Limitations of antifungal prophylaxis in preventing invasive Candida surgical site infections after liver transplant surgery

Invasive primary Candida surgical site infections (IP-SSIs) are a common complication of liver transplantation, and targeted antifungal prophylaxis is an efficient strategy to limit their occurrence. We performed a retrospective single-center cohort study among adult single liver transplant recipients at Duke University Hospital in the period between 1 January 2015 and 31 December 2020. The study aimed to determine the rate of Candida IP-SSI according to the peri-transplant antifungal prophylaxis received. Of 470 adult single liver transplant recipients, 53 (11.3%) received micafungin prophylaxis, 100 (21.3%) received fluconazole prophylaxis, and 317 (67.4%) did not receive systemic antifungal prophylaxis in the peri-transplant period. Ten Candida IP-SSIs occurred among 5 of 53 (9.4%) micafungin recipients, 1 of 100 (1.0%) fluconazole recipients, and 4 of 317 (1.3%) recipients who did not receive antifungal prophylaxis. Our study highlights the limitations of antifungal prophylaxis in preventing invasive Candida IP-SSI after liver transplant surgery. We hypothesize that pathogen, host, and pharmacokinetic-related factors contributed to the occurrence of Candida IP-SSI despite antifungal prophylaxis. Our study reinforces the need for a risk-based, multi-pronged approach to fungal prevention, including targeted antifungal administration in patients with risks for invasive candidiasis and close monitoring, especially among patients with surgically complex procedures, with timely control of surgical leaks.

The burden and outcomes of firearm injuries at two district-level emergency centres in Cape Town, South Africa: A descriptive analysis

BACKGROUND

In South Africa (SA), injuries are the second leading cause of years of healthy life lost, and interpersonal violence dominates the SA injury profile. Half of all injury-related deaths in SA are intentional, and firearms contribute to a quarter of these deaths. Injury surveillance systems are essential to develop, implement and monitor strategies that reduce preventable trauma.

OBJECTIVES

To describe the burden of patients with firearm injuries and their outcomes at district-level emergency centres in the Western Cape.

METHODS

This study was a retrospective analysis of a prospectively collected database. All patients who presented to two district-level emergency centres with a firearm injury over a 12-month period (1 January 2019 - 31 December 2019) were eligible for inclusion.

RESULTS

Firearm injuries represented 5.7% of the trauma burden at the two district emergency centres. Of the 776 patients with firearm injuries who were included, the median age was 27 years, and 91% were male. A total of 520 (67%) patients self-presented, and there were 18 (2.3%) deaths in the emergency centre and a further 23 (3%) as inpatients. Of the total where wound location was determined (n=595), 30.4% sustained more than one firearm injury, and 112 out of the 167 admitted to Mitchells Plain Hospital required at least one visit to theatre. This accounted for 413 theatre hours and 1 376 inpatient bed days at Mitchells Plain Hospital. A significant proportion of patients (n=219, 29%) were transferred from the emergency centres to a tertiary service for further care.

CONCLUSION

Firearm injuries represent a substantial proportion of the trauma burden at district emergency centres in the Western Cape Province. Managing patients with firearm injuries is resource intensive, as evident by their high acuity, the need for operative care, the long length of stay, the high burden on emergency medical services with interfacility transfers and the high demand for tertiary care. Data from this study aid our understanding of the prevalence and burden of firearm injuries at district level emergency centres, and multisectoral action, supported by evidence-based primary and secondary preventive strategies, is required to reduce the burden of firearm injuries, and mitigate their effects.

Dissociable Contributions of Basolateral Amygdala and Ventrolateral Orbitofrontal Cortex to Flexible Learning Under Uncertainty

Reversal learning measures the ability to form flexible associations between choice outcomes with stimuli and actions that precede them. This type of learning is thought to rely on several cortical and subcortical areas, including the highly interconnected orbitofrontal cortex (OFC) and basolateral amygdala (BLA), and is often impaired in various neuropsychiatric and substance use disorders. However, the unique contributions of these regions to stimulus- and action-based reversal learning have not been systematically compared using a chemogenetic approach particularly before and after the first reversal that introduces new uncertainty. Here, we examined the roles of ventrolateral OFC (vlOFC) and BLA during reversal learning. Male and female rats were prepared with inhibitory designer receptors exclusively activated by designer drugs targeting projection neurons in these regions and tested on a series of deterministic and probabilistic reversals during which they learned about stimulus identity or side (left or right) associated with different reward probabilities. Using a counterbalanced within-subject design, we inhibited these regions prior to reversal sessions. We assessed initial and pre-/post-reversal changes in performance to measure learning and adjustments to reversals, respectively. We found that inhibition of the ventrolateral orbitofrontal cortex (vlOFC), but not BLA, eliminated adjustments to stimulus-based reversals. Inhibition of BLA, but not vlOFC, selectively impaired action-based probabilistic reversal learning, leaving deterministic reversal learning intact. vlOFC exhibited a sex-dependent role in early adjustment to action-based reversals, but not in overall learning. These results reveal dissociable roles for BLA and vlOFC in flexible learning and highlight a more crucial role for BLA in learning meaningful changes in the reward environment.

Referral practices of recent graduate and experienced physiotherapists working in Australian primary care for people with musculoskeletal conditions

BACKGROUND

People with musculoskeletal conditions often seek care from physiotherapists. Some, particularly those at risk of poor outcomes, may benefit from referral to physiotherapists with expertise in managing musculoskeletal conditions and/or multidisciplinary care. Understanding referral practices of physiotherapists, and how experience influences those practices, may assist in implementing optimal care pathways in primary care.

AIMS

Explore (i) current referral practices of recent graduate and experienced physiotherapists who manage musculoskeletal conditions; (ii) opinions about referral to specialist physiotherapists for people at risk of poor outcomes.

METHODS

This qualitative study consisted of 23 semi-structured interviews with recent graduate (n = 9) and experienced physiotherapists (n = 14) working in primary care. Perspectives of participants' current referral practices (to whom, when and why they are referred) and referral to specialist physiotherapists were sought. Interviews were recorded and transcribed verbatim prior to analysis.

RESULTS

Referral practices for both groups were influenced by specific diagnoses, complexity of presentations, confidence, self-awareness, the clinical environment and system-related factors. Experienced physiotherapists were more confident and specific in their referrals and had established trusted networks compared with new graduates. Early referral to specialist physiotherapists was more likely when therapists were co-located. Barriers to early referral were lack of awareness, health system factors and impact on the patient (e.g., financial, time, continuity of care).

CONCLUSION

Understanding factors influencing referral decisions may improve both intra- and interprofessional care for people with musculoskeletal conditions. Referral of people at risk of poor outcomes to specialist physiotherapists may be improved by greater intraprofessional awareness and clarity of roles.

Documentation Status and Self-Rated Physical Health Among Latinx Young Adult Immigrants: the Mediating Roles of Immigration and Healthcare Stress

Previous research has demonstrated that undocumented Latinx immigrants in the USA report worse physical health outcomes than documented immigrants. Some studies suggest that immigration-related stress and healthcare related-stress may explain this relationship, but none have tested it empirically. The purpose of this study was to determine if immigration-related stress and healthcare-related stress in the USA explain the relationship between documentation status and physical health among Latinx immigrants in North Carolina. The conceptual model was tested utilizing baseline data from a longitudinal, observational, community-engaged research study of young adult (18-44 years) Latinx immigrants residing in North Carolina (N = 391). Structural equation modeling was used to determine relationships among documentation status, healthcare, and immigration stress in the past six months, and self-rated physical health. Goodness-of-fit measures indicated that data fit the model well (RMSEA = .008; CFI = 1.0; TLI = .999; SRMR = .02; CD = .157). Undocumented individuals were more likely to experience immigration stress than their documented counterparts ([Formula: see text] = - 0.37, p < 0.001). Both immigration stress ([Formula: see text] = - 0.22, p < 0.01) and healthcare stress ([Formula: see text] = - 0.14, p < 0.05) were negatively related to physical health. Additionally, immigration stress was positively related to healthcare stress ([Formula: see text] = 0.72, p < 0.001). Results demonstrate that documentation status is an important social determinant of health. Passage of inclusive immigration and healthcare policies may lessen the stress experienced by Latinx immigrants and subsequently improve physical health.

A New Era of Morphological Investigations: Reviewing methods for comparative anatomical studies

The increased use of imaging technology in biological research has drastically altered morphological studies in recent decades and allowed for the preservation of important collection specimens alongside detailed visualization of bony and soft-tissue structures. Despite the benefits associated with these newer imaging techniques, there remains a need for more “traditional” methods of morphological examination in many comparative studies. In this paper, we describe the costs and benefits of the various methods of visualizing, examining, and comparing morphological structures. There are significant differences in the costs associated with these different methods (monetary, time, equipment, and software), but also in the degree to which specimens are destroyed. We argue not for any one particular method over another in morphological studies, but instead suggest a combination of methods is useful not only for breadth of visualization, but also for the financial and time constraints often imposed on early-career research scientists.

Uncertainty in low back pain care - insights from an ethnographic study

PURPOSE

To explore how uncertainty plays out in low back pain (LBP) care and investigate how clinicians manage accompanying emotions/tensions.

MATERIALS AND METHODS

We conducted ethnographic observations of clinical encounters in a private physiotherapy practice and a public multidisciplinary pain clinic. Our qualitative reflexive thematic analysis involved abductive thematic principles informed by Fox and Katz (medical uncertainty) and Ahmed (emotions).

RESULTS

We identified three themes. (1) Sources of uncertainty: both patients and clinicians expressed uncertainty during clinical encounters (e.g., causes of LBP, mismatch between imaging findings and presentation). Such uncertainty was often accompanied by emotions - anger, tiredness, frustration. (2) Neglecting complexity: clinicians often attempted to decrease uncertainty and associated emotions by providing narrow answers to questions about LBP. At times, clinicians' denial of uncertainty also appeared to deny patients the right to make informed decisions about treatments. (3) Attending to uncertainty?: clinicians attended to uncertainty through logical reasoning, reassurance, acknowledgement, personalising care, shifting power, adjusting language and disclosing risks.

CONCLUSIONS

Uncertainty pervades LBP care and is often accompanied by emotions, emphasising the need for a healthcare culture that recognises the emotional dimensions of patient-clinician interactions and prepares clinicians and patients to be more accepting of, and clearly communicate about, uncertainty.IMPLICATIONS FOR REHABILITATIONUncertainty pervades LBP care and is often accompanied by emotions.Neglecting complexity in LBP care may compromise person-centred care.Acknowledging uncertainty can enhance communication, balance patient-clinician relationships and address human aspects of care.

A systematic review of N-of-1 trials and single case experimental designs in physiotherapy for musculoskeletal conditions

BACKGROUND

Single Case Experimental Designs (SCEDs) are especially useful for small heterogeneous samples. Their role in evaluation of physiotherapy interventions for musculoskeletal conditions has not been systematically reviewed.

OBJECTIVES

Systematically review use, purpose, and outcomes of SCEDs for physiotherapy interventions for musculoskeletal conditions.

DATA SOURCES

Electronic databases and grey literature, searched using pre-defined terms.

STUDY SELECTION OR ELIGIBILITY CRITERIA

Studies of human participants enrolled in eligible SCEDs (individual or a series).

STUDY APPRAISAL AND SYNTHESIS METHODS

We extracted study characteristics, analytic methods and results, synthesising these descriptively. We used RoBiN-T scale to assess risk of bias.

RESULTS

We included 19 SCEDs comprising 92 participants, with wide variability in design, methodology, analysis and in conditions and interventions evaluated. 95% of participants responded favourably to the tested intervention. Overall risk of bias was high, due to poor internal validity, especially regarding randomisation, blinding, inter-rater agreement and measurement of treatment adherence. Visual analysis alone was performed in 55% of studies. Assessment of provider and participant satisfaction was limited.

CONCLUSIONS AND IMPLICATIONS

of key findings: SCEDs may be well-suited to evaluation of physiotherapy interventions for musculoskeletal conditions, but the risk of bias in studies to date is high. Following SCED guidelines to minimize the risk of bias and maximise clinical usefulness is recommended.

Disordered Eating and Eating Competence in Adults With Irritable Bowel Syndrome Based on Symptom Severity

Objectives

This study seeks to assess the frequency at which disordered eating impacts patients with irritable bowel syndrome (IBS), evaluate the level of Eating Competence (EC) among patients with IBS, and determine whether EC and eating disorder (ED) risk varies according to IBS symptom severity and IBS subtype.

Methods

This cross-sectional study is based on an anonymous survey conducted from August to September 2021. Adults with IBS (N = 225) were recruited from online and social media IBS support forums. IBS symptom severity was assessed using the validated IBS Severity Scoring System (IBS-SSS), ED risk was assessed using the validated Eating Attitudes Test (EAT-26), and EC was assessed using the validated Satter Eating Competence Inventory (ecSI 2.0™). Multiple linear regression was used to predict EAT-26 total score from IBS-SSS score and age. The regression model was repeated with IBS subtype added as a covariate. One-way and two-way ANOVAs were used to examine the relationships between IBS severity level, IBS subtype, and ecSI 2.0™ total score.

Results

EC among the sample was 17% while 27% was classified as likely or very likely disordered eating. IBS severity was positively associated with ED risk (P &lt; 0.001), and EC was significantly lower in the severe IBS group compared to the moderate IBS group (P = 0.016). No relationship was detected between IBS subtype and ED risk or EC.

Conclusions

IBS severity was positively associated with ED risk and negatively associated with EC. This sheds light on the importance of assessing EC and screening for disordered eating and EDs prior to selecting therapies for patients with IBS, particularly when symptom severity is high. This study also calls to attention the relatively low rates of EC in patients with IBS, especially among those with severe IBS.

Funding Sources

None.

The effect of mode of delivery on health-related quality-of-life in mothers: a systematic review and meta-analysis

Background

Previous research is inconclusive on the effects of mode of delivery on maternal health-related quality-of-life (HRQoL). We conducted a systematic review and meta-analysis to assess the current evidence for associations between mode of delivery and postpartum health-related quality-of-life.

Methods

Electronic databases MEDLINE ALL (OVID), Web of Science, The Cochrane Library, CINAHL and EMBASE (OVID) were searched for English written articles investigating the relationship between mode of delivery and quality-of-life published form inception to 15th October 2020. Two reviewers independently screened titles and abstracts, assessed full texts, and extracted data. Meta-analysis was conducted where possible.

Results

Twenty-one studies, including 19,879 women, met the inclusion criteria. A meta-analysis of 18 studies found HRQoL scores were significantly higher for women after vaginal delivery in comparison to caesarean (emergency and elective combined) (Effect Size (ES) 0.17, 95% CI 0.01–0.25, n = 7665) with highest scores after assisted vaginal delivery (ES 0.21, 95% CI 0.13–0.30, n = 2547). Physical functioning (ES 11.18, 95% CI = 2.29–20.06, n = 1746), physical role (ES 13.10, 95% CI = 1.16–25.05, n = 1471), vitality (ES 6.31, 95% CI = 1.14–10.29, n = 1746) and social functioning (ES 5.69, 95% CI = 1.26–10.11, n = 1746) were significantly higher after vaginal delivery compared to caesarean.

Conclusions

Health-related quality-of-life scores were higher for women after vaginal delivery in comparison to caesarean section. Consequently, women should be encouraged to deliver vaginally where possible. The findings of this research should be available to the relevant population to help support informed choice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04473-w.

Supporting new graduate physiotherapists in their first year of private practice with a structured professional development program; a qualitative study

BACKGROUND

The transition from physiotherapy student to working in private practice has been identified as challenging. However, very little is known about whether structured professional development programs impact on this transition.

OBJECTIVES

To describe new graduates' perceptions of a structured professional development program, termed the Recent Graduate Program (RGP), designed to support their transition into physiotherapy private practice.

DESIGN

Qualitative analysis of data from a one-year longitudinal mixed methods study.

METHOD

A total of 72 interviews were conducted over a one-year period with 20 new graduates from 19 private practices within one publicly listed allied health organisation. Semi-structured interviews were conducted before commencing work and at three, nine and 12 months. Interviews were recorded and transcribed verbatim prior to a conventional content analysis that aimed to acquire direct information from new graduates without imposing preconceived categories or theoretical perspectives.

FINDINGS

New graduates reported that the RGP supported their growth as a practitioner and facilitated their learning, particularly when complemented by the experiential learning from client interactions. The RGP met their expectations with the formal education program and regular mentoring sessions highly valued. Informal support from peers and senior clinicians, while not part of the RGP, was also perceived to facilitate their growth and confidence as a physiotherapist.

CONCLUSIONS

This study demonstrates that the provision of a structured transition program by a private practice employer was perceived by new graduates to facilitate their learning, confidence and self-efficacy. The RGP provides a useful model by which other practices may support new graduates.

Food for all: designing sustainable and secure future seafood systems

Food from the sea can make a larger contribution to healthy and sustainable diets, and to addressing hunger and malnutrition, through improvements in production, distribution and equitable access to wild harvest and mariculture resources and products. The supply and consumption of seafood is influenced by a range of 'drivers' including ecosystem change and ocean regulation, the influence of corporations and evolving consumer demand, as well as the growing focus on the importance of seafood for meeting nutritional needs. These drivers need to be examined in a holistic way to develop an informed understanding of the needs, potential impacts and solutions that align seafood production and consumption with relevant 2030 Sustainable Development Goals (SDGs). This paper uses an evidence-based narrative approach to examine how the anticipated global trends for seafood might be experienced by people in different social, geographical and economic situations over the next ten years. Key drivers influencing seafood within the global food system are identified and used to construct a future scenario based on our current trajectory (Business-as-usual 2030). Descriptive pathways and actions are then presented for a more sustainable future scenario that strives towards achieving the SDGs as far as technically possible (More sustainable 2030). Prioritising actions that not only sustainably produce more seafood, but consider aspects of access and utilisation, particularly for people affected by food insecurity and malnutrition, is an essential part of designing sustainable and secure future seafood systems.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11160-021-09663-x.

Food for all: designing sustainable and secure future seafood systems

Food from the sea can make a larger contribution to healthy and sustainable diets, and to addressing hunger and malnutrition, through improvements in production, distribution and equitable access to wild harvest and mariculture resources and products. The supply and consumption of seafood is influenced by a range of 'drivers' including ecosystem change and ocean regulation, the influence of corporations and evolving consumer demand, as well as the growing focus on the importance of seafood for meeting nutritional needs. These drivers need to be examined in a holistic way to develop an informed understanding of the needs, potential impacts and solutions that align seafood production and consumption with relevant 2030 Sustainable Development Goals (SDGs). This paper uses an evidence-based narrative approach to examine how the anticipated global trends for seafood might be experienced by people in different social, geographical and economic situations over the next ten years. Key drivers influencing seafood within the global food system are identified and used to construct a future scenario based on our current trajectory (Business-as-usual 2030). Descriptive pathways and actions are then presented for a more sustainable future scenario that strives towards achieving the SDGs as far as technically possible (More sustainable 2030). Prioritising actions that not only sustainably produce more seafood, but consider aspects of access and utilisation, particularly for people affected by food insecurity and malnutrition, is an essential part of designing sustainable and secure future seafood systems.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11160-021-09663-x.

Trends in Fruit Quality Improvement From 15 Years of Selection in the Apple Breeding Program of Washington State University

Washington State University's apple breeding program (WABP) was initiated in 1994 to select new apple cultivars with improved eating quality, appearance, and storability that are suitable for production in the main growing regions of the state. Fruit quality is phenotyped using various instrumental measures, such as penetrometers (texture), titrator (acidity), and refractometer (soluble solids concentration; SSC), as well as sensory assessment. The selection regime of WABP occurs in three sequential phases: phase one (P1)-single, unreplicated seedlings at one site, phase two (P2)-replicated selections at three geographically diverse sites, and phase three (P3)-highly replicated elite selections at one to two grower sites. Most of the data collection of WABP occurs in P2. Knowledge of trends/changes associated with advancing selections is essential for understanding the selection criteria and progress of WABP throughout the changing compositions of advancing and culling selections. For each post-harvest trait, P2 data from harvest years 2005 to 2019 were split across sites, and between selections and reference cultivars (e.g., Cripps Pink, Gala, and Honeycrisp). Means of instrumental crispness (Cn) and inner cortex firmness for the advancing selections increased gradually over this period and were significantly higher than those for cultivars. Means of outer cortex firmness measurements were stable for selections but significantly higher than those for cultivars. The average fruit acidity of selections increased marginally over this period and was higher than that of the cultivars. Meanwhile, the average fruit SSCs of selections and cultivars were statistically indistinguishable. These 15-year trends indicate that WABP has been selecting apples with improved eating quality and storability through increased crispness and inner cortex firmness, respectively.

1119 Readdressing Consent in Head & Neck Free Flap Surgery: The Nottingham Experience

Aim

The Montgomery vs NHS Lanarkshire case in 2015 led to a paradigm shift in the consent process within surgery. It became incumbent upon clinicians to outline all “material risks” prior to a procedure. Within head and neck surgery, the Enhanced Recovery After Surgery (ERAS) pathway addresses this obligation through a multi-disciplinary approach. The aim of this audit was to assess the effect of the existing ERAS pathway on the consent process.

Method

35 head and neck oncology cases involving free flap reconstruction were identified across two audit cycles. Cases pre- and post-introduction of the ERAS pathway were analysed to assess whether the existing pathway led to improvement in consent quality.

8 key consent elements were identified based on a review of current literature and guidelines. This was our gold standard. A tick-box system was devised, and each case assigned a percentage score based on compliance with these criteria. A consent checklist was introduced within the ERAS pathway file alongside multi-disciplinary documentation which would follow the patient from the pre-operative environment through to discharge.

Results

Prior to the introduction of the ERAS pathway, there was a 58% compliance with the gold standard. Upon implementation of the ERAS protocol, compliance rose to 65%. Following introduction of the checklist, compliance rose further to 85%. This resulted in an overall increase in compliance of 27%.

Conclusions

We recommend the introduction of a focused consent checklist within any unit providing major head and neck reconstruction procedures in order to ensure informed consent, mitigating medico-legal risks post-operatively.

EBV-positive mucocutaneous ulceration

Ulceration of the oral cavity is common and a frequent reason for referral to secondary and tertiary centres. Epstein-Barr virus (EBV)-related mucocutaneous ulceration, however, is a rare cause of oral ulceration that has been described only recently. Histologically these lesions resemble lymphomas; however, their management and prognosis differ significantly. We present a case of EBV-induced oral ulceration and discuss the diagnosis and management of and available literature for the condition, which was treated successfully through conservative measures alone.

Experiences of Parents of Specialist Peer Mentored Autistic University Students

ABSTRCTBackground: Parents continue to support to autistic university students, and consequently, experience considerable stress.Aim: To explore the experiences of parents of specialist peer mentored university students and to examine these using the ICF as a theoretical framework.Method: Thirteen semi-structured interviews were completed and analyzed using thematic analysis. Directive content analysis linked the data to the ICF core set for autism spectrum disorders (ASD).Results: Five interrelated themes emerged: The mentoring relationship is a facilitator, Developing skills for university, Mentoring changes lives, Mentoring is not a substitute for other supports, and University is an emotional rollercoaster. Specialist peer mentoring was linked to Activity and Participation (44%) and Environmental factors (32%) of the ICF core set for ASD.Conclusion: These results add to the specialist peer mentoring evidence-base, and indicate perceived benefits for autistic university students and their parents. An unintended consequence was that parents broadened their participation in activities.

Civilian Penetrating Neck Trauma at a Level I Trauma Centre: A Five-Year Retrospective Case Note Review

OBJECTIVES

To report the experience of civilian penetrating neck trauma (PNT) at a UK level I trauma centre, propose an initial management algorithm and assess the degree of correlation between clinical signs of injury, operative findings, and radiological reports.

DESIGN

Retrospective case note review SETTING: UK level I trauma centre April 2012-November 2017 PARTICIPANTS: 310 cases of PNT were drawn from electronic patient records. Data was extracted on hard and soft signs of vascular or aerodigestive tract injury, clinical management, radiological imaging and patient outcomes.

MAIN OUTCOME MEASURES

Patient demographics, mechanism of injury, morbidity and mortality. The correlation between clinical signs, and radiological reports to internal injury on surgical exploration.

RESULTS

271 (87.4%) male and 39 (13.6%) female patients with a mean age 36 years (16 - 87) were identified. The most common causes of injury were assault 171 (55.2%) and deliberate self-harm 118 (38%). A knife was the most common instrument 240 (77.4%). Past psychiatric history was noted in 119 (38.4%) and 60 (19.4%) were intoxicated. 50% were definitively managed in theatre with a negative exploration rate of 38%, and 50% were managed in ED. Pre-operative radiological reports correlated with operative reports in 62% of cases with venous injury the most common positive and negative finding. Multivariate correlation was r=0.89, p=0.045 between hard signs plus positive radiology findings and internal injury on neck exploration.

CONCLUSIONS

Management of PNT by clinical and radiological signs is safe and effective, and can be streamlined by a decision-making algorithm as proposed here.

A new electron diffraction approach for structure refinement applied to Ca3Mn2O7

The digital large-angle convergent-beam electron diffraction (D-LACBED) technique is applied to Ca3Mn2O7 for a range of temperatures. Bloch-wave simulations are used to examine the effects that changes in different parameters have on the intensity in D-LACBED patterns, and atomic coordinates, thermal atomic displacement parameters and apparent occupancy are refined to achieve a good fit between simulation and experiment. The sensitivity of the technique to subtle changes in structure is demonstrated. Refined structures are in good agreement with previous determinations of Ca3Mn2O7 and show the decay of anti-phase oxygen octahedral tilts perpendicular to the c axis of the A21am unit cell with increasing temperature, as well as the robustness of oxygen octahedral tilts about the c axis up to ∼400°C. The technique samples only the zero-order Laue zone and is therefore insensitive to atom displacements along the electron-beam direction. For this reason it is not possible to distinguish between in-phase and anti-phase oxygen octahedral tilting about the c axis using the [110] data collected in this study.

How has COVID-19 affected surgical practice in Oral and Maxillofacial Surgery in the East Midlands, UK?

The impact on the provision of care within the NHS due to COVID-19 can not be understated. It has created various challenges for Oral and Maxillofacial Surgeons due to the high-risk nature of working within this specialty. The aims of this study were to identify the ongoing clinical activities at the height of pandemic, the guidance issued to staff regarding the use of personal protective equipment and the changes to maxillofacial practice. A prospective analysis was commenced within six Oral and Maxillofacial Surgery units in the East Midlands, UK with data being collected by means of a 10-item questionnaire relating to changes in patient care during this time. The responses were analysed to identify compliance with the national guidance produced by the British Association of Oral and Maxillofacial Surgeons.

An 87% response rate was obtained (26 respondents from 30 invitations). 73.1% of participants confirmed all surgical members of staff were offered fit tests for FFP3 masks. All units reported a continuation of Head and Neck cancer and emergency operations with a complete reduction in TMJ and orthognathic surgery. FFP3 masks were the most popular masks used for theatre activity whilst FFP2 and surgical masks were more widely used for examining patients and performing procedures in the emergency department. Changes in maxillofacial practice included the use of local flaps compared to free flaps, use of intermaxillary fixation (IMF) where appropriate for craniofacial trauma and routine COVID-19 testing for all inpatients.

Technological disasters and Veterinary Services

Technological disasters present a unique set of requirements for national Veterinary Services, encompassing complex issues of risk to human health, animal health and the environment. Cooperation among agencies and Ministries that do not routinely coordinate with one another during transboundary animal disease incidents or natural disaster responses may be required in technological disasters. Effective preparedness and response requires additional planning, training, exercises, and equipping to safely and efficiently provide the necessary services in a technological disaster.

Diabetic ketoacidosis: update on management

Diabetic ketoacidosis (DKA) is not a rare presentation to hospital, despite being an entirely preventable condition. A concerning number of people also develop DKA while already in hospital. Management of DKA has changed in the last decade, and national guidelines introduced, to help standardise care, spread best practice, and reduce mortality and morbidity.

Short-term condylar and glenoid fossa changes in infants with Pierre Robin sequence undergoing mandibular distraction osteogenesis

The purpose was to evaluate short-term changes in condylar and glenoid fossa morphology in infants with Pierre Robin sequence (PRS) undergoing early (age <4 months) mandibular distraction osteogenesis (MDO) for the management of severe airway obstruction. Computed tomography data from infants with PRS who had MDO were compared to those of age-matched control infants without facial skeletal dysmorphology. Surface/volume, linear, and angular measurements of the condyle and glenoid fossa were obtained and compared between infants with PRS and controls. Eleven infants with PRS met the inclusion criteria. There were five female and six male subjects with a mean age at the time of MDO of 41±32 days. Prior to MDO, PRS mandibles had a smaller condylar articulating surface area and volume than age-matched control mandibles, with a more laterally positioned condylar axis (P≤0.05). Following MDO, there were significant increases in condylar articulating surface area and volume, approaching those of normal controls, with further lateral translation of the condylar axis (P≤0.05). Condyle and glenoid fossa morphology is largely normalized following early MDO in infants with PRS. The condylar axis translates laterally as a result of MDO; this change is not observed with mandibular growth in infants without PRS.

A highly multiplexed melt-curve assay for detecting the most prevalent carbapenemase, ESBL, and AmpC genes

Resistance to third-generation cephalosporins and carbapenems in Gram-negative bacteria is chiefly mediated by beta-lactamases including extended-spectrum beta-lactamase (ESBL), AmpC, and carbapenemase enzymes. Routine phenotypic detection methods do not provide timely results, and there is a lack of comprehensive molecular panels covering all important markers. An ESBL/carbapenemase high-resolution melt analysis (HRM) assay (SHV, TEM, CTX-M ESBL families, and NDM, IMP, KPC, VIM and OXA-48-like carbapenemases) and an AmpC HRM assay (16S rDNA control, FOX, MOX, ACC, EBC, CIT, and DHA) were designed and evaluated on 111 Gram-negative isolates with mixed resistance patterns. The sensitivity for carbapenemase, ESBL, and AmpC genes was 96.7% (95% confidence interval [CI]: 82.8-99.9%), 93.6% (95% CI: 85.7-97.9%), and 93.8% (95% CI: 82.8-98.7%), respectively, with a specificity of 100% (95% CI: 95.6-100%), 93.9% (95% CI: 79.8-99.3%), and 93.7% (95% CI: 84.5-98.2%). The HRM assays enable the simultaneous detection of the 14 most important ESBL, carbapenemase, and AmpC genes and could be used as a molecular surveillance tool or to hasten detection of antimicrobial resistance for treatment management.

0162 Mental Stress Compromises Human Sleep Through a Biological, Not Psychological, Pathway

Introduction

The extent to which mental stress causes sleep disturbance is unknown as experimental studies of stress and sleep have yielded mixed results. Potential mechanisms linking stress to poor sleep are also poorly characterized. The current study aimed to 1) assess the impact of experimentally-induced mental stress on daytime sleep and 2) test candidate mechanisms including physiological and emotional stress reactivity, stress rumination, attentional threat bias, and insensitivity to future consequences.

Methods

Participants (N=30) were randomized to a control (n=14) or stress group (n=16). Both groups were given a 60-minute nap opportunity at midday (≈13:30). Prior to sleep, participants in the stress group completed a socially evaluative mental arithmetic stress task and were instructed that they would be required to give a brief speech upon awakening. Sleep was monitored with polysomnography and scored according to standard AASM criteria. Measures of heart rate (HR), blood pressure (BP) and self-reported stress were recorded during the stress task. Self-reported stress rumination was measured upon awakening. Attentional threat bias was measured using an emotional dot probe and performance on the Iowa Gambling Task quantified insensitivity to future consequences.

Results

Acute mental stress significantly increased HR and BP (all p&lt;.001, all Cohen’s d&gt;1.24) and participants reported significant increases in self-reported stress (p&lt;.001). The stress group exhibited longer sleep latency (p=.038, d=.82), shorter sleep duration (p=.044, d=.78), and worse sleep continuity (p=.045, d=.79). Subjective sleep quality was not different across groups (p=.39, d=.32). Of all candidate mechanisms, physiological reactivity was the only one significantly related to sleep measures. Greater HR reactivity predicted longer sleep latency (r=.37), shorter sleep duration (r=-.59), and worse sleep continuity (r=-.59).

Conclusion

Acute mental stress caused significant disturbances in a single episode of daytime sleep. The degree of disturbance was, to an extent, predicted by the amount of physiological reactivity to stress.

Support

This work was supported a Washington and Lee University Summer Lenfest Grant and the Summer Research Scholars Program.

Healthcare utilization and cost burden among women with endometriosis by opioid prescription status in the first year after diagnosis: a retrospective claims database analysis

Aims: Opioids do not represent standard therapy for endometriosis; however, women with endometriosis are frequently prescribed an opioid to manage related abdominal or pelvic pain. The aim of this study was to evaluate the impact of opioid use on endometriosis-related economic and healthcare burden in the United States.Materials and methods: We performed a retrospective, propensity-matched cohort analysis of the Truven MarketScan Commercial database from 1 January 2011 to 31 December 2016. Eligible women had at least 1 inpatient or 2 outpatient codes for endometriosis and 12 months of continuous enrollment before and after the index date (i.e. first recorded endometriosis diagnosis). The primary analysis examined healthcare costs and utilization for 12 months after the index date in women who filled at least 1 opioid prescription versus those who did not. The secondary analysis examined healthcare costs and utilization by the pattern of opioid use.Results: The primary analysis matched 43,516 women across 2 groups and the secondary analysis matched 13,230 women across 5 groups. In the primary analysis, total 12-month healthcare costs were significantly higher in the opioid group compared to the non-opioid group ($29,236.00 vs. $18,466.00, respectively; p < .001); the same pattern was observed for all healthcare utilization parameters. In the secondary analysis, higher morphine equivalent daily dose and proportion of days covered were associated with the highest healthcare costs and utilization compared to the non-opioid group.Limitations: Retrospective design and inability to confirm whether filled opioid prescriptions were actually taken.Conclusions: Filling an opioid prescription within 1 year after an endometriosis diagnosis was associated with significant excess healthcare burden. Patients prescribed an opioid may experience inadequate symptom management and benefit from the use of disease-specific, non-opioid therapies.

Light-induced complex formation of bacteriophytochrome RpBphP1 and gene repressor RpPpsR2 probed by SAXS

Bacteriophytochrome proteins (BphPs) are molecular light switches that enable organisms to adapt to changing light conditions through the control of gene expression. Canonical type 1 BphPs have histidine kinase output domains, but type 3 RpBphP1, in the bacterium Rhodopseudomonas palustris (Rps. palustris), has a C terminal PAS9 domain and a two-helix output sensor (HOS) domain. Type 1 BphPs form head-to-head parallel dimers; however, the crystal structure of RpBphP1ΔHOS, which does not contain the HOS domain, revealed pseudo anti-parallel dimers. HOS domains are homologs of Dhp dimerization domains in type 1 BphPs. We show, by applying the small angle X-ray scattering (SAXS) technique on full-length RpBphP1, that HOS domains fulfill a similar role in the formation of parallel dimers. On illumination with far-red light, RpBphP1 forms a complex with gene repressor RpPpsR2 through light-induced structural changes in its HOS domains. An RpBphP1:RpPpsR2 complex is formed in the molecular ratio of 2 : 1 such that one RpBphP1 dimer binds one RpPpsR2 monomer. Molecular dimers have been modeled with Pfr and Pr SAXS data, suggesting that, in the Pfr state, stable dimeric four α-helix bundles are formed between HOS domains, rendering RpBphP1functionally inert. On illumination with light of 760 nm wavelength, four α-helix bundles formed by HOS dimers are disrupted, rendering helices available for binding with RpPpsR2.

High-Throughput Phenotyping of Fire Blight Disease Symptoms Using Sensing Techniques in Apple

Washington State produces about 70% of total fresh market apples in the United States. One of the primary goals of apple breeding programs is the development of new cultivars resistant to devastating diseases such as fire blight. The overall objective of this study was to investigate high-throughput phenotyping techniques to evaluate fire blight disease symptoms in apple trees. In this regard, normalized stomatal conductance data acquired using a portable photosynthetic system, image data collected using RGB and multispectral cameras, and visible-near infrared spectral reflectance acquired using a hyperspectral sensing system, were independently evaluated to estimate the progression of fire blight infection in young apple trees. Sensors with ranging complexity - from simple RGB to multispectral imaging to hyperspectral system - were evaluated to select the most accurate technique for the assessment of fire blight disease symptoms. The proximal multispectral images and visible-near infrared spectral reflectance data were collected in two field seasons (2016, 2017); while, proximal side-view RGB images and multispectral images using unmanned aerial systems were collected in 2017. The normalized stomatal conductance data was correlated with disease severity rating (r = 0.51, P < 0.05). The features extracted from RGB images (e.g., maximum length of senesced leaves, area of senesced leaves, ratio between senesced and healthy leaf area) and multispectral images (e.g., vegetation indices) also demonstrated potential in evaluation of disease rating (|r| > 0.35, P < 0.05). The average classification accuracy achieved using visible-near infrared spectral reflectance data during the classification of susceptible from symptomless groups ranged between 71 and 93% using partial least square regression and quadratic support vector machine. In addition, fire blight disease ratings were compared with normalized difference spectral indices (NDSIs) that were generated from visible-near infrared reflectance spectra. The selected spectral bands in the range 710-2,340 nm used for computing NDSIs showed consistently higher correlation with disease severity rating than data acquired from RGB and multispectral imaging sensors across multiple seasons. In summary, these specific spectral bands can be used for evaluating fire blight disease severity in apple breeding programs and potentially as early fire blight disease detection tool to assist in production systems.

Development of a highly efficient Axiom™ 70 K SNP array for Pyrus and evaluation for high-density mapping and germplasm characterization

Background

Both a source of diversity and the development of genomic tools, such as reference genomes and molecular markers, are equally important to enable faster progress in plant breeding. Pear (Pyrus spp.) lags far behind other fruit and nut crops in terms of employment of available genetic resources for new cultivar development. To address this gap, we designed a high-density, high-efficiency and robust single nucleotide polymorphism (SNP) array for pear, with the main objectives of conducting genetic diversity and genome-wide association studies.

Results

By applying a two-step design process, which consisted of the construction of a first ‘draft’ array for the screening of a small subset of samples, we were able to identify the most robust and informative SNPs to include in the Applied Biosystems™ Axiom™ Pear 70 K Genotyping Array, currently the densest SNP array for pear. Preliminary evaluation of this 70 K array in 1416 diverse pear accessions from the USDA National Clonal Germplasm Repository (NCGR) in Corvallis, OR identified 66,616 SNPs (93% of all the tiled SNPs) as high quality and polymorphic (PolyHighResolution). We further used the Axiom Pear 70 K Genotyping Array to construct high-density linkage maps in a bi-parental population, and to make a direct comparison with available genotyping-by-sequencing (GBS) data, which suggested that the SNP array is a more robust method of screening for SNPs than restriction enzyme reduced representation sequence-based genotyping.

Conclusions

The Axiom Pear 70 K Genotyping Array, with its high efficiency in a widely diverse panel of Pyrus species and cultivars, represents a valuable resource for a multitude of molecular studies in pear. The characterization of the USDA-NCGR collection with this array will provide important information for pear geneticists and breeders, as well as for the optimization of conservation strategies for Pyrus.

Electronic supplementary material

The online version of this article (10.1186/s12864-019-5712-3) contains supplementary material, which is available to authorized users.

Long-term neuroimaging and neurological outcome of fetal spina bifida aperta after postnatal surgical repair

OBJECTIVE

Parents faced with the choice between postnatal management and prenatal surgery for spina bifida need to have up-to-date information on the expected outcomes. The aim of this study was to report the long-term physical and neurological outcomes of infants with prenatally diagnosed isolated spina bifida that underwent postnatal surgical repair and were managed by a multidisciplinary team from a large tertiary center.

METHODS

This was a retrospective cohort study of all cases of fetal spina bifida managed in a tertiary unit between October 1999 and January 2018. All cases of fetal spina bifida from the local health region were routinely referred to the tertiary unit for further perinatal management. Details on surgical procedures and neonatal neurological outcomes were obtained from institutional case records. Ambulatory status, bladder and bowel continence and neurodevelopment were assessed at a minimum of 3 years.

RESULTS

During the study period, 241 pregnancies with isolated spina bifida were seen in the unit. Of these, 84 (34.9%) women opted to continue with the pregnancy after multidisciplinary counseling by clinicians. Sixty-seven infants underwent postnatal repair of spina bifida aperta and were included in the analysis. After birth, hindbrain herniation was observed in 91.5% of infants with only seven requiring surgical decompression. Ventriculoperitoneal shunt placement was needed in 64.2% of infants, while normal cognitive development or mild impairment was demonstrated in 85.4% of cases with data for this outcome available, at a mean age of 8 years. Cumulatively, 40% of infants were walking independently or using minor support, and normal or mild impairment of bladder and bowel function was reported in 45.5% and 44.4% of infants, respectively.

CONCLUSIONS

Neurodevelopmental and neurological outcomes between prenatal and postnatal repair are similar. As with fetal surgery, conventional postnatal surgery is associated with the reversal of hindbrain herniation. Similarly, postnatal ventriculoperitoneal shunt placement appears to be required mainly in fetuses without evidence of significant fetal ventriculomegaly. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Abstract P6-20-11: The stapled peptide ALRN-6924, a dual inhibitor of MDMX and MDM2, enhances antitumor efficacy of paclitaxel and Nab-paclitaxel in TP53 wild-type MCF-7 breast cancer models

Background: MDMX and MDM2 are endogenous inhibitors of the p53 tumor suppressor protein. MDMX levels are frequently elevated in luminal breast cancer, which generally expresses wild-type p53. ALRN-6924, an α-helical stapled peptide, is the first and only dual inhibitor of MDMX and MDM2 currently in clinical trials for solid tumors and hematological malignancies. We sought to determine the antitumor efficacy of the combination of ALRN-6924 with taxanes in models of human breast cancer.

Methods: Sulforhodamine B colorimetric assay was used to assess the cytotoxicity of the combination of ALRN-6924 with taxanes in vitro. Athymic nude mice were implanted with MCF-7 tumors and treated for four weeks with ALRN-6924 alone and in combination with paclitaxel in cremaphor (Taxol®, study #1) or a nanoparticle-albumin-bound (nab) formulation (Abraxane®, study #2). In study #1, ALRN-6924 (5, 10 mg/kg) was dosed twice weekly and paclitaxel (10, 15 mg/kg) was dosed weekly, with paclitaxel administered 6 h prior to ALRN-6924. In study #2, ALRN-6924 alone (5 mg/kg) was dosed twice weekly while nab-paclitaxel (15 mg/kg) was administered weekly in combination at -24h, -6h, 0h, +6h, or +24h relative to ALRN-6924 administration.

Results: ALRN-6924 was found to have synergistic activity with paclitaxel in both MCF-7 and ZR-75-1 cell lines in vitro (Combination index: 0.874 and 0.323 respectively). In in vivo study #1, the combination of ALRN-6924 and paclitaxel significantly inhibited MCF-7 tumor growth compared to either agent alone (p&lt;0.005). Paclitaxel 15 mg/kg + ALRN-6924 5 mg/kg resulted in the greatest tumor inhibition with average tumor size decreased by 13% at four weeks versus the starting size.

In study #2, the combination of nab-paclitaxel with ALRN-6924 administered -6h to +24h relative to nab-paclitaxel resulted in improved efficacy over either single agent and a significant increase in the number of tumor regressions (up to 6/10 with 3 consecutive measurements &lt;50% of starting volume) compared to nab-paclitaxel alone (1/10, p&lt;0.005). When ALRN-6924 was administered 24h prior to nab-paclitaxel, there was a marked decrease in efficacy and no tumor regressions were observed.

In both studies, drug treatments were well tolerated with no significant weight loss in mice.

Conclusion: The significant increase in efficacy observed with ALRN-6924 in combination with paclitaxel supports further evaluation in patients with breast cancer.

Citation Format: Pairawan SS, Yuca E, Evans K, Annis A, Narasimhan N, Sutton D, Carvajal LA, Ren J-G, Santiago S, Guerlavais V, Akcakanat A, Tapia C, Illeana Dumbrava EE, Aivado M, Meric-Bernstam F. The stapled peptide ALRN-6924, a dual inhibitor of MDMX and MDM2, enhances antitumor efficacy of paclitaxel and Nab-paclitaxel in TP53 wild-type MCF-7 breast cancer models [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-20-11.

15 years of GDR: New data and functionality in the Genome Database for Rosaceae

The Genome Database for Rosaceae (GDR, https://www.rosaceae.org) is an integrated web-based community database resource providing access to publicly available genomics, genetics and breeding data and data-mining tools to facilitate basic, translational and applied research in Rosaceae. The volume of data in GDR has increased greatly over the last 5 years. The GDR now houses multiple versions of whole genome assembly and annotation data from 14 species, made available by recent advances in sequencing technology. Annotated and searchable reference transcriptomes, RefTrans, combining peer-reviewed published RNA-Seq as well as EST datasets, are newly available for major crop species. Significantly more quantitative trait loci, genetic maps and markers are available in MapViewer, a new visualization tool that better integrates with other pages in GDR. Pathways can be accessed through the new GDR Cyc Pathways databases, and synteny among the newest genome assemblies from eight species can be viewed through the new synteny browser, SynView. Collated single-nucleotide polymorphism diversity data and phenotypic data from publicly available breeding datasets are integrated with other relevant data. Also, the new Breeding Information Management System allows breeders to upload, manage and analyze their private breeding data within the secure GDR server with an option to release data publicly.

Exploring the cancer caregiver's journey through web-based Meaning-Centered Psychotherapy

OBJECTIVE

Psychosocial interventions are historically underutilized by cancer caregivers, but support programs delivered flexibly over the Internet address multiple barriers to care. We adapted Meaning-Centered Psychotherapy for cancer caregivers, an in-person psychotherapeutic intervention intended to augment caregivers' sense of meaning and purpose and ameliorate burden, for delivery in a self-administered web-based program, the Care for the Cancer Caregiver (CCC) Workshop. The present study evaluated the feasibility, acceptability, and preliminary effects of this program.

METHODS

Eighty-four caregivers were randomized to the CCC Workshop or waitlist control arm. Quantitative assessments of meaning, burden, anxiety, depression, benefit finding, and spiritual well-being were conducted preintervention (T1), within 2-weeks postintervention (T2), and 2- to 3-month follow-up (T3). In-depth semistructured interviews were conducted with a subset of participants.

RESULTS

Forty-two caregivers were randomized to the CCC Workshop. Attrition was moderate at T2 and T3, with caregiver burden and bereavement as key causes of drop-out. At T2 and T3, some observed mean change scores and effect sizes were consistent with hypothesized trends (eg, meaning in caregiving, benefit finding, and depressive symptomatology), though no pre-post significant differences emerged between groups. However, a longitudinal mixed-effects model found significant differential increases in benefit finding in favor of the CCC arm.

CONCLUSIONS

The CCC Workshop was feasible and acceptable. Based on effect sizes reported here, a larger study will likely establish the efficacy of the CCC Workshop, which has the potential to address unmet needs of caregivers who underutilize in-person supportive care services.