Single neurons in the thalamus and subthalamic nucleus process cardiac and respiratory signals in humans

Visceral signals are constantly processed by our central nervous system, enable homeostatic regulation, and influence perception, emotion, and cognition. While visceral processes at the cortical level have been extensively studied using non-invasive imaging techniques, very few studies have investigated how this information is processed at the single neuron level, both in humans and animals. Subcortical regions, relaying signals from peripheral interoceptors to cortical structures, are particularly understudied and how visceral information is processed in thalamic and subthalamic structures remains largely unknown. Here, we took advantage of intraoperative microelectrode recordings in patients undergoing surgery for deep brain stimulation (DBS) to investigate the activity of single neurons related to cardiac and respiratory functions in three subcortical regions: ventral intermedius nucleus (Vim) and ventral caudalis nucleus (Vc) of the thalamus, and subthalamic nucleus (STN). We report that the activity of a large portion of the recorded neurons (about 70%) was modulated by either the heartbeat, the cardiac inter-beat interval, or the respiration. These cardiac and respiratory response patterns varied largely across neurons both in terms of timing and their kind of modulation. A substantial proportion of these visceral neurons (30%) was responsive to more than one of the tested signals, underlining specialization and integration of cardiac and respiratory signals in STN and thalamic neurons. By extensively describing single unit activity related to cardiorespiratory function in thalamic and subthalamic neurons, our results highlight the major role of these subcortical regions in the processing of visceral signals.

Medical management of retained products of conception: A prospective observational study

OBJECTIVE(S)

To measure the success rate of primary medical therapy in managing retained products of conception (RPOC) in women with secondary postpartum haemorrhage (PPH) and to identify factors associated with need for surgical management.

STUDY DESIGN

Postpartum patients presenting to a tertiary women's hospital Emergency Department between July 2020 and December 2022 with secondary PPH and evidence of RPOC on ultrasound were recruited. Clinical information relating to the presentation was collected prospectively. Antenatal and intrapartum data were collected from medical record and Birthing Outcome System database review. The primary outcome was the success of medical management for RPOC, defined by the implementation of medical or expectant management without subsequent need for surgical intervention.

RESULTS

Forty-one patients with RPOC underwent primary medical or expectant management. Twelve patients (29%) were managed successfully with medical management, while twenty-nine (71%) proceeded to surgical management. Medical management involved antibiotics (n = 37, 90%), prostaglandin E1 analogue (n = 14, 34%) and other uterotonics (n = 3, 7%). A greater endometrial thickness on ultrasound was significantly associated with a requirement for secondary surgical intervention (p < 0.05). There was an association approaching statistical significance between a higher sonographic volume of RPOC and the failure of medical management (p = 0.07). There was no statistically significant association between the mode of delivery or the number of days postpartum with the success of medical management.

CONCLUSION(S)

For patients presenting with secondary PPH and sonographic RPOC, over two thirds required surgical management. Increased endometrial thickness was associated with an increased requirement for surgical management.

Economic cost of secondary postpartum haemorrhage: A case-control study at a tertiary hospital in Australia

BACKGROUND

Secondary postpartum haemorrhage (PPH) is a condition which affects 0.2-3.0% of women. Despite its impact on maternal morbidity, there is a lack of understanding of the cost burden of disease.

AIMS

To determine the economic cost of secondary PPH in the postpartum period, compared to the costs for women without this diagnosis.

MATERIALS AND METHODS

Data were prospectively collected on a cohort of 97 women who presented with secondary PPH to the emergency department (ED) between July 2020 and February 2021. A case-control design was then used to compare postpartum cost data from these patients to a group of 97 controls who were matched to maternal demographics, and who did not present with secondary PPH.

RESULTS

For women with secondary PPH, there were significantly more hospital attendances, and postpartum costs were higher for all cost subcategories across ED, admissions, and outpatient attendances (P < 0.0001), compared to controls. The total cost of postpartum care for 97 patients with secondary PPH was $254 377.62 with an average cost per patient of $2622.45, compared to $26 670.46 for 97 controls with an average cost of $274.95 per patient (P < 0.0001). This demonstrates a 9.5-fold increase in postpartum costs per woman with secondary PPH.

CONCLUSIONS

Secondary PPH is an under-researched condition which presents a significant cost burden for the health system. Evidence-based guidelines addressing the prevention and management of secondary PPH may assist in minimising this cost burden for both the health service and the patient.

Confronting a post-pandemic new-normal-threats and opportunities to trust-based relationships in natural resource science and management

Natural resource governance is inherently complex owing to the socio-ecological systems in which it is embedded. Working arrangements have been fundamentally transformed throughout the COVID-19 pandemic with potential negative impacts on trust-based social networks foundational to resource management and transboundary governance. To inform development of a post-pandemic new-normal in resource management, we examined trust relationships using the Laurentian Great Lakes of North America as a case study. 82.9% (n = 97/117) of Great Lakes fishery managers and scientists surveyed indicated that virtual engagement was effective for maintaining well-established relationships during the pandemic; however, 76.7% (n = 89/116) of respondents indicated in-person engagement to be more effective than virtual engagement for building and maintaining trust. Despite some shortcomings, virtual or remote engagement presents opportunities, such as: (1) care and nurturing of well-established long-term relationships; (2) short-term (1-3 years) trust maintenance; (3) peer-peer or mentor-mentee coordination; (4) supplemental communications; (5) producer-push knowledge dissemination; and, if done thoughtfully, (6) enhancing diversity, equity, and inclusion. Without change, pre-pandemic trust-based relationships foundational to cooperative, multinational, resource management are under threat.

Medical management of secondary postpartum haemorrhage: A prospective cohort study

BACKGROUND

Secondary postpartum haemorrhage (PPH) complicates ~1% of pregnancies and can cause serious maternal morbidity. However, evidence guiding optimal management is scarce and often based on case series and expert opinion.

AIMS

To measure the success of primary medical therapy in managing secondary PPH and to identify factors associated with need for surgical management.

MATERIALS AND METHODS

Postpartum patients presenting to a tertiary women's hospital emergency department between July 2020 and October 2021 with secondary PPH were recruited. Data from the acute presentation were prospectively collected. Antenatal and intrapartum data were collected from medical record review. The primary outcome was the success of medical management for secondary PPH, defined by the implementation of medical or expectant measures without subsequent need for surgical intervention.

RESULTS

One-hundred and twenty patients underwent primary medical management for secondary PPH. Ninety-eight (82%) were managed successfully with medical management and 22 (18%) required surgery. Medical management involved misoprostol (n = 33; 27.5%), antibiotics (n = 108; 90%), and less commonly other uterotonics (n = 6; 5%). Factors associated with lower rates of successful medical management included: antecedent manual removal of placenta (MROP) (odds ratio (OR) 0.2, P = 0.047), primary PPH ≥500 mL (OR 0.39, P = 0.048) or ≥1 L (OR 0.24, P = 0.009), >200 mL blood loss at presentation (OR 0.17, P = 0.015), increasing time post-delivery (OR 0.84, P = 0.044), retained products of conception (RPOC) on ultrasound (OR 0.024, P = 0.001) and vaginal birth (OR 0.27, P = 0.027).

CONCLUSION

Medical management was highly successful. Vaginal birth, MROP, primary PPH, RPOC on ultrasound and increasing time post-delivery were associated with increased need for surgical management.

Interprofessional telehealth simulations for pharmacy and nursing students: Development and evaluation of an online experience

INTRODUCTION

The authors evaluated student achievement of interprofessional education (IPE) core competencies during two formats (one hybrid and one completely online) of an IPE simulation designed for pharmacy and nursing students.

METHODS

This IPE simulation was designed to teach students to use distance technologies to collaborate on patient care. In 2019, pharmacy (n = 83) and nursing (n = 38) students attended the hybrid (in-person and online) IPE simulation (SIM 2019) with the use of a telepresence robot. In 2020, pharmacy (n = 78) and nursing (n = 48) students attended the simulations completely online (SIM 2020), without the use of a robot. Both sessions aimed to achieve IPE core competencies through interprofessional student collaboration sessions using telehealth distance technologies. Students completed quantitative and qualitative evaluation surveys for both simulations. During SIM 2020, faculty and students used an observation tool to directly assess student team collaboration skills.

RESULTS

Statistically significant improvements in self-assessment of IPE core competency scores were found in both formats of the simulation sessions. There were no statistical differences in faculty ratings with student ratings of team skills using the direct observation of team collaboration. Qualitative results indicated that students found interprofessional collaboration to be the most important lesson learned from the activity.

CONCLUSIONS

Both formats for the simulation achieved core competency learning objectives. IPE is an essential experience for health care education and is achievable online.

Using targeted sequencing and TaqMan approaches to detect acaricide (bifenthrin, bifenazate, and etoxazole) resistance associated SNPs in Tetranychus urticae collected from peppermint fields and hop yards

Tetranychus urticae (Koch) is an economically important pest of many agricultural commodities world-wide. Multiple acaricides, including bifenazate, bifenthrin, and extoxazole, are currently registered to control T. urticae. However, populations of T. urticae in many different growing regions have developed acaricide resistance through multiple mechanisms. Within T. urticae, single nucleotide polymorphisms (SNPs) have been documented in different genes which are associated with acaricide resistance phenotypes. The detection of these mutations through TaqMan qPCR has been suggested as a practical, quick, and reliable tool to inform agricultural producers of acaricide resistance phenotypes present within their fields and have potential utility for making appropriate acaricide application and integrated pest management decisions. Within this investigation we examined the use of a TaqMan qPCR-based approach to determine genotypes which have been previously associated with acaricide resistance in field-collected populations of T. urticae from peppermint fields and hop yards in the Pacific Northwest of the United States and confirmed the results with a multiplex targeted sequencing. The results suggest that a TaqMan qPCR approach accurately genotypes T. urticae populations for SNPs that have been linked to Bifenazate, Bifenthrin, and Etoxazole resistance. The results also demonstrated that different populations of mites in Washington and Idaho displayed varying frequencies of the examined SNPs. While we were able to detect the SNPs associated with the examined acaricides, the mutation G126S was not an appropriate or accurate indicator for bifenazate resistance.

OC-047 LEARNING CURVE IN HERNIA SURGERY- A REGISTER BASED STUDY

Aim

The purpose of this study was to investigate the learning curve of open anterior mesh repair for groin hernia by assessing hernia recurrence rates, surgical complications, and operative times in relation to the number of procedures performed by surgical trainees.

Materials & Methods

Nationwide data on open anterior mesh repair for groin hernia performed by surgical residents were collected from the Swedish Hernia Register between 2005 and 2020. Data were analyzed in a cohort of procedures carried out by surgeons performing their first registered repair as resident. Repairs performed by surgeons who had carried out less than 30 repairs or any repair 1992–2005 were excluded.

Results

The study group consisted of 38 854 repairs carried out by 663 surgeons. The complication rate increased from 298/9884 (3.0%) the first 15 repairs performed to 396/10978 (3.6%) repairs 31–60 and then decreased to 4/945 (0.4%) for repairs performed after the first 240 ones. Mean operation time decreased from 79 minutes (standard deciation [SD] 26 minutes) the first 15 repairs to 60 minutes (SD 23 minutes) for repairs performed after the first 240 ones. Recurrence rates remained unchanged during the learning curve.

Conclusions

It is safe for resident surgeons to perform uncomplicated, elective, anterior groin hernia mesh repair after having completed of at least 60 procedures.

Training Future Pharmacists to Optimize the Healthcare Workforce

Many efforts are taking place to improve the quality of healthcare and reduce healthcare cost. Pharmacists play a key role in optimizing the healthcare workforce, and colleges of pharmacy are adapting to this need by emphasizing skills needed to improve quality health measures, interprofessional collaboration and communication, and supplying quality drug information. The University of Hawai'i at Hilo Daniel K. Inouye College of Pharmacy has incorporated additional pharmacy practice experience electives to teach pharmacy students to analyze and optimize workflow, identify high-risk patients in need of intervention, and work collaboratively with providers to decrease patient burden. The pharmacy curriculum has also increased the number of interprofessional educational events for enhancing interprofessional collaboration and communication, including in a telehealth setting. Furthermore, the college of pharmacy has increased the number of drug information assignments and practical exams to increase competency and the speed of providing quality, evidence-based drug information to providers. This article presents on overview of the health care workforce needs and examples of the increased efforts to train future pharmacists in Hawai'i to improve healthcare access and quality of patient care, as well as decrease healthcare costs.

675 IMPROVING RECOGNITION OF DELIRIUM IN CRITICAL CARE PATIENTS

Introduction

Delirium is more prevalent in patients admitted to the critical care environment, those over 65 years old and living with frailty. By increasing the recognition of delirium we can improve management of patients and therefore reduce associated morbidity. Initial audit of this patient group highlighted that we are missing opportunities to screen for, diagnose and document the presence of delirium. This Quality Improvement project aimed to improve delirium screening, and therefore recognition, on the critical care unit at The Royal Bolton Hospital.

Method

A retrospective analysis of patients aged ≥65 years or with a CFS ≥5 admitted to critical care at The Royal Bolton Hospital over a 2-week period for each PDSA cycle. Three cycles were undertaken. The initial intervention was a local teaching session for medical and nursing staff on critical care. The second intervention was to display delirium information posters throughout critical care which encouraged recognition and screening of delirium.

Results

Prior to intervention 9% of this patient group were assessed for delirium on admission to critical care and 55% were re-assessed at some point during their admission. After the initial intervention these numbers significantly improved to 33% and 80% respectively. After the second intervention 8% were screened on admission and 69% were re-assessed. Missed opportunities to document delirium as a diagnosis remained similar throughout all cycles.

Conclusion

We can improve delirium screening via regular educational sessions for medical and nursing staff on critical care. Information posters do not appear to have as much impact. There is scope to improve documentation of delirium as a diagnosis which would further aid in management and outcomes. We suggest a further PDSA cycle with an intervention to address this.

Cost-effectiveness of antenatal multiple micronutrients and balanced energy protein supplementation compared to iron and folic acid supplementation in India, Pakistan, Mali, and Tanzania: A dynamic microsimulation study

BACKGROUND

Malnutrition among women of childbearing age is especially prevalent in Asia and sub-Saharan Africa and can be harmful to the fetus during pregnancy. In the most recently available Demographic and Health Survey (DHS), approximately 10% to 20% of pregnant women in India, Pakistan, Mali, and Tanzania were undernourished (body mass index [BMI] <18.5 kg/m2), and according to the Global Burden of Disease (GBD) 2017 study, approximately 20% of babies were born with low birth weight (LBW; <2,500 g) in India, Pakistan, and Mali and 8% in Tanzania. Supplementing pregnant women with micro and macronutrients during the antenatal period can improve birth outcomes. Recently, the World Health Organization (WHO) recommended antenatal multiple micronutrient supplementation (MMS) that includes iron and folic acid (IFA) in the context of rigorous research. Additionally, WHO recommends balanced energy protein (BEP) for undernourished populations. However, few studies have compared the cost-effectiveness of different supplementation regimens. We compared the cost-effectiveness of MMS and BEP with IFA to quantify their benefits in 4 countries with considerable prevalence of maternal undernutrition.

METHODS AND FINDINGS

Using nationally representative estimates from the 2017 GBD study, we conducted an individual-based dynamic microsimulation of population cohorts from birth to 2 years of age in India, Pakistan, Mali, and Tanzania. We modeled the effect of maternal nutritional supplementation on infant birth weight, stunting and wasting using effect sizes from Cochrane systematic reviews and published literature. We used a payer's perspective and obtained costs of supplementation per pregnancy from the published literature. We compared disability-adjusted life years (DALYs) and incremental cost-effectiveness ratios (ICERs) in a baseline scenario with existing antenatal IFA coverage with scenarios where 90% of antenatal care (ANC) attendees receive either universal MMS, universal BEP, or MMS + targeted BEP (women with prepregnancy BMI <18.5 kg/m2 receive BEP containing MMS while women with BMI ≥18.5 kg/m2 receive MMS). We obtained 95% uncertainty intervals (UIs) for all outputs to represent parameter and stochastic uncertainty across 100 iterations of model runs. ICERs for all scenarios were lowest in Pakistan and greatest in Tanzania, in line with the baseline trend in prevalence of and attributable burden to LBW. MMS + targeted BEP averts more DALYs than universal MMS alone while remaining cost-effective. ICERs for universal MMS compared to baseline IFA were $52 (95% UI: $28 to $78) for Pakistan, $72 (95% UI: $37 to $118) for Mali, $70 (95% UI: $43 to $104) for India, and $253 (95% UI: $112 to $481) for Tanzania. ICERs for MMS + targeted BEP compared to baseline IFA were $54 (95% UI: $32 to $77) for Pakistan, $73 (95% UI: $40 to $104) for Mali, $83 (95% UI: $58 to $111) for India, and $245 (95% UI: $127 to $405) for Tanzania. Study limitations include generalizing experimental findings from the literature to our populations of interest and using population-level input parameters that may not reflect the heterogeneity of subpopulations. Additionally, our microsimulation fuses multiple sources of data and may be limited by data quality and availability.

CONCLUSIONS

In this study, we observed that MMS + targeted BEP averts more DALYs and remains cost-effective compared to universal MMS. As countries consider using MMS in alignment with recent WHO guidelines, offering targeted BEP is a cost-effective strategy that can be considered concurrently to maximize benefits and synergize program implementation.

COVID-19 restrictions and recreational fisheries in Ontario, Canada: Preliminary insights from an online angler survey

The COVID-19 pandemic and corresponding public health mitigation strategies have altered many facets of human life. And yet, little is known about how public health measures have impacted complex socio-ecological systems such as recreational fisheries. Using an online snowball survey, we targeted resident anglers in Ontario, Canada, to obtain preliminary insights on how the pandemic has impacted recreational fishing and related activity. We also explored angler perspectives on pandemic-related restrictions and other aspects of fisheries management. Our results point to the value of recreational fisheries for the mental and physical well-being of participants, as well as the value and popularity of outdoor recreation during a pandemic. Although angling effort and fish consumption appeared to decline during the early phases of the pandemic, approximately 21 % of the anglers who responded to our survey self-identified as new entrants who had begun or resumed fishing in that time. Self-reported motivations to fish during the pandemic suggest that free time, importance to mental and physical health, and desires for self-sufficiency caused some anglers to fish more, whereas a lack of free time, poor or uncertain accessibility, and perceived risks caused some anglers to fish less. Respondents also expressed their desires for more clear and consistent communication about COVID-19 fishing restrictions from governments, and viewed angling as a safe pandemic activity. Information on recreational angler behaviours, motivations, and perspectives during the pandemic may prove valuable to fisheries managers and policy makers looking to optimize their strategies for confronting this and other similar crises.

Drivers of pro-environmental behaviours among outdoor recreationists: The case of a recreational fishery in Western Canada

Pro-environmental behaviours (PEBs) are important for mitigation and restoration efforts in the Anthropocene. As recreationists are motivated to engage in leisure activities to increase their own personal wellbeing, we submit that threats to wellbeing (an egocentric motivator) predict engagement in PEBs amongst recreationists. We also predict that differences in experiences across groups of recreationists leads to differences in PEB engagement. Using an online survey, we test our two hypotheses (if recreationists perceive there is a threat to their wellbeing and that their behaviours can yield environmental successes, then they will be more likely to engage in PEBs, and if recreationists differ in recreational experiences then they will demonstrate differences in PEB engagement) amongst outdoor recreationists, specifically Canadian rainbow trout and steelhead anglers in British Columbia (n = 894 respondents). We define 'threat to wellbeing' as the interaction of environmental threat-perceptions of used environments for fishing, and level of centrality fishing has to one's lifestyle. To test our first hypothesis, we conducted three linear regressions corresponding to three different PEBs related to catch-and-release (C&R) fishing. Our egocentric predictor 'threat to wellbeing' was only significant for one out of the three PEBs tested, showing mixed support for our first hypothesis. It is of note that 'environmental threat perceptions' and one's belief in successes resulting from PEB engagement were found to be significant predictors for all three PEBs tested. These results suggest that predictors of PEB may not always be transferable across PEBs relating to recreational activities, and environmental threat perception and one's belief in successes resulting from PEB engagement are strong predictors of PEBs amongst recreationists. To test our second hypothesis, we conducted a Kruskal Wallis test to determine if there were significant differences across angler groups in PEB predictor scores and PEB engagement and conducted pairwise population Z-tests to determine proportional participation rates across angler groups for the three PEBs and PEB predictors investigated. Experiences were found to shape predictors of PEBs, as well as likelihood to engage in PEBs, as different angler groups targeting different fish (i.e., rainbow trout vs steelhead) and using different aquatic habitats (i.e., rivers vs. lakes) demonstrated significantly different scores for PEB predictors, as well as significantly different likelihood to engage in two of the three PEBs tested. These findings support the notion that recreationists are not a homogenous group, and that their beliefs and resulting behaviours during recreational activities are determined by their experiences in nature and can be influenced by the species with which they interact, and the habitats they use for recreation.

Enhancing analgesic spinal cord stimulation for chronic pain with personalized immersive virtual reality

ABSTRACT

Spinal cord stimulation (SCS) is an approved treatment for truncal and limb neuropathic pain. However, pain relief is often suboptimal and SCS efficacy may reduce over time, requiring sometimes the addition of other pain therapies, stimulator revision, or even explantation. We designed and tested a new procedure by combining SCS with immersive virtual reality (VR) to enable analgesia in patients with chronic leg pain. We coupled SCS and VR by linking SCS-induced paresthesia with personalized visual bodily feedback that was provided by VR and matched to the spatiotemporal patterns of SCS-induced paresthesia. In this cross-sectional prospective interventional study, 15 patients with severe chronic pain and an SCS implant underwent congruent SCS-VR (personalized visual feedback of the perceived SCS-induced paresthesia displayed on the patient's virtual body) and 2 control conditions (incongruent SCS-VR and VR alone). We demonstrate the efficacy of neuromodulation-enhanced VR for the treatment of chronic pain by showing that congruent SCS-VR reduced pain ratings on average by 44%. Spinal cord stimulation-VR analgesia was stronger than that in both control conditions (enabling stronger analgesic effects than incongruent SCS-VR analgesia or VR alone) and kept increasing over successive stimulations, revealing the selectivity and consistency of the observed effects. We also show that analgesia persists after congruent SCS-VR had stopped, indicating carry over effects and underlining its therapeutic potential. Linking latest VR technology with recent insights from the neuroscience of body perception and SCS neuromodulation, our personalized new SCS-VR platform highlights the impact of immersive digiceutical therapies for chronic pain.Registration: clinicaltrials.gov, Identifier: NCT02970006.

OP0090 CLASSIFICATION OF PATIENTS WITH RELAPSING POLYCHONDRITIS BASED ON SOMATIC MUTATIONS IN UBA1

Background:

Somatic mutations in ubiquitin activating enzyme 1 (UBA1) cause a newly defined syndrome known as VEXAS. [1] More than fifty percent of patients currently identified with VEXAS meet diagnostic criteria for relapsing polychondritis (RP).

Objectives:

To determine the prevalence VEXAS within a cohort of patients with RP, to compare their clinical, laboratory, and immunologic features and to develop a clinical algorithm to inform genetic screening for VEXAS among patients with RP.

Methods:

Exome and targeted sequencing of the UBA1 gene was performed in a prospective observational cohort of patients with RP. Clinical and immunological characteristics of patients with RP were compared based on presence or absence of UBA1 mutations. Random forest was used to derive a clinical algorithm to identify patients with UBA1 mutations. Immune populations were quantified by multipanel flow cytometry. Categorical and continuous variables were compared using the chi square or Kruskal-Wallis test. P<0.05 defined statistical significance.

Results:

Seven of 92 patients with RP (7.6%) were confirmed to have UBA1 mutations (VEXAS-RP). Six additional patients with VEXAS-RP from other cohorts were included for subsequent analyses. Patients with VEXAS-RP were all male, older at disease onset, and commonly had fever, ear chondritis, skin involvement, deep vein thrombosis, and pulmonary infiltrates. Patients with RP as compared with VEXAS-RP had a significantly higher prevalence of airway chondritis, costochondritis and tenosynovitis/arthralgias. (Table). Mortality was significantly greater in VEXAS-RP than RP (27% vs 2% p=0.01). Maximum ESR, CRP, and mean corpuscular volume (MCV) values were significantly greater in VEXAS-RP. Absolute monocyte, lymphocyte, and platelet counts were significantly lower in VEXAS-RP. A decision tree based on male sex, MCV>100 fl and Platelet count<200 K/ul classified between VEXAS-RP and RP with 100% sensitivity and 96% specificity.

Table 1.

Clinical Characteristics of patients with RP vs VEXAS-RP

All Patientsn=98RPn=85VEXAS-RPn=13p valueDemographic CharacteristicsRace, White n (%)90 (92)77 (91)13 (100)0.59Sex, Male n (%)26 (27)13 (15)13 (100)<0.0001Age, Symptom onset, years, Median (IQR)38 (30-47)37 (28-43)56 (54-64)<0.0001Clinical SymptomsFever n (%)33 (34)20 (24)13 (100)<0.0001Ear chondritis n (%)61 (62)48 (56)13 (100)0.0015Nose chondritis n (%)83 (85)71 (84)12 (92)0.68Airway chondritis n (%)37 (38)37 (44)0 (0)0.0015Tenosynovitis/arthalgias n (%)83 (85)77 (91)6 (46)0.0005Skin involvement n (%)33 (34)22 (2611 (85)<0.0001Laboratory ValuesESR, mm/hr, median (IQR)12 (6-22)11 (5-19)66.5 (42-110)<0.0001CRP, mg/L, median (IQR)2.9 (0.8-9.6)1.9 (0.6-6.3)17.7 (9.6-99.5)<0.0001Platelet count (k/uL)246(201-299)258 (227-312)145 (100-169)<0.0001MCV fL93.05 (90-98)92.2 (89-95)105 (102-115)<0.0001Absolute lymphocyte count1.6 (1.1-2.3)1.78(1.4-2.4)0.92 (0.5-1.2)<0.0001CT scan abnormalitiesPulmonary infiltrates n (%)16 (16.33)6 (7.06)10 (77)<0.0001ComplicationsDeath n (%)6 (6)3 (4)3 (23)0.029Unprovoked DVT12 (12)4 (5)8 (62)<0.0001

N number; IQR = interquartile range

Conclusion:

Mutations in UBA1 are causal for disease in a subset of patients with RP. These patients are defined by disease onset in the fifth decade of life or later, male sex, ear/nose chondritis and hematologic abnormalities. Early identification is important in VEXAS given the associated high mortality rate.

References:

[1]Beck DB, Ferrada MA, Sikora KA, Ombrello AK, Collins JC, Pei W, Balanda N, Ross DL, Ospina Cardona D, Wu Z et al: Somatic Mutations in UBA1 and Severe Adult-Onset Autoinflammatory Disease. N Engl J Med 2020, 383(27):2628-2638.

Disclosure of Interests:

None declared

Nectar-dwelling microbes of common tansy are attractive to its mosquito pollinator, Culex pipiens L

Background

There is widespread interkingdom signalling between insects and microbes. For example, microbes found in floral nectar may modify its nutritional composition and produce odorants that alter the floral odor bouquet which may attract insect pollinators. Mosquitoes consume nectar and can pollinate flowers. We identified microbes isolated from nectar of common tansy, Tanacetum vulgare, elucidated the microbial odorants, and tested their ability to attract the common house mosquito, Culex pipiens.

Results

We collected 19 microbial isolates from T. vulgare nectar, representing at least 12 different taxa which we identified with 16S or 26S rDNA sequencing as well as by biochemical and physiological tests. Three microorganisms (Lachancea thermotolerans, Micrococcus lactis, Micrococcus luteus) were grown on culture medium and tested in bioassays. Only the yeast L. thermotolerans grown on nectar, malt extract agar, or in synthetic nectar broth significantly attracted Cx. pipiens females. The odorant profile produced by L. thermotolerans varied with the nutritional composition of the culture medium. All three microbes grown separately, but presented concurrently, attracted fewer Cx. pipiens females than L. thermotolerans by itself.

Conclusions

Floral nectar of T. vulgare contains various microbes whose odorants contribute to the odor profile of inflorescences. In addition, L. thermotolerans produced odorants that attract Cx. pipiens females. As the odor profile of L. thermotolerans varied with the composition of the culture medium, we hypothesize that microbe odorants inform nectar-foraging mosquitoes about the availability of certain macro-nutrients which, in turn, affect foraging decisions by mosquitoes.

Ten strategies for avoiding and overcoming authorship conflicts in academic publishing

For better or for worse, authorship is a currency in scholarly research and advancement. In scholarly writing, authorship is widely acknowledged as a means of conferring credit but is also tied to concepts such as responsibility and accountability. Authorship is one of the most divisive topics both at the level of the research team and more broadly in the academy and beyond. At present, authorship is often the primary way to assert and receive credit in many scholarly pursuits and domains. Debates rage, publicly but mostly privately, regarding authorship. Here we attempt to clarify key concepts related to authorship informed by our collective experiences and anchored in relevant contemporary literature. Rather than dwelling on the problems, we focus on proactive strategies for creating more just, equitable, and transparent avenues for minimizing conflict around authorship and where there is adequate recognition of the entire process of knowledge generation, synthesis, sharing, and application with partners within and beyond the academy. We frame our ideas around 10 strategies that collectively constitute a roadmap for avoiding and overcoming challenges associated with authorship decisions.

Seismic observations, numerical modeling, and geomorphic analysis of a glacier lake outburst flood in the Himalayas

Glacial lake outburst floods (GLOFs) are a substantial hazard for downstream communities in vulnerable regions, yet unpredictable triggers and remote source locations make GLOF dynamics difficult to measure and quantify. Here, we revisit a destructive GLOF that occurred in Bhutan in 1994 and apply cross-correlation-based seismic analyses to track the evolution of the GLOF remotely (~100 kilometers from the source region). We use the seismic observations along with eyewitness reports and a downstream gauge station to constrain a numerical flood model and then assess geomorphic change and current state of the unstable lakes via satellite imagery. Coherent seismic energy is evident from 1 to 5 hertz beginning approximately 5 hours before the flood impacted Punakha village, which originated at the source lake and advanced down the valley during the GLOF duration. Our analysis highlights potential benefits of using real-time seismic monitoring to improve early warning systems.

AB0933 PHYSICAL ACTIVITY DECREASES PAIN AND INFLAMMATION IN GOUT PATIENTS

Background:

Despite the high prevalence of gout, there has been little investigation into the relationship between physical activity and gout.

Objectives:

To investigate whether physically active gout patients, as assessed by the International Physical Activity Questionnaire (IPAQ) long form, have lower pain scores, decreased inflammation, assessed by C-reactive protein (CRP) levels and less flares.

Methods:

During scheduled appointments, gout patients not experiencing a flare at the time of visit were recruited from our clinics and consented to participate in the study. IPAQ were completed. Clinical data collected during the visit included age, years since diagnosis, flares per year, perceived pain at the time of visit and in the past 4 weeks, and C-reactive protein (CRP) levels.

Results:

Thirty gout patients were recruited. Ages 31-86 (mean 61); duration of gout: one- 43 years (mean 9). IPAQ, separated gout patients into physically active (n=16) and physically inactive cohorts (n=14) (p<0.001. Physically active gout patients had over 12-fold fewer gout flares per year (p<0.01); 10-fold less CRP (p<0.01, a 4.6-fold decrease in perceived pain at the time of visit (p<0.01), and a 2.8-fold decrease in perceived pain over the past 4-week period (p<0.05).

Conclusion:

This is the first study using a validated physical activity tool, IPAQ, to assess physical activity in gout patients. In this study, physically active gout patients were found to have lower CRP levels, less flares per year, and decreased pain perception compared to those that are not physically active, highlighting, the importance of incorporating physical activity as a possible adjunct treatment option during intervals between flares.

References:

[1]Benatti FB, Pedersen BK. Exercise as an anti-inflammatory therapy for rheumatic diseases-myokine regulation. Nat Rev Rheumatol 2015;11:86-97.

[2]Hagströmer M, Oja P, Sjöström M. The International Physical Activity Questionnaire (IPAQ): a study of concurrent and construct validity. Public Health Nutr 2006;9:755-62.

[3]Young NA, Jablonski K, Sharma J, Thomas E, Snoad B, Hampton J, et al. Low and Moderate Intensity Exercise Suppresses Inflammatory Responses in an Acute Mouse Model of Gout and Suggests Therapeutic Efficacy [abstract]. Arthritis Rheumatol. 2017;69 (suppl 10).

Disclosure of Interests:

Naomi Schlesinger Grant/research support from: Pfizer, AMGEN, Consultant of: Novartis, Horizon Pharma, Selecta Biosciences, Olatec, IFM Therapeutics, Mallinckrodt Pharmaceuticals, Speakers bureau: Takeda, Horizon, Kyle jablonski: None declared, Emmy schwarz: None declared, Nicholas Young: None declared

Abstract TP187: Disparities in Secondary Stroke Prevention Among Filipinos in Hawaii

Introduction: In Hawaii, Filipinos have the highest stroke mortality for unclear reasons. The objective of this study is to elucidate racial-ethnic differences in the use of antithrombotics and statins upon discharge home from hospitalization among stroke survivors.

Methods: The Get With the Guidelines-Stroke (GWTG-Stroke) data from January 2010 to December 2016 at the only Comprehensive Stroke Center in Hawaii was retrospectively reviewed. Subjects with non-ischemic stroke and with disposition other than home were excluded. Multivariable logistic regression models examined differences in appropriate medication use at discharge related to race/ethnicity compared with whites after adjusting for age, sex, insurance status, prior medication use and stroke risk factors.

Results: Among a total of 2347 patients studied (621 (26%) whites (W), 302 (13%) Filipinos (FI), 838 (36%) other Asians (OA), 538 (23%) Native Hawaiians and other Pacific Islanders (NHOPI), and 48 (2%) other race (O)), FI were prescribed less antithrombotic agents at discharge [OR 0.56; 95% CI 0.380, 0.837] than W, while there were no racial-ethnic differences among OA, NHOPI and O compared to W. Age [OR 1.02; 95% CI 1.006, 1.03], prior antithrombotic use [OR 2.04, 95% CI 1.47, 2.82] and coronary artery disease/prior myocardial infarction [OR 2.04, 95% CI 1.23, 3.39] were also independent predictors of antithrombotic prescription upon discharge.

For statin prescription upon discharge, there was no difference between FI and W. NHOPI race [OR 2.09; 95% CI 1.54, 2.83], age [OR 1.01, 95% CI 1.001, 1.02], female sex [OR 0.68; 95% CI 0.55, 0.84], prior anti-cholesterol medication use [OR 4.12, 95% CI 3.01 5.63], dyslipidemia [OR 1.91, 95% CI 1.47, 2.49] and carotid stenosis [OR 0.49, 95% CI 0.32, 0.74] were predictors of statin prescription upon discharge.

Conclusions: Filipinos are less likely to be prescribed an antithrombotic for stroke prevention compared with whites after hospitalization for stroke.

The mitochondrial genome of Tetrahymena rostrata

Tetrahymena rostrata is a ciliated protist which can parasitize the gray field slug, Deroceras reticulatum. Here, we report the sequence of the mitochondrial genome (mt genome) of a strain of T. rostrata that was isolated from the egg of D. reticulatum. Whole cell genomic DNA was sequenced using Illumina^® MiSeq and the mitochondrial DNA sequence reads were extracted and assembled. The resulting 47,235 bp assembly contained rRNAs, tRNAs, and 45 protein coding DNA sequences of which 21 encoded proteins of unknown function. Phylogenetic analysis showed T. rostrata clustered with Tetrahymena thermophila, Tetrahymena pigmentosa, Tetrahymena pyriformis, Tetrahymena paravorax, and Tetrahymena malaccensis.

Integrating HIV, syphilis, malaria and anaemia point-of-care testing (POCT) for antenatal care at dispensaries in western Kenya: discrete-event simulation modelling of operational impact

BACKGROUND

Despite WHO advocating for an integrated approach to antenatal care (ANC), testing coverage for conditions other than HIV remains low and women are referred to distant laboratories for testing. Using point-of-care tests (POCTs) at peripheral dispensaries could improve access to testing and timely treatment. However, the effect of providing additional services on nurse workload and client wait times are unknown. We use discrete-event simulation (DES) modelling to understand the effect of providing four point-of-care tests for ANC on nurse utilization and wait times for women seeking maternal and child health (MCH) services.

METHODS

We collected detailed time-motion data over 20 days from one high volume dispensary in western Kenya during the 8-month implementation period (2014-2015) of the intervention. We constructed a simulation model using empirical arrival distributions, activity durations and client pathways of women seeking MCH services. We removed the intervention from the model to obtain wait times, length-of-stay and nurse utilization rates for the baseline scenario where only HIV testing was offered for ANC. Additionally, we modelled a scenario where nurse consultations were set to have minimum durations for sufficient delivery of all WHO-recommended services.

RESULTS

A total of 183 women visited the dispensary for MCH services and 14 of these women received point-of-care testing (POCT). The mean difference in total waiting time was 2 min (95%CI: < 1-4 min, p = 0.026) for MCH women when integrated POCT was given, and 9 min (95%CI: 4-14 min, p < 0.001) when integrated POCT with adequate ANC consult times was given compared to the baseline scenario. Mean length-of-stay increased by 2 min (95%CI: < 1-4 min, p = 0.015) with integrated POCT and by 16 min (95%CI: 10-21 min, p < 0.001) with integrated POCT and adequate consult times compared to the baseline scenario. The two nurses' overall daily utilization in the scenario with sufficient minimum consult durations were 72 and 75%.

CONCLUSION

The intervention had a modest overall impact on wait times and length-of-stay for women seeking MCH services while ensuring pregnant women received essential diagnostic testing. Nurse utilization rates fluctuated among days: nurses experienced spikes in workload on some days but were under-utilized on the majority of days. Overall, our model suggests there was sufficient time to deliver all WHO's required ANC activities and offer integrated testing for ANC first and re-visits with the current number of healthcare staff. Further investigations on improving healthcare worker, availability, performance and quality of care are needed. Delivering four point-of-care tests together for ANC at dispensary level would be a low burden strategy to improve ANC.

Connectivity-based selection of optimal deep brain stimulation contacts: A feasibility study

Background

The selection of optimal deep brain stimulation (DBS) parameters is time‐consuming, experience‐dependent, and best suited when acute effects of stimulation can be observed (e.g., tremor reduction).

Objectives

To test the hypothesis that optimal stimulation location can be estimated based on the cortical connections of DBS contacts.

Methods

We analyzed a cohort of 38 patients with Parkinson's disease (24 training, and 14 test cohort). Using whole‐brain probabilistic tractography, we first mapped the cortical regions associated with stimulation‐induced efficacy (rigidity, bradykinesia, and tremor improvement) and side effects (paresthesia, motor contractions, and visual disturbances). We then trained a support vector machine classifier to categorize DBS contacts into efficacious, defined by a therapeutic window ≥2 V (threshold for side effect minus threshold for efficacy), based on their connections with cortical regions associated with efficacy versus side effects. The connectivity‐based classifications were then compared with actual stimulation contacts using receiver‐operating characteristics (ROC) curves.

Results

Unique cortical clusters were associated with stimulation‐induced efficacy and side effects. In the training dataset, 42 of the 47 stimulation contacts were accurately classified as efficacious, with a therapeutic window of ≥3 V in 31 (66%) and between 2 and 2.9 V in 11 (24%) electrodes. This connectivity‐based estimation was successfully replicated in the test cohort with similar accuracy (area under ROC = 0.83).

Conclusions

Cortical connections can predict the efficacy of DBS contacts and potentially facilitate DBS programming. The clinical utility of this paradigm in optimizing DBS outcomes should be prospectively tested, especially for directional electrodes.

Integrated point-of-care testing (POCT) for HIV, syphilis, malaria and anaemia at antenatal facilities in western Kenya: a qualitative study exploring end-users' perspectives of appropriateness, acceptability and feasibility

Background

HIV, syphilis, malaria and anaemia are leading preventable causes of adverse pregnancy outcomes in sub-Saharan Africa yet testing coverage for conditions other than HIV is low. Availing point-of-care tests (POCTs) at rural antenatal health facilities (dispensaries) has the potential to improve access and timely treatment. Fundamental to the adoption of and adherence to new diagnostic approaches are healthcare workers’ and pregnant women’s (end-users) buy-in. A qualitative approach was used to capture end-users’ experiences of using POCTs for HIV, syphilis, malaria and anaemia to assess the appropriateness, acceptability and feasibility of integrated testing for ANC.

Methods

Seven dispensaries were purposively selected to implement integrated point-of-care testing for eight months in western Kenya. Semi-structured interviews were conducted with 18 healthcare workers (14 nurses, one clinical officer, two HIV testing counsellors, and one laboratory technician) who were trained, had experience doing integrated point-of-care testing, and were still working at the facilities 8–12 months after the intervention began. The interviews explored acceptability and relevance of POCTs to ANC, challenges with testing, training and supervision, and healthcare workers’ perspectives of client experiences. Twelve focus group discussions with 118 pregnant women who had attended a first ANC visit at the study facilities during the intervention were conducted to explore their knowledge of HIV, syphilis, malaria, and anaemia, experience of ANC point-of-care testing services, treatments received, relationships with healthcare workers, and experience of talking to partners about HIV and syphilis results.

Results

Healthcare workers reported that they enjoyed gaining new skills, were enthusiastic about using POCTs, and found them easy to use and appropriate to their practice. Initial concerns that performing additional testing would increase their workload in an already strained environment were resolved with experience and proficiency with the testing procedures. However, despite having the diagnostic tools, general health system challenges such as high client to healthcare worker volume ratio, stock-outs and poor working conditions challenged the delivery of adequate counselling and management of the four conditions. Pregnant women appreciated POCTs, but reported poor healthcare worker attitudes, drug stock-outs, and fear of HIV disclosure to their partners as shortcomings to their ANC experience in general.

Conclusion

This study provides insights on the acceptability, appropriateness, and feasibility of integrating POCTs into ANC services among end-users. While the innovation was desired and perceived as beneficial, future scale-up efforts would need to address health system weaknesses if integrated testing and subsequent effective management of the four conditions are to be achieved.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3844-9) contains supplementary material, which is available to authorized users.

Orthotic management of fixed flexion deformity of the proximal interphalangeal joint following traumatic injury: A systematic review

Background/objective

Fixed flexion deformity of the proximal interphalangeal joint can commonly occur following a traumatic injury impacting on hand function and occupational performance. Numerous interventions have been proposed for fixed flexion deformity resolution. This paper investigates the efficacy of static or dynamic orthoses in reducing fixed flexion deformity contracture following traumatic proximal interphalangeal joint injury.

Methods

A multi-database search of three databases (CINAHL, EMBASE, MEDLINE) was conducted. Data extracted for each study were design, patient descriptions, degree of fixed flexion deformity pre- and post-orthoses, and prescribed interventions and exercise programmes.

Results

The search yielded 643 studies, of which eight met the inclusion criteria. Studies used heterogeneous methodologies investigating various orthotic interventions. Meta-analysis or pooling of results was not possible. Dissimilar orthotic wear regimes were noted in all studies and an alternative clinical significance outcome was found.

Conclusion

More research is required to support clinical reasoning in orthotic choice for fixed flexion deformity of the proximal interphalangeal joint post-traumatic injury.

Integrated point-of-care testing (POCT) of HIV, syphilis, malaria and anaemia in antenatal clinics in western Kenya: A longitudinal implementation study

Background

In sub-Saharan Africa, HIV, syphilis, malaria and anaemia are leading preventable causes of adverse pregnancy outcomes. In Kenya, policy states women should be tested for all four conditions (malaria only if febrile) at first antenatal care (ANC) visit. In practice, while HIV screening is conducted, coverage of screening for the others is suboptimal and early pregnancy management of illnesses is compromised. This is particularly evident at rural dispensaries that lack laboratories and have parallel programmes for HIV, reproductive health and malaria, resulting in fractured and inadequate care for women.

Methods

A longitudinal eight-month implementation study integrating point-of-care diagnostic tests for the four conditions into routine ANC was conducted in seven purposively selected dispensaries in western Kenya. Testing proficiency of healthcare workers was observed at initial training and at three monthly intervals thereafter. Adoption of testing was compared using ANC register data 8.5 months before and eight months during the intervention. Fidelity to clinical management guidelines was determined by client exit interviews with success defined as ≥90% adherence.

Findings

For first ANC visits at baseline (n = 529), testing rates were unavailable for malaria, low for syphilis (4.3%) and anaemia (27.8%), and near universal for HIV (99%). During intervention, over 95% of first attendees (n = 586) completed four tests and of those tested positive, 70.6% received penicillin or erythromycin for syphilis, 65.5% and 48.3% received cotrimoxazole and antiretrovirals respectively for HIV, and 76.4% received artemether/lumefantrine, quinine or dihydroartemisinin–piperaquine correctly for malaria. Iron and folic supplements were given to nearly 90% of women but often at incorrect doses.

Conclusions

Integrating point-of-care testing into ANC at dispensaries with established HIV testing programmes resulted in a significant increase in testing rates, without disturbing HIV testing rates. While more cases were detected and treated, treatment fidelity still requires strengthening and an integrated monitoring and evaluation system needs to be established.

Application of radiopaque micro-particle fillers for 3-D imaging of periodontal pocket analogues using cone beam CT

BACKGROUND

Periodontitis is an infectious/inflammatory disease most often diagnosed by deepening of the gingival sulcus, which leads to periodontal pockets (PPs) conventional manual periodontal probing does not provide detailed information on the three-dimensional (3-D) nature of PPs.

OBJECTIVES

To determine whether accurate 3-D analyses of the depths and volumes of calibrated PP analogues (PPAs) can be obtained by conventional cone beam computed tomography (CBCT) coupled with novel radiopaque micro-particle fillers (described in the companion paper) injected into the PPAs.

METHODS

Two PPA models were employed: (1) a human skull model with artificial gingiva applied to teeth with alveolar bone loss and calibrated PPAs, and (2) a pig jaw model with alveolar bone loss and surgically-induced PPAs The PPAs were filled with controlled amounts of radiopaque micro-particle filler using volumetric pipetting Inter-method and intra-method agreement tests were then used to compare the PPA depths and volumes obtained from CBCT images with values obtained by masked examiners using calibrated manual methods.

RESULTS

Significant inter-method agreement (0.938-0.991) and intra-method agreement (0.94-0.99) were obtained when comparing analog manual data to digital CBCT measurements enabled by the radiopaque filler.

SIGNIFICANCE

CBCT imaging with radiopaque micro-particle fillers is a plausible means of visualizing and digitally assessing the depths, volumes, and 3-D shapes of PPs This approach could transform the diagnosis and treatment planning of periodontal disease, with particular initial utility in complex cases Efforts to confirm the clinical practicality of these fillers are currently in progress.

Treatment of HCV infection in liver transplant recipients with ledipasvir and sofosbuvir without ribavirin

BACKGROUND

Ledipasvir and sofosbuvir is a well-tolerated regimen with high sustained virological response (SVR) rates in pre-liver transplant patients infected with chronic hepatitis C virus (HCV), but data in liver transplant recipients outside of clinical trials is limited.

AIM

To address this knowledge gap and assess SVR rates without the use of ribavirin in liver transplant recipients METHODS: This is a retrospective study examining the treatment of 75 post-liver transplant recipients with ledipasvir and sofosbuvir without ribavirin. Differences between SVR cohorts and predictors of SVR were analysed in an intention-to-treat (ITT) fashion.

RESULTS

A total of 408 genotype 1, HCV patients were treated with ledipasvir/sofosbuvir from October 2014 to August 2015 at our centre. Seventy-three patients were post-liver transplant and were treated with a median of 2.9 years from transplant. Ledipasvir/sofosbuvir achieved an SVR12 of 95.9%. African Americans made up 28.8% of the cohort. Sixty-three per cent of patients were treated previously, including 13.7% of patients previously treated with direct-acting antivirals. Only 2.7% had recurrent allograft cirrhosis, and the majority (90.4%) was on calcineurin inhibitor based immunosuppressive therapy. Approximately 82% of patients had chronic kidney disease (CKD) stage 2 or 3. In univariate logistic regression, only detectable week 8 viral load was predictive of failure to achieve SVR.

CONCLUSION

Our data confirm excellent SVR outcomes and favourable safety and tolerability profiles with ledipasvir/sofosbuvir without ribavirin in post-liver transplant recipients infected with HCV, despite treatment guidelines to use ribavirin.

Nanoelectrode array formation by electrolytic nanoparticle impacts

We report the fabrication of functional nanoelectrode arrays by the electrolysis of AgBr nanoparticles (NPs) impacting on a glassy carbon electrode from suspension in aqueous solution. The impacted NPs result in Ag NP deposits of similar size to the originating NP, with the coverage of these arrays easily controlled by the time of the deposition step. The NPs constituting the array are deposited randomly across the surface with little aggregation or agglomeration. The fabricated arrays are themselves electrochemically active, mediating the reduction of hydrogen peroxide, H2O2.

Do delays in radiology lead to breaches in the 4-hour rule?

AIM

To assess trends in medical imaging requests before and after the 4-hour rule commenced and to assess the imaging time component of emergency department (ED) length of stay (LOS).

MATERIALS AND METHODS

Retrospective analysis of ED patients and imaging requests 1 year prior to and 3 years after implementation of the 4-hour rule (April to December for 2011-2014) was performed at a single adult tertiary referral Level 1 trauma hospital with Level 6 ED. Logistic regression was used to evaluate trends in the number of ED patient presentations, patient triage categories, and imaging requests for these patients. The imaging component of the total ED LOS was compared for patients who met the 4-hour target and patients who did not.

RESULTS

Compared to 2011 (before the 4-hour rule), ED presentations increased 4.74% in 2012, 12.7% in 2013, 21.28% in 2014 (p<0.01). Total imaging requests increased 23.05% in 2012, 48.04% in 2013, 60.77% in 2014 (p<0.01). For patients breaching the 4-hour rule, the mean time before radiology request was 2.4-2.8 hours; mean time from imaging request to completion was 1.2-1.3 hours; mean time from imaging completion to discharge from ED was the longest component of ED LOS (4.9-5.9 hours).

CONCLUSIONS

There has been a significant increase in imaging requests, with a trend towards more CT and less radiography requests. Imaging requests for patients who breached the 4-hour target were made on average 2.4-2.8 hours after triage and average time after imaging in itself, exceeded 4 hours. Imaging is not likely a causative factor for patients breaching the 4-hour target.

Children With Autism Show Reduced Information Seeking When Learning New Tasks

Information-seeking behaviours occur when children look to adults in order to gain further information about a novel stimulus/situation. The current study investigated information seeking in children with developmental delays (DD) and those with autism spectrum disorders (ASD) during a simulated teaching situation. Twenty preschool-aged children with ASD and 15 children with DD were exposed to a series of videos where a teacher provided novel instructions and demonstrated novel actions. We found that children with DD, but not those with ASD, demonstrated information-seeking behaviours in response to instructions that exceeded their level of understanding. This suggests that children with DD may use information-seeking behaviours to compensate for their cognitive and language difficulties when novel actions are being taught, while the same is not true for children with ASD.

Geomorphic and geologic controls of geohazards induced by Nepal's 2015 Gorkha earthquake

The Gorkha earthquake (magnitude 7.8) on 25 April 2015 and later aftershocks struck South Asia, killing ~9000 people and damaging a large region. Supported by a large campaign of responsive satellite data acquisitions over the earthquake disaster zone, our team undertook a satellite image survey of the earthquakes' induced geohazards in Nepal and China and an assessment of the geomorphic, tectonic, and lithologic controls on quake-induced landslides. Timely analysis and communication aided response and recovery and informed decision-makers. We mapped 4312 coseismic and postseismic landslides. We also surveyed 491 glacier lakes for earthquake damage but found only nine landslide-impacted lakes and no visible satellite evidence of outbursts. Landslide densities correlate with slope, peak ground acceleration, surface downdrop, and specific metamorphic lithologies and large plutonic intrusions.

Broad-based nutritional supplementation in 3xTg mice corrects mitochondrial function and indicates sex-specificity in response to Alzheimer's disease intervention

Nutrition has been highlighted as a potential factor in Alzheimer's disease (AD) risk and decline and has been investigated as a therapeutic target. Broad-based combination diet therapies have the potential to simultaneously effect numerous protective and corrective processes, both directly (e.g., neuroprotection) and indirectly (e.g., improved vascular health). Here we administered either normal mouse chow with a broad-based nutritional supplement or mouse chow alone to aged male and female 3xTg mice and wildtype (WT) controls. After approximately 4 months of feeding, mice were given a battery of cognitive tasks and then injected with a radiolabeled glucose analog. Brains were assessed for differences in regional glucose uptake and mitochondrial cytochrome oxidase activity, AD pathology, and inflammatory markers. Supplementation induced behavioral changes in the 3xTg, but not WT, mice, and the mode of these changes was influenced by sex. Subsequent analyses indicated that differential response to supplementation by male and female 3xTg mice highlighted brain regional strategies for the preservation of function. Several regions involved have been shown to mediate responses to steroid hormones, indicating a mechanism for sex-based vulnerability. Thus, these findings may have broad implications for the human response to future therapeutics.

Normalization of NF-κB activity in dorsal root ganglia neurons cultured from diabetic rats reverses neuropathy-linked markers of cellular pathology

AIMS/HYPOTHESIS

Dorsal root ganglia (DRG) sensory neurons cultured from 3 to 5 month streptozotocin (STZ)-induced diabetic rats exhibit structural and biochemical changes seen in peripheral nerve fibers in vivo, including axonal swellings, oxidative damage, reduced axonal sprouting, and decreased NF-κB activity. NF-κB is a transcription factor required by DRG neurons for survival and plasticity, and regulates transcription of antioxidant proteins (e.g. MnSOD). We hypothesized that the diabetes-induced decrease in NF-κB activity in DRG contributes to pathological phenomena observed in cultured DRG neurons from diabetic rats.

METHODS

NF-κB localization was assessed in intact DRG and neuron cultures using immunostaining. NF-κB activity was manipulated in sensory neuron cultures derived from age-matched normal or 3-5 month STZ-diabetic rats using pharmacological means and lentiviral expression of shRNA. The impact of diabetes and altered NF-κB activity on neuronal phenotype involved analysis of neurite outgrowth, neurite morphology, oxidative stress (lipid peroxidation) and expression of MnSOD.

RESULTS

STZ-induced diabetes caused a significant decrease in nuclear localization of NF-κB subunits p50 and c-rel, but no change in p65 in intact DRG. Inhibition of NF-κB in normal neuron cultures significantly increased axonal swellings and oxidative stress, and reduced both neurite outgrowth and expression of MnSOD. These phenomena mimicked markers of pathology in cultured DRG neurons from diabetic rats. Enhancement of NF-κB activity in cultured diabetic DRG neurons ameliorated the sub-optimal neurite outgrowth and MnSOD levels triggered by diabetes. Exogenous insulin enhanced nuclear localization of p50 and c-rel but not p65 in diabetic neuronal cultures.

CONCLUSION/INTERPRETATION

The diabetes-induced decrease of nuclear localization of NF-κB subunits p50 and c-rel in DRG contributes to development of in vitro markers of peripheral neuropathy, possibly through impaired mitochondrial ROS scavenging by deficient MnSOD.

Results of a quantitative survey to explore both perceptions of the purposes of follow-up and preferences for methods of follow-up delivery among service users, primary care practitioners and specialist clinicians after cancer treatment

AIMS

To ascertain perceptions of reasons for follow-up after cancer treatment among service users (patients and carers), primary care practitioners and specialist clinicians (doctors and specialist nurses) and to identify levels of preference for different models of follow-up and the effect of an individual's experience on preferred models.

MATERIALS AND METHODS

A national survey designed to meet the needs of each key respondent group was carried out after a structured literature review, an extensive consultation process and a pilot scheme. Respondents were asked to assess their degree of preference for 10 pre-selected indications for follow-up. Eight models of follow-up were also identified and respondents were asked to state their experience and preference for each type. The questionnaire was distributed nationally via the 34 cancer networks in England and was available both online and in hard copy (postal). The uptake for the electronic format was in the main by primary care practitioners and specialist clinicians. Service users preferred the paper (postal) format. The survey was also publicised through the primary care and patient partnership forums at a Cancer Network Development event.

RESULTS

In total, 2928 responses were received, comprising service users (21% of the sample), primary care practitioners (32%) and specialist clinicians (47%). Eighty-six per cent of responses were received from the 10 strategic health authorities in England, with the remaining 14% from Scotland, Wales and The Isle of Man. The responses from Scotland, Wales and the Isle of Man generally occurred where they interfaced with English cancer networks or had been engaged through word of mouth by colleagues. Among all respondents the main aims of cancer follow-up were considered to be: (1) to monitor for early complications after treatment; (2) to detect recurrences early; (3) to detect late effects of treatment. The most commonly experienced method of follow-up among all respondent groups was outpatient review with a doctor. This was considered to be the most preferred follow-up option among service users (86%). The least preferred option among service users was postal follow-up (32%). Primary care practitioners and specialist clinicians were more likely than service users to have experienced alternative methods of follow-up, such as telephone follow-up, self-triggered referral and non-specialist follow-up. These models were highly rated by those who had experience of them.

CONCLUSIONS

There was a reasonable level of consensus between service users, primary care practitioners and specialist clinicians as to the reasons for follow-up. Service users seemed to have higher expectations of follow-up, particularly in relation to detecting recurrences early. As respondents were more likely to prefer a method of follow-up delivery that they had experienced than one they had not; there could be resistance to change from established methods to new methods without adequate explanation. This suggests that the communication of new methods could be critical to their successful introduction.