Assessment of Safety and Biodistribution of AAVrh.10hCLN2 Following Intracisternal Administration in Nonhuman Primates for the Treatment of CLN2 Batten Disease

CLN2 disease is a fatal, childhood autosomal recessive disorder caused by mutations in ceroid lipofuscinosis type 2 (CLN2) gene, encoding tripeptidyl peptidase 1 (TPP-1). Loss of TPP-1 activity leads to accumulation of storage material in lysosomes and resultant neuronal cell death with neurodegeneration. Genotype/phenotype comparisons suggest that the phenotype should be ameliorated with increase of TPP-1 levels to 5-10% of normal with wide central nervous system (CNS) distribution. Our previous clinical study showed that intraparenchymal (IPC) administration of AAVrh.10hCLN2, an adeno-associated vector serotype rh.10 encoding human CLN2, slowed, but did not stop disease progression, suggesting that this may be insufficient to distribute the therapy throughout the CNS (Sondhi 2020). In this study, we assessed whether the less invasive intracisternal delivery route would be safe and provide a wider distribution of TPP-1. A study was conducted in nonhuman primates (NHPs) with intracisternal delivery to cerebrospinal fluid (CSF) of AAVrh.10hCLN2 (5 × 1013 genome copies) or phosphate buffered saline (PBS). No abnormal behavior was noted. CNS magnetic resonance imaging and clinical chemistry data were all unremarkable. Histopathology of major organs had no abnormal finding attributable to the intervention or the vector, except that in one out of two animals treated with AAVrh.10hCLN2, dorsal root ganglia showed mild-to-moderate mononuclear cell infiltrates and neuronal degeneration. In contrast to our previous NHP study (Sondhi 2012) with IPC administration where TPP-1 activity was >2 × above controls in 30% of treated brains, in the two intracisternal treated NHPs, the TPP-1 activity was >2 × above controls in 50% and 41% of treated brains, and 52% and 84% of brain had >1,000 vector genomes/μg DNA, compared to 0% in the two PBS NHP. CSF TPP1 levels in treated animals were 43-62% of normal human levels. Collectively, these data indicate that AAVrh.10hCLN2 delivered by intracisternal route is safe and widely distributes TPP-1 in brain and CSF at levels that are potentially therapeutic. Clinical Trial Registration: NCT02893826, NCT04669535, NCT04273269, NCT03580083, NCT04408625, NCT04127578, and NCT04792944.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

COVID-19 Risk Factors for Cancer Patients: A First Report with Comparator Data from COVID-19 Negative Cancer Patients

Very few studies investigating COVID-19 in cancer patients have included cancer patients as controls. We aimed to identify factors associated with the risk of testing positive for SARS CoV2 infection in a cohort of cancer patients. We analyzed data from all cancer patients swabbed for COVID-19 between 1st March and 31st July 2020 at Guy's Cancer Centre. We conducted logistic regression analyses to identify which factors were associated with a positive COVID-19 test. Results: Of the 2152 patients tested for COVID-19, 190 (9%) tested positive. Male sex, black ethnicity, and hematological cancer type were positively associated with risk of COVID-19 (OR = 1.85, 95%CI:1.37-2.51; OR = 1.93, 95%CI:1.31-2.84; OR = 2.29, 95%CI:1.45-3.62, respectively) as compared to females, white ethnicity, or solid cancer type, respectively. Male, Asian ethnicity, and hematological cancer type were associated with an increased risk of severe COVID-19 (OR = 3.12, 95%CI:1.58-6.14; OR = 2.97, 95%CI:1.00-8.93; OR = 2.43, 95%CI:1.00-5.90, respectively). This study is one of the first to compare the risk of COVID-19 incidence and severity in cancer patients when including cancer patients as controls. Results from this study have echoed those of previous reports, that patients who are male, of black or Asian ethnicity, or with a hematological malignancy are at an increased risk of COVID-19.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

A systematic review of the outcomes of using voice hearing simulation in the education of health care professionals and those in training

OBJECTIVES

To identify and synthesise data from studies that have evaluated the outcomes of voice hearing simulation as an educational intervention with health care professionals and those in training.

DESIGN

The research employed a systematic review that was informed by Centre for Reviews and Dissemination DATA SOURCES: The databases Web of Science, Medline, Embase, PsycINFO, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials Register and CINAHL were systematically searched to January 2020.

REVIEW METHODS

Identified studies were screened by title (n = 509), abstract (n = 246) and full text (n = 56) using the following inclusion criteria: studies employing either qualitative and/or quantitative research methods, which have evaluated voice hearing simulation as a principal educational intervention with health care professionals during training or post-qualification.

RESULTS

Twenty six studies were included in the review. Eleven studies adopted mixed methods, five adopted quantitative methods and ten used qualitative methods. Although most of the studies were of low to medium quality the findings were encouraging and suggest that voice hearing simulation may be a useful educational intervention. Positive outcomes of simulation included improvements in empathy, attitudes, knowledge, understanding about voice hearing experiences and increased confidence in practice. The majority of participants that took part in voice hearing simulation thought that it was a powerful learning experience that should be offered to other health care professionals and those in training.

CONCLUSIONS

Voice hearing simulation is a valuable educational intervention that should be routinely used by academics when teaching health professionals and those in training about the experiences of people who hear voices. However, to confirm its true effects and optimum mode of delivery further better quality research is needed.

AB0940 BIOMARKERS IN THE DIAGNOSIS OF ACUTE HOT JOINTS: AN EVALUATION OF RESEARCH INTEREST 1960-2018

Background:

The acute hot joint presentation is a common clinical emergency, often the result of crystal arthritis or trauma. However, all diagnoses can mimic septic arthritis, which should be excluded promptly due to the potential for rapid joint destruction and significant morbidity. The gold-standard test for septic arthritis is synovial fluid culture, which can take several days to perform. Meanwhile, patients are often admitted and given antimicrobials. Other specialties have made use of rapid biomarkers to exclude infection, for example, exclusion of empyema using pleural fluid pH and glucose [1]. Such biomarkers could reduce the need for lengthy hospital admissions and inappropriate antibiotic use in the acute hot joint presentation.

Objectives:

1.Evaluate research interest over time, on the use of diagnostic biomarkers in the acute hot joint presentation.

2.Compare research interest in the use of diagnostic biomarkers in acute hot native versus acute hot prosthetic joints.

Methods:

We performed a review of the number of publications reporting the use and diagnostic accuracy of biomarkers to exclude infection in the acute hot joint presentations. The database,Scopus, was searched for English-language studies (1946-2018) using search terms relating to septic arthritis, crystal arthritis, and diagnostic markers derived from synovial fluid/aspirate. The number of papers published per year on prosthetic joints only was also calculated. Therefore, the following were recorded for each year 1946-2018: total number of studies; prosthetic joints only; native joints only. Values were plotted, with polynomial trend-lines and R2calculated.

Results:

Our search yielded 2279 relevant studies in total (561 on prosthetic joints), published 1946-2018. Only 1 study was identified for the year 1946; the next recorded publication was in 1960. Therefore, this single study was excluded as an outlier. Results are presented in Figure 1. The number of studies on diagnostic biomarkers for acute hot joints continued to increase after 1960. From 2016, the number of studies conducted in prosthetic joints outnumbered those done in native joints. Polynomial trend-lines applied to the results showed studies on native acute hot joints are predicted to decline, while those in prosthetic joints will continue to increase.

Conclusion:

Reasons for an increasing number of studies on prosthetic compared to native acute hot joints include a narrower differential diagnosis in prosthetic joints, i.e. septic vs aseptic. In contrast, native acute hot joints may be the result of various causes including crystal arthritis, inflammatory arthritis, and trauma. Having a narrower differential diagnosis may facilitate diagnostic research in prosthetic joint presentations. Furthermore, incidence of prosthetic joint infection is also greater than that of native joint infection [2]. Nonetheless, the incidence of native joint infection is increasing [3]. This, and the lack of methods by which to rapidly distinguish native joint septic arthritis from non-infective causes, indicates that more research is required in this area.

References:

[1]Heffner JE et al. Pleural fluid chemical analysis in parapneumonic effusions. A meta-analysis. Am J Respir Crit Care Med. 1995 Jun;151(6):1700–8.

[2]Roerdink RL et al. The difference between native septic arthritis and prosthetic joint infections: A review of literature. J Orthop Surg (Hong Kong).

[3]Rutherford AI et al. A population study of the reported incidence of native joint septic arthritis in the United Kingdom between 1998 and 2013. Rheumatol (United Kingdom). 2016;55(12):2176–80.

Disclosure of Interests:

None declared

Intraocular currents, Bernoulli's principle and non-drainage scleral buckling for rhegmatogenous retinal detachment

For many years, it is not fully understood how non-drainage scleral buckling surgery brings about spontaneous reattachment of the detached retina when retinal breaks remain open at the end of surgery. Various explanations have been put forward, but none more interesting than the effect of fluid currents associated with eye movements. One such explanation involved the physics of the Bernoulli's principle. Daniel Bernoulli was an eighteenth century Swiss mathematician and he described an equation based on the conservation of energy. The sum of pressure energy, potential energy and kinetic energy remains constant. Bernoulli's equation usually applies to closed system such as the flow of fluid through pipes. When fluid flows through a constriction, the speed of fluid increases, the kinetic energy increases. If there was no change in elevation (potential energy), then the increase in kinetic energy must be accompanied by a decrease in pressure energy. In ophthalmic surgery, the Bernoulli's effect is the basis for venturi pumps that drive vitrectomy and phacoemulsification machines. This essay expounds on how Bernoulli's effect might be relevant to scleral buckling for retinal detachment repair. In the era when vitrectomy is increasing the primary surgical operation for retinal detachment, the pervasive advice is to emphasise the importance of patient adopting head posture and remaining still postoperatively. The exception is non-drainage scleral buckling surgery. Early postoperative mobilisation may be vital to achieve reattachment.

Abundant and equipotent founder cells establish and maintain acute lymphoblastic leukaemia

High frequencies of blasts in primary acute lymphoblastic leukaemia (ALL) samples have the potential to induce leukaemia and to engraft mice. However, it is unclear how individual ALL cells each contribute to drive leukaemic development in a bulk transplant and the extent to which these blasts vary functionally. We used cellular barcoding as a fate mapping tool to track primograft ALL blasts in vivo. Our results show that high numbers of ALL founder cells contribute at similar frequencies to leukaemic propagation over serial transplants, without any clear evidence of clonal succession. These founder cells also exhibit equal capacity to home and engraft to different organs, although stochastic processes may alter the composition in restrictive niches. Our findings enhance the stochastic stem cell model of ALL by demonstrating equal functional abilities of singular ALL blasts and show that successful treatment strategies must eradicate the entire leukaemic cell population.

Ultra-low-dose, low-dose, and standard-dose CT of the kidney, ureters, and bladder: is there a difference? Results from a systematic review of the literature

AIM

To investigate whether reducing the radiation dose of computed tomography (CT) of the kidney, ureters, and bladder (KUB) for acute renal colic impacts upon the specificity, sensitivity, and detection of urolithiasis.

MATERIALS AND METHODS

A systematic review of the literature over a 20-year period between 1995 and 2015 was conducted of all prospective studies in the English language reporting on adult patients who underwent CT KUB or non-contrast CT for renal colic or urolithiasis. Retrospective studies and those that included pregnant females, children, non-human test subjects, cadaveric use, and simulations were excluded. Data were collected using an Excel spreadsheet and ultra-low-dose (ULD CT) and low-dose CT KUB (LD CT) was defined as a radiation dose ≤1.9 and <3.5 mSv, respectively.

RESULTS

A total of 417 articles were identified, and after screening, seven articles (1,104 patients) were included in the present study with a male:female ratio of 3:2. Of the four studies with ULD CT for both males and females, the prevalence of urolithiasis ranged from 36% and 73%, with additional pathologies found in 12-15%. The effective radiation dose of ULD CT ranged from 0.5-1.9 mSv. Overall, ULD CT and LD CT had a sensitivity of 90-100% and a specificity of 86-100% across all studies.

CONCLUSIONS

ULD CT and LD CT are effective techniques and yield high sensitivity and specificity. Although they yield comparable results against standard-dose CT KUB in detecting alternative diagnoses, they may not be as effective in detecting stones <3 mm in size or in patients with a body mass index of >30 kg/m²; however, this should be the first-line investigation for the majority of renal colic patients in the modern era.

Impact factor of medical education journals and recently developed indices: Can any of them support academic promotion criteria?

Journal Impact Factor (JIF) has been used in assessing scientific journals. Other indices, h- and g-indices and Article Influence Score (AIS), have been developed to overcome some limitations of JIF. The aims of this study were, first, to critically assess the use of JIF and other parameters related to medical education research, and second, to discuss the capacity of these indices in assessing research productivity as well as their utility in academic promotion. The JIF of 16 medical education journals from 2000 to 2011 was examined together with the research evidence about JIF in assessing research outcomes of medical educators. The findings were discussed in light of the nonnumerical criteria often used in academic promotion. In conclusion, JIF was not designed for assessing individual or group research performance, and it seems unsuitable for such purposes. Although the g- and h-indices have demonstrated promising outcomes, further developments are needed for their use as academic promotion criteria. For top academic positions, additional criteria could include leadership, evidence of international impact, and contributions to the advancement of knowledge with regard to medical education.

Role of the X-linked gene GPR174 in autoimmune Addison's disease

CONTEXT

Autoimmune endocrinopathies demonstrate a profound gender bias, but the reasons for this remain obscure. The 1000 genes on the X chromosome are likely to be implicated in this inherent susceptibility; various theories, including skewed X chromosome inactivation and fetal microchimerism, have been proposed. GPR174 is an Xq21 putative purinergic receptor that is widely expressed in lymphoid tissues. A single-nucleotide polymorphism, rs3827440, encoding Ser162Pro, has recently been associated with Graves' disease in Chinese and Polish populations, suggesting a role of this X chromosome gene in autoimmune disease.

OBJECTIVE

We investigated the role of rs3827440 in a UK cohort of patients with autoimmune Addison's disease (AAD). Samples from 286 AAD cases and 288 healthy controls were genotyped using TaqMan single-nucleotide polymorphism genotyping assays (C_25954273_10) on the Applied Biosystems 7900HT Fast real-time PCR system.

DESIGN

Using a dominant (present/absent) model, the serine-encoding T allele of rs3827440 was present in 189 of 286 AAD patients (66%) compared with 132 of 288 unaffected controls (46%) [P = .010, odds ratio 1.80 (5%-95% confidence interval 1.22-2.67)]. An allele dosage model found a significant excess of the T allele in AAD patients compared with controls [P = .03, odds ratio 1.34 (5%-95% confidence interval 1.07-1.67)].

CONCLUSION

We have demonstrated a significant association of this X chromosome-encoded immunoreceptor with AAD for the first time. This X-linked gene could have a more generalized role in autoimmunity pathogenesis: G protein-coupled receptors are promising drugable targets, and further work to elucidate the functional role of GPR174 is now warranted.

Importance of getting the numbers right: quantifying the rapid and substantial decline of an abundant marsupial, Bettongia penicillata

Context A reliable measure of population size is fundamental to ecology and conservation but is often difficult to obtain. The woylie, Bettongia penicillata, provides an example where ‘getting the numbers right’ has important implications in verifying and quantifying the recent unexpected, rapid and substantial declines across much of its range. Initial estimates prompted a conservation-status upgrade for the species to Endangered by the Australian Government. The present paper constitutes the foundational paper addressing the first steps of a decline diagnosis framework intended to identify the causes of the recent declines. Aims To verify whether the declines in woylie trap-capture rates are representative of population change; better quantify the size of the largest woylie populations; and review what is understood about the ecology of the woylie and identify key knowledge gaps that may be relevant to identifying the causes of the recent declines. Methods Monitoring data from live-cage trapping (transects and grids), sandpads, woylie diggings and nest-density surveys and spotlighting were collated. Population measures derived from trapping data included capture rates, number of individuals, abundance estimates based on capture–mark–recapture modelling and density using spatially explicit capture–recapture models (SECR). Key results The declines in woylie trap-capture rates were verified as real population declines and corresponded closely with other measures of abundance derived from the same trapping data as well as with independent measures. A 95% decline occurred in the largest extant woylie populations (in the Upper Warren region, Western Australia) between 2002 and 2008. At a species level, woylies declined ~90% (1999–2006), from a peak of ~200 000 individuals in 1999. Conclusions An accurate formal conservation status is an important factor in promoting the conservation of a species. It is recommended that the woylie be considered for Critically Endangered status under the Australian EPBC Act. Implications Adequate and effective monitoring of species is critical to detecting and quantifying population changes in a timely manner. Having an accurate measure of population size can have a significant impact on the effectiveness of conservation and management efforts.

Multiple large enteroliths associated with an incisional hernia: a rare case

The surgeon frequently encounters renal and biliary stones but rarely may also encounter enteric stones or enteroliths. An enterolith is a stony foreign body that is formed in the gastrointestinal tract. We present a rare case of multiple, large enteroliths found associated with a longstanding incarcerated incisional hernia.

Improving outcomes for psychoses through the use of psycho-education; preliminary findings

A psycho-education programme is provided for patients suffering from psychosis in Scotland's only high secure hospital. An 18-month pilot study was carried out with consecutive case sample (treatment group) and 'treatment as usual' comparison group (control group). Pre, post and 6-month follow-up assessments were carried out. A range of outcome measures were used, including two measures of knowledge: a self-report assessment tool - Forensic Assessment of Knowledge Tool and the Understanding Medication Questionnaire. Other measures were used to establish level of insight, Schedule for the Assessment of Insight and assess mental state [Positive and Negative Syndrome Scale (PANSS)]. Results from (n = 48) participants indicate no statistical difference between the treatment and control group scores on any assessment prior to commencement of the intervention, indicating a well-matched sample group. However, all four assessments showed statistically significant changes post group. Treatment group showed an ability to improve knowledge and retain information about psychosis, which may account for their improved mental state and level of insight. Despite methodological limitations and a small sample group, this project has given an early indication of the positive value of this psycho-education programme in a forensic setting.

Associations between the big five personality factors and multiple mini-interviews

Given the accumulating evidence that performance in medical school and beyond is related to personality, it is important for research to consider how personality assessment can be included as part of the process of selecting medical students. Interviews are one way of measuring personality and this study extends prior research investigating whether the multiple mini interview (MMI) is related to the five factor model of personality. In contrast to prior results (Kulasegaram et al. in Adv Health Sci Edu 15:415-423, 2010), examination of MMI scores for 868 applicants to an Australian medical school over 3 years showed significant uncorrected correlations every year with extraversion (.19, .19, .30) and conscientiousness (.20, .22, .25) and with agreeableness in 2 years (.17, .19). Investigation of personality at a facet-level revealed differing relationships with the MMI within the five factors of personality. MMI scores were also correlated in 2 years (.17, .22) with a situational judgment test of interpersonal understanding (UMAT Section 2) but were unrelated to tests of logical reasoning ability (UMAT Section 1), non-verbal reasoning (Section 3), or past academic performance (Higher School Certificate results).

Management of proximal femoral fractures 2011: Association of Anaesthetists of Great Britain and Ireland

There should be protocol-driven, fast-track admission of patients with hip fractures through the emergency department. Patients with hip fractures require multidisciplinary care, led by orthogeriatricians. Surgery is the best analgesic for hip fractures. Surgical repair of hip fractures should occur within 48 hours of hospital admission. Surgery and anaesthesia must be undertaken by appropriately experienced surgeons and anaesthetists. There must be high-quality communication between clinicians and allied health professionals. Early mobilisation is a key part of the management of patients with hip fractures. Pre-operative management should include consideration of planning for discharge from hospital. Measures should be taken to prevent secondary falls. 10. Continuous audit and targeted research is required in order to inform and improve the management of patients with hip fracture.

Is laparoscopic appendicectomy a safe procedure for trainees in the peripheral hospital setting?

Laparoscopic appendicectomy has become standard in the treatment of acute appendicitis in most hospitals in Ireland. Studies have shown that it is a safe procedure for trainees to perform. However, these studies were conducted in university teaching hospitals whereas a significant proportion of training in Ireland takes place in peripheral hospitals which provide a different training environment. The aim of this study was to determine whether laparoscopic appendicectomy is a safe procedure for surgical trainees to perform in a peripheral hospital setting. A retrospective analysis was performed of appendicectomies carried out at a peripheral hospital over a 12 month period. Comparisons were made between consultant surgeons and trainees for a variety of outcomes. Of 155 appendicectomies, 129 (83.2%) were performed laparoscopically, of which 10 (7.75%) were converted to open. Consultants performed 99 (77%) laparoscopic appendicectomies. There were no statistically significant differences between consultants and trainees in complication rates (19 (19.2%) vs. 4 (13.3%), p = 0.46), mean length of hospital stay (4.7 +/- 4.0 vs. 3.4 +/- 3.3 days, p = 0.13), or rate of conversion to open operation (9 (9.1%) vs. 1 (3.3%), p = 0.45). For cases of complicated appendicitis there were no significant differences between consultants and trainees in complication rates (12 vs. 2, p = 0.40) or length of hospital stay (6.4 +/- 3.9 vs. 4.7 +/- 5.6 days, p = 0.27). We conclude that laparoscopic appendicectomy is a safe procedure for trainees to perform in the peripheral hospital setting and should be incorporated into surgical training programs at an early stage of training.

Stellate ganglion blockade (SGB) for refractory index finger pain - a case report

OBJECTIVE

To identify through case study the presentation and possible pathophysiological cause of complex regional pain syndrome and its preferential response to stellate ganglion blockade.

SETTING

Complex regional pain syndrome can occur in an extremity after minor injury, fracture, surgery, peripheral nerve insult or spontaneously and is characterised by spontaneous pain, changes in skin temperature and colour, oedema, and motor disturbances. Pathophysiology is likely to involve peripheral and central components and neurological and inflammatory elements. There is no consistent approach to treatment with a wide variety of specialists involved. Diagnosis can be difficult, with over-diagnosis resulting from undue emphasis placed upon pain disproportionate to an inciting event despite the absence of other symptoms or under-diagnosed when subtle symptoms are not recognised. The International Association for the Study of Pain supports the use of sympathetic blocks to reduce sympathetic nervous system overactivity and relieve complex regional pain symptoms. Educational reviews promote stellate ganglion blockade as beneficial. Three blocks were given at 8, 10 and 13 months after the initial injury under local anaesthesia and sterile conditions. Physiotherapeutic input was delivered under block conditions to maximise joint and tissue mobility and facilitate restoration of function.

CONCLUSION

This case demonstrates the need for practitioners from all disciplines to be able to identify the clinical characteristics of complex regional pain syndrome to instigate immediate treatment and supports the notion that stellate ganglion blockade is preferable to upper limb intravenous regional anaesthetic block for refractory index finger pain associated with complex regional pain syndrome.

A novel hydrogen sulfide donor causes stomatal opening and reduces nitric oxide accumulation

Effects of hydrogen sulfide (H(2)S) on plant physiology have been previously studied, but such studies have relied on the use of NaSH as a method for supplying H(2)S to tissues. Now new compounds which give a less severe H(2)S shock and a more prolonged exposure to H(2)S have been developed. Here the effects of one such compound, GYY4137, has been investigated to determine its effects on stomatal closure in Arabidopsis thaliana. It was found that both NaSH and GYY4137 caused stomatal opening in the light and prevented stomatal closure in the dark. Nitric oxide (NO) has been well established as a mediator of stomatal movements and here it was found that both NaSH and GYY4137 reduced the accumulation of NO in guard cells, perhaps suggesting a mode of action for H(2)S in this system. GYY4137, and future related compounds, will be important tools to unravel the effects of plant exposure to H(2)S and to determine how H(2)S may fit into plant cell signalling pathways.

Nitric oxide scavenging by food: implications for in vivo effects of diet

Recent advice to the general public is to increase intake of fresh fruit and vegetables, a message based on the assumed benefits of the antioxidant content of plant substances. Although there have been numerous studies on the reactive oxide species scavenging of fresh food products, few studies have focused on whether or not compounds in the diet can modulate the levels of nitric oxide (NO). Nitric oxide is a key signalling molecule that controls vasodilation and blood pressure, along with a range of other physiological events. Here, it is shown that commonly used food substances, such as cabbage, broccoli, kidney bean and oranges, all have the capacity to scavenge NO from solution, and therefore can potentially alter the level of NO in humans, with ramifications for the physiological systems that NO regulates. Using spinach, at least one element of the NO scavenging ability was shown to be heat-unstable, although heat-treating of other leaf materials had little effect, showing that NO scavenging will still occur after cooking. It is proposed that the NO scavenging of dietary components needs to be investigated more thoroughly before the full effects of increasing antioxidants through increased intake of fresh fruit and vegetables can truly be understood.

The Efficacies of 3,4,3-LIHOPO and DTPA for Enhancing the Excretion of Plutonium and Americium from the Rat: Comparison with Other Siderophore Analogues

With DTPA as a comparison, the siderophore analogue code named 3,4,3-LIHOPO has been tested for its ability to remove 238Pu and 241Am from rats after their inhalation or intravenous injection as nitrate. The most effective treatment regimen for inhaled Pu was the repeated administration of 30 mumol kg-1 3,4,3-LIHOPO. By 7 days after exposure, the Pu contents of the lungs and total body were reduced respectively to 2 and 4% of those in untreated animals. These values were six and three times less than when DTPA was administered using the same protocol. For inhaled Am, 3,4,3-LIHOPO and DTPA were considered equally effective, the lung and total body contents being reduced respectively to 13 and 10% of those in controls. Some animals showed slight degenerative changes in the liver and proximal tubules of the kidneys after the repeated administration of 30 mumol kg-1 of 3,4,3-LIHOPO; however these changes were less marked than after DTPA treatment. After the intravenous injection of Pu, the most effective regimen was the single administration of 3 mumol kg-1 3,4,3-LIHOPO. The body content at 7 days was reduced to 7% controls compared with 19% after the repeated administration of 30 mumol kg-1 DTPA. At a dosage of 30 mumol kg-1, 3,4,3-LIHOPO was less effective owing to the higher retention of Pu in the liver. With repeated dosages of 30 mumol kg-1 3,4,3-LIHOPO was more effective than DTPA for the decorporation of Am; the body contents were 16 and 31% of those in controls respectively. Importantly, the body content was still reduced to 28% of control after a single administration of 3 mumol kg-1. The ligand 3,4,3-LIHOPO, which is also superior to other siderophore analogues, could represent a most significant development in the decorporation of Pu and Am.