Multiple sclerosis and COVID-19: Assessing risk perception, patient behaviors and access to disease-modifying therapies

BACKGROUND

Following the outbreak of COVID-19, global healthcare systems have had to rapidly adapt. People with multiple sclerosis (pwMS) were required to make decisions about their individual risk and consequent work and social behaviors. This study aimed to evaluate risk perception and patterns of shielding behavior amongst pwMS at the onset of the COVID-19 pandemic and the subsequent impact on patients' employment and access to disease modifying therapies (DMTs).

METHODS

Postal surveys were sent to 1690 people within a UK population-based MS cohort during the first wave of the COVID-19 pandemic. Patients were surveyed on: (i) perceived vulnerability to COVID-19; (ii) isolation behavior; (iii) interruption to DMT; (iv) employment status; (v) level of satisfaction with their current working arrangement.

RESULTS

Responses were received from 1000 pwMS. Two thirds of patients reported isolating at home during the first wave of the pandemic. This behavior was associated with increased age (p<0.0001), higher disability (p<0.0001) and use of high-efficacy DMTs (p = 0.02). The majority of patients reported feeling vulnerable (82%) with perceived vulnerability associated with higher EDSS (p<0.0001) and receiving a high-efficacy DMT (p = 0.04). Clinician-defined risk was associated with shielding behavior, with those at high-risk more likely to self-isolate/shield (p<0.0001). Patients on high-efficacy DMTs were more likely to have an interruption to their treatment (50%) during the first wave of the pandemic. Most pwMS experienced a change to their working environment, and most were satisfied with the adjustments.

CONCLUSION

This study highlights the risk perception, social behavioral practices and changes to treatment experienced by pwMS during the first wave of the COVID-19 pandemic in a large, well-described UK cohort. The results may help inform management of pwMS during future pandemic waves.

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.

1536 Neuroanatomy, Not Just for Budding Neurosurgeons. Motivations for Participating in An Extra-Curricular Neuroanatomy Course for Undergraduates

Introduction

Extra-curricular activities form an important part of undergraduate education as they give students the opportunity to explore subjects of interest. There is significant demand within the undergraduate population for further teaching in neuro-related specialities. The aim of this online twelve-week course was to provide neuroanatomy teaching in greater breadth and detail than possible in the undergraduate curriculum. We sought to gauge motivations for involvement.

Method

Delegates (n = 166) from six UK universities were asked to complete a short questionnaire examining motivations and future career plans prior to the course beginning, only those who consented were involved further in the analysis (n = 98).

Results

Motivations for involvement were predominantly to develop a greater understanding of neuroanatomy (63.3%), to support career plans (13.3%) or to support preparation for an examination or competition (8.2%). The majority (56.1%) had no particular speciality in mind. For those who did, a range of specialities including neurosurgery (24.5%), neurology (8.2%) was given.

Conclusions

There is clear interest within the undergraduate population for more specialised extra-curricular activities in addition to conventional experiences such as conferences. Online courses run over multiple weeks provide further scope for depth and exploration of subjects in further detail. In this course, the majority of delegates did not have a particular speciality in mind, demonstrating neuroanatomy to be a popular subject regardless of potential career plans. For students looking to pursue a career in neuro-related specialities, courses are perceived as important opportunities to support future career development.

22 Motivations, Barriers, And Social Media: A Qualitative Study of Uptake of Women into Neurosurgery

Objective

To explore how social media could be utilised to influence an individual’s motivation to pursue a neurosurgical career, an emerging topic area. The focus of this study was on women interested in neurosurgery.

Background

Women are significantly under-represented in neurosurgery. 18% of all neurosurgeons – including 8% of consultants – are women. Most previous studies have used quantitative methods that are not best suited to gaining an in-depth understanding of the barriers that women face in pursuing a career in neurosurgery, or what would enable more women to go into the speciality.

Method

In this qualitative study, individual semi-structured interviews were conducted until data saturation was achieved. Participants were women pre-neurosurgical trainees. The interview data was examined through a thematic analysis involving open and axial coding.

Results

Thirty women participated in the study. Four overarching themes were identified: (1) mentorship, (2) testimony from other women doing neurosurgery, (3) social media as a means of increasing interest in neurosurgery as a career choice, and (4) real-life exposure to the speciality.

Conclusions

There is scope to further improve uptake of women into neurosurgical training in the UK. Motivations and barriers to women pursuing neurosurgery should be addressed openly through early experience, role models and mentorship. Social media can help facilitate these opportunities, disseminate information and inspiration, and has the potential to undo societal biases.

1520 Decoding Neurophobia – Insights from an Undergraduate Neuroanatomy Course

Introduction

Neurophobia is a common multifaceted issue amongst students studying medical sciences at an undergraduate level associated with difficulty in understanding neuroscience topics and ongoing negative perceptions of clinical neurosciences. We sought to examine whether neurophobia was present even amongst students who participated in an extracurricular neuroanatomy teaching course.

Method

Prior to the beginning of a twelve-week online neuroanatomy course, delegates were asked to complete a short questionnaire examining perceptions of neurophobia and specialities of interest. This was repeated after the course. This course was open to all undergraduate students in the UK and covered material beyond the remits of the undergraduate curriculum.

Results

From the 166 signups, 98 students completed the pre-course questionnaire. As expected, the majority of students (n = 83) taking part did not identify as neurophobic, describing the subject area as ‘interesting’, ‘enjoyable’ and ‘challenging’. Students who identified as neurophobic described neuroanatomy as ‘complex’ or ‘overwhelming’. Some students (n = 12) continued to describe themselves as neurophobic at the end of the course, despite this 7 of those students continue to consider a future career in a neuro-related speciality.

Conclusions

The fact that students with Neurophobia attended this extra-curricular course speaks volumes of how perception and self-motivation of a student are important for learning a subject. All students who participated in this course recognised the complexity and interesting nature of neuroanatomy. This experience highlights the challenge of medical educators to provide teaching experiences that are stimulating and enjoyable, but not overwhelming.

131 Perioperative Management of Warfarin on Surgical Wards at District General Hospital

Introduction

Many patients admitted to surgical wards are on warfarin. Poor knowledge of guidelines regarding reversal and restarting of anticoagulant medications can delay surgery, lead to poor outcomes and delay the discharge of patients. The aim of this audit was to establish whether junior doctors are confident in managing warfarin according to local guidelines and to improve their knowledge and confidence.

Method

A questionnaire was used to assess confidence of junior doctors currently working in general surgical departments. An educational poster was placed in the junior doctors’ office and the questionnaire was repeated. We then conducted a teaching session on the perioperative management of warfarin and repeated the questionnaire again.

Results

Confidence in reversing and restarting warfarin was significantly higher following the teaching session (p = 0.017 and p &lt; 0.001 respectively). No significant difference was seen following the introduction of educational posters. Confidence in applying the guidelines on perioperative warfarin management was significantly higher following the teaching session (p &lt; 0.001). Following the introduction of educational posters and the formal teaching session doctors felt they knew better how to access the guidelines (not statistically significant for either guideline) and referred to them more (p = 0.0178 for warfarin reversing and p = 0.0940 for warfarin restarting guideline).

Conclusions

Having doctors who are confident in managing warfarin is crucial to avoid delays in treatment and discharge. This audit showed that a teaching session indeed improved doctors’ knowledge and confidence. Regular formal teaching is essential, and a repeat audit is planned to be performed during the next rotation.

0989 Examining The Role Of Toddler Sleep Quality On Wake EEG And Language Ability

Introduction

Sleep and the development of language are prominent concerns of many parents and until recently, many have examined these concerns tangentially. Children with developmental delays/disabilities have shown to have impaired sleep and poor sleep quality, and impairments or changes in sleep quality may play a prominent role in the acquisition of language and neuronal oscillatory patterns. This study examines the role of child sleep quality paired with a normed measure of language and wake electroencephalography (EEG). Examining the role of child sleep quality with language ability and wake EEG may provide nascent incremental utility to understanding the influences of sleep on healthy development.

Methods

Data from 109 toddlers (age range 24 to 30.5 m, M = 26.83 ± 1.58 m, 52% male) from the Brief Infant Sleep Questionnaire (BISQ), Mullen Scales of Early Learning (MSEL), and continuous EEG were collected and analyzed. EEG was recorded (32 electrode cap BioSemi) while toddlers sat in a booster seat and watched a silent video. Data were analyzed in RStudio and Matlab to examine toddler’s sleep quality (infant sleep and parent behaviors) and relations with the MSEL and EEG (controlling for child age and gender).

Results

Means and standard deviations appeared within expected limits based on the range of each variable. Toddlers with slow-developing language were associated with relatively poor sleep quality, explaining 9.75% of the variance. We find preliminary evidence to suggest a potential sleep disruption around the time when a child is undergoing a rapid expansion in their vocabulary (expressive language). Toddler’s sleep quality and language acquisition were also correlated with wake EEG (alpha and beta).

Conclusion

Sleep is regarded as an essential component supporting the myriad changes observed in early development. Sleep quality fundamentally influences healthy development across domains. Here, we showed child sleep quality is highly associated with toddler’s language ability, and wake EEG, providing new insights into the developing brain.

Support

National Institutes of Health R01DC016273, R01MH107652-03S1, and Johnson & Johnson Consumer Inc., Skillman, NJ, USA.

Structural studies of substrate and product complexes of 5-aminolaevulinic acid dehydratase from humans,Escherichia coliand the hyperthermophilePyrobaculum calidifontis

A number of X-ray analyses of an enzyme involved in a key early stage of tetrapyrrole biosynthesis are reported. Two structures of human 5-aminolaevulinate dehydratase (ALAD), native and recombinant, have been determined at 2.8 Å resolution, showing that the enzyme adopts an octameric quaternary structure in accord with previously published analyses of the enzyme from a range of other species. However, this is in contrast to the finding that a disease-related F12L mutant of the human enzyme uniquely forms hexamers [Breiniget al.(2003),Nature Struct. Biol.10, 757–763]. Monomers of all ALADs adopt the TIM-barrel fold; the subunit conformation that assembles into the octamer includes the N-terminal tail of one monomer curled around the (α/β)8barrel of a neighbouring monomer. Both crystal forms of the human enzyme possess two monomers per asymmetric unit, termedAandB. In the native enzyme there are a number of distinct structural differences between theAandBmonomers, with the latter exhibiting greater disorder in a number of loop regions and in the active site. In contrast, the second monomer of the recombinant enzyme appears to be better defined and the active site of both monomers clearly possesses a zinc ion which is bound by three conserved cysteine residues. In native human ALAD, theAmonomer also has a ligand resembling the substrate ALA which is covalently bound by a Schiff base to one of the active-site lysines (Lys252) and is held in place by an ordered active-site loop. In contrast, these features of the active-site structure are disordered or absent in theBsubunit of the native human enzyme. The octameric structure of the zinc-dependent ALAD from the hyperthermophilePyrobaculum calidifontisis also reported at a somewhat lower resolution of 3.5 Å. Finally, the details are presented of a high-resolution structure of theEscherichia coliALAD enzyme co-crystallized with a noncovalently bound moiety of the product, porphobilinogen (PBG). This structure reveals that the pyrrole side-chain amino group is datively bound to the active-site zinc ion and that the PBG carboxylates interact with the enzymeviahydrogen bonds and salt bridges with invariant residues. A number of hydrogen-bond interactions that were previously observed in the structure of yeast ALAD with a cyclic intermediate resembling the product PBG appear to be weaker in the new structure, suggesting that these interactions are only optimal in the transition state.

Fluorescent resonance energy transfer based detection of biological contaminants through hybrid quantum dot-quencher interactions

A nanoscale sensor employing fluorescent resonance energy transfer interactions between fluorescent quantum dots (QDs) and organic quencher molecules can be used for the multiplexed detection of biological antigens in solution. Detection occurs when the antigens to be detected displace quencher-labelled inactivated (or dead) antigens of the same type attached to QD-antibody complexes through equilibrium reactions. This unquenches the QDs, allowing detection to take place through the observation of photoluminescence in solution or through the fluorescence imaging of unquenched QD complexes trapped on filter surfaces. Multiplexing can be accomplished by using several different sizes of QDs, with each size QD labelled with an antibody for a different antigen, providing the ability to detect several types of antigens or biological contaminants simultaneously in near real-time with high specificity and sensitivity.

Digestive proteolytic activity in larvae of tomato moth, Lacanobia oleracea; effects of plant protease inhibitors in vitro and in vivo

Three distinct digestive protease activities, with strongly alkaline pH optima, were identified in the gut of tomato moth (Lacanobia oleracea) larvae, and characterised using specific synthetic substrates and inhibitors. These were; a trypsin-like activity, a chymotrypsin-like activity specific for substrates and inhibitors containing more than one amino acid residue, and an elastase-like activity, accounting for 40%, 30% and 20% of overall proteolysis respectively. The protease activities differed in their sensitivities to inhibition by different plant protein protease inhibitors (PIs), as estimated by I(50) values. Soya bean Kunitz trypsin inhibitor (SKTI) was the only plant PI tested to inhibit all three digestive protease activities at concentrations <40 &mgr;g/ml (approx. 5x10(-6)M). Incorporation of SKTI into a potato leaf-based artificial diet at 2% of total protein, decreased larval survival and growth (by approx. 33% and 40% respectively after 21 days) and retarded development (by approx. 2 days). However, when SKTI was expressed in transgenic potato plants at approx. 0.5% of total protein, only marginal effects on L. oleracea larvae were observed, which decreased with time. Whilst the presence of SKTI in artificial diet increased endogenous larval trypsin-like activity by up to four-fold, no effects on this activity were observed in larvae feeding on transgenic plants.

X-ray structure of 5-aminolevulinic acid dehydratase from Escherichia coli complexed with the inhibitor levulinic acid at 2.0 A resolution

5-Aminolevulinic acid dehydratase (ALAD), an early enzyme of the tetrapyrrole biosynthesis pathway, catalyzes the dimerization of 5-aminolevulinic acid to form the pyrrole, porphobilinogen. ALAD from Escherichia coli is shown to form a homo-octameric structure with 422 symmetry in which each subunit adopts the TIM barrel fold with a 30-residue N-terminal arm. Pairs of monomers associate with their arms wrapped around each other. Four of these dimers interact, principally via their arm regions, to form octamers in which each active site is located on the surface. The active site contains two lysine residues (195 and 247), one of which (Lys 247) forms a Schiff base link with the bound substrate analogue, levulinic acid. Of the two substrate binding sites (referred to as A and P), our analysis defines the residues forming the P-site, which is where the first ALA molecule to associate with the enzyme binds. The carboxyl group of the levulinic acid moiety forms hydrogen bonds with the side chains of Ser 273 and Tyr 312. In proximity to the levulinic acid is a zinc binding site formed by three cysteines (Cys 120, 122, and 130) and a solvent molecule. We infer that the second substrate binding site (or A-site) is located between the triple-cysteine zinc site and the bound levulinic acid moiety. Two invariant arginine residues in a loop covering the active site (Arg 205 and Arg 216) appear to be appropriately placed to bind the carboxylate of the A-site substrate. Another metal binding site, close to the active site flap, in which a putative zinc ion is coordinated by a carboxyl and five solvent molecules may account for the activating properties of magnesium ions.

Nonreplicating viral vectors as potential vaccines: recombinant canarypox virus expressing measles virus fusion (F) and hemagglutinin (HA) glycoproteins

The development of canarypox virus (CPV) recombinants expressing the hemagglutinin (HA) and fusion (F) glycoproteins of measles virus (MV) is described. Inoculation of the CPV-MV recombinants into avian or nonavian tissue culture substrates led to the expression of authentic MVF and MVHA as determined by radioimmunoprecipitation and surface immunofluorescence. In contrast to avian-derived tissue culture, no productive replication of the CPV recombinant was evident in tissue culture cells derived from nonavian origin. On inoculation of dogs, a species restricted for avipoxvirus replication, the recombinants elicited a protective immune response against a lethal canine distemper virus (CDV) challenge. The level of MV neutralizing antibodies and the level of protection induced against CDV challenge achieved by the host-restricted CPV vector were equivalent to that obtained by vaccinia virus vectors expressing the same MV antigens.

Vaccinia virus recombinants expressing either the measles virus fusion or hemagglutinin glycoprotein protect dogs against canine distemper virus challenge

cDNA clones of the genes encoding either the hemagglutinin (HA) or fusion (F) proteins of the Edmonston strain of measles virus (MV) were expressed in vaccinia virus recombinants. Immunofluorescence analysis detected both proteins on the plasma membranes of unfixed cells as well as internally in fixed cells. Immunoprecipitation of metabolically radiolabeled infected-cell extracts by using specific sera demonstrated a 76-kDa HA polypeptide and gene products of 60, 44, and 23 kDa which correspond to a MV F precursor and cleavage products F0, F1, and F2, respectively. Neither recombinant induced cell fusion of Vero cells when inoculated individually, but efficient cell fusion was readily observed upon coinfection of cells with both recombinants. Inoculation of dogs with the vaccinia virus-MV F recombinant (VV-MVF) did not give rise to detectable MV-neutralizing antibody. Inoculation of dogs with the vaccinia virus-MV HA recombinant (VV-MVHA) or coinoculation with both recombinants (VV-MVF and VV-MVHA) induced significant MV-neutralizing titers that were increased following a booster inoculation. Inoculation of dogs with the vaccinia virus recombinants or with MV failed to induce canine distemper virus (CDV)-neutralizing antibodies. Upon challenge with a lethal dose of virulent CDV, signs of infection were observed in dogs inoculated with (VV-MVF). No symptoms of disease were observed in dogs that had been vaccinated with VV-MVHA or with VV-MVHA and VV-MVF and then challenged with CDV. All dogs vaccinated with the recombinant viruses as well as those inoculated with MV or a vaccine strain of CDV survived CDV challenge.

Coexpression by vaccinia virus recombinants of equine herpesvirus 1 glycoproteins gp13 and gp14 results in potentiated immunity

The equine herpesvirus 1 glycoprotein 14 (EHV-1 gp14) gene was cloned, sequenced, and expressed by vaccinia virus recombinants. Recombinant virus vP613 elicited the production of EHV-1-neutralizing antibodies in guinea pigs and was effective in protecting hamsters from subsequent lethal EHV-1 challenge. Coexpression of EHV-1 gp14 in vaccinia virus recombinant vP634 along with EHV-1 gp13 (P. Guo, S. Goebel, S. Davis, M. E. Perkus, B. Languet, P. Desmettre, G. Allen, and E. Paoletti, J. Virol. 63:4189-4198, 1989) greatly enhanced the protective efficacy in the hamster challenge model over that obtained with single recombinants. The inoculum doses (log10) required for protection of 50% of hamsters were 6.1 (EHV-1 gp13), 5.2 (EHV-1 gp14), and less than 3.6 (vaccinia virus recombinant expressing both EHV-1 glycoproteins [gp13 and gp14]).

Newcastle disease virus fusion protein expressed in a fowlpox virus recombinant confers protection in chickens

A cDNA copy of the RNA encoding the fusion (F) protein of Newcastle disease virus (NDV) strain Texas, a velogenic strain of NDV, was obtained and the sequence was determined. The 1,792-base-pair sequence encodes a protein of 553 amino acids which has essential features previously established for the F protein of virulent NDV strains. These include the presence of three strongly hydrophobic regions and pairs of dibasic amino acids in the pentapeptide Arg-Arg-Gln-Arg-Arg preceding the putative cleavage site. When inserted into a fowlpox virus vector, a glycosylated protein was expressed and presented on the surface of infected chicken embryo fibroblast cells. The F protein expressed by the recombinant fowlpox virus was cleaved into two polypeptides. When inoculated into susceptible birds by a variety of routes, an immunological response was induced. Ocular or oral administration of the recombinant fowlpox virus gave partial protection, whereas both intramuscular and wing-web routes of inoculation gave complete protection after a single inoculation.

Functional changes in cellular fibronectin from late passage fibroblasts in vitro

Analysis of fibronectin synthesized by human fibroblasts, at different times during serial subcultivation, reveals functional differences. Fibronectin isolated from late passage cells is defective in promoting cell adhesion, cell spreading, and the formation of focal contacts. These changes are not the result of an inability of late passage cells to interact with fibronectin, since late passage cells become adhesive and form focal contacts in the presence of fibronectin isolated from early passage cells. Therefore, we conclude that late passage cellular fibronectin derived from late passage cells cannot support the cell substrate interactions.

Ocular quinine toxicity followed by electroretinogram, electro-oculogram, and pattern visually evoked potential

A patient who had ingested quinine as a suicide gesture was followed from 14.5 hr to 6 months with electrodiagnostic tests. The electroretinogram revealed early increased a-wave and decreased b-wave amplitudes, increased implicit times, and diminished oscillatory potentials. The electro-oculogram showed a decreased "light rise," and the pattern visually evoked potential was found to have an increased implicit time throughout the period of testing. These data indicate that there is an early direct toxic effect of quinine on the retinal cells.