Winning hearts and minds: ECG reporting in the first seizure clinic

BACKGROUND AND AIMS

An electrocardiogram (ECG) is a mandatory test for anyone presenting with loss of consciousness. Many referrals to the first seizure clinic (FSC) are caused by syncope. We assessed the sensitivity of neurologists' ECG reporting in detecting rhythm abnormalities including some potentially life-threatening cardiac conditions.

METHODS

We audited patients referred to a FSC in Glasgow over 4 years. All ECGs were interpreted by the attending neurologist as standard practice. Subsequently, two cardiologists reviewed the ECGs independently.

RESULTS

Of 160 consecutive patients, 92 patients (58%) were diagnosed as having seizures, 43 (27%) as syncope, and 25 (16%) were unclassified. Twenty eight ECGs thought to be normal by the neurologist were considered abnormal by the cardiologist, including three with long corrected QT interval. The proportion of abnormal ECGs and disparity in reporting between neurologists and cardiologists persisted independent of the underlying diagnosis.

CONCLUSION

Reporting of ECGs by non-cardiologists may not be adequately sensitive in picking up potentially life threatening cardiac conditions. Cardiologist input into FSCs is recommended to enhance the diagnostic yield.

57 Physical Activity Improvement in Elderly Hospitalised Patients at the Royal London: Exercise as Part of A Multimodal Intervention

Introduction

Approximately 65% of elderly patients admitted to hospital experience some level of deconditioning during their stay. This can lead to longer length of stays, premature admissions to care homes and loss of function whilst in hospital (British Geriatrics Society). There is evidence that exercise can be safe and effective in reversing functional decline in this population. However, there is limited evidence into the effectiveness and feasibility of running a multi modal exercise intervention (eg. Dance and Exercise) on a busy elderly care ward in the UK.

Method

An 8-week inpatient programme consisting of a 60-minute exercise classes once a week and/or 60-minute dance class once a week started on the Older Person’s Wards at the Royal London. Primary outcome measures included: 5 x Sit To Stands (5xSTS) and Falls Efficacy Scale International (FES-I). Secondary measures; Rockwood score, Barthel Index, Elderly Mobility Score (EMS), Mood, 4AT and handgrip strength. Patient satisfaction scores were also recorded.

Results

23 patients were included in the analysis, 3 patients attended the dance class, 14 attended the exercise class and 5 attended both. In total 37 sessions were completed. The average score for all outcome measures improved except one after 8 weeks. The 5xSTS times improved by an average of 7.7 seconds and the FES-I score dropped by 3.9. The Barthel score increased by 5 points. Handgrip strength increased by 2.3 kg and 57% improved on their EMS. Mood improved from 5.4/10 to 6.0/10 and 4AT from 2.7 to 1.7. Overall, 70% of participants reported enjoying the classes and 90% said they would re-attend.

Conclusion

A multifactorial intervention including seated dance and exercise sessions showed significant improvements in mobility, fear of falling, cognition and functional tasks. Further work will look into the impact on length of stay and readmissions inpatient to hospital.

An objective methodology capturing online commodity marketing and other harms

Increasingly life is lived online, yet little is known about the actual nature and extent of online content that people view due to the difficulty of recording real time exposure. This includes people's exposure to harmful commodity marketing. This study aimed to develop a methodology to assess the nature and extent of exposure to, and engagement with, unhealthy commodity marketing and other public health harms online, particularly children's exposure. A convenience sample of 16 young adult participants (aged 21-29) recorded their device usage for 2 days using Zoom software. Data were coded and analysed to assess the nature and extent of marketing for alcohol, gambling, junk food and smoking products. Four focus groups were conducted with participants to explore their data collection and coding experiences, and results assessed using thematic analysis. The study found that, with some modifications, this method was feasible for gathering real-time objective data from the online world that can be analysed for a range of public health harms, including marketing of unhealthy commodities. Larger studies are recommended to build global evidence for public health action in the online world.

Factors Influencing Carbon Stocks and Accumulation Rates in Eelgrass Meadows Across New England, USA

Increasing the protection of coastal vegetated ecosystems has been suggested as one strategy to compensate for increasing carbon dioxide (CO₂) in the atmosphere as the capacity of these habitats to sequester and store carbon exceeds that of terrestrial habitats. Seagrasses are a group of foundation species that grow in shallow coastal and estuarine systems and have an exceptional ability to sequester and store large quantities of carbon in biomass and, particularly, in sediments. However, carbon stocks (C_org stocks) and carbon accumulation rates (C_org accumulation) in seagrass meadows are highly variable both spatially and temporally, making it difficult to extrapolate this strategy to areas where information is lacking. In this study, C_org stocks and C_org accumulation were determined at 11 eelgrass meadows across New England, representing a range of eutrophication and exposure conditions. In addition, the environmental factors and structural characteristics of meadows related to variation in C_org stocks were identified. The objectives were accomplished by assessing stable isotopes of δ¹³C and δ¹⁵N as well as %C and %N in plant tissues and sediments, measuring grain size and ²¹⁰Pb of sediment cores, and through assessing site exposure. Variability in C_org stocks in seagrass meadows is well predicted using commonly measured environmental variables such as grain size distribution. This study allows incorporation of data and insights for the northwest Atlantic, where few studies on carbon sequestration by seagrasses have been conducted.

High sensitivity troponin I in hypertrophic cardiomyopathy

Background

ESC guidelines recommend measurement of troponin T in patients with hypertrophic cardiomyopathy (HCM) because high concentrations are associated with cardiovascular events, heart failure and death. The cardiac Troponin I subunit is not expressed in skeletal muscle making it a cardio-specific isoform. The use of troponin biomarkers in management of patients HCM is limited because concentrations only weakly correlate with clinical parameters. Most studies are small, and few have examined their relation with genotype and mortality.

Purpose

To assess the relationship between high-sensitive troponin I (hsTnI) and characteristics of adults with HCM.

Methods

Patients included were adults with an established diagnosis of HCM referred to a single centre for genetic testing. Demographic, clinical and imaging data were recorded at baseline. Echocardiography and cardiac magnetic resonance (CMR) were performed according to EACVI standards. Quantification of late gadolinium enhancement (LGE) was performed using the 5 SD quantitative threshold. Genotype was evaluated using a 16 gene panel in an accredited UK laboratory. Pathogenic and likely pathogenic variants were considered as a positive genotype. Serum hsTnI was measured by a two-site electrochemiluminescence immunoassay on a Roche E170 analyser. Normal values for the assay 0–34 ng/L for males and 0–16 ng/L for females.

Results

313 patients (n=200, 64% male) median age 57 (IQR 47–68) years were included. hsTnI concentration was abnormal in 69 (22%) patients. An abnormal hsTnI was more common in females (n=36, 32%) compared to males (n=33, 17%, c2 9.9, p<0.05). A pathogenic variant in a sarcomere gene was identified in 95 (30%) individuals. An abnormal hsTnI concentration was associated with higher left ventricular (LV) wall thickness (20mm v 18mm, p<0.05) and LV outflow tract (LVOT) gradient (34 v 22 mmHg) on echocardiography (n=313). Of the patients (n=204) who had a CMR, an abnormal hsTnI concentration was associated with higher LV mass (183 v 156g, p<0.05) and greater % LGE (30 v 16%, p<0.01, n=129). There was no difference in hsTnI between those with a positive or negative genotype. During follow-up, 18 patients died. Of the 9 patients that died with a normal hsTnI, two died suddenly.

Conclusions

In HCM, patients with abnormal hsTnI concentration have higher LV mass and LVOT gradient and more fibrosis. Whilst mortality is higher in those with abnormal hsTnI, sudden cardiac death may occur with a normal hsTnI. It may not be appropriate to extrapolate hsTnI sex-specific thresholds used in the diagnosis of myocardial infarction to HCM.

Funding Acknowledgement

Type of funding source: None

A Randomised Controlled Trial of Local Infiltration Analgesia Versus Femoral Nerve Block for Postoperative Analgesia Following Total Knee Arthroplasty

Background

Total knee replacement is often associated with significant postoperative pain. Although the use of a femoral nerve block is well-established, local infiltration analgesia has gained popularity in recent years. We compared single-shot local infiltration analgesia with a single-shot femoral nerve block for patients undergoing primary total knee arthroplasty.

Methods

A total of 194 patients were randomised to receive either local infiltration analgesia (150 ml bupivacaine 0.067% with adrenaline) or a femoral nerve block (20 ml 0.375% levobupivacaine). Both groups received spinal anaesthesia. The primary outcome measure was the total morphine consumption. Secondary outcome measures included: post-operative pain scores, rehabilitation goals, readiness for discharge, and physical, mental, and functional outcomes, including the Oxford Knee Score (OKS).

Results

A total of 69 patients in the local infiltration analgesia group and 79 patients in the femoral nerve block group were analysed. Median total morphine consumption was significantly greater in the local infiltration analgesia group as compared to the femoral nerve block group (54.67 mg vs 45 mg, respectively, p=0.0388). The post-operative OKS at six weeks was slightly more improved for the femoral nerve block group than for local infiltration analgesia (12.5 vs 9 point median improvements for the femoral nerve block and local infiltration analgesia groups, respectively, p=0.0261). There were no statistically significant differences in other secondary outcome measures.

Conclusion

A single-shot femoral nerve block significantly reduces the opioid requirement for primary total knee arthroplasty but is otherwise comparable to single-shot local infiltration analgesia. 

A 'hot clinic' for cold limbs: the benefit of urgent clinics for patients with critical limb ischaemia

INTRODUCTION

The national reconfiguration of vascular surgery means that arterial centres serve larger populations with increased demand on resources. Emergency general surgery ambulatory clinics facilitate timely review and intervention, avoiding admission; a critical limb ischaemia (CLI) 'hot clinic' (HC) was implemented to achieve similar for vascular patients. The aim of the study was to determine HC efficacy.

METHODS

This was a prospective cohort study comparing HC patients with emergency admission (EA) patients between 1 May and 1 December 2017. Age, sex, comorbidities, CLI severity and smoking status were noted. HC patients were provided with satisfaction surveys. Primary outcome measures were freedom from reintervention and major amputation. Secondary outcome measures included time to procedure, length of stay, returns to theatre and 30-day readmission.

RESULTS

A total of 147 patients (72 HC, 75 EA) were enrolled in the study. No statistical difference was found in age, sex, smoking status, severity of CLI or prevalence of comorbidities between the groups except that diabetes was more prevalent in EA patients (p=0.028). The median length of stay for the HC cohort was shorter (3 days vs 17 days, p<0.001), with no difference between time to procedure, return to theatre or 30-day readmission. HC patients were nearly 6 times more likely to experience freedom from reintervention (odds ratio: 5.824, p<0.001) and 2.5 times less likely to undergo amputation (odds ratio: 2.616, p=0.043). HC utilisation saved a total of 441 bed days. Over 90% of attendees responded with 100% positive feedback.

CONCLUSIONS

A vascular HC facilitates urgent review and revascularisation. It provides comparable in-hospital outcomes and better long-term outcomes, with greater efficiency than hospital admission, demonstrating its value in treating CLI.

Isospin Properties of Nuclear Pair Correlations from the Level Structure of the Self-Conjugate Nucleus ^{88}Ru

The low-lying energy spectrum of the extremely neutron-deficient self-conjugate (N=Z) nuclide _{44}^{88}Ru_{44} has been measured using the combination of the Advanced Gamma Tracking Array (AGATA) spectrometer, the NEDA and Neutron Wall neutron detector arrays, and the DIAMANT charged particle detector array. Excited states in ^{88}Ru were populated via the ^{54}Fe(^{36}Ar,2nγ)^{88}Ru^{*} fusion-evaporation reaction at the Grand Accélérateur National d'Ions Lourds (GANIL) accelerator complex. The observed γ-ray cascade is assigned to ^{88}Ru using clean prompt γ-γ-2-neutron coincidences in anticoincidence with the detection of charged particles, confirming and extending the previously assigned sequence of low-lying excited states. It is consistent with a moderately deformed rotating system exhibiting a band crossing at a rotational frequency that is significantly higher than standard theoretical predictions with isovector pairing, as well as observations in neighboring N>Z nuclides. The direct observation of such a "delayed" rotational alignment in a deformed N=Z nucleus is in agreement with theoretical predictions related to the presence of strong isoscalar neutron-proton pair correlations.

9 The ‘Colchester Older Persons’ Evaluation for Surgery (COPES)’ Clinic: A Multidisciplinary Approach to Preoperative Management of Frail, Older Patients

Introduction

In 2014-15, 2.5 million patients over 75 years old underwent surgery compared to 1.5 million in 2006-7. The population is aging with increasing numbers of comorbidities, and associated frailty.1 The Royal College of Anaesthetists recommends that preoperative assessment for these complex older patients takes a “cross-specialty approach.”2 In Colchester the COPES clinic has been introduced in which selected high-risk patients are seen by a Consultant Anaesthetist and Consultant Geriatrician. This aims to medically optimise patients prior to surgery and to facilitate shared decision making.

Methods

The new clinic was introduced in October 2018. The following data was collected from COPES clinic letters from October to February 2018-19 (n=46):Patient/ surgery characteristics: age, comorbidities, frailty score and any cognitive impairmentInterventions: changes to medication, specialty referral, intravenous iron, diabetes optimisation, otherOutcomes of surgery following the COPES clinic

Patients were asked to complete feedback forms to evaluate the service.

Results

52% of patients had 4-6, and 28% had 7-9 comorbidities. The majority had Rockwood frailty scores of 4 or 5. 28% of patients had medications changed, 48% had specialty referrals, 17% received intravenous iron, 8.7% required diabetes optimisation and 28% of patients had investigations including echocardiograms, MRI and CT scans. 12/46 patients had surgery deemed unlikely to go ahead after shared decision making with patients in conjunction with the multidisciplinary team involved in their care. 2 patients died of their comorbidities after deciding not to proceed with surgery. 12/46 patients underwent surgery; 4 developed post-operative complications, none died and the mean length of stay was 3.38 days. The remaining 22/46 patients are awaiting surgery. Patient feedback questionnaires (n=10) were overwhelmingly positive. Everyone felt that they were treated with respect and that their fears were addressed and they were clear in the next steps in management.

Conclusions

The introduction of the ‘COPES’ clinic has helped address frailty and multiple comorbidities by optimising patients’ medical conditions and allowing alternatives to surgery to be considered. Patients were very satisfied with the COPES clinic and felt it has prepared them for upcoming surgery.

References

1. Lin H. Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatrics, 2016.

2. RCoA. Guidelines for the Provision of Anaesthesia Services. www.pre-op.org/sites/default/files/GPAS%202016.pdf

P05.06 Phase 2 study to evaluate the safety, pharmacokinetics and clinical activity of PI3K/mTOR inhibitor GDC-0084 given to glioblastoma (GBM) patients with unmethylated O6-methylguanine-methyltransferase (MGMT) promoter status

BACKGROUND

GDC-0084 is a potent, oral, selective small molecule inhibitor of class I phosphoinositide 3-kinase and mammalian target of rapamycin (PI3K/mTOR). The PI3K pathway is activated in ≥ 70% of tumors, making it a compelling target for the treatment of GBM. GDC-0084 crosses the blood-brain barrier and achieves a brain / plasma ratio of approximately 1.0. GDC-0084 was given as once daily oral dosing in a phase 1 study (Wen et al, J Clin Oncol 34, 2016(15) suppl.2012) in 47 patients with recurrent high-grade gliomas. The adverse events were generally consistent with the established PI3K/mTOR inhibitor class-effects. The MTD identified was 45 mg once daily.

MATERIAL AND METHODS

This study has a 2-part design consisting of an open-label, multicenter dose-escalation study with expansion to assess the safety, tolerability, RP2D, PK, and clinical activity of GDC-0084 at QD dosing in patients with newly-diagnosed GBM with unmethylated MGMT promotor status. In the escalation phase the first cohort is completed without DLT. At the identified MTD, 20 subjects will be recruited in an expansion cohort and patients will be randomized to take GDC-0084 in fed and fasted states. Subjects in the expansion cohort will also have serial fluorodeoxyglucose-positron emission tomography (FDG-PET) imaging.

Identification of a novel TIF-IA-NF-κB nucleolar stress response pathway

p53 as an effector of nucleolar stress is well defined, but p53 independent mechanisms are largely unknown. Like p53, the NF-κB transcription factor plays a critical role in maintaining cellular homeostasis under stress. Many stresses that stimulate NF-κB also disrupt nucleoli. However, the link between nucleolar function and activation of the NF-κB pathway is as yet unknown. Here we demonstrate that artificial disruption of the PolI complex stimulates NF-κB signalling. Unlike p53 nucleolar stress response, this effect does not appear to be linked to inhibition of rDNA transcription. We show that specific stress stimuli of NF-κB induce degradation of a critical component of the PolI complex, TIF-IA. This degradation precedes activation of NF-κB and is associated with increased nucleolar size. It is mimicked by CDK4 inhibition and is dependent upon a novel pathway involving UBF/p14ARF and S44 of the protein. We show that blocking TIF-IA degradation blocks stress effects on nucleolar size and NF-κB signalling. Finally, using ex vivo culture, we show a strong correlation between degradation of TIF-IA and activation of NF-κB in freshly resected, human colorectal tumours exposed to the chemopreventative agent, aspirin. Together, our study provides compelling evidence for a new, TIF-IA-NF-κB nucleolar stress response pathway that has in vivo relevance and therapeutic implications.

Direct stimulation of adenylyl cyclase 9 by the fungicide imidazole miconazole

In mammals, nine genes encode trans-membrane adenylyl cyclase (tmAC) isoforms that synthesize the intracellular messenger compound cAMP from ATP. As cAMP is produced in virtually all types of cell, isoform-selective modulators of tmAC would have major research and therapeutic potential. This study investigated the effects of fungicide imidazoles previously shown to suppress cAMP production in various tissues on the activities of tmAC isoforms AC1, 2, or 9 stably expressed in human embryonic kidney 293 cells. Intact cells, as well as crude membranes, were exposed to various imidazoles or known stimulators of tmAC and the ensuing changes in the production of cAMP analyzed. In crude membranes, the activity of AC9 in the presence of GDP-β-S was enhanced by miconazole with an EC₅₀ of ~ 8 μM, while AC1 and AC2 were inhibited with an IC₅₀ of ~ 20 μM. Clotrimazole (10-100 μM) was an inhibitor of all the ACs tested. Substrate saturation analysis indicated that miconazole increased the V_max of AC9 by 3-fold while having no effect on the K_m. In intact cells, the effect of miconazole on cAMP production through AC9 was additive with that of isoproterenol. The stimulation of cAMP production by miconazole was inhibited by Ca²⁺, and this could be prevented by the calcineurin blocker FK506. In sum, activation of AC9 by miconazole is through a mechanism distinct from that of forskolin, activated G proteins, or the COOH-terminal mediated autoinhibition. However, it is subject to the AC9 isoform-specific inhibition by Ca²⁺/calcineurin. Differential modulation of mammalian tmAC paralogs appears to be achievable by an imidazole with phenylated side chains. Optimization of the lead compound and exploration of the underlying mechanism(s) of action in more detail could exploit this further.

Auto-inhibition of adenylyl cyclase 9 (AC9) by an isoform-specific motif in the carboxyl-terminal region

Trans-membrane adenylyl cyclase (tmAC) isoforms show markedly distinct regulatory properties that have not been fully explored. AC9 is highly expressed in vital organs such as the heart and the brain. Here, we report that the isoform-specific carboxyl-terminal domain (C2b) of AC9 inhibits the activation of the enzyme by Gs-coupled receptors (GsCR). In human embryonic kidney cells (HEK293) stably overexpressing AC9, cAMP production by AC9 induced upon the activation of endogenous β-adrenergic and prostanoid GsCRs was barely discernible. Cells expressing AC9 lacking the C2b domain showed a markedly enhanced cAMP response to GsCR. Subsequent studies of the response of AC9 mutants to the activation of GsCR revealed that residues 1268-1276 in the C2b domain were critical for auto-inhibition. Two main species of AC9 of 130 K and ≥ 170 K apparent molecular weight were observed on immunoblots of rodent and human myocardial membranes with NH₂-terminally directed anti-AC9 antibodies. The lower molecular weight AC9 band did not react with antibodies directed against the C2b domain. It was the predominant species of AC9 in rodent heart tissue and some of the human samples. There is a single gene for AC9 in vertebrates, moreover, amino acids 957-1353 of the COOH-terminus are encoded by a single exon with no apparent signs of mRNA splicing or editing making it highly unlikely that COOH-terminally truncated AC9 could arise through the processing or editing of mRNA. Thus, deductive reasoning leads to the suggestion that proteolytic cleavage of the C2b auto-inhibitory domain may govern the activation of AC9 by GsCR.

A massive core for a cluster of galaxies at a redshift of 4.3

Massive galaxy clusters have been found that date to times as early as three billion years after the Big Bang, containing stars that formed at even earlier epochs^1-3. The high-redshift progenitors of these galaxy clusters-termed 'protoclusters'-can be identified in cosmological simulations that have the highest overdensities (greater-than-average densities) of dark matter^4-6. Protoclusters are expected to contain extremely massive galaxies that can be observed as luminous starbursts ⁷ . However, recent detections of possible protoclusters hosting such starbursts^8-11 do not support the kind of rapid cluster-core formation expected from simulations ¹² : the structures observed contain only a handful of starbursting galaxies spread throughout a broad region, with poor evidence for eventual collapse into a protocluster. Here we report observations of carbon monoxide and ionized carbon emission from the source SPT2349-56. We find that this source consists of at least 14 gas-rich galaxies, all lying at redshifts of 4.31. We demonstrate that each of these galaxies is forming stars between 50 and 1,000 times more quickly than our own Milky Way, and that all are located within a projected region that is only around 130 kiloparsecs in diameter. This galaxy surface density is more than ten times the average blank-field value (integrated over all redshifts), and more than 1,000 times the average field volume density. The velocity dispersion (approximately 410 kilometres per second) of these galaxies and the enormous gas and star-formation densities suggest that this system represents the core of a cluster of galaxies that was already at an advanced stage of formation when the Universe was only 1.4 billion years old. A comparison with other known protoclusters at high redshifts shows that SPT2349-56 could be building one of the most massive structures in the Universe today.

Fast-timing measurements in neutron-rich odd-mass zirconium isotopes using LaBr3:Ce detectors coupled with Gammasphere

A fast-timing experiment was performed at the Argonne National Laboratory to measure the lifetimes of the lowest lying states of nuclei belonging to the deformed regions around mass number A≃110 and A≃150. These regions were populated via spontaneous fission of 252Cf and the gamma radiation following the decay of excited states in the fission fragments was measured using 51 Gammasphere detectors coupled with 25 LaBr3:Ce detectors. A brief description of the acquisition system and some preliminary results from the fast-timing analysis of the fission fragment 100Zr are presented. The lifetime value of τ = 840(65) ps was found for the 2+ state in 100Zr consistent within one standard deviation of the adopted value with 791 +26 -35ps. This is associated with a quadrupole deformation parameter of 0.36(2) which is within one standard deviation of the literature value of 0.3556+82 -57.