Updates in the pathogenesis and management of immune-related enterocolitis, hepatitis and cardiovascular toxicities

Immune checkpoint inhibitors (ICIs) have become a cornerstone of treatment for many solid organ malignancies. Alongside increasing use, the occurrence of immune-related adverse events (irAEs) has also increased and remains a significant challenge when treating patients with ICI. The underlying pathophysiology of irAE development for many organ systems is yet to be elucidated, but may involve unmasking of latent autoimmunity, increased T-cell recognition of shared antigens on cancer and normal tissue and ICI-triggered immune dysregulation with overactivation of proinflammatory pathways and suppression of immune control pathways. Management strategies for irAEs have historically been borrowed from paradigms for conventional autoimmune conditions such as inflammatory bowel disease and autoimmune hepatitis; however, recent translational efforts have clearly demonstrated key differences in underlying immune signalling pathways. As we begin to understand these differences, we must adapt a more targeted approach to immunosuppression and exercise a more nuanced approach with the multiple biologic agents available to mitigate ICI-related toxicity without reversing the antitumour effect of ICI. In this review, we focus on three key immune-related toxicities where recent clinical and translational work has provided nuanced insights into pathogenesis and treatment strategies: enterocolitis, hepatitis and cardiovascular toxicity including myocarditis.

CyBorD-DARA in Newly Diagnosed Transplant-Eligible Multiple Myeloma: Results from the 16-BCNI-001/CTRIAL-IE 16-02 Study Show High Rates of MRD Negativity at End of Treatment

The phase 1b 16-BCNI-001/CTRIAL-IE 16-02 CyBorD-DARA trial investigated the combination of Daratumumab with cyclophosphamide, bortezomib and dexamethasone in patients with newly diagnosed multiple myeloma (NDMM), followed by autologous stem cell transplantation and Daratumumab maintenance. CR/sCR rates were 50% after transplant and 62.5% at end of treatment. The overall percentage of patients achieving complete response or better was 77.8%. Progression-free survival rate at end of maintenance was 81.3% and estimated 2-year overall survival was 88.9%. 37.5% of patients demonstrated sustained MRD negativity to a level of 10^-5 from transplant to analysis at EOT. In this phase 1b study, we have shown CyBorD-DARA to be an effective and well-tolerated immunomodulatory agent-free regiment in transplant-eligible NDMM.

Unclassified white matter disorders: A diagnostic journey requiring close collaboration between clinical and laboratory services

BACKGROUND

Next generation sequencing studies have revealed an ever-increasing number of causes for genetic disorders of central nervous system white matter. A substantial number of disorders are identifiable from their specific pattern of biochemical and/or imaging findings for which single gene testing may be indicated. Beyond this group, the causes of genetic white matter disorders are unclear and a broader approach to genomic testing is recommended.

AIM

This study aimed to identify the genetic causes for a group of individuals with unclassified white matter disorders with suspected genetic aetiology and highlight the investigations required when the initial testing is non-diagnostic.

METHODS

Twenty-six individuals from 22 families with unclassified white matter disorders underwent deep phenotyping and genome sequencing performed on trio, or larger, family groups. Functional studies and transcriptomics were used to resolve variants of uncertain significance with potential clinical relevance.

RESULTS

Causative or candidate variants were identified in 15/22 (68.2%) families. Six of the 15 implicated genes had been previously associated with white matter disease (COL4A1, NDUFV1, SLC17A5, TUBB4A, BOLA3, DARS2). Patients with variants in the latter two presented with an atypical phenotype. The other nine genes had not been specifically associated with white matter disease at the time of diagnosis and included genes associated with monogenic syndromes, developmental disorders, and developmental and epileptic encephalopathies (STAG2, LSS, FIG4, GLS, PMPCA, SPTBN1, AGO2, SCN2A, SCN8A). Consequently, only 46% of the diagnoses would have been made via a current leukodystrophy gene panel test.

DISCUSSION

These results confirm the importance of broad genomic testing for patients with white matter disorders. The high diagnostic yield reflects the integration of deep phenotyping, whole genome sequencing, trio analysis, functional studies, and transcriptomic analyses.

CONCLUSIONS

Genetic white matter disorders are genetically and phenotypically heterogeneous. Deep phenotyping together with a range of genomic technologies underpin the identification of causes of unclassified white matter disease. A molecular diagnosis is essential for prognostication, appropriate management, and accurate reproductive counseling.

Quality Improvement Within a Mental Health Setting: Alcohol Detoxification

Aims We describe a clinical audit on alcohol detoxification, using NICE guidelines as a comparable standard. NICE guidelines recommend completing a thorough alcohol history, documentation of a physical examination including screening for Wernicke's encephalopathy, monitoring of vital signs and liver investigations. Breath alcohol level and standardised assessment of withdrawal should be completed in addition to documentation of chlordiazepoxide and thiamine prescriptions. The reported mental health service completed the first cycle of the audit as part of a large-scale, international audit on alcohol detoxification by the Prescribing Observatory for Mental Health, UK (POMH-UK). Two additional audit cycles were completed within the service to ensure continuous quality improvement and clinical effectiveness. Methods Retrospective chart reviews were performed for admissions within pre-defined 6-month periods. Inclusion criteria: ICD-10 F10 diagnosis; prescription of alcohol detoxification schedule. Results This mental health service demonstrated greater compliance with the NICE standards in comparison to other services in the POMH-UK audit. The second-cycle audit showed increased compliance in most areas compared to the initial results. The third-cycle audit focused on two specific areas that required improvement to optimise quality improvement - Breath Alcohol Level and Clinical Institute of Withdrawal Assessment, documentation of which improved from 79% to 85% and 39% to 91% respectively in the final audit cycle. Conclusion The results of this audit indicate that adherence to defined clinical standards within this mental health service exceeds that of the benchmark POMH-UK data. The effectiveness of electronic patient records in improving adherence to set clinical standards, specifically in relation to documentation of clinical parameters is evident. The report also confirms continued improved results with each audit cycle within the service.

90 IMPACT OF AN INTEGRATED CARE MODEL FOR OLDER PERSONS: EVALUATING A PILOT PROGRAMME

Background

In September 2019 Sláintecare helped establish an Integrated Care team for Older People. The aim of this service was to provide a Comprehensive Geriatric Assessment (CGA) to older people within a community network. Service user experience/feedback are critically important for development of a team and a service. To give service users a platform to evaluate the service a patient experience survey was conducted.

Methods

The survey was designed by the multidisciplinary team, consisting of 13 closed/3 open questions. A Likert scale was utilised for closed questions and thematic analysis for open questions. A question on impact of COVID-19 was also included.

150 of the 950 service users who received a CGA from June 2020 to June 2021 were selected randomly and invited to participate in the postal survey. All participants received a covering letter, questionnaire and a stamped address envelope to return their completed surveys.

Results

47% response rate (71/150). 77% were aged ≥75. 52% completed the survey themselves, 48% required assistance. 61% attended more than twice and most would prefer to attend a local spoke clinic. 96% agreed/strongly agreed that they were satisfied with the service. 99% felt they were treated with dignity/respect and had confidence in the service. 93% agreed that they were involved in care decisions. 82% reported their carers had the opportunity to discuss concerns. Themes emerging included importance of care close to home, avoiding acute hospital, difficulty parking at tertiary centres. 42% highlighted isolation and loneliness due to COVID-19 as a major issue.

Conclusion

Service users had an overwhelmingly positive experience especially when care was delivered in clinics close to their homes. Development of the hub and spoke model is acceptable and feasible to older people and their carers’ in this region and will be the focus for expansion of this service.

COVID-19 in forensic psychiatry settings: The unique vulnerability of patients in secure services

Introduction

Secure forensic mental health services treat patient with high rates of treatment resistant psychoses, typically schizophrenia. These groups have high rates of obesity and medical co-morbidities. Population based studies have identified high risk groups in the event of SARS-CoV-2 infection, including those with long term medical conditions.

Objectives

The aim of this study was to compare the vulnerability to serious adverse outcome in the event of COVID-19 infection in a forensic psychiatric patient population.

Methods

All patients of a complete National Forensic Mental Health Service (n=141) were rated for risk of adverse outcome in the event of SARS-CoV-2 infection, using two structured tools, the COVID-AGE tool and the COVID-Risk tool.

Results

Eighty-two patients (58.2%) met criteria for obesity, 32 had type II diabetes and 28 were hypertensive. Mean chronological age was 45.5 years (SD 11.4, median 44.1), while mean COVID-AGE was 59.1 years (SD 19.4, median 58.0), mean difference 13.6 years (SD 15.6) paired t=10.9, df=140, p=0.000. Three patients (2.1%) were chronologically over 70 years compared to 40 (28.4%) with a COVID-AGE over 70 (X2=6.99, df=1, p=0.008, Fishers exact test p=0.027).

Conclusions

These risk assessments may identify the extent of increased risk among a uniquely medically vulnerable patient group. Patients in secure forensic psychiatric services represent a high-risk group for adverse outcomes in the event of SARS-COV-2 infection. Population based cocooning and self-isolating guidance based on chronological age may not be sufficient. There is an urgent need for better physical health research and treatment in this group.

Diabetes care and pregnancy outcomes for women with pregestational diabetes in Ireland

AIMS

Pre-gestational diabetes mellitus (PGDM) is associated with adverse outcomes. We aimed to examine pregnancies affected by PGDM; report on these pregnancy outcomes and compare outcomes for patients with type 1 versus type 2 diabetes mellitus; compare our findings to published Irish and United Kingdom (UK) data and identify potential areas for improvement.

METHODS

Between 2016 and 2018 information on 679 pregnancies from 415 women with type 1 Diabetes Mellitus and 244 women with type 2 diabetes was analysed. Data was collected on maternal characteristics; pregnancy preparation; glycaemic control; pregnancy related complications; foetal and maternal outcomes; unscheduled hospitalisations; congenital anomalies and perinatal deaths.

RESULTS

Only 15.9% of women were adequately prepared for pregnancy. Significant deficits were identified in availability and attendance at pre-pregnancy clinic, use of folic acid, attaining appropriate glycaemic targets and appropriate retinal screening. The majority of pregnancies (n = 567, 83.5%) resulted in a live birth but the large number of infants born large for gestational age (LGA) (n = 280, 49.4%), born prematurely <37 weeks and requiring neonatal intensive care unit (NICU) admission continue to be significant issues.

CONCLUSIONS

This retrospective cohort study identifies multiple targets for improvements in the provision of care to women with pre-gestational DM which are likely to translate into better pregnancy outcomes.

An Irish National Diabetes in Pregnancy Audit: aiming for best outcomes for women with diabetes

AIMS

The purpose of this study was to identify the number of pregnancies affected by pre-gestational diabetes in the Republic of Ireland; to report on pregnancy outcomes and to identify areas for improvement in care delivery and clinical outcomes.

METHODS

Healthcare professionals caring for women with pre-gestational diabetes during pregnancy were invited to participate in this retrospective study. Data pertaining to 185 pregnancies in women attending 15 antenatal centres nationally were collected and analysed. Included pregnancies had an estimated date of delivery between 1 January and 31 December 2015.

RESULTS

The cohort consisted of 122 (65.9%) women with Type 1 diabetes and 56 (30.3%) women with Type 2 diabetes. The remaining 7 (3.8%) pregnancies were to women with maturity-onset diabetes of the young (MODY) (n = 6) and post-transplant diabetes (n = 1). Overall women were poorly prepared for pregnancy and lapses in specific areas of service delivery including pre-pregnancy care and retinal screening were identified. The majority of pregnancies 156 (84.3%) resulted in a live birth. A total of 103 (65.5%) women had a caesarean delivery and 58 (36.9%) infants were large for gestational age.

CONCLUSIONS

This audit identifies clear areas for improvement in delivery of care for women with diabetes in the Republic of Ireland before and during pregnancy.

Feasibility, reproducibility, and clinical implications of the fully automated assessment for global longitudinal strain

Background

Despite of evidence on its usefulness, measurement of global longitudinal strain (GLS) has not been widely accepted as a clinical routine because it requires proficiency and is time-consuming. Automated assessment of GLS may be a solution to these barriers. This study sought to investigate the feasibility, reproducibility, and predictive value of automated strain analysis compared with semi-automated and manual assessment for global longitudinal strain.

Methods

In this validation study, different methods for the assessment of GLS were applied to echocardiograms of 561 asymptomatic people (age 71±5 years) with heart failure (HF) risk factors, recruited from the community. All patients were followed up for new-onset of HF and cardiovascular death. Measurement of GLS was repeated using the same apical images on three different measurement packages as follows: (1) fully automated GLS (AutoStrain), (2) semi-automated GLS (automated, corrected by a trained investigator), and (3) manual GLS (standard manual assessment by a trained investigator). We defined abnormal GLS for discrimination of LV systolic dysfunction using the cut-off of GLS =18% (absolute value).

Results

AutoStrain measurements were feasible in 99.5% of patients. Calculation time for automated (0.5±0.1 min/patient) and semi-automated assessment (2.7±0.6 min/patient) were significantly shorter than that for manual assessment (4.5±1.6 min/patient) (both p&lt;0.001), and the automated assessment showed excellent reproducibility. There was considerable discordance between automated and semi-automated/manual GLS (Figure 1), but normal systolic function was reliable identified. The prediction of cardiovascular events was reliable with automated, semi-automated and manual GLS (Figure 2).

Conclusion

A novel fully automated assessment for GLS is a feasible, rapid, reproducible and clinically applicable means of assessing LV function, and measurements in the normal range predict a favorable outcome.

Figure 1

Funding Acknowledgement

Type of funding source: None

101 Dothideomycetes genomes: A test case for predicting lifestyles and emergence of pathogens

Dothideomycetes is the largest class of kingdom Fungi and comprises an incredible diversity of lifestyles, many of which have evolved multiple times. Plant pathogens represent a major ecological niche of the class Dothideomycetes and they are known to infect most major food crops and feedstocks for biomass and biofuel production. Studying the ecology and evolution of Dothideomycetes has significant implications for our fundamental understanding of fungal evolution, their adaptation to stress and host specificity, and practical implications with regard to the effects of climate change and on the food, feed, and livestock elements of the agro-economy. In this study, we present the first large-scale, whole-genome comparison of 101 Dothideomycetes introducing 55 newly sequenced species. The availability of whole-genome data produced a high-confidence phylogeny leading to reclassification of 25 organisms, provided a clearer picture of the relationships among the various families, and indicated that pathogenicity evolved multiple times within this class. We also identified gene family expansions and contractions across the Dothideomycetes phylogeny linked to ecological niches providing insights into genome evolution and adaptation across this group. Using machine-learning methods we classified fungi into lifestyle classes with >95 % accuracy and identified a small number of gene families that positively correlated with these distinctions. This can become a valuable tool for genome-based prediction of species lifestyle, especially for rarely seen and poorly studied species.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

An Adaptive Moving Mesh Method for Forced Curve Shortening Flow

We propose a novel adaptive moving mesh method for the numerical solution of a forced curve shortening geometric evolution equation. Control of the mesh quality is obtained using a tangential mesh velocity derived from a mesh equidistribution principle, where a positive adaptivity measure or monitor function is approximately equidistributed along the evolving curve. Central finite differences are used to discretize in space the governing evolution equation for the position vector, and a second-order implicit scheme is used for the temporal integration. Simulations are presented indicating the generation of meshes which resolve areas of high curvature and are of second-order accuracy. Furthermore, the new method delivers improved solution accuracy compared to the use of uniform arc-length meshes.

Referrals to the emergency assessment clinic, Whitchurch Hospital, Cardiff

A series of papers looking at the work of the walk-in psychiatric emergency service based at the Maudsley Hospital have been reported in the literature (Lim, 1983; Mindham et al, 1973; Brothwood, 1965). This clinic was established in 1952 and is one of the oldest in Europe. A similar clinic the Emergency Assessment Clinic (EAC) was introduced to Whitchurch Hospital, Cardiff in 1970.

Aggressive Recurrence of Oral Squamous Cell Carcinoma in a patient with Fanconi's Anaemia (FA)

Fanconi's Anaemia is a rare autosomal recessive disease for which the incidence of head and neck cancer can be increased 700-fold1. We report a case of a 31-year old Caucasian male with FA who initially presented in July 2007 with oral squamous cell carcinoma for which he received radical surgery and radiotherapy. He was disease-free until August 2015 when he presented with an extremely aggressive recurrence.

Abstract P4-17-02: Design, implementation and evaluation of a smoking cessation intervention for patients undergoing breast cancer surgery

Introduction:

Smoking is a risk factor for poor outcomes following breast reconstructive surgery, including wound dehiscence and infection. Women who would choose to have reconstructive surgery after mastectomy for breast cancer are unable to do so if they have not quit smoking. The specific aims of this project are to 1) design and implement an intervention to assist these patients in quitting and 2) evaluate its efficacy.

Methods:

Baseline data regarding current practices was collected via a chart review of 75 smoking breast cancer surgery patients from 1/1/2012-12/31/13. Charts were analyzed for documentation of smoking status, quit advice, resources provided and used, and smoking status at follow-up. Formative research informed the design of an Ask-Advise-Refer intervention for all new breast cancer patients seen at Mayo Clinic.

Intervention Design:

Smoking patients were identified prior to their initial Breast Cancer evaluation at Mayo Clinic, Rochester, during a standard intake call. Smoking status was documented by the rooming assistant to alert the physicians of smoking status, and physicians asked these patients about their smoking behavior, discussed the risks of smoking both for surgical procedures and breast cancer, and offered a Nicotine Dependence Consultation with a tobacco treatment specialist in an “opt-out” strategy that emphasized the importance of smoking cessation as part of the breast cancer treatment process. The advice and referral was documented in the medical record. Evaluation of the intervention was performed via a chart review of patients seen after one year of implementation.

Intervention Evaluation Results:

Breast clinic physicians documented smoking status in all patients seen after implementation. Referral to the Nicotine Dependence Center for cessation counseling increased from 29% (22/75) to 74% (20/27). Among those referred, attendance at the consultation increased from 41% (9/22) to 75% (15/20), suggesting stronger provider encouragement of cessation services. 30-day abstinence rates for those who attended a consult prior to 5/1/16 were 46% (6/13), which is consistent with baseline data.

Conclusions:

An Ask-Advise-Refer intervention for new breast cancer patients seen at Mayo Clinic, Rochester, who report current smoking, has been associated with higher rates of provider counseling on tobacco dependence, referral to available services, and patient attendance at referrals. Attending a referral greatly increases a patient's chances of quitting smoking for at least 30 days compared to average spontaneous quit rates in this population. This model is low-cost, time-efficient for providers, and applicable to most practice settings. Finding ways to make this intervention self-sustaining and applicable to multiple other practices could greatly improve our patient's health outcomes.

Citation Format: Nolan M, Ghosh K, Warner DO. Design, implementation and evaluation of a smoking cessation intervention for patients undergoing breast cancer surgery [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-17-02.

Comparative genomics of Mortierella elongata and its bacterial endosymbiont Mycoavidus cysteinexigens

Endosymbiosis of bacteria by eukaryotes is a defining feature of cellular evolution. In addition to well-known bacterial origins for mitochondria and chloroplasts, multiple origins of bacterial endosymbiosis are known within the cells of diverse animals, plants and fungi. Early-diverging lineages of terrestrial fungi harbor endosymbiotic bacteria belonging to the Burkholderiaceae. We sequenced the metagenome of the soil-inhabiting fungus Mortierella elongata and assembled the complete circular chromosome of its endosymbiont, Mycoavidus cysteinexigens, which we place within a lineage of endofungal symbionts that are sister clade to Burkholderia. The genome of M. elongata strain AG77 features a core set of primary metabolic pathways for degradation of simple carbohydrates and lipid biosynthesis, while the M. cysteinexigens (AG77) genome is reduced in size and function. Experiments using antibiotics to cure the endobacterium from the host demonstrate that the fungal host metabolism is highly modulated by presence/absence of M. cysteinexigens. Independent comparative phylogenomic analyses of fungal and bacterial genomes are consistent with an ancient origin for M. elongata - M. cysteinexigens symbiosis, most likely over 350 million years ago and concomitant with the terrestrialization of Earth and diversification of land fungi and plants.

Local modulation of chemoattractant concentrations by single cells: dissection using a bulk-surface computational model

Chemoattractant gradients are usually considered in terms of sources and sinks that are independent of the chemotactic cell. However, recent interest has focused on 'self-generated' gradients, in which cell populations create their own local gradients as they move. Here, we consider the interplay between chemoattractants and single cells. To achieve this, we extend a recently developed computational model to incorporate breakdown of extracellular attractants by membrane-bound enzymes. Model equations are parametrized, using the published estimates from Dictyostelium cells chemotaxing towards cyclic AMP. We find that individual cells can substantially modulate their local attractant field under physiologically appropriate conditions of attractant and enzymes. This means the attractant concentration perceived by receptors can be a small fraction of the ambient concentration. This allows efficient chemotaxis in chemoattractant concentrations that would be saturating without local breakdown. Similar interactions in which cells locally mould a stimulus could function in many types of directed cell motility, including haptotaxis, durotaxis and even electrotaxis.

A Method for Continuous (239)Pu Determinations in Arctic and Antarctic Ice Cores

Atmospheric nuclear weapons testing (NWT) resulted in the injection of plutonium (Pu) into the atmosphere and subsequent global deposition. We present a new method for continuous semiquantitative measurement of (239)Pu in ice cores, which was used to develop annual records of fallout from NWT in ten ice cores from Greenland and Antarctica. The (239)Pu was measured directly using an inductively coupled plasma-sector field mass spectrometer, thereby reducing analysis time and increasing depth-resolution with respect to previous methods. To validate this method, we compared our one year averaged results to published (239)Pu records and other records of NWT. The (239)Pu profiles from the Arctic ice cores reflected global trends in NWT and were in agreement with discrete Pu profiles from lower latitude ice cores. The (239)Pu measurements in the Antarctic ice cores tracked low latitude NWT, consistent with previously published discrete records from Antarctica. Advantages of the continuous (239)Pu measurement method are (1) reduced sample preparation and analysis time; (2) no requirement for additional ice samples for NWT fallout determinations; (3) measurements are exactly coregistered with all other chemical, elemental, isotopic, and gas measurements from the continuous analytical system; and (4) the long half-life means the (239)Pu record is stable through time.

A computational method for the coupled solution of reaction-diffusion equations on evolving domains and manifolds: Application to a model of cell migration and chemotaxis

In this paper, we devise a moving mesh finite element method for the approximate solution of coupled bulk-surface reaction-diffusion equations on an evolving two dimensional domain. Fundamental to the success of the method is the robust generation of bulk and surface meshes. For this purpose, we use a novel moving mesh partial differential equation (MMPDE) approach. The developed method is applied to model problems with known analytical solutions; these experiments indicate second-order spatial and temporal accuracy. Coupled bulk-surface problems occur frequently in many areas; in particular, in the modelling of eukaryotic cell migration and chemotaxis. We apply the method to a model of the two-way interaction of a migrating cell in a chemotactic field, where the bulk region corresponds to the extracellular region and the surface to the cell membrane.

Cation doping size effect for methane activation on alkaline earth metal doping of the CeO2 (111) surface

Alkaline earth metal doping of CeO₂ improves the dissociative adsorption of methane with the behaviour showing a correlation to dopant ionic radius.

Lessons for control of heroin-associated anthrax in Europe from 2009-2010 outbreak case studies, London, UK

Serologic surveillance should be implemented to identify the prevalence of this disease in persons who inject drugs.

Outbreaks of serious infections associated with heroin use in persons who inject drugs (PWIDs) occur intermittently and require vigilance and rapid reporting of individual cases. Here, we give a firsthand account of the cases in London during an outbreak of heroin-associated anthrax during 2009–2010 in the United Kingdom. This new manifestation of anthrax has resulted in a clinical manifestation distinct from already recognized forms. During 2012–13, additional cases of heroin-associated anthrax among PWIDs in England and other European countries were reported, suggesting that anthrax-contaminated heroin remains in circulation. Antibacterial drugs used for serious soft tissue infection are effective against anthrax, which may lead to substantial underrecognition of this novel illness. The outbreak in London provides a strong case for ongoing vigilance and the use of serologic testing in diagnosis and serologic surveillance schemes to determine and monitor the prevalence of anthrax exposure in the PWID community.

Control tissue in brain banking: the importance of thorough neuropathological assessment

Historically, control brain tissue was classified as such mainly by clinical history, and underwent limited neuropathological analysis. Significant progress has been made in recent years with the collection of more extensive clinical information and more specific classifications of neurodegenerative disease, aided by advances in histological processing and increasingly sensitive detection methods. We hypothesised that this may have resulted in certain pathologies previously going unidentified, due to insufficient block sampling and an inadequate range of stains, resulting in the disease not being recognised. We therefore investigated the significance of changes to our own protocols for examining control brain tissue before and after 2007. Control cases that were originally assessed before 2007 were re-assessed using our current staining protocol and antibodies, and compared with age-matched cases post-2007. We found that almost all cases that were originally described as neuropathologically normal displayed some level of pathology after re-analysis, with four cases displaying what we have termed ‘major’ pathology that previously went unidentified, emphasising on a small scale the importance of accurate neuropathological analysis of control tissue, and highlighting the inherent difficulty of traditionally classifying tissue simply as ‘disease’ or ‘control’. We hope our findings will stimulate debate within the brain banking community, with the eventual aim being standardisation of protocols for assessing controls across brain banks.