Emerging Variants of Canine Enteric Coronavirus Associated with Outbreaks of Gastroenteric Disease

A 2022 canine gastroenteritis outbreak in the United Kingdom was associated with circulation of a new canine enteric coronavirus closely related to a 2020 variant with an additional spike gene recombination. The variants are unrelated to canine enteric coronavirus-like viruses associated with human disease but represent a model for coronavirus population adaptation.

The implementation of a hepatitis C testing service in community pharmacies: I-COPTIC consensus statement

OBJECTIVES

This aimed to develop a blueprint for an effective community pharmacy Hepatitis C virus (HCV) testing service by producing a consensus statement.

STUDY DESIGN

This was a modified Delphi process.

METHODS

We recruited a heterogenous panel of experts (who had been involved in the setup or delivery of a community pharmacy HCV testing service) by purposive and chain referral methods. We had three rounds of a modified Delphi process. The first was a series of questions with free text responses and was analysed using thematic analysis, and the second and third were statements for the respondents to rate using a 7-point Likert scale. Consensus was predefined in a published protocol, and the results were reviewed by a public and patient involvement panel before the statement was finalised.

RESULTS

We had 24 participants, including community and hospital-based pharmacists, local pharmaceutical committee members, charity representatives (Hepatitis C Trust), local clinical service lead, nurse specialists and doctors. The response rate of the first, second and third rounds were 100%, 96% and 88%, respectively. After the third round, we had 60 statements that reached consensus. We discussed the accepted statements with a patient and public involvement group. We used these statements to produce the I-COPTIC statement and a graphical summary.

CONCLUSIONS

We developed a blueprint for the design of a gold standard community pharmacy HCV testing service. We believe this will support the successful implementation of community pharmacy testing for HCV. Community pharmacy testing is an important service to help achieve and maintain HCV elimination.

Comparing environmental impacts of deep-seabed and land-based mining: A defensible framework

The crises of climate change and biodiversity loss are interlinked and must be addressed jointly. A proposed solution for reducing reliance on fossil fuels, and thus mitigating climate change, is the transition from conventional combustion-engine to electric vehicles. This transition currently requires additional mineral resources, such as nickel and cobalt used in car batteries, presently obtained from land-based mines. Most options to meet this demand are associated with some biodiversity loss. One proposal is to mine the deep seabed, a vast, relatively pristine and mostly unexplored region of our planet. Few comparisons of environmental impacts of solely expanding land-based mining versus extending mining to the deep seabed for the additional resources exist and for biodiversity only qualitative. Here, we present a framework that facilitates a holistic comparison of relative ecosystem impacts by mining, using empirical data from relevant environmental metrics. This framework (Environmental Impact Wheel) includes a suite of physicochemical and biological components, rather than a few selected metrics, surrogates, or proxies. It is modified from the "recovery wheel" presented in the International Standards for the Practice of Ecological Restoration to address impacts rather than recovery. The wheel includes six attributes (physical condition, community composition, structural diversity, ecosystem function, external exchanges and absence of threats). Each has 3-5 sub attributes, in turn measured with several indicators. The framework includes five steps: (1) identifying geographic scope; (2) identifying relevant spatiotemporal scales; (3) selecting relevant indicators for each sub-attribute; (4) aggregating changes in indicators to scores; and (5) generating Environmental Impact Wheels for targeted comparisons. To move forward comparisons of land-based with deep seabed mining, thresholds of the indicators that reflect the range in severity of environmental impacts are needed. Indicators should be based on clearly articulated environmental goals, with objectives and targets that are specific, measurable, achievable, relevant, and time bound.

Patterns of evolution in MHC class II DQA and DQB exon 2 genes of Alpine mountain hares, Lepus timidus varronis, and sympatric and parapatric brown hares, L. europaeus, from Switzerland

In natural populations, hybridization is known to occur between a wide range of species. However, its evolutionary significance is less clear. Genes involved in fighting pathogens are considered excellent candidates for studying adaptive introgression, although both introgression and balancing selection can generate similar patterns of diversity and differentiation. Here, we compared DQA and DQB MHC class II and microsatellite allelic diversity of sympatric and parapatric mountain (Lepus timidus) and brown hare (L. europaeus) populations from Switzerland. We detected higher genetic diversity in brown hares compared to mountain hares at both MHC and microsatellite loci. We consider the observed patterns of microsatellite diversity both for L. europaeus and L. timidus as result of stochastic demographic processes while the pattern of MHC polymorphism of the studied hare populations can be explained by pathogen-driven selection. Rare bidirectional gene flow between both hare species seems to occur specifically for MHC alleles. However, the high number of shared alleles showing similar high frequency in both species suggests that reciprocally exchanged MHC alleles are being maintained via balancing selection. Adaptation to similar pathogen communities can also lead to parallel selection of MHC alleles. Positive selection, recombination and mutations have played different roles in shaping the patterns of MHC allelic diversity in and differentiation between both species. Results for the latter evolutionary forces do not show a better matching between the sympatric populations compared to the parapatric ones, suggesting a minor role of introgression for the observed evolutionary patterns of the studied hare species.

Shoulder Muscle Dosimetry and Post-Treatment Rehabilitation Utilization for Early-Stage Breast Cancer Patients

PURPOSE/OBJECTIVE(S)

Rehabilitation services for recovery of impaired physical function following breast cancer treatments are largely underutilized. We previously found that breast cancer survivors treated with radiation who received higher radiation doses to the pectoralis major are more likely to self-report shoulder pain and disability. This study aims to address whether radiation dose delivered to the pectoralis major (Pmaj) and pectoralis minor (Pmin) are correlated with referrals for rehabilitation services post-treatment.

MATERIALS/METHODS

A retrospective 1:1 matched case-control study was conducted for breast cancer patients who were and were not referred for breast or shoulder rehabilitation services between 2014-2019 at a single academic institution. Patients were included if they had a lumpectomy and adjuvant radiation without regional nodal irradiation. Cohorts were matched based on age, axillary surgery (none vs. sentinel lymph node biopsy (SLNB)), and use of radiation boost. We used non-parametric Mann-Whitney U tests to determine whether Pmaj or Pmin doses (mean, V50Gy, V45Gy, V40Gy, V35Gy, V30Gy, V20Gy) were different between the two groups. Muscle doses were converted to EQD2 assuming an α/β ratio of 2.5.

RESULTS

In our study of 30 patients of a median age 57 years (IQR 12.75), 20 (66.67%) patients underwent SLNB in addition to lumpectomy. Median tumor size was 1.1cm (range 0.16 - 7.30cm). Stage was 0 for 11 patients (36.67%), I for 14 patients (46.67%), and II for 5 patients (16.67%). 3D conformal radiation was delivered to the whole breast with a moderately hypofractionated (n = 17) or conventionally fractionated regimen (n = 13). The most common rehabilitation diagnoses were lymphedema (n = 8), scar management (n = 7) and shoulder pain (n = 5). Mean dose to both the Pmaj (20.8Gy vs. 18.6Gy; p = 0.02) and Pmin (30.6Gy vs. 24.6Gy; p = 0.01) were significantly higher in patients who received post-treatment rehabilitation compared to those without. The V40Gy, V35Gy, V30Gy and V20Gy (all p<0.02) for the Pmin and V35Gy, V30Gy and V20Gy for the Pmaj (all p<0.04) were also significantly higher in those who underwent rehabilitation.

CONCLUSION

In this cohort of patients with early-stage breast cancer, increased mean doses to the pectoralis muscles were correlated with increased use of rehabilitation services after radiation. Physicians might consider using these dosimetric data to complement clinical symptoms in the decision-making process for referrals for rehabilitation services. This may help facilitate earlier referral to rehabilitation interventions, which is important since early intervention is correlated with improved shoulder morbidity.

The reorganisation of emergency general surgery services during the COVID-19 pandemic in the UK: outcomes of delayed presentation, socio-economic deprivation and Black, Asian and Minority Ethnic patients

INTRODUCTION

The COVID-19 pandemic is a global public health emergency. Lockdown restrictions and the reconfiguration of healthcare systems to accommodate an increase in critical care capacity have had an impact on 'non-COVID' specialties. This study characterises the utilisation of emergency general surgery (EGS) services during the UK lockdown period at a university teaching hospital with a catchment population that represents one of the most deprived and ethnically diverse areas in the UK.

METHODS

EGS admissions during the UK lockdown period (March to May 2020) were compared with the same period in 2019. Patient demographics were recorded together with clinical presentation, hospital stay and treatment outcomes, and readmission data.

RESULTS

The study included 645 patients, comprising 223 in the COVID-19 period and 422 in the non-COVID-19 period. There was no difference in age, sex, comorbidity or socio-economic status. A lower proportion of patients of Black, Asian and Minority Ethnicity (BAME) were admitted during the pandemic (20.6% vs 35.4%, p < 0.05). The duration of symptoms prior to presentation was longer, and admission clinical parameters and serum inflammatory markers. More patients presented with an acute kidney injury (9.9% vs 4.7%, p = 0.012). There was no difference in perioperative outcomes or 30-day mortality, but more patients were readmitted following conservative management (10.6% vs 4.7%, p = 0.023).

CONCLUSIONS

The reorganisation of EGS to a senior-led model has been successful in terms of outcomes and access to treatment despite a more unwell population. There was a significantly lower proportion of BAME admissions suggesting additional barriers to healthcare access under pandemic lockdown conditions.

AMI in (bi)ventricular pacing - do not discard the ECG

BACKGROUND

There is a growing number of patients with ventricular paced rhythm, who present to the emergency department with chest pain. The diagnosis of ST-segment elevation myocardial infarction (STEMI) and subsequent percutaneous coronary intervention (PCI) is often postponed, as the 12 leads-electrocardiogram (ECG) is discarded as not interpretable. There is a growing body of literature that suggests that Smith-modified Sgarbossa criteria can be applied for the diagnosis of STEMI in patients with paced rhythms. These criteria were originally developed for the interpretation of ECGs in patients with a left bundle branch block (LBBB) and chest pain, but have been expanded to paced ECGs.

METHODOLOGY

We present three case reports with chest pain and right ventricular or biventricular pacing.

FINDINGS

In all three cases, the Smith-modified Sgarbossa was positive and the diagnosis of STEMI could have been made early on.

IMPLICATIONS

It remains important to look for ST-segment deviations and to compare the symptomatic ECG with previous asymptomatic ECGs. As the number of patients with potential acute myocardial infarction (AMI) and paced rhythms is likely to rise in the future, these criteria should be known to emergency physicians and cardiologists.

A multi-centre retrospective study of Nocardia speciation and antimicrobial susceptibility in Queensland, Australia

The study aims to characterise the species identification and antimicrobial susceptibility testing (AST) results of Nocardial isolates from adult patients across major public hospitals in Queensland, Australia, over a 15-year period. A multi-centre retrospective observational study of Nocardia sp. isolates was conducted from 7 major public hospitals in Queensland, Australia, over a 15-year period. Clinical samples from patients aged ≥ 18 years that isolated Nocardia sp. were included. Demographic and clinical data were collected, along with species identification and AST results. Overall, 484 Nocardia sp. were isolated. Most patients were male (297, 61%) with a mean (IQR) age of 60 (51-75) and a median (IQR) Charlson Comorbidity Index of 4 (2-6). Of these, 239 (49%) patients were immunosuppressed. Organisms were most frequently isolated from sputum (174, 36%), and superficial swabs (102, 21%). Patients presented with pulmonary infections (165, 35%) and superficial skin and soft tissue infections (87, 18%) most commonly. One hundred (21%) isolates were deemed pulmonary colonisation and were not treated. Of the speciated organisms, N. nova complex was the most common (93, 19%), followed by N. farcinica complex (79, 16%). Organisms were reliably susceptible to linezolid (240/245, 98%), amikacin (455/470, 97%), and trimethoprim/sulfamethoxazole (459/476, 96%), but less so to imipenem (243/472, 51%) and ceftriaxone (261/448, 58%). This is the largest Australian description of Nocardia sp. to date. Given antimicrobials are often commenced prior to AST results and sometimes even speciation, characterisation of local species and antibiogram data is important to guide empiric choices and local guidelines.

Safety and efficacy of tenecteplase in patients with wake-up stroke assessed by non-contrast CT (TWIST): a multicentre, open-label, randomised controlled trial

BACKGROUND

Current evidence supports the use of intravenous thrombolysis with alteplase in patients with wake-up stroke selected with MRI or perfusion imaging and is recommended in clinical guidelines. However, access to advanced imaging techniques is often scarce. We aimed to determine whether thrombolytic treatment with intravenous tenecteplase given within 4·5 h of awakening improves functional outcome in patients with ischaemic wake-up stroke selected using non-contrast CT.

METHODS

TWIST was an investigator-initiated, multicentre, open-label, randomised controlled trial with blinded endpoint assessment, conducted at 77 hospitals in ten countries. We included patients aged 18 years or older with acute ischaemic stroke symptoms upon awakening, limb weakness, a National Institutes of Health Stroke Scale (NIHSS) score of 3 or higher or aphasia, a non-contrast CT examination of the head, and the ability to receive tenecteplase within 4·5 h of awakening. Patients were randomly assigned (1:1) to either a single intravenous bolus of tenecteplase 0·25 mg per kg of bodyweight (maximum 25 mg) or control (no thrombolysis) using a central, web-based, computer-generated randomisation schedule. Trained research personnel, who conducted telephone interviews at 90 days (follow-up), were masked to treatment allocation. Clinical assessments were performed on day 1 (at baseline) and day 7 of hospital admission (or at discharge, whichever occurred first). The primary outcome was functional outcome assessed by the modified Rankin Scale (mRS) at 90 days and analysed using ordinal logistic regression in the intention-to-treat population. This trial is registered with EudraCT (2014-000096-80), ClinicalTrials.gov (NCT03181360), and ISRCTN (10601890).

FINDINGS

From June 12, 2017, to Sept 30, 2021, 578 of the required 600 patients were enrolled (288 randomly assigned to the tenecteplase group and 290 to the control group [intention-to-treat population]). The median age of participants was 73·7 years (IQR 65·9-81·1). 332 (57%) of 578 participants were male and 246 (43%) were female. Treatment with tenecteplase was not associated with better functional outcome, according to mRS score at 90 days (adjusted OR 1·18, 95% CI 0·88-1·58; p=0·27). Mortality at 90 days did not significantly differ between treatment groups (28 [10%] patients in the tenecteplase group and 23 [8%] in the control group; adjusted HR 1·29, 95% CI 0·74-2·26; p=0·37). Symptomatic intracranial haemorrhage occurred in six (2%) patients in the tenecteplase group versus three (1%) in the control group (adjusted OR 2·17, 95% CI 0·53-8·87; p=0·28), whereas any intracranial haemorrhage occurred in 33 (11%) versus 30 (10%) patients (adjusted OR 1·14, 0·67-1·94; p=0·64).

INTERPRETATION

In patients with wake-up stroke selected with non-contrast CT, treatment with tenecteplase was not associated with better functional outcome at 90 days. The number of symptomatic haemorrhages and any intracranial haemorrhages in both treatment groups was similar to findings from previous trials of wake-up stroke patients selected using advanced imaging. Current evidence does not support treatment with tenecteplase in patients selected with non-contrast CT.

FUNDING

Norwegian Clinical Research Therapy in the Specialist Health Services Programme, the Swiss Heart Foundation, the British Heart Foundation, and the Norwegian National Association for Public Health.

Harmonising knee pain patient-reported outcomes: a systematic literature review and meta-analysis of Patient Acceptable Symptom State (PASS) and individual participant data (IPD)

OBJECTIVE

In order to facilitate data pooling between studies, we explored harmonisation of patient-reported outcome measures (PROMs) in people with knee pain due to osteoarthritis or knee trauma, using the Patient Acceptable Symptom State scores (PASS) as a criterion.

METHODS

We undertook a systematic literature review (SLR) of PASS scores, and performed individual participant data (IPD) analysis of score distributions from concurrently completed PROM pairs. Numerical rating scales (NRS), visual analogue scales, KOOS and WOMAC pain questionnaires were standardised to 0 to 100 (worst) scales. Meta-regression explored associations of PASS. Bland Altman plots compared PROM scores within individuals using IPD from WebEx, KICK, MenTOR and NEKO studies.

RESULTS

SLR identified 18 studies reporting PASS in people with knee pain. Pooled standardised PASS was 27 (95% CI: 21 to 35; n = 6,339). PASS was statistically similar for each standardised PROM. Lower PASS was associated with lower baseline pain (β = 0.49, P = 0.01) and longer time from treatment initiation (Q = 6.35, P = 0.04). PASS scores were lowest in ligament rupture (12, 95% CI: 11 to 13), but similar between knee osteoarthritis (31, 95% CI: 26 to 36) and meniscal tear (27, 95% CI: 20 to 35). In IPD, standardised PROMs each revealed similar group mean scores, but scores within individuals diverged between PROMs (LoA between -7 to -38 and +25 to 52).

CONCLUSION

Different standardised PROMs give similar PASS thresholds in group data. PASS thresholds may be affected more by patient and treatment characteristics than between PROMs. However, different PROMs give divergent scores within individuals, possibly reflecting different experiences of pain.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Alcohol consumption and telomere length: Mendelian randomization clarifies alcohol's effects

Alcohol's impact on telomere length, a proposed marker of biological aging, is unclear. We performed the largest observational study to date (in n = 245,354 UK Biobank participants) and compared findings with Mendelian randomization (MR) estimates. Two-sample MR used data from 472,174 participants in a recent genome-wide association study (GWAS) of telomere length. Genetic variants were selected on the basis of associations with alcohol consumption (n = 941,280) and alcohol use disorder (AUD) (n = 57,564 cases). Non-linear MR employed UK Biobank individual data. MR analyses suggested a causal relationship between alcohol traits, more strongly for AUD, and telomere length. Higher genetically-predicted AUD (inverse variance-weighted (IVW) β = -0.06, 95% confidence interval (CI): -0.10 to -0.02, p = 0.001) was associated with shorter telomere length. There was a weaker association with genetically-predicted alcoholic drinks weekly (IVW β = -0.07, CI: -0.14 to -0.01, p = 0.03). Results were consistent across methods and independent from smoking. Non-linear analyses indicated a potential threshold relationship between alcohol and telomere length. Our findings indicate that alcohol consumption may shorten telomere length. There are implications for age-related diseases.

Suicide bereavement in the UK: Descriptive findings from a national survey

BACKGROUND

Those bereaved by suicide are a high-risk group of adverse health outcomes and suicidal behavior, yet little is known about the experiences and support needs of these individuals in the UK.

METHODS

We conducted a national cross-sectional study using an online survey and analyzed the experiences of 7158 participants who had been bereaved or affected by suicide.

RESULTS

Suicide had a major impact on 77% of participants, including those who had lost a friend and those exposed to suicide at a professional level. Mental and physical health problems linked to the suicide were reported in half. Adverse social outcomes and engaging in high-risk behaviors following the suicide were common. Over a third reported suicidal ideation and 8% had attempted suicide as a direct result of the suicide loss. Most had not accessed support services, with the majority viewing provision of local suicide bereavement support as inadequate.

CONCLUSIONS

Our results highlight the need for a multi-disciplinary approach in postvention and the provision of proactive outreach to support those bereaved by suicide. Postvention efforts need to acknowledge the death of a friend by suicide as a significant loss.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

UK Research and Innovation and National Institute for Health Research.

POS0164 GENETIC ANALYSIS OF WHOLE EXOME SEQUENCING IN A COHORT OF CHILDREN WITH REFRACTORY JIA REVEALS GENETIC RISK FACTORS FOR RARE JUVENILE DISEASES

Background

Juvenile idiopathic arthritis (JIA) encompasses a group of heterogeneous rheumatic diseases of childhood onset. JIA can result in long term disability and remission is the main goal of treatment. However refractory disease can occur, which is defined as the absence of response to a standard disease therapy. A genetic basis for refractory disease has yet to be explored, where deleterious rare variants can complicate diagnosis or treatment outcome.

Objectives

To investigate, through genetic analysis, whether children with JIA that is refractory carry rare genetic risk factors in genes linked to monogenic diseases.

Methods

Whole exome sequencing of 99 children with JIA was performed with the Agilent SureSelect Human All ExonV6 kit. All quality control, variant filtering and annotation was performed in Varseq (version 2.2.1). Variants with a read depth <30 and genotype quality <80 were removed. Rarity and pathogenicity filters were then applied to remove variants with an allele frequency >1% (based on ExAC, gnomAD, gnomAD exome, NHLBI and 1KGp phase 3), classified as benign or likely benign on ClinVar, with a CADD PHRED score <15 and a REVEL score >0.7. Variants were annotated if they appeared in a gene from the primary immunodeficiency PanelApp (Martin et al., 2019), in a gene associated with an arthritis phenotype or in a gene that appeared on a paediatric monogenic gene list. The variants were then classified using ACMG guidelines (Richards et al., 2015) and benign, or likely benign, classified variants were removed.

Results

A total of 628 variants were identified and we found that 20 out of the 99 children screened were heterozygous for at least one recognised variant in a gene linked to a monogenic disease. Five of these children carried more than one recognised variant linked to monogenic genes. Here we provide a number of illustrative examples: three genes, ADAR, ATP7B and MVK, were prioritised based on prior evidence of associated disease. The variant p.Pro193Ala (gnomAD allele frequency (GAD) 2.2x10-3) of ADAR has previously been deemed pathogenic in a homozygous or compound heterozygous state for Aicardi-Goutières syndrome. Adenosine deaminases (ADARs) catalyse the hydrolytic deamination of adenosine to inosine in dsRNA and is suggested to act as a suppressor of type 1 interferon-stimulated genes. Within ATP7B, two distinct variants were detected; p.Gln1142His (GAD 1.6x10-5) and p.Ile1148Thr (GAD 4.0x10-5) have previously been reported as pathogenic, in combination with a third variant, for Wilson’s disease and were carried by one individual in this cohort. ATP7B encodes copper-transporting ATPase 2, which supplies copper to ceruloplasmin. Variant p.Val377Ile (GAD 1.6x10-3) of MVK was detected in eight individuals in this cohort, interestingly five of these individuals also carried at least one HLA-DRB1 stop-gained variant. This MVK mutation has been confirmed as pathogenic in a homozygous or compound heterozygous state for mevalonate kinase deficiency. MVK converts mevalonic acid into mevalonate-5-phosphate in the cholesterol synthesis pathway. Additionally, two stop-gained loss of function HLA-DRB1 variants, p.Tyr107Ter and p.Gln125Ter, were detected in five and 20 individuals, respectively, in this cohort. HLA-DRB1 is a recognised susceptibility locus for JIA.

Conclusion

Screening of a cohort of 99 children with JIA that have refractory disease has revealed that individuals carry deleterious variants in genes linked to monogenic forms of disease. These results highlight that the genetic basis for refractory disease needs to be further investigated. Carrying additional genetic risk factors to disease may complicate disease outcome and genetic screening of children with refractory JIA may improve treatment outcome in the future.

Acknowledgements

I would like to acknowledge the CLUSTER consortium.

Disclosure of Interests

None declared

Better Understanding of the Metamorphosis of Pregnancy (BUMP): protocol for a digital feasibility study in women from preconception to postpartum

The Better Understanding the Metamorphosis of Pregnancy (BUMP) study is a longitudinal feasibility study aimed to gain a deeper understanding of the pre-pregnancy and pregnancy symptom experience using digital tools. The present paper describes the protocol for the BUMP study. Over 1000 participants are being recruited through a patient provider-platform and through other channels in the United States (US). Participants in a preconception cohort (BUMP-C) are followed for 6 months, or until conception, while participants in a pregnancy cohort (BUMP) are followed into their fourth trimester. Participants are provided with a smart ring, a smartwatch (BUMP only), and a smart scale (BUMP only) alongside cohort-specific study apps. Participant centric engagement strategies are used that aim to co-design the digital approach with participants while providing knowledge and support. The BUMP study is intended to lay the foundational work for a larger study to determine whether participant co-designed digital tools can be used to detect, track and return multimodal symptoms during the perinatal window to inform individual level symptom trajectories.

Dead-reckoning elucidates fine-scale habitat use by European badgers Meles meles

Background

Recent developments in both hardware and software of animal-borne data loggers now enable large amounts of data to be collected on both animal movement and behaviour. In particular, the combined use of tri-axial accelerometers, tri-axial magnetometers and GPS loggers enables animal tracks to be elucidated using a procedure of 'dead-reckoning'. Although this approach was first suggested 30 years ago by Wilson et al. (1991), surprisingly few measurements have been made in free-ranging terrestrial animals. The current study examines movements, interactions with habitat features, and home-ranges calculated from just GPS data and also from dead-reckoned data in a model terrestrial mammal, the European badger (Meles meles).

Methods

Research was undertaken in farmland in Northern Ireland. Two badgers (one male, one female) were live-trapped and fitted with a GPS logger, a tri-axial accelerometer, and a tri-axial magnetometer. Thereafter, the badgers' movement paths over 2 weeks were elucidated using just GPS data and GPS-enabled dead-reckoned data, respectively.

Results

Badgers travelled further using data from dead-reckoned calculations than using the data from only GPS data. Whilst once-hourly GPS data could only be represented by straight-line movements between sequential points, the sub-second resolution dead-reckoned tracks were more tortuous. Although there were no differences in Minimum Convex Polygon determinations between GPS- and dead-reckoned data, Kernel Utilisation Distribution determinations of home-range size were larger using the former method. This was because dead-reckoned data more accurately described the particular parts of landscape constituting most-visited core areas, effectively narrowing the calculation of habitat use. Finally, the dead-reckoned data showed badgers spent more time near to field margins and hedges than simple GPS data would suggest.

Conclusion

Significant differences emerge when analyses of habitat use and movements are compared between calculations made using just GPS data or GPS-enabled dead-reckoned data. In particular, use of dead-reckoned data showed that animals moved 2.2 times farther, had better-defined use of the habitat (revealing clear core areas), and made more use of certain habitats (field margins, hedges). Use of dead-reckoning to provide detailed accounts of animal movement and highlight the minutiae of interactions with the environment should be considered an important technique in the ecologist's toolkit.

SARS-CoV-2, Lung Protective Ventilation, Low Middle Income Countries, and Pediatric Intensivists as Cross Disciplinary Knowledge Translation and Implementation Science Specialists

Purpose

We hypothesized that despite the low incidence of severe SARS-CoV-2 infections in children in Guyana, due to their specific skillset in lung protective ventilation, our Pediatric Intensivists were uniquely positioned to address significant training and readiness gaps in our colleagues attending a surging critically ill Adult COVID-19 patient population.

Methods & Materials

In Guyana, there are few clinicians trained in Critical-Care Medicine (CCM). The high incidence of ventilator dependence in seriously ill SARS-CoV2 patients, combined with a dearth of CCM practitioners competent in complex mechanical ventilation management left Guyana ill prepared to manage these patients. This knowledge deficit was further exacerbated in that many clinicians at our National Infectious Diseases Hospital were co-opted into CCM roles from other specialties with little to no CCM training. We have a very small core of Pediatric Surgical Critical Care Medicine staff that was formally trained in PCCM outside of Guyana. This core was instrumental in establishing a unique and formal Pediatric Critical-Care Medicine Micro-Modular Fellowship (PCCM-MMF) program that allowed the creation of Guyana's only Pediatric ICU. A significant number of that core are also involved in Guyana‘s National COVID Task Force. Given that all graduates of our PCCM-MMF program are extensively trained in Lung Protective Ventilation, it was very appropriate to utilize them to augment Adult critical care capacity. Thirty physicians with primarily adult practices and little to no previous knowledge of ventilator management were enrolled in a multi-modal triphasic mechanical ventilation short course facilitated by PCCM staff.

Results

We were able to rapidly enable two cohorts of 15 Adult clinicians to competently address critical knowledge deficits and staffing shortfalls. We improved morbidity and mortality amongst our mechanically ventilated adult COVID-19 patients, as well as relieved significant multifactorial caregiver strain.

Conclusion

Our successful utilization of PCCM staff as Mechanical Ventilation didactic and clinical educators for an Adult patient population carries implications for cross disciplinary Knowledge Translation and Implementation Science in a wide variety of practice milieus. We are actively pursuing research opportunities to further experiment with other skill sets incorporated in our PCCM Micro-Modular Fellowship and welcome potential collaborators.

Medication related osteonecrosis of the jaws: A single centre, Far North Queensland case series

Medication‐related osteonecrosis of the jaws (MRONJ) is a painful debilitating condition which is considered rare in the medical literature available to prescribers. Dentists, however, are likely to trigger this condition through extractions and implants. Anecdotally MRONJ appears more common than first thought. This paper presents 13 cases of MRONJ diagnosed and treated by a single oral and maxillofacial surgeon based in Cairns, Far North Queensland, in a 2‐year period. The management of these cases is presented. The two cases where MRONJ resulted in the loss of dental implants are highlighted. © 2022 Australian Dental Association

Ethnic Minority Groups' Experiences of Suicide Bereavement: A Qualitative Exploratory Study

It is estimated that between 36,000 and 360,000 people are affected by suicide every year in the UK, and a proportion may develop depression and post-traumatic stress disorder, or engage in high-risk behaviours. Recent systematic analyses have revealed a clear gap in research on suicide bereavement in minority ethnic groups. This study aimed to understand the experiences and support needs of individuals from ethnic minority backgrounds bereaved by suicide and was the first in the UK to investigate this matter. The study was a secondary analysis of data. Participants were 7158 people residing in the UK who completed an online survey about their experiences of suicide. Free-text qualitative responses of 227 participants who did not identify as White British were analysed using thematic analysis. Four themes were identified: maladaptive coping strategies, emotional processes following suicide, lack of support from agencies, and the importance of mental health awareness. Ethnic minority groups reported a lack of support despite attempts to engage with services, noted the prevalence of stigma within ethnic minority groups, and expressed a need to tackle this. These preliminary results suggest that ethnic minority individuals require visible and accessible services that can successfully engage with and support them.

ARMC5-associated Bilateral Macronodular Adrenocortical Hyperplasia: A Novel Germline Variant Associated with Concomitant Papillary Thyroid Carcinoma and Meningioma

Introduction/Objective

Germline mutations in the tumor suppressor gene Armadillo-containing repeat protein 5 gene (ARMC5) have been very recently recognized as a cause for a familial form of bilateral macronodular adrenocortical hyperplasia (BMAH), itself a rare cause of Cushing syndrome. In patients with ARMC5 mutations, scattered case reports have also shown an association with meningiomas and cancers of the pancreas, breast, colon, and thyroid.

Methods/Case Report

We present the case of BMAH, arising in a 61-year-old female with a history of metastatic papillary thyroid carcinoma and meningioma. The patient presented with bilateral but asymmetric adrenal enlargement (right greater than left) and Cushing syndrome. Given history of thyroid cancer and meningioma, genetics referral was ordered. Counseling revealed a pedigree without a strongly evident familial pattern of hereditary endocrine neoplasia characteristic of any of the more common inherited dispositions to endocrine neoplasia. Additionally, a targeted capture-based NGS germline genetic sequencing study for variants in 12 genes associated with associated with hereditary thyroid cancer was performed and negative. However, based on recent scholarship regarding ARMC5, follow-up germline NGS and Sanger sequencing studies encompassing the entire coding sequences of ARMC5 were ordered. These identified a germline, heterozygous, novel (not in ClinVar) but likely pathogenic variant in (c.802C&gt;T, p.Arg268*), providing a likely explanation for the patient’s BMAH. In attempt to control the patient’s Cushing symptoms, right-sided adrenalectomy was performed, revealing a 220g adrenal gland with marked multinodular hyperplasia with solid, nested, and tubular architecture.

Results (if a Case Study enter NA)

NA

Conclusion

While case reports exist describing an association between other ARMC5 mutations and BMAH with concomitant meningiomas and/or malignancies, greater study is needed in order to better characterize the phenotypic spectrum of this disease. Our experience with this case not only reports a novel, apparently pathogenic mutation, but it documents its association with BMAH and, additionally, papillary thyroid carcinoma and meningioma.

505 Failed Femoral Nail with Significant Operative Technical Difficulty: A Practical Solution to Achieve Metalwork Extraction Using Conical Screw Remover

Introduction

There is a greater risk of delayed healing and revision surgery in atypical femoral fractures (AFFs). Although non-union in reamed intra-medullary (IM) nailing is relatively uncommon, it can lead to fracture of the nail and present a considerable challenge to the treating surgeon.

Case Report

We present a case of AFF treated with IM nail fixation. Metalwork failure of the nail prompted removal of distal locking screws and plating of the fracture site at 8 months. Failure of the plate-bone interface 3 months later led to further revision surgery to remove the broken metalwork. We focus on the significant operative difficulty encountered during removal of the failed IM metalwork and provide a novel practical solution to overcome this particular challenge - insertion of a conical cannulated screw remover under fluoroscopy guidance to create an interference fit with the distal segment of the broken nail.

Discussion

This case is an example of significant and unexpected intra-operative technical difficulty, requiring improvisation and teamwork to manage. We introduce an accessible and uncomplicated alternative to the existing techniques for removal of a broken femoral nail and in doing so hope to benefit peers and colleagues should they encounter similar difficulties in the future.

1242 A Surfacing Staghorn: Spontaneous Expulsion of a Large Renal Calculus from A Nephrocutaneous Fistula

An 83-year-old lady presented to the urology department with right flank pain in the context of a previously known right renal staghorn calculus. On examination, she was found to have a visible discharging sinus in her right flank, and the renal calculus had become visible at the skin surface. Non-contrast CT imaging confirmed that her staghorn calculus had eroded through the skin via a nephrocutaneous fistula. The stone was manually extracted percutaneously on the ward, and she was treated with intravenous antibiotics. She subsequently passed a further stone through the tract and made a good recovery.

This is a highly unusual presentation of nephrolithiasis in a developed country in the 21st century. Review of the literature suggests that surgical management is almost always indicated in patients with staghorn calculi. However surgical management options are not without risk and conservative management of staghorn disease may be appropriate in select patient groups: those with multiple co-morbidities at high risk for GA, in cases of patient refusal of surgery, or in patients with aberrant anatomical factors

Our case highlights a potential complication of conservatively managed staghorn stone disease. To our knowledge our case is the first of spontaneous expulsion of renal stone of this size to be reported in the developed world.

Clinical and Histologic Manifestations of a Novel Rectus Femoris Myotendinous Junction Injury in Rats

Background

Animal models of muscle injury have primarily relied on methods which do not mimic the chronic scarring that typically occurs adjacent to the myotendinous junction (MTJ). The goal of this study was three-fold: (i) to create a strain-induced in vivo model of rectus femoris MTJ injury in rats; (ii) to document clinical manifestations of injury using longitudinal tracking of individual animals via voluntary and compulsory (treadmill) mobility analyses and (iii) to validate and assess the model for persistent scarring through serial histologic assessment and development of a semi-quantitative grading scheme to characterize injury response over time.

Methods

Strain-induced MTJ injury was generated in male Sprague Dawley rats via needle tension directed along the transverse axis between the rectus femoris muscle and distal tendon that attaches to the patella. Animals received mobility assessments (gait analysis using a DigiGait Treadmill System and weight bearing using a Tekscan Rodent Walkway System) at days 0, 1, 3, 6, 13, 20, and 27 of the experimental protocol. Rats were euthanized at 1, 3, 7, 14, and 28 days post-injury (n = 6 rats per time-point) and hindlimbs were processed for histology.

Results

Significant changes in locomotor parameters included injured and contralateral limb paw area, max dA/dt (limb deceleration/breaking time), stride time, stance time, force time impulse, and fore/hind symmetry, and injured limb maximum force. The most significant and consistent histologic finding was a pathologic fibrotic adhesive lesion at the muscle and tendon interface along the proximal aspect of the patella just distal to the injury site. This lesion was composed of reactive fibroblasts, disorganized collagen fibers, vascular profiles, and a myxomatous ground substance stroma.

Conclusions

This work is the first to characterize the clinical and pathologic development of a chronic model of rectus femoris MTJ injury, which resulted in altered mobility likely caused by a strain-induced fibrotic scar along the anterior patella. Notably, both the functional and pathologic changes recapitulated the course of injury progression similar to what is described in humans. This work provides a unique model to study MTJ injury mechanisms for the identification of enhanced treatment options for patients who suffer from activity-related muscle conditions.

Well-differentiated gastroenteropancreatic G3 NET: findings from a large single centre cohort

Neuroendocrine neoplasms are known to have heterogeneous biological behavior. G3 neuroendocrine tumours (NET G3) are characterized by well-differentiated morphology and Ki67 > 20%. The prognosis of this disease is understood to be intermediate between NET G2 and neuroendocrine carcinoma (NEC). Clinical management of NET G3 is challenging due to limited data to inform treatment strategies. We describe clinical characteristics, treatment, and outcomes in a large single centre cohort of patients with gastroenteropancreatic NET G3. Data was reviewed from 26 cases managed at Queen Elizabeth Hospital, Birmingham, UK, from 2012 to 2019. Most commonly the site of the primary tumour was unknown and majority of cases with identifiable primaries originated in the GI tract. Majority of cases demonstrated somatostatin receptor avidity. Median Ki67 was 30%, and most cases had stage IV disease at diagnosis. Treatment options included surgery, somatostatin analogs (SSA), and chemotherapy with either platinum-based or temozolomide-based regimens. Estimated progression free survival was 4 months following initiation of SSA and 3 months following initiation of chemotherapy. Disease control was observed following treatment in 5/11 patients treated with chemotherapy. Estimated median survival was 19 months; estimated 1 year survival was 60% and estimated 2 year survival was 13%. NET G3 is a heterogeneous group of tumours and patients which commonly have advanced disease at presentation. Prognosis is typically poor, though select cases may respond to treatment with SSA and/or chemotherapy. Further study is needed to compare efficacy of different treatment strategies for this disease.