Disease-modifying therapy initiation patterns in multiple sclerosis in three large MS populations

Background

Treatment guidelines recommend early disease-modifying therapy (DMT) initiation after diagnosis of multiple sclerosis (MS). Multinational comparative studies that assess time to DMT initiation in MS may allow detection of barriers inherent to healthcare systems to explain potential adverse systematic delays in commencing DMTs.

Objectives

To investigate and compare the time to first DMT and its association with sociodemographic and clinical variables after MS diagnosis in three large MS registries.

Design

This observational study was conducted using data from the German MS Registry (GMSR), the North American Research Committee on MS Registry (NARCOMS, US data only), and the United Kingdom MS Registry (UKMSR, both self- and clinician-reported).

Methods

Data from relapsing people with MS (PwMS), with a diagnosis of MS between 2014 and 2019, and available DMT and disability status were pooled using a meta-analytic approach.

Results

A total of 5395 PwMS were included in the analysis (GMSR: n = 2658; NARCOMS: n = 447; UKMSR: n = 2290). Kaplan-Meier estimates for the time to first DMT [median months (95% CI)] were 2.0 (1.9-2.0), 3.0 (2-4), and 9.0 (7.7-10.6) for GMSR, NARCOMS, and UKMSR, respectively. Pooled multivariable Cox regression demonstrated shorter time to first DMT for PwMS diagnosed after 2017 [1.65 (1.42-1.92), p < 0.01], and longer time to DMT when a higher-efficacy DMT was selected (0.69 (0.54-0.90), p < 0.0001].

Conclusion

Time to DMT initiation differs across the populations studied, indicating that barriers may exist in early access to DMT, particularly in the United Kingdom. However, a consistent decrease in time to DMT initiation was noted since 2017 across all registries. Further studies are warranted comparing the effects of time to DMT and time to higher-efficacy DMT on long-term outcome.

Models, frameworks and theories in the implementation of programs targeted to reduce formal coercion in mental health settings: a systematic review

Introduction

Implementation models, frameworks and theories (hereafter tools) provide researchers and clinicians with an approach to understand the processes and mechanisms for the successful implementation of healthcare innovations. Previous research in mental health settings has revealed, that the implementation of coercion reduction programs presents a number of challenges. However, there is a lack of systematized knowledge of whether the advantages of implementation science have been utilized in this field of research. This systematic review aims to gain a better understanding of which tools have been used by studies when implementing programs aiming to reduce formal coercion in mental health settings, and what implementation outcomes they have reported.

Methods

A systematic search was conducted using PubMed, CINAHL, PsycINFO, Cochrane, Scopus, and Web of Science. A manual search was used to supplement database searches. Quality appraisal of included studies was undertaken using MMAT-Mixed Methods Appraisal Tool. A descriptive and narrative synthesis was formed based on extracted data. Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed in this review.

Results

We identified 5,295 references after duplicates were removed. Four additional references were found with a manual search. In total eight studies reported in nine papers were included in the review. Coercion reduction programs that were implemented included those that were holistic, and/or used professional judgement, staff training and sensory modulation interventions. Eight different implementation tools were identified from the included studies. None of them reported all eight implementation outcomes sought from the papers. The most frequently reported outcomes were acceptability (4/8 studies) and adaptation (3/8). With regards to implementation costs, no data were provided by any of the studies. The quality of the studies was assessed to be overall quite low.

Discussion

Systematic implementation tools are seldom used when efforts are being made to embed interventions to reduce coercive measures in routine mental health care. More high-quality studies are needed in the research area that also involves perspectives of service users and carers. In addition, based on our review, it is unclear what the costs and resources are needed to implement complex interventions with the guidance of an implementation tool.

Systematic review registration

[Prospero], identifier [CRD42021284959].

Safety of single-dose primaquine as a Plasmodium falciparum gametocytocide: a systematic review and meta-analysis of individual patient data

BACKGROUND

In 2012, the World Health Organization (WHO) recommended single low-dose (SLD, 0.25 mg/kg) primaquine to be added as a Plasmodium (P.) falciparum gametocytocide to artemisinin-based combination therapy (ACT) without glucose-6-phosphate dehydrogenase (G6PD) testing, to accelerate malaria elimination efforts and avoid the spread of artemisinin resistance. Uptake of this recommendation has been relatively slow primarily due to safety concerns.

METHODS

A systematic review and individual patient data (IPD) meta-analysis of single-dose (SD) primaquine studies for P. falciparum malaria were performed. Absolute and fractional changes in haemoglobin concentration within a week and adverse effects within 28 days of treatment initiation were characterised and compared between primaquine and no primaquine arms using random intercept models.

RESULTS

Data comprised 20 studies that enrolled 6406 participants, of whom 5129 (80.1%) had received a single target dose of primaquine ranging between 0.0625 and 0.75 mg/kg. There was no effect of primaquine in G6PD-normal participants on haemoglobin concentrations. However, among 194 G6PD-deficient African participants, a 0.25 mg/kg primaquine target dose resulted in an additional 0.53 g/dL (95% CI 0.17-0.89) reduction in haemoglobin concentration by day 7, with a 0.27 (95% CI 0.19-0.34) g/dL haemoglobin drop estimated for every 0.1 mg/kg increase in primaquine dose. Baseline haemoglobin, young age, and hyperparasitaemia were the main determinants of becoming anaemic (Hb < 10 g/dL), with the nadir observed on ACT day 2 or 3, regardless of G6PD status and exposure to primaquine. Time to recovery from anaemia took longer in young children and those with baseline anaemia or hyperparasitaemia. Serious adverse haematological events after primaquine were few (9/3, 113, 0.3%) and transitory. One blood transfusion was reported in the primaquine arms, and there were no primaquine-related deaths. In controlled studies, the proportions with either haematological or any serious adverse event were similar between primaquine and no primaquine arms.

CONCLUSIONS

Our results support the WHO recommendation to use 0.25 mg/kg of primaquine as a P. falciparum gametocytocide, including in G6PD-deficient individuals. Although primaquine is associated with a transient reduction in haemoglobin levels in G6PD-deficient individuals, haemoglobin levels at clinical presentation are the major determinants of anaemia in these patients.

TRIAL REGISTRATION

PROSPERO, CRD42019128185.

138 Done in 16 Seconds: extracting research ready data from NHS clinical letters

Background

Letters dictated by healthcare professionals in routine patient care form an invaluable dataset but are difficult to access and interpret. The UK MS Register (UKMSR) previously outlined (ABN2019) usage of Natural Language Processing Algorithms (NLP-A) to harvest and transform written language into analysable data in databases. We expanded the variables captured, increased the number of donating hospitals and compared the results to the previous NLP-A.

Aim

Apply the new NLP-A to a random letter selection and evaluate output and results.

Methods

A random, seeded, selection algorithm chose 100 letters from a corpus of 2690 consented in/outpatient letters from 13 Trusts. Letters were reviewed by human domain experts for Date Of Birth, NHS Number, Gender, Clinic Date, Postcode, MS Type and Expanded Disability Status Score (EDSS). NLP-A was applied and assessment made against the same variables.

Results

Run time was 15.4s, Sensitivity and Specificity > 98% in all cases except Clinic Date (Sensitivity 87%, Specificity 20%), MSType (Sensitivity 84%, Specificity 98%) and Postcode (Sensitivity 100%, Specificity 66%). Low specificity in Clinic Date illustrates disagreement on criteria between reviewer and NLP-A. These results represent a 5% increase (in common variables) in Sensitivity and Specificity over the 2019 algorithm.

Conclusion

We have improved the ability to accurately and rapidly identify required variables from the UKMSR minimum dataset using NLP-A. We are continuing to implement this on a widespread basis in the UKMSR.

135 The UK MS pregnancy register: baseline data from the first fifty enrolled patients

Background

We present baseline data on the first 50 participants recruited to the UK MS Pregnancy Register.

Methods

Data collected via questionnaires from consenting participants until 20th December 2021 were included.

Results

50 participants (all with relapsing remitting MS; mean age at diagnosis 28.0 years; mean age at recruitment 33.0 years) were included. Median EDSS was 2.5 (n=16). Gestation at recruitment ranged from 2 to 40 weeks. 78% had discussed their pregnancy in advance with their MS team. 90% of patients had ever taken DMT. Of the patients that stopped DMT (n=23), 16 reported stopping for pregnancy-related reasons. Of these, 39% stopped before pregnancy and 30% following conception. 15 women are continuing DMT during their current pregnancy, taking the following DMT: Glatiramer acetate (n=5), natalizumab (n=7), Peginterferon beta-1a (n=2), not recorded (n=1). In those with prior pregnancies, 61% (14/23) reported pregnancy loss with 1 case of a rare genetic condition in the baby. None of the prior pregnancy losses happened whilst on DMT. One participant reported previous PPH and foetal macrosomia and another reported previous pre-eclampsia.

Conclusions

These results show that a patient-facing pregnancy MS registry is feasible and can collect previous adverse pregnancy outcomes. Future results will inform clinicians and women about the safety of DMT and adjunctive medication during pregnancy and postpartum.

149 Down but not out repurposing depression treatments for multiple sclerosis with the UK MS register

Introduction

Repurposing treatments in multiple sclerosis (MS) has resulted in several candidates that are currently in phase 2 and 3 trials but to test candidate therapies requires a prolonged and costly study. Real world data offers the opportunity to assess in non-randomised data the potential of a range of commonly used therapies. The UK MS register is a UK-wide real-world dataset of 20,000 subjects where regular MS outcomes are collected. Using this dataset, we have recently shown the benefits of disease modifying therapies, and smoking cessation in MS. We aimed to determine if such a resource could be used to determine to utility of potential repurposed drug candidates

Methods

Of 20,000 subjects in the UK MS register we identified those on any antidepressants treatment who had at least 2 follow up visits from baseline after starting treatment. We then identified those who had completed the Hospital Anxiety and Depression Scale (HADS) and the Multiple Sclerosis Impact Scale (MSIS-29) scales in addition at each visit.

Results

3559 subjects on 4294 unique antidepressant treatments were identified (SSRIs: 1852, Tricyclics: 1893, SNRIs: 365. NaSSa: 164, and SARIs: 20). 533 had a baseline visit and 2 follow-up visits with HADS and MSIS-29 questionnaires, where baseline was the beginning of treatment.

Conclusions

The UK MS Register cohort of pwMS can be utilised to support real-world initiatives to inves- tigate potential repurposed candidates.

054 The individual costs of multiple sclerosis

Background

The UK Multiple Sclerosis Register (UKMSR) captures data from multiple sources including directly from people with MS (pwMS) via online questionnaires. There is little research into the non-medical (personal) costs of MS. In partnership with Sanofi we investigated healthcare resource use and costs (excluding drugs), including who bears these costs, by disease severity and type

Methods

A cost of illness questionnaire was deployed to 3035 pwMS on the UKMSR. Respondent’s answers were linked to retrospective UKMSR data. Resource consumption was categorised as being direct (medical) or indirect (non-medical) and costed by NHS and Social Services estimates for 2018.

Results

£509,003 was calculated as non-medical costs over a year and £435,488 in medical costs generated over 3 months (n=537, 6935 interventions). PwMS reported self-funding 75% of non-medical costs these were mainly home modifications. Costs, increased with disability but those with indirect costs (n=138) had higher medical costs, were more disabled and were more likely to be unemployed than those with medical interventions only (n=399).

Conclusions

The importance of disability in driving costs is again clearly illustrated with balance between indirect and direct costs consistent with the UK health environment as a whole. PwMS and their families fund 75% of non-medical costs that can facilitate early discharge and reduce the need to rehabilita- tion/nursing home services.

richard.nicholas@btinternet.com

051 The capture of a UK minimum data set for MS

Background

The UK Multiple Sclerosis Register (UKMSR) was established in 2011 to capture ‘real world’ data from people with MS (pwMS) and the NHS. Capturing clinical data from the NHS for research is time consuming for clinical staff, can involve complicated governance, security and data quality issues. UKMSR has implemented quality controls, validation rules, new capture systems and site reporting to improve this.

Method

Compare the Minimum Data Set (MDS) consisting of 7 items including demographics and EDSS for quality and quantity in the first 3 years (pilot phase) to the most recent 3 years of data capture

Results

Completion of MDS (100% valid and completed values) (2011–2014) 4 sites, n=884. MDS received= 159 (17.9%), Time to add site ~3 Months (2017–2020) 48 Sites, n= 8836. MDS received = 5791 (65.5%), Time to add site ~6 Weeks

Conclusion

The UKMSR has improved the clinical capture of MDS from a vastly increased number of patients and clinical sites. Improved validation standards and systems have increased data quality. Sites are added more quickly and rapidly notified of data quality issues for correction, making the data more useful to the site and ultimately of more utility to researchers.

richard.nicholas@btinternet.com

096 COVID-19 in MS: clinically reported outcomes from the UK MS register

Background

The UK MS Register (UKMSR) has been capturing longitudinal clinical and patient reported outcomes (PROs) since 2011. As the UK population ‘locked-down’ in March 2020 it became important that clinicians could record hospitalised MS patients due to COVID-19 and record outcome. The UKMSR provided an electronic case return form, designed collaboratively by the community.

Aim

Impacts of disability, age and treatment on mortality in pwMS with COVID-19

Method

Linear modelling and standardised hypothesis testing were performed on an outcome of died or not, impact of disability (EDSS), disease modifying therapies and age.

Results

N=132 PCR confirmed COVID-19 patients submitted, 14 missing EDSS, leaving n=118. Female n=80, n relapsing =74, n progressive = 44, mean age 49.2. Median EDSS = 5.0. Linear regression for age was found to be most significant for outcome (p=0.002). Univariate analysis found that the outcome was not independent of EDSS (ChiSq p=0.0008), DMT (ChiSq p=0.006) and MSType (ChiSq p=0.0006). In the multivariate model only, age remained significant.

Conclusions

Only age remained as a marker of poor outcome multivariate analysis. No MS Specific characteristics were found to be significant. We would encourage continued data collection from UK neurology centres to increase the utility of this data.

r.m.middleton@swansea.ac.uk

73

Overriding water table control on managed peatland greenhouse gas emissions

Global peatlands store more carbon than is naturally present in the atmosphere^1,2. However, many peatlands are under pressure from drainage-based agriculture, plantation development and fire, with the equivalent of around 3 per cent of all anthropogenic greenhouse gases emitted from drained peatland^3-5. Efforts to curb such emissions are intensifying through the conservation of undrained peatlands and re-wetting of drained systems⁶. Here we report eddy covariance data for carbon dioxide from 16 locations and static chamber measurements for methane from 41 locations in the UK and Ireland. We combine these with published data from sites across all major peatland biomes. We find that the mean annual effective water table depth (WTD_e; that is, the average depth of the aerated peat layer) overrides all other ecosystem- and management-related controls on greenhouse gas fluxes. We estimate that every 10 centimetres of reduction in WTD_e could reduce the net warming impact of CO₂ and CH₄ emissions (100-year global warming potentials) by the equivalent of at least 3 tonnes of CO₂ per hectare per year, until WTD_e is less than 30 centimetres. Raising water levels further would continue to have a net cooling effect until WTD_e is within 10 centimetres of the surface. Our results suggest that greenhouse gas emissions from peatlands drained for agriculture could be greatly reduced without necessarily halting their productive use. Halving WTD_e in all drained agricultural peatlands, for example, could reduce emissions by the equivalent of over 1 per cent of global anthropogenic emissions.

Taser use on individuals experiencing mental distress: An integrative literature review

WHAT IS KNOWN ABOUT THE SUBJECT?: People experiencing mental distress have a high rate of contact with police in community crisis events. Police use a continuum of responses when managing situations involving agitation, aggression and behavioural problems. People experiencing mental distress have been subjected to Tasers as part of the police response. Following a number of deaths and numerous reports of injuries, concerns have been raised about the safety of Tasers. WHAT THIS PAPER ADDS?: Police use of Tasers in mental health crises is relatively common. Tasers are used in a range of settings including public places, private residences and healthcare facilities. People experiencing mental distress may be subjected to more use of Tasers than the general population. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health professionals need to work with police towards greater understanding of the needs of people experiencing mental distress and to promote the use of non-coercive interventions in mental health crisis events. Mental health researchers need to explore the qualitative experiences of people who are Tasered, to provide an evidence base for Taser use with people experiencing mental distress. ABSTRACT: Introduction Conducted electrical weapons, or "Tasers," are currently used by over 15,000 law enforcement and military agencies worldwide. There are concerns regarding the effectiveness, potential for harm and overuse with people experiencing mental distress. Aim To explore the literature about police use of Tasers with people experiencing mental distress. Method An integrative review was undertaken, and qualitative and quantitative analytical approaches were used. Results Thirty-one studies were included. Of all recorded usage, overall prevalence of Taser use on people experiencing mental distress was 28%. This population appears to experience higher Taser usage than the general population. Discussion There are substantial gaps in the research literature particularly with respect to the decision-making processes involved in deploying Tasers on this population and the physical and psychological consequences of Taser use in this context. Implications for practice Police use of Tasers in mental health crises is relatively common and occurs in a variety of environments including mental health settings. Mental health professionals need to work with police towards greater understanding of the needs of people with mental illness and to promote the use of non-coercive interventions in mental health crisis events.

Efficacy of Single-Dose Primaquine With Artemisinin Combination Therapy on Plasmodium falciparum Gametocytes and Transmission: An Individual Patient Meta-Analysis

BACKGROUND

Since the World Health Organization recommended single low-dose (0.25 mg/kg) primaquine (PQ) in combination with artemisinin-based combination therapies (ACTs) in areas of low transmission or artemisinin-resistant Plasmodium falciparum, several single-site studies have been conducted to assess efficacy.

METHODS

An individual patient meta-analysis to assess gametocytocidal and transmission-blocking efficacy of PQ in combination with different ACTs was conducted. Random effects logistic regression was used to quantify PQ effect on (1) gametocyte carriage in the first 2 weeks post treatment; and (2) the probability of infecting at least 1 mosquito or of a mosquito becoming infected.

RESULTS

In 2574 participants from 14 studies, PQ reduced PCR-determined gametocyte carriage on days 7 and 14, most apparently in patients presenting with gametocytemia on day 0 (odds ratio [OR], 0.22; 95% confidence interval [CI], .17-.28 and OR, 0.12; 95% CI, .08-.16, respectively). Rate of decline in gametocyte carriage was faster when PQ was combined with artemether-lumefantrine (AL) compared to dihydroartemisinin-piperaquine (DP) (P = .010 for day 7). Addition of 0.25 mg/kg PQ was associated with near complete prevention of transmission to mosquitoes.

CONCLUSIONS

Transmission blocking is achieved with 0.25 mg/kg PQ. Gametocyte persistence and infectivity are lower when PQ is combined with AL compared to DP.

Child's Play or Sexual Abuse? Reviewing the Efficacy of the Justice Framework in Dealing with Child on Child Sexual Abuse in the United Kingdom

This literature review appraises how the justice system of the United Kingdom deals with child on child sexual abuse allegations. It is crucial to consider the impact of minor sexual abuse within the community. Sensationalized reporting of sex crimes demonizes offenders and unintentionally hides some perpetrators by not representing children can cause harm. Cases where children demonstrate sexual agency are confusing and uncomfortable to appropriate blame. A freedom of information request to the Metropolitan Police uncovered 5,500 minor sex abuse allegations in England and Wales between 2011 and 2014, including, 4,000 physical assaults and 600 rape allegations. Officials caution these figures only represent a small proportion of known sexual abuse cases but the full extent of the problem is yet to be seen. Children are being exposed to explicit imagery far beyond their developmental age causing a blurring of the lines between normal sexual curiosity, harmful behavior, sexual deviance, and abuse. Evidence suggests societal failings and technological advances have created vulnerabilities from which new and dangerous sexual norms have evolved. Therefore, this paper reviews the justice, welfare, and restorative justice frameworks to explore the efficacy of the justice system in dealing with child on child sexual abuse in the UK.

SAT0434 MINIMAL CLINICALLY IMPORTANT DIFFERENCE IN OUTCOME MEASURES FOR USE IN CLINICAL CARE AND PRAGMATIC TRIALS IN PsA

Background:

While several outcome measures have been studied for use in clinical studies of psoriatic arthritis, little is known about thresholds of meaning such as minimal clinically important improvement (MCII).

Objectives:

To investigate the distribution of scores for candidate outcome measures for pragmatic trials in PsA and to calculate the MCII for each outcome measure.

Methods:

We performed a longitudinal cohort study within the Psoriatic Arthritis Research Consortium (PARC), a multi-center study based in the US. Patients completed validated PROs (patient reported outcomes) and rheumatologists completed skin, joint, enthesis and dactylitis scores at therapy initiation and follow up 12-16 weeks later. In addition, patients completed a global assessment of response at the follow up visit, categorizing their status as improved, stayed the same, or worsened and then ratied the importance of the change on a scale from 0-7.1We then calculated and plotted the change in each of the following measures: Routine Assessment of Patient Index Data (RAPID3), clinical Disease Activity of Psoriatic Arthritis (cDAPSA), Patient Reported Outcome Measure Information System (PROMIS) Global Health short form (10a) physical health (PH) subscore, patient pain assessment, patient global assessment (0-10 NRS), and physician global assessments (0-10 NRS) of the joints and overall. We calculated the MCII as the mean change in score (with 95% confidence interval) among patients who reported improvement and rated the level of improvement as “almost none/hardly at all” or “a little important.” Additionally, we calculated Spearman’s correlation coefficients between the measures and the global assessment of response.

Results:

Among 148 unique patients, 233 therapy change visits were eligible for analysis. The average age was 52.5 years, 52% were female and mean BMI was 29.6. Baseline RAPID3 was 11.1 (SD 6), cDAPSA 17.9 (SD 13.9), PROMIS PH 42 (SD 8), patient global 4.2 (SD 2.5), TJC 5.9 (SD 7.5), and SJC 2.9 (SD 4.5). TNFi comprised 61% of drug initiations, 21% were IL17i and the remainder were other biologics and oral systemic therapies. At follow up, 63 (27%) patients rated themselves as improved whereas 103 (44%) stayed the same and 67 (29%) reported worsening. The mean change in each measure by patient-reported response (improved, stayed the same, or worsened) are shown in Figures 1A & B. In general, the mean score increased from ‘improved’ to ‘worsened’ as expected (with the exception of PROMIS PH which declines given a different direction of scoring). The MCII for each measure was as follows: RAPID3 -1.8 (-4.1 to 0.5), Patient Global -0.6 (-1.6 to 0.4), Physician Global -1 (-1.9 to -0.1), cDAPSA -5.7 (-9.8 to -1.7), and PROMIS PH 1.9 (-2.1 to 5.8). Correlation for each measure with the global assessment of response were: RAPID3 0.48, Patient Global 0.37, Physician Global 0.39, cDAPSA 0.51, and PROMIS PH 0.39.

Figure 1

A. Distribution of change (median, IQR) in RAPID3, Physician Global, Patient Global, PROMIS10a physical therapy by patient reported response.

Conclusion:

This is the first study to test thresholds of meaning for these particular measures in PsA. The MCII values are relatively low for all outcome measures. This may be related to the relatively low disease activity at baseline but is consistent with patients seen in clinical practice initiating therapy.2

References:

[1]Ward MM et al. J Clinical Epi 2014;2Ward MM et al. J Clinical Epi 2015

Figure 2

B. Distribution of change (median, IQR) in clinical DAPSA by patient reported response.

Disclosure of Interests:

Alexis Ogdie Grant/research support from: Pfizer, Novartis, Consultant of: Abbvie, Amgen, BMS, Celgene, Corrona, Janssen, Lilly, Pfizer, Novartis, M Elaine Husni Grant/research support from: Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Janssen, Novartis, Regeneron, and UCB, Jose Scher Consultant of: Novartis, Janssen, UCB, Sanofi., Ethan Craig: None declared, Soumya Reddy Grant/research support from: Amgen

Celgene

Abbvie, Consultant of: Amgen

Pfizer

Novartis

Jaansen

UCB, Jessica A. Walsh Grant/research support from: AbbVie, Pfizer, Janssen, Consultant of: AbbVie, Novartis, Eli Lilly and Company, UCB

PO 8522 ESTABLISHING AN EQUITABLE GOVERNANCE FRAMEWORK FOR AN EBOLA DATA-SHARING PLATFORM

Background

Despite the potential public health gains of enabling access to patient-level data on emerging infections, the launch of a centralised, international platform to deliver on this has not been achieved to date. Barriers include: concerns over retention of national data ownership; patient privacy; appropriate consent; loss of academic recognition; criticism or exploitation of the data generators; perceived data misuse; and the challenges of sharing benefits with communities where data is generated.

Methods

To determine the best approach to these issues in the context of Ebola, we have assembled a collaboration of partners including governments of Ebola-affected countries, non-government organisations, academic institutions, funders and public health authorities to form the Steering Committee of the Ebola Data Platform. Following stakeholder consultation, research and debate, the committee has developed a governance framework to enable access to emerging infections data, beginning with the data from the West African Ebola outbreak.

Results

Promoting fair and equitable sharing of benefits that arise from the use of data is a key element of the framework. Strategies to secure this principle include integration of platform data management activities with the national health institutions in Ebola-affected countries and collaboration with research communities in these countries to determine research priorities and plan analyses. Public health benefit in affected countries is further supported via training and strengthening of research capacity and infrastructure.

Conclusion

Developing a governance framework centered on the principle of equity has focused activities of the Ebola Data Platform on the affected health and research communities where they can have the most impact on patient outcomes, public health preparedness and future outbreak response.

Impact of surgical site infection (SSI) following gynaecological cancer surgery in the UK: a trainee-led multicentre audit and service evaluation

OBJECTIVES

Surgical site infection (SSI) complicates 5% of all surgical procedures in the UK and is a major cause of postoperative morbidity and a substantial drain on healthcare resources. Little is known about the incidence of SSI and its consequences in women undergoing surgery for gynaecological cancer. Our aim was to perform the first national audit of SSI following gynaecological cancer surgery through the establishment of a UK-wide trainee-led research network.

DESIGN AND SETTING

In a prospective audit, we collected data from all women undergoing laparotomy for suspected gynaecological cancer at 12 specialist oncology centres in the UK during an 8-week period in 2015. Clinicopathological data were collected, and wound complications and their sequelae were recorded during the 30 days following surgery.

RESULTS

In total, 339 women underwent laparotomy for suspected gynaecological cancer during the study period. A clinical diagnosis of SSI was made in 54 (16%) women. 33% (18/54) of women with SSI had prolonged hospital stays, and 11/37 (29%) had their adjuvant treatment delayed or cancelled. Multivariate analysis found body mass index (BMI) was the strongest risk factor for SSI (OR 1.08[95% CI 1.03 to 1.14] per 1 kg/m² increase in BMI [p=0.001]). Wound drains (OR 2.92[95% CI 1.41 to 6.04], p=0.004) and staple closure (OR 3.13[95% CI 1.50 to 6.56], p=0.002) were also associated with increased risk of SSI.

CONCLUSIONS

SSI is common in women undergoing surgery for gynaecological cancer leading to delays in discharge and adjuvant treatment. Resultant delays in adjuvant treatment may impact cancer-specific survival rates. Modifiable factors, such as choice of wound closure material, offer opportunities for reducing SSI and reducing morbidity in these women. There is a clear need for new trials in SSI prevention in this patient group; our trainee-led initiative provides a platform for their successful completion.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

The potential role of direct and indirect bronchial challenge testing to identify overtreatment of community managed asthma

BACKGROUND

Although airway hyperresponsiveness (AHR) is a defining feature of asthma pathophysiology, bronchial challenge testing is not routinely used in primary care asthma management.

OBJECTIVE

The aim of this study was to evaluate the potential role of direct (methacholine) and indirect (mannitol) challenge testing in community managed asthma.

METHODS

Patients currently treated for asthma from Tayside and Fife were identified by the Health Informatics Centre (HIC) and invited to take part in the study. At screening, the following tests were carried out: spirometry, methacholine and mannitol challenge, exhaled nitric oxide (FeNO); Asthma Control Questionnaire (ACQ) and Mini Asthma Quality of Life Questionnaire (AQLQ).

RESULTS

A total of 3388 asthmatics were initially identified by HIC with 423 positive responses and 123 completing the study. Seventy percent had either a positive methacholine (PC20  < 8 mg/mL) or mannitol challenge (PD15  < 635 mg), and 30% were non-responsive to both challenges. Fourteen percent of methacholine responders (n = 74) were negative to mannitol, and 16% of mannitol responders (n = 76) were negative to methacholine. Spirometry, FeNO, ACQ and AQLQ were significantly better in the non-responder group who were exposed to high-dose inhaled corticosteroids and frequent long-acting beta-agonists.

CONCLUSIONS AND CLINICAL RELEVANCE

We found that 30% of unselected patients with community managed asthma were challenge negative and could be potentially misdiagnosed or overtreated, in turn suggesting the need for supervised step-down.

Risk factors for overweight and overfatness in rural South African children and adolescents

Background

To determine risk factors for overweight/overfatness in children and adolescents from rural KwaZulu-Natal, South Africa.

Methods

Anthropometric data were collected from a cross-sectional sample (n = 1519, ages 7, 11 and 15 years) and linked to demographic information (n = 1310 and n = 1317 in overweight and overfat analyses, respectively). Candidate risk factors for overweight/overfatness were identified and tested for associations with overweight (BMI-for-age >+1SD, WHO reference) and overfatness (>85th centile body fatness, McCarthy reference) as outcomes. Associations were examined using simple tests of proportions (χ²/Mann–Whitney U tests) and multivariable logistic regression.

Results

Sex was a consistent variable across both analyses; girls at significantly increased risk of overweight and overfatness (overweight: n = 180, 73.9 and 26.1% females and males, respectively (P < 0.0001); overfat: n = 187, 72.7 and 27.3% females and males, respectively (P < 0.0001)). In regression analyses, sex and age (defined by school grade) were consistent variables, with boys at lower risk of overweight (adjusted odds ratio (AOR) 0.40 (confidence interval (CI) -0.28–0.57)) and risk of overweight increasing with age (AOR 0.65 (CI- 0.44–0.96), 0.50 (CI-0.33–0.75) and 1.00 for school grades 1, 5 and 9, respectively). Results were similar for overfatness.

Conclusions

This study suggests that pre-adolescent/adolescent females may be the most appropriate targets of future interventions aimed at preventing obesity in rural South Africa.

Use of mid-upper arm circumference for determining overweight and overfatness in children and adolescents

OBJECTIVE

To assess the use of mid-upper arm circumference (MUAC) for identification of overweight and overfatness in rural South African children and adolescents.

METHODS

Anthropometric data (weight, height, MUAC and % body fat) from a cross-sectional sample of 978 black South African 5-14-year-olds were analysed. Receiver operating characteristic (ROC) curve analysis determined the validity of MUAC as a proxy for determining overweight and overfatness.

FINDINGS

Area under the curve (AUC) results were generally high. Boys and girls aged 10-14 years had ROC-AUC for overfatness classed as 'excellent', 0.97 and 0.98 respectively. Cut-points in the MUAC distribution which optimised the ROC-AUC for identification of overfatness and obesity were determined for boys and girls aged 5-9 and 10-14 years, and had high sensitivity and specificity.

CONCLUSIONS

MUAC may have potential for clinical and surveillance applications as an accurate yet simple and widely available indicator of overweight and overfatness in children and adolescents in resource-poor settings.

Paediatric post-septal and pre-septal cellulitis: 10 years' experience at a tertiary-level children's hospital

OBJECTIVE

To assess the incidence and complications of pre-septal (pre-SC) and post-septal (post-SC) cellulitis over 10 years. Pre-SC and post-SC are also known as periorbital and orbital cellulitis, respectively.

METHODS

Retrospective analysis of CT scans. Data included the presence of pre-SC and post-SC, paranasal sinus disease (PNS) and complications.

RESULTS

Among 125 patients scanned for these suspected diagnoses, 67 had both pre-SC and post-SC, 37 had pre-SC and 4 had post-SC; there were 17 normal scans. 110 patients had PNS. 68/71 (96%) patients with post-SC had PNS. Post-SC complications included orbital and/or subperiosteal abscess (50/71: 30 medial orbital, 10 superomedial, 3 lateral, 2 anteromedial, 2 inferomedial, 1 superior, 1 anterosuperior and 1 not specified), cavernous sinus thrombosis (CST) (1), superior ophthalmic vein (SOV) thrombosis (4) and subdural frontal empyema (2); 1 patient had SOV and CST and subdural empyema.

CONCLUSION

71/125 (57%) patients had post-SC. 50/125 (40%) patients imaged for pre-SC/post-SC had orbital abscess; 44/50 (88%) of these involved the medial orbit. Patients can develop solely superior or inferior abscesses that are difficult to identify by axial imaging alone, hence coronal reformatted imaging is essential. 5/125 (4%) patients developed major complications (SOV/CST/empyema), hence imaging review of the head and cavernous sinus region is essential. A diagnosis of post-SC on CT should alert the radiologist because this diagnosis can be associated with an increased incidence (5/71, 7%) of complications.

ADVANCES IN KNOWLEDGE

We recommend that all patients with a suspected diagnosis of post-SC should undergo CT scan (post-contrast orbits and post-contrast head, with multiplanar reformats and a careful review of the SOV and the cavernous sinus). Particular attention should be paid to exclude intracranial complications including subdural empyema and cerebral abscess. As soon as a diagnosis of post-SC is made, in addition to informing the referring clinical team, urgent opinion should be sought from ear, nose and throat (ENT), neurology and ophthalmology with a view to urgently drain of the paranasal sinuses`.

Stoma siting using CT guidance in a multiply scarred abdomen

The creation of a stoma in a multiply scarred abdomen is often difficult because of intra-abdominal adhesions and limited suitable skin sites. We report a simple technique utilising computed tomography which allowed the easy creation of a defunctioning loop colostomy in such an abdomen by simple trephine rather than laparotomy.

Clinical findings in 33 subjects with large supernumerary marker(15) chromosomes and 3 subjects with triplication of 15q11-q13

We present clinical data on 33 subjects with additional copies of the Prader-Willi-Angelman critical region (PWACR) contained in a supernumerary marker chromosome (SMC). Twenty-three subjects had a typical large non-mosaic SMC(15) containing two copies of the PWACR. They showed a variable but generally severe phenotype of learning disability and autism, with seizures in approximately two-thirds. The other 10 differed from this typical pattern in respect of mosaicism, variation in copy number, or arrangement of the PWACR within the SMC or number of SMC per cell. Clinical severity increased with the number of additional copies of the PWACR and decreased with mosaicism for a normal cell line. There was a trend for a larger number of seizures to be associated with more severe learning disability. Three subjects with interstitial triplications of 15q11-q13 showed a range of phenotypes similar to those of the typical large SMC(15). All additional copies of the PWACR in this series were maternally-derived. FISH and molecular data localizing the breakpoints of the rearrangements have been previously published or are included in this report. No correlations were found between specific clinical features and variations in breakpoints proximal and distal to the PWACR.

Somatostatin receptor gene expression in human ocular tissues: RT-PCR and immunohistochemical study

PURPOSE

Somatostatin (SST) analogues have been used to treat proliferative diabetic retinopathy, pseudotumor cerebri, thyroid orbitopathy, and cystoid macular edema. There is a paucity of published data in regards to cell-specific distribution of SST receptors (SSTR) in normal human eye tissues. Gene expression for all five known SSTRs in normal human ciliary body/iris, retina, choroid, and cultured retinal pigment epithelial (RPE) cells were studied.

METHODS

mRNA was isolated from human ocular tissues (iris/ciliary body, retina, and choroid) dissected from eight pairs of normal eyes (9-62 years) and from RPE cells grown in culture. RT-PCR was done for all five SSTRs in all analyzed tissues. Immunohistochemistry for SSTR1 and SSTR2 was performed on eight pairs of normal human eyes (28-74 years) imbedded in paraffin.

RESULTS

SSTR1 to 5 genes are expressed in retina, SSTR1 and SSTR2 genes in cultured RPE cells, and SSTR1, 2, and 4 in ciliary body and choroid. SSTR1 and SSTR2 immunoreactivity (-ir) was observed on a variety of cells within all analyzed tissues including cornea, iris, trabecular meshwork, Schlemm's canal, ciliary processes, ciliary muscle, retina, choroid, cultured RPE cells, and optic nerve.

CONCLUSIONS

SSTR genes are widely expressed in normal human eye tissues, with genes for SSTR1 and SSTR2 being the most widely expressed. Genes for all SSTRs are expressed in retina. SSTR1-ir and SSTR2-ir were observed in all analyzed ocular tissues. Detailed knowledge of SSTRs distribution and function in the human eye will result in a better understanding of their role in health and disease.

Inhibition of HIV-1 virion production by a transdominant mutant of integrase interactor 1

Integase interactor 1 (INI1), also known as hSNF5, is a protein that interacts with HIV-1 integrase. We report here that a cytoplasmically localized fragment of INI1 (S6; aa183-294) containing the minimal integrase-interaction domain potently inhibits HIV-1 particle production and replication. Mutations in S6 or integrase that disrupt integrase-INI1 interaction abrogated the inhibitory effect. An integrase-deficient HIV-1 transcomplemented with integrase fused to Vpr was not affected by S6. INI1 was specifically incorporated into virions and was required for efficient HIV-1 particle production. These results indicate that INI1 is required for late events in the viral life cycle, and that ectopic expression of S6 inhibits HIV-1 replication in a transdominant manner via its specific interaction with integrase within the context of Gag-Pol, providing a novel strategy to control HIV-1 replication.

Cytoplasmic recruitment of INI1 and PML on incoming HIV preintegration complexes: interference with early steps of viral replication

During the early phase of the retroviral life cycle, only a fraction of internalized virions end up integrating their genome into the chromosome, even though the resulting proviruses are almost systematically expressed. Here, we reveal that incoming retroviral preintegration complexes trigger the exportin-mediated cytoplasmic export of the SWI/SNF component INI1 and of the nuclear body constituent PML. We further show that the HIV genome associates with these proteins before nuclear migration. In the presence of arsenic, PML is sequestered in the nucleus, and the efficiency of HIV-mediated transduction is markedly increased. These results unveil a so far unsuspected cellular response that interferes with the early steps of HIV replication.

Evidence for a conserved system for iron metabolism in the mitochondria of Saccharomyces cerevisiae

nifU of nitrogen-fixing bacteria is involved in the synthesis of the Fe-S cluster of nitrogenase. In a synthetic lethal screen with the mitochondrial heat shock protein (HSP)70, SSQ1, we identified a gene of Saccharomyces cerevisiae, NFU1, which encodes a protein with sequence identity to the C-terminal domain of NifU. Two other yeast genes were found to encode proteins related to the N-terminal domain of bacterial NifU. They have been designated ISU1 and ISU2. Isu1, Isu2, and Nfu1 are located in the mitochondrial matrix. ISU genes of yeast carry out an essential function, because a Deltaisu1Deltaisu2 strain is inviable. Growth of Deltanfu1Delta isu1 cells is significantly compromised, allowing assessment of the physiological roles of Nfu and Isu proteins. Mitochondria from Deltanfu1Deltaisu1 cells have decreased activity of several respiratory enzymes that contain Fe-S clusters. As a result, Deltanfu1Deltaisu1 cells grow poorly on carbon sources requiring respiration. Deltanfu1Deltaisu1 cells also accumulate abnormally high levels of iron in their mitochondria, similar to Deltassq1 cells, indicating a role for these proteins in iron metabolism. We suggest that NFU1 and ISU1 gene products play a role in iron homeostasis, perhaps in assembly, insertion, and/or repair of mitochondrial Fe-S clusters. The conservation of these protein domains in many organisms suggests that this role has been conserved throughout evolution.

Interaction between the nucleotide exchange factor Mge1 and the mitochondrial Hsp70 Ssc1

Function of Hsp70s such as DnaK of the Escherichia coli cytoplasm and Ssc1 of the mitochondrial matrix of Saccharomyces cerevisiae requires the nucleotide release factors, GrpE and Mge1, respectively. A loop, which protrudes from domain IA of the DnaK ATPase domain, is one of six sites of interaction revealed in the GrpE:DnaK co-crystal structure and has been implicated as a functionally important site in both DnaK and Ssc1. Alanine substitutions for the amino acids (Lys-108 and Arg-213 of Mge1) predicted to interact with the Hsp70 loop were analyzed. Mge1 having both substitutions was able to support growth in the absence of the essential wild-type protein. K108A/R213A Mge1 was able to stimulate nucleotide release from Ssc1 and function in refolding of denatured luciferase, albeit higher concentrations of mutant protein than wild-type protein were required. In vitro and in vivo assays using K108A/R213A Mge1 and Ssc1 indicated that the disruption of contact at this site destabilized the interaction between the two proteins. We propose that the direct interaction between the loop of Ssc1 and Mge1 is not required to effect nucleotide release but plays a role in stabilization of the Mge1-Ssc1 interaction. The robust growth of the K108A/R213A MGE1 mutant suggests that the interaction between Mge1 and Ssc1 is tighter than required for function in vivo.

The role of forensic anthropology in the recovery and analysis of Branch Davidian compound victims: assessing the accuracy of age estimations

Age-at-death estimations of 44 individuals (27 adults, 17 children) from the Branch Davidian sample were compared with their actual ages. Estimations were evaluated for bias and accuracy for the actual age at death. Although the overall average estimates correlated well with the actual ages (r = 0.946), several individuals displayed high residual requiring further analysis and review. These individuals displayed age-related features that did not correspond with the expected morphology for individuals of their ages. Several age estimation techniques scored these individuals with all bias in the same direction. These examples should serve as cautionary reminders that biology does not always correlate with expected outcomes, particularly in such multifaceted traits such as age.