Development of a robotic cluster for automated and scalable cell therapy manufacturing

BACKGROUND AIMS

The production of commercial autologous cell therapies such as chimeric antigen receptor T cells requires complex manual manufacturing processes. Skilled labor costs and challenges in manufacturing scale-out have contributed to high prices for these products.

METHODS

We present a robotic system that uses industry-standard cell therapy manufacturing equipment to automate the steps involved in cell therapy manufacturing. The robotic cluster consists of a robotic arm and customized modules, allowing the robot to manipulate a variety of standard cell therapy instruments and materials such as incubators, bioreactors, and reagent bags. This system enables existing manual manufacturing processes to be rapidly adapted to robotic manufacturing, without having to adopt a completely new technology platform. Proof-of-concept for the robotic cluster's expansion module was demonstrated by expanding human CD8+ T cells.

RESULTS

The robotic cultures showed comparable cell yields, viability, and identity to those manually performed. In addition, the robotic system was able to maintain culture sterility.

CONCLUSIONS

Such modular robotic solutions may support scale-up and scale-out of cell therapies that are developed using classical manual methods in academic laboratories and biotechnology companies. This approach offers a pathway for overcoming manufacturing challenges associated with manual processes, ultimately contributing to the broader accessibility and affordability for personalized immunotherapies.

Controlling crystal cleavage in focused ion beam shaped specimens for surface spectroscopy

Our understanding of quantum materials is commonly based on precise determinations of their electronic spectrum by spectroscopic means, most notably angle-resolved photoemission spectroscopy (ARPES) and scanning tunneling microscopy. Both require atomically clean and flat crystal surfaces, which are traditionally prepared by in situ mechanical cleaving in ultrahigh vacuum chambers. We present a new approach that addresses three main issues of the current state-of-the-art methods: (1) Cleaving is a highly stochastic and, thus, inefficient process; (2) fracture processes are governed by the bonds in a bulk crystal, and many materials and surfaces simply do not cleave; and (3) the location of the cleave is random, preventing data collection at specified regions of interest. Our new workflow is based on focused ion beam machining of micro-strain lenses, in which shape (rather than crystalline) anisotropy dictates the plane of cleavage, which can be placed at a specific target layer. As proof-of-principle, we show ARPES results from micro-cleaves of Sr2RuO4 along the ac plane and from two surface orientations of SrTiO3, a notoriously difficult to cleave cubic perovskite.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Fate of Quasiparticles at High Temperature in the Correlated Metal Sr_{2}RuO_{4}

We study the temperature evolution of quasiparticles in the correlated metal Sr_{2}RuO_{4}. Our angle resolved photoemission data show that quasiparticles persist up to temperatures above 200 K, far beyond the Fermi liquid regime. Extracting the quasiparticle self-energy, we demonstrate that the quasiparticle residue Z increases with increasing temperature. Quasiparticles eventually disappear on approaching the bad metal state of Sr_{2}RuO_{4} not by losing weight but via excessive broadening from super-Planckian scattering. We further show that the Fermi surface of Sr_{2}RuO_{4}-defined as the loci where the spectral function peaks-deflates with increasing temperature. These findings are in semiquantitative agreement with dynamical mean field theory calculations.

The development and acceptability of an educational and training intervention for recruiters to neonatal trials: the TRAIN project

BACKGROUND

Suboptimal or slow recruitment affects 30-50% of trials. Education and training of trial recruiters has been identified as one strategy for potentially boosting recruitment to randomised controlled trials (hereafter referred to as trials). The Training tRial recruiters, An educational INtervention (TRAIN) project was established to develop and assess the acceptability of an education and training intervention for recruiters to neonatal trials. In this paper, we report the development and acceptability of TRAIN.

METHODS

TRAIN involved three sequential phases, with each phase contributing information to the subsequent phase(s). These phases were 1) evidence synthesis (systematic review of the effectiveness of training interventions and a content analysis of the format, content, and delivery of identified interventions), 2) intervention development using a Partnership (co-design/co-creation) approach, and 3) intervention acceptability assessments with recruiters to neonatal trials.

RESULTS

TRAIN, accompanied by a comprehensive intervention manual, has been designed for online or in-person delivery. TRAIN can be offered to recruiters before trial recruitment begins or as refresher sessions during a trial. The intervention consists of five core learning outcomes which are addressed across three core training units. These units are the trial protocol (Unit 1, 50 min, trial-specific), understanding randomisation (Unit 2, 5 min, trial-generic) and approaching and engaging with parents (Unit 3, 70 min, trial-generic). Eleven recruiters to neonatal trials registered to attend the acceptability assessment training workshops, although only four took part. All four positively valued the training Units and resources for increasing recruiter preparedness, knowledge, and confidence. More flexibility in how the training is facilitated, however, was noted (e.g., training divided across two workshops of shorter duration). Units 2 and 3 were considered beneficial to incorporate into Good Clinical Practice Training or as part of induction training for new staff joining neonatal units.

CONCLUSION

TRAIN offers a comprehensive co-produced training and education intervention for recruiters to neonatal trials. TRAIN was deemed acceptable, with minor modification, to neonatal trial recruiters. The small number of recruiters taking part in the acceptability assessment is a limitation. Scale-up of TRAIN with formal piloting and testing for effectiveness in a large cluster randomised trial is required.

ScMiles2: A Script to Conduct and Analyze Milestoning Trajectories for Long Time Dynamics

Milestoning is a theory and an algorithm that computes kinetics and thermodynamics at long time scales. It is based on partitioning the (phase) space into cells and running a large number of short trajectories between the boundaries of the cells. The termination points of the trajectories are analyzed with the Milestoning theory to obtain kinetic and thermodynamic information. Managing the tens to hundreds of thousands of Milestoning trajectories is a challenge, which we handle with a python script, ScMiles. Here, we introduce a new version of the python script ScMiles2 to conduct Milestoning simulations. Major enhancements are: (i) post analysis of Milestoning trajectories to obtain the free energy, mean first passage time, the committor function, and exit times; (ii) similar to (i) but the post analysis is for a single long trajectory; (iii) we support the use of the GROMACS software in addition to NAMD; (iv) a restart option; (v) the automated finding, sampling, and launching trajectories from new milestones that are found on the fly; and (vi) support Milestoning calculations with several coarse variables and for complex reaction coordinates. We also evaluate the simulation parameters and suggest new algorithmic features to enhance the rate of convergence of observables. We propose the use of an iteration-averaged kinetic matrix for a rapid approach to asymptotic values. Illustrations are provided for small systems and one large example.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Placental growth factor in assessment of women with suspected pre-eclampsia to reduce maternal morbidity: a stepped wedge cluster randomised control trial (PARROT Ireland)

OBJECTIVE

To determine whether the addition of placental growth factor (PlGF) measurement to current clinical assessment of women with suspected pre-eclampsia before 37 weeks' gestation would reduce maternal morbidity without increasing neonatal morbidity.

DESIGN

Stepped wedge cluster randomised control trial from 29 June 2017 to 26 April 2019.

SETTING

National multisite trial in seven maternity hospitals throughout the island of Ireland PARTICIPANTS: Women with a singleton pregnancy between 20⁺⁰ to 36⁺⁶ weeks' gestation, with signs or symptoms suggestive of evolving pre-eclampsia. Of the 5718 women screened, 2583 were eligible and 2313 elected to participate.

INTERVENTION

Participants were assigned randomly to either usual care or to usual care plus the addition of point-of-care PlGF testing based on the randomisation status of their maternity hospital at the time point of enrolment.

MAIN OUTCOMES MEASURES

Co-primary outcomes of composite maternal morbidity and composite neonatal morbidity. Analysis was on an individual participant level using mixed-effects Poisson regression adjusted for time effects (with robust standard errors) by intention-to-treat.

RESULTS

Of the 4000 anticipated recruitment target, 2313 eligible participants (57%) were enrolled, of whom 2219 (96%) were included in the primary analysis. Of these, 1202 (54%) participants were assigned to the usual care group, and 1017 (46%) were assigned the intervention of additional point-of-care PlGF testing. The results demonstrate that the integration of point-of-care PlGF testing resulted in no evidence of a difference in maternal morbidity-457/1202 (38%) of women in the control group versus 330/1017 (32%) of women in the intervention group (adjusted risk ratio (RR) 1.01 (95% CI 0.76 to 1.36), P=0.92)-or in neonatal morbidity-527/1202 (43%) of neonates in the control group versus 484/1017 (47%) in the intervention group (adjusted RR 1.03 (0.89 to 1.21), P=0.67).

CONCLUSIONS

This was a pragmatic evaluation of an interventional diagnostic test, conducted nationally across multiple sites. These results do not support the incorporation of PlGF testing into routine clinical investigations for women presenting with suspected preterm pre-eclampsia, but nor do they exclude its potential benefit.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02881073.

The effect of the Australian bushfires and the COVID-19 pandemic on health behaviours in people with multiple sclerosis

BACKGROUND

Crises and disasters disproportionally impact people with chronic health conditions such as multiple sclerosis (MS).

OBJECTIVE

To assess the impact of the COVID-19 pandemic and the Australian Black Summer Bushfires on health behaviours in people with MS.

METHODS

People with MS, carers, healthcare and advocacy professionals were recruited online between May-July 2020 for an online survey and telephone interviews.

RESULTS

Survey items relating to health behaviours were completed by 113 people with MS, and 18 people with MS, 4 MS advocates, 5 healthcare professionals, and 2 carers were interviewed. The bushfires affected 34.5% and the pandemic affected 74.3% of survey participants with MS. The pandemic and bushfires caused a decrease in physical activity in 53.8% and 55.3% of participants respectively, as well as increases in unhealthy eating (43.6% and 24.3% respectively) and alcohol consumption (35.4% and 10.5% respectively), and a decrease in typical sleeping patterns (40.5% and 39.5% respectively). Conversely, 27.5% of participants reported an increase in physical activity during the pandemic. Interview data detailed the circumstances and motivations for changes in health behaviours, as well as consequences, including reduced mobility, fitness, mood disturbances, and weight gain.

CONCLUSION

There is a need to increase support and health promotion for people with MS to maintain or initiate positive health behaviours, especially in times of adversity.

Selenium status in a Northern Irish pregnant cohort with iodine deficiency

Selenium and iodine are trace elements that are maximally concentrated in the thyroid. Iodine is a substrate for thyroid hormone synthesis, while the selenoproteins protect the thyroid from the oxidative stress incurred. We measured plasma selenium concentration in 241 pregnant women in 1st trimester, previously reported to have iodine deficiency. Mean age was 30.3 years (SD 5.4), BMI 26.2 kg/m² (SD 4.9) and 53% reported taking supplements. Median urinary iodine concentration was 73 μg/L (IQR 37-122) (WHO recommendation, ≥150 μg/L). Mean plasma selenium concentration was 75 µg/L (SD 7.7) which is below the 80-125 µg/L reported to be optimal. Four-day food diaries revealed a selenium intake of 43 µg/day (SD 15.9), also below the 55-70 µg/day reported to be optimal. This is the first report of selenium status in pregnancy on the island of Ireland. The possible combined effects of iodine and selenium deficiencies in pregnancy merit further investigation.

Effect of a Nurse-Led Protocol on Time to Treatment of Partial Occlusions in Central Venous Access Devices in Pediatric Oncology

Central venous access devices (CVADs) are the standard of care in pediatric oncology. Occlusion is a common complication that can lead to delays in therapy, readmission, and CVAD removal and reinsertion. Early treatment of partial occlusions using a standardized protocol may restore patency and increase life span of CVADs. The objective of this study was to develop and evaluate a nurse-led protocol to manage partial CVAD occlusions in pediatric oncology and autologous bone marrow transplant patients. The protocol enabled nurses to manage partially occluded CVADs by administering thrombolytic therapy following an algorithm and patient-specific standing order. The primary outcome was time from recognition of the partial occlusion to instillation of a thrombolytic. Secondary outcomes were thrombolytic dwell time, number of complete occlusions, and CVAD life span. We used a quasi-experimental, after-only, nonequivalent control group design to compare patients not exposed (retrospective cohort, n = 137) and patients exposed (prospective cohort, n = 101) to the nurse-led protocol. Mann-Whitney U tests were used to compare time to treatment, dwell time, and CVAD life span between cohorts, and χ² was used to compare the proportion of occlusions classified as complete. Time to treatment was significantly lower in the prospective cohort (M = 99.9 minutes) versus the retrospective cohort (M = 483.7 minutes), U = 1366.50, p < .01, as was thrombolytic dwell time, U = 282.50, p < .01. Proportion of complete occlusions and CVAD life span did not differ between cohorts. The nurse-led protocol was effective to manage partial CVAD occlusions in pediatric oncology patients.

Pressure and force on the canine neck when exercised using a collar and leash

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A double layer polyester/nylon collar decreased mean contact pressure on the neck when compared to single layer collars.

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Peak forces were highest under a double layer polyester/nylon collar in all 3 directions of travel – clockwise, anticlockwise and straight.

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No significant differences between collar material and direction of travel were found when comparing mean contact pressure.

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Highest forces were identified when a dog walks in an anticlockwise direction away from a handler.

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Average overall peak force was 30.2 N.

The aim of this study was to assess the pressure and force applied to the canine neck at walk when using collars of different material.

Three different collars of equal size but different construction were used. A double-layer polyester and nylon weave (DN), a single layer nylon weave (SN), and a single layer canvas (SC). Eight dogs wore all three types of collar and were led in a randomized order through a course containing straight, clockwise and counterclockwise sections. Force and pressure were measured and recorded using a Tekscan^Ⓡ F-Scan In-shoe system and analyzed using SPSS statistical software.

Peak force and contact pressure were significantly higher under DN collar when compared with the others (p < 0.0005 and p = 0.001, respectively). Whilst differences in mean force were not observed between collars, there were significant differences depending on the direction of travel of the dog (p < 0.0005), being highest in a counter-clockwise direction, and lowest in a straight line. Peak contact pressure was not significantly different in any condition.

Results suggest that collar construction material will alter contact pressures and peak force exerted on the neck, and that a double layer nylon weave collar with ethylene-vinyl acetate cushioning has a higher contact pressure than either a single layer nylon or canvas construction, which may be contrary to an owners expectations when purchasing a collar. Furthermore, forces will vary depending on the direction of travel in relation to the handler.

P5336Waist:Hip ratio (WHR): a better predictor of cardiovascular risk (CVR) than BMI in people living with HIV

Introduction

Antiretroviral therapy (ART) has dramatically reduced morbidity and mortality among people living with HIV (PLWH), including wasting syndrome. Metabolic and cardiovascular diseases are leading causes of death for PLWH in high-income countries.

Obesity is increasing in the HIV population but a lack of data exists in PLWH, and the association with cardiovascular risk. The aim to determine if central obesity (measured using waist to hip ratio) is a better predictor of CV risk than Body Mass Index (BMI) which is the current standard to define obesity in PLWH.

Methods

Single centre, prospective study performed in a large metropolitan HIV unit. 129 PLWH had weight, height, waist and hip circumference, and blood pressure (BP) recorded. Data on sex, age, ethnicity, past medical history including CV risk factors and kidney disease, smoking status and postcode was used to calculate waist to hip ratio (W/H), BMI and Q-Risk2.

Results

The study population included 30 (23%) women and 98 (77%) men; 76 (59%) Caucasian, 38 (30%) black African/Caribbean and 14 (11%) were other ethnicity. In total, 43 (34%) were overweight and 31 (24%) obese using BMI measurement, this changed to 25 (20%) and 39 (30%) when using WHR.

Q-Risk2 demonstrated that 82 PLWH (64%) had mild risk, 25 (20%) moderate, and 21 (16%) were high cardiovascular risk (excluding HIV as a risk factor).

There was significant correlation between WHR and Q-Risk2 (r=0.44, p<0.01,graph A) but not between BMI and Q-Risk2 (r=0.13, p=0.15, graph B). ROC analysis demonstrates that WHR is able to predict Q-Risk2 (AUC 0.74, 95% CI 0.66–0.82, p<0.01) with a cut-off of 0.98 having 67% sensitivity and 81% for predicting Q-Risk2 >20 (high risk). WHR performed significantly better than BMI (AUC 0.58, 95% CI 0.49–0.67, p=0.24) at predicting Q-Risk2 (p=0.02 for difference, graph C).

W/H ratio and BMI against Q-Risk 2

Conclusion

Temporal change in waist circumference can indicate change in abdominal fat, with increased abdominal fat being associated with increased CV risk. WHR is superior to BMI at predicting high risk (Q-Risk >20%). It should be included as part of routine clinical assessment and lifestyle intervention implemented to reduce CV risk in PLWH.

Cigarette smoking and the occurrence of influenza - Systematic review

OBJECTIVES

The association of current smoking with influenza infection is not widely recognised. The aim of this systematic review was to summarise published evidence and quantify the risk of influenza infection in tobacco smokers compared to non-smokers.

METHODS

We systematically searched MEDLINE, EMBASE, CINAHL, LILACS and Web of Science, from inception to 7 November 2017, to identify relevant randomised control trials, cohort and case-control studies. Study quality was assessed using the Newcastle-Ottawa Scale. We included studies defining influenza as a clinical syndrome and those using confirmatory microbiological tests. Pooled odds ratios (ORs) were estimated by using random effects model.

RESULTS

The mean quality score across the nine included studies (n = 40,685 participants) was 5.4 of 9 (SD 1.07). Current smokers were over 5 times more likely to develop laboratory-confirmed influenza than non-smokers (pooled OR 5.69 (95% CI 2.79-11.60), 3 studies). For studies reporting the occurrence of an influenza-like illness (ILI), current smokers were 34% more likely to develop ILI than non-smokers (pooled OR 1.34 (95% CI 1.13-1.59), 6 studies).

CONCLUSION

Current smokers have an increased risk of developing influenza compared to non-smokers. The association was strongest in studies examining cases with laboratory confirmed influenza.

Nodal disease predicts recurrence whereas other traditional factors affect survival in a cohort of South African patients with differentiated thyroid carcinoma

Background and aim

Information on patients with differentiated thyroid carcinoma in South Africa is limited. The objective of this study was to review demographics and tumour characteristics in a cohort of patients with differentiated thyroid carcinoma, presenting to Groote Schuur Hospital and evaluate risk factors for recurrence and survival.

Patients and methodology

Retrospective demographic and clinical data were collected on all patients referred between January 2003 and December 2013. Prognostic factors for recurrence free survival and cancer specific survival were assessed using univariate and multivariate analyses.

Results

The total number of patients was 231.The median age at presentation was 44 years and 82% were female patients. The pathological sub-types were papillary (60.6%), follicular (38.9%) and poorly differentiated (0.5%). Total thyroidectomy was performed in 191 patients and 30 patients required neck dissections. A total of 171 (74%) patients received ¹³¹Iodine. The recurrence free and cause specific survival rates at 10 years were 83 and 91%, respectively. Nodal disease at presentation was the only significant risk factor for recurrence (p <  0.001) on multivariate analysis. Significant risk factors for cause specific mortality were age ≥ 45 years (p = 0.006), follicular pathology (p = 0.004), extra-thyroid extension (p = 0.013) and residual tumour (p = 0.004).

Conclusions

Consistent with international trends, patients with differentiated thyroid carcinoma treated at Groote Schuur Hospital had a favourable prognosis. The known risk factors associated with recurrence and survival in this South African cohort were consistent with those reported in developed countries.

Research protocol: The initiation, design and establishment of the Global Angelman Syndrome Registry

BACKGROUND

Angelman syndrome (AS) is a rare neurodevelopmental disorder affecting between 1 in 15 000 and 1 in 24 000 individuals. The condition results in severe developmental and expressive language delays, motor impairments and a unique behavioural phenotype consisting of excessive laughter, smiling and sociability. While many studies have contributed knowledge about the causes and natural history of the syndrome, large scale longitudinal studies are required to advance research and therapeutics for this rare syndrome.

METHOD

This article describes the protocol for the Global Angelman Syndrome Registry, and some initial findings. Due to the rarity of AS and the variability in symptom presentation, the registry team will strive for complete case ascertainment. Parents and caregivers will submit data to the registry via a secure internet connection. The registry consists of 10 modules that cover patient demographics; developmental, diagnostic, medical and surgical history, behaviour and development, epilepsy, medications and interventions and sleep.

RESULTS

Since its launch at https://angelmanregistry.info in September 2016, almost 470 individuals with AS have been signed up to the registry worldwide: 59% are from North and South America, 23% are from Europe, 17% are from the Asia Pacific region and 1% are from the Middle East or Africa. The majority of registrants are children, with only 16% aged over 20 years. Most participants indicated a chromosome deletion (76%), with fewer participants indicating a mutation, uniparental disomy or imprinting defect (20%).

CONCLUSION

Findings indicate a need to consider recruitment strategies that target caregivers of older children and adults, and parents and caregivers from non-English speaking backgrounds.

Insulin Autoimmune Syndrome: a rare case of hypoglycaemia resolving with immunosuppression

We report a case of a 58-year-old male presenting with confusion and hypoglycaemia. There had been no prior exposure to oral hypoglycaemic agents or insulin. He was found to have inappropriate endogenous hyperinsulinaemia. Insulinoma was excluded by detailed endocrine assessment. Insulin antibodies were positive in keeping with a diagnosis of insulin autoimmune syndrome (IAS). He was treated with prednisolone 5mg once daily and nutritional supplements leading to resolution of acute confusion and hypoglycaemic episodes. The patient also had severe psoriasis and following discharge was treated with a variety of immunosuppressant therapies. This was associated with disappearance of insulin antibodies after twelve months of follow up. While it is possible that there was spontaneous resolution of insulin antibodies, we speculate that his prednisolone and immunosuppressant therapy may have suppressed insulin antibody production. There are several well recognised associations with IAS and autoimmune conditions, including Grave's disease, systemic lupus erythematous and rheumatoid arthritis. To our knowledge this is the first reported case of insulin autoimmune syndrome, resolving with immunosuppressant treatment of psoriasis.

Triticeal cartilage: the forgotten cartilage

Introduction

The triticeal cartilage (TC) is a small cartilage found within the thyrohyoid membrane. The TC has a variable prevalence between and within individuals. It has been suggested that absence of a TC results from its failure to separate from the superior horn of the thyroid cartilage (SHTC) and that individuals without a TC will have a longer SHTC. This study aims to identify the prevalence of the TC and investigate the relationship between the length of the SHTC and presence of a TC.

Methods

Eighty seven adult cadavers underwent dissection. Data were collected on presence or absence of a TC and lengths of SHTC.

Results

A TC was identified in 28 cadavers (33%). In cadavers with a unilateral TC, there was no significant difference between the lengths of the SHTC on sides with a TC (1.6 mm, ±SEM 0.12 mm) to sides without a TC (1.7 mm, ±SEM 0.10 mm) (P = 0.47). In cadavers with no TCs, the length of the SHTCs (1.8 mm, ±SEM 0.04 mm) was significantly longer than the SHTCs of cadavers with a TC present bilaterally (1.4 mm, ±SEM 0.12 mm) (P = 0.02).

Conclusions

A TC was found in 33% of cadavers. This study demonstrates a relationship between the presence of a TC and the length of the SHTC only in cadavers with a TC present or absent bilaterally.

A Mixed-Methods Evaluation of a Social Paediatrics Block Rotation for Paediatric Residents

BACKGROUND: Poverty and social injustice have a direct link to health outcomes and health care utilization, especially for children. Understanding the complexity of impact of social determinants on health is essential in providing effective, compassionate care to vulnerable populations. Currently, there is a paucity of literature on the impact of various models of advocacy curricula on pediatric residents and future involvement in advocacy. Social Pediatrics is an approach to child health that focuses on the child, in illness, and in health, within the context of their society, environment, school, and family.

OBJECTIVES: 1) To determine if a social pediatrics rotation greater enables residents to become involved in advocacy projects during their residency and interest for career. 2) To identify resident knowledge translation of the social determinants of health and their impact on the pediatric population. 3) To characterize the barriers and enablers, if any, for residents to engage in advocacy.

DESIGN/METHODS: The Social Pediatrics rotation was embedded in the second year of a postgraduate pediatric curriculum. Knowledge and attitudes of resident participants before and after the rotation was assessed with written tests and surveys. A qualitative descriptive study of community partners and resident perspectives was semi-structured interviews, thematic coding and analysis via an inductive-iterative approach.

RESULTS: 21 residents completed pre-and post- written knowledge tests, and 12 residents completed optional attitudinal surveys. Knowledge increased from 68% prior to rotation, to 80% (p &lt; 0.001) following the rotation. All residents completing written surveys indicated increased likelihood of participating in social pediatrics and advocacy in practice following this rotation. Results from 6 resident and 5 community partner interviews included: enhanced knowledge of social determinants of health, residency curricula development with further mental health placements, future practice models involving vulnerable populations, multi-disciplinary learning opportunities, and advocacy projects both at the patient and community level. Community partners shared experiences of residents demonstrating enthusiasm and engagement in placements, some logistical challenges but value in experiences outside hospital environment, particularly in learning from multidisciplinary team.

CONCLUSION: Pediatric residents demonstrate increase in knowledge of social determinants of health and an increased interest in community advocacy initiatives and vulnerable populations following a block rotation in Social Pediatrics. Community partners valued engagement with pediat-ric residents, identifying key learning opportunities in these unique environments and report few barriers to continued involvement. Future directions include impact on advocacy work or career decisions, and multi-centre collaboration.

Understanding dislocation mechanics at the mesoscale using phase field dislocation dynamics

In this paper, we discuss the formulation, recent developments and findings obtained from a mesoscale mechanics technique called phase field dislocation dynamics (PFDD). We begin by presenting recent advancements made in modelling face-centred cubic materials, such as integration with atomic-scale simulations to account for partial dislocations. We discuss calculations that help in understanding grain size effects on transitions from full to partial dislocation-mediated slip behaviour and deformation twinning. Finally, we present recent extensions of the PFDD framework to alternative crystal structures, such as body-centred cubic metals, and two-phase materials, including free surfaces, voids and bi-metallic crystals. With several examples we demonstrate that the PFDD model is a powerful and versatile method that can bridge the length and time scales between atomistic and continuum-scale methods, providing a much needed understanding of deformation mechanisms in the mesoscale regime.

The optimal organization of gynecologic oncology services: a systematic review

BACKGROUND

A system-level organizational guideline for gynecologic oncology was identified by a provincial cancer agency as a key priority based on input from stakeholders, data showing more limited availability of multidisciplinary or specialist care in lower-volume than in higher-volume hospitals in the relevant jurisdiction, and variable rates of staging for ovarian and endometrial cancer patients.

METHODS

A systematic review assessed the relationship of the organization of gynecologic oncology services with patient survival and surgical outcomes. The electronic databases medline and embase (ovid: 1996 through 9 January 2015) were searched using terms related to gynecologic malignancies combined with organization of services, patterns of care, and various facility and physician characteristics. Outcomes of interest included overall or disease-specific survival, short-term survival, adequate staging, and degree of cytoreduction or optimal cytoreduction (or both) for ovarian cancer patients by hospital or physician type, and rate of discrepancy in initial diagnoses and intraoperative consultation between non-specialist pathologists and gyne-oncology-specialist pathologists.

RESULTS

One systematic review and sixteen additional primary studies met the inclusion criteria. The evidence base as a whole was judged to be of lower quality; however, a trend toward improved outcomes with centralization of gynecologic oncology was found, particularly with respect to the gynecologic oncology care of patients with advanced-stage ovarian cancer.

CONCLUSIONS

Improvements in outcomes with centralization of gynecologic oncology services can be attributed to a number of factors, including access to specialist care and multidisciplinary team management. Findings of this systematic review should be used with caution because of the limitations of the evidence base; however, an expert consensus process made it possible to create recommendations for implementation.

Development and Evaluation of a Decision Aid About Prenatal Testing for Women of Advanced Maternal Age

OBJECTIVE

To develop and evaluate a decision aid designed to prepare patients of advanced maternal age for counseling about prenatal diagnostic testing.

SETTING

A regional genetics center.

DESIGN

A before/after study.

INTERVENTIONS

Participants used an audioguided workbook to learn about options and outcomes and to clarify personal risks, values, questions, and predispositions.

SUBJECTS

21 women of advanced maternal age and 17 spouses.

MAIN OUTCOME MEASURES

Knowledge of prenatal testing alternatives, decisional conflict, level of anxiety, and acceptability of the decision aid.

RESULTS

After using the decision aid, participants had significantly reduced decisional conflict (uncertainty) and a significant increase in knowledge. There was no effect on state or trait anxiety. More than three-quarters of participants were satisfied with the length, clarity, balance, and acceptability of the decision aid.

CONCLUSIONS

The decision aid shows promise as a useful aid for preparing couples for counseling.

Umbilical and fetal middle cerebral artery Doppler reference ranges in a twin population followed longitudinally from 24 to 38 weeks' gestation

OBJECTIVE

To construct monochorionic diamniotic (MCDA) and dichorionic diamniotic (DCDA) twin reference ranges for umbilical artery (UA) pulsatility index (PI), UA resistance index (RI), fetal middle cerebral artery (MCA) PI and peak systolic velocity (PSV) and cerebroplacental ratio (CPR) from 24 weeks' to 38 weeks' gestation and compare these with published normal values for singleton pregnancies.

METHODS

This prospective multicenter cohort study included 1028 unselected twin pairs recruited over a 2-year period. Participants with dichorionic twins underwent fortnightly ultrasound surveillance from 24 weeks' gestation, with monochorionic twins being followed every 2 weeks from 16 weeks until delivery. A total of 7536 fetal Doppler examinations in 618 twin pregnancies were included in the analysis, with reference ranges for MCDA and DCDA pregnancies constructed for each of the Doppler indices using multilevel modeling.

RESULTS

UA-PI and UA-RI appear to be higher in twins than in singletons, and MCA-PI and MCA-PSV appear to be lower. The CPR also appears to be lower in twins than in singletons. Similar MCA indices were observed in MCDA and DCDA twins.

CONCLUSION

We have established longitudinal reference ranges for UA-PI and UA-RI, MCA-PI and MCA-PSV and CPR in twin pregnancies, which appear to differ from those in singleton pregnancies. The derived twin-specific reference ranges may be more appropriate in the surveillance of these high-risk pregnancies. Applying the singleton CPR cut-off of ≤ 1.0 may lead to a large number of false-positive diagnoses of cerebral redistribution in twin fetuses.