The impact of the COVID-19 pandemic on speech and language therapy services in Ireland: A mixed-methods survey at two time points during the pandemic

BACKGROUND

During the COVID-19 pandemic, Ireland implemented a series of stringent public health measures, including lockdowns and suspension of non-urgent clinical services.

AIMS

To investigate the impact of the COVID-19 pandemic on the demand for and delivery of speech and language therapy (SLT) services in Ireland in 2020.

METHODS & PROCEDURES

Two iterations of a cross-sectional, mixed-methods online survey were distributed to speech and language therapists (SLTs) and SLT students in Ireland in the spring and autumn of 2020 using a combination of purposive and snowball sampling. The spring survey yielded 407 responses (including 14 from SLT students), while 197 respondents took part in the autumn (13 students). Survey analysis focused on questions related to the impact of the COVID-19 pandemic on delivery and demand for SLT services (student responses were excluded from analysis owing to low response rate). The largest group in respect of experience were senior SLTs (58% in both surveys). The work settings most strongly represented were HSE primary care (34.4%) and disability services (26.5%) in the spring, and HSE primary care (39.1%), acute hospitals (22.8%) and disability services (20.8%) in the autumn. We used descriptive statistics, including distribution analysis, to analyse the quantitative data. Free text data were interrogated through a variant of a conventional qualitative content analysis.

OUTCOMES & RESULTS

In the spring, cessation of face-to-face services featured prominently (reported by 65.6% versus 14.2% in the autumn), across SLTs' work settings, except acute hospitals. Lower demand was reported by 42.5% in the spring, while in the autumn, 48.7% indicated that demand was higher. SLTs experienced large-scale redeployment (spring: 45.9%, autumn: 38.4%), with HSE primary care SLTs redeployed most (spring: 71.7%; autumn: 62.3%). The need to suddenly pivot to telehealth was a significant challenge in terms of training, technology and logistics. New ways of working emerged and gradually, telehealth became more embedded. SLTs also had to adapt to working with evolving public health measures, such as space restrictions and personal protective equipment (PPE) requirements. Across the two survey iterations, SLTs reported tensions between demands and capacity: while referrals and demand initially decreased in the spring, this led to increased backlog and longer waiting lists, ongoing and increasing pressure on clinicians and services, and negatively impacted clients and families.

CONCLUSIONS & IMPLICATIONS

The COVID-19 pandemic had a significant negative impact on SLT services in Ireland. Going forward, the SLT profession and its services will require sustained support to mitigate long-term negative consequences, such as increased waiting lists.

WHAT THIS PAPER ADDS

What is already known on this subject The negative impact of the COVID-19 pandemic on SLT services has been examined in several countries. Ireland imposed more stringent pandemic-management measures than many other countries, and it was therefore warranted to investigate how SLT services in the country were affected. What this study adds to the existing knowledge Face-to-face SLT services effectively ceased in most non-urgent contexts in spring 2020. This coincided with large-scale redeployment of SLTs to non-SLT contexts. By autumn 2020, demand had increased again, but not all services had recommenced, and redeployment was still a factor. Although SLTs adapted to the ongoing changes imposed by the pandemic, they voiced concern about increasing backlogs and longer waiting lists, ongoing and increasing pressure on both SLTs and services, and negative impacts on clients and families. What are the actual and clinical implications of this work? The COVID-19 pandemic had a significant negative impact on SLT services in Ireland. Going forward, the SLT profession and its services will require sustained support to mitigate long-term negative consequences, such as increased waiting lists.

[Episodic bleeding events due to arteriovenous malformation (AVM) in the region of the distal ileum in a young male patient]

We report the case of a 32-year-old male patient who presented with episodic, self-limiting gastrointestinal bleeding events. After both esophagogastroduodenoscopy (EGD) and colonoscopy remained unremarkable, capsule endoscopy revealed an unexplained mucosal lesion that presented as an ulcerated process on spiral enteroscopy. Appropriate enteroscopic ink marking was followed by surgical partial resection of the distal ileum, with histopathology revealing evidence of an arteriovenous malformation (AVM). This case emphasizes the importance of deep enteroscopy both in the diagnosis and to facilitate therapeutic resection in rare gastrointestinal bleeding events affecting young people.

Pulmonary blood flow in children with univentricular heart and unilateral diaphragmatic paralysis

OBJECTIVES

Spontaneous breathing has an important effect on pulmonary arterial blood flow in patients with Glenn/Fontan circulation. Unilateral diaphragmatic paralysis (DP) is a frequent complication after heart surgery in congenital heart disease. The aim of this study was to investigate the influence of unilateral DP on blood flow distribution in the pulmonary arteries with Glenn/Fontan circulation.

METHODS

Magnetic resonance phase-contrast imaging was used to evaluate stroke volume index (SVI) in the left and right pulmonary arteries in patients with Glenn/Fontan circulation with unilateral DP. Data for 18 patients with univentricular heart and unilateral DP were analysed, 8 in the Glenn stage and 10 in the Fontan stage. Ten patients had right-sided DP, and 8 had left-sided DP. A diaphragmatic plication was performed in 7 patients. The control group consisted of 36 patients with Glenn (n = 16)/Fontan (n = 20) circulation without DP.

RESULTS

In both left- and right-sided DP, the SVI to the ipsilateral side was significantly lower than in controls [2.81 (1.45-4.50) ml/m2 left vs 11.97 (7.36-16.37) ml/m2 in controls, P < 0.0002; 8.2 (4.49-12.64) ml/m2 with right vs 12.64 (9.66-16.61) ml/m2 in controls; P = 0.0284]. The SVI to the contralateral side showed a slight but non-significant increase in the presence of unilateral DP.

CONCLUSIONS

Unilateral DP in patients with Glenn/Fontan circulation has a negative impact on pulmonary arterial SVI on the side of the paralysis.

Dynamic behaviour of platinum and copper dopants in gold nanoclusters supported on ceria catalysts

Understanding the behaviour of active catalyst sites at the atomic level is crucial for optimizing catalytic performance. Here, the evolution of Pt and Cu dopants in Au25 clusters on CeO2 supports is investigated in the water-gas shift (WGS) reaction, using operando XAFS and DRIFTS. Different behaviour is observed for the Cu and Pt dopants during the pretreatment and reaction. The Cu migrates and builds clusters on the support, whereas the Pt creates single-atom active sites on the surface of the cluster, leading to better performance. Doping with both metals induces strong interactions and pretreatment and reaction conditions lead to the growth of the Au clusters, thereby affecting their catalytic behaviour. This highlights importance of understanding the behaviour of atoms at different stages of catalyst evolution. These insights into the atomic dynamics at the different stages are crucial for the precise optimisation of catalysts, which ultimately enables improved catalytic performance.

Heat and shear stability of particle stabilised foams for application in gluten-free bread

Bread forms an integral part of the daily diet in many cultures worldwide. At the same time, a significant number of people try to avoid wheat-based products for either health reasons or due to personal preferences. The absence of a protein network in gluten free bread affects its structure, taste, texture and shelf-life. This paper suggests a technological solution to this issue that uses a pre-foamed mass of gluten free raw materials which is mixed with the bread's ingredients, then kneaded and baked to form a high quality gluten free bread. To survive the high shear stresses during kneading and temperature increase during baking, the foam requires exceptional stability. This stability was achieved through particle stabilisation of the bubble interfaces. Both of the tested foams (with and without particles) exhibited thermal stability up to 80 °C. However, resistance to shear stresses was higher in the particle stabilised foams. Of all the tested particles, linseed press cake and banana powder led to the best results. In conclusion, particle stabilised foams seem very well suited to applications in gluten free baked goods. Further application potential is seen for vegan foamed desserts.

Consonant articulation acoustics and intelligibility in Swedish speakers with Parkinson's disease: a pilot study

Imprecise consonant articulation is common in speakers with Parkinson's disease and can affect intelligibility. The research on the relationship between acoustic speech measures and intelligibility in Parkinson's disease is limited, and most of the research has been conducted on English. This pilot study investigated aspects of consonant articulation acoustics in eleven Swedish speakers with Parkinson's disease and six neurologically healthy persons. The focus of the study was on consonant cluster production, articulatory motion rate and variation, and voice onset time, and how these acoustic features correlate with speech intelligibility. Among the measures in the present study, typicality ratings of heterorganic consonant clusters /spr/ and /skr/ had the strongest correlations with intelligibility. Measures based on syllable repetition, such as repetition rate and voice onset time, showed varying results with weak to moderate correlations with intelligibility. One conclusion is that some acoustic measures may be more sensitive than others to the impact of the underlying sensory-motor impairment and dysarthria on speech production and intelligibility in speakers with Parkinson's disease. Some aspects of articulation appear to be equally demanding in terms of acoustic realisation for elderly healthy speakers and for speakers with Parkinson's disease, such as sequential motion rate measures. Clinically, this would imply that for the purpose of detecting signs of disordered speech motor control, choosing measures with less variation among older speakers without articulation impairment would lead to more robust results.

Fitness to fly for children and adolescents after Fontan palliation

Introduction

At cruising altitude, the cabin pressure of passenger aircraft needs to be adjusted and, therefore, the oxygen content is equivalent to ambient air at 2,500 masl, causing mild desaturation and a rising pulmonary vascular resistance (PVR) in healthy subjects. For Fontan patients with passive pulmonary perfusion, a rising PVR can cause serious medical problems. The purpose of this fitness to fly investigation (FTF) is to assess the risk of air travel for children and adolescents after Fontan palliation.

Methods

We investigated 21 Fontan patients [3-14y] in a normobaric hypoxic chamber at a simulated altitude of 2,500 m for 3 h. Oxygen saturation, heart rate, and regional tissue saturation in the forehead (NIRS) were measured continuously. Before entering the chamber, after 90 and 180 min in the hypoxic environment, blood gas analysis and echocardiography were performed.

Results

Heart rate and blood pressure did not show significant intraindividual changes. Capillary oxygen saturation (SaO₂) decreased significantly after 90 min by a mean of 5.6 ± 2.87% without further decline. Lactate, pH, base excess, and tissue saturation in the frontal brain did not reach any critical values. In the case of open fenestration between the tunnel and the atrium delta, P did not increase, indicating stable pulmonary artery pressure.

Conclusion

All 21 children finished the investigation successfully without any adverse events, so flying short distance seems to be safe for most Fontan patients with good current health status. As the baseline oxygen saturation does not allow prediction of the maximum extent of desaturation and adaption to a hypoxic environment takes up to 180 min, the so-called hypoxic challenge test is not sufficient for these patients. Performing an FTF examination over a period of 180 min allows for risk assessment and provides safety to the patients and their families, as well as the airline companies.

Conversations in dementia with Lewy bodies: Resources and barriers in communication

BACKGROUND

In dementia with Lewy bodies (DLB), limitations in linguistic and cognitive abilities may lead to difficulties in participating in conversations. The conversational outcome is also dependent on how the conversation partner adjusts to potential communicative challenges.

AIMS

This study explored resources and barriers in communication in DLB.

METHODS & PROCEDURES

Linguistic and cognitive function was explored through standard clinical testing. The dyad's perception of function in daily life was explored through semi-structured interviews analysed with content analysis. Interactional patterns and participation in casual conversation was analysed with conversation analysis.

OUTCOME & RESULTS

The results show how the husband diagnosed with DLB performed with high scores across most cognitive and linguistic test tasks. The interview data, however, revealed how both he and his wife experienced significant challenges regarding, for example, conversational tempo, as well as negative feelings relating to adjusting to these conversational changes. The interactional data from the casual conversation revealed, among other patterns, how the wife engaged in most of the storytelling in the conversation. The husband contributed details when his wife asked for help, or he acknowledged a faulty or missing detail in his wife's storyline. Thus, they both oriented to the husband's competence in monitoring and keeping track of the conversational content, despite challenges in taking the floor.

CONCLUSIONS & IMPLICATIONS

A holistic picture of communication in DLB necessitates the use of different evaluation approaches. Both monological (e.g., test tasks revealing cognitive and linguistic resources) and dialogical information sources (e.g., observations of conversations revealing adjustments in conversations), as well as the perceptions of those engaging in everyday conversations (i.e., people with DLB and their conversation partner(s)), need to be evaluated when assessing resources and barriers in communication.

WHAT THIS PAPER ADDS

What is already known on the subject It is well-known that dementia with Lewy bodies (DLB) affects language and cognition. In conversations, persons with DLB experience difficulties in turn-taking, topic initiation, entering conversations and keeping up with the conversational tempo. What this study adds This study sheds light on conversations in one dyad where the husband has been diagnosed with DLB. The results from three different information sources (testing of language and cognition, interviews and a video-recorded conversation) reveal patterns of resources and barriers that at first appear to contradict each other. However, the contradictions can be resolved when these discrepancies are examined in light of the differences in task structure, in terms of, for example, predetermined topics and how turn-taking is managed. What are the potential or actual clinical implications of this work? In order to gather a holistic picture of a person's conversational abilities, clinicians need to include information from both monological tasks (e.g., linguistic testing) as well as dialogical tasks (e.g., video recordings from conversation). The results also need to be evaluated in light of all conversation partners' perspectives on function in daily life. Furthermore, it is important to consider the nature of assessment tasks (particularly their interactional structure) when interpreting assessment results.

Quantifying and Predicting Ongoing Human Immunodeficiency Virus Type 1 Transmission Dynamics in Switzerland Using a Distance-Based Clustering Approach

BACKGROUND

Despite effective prevention approaches, ongoing human immunodeficiency virus 1 (HIV-1) transmission remains a public health concern indicating a need for identifying its drivers.

METHODS

We combined a network-based clustering method using evolutionary distances between viral sequences with statistical learning approaches to investigate the dynamics of HIV transmission in the Swiss HIV Cohort Study and to predict the drivers of ongoing transmission.

RESULTS

We found that only a minority of clusters and patients acquired links to new infections between 2007 and 2020. While the growth of clusters and the probability of individual patients acquiring new links in the transmission network was associated with epidemiological, behavioral, and virological predictors, the strength of these associations decreased substantially when adjusting for network characteristics. Thus, these network characteristics can capture major heterogeneities beyond classical epidemiological parameters. When modeling the probability of a newly diagnosed patient being linked with future infections, we found that the best predictive performance (median area under the curve receiver operating characteristic AUCROC = 0.77) was achieved by models including characteristics of the network as predictors and that models excluding them performed substantially worse (median AUCROC = 0.54).

CONCLUSIONS

These results highlight the utility of molecular epidemiology-based network approaches for analyzing and predicting ongoing HIV transmission dynamics. This approach may serve for real-time prospective assessment of HIV transmission.

The InSight HP3 Penetrator (Mole) on Mars: Soil Properties Derived from the Penetration Attempts and Related Activities

The NASA InSight Lander on Mars includes the Heat Flow and Physical Properties Package HP³ to measure the surface heat flow of the planet. The package uses temperature sensors that would have been brought to the target depth of 3-5 m by a small penetrator, nicknamed the mole. The mole requiring friction on its hull to balance remaining recoil from its hammer mechanism did not penetrate to the targeted depth. Instead, by precessing about a point midway along its hull, it carved a 7 cm deep and 5-6 cm wide pit and reached a depth of initially 31 cm. The root cause of the failure - as was determined through an extensive, almost two years long campaign - was a lack of friction in an unexpectedly thick cohesive duricrust. During the campaign - described in detail in this paper - the mole penetrated further aided by friction applied using the scoop at the end of the robotic Instrument Deployment Arm and by direct support by the latter. The mole tip finally reached a depth of about 37 cm, bringing the mole back-end 1-2 cm below the surface. It reversed its downward motion twice during attempts to provide friction through pressure on the regolith instead of directly with the scoop to the mole hull. The penetration record of the mole was used to infer mechanical soil parameters such as the penetration resistance of the duricrust of 0.3-0.7 MPa and a penetration resistance of a deeper layer ( > 30 cm depth) of 4.9 ± 0.4 MPa . Using the mole's thermal sensors, thermal conductivity and diffusivity were measured. Applying cone penetration theory, the resistance of the duricrust was used to estimate a cohesion of the latter of 2-15 kPa depending on the internal friction angle of the duricrust. Pushing the scoop with its blade into the surface and chopping off a piece of duricrust provided another estimate of the cohesion of 5.8 kPa. The hammerings of the mole were recorded by the seismometer SEIS and the signals were used to derive P-wave and S-wave velocities representative of the topmost tens of cm of the regolith. Together with the density provided by a thermal conductivity and diffusivity measurement using the mole's thermal sensors, the elastic moduli were calculated from the seismic velocities. Using empirical correlations from terrestrial soil studies between the shear modulus and cohesion, the previous cohesion estimates were found to be consistent with the elastic moduli. The combined data were used to derive a model of the regolith that has an about 20 cm thick duricrust underneath a 1 cm thick unconsolidated layer of sand mixed with dust and above another 10 cm of unconsolidated sand. Underneath the latter, a layer more resistant to penetration and possibly containing debris from a small impact crater is inferred. The thermal conductivity increases from 14 mW/m K to 34 mW/m K through the 1 cm sand/dust layer, keeps the latter value in the duricrust and the sand layer underneath and then increases to 64 mW/m K in the sand/gravel layer below.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11214-022-00941-z.

Triggers of Change in Sexual Behavior Among People With HIV: The Swiss U U Statement and COVID-19 Compared

We assessed changes in sexual behavior among people with human immunodeficiency virus (HIV) over 20 years. Condom use with stable partners steadily declined from over 90 to 29 since the Swiss U U statement, with similar trajectories between men who have sex with men (MSM) and heterosexuals. Occasional partnership remained higher among MSM compared to heterosexuals even during coronavirus disease 2019 (COVID-19) social distancing.

Risk Factors and Incidence of Sexually Transmitted Infections in the Swiss HIV Cohort Study

Background

Sexually transmitted infections (STIs) are common among people with human immunodeficiency virus (PWH), but there are limited data about risk factors and incidence of STIs in large, representative cohort studies.

Methods

We assessed incidence and risk factors of STIs reported by treating physicians within the Swiss HIV Cohort Study (SHCS). Sexually transmitted infections and demographic, clinical, and behavioral characteristics were prospectively collected at 6-month follow-up visits between October 2017 and November 2019. We used multilevel Poisson regression to assess incidence rate ratios of different STIs.

Results

Among 10 140 study participants, a total of 1634 STIs in 1029 SHCS participants were reported over 17 766 person-years of follow up (PYFUP). The overall incidence of any reported STI was 91.9 per 1000 PYFU (95% confidence interval [CI], 85.8 -98.5). Among the 1634 STI episodes, there were 573 (35.1%) incident cases of syphilis, 497 gonorrhea (30.4%), and 418 chlamydia (25.6%). Men who have sex with men (MSM) younger than 50 years represented 21% of the study population, but accounted for 61% of reported STIs. Male sex (adjusted incidence rate ratio [aIRR], 2.03; 95% CI, 1.36-3.02), MSM (aIRR, 3.62; 95% CI, 2.88-4.55), age group 18-34 years (aIRR, 1.78; 95% CI, 1.51-2.10), history of sexual relationships with occasional partners (aIRR, 6.87; 95% CI, 5.40-8.73), and reporting injecting drug use (aIRR, 2.48; 95% CI, 1.91-3.23) were associated with a higher risk of incident STIs.

Conclusions

Sexually transmitted infections were frequent among PWH and varied considerably between age and risk groups. Screening programs and recommendations for STI testing need to be adapted according to risk factors and demographic characteristics.

Swedish Clinical Professionals' Perspectives on Evaluating Cognitive and Communicative Function in Dementia

Objectives: This study investigated Swedish clinical professionals' experiences of diagnostic pathways in dementia, focusing on the assessment of cognitive and communicative abilities.Methods: Interdisciplinary teams in Memory Clinics, General Practitioners in Primary Health Care, and Speech Language Pathologists were interviewed. The transcripts were analyzed using qualitative Content Analysis.Results: The study sheds light upon the perceived barriers and facilitators of good practice, e.g. time and clinical collaborations. Perspectives among professionals vary as to how informal and formal information and procedures are to be integrated and weighted. External factors (e.g. physical proximity of professions) have considerable influence on information availability, transmission, and diagnostic processes. Communication impairment does not emerge as a clinical priority.Conclusions: Published clinical guidelines notwithstanding, there is in practice no "gold standard" regarding diagnostic processes. Reorganization of services that impact feasibility of cross-disciplinary contact may negatively impact diagnostics.Clinical implications: Interprofessional collaboration is impacted by many factors, e.g. physical proximity and availability of specific professions. In order to optimize collaboration in dementia diagnosis, communication channels between professions need to be optimized. Additionally, making clinical impressions and "gut-feelings" explicit could contribute valuable information to the diagnostic process.

Exome sequencing in individuals with cardiovascular laterality defects identifies potential candidate genes

The birth prevalence of laterality defects is about 1.1/10,000 comprising different phenotypes ranging from situs inversus totalis to heterotaxy, mostly associated with complex congenital heart defects (CHD) and situs abnormalities such as intestinal malrotation, biliary atresia, asplenia, or polysplenia. A proportion of laterality defects arise in the context of primary ciliary dyskinesia (PCD) accompanied by respiratory symptoms or infertility. In this study, exome sequencing (ES) was performed in 14 case-parent trios/quattros with clinical exclusion of PCD prior to analysis. Moreover, all cases and parents underwent detailed clinical phenotyping including physical examination, echocardiography by a skilled paediatric cardiologist and abdominal ultrasound examinations not to miss mildly affected individuals. Subsequent survey of the exome data comprised filtering for monoallelic de novo, rare biallelic, and X-linked recessive variants. In two families, rare variants of uncertain significance (VUS) in PKD1L1 and ZIC3 were identified. Both genes have been associated with laterality defects. In two of the remaining families, biallelic variants in LMBRD1 and DNAH17, respectively, were prioritized. In another family, an ultra-rare de novo variant in WDR47 was found. Extensive exome survey of 2,109 single exomes of individuals with situs inversus totalis, heterotaxy, or isolated CHD identified two individuals with novel monoallelic variants in WDR47, but no further individuals with biallelic variants in DNAH17 or LMBRD1. Overall, ES of 14 case-parent trios/quattros with cardiovascular laterality defects identified rare VUS in two families in known disease-associated genes PKD1L1 and ZIC3 and suggests DNAH17, LMBRD1, and WDR47 as potential genes involved in laterality defects.

The latest development of the DELAD project for sharing corpora of speech disorders

Corpora of speech of individuals with communication disorders (CSD) are invaluable resources for education and research, but they are costly and hard to build and difficult to share for various reasons. DELAD, which means 'shared' in Swedish, is a project initiated by Professors Nicole Müller and Martin Ball in 2015 that aims to address this issue by establishing a platform for researchers to share datasets of speech disorders with interested audiences. To date four workshops have been held, where selected participants, covering various expertise including researchers in clinical phonetics and linguistics, speech and language therapy, infrastructure specialists, and ethics and legal specialists, participated to discuss relevant issues in setting up such an archive. Positive and steady progress has been made since 2015, including refurbishing the DELAD website (http://delad.net/) with information and application forms for researchers to join and share their datasets and linking with the CLARIN K-Centre for Atypical Communication Expertise (https://ace.ruhosting.nl/) where CSD can be hosted and accessed through the CLARIN B-Centres, The Language Archive (https://tla.mpi.nl/tools/tla-tools/) and TalkBank (https://talkbank.org/). The latest workshop, which was funded by CLARIN (Common Language Resources and Technology Infrastructure) was held as an online event in January 2021 on topics including Data Protection Impact Assessments, reviewing changes in ethics perspectives in academia on sharing CSD, and voice conversion as a mean to pseudonomise speech. This paper reports the latest progress of DELAD and discusses the directions for further advance of the initiative, with information on how researchers can contribute to the repository.

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

Picture description in the assessment of connected speech intelligibility in Parkinson's disease: A pilot study

Introduction

Assessment of intelligibility in dysarthria tends to rely on oral reading of sentences or words. However, self-generated utterances are closer to a client's natural speech. This study investigated how transcription of utterances elicited by picture description can be used in the assessment of intelligibility in speakers with Parkinson's disease.

Methods

Speech samples from eleven speakers with Parkinson's disease and six neurologically healthy persons were audio-recorded. Forty-two naive listeners completed transcriptions of self-generated sentences from a picture description task and orally read sentences from the Swedish Test of Intelligibility, as well as scaled ratings of narrative speech samples.

Results

Intelligibility was higher in orally read than self-generated sentences and higher for content words than for the whole sentence in self-generated sentences for most of the speakers, although these within-group differences were not statistically significant at the group level. Adding contextual leads for the listeners increased intelligibility in self-generated utterances significantly but with individual variation. Although correlations between the intelligibility measures were at least moderate or strong, there was a considerable inter- and intra-speaker variability in intelligibility scores between tasks for the speakers with Parkinson's disease, indicating individual variation of factors that impact intelligibility. Intelligibility scores from neurologically healthy speakers were generally high across tasks with no significant differences between the conditions.

Conclusion

Within-speaker variability supports literature recommendations to use multiple methods and tasks when assessing intelligibility. The inclusion of transcription of self-generated utterances elicited by picture description to the intelligibility assessment has the potential to provide additional information to assessment methods based on oral reading of pre-scripted sentences and to inform the planning of interventions.

Adequate exercise response at artificial altitude in Fontan patients

PURPOSE

For Fontan-palliated patients, altitude exposure is still a part of discussion since the extent of hypoxic pulmonary vasoconstriction potentially resulting in decreasing cardiac output (Qc), especially during physical exercise, is still unclear. We investigated the effects of normobaric hypoxia (15.2% O₂) simulating 2,500 m above sea level on cardiopulmonary and metabolic parameters and the benefit of daily physical activity (PA) on hypoxic exercise capacity.

METHODS

A total of 21 Fontan patients (14-31 years) and 20 healthy controls performed cardiopulmonary exercise tests on a bicycle ergometer in normoxia and hypoxia until subjective exhaustion, measuring capillary lactate (cLa) every 2 min. In between, participants underwent an activity tracking over 5 days with a triaxial accelerometer.

RESULTS

Hypoxic exercise was well tolerated by Fontan patients, and no adverse clinical events were observed. Fontan patients showed reduced physical capacity under both conditions compared to controls (63% normoxia, 62% hypoxia), but the relative impairment due to hypoxia was similar for both (≈10%). Up to workloads of 2 W/kg oxygen uptake ( V . O₂) and heart rate (HR) developed similarly in patients and controls. cLa increased faster in relation to workload in Fontan patients, but remained significantly lower at peak workload (normoxia 3.88 ± 1.19 mmol/l vs. 7.05 ± 2.1 mmol/l; hypoxia 4.01 ± 1.12 mmol/l vs. 7.56 ± 1.82 mmol/l). Qc was diminished but could be increased similar to controls. Fontan patients with higher PA levels showed a higher V . O_2peak in hypoxia.

CONCLUSION

Exercise during short-time artificial altitude exposure seems to be safe for young Fontan patients. Further studies are needed to validate longer exposure under real conditions. V . O₂, HR, and Qc might not be a limiting factor for exercise until workloads of 2 W/kg. Higher daily PA levels might improve physical capacity under altitude conditions.

Systemic ventricular function in Fontan patients at rest and after exercise at altitude

OBJECTIVE

Physical activity at high altitude is expected to pose risks for patients with Fontan circulation and to impair systemic ventricular function. This study aims to determine the effect of high-altitude hypoxia on ventricular function in Fontan patients at rest and after exercise. We hypothesize that systemic ventricular function deteriorates under hypoxic conditions in Fontan patients.

METHODS

In this prospective study, 21 Fontan patients (NYHA class I-II) and 21 age-, gender- and body mass index-matched healthy controls were enrolled (median age 17.9 and 16.9 years). Transthoracic echocardiography was performed at rest, after peak (PE) and after continuous exercise (CE) in normoxia and hypoxia at simulated altitude (2,500 m above sea level). The effect of hypoxia on echocardiographic parameters was quantified by linear mixed-effects models and the difference between normoxia and hypoxia (Δ= hypoxia-normoxia).

RESULTS

At rest, cardiac output (CO) estimated by outflow tract velocity time integral × heart rate and annular plane systolic excursion (APSE) were lower in hypoxia compared to normoxia in Fontan patients (CO: Δ = -12.0%, n.s.; APSE: Δ = -9.6%, p < 0.001), an increase was observed in controls (CO: Δ = 8.5%, n.s.; APSE: Δ = 2.5%, n.s.). Other parameters of systolic and diastolic function did not show relevant changes. After exercise under hypoxic conditions, Fontan patients did not show relevant deterioration of systolic function compared to normoxia. Late, active diastolic filling reflected by A-wave velocity remained unchanged in Fontan patients, but increased in controls. Under hypoxic conditions, CO and workload were higher after CE than PE in Fontan patients (CO: PE Δ = 1,530 vs. CE 1630), whereas controls showed higher work load and CO estimates after PE than CE as expected (CO: PE Δ = 2,302 vs. CE 2149).

CONCLUSION

Fontan patients clinically tolerated short-term altitude exposure up to two hours and exercise and showed no consistent deterioration of systolic systemic ventricular function, but parameters of myocardial contractility, heart rate and cardiac output did not increase as observed in controls. This is likely to be multifactorial and may include intrinsic cardiac dysfunction as well as preload inadequacy and the lack of augmented atrial contraction. CE may be better tolerated than PE.

National Survey Regarding Motivation and Conditions of Physicians Working in a Pediatric Cardiac Intensive Care Unit

Background  The professional demands on the expertise in pediatric intensive care have continuously increased in recent years. Due to a lack of applicants, the staffing of a continuous shift service with qualified medical staff poses major challenges to the hospitals.

Methods  A web-based questionnaire with 27 predominantly matrix questions on working conditions and motivation for working in this area was sent to pediatric hospitals throughout Germany.

Results  165 doctors responded to the survey. The average age of the participants was 35.2 years. The average weekend work load reported by 79% of the respondents was 2 weekends per month, 70% of the study participants performed five to seven night shifts per month. 92% of the respondents stated that they basically enjoyed working in the intensive care unit (ICU). When asked to prioritize the working conditions, an appreciative working atmosphere in the team was named as priority 1 by 57%, followed by good guidance in the independent performance of interventions (25%) and good working conditions (19%).

Discussion  The survey result shows that neither aspects of work–life balance nor payments are the key issues selecting the interesting, but physically and emotionally demanding job in pediatric ICU.

Conclusion  When evaluating vocational training in pediatric intensive care medicine, the immediate working atmosphere in the team with mutual respect and understanding and the guidance in training are more important than the general conditions.

Evaluation of a Paper-Based Checklist versus an Electronic Handover Tool Based on the Situation Background Assessment Recommendation (SBAR) Concept in Patients after Surgery for Congenital Heart Disease

(1) Background: we compare a new SBAR based electronic handover tool versus a paper-based checklist for handover in a pediatric intensive care unit (PICU). (2) Methods: this is a randomized, observational study of 40 electronic vs. 40 paper checklist handovers after pediatric cardiac surgery, with a 48 items checklist for comparison of reporting frequencies and notification of disturbances and noise. PICU staff satisfaction was evaluated by a 12-item questionnaire. (3) Results: in 14 out of 40 cases, there were problems with data processing (incomplete or no data processing). Some item groups (e.g., hemodynamics) were consistently reported at higher frequencies than other groups. Items not specifically asked for did not get reported. Some items, automatically processed in the SBAR handover page, did not get reported. Many handovers suffered a noisy and distracting atmosphere. There was no difference in staff satisfaction between the two handover approaches. Nurses were highly unsatisfied with the general approach by which the handover was performed. (4) Conclusions: human error appears to be a main factor for unreliable data processing. Software is still too complicated, and multitasking is a stressful and error prone event. Handover is a complex task with many factors required for a successful completion.

XIAP restrains TNF-driven intestinal inflammation and dysbiosis by promoting innate immune responses of Paneth and dendritic cells

Deficiency in X-linked inhibitor of apoptosis protein (XIAP) is the cause for X-linked lymphoproliferative syndrome 2 (XLP2). About one-third of these patients suffer from severe and therapy-refractory inflammatory bowel disease (IBD), but the exact cause of this pathogenesis remains undefined. Here, we used XIAP-deficient mice to characterize the mechanisms underlying intestinal inflammation. In Xiap−/− mice, we observed spontaneous terminal ileitis and microbial dysbiosis characterized by a reduction of Clostridia species. We showed that in inflamed mice, both TNF receptor 1 and 2 (TNFR1/2) cooperated in promoting ileitis by targeting TLR5-expressing Paneth cells (PCs) or dendritic cells (DCs). Using intestinal organoids and in vivo modeling, we demonstrated that TLR5 signaling triggered TNF production, which induced PC dysfunction mediated by TNFR1. TNFR2 acted upon lamina propria immune cells. scRNA-seq identified a DC population expressing TLR5, in which Tnfr2 expression was also elevated. Thus, the combined activity of TLR5 and TNFR2 signaling may be responsible for DC loss in lamina propria of Xiap−/− mice. Consequently, both Tnfr1−/−Xiap−/− and Tnfr2−/−Xiap−/− mice were rescued from dysbiosis and intestinal inflammation. Furthermore, RNA-seq of ileal crypts revealed that in inflamed Xiap−/− mice, TLR5 signaling was abrogated, linking aberrant TNF responses with the development of a dysbiosis. Evidence for TNFR2 signaling driving intestinal inflammation was detected in XLP2 patient samples. Together, these data point toward a key role of XIAP in mediating resilience of TLR5-expressing PCs and intestinal DCs, allowing them to maintain tissue integrity and microbiota homeostasis.

Building capacity: getting evidence-based practice into healthcare professional curricula

Fostering a culture of clinical effectiveness in healthcare is crucial to achieving optimum outcomes for patients. Evidence-based practice (EBP) is a cornerstone of clinical effectiveness. An EBP capacity-building project commenced in Ireland in 2016, in collaboration with the Centre of Evidence-Based Medicine in Oxford. A key part of this project, reported here, was the development of a competency framework for education in EBP and clinical effectiveness to ensure responsiveness of education standards and curricula of healthcare professionals in this area.

METHODS

Following a review of national and international reports, professional guidance documents and empirical literature pertaining to clinical effectiveness education (CEE), a preliminary competency framework was developed. Stakeholder consultations were conducted over a 6-month period, which consisted of 13 focus groups (n=45) and included representatives from clinical practice, higher education and professional training sectors, regulator/accrediting bodies, the Department of Health (Ireland) and patient/service user groups.

RESULTS

An overarching interprofessional competency framework for CEE was proposed and included the following domains: EBP, quality improvement processes, implementation strategies and collaborative practice: a total of 16 competencies and 60 indicators.

CONCLUSION

A competency framework for CEE for health and social care professionals is presented. It is intended that this framework will provide guidance to healthcare educators and regulators in the construction and revision of curricula, learning outcomes, teaching and assessment strategies, and graduate/clinician attributes.

[Harassment and social context : How to identify allies ?]

The outpatient management of patients who are victims of harassment can be a challenge for primary care physicians. Focusing on the psychosocial environment in which the events develop can help to highlight the conditions that allow the phenomenon to exist and to detect people who could be of valuable help to the victim. The aim of this article is to provide a more comprehensive view of the phenomenon of harassment, emphasizing the role played by the context and the social group, in order to give caregivers additional tools for the support and treatment of victims.

Altitude exposure in pediatric pulmonary hypertension-are we ready for (flight) recommendations?

Patients with congenital heart disease are surviving further into adulthood and want to participate in multiple activities. This includes exposure to high altitude by air travel or recreational activities, such as hiking and skiing. However, at an altitude of about 2,500 m, the barometric environmental pressure is reduced and the partial pressure of inspired oxygen drops from 21% to 15% (hypobaric hypoxia). In physiologic response to high-altitude-related hypoxia, pulmonary vasoconstriction is induced within minutes of exposure followed by compensatory hyperventilation and increased cardiac output. Even in healthy children and adults, desaturation can be profound and lead to a significant rise in pulmonary pressure and resistance. Individuals with already increased pulmonary pressure may be placed at risk during high-altitude exposure, as compensatory mechanisms may be limited. Little is known about the physiological response and risk of developing clinically relevant events on altitude exposure in pediatric pulmonary hypertension (PAH). Current guidelines are, in the absence of clinical studies, mainly based on expert opinion. Today, healthcare professionals are increasingly faced with the question, how best to assess and advise on the safety of individuals with PAH planning air travel or an excursion to mountain areas. To fill the gap, this article summarises the current clinical knowledge on moderate to high altitude exposure in patients with different forms of pediatric PAH.

Long-term outcome of persons with diabetic and non-diabetic neuro-osteoarthropathy after foot correction using external fixation

AIM

Diabetic neuro-osteoarthropathy (Charcot foot) is a serious form of diabetic foot syndrome, often leading to severe deformity of the foot and subsequently to ulcers and osteomyelitis. The aim of this retrospective study was to determine the success rate and long-term outcomes for a Charcot foot operation using external fixation in 115 individuals who underwent surgery between July 2008 and December 2012.

METHODS

Some 115 consecutive persons, 78 (68%) men and 37 (32%) women, were enrolled in this study. The eligibility criterion for this retrospective study was reconstructive foot surgery using a Hoffmann II external fixator in diabetic and non-diabetic neuro-osteoarthropathy. The main examination parameters in the follow-up were walking ability, amputation and mortality. Average follow-up was 5.7 (± 3.2) years.

RESULTS

Ninety-seven per cent of people were able to walk after the operation with bespoke shoes or an orthosis. At follow-up, 77% were able to walk and 51% were fully mobile even outside the home. Subsequent amputations were performed in 29 individuals (26%), with 17 (15%) minor and 12 (11%) major amputations. Forty-seven individuals died before follow-up, the majority (53%) from cardiovascular events. Average survival time post surgery was 4.5 (± 2.9) years.

CONCLUSION

Reconstruction surgery using external fixation is a very useful method for maintaining walking ability in the case of conservatively non-treatable diabetic and non-diabetic neuro-osteoarthropathy. Individuals with severe Charcot foot disease had a low rate of major amputations. Osteomyelitis was the main reason for major amputations.

Safety Monitoring of Gene Therapy for Spinal Muscular Atrophy with Onasemnogene Abeparvovec -A Single Centre Experience

BACKGROUND

Recently gene therapy with onasemnogene abeparvovec has been approved for the treatment of spinal muscular atrophy (SMA). As the experience from clinical trials is limited, there are still uncertainties for which patient population the treatment can be considered safe and effective.

METHODS

We report our experience with eight consecutive patients with SMA who were treated with the standard dose of onasemnogene abeparvovec (1.1×1014 vg/kg) at the University Hospital Bonn, Germany. All patients received prophylactic immunosuppression with 1 mg/kg/d prednisolone for four weeks starting on the day before gene therapy.

RESULTS

We treated eight patients (4 male, 4 female, age range 10-37 months) with a body weight between 7.1 and 11.9 kg. All patients had 2 or 3 copies of the SMN2-gene and were previously treated with nusinersen. Following treatment with onasemnogene abeparvovec all patients showed a temporary increase of the body temperature and an increase of transaminase levels. In all but one patient it was necessary to increase or prolong the standard steroid dose to control the immune response. In one severe case, liver damage was associated with impaired liver function. This patient received a steroid pulse therapy for five days. Blood counts revealed asymptomatic thrombocytopenia (<150×109/L) in 6/8 patients and a significant increase of monocytes following gene therapy. Liver values and blood counts returned to almost normal levels during the post-treatment observation period. Troponin I increased above normal limit in 4/8 patients but was not associated with any abnormalities on cardiac evaluation.

CONCLUSIONS

In a broader spectrum of patients, treatment with onasemnogene abeparvovec was associated with a higher rate of adverse events. In our cases it was possible to control the immune response by close monitoring and adaptation of the immunosuppressive regimen. Further research is needed to better understand the immune response following gene therapy and ideally to identify patients at risk for a more severe reaction.

Opioid requirements after locoregional anaesthesia in dogs undergoing tibial plateau levelling osteotomy: a pilot study

OBJECTIVE

To determine the intraoperative and early postoperative opioid requirement after ultrasound-guided sciatic and/or femoral nerve block or epidural anaesthesia in dogs undergoing tibial plateau levelling osteotomy (TPLO).

STUDY DESIGN

Prospective, masked, pilot, randomized, clinical trial.

ANIMALS

A total of 40 client-owned dogs undergoing TPLO.

METHODS

Each dog was randomly assigned to group SF (combined sciatic and femoral nerve block), group S (sciatic nerve block), group F (femoral nerve block) or group E (epidural anaesthesia). A total of 0.3 mL kg^-1 of ropivacaine 0.5% was administered to each nerve or in the epidural space. Intraoperatively, fentanyl (2 μg kg^-1) was administered intravenously when heart rate, mean arterial pressure or respiratory rate increased by >30% compared with baseline values. Postoperatively, a visual analogue scale (VAS) and a modified German version of the French pain scale (4AVet) were used to assess pain every 30 minutes for 150 minutes and again once the morning after surgery. Methadone (0.1 mg kg^-1) was administered intravenously if the VAS was ≥ 4 cm [maximal value 10 cm; median (interquartile range)] or the composite pain score was ≥5 [maximal value 15; median (interquartile range)]. Significance was defined as p ≤ 0.05.

RESULTS

Groups SF and E required less total intraoperative and early postoperative opioid doses compared with groups S and F (p = 0.031). No dogs in group SF had a block failure or required postoperative methadone. A reduced methadone requirement was found in group SF compared with all the other groups up to 150 minutes after recovery (p = 0.041).

CONCLUSIONS AND CLINICAL RELEVANCE

Combined sciatic and femoral nerve block and epidural anaesthesia lead to less cumulative consumption of perioperative opioids than single nerve blockade. Sciatic or femoral nerve block alone might be insufficient to control nociception and early postoperative pain in dogs undergoing TPLO.

Age-related hearing loss and provider-patient communication across primary and secondary care settings: a cross-sectional study

BACKGROUND

The prevalence of age-related hearing loss (ARHL) increases with age. Older adults are amongst the most dependent users of healthcare and most vulnerable to medical error. This study examined health professionals' strategies, as well as level of formal training completed, for communication with older adults with ARHL, and their views on the contribution of ARHL to suboptimal quality of patient care.

METHODS

A 17-item questionnaire was distributed to a sample of Irish primary care physicians, as well as hospital-based clinicians providing inpatient palliative care and geriatric services.

RESULTS

A total of 172 primary care physicians and 100 secondary care providers completed the questionnaire. A total of 154 (90%) primary and 97 (97%) secondary care providers agreed that ARHL had a negative impact on quality of care. Across both settings, 10% of respondents reported that communication issues contributed to multiple medication error events each year. Although only 3.5% of secondary care providers and 13% of primary care physicians attended formal training on communication with hearing-impaired patients, 66.5% of respondents were confident in their capacity to communicate with these patients. Primary care physicians reported that they either never used assistive hearing technology (44%) or were unfamiliar with this technology (49%).

CONCLUSIONS

Primary and secondary care health providers reported that ARHL reduces patient care quality and may initiate errors leading to patient harm. Formal training addressing the communication needs of ARHL patients appears to be underdeveloped, and there is a limited familiarity with assistive hearing technology. This is both an error in health professional training and healthcare services.

Experiencing dementia: How does assessment of cognition and language relate to daily life?

This Swedish study investigates how persons living with dementia report their experiences of cognitive and linguistic testing, as well as their perspectives on the communicative resources and barriers they experience in daily interactions. Eight dyads were included in this qualitative exploratory study; eight persons with dementia and eight family members with whom they interact with daily. Semi-structured interviews, with questions focusing on experiences of diagnostic pathways as well as communicative and cognitive function in daily life, were carried out together with standard clinical testing. The data were analysed using qualitative content analysis. The results shed light on the experiences of uncertainty during the dementia assessment process related to the assessment tasks, the consequences of the assessment and receiving a diagnosis. We interpret this as a result of the unfamiliar clinical focus on function as measured in decontextualised tasks, compared to the participants’ view based on their abilities in everyday life. The study also reveals that adjustments in daily life that are necessitated by the consequences of neurological change are often developed in collaboration between the person with dementia and their conversation partners. There are, however, reports of conflicting feelings by the persons diagnosed with dementia, and by their families, as well as their views on how to best handle change, while maintaining a sense of being a competent person through the progression of disease.

Changes in incidence of severe hypoglycaemia in people with type 2 diabetes from 2006 to 2016: analysis based on health insurance data in Germany considering the anti-hyperglycaemic medication

AIM

To investigate the incidence of severe hypoglycaemia over the past 10 years, taking into account changes in anti-hyperglycaemic therapy.

METHODS

This retrospective population-based study used German health insurance data. All adults diagnosed with documented type 2 diabetes (extrapolated to the German population: 6.6 million in 2006; 7.9 million in 2011; 8.86 million in 2016) were screened for severe hypoglycaemia. Anti-hyperglycaemic agents were identified by Anatomical Therapeutic Chemical (ATC) code.

RESULTS

The event rate for severe hypoglycaemia was 460 per 100 000 people in 2006, 490 per 100 000 in 2011 and 360 per 100 000 in 2016. The proportion of people with severe hypoglycaemia receiving sulfonylureas, as well as receiving combination therapy of metformin and sulfonylureas decreased from 2006 to 2016 (23.6% vs. 6.2%) Among those with severe hypoglycaemia in 2006, there were no prescriptions for dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists or sodium-glucose co-transporter 2 (SGLT2) agonists. The proportions of people with severe hypoglycaemia receiving DPP-4 inhibitors, GLP-1 receptor agonists or SGLT2 agonists in 2011 and 2016 were low. The proportion of people receiving human insulin also decreased (from 11.3% in 2006 to 10.3% in 2011 and 4.3% in 2016); the proportion of people receiving insulin analogues increased from 5.4% in 2006 to 11.5% in 2016. Therapy with mixed insulins was used by 19.7% of people with severe hypoglycaemia in 2006, by 14.0% in 2011 and by 7.3% in 2016. People undergoing therapy with insulin analogues have the highest risk of severe hypoglycaemia adjusted by age, gender, nephropathy diagnosis and year of survey [odds ratio (OR) 14.4, 95% confidence interval (95% CI) 13.5-15.5].

CONCLUSION

The incidence of severe hypoglycaemic events in Germany increased between 2006 and 2011, and decreased in 2016.

Changes in Renal Function After Switching From TDF to TAF in HIV-Infected Individuals: A Prospective Cohort Study

Background

Replacing tenofovir disoproxil fumarate (TDF) with tenofovir alafenamide (TAF) improves renal tubular markers in HIV-infected individuals but the impact on estimated glomerular filtration rate (eGFR) remains unclear.

Methods

In all participants from the Swiss HIV Cohort Study who switched from TDF to TAF-containing antiretroviral regimen or continued TDF, we estimated changes in eGFR and urine protein-to-creatinine ratio (UPCR) after 18 months using mixed-effect models.

Results

Of 3520 participants (26.6% women, median age 50 years), 2404 (68.5%) switched to TAF. Overall, 1664 (47.3%) had an eGFR &lt;90 mL/min and 1087 (30.9%) an UPCR ≥15 mg/mmol. In patients with baseline eGFR ≥90 mL/min, eGFR decreased with the use of TDF and TAF (−1.7 mL/min). Switching to TAF was associated with increases in eGFR of 1.5 mL/min (95% confidence interval [CI], .5–2.5) if the baseline eGFR was 60–89 mL/min, and 4.1 mL/min (95% CI, 1.6–6.6) if &lt;60 mL/min. In contrast, eGFR decreased by 5.8 mL/min (95% CI, 2.3–9.3) with continued use of TDF in individuals with baseline eGFR &lt;60 mL/min. UPCR decreased after replacing TDF by TAF, independent of baseline eGFR.

Conclusions

Switching from TDF to TAF improves eGFR and proteinuria in patients with renal dysfunction.

The role of consistency in use of morphosyntactic forms in child-directed speech in the acquisition of Irish, a minority language undergoing rapid language change

Irish is a rapidly changing minority language spoken as the main community language in some areas of the officially Irish-speaking Gaeltacht regions in Ireland. We analyse narratives from 17 parent-child dyads, living in one such area. All children, aged 3-6;4, had high exposure to the local variety of Irish. The input quality was measured by specifying consistency and accuracy of use of morphosyntactic forms in parental narratives directed to their children. The same morphosyntactic forms were analysed in narrative retell by the children. The children produced with high accuracy those forms that the parents used consistently and accurately. For the forms where parents' usage was inconsistent, large variation in the children's usage was observed. The findings suggest that consistency and accuracy in the use of morphosyntactic forms in the parental language is an important factor in language acquisition; however, its influence might be confounded by other factors.

Physical activity and heart rate monitoring in Fontan patients - Should we recommend activities in higher intensities?

OBJECTIVE

Exercise capacity is impaired in Fontan palliated patients. The change in daily activity behaviour with an increase in sedentary lifestyle results in low physical activity levels. This might have a greater impact on patients with chronic heart disease in contrast to healthy controls. For a better understanding, we compared data from cardiopulmonary exercise testing (CPET) with heart rates and physical activity in daily life.

METHODS

21 Fontan patients and 20 age, sex and BMI matched controls underwent CPET and 5 days of daily life activity tracking with a triaxial accelerometer (wGT3x-BT, Actigraph) including heart rate monitoring with an optical heart rate sensor.

RESULTS

27% of our Fontan teenagers and 71% of the Fontan adults reached the specific WHO recommendations for moderate to vigorous physical activity (MVPA) during everyday life (EDL), without differences to controls. There was a strong correlation between MVPA and [Formula: see text] for all Fontan patients (p = 0.0035, Pearson r = 0.788). Daily MVPA correlated to peak oxygen uptake and lactate production. Up to workloads of 2 W/kg and in daily life heart rates in Fontan patients were similar to controls.

CONCLUSIONS

Daily MVPA is alarmingly low without any differences between Fontan patients and controls. Heart rate behaviour was similar and does not seem to be a limiting factor for physical activity in daily life. Higher intensity activities should be implemented regularly in EDL for Fontan patients. Proof is needed as to whether sports in moderate or possibly even in vigorous activity (e.g. high-intensity interval training) improve exercise capacity the most.

Altered Hemorheology in Fontan Patients in Normoxia and After Acute Hypoxic Exercise

Background

The Fontan circulation is a unique palliation procedure for several congenital heart defects. Impaired exercise capacity has previously been demonstrated in these patients and also a higher risk for cardiopulmonary mortality. Hemorheology was shown to affect cardiopulmonary capacity and in turn to be affected by regular exercise and hypoxia but none of these have been investigated in Fontan patients so far. The aim of this study was to detect general differences in hemorheology in normoxia as well as possible altered hemorheological responses to hypoxia exposure and hypoxic exercise between Fontan patients and healthy controls.

Methods and Findings

26 Fontan patients and 20 healthy controls performed an acute exercise test (AET) on a bicycle ergometer under hypoxia with ambient 15.2% oxygen saturation (sO₂). Blood samples were taken at rest in normoxia (T0), at rest in hypoxia (T1), after maximum exhaustion in hypoxia (T2), and after 50 min recovery in normoxia (T3). Hemorheological and blood parameters were investigated. Additionally, arterial stiffness was tested at T0. Red blood cell (RBC) deformability, NOx, erythropoietin (EPO) concentration, RBC count, hemoglobin (Hb) concentration and hematocrit (hct) were significantly increased in Fontan patients compared to controls. Same was observed for arterial stiffness. No changes were observed for RBC aggregation, fibrinogen concentration, free radical levels and vascular endothelial growth factor (VEGF). Hypoxia exposure did not change parameters, whereas exercise in hypoxia increased aggregation and hct significantly in both groups. Fontan patients showed significantly increased aggregation-disaggregation balance compared to controls.

Conclusion

Acute hypoxia exposure and exercise under hypoxia might have similar impact on hemorheology in Fontan patients and controls and was clinically well tolerated. Nevertheless, exercise alters aggregation and possibly hemodynamics which requires special attention in Fontan patients.

Targeting bromodomain-containing protein 4 (BRD4) inhibits MYC expression in colorectal cancer cells

The transcriptional regulator BRD4 has been shown to be important for the expression of several oncogenes including MYC. Inhibiting of BRD4 has broad antiproliferative activity in different cancer cell types. The small molecule JQ1 blocks the interaction of BRD4 with acetylated histones leading to transcriptional modulation. Depleting BRD4 via engineered bifunctional small molecules named PROTACs (proteolysis targeting chimeras) represents the next-generation approach to JQ1-mediated BRD4 inhibition. PROTACs trigger BRD4 for proteasomale degradation by recruiting E3 ligases. The aim of this study was therefore to validate the importance of BRD4 as a relevant target in colorectal cancer (CRC) cells and to compare the efficacy of BRD4 inhibition with BRD4 degradation on downregulating MYC expression. JQ1 induced a downregulation of both MYC mRNA and MYC protein associated with an antiproliferative phenotype in CRC cells. dBET1 and MZ1 induced degradation of BRD4 followed by a reduction in MYC expression and CRC cell proliferation. In SW480 cells, where dBET1 failed, we found significantly lower levels of the E3 ligase cereblon, which is essential for dBET1-induced BRD4 degradation. To gain mechanistic insight into the unresponsiveness to dBET1, we generated dBET1-resistant LS174t cells and found a strong downregulation of cereblon protein. These findings suggest that inhibition of BRD4 by JQ1 and degradation of BRD4 by dBET1 and MZ1 are powerful tools for reducing MYC expression and CRC cell proliferation. In addition, downregulation of cereblon may be an important mechanism for developing dBET1 resistance, which can be evaded by incubating dBET1-resistant cells with JQ1 or MZ1.

Blood CD9+ B cell, a biomarker of bronchiolitis obliterans syndrome after lung transplantation

Bronchiolitis obliterans syndrome is the main limitation for long-term survival after lung transplantation. Some specific B cell populations are associated with long-term graft acceptance. We aimed to monitor the B cell profile during early development of bronchiolitis obliterans syndrome after lung transplantation. The B cell longitudinal profile was analyzed in peripheral blood mononuclear cells from patients with bronchiolitis obliterans syndrome and patients who remained stable over 3 years of follow-up. CD24^hi CD38^hi transitional B cells were increased in stable patients only, and reached a peak 24 months after transplantation, whereas they remained unchanged in patients who developed a bronchiolitis obliterans syndrome. These CD24^hi CD38^hi transitional B cells specifically secrete IL-10 and express CD9. Thus, patients with a total CD9⁺ B cell frequency below 6.6% displayed significantly higher incidence of bronchiolitis obliterans syndrome (AUC = 0.836, PPV = 0.75, NPV = 1). These data are the first to associate IL-10-secreting CD24^hi CD38^hi transitional B cells expressing CD9 with better allograft outcome in lung transplant recipients. CD9-expressing B cells appear as a contributor to a favorable environment essential for the maintenance of long-term stable graft function and as a new predictive biomarker of bronchiolitis obliterans syndrome-free survival.