Recognising and responding to physical and mental health issues in neurodivergent girls and women

People experience life and interact with others in many ways. The term 'neurodivergence' refers to variations from what is considered typical. Research and education into conditions that cooccur with neurodivergence are essential in shaping clinicians' approaches to people who may present with a wide range of symptoms. Neurodivergence may influence a person's style of communication, learning, attitudes, and behaviour, and they often experience inequity and rejection. This review highlights the huge burden of cooccurring conditions carried by neurodivergent women and girls whose medical issues have largely gone under the radar. We suggest how clinicians might increase their awareness of diagnosis and management of their problems with mutual benefit.

The diagnosis and management of systemic autoimmune rheumatic disease-related interstitial lung disease: British Society for Rheumatology guideline scope

Interstitial lung disease (ILD) is a significant complication of many systemic autoimmune rheumatic diseases (SARDs), although the clinical presentation, severity and outlook may vary widely between individuals. Despite the prevalence, there are no specific guidelines addressing the issue of screening, diagnosis and management of ILD across this diverse group. Guidelines from the ACR and EULAR are expected, but there is a need for UK-specific guidelines that consider the framework of the UK National Health Service, local licensing and funding strategies. This article outlines the intended scope for the British Society for Rheumatology guideline on the diagnosis and management of SARD-ILD developed by the guideline working group. It specifically identifies the SARDs for consideration, alongside the overarching principles for which systematic review will be conducted. Expert consensus will be produced based on the most up-to-date available evidence for inclusion within the final guideline. Key issues to be addressed include recommendations for screening of ILD, identifying the methodology and frequency of monitoring and pharmacological and non-pharmacological management. The guideline will be developed according to methods and processes outlined in Creating Clinical Guidelines: British Society for Rheumatology Protocol version 5.1.

Estimating the prevalence and predictors of musculoskeletal disorders in Tanzania: a cross-sectional pilot study

Introduction

musculoskeletal (MSK) disorders account for approximately 20% of all years lived with disability worldwide however studies of MSK disorders in Africa are scarce. This pilot study aimed to estimate the community-based prevalence of MSK disorders, identify predictors, and assess the associated disability in a Tanzanian population.

Methods

a cross-sectional study was conducted in one village in the Kilimanjaro region from March to June 2019. The Gait, Arms, Legs, Spine (GALS) or paediatric GALS (pGALS) examinations were used during household and school visits. Individuals positive in GALS/pGALS screening were assessed by the regional examination of the musculoskeletal system (REMS) and Modified Health Assessment Questionnaire (MHAQ).

Results

among the 1,172 individuals enrolled in households, 95 (8.1%, 95% CI: 6.6 - 9.8) showed signs of MSK disorders using the GALS/pGALS examination and 37 (3.2%, 95% CI: 2.2 - 4.3) using the REMS. Among 682 schools enrolled children, seven showed signs of MSK disorders using the GALS/pGALS examination (1.0%, 95% CI: 0.4 - 2.1) and three using the REMS (0.4%, 95% CI: 0.0 - 1.3). In the household-enrolled adult population, female gender and increasing age were associated with GALS and REMS-positive findings. Among GALS-positive adults, increasing age was associated with REMS-positive status and increasing MHAQ score.

Conclusion

this Tanzanian study demonstrates a prevalence of MSK disorders and identifies predictors of MSK disorders comparable to those seen globally. These findings can inform the development of rheumatology services and interventions in Tanzania and the design of future investigations of the determinants of MSK disorders, and their impacts on health, livelihoods, and well-being.

The association of clinical and patient factors with chemotherapy-induced peripheral neuropathy (CIPN) in colorectal cancer: secondary analysis of the SCOT trial

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) is a common adverse effect of oxaliplatin. CIPN can impair long-term quality of life and limit the dose of chemotherapy. We investigated the association of CIPN over time with age, sex, body mass index, baseline neuropathy, and chemotherapy regimen in people treated with adjuvant oxaliplatin-containing chemotherapy for colorectal cancer.

PATIENTS AND METHODS

We carried out secondary analysis of data from the SCOT randomised controlled trial. SCOT compared 3 months to 6 months of oxaliplatin-containing adjuvant chemotherapy in 6088 people with colorectal cancer recruited between March 2008 and November 2013. Two different chemotherapy regimens were used: capecitabine with oxaliplatin (CAPOX) or fluorouracil with oxaliplatin (FOLFOX). CIPN was recorded with the Functional Assessment of Cancer Therapy/Gynaecologic Oncology Group-Neurotoxicity 4 tool in 2871 participants from baseline (randomisation) for up to 8 years. Longitudinal trends in CIPN [averages with 95% confidence intervals (CIs)] were plotted stratified by the investigated factors. Analysis of covariance (ANCOVA) was used to analyse the association of factors with CIPN adjusting for the SCOT randomisation arm and oxaliplatin dose. P < 0.01 was adopted as cut-off for statistical significance to account for multiple testing.

RESULTS

Patients receiving CAPOX had lower CIPN scores than those receiving FOLFOX. Chemotherapy regimen was associated with CIPN from 6 months (P < 0.001) to 2 years (P = 0.001). The adjusted ANCOVA coefficient for CAPOX at 6 months was -1.6 (95% CIs -2.2 to -0.9) and at 2 years it was -1.6 (95% CIs -2.5 to -0.7). People with baseline neuropathy scores ≥1 experienced higher CIPN than people with baseline neuropathy scores of 0 (P < 0.01 for all timepoints apart from 18 months). Age, sex, and body mass index did not link with CIPN.

CONCLUSIONS

A neuropathy assessment before treatment with oxaliplatin can help identify people with an increased risk of CIPN. More research is needed to understand the CIPN-inducing effect of different chemotherapy regimens.

Knowledge, attitudes, and perception of air pollution in Ireland

Aim

Air pollution remains a major global public health challenge; and Ireland is no exception to the human health implications of exposure ambient air pollutants. Accurate and timely information can be critical to mitigate the harmful effects of air pollution. This study aimed to assess the knowledge, perceptions, and attitudes to poor air quality in Ireland to assist stakeholders in developing and implementing effective communication pieces and policies about the management of air pollution.

Study design

Cross-sectional population-based cohort.

Method

Quantitative data on knowledge, attitudes, and perceptions (KAP) were collected from respondents living across Ireland, and the results were analysed with SPSS (Version 28.0).

Results

Among the 1005 respondents included in this study, the mean [SD] age was 46.1 [15.3] years; 53% were female (n = 530); and 66% and 35% of respondents were aware of air pollution and its adverse effects on health at a national and local level respectively (n = 668 and n = 353 respectively). In addition, there were significant relationships between socio-demographic and air pollution awareness. There were correlation between respondent's age, gender, socio-economic group, and locality in Ireland.

Conclusion

This study demonstrates that environmental health literacy around air pollution in critically lacking among respondents. Given that air pollution is an increasingly important global priority, opportunities need to create to improve reach and impact of communication of air quality health risk and mitigation measures.

Extra-mandibular Osteoradionecrosis after the Treatment of Head and Neck Cancer

AIMS

Osteoradionecrosis (ORN) is a serious toxicity of head and neck radiotherapy. It predominantly affects the mandible. Extra-mandibular ORN is rare. The aim of this study was to report the incidence and outcomes of extra-mandibular ORNs from a large institutional database.

MATERIALS AND METHODS

In total, 2303 head and neck cancer patients were treated with radical or adjuvant radiotherapy. Of these, extra-mandibular ORN developed in 13 patients (0.5%).

RESULTS

Maxillary ORNs (n = 8) were a consequence of the treatment of various primaries (oropharynx = 3, sinonasal = 2, maxilla = 2, parotid = 1). The median interval from the end of radiotherapy to the development of ORN was 7.5 months (range 3-42 months). The median radiotherapy dose in the centre of the ORN was 48.5 Gy (range 22-66.5 Gy). Four patients (50%) healed in 7, 14, 20 and 41 months. All temporal bone ORNs (n = 5) developed after treatment to the parotid gland (of a total of 115 patients who received radiotherapy for parotid gland malignancy). The median interval from the end of radiotherapy to the development of ORN was 41 months (range 20-68 months). The median total dose in the centre of the ORN was 63.5 Gy (range 60.2-65.3 Gy). ORN healed in only one patient after 32 months of treatment with repeated debridement and topical betamethasone cream.

CONCLUSION

Extra-mandibular ORN is a rare late toxicity and this current study provides useful information on its incidence and outcome. The risk of temporal bone ORN should be considered in the treatment of parotid malignancies and patients should be counselled. More research is required to determine the optimal management of extra-mandibular ORN, particularly on the role of the PENTOCLO regimen.

Role of Adjuvant Radiotherapy in Acinic Cell Carcinoma of the Salivary Glands: A Systematic Review

A systematic review was carried out to evaluate if adjuvant radiotherapy for acinic cell carcinomas (ACCs) of salivary glands improves survival. Twelve retrospective studies published between 2000 and 2020 that analysed the effect of radiotherapy on salivary gland neoplasms and ACCs of salivary glands and met the inclusion criteria were included in the review. The overall quality of the studies was moderate to low. There was no high-quality evidence for improved survival with radiotherapy for ACCs of the salivary gland. Some evidence suggests that there may be an advantage for patients with high-grade tumours, but these data should be interpreted with caution due to the small number of patients and low-quality evidence. Good quality of evidence is lacking. Recommendation for adjuvant radiotherapy for tumours with poor prognostic factors will require discussion and shared decision-making with the patients.

Four-factor risk score for the prediction of interstitial lung disease in rheumatoid arthritis

OBJECTIVE

Interstitial lung disease (ILD) is one of the commonest systemic complications in patients with rheumatoid arthritis (RA) and carries a significant morbidity and mortality burden. We aimed to identify key variables to risk-stratify RA patients in order to identify those at increased risk of developing ILD. We propose a probability score based on the identification of these variables.

METHODS

A retrospective, multicentre study using clinical data collected between 2010 and 2020, across 20 centres.

RESULTS

A total of 430 RA (210 with ILD confirmed on high-resolution computed tomography (HRCT)) patients were evaluated. We explored several independent variables for the risk of developing ILD in RA and found that the key significant variables were smoking (past or present), older age and positive rheumatoid factor/anti-cyclic citrullinated peptide. Multivariate logistic regression models were used to form a scoring system for categorising patients into high and low risk on a scale of 0-9 points and a cut-off score of 5, based on the area under the receiver operating characteristic curve of 0.76 (CI 95% 0.71-0.82). This yielded a sensitivity of 86% and a specificity of 58%. High-risk patients should be considered for investigation with HRCT and monitored closely.

CONCLUSION

We have proposed a new model for identifying RA patients at risk of developing ILD. This approach identified four simple clinical variables: age, anti-cyclic citrullinated peptide antibodies, Rheumatoid factor and smoking, which allowed development of a predictive scoring system for the presence of ILD in patients with RA.

The Impact of COVID-19 on Radiotherapy Services in Scotland, UK: A Population-based Study

AIMS

The effect of the COVID-19 pandemic on cancer radiotherapy services is largely unknown. The aim of the present study was to investigate the impact of the resultant contingency plans on radiotherapy cancer services in Scotland.

MATERIALS AND METHODS

Detailed data of radiotherapy activity at our centre were collected from 1 April 2019 to 31 March 2021. Differences in mean weekly radiotherapy courses, dose and fractionation patterns and treatment intent were compared with corresponding pre-pandemic months for all treatment sites. Qualitative data were collected for a subgroup of radical radiotherapy patients.

RESULTS

Total radiotherapy courses decreased from 6968 to 6240 (-10%) compared with the previous year, prior to the pandemic. Average weekly radiotherapy courses delivered were 134 (standard deviation ±13), decreasing by 10% to 120 (standard deviation 15) (Welch's t-test, P < 0.001). The greatest decrease in new start treatment courses was observed from May to August 2020 (-7.7%, -24.0%, -16.7% and -18.7%) compared with the corresponding months in 2019. A significant reduction was seen for female patients <70 years (-16%) compared with females >70 years (-8%) or their male counterparts (-7% and -6%, respectively). By diagnosis, the largest reductions between pre- and post-pandemic levels were for anal (-26%), breast (-18%) and prostate (-14%) cancer. Contrarily, a significant increase was found for bladder (28%) and oesophageal (11%) cancers.

CONCLUSIONS

Over the first 12 months of the COVID-19 pandemic, radiotherapy activity significantly decreased compared with the 12 months prior. Due to issued guidance, the use of hypofractionated regimens increased, contributing to the reduction in treatments for some tumour sites. An increase in other tumour sites can probably be attributed to the reduction or cancellation of surgical interventions. These results will inform our understanding of the indirect consequences of the pandemic on radiotherapy services.

Randomised controlled trial of the short-term effects of osmotic-release oral system methylphenidate on symptoms and behavioural outcomes in young male prisoners with attention deficit hyperactivity disorder: CIAO-II study

BACKGROUND

Research has shown that 20-30% of prisoners meet the diagnostic criteria for attention-deficit hyperactivity disorder (ADHD). Methylphenidate reduces ADHD symptoms, but effects in prisoners are uncertain because of comorbid mental health and substance use disorders.

AIMS

To estimate the efficacy of an osmotic-release oral system methylphenidate (OROS-methylphenidate) in reducing ADHD symptoms in young adult prisoners with ADHD.

METHOD

We conducted an 8-week parallel-arm, double-blind, randomised placebo-controlled trial of OROS-methylphenidate versus placebo in male prisoners (aged 16-25 years) meeting the DSM-5 criteria for ADHD. Primary outcome was ADHD symptoms at 8 weeks, using the investigator-rated Connors Adult ADHD Rating Scale (CAARS-O). Thirteen secondary outcomes were measured, including emotional dysregulation, mind wandering, violent attitudes, mental health symptoms, and prison officer and educational staff ratings of behaviour and aggression.

RESULTS

In the OROS-methylphenidate arm, mean CAARS-O score at 8 weeks was estimated to be reduced by 0.57 points relative to the placebo arm (95% CI -2.41 to 3.56), and non-significant. The responder rate, defined as a 20% reduction in CAARS-O score, was 48.3% for the OROS-methylphenidate arm and 47.9% for the placebo arm. No statistically significant trial arm differences were detected for any of the secondary outcomes. Mean final titrated dose was 53.8 mg in the OROS-methylphenidate arm.

CONCLUSIONS

ADHD symptoms did not respond to OROS-methylphenidate in young adult prisoners. The findings do not support routine treatment with OROS-methylphenidate in this population. Further research is needed to evaluate effects of higher average dosing and adherence to treatment, multi-modal treatments and preventative interventions in the community.

The relationship between myocardial microstructure and strain in chronic infarction using cardiovascular magnetic resonance diffusion tensor imaging and feature tracking

BACKGROUND

Cardiac diffusion tensor imaging (cDTI) using cardiovascular magnetic resonance (CMR) is a novel technique for the non-invasive assessment of myocardial microstructure. Previous studies have shown myocardial infarction to result in loss of sheetlet angularity, derived by reduced secondary eigenvector (E2A) and reduction in subendocardial cardiomyocytes, evidenced by loss of myocytes with right-handed orientation (RHM) on helix angle (HA) maps. Myocardial strain assessed using feature tracking-CMR (FT-CMR) is a sensitive marker of sub-clinical myocardial dysfunction. We sought to explore the relationship between these two techniques (strain and cDTI) in patients at 3 months following ST-elevation MI (STEMI).

METHODS

32 patients (F = 28, 60 ± 10 years) underwent 3T CMR three months after STEMI (mean interval 105 ± 17 days) with second order motion compensated (M2), free-breathing spin echo cDTI, cine gradient echo and late gadolinium enhancement (LGE) imaging. HA maps divided into left-handed HA (LHM, - 90 < HA < - 30), circumferential HA (CM, - 30° < HA < 30°), and right-handed HA (RHM, 30° < HA < 90°) were reported as relative proportions. Global and segmental analysis was undertaken.

RESULTS

Mean left ventricular ejection fraction (LVEF) was 44 ± 10% with a mean infarct size of 18 ± 12 g and a mean infarct segment LGE enhancement of 66 ± 21%. Mean global radial strain was 19 ± 6, mean global circumferential strain was - 13 ± - 3 and mean global longitudinal strain was - 10 ± - 3. Global and segmental radial strain correlated significantly with E2A in infarcted segments (p = 0.002, p = 0.011). Both global and segmental longitudinal strain correlated with RHM of infarcted segments on HA maps (p < 0.001, p = 0.003). Mean Diffusivity (MD) correlated significantly with the global infarct size (p < 0.008). When patients were categorised according to LVEF (reduced, mid-range and preserved), all cDTI parameters differed significantly between the three groups.

CONCLUSION

Change in sheetlet orientation assessed using E2A from cDTI correlates with impaired radial strain. Segments with fewer subendocardial cardiomyocytes, evidenced by a lower proportion of myocytes with right-handed orientation on HA maps, show impaired longitudinal strain. Infarct segment enhancement correlates significantly with E2A and RHM. Our data has demonstrated a link between myocardial microstructure and contractility following myocardial infarction, suggesting a potential role for CMR cDTI to clinically relevant functional impact.

The impact on ambient air pollution and asthma-related admissions of COVID-19 transport restrictions

 

Exposure to air pollution is a known risk factor for asthma exacerbations, emergency attendances and hospitalisations. In Europe, the main source of air pollution is the transport industry, and so the COVID-19 transport restrictions provided an opportunity to examine if reduction in traffic had a demonstrable impact on ambient air quality and asthma-related admissions. Routinely collected data was used to conduct a retrospective population cohort study. The Environmental Protection Agency provided daily nitrogen dioxide (NO2) and particulate matter (PM) concentrations for Dublin, and all asthma-related admissions were collected from the Hospital In-Patient Enquiry system. The two years prior to the pandemic were compared with the period of transport restrictions (from March 2020). During the period of restrictions, there was a significant reduction in the mean number of daily asthma admissions (2.8 v 4.5 admissions p < 0.001). There was also a significant decrease in mean daily concentrations in two pollutants: NO2 (16.7 v 24.0µg/m3 p < 0.001) and PM2.5 (7.8 v 8.9µg/m3 p = 0.002). Only NO2 had a statistically significant correlation with asthma admissions (r = 0.132 p < 0.001). Transport restrictions introduced to mitigate against COVID-19 led to improvements in air quality, as seen by the reductions in pollutant concentrations. Previously described associations between pollutants and asthma, would suggest that these improvements in air quality contributed to the reduction in asthma admissions. Whereas the primary source of NO2 is transport emissions, PM is made up of particles from multiple sources, which likely explains the lack of correlation between asthma admissions and PM. Public Health need to advocate for transport policies which can improve air quality, and as a result, public health.

Key messages

Public Health Response to Outbreaks of Highly Pathogenic Avian Influenza (H5N1)

Aim

Human infections from highly pathogenic avian influenza (HPAI) H5N1 are associated with significant morbidity and mortality internationally. This study aimed to use routinely available data to examine key strategies to prevent H5N1 transmission to humans during outbreaks in poultry in residents in Cavan, Louth, Meath and Monaghan.

Study design

Cross-sectional based study.

Methods

Data were obtained from Health Protection Team (HPT) in the Department of Public Health (DPH), HSE North-East and Department of Agriculture, Food, and the Marine (DAFM). Data entry and analyses were conducted using Microsoft Excel 2016.

Results

The public health response focussed on contact tracing, monitoring, and follow-up for household, farm-workers, and DAFM staff exposed on the affected farms. A total of 157 contact episodes were identified. Contacts received advice about active monitoring from their last exposure. A total of 111 (80%) were recommended chemoprophylaxis for exposure to HPAI H5N1. During the active monitoring period, two contacts developed acute respiratory symptoms, and parainfluenza 3 and rhino/enterovirus were identified in these individuals respectively.

Conclusions

The findings of this study, using routinely gathered data, highlighted that collaboration between public health and DAFM at regional and national level was key to rapid response to these outbreaks of HPAI in domesticated poultry. In addition, the public health response was successful in preventing H5N1 transmission from domesticated birds to humans.

Key messages

• HPAI H5N1 virus infections transmissions from poultry to humans is low.

• Effective public health measures are crucial to further mitigate the risks to an absolute minimum.

Adolescent Binge Drinking in the West of Ireland: Associated Risk and Protective Factors

 

This study aimed to examine potential risk and protective factors for binge drinking among a cohort of 15-16-year-old adolescents in the West of Ireland. This study was a cross-sectional secondary analysis of 4,473 15-16-year-olds who participated in the 2020 Planet Youth survey. Binge drinking was defined as ever consumption of five or more drinks in a two-hour period or less. Data were analysed using SPSS version 27. Multivariable logistic regression was used to examine independent associations between potential risk and protective factors and binge drinking. A p-value of &lt; 0.05 was deemed statistically significant. The prevalence of binge drinking among participants was 34.1%. Female gender (aOR 0.55, 95% CI 0.46-0.67, p &lt; 0.001) and non-White ethnicity (aOR 0.49, 95% CI 0.31-0.77, p = 0.002) were associated with reduced odds of ever binge drinking. Self-rated ‘bad/very bad’ mental health (aOR 1.61, 95% CI 1.26-2.06, p &lt; 0.001), current cigarette use (aOR 4.06, 95% CI 3.01-5.47, p &lt; 0.001) and current cannabis use (aOR 2.79, 95% CI 1.80-4.31, p &lt; 0.001) were associated with increased odds of ever binge drinking. Parental supervision (aOR 0.80, 95% CI 0.73-0.88, p &lt; 0.001) and negative parental reaction to adolescent drunkenness (aOR 0.51, 95% CI 0.42-0.61, p &lt; 0.001) reduced the odds of ever binge drinking among participants. Getting alcohol from parents was associated with increased odds of ever binge drinking (aOR 1.79, 95% CI 1.42-2.25, p &lt; 0.001). Adolescents with friends who drink alcohol had almost 5 times higher odds of ever binge drinking (aOR 4.59, 95% CI 2.65-7.94, p &lt; 0.001). Participating in team sports was also associated with increased odds of ever binge drinking (aOR 1.30, 95% CI 1.07-1.57, p = 0.008 for 1-4 times/week, aOR 1.52, 95% CI 1.07-2.16, p = 0.020 for ≥5 times/week). This study highlights key influences of adolescents’ social environment on their binge drinking, and a need for renewed public health efforts to protect adolescents from alcohol-related harm.

Key messages

• This study identified a high prevalence of ever binge drinking among adolescents in the West of Ireland - this is highly concerning as adolescents are vulnerable to alcohol-related harm.

• This study identified factors in the social environment of adolescents associated with binge drinking. This can inform public health action to protect adolescents from alcohol-related harm.

Establishing intersectoral ‘Schools Teams’ to mitigate SARS-CoV-2 school transmission, 2020/2021

 

The SARS-CoV-2 pandemic disrupted the lives of up to 100,000 school-going children in Ireland. Consequently, intersectoral ‘Schools Teams’ were established for the 2020/2021 school year to reduce SARS-CoV-2 transmission in school settings. This novel public health intervention provides learning to inform future cross-sectoral collaborative work in Public Health in responding to infectious disease threats. For the 2020/2021 school year in Ireland, intersectoral Schools Teams were formed within each of eight regional Departments of Public Health to manage mitigation of SARS-CoV-2 transmission in school settings. These teams comprised of staff from Departments of Public Health and redeployed staff from the Department of Education. A nationally agreed schools process was followed by Schools Teams to manage SARS-CoV-2 cases and outbreaks in schools. Relevant cases were referred to the regional Schools Team for a public health risk assessment (PHRA). Close contacts were determined using appropriate definitions of close contact within a school setting through the PHRA. This model with centralised procedures and linked health/education teams was novel and adaptable to additional settings. Results from the East region of Ireland showed testing of close contacts of COVID-19 was conducted in 71.8% (676/942) of schools, with 43881 tests completed. Most Schools Team members reported efficient communication within the team (88.7%), a positive team culture (96.3%) and feeling comfortable in their roles following training (82.7%). The majority of members felt the team was able to effectively support schools to reduce COVID-19 transmission (92.5%). Lessons learnt include the synergistic working of educational and health professionals towards a common goal, maximising the skills of all, ensuring a better outcome for school children. Involving educational teams in active contact tracing of COVID-19 cases in schools maximised engagement of the educational sector in the COVID-19 response.

Key messages

• Establishing intersectoral ‘Schools Teams’ pooled skills, resources and expertise, enabling development of synergistic solutions to a complex problem.

• This exemplifies a large national cross-sectoral collaborative working process involving education and public health sectors, providing a model for future responses to infectious disease threats.

Heart failure is associated with low circulating levels of secreted frizzled receptor protein 5 (Sfrp5)

Background/Introduction

Obesity and metabolic dysregulation are closely associated with the pathophysiology of multiple cardiovascular diseases (CVD). To date, the pathophysiological mechanism(s) of obesity and its link with cardiovascular systems remain largely unknown. Adipose tissue inflammation as a result of excessive fat expansion in obesity, leading to increased systemic production of growth factors and recruitment of inflammatory cells have been postulated to be a major factor. Secreted frizzled-related protein 5 (SFRP5) is an anti-inflammatory adipokine that is linked with obesity and metabolic regulation and has been indicated to affect cardiovascular functions. Currently, the role of circulating SFRP5 levels as a biomarker for cardiovascular diseases are poorly understood, with studies yielding discordant results.

Purpose

This study aims to evaluate the relationship between circulating SFRP5 and cardiovascular functions in a cohort of patients with established CVD.

Methods

Patients (n=262, 148 male (56.5%), age (68±11 yrs)) presenting to the cardiology unit for cardiovascular investigations were recruited into the study. Plasma SFRP5 levels were measured via enzyme-linked immunosorbent assay (ELISA). Associations between plasma SFRP5 levels, cardiovascular functions, and patients' co-morbidities were analysed using univariate and multivariate analyses.

Results

Plasma SFRP5 levels were significantly lower in patients presenting with: heart failure (HF) vs non-HF (median; (10.7 vs 31.0; p&lt;0.001); coronary artery disease (CAD) vs non-CAD; (11.0 vs 33.8; p&lt;0.001); and atrial fibrillation (AF) vs non-AF; (11.2 vs 23.2; p=0.001). On univariate analyses, SFRP5 levels also significantly positively correlated with left ventricular ejection fraction (LVEF) (r=0.52, p&lt;0.001), estimated glomerular filtration rate (eGFR) (r=0.16, p=0.02), total cholesterol levels and triglycerides (r=0.29, p&lt;0.001; r=0.17, p&lt;0.01 respectively). Low SFRP5 levels were correlated with high C-reactive protein (CRP) and E/E' (r=−0.29, p&lt;0.001, r=−0.30, p&lt;0.001, respectively). Patients with HF, CAD, statin use, low LVEF, low triglycerides, high CRP and high eGFR were associated with lower SFRP5 levels independent of age, BMI or diabetes on multivariate analysis (overall model r=0.729, SE=0.638).

Conclusion

Our results show that low plasma SFRP5 levels are independently associated with HF, CAD, and impaired systolic and diastolic functions. These results suggest that SFRP5 may regulate cardiovascular functions independent of obesity and metabolic regulations.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Heart Foundation of Australia Future Leader FellowshipsNSW Ministry of Health EMC FellowshipHeart Foundation of Australia Future Leader Fellowship

Mechanism(s) for age-related sex differences in diet-induced cardiomyopathy: role of RNA methylation

Background/Introduction

Age and sexual dimorphism contribute to the differential cardiometabolic dysfunctions associated with diet-induced obesity. However, the underlying mechanisms remain elusive. RNA modifications via RNA m6A methylation, is an emerging mediator of RNA stability, translation and localization responsible for regulation of multiple biological functions. RNA m6A modifications are regulated by “writers”, “erasers” and “readers”. The role of RNA methylation machinery genes in the heart is largely unexplored, and may provide insight into the influence of age and sex on cardiometabolic dysfunction.

Purpose

We aim to determine differential RNA methylation changes within the heart in a diet-induced cardiomyopathy mouse model, stratified according to age and sex.

Methods

Male and female C57BL/6 mice (6–8wk-old) were fed normal chow (NC) or high-fat/high-sucrose (HFHS) diet for 1 or 4 months. Echocardiographic measurements were performed at 1 and 4 months according to the American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines. At study endpoint, glucose and insulin tolerance testing was conducted by injecting mice intraperitoneally with 2g/kg glucose or 0.6U/kg insulin, and monitoring blood glucose levels over a 2 hour period. RNA from heart tissue was subjected to quantitative PCR for RNA methylation machinery genes (FTO, ALKBH5, METTL3, METTL4, METTL14, YTHDF1 and YTHDF2). PPIA was used to normalise qPCR data.

Results

Both male and female mice showed evidence of age- and diet-induced metabolic dysfunction, however, males and females showed markedly different metabolic impairments. For example, glucose tolerance was exacerbated by 4 months of HFHS diet in males but not females; and only females showed impaired insulin tolerance. Echocardiography showed that males had systolic (stoke volume, cardiac output) and diastolic (E/A ratio) dysfunction after 4 months of HFHS diet, while females were unperturbed. We identified that METTL3 and METTL14, the “writers” of m6A methylation, were consistently increased in male mouse hearts at 1 vs 4 months of age but were unchanged or decreased in females, irrespective of diet. Conversely, YTHDF1, a “reader”, was unchanged in male mouse hearts at 1 vs. 4 months of age but was significantly increased in female hearts.

Conclusion

Our study confirms that markedly different cardiometabolic impairments occur in male versus female mice in response to long-term HFHS diet. Despite significant metabolic impairment in both sexes, cardiac dysfunction was only evident in males. RNA methylation machinery genes were differentially expressed in mouse hearts according to age and sex, suggesting that RNA methylation may be involved in age-related sexual dimorphism in cardiometabolic impairments.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Heart Foundation

Doxorubicin-induced upregulation of follistatin-like 3 (FSTL3): a new therapeutic target

Introduction

Doxorubicin (DOX) is among the most used anticancer drugs with associated cardiotoxicity. Follistatin-like 3 (FSTL3), a secreted member of the follistatins family that can selectively bind to members of the TGF-β superfamily, is involved in regulation of cardiac hypertrophy and heart failure. FSTL3 is also upregulated in breast and colorectal cancer tumours, is also an unfavourable prognostic indicator for various cancers.

Purpose

We aim to determine the dual role of FSTL3 in prevention of DOX-induced cardiotoxicity and synergistic anti-cancer effects.

Methods

Human cardiomyocytes (HCMs) were treated with DOX at 1uM (EC50) for 72 hours. Cell viability was assessed via CellTiter-Glo®. Secreted FSTL3 levels, as measured by ELISA (R&D systems). FSTL3 and TGF-β mRNA levels were measured by qPCR. Co-treatment of DOX with human anti-FSTL3 antibodies (Aviva Systems Biology) at 10ug/mL were introduced for 72hrs treatment.

Results

Secreted FSTL3 levels were significantly increased in DOX-treated HCMs at 72hrs compared to control (n=5, p&lt;0.001). Consistently, FSTL3 and TGF-β mRNA levels, in collected HCMs were significantly increased in DOX-treated cells. Co-treatment of DOX with human anti-FSTL3 antibodies at 10ug/mL significantly improved HCM viability compared to IgG control group. Conversely, anti-FSTL3 antibodies provided synergistic anti-cancer effects with DOX: MCF-7 breast cancer cells were significantly reduced when co-treated with DOX and anti-FSTL3 antibody vs. IgG controls.

Conclusion

We show, for the first time, that: 1) FSTL3 is secreted directly from HCMs; 2) FSTL3 levels (both circulating and mRNA) is markedly elevated with DOX treatment; 3) neutralisation of FSTL3 in DOX-treated HCMs, restored HCM viability; and 4) exhibit synergistic anti-cancer effects with DOX. Taken together, FSTL3 is a potential target for dual anti-cancer and cardioprotective effects.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Heart Foundation of Australia Future Leader FellowshipsNSW Ministry of Health EMC FellowshipNSW Ministry of Health Translational Research Grant

Public health response to outbreaks of highly pathogenic avian influenza (H5N1) among poultry in Northeast of Ireland, November 2021 to January 2022

OBJECTIVES

Human infections from highly pathogenic avian influenza (HPAI) H5N1 are associated with significant morbidity and mortality internationally. This study aimed to use routinely available data to examine key strategies to prevent H5N1 transmission to humans during outbreaks in poultry in residents in Cavan, Louth, Meath and Monaghan.

STUDY DESIGN

This was a cross-sectional based study.

METHODS

Data were obtained from Health Protection Team in the Department of Public Health, HSE North East and Department of Agriculture, Food, and the Marine (DAFM). Data entry and analyses were conducted using Microsoft Excel 2016.

RESULTS

The public health response focussed on contact tracing, monitoring and follow-up for household, farm workers and DAFM staff exposed on the affected farms. A total of 157 contact episodes were identified. Contacts received advice about active monitoring from their last exposure. A total of 111 (80%) were recommended chemoprophylaxis for exposure to HPAI H5N1. During the active monitoring period, two contacts developed acute respiratory symptoms, and parainfluenza 3 and rhino/enterovirus were identified in these individuals, respectively.

CONCLUSIONS

The findings of this study, using routinely gathered data, highlighted that collaboration between public health and DAFM at regional and national levels was key to rapid response to these outbreaks of HPAI in domesticated poultry. In addition, the public health response appears to have been successful in preventing H5N1 transmission from domesticated birds to humans.

P-698 Pituitary functioning gonadotroph adenomas (FGA)-induced ovarian hyperstimulation syndrome (OHSS): results from tertiary neuroendocrine centres in the UK

Study question

There are no published series of OHSS due to FGA. What FGA features should clinicians look for during OHSS, and what treatments are effective?

Summary answer

FGA tumour size is always &gt;10mm. Other pituitary hormones may be deficient. Surgical resection of FGA is an effective treatment for OHSS.

What is known already

Pituitary adenomas affect 1:1000 adults and are classified as functioning or non-functioning. Non-functioning pituitary adenomas do not secrete hormones, but most commonly stain histologically gonadotroph cells. Functional pituitary adenomas secrete hormones such as prolactin causing prolactinoma. However, it is rare for a pituitary tumour to cause clinical features of excessive gonadotrophins (functioning gonadotroph adenoma; FGA).

Single case reports, but no case series, have been published on the presentation of FGA-induced OHSS in women.

Surgical excision of adenomas has been reported to cause remission of symptoms, though systematic data are lacking owing to rarity of these tumours.

Study design, size, duration

National case series from tertiary neuroendocrine units in England, Wales and Scotland.

Participants/materials, setting, methods

Eight high-volume pituitary endocrine tertiary units within England, Wales and Scotland audited their records for any cases of FGA-induced OHSS; only seven patients have been identified to date. In all cases, there had been no recent exposure to assisted reproductive technologies (ART) or drugs known to induce OHSS including gonadotrophins or selective oestrogen receptor modulators (SERMS).

Main results and the role of chance

Seven cases of FGA were identified with mean age 31.6 years (range 16-48) at diagnosis. Two-of-seven women presented acutely unwell with abdominal pain, distention and palpable mass requiring oophorectomy for ovarian torsion/ruptured ovarian cyst. The remaining five women presented with abdominal pain (n = 2), thyrotoxicosis (n = 1), menstrual irregularities/galactorrhoea (n = 1) and visual disturbances (n = 1). All women experienced intermittent pelvic pain during medical attendance. Pelvic ultrasound demonstrated enlarged multiseptated ovaries (volume ranging 27-442cm3). Ascites was noted in one woman. Six women had visual field defects due to optic chiasm compression on formal assessment. Median FSH was 26.10 u/L (8.3-33), but LH was &lt;2.5 u/L in all cases. Estradiol (E2) far exceeded the reference range in 5/7 women (2990 to &gt; 18000pmol/L);E2 was at the upper limit of normal in the remaining 2/7 women (960-1450pmol/L). Hyperprolactinaemia, hyperthyroidism and other pituitary hormones deficiency were noted in 6/7, 1/7 and 4/7 women respectively. All FGAs were macroadenomas with diameters ranging 16-48mm. Two patients were administered a somatostatin analogue prior to surgery, but FSH, E2 and tumour size did not change. Transsphenoidal surgery was performed in 6/7 women, and always improved symptomatic and biochemical features of OHSS; however, residual FGA tumour was present post-operatively in all cases studied.

Limitations, reasons for caution

It is possible that some ‘non-functioning’ gonadotroph adenomas cause subclinical problems including menstrual irregularity and mild OHSS which were never diagnosed.

We have insufficient data to determine the prognosis for future pregnancy after FGA-induced OHSS.

This study utilised historical case-notes, so some data is missing.

Wider implications of the findings

The ‘spontaneous’ presentation of OHSS may be confusing for clinicians. We report that FGA is an important cause of spontaneous OHSS which has well-defined biochemical and radiological characteristics, which may be treated effectively in the short-to-medium with pituitary surgery. Results of this study may provide greater awareness of FGA-induced OHSS.

Trial registration number

N/A

Nintedanib in Patients With Autoimmune Disease-Related Progressive Fibrosing Interstitial Lung Diseases: Subgroup Analysis of the INBUILD Trial

Objective

To analyze the efficacy and safety of nintedanib in patients with fibrosing autoimmune disease–related interstitial lung diseases (ILDs) with a progressive phenotype.

Methods

The INBUILD trial enrolled patients with a fibrosing ILD other than idiopathic pulmonary fibrosis, with diffuse fibrosing lung disease of >10% extent on high‐resolution computed tomography, forced vital capacity percent predicted (FVC%) ≥45%, and diffusing capacity of the lungs for carbon monoxide percent predicted ≥30% to <80%. Patients fulfilled protocol‐defined criteria for progression of ILD within the 24 months before screening, despite management deemed appropriate in clinical practice. Subjects were randomized to receive nintedanib or placebo. We assessed the rate of decline in FVC (ml/year) and adverse events (AEs) over 52 weeks in the subgroup with autoimmune disease–related ILDs.

Results

Among 170 patients with autoimmune disease–related ILDs, the rate of decline in FVC over 52 weeks was −75.9 ml/year with nintedanib versus −178.6 ml/year with placebo (difference 102.7 ml/year [95% confidence interval 23.2, 182.2]; nominal P = 0.012). No heterogeneity was detected in the effect of nintedanib versus placebo across subgroups based on ILD diagnosis (P = 0.91). The most frequent AE was diarrhea, reported in 63.4% and 27.3% of subjects in the nintedanib and placebo groups, respectively. AEs led to permanent discontinuation of trial drug in 17.1% and 10.2% of subjects in the nintedanib and placebo groups, respectively.

Conclusion

In the INBUILD trial, nintedanib slowed the rate of decline in FVC in patients with progressive fibrosing autoimmune disease–related ILDs, with AEs that were manageable for most patients.

Video Abstract

P098 Estimating the prevalence and predictors of musculoskeletal disability in Tanzania: a pilot study

Background/Aims

Musculoskeletal (MSK) disorders are among the major causes of disability worldwide, accounting for 20% of all years lived with disability. MSK disorders are linked to other non-communicable diseases (NCDs) as their adverse impact on mobility may promote the development of other NCDs. Prevalence studies of MSK disorders in Africa are limited with most coming from South Africa, while none have been previously performed in Tanzania. Screening for MSK disorders is not routinely conducted in health care facilities and there are no registered consultants working in this field in Tanzania. This pilot study aimed to provide an initial estimate of the prevalence and predictors of MSK disability to inform the design of a more detailed study of MSK disorders in Tanzania.

Methods

A cross-sectional pilot study was conducted in Kirima village, Hai District, Kilimanjaro region which has a total population of 1,911 people. We obtained ethical approval to invite each eligible individual to consent to supervised examination using the Gait, Arms, Legs and Spine (GALS) assessment tool (adults aged 18 years and over) or the paediatric GALS (pGALS) assessment tool (children aged 5 to 17 years old). In those where these screening tools detected an abnormality, we then performed a full Regional Examination of Musculoskeletal System (REMS). We also assessed functional status and physical disability in all GALS positive subjects using the Modified Health Assessment Questionnaire (MHAQ) tool. All adults were assessed during planned accompanied household visits, while a substantial number of the children were assessed while at school. Multivariable logistic regression analyses were carried out to assess the influence of demographic variables on GALS, REMS and MHAQ outcomes.

Results

A substantial number of adults (270) and children (491) could not be contacted or declined to consent to examination. Among the 1150 people who did consent, the prevalence of GALS/pGALS positivity was 8.2% (95% CI: 6.6-9.8), while REMS was positive in 3.5% (95% CI: 2.4-4.5). Female gender and increasing age were both significantly associated with each of GALS and REMS positivity. The MHAQ score was strongly associated with REMS positivity and significantly associated with GALS positivity, equating to worse function and greater disability.

Conclusion

These initial prevalence estimates and predictors of MSK disability are comparable to those seen elsewhere in the world. Greater detail on the prevalence of specific MSK disorders in Tanzania will require larger and more detailed studies.

Disclosure

N.M. Yongolo: None. C. Bunn: None. J. Halliday: None. B. Mtesha: None. C. Kelly: None. A. Mwingwa: None. S. Biswaro: None. S. Siebert: None. A. Hemed: None. R. Walker: None. E. McIntosh: None. B. Mmbaga: None.

P033 The intriguing association between fibromyalgia, hypermobility and neurodivergence: a pilot study

Background/Aims

Fibromyalgia (FM) is a common disorder with an estimated UK prevalence of 4%. An association with hypermobility spectrum disorder (HSD) has been recognised for several years and is increasingly recognised as a common precedent to chronic pain and FM. It has been recently suggested that these patients may have a higher rate of autistic spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD) or other neurodivergent conditions than the general population. This is supported by the observation that neurodivergence is strongly associated with chronic pain and disability.

Methods

We sought to assess the prevalence of ASD/ADHD among all first- and second-degree relatives of index patients who had presented to secondary care with the combination of FM, HSD and either ASD or ADHD. Eight consecutive index cases with this combination agreed to research their relatives and prepare a detailed family tree listing all family members, identified only by age and gender. They were asked to record the presence of all confirmed diagnoses of FM, HSD and ASD/ADHD among their first- and second-degree relatives. We then calculated the prevalence of each of these conditions among the close blood relatives of our index cases and compared this to the prevalence derived from a control group of index cases with osteoarthritis.

Results

Our eight index cases (seven female) had a mean age of 38 years. They identified 80 relatives, among whom 31 (39%) had a diagnosis of ASD/ADHD, compared to a prevalence of 2.8% in the relatives of our control group (p &lt; 0.01). The prevalence of HSD among the relatives was 30% (vs 8% in controls) and the prevalence of FM was 18% (vs 3% in controls). There was significant overlap, with the prevalence of HSD and FM among relatives with ASD/ADHD being recorded as 50% and 30% respectively. 62% of the relatives were female.

Conclusion

Neurodivergent conditions are present from birth and therefore predate the onset of both HSD and FM. This pilot study confirmed that patients with the combination of FM and HSD have a much higher prevalence of neurodivergence than the general population, and that their close relatives also exhibit this association. Females are disproportionately over-represented in contrast to the distribution of neurodivergent conditions in the community, where males predominate. We noted that females with FM and HSD were more likely to have ASD, while males tended to carry a diagnosis of ADHD. One recent study suggested gene clustering among people with neurodivergence and those with FM / HSD. However, the reasons for, and mechanism of, this association remain to be defined. Much more work is needed to assess the evolution of pain among people with neurodivergent conditions if we are to learn how to intervene effectively.

Disclosure

T.B. Yearoo: None. C. Kelly: None.

P208 A retrospective survey of arthritis among inpatients at a consultant hospital in Northern Tanzania from 2017 to 2019

Background/Aims

Musculoskeletal (MSK) disorders affect many people worldwide, but there is minimal access to medical care in low and middle-income countries (LMICs). Few hospital-based studies on MSK disorders have been conducted and there are limited prevalence data on MSK diseases in sub-Saharan Africa (SSA). Arthritis is the most common MSK condition, both reducing physical activity and increasing the risk of disability and other non-communicable diseases (NCDs). Given the high prevalence of MSK disorders and the associated significant clinical and economic burden in developed countries, an estimate of the frequency of these conditions in SSA is overdue. We aimed to determine the recorded prevalence of arthritis and related clinical features among patients admitted to a tertiary care hospital in Northern Tanzania from 2017-19.

Methods

Ethical approval was obtained to review the medical records retrospectively for all patients aged over 13 admitted to medical wards at Kilimanjaro Christian Medical Centre, a zonal tertiary care hospital, over this 3-year period. We collected demographic characteristics including age, gender, diagnoses and outcome. Diagnoses specifying arthritis were specifically sought. The prevalence of arthritis among inpatients over this period estimated. Analysis was conducted using STATA version 15 with categorical variables summarized using frequency and percentage.

Results

A total of 8023 patient files were examined with a slight majority of males 4181 (52.1%). An arthritis was recorded in 129 (1.6%) with 71 (55%) aged ≥60 years and 74 (57.4%) being female. The commonest presenting symptoms were joint pain in 69 (53.5%), swelling in 38 (29.5%) and stiffness in 18 (14%). A precise diagnosis for the arthritis was rarely recorded, although rheumatoid arthritis and gout were specified in a minority. Overall mortality was 12.4% among patients with arthritis. In addition, a diagnosis of systemic lupus erythematosus was recorded in a further 16 (0.2%) patients.

Conclusion

The recorded prevalence of arthritis among hospital inpatients in this LMIC study was low but the associated mortality appeared high. The retrospective nature of the data is highly likely to have underestimated the true prevalence of MSK disease and emphasizes the need for improved awareness of MSK diagnostic and management strategies. A teaching and training program has been developed to assist with this.

Disclosure

N.M. Yongolo: None. S.J. Krauth: None. S.M. Biswaro: None. B. Moshi: None. M. Mwanswila: None. A. Hemed: None. R. Njau: None. N. Allen Ng’unda: None. R. Walker: None. K. Kilonzo: None. S. Siebert: None. J. Halliday: None. E. McIntosh: None. C. Kelly: None. B. Mmbaga: None. G. Temu: None.

P105 Prevalence and associated factors of musculoskeletal joint disease in the community setting in Hai district, northern Tanzania

Background/Aims

There is little evidence on the prevalence of musculoskeletal (MSK) joint disorders, in particular around inflammatory and degenerative arthritis, in sub-Saharan Africa. In Tanzania specifically, the prevalence and distribution of these conditions in the population has never been studied and the nature of existing joint disorders and the associated factors are therefore unknown. The aim of this study is to establish the prevalence of MSK joint disease and associated factors among the rural population in Tanzania.

Methods

Households in the Hai district were randomly selected using a two-stage cluster sampling approach with villages selected with a probability proportional to size. Consenting individuals aged 5 years and above were screened for the presence of MSK joint problems using the Gait Arms Legs and Spine (GALS) examination. Individuals screened positive by the GALS exam, were further assessed using the Regional Examination of the Musculoskeletal System (REMS). Demographic and other information were gathered via questionnaire and subsequently checked for association with a positive REMS exam. Data were analysed in STATA using a mixed model logistic regression with village, household, and examiner as random effects.

Results

The overall prevalence of MSK joint disease (REMS positive) among the 2697 examined individuals (1969 Adults & 728 children &lt;18 years) was 5.9 % (CI: 5.1%-6.9%). Adult females have significantly higher odds of screening positive than adult males (Odds Ratio (OR): 2.2; CI: 1.5-3.2; p &lt; 0.01). The prevalence of MSK joint problems varied significantly with age, with only 0.1 % (CI: 0%-0.75%) of children aged 5-18 years screening positive with REMS compared to 1.3% (CI: 0.7%-2.3%) of people aged 18-45 years, 9.1% (CI: 7.0%-11.6%) aged 46-65 years, 21.7% (CI: 17.1%-26.8%) aged 66-85 years, and 31.8% (CI: 20.6%-44.7%) of those aged over 85. We found that people living in mid-level altitudes had the highest odds of screening positive with REMS (OR midland vs lowland = 2.1; CI: 1.4-3.3, p = 0.01; OR highland vs lowland = 1.5; CI: 1-2.3, p = 0.081).

Conclusion

Our study provides new insight into the prevalence and distribution of MSK joint disease in rural communities in Tanzania and into the factors associated with higher odds of screening positive with the REMS examination. Results from this study will help build the evidence around the prevalence of MSK joint diseases and factors associated with them in Tanzania. This will enable researchers and practitioners to facilitate the diagnosis and management of Arthritis and other MSK conditions in the population and to improve the health of people living with these diseases in Tanzania.

Disclosure

S.J. Krauth: None. N. Yongolo: None. S. Biswaro: None. C. Kelly: None. R.W. Walker: None. S. Siebert: None. M. Deidda: None. S. Wyke: None. J. Halliday: None. B.T. Mmbaga: None. E. McIntosh: None.

Identification of Distinct Long COVID Clinical Phenotypes Through Cluster Analysis of Self-Reported Symptoms

Background

We aimed to describe the clinical presentation of individuals presenting with prolonged recovery from coronavirus disease 2019 (COVID-19), known as long COVID.

Methods

This was an analysis within a multicenter, prospective cohort study of individuals with a confirmed diagnosis of COVID-19 and persistent symptoms >4 weeks from onset of acute symptoms. We performed a multiple correspondence analysis (MCA) on the most common self-reported symptoms and hierarchical clustering on the results of the MCA to identify symptom clusters.

Results

Two hundred thirty-three individuals were included in the analysis; the median age of the cohort was 43 (interquartile range [IQR], 36–54) years, 74% were women, and 77.3% reported a mild initial illness. MCA and hierarchical clustering revealed 3 clusters. Cluster 1 had predominantly pain symptoms with a higher proportion of joint pain, myalgia, and headache; cluster 2 had a preponderance of cardiovascular symptoms with prominent chest pain, shortness of breath, and palpitations; and cluster 3 had significantly fewer symptoms than the other clusters (2 [IQR, 2–3] symptoms per individual in cluster 3 vs 6 [IQR, 5–7] and 4 [IQR, 3–5] in clusters 1 and 2, respectively; P < .001). Clusters 1 and 2 had greater functional impairment, demonstrated by significantly longer work absence, higher dyspnea scores, and lower scores in SF-36 domains of general health, physical functioning, and role limitation due to physical functioning and social functioning.

Conclusions

Clusters of symptoms are evident in long COVID patients that are associated with functional impairments and may point to distinct underlying pathophysiologic mechanisms of disease.

Pathologic complete response (pCR) to neoadjuvant treatment with or without atezolizumab in triple negative, early high-risk and locally advanced breast cancer. NeoTRIP Michelangelo randomized study

BACKGROUND

High-risk triple negative breast cancers (TNBC) are characterized by poor prognosis, rapid progression to metastatic stage and onset of resistance to chemotherapy, thus representing an area in need of new therapeutic approaches. PD-L1 expression is an adaptive mechanism of tumour resistance to tumour infiltrating lymphocytes, which in turn are needed for response to chemotherapy. Overall, available data support the concept that blockade of PD-L1/PD-1 check-point may improve efficacy of classical chemotherapy.

PATIENTS AND METHODS

Two-hundred-eighty patients with TNBC were enrolled in this multicentre study (NCT002620280) and randomized to neoadjuvant carboplatin AUC 2 and nab-paclitaxel 125 mg/m² iv on days 1 and 8, without (N = 142) or with (N = 138) atezolizumab 1200 mg iv on day 1. Both regimens were given q3 weeks for 8 cycles before surgery and 4 cycles of an adjuvant anthracycline regimen. The primary aim of the study is to compare event-free survival, an important secondary aim was the rate of pathological complete remission (pCR defined as absence of invasive cells in breast and lymph nodes). The primary population for all efficacy endpoints is the intention-to-treat population.

RESULTS

The intention-to-treat analysis revealed that pCR rate after treatment with atezolizumab (48.6%) did not reach statistical significance compared to no atezolizumab [44.4%: odds ratio (OR) 1.18; 95% CI 0.74-1.89; P = 0.48]. Treatment-related adverse events were similar with either regimen except for a significantly higher overall incidence of serious adverse events and liver transaminases abnormalities with atezolizumab.

CONCLUSIONS

The addition of atezolizumab to nab-paclitaxel and carboplatin did not significantly increase the rate of pCR in women with TNBC. In multivariate analysis the presence of PD-L1 expression was the most significant factor influencing rate of pCR (OR 2.08). Continuing follow up for the event-free survival is ongoing, and molecular studies are under way.

An examination of how to engage migrants in the research process: building trust through an 'insider' perspective

Introduction: Ensuring all members of society can equally participate in research and the provision of services is a challenging goal. Increased migration has been mirrored by media narratives of social threat, leaving many migrants feeling differentiated and distrustful of mainstream society.Objectives: We explore how migrant and ethnic minority populations can be given the opportunity to participate in the research process. In this work, we iteratively and jointly developed a range of engagement strategies that adopt an 'insider' approach; seeking to eliminate feelings of differentiation and 'otherness' by establishing mutual trust.Design: Recruitment activities were carried out with 8 focus groups of first-generation South Asian migrants (the largest ethnic minority group in England). Our analysis was grounded in the broad principles of action research with reflective evaluation of our recruitment process using field observations and relevant focus group data; asking whether we tackled barriers to engagement.Results: Our findings show that 'otherness' can be reduced by establishing a trustworthy researcher-community relationship, but also that this relationship is complex, and needs to acknowledge residual mistrust. Alongside, researchers need to enable opportunities for empowered interaction, with flexible strategies to negotiate potential power divides.Conclusions: We can successfully create opportunities for engagement but there is no 'one size fits all'. Engagement requires tailored approaches that embrace flexibility, and position both engagement and non-engagement as positive and empowered choices.

The spectrum and burden of in-patient paediatric musculoskeletal diseases in Northern Tanzania

BACKGROUND

Musculoskeletal diseases (MSD) are a major contributor to the global burden of disease and disability, and disproportionally affect low- and middle-income countries; however, there is a dearth of epidemiological data. Affected children often face increased morbidity, social isolation and economic hardship.

AIM

To assess the spectrum and burden of paediatric MSD in children aged 5-18 years admitted to a major referral hospital in Tanzania.

METHODS

This was a retrospective cohort study of children aged 5-18 years admitted to Kilimanjaro Christian Medical Centre (KCMC) whose initial diagnosis was recognised as a musculoskeletal condition by the International Classification of Diseases-10 between 1 January and 31 December 2017.

RESULTS

During 2017, 163 cases of confirmed paediatric MSD were admitted to KCMC, representing 21.2% of all admissions of children aged 5-18 years (n = 769). Bone disease was the most common diagnosis. They comprised 106 (65.0%) traumatic fractures, 31 (19.0%) osteo-articular infections, 9 (5.5%) malunions and 3 (1.8%) pathological fractures. Congenital defects and rheumatic disease were relatively uncommon, accounting for only 6 (3.7%) and 4 (2.5%) MSD admissions, respectively.

CONCLUSION

The majority of cases of MSD were related to fractures, followed by osteo-articular infections, while recognised cases of rheumatic disease were rare. The study, although small, identified the sizeable burden and spectrum of paediatric MSD admitted to a hospital in Tanzania over a 12-month period and highlights the need for larger studies to inform the optimal allocation of health resources.

ABBREVIATION

CI: confidence interval; HIC: high-income countries; HIV: human immunodeficiency virus; ICD-10: International Classification of Diseases 10; IQR: interquartile range; JIA: juvenile idiopathic arthritis; KCMC: Kilimanjaro Christian Medical Centre; LMIC: low- and middle-income countries; MSD: musculoskeletal diseases: NAI: non-accidental injury; NIHR: National Institute for Health Research; PAFLAR: Paediatric Society of the African League Against Rheumatism; RTA: road traffic accidents; SCD: sickle cell disease; SLE: systemic lupus erythematosus; SSA: sub-Saharan Africa.

How to differentiate between Eosinophilic Granulomatous Polyangiitis and Henoch-Schönlein Purpura

We present a 29-year-old gentleman admitted with eight years of recurrent, bilateral, erythematous, macular rash involving the legs, occurring every summer. Other symptoms included intermittent joint aches with dysaesthesia. He was investigated previously with a renal biopsy, a skin biopsy and endoscopy and had been diagnosed as Henoch-Schönlein Purpura (HSP). However, his past medical history included progressive asthma and sinusitis. Investigations revealed peripheral eosinophilia, positive rheumatoid factor and elevated IgE levels with mild renal impairment. During admission, he became hypoxic. A CT pulmonary angiogram (CTPA) showed changes consistent with early pulmonary manifestations of EGPA, which improved on a repeat scan after commencing the patient on high dose prednisolone. Revising the diagnosis, his condition fulfilled criteria for ANCA negative EGPA rather than HSP.

The Links Between Fibromyalgia, Hypermobility and Neurodivergence

Fibromyalgia and joint hypermobility are common coexisting conditions among younger females that are often accompanied with additional features of autonomic dysfunction. Mental health is frequently impacted with these conditions and an association with neurodivergence has been recently established. Neurodivergence is also prevalent among close relatives. Reasons for this association are poorly understood, although genetics, adverse early life experiences and autoimmunity all contribute. Pharmacological responses may differ in neurodivergence, while psychological support requires adaptation for individual sensitivities. Screening patients with fibromyalgia and hypermobility for neurodivergent traits and vice versa may facilitate diagnosis and management.

Phase 2 study of anastrozole in rare cohorts of patients with estrogen receptor/progesterone receptor positive leiomyosarcomas and carcinosarcomas of the uterine corpus: The PARAGON trial (ANZGOG 0903)

BACKGROUND

Aromatase inhibitors have been used empirically to treat a subset of patients with hormone receptor positive uterine leiomyosarcomas(LMS) and carcinosarcomas (UCS) mainly supported by retrospective data. We evaluated the activity of anastrozole in two rare cohorts; patients with recurrent/metastatic LMS and UCS enrolled in PARAGON, a basket trial of anastrozole in estrogen receptor (ER+)/progesterone receptor positive (PR+) gynecological cancers.

METHOD

An investigator-initiated, single-arm, prospective open-label trial of anastrozole 1 mg/day in patients with ER &/or PR + ve LMS or UCS with measurable disease, treated until progression or unacceptable toxicity. Primary endpoint was clinical benefit (complete/partial response + stable disease) rate (CBR) at 3 months. Secondary endpoints include progression-free survival (PFS), quality of life and toxicity.

RESULTS

39 eligible patients were enrolled, 32 with LMS and 7 with UCS. For the LMS cohort CBR at 3 months was 35% (95% CI: 21-53%) with a median duration of clinical benefit of 5.8 months. Best response was a partial response in one patient. Two patients remained on treatment for more than one year. The median progression-free survival was 2.8 months (95% CI: 2.6-4.9). For the UCS cohort CBR at 3 months was 43% (95% CI: 16-75%) with a median duration of clinical benefit of 5.6 months. Stable disease was seen in 3 patients but no objective responses were seen. The median progression-free survival was 2.7 months (95% CI, 1.1-8.2). Safety was acceptable with 5/39 evaluable patients showing grade 3 toxicities.

CONCLUSION

Whilst objective response rates with anastrozole are low, the clinical benefit rate and good tolerance suggests that aromatase inhibitor therapy may have a role in a subset of patients with metastatic LMS and UCS.

Gender minority youth: Shifting the paradigm from risk to resilience

Background

Discourse on the lives, health, and well-being of transgender and other gender minority (TGM) youth frequently revolves around narratives of risk and victimisation. While TGM youth undeniably face many challenges, such singular discourses belie a more complex picture of TGM youth lives and problematically position them as passive victims rather than as social subjects with agency.

Methods

The “LGBTI+ Landscape and Knowledge Gap Analysis” aimed to systematically map research evidence on sexual and gender minority (SGM) youth in Ireland and other European countries. A scoping review methodology was employed in which the systematic concept searches were linked to the five outcomes of Ireland's Better Outcomes, Better Futures national youth policy framework, which in turn are aligned with the fifteen objectives of the Irish LGBTI+ National Youth Strategy.

Results

One hundred and twenty-six pieces of evidence were included in the final sample for analysis, which were mapped to the fifteen objectives of the National Youth Strategy. Particular attention was given to the positive aspects and protective factors identified throughout the literature. The evidence showed that while TGM youth disproportionately experience stigma, discrimination and unequal health outcomes, there were sources of resilience at the micro-, meso-, and macro- levels that serve as protective factors against health inequalities.

Conclusions

Discourse that focuses exclusively on the ‘at-riskness' of trans and gender minority young people presents a one-dimensional perspective that fails to capture the reality and richness of their lives. Over-emphasising individual risk factors may obscure the structural and social factors that underpin the health inequalities experienced by TGM youth.

A systematic review of the determinants of the nutritional quality of food for homeless populations

Introduction

Studies assessing the nutritional quality of food provided to homeless population show deficiencies in micronutrients and excess fat, sugar and salt. The availability of cheap, energy-dense and nutrient poor food has changed the profile of people living with homelessness from primarily underweight to obese in western countries. Many factors influence the nutritional quality of food provided to the homelessness population such as budget and time constraints, food donations and limited equipment. Nutrient intakes in this population are unlikely to be met outside of charitable meal programmes, making the nutritional quality of these meals crucial. This review will synthesise qualitative literature with the aim of understanding of the determinants of the nutritional quality of food provided to the homeless population.

Methods

This qualitative evidence synthesis will include English language primary research empirical studies from Europe, North America and Oceania. Searches will be conducted on Web of Science, CINAHL, Embase, Scopus, PsycINFO, Google Scholar, OpenGrey and ProQuest. Quality appraisal will be conducted using the Standards for Reporting Qualitative Research tool. Two independent reviewers will be included in study selection, data extraction and quality appraisal. A third reviewer will resolve conflicts.

Results

Demographic data on study participants and findings and quotations will be extracted. Thematic synthesis will be employed. Results will be organised based on a determinants of health model, to highlight areas where change may be effective, thereby making it more likely to be useful to practitioners and researchers. The iterative steps in the systematic review process will be the focus of this presentation.

Conclusions

Findings from this review will be used to develop best-practice guidelines for policy makers and service providers to improve the nutritional quality of food provided in the homeless sector.

Key messages

The determinants of the nutritional quality of food provided to the homeless population are influenced by multiple factors. This review will provide a comprehensive assessment of these determinants. This presentation will detail the iterative steps undertaken to conduct this systematic review.

SARS-CoV-2 in a long-term care facility: lessons learnt and importance of repeated mass testing

 

The COVID-19 pandemic has had a devastating impact on long-term care facilities worldwide. Reflecting on public health management of COVID-19 outbreaks in these settings is crucial to identify lessons learnt and improve outbreak control strategies for the future. A confirmed case of COVID-19 in a private nursing home facility was notified to the Department of Public Health West on December 30th 2020. Immediate actions included case investigation, contact tracing, implementation of infection prevention and control (IPC) measures and mass testing of all residents and staff. On December 31st 2 more confirmed cases were notified. A multidisciplinary outbreak control team was convened. Testing of SARS-CoV-2 samples was via reverse transcription polymerase chain reaction. IPC site visits were made. Seven further mass testing rounds were completed at 5-7-day intervals. Data collation and descriptive analyses were performed using Microsoft Excel. There were 56 laboratory-confirmed COVID-19 cases associated with the outbreak (28 residents, 28 staff). Overall attack rate was 52.8% (66.7% for residents, 44.0% for staff). Over half of all cases (51.7%) were detected from the first and second mass testing rounds (positivity rates 34.2% and 27.8% respectively) in the first week of the outbreak. Mean age of resident cases was 81.5 years. The majority (96.4%) were symptomatic (diarrhoea 64.3%, fever 57.1% and anorexia 25%). Hospitalisation and case fatality rates for residents were 21.4% and 41.4% respectively. Mean age of staff cases was 35.5 years. One-quarter were asymptomatic, with no hospitalisations or deaths. The outbreak was declared over on February 16th 2021. Residents of long-term care facilities are extremely vulnerable to COVID-19. Mass testing is a critically important outbreak control strategy which can facilitate rapid case finding and contact tracing in these settings, minimising the potential for further spread of infection and harm to residents and staff.

Key messages

Residents of long-term care facilities are extremely vulnerable to COVID-19, and may present with atypical clinical symptoms and signs of this disease. A low threshold for testing is required. Mass testing is a crucial COVID-19 outbreak control strategy in long-term care facilities to enable rapid case finding and contact tracing, minimising the potential for further spread of infection.

A rapid review of factors influencing food decisions among economically disadvantaged families

Introduction

The importance of external and household family food environments in establishing healthy eating habits during childhood is well reported. Deprived areas are at a nutritional disadvantage due to the high prevalence of fast food outlets and convenience stores. Little is known about the impact of food environments on food-related behaviours of low-income families. This rapid review aimed to synthesise available qualitative evidence on parental perspectives of environmental factors that influence food planning, purchasing and processing among economically disadvantaged families with children.

Methods

This review included qualitative and mixed-methods studies published after 2000 from Europe, North America and Oceania. Search strategies included seven concepts: family, food, perceptions, influences, environment, socio-economic status and study type. Thematic synthesis was employed.

Results

Fourteen articles from the USA, Australia and the UK remained following screening by two reviewers. All parents had a desire to provide healthy food for their children, but they were impeded by child food preferences and beliefs about food behaviours and nutrition. In the external environment, food outlets/availability, cost and marketing influenced food choices amongst parents. Social determinants had a dominant negative influence on food decisions, including hectic daily schedules and time constraints and most importantly limited finances. Social support and support from nutrition programmes and cooking interventions had a positive influence on family food decisions.

Conclusions

This synthesis of qualitative evidence highlights the challenges and opportunities that low-income parents face to feed their families. Improvements in parental food choices and feeding behaviours can only be improved if inequities in health, such as access to affordable healthy food, are addressed.

Key messages

This review concluded that income, time constraints, food cost and limited food availability/outlets can have a negative effect on family food decisions. Social supports such as cooking programmes play a positive role in ensuring healthy food options for families.

Ductal Carcinoma in Situ in Ireland, 2008-2020: Screening Data related to Low-Risk Management Trials

Background

Four clinical trials are on-going to determine if active surveillance is a feasible management option for patients with low-risk ductal carcinoma in situ (DCIS), in response to concerns that breast cancer screening programmes have increased the incidence of DCIS, some of which may never progress to invasive cancer. This study aimed to describe the epidemiology of screen-detected DCIS in Ireland through the BreastCheck, the national breast screening programme in Ireland (commenced 2000 but fully national since 2008).

Methods

This was a cross-sectional analysis of anonymised BreastCheck data provided by the National Screening Service, including all cases of screen-detected DCIS between 2008 and 2020. Statistical tests included Mann-Whitney U, Chi square, and multivariable logistic regression.

Results

2,240 women were diagnosed with DCIS through BreastCheck between 2008 and 2020 (1353 (60.4%) high-grade and 876 (39.1%) low/intermediate grade). The overall rate of screen-detected DCIS incidence has remained relatively stable during this time. Women with high- grade DCIS were older than women with low/intermediate DCIS (57 (IQR 53-61) years v 56 (IQR 56-61) years; p &lt; 0.001). They were also more likely to have been diagnosed at a subsequent screening episode than at an initial episode (71.0% v 57.5%; p &lt; 0.001). After adjustment (deprivation score, screening unit and year) the odds ratio for high-grade was 1.62 (95% CI 1.30-2.03; p &lt; 0.001) for subsequent compared with initial screening episode.

Conclusions

When trial results are available, these data will assist with service planning should active surveillance be approved as a management option. Based on trial inclusion criteria, up to 40% of women diagnosed with DCIS through BreastCheck may be eligible for consideration for active surveillance. These women are younger and often diagnosed on initial screening episode, so may require longer active follow-up.

Key messages

Majority of DCIS in national screening programme is high grade. Randomised controlled trial evidence will provide guidance on management of low-risk DCIS.

Changes in food-related practices among families in Ireland as a consequence of COVID-19

Introduction

The COVID-19 pandemic has had an inordinate influence on people's lives, including impacts on food behaviours. This study explored the impacts of the COVID-19 crisis and ensuing public health restrictions on food-related practices of families living on a tight budget on the Island of Ireland.

Methods

Photovoice and creative mapping methods were used whereby parents were requested to take photos of factors influencing food-related decisions and draw maps of their food environments. These items were then used during qualitative interviews with 28 parents from across the Island of Ireland as a reference for discussions around the food environment and food decision-making processes of economically disadvantaged parents. Data were analysed using deductive thematic analysis.

Results

The findings were situated in Bronfenbrenner's Social Ecological Theoretical framework, conceptualising the COVID-19 crisis as an exogenous socio-historical factor that exerted significant influence on the food-related practices of families in Ireland. The pandemic and responses to it altered patterns of food purchasing, preparation, decision-making and consumption. Changes to practices included increased unhealthy snacking and grazing and consuming fewer meals outside the home. Participants on particularly low incomes relied more on benefits and subsidised food sources and consumed more cheap, processed and frozen foods.

Conclusions

This study provides insight into the impacts of the COVID-19 crisis on dietary habits. The observed changes to food practices may compound food insecurity and already high levels of obesity, particularly among children and young people, and have future implications on prevalence of nutrition-related conditions. This highlights the need for healthcare professionals and policy-makers to be cognisant of the mounting health issues that will need to be addressed in the wake of COVID-19.

Key messages

The COVID-19 crisis significantly impacted on family food related behaviours in Ireland.

Post-COVID health promoters should re-focus efforts on healthy eating initiatives.

Long-term research impact: the case of adolescents having ‘good places to spend free time’ in Ireland

Background

Demonstrating long-term impacts of research can be fraught with methodological challenges, especially when approached retrospectively. Potential accusations of bias or over-interpretation, and a lack of clear and specific causal data, can be real obstacles. This paper presents a case study of research impact, including enablers and context to aid interpretation. To develop a national set of child wellbeing indicators in line with UNCRC commitments, a participative study of children's understandings of wellbeing was undertaken to accompany a Delphi study with experts. The children contributed a number of unique indicators, including having ‘good places to spend free time'.

Methods

Public actions which aimed to meet Irish commitments to child wellbeing were documented. Collected evidence comprised the development of, and reporting on, a national set of wellbeing indictors for children, the development and implementation of two national policies and cyclical monitoring data, collected through the nationally representative data sets of the Health Behaviour in School-aged Children (HBSC) study in Ireland, 2002-2018.

Results

Measurement of stakeholder-informed indicators helped stimulate national policies on play (2004) and recreation (2007). Partnership-based policy implementation led to increases in spaces for play and recreation. Trends data from the HBSC study revealed significant and meaningful increases in ‘good places to go spend free time' for children aged 10-17 from 45.1% in 2002 to 63.5% in 2018, and for all socio-demographic sub-groups. Temporal analyses showed that increases followed policy implementation.

Conclusions

This impact case study links an original participative study, though policy development and implementation, to long-term improvements in Irish children reporting having ‘good places to spend free time'. An understanding of the decision-making context at key points is important to aid interpretation of the evidence under investigation.

Key messages

Commitment to child participation influenced national indicator adoption, policy development and implementation, with subsequent improvements to children’s health-related environments. The quality and specificity of data needed to demonstrate long-term research impact is challenging and interpretation requires contextualisation to avoid leaps of faith.