Applying models of care for total hip and knee arthroplasty: External validation of a published predictive model to identify extended stay risk prior to lower-limb arthroplasty

OBJECTIVE

This study aimed to externally validate a reported model for identifying patients requiring extended stay following lower limb arthroplasty in a new setting.

DESIGN

External validation of a previously reported prognostic model, using retrospective data.

SETTING

Medium-sized hospital orthopaedic department, Australia.

PARTICIPANTS

Electronic medical records were accessed for data collection between Sep-2019 and Feb-2020 and retrospective data extracted from 200 randomly selected total hip or knee arthroplasty patients.

INTERVENTION

Participants received total hip or knee replacement between 2-Feb-16 and 4-Apr-19. This study was a non-interventional retrospective study.

MAIN MEASURES

Model validation was assessed with discrimination, calibration on both original and adjusted forms of the candidate model. Decision curve analysis was conducted on the outputs of the adjusted model to determine net benefit at a predetermined decision threshold (0.5).

RESULTS

The original model performed poorly, grossly overestimating length of stay with mean calibration of -3.6 (95% confidence interval -3.9 to -3.2) and calibration slope of 0.52. Performance improved following adjustment of the model intercept and model coefficients (mean calibration 0.48, 95% confidence interval 0.16 to 0.80 and slope of 1.0), but remained poorly calibrated at low and medium risk threshold and net benefit was modest (three additional patients per hundred identified as at-risk) at the a-priori risk threshold.

CONCLUSIONS

External validation demonstrated poor performance when applied to a new patient population and would provide limited benefit for our institution. Implementation of predictive models for arthroplasty should include practical assessment of discrimination, calibration and net benefit at a clinically acceptable threshold.

Corrigendum: Adaptive yoga versus low-impact exercise for adults with chronic acquired brain injury: a pilot randomized control trial protocol

[This corrects the article DOI: 10.3389/fnhum.2023.1291094.].

Adaptive yoga versus low-impact exercise for adults with chronic acquired brain injury: a pilot randomized control trial protocol

Background

Each year, millions of Americans sustain acquired brain injuries (ABI) which result in functional impairments, such as poor balance and autonomic nervous system (ANS) dysfunction. Although significant time and energy are dedicated to reducing functional impairment in acute phase of ABI, many individuals with chronic ABI have residual impairments that increase fall risk, decrease quality of life, and increase mortality. In previous work, we have found that yoga can improve balance in adults with chronic (i.e., ≥6 months post-injury) ABI. Moreover, yoga has been shown to improve ANS and brain function in healthy adults. Thus, adults with chronic ABI may show similar outcomes. This protocol details the methods used to examine the effects of a group yoga program, as compared to a group low-impact exercise, on primary and secondary outcomes in adults with chronic ABI.

Methods

This study is a single-blind randomized controlled trial comparing group yoga to group low-impact exercise. Participants must be ≥18 years old with chronic ABI and moderate balance impairments. Group yoga and group exercise sessions occur twice a week for 1 h for 8 weeks. Sessions are led by trained adaptive exercise specialists. Primary outcomes are balance and ANS function. Secondary outcomes are brain function and structure, cognition, quality of life, and qualitative experiences. Data analysis for primary and most secondary outcomes will be completed with mixed effect statistical methods to evaluate the within-subject factor of time (i.e., pre vs. post intervention), the between-subject factor of group (yoga vs. low-impact exercise), and interaction effects. Deductive and inductive techniques will be used to analyze qualitative data.

Discussion

Due to its accessibility and holistic nature, yoga has significant potential for improving balance and ANS function, along with other capacities, in adults with chronic ABI. Because there are also known benefits of exercise and group interaction, this study compares yoga to a similar, group exercise intervention to explore if yoga has a unique benefit for adults with chronic ABI.Clinical trial registration:ClinicalTrials.gov, NCT05793827. Registered on March 31, 2023.

Early and intensive Motor Training for people with spinal cord injuries (the SCI-MT Trial): description of the intervention

STUDY DESIGN

Descriptive.

OBJECTIVES

The primary objective is to describe the intervention that will be provided in a large multi-centre randomised controlled trial titled: Early and Intensive Motor Training for people with Spinal Cord Injuries (the SCI-MT Trial). The secondary objective is to describe the strategies that will be used to operationalise and standardise the Motor Training provided to participants while keeping the intervention person-centred.

METHODS

The paper focuses on the rationale and principles of Motor Training for people with spinal cord injuries (SCI). The description of the intervention is based on the Template for Intervention Description and Replication (TIDieR) checklist. Specifically, it addresses the following 6 criteria of the TIDieR checklist: why the effectiveness of Motor Training is being examined; what, how, where and when the Motor Training will be administered; and how much Motor Training will be provided.

RESULTS

A detailed intervention manual has been developed to help standardise the delivery of the intervention.

CONCLUSIONS

This paper describes the details of a complex intervention administered as part of a large randomised controlled trial. It will facilitate the subsequent interpretation of the trial results and enable the intervention to be reproduced in clinical practice and future trials.

Integrating Internal Fragments in the Interpretation of Top-Down Sequencing Data of Larger Oligonucleotides

In the context of direct top-down analysis or concerted bottom-up characterization of nucleic acid samples, the waning yield of terminal fragments as a function of precursor ion size poses a significant challenge to the gas-phase sequencing of progressively larger oligonucleotides. In this report, we examined the behavior of oligoribonucleotide samples ranging from 20 to 364 nt upon collision-induced dissociation (CID). The experimental data showed a progressive shift from terminal to internal fragments as a function of size. The systematic evaluation of experimental factors, such as collision energy, precursor charge, sample temperature, and the presence of chaotropic agents, showed that this trend could be modestly alleviated but not suppressed. This inexorable effect, which has been reported also for other activation techniques, prompted a re-examination of the features that have traditionally discouraged the utilization of internal fragments as a source of sequence information in data interpretation procedures. Our simulations highlighted the ability of internal fragments to produce self-consistent ladders with either end corresponding to each nucleotide in the sequence, which enables both proper alignment and correct recognition of intervening nucleotides. In turn, contiguous ladders display extensive overlaps with one another and with the ladders formed by terminal fragments, which unambiguously constrain their mutual placement within the analyte sequence. The experimental data borne out the predictions by showing ladders with extensive overlaps, which translated into uninterrupted "walks" covering the entire sequence with no gaps from end to end. More significantly, the results showed that combining the information afforded by internal and terminal ladders resulted in much a greater sequence coverage and nucleotide coverage depth than those achievable when either type of information was considered separately. The examination of a series of 58-mer oligonucleotides with high sequence homology showed that the assignment ambiguities engendered by internal fragments did not significantly exceed those afforded by the terminal ones. Therefore, the balance between potential benefits and perils of including the former makes a compelling argument for the development of integrated data interpretation strategies, which are better equipped for dealing with the changing fragmentation patterns obtained from progressively larger oligonucleotides.

Anxiety exacerbation in a patient with chronic myeloid leukemia receiving dasatinib and venlafaxine

INTRODUCTION

Tyrosine kinase inhibitor (TKI) use leads to near-normal life expectancy in patients with chronic myeloid leukemia (CML); unfortunately for some patients, adverse drug effects (ADEs) and medication burden associated with TKI therapy can lead to decreased quality of life. Additionally, TKIs have drug interactions that may negatively impact patients' management of co-morbidities or lead to increased ADEs.

CASE REPORT

A 65-year-old female with a history of anxiety treated and controlled with venlafaxine experienced increased and resistant anxiety and insomnia after starting dasatinib for CML.

MANAGEMENT AND OUTCOME

On dasatinib, the patient experienced worsening anxiety and insomnia. The stress of a new leukemia diagnosis, drug interactions, and ADEs from dasatinib were considered possible causes. Dose adjustments to dasatinib and venlafaxine were made to control the patient's symptoms. However, the patient's symptoms did not resolve. After being on dasatinib for 2.5 years, the patient discontinued TKI therapy due to being in a deep molecular remission and given ongoing challenges managing anxiety. Within 4 months of stopping dasatinib, the patient reported an improvement in anxiety and overall emotional wellbeing. She continues to feel better and remains in a complete molecular remission 20 months off treatment.

DISCUSSION

This case demonstrates a possible previously unknown drug interaction with dasatinib as well as a possible rarely reported ADE of dasatinib. Additionally, it highlights the difficulties patients with psychiatric disorders may face on TKI therapy and challenges providers may have in identifying rare psychiatric ADEs, thus emphasizing the need for documentation of these types of cases.

Daily mindfulness, negative affect, and eating behaviors in adolescents at risk for excess weight gain

OBJECTIVE

Loss-of-control and overeating are common in adolescents with high body mass index (BMI). Mindfulness may affect negative affect, and both may relate to loss-of-control and overeating. Yet, there is limited understanding of these associations in adolescents' daily lives.

METHODS

Forty-five adolescents (77% female; Mage  = 14.4 years, SDage  = 1.7 years) with high weight (92% with BMI [kg/m2 ] ≥85th percentile for age/sex) provided daily, repeated measurements of mindfulness, negative affect, loss-of-control, and overeating for ~7 days (M = 5.6 days; range = 1-13). Multilevel mixed modeling was conducted to test within-person (intraindividual) and between-person (interindividual) associations for the same-day (concurrent) and next-day (time-ordered/prospective).

RESULTS

There were within-person and between-person associations of higher mindfulness with lower negative affect on the same-day and next-day. Greater between-person mindfulness related to lower odds of adolescents' loss-of-control occurrence (same-day) and conversely, more perceived control over eating (same-day and next-day). Greater within-person mindfulness related to less odds of next-day overeating.

DISCUSSION

Dynamic relations exist among mindfulness, negative affect, and eating in adolescents at-risk for excess weight gain. Mindfulness may be an important element to consider in loss-of-control and overeating. Future work using momentary-data within an experimental design would help disentangle the intraindividual effects of increasing mindfulness/decreasing negative affect on disordered eating.

PUBLIC SIGNIFICANCE

Loss-of-control and overeating are common in teenagers with high weight. Greater mindfulness-present-moment, non-judgmental attention-and less negative emotions may relate to healthier eating, but we do not know how these processes play out in teenagers' daily lives. Addressing this knowledge gap, the current findings showed that greater daily mindfulness, but not negative affect, related to less loss-of-control/overeating, suggesting the importance of mindfulness for eating patterns in teenagers' daily lives.

Approach to the diagnosis and management of snakebite envenomation in South Africa in humans: Special patient groups and surgical aspects

This article explores the management of snakebite to vulnerable patient groups, namely children and pregnant women as well as providing detail on the current best practice when caring for venom ophthalmia and surgical wounds resulting from snakebite. Finally, the optimal free-to-use medical record for accurate documentation of snakebite incidents is provided for use by South African practitioners.

Approach to the diagnosis and management of snakebite envenomation in South Africa in humans

Snake bite management is largely driven by expert opinion and consensus, however there are a few large retrospective studies and RCT's that have improved the quality of medical guidance currently available. South African snakes are different in the venomous potential and it behooves the hospital provider and the average medical practitioner to know the current best practice concepts concerning assessment, treatment and antivenom use. The recent SASS meeting in July 2022 provided an update and national consensus from which this Hospital Care document is derived.

NET-02: a randomised, non-comparative, phase II trial of nal-IRI/5-FU or docetaxel as second-line therapy in patients with progressive poorly differentiated extra-pulmonary neuroendocrine carcinoma

Background

The prognosis for patients with poorly-differentiated extra-pulmonary neuroendocrine carcinoma (PD-EP-NEC) is poor. A recognised first-line (1L) treatment for advanced disease is etoposide/platinum-based chemotherapy with no standard second-line (2L) treatment.

Methods

Patients with histologically-confirmed PD-EP-NEC (Ki-67 > 20%; Grade 3) received IV liposomal irinotecan (nal-IRI) (70 mg/m2 free base)/5-FU (2400 mg/m2)/folinic acid, Q14 days (ARM A), or IV docetaxel (75 mg/m2), Q21 days (ARM B), as 2L therapy. Primary endpoint was 6-month progression-free survival (PFS) rate (80% power to demonstrate one-sided 95% lower confidence interval excluded 15% (target level of efficacy: 30%)). Secondary endpoints: objective response rate (ORR), median PFS, overall survival (OS), toxicity and patient-reported quality-of-life (QoL) (ClinicalTrials.gov: NCT03837977).

Findings

Of 58 patients (29 each arm); 57% male, 90% ECOG PS 0/1, 10% PS 2, 89.7% Ki-67 ≥ 55%, primary site: 70.7%-gastrointestinal, 18.9%-other, 10.3%-unknown, 91.4%/6.9%/1.7% were resistant/sensitive/intolerant to 1L platinum-based treatment, respectively. The primary end-point of 6-month PFS rate was met by ARM A: 29.6% (lower 95% Confidence-Limit (CL) 15.7), but not by ARM B: 13.8% (lower 95%CL:4.9). ORR, median PFS and OS were 11.1% (95%CI:2.4-29.2) and 10.3% (95%CI:2.2-27.4%); 3 months (95%CI:2-6) and 2 months (95%CI:2-2); and 6 months (95%CI:3-10) and 6 months (95%CI:3-9) in ARMS A and B, respectively. Adverse events ≥ grade 3 occurred in 51.7% and 55.2% (1 and 6 discontinuations due to toxicity in ARMS A and B), respectively. QoL was maintained in ARM A, but not ARM B.

Interpretation

nal-IRI/5-FU/folinic acid, but not docetaxel, met the primary endpoint, with manageable toxicity and maintained QoL, with no difference in OS. ORR and median PFS were similar in both arms. This study provides prospective efficacy, toxicity and QoL data in the 2L setting in a disease group of unmet need, and represents some of the strongest evidence available to recommend systemic treatment to these patients.

Funding

Servier.

Caffeine Augments the Lactate and Interleukin-6 Response to Moderate-Intensity Exercise

INTRODUCTION

The release of interleukin (IL)-6 from contracting skeletal muscle is thought to contribute to some of the health benefits bestowed by exercise. This IL-6 response seems proportional to exercise volume and to lactate production. Unfortunately, high volumes of exercise are not feasible for all people. Caffeine augments the magnitude of increase in circulating IL-6 in response to high-intensity and long-duration exercise. Caffeine also increases circulating concentrations of lactate during exercise. We hypothesized that caffeine, ingested before short-duration, moderate-intensity exercise, would lead to greater circulating concentrations of lactate and IL-6 in a study population comprising both male and female individuals.

METHODS

Twenty healthy adults (10 men and 10 women age 25 ± 7 yr (mean ± SD)) completed 30 min of moderate-intensity cycle ergometer exercise, at an intensity corresponding to 60% peak oxygen uptake, after ingesting either caffeine (6 mg·kg -1 ) or placebo. Arterialized-venous blood was collected throughout each of the exercise sessions.

RESULTS

Compared with placebo, caffeine increased circulating concentrations of lactate at the end of exercise (5.12 ± 3.67 vs 6.45 ± 4.40 mmol·L -1 , P < 0.001) and after 30 min of inactive recovery (1.83 ± 1.59 vs 2.32 ± 2.09 mmol·L -1 , P = 0.006). Circulating IL-6 concentrations were greatest after 30 min of inactive recovery ( P < 0.001) and higher with caffeine (2.88 ± 2.05 vs 4.18 ± 2.97, pg·mL -1 , P < 0.001). Secondary analysis indicated sex differences; caffeine increased the IL-6 response to exercise in men ( P = 0.035) but not in women ( P = 0.358).

CONCLUSIONS

In response to moderate-intensity exercise, caffeine evoked greater circulating lactate concentrations in men and women but only increased the IL-6 response to exercise in men. These novel findings suggest that for men unwilling or unable to perform high-intensity and/or long-duration exercise, caffeine may augment the health benefits of relatively short, moderate-intensity exercise.

Case series of medication-related osteonecrosis of the jaw (MRONJ) patients prescribed a drug holiday

The role of a drug holiday in the management of medication-related osteonecrosis of the jaw (MRONJ) remains controversial. Current UK guidance does not recommend this practice given the lack of conclusive evidence, and potential risk of skeletal-related events or cancer metastasis. This paper aims to describe a series of fifty patients with confirmed MRONJ who were prescribed a drug holiday as part of their management. Data were collected on exposures including: anti-resorptive and/or anti-angiogenic drug history, duration of drug, method of administration, concurrent therapy, MRONJ stage, management of MRONJ and duration of drug holiday. The primary outcome was complete healing as documented in the clinical notes. Multivariate Cox regression analysis was performed to evaluate the association between exposures and primary MRONJ outcome. Models were adjusted for age, sex, and index of multiple deprivation. Survival analysis was performed using a log-rank test, censoring any patients with no primary outcome recorded (p < 0.05). A total of 44% of patients stopped their medication for >36 months. Over half of all MRONJ cases presented in the posterior mandible and dental extraction was the most common precipitating factor (76%). Almost three-quarters (72%) of patients achieved complete healing. MRONJ recurrence (new site) was reported at 30%, mainly in those with incomplete healing of the initial area. There was a lack of evidence for an association between all recorded exposures and the primary MRONJ outcome using multivariate Cox regression. Similarly, we did not demonstrate evidence for an association between the duration of the drug holiday and MRONJ outcome. Our results support published guidelines, which do not recommend the discontinuation of bone modifying drugs for the prevention of MRONJ, or as part of treatment for established MRONJ.

The association of body mass index and odds of type 2 diabetes mellitus varies by race/ethnicity

OBJECTIVE

This study aimed to examine the association between body mass index (BMI; weight [kilogram]/height² [meter]) and type 2 diabetes mellitus (T2DM) among the largest three largest racial/ethnic groups in the United States.

METHODS

We compiled 10 waves of the continuous National Health and Nutrition Examination Survey from 1999-2000 through 2017-2018. Participants (N = 45,514) were those who had data on BMI, HbA_1c, and demographics. We estimated associations between BMI and prediabetes/T2DM odds for Black, Latine, and White participants.

RESULTS

BMI was associated with 10% higher odds of prediabetes/T2DM vs. having normal HbA_1c levels (odds ratio = 1.10, 95% confidence interval = 1.10-1.11) for Latine and White individuals. However, the association between BMI and prediabetes/T2DM was significantly weaker among Black individuals. When focusing on T2DM prevalence, the association with BMI for Black participants was even weaker (odds ratio = 0.97, 95% confidence interval = 0.95-0.98).

CONCLUSIONS

The unstable associations between BMI and T2DM across race indicate that BMI has received unwarranted focus as a prime predictor of T2DM. Relying on BMI introduces bias in T2DM risk estimations especially in Black individuals. Focusing on BMI places the onus on individuals to change and increases weight stigma, which can worsen health outcomes. Instead, policymakers should focus on social determinants of T2DM and its concomitant racial/ethnic disparities.

Persistent knee extension deficits are common after anterior cruciate ligament reconstruction: a systematic review and meta-analysis of randomised controlled trials

PURPOSE

Knee extension deficits complicate recovery from ACL injury and reconstruction; however, the incidence of knee extension loss is not well defined. The aim of this review was to identify the incidence of loss of extension (LOE) following ACL rupture and reconstruction, explore the definitions of knee extension deficits reported and identify prognostic factors affecting LOE incidence.

METHODS

A systematic search was conducted in Medline, Cochrane Library and PEDro for studies in publication up to November 2021, with no restrictions on publication year. References were screened and assessed for inclusion using predetermined eligibility criteria. Randomised controlled trials (RCTs) that quantified knee angle, loss of extension or incidence of extension deficit were included for quality assessment and data extraction. Statistical summaries were generated and meta-analyses performed in two parts to examine: (i) the probability of a datapoint being zero incidence compared to a nonzero incidence and (ii) the relationship between the predictors and nonzero LOE incidence.

RESULTS

A sample of 15,494 studies were retrieved using the search criteria, with 53 studies meeting eligibility criteria. The pooled results from 4991 participants were included for analysis, with 4891 participants who had undergone ACLR. The proportion of included studies judged at an overall low risk of bias was small (7.8%). The observed group and study were the most important predictors for whether a datapoint reported an incidence of extension deficit. Time to follow-up (P < 0.001) and graft type (P = 0.02) were found to have a significant influence on nonzero LOE incidence (%). Covariate adjusted estimates of average LOE indicated 1 in 3 patients presenting with LOE at 12 month follow-up, reducing to 1 in 4 at 2 years.

CONCLUSIONS

This review examined the definitions for the measurement and interpretation of postoperative knee extension and established the trajectory of knee extension deficit after ACL injury and reconstruction. While factors associated with loss of extension were identified, the exact trajectory of knee extension deficits was difficult to infer due to discrepancies in measurement techniques and patient variation. On average, 1 in 3 patients may present with loss of extension of at least 3 degrees at 12-month follow-up, decreasing to 1 in 4 at 2 years. These results may be used by clinicians as an upper threshold for acceptable complication rates following ACLR. Future work should focus on LOE as a clinically relevant complication of ACL injury and treatment with appropriate attention to standardisation of definitions, measurements and better understanding of natural history.

PROSPERO REGISTRATION NUMBER

CRD42018092295.

LEVEL OF EVIDENCE

Level I.

Edible marijuana and cycle ergometer exercise

Purpose: There is extensive public and scientific interest in the influence of cannabis and the psychoactive cannabinoid, delta-9-tetrahydrocannabinol (THC), on exercise performance. Unfortunately, recent, up-to-date studies are lacking. The aim of the current study was to address the hypothesis that ingestion of edible marijuana, prior to exercise, would have unfavorable effects on the physiological response to exercise and on exercise performance. Methods: 17 Healthy adult male and female habitual exercisers, who were regular users of cannabis products, were screened for study participation. 10 were enrolled, and data from 9 [8 males, 1 female, aged 25±3 years, with peak oxygen uptake of 56.5±11.7 ml/kg/min (mean ± SD)] were retained. Participation included two exercise sessions, each preceded by self-administration and ingestion of either edible marijuana (containing 10 mg THC) or placebo. Cardio-respiratory responses (via indirect calorimetry) to stationary cycle ergometer exercise (8 min at 50, 100 and 150 W) were recorded before completion of a 20-min Functional Threshold Power test (FTP²⁰) and a sprint test involving maximal effort until volitional fatigue. Results: Edible marijuana increased the concentration of circulating THC and THC metabolites, and evoked sensations of intoxication and altered psychoactive state. Cardio-respiratory responses to staged cycle ergometer exercise were normal and were unaffected by edible marijuana. Compared with placebo, edible marijuana did not influence FTP²⁰ (Placebo 253±75 vs THC: 251±72 W (mean±SD); p > 0.45) or peak power output during the sprint test (Placebo: 710±201 vs. THC: 732±136 W; p = 0.864). Conclusion: 10 mg of THC, when ingested prior to exercise by regular exercisers and habitual users of cannabis, had little effect on the physiological response to standardized cycle ergometer exercise, and was neither ergogenic nor ergolytic.

Oral oncolytic monitoring pilot with patient-reported outcomes and adherence assessments

INTRODUCTION

Patients on oral oncolytics are responsible for self-monitoring adherence and adverse drug reactions (ADRs). Oncology pharmacists are in position to focus on quality and safety of care for patients on oncolytics while providing communication between the patient, physician, and specialty pharmacies. This pilot aimed to monitor patients treated by our leukemia team initiated on oral oncolytics.

METHODS

From July 2020 to February 2021, patients treated by our leukemia team newly started on oncolytics were included. Pharmacists performed medication reconciliation and drug interaction screening on initiation of oral oncolytic. Pharmacists followed up at predefined intervals. On follow up adherence was assessed using the Morisky Medication Adherence Scale-8 (MMAS-8) and patient reported outcomes (PROs) were assessed using the revised Edmonton Symptom Assessment Scale (ESAS-r). After each follow-up, a note was placed in the chart with assessment scores and recommendations.

RESULTS

A total of 32 patients were screened with 19 patients included. Oral oncolytics included: imatinib (4), dasatinib (5), ponatinib (1), gilteritinib (2), enasidenib (1), and venetoclax (6). Fourteen drug interactions were identified, 11 medications discontinued, nine medications added, and two medications doses were changed. Twenty-six adherence assessments were performed with 21, 4, and 1 assessment demonstrating adherence, medium adherence, and low adherence, respectively. 62 ESAS-r assessments were performed with 64% reported as no symptoms, 17% as mild, 13% as moderate, and 5% as severe symptoms. Twenty laboratory tests were ordered from pharmacist recommendation on initiation and follow-up.

CONCLUSION

This pilot demonstrated the role pharmacists play in oral oncolytic monitoring and symptom management.

Pre- and peri-operative clinical information, physiological observations and outcome measures following flexible ureterorenoscopy (FURS), for the treatment of kidney stones. A single-centre observational clinical pilot-study in 51 patients

BACKGROUND

Kidney stone disease contributes to a significant proportion of routine urological practice and remains a common cause of worldwide morbidity. The main aim of this clinical-pilot study was to investigate the effect of flexible ureterorenoscopy (FURS) on pre- and peri-operative clinical information, physiological observations and outcome measures.

METHODS

Included were 51 patients (31 males, 20 females), who underwent elective FURS, for the treatment of kidney stones. Pre-operative and peri-operative clinical information, and post-operative physiological observations and outcome measures were collected using a standard case report form. Pre-operative clinical information included age, gender, BMI, previous history of stone formation and hypertension. Pre-operative stone information included the size (mm), Hounsfield units (HU), laterality and intra-renal anatomical location. Peri-operative surgical details included surgical time in minutes; Laser use; Duration and energy of laser; and post-operative stenting. The physiological outcomes measured included systolic and diastolic blood pressure (mmHg), Likert pain score, temperature, heart rate (bpm) and respiration rate (bpm). Following initial descriptive analysis, a series of Pearson's correlation coefficient tests were performed to investigate the relationship between surgical factors other variable factors.

RESULTS

A series of significant, positive correlations were observed between; age and surgical time (p = 0.014, r = 0.373); stone size and Hounsfield unit (p = 0.029, r = 0.406); surgical time and duration of laser (p < 0.001, r = 0.702); surgical time and BMI (p = 0.035, r = 0.322); baseline heart rate and Hounsfield unit (p = 0.026, r = - 0.414); base line heart rate and BMI (p = 0.030, r = 0.307).; heart rate at 120-min post FURS and age (p = 0.038, r = - 0.308); baseline pain score and BMI (p = 0.010, r = 0.361); baseline respiration rate and BMI (p = 0.037, r = 0.296); respiration rate at 240-min post FURS and BMI (p = 0.038, r = 0.329); respiration rate at 120 min post FURS and age (p = 0.022, r = - 0.330). Four patients developed post-operative complications (3-UTIs with urinary retention, 1-urosepsis).

CONCLUSIONS

We report that following FURS there is an association between various physiological, clinical and surgical parameters. Although these correlations are weak, they warrant further investigation as these may be linked with untoward complications, such as infection that can occur following FURS. This data, however, will need to be validated and reproduced in larger multi-centre studies.

Baseline Analysis of Patients Presenting for Surgical Review of Anterior Cruciate Ligament Rupture Reveals Heterogeneity in Patient-Reported Outcome Measures

Despite the establishment of successful surgical techniques and rehabilitation protocols for anterior cruciate ligament (ACL) reconstruction, published return to sport rates are less than satisfactory. This has led orthopaedic surgeons and researchers to develop more robust patient selection methods, and investigate prognostic patient characteristics. No previous studies have integrated baseline characteristics and responses to patient-reported outcome measures (PROMs) of patients with ACL rupture presenting for surgical review. Patients electing to undergo ACL reconstruction under the care of a single orthopaedic surgeon at a metropolitan public hospital were enrolled in a clinical quality registry. Patients completed Veterans RAND 12-item Health Survey (VR-12) Physical Component Summary and Mental Component Summary scores, Tegner activity scale, and International Knee Documentation Committee (IKDC) questionnaires at presentation. Total scores were extracted from the electronic registry, and a machine learning approach (k-means) was used to identify subgroups based on similarity of questionnaire responses. The average scores in each cluster were compared using analysis of variance (ANOVA; Kruskal-Wallis) and nominal logistic regression was performed to determine relationships between cluster membership and patient age, gender, body mass index (BMI), and injury-to-examination delay. A sample of 107 patients with primary ACL rupture were extracted, with 97 (91%) available for analysis with complete datasets. Four clusters were identified with distinct patterns of PROMs responses. These ranged from lowest (Cluster 1) to highest scores for VR-12 and IKDC (Cluster 4). In particular, Cluster 4 returned median scores within 6 points of the patient acceptable symptom state for the IKDC score for ACL reconstruction (70.1, interquartile range: 59-78). Significant (p < 0.05) differences in PROMs between clusters were observed using ANOVA, with variance explained ranging from 40 to 69%. However, cluster membership was not significantly associated with patient age, gender, BMI, or injury-to-examination delay. Patients electing to undergo ACL reconstruction do not conform to a homogenous group but represent a spectrum of knee function, general physical and mental health, and preinjury activity levels, which may not lend itself to uniform treatment and rehabilitation protocols. The factors driving these distinct responses to PROMs remain unknown but are unrelated to common demographic variables.

A Call for Caution in Use of Pertussis Vaccine Effectiveness Studies to Estimate Waning Immunity: A Canadian Immunization Research Network Study

BACKGROUND

Vaccine effectiveness (VE) studies provide essential evidence on waning vaccine-derived immunity, a major threat to pertussis control. We evaluated how study design affects estimates by comparing 2 case-control studies conducted in Ontario, Canada.

METHODS

We compared results from a test-negative design (TND) with a frequency-matched design (FMD) case-control study using pertussis cases from 2005-2015. In the first study, we identified test-negative controls from the public health laboratory that diagnosed cases and, in the second, randomly selected controls from patients attending the same physicians that reported cases, frequency matched on age and year. We compared characteristics of cases and controls using standardized differences.

RESULTS

In both designs, VE estimates for the early years postimmunization were consistent with clinical trials (TND, 84%; FMD, 89% at 1-3 years postvaccination) but diverged as time since last vaccination increased (TND, 41%; FMD, 74% by 8 years postvaccination). Overall, we observed lower VE and faster waning in the TND than the FMD. In the TND but not FMD, controls differed from cases in important confounders, being younger, having more comorbidities, and higher healthcare use. Differences between the controls of each design were greater than differences between cases. TND controls were more likely to be unvaccinated or incompletely vaccinated than FMD controls (P < .001).

CONCLUSIONS

The FMD adjusted better for healthcare-seeking behavior than the TND. Duration of protection from pertussis vaccines is unclear because estimates vary by study design. Caution should be exercised by experts, researchers, and decision makers when evaluating evidence on optimal timing of boosters.

Toward genetic modification of plant-parasitic nematodes: delivery of macromolecules to adults and expression of exogenous mRNA in second stage juveniles

Plant-parasitic nematodes are a continuing threat to food security, causing an estimated 100 billion USD in crop losses each year. The most problematic are the obligate sedentary endoparasites (primarily root knot nematodes and cyst nematodes). Progress in understanding their biology is held back by a lack of tools for functional genetics: forward genetics is largely restricted to studies of natural variation in populations and reverse genetics is entirely reliant on RNA interference. There is an expectation that the development of functional genetic tools would accelerate the progress of research on plant-parasitic nematodes, and hence the development of novel control solutions. Here, we develop some of the foundational biology required to deliver a functional genetic tool kit in plant-parasitic nematodes. We characterize the gonads of male Heterodera schachtii and Meloidogyne hapla in the context of spermatogenesis. We test and optimize various methods for the delivery, expression, and/or detection of exogenous nucleic acids in plant-parasitic nematodes. We demonstrate that delivery of macromolecules to cyst and root knot nematode male germlines is difficult, but possible. Similarly, we demonstrate the delivery of oligonucleotides to root knot nematode gametes. Finally, we develop a transient expression system in plant-parasitic nematodes by demonstrating the delivery and expression of exogenous mRNA encoding various reporter genes throughout the body of H. schachtii juveniles using lipofectamine-based transfection. We anticipate these developments to be independently useful, will expedite the development of genetic modification tools for plant-parasitic nematodes, and ultimately catalyze research on a group of nematodes that threaten global food security.

Increasing Incidence of Invasive Group A Streptococcus Disease in First Nations Population, Alberta, Canada, 2003-2017

The incidence of invasive group A Streptococcus (iGAS) disease in the general population in Alberta, Canada, has been steadily increasing. To determine whether rates for specific populations such as First Nations are also increasing, we investigated iGAS cases among First Nations persons in Alberta during 2003-2017. We identified cases by isolating GAS from a sterile site and performing emm typing. We collected demographic, social, behavioral, and clinical data for patients. During the study period, 669 cases of iGAS in First Nations persons were reported. Incidence increased from 10.0 cases/100,000 persons in 2003 to 52.2 cases/100,000 persons in 2017. The 2017 rate was 6 times higher for the First Nations population than for non-First Nations populations (8.7 cases/100,000 persons). The 5 most common emm types from First Nations patients were 59, 101, 82, 41, and 11. These data indicate that iGAS is severely affecting the First Nations population in Alberta, Canada.

Universal Bound to the Amplitude of the Vortex Nernst Signal in Superconductors

A liquid of superconducting vortices generates a transverse thermoelectric response. This Nernst signal has a tail deep in the normal state due to superconducting fluctuations. Here, we present a study of the Nernst effect in two-dimensional heterostructures of Nb-doped strontium titanate (STO) and in amorphous MoGe. The Nernst signal generated by ephemeral Cooper pairs above the critical temperature has the magnitude expected by theory in STO. On the other hand, the peak amplitude of the vortex Nernst signal below T_{c} is comparable in both and in numerous other superconductors despite the large distribution of the critical temperature and the critical magnetic fields. In four superconductors belonging to different families, the maximum Nernst signal corresponds to an entropy per vortex per layer of ≈k_{B}ln2.

What should every dental health professional know about electronic cigarettes?

Electronic cigarettes (E-cigarettes) have become increasingly popular around the world. Currently, dental professionals' knowledge and attitudes are varied with many clinicians unclear regarding the impact of E-cigarette products on the oral and general health of their patients. With developing social and health-related challenges, advice of dental and medical associations and other regulatory bodies on E-cigarette use is changing. Growing evidence demonstrating the risks of E-cigarette usage has prompted a review of legislation in the United Kingdom (UK), United States of America (USA), Australia and Canada to include the sale and availability of E-cigarettes, particularly those containing nicotine. Further consideration within the scientific and public health community is being given to assessing demographic usage patterns particularly uptake by non-smokers and adolescents, efficacy as a cessation tool, the impact of vapour on bystanders and direct injuries via explosions as well as emerging lung injuries. This article aims to provide a summary of the most up to date evidence relating to E-cigarette use, the latest position of dental associations and the oral health implications of E-cigarettes compared to conventional smoking. The article also aims to collate this information in order to provide dental clinicians with guidance on how to advise patients, specifically in answering common questions posed regarding E-cigarette use.

Important marine areas for the conservation of northern rockhopper penguins within the Tristan da Cunha Exclusive Economic Zone

The designation of Marine Protected Areas has become an important approach to conserving marine ecosystems that relies on robust information on the spatial distribution of biodiversity. We used GPS tracking data to identify marine Important Bird and Biodiversity Areas (IBAs) for the Endangered northern rockhopper penguin Eudyptes moseleyi within the Exclusive Economic Zone (EEZ) of Tristan da Cunha in the South Atlantic. Penguins were tracked throughout their breeding season from 3 of the 4 main islands in the Tristan da Cunha group. Foraging trips remained largely within the EEZ, with the exception of those from Gough Island during the incubation stage. We found substantial variability in trip duration and foraging range among breeding stages and islands, consistent use of areas among years and spatial segregation of the areas used by neighbouring islands. For colonies with no or insufficient tracking data, we defined marine IBAs based on the mean maximum foraging range and merged the areas identified to propose IBAs around the Tristan da Cunha archipelago and Gough Island. The 2 proposed marine IBAs encompass 2% of Tristan da Cunha’s EEZ, and are used by all northern rockhopper penguins breeding in the Tristan da Cunha group, representing ~90% of the global population. Currently, one of the main threats to northern rockhopper penguins within the Tristan da Cunha EEZ is marine pollution from shipping, and the risk of this would be reduced by declaring waters within 50 nautical miles of the coast as ‘areas to be avoided’.

Molecular Profiling in Daily Clinical Practice: Practicalities in Advanced Cholangiocarcinoma and Other Biliary Tract Cancers

BACKGROUND

Molecular profiling is becoming increasingly relevant in the management of patients with advanced cancer; to identify targetable aberrations and prognostic markers to enable a precision medicine strategy.

METHODS

Eligible patients were those diagnosed with advanced biliary tract cancer (BTC) including intrahepatic (iCCA) and extrahepatic cholangiocarcinoma (eCCA), gallbladder cancer (GBC), and ampullary carcinoma (Amp) who underwent molecular profiling between April 2017 and June 2020 based on analysis of either tumour samples (FoundationOne CDx®/Oncomine® platforms) or ctDNA (FoundationOne Liquid® platform (Foundation Medicine, Cambridge, MA, USA)). Baseline patient characteristics and molecular profiling outcomes were extracted. The primary aim was to describe sample failure rate. Secondary aims included description of reason for sample failure, summary of findings derived from molecular profiling, and assessment of concordance between paired tissue and ctDNA samples.

RESULTS

A total of 149 samples from 104 individual patients diagnosed with advanced BTC were identified and eligible for this analysis: 68.2% iCCA, 100% advanced stage; 94.2% received palliative therapy. The rate of sample failure was 26.8% for tissue and 15.4% for ctDNA; p-value 0.220, predominantly due to insufficient (defined as <20%) tumour content in the sample (the reason for 91.2% of tissue sample failure). Of the 112 samples successfully analysed, pathological molecular findings were identified in the majority of samples (88.4%) and identification of pathological findings using ctDNA, was possible regardless of whether the patient was on active treatment at time of blood acquisition or not (p-value 1.0). The rate of targetable alterations identified was 40.2% across all successfully-analysed samples (39 iCCA; 6 non-iCCA): IDH1 mutations (19.1% of individual patients), FGFR2 alterations (10.1% and 5.6% of individual patients had FGFR2 fusions and mutations, respectively); 10.6% of all patients (12.4% of patients with successfully analysed samples) entered trials with matched targeted therapies as a consequence. Concordance of findings for paired tissue and paired tissue-ctDNA was high (3/3; 100% and 6/6; 100%, respectively). Twelve ctDNA samples were taken prior to palliative treatment initiation, median maximum mutant allele frequency (MAF) was 0.47 (range 0.21-19.8); no significant association between reported maximum MAF and progression-free survival (PFS) or overall survival (OS) (all Cox regression p-values > 0.273). A total of 15 patients (16.6%) harboured alterations in DNA damage repair (DDR) genes; when treated with platinum-based chemotherapy, there was a trend towards increased partial response rate (21.4% vs. 15.9%; p-value 0.653), radiological benefit rate (64.3% vs. 36.2%; p-value 0.071), and longer OS (median OS 20.4 months (95% CI 7.9-26.7) vs. 13.3 (95 CI 11.0-16.4); Cox Regression HR 0.79 (95% CI 0.39-1.61), p-value 0.527).

CONCLUSIONS

Molecular profiling is of use for identification of novel therapeutic strategies for patients with advanced BTC (mainly iCCA). One in four archived tissue samples may have insufficient tumour content for molecular profiling; ctDNA-based approaches may overcome these obstacles.

The role of specific biomarkers, as predictors of post-operative complications following flexible ureterorenoscopy (FURS), for the treatment of kidney stones: a single-centre observational clinical pilot-study in 37 patients

BACKGROUND

The number of patients diagnosed and subsequently treated for kidney stones is increasing, and as such the number of post-operative complications is likely to increase. At present, little is known about the role of specific biomarkers, following flexible ureterorenoscopy (FURS) for the surgical treatment of kidney stones. The main aim of the study was to evaluate the role of kidney and infection biomarkers, in patients undergoing FURS.

METHODS

Included were 37 patients (24 males, 13 females), who underwent elective FURS, for the treatment of kidney stones. Venous blood samples were collected from each patient: pre-operatively, and at 30 min, 2 and 4 h post-operatively. Changes to kidney (NGAL, Cystatin-C) and infection (MPO, PCT) biomarkers was quantified by means of ELISA, Biomerieux mini-vidas and Konelab 20 analysers.

RESULTS

Four patients developed post-operative complications (3 - UTIs with urinary retention, 1 - urosepsis. NGAL concentration increased significantly following FURS (p = 0.034). Although no significant changes were seen in Cystatin C, MPO and PCT (p ≥ 0.05) some key clinical observation were noted. Limiting factors for this study were the small number of patients recruited and restriction in blood sampling beyond 4 h.

CONCLUSIONS

Although not confirmative, changes seen to biomarkers such as Cystatin C, NGAL and MPO in our observational clinical pilot-study may warrant further investigation, involving larger cohorts, to fully understand the role of these biomarkers and their potential association with post-operative complications which can develop following FURS.

Implementation and quality assessment of a clinical orthopaedic registry in a public hospital department

BACKGROUND

The aim of this study was to demonstrate a novel method of assessing data quality for an orthopaedic registry and its effects on data quality metrics.

METHODS

A quality controlled clinical patient registry was implemented, comprising six observational cohorts of shoulder and knee pathologies. Data collection procedures were co-developed with clinicians and administrative staff in accordance with the relevant dataset and organised into the registry database software. Quality metrics included completeness, consistency and validity. Data were extracted at scheduled intervals (3 months) and quality metrics reported to stakeholders of the registry.

RESULTS

The first patient was enrolled in July 2017 and the data extracted for analysis over 4 quarters, with the last audit in August 2018 (N = 189). Auditing revealed registry completeness was 100% after registry deficiencies were addressed. However, cohort completeness was less accurate, ranging from 12 to 13% for height & weight to 90-100% for operative variables such as operating surgeon, consulting surgeon and hospital. Consistency and internal validation improved to 100% after issues in registry processes were rectified.

CONCLUSIONS

A novel method to assess data quality in a clinical orthopaedic registry identified process shortfalls and improved data quality over time. Real-time communication, a comprehensive data framework and an integrated feedback loop were necessary to ensure adequate quality assurance. This model can be replicated in other registries and serve as a useful quality control tool to improve registry quality and ensure applicability of the data to aid clinical decisions, especially in newly implemented registries.

TRIAL REGISTRATION

ACTRN12617001161314; registration date 8/08/2017. Retrospectively registered.

Disparities in Opioid Pain Management for Long Bone Fractures

An expanding body of evidence has established that racial disparities exist in the US healthcare system, manifesting in poorer health outcomes for members of the non-white population. This study examines whether disparities exist in the type of analgesia ordered for long bone fractures and the time to medication administration in a community teaching hospital serving a large Hispanic population. We reviewed de-identified data of 115 patients from the emergency department of a community Level II Trauma Center in central Florida with diagnosed long bone fractures and examined the clinical and demographic variables associated with the type of analgesic administered and factors associated with delays in medication administration. We found that women reported higher pain scores than men, but there was no difference in the type of pain medication administered. There was no difference in pain scores between white and non-white patients; however, white patients were more likely to receive opiates for their long bone fractures compared with non-white patients (70 vs 50%, p < 0.0001). Opioid pain medications were prescribed significantly more often to adult and elderly patients compared with pediatric patients who were more likely to receive acetaminophen compared with both other patient groups (p < 0.001). In summary, we found that pain score was not associated with the class of pain medication administered, but that race and age were. This study questions the utility of the pain score for acute injuries and raises concerns about the role of physician bias in analgesia administration.

Sodium Glucose Co-Transporter 2 Inhibition Does Not Favorably Modify the Physiological Responses to Dietary Counselling in Diabetes-Free, Sedentary Overweight and Obese Adult Humans

Sedentary obesity is associated with increased risk of many cardio-metabolic diseases, including type 2 diabetes. Weight loss is therefore a desirable goal for sedentary adults with obesity. Weight loss is also a well-documented side effect of sodium glucose co-transporter 2 (SGLT2) inhibition, a pharmaceutical strategy for diabetes treatment. We hypothesized that, compared with placebo, SGLT2 inhibition as an adjunct to out-patient dietary counselling for weight loss would lead to more favorable modification of body mass and composition, and greater improvement in glucose regulation and lipid profile. Using a randomized, double-blind, repeated measures parallel design, 50 sedentary men and women (body mass index: 33.4 ± 4.7 kg/m²; mean ± SD) were assigned to 12 weeks of dietary counselling, supplemented with daily ingestion of either a placebo or SGLT2 inhibitor (dapagliflozin: up to 10 mg/day). Dietary counselling favorably modified body mass, body fat, glucose regulation, and fasting concentrations of triglyceride and very low-density lipoprotein cholesterol (main effects of counselling: p < 0.05); SGLT2 inhibition did not influence any of these adaptations (counselling × medication interactions: p > 0.05). However, SGLT2 inhibition when combined with dietary counselling led to greater loss of fat-free mass (counselling × medication interaction: p = 0.047) and attenuated the rise in high-density lipoprotein cholesterol (counselling × medication interaction: p = 0.028). In light of these data and the health implications of decreased fat-free mass, we recommend careful consideration before implementing SGLT2 inhibition as an adjunct to dietary counselling for weight loss in sedentary adults with obesity.

42 Screening for Atrial Fibrillation in Housebound Individuals: An Evaluation of the Use of the AliveCor Kardia Device

Background

The Croydon Rapid Response service is a multidisciplinary team providing admission avoidance support for people at crisis in their own homes or care homes. This population includes many living with frailty, the majority of whom are housebound.

Introduction

Atrial fibrillation (AF) is common, and often asymptomatic, and a significant risk factor for developing an ischaemic stroke. There is an ambition across health systems to improve identification of people with AF to better manage their risk of stroke. Screening is often performed using ECG readings typically performed in healthcare settings such as GP surgeries or hospitals.

The Croydon Rapid Response Team were provided with 10 AliveCor Kardia devices as part of a programme funded by the Health Innovation Network, with the aim to screen for AF aiming in traditionally hard-to-reach populations such as those people who are, through ill health or poor mobility, unable to leave their own home.

Methods

Activity use of the AliveCor Kardia devices were collated from centralised activity data based on the device serial numbers. Data collected were reviewed over a 12 month period. After 12 months use a survey was performed of clinician’s views on the devices.

Results

Over a 12 month period (March 2018 – February 2019) 389 recordings were performed across all Kardia devices. One device was lost within 1 month of the roll-out. Of the 389 recordings performed, possible AF was identified in 56 cases (14% of those screened). Survey results were received from 6 clinicians. 1 clinician used the device everyday in their practice. 2 staff members report using it 1-2/week, 3 staff members report using it 1-2/month.100% of respondents described the device as easy to use and helpful in clinical practice.100% of respondents agreed that they were clear how to manage a positive result.None of the respondents described increased workload due to the device and screening programme.

Conclusions

The AliveCor Kardia device is an acceptable and effective tool to aid detection of AF in housebound individuals seen by the Rapid Response team. The scheme should be considered for extension to other community teams, and further diagnostic equipment such as 12 lead ECG should be considered to complete the pathway.

97 Complexity In Croydon

Introduction

The Complex Care Support Team (CCST) are a newly-formed, integrated service, caring for Croydon residents when existing services decide additional multidisciplinary team input is required.

There is no single definition of healthcare complexity. Most cases encountered by the team have involved many different services and professionals. The team have found that by forging relationships and co-ordinating care across organisational boundaries, some of the “complexities” can be mitigated. We aim to develop our understanding of the needs of this population and the underlying drivers for complexity in Croydon.

Methods

The records on EMIS, CERNER and ePJS were reviewed from the inaugural two months of the service, for:Rockwood Frailty ScoreNumber of medicationsNumber of long-term conditionsED attendances or admissions to hospital over the preceding year.

After team discussion on every case, underlying causes of complexity were assigned to four groups: medical, psychological, social and systems failure.

Results

Of the 57 people accepted by CCST over 2 months, 39 required reviewing in person. 5 records were not completed, so 34 cases were included for evaluation. The age range of this cohort was 49-92, with 17 male and 17 female. Results revealed significant frailty, multimorbidity and polypharmacy. 91% had two or more underlying drivers for complexity, with the largest underlying driver being systems failure, in 85% of cases.

Conclusions

This work improves our understanding of the needs of the population deemed the most “complex” in Croydon. The likelihood of multiple underlying drivers for complexity was high, highlighting how complex health issues are likely to span both professional and organisational boundaries. This can in itself be a significant underlying driver for complexity, illustrated here as “systems failure”. In developing current and future services, this work reinforces the vital benefits of multidisciplinary and cross-organisational working currently occurring in CCST.

82 Virtual Reality Home Visit Simulation: Pilot Study

Introduction

There are multiple drivers to move healthcare into community settings, including people’s own homes. Traditional healthcare training, particularly medical training, is largely hospital-based, and hospital-based models of care. Few professions have explicit training in how best to assess an individual at home, and the additional elements to examine when visiting an induvial in their own home. To meet this training need Croydon Health Services were successful in a bid for funding to develop training to meet this gap. With this funding, a programme was developed and after attempts at simulation home visits in the simulation centre, a virtual reality (VR) home visit scenario was devised and filmed in the community using a professional actor to simulate a housebound individual. The recording was then professionally edited by a specialist VR team to maximise its effectiveness including interactive educational elements.

Methods

A pilot study examining the acceptability of the virtual reality home visit scenario was designed. A user group of medical staff with limited community experience participated in undertaking the virtual reality scenarios, delivered via Samsung Note 8 devices combined with Samsung Gear VR headsets. Feedback was received from participants by standardised paper-based surveys.

Results

7 responses were obtained. 100% of respondents described the scenario as easy to use, as well as agreeing that the same experience could not be gained from watching a standard video of the same scenario. 100% of respondents felt that the on-screen information was helpful.

Feedback on areas for improvement suggested a desire for greater interactivity of other aspects of home assessment, and a desire to improve interactivity with the simulated patient, including history taking.

Conclusions

Virtual reality home visit simulations are an acceptable and effective tool to introduce new concepts to staff. Further development should aim to maximise interactivity in the scenario and explore options for greater interaction with the simulated patient. Further role out of the virtual reality is planned for local and regional training sessions.

Intermittent low dose carbon monoxide inhalation does not influence glucose regulation in overweight adults: a randomized controlled crossover trial

NEW FINDINGS

What is the central question of this study? Low dose carbon monoxide (CO) inhalation plays a role in regulating proteins involved in glucose metabolism; does low dose CO improve glucose and insulin responses to an oral glucose tolerance test in overweight adults? What is the main finding and its importance? Five days of intermittent CO inhalation does not alter the glucose or insulin responses to ingestion of a glucose bolus in overweight adults. Low dose CO is utilized in various physiological assessment procedures; these findings allow researchers and clinicians to utilize these procedures without concern of altering glucose metabolism.

ABSTRACT

Low dose carbon monoxide (CO) inhalation upregulates several proteins important for glucose metabolism. Such changes could be clinically significant and may be relevant to those who use CO as a research tool. We hypothesized that low dose CO inhalation would improve glucose and insulin responses to an oral glucose bolus in overweight humans. Eleven young adults (5 men, 6 women; body mass index: 25-35 kg m^-2 ) were included in this randomized, placebo-controlled, single-blinded crossover study. Following screening, participants completed two 7-day protocols with a 4-week washout. Twenty-four hours prior to and following five consecutive days of either once daily CO (men: 1.2 ml (kg body mass)^-1 ; women: 1.0 ml (kg body mass)^-1 ) or placebo (room air) inhalation, participants underwent oral glucose tolerance tests (OGTT). For key outcome variables, there were no significant main effects or interactions across condition or time point (mean ± SD), including fasting glucose (mg dl^-1 : pre-placebo: 85.2 ± 10.1; post-placebo: 82.9 ± 10.6; pre-CO: 83.6 ± 7.7; post-CO: 84.0 ± 9.0), 2 h post glucose (mg dl^-1 : pre-placebo: 100.9 ± 20.0; post-placebo: 98.7 ± 13.1; pre-CO: 94.2 ± 23.2; post-CO: 94.4 ± 14.9), or the Matsuda index (pre-placebo: 16.1 ± 11.5; post-placebo: 20.3 ± 24.7; pre-CO: 15.6 ± 15.3; post-CO: 17.5 ± 16.8). In conclusion, 5 days of low dose CO administration did not influence glucose and insulin responses to an OGTT in overweight adults. Low dose CO inhalation is utilized in a variety of physiological assessment procedures; these findings allow researchers to utilize these procedures without concern of altering glucose metabolism.

Increasing Energy Flux to Maintain Diet-Induced Weight Loss

Long-term maintenance of weight loss requires sustained energy balance at the reduced body weight. This could be attained by coupling low total daily energy intake (TDEI) with low total daily energy expenditure (TDEE; low energy flux), or by pairing high TDEI with high TDEE (high energy flux). Within an environment characterized by high energy dense food and a lack of need for movement, it may be particularly difficult for weight-reduced individuals to maintain energy balance in a low flux state. Most of these individuals will increase body mass due to an inability to sustain the necessary level of food restriction. This increase in TDEI may lead to the re-establishment of high energy flux at or near the original body weight. We propose that following weight loss, increasing physical activity can effectively re-establish a state of high energy flux without significant weight regain. Although the effect of extremely high levels of physical activity on TDEE may be constrained by compensatory reductions in non-activity energy expenditure, moderate increases following weight loss may elevate energy flux and encourage physiological adaptations favorable to weight loss maintenance, including better appetite regulation. It may be time to recognize that few individuals are able to re-establish energy balance at a lower body weight without permanent increases in physical activity. Accordingly, there is an urgent need for more research to better understand the role of energy flux in long-term weight maintenance.

Anatomical Variability of Intercondylar Fossa Geometry in Patients Diagnosed with Primary Anterior Cruciate Ligament Rupture

The aims of this study were to (1) describe the three-dimensional characteristics and sources of anatomical variability in the geometry of the intercondylar fossa ("notch") in an anterior cruciate ligament (ACL)-injured sample and (2) assess the relationship between patient factors and anatomical variability of the fossa in the context of impingement risk. A retrospective analysis of preoperative magnetic resonance imaging (MRI) for 49 patients with ACL rupture was performed. Scans were examined in the axial plane using an online picture archiving and communication system (PACS) viewer and fossa width and angle assessed at multiple slices, as well as anteroposterior depth, fossa height, and calculated total volume. Principal component analysis was performed to prioritize the sources of variability. A multivariate linear regression was performed to assess relationships between different patient factors, controlling for imaging parameters and principal component loadings. Geometric properties were normally distributed for all but fossa volume, height, and distal angle. Three principal components (PCs) were identified explaining 80% of total variance, shape (PC1), size in the coronal plane (PC2), and size in the sagittal plane (PC3). Patient factors were significantly (P < 0.05) related to PC loadings; however, a substantial amount of variance in each model remained unexplained. Intercondylar fossa characteristics vary considerably within ACL-injury patients with shape and size in coronal and axial planes, explaining most of the variance. Although patient factors are associated with anatomical characteristics, further work is required to identify the correct combination of factors accurately predicting geometry of the fossa for planning ACL reconstruction. Clin. Anat. 33:610-618, 2020. © 2019 Wiley Periodicals, Inc.