Clinically significant findings in a decade-long retrospective study of prenatal chromosomal microarray testing

BACKGROUND

Chromosomal microarray (CMA) is commonly utilized in the obstetrics setting. CMA is recommended when one or more fetal structural abnormalities is identified. CMA is also commonly used to determine genetic etiologies for miscarriages, fetal demise, and confirming positive prenatal cell-free DNA screening results.

METHODS

In this study, we retrospectively examined 523 prenatal and 319 products-of-conception (POC) CMA cases tested at Nationwide Children's Hospital from 2011 to 2020. We reviewed the referral indications, the diagnostic yield, and the reported copy number variants (CNV) findings.

RESULTS

In our cohort, the diagnostic yield of clinically significant CNV findings for prenatal testing was 7.8% (n = 41/523) compared to POC testing (16.3%, n = 52/319). Abnormal ultrasound findings were the most common indication present in 81% of prenatal samples. Intrauterine fetal demise was the common indication identified in POC samples. The most common pathogenic finding observed in all samples was isolated trisomy 21, detected in seven samples.

CONCLUSION

Our CMA study supports the clinical utility of prenatal CMA for clinical management and identifying genetic etiology in POC arrays. In addition, it provides insight to the spectrum of prenatal and POC CMA results as detected in an academic hospital clinical laboratory setting that serves as a reference laboratory.

Novel inherited CDX2 variant segregating in a family with diverse congenital malformations of the genitourinary system

Anorectal malformations (ARMs) constitute a group of congenital defects of the gastrointestinal and urogenital systems. They affect males and females, with an estimated worldwide prevalence of 1 in 5000 live births. These malformations are clinically heterogeneous and can be part of a syndromic presentation (syndromic ARM) or as a nonsyndromic entity (nonsyndromic ARM). Despite the well-recognized heritability of nonsyndromic ARM, the genetic etiology in most patients is unknown. In this study, we describe three siblings with diverse congenital anomalies of the genitourinary system, anemia, delayed milestones, and skeletal anomalies. Genome sequencing identified a novel, paternally inherited heterozygous Caudal type Homeobox 2 (CDX2) variant (c.722A > G (p.Glu241Gly)), that was present in all three affected siblings. The variant identified in this family is absent from population databases and predicted to be damaging by most in silico pathogenicity tools. So far, only two other reports implicate variants in CDX2 with ARMs. Remarkably, the individuals described in these studies had similar clinical phenotypes and genetic alterations in CDX2 CDX2 encodes a transcription factor and is considered the master regulator of gastrointestinal development. This variant maps to the homeobox domain of the encoded protein, which is critical for interaction with DNA targets. Our finding provides a potential molecular diagnosis for this family's condition and supports the role of CDX2 in anorectal anomalies. It also highlights the clinical heterogeneity and variable penetrance of ARM predisposition variants, another well-documented phenomenon. Finally, it underscores the diagnostic utility of genomic profiling of ARMs to identify the genetic etiology of these defects.

Five-Fraction Stereotactic Radiation for Head and Neck Paragangliomas

PURPOSE/OBJECTIVE(S)

Paragangliomas of the head and neck (HN) are benign, slow-growing neoplasms that are rarely functional. Treatment is often indicated for patients presenting with mass effect, cranial neuropathies, or pulsatile tinnitus. Radiotherapy, traditionally conventionally fractionated, is often used for primary, post-operative, and salvage therapy, given its excellent control rates and reduced risks to adjacent neurovascular structures. Stereotactic ablative radiation (SAbR) offers shorter treatment time, and modern techniques eliminate margins to improve organ-at-risk avoidance. SAbR may offer additional radiobiological sparing of normal structures over single-fraction SAbR. We aimed to evaluate tumor and symptom response, acute and late toxicity rates, and recurrence patterns in HN paraganglioma patients treated with 25 Gy in 5 fractions.

MATERIALS/METHODS

Retrospective chart review collected baseline patient and tumor information, treatment and dosimetry details, acute and long-term toxicity grades (per the CTCAE v. 5.0), symptom and tumor response, and survival. Local control was defined as the absence of local enlargement (per RECIST v. 1.1) or marginal failure and was estimated using the Kaplan-Meier method.

RESULTS

Between December 2009-March 2020, 39 patients received 25 Gy in 5 fractions to 43 HN paragangliomas, of which 17 were treated in 11 patients with hereditary paraganglioma-pheochromocytoma syndrome. Fifteen targets were post-operative recurrent or residual tumors. There were 27 jugulotympanic tumors, 4 jugular, 1 tympanic, 8 vagal, 5 carotid body, and 2 jugulotympanic or vagal. Median follow-up time was 3.3 years (range 0-11.4 years), and 21 targets had at least 4 years of follow-up. Tumor volume decreased by a median of 37%. Three-year local control was 100%. One patient, known to harbor an SDHD mutation, had 2 out-of-field recurrences within the post-operative bed at 7.1 years. Two patients experienced 2 marginal recurrences within the post-operative bed at 6.1 and 8.4 years: one had an SDHB mutation and developed metastatic disease, and the other did not have genetic testing. The most common grade 1-2 acute toxicities were headache and fatigue; the most common grade 1-2 late toxicities were dysphagia and otalgia. There were no grade >2 acute toxicities. A late grade 3 aspiration event was seen in 1 patient who presented with paralyzed vocal cord requiring multiple medialization laryngoplasties. Within 6 months of SAbR, 18% of symptoms or toxicities improved or resolved; 34% improved or resolved more than 6 months after SAbR.

CONCLUSION

This is the largest series of HN paragangliomas treated with SAbR, detailing a 10-year experience with a 5-fraction regimen that is well-tolerated and achieves excellent local control. Post-SAbR recurrences occurred outside of the radiation field but within the post-operative bed, suggesting that some post-operative patients may benefit from expanded radiation volumes or close surveillance for salvage therapy.

Long-term outcomes of SBRT for PSMA PET detected oligometastatic prostate cancer

BACKGROUND

Oligometastatic disease in prostate cancer (PCa) is a challenging clinical scenario encountered more frequently with the widespread adoption of PSMA-PET. SBRT aims to defer androgen deprivation and may deliver sustained biochemical failure (BF) free survival in selected patients. Little long-term data is currently available regarding the effectiveness of this approach.

METHODS

A retrospective single institution study of PSMA-PET directed SBRT without initial ADT for oligo-metachronous PCa. Median dose/fractionation was 24 Gy in 2# to bones and 30 Gy in 3# to lymph nodes. The primary endpoint was time to BF (PSA + 0.2 ug/L above nadir). Secondary endpoints included time to ADT for relapse (i.e. palliative ADT), BF defined as PSA nadir + 2 ug/L, toxicity, patterns of failure and survival. Patients were excluded if they received ADT with their SBRT, had short disease-free interval, or > 3 metastases on PSMA-PET.

RESULTS

103 patients treated from November-2014 to December-2019 were analysed from our prospective database. Median follow-up was 5 years. 64 patients were treated for nodal only disease, 35 bone only and 4 mixed. 15% were free of any BF at 5 years with median time to BF of 1.1 years. 32% (33/103) of patients had further curative-intent radiation treatment following their first BF after SBRT, including subsequent SBRT. Eight patients underwent potentially curative treatment for their second or third relapse. Allowing for salvage treatment, 29/103 (28%) were biochemically disease free at last follow up. At 5 years, 39% of patients had never received any ADT and 55% had not started ADT for relapse with a median time to ADT for relapse of 5.5 years. There were 2 grade 3 toxicities (rib fracture and lymphoedema), and no local failures.

CONCLUSION

PSMA-PET guided SBRT for oligo-metachronous PCa recurrence in appropriately triaged patients results in excellent local control, low toxicity and over 50% ADT free at 5 years.

407 Surgical Site Infection of Renal Transplant Patients Stratified by BMI

Aim

Surgical site infection increases with BMI with values ranging from 20% to greater than 40%. There are increasing numbers of obese patients (BMI >30) undergoing transplants and this audit aims to review the incidence and grade of surgical site infection (SSI) of renal transplant recipients stratified by BMI.

Method

65 renal transplants were performed between April 2020-March 2021 with 58 kidneys from deceased donors and 7 kidneys from live donors. A retrospective review of clinical attendances, GP letters, prescriptions, imaging, and re-admissions was completed. Nearly one-third of the patients had pre-transplant diabetes (32%), and their median BMI was 28 (range 19–40.7). The incidence of SSI was reported after 3 months follow up and graded using the Clavien-Dindo Classification.

Results

The overall rate of SSI was 15%. SSI was 12.8% in patients with BMI<30, 15.8% in BMI 30–34.9, 33.3% in BMI 35–35.9, and 0 in BMI>40 (only one recipient). There was no significant correlation between diabetes and SSI, with 19% of SSI reported in diabetic patients versus 14% in patients without diabetes (p-value=0.7). Two patients had a Clavien-Dindo grade I infection, 1 grade II, and 7 Grade III, with no grade IV or V SSI. No patients required operative management of SSI.

Conclusions

The overall rates of SSI stratified by BMI were within expected limits. Diabetes was not an independent predictor of SSI. No complication required general anesthesia or surgical treatment. When SSI did occur in obese patients it did cause considerable morbidity through number of attendances for dressing changes over 3 months.

663 Potential for Prophylactic Antibiotics in Renal Transplantation: A Retrospective Study of Kidney Perfusion Fluid Cultures and Kidney Cold Ischaemic Time

Aim

Infection is a significant cause of morbidity in kidney transplantation, and it is believed that an increased cold ischemic time is an independent risk factor. Identification of common pathogens in perfusion fluids, as well as the safe limit of cold ischaemic time can be used to reduce the risk of postoperative complications. There are currently no guidelines for prophylactic antibiotics.

Method

This is a retrospective review of the microbiological analysis of kidney perfusion fluids samples for a recipient transplant between 2017–2020. 100 patients were identified in this time period and this data was compared against the cold ischaemic time of the donor kidney.

Results

23% (22/96) samples were positive for bacteria with the majority being gram positive cocci. The most common bacteria grown was Coagulase Negative Staphylococcus (44% - 11/25). However, a broad spectrum of bacteria was grown including Hafnia, Pseudomonas, Klebsiella, Kocuria and E-coli. 3% (3/96) of samples grew two different species of bacteria.

The mean cold ischemic time for all transplants was 799 minutes with a range of 281–1618 minutes. The mean for infected samples was 935 mins with a range of 645–1410. Samples that grew 2 bacteria had a range of 913–941 mins.

Conclusions

There is potential to reduce the risk of infection with the use of broad-spectrum induction antibiotics and it is important that potential bacterial species and common resistance profiles are covered. There is a possible correlation between increased cold ischaemic time and bacterial growth in perfusion fluid however further research is warranted.

Making community pharmacies psychologically informed environments: a pilot study to improve delivery of care for people with a drug problem

Introduction

Community pharmacies are key in the delivery of care to people who use drugs (PWUD), providing specialist harm reduction, and treatment interventions such as naloxone, Injecting Equipment Provision and opiate replacement treatment. PWUD are disproportionately burdened with mental ill-health and frequently report trauma history which impacts on engagement. A successful approach in the homeless sector, is that of Psychologically Informed Environments (PIE). The core elements of a PIE are: creating a space which engenders a sense of safety and wellbeing; reflective practice so staff can develop a shared model of working; training and support for staff; and considering the therapeutic aspects of service provision to vulnerable people (1).

Aim

This pilot study tested training pharmacy staff in applying a psychologically informed environments approach to improve the delivery of care to PWUD.

Methods

Three pharmacies were recruited from those with high involvement with PWUD. A range of location and type of pharmacy were included. Whole pharmacy teams were invited to an evening training session. Bespoke training was provided by clinical psychologists with PIE expertise.

Training was assessed by anonymous quantitative questionnaires using rating scales. Changes in the attitudes of staff were assessed by questionnaire before and 6 months after training. Descriptive statistics were applied. Qualitative interviews with staff at 6 months (planned for 3 months) explored what changes, were made after PIE training to adapt the delivery of care. The study used peer researcher-led telephone interviews for patient/client feedback on observed changes and experiences in participating pharmacies. Recruitment was via the three pharmacy teams due to covid restrictions. Thematic analysis was applied to qualitative data. Normalisation Process Theory provided a framework for assessing change.

Results

Three pharmacies (16 staff) participated. Training evaluation was positive; all participants rating training structure and delivery as very good or excellent. Covid-19 lockdowns restricted follow-up data collection which took place at six months rather than three. Attitude scores were positive (>0) for all participants at baseline (median 15.0) increasing to 20.0 at 6 months. This was not statistically significant (S=4, p=0.549).

Staff interviews revealed training had encouraged staff to reflect on communication and considered the impact of current practice which could be discriminatory e.g. their use of first names, use of private areas and level of explanation to people. The increased mental health challenges for patients from Covid-19 restrictions gave an opportunity for staff to apply their new skills to this patient group and others who were struggling with isolation, as staff across pharmacies noted mental health challenges for patients. Five patients from two pharmacies were interviewed but time delays in data collection meant changes in delivery of care were difficult to recall.

Conclusion

The study was limited by small sample size and covid-related delays. However, findings indicated that training whole pharmacy teams in PIE was well received and justifies a larger study. The approach allowed staff to reflect on practice and identify previous, potentially discriminatory practice. The importance of clear and compassionate communication was evident.

Reference

(1) Johnson R, Haigh R. Social psychiatry and social policy for the 21st century ‐ new concepts for new needs: the ‘psychologically‐informed environment.’ Ment Heal Soc Incl. 2010;14(4):30–5.

Attachment and symptom reporting in adolescents and young adults after a concussion

BACKGROUND

The incidence of hospital-treated concussion is 100-300/100,000 person years. Reporting of long-lasting post-concussion symptoms (PCS) is estimated at 5-15%. Attachment insecurity is a potential vulnerability factor for physical illness and poorer disease outcomes in general. This study aimed to explore associations between attachment insecurity and PCS in young people sustaining a concussion.

METHODS

This cross-sectional study was embedded in a cohort of 15-30-year-old patients (n = 3080) 3 months after sustaining a concussion. Data were obtained from a database and questionnaires. PCS were measured by the Rivermead Post-Concussion Symptoms Questionnaire and attachment dimensions (anxiety and avoidance) by the Experiences in Close Relationships-Relationship Structures Questionnaire. Multiple linear regression models were performed to investigate the association between the attachment dimensions and PCS with adjustment for demographic, injury-related and psychological factors and with additional testing for interaction between the attachment dimensions.

RESULTS

In the final study sample, comprising 973 patients (31.6%), we found an interaction between the attachment dimensions. Hence, the effect of attachment anxiety on PCS was statistically insignificant at low avoidance (25th percentile) but significant at high avoidance (75th percentile, β = 0.64 (95%CI: 0.02; 1.26)), whereas the effect of attachment avoidance was significant regardless of level of attachment anxiety (25th percentile, β = 1.09 (95%CI: 0.18; 2.01); 75th percentile, β = 2.71 (95%CI: 1.80; 3.61)).

CONCLUSION

Attachment insecurity, especially characterised by high avoidance in combination with high anxiety, also called fearful attachment, is associated with PCS. Considering the attachment perspective can potentially improve health care for this patient group.

1223 Cholelithiasis and Choledocholithiasis with Migration of Stones into Right Psoas Muscle Cavity

Aim

To highlight the importance of appropriate imaging modalities for abnormal clinical presentations.

Method

Xyo woman presented with severe right upper-quadrant pain to the emergency department. Prior history of colicky abdominal pain for 1 year, right-sided nephrectomy and hypertension. She stated that the current epsiode of pain was the worst so far, becoming more persistent, prompting her to call an ambulance. Cholecystitis was suspected, so a Computed Tomography abdomen/pelvis was performed. A dilated, inflamed gallbladder was noted in contact with the right psoas major, with what appeared to be an abscess in the right psoas major.

Results

A Magnetic Resonance Cholangiopancreatography was performed, which demonstrated that the aforementioned abscess was in fact a large cavity within the psoas major, containing up to 15 gallstones. Cholelithiasis was also seen, with common bile duct dilatation and evidence of a common bile duct stone. An Endoscopic Retrograde Cholangiopancreatography was performed, and X recovered well post-procedure with analgesia and antibiotics.

Conclusions

Acute cholecystitis/intra-abdominal gallstones may result in abscess/cavity formations and abnormal biliary clinical presentations. It is important therefore to fully investigate abnormal hepatobiliary imaging with multiple imaging modalities to allow for accurate diagnosis and appropriate further management of presentations.

Emerging stock market volatility and economic fundamentals: the importance of US uncertainty spillovers, financial and health crises

This paper studies the US and global economic fundamentals that exacerbate emerging stock markets volatility and can be considered as systemic risk factors increasing financial stability vulnerabilities. We apply the bivariate HEAVY system of daily and intra-daily volatility equations enriched with powers, leverage, and macro-effects that improve its forecasting accuracy significantly. Our macro-augmented asymmetric power HEAVY model estimates the inflammatory effect of US uncertainty and infectious disease news impact on equities alongside global credit and commodity factors on emerging stock index realized volatility. Our study further demonstrates the power of the economic uncertainty channel, showing that higher US policy uncertainty levels increase the leverage effects and the impact from the common macro-financial proxies on emerging markets' financial volatility. Lastly, we provide evidence on the crucial role of both financial and health crisis events (the 2008 global financial turmoil and the recent Covid-19 pandemic) in raising markets' turbulence and amplifying the volatility macro-drivers impact, as well.

SUPPLEMENTARY INFORMATION

The online version supplementary material available at 10.1007/s10479-021-04042-y.

The status of the radiation safety culture within the higher education, research and teaching sectors in the UK

This article reports on the research by a working group, comprising members from the Association of University Radiation Protection Officers, on the radiation safety culture in the UK higher education, research and teaching (HERT) sectors. The impetus for this research arises from the work of the International Radiation Protection Association and their emphasis that embedding radiation safety culture within an organisation is the most effective way of delivering the standards of radiation safety and security that society expects. The deficiency in radiation safety culture has been a large contributor to major nuclear disasters, such as Chernobyl and Fukushima Daiichi. The working group designed an online survey aimed at higher education students, higher education academics, and researchers. The survey did not try to obtain an indication of safety performance, but of people's views on behaviours and attitudes of radiation safety that reflect the current radiation safety culture in their organisation. The findings of the survey are reported in this article along with a discussion of the analysis and recommendations for improving radiation safety culture. The responses from the survey strongly indicate that the radiation safety culture in UK HERT sectors has worrying shortfalls, particularly in communication and training.

Is it safe for extended-role radiographers to measure migration percentage in children with cerebral palsy?

INTRODUCTION

In the surveillance of children with cerebral palsy, the measurement of migration percentage is used to identify children at risk of hip dislocation. Early identification of children at risk facilitates early intervention with less invasive surgical procedures to prevent further deterioration. The aim of this study is to evaluate the safety of the measurements of migration percentage for surveillance in cerebral palsy by extended-role radiographers by evaluating the reliability and validity of measurements performed by these professionals.

METHODS

A sample of thirty pelvic x-rays were selected from the local cerebral palsy database. A range of hip displacement was selected including some challenging borderline x-rays. All ten extended-role radiographers completed measurements using TraumaCAD which were repeated at a minimum of 4 weeks. Inter-rater and intra-rater reliability was calculated using intraclass correlation coefficients. The accuracy and safety of the system was evaluated by converting measurements into referral categories (red, amber or green) and cohen's kappa was calculated when categories were compared to measurements to orthopaedic surgeon RESULTS: The inter-rater reliability between radiographers was 0.938 (95% CI 0.914-0.991). The intra-rater reliability was 0.941 (95% CI 0.931-0.949). The percentage agreement was 94.8% for green, 93.8% for amber and 98.2% for red hips. The weighted kappa value was 0.923 (95% CI 0.889-0.957).

CONCLUSION

The reliability and accuracy of radiographer measurement of migration percentage is excellent. It is safe for radiographers to calculate the migration percentage using semi-automated software for the surveillance of children with cerebral palsy.

IMPLICATIONS FOR PRACTICE

We recommend the measurement of migration percentage may be performed by extended-role radiographers to deliver accurate and reliable measurements for use in cerebral palsy surveillance.

When moments matter: Finding answers with rapid exome sequencing

Background

When time is of the essence in critical care cases, a fast molecular diagnosis is often necessary to help health care providers quickly determine best next steps for treatments, prognosis, and counseling of their patients. In this paper, we present the diagnostic rates and improved quality of life for patients undergoing clinical rapid exome sequencing.

Methods

The clinical histories and results of 41 patients undergoing rapid exome sequencing were retrospectively reviewed.

Results

Clinical rapid exome sequencing identified a definitive diagnosis in 13/41 (31.7%) and other relevant findings in 17 of the patients (41.5%). The average time to verbal report was 7 days; to written report was 11 days.

Conclusions

Our observations demonstrate the utility and effectiveness of rapid family‐based diagnostic exome sequencing in improving patients care.

Could an online or digital aid facilitate discussions about sexual health with older Australians in general practice?

Background and objectives

Older patients want to discuss sexual health with general practitioners (GPs) but feel uncomfortable doing so, as do their GPs. Online and digital aids (ODAs) are used in other clinical contexts and could provide an effective tool to overcome this discomfort. The aim of this study was to explore health practitioners’ views on the type of ODA that could be used to facilitate sexual health discussions between older patients (aged ≥60 years) and health practitioners.

Methods

Thirty-seven interviews were conducted in Victoria, Australia, between March and June 2017. Participants comprised 15 GPs, 12 practice nurses or practice managers and 10 key informants (five in sexual health, five in ODAs).

Results

Most ODAs currently available target younger populations. Checklists or self‑service kiosks may provide effective means to facilitate sexual health discussions with older patients in primary care.

Discussion

ODAs are acceptable and feasible to implement in younger populations but need testing with older patients. Health professionals need training to deal with sexual health matters arising from using such aids.

Do you talk to your older patients about sexual health? Health practitioners’ knowledge of, and attitudes towards, management of sexual health among older Australians

BACKGROUND AND OBJECTIVES

Research suggests that older patients want to talk about sexual health, but are reluctant to initiate these discussions with health practitioners. Little is known of the practitioners’ perspectives. The objective of this study was to explore health practitioners’ knowledge of and attitudes towards management of sexual health among older patients.

METHOD

Semi-structured interviews were conducted with 15 general practitioners (GPs) and six practice nurses in rural/metropolitan general practices in March to June 2017 in Victoria, Australia.

RESULTS

Most GPs believed it was appropriate to discuss sexual health with older patients but did not routinely do so. Common barriers included age and gender discordance between GP and patient, complexity of patient comorbidities and patient–doctor relationships. Practice nurses identified the limitations of their role as a barrier, although some nurses initiated discussions during health assessments.

DISCUSSION

Health practitioners generally believed the responsibility for initiation of sexual health discussions rested with patients, but understood patients’ reluctance. They saw the need for an intervention to assist in such discussions.

Extracorporeal shockwave therapy for treatment of superficial digital flexor tendonitis in racing Thoroughbreds: 8 clinical cases

Extracorporeal shock wave therapy (ESWT) was administered to 8 racing Thoroughbreds with superficial digital flexor (SDF) tendon injuries sustained during racing or race training. The tendons were assessed ultrasonographically. The ability of the horse to return to racing was monitored. Five of 8 horses raced successfully, 2 re-injured the tendon during retraining, and 1 horse was retired due to age and lesion severity.