Selective approach to preoperative echocardiography in esophageal atresia

PURPOSE

Preoperative echocardiography is used routinely in neonates with esophageal atresia to identify patients in whom congenital cardiac disease will impact upon anesthetic and surgical decision-making. We aimed to determine the suitability of selective preoperative echocardiography.

METHODS

We performed a single-center retrospective review of neonates with esophageal atresia over 6 years (2010-2015) at our tertiary pediatric institution. Data included preoperative clinical examination, chest x-ray, and echocardiography. Endpoints were cardiovascular, respiratory, radiological, and echocardiography findings. Selective strategies were assessed using sensitivity, specificity, positive predictive value, and negative predictive value.

RESULTS

We identified 115 neonates with esophageal atresia. All underwent preoperative echocardiography. Cardiac defects were identified in 49/115 (43%) (major 9/115, moderate 4/115). Sensitivity, specificity, positive predictive value, and negative predictive value of abnormal clinical and radiologic assessment for major and moderate cardiac defects were 92%, 25%, 13%, 96%; for clinical examination alone were 92%, 25%, 14%, 96%; for absence of murmur, cyanosis, and abnormal respiratory examination were 92%, 28%, 13%, 97%. Selective strategies reduce echocardiograms performed by 22%.

CONCLUSION

Selective strategies allow for identification of neonates with esophageal atresia who may have deferral of echocardiogram unill after surgery. Selection may improve timeliness of care and resource utilization, without compromising patient safety.

Tackle injury epidemiology and performance in rugby league - narrative synthesis

Background

In rugby league (RL), the ability to repeatedly engage in the tackle, whether as a ball carrier or tackler, is essential for team success and player performance. It is also the leading cause of injury, with over 90% of total injuries occurring during the tackle in professional and amateur cohorts. To effectively reduce the risk of injury and optimise performance, establishing the extent of the 'problem', through injury surveillance or descriptive performance studies is required.

Objective

The purpose of this narrative synthesis was to systematically search and synthesise tackle injury epidemiology and tackle performance frequency in RL. To achieve this objective, a systematic review was conducted.

Methods

The search was limited to English-only articles published between January 1995 and October 2018. Based on the search criteria, a total of 53 studies were found: 32 focused on tackle injury epidemiology (nine cases studies) and 21 focused on tackle frequency.

Results

In general, over 600 tackles may occur during an RL match. Tackle injury frequencies (both overall and time-loss injuries) ranged between 47%-94% at the professional level, and between 38%-96% for the lower levels of play. A greater proportion of injuries occurring in professional RL are severe time-loss injuries when compared to lower levels of play. Most time-loss and overall injuries occur to players who are tackled, i.e., ball carriers, across all levels of play.

Conclusion

This narrative synthesis will facilitate tackle injury prevention and performance research in RL, and act as a reference document for coaches and practitioners.

The impact of anti-mould prophylaxis on Aspergillus PCR blood testing for the diagnosis of invasive aspergillosis

BACKGROUND

The performance of the galactomannan enzyme immunoassay (GM-EIA) is impaired in patients receiving mould-active antifungal therapy. The impact of mould-active antifungal therapy on Aspergillus PCR testing needs to be determined.

OBJECTIVES

To determine the influence of anti-mould prophylaxis (AMP) on the performance of PCR blood testing to aid the diagnosis of proven/probable invasive aspergillosis (IA).

METHODS

As part of the systematic review and meta-analysis of 22 cohort studies investigating Aspergillus PCR blood testing in 2912 patients at risk of IA, subgroup analysis was performed to determine the impact of AMP on the accuracy of Aspergillus PCR. The incidence of IA was calculated in patients receiving and not receiving AMP. The impact of two different positivity thresholds (requiring either a single PCR positive test result or ≥2 consecutive PCR positive test results) on accuracy was evaluated. Meta-analytical pooling of sensitivity and specificity was performed by logistic mixed-model regression.

RESULTS

In total, 1661 (57%) patients received prophylaxis. The incidence of IA was 14.2%, significantly lower in the prophylaxis group (11%-12%) compared with the non-prophylaxis group (18%-19%) (P < 0.001). The use of AMP did not affect sensitivity, but significantly decreased specificity [single PCR positive result threshold: 26% reduction (P = 0.005); ≥2 consecutive PCR positive results threshold: 12% reduction (P = 0.019)].

CONCLUSIONS

Contrary to its influence on GM-EIA, AMP significantly decreases Aspergillus PCR specificity, without affecting sensitivity, possibly as a consequence of AMP limiting the clinical progression of IA and/or leading to false-negative GM-EIA results, preventing the classification of probable IA using the EORTC/MSGERC definitions.

Rugby league ball carrier injuries: The relative importance of tackle characteristics during the European Super League

Rugby league carries a high injury incidence with 61% of injuries occurring at tackles. The ball carrier has a higher injury incidence than the defender, therefore understanding mechanisms occurring during injurious tackles are important. Given the dynamic, open nature of tackling, characteristics influencing tackle outcome likely encompass complex networks of dependencies. This study aims to identify important classifying characteristics of the tackle related to ball carrier injurious and non-injurious events in rugby league and identify the characteristics capability to correctly classify those events. Forty-one ball carrier injuries were identified and 205 matched non-injurious tackles were identified as controls. Each case and control were analysed retrospectively through video analysis. Random forest models were built to (1) filter tackle characteristics possessing relative importance for classifying tackles resulting in injurious/non-injurious outcomes and (2) determine sensitivity and specificity of tackle characteristics to classify injurious and non-injurious events. Six characteristics were identified to possess relative importance to classify injurious tackles. This included 'tackler twisted ball carrier's legs when legs were planted on ground', 'the tackler and ball carrier collide heads', 'the tackler used body weight to tackle ball carrier', 'the tackler has obvious control of the ball carrier' 'the tackler was approaching tackle sub-maximally' and 'tackler's arms were below shoulder level, elbows were flexed'. The study identified tackle characteristics that can be modified in attempt to reduce injury. Additional injury data are needed to establish relationship networks of characteristics and analyse specific injuries. Sensitivity and specificity results of the random forest were 0.995 and 0.525.

The accuracy of femoral component rotational measurements using computed tomography—a cadaveric study

Background

CT scans can be used to assess the rotational alignment of the femoral component following total knee arthroplasty (TKA). This is done by calculating the posterior condylar angle (PCA).

However, the methods used may not account for the biomechanical functionality of the TKA components. This cadaveric study aimed to determine whether the axis of scanning (mechanical or anatomical) alters the results of PCA calculations.

Methods

CT scans of 12 cadaveric adult femora were performed along the anatomical axis and the mechanical axis. The PCA was determined on each CT scan by measuring the relationship of the prosthetic posterior condyles to the surgical epicondylar axis of the femur. The mechanical and anatomical axis groups were further subdivided into best-fit and multi-slice subgroups. As a control, the posterior condylar angle was also calculated on photographic images of each femur. Bland-Altman plots were used to determine the correlation between the PCA values obtained from the different scanning axes and measurement techniques.

Results

There was no significant difference between the PCA measurements derived from anatomical and mechanical axis CT scans. The Pearson correlation co-efficient also indicated good correlation between the two scanning axes.

Conclusion

The axis of scanning does not significantly affect the PCA measurements. Therefore, the measurements may be reliably used for clinical decision-making, regardless of the axis of CT scanning.

GARLA: Integrating Traditional and Modern Methodologies in Anatomy Education

GARLA is an anatomy curriculum that combines dissection with applied anatomy. A two-week intensive dissection Boot-Camp is followed by a tripartite curriculum consisting of Gross Anatomy using a mixed reality headset, radiology, and physical exam/ultrasound skills. Student feedback has generally been positive.

Vestibular rehabilitation in multiple sclerosis: study protocol for a randomised controlled trial and cost-effectiveness analysis comparing customised with booklet based vestibular rehabilitation for vestibulopathy and a 12 month observational cohort study of the symptom reduction and recurrence rate following treatment for benign paroxysmal positional vertigo

Background

Symptoms arising from vestibular system dysfunction are observed in 49–59% of people with Multiple Sclerosis (MS). Symptoms may include vertigo, dizziness and/or imbalance. These impact on functional ability, contribute to falls and significant health and social care costs. In people with MS, vestibular dysfunction can be due to peripheral pathology that may include Benign Paroxysmal Positional Vertigo (BPPV), as well as central or combined pathology. Vestibular symptoms may be treated with vestibular rehabilitation (VR), and with repositioning manoeuvres in the case of BPPV. However, there is a paucity of evidence about the rate and degree of symptom recovery with VR for people with MS and vestibulopathy. In addition, given the multiplicity of symptoms and underpinning vestibular pathologies often seen in people with MS, a customised VR approach may be more clinically appropriate and cost effective than generic booklet-based approaches. Likewise, BPPV should be identified and treated appropriately.

Methods/ design

People with MS and symptoms of vertigo, dizziness and/or imbalance will be screened for central and/or peripheral vestibulopathy and/or BPPV. Following consent, people with BPPV will be treated with re-positioning manoeuvres over 1–3 sessions and followed up at 6 and 12 months to assess for any re-occurrence of BPPV. People with central and/or peripheral vestibulopathy will be entered into a randomised controlled trial (RCT). Trial participants will be randomly allocated (1:1) to either a 12-week generic booklet-based home programme with telephone support or a 12-week VR programme consisting of customised treatment including 12 face-to-face sessions and a home exercise programme. Customised or booklet-based interventions will start 2 weeks after randomisation and all trial participants will be followed up 14 and 26 weeks from randomisation. The primary clinical outcome is the Dizziness Handicap Inventory at 26 weeks and the primary economic endpoint is quality-adjusted life-years. A range of secondary outcomes associated with vestibular function will be used.

Discussion

If customised VR is demonstrated to be clinically and cost-effective compared to generic booklet-based VR this will inform practice guidelines and the development of training packages for therapists in the diagnosis and treatment of vestibulopathy in people with MS.

Trial registration

ISRCTN Number: 27374299

Date of Registration 24/09/2018

Protocol Version 15 25/09/2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-020-01983-y.

Performance Scaling in Magnetized Liner Inertial Fusion Experiments

We present experimental results from the first systematic study of performance scaling with drive parameters for a magnetoinertial fusion concept. In magnetized liner inertial fusion experiments, the burn-averaged ion temperature doubles to 3.1 keV and the primary deuterium-deuterium neutron yield increases by more than an order of magnitude to 1.1×10^{13} (2 kJ deuterium-tritium equivalent) through a simultaneous increase in the applied magnetic field (from 10.4 to 15.9 T), laser preheat energy (from 0.46 to 1.2 kJ), and current coupling (from 16 to 20 MA). Individual parametric scans of the initial magnetic field and laser preheat energy show the expected trends, demonstrating the importance of magnetic insulation and the impact of the Nernst effect for this concept. A drive-current scan shows that present experiments operate close to the point where implosion stability is a limiting factor in performance, demonstrating the need to raise fuel pressure as drive current is increased. Simulations that capture these experimental trends indicate that another order of magnitude increase in yield on the Z facility is possible with additional increases of input parameters.

COVID-19-Associated Cytotoxic Lesions of the Corpus Callosum

There are very limited published data on the neurologic complications associated with coronavirus disease 2019 (COVID-19) in the pediatric population. Here we present the first 2 pediatric cases of presumed COVID-19 related cytotoxic lesions of the corpus callosum. Similar to reports in adults, these cases suggest that the COVID-19 infection in children may rarely mediate a hyperinflammatory response that can cause CNS pathology. As the pandemic continues further, the presentation of cytotoxic lesions of the corpus callosum should prompt radiologists to consider COVID-19, among other known causes.

A neutron recoil-spectrometer for measuring yield and determining liner areal densities at the Z facility

A proof-of-principle CR-39 based neutron-recoil-spectrometer was built and fielded on the Z facility. Data from this experiment match indium activation yields within a factor of 2 using simplified instrument response function models. The data also demonstrate the need for neutron shielding in order to infer liner areal densities. A new shielded design has been developed. The spectrometer is expected to achieve signal-to-background greater than 2 for the down-scattered neutron signal and greater than 30 for the primary signal.

Age and gender related differences in infection, thromboembolism, revision and death in knee arthroplasty in a Scottish population

BACKGROUND AND AIMS

The aim of this large population based study was to investigate the effect of patient age and gender on the complication rates of knee arthroplasty surgery using data from the Scottish Arthroplasty Project joint registry.

METHODS AND RESULTS

55,636 knee arthroplasty procedures were included in the study and divided into four age categories (<55, 55-64, 65-75 and >75 years) for comparison of the 90-day deep vein thrombosis or pulmonary embolism (DVT/PE) and one-year infection rates and the mortality and revision rates up to ten-year follow up. The mean rate of DVT/PE was 1.4% with significantly higher rates in elderly patients (p = 0.0006). The mean one-year infection rate was 1.6% with a significantly increased rate of 1.9% in males (p = 0.0001). Mortality rates increased with age, the 10-year mortality in patients >75 years of age was 44.8%. Revision rates were increased in males and younger patients.

CONCLUSION

Elderly patients showed higher rates of thromboembolic complications. There was no difference in infection rates between different age groups. The infection rate was higher in males. Younger patients need to be counselled about the increased risk of revision at 10 years.

FRI0489 ARE WE MISSING CASES OF HAEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS (HLH)? A FIVE YEAR RETROSPECTIVE SERVICE EVALUATION OF RECOGNITION AND RESPONSE TO FERRITIN >10,000MG/L IN THE ADULT POPULATION OF A LARGE UK HOSPITAL TRUST

Background:

Haemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome presenting with fever, cytopaenias and multi organ failure, and carries a high mortality rate1. Primary HLH is genetic and presents in infancy. Secondary HLH (sHLH) presents in children or adults, and macrophage activation syndrome (MAS)1is sHLH in the context of rheumatological disease. Risk factors include immunosuppression, infection, malignancy and autoimmunity. The HScore can be used to calculate probability of HLH2. Gold standard diagnosis is bone marrow aspirate (BMA)1. In paediatrics, ferritin >10,000μg/L is highly specific for HLH3, but less so in adults4. There is no validated treatment pathway for sHLH. Current recommendations are methylprednisolone and IVIG first line, and anakinra or etoposide if these are ineffective1.

Objectives:

This service evaluation assessed patients with a ferritin >10,000μg/L in Portsmouth Hospitals NHS Trust (PHT) against diagnostic criteria and recommended treatment for sHLH, with the aim of sharing results to improve recognition and management.

Methods:

Serum ferritin results >10,000μg/L from 1st March 2014 to 31st March 2019 were requested from PHT central laboratories. Paediatric and duplicate results were excluded. Electronic patient records were used to collect the parameters of the HScore2. HScore and probability of sHLH was calculated using a validated calculator2,5. Patient notes were requested for patients with missing data or probability of HLH >1%.

Results:

Fifty four results were obtained from central laboratories, of which thirty eight were eligible for analysis. Mean age was 63.6 (range 19 to 96), 34.2% male. 47.4% died within one year of ferritin >10,000μg/L. One patient was diagnosed with Adult Onset Still’s Disease. Of the remainder, 73% had risk factors for sHLH.

Accurate assessment of sHLH incidence was not possible due to incomplete data, particularly triglycerides, fibrinogen, and BMA. AST is not routinely collected in PHT, therefore ALT was used for audit. Within these limits, fifteen patients had a probability >1% of sHLH, and five had a probability >50%. Only one patient had confirmed haemophagocytosis on BMA, and was treated for sHLH with oral steroids in addition to usual care.

Conclusion:

Although only one patient had confirmed sHLH on BMA, five patients had a >50% probability of sHLH despite missing parameters for the HScore. It can be seen that potential cases of sHLH might easily be missed. Using a lower level ferritin cut-off for inclusion may have led to an even higher number of potential sHLH cases in our adult patient population. We suggest that sHLH should be considered as a plausible diagnosis in patients with raised ferritin, cytopaenias or organ failure. Local education work is planned to raise awareness of these learning points.

References:

[1]Carter S, Tattersall R, Ramanan A. Macrophage activation syndrome in adults: recent advances in pathophysiology, diagnosis and treatment. Rheumatology 2019; 55(1):5-17

[2]Fardet L, et al. Development and validation of the HScore, a score for the diagnosis of reactive hemophagocytic syndrome. Arthritis Rheum. 2014; 66(9):2613–20.

[3]Allen CE, et al. Highly elevated ferritin levels and the diagnosis of hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer. 2008;50(6):1227–35.

[4]Schram AM, et al. Marked hyperferritinemia does not predict for HLH in the adult population. Blood. 2015; 125(10):1548-1552

[5]Fardet L. HScore. 2014.http://saintantoine.aphp.fr/score/

Disclosure of Interests:

Lucy Kitchen: None declared, Bryony Jones: None declared, Gurdeep Dulay Grant/research support from: Educational grants to attend congress meetings/conferences from Roche, Chugai, UCB, Internis, Pfizer, Lilly, Sandoz, Consultant of: Honoraria for advisory board services from Roche, Chugai, Novartis, Speakers bureau: Speaker fees from Roche, Chugai, Novartis, Amgen, Lilly, Sandoz

SAT0615-HPR FACTORS ASSOCIATED WITH PATIENT ACTIVATION IN PEOPLE WITH RHEUMATIC CONDITIONS

Background:

Patient activation describes the skills, abilities and confidence someone uses to actively manage their health. Patient activation abilities in rheumatology are unclear, and there is little knowledge about factors that explain variation in patient activation. Therefore, understanding these factors can contribute to the development of appropriate, rheumatology-specific interventions targeting activation. The Patient Activation Measure (PAM) captures patient activation and provides people with both a score and a level to describe how able they are to actively manage their health.

Objectives:

To explore longitudinal changes to patient activation (measured using the PAM) (Hibbardet al., 2005), and the PAM’s associations with related constructs (including self-efficacy, health literacy and health beliefs) in a sample of participants with inflammatory arthritis.

Methods:

A postal survey was administered at two time points that were nine months apart. This survey captured the PAM and a range of clinical, demographic and psychosocial variables in a sample of rheumatology patients from 6 NHS sites in England. The measures included in the survey had been selected based on both theory and prior qualitative research and the survey pack was designed in collaboration with a patient partner. Following data collection, candidate variables for a multiple regression analysis were initially identified using univariable analysis. These variables were included in a forced entry multiple regression at each time point, and the variables that were statistically significant contributors at a 0.1 level were included in the final models. Changes to PAM scores over time were investigated using a Wilcoxon matched-pair signed rank test.

Results:

251 participants completed the first survey and 154 participants completed both full surveys. Self-efficacy, illness beliefs, health literacy and health locus of control were consistently associated with variance in PAM scores. The first three factors were also predictive of variance in PAM levels. With the 154 participants who fully completed both surveys, there was a statistically significant difference in participants’ PAM scores between the two surveys.

Conclusion:

The findings suggest factors that may be targets for interventions that aim to increase patient activation. The changes to PAM scores across the data collection period also suggest that when using the PAM as a clinical tool, healthcare professionals would benefit from incorporating regular reviews and preparations for any increases or reductions in patient activation.

References:

[1]Hibbard, J.H., Mahoney, E.R., Stockard, J. and Tusler, M. (2005) Development and testing of a short form of the patient activation measure.Health Services Research. 40 (6 I), pp. 1918–1930.

Disclosure of Interests:

Bethan Jones Speakers bureau: Honorarium for Lilly in their work with the British Society of Rheumatology for the delivery of 2 webinars due to be held on 30th January 2020., Andrew Hunt: None declared, Sarah Hewlett Grant/research support from: Received independent learning grant from Pfizer for the STRIDE project. However, the work has been completed and the grant closed, Diana Harcourt: None declared, Emma Dures Grant/research support from: Independent Learning Grant from Pfizer, combined funding for a research fellow from Celgene, Abbvie and Novartis, Paid instructor for: A fee from Novartis to deliver training to nurses.

Tenckhoff Catheter Salvage by Closed Stiff-Wire Manipulation without Fluoroscopic Control

Objective

To describe the results of Tenckhoff catheter salvage by a modified, closed, stiff-wire manipulation technique without the use of general anesthesia or fluoroscopy, and compare this with previously described techniques.

Design

Retrospective study in patients treated with continuous ambulatory peritoneal dialysis (CAPD) over a 41-month period.

Setting

Renal unit in an inner city hospital.

Patients

Eighteen patients using CAPD who had 22 episodes of outflow failure due to radiologically confirmed malposition of straight two-cuff Tenckhoff catheters.

Interventions

Closed stiff-wire manipulation of malpositioned Tenckhoff catheter without the use of general anesthesia or fluoroscopy.

Main Outcome Measures

Initial success rate of manipulation, catheter and technique (CAPD) survival, and procedure-related complications.

Results

Catheter manipulation was technically successful in 21 of 22 cases. An additional six episodes of malposition occurred ranging from 2 to 630 days after the primary manipulation (median 7 days). A second manipulation was carried out in four cases that resulted in long-term success in two. Three patients were forced to discontinue CAPD for reasons other than catheter malposition, and the overall success rate at 1 month (patient successfully performing CAPD) was 59.1% (±0.1 %). No major complications were experienced during the procedure and no episodes of peritonitis occurred.

Conclusion

The technique described is relatively straightforward, does not require fluoroscopy or general anesthetic, and its success is comparable to previously reported methods of Tenckhoff catheter salvage. We would recommend this technique of catheter salvage in patients with Tenckhoff catheter malposition in whom conservative treatment has failed.

Objective sleep patterns and validity of self-reported sleep monitoring across different playing levels in rugby union

Background

Growing evidence highlights that elite rugby union players experience poor sleep quality and quantity which can be detrimental for performance.

Objectives

This study aimed to i) compare objective sleep measures of rugby union players between age categories over a one week period, and ii) compare self-reported measures of sleep to wristwatch actigraphy as the criterion.

Methods

Two hundred and fifty-three nights of sleep were recorded from 38 players representing four different age groups (i.e. under 16, under 18, senior academy, elite senior) in a professional rugby union club in the United Kingdom (UK). Linear mixed models and magnitude-based decisions were used for analysis.

Results

The analysis of sleep schedules showed that U16 players went to bed and woke up later than their older counterparts (small differences). In general, players obtained seven hours of sleep per night, with trivial or unclear differences between age groups. The validity analysis highlighted a large relationship between objective and subjective sleep measures for bedtime (r = 0.56 [0.48 to 0.63]), and get up time (r = 0.70 [0.63 to 0.75]). A large standardised typical error (1.50 [1.23 to 1.88]) was observed for total sleep time.

Conclusion

This study highlights that differences exist in sleep schedules between rugby union players in different age categories that should be considered when planning training. Additionally, self-reported measures overestimated sleep parameters. Coaches should consider these results to optimise sleep habits of their players and should be careful with self-reported sleep measures.

Changing player behaviour in sport during the COVID-19 pandemic: Shake on it?

To prevent the spread of infection during matches and training activities is a major challenge facing all sports returning from the enforced COVID-19 shutdown. During training and matches, rugby league players make contact with others which can result in SARS-CoV-2 virus transmission. While these interactions characterise the appeal of the game, a number of them can be avoided, including shaking hands and conversing after the match. This paper presents a framework underpinned by behavioural science (capability, opportunity, motivation and behaviour model, COM-B) to support stakeholders in helping players adopt new social distance norms and behaviours. This framework helps to ensure the players have the capability, opportunity, and motivation to adopt new COVID-19 risk minimising behaviours, which they will need to commit to 100%.

Prenatal Management of Pregnancies at Risk of Fetal Neonatal Alloimmune Thrombocytopenia (FNAIT): Scientific Impact Paper No. 61

WHAT IS IT?: Fetal neonatal alloimmune thrombocytopenia (FNAIT), also known as neonatal alloimmune thrombocytopenia (NAIT) or fetomaternal alloimmune thrombocytopenia (FMAIT), is a rare condition which affects a baby's platelets. This can put them at risk of problems with bleeding, particularly into the brain. One baby per week in the UK may be seriously affected and milder forms can affect one in every 1000 births. HOW IS IT CAUSED?: Platelets are blood cells that are very important in helping blood to clot. All platelets have natural proteins on their surface called human platelet antigens (HPAs). In babies, half of these antigens are inherited from the mother and half from the father. During pregnancy, some of the baby's platelets can cross into the mother's bloodstream. In most cases, this does not cause a problem. But in cases of FNAIT, the mother's immune system does not recognise the baby's HPAs that were inherited from the father and develops antibodies, which can cross the placenta and attack the baby's platelets. These antibodies are called anti-HPAs, and the commonest antibody implicated is anti-HPA-1a, but there are other rarer antibody types. If this happens, the baby's platelets may be destroyed causing their platelet count to fall dangerously low. If the platelet count is very low there is a risk to the baby of bleeding into their brain before they are born. This is very rare but if it happens it can have serious effects on the baby's health. HOW IS IT INHERITED?: A baby inherits half of their HPAs from its mother and half from its father. Consequently, a baby may have different HPAs from its mother. As the condition is very rare, and even if the baby is at risk of the condition we have no way of knowing how severely they will be affected, routine screening is not currently recommended. WHAT CAN BE DONE?: FNAIT is usually diagnosed if a previous baby has had a low platelet count. The parents are offered blood tests and the condition can be confirmed or ruled out. There are many other causes of low platelets in babies, which may also need to be tested for. As the condition is so rare, expertise is limited to specialist centres and normally a haematologist and fetal medicine doctor will perform and interpret the tests together. Fortunately, there is an effective treatment for the vast majority of cases called immunoglobulin, or IVIg. This 'blood product' is given intravenously through a drip every week to women at risk of the condition. It may be started from as early as 16 weeks in the next pregnancy, until birth, which would be offered at around 36-37 weeks. Less common treatments that may be considered depending on individual circumstances include steroid tablets or injections, or giving platelet transfusions to the baby. WHAT DOES THIS PAPER TELL YOU?: This paper considers the latest evidence in relation to treatment options in the management of pregnancies at risk of FNAIT. Specifically, we discuss the role of screening, when IVIg should be started, what dose should be used, and what evidence there is for maternal steroids. We also consider in very rare selected cases, the use of fetal blood sampling and giving platelet transfusions to the baby before birth. Finally, we consider the approaches to blood testing mothers to tell if babies are at risk, which is offered in some countries, and development of new treatments to reduce the risk of FNAIT.

Optimisation and validation of a PCR to detect viable Tenacibaculum maritimum in salmon skin tissue samples

A PCR protocol was optimised and validated for the detection of viable Tenacibaculum maritimum cells in salmon skin tissue. Viability conventional (vPCR) and quantitative PCR (v-qPCR) assays both had a limit of detection of 10³ CFU mL^-1 viable cells. The v-qPCR assay showed a linear quantification over 4 log units. Conventional vPCR showed complete signal suppression when only dead cells were present at concentrations lower than 10⁶ CFU mL^-1. While the v-qPCR did not result in complete suppression when only dead cells were present, a method was developed to determine if viable cells were present based on the % Δ in cycle threshold (Ct) value. The procedure was validated for high-throughput processing and an enrichment protocol was validated to reliably detect low concentrations of viable cells both with and without a high background of dead cells. Performing this protocol on naturally infected tissues showed that vPCR and v-qPCR reduced the potential for false positives compared to using conventional PCR and qPCR. The optimised protocol developed for this study provides an efficient, reliable and robust alternative for the detection of viable T. maritimum in skin tissue.

TP1-9 Vestibular dysfunction in acute traumatic brain injury

Objectives

Vestibular dysfunction following traumatic brain injury (TBI) is a major cause of morbidity and unemployment and has impact on the patient’s ability to rehabilitate. Chronically, up to a quarter of TBI cases have cryptogenic dizziness and imbalance, possibly due to chronic brain adaptation that masks the diagnosis. Establishing the spectrum of vestibular diagnoses in acute TBI – when they may be more obvious – may aid diagnosis in chronic TBI cases.

Design

Prospective audit of referrals to specialist neuro-otology team.

Subjects

Consecutive Major Trauma Ward TBI in-patients admitted between June 2014 and May 2015.

Methods

All cases were screened by the therapists for vestibular symptoms and/or signs and referred for specialist neuro-otology review.

Results

Of 111 patients screened, 96 had features of vestibular dysfunction. Of 96 cases, SYMPTOMS (i.e. subjective report) included: – imbalance (58.3%) – headache (50%) -dizziness (40%) Of 96 cases, SIGNS (i.e. examination) included: – gait ataxia (75.5%) – broken smooth pursuit (61.2%) – positive Hallpike (51%) – positive head impulse test (18%). The data indicate that BPPV affects 49% and headache with migraine-like features affect 40.8%. Acute peripheral unilateral vestibular loss affects 18% TBI cases.

Conclusions

Vestibular dysfunction in TBI is common, typically involving peripheral and central structures, often in the same case, and requires specialist neuro-otological management.