Clinical validation of C12FDG as a marker associated with senescence and osteoarthritic phenotypes

Chronic conditions associated with aging have proven difficult to prevent or treat. Senescence is a cell fate defined by loss of proliferative capacity and the development of a pro-inflammatory senescence-associated secretory phenotype comprised of cytokines/chemokines, proteases, and other factors that promotes age-related diseases. Specifically, an increase in senescent peripheral blood mononuclear cells (PBMCs), including T cells, is associated with conditions like frailty, rheumatoid arthritis, and bone loss. However, it is unknown if the percentage of senescent PBMCs associated with age-associated orthopedic decline could be used for potential diagnostic or prognostic use in orthopedics. Here, we report senescent cell detection using the fluorescent compound C12FDG to quantify PBMCs senescence across a large cohort of healthy and osteoarthritic patients. There is an increase in the percent of circulating C12FDG+ PBMCs that is commensurate with increases in age and senescence-related serum biomarkers. Interestingly, C12FDG+ PBMCs and T cells also were found to be elevated in patients with mild to moderate osteoarthritis, a progressive joint disease that is strongly associated with inflammation. The percent of C12FDG+ PBMCs and age-related serum biomarkers were decreased in a small subgroup of study participants taking the senolytic drug fisetin. These results demonstrate quantifiable measurements in a large group of participants that could create a composite score of healthy aging sensitive enough to detect changes following senolytic therapy and may predict age-related orthopedic decline. Detection of peripheral senescence in PBMCs and subsets using C12FDG may be clinically useful for quantifying cellular senescence and determining how and if it plays a pathological role in osteoarthritic progression.

Observation of Seven Astrophysical Tau Neutrino Candidates with IceCube

We report on a measurement of astrophysical tau neutrinos with 9.7 yr of IceCube data. Using convolutional neural networks trained on images derived from simulated events, seven candidate ν_{τ} events were found with visible energies ranging from roughly 20 TeV to 1 PeV and a median expected parent ν_{τ} energy of about 200 TeV. Considering backgrounds from astrophysical and atmospheric neutrinos, and muons from π^{±}/K^{±} decays in atmospheric air showers, we obtain a total estimated background of about 0.5 events, dominated by non-ν_{τ} astrophysical neutrinos. Thus, we rule out the absence of astrophysical ν_{τ} at the 5σ level. The measured astrophysical ν_{τ} flux is consistent with expectations based on previously published IceCube astrophysical neutrino flux measurements and neutrino oscillations.

Emerging data in COVID-19 create urgent challengers for health providers: Updates on COVID-19 vaccine and Paxlovid

In this original research we present new emerging data in COVID-19 that create urgent challenges for health providers in prevention and treatment. Health providers should be aware that COVID-19 cases, hospitalizations, and deaths have increased markedly in August 2023. Further, recent data demonstrate a new emerging strain resistant to prior natural and vaccine immunity. The most recent emerging data show that only this updated COVID-19 vaccine produces the same immune response as previous vaccines that reduced mortality by over 95 % and morbidity by over 99 %. This recommendation encompasses all adults and children aged 6 months and older, regardless of whether they have had a prior COVID-19 infection or even if they have never received a prior vaccination. This updated COVID-19 vaccine, approved in September 2023, will be the best means to prevent COVID-19 during this upcoming season of respiratory viruses. In the meanwhile, all members of the US population regardless of previous natural infection, vaccines, or boosters are equally susceptible. At present, health providers should counsel all their patients about masking, social distancing, and avoiding crowds, especially indoors where regions of extreme weather conditions are keeping people indoors in closed quarters. In the treatment of COVID-19 the major clinical challenge to health providers, especially in their Black patients, is to prescribe Paxlovid during the first 5 days after onset of symptoms and a positive test.

The Nitrous Oxide Project: assessment of advocacy and national directives to deliver mitigation of anaesthetic nitrous oxide

The environmental emissions attributed to anaesthetic nitrous oxide across the NHS are comparable to the carbon dioxide released by 135,000 flights from Frankfurt to New York. Much of these emissions are attributable to cumbersome and inadequately managed piped systems, resulting in excessive loss and waste. Since 2020, multiple hospital sites have been engaging with the Nitrous Oxide Project, a quality improvement method supporting a 'lean systems' approach to the provision of nitrous oxide. This review considers the frameworks supporting medical gas management in UK healthcare systems, and the impact of professional advocacy and medical gas stewardship to drive anaesthetic nitrous oxide mitigation in the NHS. Nitrous oxide mitigation efforts by grassroots and professional advocacy networks are enhanced through national centralised emission monitoring, distribution of data, technical information and provision of quality analysis. Given the climate harms of nitrous oxide, concerted efforts should be made to rationalise its use, and resources should be committed to supporting this at local, regional and national levels.

Towards co-design of rehabilitation technologies: a collaborative approach to prioritize usability issues

Introduction

Early stakeholder engagement is critical to the successful development and translation of rehabilitation technologies, a pivotal step of which is usability testing with intended end-users. To this end, several methods employ end-user feedback to identify usability and implementation issues. However, the process of prioritizing identified issues seldom leverages the knowledge and expertise of the range of stakeholders who will ultimately affect the demand and supply of a device. This paper describes a novel method to prioritize end-user feedback using transdisciplinary stakeholder consultation and address it in subsequent product development. The proposed approach was demonstrated using a case study relating to the development of a novel technology for neural recovery after spinal cord injury.

Method

Feedback from five individuals with chronic spinal cord injury was collected during two-hour usability evaluation sessions with a fully functional high-fidelity system prototype. A think-aloud and semi-structured interview protocol was used with each participant to identify usability and acceptability issues relating to the system in a 3-phase approach. Phase 1 involved extracting usability issues from think-aloud and semi-structured interview data. Phase 2 involved rating the usability issues based on their significance, technical feasibility, and implementation priority by relevant internal and external stakeholders. Finally, Phase 3 involved aggregating the usability issues according to design and implementation elements to facilitate solution generation, and these solutions were then raised as action tasks for future design iterations.

Results

Sixty usability issues representing nine facets of usability were rated. Eighty percent of issues were rated to be of moderate to high significance, 83% were rated as being feasible to address, and 75% were rated as addressable using existing project resources. Fifty percent of the issues were rated to be a high priority for implementation. Evaluation of the grouped issues identified 21 tasks which were mapped to the product roadmap for integration into future design iterations.

Discussion

This paper presents a method for meaningful transdisciplinary stakeholder engagement in rehabilitation technology development that can extended to other projects. Alongside a worked example, we offer practical considerations for others seeking to co-develop rehabilitation technologies.

Pain management in victims of disasters

Pain is widely studied and is considered a major clinical, social, and economic problem worldwide, although it remains poorly understood. For disaster victims, the complex picture, biologically, psychologically, and socially, only makes the situation even more complicated. This narrative review aims to describe specific aspects of pain and pain management in disaster victims. We reviewed relevant literature, both on pain management and selected specific data related to conflict victims. We discuss the complexity of the picture, its different aspects, and mechanisms. We discuss the limitations of current approaches and propose a simple strategy, including mitigation plans, all illustrated by a case study based on a personal experience in the Gaza Strip in 2022. The vulnerability factors are well known, as well as the tangle of intense acute pain and the persistence of pain in the subacute and chronic phase. However, the management of acute pain is, in a disaster context, more constrained than chosen. Empirical evidence suggests a focus on modifiable risk factors as well as the evaluation of strategies guiding future management. This management may depend on obstacles and barriers, linked to the context of the disaster, the availability of medicines, techniques, skills as well as linguistic and cultural barriers. Our proposal includes systematic assessment and, in a later phase, tailored and personalized treatment. In the chronic phase of rehabilitation and follow-ups, the essential place for management of psychological and social aspects become predominant. In disaster areas, including during and after conflict, the management, and recommendations for the management of acute and chronic pain are complex, distinct but interdependent. Acute pain must be systematically assessed and treated while personalized care pathways are desirable at a later stage. Psychological and social considerations are essential. Data collection should be systematically considered.

Major pneumothorax during pediatric cardiac MRI procedure under general anesthesia: step-by-step analysis and importance of a well-known environment and material

BACKGROUND

To perform step-by-step analysis of the different factors (material, anesthesia technique, human, and location) that led to major pneumothorax during an infrequent pediatric cardiac MRI and to prevent its occurrence in the future. Anesthesia equipment used in a remote location is often different than those in operating rooms. For magnetic resonance imaging (MRI), ventilation devices and monitors must be compatible with the magnetic fields. During cardiac MRI numerous apneas are required and, visual contact with the patient is limited for clinical evaluation. Anesthesia-related barotrauma and pneumothorax are rare in children and the first symptoms can be masked.

CASE PRESENTATION

A 3-year-old boy with atrial septal defect (ASD) and suspicious partial anomalous pulmonary venous return was anesthetized and intubated to perform a follow up with MRI. Sevoflurane maintenance and ventilation were performed using a circular CO2 absorber device, co-axial circuit, and 500 mL pediatric silicone balloon. Apneas were facilitated by Alfentanyl boluses and hyperventilation. A few moderated desaturations occurred during the imaging sequences without hemodynamic changes. At the end of the MRI, facial subcutaneous emphysema was observed by swollen eyelids and crackling snow neck palpation. A complete left pneumothorax was diagnosed by auscultation, sonography examination, and chest radiograph. Pneumo-mediastinum, -pericardium and -peritoneum were present. A chest drain was placed, and the child was extubated and transferred to the pediatric intensive care unit (PICU). Despite the anesthesiologist's belief that PEEP was minimal, critical analysis revealed that PEEP was maintained at a high level throughout anesthesia. After the initial barotrauma, repeated exposure to high pressure led to the diffusion of air from the pleura to subcutaneous tissues and mediastinal and peritoneal cavities. Equipment check revealed a functional circular circuit; however, the plastic adjustable pressure-limiting valve (APL) closed within the last 30° rotation. The balloon was found to be more rigid and demonstrated significantly reduced compliance.

CONCLUSIONS

Anesthetists require proficiency is using equipment in non-OR locations and this equipment must be properly maintained and checked for malfunctions. Controlling the human factor risks by implementing checklists, formations, and alarms allows us to reduce errors. The number of pediatric anesthesia performed routinely appeared to be essential for limiting risks and reporting our mistakes will be a benefit for all who care about patients.

Do we need to reframe risk once again?

Twenty years ago we wrote an article entitled 'Re-framing risk: The changing context of disaster mitigation and preparedness'. We sought to summarise the changes that were underway at the time in the discourse on disaster risk. At the time the article was seen as rather provocative as it sought to summarise the way that new perspectives were emerging in how we perceived risk. Ben Wisner nudged us to reflect on what happened to that reframing and whether it may be time to re-frame things once again. This reflection has led to several streams of thought.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Virtual Reality: The Future of Invasive Procedure Training?

Invasive procedures are associated with adverse events that are both hazardous to patients and expensive to treat. A trainee is expected to perform complex sterile invasive procedures in a dynamic environment under time pressure while maintaining patient safety at the highest standard of care. For mastery in performing an invasive procedure, the automatism of the technical aspects is required, as well as the ability to adapt to patient conditions, anatomic variability, and environmental stressors. Virtual reality (VR) simulation training is an immersive technology with immense potential for medical training, potentially enhancing clinical proficiency and improving patient safety. Virtual reality can project near-realistic environments onto a head-mounted display, allowing users to simulate and interact with various scenarios. Virtual reality has been used extensively for task training in various healthcare-related disciplines and other fields, such as the military. These scenarios often incorporate haptic feedback for the simulation of physical touch and audio and visual stimuli. In this manuscript, the authors have presented a historical review, the current status, and the potential application of VR simulation training for invasive procedures. They specifically explore a VR training module for central venous access as a prototype for invasive procedure training to describe the advantages and limitations of this evolving technology.

Is learning being supported when information is provided to informal carers during inpatient stroke rehabilitation? A qualitative study

Purpose: To explore how health professionals provide information to informal carers during inpatient stroke rehabilitation and whether these practices align with adult learning principles.Methods: Informal carers and survivors of stroke who had completed inpatient rehabilitation, and health professionals working in inpatient stroke rehabilitation were interviewed. Directed qualitative content analysis was conducted using an adult learning model, to determine how closely reported practices aligned to adult learning principles.Results: 14 carers, 6 survivors of stroke and 17 health professionals participated. Carers (79% female, 57% spouse/partner) reported having incomplete knowledge during rehabilitation, lacking information about mechanisms of stroke recovery, rehabilitation processes, long-term effects of stroke, and navigating post-discharge services. Health professionals supported carers to address their learning needs related to safety of caring for stroke survivors. Carers indicated they were responsible for their own non-safety related learning. Health professionals tended not to check carers' understanding of information provided nor offer learning opportunities beyond written or verbal information.Conclusions: Health professionals consistently provide certain information to carers during inpatient rehabilitation, but adult learning principles are not routinely applied when information is provided. Fostering adult learning among informal carers may improve preparedness of carers to support stroke survivors after discharge from inpatient rehabilitation.

Not as simple as it seems: extensive facility and training gaps in nursing home bathing

Standardized observation of bed baths and showers for 100 residents in 8 nursing homes revealed inadequate cleansing of body sites (88%-100% failure) and >90% process failure involving lather, firm massage, changing dirty wipes or cloths, and following clean-to-dirty sequence. Insufficient water warmth affected 86% of bathing opportunities. Bathing training and adequate resources are needed.

Fisetin Attenuates Cellular Senescence Accumulation During Culture Expansion of Human Adipose-Derived Stem Cells

Mesenchymal stem cells (MSCs) have long been viewed as a promising therapeutic for musculoskeletal repair. However, regulatory concerns including tumorgenicity, inconsistencies in preparation techniques, donor-to-donor variability, and the accumulation of senescence during culture expansion have hindered the clinical application of MSCs. Senescence is a driving mechanism for MSC dysfunction with advancing age. Often characterized by increased reactive oxygen species, senescence-associated heterochromatin foci, inflammatory cytokine secretion, and reduced proliferative capacity, senescence directly inhibits MSCs efficacy as a therapeutic for musculoskeletal regeneration. Furthermore, autologous delivery of senescent MSCs can further induce disease and aging progression through the secretion of the senescence-associated secretory phenotype (SASP) and mitigate the regenerative potential of MSCs. To alleviate these issues, the use of senolytic agents to selectively clear senescent cell populations has become popular. However, their benefits to attenuating senescence accumulation in human MSCs during the culture expansion process have not yet been elucidated. To address this, we analyzed markers of senescence during the expansion of human primary adipose-derived stem cells (ADSCs), a population of fat-resident MSCs commonly used in regenerative medicine applications. Next, we used the senolytic agent fisetin to determine if we can reduce these markers of senescence within our culture-expanded ADSC populations. Our results indicate that ADSCs acquire common markers of cellular senescence including increased reactive oxygen species, senescence-associated β-galactosidase, and senescence-associated heterochromatin foci. Furthermore, we found that the senolytic agent fisetin works in a dose-dependent manner and selectively attenuates these markers of senescence while maintaining the differentiation potential of the expanded ADSCs.

Non-pharmacological interventions for attention-deficit hyperactivity disorder in children and adolescents

Attention-deficit hyperactivity disorder (ADHD) affects approximately 5% of children and adolescents globally and is associated with negative life outcomes and socioeconomic costs. First-generation ADHD treatments were predominantly pharmacological; however, increased understanding of biological, psychological, and environmental factors contributing to ADHD has expanded non-pharmacological treatment possibilities. This Review provides an updated evaluation of the efficacy and safety of non-pharmacological treatments for paediatric ADHD, discussing the quality and level of evidence for nine intervention categories. Unlike medication, no non-pharmacological treatments showed a consistent strong effect on ADHD symptoms. When considering broad outcomes (eg, impairment, caregiver stress, and behavioural improvement), multicomponent (cognitive) behaviour therapy joined medication as a primary ADHD treatment. With respect to secondary treatments, polyunsaturated fatty acids showed a consistent modest effect on ADHD symptoms when taken for at least 3 months. Additionally, mindfulness and multinutrient supplementation with four or more ingredients showed modest efficacy on non-symptom outcomes. All other non-pharmacological treatments were safe; clinicians might tolerate their use but should educate families of childrenand adolescents with ADHD on the disadvantages, including costs, burden to the service user, absence of proven efficacy relative to other treatments, and delay of proven treatment.

Phylogenomic analyses of Sapindales support new family relationships, rapid Mid-Cretaceous Hothouse diversification, and heterogeneous histories of gene duplication

Sapindales is an angiosperm order of high economic and ecological value comprising nine families, c. 479 genera, and c. 6570 species. However, family and subfamily relationships in Sapindales remain unclear, making reconstruction of the order's spatio-temporal and morphological evolution difficult. In this study, we used Angiosperms353 target capture data to generate the most densely sampled phylogenetic trees of Sapindales to date, with 448 samples and c. 85% of genera represented. The percentage of paralogous loci and allele divergence was characterized across the phylogeny, which was time-calibrated using 29 rigorously assessed fossil calibrations. All families were supported as monophyletic. Two core family clades subdivide the order, the first comprising Kirkiaceae, Burseraceae, and Anacardiaceae, the second comprising Simaroubaceae, Meliaceae, and Rutaceae. Kirkiaceae is sister to Burseraceae and Anacardiaceae, and, contrary to current understanding, Simaroubaceae is sister to Meliaceae and Rutaceae. Sapindaceae is placed with Nitrariaceae and Biebersteiniaceae as sister to the core Sapindales families, but the relationships between these families remain unclear, likely due to their rapid and ancient diversification. Sapindales families emerged in rapid succession, coincident with the climatic change of the Mid-Cretaceous Hothouse event. Subfamily and tribal relationships within the major families need revision, particularly in Sapindaceae, Rutaceae and Meliaceae. Much of the difficulty in reconstructing relationships at this level may be caused by the prevalence of paralogous loci, particularly in Meliaceae and Rutaceae, that are likely indicative of ancient gene duplication events such as hybridization and polyploidization playing a role in the evolutionary history of these families. This study provides key insights into factors that may affect phylogenetic reconstructions in Sapindales across multiple scales, and provides a state-of-the-art phylogenetic framework for further research.

A global review of the state of the evidence of household air pollution's contribution to ambient fine particulate matter and their related health impacts

Direct exposure to household fine particulate air pollution (HAP) associated with inefficient combustion of fuels (wood, charcoal, coal, crop residues, kerosene, etc.) for cooking, space-heating, and lighting is estimated to result in 2.3 (1.6-3.1) million premature yearly deaths globally. HAP emitted indoors escapes outdoors and is a leading source of outdoor ambient fine particulate air pollution (AAP) in low- and middle-income countries, often being a larger contributor than well-recognized sources including road transport, industry, coal-fired power plants, brick kilns, and construction dust. We review published scientific studies that model the contribution of HAP to AAP at global and major sub-regional scales. We describe strengths and limitations of the current state of knowledge on HAP's contribution to AAP and the related impact on public health and provide recommendations to improve these estimates. We find that HAP is a dominant source of ambient fine particulate matter (PM2.5) globally - regardless of variations in model types, configurations, and emission inventories used - that contributes approximately 20 % of total global PM2.5 exposure. There are large regional variations: in South Asia, HAP contributes ∼ 30 % of ambient PM2.5, while in high-income North America the fraction is ∼ 7 %. The median estimate indicates that the household contribution to ambient air pollution results in a substantial premature mortality burden globally of about 0.77(0.54-1) million excess deaths, in addition to the 2.3 (1.6-3.1) million deaths from direct HAP exposure. Coordinated global action is required to avert this burden.

Barriers and Facilitators in Implementation of an Esophagectomy Care Pathway: a Qualitative Analysis

INTRODUCTION

A new postoperative esophagectomy care pathway was recently implemented at our institution. Practice pattern change among provider teams can prove challenging; therefore, we sought to study the barriers and facilitators toward pathway implementation at the provider level.

METHODS

This qualitative study was guided by the Theoretical Domains Framework (TDF) to study the adoption and implementation of a post-esophagectomy care pathway. Sixteen in-depth interviews were conducted with providers involved with the pathway. Matrix analysis was used to analyze the data.

RESULTS

Providers included attending surgeons (n = 6), advanced practice providers (n = 8), registered dietitian (n = 1), and clinic staff (n = 1). TDF domains that were salient across our findings included knowledge, beliefs about consequences, social influences, and environmental context and resources. Identified facilitators included were electronic health record tools, such as note templates including pathway components and a pathway-specific order set, patient satisfaction, and preliminary data indicating clinical benefits such as a reduced anastomotic leak rate. The major barrier reported was a hesitance to abandon previous practice patterns, most prevalent at the attending surgeon level.

CONCLUSION

The TDF enabled us to identify and understand the individuals' perceived barriers and facilitators toward adoption and implementation of a postoperative esophagectomy pathway. This analysis can help guide and improve adoption of surgical patient care pathways among providers.

Rare diseases and space health: optimizing synergies from scientific questions to care

Knowledge transfer among research disciplines can lead to substantial research progress. At first glance, astronaut health and rare diseases may be seen as having little common ground for such an exchange. However, deleterious health conditions linked to human space exploration may well be considered as a narrow sub-category of rare diseases. Here, we compare and contrast research and healthcare in the contexts of rare diseases and space health and identify common barriers and avenues of improvement. The prevalent genetic basis of most rare disorders contrasts sharply with the occupational considerations required to sustain human health in space. Nevertheless small sample sizes and large knowledge gaps in natural history are examples of the parallel challenges for research and clinical care in the context of both rare diseases and space health. The two areas also face the simultaneous challenges of evidence scarcity and the pressure to deliver therapeutic solutions, mandating expeditious translation of research knowledge into clinical care. Sharing best practices between these fields, including increasing participant involvement in all stages of research and ethical sharing of standardized data, has the potential to contribute to humankind's efforts to explore ever further into space while caring for people on Earth in a more inclusive fashion.

Specialist multidisciplinary input maximises rare disease diagnoses from whole genome sequencing

Diagnostic whole genome sequencing (WGS) is increasingly used in rare diseases. However, standard, semi-automated WGS analysis may overlook diagnoses in complex disorders. Here, we show that specialist multidisciplinary analysis of WGS, following an initial 'no primary findings' (NPF) report, improves diagnostic rates and alters management. We undertook WGS in 102 adults with diagnostically challenging primary mitochondrial disease phenotypes. NPF cases were reviewed by a genomic medicine team, thus enabling bespoke informatic approaches, co-ordinated phenotypic validation, and functional work. We enhanced the diagnostic rate from 16.7% to 31.4%, with management implications for all new diagnoses, and detected strong candidate disease-causing variants in a further 3.9% of patients. This approach presents a standardised model of care that supports mainstream clinicians and enhances diagnostic equity for complex disorders, thereby facilitating access to the potential benefits of genomic healthcare. This research was made possible through access to the data and findings generated by the 100,000 Genomes Project: http://www.genomicsengland.co.uk .

Safety and efficacy of a biodegradable implant releasing tenofovir alafenamide for vaginal protection in a macaque model

OBJECTIVES

To advance the initiative of ending the global epidemic, long-lasting HIV protection is needed through sustained release of antiretroviral drugs for months to years. We investigated in macaques the safety and efficacy of biodegradable polycaprolactone implants releasing tenofovir alafenamide for HIV pre-exposure prophylaxis (PrEP).

METHODS

Implants were administered subcutaneously in the arm using a contraceptive trocar. Efficacy against vaginal simian-HIV (SHIV) infection was investigated in six pigtailed macaques that received two tenofovir alafenamide implants (0.35 mg/day), one in each arm, for a total release rate of tenofovir alafenamide at 0.7 mg/day. Macaques were exposed to SHIV twice weekly for 6 weeks. Statistical analyses were used to compare outcome with eight untreated controls. Histological assessments were performed on skin biopsies collected near implantation sites.

RESULTS

Median (range) tenofovir diphosphate level in PBMCs was 1519 (1068-1898) fmol/106 cells. All macaques with tenofovir alafenamide implants were protected against vaginal SHIV infection. In contrast, 7/8 controls were infected after a median of 4 SHIV exposures (P = 0.0047). Histological assessment of tissues near tenofovir alafenamide implant sites showed inflammation and necrosis in 5/6 animals, which were not evident by visual inspection.

CONCLUSIONS

We demonstrated complete protection against vaginal SHIV infection with two implants releasing a total of 0.7 mg of tenofovir alafenamide per day. We also identified tenofovir diphosphate concentrations in PBMCs associated with complete vaginal protection. Consistent with previous findings, we observed adverse local toxicity and necrosis near the tenofovir alafenamide implant site. Improved tenofovir alafenamide implants that are safe and maintain high efficacy have the potential to provide long-lasting protection against vaginal HIV infection.

Lessons Learned From Conducting Community-Based Research on HIV Prevention With Youth During COVID-19

Mitigating HIV burden among Black youth requires true community engagement. This brief report identifies challenges, strategies, and lessons learned from transitioning our three-phased, community-engaged HIV prevention project with Black youth to a remote format during COVID-19. The project involved (1) building a community-academic partnership on youth sexual health, (2) participatory youth workshops, and (3) youth surveys and interviews about HIV prevention. Feedback from community-academic partnership, pile sorting themes, and preliminary qualitative analyses guided this report. Challenges included a disruption to in-person engagement while strategies included relying heavily on pre-existing partnerships to recruit youth for interviews. We learned that pre-existing community engagement was essential for completing phase three remotely. More education is needed to support Pre-Exposure Prophylaxis (PrEP) awareness for HIV prevention and there is a need to address structural barriers to healthcare engagement such as community violence and mental illness. Community-engaged HIV research focused on youth can adapt if anchored in community relationships. Future studies must work to more fully center youth's voices and address the structural issues that may inhibit them from engaging in HIV prevention.

Computational Insights into the Catalytic Mechanism of Is‐PETase: An Enzyme Capable of degrading poly(ethylene) terephthalate

Is-PETase has become an enzyme of significant interest due to its ability to catalyse the degradation of polyethylene terephthalate (PET) at mesophilic temperatures. We performed hybrid quantum mechanics and molecular mechanics (QM/MM) at the DSD-PBEP86-D3/ma-def2-TZVP/CHARMM27//rev-PBE-D3/dev2-SVP/CHARMM level to calculate the energy profile for the degradation of a suitable PET model by this enzyme. Very low overall barriers are computed for serine protease-type hydrolysis steps (as low as 34.1 kJ mol^-1 ). Spontaneous deprotonation of the final product, terephthalic acid, with a high computed driving force indicates that product release could be rate limiting.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Comprehensive Ultrasound Course for Special Operations Combat and Tactical Medics

BACKGROUND

Advances in ultrasound technology with enhanced portability and high-quality imaging has led to a surge in its use on the battlefield by nonphysician providers. However, there is a consistent need for comprehensive and standardized ultrasound training to improve ultrasound knowledge, manual skills, and workflow understanding of nonphysician providers.

MATERIALS AND METHODS

Our team designed a multimodal ultrasound course to improve ultrasound knowledge, manual skills, and workflow understanding of nine Special Operations combat medics and Special Operations tactical medics. The course was based on a flipped classroom model with a total time of 43 hours, consisting of an online component followed by live lectures and hands-on workshops. The effectiveness of the course was determined using a knowledge exam, expert ratings of manual skills using a global rating scale, and an objective structured clinical skills examination (OSCE).

RESULTS

The average knowledge exam score of the medics increased from pre-course (56% ± 6.8%) to post-course (80% ± 5.0%, p < .001). Based on expert ratings, their manual skills improved from baseline to day 4 of the course for image finding (p = .007), image optimization (p = .008), image acquisition speed (p = .008), final image quality (p = .008), and global assessment (p = .008). Their average score at every OSCE station was > 91%.

CONCLUSION

A comprehensive multimodal training program can be used to improve military medics' ultrasound knowledge, manual skills, and workflow understanding for various applications of ultrasound. Further research is required to develop a reliable, sustainable course.

Comparative Pharmacokinetics and Local Tolerance of Tenofovir Alafenamide (TAF) From Subcutaneous Implant in Rabbits, Dogs, and Macaques

The administration of antiretrovirals (ARVs) for HIV pre-exposure prophylaxis (PrEP) is highly efficacious and may benefit from new long-acting (LA) drug delivery approaches. This paper describes a subcutaneous, reservoir-style implant for the LA delivery of tenofovir alafenamide (TAF) and documents the preclinical assessment of implant safety and pharmacokinetics (PK) in New Zealand White (NZW) rabbits (3 groups of n = 5), beagle dogs (2 groups of n = 6), and rhesus macaques (2 groups of n = 3). Placebo implants were placed in rabbits (n = 10) and dogs (n = 12). Implant parameters, including selection of the TAF form, choice of excipient, and PCL formulation were tuned to achieve targeted concentrations of the active anabolite of TAF, tenofovir diphosphate (TFV-DP), within peripheral blood mononuclear cells (PBMCs) and mucosal tissues relevant to HIV transmission. Sustained concentrations of TFV-DP in PBMCs over 100 fmol/10⁶ cells were achieved in all animal species indicating that the implants effectively delivered TAF for 3-6 months. Unlike placebo implants without TAF, all active implants resulted in local adverse events (AEs) proximal to the implant ranging in severity from mild to moderate and included dermal inflammation and necrosis across all species. Despite these AEs, the implant performed as designed and achieved a constant drug release profile, supporting the continued development of this drug delivery platform.

Selection and characterization of DNA aptamers for the rat major urinary protein 13 (MUP13) as selective biorecognition elements for sensitive detection of rat pests

Among invasive mammalian predators, rats represent a major threat, endangering ecosystem functioning worldwide. After rat-control operations, detecting their continued presence or reinvasion requires more sensitive and lower cost detection technologies. Here, we develop a new sensing paradigm by using a specific rat urine biomarker (MUP13) to unambiguously signal the presence of rats. As the first step towards a new remote surveillance technology, aptamers were selected to MUP13 using the Flu-Mag SELEX method. Six aptamer candidates were initially screened by dot blot and two of them (Apt-2.5 and Apt-1.4) exhibited high affinity and specificity. Both aptamers were further characterized by bead-based assay to confirm affinity and selectivity. The lead aptamer candidates were then applied to fluorescence anisotropy (FA) and surface plasmon resonance (SPR)-based biosensor platforms, showing dissociation constants in the nanomolar range and high specificity towards their target. The SPR biosensor had limits of detection of 13.8 and 7.5 nM for Apt-2.5 and Apt-1.4, respectively, which are more than three orders of magnitude lower than the physiological concentrations found in rat urine. Selectivity of the aptamers, when comparing with other major urinary proteins, was excellent, indicating strong efficacy in specific detection of rats. In order to validate the aptamer Apt-2.5 for use with real world samples a FA-based assay was performed on a rat urine sample. The assay showed that the aptamer could detect recombinant MUP13 spiked in filtered urine and the natural MUP13 in unfiltered urine, as a first step into translation to real world application. These are the first known assays to detect and quantify a MUP biomarker of rats.

Glycogen Storage Disease Type Ia: Current Management Options, Burden and Unmet Needs

Glycogen storage disease type Ia (GSDIa) is caused by defective glucose-6-phosphatase, a key enzyme in carbohydrate metabolism. Affected individuals cannot release glucose during fasting and accumulate excess glycogen and fat in the liver and kidney, putting them at risk of severe hypoglycaemia and secondary metabolic perturbations. Good glycaemic/metabolic control through strict dietary treatment and regular doses of uncooked cornstarch (UCCS) is essential for preventing hypoglycaemia and long-term complications. Dietary treatment has improved the prognosis for patients with GSDIa; however, the disease itself, its management and monitoring have significant physical, psychological and psychosocial burden on individuals and parents/caregivers. Hypoglycaemia risk persists if a single dose of UCCS is delayed/missed or in cases of gastrointestinal intolerance. UCCS therapy is imprecise, does not treat the cause of disease, may trigger secondary metabolic manifestations and may not prevent long-term complications. We review the importance of and challenges associated with achieving good glycaemic/metabolic control in individuals with GSDIa and how this should be balanced with age-specific psychosocial development towards independence, management of anxiety and preservation of quality of life (QoL). The unmet need for treatment strategies that address the cause of disease, restore glucose homeostasis, reduce the risk of hypoglycaemia/secondary metabolic perturbations and improve QoL is also discussed.

Development and uptake of the National Heart Foundation of Australia Smart Heart Guideline App

Background

Many organisations have developed Smartphone mobile applications (apps) to improve access and uptake of clinical guidelines, including the European Society of Cardiology and the American Heart Foundation. The National Heart Foundation of Australia publish clinical guidelines in collaboration with the Cardiac Society of Australia and New Zealand. We aimed to develop an app for three national guidelines: 1) the Australian clinical guidelines for the prevention and detection of atrial fibrillation 2018; 2) the Australian clinical guidelines for the detection and management of heart failure in Australia 2018; and 3) the Australian clinical guidelines for the management of acute coronary syndromes 2016.

Purpose

To develop a mobile app for Australian health professionals to improve access and uptake of national cardiac clinical guidelines.

Methods

A national health professional mobile app online survey was developed and distributed in 2017. Survey items included the frequency of searching for information about the prevention or management of cardiovascular disease, the methods of searching, and the likelihood of using an Australian-specific mobile app to access clinical guidelines. Following analysis of survey responses, a software developer was contracted to develop the app, which included user-testing. The Smart Heart Guidelines App was registered with the regulatory body in Australia, the Therapeutic Goods Administration, and made freely available from October 2019 on iOS and Android operating systems. The app was promoted using electronic direct mail, social media techniques (Twitter and LinkedIn), on our organisation's website and via printed flyers and materials at regional and national event stands at conferences. Data from the Apple App Store was analysed between 1 October 2019 – 1 October 2020 to evaluate app use.

Results

The health professional survey (respondents n=504; nurses 39%, allied health professionals 26%; GP/cardiologist 9%; researcher 8%; other 18%) showed most (n=447; 89%) reported accessing the Heart Foundation's resources electronically. The majority (n=355; 70%) reported they would be likely to use an Australian-specific app. Data from the Apple App Store indicated over 30,300 impressions (the number of times the Smart Heart App appeared in an App Store search) during the first year the app was available. This resulted in approximately 4,400 app downloads, with consistent “search-to-download rates” throughout the year (monthly average rate 22%). Of the downloads, 3,200 (82%) were a direct result of searching for the Smart Heart App, indicating promotional activities were effective.

Conclusion

Development of the Smart Heart Guideline App in Australia was indicated by health professionals to improve access to national cardiac clinical guidelines. Consistent app downloads and use during the first-year support further research, development, promotion, and evaluation of the app.

Funding Acknowledgement

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

Intracranial pressure directly predicts headache morbidity in idiopathic intracranial hypertension

Objective

Headache is the predominant disabler in idiopathic intracranial hypertension (IIH). The aim was to characterise headache and investigate the association with intracranial pressure.

Methods

IIH:WT was a randomised controlled parallel group multicentre trial in the United Kingdom investigating weight management methods in IIH. Participants with active IIH (evidenced by papilloedema) and a body mass index (BMI) ≥35 kg/m² were recruited. At baseline, 12 months and 24 months headache characteristics and quality of life outcome measures were collected and lumbar puncture measurements were performed.

Results

Sixty-six women with active IIH were included with a mean age of 32.0 years (SD ± 7.8), and mean body mass index of 43.9 ± 7.0 kg/m². The headache phenotype was migraine-like in 90%. Headache severity correlated with ICP at baseline (r = 0.285; p = 0.024); change in headache severity and monthly headache days correlated with change in ICP at 12 months (r = 0.454, p = 0.001 and r = 0.419, p = 0.002 respectively). Cutaneous allodynia was significantly correlated with ICP at 12 months. (r = 0.479, p < 0.001). Boot strap analysis noted a positive association between ICP at 12 and 24 months and enabled prediction of both change in headache severity and monthly headache days. ICP was associated with significant improvements in quality of life (SF-36).

Conclusions

We demonstrate a positive relationship between ICP and headache and cutaneous allodynia, which has not been previously reported in IIH. Those with the greatest reduction in ICP over 12 months had the greatest reduction in headache frequency and severity; this was associated with improvement of quality of life measures.

Trial registration

This work provides Class IIa evidence of the association of raised intracranial pressure and headache. ClinicalTrials.gov number, NCT02124486.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-021-01321-8.

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

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

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

CONCLUSION

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

Erratum: Azimuthal Anisotropy of K_{S}^{0} and Λ+Λ[over ¯] Production at Midrapidity from Au+Au Collisions at sqrt[s]_{NN}=130 GeV [Phys. Rev. Lett. 89, 132301 (2002)]

This corrects the article DOI: 10.1103/PhysRevLett.89.132301.

Erratum: Azimuthal Anisotropy at the Relativistic Heavy Ion Collider: The First and Fourth Harmonics [Phys. Rev. Lett. 92, 062301 (2004)]

This corrects the article DOI: 10.1103/PhysRevLett.92.062301.

The interest of 100 versus 200 Hz tetanic stimulations to quantify low levels of residual neuromuscular blockade with mechanomyography: a pilot study

A more sensitive method than the train-of-four ratio seems required to detect low levels of residual neuromuscular blockade before tracheal extubation. The goal of the study was to determine the potential benefit of 5 s of 100 versus 200 Hz tetanic stimulation to quantify the residual block with mechanomyography in anesthetised patients. Twenty informed and consenting 18- to 80-year-old patients undergoing nose surgery were included. On the left hand, neuromuscular transmission was continuously monitored by acceleromyography. On the right side, a new mecanomyographic device (Isometric Thumb Force^©) recorded the force of thumb adduction (N) developed during 5 s of 100- and 200 Hz tetanic stimulations of the ulnar nerve at three consecutive times: baseline before inducing the neuromuscular blockade, at the time of contralateral train-of-four ratio 0.9 recovery, and 3 min after additional sugammadex reversal. Tetanic Fade Ratios (TFR = F residual/F max) were compared between 100 and 200 Hz stimulations using Student's t test. At the time of TOF ratio 0.9 recovery, both 100 and 200 Hz TFR were significantly decreased compared to baseline (0.61 and 0.16 on average, respectively, p < 0.0001). The 200 Hz TFR was significantly lower than the 100 Hz TFR (p < 0.0001). There were no differences between baseline and post-reversal TFR. The 200 Hz TFR has the potential to better describe low levels of residual neuromuscular blockade than the TOF ratio and 100 Hz TFR and would benefit from further investigations. Retrospectively registered in the Australian and New Zealand Clinical Trials Registry ACTRN12619000273189.

Review of neurological rehabilitation for Multiple Sclerosis in the British Military

Multiple sclerosis (MS) is a progressive neurological disorder, classically presenting in working age adults, including those in the Armed Forces. The Defence Medical Rehabilitation Centre (DMRC) Stanford Hall offers vocationally focused neurorehabilitation services for service personnel (SP) with MS, with the goal to minimise disability, maximise independence and remain able to work.This paper has two aims. First, it briefly provides a clinical update of MS, focusing on pathology, presentation, diagnosis and management. Finally, it will describe the role of DMRC and data from the last decade in the management of MS.Our findings suggest not all SP with MS are being referred to DMRC, and some of those who do have significant delays, potentially impacting on patient support, symptom management and occupational outcomes. It is hoped that this paper will improve awareness and recognition of MS for Armed Forces personnel.

Ultrasound findings of finger, wrist and knee joints in Mucopolysaccharidosis Type I

INTRODUCTION

Musculoskeletal findings in MPS can progress after enzyme replacement. Our aim was to examine synovial recesses, tendons, retinacula and pulleys using ultrasonography for structural and inflammatory changes.

MATERIAL AND METHODS

The wrist, metacarpophalangeal (MCP), proximal and distal interphalangeal (PIP and DIP) joints, the finger flexor tendons and the knee including entheses of quadriceps and patella tendons were assessed clinically. Ultrasonography of the various synovial recesses of the wrist as well as the extensor retinaculum, carpal tunnel, MCP, PIP and DIP joints of the second finger, extensor and flexor tendons, A1-5 pulleys and the knee joint including relevant entheses followed. Significance of differences between patient values and available normative data were assessed using t-tests.

RESULTS

Ultrasonography showed significant abnormal intraarticular material in the wrist without a clear distribution to synovial recesses and without effusions. Doppler signals were found in a perisynovial distribution and not intrasynovial as expected in in inflammatory arthritis. Findings were similar in the knee but not the fingers. Flexor and extensor tendons were also mostly normal in their structure but significant thickening of retinaculae and the flexor tendon pulleys was seen (p<0.0001 compared to normal).

CONCLUSION

MPS I patients showed intraarticular deposition of abnormal material in the wrist and knee but not in the finger joints where significant thickening of retinaculae/pulleys controlling tendon position was dominant. No ultrasound findings of inflammatory pathology were demonstrated but rather a secondary reaction to abnormal deposition and direct damage of GAG.

Resorbable additively manufactured scaffold imparts dimensional stability to extraskeletally regenerated bone

Dimensionally stable vertical bone regeneration outside of the existing bony envelope is a major challenge in the field of orofacial surgery. In this study, we demonstrate that a highly porous, resorbable scaffold fabricated using additive manufacturing techniques enables reproducible extra-skeletal bone formation and prevents bone resorption. An additively manufactured medical grade polycaprolactone (mPCL) biphasic scaffold mimicking the architecture of the jaw bone, consisting of a 3D-printed outer shell overlying an inner highly porous melt electrowritten scaffold, was assessed for its ability to support dimensionally stable bone regeneration in an extraskeletal ovine calvarial model. To investigate bone formation capacity (stage 1), 7 different constructs placed under a protective dome were assessed 8 weeks post-implantation: Empty control, Biphasic scaffold with hydrogel (PCL-Gel), PCL-Gel with 75 or 150 μg of BMP-2 (PCL-BMP-75 and PCL-BMP-150), hydrogel only (Gel), Gel containing 75 or 150 μg of BMP-2 (Gel-BMP-75 and Gel-BMP-150). To assess dimensional stability (stage 2), in a separate cohort, 5 animals were similarly implanted with 2 samples of each of the Gel-BMP-150 and PCL-BMP-150 groups, and after 8 weeks of healing, the protective domes were removed and titanium implants were placed in the regenerated bone and allowed to heal for a further 8 weeks. Bone formation and osseointegration were assessed using micro-computed tomography, histology and histomorphometry. In stage 1, enhanced bone formation was found in the BMP-2 containing groups, especially the PCL-BMP constructs whereby regeneration of full bone height was achieved in a reproducible manner. There was no significant bone volume increase with the higher dose of BMP-2. In the dimensional stability assessment (stage 2), after the rtemoval of the protective dome, the biphasic scaffold prevented bone resorption whereas in the absence of the scaffold, the bone previously formed in the hydrogel underwent extensive resorption. This was attributed to the space maintenance properties and dimensional stability of the biphasic scaffold. Titanium implants osseointegrated into the newly formed bone within the biphasic scaffolds. In conclusion, additively manufactured biphasic scaffolds functionalized with BMP-2 facilitated dimensionally stable bone regeneration that supported dental implant osseointegration.

NATO and evidence-based military and disaster medicine: case for Vigorous Warrior Live Exercise Series

The North Atlantic Treaty Organization (NATO) is the premier and only security alliance uniting 30 countries and growing with many partner states in the provision of collective security and against threats posed by conflict and natural disasters. Security of countries and communities is increasingly threatened by a broad spectrum of unconventional types of war and disease threats - from hybrid and asymmetric to multi-domain and peer-to-peer/near-peer conflict. The NATO Centre of Excellence for Military Medicine (MILMED COE) is the centre of gravity for medical best practices and promotion of medical doctrine across the NATO alliance. Disaster medicine is multidisciplinary and in NATO, multinational, requiring best practices that are driven by data and evidence to prevent death on the battlefield and prepare for future conflicts. "Vigorous Warrior" is a live military and disaster medicine exercise series using both civilian and military actors across all sectors of health focused on health security and identifying lessons learned to ready the alliance for future threats. In this brief report, we make the case that the Vigorous Warrior exercise exposes gaps, highlights challenges and generates an evidence base to make NATO military medicine systems more robust, more efficient and in provision of best medical practices. We specifically argue that clinical data capture must be duplicated and continuous across the alliance to ensure evidence-based medicine stays current in NATO military medical doctrine.