Human Genetics Society of Australasia Position Statement: Predictive and Presymptomatic Genetic Testing in Adults and Children

This Position Statement provides guidelines for health professionals who work with individuals and families seeking predictive genetic testing and laboratory staff conducting the tests. It presents the major practical, psychosocial and ethical considerations associated with presymptomatic and predictive genetic testing in adults who have the capacity to make a decision, children and young people who lack capacity, and adults living with reduced or fluctuating cognitive capacity.Predictive Testing Recommendations: (1) Predictive testing in adults, young people and children should only be offered with pretest genetic counseling, and the option of post-test genetic counseling. (2) An individual considering whether to have a predictive test should be supported to make an autonomous and informed decision. Regarding Children and Young People: (1) Predictive testing should only be offered to children and young people for conditions where there is likely to be a direct medical benefit to them through surveillance, use of prevention strategies, or other medical interventions in the immediate future. (2) Where symptoms are likely to develop in childhood, in the absence of direct medical benefit from this knowledge, genetic health professionals and parents/guardians should discuss whether undertaking predictive testing is the best course of action for the child and the family as a whole. (3) Where symptoms are likely to develop in adulthood, the default position should be to postpone predictive testing until the young person achieves the capacity to make an autonomous and informed decision. This is applicable regardless of whether there is some action that can be taken in adulthood.

Clinical utilities and end-user experience of pharmacogenomics: 39 mo of clinical implementation experience in an Australian hospital setting

BACKGROUND

Pharmacogenomics (PG) testing is under-utilised in Australia. Our research provides Australia-specific data on the perspectives of patients who have had PG testing and those of the clinicians involved in their care, with the aim to inform wider adoption of PG into routine clinical practice.

AIM

To investigate the frequency of actionable drug gene interactions and assess the perceived utility of PG among patients and clinicians.

METHODS

We conducted a retrospective audit of PG undertaken by 100 patients at an Australian public hospital genetics service from 2018 to 2021. Via electronic surveys we compared and contrasted the experience, understanding and usage of results between these patients and their clinicians.

RESULTS

Of 100 patients who had PG, 84% were taking prescription medications, of which 67% were taking medications with actionable drug-gene interactions. Twenty-five out of 81 invited patients and 17 out of 89 invited clinicians completed the surveys. Sixty-eight percent of patients understood their PG results and 48% had medications changed following testing. Paired patient-clinician surveys showed patient-perceived utility and experience was positive, contrasting their clinicians’ hesitancy on PG adoption who identified insufficient education/training, lack of clinical support, test turnaround time and cost as barriers to adoption.

CONCLUSION

Our dichotomous findings between the perspectives of our patient and clinician cohorts suggest the uptake of PG is likely to be driven by patients and clinicians need to be prepared to provide information and guidance to their patients.

Informing a value care model: lessons from an integrated adult neurogenomics clinic

BACKGROUND

Advances in genomics provide improved opportunities for diagnosis of complex neurogenetic disorders, yet the optimal approach to translate these benefits to the outpatient clinic is unclear.

AIMS

We retrospectively reviewed referral indications and outcomes of an integrated multidisciplinary team (MDT) clinic pathway for adults with suspected neurogenetic disorders. The associated cost implications were estimated.

METHODS

Consecutive patients who attended the neurogenomics clinic from January 2017 to April 2020 were included. The clinic comprised neurologists, clinical geneticists and genetic counsellors, who assessed each patient concurrently.

RESULTS

Ninety-nine new patients were referred spanning 45 different clinical diagnoses. Following MDT clinical assessment, 23% (23/99) of referral diagnoses were revised prior to molecular testing. Eighty-one patients (82%) underwent genetic testing, including 43 exome-based panels, 15 whole-genome sequencing, 14 single gene tests, 27 repeat-primed polymerase chain reaction testing and two chromosomal microarrays. Overall, 33/99 patients (33%) received a diagnosis, either a molecular diagnosis (n = 24, of which 22 were diagnostic and two were predictive) or a clinical diagnosis (n = 9). Of the clinical diagnosis cohort, five patients received a diagnosis without molecular testing and four patients whose negative testing (one diagnostic and three predictive) allowed exclusion of genetic differentials and, hence, confirmation of clinical diagnoses. The diagnostic rate following MDT and diagnostic testing was 30% (28/94), excluding the five predictive testing cases. MDT assessment aligned with eventual molecular diagnoses in 96% of cases. The estimated average costs were AU$1386 per patient undergoing MDT assessment and AU$4159 per diagnosis achieved.

CONCLUSIONS

We present an integrated multidisciplinary neurogenomics clinic pathway providing a diagnostic yield of 33% (30% excluding predictive testing cases), with costing implications. The relatively high diagnostic yield may be attributed to multidisciplinary input integrating accurate phenotyping of complex disorders and interpretation of genomic findings.

Sex Differences in Outcome and Prescribing Practice in ST-elevation MI Patients with Multivessel Disease and Incomplete Revascularisation

Objective: To investigate the extent to which multivessel disease, incomplete revascularisation and prescribing differences contribute to sex-based outcome disparities in patients with ST-elevation MI (STEMI) and establish whether differences in cardiac death and MI (CDMI) rates persist at long-term follow-up. Methods and results: This observational study evaluates sex-based outcome differences (median follow-up 3.6 years; IQR [2.4–5.4]) in a consecutive cohort of patients (n=2,083) presenting with STEMI undergoing percutaneous coronary intervention). Of the studied patients 20.3% (423/2,083) were women and 38.3% (810/2,083) had multivessel disease (MVD). Incomplete revascularisation was common. The median residual SYNTAX score (rSS) was 5.0 (IQR [0–9]) in women and 5.0 (IQR [1–11]) in men (p=0.369), and in patients with MVD it was 9 (IQR [6–17]) in women and 10 (IQR [6–15]) in men (p=0.838). The primary endpoint CDMI occurred in 20.3% of women (86/423) and in 13.2% of men (219/1,660) (p=0.028). Differences persisted following multivariable risk adjustment: female sex was independently associated with CDMI (aHR 1.33; IQR [1.02–1.74]). Women with MVD had CDMI more often than all other groups (p<0.001 for all). Significant sex-based prescribing differences were evident: women were less likely to receive guideline-recommended potent P2Y12 inhibitors than men (31% versus 43%; p=0.012), and differences were particularly evident in patients with MVD (25% in women versus 45% in men, p=0.011). Conclusion: Sex-based differences in STEMI patient outcome persist at long-term follow-up. Poor outcomes were disproportionately found in women with MVD and those with rSS>8. Observed differences in P2Y12 prescribing practices may contribute to poor outcomes for women with MVD and incomplete revascularisation.

Late outcomes of ST-elevation myocardial infarction treated by pharmaco-invasive or primary percutaneous coronary intervention

AIMS

Pharmaco-invasive percutaneous coronary intervention (PI-PCI) is recommended for patients with ST-elevation myocardial infarction (STEMI)who are unable to undergo timely primary PCI (pPCI). The present study examined late outcomes after PI-PCI (successful reperfusion followed by scheduled PCI or failed reperfusion and rescue PCI)compared with timely and late pPCI (>120 min from first medical contact).

METHODS AND RESULTS

All patients with STEMI presenting within 12 h of symptom onset, who underwent PCI during their initial hospitalization at Liverpool Hospital (Sydney), from October 2003 to March 2014, were included. Amongst 2091 STEMI patients (80% male), 1077 (52%)underwent pPCI (68% timely, 32% late), and 1014 (48%)received PI-PCI (33% rescue, 67% scheduled). Mortality at 3 years was 11.1% after pPCI (6.7% timely, 20.2% late) and 6.2% after PI-PCI (9.4% rescue, 4.8% scheduled); P < 0.01. After propensity matching, the adjusted mortality hazard ratio (HR) for timely pPCI compared with scheduled PCI was 0.9 (95% CIs 0.4-2.0) and compared with rescue PCI was 0.5 (95% CIs 0.2-0.9). The adjusted mortality HR for late pPCI, compared with scheduled PCI was 2.2 (95% CIs 1.2-3.1)and compared with rescue PCI, it was 1.5 (95% CIs 0.7-2.0).

CONCLUSION

Patients who underwent late pPCI had higher mortality rates than those undergoing a pharmaco-invasive strategy. Despite rescue PCI being required in a third of patients, a pharmaco-invasive approach should be considered when delays to PCI are anticipated, as it achieves better outcomes than late pPCI.

Reperfusion strategy and late clinical outcomes of patients with ST-elevation myocardial infarction (STEMI) in the absence of standard modifiable risk factors (SMuRFs)

Introduction

There is growing evidence that patients presenting with STEMI in the absence of standard modifiable cardiovascular risk factors (SMuRFs; smoking, hypertension, hypercholesterolemia, diabetes) have poorer outcomes compared to those with atleast one SMuRF. It has been hypothesised that this may be in part due to decreased administration of pharmacotherapies in the post-infarct period due to perceived low risk. Long term outcomes of patients without SMuRFs based on reperfusion strategy received during the index admission have not been investigated.

Purpose

We sought to analyse late clinical outcomes of STEMI patients with and without SMuRFs based on reperfusion strategy received during the index admission.

Methods

All patients who underwent PCI between 2003 and 2014 were identified from a PCI centre STEMI database. Late clinical outcomes of patients with and without SMuRFs were analysed overall and based on reperfusion strategy [primary PCI (pPCI) vs pharmaco-invasive PCI (PI-PCI)]. Propensity matching was used to account for differences in baseline characteristics between the groups.

Results

Amongst 2,091 STEMI patients, 531 (25%) had no SMuRFs (51% pPCI, 49% PI-PCI) and 1560 (75%) had ≥1 SMuRF (52% pPCI, 48% PI-PCI). Unadjusted late mortality in SMuRF-less patients was 13.4% (18.8% pPCI, 7.7% PI-PCI) and for those with ≥1 SMuRF was 9.7% (11.0% pPCI, 8.4% PI-PCI). After propensity-matching clinical and angiographic characteristics, 5 year mortality rates were significantly higher for patients without SMuRFs compared to those with SMuRFs [HR 1.36, CI: 1.03–1.81, p=0.031]. This difference was attenuated for patients who underwent pPCI [HR 1.72, CI: 1.22–2.43, p=0.002]. Interestingly, this discrepancy was not observed amongst individuals who underwent pharmaco-invasive PCI [HR 1.13, CI: 0.53–1.48, p=0.638], as SMuRF-less patients had similar mortality rates to their counterparts. Long term rates of reinfarction, stent thrombosis and target vessel revascularisation were similar between the groups. Additionally, there was no significant difference in rates of stroke and major bleeding amongst all 4 subgroups.

Conclusion

Patients presenting with STEMI in the absence of SMuRFs have increased overall late mortality compared to those with at least one SMuRF. However, this difference was not observed in patients who underwent a pharmaco-invasive strategy, whereby patients without SMuRFs had similar outcomes to those with SMuRFs after adjusting for confounders. Our findings suggest the use of a pharmaco-invasive strategy in appropriate SMuRF-less patients presenting with STEMI.

Funding Acknowledgement

Type of funding sources: None.

Experiences of Children and Youth With Concussion: A Qualitative Study

IMPORTANCE

Concussions are common among children and youth. To date, the pediatric concussion literature has focused on quantitative reports of the effects of concussion and return-to-activity guidelines. However, the subjective experiences of children and youth returning to occupations postconcussion have largely been ignored. An understanding of these experiences is critical to inform effective concussion management.

OBJECTIVE

To investigate the experiences of children and youth returning to occupations after sustaining a concussion and the impacts on their future engagement in occupation.

DESIGN

Qualitative interpretive description was used for data analysis and interpretation.

SETTING

Community.

PARTICIPANTS

Children and youth ages 11 to 18 yr from a cohort study were recruited to be interviewed about their experiences of engaging in occupations postconcussion.

OUTCOMES AND MEASURES

Interviews were conducted 3 to 24 mo postconcussion, transcribed verbatim, and analyzed using interpretive description to identify themes.

RESULTS

Eight children and youth (5 male, 3 female) were included. Analyses revealed three themes of the experiences of children and youth returning to occupations after concussion: diverse experiences of concussion, knowledge is key to concussion management, and concussions affect occupational engagement.

CONCLUSIONS AND RELEVANCE

This study highlights the importance of considering a person's needs to enable effective concussion treatment plans. The results suggest the need for an occupation-based framework to guide interventions in pediatric concussion management. What This Article Adds: Our findings indicate that children and youth report variable recovery patterns, a lack of knowledge about concussion recovery, and a negative effect of concussion on occupational engagement.

A novel synonymous KMT2B variant in a patient with dystonia causes aberrant splicing

Background

Heterozygous KMT2B variants are a common cause of dystonia. A novel synonymous KMT2B variant, c.5073C>T (p.Gly1691=) was identified in an individual with childhood‐onset progressive dystonia.

Methods

The splicing impact of c.5073C>T was assessed using an in vitro exon‐trapping assay. The genomic region of KMT2B exons 23–26 was cloned into the pSpliceExpress plasmid between exon 2 and 3 of the rat Ins2 gene. The c.5073C>T variant was then introduced through site‐directed mutagenesis. The KMT2B wild‐type and c.5073C>T plasmids were transfected separately into HeLa cells and RNA was extracted 48 hours after transfection. The RNA was reverse transcribed to produce cDNA, which was PCR amplified using primers annealing to the flanking rat Ins2 sequences.

Results

Sanger sequencing of the PCR products revealed that c.5073C>T caused a novel splice donor site and therefore a 5‐bp deletion of KMT2B exon 23 in mature mRNA, leading to a coding frameshift and premature stop codon (p.Lys1692AsnfsTer7).

Conclusion

To our knowledge, this is the first report of a KMT2B synonymous variant associated with dystonia. Reassessment of synonymous variants may increase diagnostic yield for inherited disorders including monogenic dystonia. This is of clinical importance, given the generally favourable response to deep brain stimulation for KMT2B‐related dystonia.

Standardized practices for RNA diagnostics using clinically accessible specimens reclassifies 75% of putative splicing variants

PURPOSE

Genetic variants causing aberrant premessenger RNA splicing are increasingly being recognized as causal variants in genetic disorders. In this study, we devise standardized practices for polymerase chain reaction (PCR)-based RNA diagnostics using clinically accessible specimens (blood, fibroblasts, urothelia, biopsy).

METHODS

A total of 74 families with diverse monogenic conditions (31% prenatal-congenital onset, 47% early childhood, and 22% teenage-adult onset) were triaged into PCR-based RNA testing, with comparative RNA sequencing for 19 cases.

RESULTS

Informative RNA assay data were obtained for 96% of cases, enabling variant reclassification for 75% variants that can be used for genetic counseling (71%), to inform clinical care (32%) and prenatal counseling (41%). Variant-associated mis-splicing was highly reproducible for 28 cases with samples from ≥2 affected individuals or heterozygotes and 10 cases with ≥2 biospecimens. PCR amplicons encompassing another segregated heterozygous variant was vital for clinical interpretation of 22 of 79 variants to phase RNA splicing events and discern complete from partial mis-splicing.

CONCLUSION

RNA diagnostics enabled provision of a genetic diagnosis for 64% of recruited cases. PCR-based RNA diagnostics has capacity to analyze 81.3% of clinically significant genes, with long amplicons providing an advantage over RNA sequencing to phase RNA splicing events. The Australasian Consortium for RNA Diagnostics (SpliceACORD) provide clinically-endorsed, standardized protocols and recommendations for interpreting RNA assay data.

1307 Linking Pre-ST Trainees into The Surgical Profession - An Example from OMFS Of A Structured Introduction to The Speciality

Introduction

Inspiration and support are two of the key principles that enthuse junior trainees to pursue a career in surgery. Exposure to Oral and Maxillofacial Surgery (OMFS) is minimal at undergraduate level and can present a challenge for those postgraduate individuals who wish to gain more experience before applying to further training. This has prompted the formation of a support programme comprised of two stages: Taste of OMFS and Mentoring and Support Programme (MSP).

Method

Feedback was captured from OMFS junior trainees and educational supervisors on the existing junior trainee programme. It was concluded that a new programme was required to create a more structured system to help support trainees achieve their goals within OMFS. Taste in OMFS aims to provoke intrigue in the specialty. Individuals who are inspired to experience more can advance on to the MSP which consists of checklists, carefully designed to help the trainee obtain adequate exposure and achieve the recommended requirements for second-degree and specialty training applications.

Results

The new programme was trialed by existing junior trainee programme members over a six-month period. The results were encouraging with positive feedback on the structure of both sections. This, in combination with ideas generated from a focus group has helped create the final version, now published and accessible on the British Association of Oral and Maxillofacial Surgeons website.

Conclusions

We hope to raise awareness of this dynamic programme which can be tailored to each individual, in the hope that more junior trainees pursue a career within OMFS.

The UK Mentoring and Support Programme (MSP) for those considering a career in Oral and Maxillofacial Surgery (OMFS). A review of a 'Register Interest in OMFS' website and the MSP as two key resources created by the British Association of Oral and Maxillofacial Surgeons to promote recruitment and retention (2008-2020)

In 2008, to create a rapid route for information transfer in relation training and recruitment for OMFS trainees, the British Association of Oral and Maxillofacial Surgeons (BAOMS) created a website to "Register Your Interest in OMFS" (RYIO). From 2011 a Mentoring and Support Programme (MSP) was created to provide focussed guidance for trainees aiming for specialty training. This paper reviews the effectiveness and cost of these programmes. Between 2008 and 2020, 1744 individuals used RYIO on 2715 occasions. Of these registrations, 1772 were by dentists, 193 dental students, 589 doctors and 161 medical students. 2354 were from UK and Ireland and 351 from the rest of the world. 188 registrants subsequently became UK OMFS trainees or specialists. All registrants valued the information provided. In response to RYIO trainee feedback the new 'Taste of OMFS 2020' programme was created. The MSP was originally called the Junior Trainee Programme (JTP). The MSP scheme provides a layer of mentorship/support which runs parallel to the medical/dental training post or period of study. Of 180 members of MSP, 72 have obtained specialty training posts in OMFS. There are 88 current members. Full information is available on the BAOMS website www.baoms.org.uk. Reviewing both programmes, participant feedback is excellent with tangible results whilst cost effectiveness is high.

Administration of intravenous iron and tranexamic acid in the management of postoperative iron deficiency anaemia following free flap reconstruction: re-audit

Following free tissue transfer, intravenous iron (IVI) has a role in reducing the rates of blood transfusion and more rapidly restoring haemoglobin (Hb) levels. Anaemia has a detrimental effect on survival, postoperative complications, fatigue, and health-related quality of life, therefore early correction is recommended. The aim of this re-audit is to assess the use of IVI, of tranexamic acid intraoperatively, and of perioperative blood transfusions. A total of 148 consecutive patients who underwent ablative surgery and free flap reconstruction between May 2018 and September 2019 were audited. The median (IQR) age was 66 (59,72) years and 36% were female. For two-thirds, surgery was for cancer located in the oral cavity and two-thirds of the free flaps were soft tissue. Tranexamic acid (TXA) was used intraoperatively for 30%, red blood cells (RBC) were transfused for 20% and 55 patients (37%) received IV iron. This compares with 4%, 26%, and 0, respectively, in the initial audit. Those having IVI were more likely (56%) to have had a composite flap, a lower postoperative haemoglobin and lower discharge Hb. The Hb between four and twelve weeks' follow up, known for 40, was a median (IQR) of 122 (104,138). There were no adverse reactions to IV iron. Although it is straightforward to administer IVI postoperatively, this re-audit demonstrates that it can be a challenge to embed change in protocols. Through raised awareness of the benefits of IVI, lack of adverse events and clarification of selection criteria, it is hoped that rates of IVI use will increase.

Technical considerations when designing a gene expression panel for renal transplant diagnosis

Gene expression analysis is emerging as a new diagnostic tool in transplant pathology, in particular for the diagnosis of antibody-mediated rejection. Diagnostic gene expression panels are defined on the basis of their pathophysiological relevance, but also need to be tested for their robustness across different preservatives and analysis platforms. The aim of this study is the investigate the effect of tissue sampling and preservation on candidate genes included in a renal transplant diagnostic panel. Using the NanoString platform, we compared the expression of 219 genes in 51 samples, split for formalin-fixation and paraffin-embedding (FFPE) and RNAlater preservation (RNAlater). We found that overall, gene expression significantly correlated between FFPE and RNAlater samples. However, at the individual gene level, 46 of the 219 genes did not correlate across the 51 matched FFPE and RNAlater samples. Comparing gene expression results using NanoString and qRT-PCR for 18 genes in the same pool of RNA (RNAlater), we found a significant correlation in 17/18 genes. Our study indicates that, in samples from the same routine diagnostic renal transplant biopsy procedure split for FFPE and RNAlater, 21% of 219 genes of potential biological significance do not correlate in expression. Whether this is due to fixatives or tissue sampling, selection of gene panels for routine diagnosis should take this information into consideration.

Systematic review and literature appraisal on methodology of conducting and reporting critical-care echocardiography studies: a report from the European Society of Intensive Care Medicine PRICES expert panel

Background

The echocardiography working group of the European Society of Intensive Care Medicine recognized the need to provide structured guidance for future CCE research methodology and reporting based on a systematic appraisal of the current literature. Here is reported this systematic appraisal.

Methods

We conducted a systematic review, registered on the Prospero database. A total of 43 items of common interest to all echocardiography studies were initially listed by the experts, and other “topic-specific” items were separated into five main categories of interest (left ventricular systolic function, LVSF n = 15, right ventricular function, RVF n = 18, left ventricular diastolic function, LVDF n = 15, fluid management, FM n = 7, and advanced echocardiography techniques, AET n = 17). We evaluated the percentage of items reported per study and the fraction of studies reporting a single item.

Results

From January 2000 till December 2017 a total of 209 articles were included after systematic search and screening, 97 for LVSF, 48 for RVF, 51 for LVDF, 36 for FM and 24 for AET. Shock and ARDS were relatively common among LVSF articles (both around 15%) while ARDS comprised 25% of RVF articles. Transthoracic echocardiography was the main echocardiography mode, in 87% of the articles for AET topic, followed by 81% for FM, 78% for LVDF, 70% for LVSF and 63% for RVF. The percentage of items per study as well as the fraction of study reporting an item was low or very low, except for FM. As an illustration, the left ventricular size was only reported by 56% of studies in the LVSF topic, and half studies assessing RVF reported data on pulmonary artery systolic pressure.

Conclusion

This analysis confirmed sub-optimal reporting of several items listed by an expert panel. The analysis will help the experts in the development of guidelines for CCE study design and reporting.

P333Late mortality after pharmaco-invasive PCI for STEMI

Background

Worldwide, and in Australia, a large proportion of patients with ST-segment elevation myocardial infarction (STEMI) are unable to undergo timely primary percutaneous coronary intervention (PCI), and so are transferred for PCI after receiving fibrinolytic therapy (so-called pharmaco-invasive PCI).

Methods

Our Hospital, the primary PCI centre for Southwest Sydney, Australia receives patients for both primary PCI and transferred post- fibrinolytic therapy for rescue or prognostic PCI. Associations were determined between late outcomes (bleeding according to Bleeding Academic Research Consortium (BARC) criteria and mortality) and reperfusion strategy, either primary PCI, or pharmaco-invasive PCI, in patients undergoing PCI for STEMI during hospitalization.

Results

Among 2083 consecutive patients (80% male) with STEMI who underwent PCI (1076 [52%] primary PCI and 1007 [48%] pharmaco-invasive PCI), mortality at 3 years was 8.7%,11.1% after primary PCI and 6.2% after pharmaco-invasive PCI (9.4% after rescue PCI and 4.6% after prognostic PCI); p<0.001 (Figure). Rates of type 2–5 BARC bleeding post-PCI were 35% after primary PCI and 24% after pharmaco-invasive PCI (42% after rescue PCI and 15% after prognostic PCI); p<0.001. while the rate of major bleeding type 3b-5 were 5% after primary PCI and 3% after pharmaco-invasive PCI (8% after rescue PCI and 1% after prognostic PCI); p=0.112.The independent predictors of 3 year mortality were, pre-PCI cardiogenic shock HR=0.25 [95% CI: 0.16–0.39], p<0.001), age (HR=1.05 [95% CI: 1.03–1.06], p<0.001), TIMI 3 flow post-PCI (HR=5.25 [95% CI: 2.51–11.00], p≤0.001), eGFR<60mL/min/1.73m2 (HR=2.90 [95% CI: 1.93–4.34], p≤0.001), post PCI bleeding (HR=2.17 [95% CI: 1.53–3.08], p≤0.001), anterior infarction (HR=1.76 [95% CI: 1.23–2.51], p=0.002), and female gender (HR=1.56 [95% CI: 1.07–2.27], p=0.022); and primary PCI (HR=1.6 [95% CI: 1.18–2.19; p=0.003]. On multi-variable analysis, age, cardiogenic shock presentation, rescue PCI, intra-aortic balloon pump, Pre-procedural anaemia, (all p<0.001) and eGFR<60mL/min/1.73m2 (p=0.006) were associated with bleeding.

Figure 1. Late survival after primary & PI PCI

Conclusion

Among patients with STEMI who underwent pharmaco-invasive PCI had lower mortality rates than to those who had primary PCI, though procedural selection criteria may have been different; bleeding rates were similar. Among suitable patients pharmaco-invasive PCI should be evaluated in large clinical trials.

Correction to: A decade of progress in critical care echocardiography: a narrative review

The original version of this article unfortunately contained a mistake.

The surface eroding thermocouple for fast heat flux measurement in DIII-D

A novel type of surface eroding thermocouple (SETC) has been tested and demonstrated in the small angle slot (SAS) divertor of DIII-D for fast local heat flux measurements. The thermojunction of the SETC is formed between two thin (10 μm) ribbons, which are filed over to create microfiber junctions. These thermocouples are able to be exposed directly to the plasma at surface temperatures exceeding 2000 °C and are capable of sub-10 ms time resolution. Before installation in SAS, the SETCs were exposed in the lower DIII-D divertor during L-mode and H-mode discharges, from which results are presented. In preliminary tests, SETCs proved to be a qualified diagnostic to accurately measure both the intra-edge localized mode (ELM) and inter-ELM heat flux during H-mode shots with high frequency ELMs (hundreds of Hz) and to resolve heat flux profiles during strike point sweeps. The heat fluxes measured by using SETCs are consistent with the heat fluxes measured by using IR cameras and Langmuir probes. These new diagnostic capabilities will complement the existing IR camera measurements and will be of particularly significant value to measure surface heat flux in the SAS divertor or other regions where the IR camera lacks line of sight.

Development of a stochastic agent-based model to evaluate surveillance strategies for detection of emergent porcine reproductive and respiratory syndrome strains

Background

The objective of the current study was to develop a stochastic agent-based model using empirical data from Ontario (Canada) swine sites in order to evaluate different surveillance strategies for detection of emerging porcine reproductive and respiratory syndrome virus (PRRSV) strains at the regional level. Four strategies were evaluated, including (i) random sampling of fixed numbers of swine sites monthly; (ii) risk-based sampling of fixed numbers, specifically of breeding sites (high-consequence sites); (iii) risk-based sampling of fixed numbers of low biosecurity sites (high-risk); and (iv) risk-based sampling of breeding sites that are characterized as low biosecurity sites (high-risk/high-consequence). The model simulated transmission of a hypothetical emerging PRRSV strain between swine sites through three important industry networks (production system, truck and feed networks) while considering sites’ underlying immunity due to past or recent exposure to heterologous PRRSV strains, as well as demographic, geographic and biosecurity-related PRRS risk factors. Outcomes of interest included surveillance system sensitivity and time to detection of the three first cases over a period of approximately three years.

Results

Surveillance system sensitivities were low and time to detection of three first cases was long across all examined scenarios.

Conclusion

Traditional modes of implementing high-risk and high-consequence risk-based surveillance based on site’s static characteristics do not appear to substantially improve surveillance system sensitivity. Novel strategies need to be developed and considered for rapid detection of this and other emerging swine infectious diseases. None of the four strategies compared herein appeared optimal for early detection of an emerging PPRSV strain at the regional level considering model assumptions, the underlying population of interest, and absence of other forms of surveillance.

Outcome of Halo Immobilisation of 104 Cases of Cervical Spine Injury

Study design: Retrospective review Objectives: To present and discuss the outcome of halo jacket immobilisation of cervical spine injuries. Setting: National Spinal Injuries Unit in a Scottish University teaching Hospital. Methods: Retrospective review of case-notes and radiographs of all patients treated with halo jacket both as primary means of immobilisation or as adjunct to surgical stabilisation between 1992–1999 and followed up at a weekly halo clinic. Results: Out of a total one hundred and four patients with cervical spine injury, eighty-six were treated with Halo jacket as primary means of cervical immobilisation. Halo was used as adjunct to surgical stabilisation for the rest. There were nine cases of true failure. This is a failure rate of 10% for primary halo immobilisation. Of the nine patients who had failure of bony healing, four had fibrous healing, three had surgery to stabilise spine, two were subsequently lost to follow-up. The highest incidence of recurrence of subluxation occurred in patients with fracture/subluxation with a healing rate of 85%. Patients with ankylosing spondylitis did well. Odontoid fractures had 18% failure rate. The commonest complication was loss of reduction, followed by pin-site infection. Conclusion: Halo is an effective non-surgical treatment for the injured cervical spine at both upper and lower levels.

Evaluation of a two rubber band technique for finger ring removal

INTRODUCTION

Rings are required to be removed from a finger in many clinical situations. Rings that are difficult to remove is a problem encountered frequently. Many techniques have been reported for this problem. This study looks at the effectiveness of a single technique for removing difficult rings from fingers.

METHODS

A two rubber band technique was used in this study of 69 difficult to remove rings. Success of the technique and time to removal were recorded.

RESULTS

Difficult rings were removed in 92.5% of cases, in a mean time of 10.7 seconds. No fingers or rings suffered damage during the study.

CONCLUSIONS

This two rubber band technique is a rapid, safe and effective method for removing rings that cannot be removed easily.

Evidence of horsemanship and dogmanship and their application in veterinary contexts

This review collates peer-reviewed evidence for desirable attributes for those who work with dogs and horses. It is written with a particular focus on the veterinary profession. Although veterinarians and veterinary nurses (VNs) occupy variable roles when interacting with their patients, several behavioural attributes emerge as helpful across the range of such roles. In light of recent research on the value of considering animals' arousal and affective state as predictors of behaviour and welfare, best practice in human-horse and human-dog-interactions is outlined. The attributes of affiliation, safety and positive reinforcement seem to contribute greatly to the development and maintenance of moderate arousal and positive affect in animals. The information in this review article is offered in an attempt to show why veterinary professionals with good horsemanship are likely to remain safe, and to introduce the concept of dogmanship. In the light of the peer-reviewed evidence assembled here, it is arguable that veterinary teams, comprising both veterinarians and VNs, can become scholars in these areas. The benefits of this approach for practitioner safety, animal welfare and client satisfaction are likely to be significant.

Immunotherapy following relapse of acute leukaemia after T-cell-replete allogeneic peripheral blood progenitor cell transplantation: importance of new onset chronic graft-versus-host disease

INTRODUCTION

To further define the relative impact of immunotherapy and subsequent development of graft-versus-host disease (GVHD) on survival in patients with relapsed acute leukaemia postallogeneic hematopoietic stem cell transplant (SCT), we performed a single-centre retrospective analysis of 32 actively treated patients between 2003 and 2011.

METHODS

A total of 13 patients were identified who were treated actively with cessation of immunosuppression ± Fludarabine, Cytarabine, G-CSF (FLAG) induction, but no donor leucocyte infusion (DLI) (non-DLI group) and 19 patients received the same step-wise therapy plus G-CSF mobilized DLI (G-DLI group).

RESULTS

Groups were not statistically different with regards to baseline characteristics; however, the G-DLI group contained more sibling donors as opposed to unrelated donors than the non-DLI group. With a median follow-up of 47 months, the median overall survival (OS) of the non-DLI and G-DLI groups was not statistically different (8 months vs. 9 months, respectively, P = 0.5). Survival at 3 years was <10% in both groups. Univariate analysis identified response to FLAG, and new onset chronic GVHD as the only factors associated with improved OS.

CONCLUSION

Second donor stem cell infusions are unwarranted in the treatment of relapse after allogeneic SCT and therapeutic strategies should focus on cytoreduction followed by immune modulation with the aim of invoking chronic GVHD.

Acupuncture for treatment of arthralgia secondary to aromatase inhibitor therapy in women with early breast cancer: pilot study

BACKGROUND

Aromatase inhibitors (AIs) are recommended as adjuvant hormone treatment for postmenopausal women with early breast cancer. A substantial proportion of women taking AIs experience joint pain and stiffness. Studies have suggested that acupuncture may be effective in treating joint pain.

OBJECTIVE

A pilot study was conducted to evaluate the feasibility, safety and efficacy of using acupuncture to treat AI-induced arthralgia.

METHODS

A total of 32 patients were randomised to receive either sham or real electroacupuncture (EA) twice weekly for 6 weeks. Outcomes of joint pain, stiffness and physical function were measured with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), overall pain severity and interference with the BPI-SF and quality of life (QOL) with the Functional Assessment of Cancer Therapy-General (FACT-G) instrument. Hand strength was assessed by a grip test, and a serum marker of inflammation (C reactive protein (CRP)) was also measured. All assessments were performed at baseline, 6 weeks and 12 weeks, except for blood samples at baseline and 6 weeks only.

RESULTS

No serious adverse events were reported during or after acupuncture treatments. There were no significant differences in outcome measures. However, positive trends were observed in stiffness and physical function at week 12 in favour of real EA.

CONCLUSIONS

Findings suggest that acupuncture is feasible and safe in patients with breast cancer with joint pain caused by AI. A larger study with adequately powered to confirm these results and detect clinically relevant effects is needed.

Prevention of knot slippage with the use of cyanoacrylate glue: a mechanical study

PURPOSE

To assess the effect of cyanoacrylate glue on knot slippage and strength in vitro.

METHODS

Ethibond 3/0 was tested using a tensile tester. A single drop of cyanoacrylate glue was applied to the knots. Seven knot configurations (10 samples each) were tested: (1) a surgeon's knot (S) plus 4 square throws (+4) without glue (control group), (2) S plus one square throw (+1) without glue, (3) S+1 with glue, (4) S with glue, (5) S+1 wet posttie without glue, (6) S+1 wet pre-tie without glue, and (7) S+1 wet pre-tie with glue. Wet sutures were immersed in normal saline for 24 hours prior to knot tying. Wet pre- and post-tie sutures were immersed for one minute prior to knot tying and tensile testing, respectively. Outcome measures were the mode of failure (knot slippage or suture snapping) and the ultimate tensile strength.

RESULTS

All knots without glue failed owing to knot slippage, except for the controls, whereas all knots with glue failed owing to suture snapping. The ultimate tensile strength was significantly higher in knots with glue and controls than in knots without glue. The ultimate tensile strength did not differ significantly between S+4 without glue and S with glue (p=0.48), indicating that glue could reinforce knots and reduce the number of throws needed. Wet suture is protective against failure (p<0.01).

CONCLUSION

Cyanocrylate glue may have clinical applications for flexor tendon repairs for which a reduced knot size is advantageous.

Renal allograft recipients fail to increase interferon-γ during invasive fungal diseases

Invasive fungal diseases are a major cause of death in renal allograft recipients. We previously reported that adjunctive recombinant human interferon-γ therapy has clinical utility for invasive fungal diseases after renal transplantation. We have now developed a rapid peripheral blood-based quantitative real-time PCR assay that enables accurate profiling of cytokine imbalances. Our preliminary studies in renal transplant patients with invasive fungal diseases suggest that they fail to mount an adequate interferon-γ response to the fungal infection. In addition, they have reduced IL-10 and increased TNF-α when compared to stable renal transplant patients. These preliminary cytokine profiling-based observations provide a possible explanation for the therapeutic benefit of adjunctive human interferon-γ therapy in renal allograft recipients with invasive fungal diseases.

High-harmonic fast-wave power flow along magnetic field lines in the scrape-off layer of NSTX

A significant fraction of high-harmonic fast-wave (HHFW) power applied to NSTX can be lost to the scrape-off layer (SOL) and deposited in bright and hot spirals on the divertor rather than in the core plasma. We show that the HHFW power flows to these spirals along magnetic field lines passing through the SOL in front of the antenna, implying that the HHFW power couples across the entire width of the SOL rather than mostly at the antenna face. This result will help guide future efforts to understand and minimize these edge losses in order to maximize fast-wave heating and current drive.

No beneficial effects of levosimendan in acute porcine endotoxaemia

BACKGROUND

Levosimendan has been proposed as an attractive alternative to adrenergic agents for the treatment of sepsis-induced heart failure and haemodynamic derangements. Its use in this setting is, however, still not well investigated. The aim of this study was to test the hypothesis that levosimendan is able to attenuate endotoxin-induced pulmonary hypertension and improve myocardial function in a porcine model. The secondary aims were to investigate its effect on renal and liver function, and the plasma cytokine response.

METHODS

Endotoxaemia was induced in 18 pigs, randomized to placebo and Levosimendan groups. All pigs were fluid resuscitated and Noradrenalin infusion was given according to a predefined protocol. Systemic haemodynamics and myocardial function were measured using pulmonary artery catheterization and transthoracic echocardiography. Renal and liver function tests and cytokine concentrations were measured in plasma.

RESULTS

Levosimendan did not attenuate endotoxin-induced pulmonary hypertension and did not improve myocardial function. There were no differences in renal or liver function. Increases in arterial lactate and decreases in base excess were observed in the Levosimendan group, as well as significant increases in plasma interleukin (IL)-6 and IL-8.

CONCLUSIONS

Contrary to our hypothesis, levosimendan given in conjunction with a protocolized vasopressor and fluid resuscitation did not improve cardiac, renal or liver function in this model of acute porcine endotoxaemia. Hyperlactataemia, acidosis and increases in plasma pro-inflammatory cytokines were observed, the mechanisms and implications of which remain unclear.