinolytic activity.

METHODS

All trauma activations at an ACS-verified level 1 trauma center received a TEG analysis upon arrival from December 2019 to June 2021. A retrospective review of the results and outcomes was conducted, and TBI patients were compared to patients without TBI. Linear regression was used to evaluate the effect of patient and injury factors on fibrinolysis. Hyperfibrinolysis was defined as LY30 ​> ​7.7%, physiologic fibrinolysis as LY30 0.6-7.7%, and fibrinolytic shutdown as LY30 ​< ​0.6%.

RESULTS

A total of 1369 patients received an admission TEG analysis. Patients with TBI had a significantly higher median ISS (16 vs. 8, p ​< ​0.001), lower median admission Glasgow Coma Scale (14 vs. 15, p ​< ​0.001), longer intensive care unit length of stay (3 vs. 2 days, p ​< ​0.0001), increased ventilator days (216 vs. 183, p ​< ​0.001), higher mortality (14.6% vs. 5.1%, p ​< ​0.001), but lower shock index (0.6 vs. 0.7, p ​< ​0.0001) compared to those without TBI. Median LY30 was found to be decreased in the TBI group (0.1 vs. 0.2, p ​= ​0.0006). Patients with TBI were found to have a higher rate of fibrinolytic shutdown compared those without TBI (68.7% vs. 63.5%, p ​= ​0.054). ISS, sex, and shock index were found to be predictive of LY30 on linear regression, but TBI was not (Β: 0.09, SE: 0.277, p ​= ​0.745). The rate of DVT/PE did not appear to be elevated in patients with TBI (0.8%) and without TBI (1.2%).

CONCLUSIONS

Trauma patients with and without TBI were found to have high rates of fibrinolytic shutdown. Although there was a high incidence of fibrinolytic shutdown, it did not appear to have an impact on the rate of thrombotic complications. The clinical significance of these results is unclear and differs significantly from recent reports which demonstrated that TBI is associated with a 25% rate of fibrinolytic shutdown. Further investigation is needed to better define the fibrinolytic pathway in patients with trauma and TBI to develop optimal treatment algorithms.

Impact of Heat and Drought Stress on Grasspea and Its Wild Relatives

Grasspea (Lathyrus sativus L.) is recognized as a highly drought-tolerant legume. However, excessive consumption of its seeds and green tissues causes neurolathyrism, a condition characterized by an irreversible paralysis of the legs induced by a neurotoxin amino acid called β-N-oxalyl-L-α, β- diaminopropionic acid (β-ODAP). The present study investigated the effects of heat, and combined heat + drought during the reproductive phase on physiological and phenological parameters, yield-related factors, ODAP content, and seed protein of 24 genotypes representing 11 Lathyrus species under controlled conditions. Analysis of variance revealed a highly significant effect (p < 0.001) of stress treatments and genotypes for all the traits. In general, heat stress individually or in combination with drought expedited phenology, reduced relative leaf water content, stimulated proline synthesis, and influenced chlorophyll concentration; the effects were more severe under the combined heat + drought stress. ODAP content in seeds ranged from 0.06 to 0.30% under no-stress conditions. However, under heat stress, there was a significant increase of 33% in ODAP content, and under combined stress (heat + drought), the increase reached 83%. Crude protein content ranged from 15.64 to 28.67% among no stress plants and decreased significantly by 23% under heat stress and by 36% under combined stress. The findings of this study also indicated substantial reductions in growth and grain yield traits under both heat stress and combined heat + drought stress. Six accessions namely IG 66026, IG 65018, IG 65687, IG 118511, IG 64931, and IG65273 were identified as having the most favorable combination of yield, protein content, and seed ODAP levels across all conditions. ODAP content in these six accessions varied from 0.07 to 0.11% under no stress and remained at moderate levels during both heat stress (0.09-0.14%) and combined stress (0.11-0.17%). IG 66026 was identified as the most stable genotype under drought and heat stress conditions with high protein content, and low ODAP content. By identifying those promising accessions, our results have established a basis for forthcoming grasspea breeding initiatives while paving the way for future research exploration into the fundamental mechanisms driving ODAP variation in the presence of both heat and drought stress conditions.

Longitudinal data resource from the Wellbeing of Older People cohort of people aged >50 years in Uganda and South Africa from 2009 to 2019

BACKGROUND

The population of people aged ≥60 years continues to increase globally, and has been projected by the United Nations Population Division to increase to 21% of the total population by 2050. In addition, the number of older people living with HIV has continued to increase owing to the introduction of antiretroviral therapy as a treatment for HIV-infected people. Most of the older people living with HIV are in sub-Saharan Africa, an area that faces the biggest burden of HIV globally. Despite the high burden, there are limited reliable data on how HIV directly and indirectly affects the health and wellbeing of older people within this region.

OBJECTIVE

To showcase the availability of data on how HIV directly and indirectly affects the health and wellbeing of older people in Uganda and South Africa (SA).

METHODS

The World Health Organization Study on global AGEing and adult health (SAGE), in collaboration with Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI and LSHTM) Uganda Research Unit and the Africa Health Research Institute (AHRI) in SA, started the SAGE Wellbeing of Older People Study (WOPS) in Uganda and SA in 2009. Since initiation, respondents have been surveyed every 2 years, with four waves of surveys conducted in Uganda and three waves in South Africa.

RESULTS

The available datasets consist of two cohorts of people, aged >50 years, who were surveyed every 2 years between 2009 and 2018. The prevalence of HIV positivity over this period increased from 39% to 54% in Uganda and 48% to 62% in SA. The datasets provide comparisons of variables at a household level and at an individual level. At the individual level, the following measures can be compared longitudinally for a 10-year period for the following variables: sociodemographic characteristics; work history and benefits; health states and descriptions; anthropometrics performance tests and biomarkers; risk factors and preventive health behaviours; chronic conditions and health services coverage; healthcare utilisation; social cohesion; subjective wellbeing and quality of life; and impact of caregiving.

CONCLUSION

This article describes the WOPS in Uganda and SA, the population coverage of this study, and the survey frequency of WOPS, survey measures, data resources available, the data resource access and the strengths and weaknesses of the study. The article invites interested researchers to further analyse the data and answer research questions of interest to enhance the impact of these data.

Towards optimal use of antithrombotic therapy of people with cancer at the end of life: A research protocol for the development and implementation of the SERENITY shared decision support tool

BACKGROUND

Even though antithrombotic therapy has probably little or even negative effects on the well-being of people with cancer during their last year of life, deprescribing antithrombotic therapy at the end of life is rare in practice. It is often continued until death, possibly resulting in excess bleeding, an increased disease burden and higher healthcare costs.

METHODS

The SERENITY consortium comprises researchers and clinicians from eight European countries with specialties in different clinical fields, epidemiology and psychology. SERENITY will use a comprehensive approach combining a realist review, flash mob research, epidemiological studies, and qualitative interviews. The results of these studies will be used in a Delphi process to reach a consensus on the optimal design of the shared decision support tool. Next, the shared decision support tool will be tested in a randomised controlled trial. A targeted implementation and dissemination plan will be developed to enable the use of the SERENITY tool across Europe, as well as its incorporation in clinical guidelines and policies. The entire project is funded by Horizon Europe.

RESULTS

SERENITY will develop an information-driven shared decision support tool that will facilitate treatment decisions regarding the appropriate use of antithrombotic therapy in people with cancer at the end of life.

CONCLUSIONS

We aim to develop an intervention that guides the appropriate use of antithrombotic therapy, prevents bleeding complications, and saves healthcare costs. Hopefully, usage of the tool leads to enhanced empowerment and improved quality of life and treatment satisfaction of people with advanced cancer and their care givers.

A qualitative exploration of stakeholder perspectives on the implementation of a whole school approach to mental health and emotional well-being in Wales

Early intervention to support mental health and well-being of school-aged children may be of significant benefit in preventing escalation of mental health problems in later life. While there are limitations to current understanding of the best ways for schools to support mental well-being, a whole school approach (WSA), involving all those who are part of the school system in creating and sustaining a supportive environment where health is prioritized, may be effective. This research explored stakeholder views of this approach, as part of a contract commissioned by the Welsh Government to conduct an evaluability assessment of a WSA. Semistructured focus groups and interviews were completed with stakeholders from the health and education sectors, as well as parents, to explore how a WSA may operate in a Welsh context and barriers and facilitators to potential implementation and outcomes. Findings suggest that existing pressures on schools may impact implementation of a WSA, with school staff already time poor and many staff experiencing their own mental well-being challenges. Implementation may be supported by clear guidance at local and national levels, funding for staff time and training and stakeholder involvement at all stages. Long-term monitoring and evaluation are also needed to understand system changes.

Did the UK's public health shielding policy protect the clinically extremely vulnerable during the COVID-19 pandemic in Wales? Results of EVITE Immunity, a linked data retrospective study

INTRODUCTION

The UK shielding policy intended to protect people at the highest risk of harm from COVID-19 infection. We aimed to describe intervention effects in Wales at 1 year.

METHODS

Retrospective comparison of linked demographic and clinical data for cohorts comprising people identified for shielding from 23 March to 21 May 2020; and the rest of the population. Health records were extracted with event dates between 23 March 2020 and 22 March 2021 for the comparator cohort and from the date of inclusion until 1 year later for the shielded cohort.

RESULTS

The shielded cohort included 117,415 people, with 3,086,385 in the comparator cohort. The largest clinical categories in the shielded cohort were severe respiratory condition (35.5%), immunosuppressive therapy (25.9%) and cancer (18.6%). People in the shielded cohort were more likely to be female, aged ≥50 years, living in relatively deprived areas, care home residents and frail. The proportion of people tested for COVID-19 was higher in the shielded cohort (odds ratio [OR] 1.616; 95% confidence interval [CI] 1.597-1.637), with lower positivity rate incident rate ratios 0.716 (95% CI 0.697-0.736). The known infection rate was higher in the shielded cohort (5.9% vs 5.7%). People in the shielded cohort were more likely to die (OR 3.683; 95% CI: 3.583-3.786), have a critical care admission (OR 3.339; 95% CI: 3.111-3.583), hospital emergency admission (OR 2.883; 95% CI: 2.837-2.930), emergency department attendance (OR 1.893; 95% CI: 1.867-1.919) and common mental disorder (OR 1.762; 95% CI: 1.735-1.789).

CONCLUSION

Deaths and healthcare utilisation were higher amongst shielded people than the general population, as would be expected in the sicker population. Differences in testing rates, deprivation and pre-existing health are potential confounders; however, lack of clear impact on infection rates raises questions about the success of shielding and indicates that further research is required to fully evaluate this national policy intervention.

Genomics and biochemical analyses reveal a metabolon key to β-L-ODAP biosynthesis in Lathyrus sativus

Grass pea (Lathyrus sativus L.) is a rich source of protein cultivated as an insurance crop in Ethiopia, Eritrea, India, Bangladesh, and Nepal. Its resilience to both drought and flooding makes it a promising crop for ensuring food security in a changing climate. The lack of genetic resources and the crop's association with the disease neurolathyrism have limited the cultivation of grass pea. Here, we present an annotated, long read-based assembly of the 6.5 Gbp L. sativus genome. Using this genome sequence, we have elucidated the biosynthetic pathway leading to the formation of the neurotoxin, β-L-oxalyl-2,3-diaminopropionic acid (β-L-ODAP). The final reaction of the pathway depends on an interaction between L. sativus acyl-activating enzyme 3 (LsAAE3) and a BAHD-acyltransferase (LsBOS) that form a metabolon activated by CoA to produce β-L-ODAP. This provides valuable insight into the best approaches for developing varieties which produce substantially less toxin.

Designed Transmembrane Proteins Inhibit the Erythropoietin Receptor in a Custom Binding Topology

Transmembrane (TM) domains as simple as a single span can perform complex biological functions using entirely lipid-embedded chemical features. Computational design has potential to generate custom tool molecules directly targeting membrane proteins at their functional TM regions. Thus far, designed TM domain-targeting agents have been limited to mimicking binding modes and motifs of natural TM interaction partners. Here, we demonstrate the design of de novo TM proteins targeting the erythropoietin receptor (EpoR) TM domain in a custom binding topology competitive with receptor homodimerization. The TM proteins expressed in mammalian cells complex with EpoR and inhibit erythropoietin-induced cell proliferation. In vitro, the synthetic TM domain complex outcompetes EpoR homodimerization. Structural characterization reveals that the complex involves the intended amino acids and agrees with our designed molecular model of antiparallel TM helices at 1:1 stoichiometry. Thus, membrane protein TM regions can now be targeted in custom designed topologies.

A global perspective on bacterial diversity in the terrestrial deep subsurface

While recent efforts to catalogue Earth's microbial diversity have focused upon surface and marine habitats, 12-20 % of Earth's biomass is suggested to exist in the terrestrial deep subsurface, compared to ~1.8 % in the deep subseafloor. Metagenomic studies of the terrestrial deep subsurface have yielded a trove of divergent and functionally important microbiomes from a range of localities. However, a wider perspective of microbial diversity and its relationship to environmental conditions within the terrestrial deep subsurface is still required. Our meta-analysis reveals that terrestrial deep subsurface microbiota are dominated by Betaproteobacteria, Gammaproteobacteria and Firmicutes, probably as a function of the diverse metabolic strategies of these taxa. Evidence was also found for a common small consortium of prevalent Betaproteobacteria and Gammaproteobacteria operational taxonomic units across the localities. This implies a core terrestrial deep subsurface community, irrespective of aquifer lithology, depth and other variables, that may play an important role in colonizing and sustaining microbial habitats in the deep terrestrial subsurface. An in silico contamination-aware approach to analysing this dataset underscores the importance of downstream methods for assuring that robust conclusions can be reached from deep subsurface-derived sequencing data. Understanding the global panorama of microbial diversity and ecological dynamics in the deep terrestrial subsurface provides a first step towards understanding the role of microbes in global subsurface element and nutrient cycling.

Pilot protocol for the Parent and Infant Inter(X)action Intervention (PIXI) feasibility study

This paper provides the detailed protocol for a pilot study testing the feasibility, acceptability, and initial efficacy of a targeted two-phase, remotely delivered early intervention program for infants with neurogenetic conditions (NGC) and their caregivers. The Parent and Infant Inter(X)action Intervention (PIXI) is designed to support parents and infants with a NGC diagnosed in the first year of life. PIXI is implemented in two phases, with the first phase focusing on psychoeducation, parent support, and how to establish routines for supporting infant development. Phase II helps parents learn targeted skills to support their infant's development as symptoms may begin to emerge. The proposed non-randomized feasibility pilot study will establish the feasibility of a year-long virtually implemented intervention program to support new parents of an infant diagnosed with an NGC.

Realist analysis of whether emergency departments with primary care services generate 'provider-induced demand'

Background

It is not known whether emergency departments (EDs) with primary care services influence demand for non-urgent care (‘provider-induced demand’). We proposed that distinct primary care services in EDs encourages primary care demand, whereas primary care integrated within EDs may be less likely to cause additional demand. We aimed to explore this and explain contexts (C), mechanisms (M) and outcomes (O) influencing demand.

Methods

We used realist evaluation methodology and observed ED service delivery. Twenty-four patients and 106 staff members (including Clinical Directors and General Practitioners) were interviewed at 13 EDs in England and Wales (240 hours of observations across 30 days). Field notes from observations and interviews were analysed by creating ‘CMO’ configurations to develop and refine theories relating to drivers of demand.

Results

EDs with distinct primary care services were perceived to attract demand for primary care because services were visible, known or enabled direct access to health care services. Other influencing factors included patients’ experiences of accessing primary care, community care capacity, service design and population characteristics.

Conclusions

Patient, local-system and wider-system factors can contribute to additional demand at EDs that include primary care services. Our findings can inform service providers and policymakers in developing strategies to limit the effect of potential influences on additional demand when demand exceeds capacity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00709-2.

Care navigation increases initiation of hepatitis C treatment following release from prison in a prospective randomised controlled trial: The C-LINK Study

Background

Prison-based hepatitis C treatment is safe and effective; however, many individuals are released untreated due to time or resource constraints. On community re-entry, individuals face a number of immediate competing priorities, and in this context, linkage to hepatitis C care is low. Interventions targeted at improving healthcare continuity after prison release have yielded positive outcomes for other health diagnoses; however, data regarding hepatitis C transitional care are limited.

Methods

We conducted a prospective randomized controlled trial comparing a hepatitis C care navigator intervention with standard of care for individuals released from prison with untreated hepatitis C infection. The primary outcome was prescription of hepatitis C direct-acting antivirals (DAA) within 6 months of release.

Results

Forty-six participants were randomized. The median age was 36 years and 59% were male. Ninety percent (n = 36 of 40) had injected drugs within 6 months before incarceration. Twenty-two were randomized to care navigation and 24 were randomized to standard of care. Individuals randomized to the intervention were more likely to commence hepatitis C DAAs within 6 months of release (73%, n = 16 of 22 vs 33% n = 8 of 24, P < .01), and the median time between re-entry and DAA prescription was significantly shorter (21 days [interquartile range {IQR}, 11–42] vs 82 days [IQR, 44–99], P = .049).

Conclusions

Care navigation increased hepatitis C treatment uptake among untreated individuals released from prison. Public policy should support similar models of care to promote treatment in this high-risk population. Such an approach will help achieve hepatitis C elimination as a public health threat.

Pretreatment Normal WM Magnetization Transfer Ratio Predicts Risk of Radiation Necrosis in Patients with Medulloblastoma

BACKGROUND AND PURPOSE

Radiation necrosis, for which abnormal WM enhancement is a hallmark, is an uncommon complication of craniospinal irradiation in children with medulloblastoma. The magnetization transfer ratio measures macromolecular content, dominated by myelin in the WM. We investigated whether the pretreatment supratentorial (nonsurgical) WM magnetization transfer ratio could predict patients at risk for radiation necrosis after radiation therapy for medulloblastoma.

MATERIALS AND METHODS

Ninety-five eligible patients with medulloblastoma (41% female; mean age, 11.0 [SD, 5.4]  years) had baseline balanced steady-state free precession MR imaging before proton or photon radiation therapy. Associations among baseline supratentorial magnetization transfer ratio, radiation necrosis (spontaneously resolving/improving parenchymal enhancement within the radiation field)³, age, and the presence of visible brain metastases were explored by logistic regression and parametric/nonparametric techniques as appropriate.

RESULTS

Twenty-three of 95 (24.2%) children (44% female; mean age, 10.7 [SD, 6.7] years) developed radiation necrosis after radiation therapy (19 infratentorial, 1 supratentorial, 3 both). The mean pretreatment supratentorial WM magnetization transfer ratio was significantly lower in these children (43.18 versus 43.50, P = .03). There was no association between the supratentorial WM magnetization transfer ratio and age, sex, risk/treatment stratum, or the presence of visible brain metastases.

CONCLUSIONS

A lower baseline supratentorial WM magnetization transfer ratio may indicate underlying structural WM susceptibility to radiation necrosis and may identify children at risk for developing radiation necrosis after craniospinal irradiation for medulloblastoma.

Protocol of a randomised clinical trial to integrate mental health services into primary care for postconflict populations in Northern Sri Lanka (COMGAP-S)

INTRODUCTION

Sri Lanka has a long history of armed conflict and natural disasters increasing the risk of mental health disorders in the population. Due to a lack of specialist services, there is a treatment gap between those seeking and those able to access mental health services. The aim of this research programme is to integrate mental health services into primary care to meet the needs of this postconflict population.

METHODS AND ANALYSIS

This is a stepped wedge cluster design randomised clinical trial of the WHO mental health Gap Action Programme primary care mental health training intervention. We will provide a 10-day training to primary care practitioners of 23 randomly selected primary care facilities aimed at increasing their ability to identify, treat and manage common mental health disorders. Public health professionals and community representatives will receive a tailored training intervention to increase mental health awareness. Refresher courses will occur at 3 and 6 months post training. Supervision and monitoring will occur for 1 month pre and post training. Target sample sizes have been calculated separately for each group of participants and for each outcome.

ETHICS AND DISSEMINATION

This trial has received ethical approval from the Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, UK (SC/jc/FMFREP/16/17 076) and from the Faculty of Medicine, University of Jaffna, Sri Lanka (J/ERC/17/81/NDR/0170) and non-engagement approval has been received from the funding body, the Centers for Disease Control and Prevention (2018-015). All participants gave written consent. Dissemination of study results will be completed through publication of academic articles, conference presentations, town hall meetings, written pamphlets in plain language, reports to Ministry of Health and other government organisations and through social media outlets.

TRIAL REGISTRATION NUMBERS

ISRCTN registry: ISRCTN62598070. SLCTR registration number: SLCTR/2018/008.

Pantothenate kinase activation relieves coenzyme A sequestration and improves mitochondrial function in mice with propionic acidemia

[Figure: see text].

Bridging the age gap in breast cancer: impact of omission of breast cancer surgery in older women with oestrogen receptor-positive early breast cancer on quality-of-life outcomes

BACKGROUND

Primary endocrine therapy may be an alternative treatment for less fit women with oestrogen receptor (ER)-positive breast cancer. This study compared quality-of-life (QoL) outcomes in older women treated with surgery or primary endocrine therapy.

METHODS

This was a multicentre, prospective, observational cohort study of surgery or primary endocrine therapy in women aged over 70 years with operable breast cancer. QoL was assessed using European Organisation for Research and Treatment of cancer QoL questionnaires QLQ-C30, -BR23, and -ELD14, and the EuroQol Five Dimensions 5L score at baseline, 6 weeks, and 6, 12, 18, and 24 months. Propensity score matching was used to adjust for baseline variation in health, fitness, and tumour stage.

RESULTS

The study recruited 3416 women (median age 77 (range 69-102) years) from 56 breast units. Of these, 2979 (87.2 per cent) had ER-positive breast cancer; 2354 women had surgery and 500 received primary endocrine therapy (125 were excluded from analysis due to inadequate data or non-standard therapy). Median follow-up was 52 months. The primary endocrine therapy group was older and less fit. Baseline QoL differed between the groups; the mean(s.d.) QLQ-C30 global health status score was 66.2(21.1) in patients who received primary endocrine therapy versus 77.1(17.8) among those who had surgery plus endocrine therapy. In the unmatched analysis, changes in QoL between 6 weeks and baseline were noted in several domains, but by 24 months most scores had returned to baseline levels. In the matched analysis, major surgery (mastectomy or axillary clearance) had a more pronounced adverse impact than primary endocrine therapy in several domains.

CONCLUSION

Adverse effects on QoL are seen in the first few months after surgery, but by 24 months these have largely resolved. Women considering surgery should be informed of these effects.

Storage and export of microbial biomass across the western Greenland Ice Sheet

The Greenland Ice Sheet harbours a wealth of microbial life, yet the total biomass stored or exported from its surface to downstream environments is unconstrained. Here, we quantify microbial abundance and cellular biomass flux within the near-surface weathering crust photic zone of the western sector of the ice sheet. Using groundwater techniques, we demonstrate that interstitial water flow is slow (~10⁻² m d⁻¹), while flow cytometry enumeration reveals this pathway delivers 5 × 10⁸ cells m⁻² d⁻¹ to supraglacial streams, equivalent to a carbon flux up to 250 g km⁻² d⁻¹. We infer that cellular carbon accumulation in the weathering crust exceeds fluvial export, promoting biomass sequestration, enhanced carbon cycling, and biological albedo reduction. We estimate that up to 37 kg km⁻² of cellular carbon is flushed from the weathering crust environment of the western Greenland Ice Sheet each summer, providing an appreciable flux to support heterotrophs and methanogenesis at the bed.

Microbes that colonise ice sheet surfaces are important to the carbon cycle, but their biomass and transport remains unquantified. Here, the authors reveal substantial microbial carbon fluxes across Greenland’s ice surface, in quantities that may sustain subglacial heterotrophs and fuel methanogenesis.

The practical utility of genetic screening in school settings

Can genetic screening be used to personalize education for students? Genome-wide association studies (GWAS) screen an individual's DNA for specific variations in their genome, and how said variations relate to specific traits. The variations can then be assigned a corresponding weight and summed to produce polygenic scores (PGS) for given traits. Though first developed for disease risk, PGS is now used to predict educational achievement. Using a novel simulation method, this paper examines if PGS could advance screening in schools, a goal of personalized education. Results show limited potential benefits for using PGS to personalize education for individual students. However, further analysis shows PGS can be effectively used alongside progress monitoring measures to screen for learning disability risk. Altogether, PGS is not useful in personalizing education for every child but has potential utility when used simultaneously with additional screening tools to help determine which children may struggle academically.

P90 PERCEIVE: PrEdiction of Risk and Communication of outcome following major lower limb amputation - a collaboratIVE study

Introduction

Major Lower Limb Amputation (MLLA) is a life changing event with significant morbidity and mortality. Inaccurate risk prediction can lead to poor decision making, resulting in delay to definitive surgery, or undertaking amputation when not in the patient’s best interest. We aim to answer: In adult patients undergoing MLLA for chronic limb threatening ischaemia or diabetes, how accurately do health care professionals prospectively predict outcomes after MLLA, and how does this compare to existing prediction tools?

Methods

A multicentre prospective observational cohort study is being delivered through the Vascular and Endovascular Research Network. Dissemination was via an existing network of contacts and social media.

Consecutive data will be collected for seven months from site launch date, including demographic data and pre-operative outcome predictions from surgeons, anaesthetists, and allied healthcare professionals. Follow-up data will comprise 30-day (mortality, morbidity, MLLA revision, surgical site infection, and blood transfusion) and 1-year (mortality, MLLA revision and ambulation). The accuracy of surgeons’ predictions will be evaluated and compared to pre-existing risk prediction scoring tools.

Results

PERCEIVE launched on 01/10/2020 with 23 centres (16 UK, 7 international) registered to collect data. 50 other centres (27 UK, 23 international) have expressed interest/are pursuing local audit/ethical approval. We aim to collect data on clinicians estimate of outcomes for over 500 patients.

Discussion

This study will utilise a trainee research network to provide data on the accuracy of healthcare professionals’ predictions of outcomes following MLLA and compare this to the utility of existing prediction tools in this patient cohort.

Evidence-based orthopaedic trauma care in the United Kingdom: Guidelines, registries, carrots and sticks

In the United Kingdom (UK), orthopaedic trauma surgeons utilise evidence-based practice through distillation of high-quality primary research, interrogation of registries and implementation of evidence-based guidelines. Concurrent with this ambition of providing exemplar care based on robust patient centred research, there has evolved a culture of remuneration 'by results'. Therefore, there is a drive for excellence combined with a system of collation and validation of data input as well as remuneration where care excels. There are several organisations involved in each stage of this process, the output of which has much that is pertinent to the globally similar consequences of physical injury. However, their relevance and impact within the UK is magnified as they are written against the backdrop of a unified healthcare system. In this article, we will describe the roles of the different organisations guiding and regulating trauma practice across the UK and discuss how the interplay of these impacts on clinical care.

Bridging the age gap in breast cancer: cluster randomized trial of two decision support interventions for older women with operable breast cancer on quality of life, survival, decision quality, and treatment choices

BACKGROUND

Rates of surgery and adjuvant therapy for breast cancer vary widely between breast units. This may contribute to differences in survival. This cluster RCT evaluated the impact of decision support interventions (DESIs) for older women with breast cancer, to ascertain whether DESIs influenced quality of life, survival, decision quality, and treatment choice.

METHODS

A multicentre cluster RCT compared the use of two DESIs against usual care in treatment decision-making in older women (aged at least ≥70 years) with breast cancer. Each DESI comprised an online algorithm, booklet, and brief decision aid to inform choices between surgery plus adjuvant endocrine therapy versus primary endocrine therapy, and adjuvant chemotherapy versus no chemotherapy. The primary outcome was quality of life. Secondary outcomes included decision quality measures, survival, and treatment choice.

RESULTS

A total of 46 breast units were randomized (21 intervention, 25 usual care), recruiting 1339 women (670 intervention, 669 usual care). There was no significant difference in global quality of life at 6 months after the baseline assessment on intention-to-treat analysis (difference -0.20, 95 per cent confidence interval (C.I.) -2.69 to 2.29; P = 0.900). In women offered a choice of primary endocrine therapy versus surgery plus endocrine therapy, knowledge about treatments was greater in the intervention arm (94 versus 74 per cent; P = 0.003). Treatment choice was altered, with a primary endocrine therapy rate among women with oestrogen receptor-positive disease of 21.0 per cent in the intervention versus 15.4 per cent in usual-care sites (difference 5.5 (95 per cent C.I. 1.1 to 10.0) per cent; P = 0.029). The chemotherapy rate was 10.3 per cent at intervention versus 14.8 per cent at usual-care sites (difference -4.5 (C.I. -8.0 to 0) per cent; P = 0.013). Survival was similar in both arms.

CONCLUSION

The use of DESIs in older women increases knowledge of breast cancer treatment options, facilitates shared decision-making, and alters treatment selection. Trial registration numbers: EudraCT 2015-004220-61 (https://eudract.ema.europa.eu/), ISRCTN46099296 (http://www.controlled-trials.com).

The migratory pathways of the cells that form the endocardium, dorsal aortae, and head vasculature in the mouse embryo

Background

Vasculogenesis in amniotes is often viewed as two spatially and temporally distinct processes, occurring in the yolk sac and in the embryo. However, the spatial origins of the cells that form the primary intra-embryonic vasculature remain uncertain. In particular, do they obtain their haemato-endothelial cell fate in situ, or do they migrate from elsewhere? Recently developed imaging techniques, together with new Tal1 and existing Flk1 reporter mouse lines, have allowed us to investigate this question directly, by visualising cell trajectories live and in three dimensions.

Results

We describe the pathways that cells follow to form the primary embryonic circulatory system in the mouse embryo. In particular, we show that Tal1-positive cells migrate from within the yolk sac, at its distal border, to contribute to the endocardium, dorsal aortae and head vasculature. Other Tal1 positive cells, similarly activated within the yolk sac, contribute to the yolk sac vasculature. Using single-cell transcriptomics and our imaging, we identify VEGF and Apela as potential chemo-attractants that may regulate the migration into the embryo. The dorsal aortae and head vasculature are known sites of secondary haematopoiesis; given the common origins that we observe, we investigate whether this is also the case for the endocardium. We discover cells budding from the wall of the endocardium with high Tal1 expression and diminished Flk1 expression, indicative of an endothelial to haematopoietic transition.

Conclusions

In contrast to the view that the yolk sac and embryonic circulatory systems form by two separate processes, our results indicate that Tal1-positive cells from the yolk sac contribute to both vascular systems. It may be that initial Tal1 activation in these cells is through a common mechanism.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12861-021-00239-3.

"Just tell me what's going on": The views of parents of children with genetic conditions regarding the research use of their child's electronic health record

OBJECTIVE

The purpose of this study was to understand the ethical, legal, and social issues described by parents of children with known or suspected genetic conditions that cause intellectual and developmental disabilities regarding research use of their child's electronic health record (EHR).

MATERIALS AND METHODS

We conducted 4 focus groups with parents of children with a known (n = 12) or suspected (n = 11) genetic condition, as well as 2 comparison groups with parents who had a child with no known genetic condition (n = 15). Focus group transcripts were coded and analyzed using directed content analysis.

RESULTS

After weighing the risks and benefits, parents of children with known or suspected genetic conditions were willing to share their child's EHR for research studies under certain conditions. Preferences were for studies conducted by universities or nonprofits that might benefit their child or others with the same condition. Parents also valued return of research results.

DISCUSSION

Trust, transparency, altruism, and concerns about privacy emerged as factors that affect parents' willingness to allow research use of their child's EHR.

CONCLUSION

Researchers should consider how to build trust with parents by increasing transparency of the research process and explaining specifically how they will ensure the confidentiality of EHR data.

Preferences for Accessing Electronic Health Records for Research Purposes: Views of Parents Who Have a Child With a Known or Suspected Genetic Condition

OBJECTIVES

The purpose of this study was to examine parental preferences for researchers accessing their child's electronic health record across 3 groups: those with a child with (1) a known genetic condition (fragile X syndrome FXS), (2) a suspected genetic condition (autism spectrum disorder [ASD]), and (3) no known genetic condition (typically developing).

METHODS

After extensive formative work, a discrete choice experiment was designed consisting of 5 attributes, each with 2 or 3 levels, including (1) type of researcher, (2) the use of personally identifiable information, (3) the use of sensitive information, (4) personal importance of research, and (5) return of results. Stratified mixed logit and latent class conditional logit models were examined.

RESULTS

Parents of children with FXS or ASD had relatively higher preferences for research conducted by nonprofits than parents of typically developing children. Parents of children with ASD also preferred research using non-identifiable and nonsensitive information. Parents of children with FXS or ASD also had preferences for research that was personally important and returned either summary or individual results. Although a few child and family characteristics were related to preferences, they did not overall define the subgroups of parents.

CONCLUSIONS

Although electronic health record preference research has been conducted with the general public, this is the first study to examine the opinions of parents who have a child with a known or suspected genetic condition. These parents were open to studies using their child's electronic health record because they may have more to gain from this type of research.

Preferences for the research use of electronic health records among young adults with fragile X syndrome or autism spectrum disorder

BACKGROUND

Health researchers are increasingly using electronic health records (EHRs) to study the health care needs of people with neurodevelopmental disorders (NDDs). However, little is known about the preferences of people with NDDs for sharing EHRs for research.

OBJECTIVE

To explore preferences for sharing EHRs for research among young adults ages 18-40 who make their own legal decisions and who have autism spectrum disorder (ASD), fragile X syndrome (FXS), or no NDDs.

METHODS

We conducted a qualitative study with seven focus groups: 2 ASD groups, 3 FXS groups, and 2 no-NDD groups. We asked participants about factors that could affect their willingness to share their EHRs for research: type of organization, type of information, study purpose, duration, contact frequency, return of results, benefits, and risks. We analyzed the qualitative data using directed content analysis.

RESULTS

Participants with NDDs valued personally relevant and directly beneficial EHR research. Participants with NDDs expressed willingness to share sensitive data if the study was personally relevant. Most participants wanted to receive results, but only participants with FXS indicated it would affect their willingness to participate. Participants were concerned about privacy risks, discrimination, researcher misconduct, and financial conflicts of interest.

CONCLUSION

This study provides initial evidence suggesting that young adults with NDDs prefer EHR research that is personally relevant, benefits themselves and their communities, and is conducted in the context of trusting, reciprocal participant-researcher relationships. The findings point to the need for researchers to improve the informed consent process and to better engage individuals with NDDs in research.

Decisional Capacity for Informed Consent in Males and Females with Fragile X Syndrome

Although informed consent is critical for all research, there is increased ethical responsibility as individuals with intellectual or developmental disabilities (IDD) become the focus of more clinical trials. This study examined decisional capacity for informed consent to clinical trials in individuals with fragile X syndrome (FXS). Participants were 152 adolescents and adults (80 males, 72 females) with FXS who completed a measure of decisional capacity and a comprehensive battery of neurocognitive and psychiatric measures. Females outperformed males on all aspects of decisional capacity. The ability to understand aspects of the clinical trial had the strongest association with the ability to appreciate and reason about the decision. Scaffolding improved understanding, suggesting researchers can take steps to improve decisional capacity and the informed consent process.

Genetic relatedness of ceftriaxone-resistant and high-level azithromycin resistant Neisseria gonorrhoeae cases, United Kingdom and Australia, February to April 2018

Between February and April 2018, three ceftriaxone-resistant and high-level azithromycin-resistant Neisseria gonorrhoeae cases were identified; one in the United Kingdom and two in Australia. Whole genome sequencing was used to show that the isolates from these cases belong to a single gonococcal clone, which we name the A2543 clone.

Ethical, Legal, and Social Issues Related to the Inclusion of Individuals With Intellectual Disabilities in Electronic Health Record Research: Scoping Review

Background

Data from electronic health records (EHRs) are increasingly used in the field of genetic research to further precision medicine initiatives. However, many of these efforts exclude individuals with intellectual disabilities, which often stem from genetic conditions. To include this important subpopulation in EHR research, important ethical, legal, and social issues should be considered.

Objective

The goal of this study was to review prior research to better understand what ethical, legal, and social issues may need further investigation when considering the research use of EHRs for individuals with genetic conditions that may result in intellectual disability. This information will be valuable in developing methods and best practices for involving this group in research given they are considered a vulnerable population that may need special research protections.

Methods

We conducted a scoping review to examine issues related to the use of EHRs for research purposes and those more broadly associated with genetic research. The initial search yielded a total of 460 unique citations. We used an evaluative coding process to determine relevancy for inclusion.

Results

This approach resulted in 59 articles in the following areas: informed consent, privacy and security, return of results, and vulnerable populations. The review included several models of garnering informed consent in EHR or genetic research, including tiered or categorical, blanket or general, open, and opt-out models. Second, studies reported on patients’ concerns regarding the privacy and security of EHR or genetic data, such as who has access, type of data use in research, identifiability, and risks associated with privacy breach. The literature on return of research results using biospecimens examined the dissension in the field, particularly when sharing individualized genetic results. Finally, work involving vulnerable populations highlighted special considerations when conducting EHR or genetic research.

Conclusions

The results frame important questions for researchers to consider when designing EHR studies, which include individuals with intellectual disabilities, including appropriate safeguards and protections.

MRI Patterns of Extrapontine Lesion Extension in Diffuse Intrinsic Pontine Gliomas

BACKGROUND AND PURPOSE

Diffuse intrinsic pontine glioma is a devastating childhood cancer that despite being primarily diagnosed by MR imaging alone, lacks robust prognostic imaging features. This study investigated patterns and quantification of extrapontine lesion extensions as potential prognostic imaging biomarkers for survival in children with newly diagnosed diffuse intrinsic pontine glioma.

MATERIALS AND METHODS

Volumetric analysis of baseline MR imaging studies was completed in 131 patients with radiographically defined typical diffuse intrinsic pontine gliomas. Extrapontine tumor extension was classified according to the direction of extension: midbrain, medulla oblongata, and right and left middle cerebellar peduncles; various extrapontine lesion extension patterns were evaluated. The Kaplan-Meier method was used to estimate survival differences; linear regression was used to evaluate clinical-radiographic variables prognostic of survival.

RESULTS

At least 1 extrapontine lesion extension was observed in 125 patients (95.4%). Of the 11 different extrapontine lesion extension patterns encountered in our cohort, 2 were statistically significant predictors of survival. Any extension into the middle cerebellar peduncles was prognostic of shorter overall survival (P = .01), but extension into both the midbrain and medulla oblongata but without extension into either middle cerebellar peduncle was prognostic of longer overall survival compared with those having no extension (P = .04) or those having any other pattern of extension (P < .001).

CONCLUSIONS

Within this large cohort of patients with typical diffuse intrinsic pontine gliomas, 2 specific extrapontine lesion extension patterns were associated with a significant overall survival advantage or disadvantage. Our findings may be valuable for risk stratification and radiation therapy planning in future clinical trials.

Linking a rapid throughput plate-assay with high-sensitivity stable-isotope label LCMS quantification permits the identification and characterisation of low β-L-ODAP grass pea lines

BACKGROUND

Grass pea (Lathyrus sativus) is an underutilised crop with high tolerance to drought and flooding stress and potential for maintaining food and nutritional security in the face of climate change. The presence of the neurotoxin β-L-oxalyl-2,3-diaminopropionic acid (β-L-ODAP) in tissues of the plant has limited its adoption as a staple crop. To assist in the detection of material with very low neurotoxin toxin levels, we have developed two novel methods to assay ODAP. The first, a version of a widely used spectrophotometric assay, modified for increased throughput, permits rapid screening of large populations of germplasm for low toxin lines and the second is a novel, mass spectrometric procedure to detect very small quantities of ODAP for research purposes and characterisation of new varieties.

RESULTS

A plate assay, based on an established spectrophotometric method enabling high-throughput ODAP measurements, is described. In addition, we describe a novel liquid chromatography mass spectrometry (LCMS)-based method for β-L-ODAP-quantification. This method utilises an internal standard (di-13C-labelled β-L-ODAP) allowing accurate quantification of β-L-ODAP in grass pea tissue samples. The synthesis of this standard is also described. The two methods are compared; the spectrophotometric assay lacked sensitivity and detected ODAP-like absorbance in chickpea and pea whereas the LCMS method did not detect any β-L-ODAP in these species. The LCMS method was also used to quantify β-L-ODAP accurately in different tissues of grass pea.

CONCLUSIONS

The plate-based spectrophotometric assay allows quantification of total ODAP in large numbers of samples, but its low sensitivity and inability to differentiate α- and β-L-ODAP limit its usefulness for accurate quantification in low-ODAP samples. Coupled to the use of a stable isotope internal standard with LCMS that allows accurate quantification of β-L-ODAP in grass pea samples with high sensitivity, these methods permit the identification and characterisation of grass pea lines with a very low ODAP content. The LCMS method is offered as a new 'gold standard' for β-L-ODAP quantification, especially for the validation of existing and novel low- and/or zero-β-L-ODAP genotypes.

PP31 Strategies to manage emergency ambulance telephone callers with sustained high needs – an evaluation using linked data (STRETCHED)

Background

Ambulance services across the UK have recognised a clinical and operational problem with persistent high users of the 999 service, but there is a lack of evidence about what works in this setting and how. We aim to evaluate the effectiveness, safety and efficiency of multi-agency case management approaches to the care of people who frequently call the emergency ambulance service, and gain understanding of barriers and facilitators to implementation.

Methods

We will carry out a mixed methods evaluation using anonymised linked routine data outcomes in a ‘natural experiment’ cohort design in four UK ambulance services, with one case management intervention site and one control site within each service. We will describe the epidemiology of ‘frequent calling’; assess the effects of case management on process, outcomes, safety and costs up to six months for 300 high users per service (n-1200); and examine the views of stakeholders, including patients, through qualitative methods. We will synthesise quantitative and qualitative findings, informed by a logic model describing predicted mechanisms of change.

Results

We received confirmation of NIHR grant funding for this study in 2018 so do not yet have results to report.

Conclusions

Telephone callers with sustained high needs represent a significant, high profile policy challenge to emergency ambulance services. Such callers may be indicative of gaps elsewhere in the health care system, which could be more effectively addressed by pro-active care. The STRETCHED study provides the opportunity to contribute to the currently sparse evidence base on interventions for this patient group.

The Isoniazid Metabolites Hydrazine and Pyridoxal Isonicotinoyl Hydrazone Modulate Heme Biosynthesis

In a mouse model, rifampicin and isoniazid combination treatment results in cholestatic liver injury that is associated with an increase in protoporphyrin IX, the penultimate heme precursor. Both ferrochelatase (FECH/Fech) and aminolevulinic acid synthase 1 (ALAS1/Alas1) are crucial enzymes in regulating heme biosynthesis. Isoniazid has recently been reported to upregulate Alas1 but downregulate Fech protein levels in mice; however, the mechanism by which isoniazid mediates disruption of heme synthesis has been unclear. Two metabolites of isoniazid, pyridoxal isonicotinoyl hydrazone (PIH, the isoniazid-vitamin B6 conjugate) and hydrazine, have been detected in the urine of humans treated with isoniazid. Here we show that, in primary human hepatocytes and the human hepatocellular carcinoma cell line HepG2/C3A, (1) isoniazid treatment increases Alas1 protein levels but decreases Fech levels; (2) hydrazine treatment upregulates Alas1 protein and Alas1 mRNA levels; (3) PIH treatment decreases Fech protein levels, but not Fech mRNA levels; and (4) PIH is detected after isoniazid treatment, with levels increasing further when exogenous vitamin B6 analogs are coadministered. In addition, the PIH-mediated downregulation of human FECH is associated with iron chelation. Together, these data demonstrate that hydrazine upregulates ALAS1, whereas PIH downregulates FECH, suggesting that the metabolites of isoniazid mediate its disruption of heme biosynthesis by contributing to protoporphyrin IX accumulation.

Can clinical assessment differentiate partial thickness rotator cuff tears from full thickness rotator cuff tears? A secondary analysis

Purpose: Shoulder pain causes significant disability, with rotator cuff disease as a common diagnosis. Differentially diagnosing partial tears of the rotator cuff tendons is difficult despite use of imaging and clinical examination. Our objective was to determine if a clinical assessment framework could discriminate between patients with partial and full thickness tears.Materials and Methods: Pre-operative baseline data from two randomized controlled trials of 452 adult patients awaiting rotator cuff repair were analyzed in this secondary analysis. Nineteen items from a pre-defined clinical assessment framework were investigated for association with the outcome of surgically confirmed partial or full thickness tear. Logistic regression tested independent associations and multivariable models were developed to create the most parsimonious model.Results: Thirty-two participants (7%) had partial thickness tears. Constant Power Score was the sole item associated with partial thickness tears (OR 1.07, 95% CI 1.02-1.12). Traumatic mechanism of injury trended toward significance (OR 2.17, 95% CI 1.06-4.48).Conclusions: Greater abduction strength (i.e., Constant Power Score) was associated with partial thickness tears. Other clinical assessment items did not differentiate between partial and full tears. Our results add to the growing body of research showing most clinical findings are not associated with a diagnosis in rotator cuff disease.Implications for RehabilitationGreater shoulder abduction strength (as measured with the Constant Power Score) was associated with partial thickness rotator cuff tears.Most findings within our clinical assessment framework did not distinguish between partial thickness and full thickness rotator cuff tears and thus, did not contribute to a differential pathoanatomical diagnosis.Since structural integrity of the rotator cuff and patient presentation show poor association, and rehabilitation intervention is often impairment-based, pathoanatomical diagnosis may not adequately direct non-surgical treatment. Including movement-based diagnoses or treatment classification systems in evaluation of rotator cuff disease may improve selection of appropriate conservative treatment.