Pathophysiology of Influenza D Virus Infection in Specific-Pathogen-Free Lambs with or without Prior Mycoplasma ovipneumoniae Exposure

Polymicrobial pneumonias occur frequently in cattle, swine, and sheep, resulting in major economic losses. Individual pathogens comprising these complex infections may be mild on their own but can instead exhibit synergism or increase host susceptibility. Two examples of such pathogens, Mycoplasma ovipneumoniae (M. ovipneumoniae) and influenza D viruses (IDVs), naturally infect domestic sheep. In sheep, the role of M. ovipneumoniae in chronic nonprogressive pneumonia is well-established, but the pathogenesis of IDV infection has not previously been studied. We utilized a specific-pathogen-free sheep flock to study the clinical response to IDV infection in naïve vs. M. ovipneumoniae-exposed lambs. Lambs were inoculated intranasally with M. ovipneumoniae or mock infection, followed after four weeks by infection with IDV. Pathogen shedding was tracked, and immunological responses were evaluated by measuring acute phase response and IDV-neutralizing antibody titers. While lamb health statuses remained subclinical, M. ovipneumoniae-exposed lambs had significantly elevated body temperatures during IDV infection compared to M. ovipneumoniae-naïve, IDV-infected lambs. Moreover, we found a positive correlation between prior M. ovipneumoniae burden, early-infection IDV shedding, and IDV-neutralizing antibody response. Our findings suggest that IDV infection may not induce clinical symptoms in domestic sheep, but previous M. ovipneumoniae exposure may promote mild IDV-associated inflammation.

Examination of Genetic Susceptibility in Radiation-Associated Meningioma

Previous epidemiological studies have demonstrated elevated susceptibility to ionizing radiation in some families, thus suggesting the presence of genetic components that conferred increased rate of radiation-associated meningioma (RAM). In this study, we exome-sequenced and investigated the segregation pattern of rare deleterious variants in 11 RAM pedigrees. In addition, we performed a rare-variant association analysis in 92 unrelated familial cases of RAM that were ancestry-matched with 88 meningioma-free controls. In the pedigree analysis, we found that each family carried mostly a unique set of rare deleterious variants. A follow-up pathway analysis of the union of the genes that segregated within each of the 11 pedigrees identified a single statistically significant (q value = 7.90E-04) “ECM receptor interaction” set. In the case-control association analysis, we observed no statistically significant variants or genes after multiple testing correction; however, examination of ontological categories of the genes that associated with RAM at nominal P values <0.01 identified biologically relevant pathways such as DNA repair, cell cycle and apoptosis. These results suggest that it is unlikely that a small number of highly penetrant genes are involved in the pathogenesis of RAM. Substantially larger studies are needed to identify genetic risk variants and genes in RAM.

Changes to objective structured clinical examinations (OSCE) at Australian medical schools in response to the COVID-19 pandemic

INTRODUCTION

Objective Structured Clinical Examinations (OSCE) are used to assess clinical skills. We investigated how exit OSCEs changed in Australian medical schools in response to the COVID-19 pandemic.

MATERIALS AND METHODS

The lead ACCLAiM assessment academic from 12 eligible Australian medical school members of the Australian Collaboration for Clinical Assessment in Medicine (ACCLAiM) received a 45-item semi-structured online questionnaire.

RESULTS

All schools (12/12) responded. Exit OSCEs were not used by one school in 2019, and 3/11 schools in 2020. Of eight remaining schools, four reduced station numbers and testing time. The minimum OSCE testing time decreased from 64 min in 2019 to 54 min in 2020. Other modifications included: a completely online 'e-OSCE' (n = 1); hybrid delivery (n = 4); stations using: videos of patient encounters (n = 3), telephone calls (n = 2), skill completion without face-to-face patient encounters (n = 3). The proportion of stations involving physical examination reduced from 33% to 17%. Fewer examiners were required, and university faculty staff formed a higher proportion of examiners.

CONCLUSIONS

All schools changed their OSCEs in 2020 in response to COVID-19. Modifications varied from reducing station numbers and changing delivery methods to removing OSCE and complete assessment re-structuring. Several innovative methods of OSCE delivery were implemented to preserve OSCE validity and reliability whilst balancing feasibility.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Experimental infection of specific-pathogen-free domestic lambs with Mycoplasma ovipneumoniae causes asymptomatic colonization of the upper airways that is resistant to antibiotic treatment

Mycoplasma ovipneumoniae (M. ovipneumoniae) is a respiratory pathogen associated with mild to moderate respiratory disease in domestic lambs and severe pneumonia outbreaks in wild ruminants such as bighorn sheep. However, whether M. ovipneumoniae by itself causes clinical respiratory disease in domestic sheep in the absence of secondary bacterial pathogens is still unclear. The goal of our study was to better understand the role of M. ovipneumoniae as a respiratory pathogen in domestic sheep and to explore potential antibiotic treatment approaches. Therefore, we inoculated four 4-month-old, specific-pathogen-free lambs with fresh nasal wash fluids from M. ovipneumoniae-infected sheep. The lambs were monitored for M. ovipneumoniae colonization, M. ovipneumoniae-specific antibodies, clinical signs, and cellular and molecular correlates of lung inflammation for eight weeks. All lambs then were treated with gamithromycin and observed for an additional four weeks. M. ovipneumoniae inoculation resulted in stable colonization of the upper respiratory tract in all M. ovipneumoniae-inoculated, but in none of the four mock-infected control lambs. All M. ovipneumoniae-infected lambs developed a robust antibody response to M. ovipneumoniae within 2 weeks. However, we did not observe significant signs of respiratory disease, evidence of lung damage or inflammation in any of the infected lambs. Interestingly, treatment with gamithromycin, which blocked growth of the M. ovipneumoniae in vitro, failed to reduce M. ovipneumoniae colonization. These observations indicate that, in the absence of co-infections, M. ovipneumoniae caused asymptomatic colonization of the upper respiratory tract that was resistant to clearance by the host immune response and by gamithromycin treatment.

Technology-enabled multidisciplinary team in-reach for oral corticosteroid stewardship and optimizing care of suspected airways disease exacerbations

Overuse of corticosteroids is an important problem not only in asthma but also the management of other airways diseases including bronchiectasis and COPD and results in associated risks of serious side effects and irreversible harm. We report a pilot using an in-reach solution to review patients, optimise their care and facilitate early discharge. We discharged >20% of our patients immediately, which is potentially a significant reduction in hospital bed use and, most importantly, through this approach we were able to establish early diagnosis and reduce inappropriate oral corticosteroid use.

1270 Secondary Survey Documentation in Trauma Patients - A Review Following Implementation of a Dedicated Trauma Ward

Introduction

A secondary survey is a detailed head to toe assessment performed in trauma patients following initial primary survey and patient stabilisation. It forms part of the ATLS guidelines and is an important tool in the recognition of patient injury. We performed an audit within the Regional Trauma Unit to assess the standard of documentation of secondary surveys in trauma admissions. We then repeated this audit following staff teaching and the implementation of a dedicated Trauma Ward, with an aim of improving secondary survey documentation and the early recognition and management of associated injuries.

Method

Admission notes for all trauma patients admitted in the three months prior to the opening of the dedicated Trauma Ward were reviewed for documentation of a secondary survey (n = 30), with the incidence of any missed injuries on follow up recorded. A further audit loop was then performed on all trauma admissions following the opening of the Trauma Ward and trauma staff teaching (n = 52).

Results

Complete documentation of a full secondary survey improved from 10% to 98% for trauma patient admissions. This also improved early identification of initially missed injuries from the primary survey including extremity fractures, chest trauma, and multi-ligament knee injuries.

Conclusions

Secondary surveys are an important tool in assessing trauma patients and can help identify significant injuries. The implementation of a dedicated Trauma Ward along with teaching to the trauma staff has led to an improvement in performance of secondary surveys with a direct improvement in identifying associated injuries in trauma patients.

858 Transoral Robotic Surgery: Comparing the Geography of Research Publications with The Global Burden of Disease

Introduction

Transoral robotic surgery (TORS) is increasingly used for the resection of oropharyngeal tumours. It is unclear if there is equitable access to this innovative technique worldwide, specifically in areas of greatest need. This study aimed to map the geographic distribution of publications on TORS and compare this to global disease burden.

Method

Systematic searches identified all studies of TORS from inception to 2018. The country of origin of each study was identified. The incidence and age standardised rate (ASR) of oropharyngeal cancer for each country was obtained from The Global Cancer Observatory (GLOBOCAN) database. World Bank classifications of countries by income level were obtained.

Results

A total of 132 studies were identified. The majority (96%) were published in high-income countries, 2% in lower-middle, and 2% in upper-middle income countries. Eighty-nine were published in the USA, the country with the second-highest incidence of oropharyngeal cancer worldwide (13% of total), but 20th by ASR. The greatest incidence was in India (21%), however this was the source of only 2% of studies. Of the ten countries with the highest incidence, eight were represented in published studies, in comparison to four of the top 10 by ASR.

Conclusions

There is evident disparity in the geographical distribution of published studies of TORS. This disparity may represent unequal access to surgical technologies, or a lack of evaluation of the technology in different healthcare settings. This may impact the generalisability of research findings. Equitable access to novel surgical technologies is ethical and can help address global disease burden.

474 Increasing the Availability of Operation Notes at Hand Surgery Follow-Up Through the Use of Electronic Operation Notes

Introduction

The availability of operation notes is crucial to provide high-quality post-operative care. This clinical audit evaluates the availability of operation notes at post-operative follow-up, in a Tertiary Hand Unit, before and after implementation of electronic operation notes.

Method

This was a prospective audit analysing the availability of operation notes at the first post-operative hand surgery appointment. The initial data collection was over a 6-week period (July – August 2019). Following this, a standardised electronic operation note template was created in line with BSSH Hand Trauma Guidelines and RCS Good Surgical Practice. Six months later, a re-audit was conducted over a 4-week period (March 2020).

Results

The initial audit included 104 adult patients, with operation notes available for 64% (n = 67) of patients, and 94% (n = 63) of those were in paper format. Following implementation of electronic operation notes, the re-audit included 53 adult patients. For these patients, 96% (n = 51) of their operation notes were available, and 96% (n = 49) of the operation notes were electronic.

Conclusions

These findings demonstrate that electronic operation notes greatly increased the availability of operation notes at follow-up This innovation has significant implications for upholding well-coordinated continuity of care for patients undergoing surgery.