Longitudinal Metabolite Changes in Progressive Multiple Sclerosis: A Study of 3 Potential Neuroprotective Treatments

BACKGROUND

1H-magnetic resonance spectroscopy (1H-MRS) may provide a direct index for the testing of medicines for neuroprotection and drug mechanisms in multiple sclerosis (MS) through measures of total N-acetyl-aspartate (tNAA), total creatine (tCr), myo-inositol (mIns), total-choline (tCho), and glutamate + glutamine (Glx). Neurometabolites may be associated with clinical disability with evidence that baseline neuroaxonal integrity is associated with upper limb function and processing speed in secondary progressive MS (SPMS).

PURPOSE

To assess the effect on neurometabolites from three candidate drugs after 96-weeks as seen by 1H-MRS and their association with clinical disability in SPMS.

STUDY-TYPE

Longitudinal.

POPULATION

108 participants with SPMS randomized to receive neuroprotective drugs amiloride [mean age 55.4 (SD 7.4), 61% female], fluoxetine [55.6 (6.6), 71%], riluzole [54.6 (6.3), 68%], or placebo [54.8 (7.9), 67%].

FIELD STRENGTH/SEQUENCE

3-Tesla. Chemical-shift-imaging 2D-point-resolved-spectroscopy (PRESS), 3DT1.

ASSESSMENT

Brain metabolites in normal appearing white matter (NAWM) and gray matter (GM), brain volume, lesion load, nine-hole peg test (9HPT), and paced auditory serial addition test were measured at baseline and at 96-weeks.

STATISTICAL TESTS

Paired t-test was used to analyze metabolite changes in the placebo arm over 96-weeks. Metabolite differences between treatment arms and placebo; and associations between baseline metabolites and upper limb function/information processing speed at 96-weeks assessed using multiple linear regression models. P-value<0.05 was considered statistically significant.

RESULTS

In the placebo arm, tCho increased in GM (mean difference = -0.32 IU) but decreased in NAWM (mean difference = 0.13 IU). Compared to placebo, in the fluoxetine arm, mIns/tCr was lower (β = -0.21); in the riluzole arm, GM Glx (β = -0.25) and Glx/tCr (β = -0.29) were reduced. Baseline tNAA(β = 0.22) and tNAA/tCr (β = 0.23) in NAWM were associated with 9HPT scores at 96-weeks.

DATA CONCLUSION

1H-MRS demonstrated altered membrane turnover over 96-weeks in the placebo group. It also distinguished changes in neuro-metabolites related to gliosis and glutaminergic transmission, due to fluoxetine and riluzole, respectively. Data show tNAA is a potential marker for upper limb function.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY: Stage 4.

The evolutionary drivers and correlates of viral host jumps

Most emerging and re-emerging infectious diseases stem from viruses that naturally circulate in non-human vertebrates. When these viruses cross over into humans, they can cause disease outbreaks, epidemics and pandemics. While zoonotic host jumps have been extensively studied from an ecological perspective, little attention has gone into characterizing the evolutionary drivers and correlates underlying these events. To address this gap, we harnessed the entirety of publicly available viral genomic data, employing a comprehensive suite of network and phylogenetic analyses to investigate the evolutionary mechanisms underpinning recent viral host jumps. Surprisingly, we find that humans are as much a source as a sink for viral spillover events, insofar as we infer more viral host jumps from humans to other animals than from animals to humans. Moreover, we demonstrate heightened evolution in viral lineages that involve putative host jumps. We further observe that the extent of adaptation associated with a host jump is lower for viruses with broader host ranges. Finally, we show that the genomic targets of natural selection associated with host jumps vary across different viral families, with either structural or auxiliary genes being the prime targets of selection. Collectively, our results illuminate some of the evolutionary drivers underlying viral host jumps that may contribute to mitigating viral threats across species boundaries.

Evaluative contexts facilitate implicit mentalizing: relation to the broader autism phenotype and mental health

One promising account for autism is implicit mentalizing difficulties. However, this account and even the existence of implicit mentalizing have been challenged because the replication results are mixed. Those unsuccessful replications may be due to the task contexts not being sufficiently evaluative. Therefore, the current study developed a more evaluative paradigm by implementing a prompt question. This was assessed in 60 non-autistic adults and compared with a non-prompt version. Additionally, parents of autistic children are thought to show a genetic liability to autistic traits and cognition and often report mental health problems, but the broader autism phenotype (BAP) is an under-researched area. Thus, we also aimed to compare 33 BAP and 26 non-BAP mothers on mentalizing abilities, autistic traits, compensation and mental health. Our results revealed that more evaluative contexts can facilitate implicit mentalizing in BAP and non-BAP populations, and thus improve task reliability and replicability. Surprisingly, BAP mothers showed better implicit mentalizing but worse mental health than non-BAP mothers, which indicates the heterogeneity in the broader autism phenotype and the need to promote BAP mothers' psychological resilience. The findings underscore the importance of contexts for implicit mentalizing and the need to profile mentalizing and mental health in BAP parents.

Experiential Avoidance in Advanced Cancer: a Mixed-Methods Systematic Review

BACKGROUND

People with advanced cancer experience psychological distress due to physical symptoms, functional decline, and a limited prognosis. Difficult thoughts, feelings, and emotions may exacerbate distress and lead to avoidance of these experiences which is sometimes referred to as experiential avoidance (EA). Advanced cancer patients may be more likely to engage in EA especially when no obvious solutions to their problems exist. This study aims to examine the terms used to describe EA, the processes that might indicate EA, associations between EA and psychological distress, and to understand why individuals might engage in EA.

METHODS

A mixed-methods review. Literature search of Medline, Embase, Psych INFO, and CINAHL 1980-October 2019.

INCLUSION

adults ≥ 18 years; advanced cancer not amenable to cure.

EXCLUSION

no measures of EA or psychological distress. Risk of bias and study quality assessed. Evidence of statistical techniques collected. Themes coded, grouped, and developed based on meaning.

RESULTS

Nineteen studies identified, 13 quantitative studies and 6 qualitative. The quantitative of which 6 compared early-stage cancers with advanced cancers and examined subscales of EA alongside mood, quality of life, and psychological distress. EA covers a range or terms of which 'avoidant coping' is the commonest. EA is manifest as cognitive, behavioural, and emotional avoidance. A thematic synthesis suggests the function of EA is to protect people from distress, and from confronting or expressing difficult emotions by avoiding communication about cancer, controlling negative information, and maintaining normality and hope and optimism.

CONCLUSIONS

EA may be beneficial in the short term to alleviate distress, but in the longer term, it can impair function and limit engagement in life. Greater clinical awareness of the complexity of EA behaviours is needed. Clinicians and researchers should define EA precisely and be aware of the function it may serve in the short and longer term. Future research studies may consider using specific measures of EA as a primary outcome, to assess the impact of psychological interventions such as ACT.

Enzymatic synthesis of benzylisoquinoline alkaloids using a parallel cascade strategy and tyrosinase variants

Benzylisoquinoline alkaloid derived pharmaceuticals are widely applied in modern medicines. Recent studies on the microbial production of benzylisoquinolines have highlighted key biological syntheses towards these natural products. Routes to non-natural benzylisoquinolines have been less explored, particularly halogenated compounds which are more challenging. Here, we show the use of a tyrosinase, tyrosine decarboxylase, transaminase, and norcoclaurine synthase which are combined in a parallel cascade design, in order to generate halogenated benzylisoquinoline alkaloids in high enantiomeric excess. Notably, mutagenesis studies are applied to generate tyrosinase mutants, which enhance the acceptance of halogenated tyrosines for use in the biocatalytic cascades developed.

Workplace interventions for cardiovascular diseases: protocol of a systematic review and meta-analysis

INTRODUCTION

Cardiovascular diseases (CVDs) are the number one cause of death globally, impacting on public and private sectors. Current traditional interventions to prevent CVDs are mainly provided in healthcare centres and even when they are effective, they are not enough to reduce the rising prevalence; therefore, additional strategies are needed. Evidence suggests that health interventions in the workplace supply numerous benefits improving cardiovascular risk factor profiles in individuals. Hence, the aim of this systematic review and meta-analysis is to collate the evidence from randomised controlled trials, cluster randomised trials and quasi-experimental studies of workplace interventions to determine their effectiveness in terms of improving cardiovascular risk factors and preventing CVDs.

METHODS AND ANALYSIS

EMBASE, PsycINFO, PubMed, the Cochrane Central Register of Controlled Trials, LILACS, Scopus, Web of Science, WHO International Clinical Trials Registry Platform, ClinicalTrials.gov and ProQuest Dissertations & Theses Global will be searched to include articles on workplace interventions in adults for CVDs events, cardiometabolic risk factors or behavioural risk factors. The study selection, data extraction, risk of bias and the assessment of the quality of the body of evidence will be conducted by two reviewers working in parallel and disagreements will be resolved by consensus or consultations with a third reviewer. Data synthesis will be done by meta-analysis using random-effects models when possible, otherwise the vote counting method will be applied. Statistical heterogeneity will be assessed by a χ² test and I² statistics. The quality of the body of evidence for each outcome will be assessed by applying the Grading of Recommendations, Assessment, Development and Evaluation approach.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review protocol. The results of the systematic review will be published in a peer-reviewed journal and will be publicly available.

PROSPERO REGISTRATION NUMBER

CRD42021276161.

Intimate physical contact between people from different households during the COVID-19 pandemic: a mixed-methods study from a large, quasi-representative survey (Natsal-COVID)

OBJECTIVES

Physical distancing as a non-pharmaceutical intervention aims to reduce interactions between people to prevent SARS-CoV-2 transmission. Intimate physical contact outside the household (IPCOH) may expand transmission networks by connecting households. We aimed to explore whether intimacy needs impacted adherence to physical distancing following lockdown in Britain in March 2020.

METHODS

The Natsal-COVID web-panel survey (July-August 2020) used quota-sampling and weighting to achieve a quasi-representative population sample. We estimate reporting of IPCOH with a romantic/sexual partner in the 4 weeks prior to interview, describe the type of contact, identify demographic and behavioural factors associated with IPCOH and present age-adjusted ORs (aORs). Qualitative interviews (n=18) were conducted to understand the context, reasons and decision making around IPCOH.

RESULTS

Of 6654 participants aged 18-59 years, 9.9% (95% CI 9.1% to 10.6%) reported IPCOH. IPCOH was highest in those aged 18-24 (17.7%), identifying as gay or lesbian (19.5%), and in steady non-cohabiting relationships (56.3%). IPCOH was associated with reporting risk behaviours (eg, condomless sex, higher alcohol consumption). IPCOH was less likely among those reporting bad/very bad health (aOR 0.54; 95% CI 0.32 to 0.93) but more likely among those with COVID-19 symptoms and/or diagnosis (aOR 1.34; 95% CI 1.10 to 1.65). Two-thirds (64.4%) of IPCOH was reported as being within a support bubble. Qualitative interviews found that people reporting IPCOH deliberated over, and made efforts to mitigate, the risks.

CONCLUSIONS

Given 90% of people did not report IPCOH, this contact may not be a large additional contributor to SARS-CoV-2 transmission, although heterogeneity exists within the population. Public health messages need to recognise how single people and partners living apart balance sexual intimacy and relationship needs with adherence to control measures.

A look into retinal organoids: methods, analytical techniques, and applications

Inherited retinal diseases (IRDs) cause progressive loss of light-sensitive photoreceptors in the eye and can lead to blindness. Gene-based therapies for IRDs have shown remarkable progress in the past decade, but the vast majority of forms remain untreatable. In the era of personalised medicine, induced pluripotent stem cells (iPSCs) emerge as a valuable system for cell replacement and to model IRD because they retain the specific patient genome and can differentiate into any adult cell type. Three-dimensional (3D) iPSCs-derived retina-like tissue called retinal organoid contains all major retina-specific cell types: amacrine, bipolar, horizontal, retinal ganglion cells, Müller glia, as well as rod and cone photoreceptors. Here, we describe the main applications of retinal organoids and provide a comprehensive overview of the state-of-art analysis methods that apply to this model system. Finally, we will discuss the outlook for improvements that would bring the cellular model a step closer to become an established system in research and treatment development of IRDs.

An artificial intelligence approach for selecting effective teacher communication strategies in autism education

Effective inclusive education is key in promoting the long-term outcomes of children with autism spectrum conditions (ASC). However, no concrete consensus exists to guide teacher-student interactions in the classroom. In this work, we explore the potential of artificial intelligence as an approach in autism education to assist teachers in effective practice in developing social and educational outcomes for children with ASC. We form a protocol to systematically capture such interactions, and conduct a statistical analysis to uncover basic patterns in the collected observations, including the longer-term effect of specific teacher communication strategies on student response. In addition, we deploy machine learning techniques to predict student response given the form of communication used by teachers under specific classroom conditions and in relation to specified student attributes. Our analysis, drawn on a sample of 5460 coded interactions between teachers and seven students, sheds light on the varying effectiveness of different communication strategies and demonstrates the potential of this approach in making a contribution to autism education.

Nutritional interventions for heart failure patients who are malnourished or at risk of malnutrition or cachexia: a systematic review and meta-analysis

Malnutrition is common in heart failure (HF), and it is associated with higher hospital readmission and mortality rates. This review aims to answer the question whether nutritional interventions aiming to increase protein and energy intake are effective at improving outcomes for patients with HF who are malnourished or at risk of malnutrition or cachexia. Systematic searches of four databases (Medline, Embase, CINAHL and Cochrane Central Register of Controlled Trials (CENTRAL)) were conducted on 21 June 2019. Randomized controlled trials (RCTs) or other interventional studies using protein or energy supplementation for adult HF patients who are malnourished or at risk of malnutrition or cachexia were included. Two independent reviewers assessed study eligibility and risk of bias. Five studies (four RCTs and one pilot RCT) met the inclusion criteria. The majority of studies were small and of limited quality. The pooled weighted mean difference (WMD) for body weight showed a benefit from the nutritional intervention by 3.83 kg (95% confidence interval (CI) 0.17 to 7.50, P = 0.04) from three trials with no significant benefit for triceps skinfold thickness (WMD = - 2.14 mm, 95% CI - 9.07 to 4.79, P = 0.55) from two trials. The combination of personalized nutrition intervention with conventional treatment led to a decrease in all-cause mortality and hospital readmission in one study. Findings of this review suggest that nutritional interventions could potentially improve outcomes in HF patients who are malnourished or at risk of malnutrition. However, the strength of the evidence is poor, and more robust studies with a larger number of participants are needed.

The Role of Decision-Making in Psychological Wellbeing and Risky Behaviours in Autistic Adolescents Without ADHD: Longitudinal Evidence from the UK Millennium Cohort Study

This study examined the development of decision-making and its association with psychological wellbeing and risky behaviours in adolescents with and without autism. Participants included 270 autistic and 9,713 typically developing adolescents. In both samples, those with a diagnosis of attention-deficit/hyperactivity disorder (ADHD) were excluded. Data came from the Millennium Cohort Study, a nationally representative population-based birth cohort. Decision-making was assessed using the Cambridge Gambling Task at ages 11 and 14. Psychological wellbeing (happiness, self-esteem, depressive symptoms and self-harm) and risky/antisocial behaviours were self-reported at age 14. After adjusting for sex, cognitive ability, spatial working memory, socioeconomic status and pubertal status, autistic adolescents showed comparable quality of decision-making to that of their peers at both ages but also a more deliberative decision-making style as they aged. Only in autistic adolescents was this decision-making style associated with positive outcomes.

Evolving robotic surgery training and improving patient safety, with the integration of novel technologies

INTRODUCTION

Robot-assisted surgery is becoming increasingly adopted by multiple surgical specialties. There is evidence of inherent risks of utilising new technologies that are unfamiliar early in the learning curve. The development of standardised and validated training programmes is crucial to deliver safe introduction. In this review, we aim to evaluate the current evidence and opportunities to integrate novel technologies into modern digitalised robotic training curricula.

METHODS

A systematic literature review of the current evidence for novel technologies in surgical training was conducted online and relevant publications and information were identified. Evaluation was made on how these technologies could further enable digitalisation of training.

RESULTS

Overall, the quality of available studies was found to be low with current available evidence consisting largely of expert opinion, consensus statements and small qualitative studies. The review identified that there are several novel technologies already being utilised in robotic surgery training. There is also a trend towards standardised validated robotic training curricula. Currently, the majority of the validated curricula do not incorporate novel technologies and training is delivered with more traditional methods that includes centralisation of training services with wet laboratories that have access to cadavers and dedicated training robots.

CONCLUSIONS

Improvements to training standards and understanding performance data have good potential to significantly lower complications in patients. Digitalisation automates data collection and brings data together for analysis. Machine learning has potential to develop automated performance feedback for trainees. Digitalised training aims to build on the current gold standards and to further improve the 'continuum of training' by integrating PBP training, 3D-printed models, telementoring, telemetry and machine learning.

Assessment of nutritional status in children with kidney diseases-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

In children with kidney diseases, an assessment of the child's growth and nutritional status is important to guide the dietary prescription. No single metric can comprehensively describe the nutrition status; therefore, a series of indices and tools are required for evaluation. The Pediatric Renal Nutrition Taskforce (PRNT) is an international team of pediatric renal dietitians and pediatric nephrologists who develop clinical practice recommendations (CPRs) for the nutritional management of children with kidney diseases. Herein, we present CPRs for nutritional assessment, including measurement of anthropometric and biochemical parameters and evaluation of dietary intake. The statements have been graded using the American Academy of Pediatrics grading matrix. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs based on the clinical judgment of the treating physician and dietitian. Audit and research recommendations are provided. The CPRs will be periodically audited and updated by the PRNT.

The Pair Test: A computerised measure of learning and memory

There is increasing interest in the assessment of learning and memory in typically developing children as well as in children with neurodevelopmental disorders. However, neuropsychological assessments have been hampered by the dearth of standardised tests that enable direct comparison between distinct memory processes or between types of stimulus materials. We developed a tablet-based paired-associate learning paradigm, the Pair Test, based on neurocognitive models of learning and memory. The aims are to (i) establish the utility of this novel memory tool for use with children across a wide age range, and (ii) examine test validity, reliability and reproducibility of the construct. The convergent validity of the test was found to be adequate, and higher test reliability was shown for the Pair Test compared to standardised measures. Moderate test-retest reproducibility was shown, despite a long time interval between sessions (14 months). Moreover, the Pair Test is able to capture developmental changes in memory, and can therefore chart the developmental trajectory of memory and learning functions across childhood and adolescence. Finally, we used this novel instrument to acquire normative data from 130 typically developing children, aged 8-18 years. Age-stratified normative data are provided for learning, delayed recall and delayed recognition, for measures of verbal and non-verbal memory. The Pair Test thus provides measures of learning and memory accounting for encoding, consolidation and retrieval processes. As such, the standardised test results can be used to determine the status of learning and memory in healthy children, and also to identify deficits in paediatric patients at risk of damage to the neural network underlying mnemonic functions.

The direct and indirect impact of the COVID-19 pandemic on the care of patients with pituitary disease: a cross sectional study

PURPOSE

The coronavirus disease 2019 (COVID-19) pandemic is widely believed to have had a major impact on the care of patients with pituitary disease. The virus itself may directly result in death, and patients with adrenal insufficiency, often a part of hypopituitarism, are thought to represent a particularly susceptible subgroup. Moreover, even in patients that do not contract the virus, the diversion of resources by healthcare institutions to manage the virus may indirectly result in delays in their management. To this end, the aim of this study was to determine the direct and indirect impact of the COVID-19 pandemic on patients with pituitary disease.

METHODS

A cross-sectional study design was adopted, with all adult patients seen by our pituitary service in the year prior to the nationwide lockdown on March 23rd 2020 invited to participate in a telephone survey.

RESULTS

In all, 412 patients (412/586; 70.3%) participated in the survey. 66 patients (66/412; 16.0%) reported having suspected COVID-19 infection. Of the 10 patients in this group tested for COVID-19 infection, three received a positive test result. No deaths due to COVID-19 were identified. 267 patients (267/412; 64.8%) experienced a delay or change in the planned care for their pituitary disease, with 100 patients (100/412; 24.3%) perceiving an impact to their care.

CONCLUSIONS

Whilst only a small percentage of patients had confirmed or suspected COVID-19 infection, over half were still indirectly impacted by the pandemic through a delay or change to their planned care.

Trajectories in nanotechnology: embracing complexity, seeking analogies

This account comprises personal reflections on the field of nanosystems primarily designed for the delivery of biologically active agents. It emphasises the colloidal nature of nanoparticles obeying the same physical laws that dictate the behaviour of disperse systems. Research reveals not only intrinsic complexities but a variety of possible trajectories in vivo and ex vivo, issues of stability, interactions and behaviour in a range of often constrained environments. Such are the variations in the chemical and physical nature of the nanosystems and the active agents they carry, their putative "targets" and the many biological systems and models in which they are employed, it is not possible to generalise. Stochastic events may exclude precise prediction or extrapolation of outcomes, but embracing and studying complexity lead to new insights, often aided by consideration of analogies in cognate areas. This is part of the process of illumination. Unexpected results provide the true essence and excitement of scientific endeavour. Simplification is perhaps its antithesis.

Perceptions, attitudes and training needs of primary healthcare professionals in identifying and managing frailty: a qualitative study

PURPOSE

Although frailty can be delayed or prevented by appropriate interventions, these are often not available in countries lacking formal education and infrastructure in geriatrics. The aim of this study was to: (a) explore ideas, perceptions and attitudes of primary health care (PHC) professionals towards frailty in a country where geriatrics is not recognised as a specialty; (b) explore PHC professionals' training needs in frailty; and (c) define components of a frailty educational programme in PHC.

METHODS

Qualitative design, using two focus groups with PHC professionals conducted in Thessaloniki, Greece. Focus groups were audio recorded and transcribed. Data were analysed with thematic analysis.

RESULTS

In total 31 PHC professionals (mean age: 46 years; gender distribution: 27 females, 4 males) participated in the study (physicians n = 17; nurses n = 12; health visitors n = 2). Four main themes were identified: (1) Perceptions and understanding of frailty; (2) Facilitators and barriers to frailty identification and management; (3) Motivation to participate in a frailty training programme; (4) Education and training. The main barriers for the identification and management of frailty were associated with the healthcare system, including duration of appointments, a focus on prescribing, and problems with staffing of allied health professionals, but also a lack of education. Training opportunities were scarce and entirely based on personal incentive. Professionals were receptive to training either face-to-face or online. A focus on learning practical skills was key.

CONCLUSION

Education and training of professionals and interdisciplinary collaboration are essential and much needed for the delivery of person-centred care for people with frailty living in the community.

Altered sensory innervation and pain hypersensitivity in a model of young painful arthritic joints: short- and long-term effects

BACKGROUND

Early life experience can cause long-term alterations in the nociceptive processes underlying chronic pain, but the consequences of early life arthritic joint inflammation upon the sensory innervation of the joint is not known. Here, we measure pain sensitivity and sensory innervation in a young, juvenile and adult rodent model of arthritic joints and test the consequences of joint inflammation in young animals upon adult arthritic pain and joint innervation.

METHODS

Unilateral ankle joint injections of complete Freund's adjuvant (CFA) (6-20 µl) were performed in young, postnatal day (P)8, adolescent (P21) and adult (P40) rats. A separate cohort of animals were injected at P8, and again at P40. Hindpaw mechanical sensitivity was assessed using von Frey monofilaments (vF) for 10 days. Nerve fibres were counted in sections through the ankle joint immunostained for calcitonin gene-related peptide (CGRP) and neurofilament 200 kDa (NF200).

RESULTS

Ankle joint CFA injection increased capsular width at all ages. Significant mechanical pain hypersensitivity and increased number of joint CGRP + ve sensory fibres occurred in adolescent and adult, but not young, rats. Despite the lack of acute reaction, joint inflammation at a young age resulted in significantly increased pain hypersensitivity and CGRP+ fibre counts when the rats were re-inflamed as adults.

CONCLUSIONS

Joint inflammation increases the sensory nociceptive innervation and induces acute pain hypersensitivity in juvenile and adult, but not in young rats. However, early life joint inflammation 'primes' the joint such that adult inflammatory pain behaviour and nociceptive nerve endings in the joint are significantly increased. Early life joint inflammation may be an important factor in the generation and maintenance of chronic arthritic pain.

Covid-19 and the Apocalypse: Religious and Secular Perspectives

The current Covid-19 pandemic has led to existential crises. One way of finding meaning in this is through apocalyptic narratives. We differentiate between religious (based upon eschatology) and secular apocalypticism (based upon radical political and economic change) and argue that both are to be found in the wake of Covid-19 infection. For religious believers, the apocalypse signifies the rapture of the faithful into heaven while those on earth will undergo the tribulations. For secular believers, the apocalypse signifies sociopolitical change. The paper ends by speculating upon the socio-political and economic changes during and after the pandemic- the New Jerusalem.

Mental health of clinical staff working in high-risk epidemic and pandemic health emergencies a rapid review of the evidence and living meta-analysis

PURPOSE

The SARS-CoV-2 / COVID-19 pandemic has raised concerns about the potential mental health impact on frontline clinical staff. However, given that poor mental health is common in acute medical staff, we aimed to estimate the additional burden of work involving high exposure to infected patients.

METHODS

We report a rapid review, meta-analysis, and living meta-analysis of studies using validated measures from outbreaks of COVID-19, Ebola, H1N1 influenza, Middle East respiratory syndrome (MERS), and severe acute respiratory syndrome (SARS).

RESULTS

A random effects meta-analysis found that high-exposure work is not associated with an increased prevalence of above cut-off scoring (anxiety: RR = 1.30, 95% CI 0.87-1.93, Total N = 12,473; PTSD symptoms: RR = 1.16, 95% CI 0.75-1.78, Total N = 6604; depression: RR = 1.50, 95% CI 0.57-3.95, Total N = 12,224). For continuous scoring, high-exposure work was associated with only a small additional burden of acute mental health problems compared to low-exposure work (anxiety: SMD = 0.16, 95% CI 0.02-0.31, Total N = 6493; PTSD symptoms: SMD = 0.20, 95% CI 0.01-0.40, Total N = 5122; depression: SMD = 0.13, 95% CI -0.04-0.31, Total N = 4022). There was no evidence of publication bias.

CONCLUSION

Although epidemic and pandemic response work may add only a small additional burden, improving mental health through service management and provision of mental health services should be a priority given that baseline rates of poor mental health are already very high. As new studies emerge, they are being added to a living meta-analysis where all analysis code and data have been made freely available: https://osf.io/zs7ne/ .

Protein energy wasting; what is it and what can we do to prevent it?

Some children with declining height and BMI SDS fail to respond to optimisation of nutritional intake. As well as poor growth, they have muscle wasting and relative preservation of body fat. This is termed protein energy wasting (PEW). The process results from an interaction of chronic inflammation alongside poor nutritional intake. This review discusses the causes and potential preventative therapies for PEW.

Unaligned connections or enlarging engagements? Tertiary education in developing countries and the implementation of the SDGs

Given that tertiary education (TE) is a sector often associated with exclusion, particularly in low- and middle-income countries (LMICs), where only a small proportion of the population gain access, how well placed is this sector to support the implementation of the SDGs? This article extends our reflections from a recent rigorous review of literature, published from 2010, which looked at the role of tertiary education in low- and lower-middle-income countries. The review noted the sparse literature on a range of development outcomes, with limited attention to some of the key themes of inclusion and sustainability associated with the SDGs. Many studies report on some form of limited connection between TE and development outcomes, also drawing attention to contextual conditions beyond TE that contribute to this. The article considers the reasons for these findings, and some of the difficulties of forming conclusions on a still limited base of research evidence. A second theme in the literature reviewed highlights that where TE establishes partnerships, engagements or cross-institutional alliances, joint and valuable learning in support of the SDGs ensues, enhancing practice and building institutions. Some of the implications of these findings for the positioning of TE in developing countries in the wake of COVID-19 are considered.

Sporting activity after craniosynostosis surgery in children: a source of parental anxiety

PURPOSE

Craniosynostosis correction involves major skull surgery in infancy-a potential source of worry for parents when their treated children begin involvement in sports.

METHODS

Electronic multiple choice survey of parents of children who had undergone craniosynostosis surgery in infancy using 5-point Likert scales.

RESULTS

Fifty-nine completed surveys were obtained from parents of children who had undergone previous craniosynostosis surgery. Mean age of children was 7.8 years (range 3 months to 22 years), with 36 non-syndromic and 23 syndromic cases. The most common surgery was fronto-orbital remodelling (18). Fifty-two of 59 were involved in athletic activity. The most intense sport type was non-contact in 23, light contact in 20, heavy contact in 4 and combat in 5. Participation level was school mandatory in 12, school club in 17, non-school sport club in 21 and regional representative in 2. One child had been advised to avoid sport by an external physician. Mean anxiety (1-5 Likert) increased with sport intensity: non-contact 1.7, light contact 2.2, heavy contact 3.5 and combat 3.6. Twenty-nine of 59 parents had been given specific advice by the Craniofacial Team regarding athletic activity, 28 of which found useful. Three sport-related head injuries were reported, none of which required hospitalisation.

CONCLUSION

Little information exists regarding sports for children after craniosynostosis surgery. This study suggests that parental anxiety remains high, particularly for high impact/combat sports, and that parents would like more information from clinicians about the safety of post-operative sporting activities.

Rapid Conversion of a Biomedical Engineering Laboratory from in Person to Online

Temporary higher education institution closures in response to the 2020 COVID-19 pandemic disrupted student teaching. This paper reports on the rapid conversion of an in person laboratory session to online delivery, within 24 h of the previously scheduled in person session, and two working days after the end of face-to-face teaching at the authors’ institution. To ensure teaching continuity for students, and address intended learning outcomes (ILOs) where possible, we created online material rapidly in a manner familiar to students. Online material followed the same structure as a previously released laboratory script, intended for the in person session, and was presented on the institutional Virtual Learning Environment. The online material comprised experimental data in tables and equipment readouts, brief descriptions, and short videos demonstrating the experimental methods. We assess to what extent the ILOs were met, and argue that clear ILOs help guide changes to teaching methods, to reduce any disruption to student learning. Four aspects of the initiative are highlighted: rapid delivery; familiar structure; familiar delivery; and videos used for emphasis.

Mesenchymal stromal cells and platelet-rich plasma promote tendon allograft healing in ovine anterior cruciate ligament reconstruction

PURPOSE

The effect of bone marrow mesenchymal stromal cells (BMSCs) and platelet-rich plasma (PRP) on tendon allograft maturation in a large animal anterior cruciate ligament (ACL) reconstruction model was reported for the first time. It was hypothesised that compared with non-augmented ACL reconstruction, BMSCs and PRP would enhance graft maturation after 12 weeks and this would be detected using magnetic resonance imaging (MRI).

METHODS

Fifteen sheep underwent unilateral tendon allograft ACL reconstruction using aperture fixation and were randomised into three groups (n = 5). Group 1 received 10 million allogeneic BMSCs in 2 ml fibrin sealant; Group 2 received 12 ml PRP in a plasma clot injected into the graft and bone tunnels; and Group 3 (control) received no adjunctive treatment. At autopsy at 12 weeks, a graft maturation score was determined by the sum for graft integrity, synovial coverage and vascularisation, graft thickness and apparent tension, and synovial sealing at tunnel apertures. MRI analysis (n = 2 animals per group) of the signal-noise quotient (SNQ) and fibrous interzone (FIZ) was used to evaluate intra-articular graft maturation and tendon-bone healing, respectively. Spearman's rank correlation coefficient (r) of SNQ, autopsy graft maturation score and bone tunnel diameter were analysed.

RESULTS

The BMSC group (p = 0.01) and PRP group (p = 0.03) had a significantly higher graft maturation score compared with the control group. The BMSC group scored significantly higher for synovial sealing at tunnel apertures (p = 0.03) compared with the control group. The graft maturation score at autopsy significantly correlated with the SNQ (r = - 0.83, p < 0.01). The tunnel diameter of the femoral tunnel at the aperture (r = 0.883, p = 0.03) and mid-portion (r = 0.941, p = 0.02) positively correlated with the SNQ.

CONCLUSIONS

BMSCs and PRP significantly enhanced graft maturation, which indicates that orthobiologics can accelerate the biologic events in tendon allograft incorporation. Femoral tunnel expansion significantly correlated with inferior maturation of the intra-articular graft. The clinical relevance of this study is that BMSCs and PRP enhance allograft healing in a translational model, and biological modulation of graft healing can be evaluated non-invasively using MRI.

Mitochondrial DNA mutations in renal disease: an overview

Kidneys have a high energy demand to facilitate the reabsorption of the glomerular filtrate. For this reason, renal cells have a high density of mitochondria. Mitochondrial cytopathies can be the result of a mutation in both mitochondrial and nuclear DNA. Mitochondrial dysfunction can lead to a variety of renal manifestations. Examples of tubular manifestations are renal Fanconi Syndrome, which is often found in patients diagnosed with Kearns-Sayre and Pearson's marrow-pancreas syndrome, and distal tubulopathies, which result in electrolyte disturbances such as hypomagnesemia. Nephrotic syndrome can be a glomerular manifestation of mitochondrial dysfunction and is typically associated with focal segmental glomerular sclerosis on histology. Tubulointerstitial nephritis can also be seen in mitochondrial cytopathies and may lead to end-stage renal disease. The underlying mechanisms of these cytopathies remain incompletely understood; therefore, current therapies focus mainly on symptom relief. A better understanding of the molecular disease mechanisms is critical in order to improve treatments.

Altered DNA methylation profiles in blood from patients with sporadic Creutzfeldt-Jakob disease

Prion diseases are fatal and transmissible neurodegenerative disorders caused by the misfolding and aggregation of prion protein. Although recent studies have implicated epigenetic variation in common neurodegenerative disorders, no study has yet explored their role in human prion diseases. Here we profiled genome-wide blood DNA methylation in the most common human prion disease, sporadic Creutzfeldt–Jakob disease (sCJD). Our case–control study (n = 219), when accounting for differences in cell type composition between individuals, identified 38 probes at genome-wide significance (p < 1.24 × 10^–7). Nine of these sites were taken forward in a replication study, performed in an independent case–control (n = 186) cohort using pyrosequencing. Sites in or close to FKBP5, AIM2 (2 probes), UHRF1, KCNAB2 successfully replicated. The blood-based DNA methylation signal was tissue- and disease-specific, in that the replicated probe signals were unchanged in case–control studies using sCJD frontal-cortex (n = 84), blood samples from patients with Alzheimer’s disease, and from inherited and acquired prion diseases. Machine learning algorithms using blood DNA methylation array profiles accurately distinguished sCJD patients and controls. Finally, we identified sites whose methylation levels associated with prolonged survival in sCJD patients. Altogether, this study has identified a peripheral DNA methylation signature of sCJD with a variety of potential biomarker applications.

Long-term mesh complications and reoperation after laparoscopic mesh sacrohysteropexy: a cross-sectional study

INTRODUCTION AND HYPOTHESIS

The paucity of long-term safety and efficacy data to support laparoscopic mesh sacrohysteropexy is noteworthy given concerns about the use of polypropylene mesh in pelvic floor surgery. This study is aimed at determining the incidence of mesh-associated complications and reoperation following this procedure.

METHODS

This was a cross-sectional postal questionnaire study of women who underwent laparoscopic mesh sacrohysteropexy between 2010 and 2018. Potential participants were identified from surgical databases of five surgeons at two tertiary urogynaecology centres in the UK. The primary outcome was patient-reported mesh complication requiring removal of hysteropexy mesh. Secondary outcomes included other mesh-associated complications, reoperation rates and Patient Global Impression of Improvement (PGI-I) in prolapse symptoms. Descriptive statistics and Kaplan-Meier survival analyses were used.

RESULTS

Of 1,766 eligible participants, 1,121 women responded (response proportion 63.5%), at a median follow-up of 46 months. The incidence of mesh complications requiring removal of hysteropexy mesh was 0.4% (4 out of 1,121). The rate of chronic pain service use was 1.8%, and newly diagnosed systemic autoimmune disorders was 5.8%. The rate of reoperation for apical prolapse was 3.7%, and for any form of pelvic organ prolapse it was 13.6%. For PGI-I, 81.4% of patients were "much better" or "very much better".

CONCLUSIONS

Laparoscopic mesh sacrohysteropexy has a low incidence of reoperation for mesh complications and apical prolapse, and a high rate of patient-reported improvement in prolapse symptoms. With appropriate clinical governance measures, the procedure offers an alternative to vaginal hysterectomy with apical suspension. However, long-term comparative studies are still required.

A perspective on the early days of RAS research

The name of the oncogene, ras, has its origin in studies of murine leukemia viruses in the 1960s by Jenny Harvey (H-ras) and by Werner Kirsten (K-ras) which, at high doses, produced sarcomas in rats. Transforming retroviruses were isolated, and its oncogene was named ras after rat sarcoma. From 1979, cellular ras sequences with transforming properties were identified by transfection of tumor DNA initially by Robert Weinberg from rodent tumors, and the isolation of homologous oncogenes from human tumors soon followed, including HRAS and KRAS, and a new member of the family named NRAS. I review these discoveries, placing emphasis on the pioneering research of Christopher Marshall and Alan Hall, who subsequently made immense contributions to our understanding of the functions of RAS and related small GTPases to signal transduction pathways, cell structure, and the behavior of normal and malignant cells.

Mouse models of atherosclerosis and their suitability for the study of myocardial infarction

Atherosclerotic plaques impair vascular function and can lead to arterial obstruction and tissue ischaemia. Rupture of an atherosclerotic plaque within a coronary artery can result in an acute myocardial infarction, which is responsible for significant morbidity and mortality worldwide. Prompt reperfusion can salvage some of the ischaemic territory, but ischaemia and reperfusion (IR) still causes substantial injury and is, therefore, a therapeutic target for further infarct limitation. Numerous cardioprotective strategies have been identified that can limit IR injury in animal models, but none have yet been translated effectively to patients. This disconnect prompts an urgent re-examination of the experimental models used to study IR. Since coronary atherosclerosis is the most prevalent morbidity in this patient population, and impairs coronary vessel function, it is potentially a major confounder in cardioprotective studies. Surprisingly, most studies suggest that atherosclerosis does not have a major impact on cardioprotection in mouse models. However, a major limitation of atherosclerotic animal models is that the plaques usually manifest in the aorta and proximal great vessels, and rarely in the coronary vessels. In this review, we examine the commonly used mouse models of atherosclerosis and their effect on coronary artery function and infarct size. We conclude that none of the commonly used strains of mice are ideal for this purpose; however, more recently developed mouse models of atherosclerosis fulfil the requirement for coronary artery lesions, plaque rupture and lipoprotein patterns resembling the human profile, and may enable the identification of therapeutic interventions more applicable in the clinical setting.

Burnstock and the legacy of the inhibitory junction potential and P2Y1 receptors

The synaptic event called the inhibitory junction potential (IJP) was arguably one of the more important discoveries made by Burnstock and arguably one of his finer legacies. The discovery of the IJP fundamentally changed how electromechanical coupling was visualised in gastrointestinal smooth muscle. Its discovery also set in motion the search for novel inhibitory neurotransmitters in the enteric nervous system, eventually leading to proposal that ATP or a related nucleotide was a major inhibitory transmitter. The subsequent development of purinergic signalling gave impetus to expanding the classification of surface receptors for extracellular ATP, not only in the GI tract but beyond, and then led to successive phases of medicinal chemistry as the P2 receptor field developed. Ultimately, the discovery of the IJP led to the successful cloning of the first P2Y receptor (chick P2Y1) and expansion of mammalian ATP receptors into two classes: metabotropic P2Y receptors (encompassing P2Y1, P2Y2, P2Y4, P2Y6, P2Y11–14 receptors) and ionotropic P2X receptors (encompassing homomeric P2X1–P2X7 receptors). Here, the causal relationship between the IJP and P2Y1 is explored, setting out the milestones reached and achievements made by Burnstock and his colleagues.

Teaching with digital technology

In this survey paper, we describe the state of the field of research on teaching mathematics with technology with an emphasis on the secondary school phase. We synthesize themes, questions, results and perspectives emphasized in the articles that appear in this issue alongside the relevant foundations of these ideas within the key journal articles, handbooks and conference papers. Our aim is to give an overview of the field that provides opportunities for readers to gain deeper insights into theoretical, methodological, practical and societal challenges that concern teaching mathematics with technology in its broadest sense. Although this collection of articles was developed prior to the global coronavirus pandemic, we have taken the opportunity to survey the contributing authors to provide some country perspectives on the impact the pandemic has had on mathematics teaching with technology in the period January-July 2020. We conclude the survey paper by identifying some areas for future research in this increasingly relevant topic.

A novel reusable anti-COVID-19 transparent face respirator with optimized airflow

This novel face mask is designed to be a reusable respirator with a small and highly efficient disposable fabric filter. Respirator material requirements are reduced by 75% compared to traditional designs and allow repeated cleaning or sterilization. The probability of virus particle inhalation is reduced using novel air filtration pathways, through square-waveform design to increase filter airflow. Air enters the mask from right and left side filters, while the area in front of the mouth is isolated. Clear epoxy is used for a transparent frame, allowing lip-reading, and mask edges contain a silicone seal preventing bypass of the filters. The mask is manufactured using silicone molds, eliminating electricity requirements making it economical and viable in developing countries. Computational fluid dynamics numerical studies and Fluent ANSYS software were used to simulate airflow through the filter to optimize filter air path geometry and validate mask design with realistic human requirements. The breathing cycle was represented as a transient function, and N95 filter specifications were selected as a porous medium. The novel design achieved 1.2 × 10⁻³ kg s⁻¹, 20% higher than human requirements, with air streamlines velocity indicating local high speed, forcing and trapping virus particles against filter walls through centrifugal forces.

High-Resolution Manometry-Observations After 15 Years of Personal Use-Has Advancement Reached a Plateau?

PURPOSE OF REVIEW

In the absence of mucosal or structural disease, the aim of investigating the oesophagus is to provide clinically relevant measurements of function that can explain the cause of symptoms, identify pathology and guide effective management. One of the most notable recent advances in the field of oesophageal function has been high-resolution manometry (HRM). This review explores how innovation in HRM has progressed and has far from reached a plateau.

RECENT FINDINGS

HRM technology, methodology and utility continue to evolve; simple additions to the swallow protocol (e.g. eating and drinking), shifting position, targeting symptoms and adding impedance sensors to the HRM catheter have led to improved diagnoses, therapeutic decision-making and outcomes. Progress in HRM persists and shows little sign of abating. The next iteration of the Chicago Classification of motor disorders will highlight these advances and will also identify opportunities for further research and innovation.

Management strategies for children with COVID-19: ESPR practical recommendations

During the outbreak of the COVID-19 pandemic, guidelines have been issued by international, national and local authorities to address management and the need for preparedness. Children with COVID-19 differ from adults in that they are less often and less severely affected. Additional precautions required in the management of children address their increased radiosensitivity, need for accompanying carers, and methods for dealing with children in a mixed adult-paediatric institution. In this guidance document, our aim is to define a pragmatic strategy for imaging children with an emphasis on proven or suspected COVID-19 cases. Children suspected of COVID-19 should not be imaged routinely. Imaging should be performed only when expected to alter patient management, depending on symptoms, preexisting conditions and clinical evolution. In order to prevent disease transmission, it is important to manage the inpatient caseload effectively by triaging children and carers outside the hospital, re-scheduling nonurgent elective procedures and managing symptomatic children and carers as COVID-19 positive until proven otherwise. Within the imaging department one should consider conducting portable examinations with COVID-19 machines or arranging dedicated COVID-19 paediatric imaging sessions and performing routine nasopharyngeal swab testing before imaging under general anaesthesia. Finally, regular personal hygiene, appropriate usage of personal protective equipment, awareness of which procedures are considered aerosol generating and information on how to best disinfect imaging machinery after examinations should be highlighted to all staff members.

Novel Biomarkers in Sinonasal Cancers: from Bench to Bedside

PURPOSE OF REVIEW

Sinonasal cancers are a heterogenous group of rare cancers for which histopathological diagnosis can be very challenging and treatment options are limited for advanced disease in particular. Here, we review the candidacy of novel diagnostic and prognostic biomarkers, and therapeutic targets for sinonasal cancers.

RECENT FINDINGS

Molecular multidimensional analyses of sinonasal cancers have been lagging behind other major cancers, but there are numerous publications describing the discovery of novel candidate biomarkers, e.g. the methylation classifier, originally developed for brain cancers, and gene expression panels for the prediction of response to induction chemotherapy in sinonasal undifferentiated carcinoma. The most promising biomarkers are summarized and discussed further with regard to their clinical applicability and future potential. Many of the described novel biomarkers for sinonasal cancers will eventually overcome the pitfalls associated with the frequently non-specific immunohistological tests. With comprehensive, multidimensional molecular testing of these tumours in collaborative consortia projects, our better understanding of the molecular mechanisms of sinonasal cancers and their carcinogenesis will determine the most useful diagnostic and prognostic biomarkers, allow stringent multi-institutional validation and guide trials on targeted therapies.

Automated White Matter Hyperintensity Segmentation Using Bayesian Model Selection: Assessment and Correlations with Cognitive Change

Accurate, automated white matter hyperintensity (WMH) segmentations are needed for large-scale studies to understand contributions of WMH to neurological diseases. We evaluated Bayesian Model Selection (BaMoS), a hierarchical fully-unsupervised model selection framework for WMH segmentation. We compared BaMoS segmentations to semi-automated segmentations, and assessed whether they predicted longitudinal cognitive change in control, early Mild Cognitive Impairment (EMCI), late Mild Cognitive Impairment (LMCI), subjective/significant memory concern (SMC) and Alzheimer's (AD) participants. Data were downloaded from the Alzheimer's disease Neuroimaging Initiative (ADNI). Magnetic resonance images from 30 control and 30 AD participants were selected to incorporate multiple scanners, and were semi-automatically segmented by 4 raters and BaMoS. Segmentations were assessed using volume correlation, Dice score, and other spatial metrics. Linear mixed-effect models were fitted to 180 control, 107 SMC, 320 EMCI, 171 LMCI and 151 AD participants separately in each group, with the outcomes being cognitive change (e.g. mini-mental state examination; MMSE), and BaMoS WMH, age, sex, race and education used as predictors. There was a high level of agreement between BaMoS' WMH segmentation volumes and a consensus of rater segmentations, with a median Dice score of 0.74 and correlation coefficient of 0.96. BaMoS WMH predicted cognitive change in: control, EMCI, and SMC groups using MMSE; LMCI using clinical dementia rating scale; and EMCI using Alzheimer's disease assessment scale-cognitive subscale (p < 0.05, all tests). BaMoS compares well to semi-automated segmentation, is robust to different WMH loads and scanners, and can generate volumes which predict decline. BaMoS can be applicable to further large-scale studies.

Cardiovascular Magnetic Resonance and Sport Cardiology: a Growing Role in Clinical Dilemmas

Exercise training induces morphological and functional cardiovascular adaptation known as the "athlete's heart" with changes including dilatation, hypertrophy, and increased stroke volume. These changes may overlap with pathological appearances. Distinguishing athletic cardiac remodelling from cardiomyopathy is important and is a frequent medical dilemma. Cardiac magnetic resonance (CMR) has a role in clinical care as it can refine discrimination of health from a disease where ECG and echocardiography alone have left or generated uncertainty. CMR can more precisely assess cardiac structure and function as well as characterise the myocardium detecting key changes including myocardial scar and diffuse fibrosis. In this review, we will review the role of CMR in sports cardiology.

The diagnostic role of diffusional kurtosis imaging in glioma grading and differentiation of gliomas from other intra-axial brain tumours: a systematic review with critical appraisal and meta-analysis

Purpose

We aim to illustrate the diagnostic performance of diffusional kurtosis imaging (DKI) in the diagnosis of gliomas.

Methods

A review protocol was developed according to the (PRISMA-P) checklist, registered in the international prospective register of systematic reviews (PROSPERO) and published. A literature search in 4 databases was performed using the keywords ‘glioma’ and ‘diffusional kurtosis’. After applying a robust inclusion/exclusion criteria, included articles were independently evaluated according to the QUADAS-2 tool and data extraction was done. Reported sensitivities and specificities were used to construct 2 × 2 tables and paired forest plots using the Review Manager (RevMan®) software. A random-effect model was pursued using the hierarchical summary receiver operator characteristics.

Results

A total of 216 hits were retrieved. Considering duplicates and inclusion criteria, 23 articles were eligible for full-text reading. Ultimately, 19 studies were eligible for final inclusion. The quality assessment revealed 9 studies with low risk of bias in the 4 domains. Using a bivariate random-effect model for data synthesis, summary ROC curve showed a pooled area under the curve (AUC) of 0.92 and estimated sensitivity of 0.87 (95% CI 0.78–0.92) in high-/low-grade gliomas’ differentiation. A mean difference in mean kurtosis (MK) value between HGG and LGG of 0.22 (95% CI 0.25–0.19) was illustrated (p value = 0.0014) with moderate heterogeneity (I² = 73.8%).

Conclusion

DKI shows good diagnostic accuracy in the differentiation of high- and low-grade gliomas further supporting its potential role in clinical practice. Further exploration of DKI in differentiating IDH status and in characterising non-glioma CNS tumours is however needed.

Electronic supplementary material

The online version of this article (10.1007/s00234-020-02425-9) contains supplementary material, which is available to authorized users.

Rathke's cleft cysts following transsphenoidal surgery: long-term outcomes and development of an optimal follow-up strategy

BACKGROUND

In patients with symptomatic Rathke's cleft cyst, transsphenoidal surgery is highly effective at preventing further visual loss and usually allows for some recovery of vision. However, cyst recurrence and the need for re-operation are well recognized. To this end, the aim of this study was to investigate patterns of recurrence and long-term outcomes and to use this information to develop an optimal follow-up strategy.

METHOD

A prospectively maintained database was searched over a 10-year period between 1 January 2008 and the 1 January 2018 to identify all adults that underwent transsphenoidal surgery with a new diagnosis of Rathke's cleft cyst. A retrospective case note review was performed for each patient to extract data on their presentation, investigation, treatment, and outcome.

RESULTS

In all, 61 eligible patients were identified. The median follow-up was 34 months (range 2-112 months). In the 22 patients with pre-operative visual loss, the outcomes at 6 months were as follows: normal vision (2/22; 9.1%), improved but not normal (7/22; 31.8%), stable (12/22; 54.5%), worse but not blind (1/22; 4.5%), and blind (0/22; 0%). The overall rate of regrowth and re-operation in our study was 19.7 and 11.5%, respectively. The only factor that was significantly associated with recurrence was the presence of residual cystic disease on the post-operative MRI (p < 0.001).

CONCLUSIONS

We propose a follow-up strategy that stratifies patients at "low risk" if there is no residual cyst, with increasing interval scans, or "high risk" if there is residual cyst, with annual visual assessment and scans.

Fertility History and Biomarkers Using Prospective Data: Evidence From the 1958 National Child Development Study

Research on the later-life health implications of fertility history has predominantly considered associations with mortality or self-reported indicators of health. Most of this previous research has either not been able to account for selection factors related to both early-life and later-life health or has had to rely on retrospectively reported accounts of childhood circumstances. Using the 1958 National Child Development Study, and in particular the biomedical survey conducted in 2002-2003, we investigate associations between fertility histories (number of children and age at first and at last birth) and biomarkers for cardiometabolic risk and respiratory function in midlife among both men and women. Results from models that adjusted for a very wide range of childhood factors, including early-life socioeconomic position, cognitive ability, and mental health, showed weak associations between parity and biomarkers. However, we found an inverse association between age at first birth and biomarkers indicative of worse cardiometabolic health, with poorer outcomes for those with very young ages at entry to parenthood and increasingly better outcomes for those becoming parents at older ages. A very young age at last birth was also associated with less favorable biomarker levels, especially among women. Results highlight the value of prospectively collected data and the availability of biomarkers in studies of life course determinants of health in midlife and later.

On Photographing Artists' Books

Artists' books are challenging to photograph. They function as a unit of tightly conceptually-bound visual, textual and material elements in addition to a heightened self-awareness of the work's booksness. Binding, size, weight, and shape of the book, translucency, texture, thickness of paper, placement of images and/or text on the page or off the page interact with other graphic elements; they control, and direct the reader towards the expressive components of meaning which arise from pace, haptic experience, and visual or structural stylistic choices. Most of such information gets sacrificed in the process of documentation. Here I discuss some of such issues of photographing artists books for this journal and my solutions to replicating each artists' book within the physical and thematic constraints of this publication: I tried not only to visualize the books' content but also to translate some of the experience of how that content makes itself meaningful to the reader.

Energy and protein requirements for children with CKD stages 2-5 and on dialysis-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

Dietary management in pediatric chronic kidney disease (CKD) is an area fraught with uncertainties and wide variations in practice. Even in tertiary pediatric nephrology centers, expert dietetic input is often lacking. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, was established to develop clinical practice recommendations (CPRs) to address these challenges and to serve as a resource for nutritional care. We present CPRs for energy and protein requirements for children with CKD stages 2-5 and those on dialysis (CKD2-5D). We address energy requirements in the context of poor growth, obesity, and different levels of physical activity, together with the additional protein needs to compensate for dialysate losses. We describe how to achieve the dietary prescription for energy and protein using breastmilk, formulas, food, and dietary supplements, which can be incorporated into everyday practice. Statements with a low grade of evidence, or based on opinion, must be considered and adapted for the individual patient by the treating physician and dietitian according to their clinical judgment. Research recommendations have been suggested. The CPRs will be regularly audited and updated by the PRNT.

The dietary management of calcium and phosphate in children with CKD stages 2-5 and on dialysis-clinical practice recommendation from the Pediatric Renal Nutrition Taskforce

In children with chronic kidney disease (CKD), optimal control of bone and mineral homeostasis is essential, not only for the prevention of debilitating skeletal complications and achieving adequate growth but also for preventing vascular calcification and cardiovascular disease. Complications of mineral bone disease (MBD) are common and contribute to the high morbidity and mortality seen in children with CKD. Although several studies describe the prevalence of abnormal calcium, phosphate, parathyroid hormone, and vitamin D levels as well as associated clinical and radiological complications and their medical management, little is known about the dietary requirements and management of calcium (Ca) and phosphate (P) in children with CKD. The Pediatric Renal Nutrition Taskforce (PRNT) is an international team of pediatric renal dietitians and pediatric nephrologists, who develop clinical practice recommendations (CPRs) for the nutritional management of various aspects of renal disease management in children. We present CPRs for the dietary intake of Ca and P in children with CKD stages 2-5 and on dialysis (CKD2-5D), describing the common Ca- and P-containing foods, the assessment of dietary Ca and P intake, requirements for Ca and P in healthy children and necessary modifications for children with CKD2-5D, and dietary management of hypo- and hypercalcemia and hyperphosphatemia. The statements have been graded, and statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs based on the clinical judgment of the treating physician and dietitian. These CPRs will be regularly audited and updated by the PRNT.

Performance assessment of water reuse strategies using integrated framework of urban water metabolism and water-energy-pollution nexus

This paper evaluates the metabolism-based performance of a number of centralised and decentralised water reuse strategies and their impact on integrated urban water systems (UWS) based on the nexus of water-energy-pollution. The performance assessment is based on a comprehensive and quantitative framework of urban water metabolism developed for integrated UWS over a long-term planning horizon. UWS performance is quantified based on the tracking down of mass balance flows/fluxes of water, energy, materials, costs, pollutants, and other environmental impacts using the WaterMet² tool. The assessment framework is defined as a set of key performance indicators (KPIs) within the context of the water-energy-pollution nexus. The strategies comprise six decentralised water reuse configurations (greywater or domestic wastewater) and three centralised ones, all within three proportions of adoption by domestic users (i.e. 20, 50, and 100%). This methodology was demonstrated in the real-world case study of San Francisco del Rincon and Purisima del Rincon cities in Mexico. The results indicate that decentralised water reuse strategies using domestic wastewater can provide the best performance in the UWS with respect to water conservation, green house gas (GHG) emissions, and eutrophication indicators, while energy saving is almost negligible. On the other hand, centralised strategies can achieve the best performance for energy saving among the water reuse strategies. The results also show metabolism performance assessment in a complex system such as integrated UWS can reveal the magnitude of the interactions between the nexus elements (i.e. water, energy, and pollution). In addition, it can also reveal any unexpected influences of these elements that might exist between the UWS components and overall system.

Market integration reduces kin density in women's ego-networks in rural Poland

It is widely assumed that as populations become more market integrated the 'inner circles' of people's social networks become less densely connected and family-oriented. This 'loosening' of kin networks may fundamentally alter the social dynamics of reproduction, facilitating demographic transitions to low fertility. Few data exist to test this hypothesis. Previous research in urbanized populations has not explicitly measured kin density in ego-networks, nor assessed how market integration influences network structure at different levels of aggregation. Here I analyze the ego-networks of ~2000 women in 22 rural Polish communities transitioning from subsistence farming to market-dependence. I compare how ego-network size, density and kin density co-vary with household and community-level market integration. Market integration is associated with less kin-dense networks, but not necessarily less dense ones, and is unrelated to network size. Declining kin density during economic transitions may be a critical mechanism for the broader cultural transmission of low fertility values.

Science Education in the Light of COVID-19: The Contribution of History, Philosophy and Sociology of Science

In this position paper, I examine how the history, philosophy and sociology of science (HPS) can contribute to science education in the era of the COVID-19 pandemic. I discuss shortcomings in the ways that history is often used in school science, and examine how knowledge of previous pandemics might help in teaching about COVID-19. I look at the potential of issues to do with measurement in the context of COVID-19 (e.g. measurement of mortality figures) to introduce school students to issues about philosophy of science, and I show how COVID-19 has the affordance to broaden and deepen the moral philosophy that students typically meet in biology lessons. COVID-19 also provides opportunities to introduce students to sociological ways of thinking, examining data and questioning human practices. It can also enable students to see how science, economics and politics inter-relate. In the final part of the paper, I suggest that there are strong arguments in favour of an interdisciplinary approach in tackling zoonoses like COVID-19 and that there is much to be said for such interdisciplinarity in school science lessons when teaching about socio-scientific issues and issues intended to raise scientific literacy.

Subarachnoid haemorrhage with negative initial neurovascular imaging: a systematic review and meta-analysis

Background

In patients with spontaneous subarachnoid haemorrhage (SAH), a vascular cause for the bleed is not always found on initial investigations. This study aimed to systematically evaluate the delayed investigation strategies and clinical outcomes in these cases, often described as “non-aneurysmal” SAH (naSAH).

Methods

A systematic review was performed in concordance with the PRISMA checklist. Pooled proportions of primary outcome measures were estimated using a random-effects model.

Results

Fifty-eight studies were included (4473 patients). The cohort was split into perimesencephalic naSAH (PnaSAH) (49.9%), non-PnaSAH (44.7%) and radiologically negative SAH identified on lumbar puncture (5.4%). The commonest initial vascular imaging modality was digital subtraction angiography. A vascular abnormality was identified during delayed investigation in 3.9% [95% CI 1.9–6.6]. There was no uniform strategy for the timing or modality of delayed investigations. The pooled proportion of a favourable modified Rankin scale outcome (0–2) at 3–6 months following diagnosis was 92.0% [95% CI 86.0–96.5]. Complications included re-bleeding (3.1% [95% CI 1.5–5.2]), hydrocephalus (16.0% [95% CI 11.2–21.4]), vasospasm (9.6% [95% CI 6.5–13.3]) and seizure (3.5% [95% CI 1.7–5.8]). Stratified by bleeding pattern, we demonstrate a higher rate of delayed diagnoses (13.6% [95% CI 7.4–21.3]), lower proportion of favourable functional outcome (87.2% [95% CI 80.1–92.9]) and higher risk of complications for non-PnaSAH patients.

Conclusion

This study highlights the heterogeneity in delayed investigations and outcomes for patients with naSAH, which may be influenced by the initial pattern of bleeding. Further multi-centre prospective studies are required to clarify optimal tailored management strategies for this heterogeneous group of patients.

Electronic supplementary material

The online version of this article (10.1007/s00701-019-04025-w) contains supplementary material, which is available to authorized users.

The diabesity epidemic in the light of evolution: insights from the capacity-load model

The global nutrition transition, which embraces major changes in how food is produced, distributed and consumed, is associated with rapid increases in the prevalence of obesity, but the implications for diabetes differ between populations. A simple conceptual model treats diabetes risk as the function of two interacting traits: 'metabolic capacity,' which promotes glucose homeostasis, and 'metabolic load', which challenges glucose homoeostasis. Population variability in diabetes prevalence is consistent with this conceptual model, indicating that the effect of obesity varies by ethnicity. Evolutionary life history theory can help explain why variability in metabolic capacity and metabolic load emerges. At the species level (hominin evolution), across human populations and within individual life courses, phenotypic variability emerges under selective pressure to maximise reproductive fitness rather than metabolic health. Those exposed to adverse environments may express or develop several metabolic traits that are individually beneficial for reproductive fitness, but which cumulatively increase diabetes risk. Public health interventions can help promote metabolic capacity, but there are limits to the benefits that can emerge within a single generation. This means that efforts to curb metabolic load (obesity, unhealthy lifestyles) must remain at the forefront of diabetes prevention. Such efforts should go beyond individuals and target the broader food system and socioeconomic factors, in order to maximise their efficacy.