Neurodevelopmental outcomes in children and adults with Fetal Valproate Spectrum Disorder: A contribution from the ConcePTION project

AIM

To describe the neurodevelopmental phenotype of older children and adults with a diagnosis of Fetal Valproate Spectrum Disorder (FVSD).

METHODS

In this cross-sectional study, 90 caregivers were recruited and completed a series of questionnaires regarding the neurodevelopmental outcomes of 146 individuals aged 7-37 years (M = 18.1), including individuals with a formal diagnosis of FVSD (n = 99), individuals exposed to Valproate but without an FVSD diagnosis (n = 24), and individuals not exposed to Valproate (N = 23). The mean dose of valproate exposure for individuals with an FVSD diagnosis was 1470 mg/day.

RESULTS

Individuals with a diagnosis of FVSD showed significantly higher levels of moderate (43.4%) and severe (14.4%) cognitive impairment than other groups (p = 0.003), high levels of required formal educational support (77.6%), and poorer academic competence than individuals not exposed to Valproate (p = 0.001). Overall psychosocial problems (p = 0.02), internalising problems (p = 0.05) and attention problems (p = 0.001), but not externalising problems, were elevated in individuals with a diagnosis of FVSD. Rates of neurodevelopmental disorders, particularly autistic spectrum disorders (62.9%) and sensory problems (80.6%) are particularly central to the FVSD phenotype. There was no evidence of a statistical dose-dependent effect, possibly due to the high mean dose of exposure having a uniformly negative impact across the sample. Individuals with FVSD had required a significant number of health and child development services.

INTERPRETATION

Children and young adults with a diagnosis of FVSD are at an increased risk of a range of altered neurodevelopmental outcomes, highlighting the need for a multidisciplinary approach to clinical management across the lifespan.

Prevalence of Trauma History and Symptoms in Patients Who Have Received Vaginal Brachytherapy as Part of their Endometrial Cancer Treatment

PURPOSE/OBJECTIVE(S)

Vaginal brachytherapy (VBT) is an essential component of curative intent treatment for many patients with endometrial cancer. The prevalence of trauma history in this population is unknown and is important to understand considering VBT requires patients to have an instrument vaginally inserted while in the vulnerable lithotomy position. We aim to retrospectively identify patients treated with VBT for early-stage endometrial cancer and collect survey data to assess the prevalence of trauma history, whether VBT re-induced trauma symptoms, and whether VBT was considered an independent traumatic event by patients.

MATERIALS/METHODS

We retrospectively identified patients with endometrial cancer treated with VBT at our institution from January 2017 to August 2022. Patients were mailed a cover letter and unique-identifier coded survey that included the Brief Trauma Questionnaire (BTQ) and Primary Care Post Traumatic Stress Disorder Screen for DSM-V (PC-PTSD-5), both validated instruments. Patients were instructed to fill out the surveys as it relates to their trauma history prior to VBT and again considering any trauma symptomatology related to VBT. BTQ was interpreted as positive if the patient responded yes to any question. PC-PTSD-5 was interpreted positive if the patient responded yes to at least 3 questions. Electronic medical record review was performed to identify clinical and pathologic features. Descriptive statistics and qualitative analysis were used to assess survey responses.

RESULTS

A total of 51 of 206 patients returned the survey at the time of interim analysis. 43 patients (84%) screened positive on the BTQ for having trauma history. Of those patients, 7 (16%) screened positive on the PC-PTSD-5 for a probable PTSD diagnosis. Additionally, 22 (51%)/18 (42%) patients answered yes to at least one/two symptoms on the PC-PTSD-5 respectively. Of the patients who answered yes to at least one question on the PC-PTSD-5, 18% (4 patients) responded that VBT triggered flashbacks of their past trauma. Regarding PC-PTSD-5 considering trauma symptomatology related to VBT, 20 patients (39%) answered yes to any question, though only 2 patients (4%) met the threshold to screen positive for probable PTSD. 20 patients (39%) indicated they would have accepted a referral to psychology before or during VBT. Suggested improvements made via free text responses included minimizing the time the cylinder was inserted and eliminating the need to transfer via hallway from the simulation room to the treatment room.

CONCLUSION

This study provides a baseline for understanding the prevalence of trauma history and trauma related to VBT in patients with endometrial cancer. This data can be used to guide patient centered discussions of endometrial cancer care, importantly including to counsel patients that a possible toxicity of VBT is trauma symptomatology, particularly for those with a history of trauma.

Nursing, midwifery, and allied health professions research capacities and cultures: a survey of staff within a university and acute healthcare organisation

BACKGROUND

There is an increasing focus on the development of research capacity and culture in Nursing, Midwifery and Allied Health Professions (NMAHP). However, better understanding of the existing research success and skills, motivators, barriers, and development needs of NMAHP professionals is required to inform this development. This study sought to identify such factors within a university and an acute healthcare organisation.

METHODS

An online survey, incorporating the Research Capacity and Culture tool, was administered to NMAHP professionals and students at a university and an acute healthcare organisation in the United Kingdom. Ratings of success/skill levels of teams and individuals were compared between professional groups using Mann-Whitney U tests. Motivators, barriers, and development needs were reported using descriptive statistics. Descriptive thematic analysis was used for open-ended text responses.

RESULTS

A total of 416 responses were received (N&M n = 223, AHP n = 133, Other n = 60). N&M respondents were more positive than their AHP counterparts about the success/skill levels of their teams. There were no significant differences between N&M and AHP in their ratings of individual successes/skills. Finding and critically reviewing relevant literature were identified as specific individual strengths; with weaknesses in securing research funding, submitting ethics applications, writing for publication, and advising less experienced researchers. The main motivators for research were to develop skills, increased job satisfaction, and career advancement; whilst barriers included lack of time for research and other work roles taking priority. Key support needs identified included mentorship (for teams and individuals) and in-service training. Open-ended questions generated main themes of 'Employment & staffing', 'Professional services support', 'Clinical & academic management', 'Training & development', 'Partnerships' and 'Operating principles'. Two cross-cutting themes described issues common to multiple main themes: 'Adequate working time for research' and 'Participating in research as an individual learning journey'.

CONCLUSIONS

Rich information was generated to inform the development of strategies to enhance research capacity and culture in NMAHP. Much of this can be generic but some nuances may be required to address some specific differences between professional groups, particularly related to perceived team success/skills and priorities identified for support and development.

Ischaemic stroke with multi-focal venous and arterial thrombosis due to hyperhomocysteinemia: anabolic androgenic steroid use and MTHFR c.667 C > T variant - a case report

BACKGROUND

Severely elevated serum homocysteine is a rare cause of ischaemic stroke and extra-cranial arterial and venous thrombosis. Several factors can lead to mild elevation of homocysteine including dietary folate and B12 deficiency, and genetic variants of the methylenetetrahydrofolate reductase (MTHFR) enzyme. The use of Anabolic androgenic steroid (AAS) is under-reported, but increasingly linked to ischaemic stroke and can raise homocysteine levels.

CASE REPORT

We present a case of a man in his 40s with a large left middle cerebral artery (MCA) territory ischaemic stroke and combined multifocal, extracranial venous, and arterial thrombosis. His past medical history was significant for Crohn's disease and covert use of AAS. A young stroke screen was negative except for a severely elevated total homocysteine concentration, folate and B12 deficiencies. Further tests revealed he was homozygous for the methylenetetrahydrofolate reductase enzyme thermolabile variant (MTHFR c.667 C > T). The etiology of this stroke was a hypercoagulable state induced by raised plasma homocysteine. Raised homocysteine in this case was likely multifactorial and related to chronic AAS use in combination with the homozygous MTHFR c.677 C > T thermolabile variant, folate deficiency and, vitamin B12 deficiency.

CONCLUSION

In summary, hyperhomocysteinemia is an important potential cause of ischaemic stroke and may result from genetic, dietary, and social factors. Anabolic androgenic steroid use is an important risk factor for clinicians to consider, particularly in cases of young stroke with elevated serum homocysteine. Testing for MFTHR variants in stroke patients with raised homocysteine may be useful to guide secondary stroke prevention through adequate vitamin supplementation. Further studies looking into primary and secondary stroke prevention in the high-risk MTHFR variant cohort are necessary.

104 SPONTANEOUS ILIOPSOAS TENDON RUPTURE AND PSOAS HAEMATOMA ON ASPIRIN MONOTHERAPY: A CASE REPORT

Background

Spontaneous Iliopsoas Tendon (IPT) rupture is a rare condition, with a prevalence of 0.66%, occurring most commonly in athletes. Risk factors for non-athletic IPT rupture include age, female gender and steroid use. Psoas haematomas are associated with surgery, anticoagulation and coagulopathies. Only a handful of case reports have associated psoas haematoma with single antiplatelet use. We present the case of a patient who developed psoas tendon rupture and psoas haematoma.

Methods

A 77-year-old female presented with a four week history of declining mobility and left hip pain, without history of trauma. Past medical history included chronic lymphoedema and an NSTEMI, for which she was taking aspirin monotherapy. On examination, she had reduced power on left hip flexion and a tender anterior thigh, with normal sensation. CT showed asymmetric thickening of the left iliacus muscle and surrounding fat stranding. MRI demonstrated partial IPT tear with oedema extending into the iliacus muscle.

Results

After several weeks of rehabilitation, her mobility deteriorated again. A second CT was performed, which showed new expansion and fat stranding of the right iliopsoas muscle and tendon compatible with acute haemorrhage. Aspirin was held for four weeks, and she was discharged after completing rehabilitation. Her baseline mobility had disimproved and she required assistance and a frame on discharge.

Conclusion

IPT rupture and psoas haematoma are atypical causes of atraumatic hip pain in older adults. Nevertheless, they can cause significant disability. MRI is recommended as the gold standard for diagnosis. Treatment is commonly conservative, focused on physiotherapy and pain control to maintain mobility. While aspirin is not commonly associated with tendon rupture or haemorrhage, it is widely used in primary prevention of cardiovascular disease and due consideration should be given to stopping it following the occurrence of haemorrhage.

Is Ireland ready for tobacco endgame? A national survey of knowledge and attitudes to tobacco endgame

Background

In 2013 ‘Tobacco-Free Ireland’ (TFI) shifted Irish national policy from tobacco control to “tobacco endgame”: policies, plans and interventions seeking to end the tobacco epidemic completely. Recent trends suggest the current 2025 TFI goal will not be achieved. This cross-sectional study is a timely assessment of public knowledge and attitude to re-focus Irish “tobacco endgame” planning.

Methods

A literature-informed, pre-tested survey instrument was telephone-administered to a representative sample of 1000 members of the Irish public aged ≥15 years recruited via random digit dialling in February 2022. Prevalence of “tobacco endgame” views was measured; logistic regression determined factors associated with key responses.

Results

Response rate was 30% (n = 1,000, post-hoc weighting applied). While TFI goal awareness was low (34%), support was high (75%), albeit most (61%) recognised postponement beyond 2025 was required for achievability. There was majority support for 18/22 endgame measures assessed. Product-focused tactics were popular, while views on targeting users were mixed: e.g. 86% supported a reduction in tobacco-product nicotine content; 40% supported introduction of a tobacco-user license. Phasing-out tobacco sales was highly-supported (83%); however, this was contingent on special supports for those currently addicted. Support for the TFI goal was higher among non-tobacco users (aOR 2.66, 95%CI 1.89-3.76), females (aOR 1.57, 95%CI 1.17-2.11) and those of higher social class (aOR 1.72, 95%CI 1.25-2.35).

Conclusions

While achievement by 2025 is increasingly unrealistic, findings strongly affirm Irish public opinion is ready for “tobacco endgame”. Recognition of the needs of currently addicted tobacco users and focusing on subgroups with lower support levels should be integral to equitable “tobacco endgame” planning and communication. This study should mobilise renewed Irish political commitment to bold actions aimed at ending smoking-related harm.

Key messages

• There is strong support for tobacco endgame measures among the Irish population, which is a supportive factor for bold political leadership to make these radical ideas a reality.

• Public preference for product and non-user-focused measures aligns with tobacco endgame discourse and should aid policy reframing to tackle structures and dynamics sustaining the tobacco epidemic.

Light to intermediate oil sheens increase Manx shearwater feather permeability

Oil pollution has profound negative impacts on the marine environment, with seabirds particularly vulnerable to oiling, due to the amount of time spent on the sea surface foraging or resting. Exposure to oil can affect feather structure and influence waterproofing, buoyancy and thermoregulation. We investigated the effects of surface crude oil on the feather structure of Manx shearwaters (Puffinus puffinus), a seabird species that spends a high proportion of time on the water surface. Sampled body contour feathers were exposed to varying thicknesses of surface crude oil before assessing their resistance to water permeation, increase in mass and clumping of feather barbules. Surface oil as thin as 0.1 µm was enough to increase feather permeability, while greatest impacts on permeability were caused by exposure to dark colour surface sheens 3 µm in thickness. Increases in feather mass of up to 1000% were noted in heavy oiling scenarios due to contact with thicker oil slicks, which may significantly affect wing loading and energetic expenditure.

Increasing the use of perioperative risk scoring in emergency laparotomy: nationwide quality improvement programme

Background

Emergency laparotomy is associated with high morbidity and mortality. The early identification of high-risk patients allows for timely perioperative care and appropriate resource allocation. The aim of this study was to develop a nationwide surgical trainee-led quality improvement (QI) programme to increase the use of perioperative risk scoring in emergency laparotomy.

Methods

The programme was structured using the active implementation framework in 15 state-funded Irish hospitals to guide the staged implementation of perioperative risk scoring. The primary outcome was a recorded preoperative risk score for patients undergoing an emergency laparotomy at each site.

Results

The rate of patients undergoing emergency laparotomy receiving a perioperative risk score increased from 0–11 per cent during the exploratory phase to 35–100 per cent during the full implementation phase. Crucial factors for implementing changes included an experienced central team providing implementation support, collaborator engagement, and effective communication and social relationships.

Conclusions

A trainee-led QI programme increased the use of perioperative risk assessment in patients undergoing emergency laparotomy, with the potential to improve patient outcomes and care delivery.

POS0661 MAJOR COST SAVINGS ASSOCIATED WITH BIOLOGIC DOSE REDUCTION IN PATIENTS WITH INFLAMMATORY ARTHRITIS

Background

Anti-TNF drugs have dramatically improved the management of inflammatory arthritis (IA).

Although the introduction of biosimilars have reduced the cost, chronic use of biologic agents

has a high impact on healthcare expenditure. This study evaluated the cost effectiveness of a

dose reduction strategy for the most commonly used anti- TNF drugs over a period of 10 years

in patients with IA in remission.

Objectives

The purpose of this study was to explore whether patients with Inflammatory Arthritis (IA) (Rheumatoid Arthritis (RA), Psoriatic Arthritis (PsA) or Ankylosing Spondylitis (AS) would remain in remission after 10 year period, following a reduction in biologic dosing frequency and to calculate the cost savings associated with dose reduction.

Methods

This prospective, non-blinded, non-randomised study was commenced in 2010. Patients

with IA, Rheumatoid arthritis (RA),ankylosing spondylitis (AS) and Psoriatic arthritis (PsA)

who were in remission as defined by disease activity indices (DAS28<2.6, BASDAI<4), and

were offered Anti TNF dose reduction. Patients on etanercept were reduced from 50mg

weekly to fortnightly, adalimumab 40mg once monthly instead of fortnightly. Patients were

assessed for disease activity at 1, 4 and 10 years following reduction in dosing

frequency.Cost saving was calculated by deducting the total annual cost of the biologic

agent used over 10 years compared with the cost if the dosing interval had not changed.

Results

Seventy nine patients with inflammatory arthritis in remission were recruited. 57% had rheumatoid arthritis (n=45), 13% psoriatic arthritis (n=10) and 30% ankylosing spondylitis (n=24). 57% (n=45) were taking etanercept and 43% (n=34) adalimumab. The percentage of patients who maintained dose reduction at 10 years was 9% (n=7). Of the total 48 patients who were successfully dose reduced at year 1 (n=42), (69%, n=29) were able to maintain the dose reduction up to 4 years and 9% (n=7) maintained this dose reduction up to year 10. The estimated cost saving was €4,928 per patient per year. Estimated cost savings for 7 patients on reduced dose was €344,952.88 over 10 years.

Conclusion

Anti TNF dose reduction strategy in patients with IA results in substantial cost savings. Implementation of a dose reduction strategy while monitoring of disease activity reduces the financial impact of the use of biologic therapies. Further studies should be done to identify which patients are more likely to remain in remission while on dose reduction.

References

[1]Bonafede MM, Gandra SR, Watson C, Princic N, Fox KM. Cost per treated patient for etanercept, adalimumab, and infliximab across adult indications: a claims analysis. Adv Ther. 2012 Mar;29(3):234-48. doi: 10.1007/s12325-012-0007-y. Epub 2012 Mar 9. PMID: 22411424.

[2]Joaquín Borrás-Blasco, Antonio Gracia-Pérez, J Dolores Rosique-Robles, MD Elvira Casterá & F Javier Abad (2014) Clinical and economic impact of the use of etanercept 25 mg once weekly in rheumatoid arthritis, psoriatic arthropathy and ankylosing spondylitis patients, Expert Opinion on Biological Therapy, 14:2, 145-150, DOI: 10.1517/14712598.2014.868433

[3]Carter CT, Changolkar AK, Scott McKenzie R. Adalimumab, etanercept, and infliximab utilization patterns and drug costs among rheumatoid arthritis patients. J Med Econ. 2012;15(2):332-9. doi: 10.3111/13696998.2011.649325. Epub 2012 Jan 6. PMID: 22168788.

Disclosure of Interests

None declared

212 BUILT ENVIRONMENT OF NURSING HOMES AND INFECTION CONTROL AND PANDEMIC PREPAREDNESS

Background

The disproportionately high death rate of nursing home (NH) residents from COVID-19 in many countries, including Ireland, has focussed attention on infection prevention and control, including the built environment, in nursing homes. This has been a poorly researched topic to date, and we undertook a systematic review of evidence for architectural design measures which support infection control and pandemic preparedness.

Methods

Databases were screened for keywords related to NHs, built environment, infection prevention and control, and COVID-19; relevant papers were uploaded onto Covidence and screened for relevance. Data extracted from included articles was tabulated under 8 specific aspects of the built environment.

Results

Of 17 papers included in the final analysis, four studies found that larger nursing homes carried an increased risk of COVID-19 infection. Crowding in NHs was also a risk factor for infection, with a high crowding index associated with COVID-19 infection in five studies. Green House care homes, which are based on small clusters of domestic dwellings, fared better than traditional NHs. Two papers found an association between the location of NHs and the risk of COVID-19 infection, with urban NHs and those in areas of high prevalence being more at risk. Two papers identified internal fittings as a target for infection prevention and control. Seven papers highlighted the role of adequate ventilation in NHs in the prevention of spread of COVID-19. Only one paper described easy access to the outdoors as beneficial to infection control.

Conclusion

Residents of NHs are amongst the most vulnerable to COVID-19 infection. When designing and building NHs, the role of the built environment in controlling the spread of the virus should not be underestimated.

This research supported by Science Foundation Ireland.

Sleepiness and safety at work among night shift NHS nurses

BACKGROUND

Sleepiness associated with night shift working (NSW) is known to adversely affect workers' health and well-being. It has been associated with adverse safety outcomes and is a recognized workplace hazard among healthcare workers.

AIMS

This study was aimed to assess the prevalence of self-reported sleepiness in NSW nurses and midwives. This study also explored the consequences of sleepiness on safety at work and driving.

METHODS

A cross-sectional study of NSW nurses and midwives was conducted at an National Health Service (NHS) hospital trust from 16 March 2020 to 1 June 2020. Data were collected by online questionnaire and included information on demographics, shift work and safety aspects. Sleepiness was assessed with the Epworth Sleepiness Scale (ESS).

RESULTS

Data collection coincided with the first coronavirus pandemic peak in England. Out of 1985 eligible NSW nurses and midwives, 229 participated in the study, with a response rate of 12%. The prevalence of sleepiness was 28%. Following a night shift, 49% of nurses reported nodding off at the wheel and 44% reported a near-miss car accident in past 12 months. An abnormal ESS score was significantly associated with near-miss car accidents (odds ratio [OR] 2.75, 95% confidence interval [CI] 1.31-5.77) and with low confidence in undertaking complex tasks at night (OR 2.64, 95% CI 1.20-5.84).

CONCLUSIONS

More than a quarter of NSW nurses and midwives reported excessive daytime sleepiness although, due to the low response rate, this may not be representative. Adverse driving events were common. Elevated ESS scores correlated well with safety issues relating to work and driving.

The impact of COVID-19 on the social inclusion of older adults with an intellectual disability during the first wave of the pandemic in Ireland

BACKGROUND

Social restrictions and service closures from COVID-19 have negatively impacted social inclusion and well-being for some people with intellectual disabilities (IDs).

METHODS

The fourth wave of a national longitudinal study on ageing in people with ID in Ireland was interrupted during the COVID-19 outbreak. Social inclusion data for pre-existing participants interviewed before COVID-19 (n = 444) were compared with data for pre-existing participants interviewed during/after lockdown (n = 62).

RESULTS

More people interviewed after lockdown reported frequent family contact. Significantly greater numbers in the post-lockdown group reported access to and use of technology than the pre-lockdown group. Technology use was higher among those living in grouped residences supported by services compared with individuals living independently or with family.

CONCLUSIONS

During the early stages of the COVID-19 pandemic in Ireland, many older adults with ID stayed connected with family and reported rates of contact higher than were reported by others before COVID-19. This connection may have been supported by a significant increase in technology use during the pandemic. However, uneven use of technology may disadvantage some including individuals living with family or independently. Given that COVID-19 restrictions are likely to continue to restrict social opportunities, increased digital support may assist more people with ID to use technology to maintain their social connections.

Women's mobility and transport in the peripheries of three African cities: Reflecting on early impacts of COVID-19

This paper reflects on the mobility experiences of women in African cities in COVID-19, based on research conducted both prior to and following entry into the COVID-19 'moment'. It draws on material collected during an ongoing action research study aimed at addressing the everyday transport and mobility challenges faced by young women living in poor peripheral communities of three African cities - Abuja, Cape Town and Tunis. The project has the specific objective of supporting young women's improved access to employment opportunities through trialling various mobility/transport-related skills interventions (based on prior in-depth analysis of mobility constraints). With the onset of COVID-19 some readjustments to the research focus and planned interventions became necessary. The research teams, together with an NGO partner, are now working to chart how young women's everyday experiences of mobility and transport - both as transport users and as transport sector workers - are changing as processes of lockdown and their relaxation evolve. The paper covers the period from early 2019 through to March 2021, and offers reflections regarding 'lived experiences' of mobility practice pre-pandemic, during the pandemic, and the potential longer-term mobility-related impacts for women resident in low-income neighbourhoods in a post-COVID-19 era. This leads to consideration of key policy lessons. There is potential for prioritisation of Non-Motorised Transport interventions towards a green restart that would benefit women (for instance through promoting women's cycling), and for growing women's participation as transport operators, even perhaps the usage of drones to aid women's safer pedestrian travel. But such interventions will require far greater representation of women in COVID-19 and wider transport decision-making entities than has hitherto been the case.

140 Lessons From the Front Line: Communication is Key

Introduction

As junior doctors, we very rarely receive formal teaching on communication after medical school, with telephone encounters and difficult conversations over technology being a vital yet missing part of our education. The COVID-19 pandemic has required us to adapt how we communicate with patients’ families due to hospital visiting restrictions. In an era where tragically deterioration and death have been much more commonplace, we looked to identify areas where junior doctors felt their communication skills could be improved, and implemented a teaching programme to deliver this.

Methods

Pre-teaching questionnaires were distributed to a range of grades of junior doctors working in University Hospital of Llandough, Cardiff. The questionnaires were distributed at the beginning of June 2020, after 3 months of working in pandemic conditions. A teaching session on telephone and video communication skills was delivered by a local palliative care consultant. Post-teaching, a repeat questionnaire was undertaken to assess response and identify key learning points.

Results

Pre-teaching, 100% of the 22 respondents had had to participate in difficult conversations over the phone, 82% had had no formal phone based communication skills training and 81.82% felt some form of formal teaching would be helpful. Post-teaching, 12 junior doctors provided feedback with an average 37% increase in confidence to undertake difficult conversations. Key learning points from the session highlighted the importance of preparation, regularly updating the family to build trust and rapport, and integrating family updates via tele-communication into daily ward life.

Conclusions

Education around telephone communication skills is critical to enable us to adapt our skills in accordance with the demands of the pandemic, to continue to support relatives and to engage with technology with confidence. Increased preparation is required to navigate difficult conversations via technology, and successful communication requires clinicians to take responsibility for initiating regular family updates.

141 Face Time’ for the First Time: Patients, Families and Junior Doctors

Introduction

Over the course of the COVID-19 pandemic, supporting effective communication between patients and their families has been a recognised challenge in the healthcare environment. Virtual communication via telecommunication and video-calling is more important than ever, but with minimal clinician education, preparation and relevant technological infrastructure available in the context of a global pandemic, we have recognised communication as an area for improvement as junior doctors working on a COVID-19 ward.

Methods

We interviewed via telephone 22 nominated next of kin relatives of patients admitted to a COVID-19 ward in the University Hospital of Llandough during May 2020 using a pre-prepared survey. We then provided relatives with the opportunity to engage with video-call updates from a doctor (with the patient’s permission). In appropriate scenarios, we used video calling to break bad news and to facilitate difficult communications with family members. These video calls were provided via Accurx, an NHS approved video communication system.

Results

Initial survey results showed an average understanding score of their relative’s current clinical plan of 5.5/10, with 63% of respondents saying they did not feel well informed. Nearly a quarter of respondents (22%) had received difficult news over the phone during the COVID-19 pandemic, and 86% said they would find video communication useful. Post-intervention survey results suggested a unanimous improvement in relative satisfaction, with relatives reporting an increased understanding around the admission, reassurance around the quality of care being given and less isolation from the patient.

Conclusions

The COVID-19 pandemic has provided novel communication challenges to physicians, promoting flexibility and adaptation to some of the core inter-personal skills we develop throughout training. Technology plays a huge role in this, and the use of video calling in particular can preserve non-verbal communication within the doctor-relative relationship and improve emotional connection between patients and their loved ones.

Postmortem Analyses in a Patient With Succinic Semialdehyde Dehydrogenase Deficiency (SSADHD): II. Histological, Lipid, and Gene Expression Outcomes in Regional Brain Tissue

This study has extended previous metabolic measures in postmortem tissues (frontal and parietal lobes, pons, cerebellum, hippocampus, and cerebral cortex) obtained from a 37-year-old male patient with succinic semialdehyde dehydrogenase deficiency (SSADHD) who expired from SUDEP (sudden unexplained death in epilepsy). Histopathologic characterization of fixed cortex and hippocampus revealed mild to moderate astrogliosis, especially in white matter. Analysis of total phospholipid mass in all sections of the patient revealed a 61% increase in cortex and 51% decrease in hippocampus as compared to (n = 2-4) approximately age-matched controls. Examination of mass and molar composition of major phospholipid classes showed decreases in phospholipids enriched in myelin, such as phosphatidylserine, sphingomyelin, and ethanolamine plasmalogen. Evaluation of gene expression (RT² Profiler PCR Arrays, GABA, glutamate; Qiagen) revealed dysregulation in 14/15 GABA_A receptor subunits in cerebellum, parietal, and frontal lobes with the most significant downregulation in ∊, θ, ρ1, and ρ2 subunits (7.7-9.9-fold). GABA_B receptor subunits were largely unaffected, as were ionotropic glutamate receptors. The metabotropic glutamate receptor 6 was consistently downregulated (maximum 5.9-fold) as was the neurotransmitter transporter (GABA), member 13 (maximum 7.3-fold). For other genes, consistent dysregulation was seen for interleukin 1β (maximum downregulation 9.9-fold) and synuclein α (maximal upregulation 6.5-fold). Our data provide unique insight into SSADHD brain function, confirming astrogliosis and lipid abnormalities previously observed in the null mouse model while highlighting long-term effects on GABAergic/glutamatergic gene expression in this disorder.

MRI-visible perivascular spaces as an imaging biomarker in Fabry disease

Introduction

Fabry disease (FD) is an X-linked lysosomal storage disorder resulting in vascular glycosphingolipid accumulation and increased stroke risk. MRI findings associated with FD include white matter hyperintensities (WMH) and cerebral microbleeds (CMBs), suggesting the presence of cerebral small vessel disease. MRI-visible perivascular spaces (PVS) are another promising marker of small vessel disease associated with impaired interstitial fluid drainage. We investigated the association of PVS severity and anatomical distribution with FD.

Patients and methods

We compared patients with genetically proven FD to healthy controls. PVS, WMH, lacunes and CMBs were rated on standardised sequences using validated criteria and scales, blinded to diagnosis. A trained observer (using a validated rating scale), quantified the total severity of PVS. We used logistic regression to investigate the association of severe PVS with FD.

Results

We included 33 FD patients (median age 44, 44.1% male) and 20 healthy controls (median age 33.5, 50% male). Adjusting for age and sex, FD was associated with more severe basal ganglia PVS (odds ratio (OR) 5.80, 95% CI 1.03–32.7) and higher total PVS score (OR 4.03, 95% CI 1.36–11.89). Compared with controls, participants with FD had: higher WMH volume (median 495.03 mm³ vs 0, p = 0.0008), more CMBs (21.21% vs none, p = 0.04), and a higher prevalence of lacunes (21.21% vs. 5%, p = 0.23).

Conclusions

PVS scores are more severe in FD than control subjects. Our findings have potential relevance for FD diagnosis and suggest that impaired interstitial fluid drainage might be a mechanism of white matter injury in FD.

Purified β-glucans from the Shiitake mushroom ameliorates antibiotic-resistant Klebsiella pneumoniae-induced pulmonary sepsis

Bacterial infection remains the main cause of acute respiratory distress syndrome and is a leading cause of death and disability in critically ill patients. Here we report on the use of purified β-glucan (lentinan) extracts from Lentinus edodes (Shiitake) mushroom that can reduce infection by a multidrug-resistant clinical isolate of Klebsiella pneumoniae in a rodent pneumonia model, likely through immunomodulation. Adult male Sprague-Dawley rats were subjected to intra-tracheal administration of K. pneumoniae to induce pulmonary sepsis and randomized to three groups; vehicle control (Vehicle, n = 12), commercial lentinan (CL, n = 8) or in-house extracted lentinan (IHL, n = 8) were administered intravenously 1 h postinfection. Physiological parameters and blood gas analysis were measured, bacterial counts from bronchoalveolar-lavage (BAL) were determined, along with differential staining of white cells and measurement of protein concentration in BAL 48 h after pneumonia induction. Use of IHL extract significantly decreased BAL CFU counts. Both CL and IHL extractions reduced protein concentration in BAL. Use of IHL resulted in an improvement in physiological parameters compared to controls and CL. In conclusion, administration of lentinan to treat sepsis-induced lung injury appears safe and effective and may exert its effects in an immunomodulatory manner.

Implementation and analysis of a telephone support service during COVID-19

Background

During the COVID-19 pandemic, it has been essential for occupational health services (OHS) providers to react rapidly to increased demand and to utilize resources in novel ways. The impact of the COVID-19 pandemic on the psychological well-being of staff is already identified as an area of high risk; therefore, providing timely access to psychological support may be vital, although limited evidence is available on how these risks are best managed.

Aims

To describe implementation and analysis of a psychology-led COVID-19 telephone support line in a National Health Service OHS.

Methods

Data from calls made to the support line were collected over the first 4 weeks of service implementation. Numerical data including frequency of calls and average waiting time were first considered. A content analysis was then conducted on call notes to identify prevalence of themes.

Results

Six hundred and fifty-five calls were received, and 362 notes included sufficient information for use within the content analysis. Frequency of calls peaked within the first week followed by a reduction in the number of calls received per day over time. Most calls included discussion around clarification of guidance (68%) with a smaller subset of calls offering support around anxiety (29%). Prevalence of themes did not appear to change over time.

Conclusions

Clear and timely information is vital to support the well-being of healthcare staff. A psychologically informed telephone support line was a good use of occupational health service resources in the interim while more tailored advice and services could be established.

Experimental Assessment of Two Non-Contrast MRI Sequences Used for Computational Fluid Dynamics: Investigation of Consistency Between Techniques

Purpose

Recent studies have noted a degree of variance between the geometries segmented by different groups from 3D medical images that are used in computational fluid dynamics (CFD) simulations of patient-specific cardiovascular systems. The aim of this study was to determine if the applied sequence of magnetic resonance imaging (MRI) also introduced observable variance in CFD results.

Methods

Using a series of phantoms MR images of vessels of known diameter were assessed for the time-of-flight and multi-echo data image combination sequences. Following this, patient images of arterio-venous fistulas were acquired using the same sequences. Comparisons of geometry were made using the phantom and patient images, and of wall shear stress quantities using the CFD results from the patient images.

Results

Phantom images showed deviations in diameter between 0 and 15% between the sequences, depending on vessel diameter. Patient images showed different geometrical features such as narrowings that were not present on both sequences. Distributions of wall shear stress (WSS) quantities differed from simulations between the geometries obtained from the sequences.

Conclusion

In conclusion, choosing different MRI sequences resulted in slightly different geometries of the same anatomy, which led to compounded errors in WSS quantities from CFD simulation.

Electronic supplementary material

The online version of this article (10.1007/s13239-020-00473-z) contains supplementary material, which is available to authorized users.

SAT0099 BMI AND TREATMENT SURVIVAL IN RA PATIENTS STARTING TREATMENT WITH TNFΑ-INHIBITORS: LONG TERM FOLLOW-UP IN THE REAL LIFE METEOR REGISTRY

Background:

BMI appears to be associated with treatment response on TNFi(nhibitors) in rheumatoid arthritis (RA), but large heterogeneity between studies exists. More extreme BMI categories are rarely studied and it is unclear if differences exist between various TNFi.1

Table 1

Characteristics of RA patients

Female, n (%)935 (79.8)Age, years*51.0 ±13.7Current smokers, n (%)256 (23.2)RF Positivity, n (%)404 (55.6)Anti-CCP Positivity, n (%)430 (58.2)X-ray Erosion, n (%)317 (61.9)ESR, mm/h*31.2±21.9CRP, mg/L*17.2±3.9DAS 28-CRP*3.8±1.6VAS global*46.6±28.6HAQ*0.9±0.7First TNFi Etanercept, n (%)525 (38.7) Adalimumab, n (%)379 (27.9) Infliximab, n (%)118 (8.7) Certolizumab, n (%)188 (13.8) Golimumab, n (%)147 (10.9)

* mean ±S.D

RF, Rheumatoid factor; Anti-CCP, Anti- cyclic citrullinated peptid; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; DAS28–CRP, Disease Activity Score using 28 joints–CRP; VAS, Visual analog scale; HAQ, Health Assessment Questionnaire

Objectives:

To study whether there is an association between BMI category and drug survival in RA patients starting treatment with various TNFi in a real life longitudinal international registry.

Methods:

Data from 5230 RA patients starting a TNFi were included from the METEOR registry. Timing of follow-up visits was daily practice based. Follow-up was censored at 5000 days (±13.5 years). Patients were divided into 6 BMI categories (WHO definition): underweight BMI <18.5, normal weight BMI 18.5-25, pre-obesity BMI 25-30, obesity class I BMI 30-35, class II BMI 35-40, and class III BMI >40. Missing data were imputed using chained equations. The association between BMI category and time on treatment was investigated using Kaplan-Meier (KM) curves and Cox regression analyses, for time on first TNFi and for the first prescribed course of adalimumab (ADA), etanercept (ETA) and infliximab (IFX) separately. All analyses were adjusted for the potential confounders age, gender, smoking, baseline DAS28, concomitant glucocorticoid use and country. Potential effect modification by reported pain was tested by adding an interaction term between BMI category and baseline pain category (VAS pain 0-25, 25-50, 50-75 and 75-100).

Results:

Most patients had a normal weight (46%) or pre-obesity (32%). 4% of patients were underweight, 10% had obesity class I, 3% obesity class II and 1% obesity class III. N=2936 patients ever started ETA, n=2069 ADA, n=1390 IFX, n=263 certolizumab and n=84 golimumab. The KM curve in fig 1A shows TNFi survival in patient starting their first TNFi per BMI category. Patients with normal weight and pre-obesity had longest drug survival and patients with obesity class II and especially patients with obesity class III had shortest drug survival. The adjusted Cox regression support these findings, with statistically significantly shorter drug survival for patients with obesity class III [HR (95% CI) 1.67 (1.29; 2.18)] and class II [1.28 (1.06; 1.54)], but also for underweight patients [1.3 (1.07; 1.58)], compared to normal weight patients. KM curves for individual TNFi showed shorter drug survival on ADA for patients with obesity class II and III (fig 1B), on ETA for patients with obesity, especially in class III (fig 1C) and on IFX, for patients with obesity class II and III and underweight patients (fig 1D). After adjustment in Cox regression, statistical significant BMI-drug survival associations remained for patients with pre-obesity starting ADA [HR (95% CI) 0.86 (0.75; 0.99)], for patients starting ETA with obesity class II [HR (95% CI) 1.27 (0.98; 1.65) or class III [1.79 (1.25; 2.55)] and for patients on IFX who were underweight [HR (95% CI) 1.82 (1.20; 2.76)] or in obesity class II [1.49 (0.98; 2.26)]. No effect modification was found for reported pain.

Conclusion:

Both underweight (as identified in IFX treated patients) and overweight patients (in ADA, ETA and IFX treated patients) discontinued a first TNFi treatment earlier than normal weight patients. Reported pain was not the main determinant. It remains uncertain what determines TNFi survival in individual patients.

References:

[1] Singh, et al.PloS One2018; 13:e0195123

Disclosure of Interests:

Sytske Anne Bergstra: None declared, David Vega-Morales: None declared, Elizabeth Murphy: None declared, Marieke de Buck: None declared, Karen Solomon-Escoto: None declared, Thomas Huizinga Grant/research support from: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Consultant of: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Cornelia Allaart: None declared

Antarctic Futures: An Assessment of Climate-Driven Changes in Ecosystem Structure, Function, and Service Provisioning in the Southern Ocean

In this article, we analyze the impacts of climate change on Antarctic marine ecosystems. Observations demonstrate large-scale changes in the physical variables and circulation of the Southern Ocean driven by warming, stratospheric ozone depletion, and a positive Southern Annular Mode. Alterations in the physical environment are driving change through all levels of Antarctic marine food webs, which differ regionally. The distributions of key species, such as Antarctic krill, are also changing. Differential responses among predators reflect differences in species ecology. The impacts of climate change on Antarctic biodiversity will likely vary for different communities and depend on species range. Coastal communities and those of sub-Antarctic islands, especially range-restricted endemic communities, will likely suffer the greatest negative consequences of climate change. Simultaneously, ecosystem services in the Southern Ocean will likely increase. Such decoupling of ecosystem services and endemic species will require consideration in the management of human activities such as fishing in Antarctic marine ecosystems.

An iPSC-Derived Myeloid Lineage Model of Herpes Virus Latency and Reactivation

Herpesviruses undergo life-long latent infection which can be life-threatening in the immunocompromised. Models of latency and reactivation of human cytomegalovirus (HCMV) include primary myeloid cells, cells known to be important for HCMV latent carriage and reactivation in vivo. However, primary cells are limited in availability, and difficult to culture and to genetically modify; all of which have hampered our ability to fully understand virus/host interactions of this persistent human pathogen. We have now used iPSCs to develop a model cell system to study HCMV latency and reactivation in different cell types after their differentiation down the myeloid lineage. Our results show that iPSCs can effectively mimic HCMV latency/reactivation in primary myeloid cells, allowing molecular interrogations of the viral latent/lytic switch. This model may also be suitable for analysis of other viruses, such as HIV and Zika, which also infect cells of the myeloid lineage.

The natural history of classic galactosemia: lessons from the GalNet registry

BACKGROUND

Classic galactosemia is a rare inborn error of carbohydrate metabolism, caused by a severe deficiency of the enzyme galactose-1-phosphate uridylyltransferase (GALT). A galactose-restricted diet has proven to be very effective to treat the neonatal life-threatening manifestations and has been the cornerstone of treatment for this severe disease. However, burdensome complications occur despite a lifelong diet. For rare diseases, a patient disease specific registry is fundamental to monitor the lifespan pathology and to evaluate the safety and efficacy of potential therapies. In 2014, the international Galactosemias Network (GalNet) developed a web-based patient registry for this disease, the GalNet Registry. The aim was to delineate the natural history of classic galactosemia based on a large dataset of patients.

METHODS

Observational data derived from 15 countries and 32 centers including 509 patients were acquired between December 2014 and July 2018.

RESULTS

Most affected patients experienced neonatal manifestations (79.8%) and despite following a diet developed brain impairments (85.0%), primary ovarian insufficiency (79.7%) and a diminished bone mineral density (26.5%). Newborn screening, age at onset of dietary treatment, strictness of the galactose-restricted diet, p.Gln188Arg mutation and GALT enzyme activity influenced the clinical picture. Detection by newborn screening and commencement of diet in the first week of life were associated with a more favorable outcome. A homozygous p.Gln188Arg mutation, GALT enzyme activity of ≤ 1% and strict galactose restriction were associated with a less favorable outcome.

CONCLUSION

This study describes the natural history of classic galactosemia based on the hitherto largest data set.

Acute Pain Management Pharmacology for the Patient with Concurrent Renal or Hepatic Disease

The clinical utility of most analgesic drugs is altered in the presence of patients with impaired renal or hepatic function not simply because of altered clearance of the parent drug, but also through production and accumulation of toxic or therapeutically active metabolites. Some analgesic agents may also aggravate pre-existing renal and hepatic disease.

A search was performed, taking in published articles and pharmaceutical data to determine available evidence for managing acute pain effectively and safely in these two patient groups. The resulting information consisted mainly of small group pharmacokinetic studies or case reports, which included a large variation in degree of organ dysfunction.

In the presence of renal impairment, those drugs which exhibit the safest pharmacological profile are alfentanil, buprenorphine, fentanyl, ketamine, paracetamol (except with compound analgesics), remifentanil and sufentanil: none of these deliver a high active metabolite load, or suffer from significantly prolonged clearance. Amitriptyline, bupivacaine, clonidine, gabapentin, hydromorphone, levobupivacaine, lignocaine, methadone, mexiletine, morphine, oxycodone and tramadol have been used in the presence of renal failure, but do require specific precautions, usually dose reduction. Aspirin, dextropropoxyphene, non-steroidal anti-inflammatory drugs and pethidine, should not be used in the presence of chronic renal failure due to the risk of significant toxicity.

In the presence of hepatic impairment, most drugs are subject to significantly impaired clearance and increased oral bioavailability, but are poorly studied in the clinical setting. The agent least subject to alteration in this context is remifentanil; however the drugs’ potency has other inherent dangers. Other agents must only be used with caution and close patient monitoring. Amitriptyline, carbamazepine and valproate should be avoided as the risk of fulminant hepatic failure is higher in this population, and methadone is contraindicated in the presence of severe liver disease.

“Semenly” Harmless Back Pain: An Unusual Presentation of a Subcutaneous Abscess

Aims We report, with review of the literature, the case of a patient who developed a subcutaneous abscess after intravenously injecting his own semen in an attempt to treat longstanding back pain. He had devised this “cure” independent of medical advice. Methods A review of EMBASE, PubMed, google scholar and the wider internet was conducted with an emphasis on parenteral semen for the treatment of back pain and for other medical and non-medical uses. Results There were no other reported cases of intravenous semen injection found across the medical literature. A broader search of internet sites and forums found no documentation of semen injection for back pain treatment or otherwise. Conclusion While suicide attempt by intravenous injection of harmful substances is well described, this unique case demonstrates risks involved with innovative treatments prior to clinical research in the form of phased trials inclusive of safety and efficacy assessments.

Exercise Rehabilitation Services Provided by Physiotherapy Departments in Cancer Care in Ireland

Aims This study aimed to identify the physiotherapy exercise rehabilitation services available to patients with cancer in Ireland and to identify barriers to the provision of services. Methods Physiotherapy department managers in specialised cancer centres, public and private hospitals and palliative care settings were surveyed to establish the availability of exercise rehabilitation services for patients with cancer. Results Of 40 managers contacted, 24 responded providing information about 26 services. Ten services employed a dedicated oncology physiotherapist. Exercise classes were offered to patients with cancer by five services, primarily within the palliative care setting. In the 17 hospitals which provided surgery, ten provided oncology specific post-operative exercise rehabilitation and one offered a prehabilitation programme. Limited human and physical resources and absence of established physiotherapy pathways were cited barriers to service provision. Conclusion Exercise rehabilitation is not an element of standard care for patients with cancer in Ireland.

Treatment of allergic rhinitis using mobile technology with real-world data: The MASK observational pilot study

BACKGROUND

Large observational implementation studies are needed to triangulate the findings from randomized control trials as they reflect "real-world" everyday practice. In a pilot study, we attempted to provide additional and complementary insights on the real-life treatment of allergic rhinitis (AR) using mobile technology.

METHODS

A mobile phone app (Allergy Diary, freely available in Google Play and Apple App stores) collects the data of daily visual analog scales (VAS) for (i) overall allergic symptoms, (ii) nasal, ocular, and asthma symptoms, (iii) work, as well as (iv) medication use using a treatment scroll list including all medications (prescribed and over the counter (OTC)) for rhinitis customized for 15 countries.

RESULTS

A total of 2871 users filled in 17 091 days of VAS in 2015 and 2016. Medications were reported for 9634 days. The assessment of days appeared to be more informative than the course of the treatment as, in real life, patients do not necessarily use treatment on a daily basis; rather, they appear to increase treatment use with the loss of symptom control. The Allergy Diary allowed differentiation between treatments within or between classes (intranasal corticosteroid use containing medications and oral H1-antihistamines). The control of days differed between no [best control], single, or multiple treatments (worst control).

CONCLUSIONS

This study confirms the usefulness of the Allergy Diary in accessing and assessing everyday use and practice in AR. This pilot observational study uses a very simple assessment (VAS) on a mobile phone, shows novel findings, and generates new hypotheses.

Scarf osteotomy without internal fixation for correction of hallux valgus: A clinical and radiographic review of 148 cases

BACKGROUND

Hallux valgus is a common condition with in excess of 120 procedures described in the literature for its correction. Traditionally, distal metatarsal osteotomies have been employed in the treatment of mild deformities, with proximal osteotomies being reserved for more severe presentations. The Scarf osteotomy without internal fixation allows large translations which can successfully correct severe hallux valgus deformities, without limitations related to screw placement.

METHODS

This is a retrospective single surgeon case series performed over a three year period. One hundred and forty-eight cases were identified, with an average follow up time of 16.5 months. Visual analogue scales were used to obtain preoperative and postoperative pain and cosmetic scores, with the Foot and Ankle Disability Index (FADI) index used to assess functional status. The hallux valgus angle (HVA) and intermetatarsal angle (IMA) were assessed on preoperative and postoperative AP weight-bearing foot X-rays.

RESULTS

The mean pain score improved from 7.04/10 preoperatively to 0.29/10 postoperatively. The mean cosmetic score improved from 2.1/10 to 9.1/10 postoperatively. The mean preoperative HVA and IMA were 35.04° and 15.04°, respectively. The mean postoperative HVA and IMA were 11.54° and 4.83°, respectively. The mean postoperative FADI score was 103.4/104. We report a loss of correction in two cases. One revision surgery was performed.

CONCLUSIONS

We report a large series of cases of the modified Scarf osteotomy as described by Maestro-a versatile, cost-effective, safe and reliable technique with the potential for three dimensional correction. Whilst this is a technically demanding procedure, we recommend the use of the modified Scarf osteotomy in the treatment of a wide range of hallux valgus deformities.

A massive core for a cluster of galaxies at a redshift of 4.3

Massive galaxy clusters have been found that date to times as early as three billion years after the Big Bang, containing stars that formed at even earlier epochs^1-3. The high-redshift progenitors of these galaxy clusters-termed 'protoclusters'-can be identified in cosmological simulations that have the highest overdensities (greater-than-average densities) of dark matter^4-6. Protoclusters are expected to contain extremely massive galaxies that can be observed as luminous starbursts ⁷ . However, recent detections of possible protoclusters hosting such starbursts^8-11 do not support the kind of rapid cluster-core formation expected from simulations ¹² : the structures observed contain only a handful of starbursting galaxies spread throughout a broad region, with poor evidence for eventual collapse into a protocluster. Here we report observations of carbon monoxide and ionized carbon emission from the source SPT2349-56. We find that this source consists of at least 14 gas-rich galaxies, all lying at redshifts of 4.31. We demonstrate that each of these galaxies is forming stars between 50 and 1,000 times more quickly than our own Milky Way, and that all are located within a projected region that is only around 130 kiloparsecs in diameter. This galaxy surface density is more than ten times the average blank-field value (integrated over all redshifts), and more than 1,000 times the average field volume density. The velocity dispersion (approximately 410 kilometres per second) of these galaxies and the enormous gas and star-formation densities suggest that this system represents the core of a cluster of galaxies that was already at an advanced stage of formation when the Universe was only 1.4 billion years old. A comparison with other known protoclusters at high redshifts shows that SPT2349-56 could be building one of the most massive structures in the Universe today.