Complications of fibrotic interstitial lung disease for the general radiologist

Interstitial lung diseases (ILDs) are a heterogeneous group of conditions characterised by non-infective inflammation and scarring of the lung parenchyma. They are not infrequently encountered by the general radiologist in both acute and outpatient reporting settings who may even be the first to make the diagnosis. In the acute setting, patients with ILD can present with respiratory deterioration due to a number of causes and in addition to the common causes of dyspnoea, an acute exacerbation of ILD needs to be considered. An exacerbation can be initiated by common triggers such as infection, pulmonary embolism (PE), and heart failure, and it can also be initiated by an insult to the lung or occur due to an unknown cause. Particular care needs to be taken when interpreting computed tomography (CT) examinations in these patients as the findings of an acute exacerbation are non-specific and patient and technical factors can cause spurious appearances including dependent changes, breathing artefact and contrast medium opacification. In the non-acute setting, patients with ILD are at increased risk of lung cancer and pulmonary hypertension (PH), with lung cancer being a particularly important consideration as treatments carry the risk of triggering an acute exacerbation or deterioration in lung function. Overall, this review aims to provide an overview for the general radiologist of additional factors to consider when interpreting scans in patients with ILD and how the presence of ILD impacts the differential diagnoses and complications that can occur in these patients in both acute and non-acute settings.

Improved nationwide survival of sarcoma patients with a network of reference centers

BACKGROUND

We investigated the impact of the implementation of a network of reference centers for sarcomas (NETSARC) on the care and survival of sarcoma patients in France since 2010.

PATIENTS AND METHODS

NETSARC (netsarc.org) is a network of 26 reference sarcoma centers with specialized multidisciplinary tumor boards (MDTBs), funded by the French National Cancer Institute (INCa) since 2010. Its aims are to improve the quality of diagnosis and care of sarcoma patients. Patients' characteristics, treatments, and outcomes are collected in a nationwide database. The objective of this analysis was to compare the survival of patients in three periods: 2010-2012 (non-exhaustive), 2013-2015, and 2016-2020.

RESULTS

A total of 43 975 patients with sarcomas, gastrointestinal stromal tumors (GISTs), or connective tissue tumors of intermediate malignancy were included in the NETSARC+ database since 2010 (n = 9266 before 2013, n = 12 274 between 2013 and 2015, n = 22 435 in 2016-2020). Median age was 56 years, 50.5% were women, and 13.2% had metastasis at diagnosis. Overall survival was significantly superior in the period 2016-2020 versus 2013-2015 versus 2010-2012 for the entire population, for patients >18 years of age, and for both metastatic and non-metastatic patients in univariate and multivariate analyses (P < 0.0001). Over the three periods, we observed a significantly improved compliance to clinical practice guidelines (CPGs) nationwide: the proportion of patients biopsied before surgery increased from 62.9% to 72.6%; the percentage of patients presented to NETSARC MDTBs before first surgery increased from 31.7% to 44.4% (P < 0.0001). The proportion of patients with R0 resection on first surgery increased (from 36.1% to 46.6%), while R2 resection rate decreased (from 10.9% to 7.9%), with a better compliance and improvement in NETSARC centers.

CONCLUSIONS

The implementation of the national reference network for sarcoma was associated with an improvement of overall survival and compliance to guidelines nationwide in sarcoma patients. Referral to expert networks for sarcoma patients should be encouraged, though a better compliance to CPGs can still be achieved.

Plasma exchange for the management of digoxin toxicity in an individual with an acute kidney injury: A case report

Digoxin toxicity can be life-threatening. Digoxin-specific antibody (DSA) fragments are used in severe digoxin toxicity, binding to serum-free digoxin and enabling increased renal excretion. In severe renal impairment, clearance of these complexes is prolonged, leading to rebound toxicity. Digoxin and DSA complexes are not dialysable. We present a case of a gentleman with severe digoxin toxicity and acute kidney injury (AKI). Despite receiving DSA doses, his digoxin levels rebounded and symptoms persisted. Based on published case reports, plasma exchange (PEX) after further dosing was arranged. PEX facilitated the removal of digoxin-DSA complexes, bypassing renal excretion. During PEX, clinical signs improved and were sustained. He did not require further dialysis or PEX, renal function recovered and he was discharged. This case highlights challenges in the management of severe digoxin toxicity in patients with a concurrent AKI. The use of PEX enabled digoxin-DSA complex removal and should be considered in these circumstances.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Sclerosing Epithelioid Fibrosarcoma (SEF) versus Low Grade Fibromyxoid Sarcoma (LGFMS): Presentation and outcome in the nationwide NETSARC+ series of 330 patients over 13 years

Sclerosing Epithelioid Fibrosarcoma (SEF) and Low Grade Fibromyxoid Sarcoma (LGFMS) are ultrarare sarcomas sharing common translocations whose natural history are not well known. We report on the nationwide exhaustive series of 330 patients with SEF or LGFMS in NETSARC+ since 2010.

PATIENTS AND METHODS

NETSARC (netsarc.org) is a network of 26 reference sarcoma centers with specialized multidisciplinary tumor boards (MDTB). Since 2010, (i) pathological review has been mandatory for sarcoma,and (ii) tumour/patients' characteristics have been collected in the NETSARC+ nationwide database. The characteristics of patients with SEF and LGFMS and their outcome are compared.

RESULTS

35/73 (48%) and 125/257(49%) of patients with SEF and LGFMS were female. More visceral, bone and trunk primary sites were observed in SEF (p < 0.001). 30% of SEF vs 4% of LGFMS patients had metastasis at diagnosis (p < 0.0001). Median size of the primary tumor was 51 mm (range 10-90) for LGFMS vs 80 (20-320) for SEF (p < 0.001). Median age for LGFMS patients was 12 years younger than that of SEF patients (43 [range 4-98] vs 55 [range 10-91], p < 0.001). Neoadjuvant treatment was more often given to SEF (16% vs 9%, p = 0.05). More patients with LGFMS were operated first in reference centers (51% vs 26%, p < 0.001). The R0 rate on the operative specimen was 41% in LGFMS vs 16% in SEF (p < 0.001). Median event-free survival (EFS) of patients with SEF and LGFMS were 32 vs 136 months (p < 0.0001). The median overall survival (OS) was not reached. Fifty-months OS was 93% vs 81% for LGFMS vs SEF (p = 0.05). Median OS was 77 months after first relapse, similar for SEF and LGFMS. In multivariate analysis, age, tumor size, metastasis at diagnosis were independent prognostic factors for OS in LGFMS.

CONCLUSIONS

Although sharing close molecular alterations, SEF and LGFMS have a different natural history, clinical presentation and outcome, with a higher risk of metastatic relapse in SEF. Survival after relapse is longer than with other sarcomas, and similar for SEF and LGFMS.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Globe and adnexal trauma at Australian trauma centres

INTRODUCTION

In multisystem trauma, the assessment and management of globe and adnexal trauma is often complex. Ophthalmology input may assist managing such patients. To understand the role of ophthalmology in tertiary trauma centres we report on the management of globe and adnexal trauma at two tertiary trauma centres in Sydney, Australia.

METHOD

A retrospective case series was completed at Royal North Shore Hospital (RNSH) and Royal Prince Alfred Hospital (RPAH) on patients admitted between January 2015 and December 2019. International Classification of Disease, Tenth Revision codes, diagnostic and procedural coding data were used to identify patients admitted with globe and/or adnexal trauma. Data extracted from medical records included demographics, mechanism of injury, ocular examination and specialist ophthalmic referral.

RESULTS

Over 5-years, 773 patients, average age of 53.2years and 62% male, were admitted to RNSH and RPAH with globe and/or adnexal trauma. Most patients (83%) first presented to RNSH or RPAH. The most common mechanism of injury was falls (45%) followed by burns (13%). Two-hundred and thirty-five patients had multisystem trauma, of these patients, 121 (51%) suffered globe trauma with 49 (21%) classified as severe. Three patients were not diagnosed initially due to delayed ophthalmology referral.

CONCLUSION

Falls followed by burns were common causes of globe and adnexal trauma in Sydney, Australia. The presence of orbital/mid-facial injury may indicate a patient has globe trauma. In multisystem trauma, globe trauma may be diagnosed late or not identified. Ophthalmology review has an important role in diagnosing and managing globe trauma in multisystem trauma.

Cyber-WISE: A Cyber-Physical Deep Wireless Indoor Positioning System and Digital Twin Approach

In recent decades, there have been significant research efforts focusing on wireless indoor localization systems, with fingerprinting techniques based on received signal strength leading the way. The majority of the suggested approaches require challenging and laborious Wi-Fi site surveys to construct a radio map, which is then utilized to match radio signatures with particular locations. In this paper, a novel next-generation cyber-physical wireless indoor positioning system is presented that addresses the challenges of fingerprinting techniques associated with data collection. The proposed approach not only facilitates an interactive digital representation that fosters informed decision-making through a digital twin interface but also ensures adaptability to new scenarios, scalability, and suitability for large environments and evolving conditions during the process of constructing the radio map. Additionally, it reduces the labor cost and laborious data collection process while helping to increase the efficiency of fingerprint-based positioning methods through accurate ground-truth data collection. This is also convenient for working in remote environments to improve human safety in locations where human access is limited or hazardous and to address issues related to radio map obsolescence. The feasibility of the cyber-physical system design is successfully verified and evaluated with real-world experiments in which a ground robot is utilized to obtain a radio map autonomously in real-time in a challenging environment through an informed decision process. With the proposed setup, the results demonstrate the success of RSSI-based indoor positioning using deep learning models, including MLP, LSTM Model 1, and LSTM Model 2, achieving an average localization error of ≤2.16 m in individual areas. Specifically, LSTM Model 2 achieves an average localization error as low as 1.55 m and 1.97 m with 83.33% and 81.05% of the errors within 2 m for individual and combined areas, respectively. These outcomes demonstrate that the proposed cyber-physical wireless indoor positioning approach, which is based on the application of dynamic Wi-Fi RSS surveying through human feedback using autonomous mobile robots, effectively leverages the precision of deep learning models, resulting in localization performance comparable to the literature. Furthermore, they highlight its potential for suitability for deployment in real-world scenarios and practical applicability.

Academic clinician frontline-worker wellbeing and resilience during the COVID-19 pandemic experience: Were there gender differences?

Prior research suggests COVID-19 has amplified stress on Academic Clinician Frontline-Workers (ACFW). The aim of this paper is: (1) to better understand the experiences of ACFW during the COVID-19 pandemic including their mental-emotional wellbeing, academic productivity, clinical experiences, and (2) to examine any gender differences. A cross-sectional survey was administered to University of Minnesota/M Health Fairview systems' faculty February-June 2021. Of the 291 respondents, 156 were clinicians, with 91 (58 %) identifying as Frontline-Workers (ACFW). Faculty wellbeing was assessed using validated measures in addition to measures of productivity and sociodemographics. For example, ACFW reported a higher Work-Family Conflict (WFC) scores compared to non-ACFW (26.5 vs. 24.1, p = 0.057) but did not report higher Family-Work Conflict (FWC) scores (17.7 vs. 16.3, p = 0.302). Gender sub-analyses, revealed that women ACFW compared to men ACFW reported higher WFC scores (27.7 vs. 24.1, p = 0.021) and FWC (19.3 vs. 14.3, p = 0.004). Academically, ACFW reported submitting fewer grants and anticipated delays in promotion and tenure due to the COVID-19 (p = 0.035). Results suggest COVID-19 has exacerbated ACFW stress and gender inequities. Reports of anticipated delay in promotion for ACFW may pose a challenge for the long-term academic success of ACFW, especially women ACFW. In addition, women may experience higher FWC and WFC as compared to men. Schools of academic medicine should consider re-evaluating promotion/tenure processes and creating resources to support women ACFW as well as ACFW caregivers.

Epithelioid hemangio-endothelioma (EHE) in NETSARC: The nationwide series of 267 patients over 12 years

EPITHELIOID HEMANGIOENDOTHELIOMA

A NATIONWIDE STUDY: Epithelioid hemangioendothelioma (EHE) is an ultrarare sarcoma whose natural history and treatment is not well defined. We report on the presentation and outcome of 267 patients with EHE in the NETSARC+ network since 2010 in France.

PATIENTS AND METHODS

NETSARC (netsarc.org) is a network of 26 reference sarcoma centres with specialised multidisciplinary tumour boards (MDTB), funded by the French National Cancer Institute (NCI), Institut National du Cancer (INCA). Since 2010, presentation to an MDTB and second pathological review are mandatory for sarcoma patients. Patients' characteristics are collected in a nationwide database regularly monitored with stable incidence since 2013. The characteristics of patients with EHE at diagnosis are presented as well as progression-free survival (PFS), overall survival (OS), and outcome under treatment.

RESULTS

Two hundred and sixty-seven patients with EHE were included in the NETSARC+ database since 2010. Median age in the series was 51 (range 10-90) years, 58% were women. Median tumour size was 37 mm (4-220). Forty-eight percent, 42%, and 10% were visceral, soft parts, or bone primaries. The most frequent sites were liver (28%), lung (13%). 40% were reported to have systemic (i.e. multifocal or metastatic disease) at diagnosis. With a median follow-up of 20 months, OS and PFS rates at 24 months were 82% and 67%, with 10-year projected OS and PFS of 62% and 21% respectively. Male and M+ patients at diagnosis had a significantly worse OS, but not PFS. Local treatment was associated with a favourable survival in localised but not in patients with advanced stage at diagnosis. For 23 patients receiving medical treatment, PFS and OS were 50.2% and 33.2% at 60 months were respectively.

CONCLUSIONS

EHE is a frequently metastatic sarcoma at diagnosis with a unique natural history. This study shows in a nationwide series over 12 years that most patients progressed but are still alive at 10 years, both in localised and metastatic stages.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Impact of severe acute respiratory syndrome coronavirus 2 on ectopic pregnancy management in the United Kingdom: a multicentre observational study

Objective

To describe the impact of coronavirus disease 2019 (COVID‐19) on the management of women with ectopic pregnancy.

Design

A multicentre observational study comparing outcomes from a prospective cohort during the pandemic [COVID‐19‐ectopic pregnancy registry (CEPR)] compared with a historical pre‐pandemic cohort [non‐COVID‐19‐ectopic pregnancy registry (NCEPR)].

Setting

Five London university hospitals.

Population and methods

Consecutive patients diagnosed clinically and/or radiologically with ectopic pregnancy (March 2020–August 2020) were entered into the CEPR and results were compared with the NCEPR cohort (January 2019–June 2019). An adjusted analysis was performed for potentially confounding variables.

Main outcome measures

Patient demographics, management (expectant, medical and surgical), length of treatment, number of hospital visits (non‐surgical management), length of stay (surgical management) and 30‐day complications.

Results

Three hundred and forty‐one women met the inclusion criteria: 162 CEPR and 179 NCEPR. A significantly lower percentage of women underwent surgical management versus non‐surgical management in the CEPR versus NCEPR (58.6%; 95/162 versus 72.6%; 130/179; P = 0.007). Among patients managed with expectant management, the CEPR had a significantly lower mean number of hospital visits compared with NCEPR (3.0, interquartile range [IQR] [3, 5] versus 9.0, [5, 14]; P = <0.001). Among patients managed with medical management, the CEPR had a significantly lower median number of hospital visits versus NCEPR (6.0, [5, 8] versus 9, [6, 10]; P = 0.003). There was no observed difference in complication rates between cohorts.

Conclusion

Women were found to undergo significantly higher rates of non‐surgical management during the COVID‐19 first wave compared with a pre‐pandemic cohort. Women managed non‐surgically in the CPER cohort were also managed with fewer hospital attendances. This did not lead to an increase in observed complication rates.

Tweetable abstract

A higher rate of non‐surgical management of ectopic pregnancy during the COVID‐19 pandemic did not increase complication rates.

A higher rate of non‐surgical management of ectopic pregnancy during the COVID‐19 pandemic did not increase complication rates.

219 Documentation of Scrotal Examination in Male Children with Abdominal Pain

Background

Abdominal pain is a common presentation in all age groups with 7-10% of emergency department admissions.

Method

This registered audit looks at male children (aged &lt;16), admitted with abdominal pain during this period. Approximately 2,877 children under the age of sixteen were admitted, 1,582 males. This equates to 55% of children admitted within 3 months. Manual note analysis from ED records identified 53 males &lt;16 years of age with abdominal pain for inspection of documentation.

Results

45% of inspected notes had documented genital and scrotal examination, none of which had a documented consent. In addition, 21% had a documented chaperone for the intimate examination. None of the cases had BOTH consent and presence of chaperone documented.

Conclusions

A common presentation in children lacks significant elements of documentation. This is noted in multiple specialties. Potentially overlooked aspects of examination can lead to missed or delayed identification of time sensitive diagnosis namely testicular torsion, with possible substantial legal, professional, and financial consequences.

To improve the quality of documentation, education at junior doctor level has been carried out, with further analysis to take place and with the view to incorporate the three elements of an intimate examination: consent, chaperone, and findings.

Highly pathogenic avian influenza virus H5N6 (clade 2.3.4.4b) has a preferable host tropism for waterfowl reflected in its inefficient transmission to terrestrial poultry

Highly-pathogenic avian influenza virus (HPAIV) H5N6 (clade 2.3.4.4b) incurred into Europe in late 2017 and was predominantly detected in wild birds, with very few terrestrial poultry cases. Pekin ducks directly-infected with a UK virus (H5N6-2017) were donors of infection to investigate contact transmission to three recipient species: Ducks, chickens and turkeys. H5N6-2017 transmission to ducks was 100% efficient, but transmission to in-contact galliforme species was infrequent and unpredictable, thereby reflecting the European 2017-2018 H5N6 epidemiology. Although only two of 28 (7%) infected ducks died, the six turkeys and one chicken which became infected all died and displayed systemic H5N6-2017 dissemination, while pathogenesis in ducks was generally milder. Analysis of H5N6-2017 progeny in the contacts revealed no emergent polymorphisms in an infected duck, but the galliforme species included changes in the polymerase (PB2 A199T, PA D347A), matrix (M1 T218A) and neuraminidase genes (T88I). H5N6-2017 environmental contamination was associated with duck shedding.

A computational method for immune repertoire mining that identifies novel binders from different clonotypes, demonstrated by identifying anti-pertussis toxoid antibodies

Due to their shared genetic history, antibodies from the same clonotype often bind to the same epitope. This knowledge is used in immune repertoire mining, where known binders are used to search bulk sequencing repertoires to identify new binders. However, current computational methods cannot identify epitope convergence between antibodies from different clonotypes, limiting the sequence diversity of antigen-specific antibodies that can be identified. We describe how the antibody binding site, the paratope, can be used to cluster antibodies with common antigen reactivity from different clonotypes. Our method, paratyping, uses the predicted paratope to identify these novel cross clonotype matches. We experimentally validated our predictions on a pertussis toxoid dataset. Our results show that even the simplest abstraction of the antibody binding site, using only the length of the loops involved and predicted binding residues, is sufficient to group antigen-specific antibodies and provide additional information to conventional clonotype analysis.

Abbreviations: BCR: B-cell receptor; CDR: complementarity-determining region; PTx: pertussis toxoid

Sub-megahertz linewidth 780.24 nm distributed feedback laser for 87Rb applications

A distributed feedback GaAs-based semiconductor laser with a laterally coupled grating is demonstrated at a wavelength of 780.24 nm with up to 60 mW power. A mode expander and aluminum-free active layers have been used to reduce the linewidth to 612 kHz while maintaining high output power. The laser demonstrates over 40 dB side-mode suppression ratio with >0.3nm of tuning suitable for atom cooling experiments with the D2 ⁸⁷Rb atomic transition. This laser has substantial potential to be integrated into miniaturized cold atom systems.

Implementation of a Perceptual Controller for an Inverted Pendulum Robot

Perceptual Control Theory (PCT) theorizes that a creature’s behaviour is varied so that their perception can reach and maintain certain fixed limits, despite external disturbances. The distinguishing characteristic of PCT is that the controlled variables are the inputs (perceptions, as opposed to the system outputs). This paper presents the first direct comparison of a PCT controller for a mobile robot (a two-wheeled ‘inverted pendulum’ balancing robot) with a classical control method, LQR. Simulations and experimental validation results show that the performance of the PCT controller is comparable to the LQR controller and better at disturbance rejection.

Fate of Salmonella ssp., Listeria monocytogenes, and Campylobacter ssp., During Fermentation and Drying of Duck Salami

ObjectivesCreating artisanal, dry salami products is an increasing trend for charcuterie companies in the United States. These raw, ready-to-eat products are required by USDA-FSIS to have a scientifically valid HACCP system addressing relevant biological hazards. To our knowledge, no literature exists for the validation (at least a 5 Log10 reduction of pathogens per FSIS) of salami products containing duck. Therefore, an experiment was designed to validate the safety of duck salami. The objectives of this study were to validate the safety of fermented and dried duck salami and to investigate if a duck salami manufacturing processes could achieve a 5 LOG10 (CFU/g) reduction of Salmonella ssp., Listeria monocytogenes, and Campylobacter ssp.Materials and MethodsDuck trim and pork belly (70% duck trim, 30% pork belly) were placed in a mixed culture bath approximating three liters. The culture bath was made by growing individually and then combining three strains each of Salmonella spp. and Listeria monocytogenes, two strains of Campylobacter jejuni, and one strain of Campylobacter coli. After inoculation, meat was air dried (30 min @ 23°C), tumbled with one liter of 2.5% BeefxideÒantimicrobial treatment (lactic and citric acid and hydrogen peroxide), and placed in a walk-in cooler (2–4°C) overnight. After inoculation and antimicrobial treatment (∼24 h), the meat was ground (6mm grinding plate) and seasoned with salt (2.5%), cure (NaNO3 & NaNO2), spices, and starter culture. The ground duck-pork mixture was stuffed into 55mm collagen casings, fermented for 48 h (23°C, 95% rH), and dried (12°C, 75% rH) to ∼45% weight loss (approx. 5 wk). Salamis were then vacuum packaged and stored at 23°C (approx. 4 wk). Three independent replications were conducted, and pathogen concentrations, pH, and water activity (aw) were analyzed at Days 0, 1, 2, 3, 5, 10, and weekly until Day 66 during each replication. Critical parameters for production included a final pH less than 5.3 and final aw less than 0.90.ResultsA 5 LOG10(CFU/g) reduction was achieved for all three pathogens. Salmonella achieved a 5.47 LOG10(CFU/g) (p < 0.0001) reduction by Day 38, Listeria monocytogenes achieved a 5.20 LOG10(CFU/g) (p < 0.0001) reduction by Day 59, and Campylobacter achieved a 6.85 LOG10(CFU/g) (p < 0.0001) reduction by Day 45. Final reductions of 7.03 (p < 0.0001), 5.90 (p < 0.0001), and 7.19 (p < 0.0001) LOG10(CFU/g) were achieved for Salmonella spp., Listeria monocytogenes, and Campylobacter spp., respectively. During the entire fermentation and drying process, populations of each species never increased by more than 1 LOG10 (CFU/cm2). A final pH of 5.11 and a final aw of 0.81 were also achieved.ConclusionThe results of this study indicate that the parameters used to ferment and dry this product are able to achieve a 5 LOG10 (CFU/g) reduction of each pathogen to validate the safe production of duck salami.

Detection of Simulated Fukushima Daichii Fuel Debris Using a Remotely Operated Vehicle at the Naraha Test Facility

The use of robotics in harsh environments, such as nuclear decommissioning, has increased in recent years. Environments such as the Fukushima Daiichi accident site from 2011 and the Sellafield legacy ponds highlight the need for robotic systems capable of deployment in hazardous environments unsafe for human workers. To characterise these environments, it is important to develop robust and accurate localization systems that can be combined with mapping techniques to create 3D reconstructions of the unknown environment. This paper describes the development and experimental verification of a localization system for an underwater robot, which enabled the collection of sonar data to create 3D images of submerged simulated fuel debris. The system was demonstrated at the Naraha test facility, Fukushima prefecture, Japan. Using a camera with a bird’s-eye view of the simulated primary containment vessel, the 3D position and attitude of the robot was obtained using coloured LED markers (active markers) on the robot, landmarks on the test-rig (passive markers), and a depth sensor on the robot. The successful reconstruction of a 3D image has been created through use of a robot operating system (ROS) node in real-time.

Analysis of unstable degradation impurities of a benzodiazepine and their quantification without isolation using multiple linear regression

This manuscript presents a novel methodology for calculating the relative response factors (RRFs) of unstable degradation impurities of molibresib (1). The degradation impurities were observed by HPLC during stress testing and were accompanied by large mass balance deficits. However, the impurities could not be isolated for traditional RRF determination due to their instability. The RRFs of two degradation impurities were determined without isolation by multiple linear regression analysis of HPLC-UV data. The results permitted accurate quantification of the degradants. The benefits and drawbacks of the approach are discussed, including suggested validation acceptance criteria.

Advanced motions for hexapods

Advanced motions, which utilize footholds on walls, offer considerably more opportunities for hexapods in accessing confined environment. However, there has been no research on the practical application of such motions on a hexapod. These motions are kinematically viable for the standard hexapod design with three degrees of freedom per leg but the joint requirements have yet to be identified. This article presents the motion analysis for two forms of advanced motion, wall walking and chimney walking, to study the joint requirement for executing such motions. The analysis has been verified through a series of experiments demonstrating that a hexapod with a standard design is capable of executing advanced motions.

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

OBJECTIVE

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Attenuated post-fire fauna succession: the effects of surrounding landscape context on post-fire colonisation of fauna

Context After fire, immigration from outside burnt areas is important for the recovery of faunal communities. However, for recovery to occur, the matrix around the fire must support source populations of immigrants. Therefore, the landscape context of fires may be a critical determinant of the species pool available for (re)colonisation, hence post-fire community composition. Increasingly, fires occur in fragmented systems, and there is limited knowledge of how the surrounding landscape interacts with post-fire community recovery. Aim The present study aimed to examine how landscape context influences faunal communities after large wildfires. Methods Three reserves burnt by wildfire were examined ~18 months before the study in the Mallee region of south-eastern Australia. In all cases the burnt area consisted of natural mallee woodland. Two fires occurred within a matrix of extensive natural vegetation, while the third fire burnt &gt;80% of a reserve situated within a highly fragmented, largely agricultural landscape. Birds, reptiles and mammals were surveyed at 90 sites inside and outside the fire boundaries, and relationships of species occurrence to reserve location, burnt versus unburnt status and distance from fire edge were all examined. Key results Post-fire faunal communities reflected the species in the surrounding unburnt landscape. Notably, open habitat specialists, invasive species and species that can persist in small habitat patches were prominent within the fragmented system. Post-fire fauna communities were also influenced by variation of the natural vegetation surrounding the fire. The occurrence of species with low dispersal ability (i.e. reptiles) was influenced by local (patch scale) vegetation structure. 2Conclusions The landscape context of fires is a major driver of the composition of post-fire faunal communities. Our results highlight the potential loss of species sensitive to fragmentation from fire-prone natural vegetation within modified landscapes, and that a reduced pool of potential immigrants leads to ‘attenuated succession’, compromising recovery of the pre-fire community. Implications Post-fire colonists reflect the surrounding landscapes species pool, such that reserves surrounded by fragmented or otherwise low quality habitat are at risk of attenuated succession after fire. Landscape context should be incorporated into conservation planning in fire-prone ecosystems, including consideration of surrounding habitat quality and connectivity and protecting long unburnt vegetation.

Oxaliplatin, 5-Fluorouracil and Nab-paclitaxel as perioperative regimen in patients with resectable gastric adenocarcinoma: A GERCOR phase II study (FOXAGAST)

BACKGROUND

5-Fluorouracil (5-FU) and platinum-based perioperative chemotherapy is standard of care for resectable gastric adenocarcinoma (RGA). Nanoparticle albumin-bound (Nab-) paclitaxel is active in advanced disease but has never been evaluated in the perioperative setting. The objective was to evaluate the efficacy of Nab-paclitaxel in combination with FOLFOX for RGA patients.

METHODS

We performed a non-randomised, open-label, phase II study. RGA patients were assigned to receive neoadjuvant Nab-paclitaxel (150 mg/m²) and FOLFOX q2w for six cycles. Six additional post-operative cycles were kept at the investigator's discretion. The primary end-point was complete pathological response (tumour regression grade [TRG1]) rate. According to Fleming design, 49 patients were required to test H₀ (10% TRG1) and H₁ (25% TRG1). To reject H₀, TRG1 had to be achieved in 8 patients.

RESULTS

Forty-nine patients were included. Median number of neoadjuvant chemotherapy cycles was 6 (range, 3-6). Median dose intensity for Nab-paclitaxel, oxaliplatin and 5-FU was 96% (38-103%), 97% (47-103%) and 99% (50-112%), respectively. Surgery could not be performed in 5 (10.2%) patients. Tumour resection was R0 for 42 of 44 (95.5%) patients. Pathological review classified tumours as TRG1 to TRG5 for 8 (16.3%), 11 (22.5%), 4 (8.2%), 18 (36.7%) and 3 (6.1%) patients, respectively. Grade 3 or worse toxicities during neoadjuvant chemotherapy were non-febrile neutropenia (20.4%), nausea (8.2%), diarrhoea (8.2%) and neuropathy (6.1%). Of 44 patients, 14 (31.8%) experienced surgery-related complications and three (6.8%) died of surgical complications.

CONCLUSION

This regimen shows promising activity. Toxicity is manageable but a meaningful rate of surgical complications was observed. This strategy deserves investigation in phase III studies.

A feasibility study of a novel low-level light therapy for digital ulcers in systemic sclerosis

Background: Locally acting, well-tolerated treatments for systemic sclerosis (SSc) digital ulcers (DUs) are needed.

Objectives: Our primary aim was to investigate the safety, feasibility, and tolerability of a novel low-level light therapy (LTTT). A secondary aim was to tentatively assess efficacy.

Methods: A custom-built device comprising infrared (850 nm), red (660 nm), and violet (405 nm) LEDs was utilized. DUs were irradiated with 10 J/cm² twice weekly for 3 weeks, with follow-up at weeks 4 and 8. Any safety concerns were documented. Patient opinion on time to deliver, feasibility, and pain visual analogue score (VAS; 0–100, 100 most severe) was collected. Patient and clinician DU global assessment VAS were documented. DUs were evaluated by laser Doppler perfusion imaging pre- and post-irradiation.

Results: In all, 14 DUs in eight patients received a total of 46 light exposures, with no safety concerns. All patients considered LTTT ‘took just the right amount of time’ and was ‘feasible’, with a low associated mean pain VAS of 1.6 (SD: 5.2). Patient and clinician global DC VAS improved during the study (mean change: –7.1 and –5.2, respectively, both p < .001). DU perfusion significantly increased post-irradiation.

Conclusions: LTTT for DUs is safe, feasible, and well tolerated. There was an early tentative suggestion of treatment efficacy.

Precipitation SELEX: identification of DNA aptamers for calcium phosphate materials synthesis

DNA aptamers that enhance calcium phosphate mineral formation were identified using a novel precipitation SELEX method. The evolved DNA library was substantially enriched in G nucleotides and in predicted G-quadruplex structures, suggesting their importance in the mechanism of mineralization. This work could readily be extended to provide additional novel DNA aptamers for materials synthesis.

A Remote-operated System to Map Radiation Dose in the Fukushima Daiichi Primary Containment Vessel

This paper describes the development of a submersible system based on a remote-operated vehicle coupled with radiation detectors to map the interior of the reactors at the Fukushima Daiichi nuclear power station. It has the aim oflocating fuel debris. The AVEXIS submersible vehicle used in this study has been designed as a low-cost, potentially disposable, inspection platform that is the smallest of its class and is capable of being deployed through a 150 mm diameter access pipe. To map the gamma-ray environment, a cerium bromide scintillator detector with a small form factor has been incorporated into the AVEXIS to identify radioactive isotopes via gamma-ray spectroscopy. This provides the combined system with the potential to map gamma-ray spectra and particle locations throughout submerged, contaminated facilities, such as Units 1, 2 and 3 of the Fukushima Daiichi nuclear power plant. The hypothesis of this research is to determine the sensitivity of the combined system in a submerged environment that replicates the combination of gamma radiation and water submersion but at lower dose rates.

Mal de Debarquement Syndrome: a survey on subtypes, misdiagnoses, onset and associated psychological features

Introduction

Mal de Debarquement Syndrome (MdDS) is a neurological condition typically characterized by a sensation of motion, that persists longer than a month following exposure to passive motion (e.g., cruise, flight, etc.). The most common form of MdDS is motion triggered (MT). However, recently it has been acknowledged that some patients develop typical MdDS symptoms without an apparent motion trigger. These cases are identified here as spontaneous or other onset (SO) MdDS. This study aimed to address similarities and differences between the MdDS subtypes. Diagnostic procedures were compared and extensive diagnostic guidelines were proposed. Second, potential triggers and associated psychological components of MdDS were revealed.

Methods

This was a retrospective online survey study for MT and SO MdDS patients. Participants were required to respond to a set of comprehensive questions regarding epidemiological details, as well as the diagnostic procedures and onset triggers.

Results

There were 370 patients who participated in the surveys. It is indicated that MdDS is often misdiagnosed; more so for the SO group. In addition to the apparent self-motion, both groups reported associated levels of stress, anxiety and depression.

Discussion

It appears at present that both MdDS subtypes are still poorly recognised. This was the first attempt to evaluate the diagnostic differences between MdDS subtypes and to propose a set of comprehensive diagnostic guidelines for both MdDS subtypes. In addition, the current research addressed that associated symptoms such as stress, anxiety and depression should also be considered when treating patients. We hope this study will help the medical community to broaden their awareness and diagnostic knowledge of this condition.

Electronic supplementary material

The online version of this article (10.1007/s00415-017-8725-3) contains supplementary material, which is available to authorized users.