Application of quasimetagenomics methods to define microbial diversity and subtype Listeria monocytogenes in dairy and seafood production facilities

IMPORTANCE

In developed countries, the human diet is predominated by food commodities, which have been manufactured, processed, and stored in a food production facility. Little is known about the application of metagenomic sequencing approaches for detecting foodborne pathogens, such as L. monocytogenes, and characterizing microbial diversity in food production ecosystems. In this work, we investigated the utility of 16S rRNA amplicon and quasimetagenomic sequencing for the taxonomic and phylogenetic classification of Listeria culture enrichments of environmental swabs collected from dairy and seafood production facilities. We demonstrated that single-nucleotide polymorphism (SNP) analyses of L. monocytogenes metagenome-assembled genomes (MAGs) from quasimetagenomic data sets can achieve similar resolution as culture isolate whole-genome sequencing. To further understand the impact of genome coverage on MAG SNP cluster resolution, an in silico downsampling approach was employed to reduce the percentage of target pathogen sequence reads, providing an initial estimate of required MAG coverage for subtyping resolution of L. monocytogenes.

Mortality rates and cause of mortality in patients with mildly elevated pulmonary pressures versus PH: insights from the retrospective EVIDENCE-PAH study

Background

Normal mean pulmonary artery pressure (mPAP) does not exceed 20 mmHg and normal pulmonary vascular resistance (PVR) does not exceed 2 Wood Units (WU). The thresholds used to define pre-capillary pulmonary hypertension (PH) – mPAP ≥25 mmHg and PVR >3 WU – are being evaluated. It is unclear if treatment would benefit patients with mildly elevated mPAP (≥21–<25 mmHg).

Purpose

The EVIDENCE-PAH study aims to describe mortality and hospitalisation outcomes, clinical characteristics, therapies, and quality of life during long-term follow-up of a national cohort of patients with different levels of mPAP and PVR. We report preliminary analyses focusing on mortality and its cause in patients stratified by their baseline (BL) mPAP.

Methods

This retrospective analysis included PAH-treatment-naïve patients with suspected PH who received a first right heart catheterisation (RHC) between 2009 and 2017 at any of the 7 UK tertiary PH centres, which assess all PH patients in the UK. A sample of patients with BL mPAP ≥25 mmHg (stratified by PVR and treatable versus non-treatable PH) was used as a control in this analysis. Baseline characteristics, mortality and cause of mortality were stratified by mPAP (<21, ≥21–<25, ≥25 mmHg) at BL (first RHC). Mortality was also stratified by BL PVR (<1, 1–<2, 2–<3, 3–<6, ≥6 WU). Mortality analysis was done without matching cohorts. Mortality data were obtained from the Office for National Statistics, NHS Digital.

Results

In total, 2926 patients were analysed (968, 689 and 1269 with mPAP <21, ≥21–<25, ≥25 mmHg, respectively). Mean observation was 6.1 years. BL characteristics are in Table. Survival worsened with increasing mPAP (p<0.0001) and increasing PVR (p<0.01) (Figure). After 5 years of follow-up, 187 (27.1%) patients with mPAP ≥21–<25 mmHg had died, compared with 162 (16.7%) and 595 (46.9%) patients in the lower and higher mPAP groups, respectively. In patients with mPAP ≥21–<25 mmHg, the most common main cause of death was respiratory disease (36.4%) – with scleroderma lung disease and interstitial lung disease accounting for 69.1% of these deaths – followed by cardiac disease (16.6%) and malignancy (15.0%) (Table). PH was the main cause of death for only 1.6% of patients with mildly elevated mPAP and it was a contributor to death in 6.8% (BL mPAP <21 mmHg), 10.2% (≥21–<25 mmHg), and 40.2% (≥25 mmHg) of cases.

Conclusion

Long-term survival in patients with mPAP ≥21–<25 mmHg was worse than in those with normal mPAP, and better than in those with the current definition of PH. While the main cause of death was mostly unrelated to PH and further analysis is needed to understand the impact of underlying disease, mildly elevated mPAP appears to confer a worse prognosis and should be closely monitored. These data show the relevant disease burden in patients with mPAP ≥21–<25 mmHg and the need to understand if they could benefit from treatment. PVR may be key in determining patients who might benefit.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Actelion Pharmaceuticals Ltd., a Janssen pharmaceutical company of Johnson & Johnson.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Ethnic disparities in multi-morbidity in women of reproductive age in the UK: a data linkage study

Introduction

Few studies have explored ethnic inequalities in physical and mental health in women at preconception.

Objectives

Explore inequalities in multimorbidity in women of reproductive age.

Methods

Data from Lambeth DataNet, anonymized primary care records of this ethnically diverse London borough, linked to anonymized electronic mental health records (“CRIS secondary care database”) were extracted on preconception risk factors including BMI, smoking, alcohol, substance misuse, micronutrient deficiencies and physical health diagnoses for women aged 15-40 with an episode of secondary mental health care (January 2008-December 2018) and no pregnancy codes (n=3,633) and a 4:1 age-matched comparison cohort (n=14,532) .

Results

Women in contact with mental health services (whether with or without SMI diagnoses) had a higher prevalence of all risk factors and physical health diagnoses studied after adjustment for deprivation and ethnicity. Women from minority ethnic groups [79.5% of total sample] were less likely to be diagnosed with depression in primary care compared to White British women [adj OR 0.66 (0.55- 0.79) p<0.001] and Black women were more likely to have a severe mental illness [adj OR 3.41(2.63-4.43), p<0.001]. Black and Asian women were less likely to smoke or misuse substances and more likely to be vitaminD deficient. Black women were also significantly more likely to be overweight [adj OR 4.56(3.96-5.24 p <0.001] and have two or more physical health conditions [adj OR 2.98(2.19-4.07) p<0.001] than White British women after adjustment for deprivation and SMI diagnoses.

Conclusions

Our results highlight a need for culturally centered integrative models of care across primary and secondary mental health services.

Disclosure

Closing the Gap is funded by UK Research and Innovation and their support is gratefully acknowledged (Grant reference: ES/S004459/1). Any views expressed here are those of the project investigators and do not necessarily represent the views of the Closing

Women with Lived Experience in the Perinatal Period: What do they want from Their Doctors?

Introduction

Best practice requires the treating physician to understand the needs and hopes of his/her patient, particularly in relation to pregnancy and childbirth preferences. This is even more necessary for women with Severe Mental Illness (SMI) because of the complicated decisions they face balancing the need to continue medication in pregnancy to prevent relapse against any possible harm to the foetus. Objectives: To explore what women themselves view as most important when discussing pregnancy and childbirth with psychiatrists and what barriers there are to a) having a meaningful conversation and b) achieving optimum outcomes. Qualitative methods were used to analyse the data from in-depth interviews with 21 women, recruited from a South London NHS organisation (76%) and the UK’s national bipolar charity (24%). The views of 25 health professionals, including 19 psychiatrists, were also collected and analysed. Results: Many themes emerged but principally women wanted: information, continuity of care, better training for health professionals, to co-produce a detailed care plan, access to a Mother and Baby Unit, peer support and more research on medications in pregnancy. Conclusions: This study highlighted the importance of understanding women’s needs and fears and giving them the necessary information to make the difficult decisions that face them. Such understanding is likely to lead to more positive therapeutic relationships and better long-term outcomes.

Disclosure

No significant relationships.

Clinical and radiographic assessment and restoration of maxillary sinus function in relation to oro-antral fistula closure: a systematic review

BACKGROUND

The purpose of this study was to determine current practice in assessment of maxillary sinus health during oro-antral fistula closure.

METHOD

A systematic review using specific MeSH headings between 1990 and September 2021 on Medline, Ovid, and PubMed was performed. The inclusion criterion was closure of oro-antral fistula in adult patients. Exclusion criteria were oro-antral fistula arising in children; or from trauma, malignancy, or developmental abnormality; or any osteonecrotic lesion of bone. Risk of bias for individual papers was not assessed. Oxford Centre for Evidence Based Medicine levels of evidence were recorded.

RESULTS

4309 papers were identified, and 119 were eligible for review. Nineteen were from otolaryngology (16%), 25 from combined ear, nose, and throat (ENT) and oral/oral and maxillofacial (OS/OMF) surgery (21%), and 75 from OS/OMF surgery (63%). Preoperative rhinoscopy and cross-sectional imaging were reported in 33 papers (28%), reflecting the role of ENT with or without OS/OMFS. Sixty-eight did not record any formal assessment of maxillary sinus health (57%), of which 60 were from OS/OMF surgery (50%). Use of computed tomography was reported in 58 papers (49%), and use of cone beam computed tomography was reported in 8 papers (7%) but did not correlate with assessment of sinus health.

DISCUSSION

Most surgery for oro-antral fistual closure was undertaken without objective assessment of maxillary sinus health, pre- or postoperatively. The involvement of ENT was associated with formal assessment of maxillary sinus health.

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

Suicide and self-harm in women with mental disorders during pregnancy and the year after birth

Introduction

There is little prospective data on the risk factors for later suicide in women who experience perinatal mental disorders, particularly beyond one-year postnatal.

Objectives

Among a cohort of women who were in contact with a mental healthcare provider during the perinatal period, to: (1) Describe sociodemographic and clinical characteristics of the women who died by suicide (2) Understand when, in relation to childbirth, most suicides tended to occur.

Methods

Data-linkage of de-identified service-user electronic healthcare records, national hospital episode statistics and mortality data generated a cohort of women in contact with a mental healthcare service provider in London, UK, perinatally. Using Natural Language Processing and structured field extraction, we identified clinical, socio-demographic characteristics, self-harm exposure, and suicide.

Results

Among 5204 women, clinical and demographic characteristics of women who did and did not die by suicide were similar apart from indicators of illness severity including perinatal sedative medication prescription, clinician-rated functional impairment and smoking, which were more common in women who died by suicide. Suicide deaths occurred most frequently in the second year post-delivery. The most common method of suicide ocurring wihtin two years was by violent means, whereas after two years postnatal, the most common method was non-violent.

Conclusions

Our findings support the extension of perinatal mental healthcare service provision to two years post-delivery.

Disclosure

No significant relationships.

Neuregulin-4 contributes to the establishment of cutaneous sensory innervation

Recent work has shown that neuregulin‐4 (NRG4) is a physiological regulator of the growth of sympathetic axons and CNS dendrites in the developing nervous system. Here, we have investigated whether NRG4 plays a role in sensory axon growth and the establishment of cutaneous sensory innervation. Imaging early nerve fibers in the well‐characterized cutaneous trigeminal territory, the brachial plexus, and thorax revealed very marked and highly significant decreases in nerve fiber length and branching density in Nrg4^−/− embryos compared with Nrg4^+/+ littermates. NRG4 promoted neurotrophin‐independent sensory axon growth from correspondingly early trigeminal ganglion and DRG neurons in culture but not from enteroceptive nodose ganglion neurons. High levels of Nrg4 mRNA were detected in cutaneous tissues but not in sensory ganglia. Our findings suggest that NRG4 is an important target‐derived factor that participates in the establishment of early cutaneous sensory innervation.

Real world experience with heart failure risk status generated by cardiac resynchronisation therapy defibrillators: high heart failure risk status incidence, causes and timing of remote transmissions

Background

Proactive patient monitoring is of paramount importance in effective management of heart failure (HF) patients. Cardiac implantable electronic devices (CIEDs) used in HF patients are able to derive long-term trends in physiologic parameters and provide timely warning to clinicians. Little is known, however, on the real-world experience with device-generated HF risk-stratifying algorithms.

Purpose

Heart Failure Risk Score (HFRS) takes into account nine parameters and is calculated automatically based on long-term clinical trends. Remote transmissions provide information on the risk of HF event in next 30 days categorized as low, medium or high based on a maximum daily risk status in prior 30 days. We aimed to evaluate the ability of HFRS to alert HF specialists on the actual HF risk status.

Methods

The prospective registry included all patients with CIEDs featuring integrated Heart Failure Risk Score (HFRS) followed via Medtronic CareLink remote monitoring system and enabled for Co-management (CM) from May 2015 to August 2019 in a tertiary centre. High HFRS does not trigger automatic alert transmission. Study follow-up spanned between start of CM and last transmission in 2019. Inclusion criteria were CRT-D in situ, active Home Monitor, switched on OptiVol 2.0 remote alert and transmission data available on CareLink following study period completion. Transmissions were scheduled 3-monthly.

Results

Out of 229 consecutive patients, 132 met study criteria. Mean age was 74±10 years, 18% were female. Median follow-up duration was 2.7 years (IQR 1.3). Total number of transmissions was 2652, median per patient was 18 (IQR 13); scheduled, unscheduled and care alerts constituted 42%, 44% and 14%, respectively. One third of transmissions were automatically sent for CM review. There were 398 high HFRS episodes. OptiVol fluid index was below the threshold throughout 128 (32%) episodes. Missed episodes (not transmitted within 30 days from the final day of high HFRS) amounted to 130 (33%) and the reasons behind this included OptiVol alerting before the first day of high HFRS or persistently elevated when HFRS changed from low/medium to high (52%), low OptiVol index during the episode (38%) or other (10%). Median duration of high HFRS was 7 days (IQR 12, range, 1–187). Among timely picked-up high HFRS episodes, 38% were transmitted during the relevant episode and 62% afterwards with median delay of 10 days (IQR 15) from the last day of high HFRS; 21% of transmissions showing high HFRS were not highlighted for CM review which correlated with low OptiVol index, P&lt;0.001. The factors contributing to high HFRS included: raised OptiVol (60%), patient activity (83%), AT/AF (46%), ventricular rate (VR) during AF (6%), % of VP (40%), shocks (2%), treated VT/VF (2%), night VR (72%) and HR variability (34%).

Conclusions

In a real-world clinical setting high HFRS was frequently under-reported. The investigation into clinical implications is warranted.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Our department has benefited from unrestricted grants from Boston Scientific and Medtronic Inc during the last 5 years.

Cardiopulmonary exercise testing as a guideline indicator for mitral valve intervention

Background

Primary mitral regurgitation (MR) is one of the most common heart valvular pathologies. However, optimum timing of surgery remains controversial.

Purpose

To describe changes in cardiopulmonary exercise testing (CPET) parameters after surgery for severe primary MR.

Methods

In a single centre prospective study, patients undergoing surgery under current ESC guidelines for severe primary MR underwent assessment with transthoracic echocardiogram, CPET, cardiac MRI and quality of life questionnaire pre-operatively and at six months after surgery. The primary outcome was a per protocol analysis of impaired post-operative functional capacity (defined as post-operative left ventricular ejection fraction on transthoracic echocardiogram &lt;50% and/or post-operative percentage predicted peak VO2 ≤84%).

Results

43 of the 50 patients recruited between February 2017 and October 2018 were included in the per protocol analysis. Thirty five patients (72.9%) had impaired post-operative functional capacity. In the overall cohort (n=43), there was a significant fall post-operatively in percentage predicted peak VO2 (ppVO2) (81.8±15.7% vs. 76.2±16.2%, p&lt;0.01) and anaerobic threshold (AT) (48.0±11.1% vs. 44.3±10.1%, p=0.01). In patients with a class I indication for surgery (n=30), there was no significant change post-operatively in ppVO2 (79.6±15.7% vs. 75.6±16.7%, p=0.09) or AT (49.9±11.4% vs. 46.4±10.2%, p-0.09). However, in patients with a class II indication for surgery (n=13), there was a significant change post-operatively in ppVO2 (86.9±15.1% vs. 77.4±15.9%, p&lt;0.01), but not in AT (43.5±9.6% vs. 39.5±8.3%, p=0.16).

In the multivariable analysis, pre-operative left ventricular ejection fraction ≤60% (hazard ratio, 1.69; 95% confidence interval, 1.56 to 480.1, p=0.04) and pre-operative percentage predicted peak VO2 ≤84% (hazard ratio, 1.22; 95% confidence interval, 2.13 to 107.1, p&lt;0.01) were independent predictors for impaired post-operative functional capacity.

Conclusions

Pre-operative percentage predicted peak VO2 ≤84% is an independent predictor of impaired post-operative functional capacity. Subject to a confirmatory study, this may help to refine current ESC guidelines for intervention for severe primary MR.

Change in ppVO2 after surgery

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Rosetrees Trust and Friends of Hammersmith Hospital

Enhanced triage for patients with suspected cardiac chest pain: the History and Electrocardiogram-only Manchester Acute Coronary Syndromes decision aid

Supplemental Digital Content is available in the text.

Several decision aids can ‘rule in’ and ‘rule out’ acute coronary syndromes (ACS) in the Emergency Department (ED) but all require measurement of blood biomarkers. A decision aid that does not require biomarker measurement could enhance risk stratification at triage and could be used in the prehospital environment. We aimed to derive and validate the History and ECG-only Manchester ACS (HE-MACS) decision aid using only the history, physical examination and ECG.

BET 1: is the patient’s perception of shortness of breath a useful triage tool in exacerbations of COPD?

A shortcut review was carried out to establish whether the degree of breathlessness in patients with an acute exacerbation of COPD is indicative of the severity of the exacerbation. Three hundred and forty-seven papers were found using the reported searches, of which five presented the best available evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these five papers are tabulated. It is concluded that increased shortness of breath is associated with a worse prognosis in patients with acute exacerbations of COPD. Dyspnoea assessment should be included in the triage process.

BET 2: Is keeping the eyes shut while fitting predictive of a psychogenic cause for seizures?

A short cut review was carried out to establish whether the presence of eye closure in a patient that appears to be fitting is useful in determining whether the fit is epileptic or non-epileptic 497 papers were found using the reported searches, of which nine presented the best available evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of eight of these papers are tabulated. It is concluded that if a patient has their eyes shut during a fit then it is likely that the fit is psychogenic. However, some epileptic patients do have their eyes shut during seizures and many patients with psychogenic seizures have their eyes open so eye closure alone cannot be used for final diagnosis.

P1282 Follow-up evaluation of right chambers mechanics is associated with prognosis in group 1 pulmonary arterial hypertension

Background

Pulmonary arterial hypertension (PAH) is a severe disease that progressively leads to right ventricular (RV) failure and cardiovascular death. Evaluation of right heart mechanics by means of 2-dimensional speckle tracking echocardiography (2D-STE) has displayed to be a promising tool to estimate prognosis in PAH patients.

Purpose

To evaluate the association between right ventricular free wall longitudinal strain (RVFWLS) and right peak atrial longitudinal strain (RPALS) at follow-up after initiation of specific vasodilator therapy in PAH patients, with outcomes.

Methods

83 subjects diagnosed with PAH Group 1 at three University Hospitals (Hammersmith Hospital, London, United Kingdom; Trieste University Hospital, Trieste, Italy; FTGM, Pisa, Italy), who were naive from specific treatment for PAH at the time of diagnosis, were retrospectively enrolled in this study. Standard echocardiographic parameters were collected. Outcomes were defined as the combination of all-cause mortality, hospitalization for PAH and first prostanoid administration. We investigated the correlation between RVFWLS and RPALS with outcomes adjusting for validated echocardiographic parameters strongly associated with prognosis in PAH (right atrial area – RAA and pericardial effusion – PE) and patients’ haemodynamics.

Results

30 patients experienced outcomes during a median follow-up time of 33 months. Median RVFWLS at follow-up was -15.8% (IQR: -12.1%/- 21.1%). Median RPALS at follow-up was 25% (IQR: 17.9%/36.6%). In the multivariate analysis, RVFLWS at follow-up was independently associated with outcomes (95% confidence interval [CI]: 1.01 – 1.24, p = 0.04), irrespectively from RAA (95% CI: 0.98 – 1.20, p = 0.12) and pulmonary arterial systolic pressure (PASP, 95% CI: 0.99 – 1.06, p = 0.12). We also observed a trend towards superiority of RPALS at follow-up (95% CI 0.90 – 1.00, p = 0.07) over RAA (95% CI: 0.98 – 1.20, p = 0.14) and PASP (95% CI: 0.99 - 1.05, p= 0.31). Finally, RPALS (95% CI: 0.88 – 1.00, p = 0.05) was independently associated with outcomes over PE (95% CI: 0.14 – 1.89, p = 0.32) and RVFWLS (95% CI: 0.97 – 1.20, p = 0.16).

Conclusions

In PAH group 1, assessment of both RVFWLS and RPALS at follow-up is associated with outcomes, independently from standard echocardiographic parameters.

CD40 forward signalling is a physiological regulator of early sensory axon growth

Multiple members of the tumour necrosis factor superfamily (TNFSF) regulate the growth and branching of neural processes late in development, when neurons are establishing and refining connections. Here, we present the first evidence that a TNFSF member acts much earlier in development, when axons are growing to their targets. CD40L transiently enhanced axon growth from embryonic mouse DRG neurons cultured at this early stage. Early spinal nerves of embryos lacking the CD40L receptor (Cd40^−/− mice) were significantly shorter in vivo than those of Cd40^+/+ littermates. CD40L was synthesized in early DRG targets and was co-expressed with CD40 in early DRG neurons. Whereas CD40L enhanced early axon growth independently of neurotrophins, disruption of a CD40L/CD40 autocrine loop impaired early neurotrophin-promoted axon growth. In marked contrast to the widespread regulation of axon and dendrite growth by CD40L reverse signalling later in development, CD40-Fc, which activates reverse signalling, had no effect on early sensory axon growth. These results suggest that CD40 forward signalling is a novel physiological regulator of early axon growth that acts by target-derived and autocrine mechanisms.

Summary: CD40L, a novel physiological regulator of early sensory axon growth at the stage when sensory axons are growing to their targets, activates CD40 forward signalling by target-derived and autocrine mechanisms.

BET 1: The role of topical phenylephrine in non-traumatic epistaxis

A short cut review of the literature was carried out to establish whether topical phenylephrine was an effective treatment for non-traumatic epistaxis. A single paper looked at this modality comparing it to another topical treatment. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses are tabulated. It is concluded that further more robust studies are needed to answer this question.

Physician attitudes about non-medical switching to biosimilars: results from an online physician survey in the United States

OBJECTIVE

This study was designed to understand the level of familiarity of US rheumatologists, gastroenterologists and dermatologists with biosimilar therapies, their experience with non-medical switching (switching medications for reasons unrelated to patient health) of patients between biologics and their attitudes towards switching from a biologic to a biosimilar.

METHODS

A total of 297 US physicians who currently prescribe biologics for their patients completed a 15-minute online survey. Rheumatologists, dermatologists and gastroenterologists were included.

RESULTS

The majority of physicians (84%) did not want stable patients undergoing a non-medical switch to a biosimilar. While 60% of physicians believed non-medical switching to biosimilars may have a positive impact on healthcare system costs, multiple negative impacts were also expected. A majority of physicians anticipated a negative impact on patient mental health (59%), treatment efficacy (57%), patient safety (53%) and physician office management (60%).

CONCLUSIONS

The majority of physicians had concerns regarding non-medical switching to biosimilars and the impact such switching would have on patient care and physician practice.

Patient attitudes about non-medical switching to biosimilars: results from an online patient survey in the United States

OBJECTIVE

To evaluate patient attitudes regarding non-medical switching (NMS) to biosimilars among patients with autoimmune disease currently receiving a biologic.

METHODS

An online survey was conducted among patients meeting the following criteria: ≥18 years of age; residing in the US; diagnosis of rheumatoid arthritis, Crohn's disease, ulcerative colitis, psoriasis or psoriatic arthritis; currently taking a biologic; and consenting to participate. Patients answered questions about their attitudes and experiences related to NMS. Descriptive statistics were used to summarize responses.

RESULTS

A total of 1696 patients completed the 20-min survey. Eighty-five per cent of patients were concerned that biosimilars wouldn't treat their disease as well; 85% didn't want to switch to a biosimilar if their current biologic was helping their disease; and 83% were concerned that switching may cause more side-effects. Twenty per cent of patients had previously received notification about a potential NMS to another biologic (that was not a biosimilar) from their insurance company. Of these, 79% took at least one action to avoid the NMS and 45% ultimately switched. Of these patients (n = 150), 67% indicated that their previous biologic worked well for them and 70% didn't want to switch to another biologic. Most patients who switched (67%) did so to avoid paying a higher cost. More than half (56%) went without therapy for administrative reasons during the period of transition from the old biologic to the other treatment.

CONCLUSIONS

Patients reported multiple concerns about NMS that might impact treatment outcomes, and many of the patients who non-medically switched in this survey missed treatments. Future studies should be conducted on patient expectations and experiences with NMS to understand the impact on healthcare delivery, treatment persistency, and patient outcomes. The patient perspective and experience should be considered by decision-makers when developing coverage policies for biosimilar medications and associated communication strategies.

Hypofractionated dose painting IMRT using 20 fractions for intermediate to high-risk localized prostate cancer: Two-year outcome data (BIOPROP20, NCT02125175)

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Background: Prostate dose painting (boosting intra-prostatic tumour volumes) may improve biochemical relapse-free survival similar to whole organ dose-escalation without the associated increased toxicity. We present a pre-defined secondary endpoint of 2 year outcome for patients at one of two UK centres in a phase II trial (BIOPROP20) on dose-painting radiotherapy for intermediate to high risk patients treated with 60Gy/20# and concurrent 68Gy boost. Methods: Pinnacle software was used for VMAT planning and boost volumes were outlined by18F choline PET/CT and mpMRI. Patients with positive lymph nodes also had concurrent pelvic radiotherapy of 45Gy with boost to 50Gy. Patients were followed up until year 2 with PSA and toxicity scores. Results: Overall 56 patients were treated, 5 with pelvic radiotherapy. Median age and PSA was 67.5 years (range 50 - 77) and 10.0ng/ml (3.9 - 39.4). All patients had tumour volumes > 10mm diameter on pre-biopsy mpMRI. 13 and 43 patients had intermediate and high risk disease. Median % LN risk was 18% (15 - 40). ADT duration was 6 months, 2 years, and 3 years for 42, 5, and 9 patients. At the 2 year follow up review, no grade 3 late toxicity was observed. For prostate only dose painting, grade 2 GU and GI toxicity was noted in 6% and 2% respectively. For prostate and nodal dose painting, no grade 2 toxicity was noted. Median IPSS score was 5 and 9, and median PSA was 0.3 and 0.1, in the two groups respectively. 1 patient had biochemical and metastatic relapse at 18 months (prostate, pelvic nodes and bone metastasis) and 1 patient had died of unrelated disease. Conclusions: Prostate radiotherapy with hypofractionated dose painting schedule of 60Gy/20# with 68Gy boost to intra-prostatic lesions was well tolerated at 2 years follow up. Clinical trial information: NCT02125175. [Table: see text]

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

TWE-PRIL reverse signalling suppresses sympathetic axon growth and tissue innervation

TWE-PRIL is a naturally occurring fusion protein of components of two TNF superfamily members: the extracellular domain of APRIL; and the intracellular and transmembrane domains of TWEAK with no known function. Here, we show that April^−/− mice (which lack APRIL and TWE-PRIL) exhibited overgrowth of sympathetic fibres in vivo, and sympathetic neurons cultured from these mice had significantly longer axons than neurons cultured from wild-type littermates. Enhanced axon growth from sympathetic neurons cultured from April^−/− mice was prevented by expressing full-length TWE-PRIL in these neurons but not by treating them with soluble APRIL. Soluble APRIL, however, enhanced axon growth from the sympathetic neurons of wild-type mice. siRNA knockdown of TWE-PRIL but not siRNA knockdown of APRIL alone also enhanced axon growth from wild-type sympathetic neurons. Our work reveals the first and physiologically relevant role for TWE-PRIL and suggests that it mediates reverse signalling.

Summary:In vivo and in vitro studies of superior cervical ganglion neurons of April^−/− mice reveal that TWE-PRIL is a physiological regulator of NGF-promoted sympathetic axon growth, acting as a reverse signalling receptor.

How events in emergency medicine impact doctors' psychological well-being

Background

Emergency medicine is a high-pressured specialty with exposure to disturbing events and risk. We conducted a qualitative study to identify which clinical events resulted in emotional disruption and the impact of these events on the well-being of physicians working in an ED.

Methods

We used the principles of naturalistic inquiry to conduct narrative interviews with physicians working in the ED at Central Manchester University Hospitals NHS Foundation Trust, between September and October 2016. Participants were asked, ‘Could you tell me about a time when an event at work has continued to play on your mind after the shift in which it occurred was over?’ Data were analysed using framework analysis. The study had three a priori themes reported here. Other emergent themes were analysed separately.

Results

We interviewed 17 participants. Within the first a priori theme (‘clinical events’) factors associated with emotional disruption included young or traumatic deaths, patients or situations that physicians could relate to, witnessing the impact of death on relatives, the burden of responsibility (including medical error) and conflict in the workplace. Under theme 2 (psychological and physical effects), participants reported substantial upset leading to substance misuse, sleep disruption and neglecting their own physical needs through preoccupation with caring. Within theme 3 (impact on relationships), many interviewees described becoming withdrawn from personal relationships following clinical events, while others described feeling isolated because friends and family were non-medical.

Conclusions

Clinical events encountered in the ED can affect a physician’s psychological and physical well-being. For many participants these effects were negative and long lasting.

A pilot randomised controlled trial investigating a mindfulness-based stress reduction (MBSR) intervention in individuals with pulmonary arterial hypertension (PAH): the PATHWAYS study

BACKGROUND

Pulmonary arterial hypertension (PAH) is an uncommon condition with progressive heart failure and premature death. Treatment costs up to £120,000 per patient per year, and the psychological burden of PAH is substantial. Mindfulness-based stress reduction (MBSR) is an intervention with the potential to reduce this burden, but to date, it has not been applied to people with pulmonary hypertension. We wished to determine whether a trial of MBSR for people with PAH would be feasible.

METHODS

A customised gentle MBSR programme of eight sessions was developed for people with physical disability due to PAH, and they were randomised to group-based MBSR or treatment as usual. The completeness of outcome measures including Beck Anxiety Index, Beck Depression Inventory and standard physical assessment at 3 months after randomisation were recorded. Health care utilisation was measured. Attendance at the sessions and the costs involved in delivering the intervention were assessed. Semi-structured interviews were conducted to explore the acceptability of the MBSR intervention and when appropriate the reasons for trial non-participation.

RESULTS

Fifty-two patients were recruited, but only 34 were randomised due to patients finding it difficult to travel to sessions. Twenty-two completed all questionnaires and attended all clinics, both routine and additional in order to collect outcomes measures. The MSBR sessions were delivered in Bristol, Cardiff and London, costing, on average, between £2234 (Cardiff) and £4128 (London) per patient to deliver. Attendance at each session averaged between two patients in Bristol and Cardiff and three in London. For those receiving treatment as usual, clinician blinding was achievable. Interviews revealed that people who attended MBSR found it interesting and helpful in managing their symptoms and minimising the psychological component of their disease.

CONCLUSIONS

We found that attendance at group MBSR was poor in people with chronic PAH within the context of a trial. Achieving better MBSR intervention attendance or use of an Internet-based programme might maximise the benefit of MBSR.

Characteristics of people with severe mental illness who obtain employment

Aims and method

We explored sociodemographic and clinical factors associated with obtaining employment for people with severe mental illness. Standardised validated interviews and questionnaires were administered to participants who had been recruited into a randomised controlled trial of supported employment.

Results

Older age and diagnosis of schizophrenia were found to be independent predictors of unemployment in the previous year. Other factors of unemployment such as ethnicity and educational level were not associated with obtaining employment.

Clinical implications

Older people and those with a diagnosis of schizophrenia may need additional targeted help in obtaining employment if they are to be helped to meet their vocational aims. Further research is needed to determine how this can be done most effectively.

Cross-sectional interview study of fertility, pregnancy, and urogenital schistosomiasis in coastal Kenya: Documented treatment in childhood is associated with reduced odds of subfertility among adult women

Background

Previous research has documented an increased risk of subfertility in areas of sub-Saharan Africa, as well as an ecological association between urogenital schistosomiasis prevalence and decreased fertility. This pilot project examined reproductive patterns and the potential effects of childhood urogenital Schistosoma haematobium infection and individual treatment experience on adult subfertility among women who were long-term residents in an S. haematobium-endemic region of coastal Kenya.

Methodology/Principal findings

We analyzed findings from 162 in-depth interviews with women of childbearing age in a rural, coastal community, linking them, if possible, to their individual treatment records from previous multi-year longitudinal studies of parasitic infections. Reproductive histories indicated a much local higher local rate of subfertility (44%) than worldwide averages (8–12%). Although, due to the very high regional prevalence of schistosomiasis, a clear relationship could not be demonstrated between a history of S. haematobium infection and adult subfertility, among a convenience sub-sample of 61 women who had received documented treatment during previous interventional trials, a significant association was found between age at first anti-schistosomal treatment and later fertility in adulthood, with those women treated before age 21 significantly less likely to have subfertility (P = 0.001).

Conclusions/Significance

The high subfertility rate documented in this pilot study suggests the importance of programs to prevent and treat pelvic infections in their early stages to preclude reproductive tract damage. The available documented treatment data also suggest that early anti-schistosomal treatment may prevent the fertility-damaging effects of urogenital schistosomiasis, and lend support for programs that provide universal treatment of children in S. haematobium-endemic regions.

Infertility is an unwelcome complication of many infectious diseases. In sub-Saharan Africa, where women experience the highest rates of subfertility in the world, the helminthic parasite Schistosoma haematobium, is also highly prevalent. Chronic and repeated infections with S. haematobium cause inflammation of the pelvic organs and kidneys, a condition known as urogenital schistosomiasis. Past studies have statistically linked past and present S. haematobium infection to the risk of infection-associated female genital lesions and with risk for subfertility in adulthood. The present study used in-depth interviews to document reproductive health histories of 162 women, aged 15 to 62, residing in an S. haematobium-endemic area of coastal Kenya, in order to examine the association of their earlier anti-schistosomal treatment with their fertility patterns. A self-reported history of past treatment was not associated with lower odds of infertility. However, among 61 with verified treatments given during previous local campaigns, it was found that women who were treated before age 21 experienced significantly fewer period of subfertility during their adult life. The findings suggest that anti-schistosomal treatment during childhood may prevent the fertility-damaging effects of urogenital schistosomiasis. They also lend support for programs that provide universal treatment of children in S. haematobium-endemic regions.

Social-media-enabled learning in emergency medicine: a case study of the growth, engagement and impact of a free open access medical education blog

Background

Clinicians are increasingly using social media for professional development and education. In 2012, we developed the St.Emlyn’s blog, an open access resource dedicated to providing free education in the field of emergency medicine.

Objective

To describe the development and growth of this international emergency medicine blog.

Method

We present a narrative description of the development of St.Emlyn’s blog. Data on scope, impact and engagement were extracted from WordPress, Twitter and Google Analytics.

Results

The St.Emlyn’s blog demonstrates a sustained growth in size and user engagement. Since inception in 2012, the site has been viewed over 1.25 million times with a linear year-on-year growth. We have published over 500 blog posts, each of which attracts a mean of 2466 views (range 382–69 671). The site has been viewed in nearly every country in the world, although the majority (>75%) of visitors come from the USA, UK and Australia.

Summary

This case study of an emergency medicine blog quantifies the reach and engagement of social-media-enabled learning in emergency medicine.

TNF superfamily member APRIL enhances midbrain dopaminergic axon growth and contributes to the nigrostriatal projection in vivo

We have studied the role of the tumor necrosis factor superfamily member APRIL in the development of embryonic mouse midbrain dopaminergic neurons in vitro and in vivo. In culture, soluble APRIL enhanced axon growth during a window of development between E12 and E14 when nigrostriatal axons are growing to their targets in the striatum in vivo. April transcripts were detected in both the striatum and midbrain during this period and at later stages. The axon growth–enhancing effect of APRIL was similar to that of glial cell-derived neurotrophic factor (GDNF), but in contrast to GDNF, APRIL did not promote the survival of midbrain dopaminergic neurons. The effect of APRIL on axon growth was prevented by function-blocking antibodies to one of its receptors, BCMA (TNFRSF13A), but not by function-blocking antibodies to the other APRIL receptor, TACI (TNFRSF13B), suggesting that the effects of APRIL on axon growth are mediated by BCMA. In vivo, there was a significant reduction in the density of midbrain dopaminergic projections to the striatum in April −/− embryos compared with wild type littermates at E14. These findings demonstrate that APRIL is a physiologically relevant factor for the nigrostriatal projection. Given the importance of the degeneration of dopaminergic nigrostriatal connections in the pathogenesis and progression of Parkinson's disease, our findings contribute to our understanding of the factors that establish nigrostriatal integrity.

Zeb2 is a negative regulator of midbrain dopaminergic axon growth and target innervation

Neural connectivity requires neuronal differentiation, axon growth, and precise target innervation. Midbrain dopaminergic neurons project via the nigrostriatal pathway to the striatum to regulate voluntary movement. While the specification and differentiation of these neurons have been extensively studied, the molecular mechanisms that regulate midbrain dopaminergic axon growth and target innervation are less clear. Here we show that the transcription factor Zeb2 cell-autonomously represses Smad signalling to limit midbrain dopaminergic axon growth and target innervation. Zeb2 levels are downregulated in the embryonic rodent midbrain during the period of dopaminergic axon growth, when BMP pathway components are upregulated. Experimental knockdown of Zeb2 leads to an increase in BMP-Smad-dependent axon growth. Consequently there is dopaminergic hyperinnervation of the striatum, without an increase in the numbers of midbrain dopaminergic neurons, in conditional Zeb2 (Nestin-Cre based) knockout mice. Therefore, these findings reveal a new mechanism for the regulation of midbrain dopaminergic axon growth during central nervous system development.

BET 1: Lidocaine with propofol to reduce pain on injection

A short review was carried out to see if mixing lidocaine with propofol is a safe and effective method in reducing the commonly reported pain at the injection site. Four relevant papers were found using the described search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. Although a promising idea, a paucity of good quality evidence suggests further needed research.

BET 1: IN PATIENTS WITH SUSPECTED ACUTE CORONARY SYNDROME, DOES WELLENS' SIGN ON THE ELECTROCARDIOGRAPH IDENTIFY CRITICAL LEFT ANTERIOR DESCENDING ARTERY STENOSIS?

Wellens' syndrome consists of a history suggestive of an acute coronary syndrome and biphasic or deeply inverted T waves in ECG leads V2-V3. A shortcut review was carried out to establish whether this ECG pattern identifies patients with a critical left anterior descending artery stenosis. Six relevant papers were found. The clinical bottom line is that biphasic T-wave inversion in lead V2-V3 should alert the clinician to a probable critical stenosis of the left anterior descending artery.

BET 1: Does apnoeic oxygenation reduce the risk of desaturation in patients requiring endotracheal intubation?

A shortcut review of the literature was carried out to establish whether the use of apnoeic oxygenation technique during endotracheal intubation reduces the incidence of critical desaturation. Four trials were found to be directly relevant to the three-part question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that there is emerging evidence that the use of apnoeic oxygenation decreases the incidence of critical desaturation during endotracheal intubation. Due to the heterogeneity of trials, however, further well-constructed and emergency department (ED)-based studies are probably warranted before conclusion can be drawn for daily emergency medicine practice.

Confirming improved detection of gadolinium in bone using in vivo XRF

The safety of using Gd in MRI contrast agents has recently been questioned, due to recent evidence of the retention of Gd in individuals with healthy renal function. Bone has proven to be a storage site for Gd, as unusually high concentrations have been measured in femoral heads of patients undergoing hip replacement surgery, as well as in autopsy samples. All previous measurements of Gd in bone have been invasive and required the bone to be removed from the body. X-ray fluorescence (XRF) offers a non-invasive and non-destructive method for carrying out in vivo measurements of Gd in humans. An updated XRF system provides improved detection limits in a short measurement time of 30-min. A new four-detector system and higher activity Cd-109 excitation source of 5GBq results in minimum detection limits (MDLs) of 1.64-1.72μgGd/g plaster for an average overlaying tissue thickness of the tibia. These levels are well within the range of previous in vitro Gd measurements. Additional validation through comparison with ICP-MS measurements has confirmed the ability of the XRF system for detecting Gd further, proving it is a feasible system to carry out human measurements.