Retaining dermatology patients in primary care through dialogue with secondary care providers: A service evaluation

BACKGROUND

There are long patient waiting lists for specialist care. A dermatology dialogue service between primary and secondary care (DDPS) was developed in eastern England. Primary care referrers uploaded patient images of skin conditions for review by and dialogue with consultant dermatologists in an attempt to retain patients in primary care rather than refer them to secondary care.

METHODS

Evaluation of service performance against specific targets, including reduction in secondary care waiting list growth over the period April 2021-March 2022 inclusive. Service activity was summarized in terms of speed of resolution, case numbers, and dispositions. Clinician and patient satisfaction were assessed using structured questionnaires. Actual numbers of new referrals were compared to projections based on historical data. Waiting list growth was compared to other specialties and other commissioning areas. Waiting times to initial treatment were monitored.

RESULTS

Over 3300 patients were enrolled and > 90% of dialogues were resolved within 36 hours. Clinician and patient satisfaction were high. Frequently asked questions and conditions were highlighted by dermatologists to design and deliver an educational event for primary care clinicians that was well received. Waiting list growth for dermatology patients in the commissioning area was smaller than for other major specialties, and generally smaller than growth for dermatology waiting lists commissioned by other NHS commissioners. There was no negative impact on the urgent priority (cancer pathway) waiting list.

CONCLUSION

The DDPS was satisfactory for clinicians and patients and coincided with lower growth in dermatology waiting lists than might otherwise have been expected.

Evaluation of high dose N- Acetylcysteine on airway inflammation and quality of life outcomes in adults with bronchiectasis: A randomised placebo-controlled pilot study

BACKGROUND

High dose N acetylcysteine (NAC), a mucolytic, anti-inflammatory and antioxidant agent has been shown to significantly reduce exacerbations, and improve quality of life in placebo controlled, double blind randomised (RCT) studies in patients with COPD, and in an open, randomised study in bronchiectasis. In this pilot, randomised, double-blind, placebo-controlled study, we wished to investigate the feasibility of a larger clinical trial, and the anti-inflammatory and clinical benefits of high dose NAC in bronchiectasis.

AIMS

Primary outcome: to assess the efficacy of NAC 2400 mg/day at 6 weeks on sputum neutrophil elastase (NE), a surrogate marker for exacerbations. Secondary aims included assessing the efficacy of NAC on sputum MUC5B, IL-8, lung function, quality of life, and adverse effects.

METHODS

Participants were randomised to receive 2400 mg or placebo for 6 weeks. They underwent 3 visits: at baseline, week 3 and week 6 where clinical and sputum measurements were assessed.

RESULTS

The study was stopped early due to the COVID pandemic. In total 24/30 patients were recruited, of which 17 completed all aspects of the study. Given this, a per protocol analysis was undertaken: NAC (n = 9) vs placebo (n = 8): mean age 72 vs 62 years; male gender: 44% vs 50%; baseline median FEV11.56 L (mean 71.5 % predicted) vs 2.29L (mean 82.2% predicted). At 6 weeks, sputum NE fell by 47% in the NAC group relative to placebo (mean fold difference (95%CI: 0.53 (0.12,2.42); MUC5B increased by 48% with NAC compared with placebo. Lung function, FVC improved significantly with NAC compared with placebo at 6 weeks (mean fold difference (95%CI): 1.10 (1.00, 1.20), p = 0.045. Bronchiectasis Quality of life measures within the respiratory and social functioning domains demonstrated clinically meaningful improvements, with social functioning reaching statistical significance. Adverse effects were similar in both groups.

CONCLUSION

High dose NAC exhibits anti-inflammatory benefits, and improvements in aspects of quality of life and lung function measures. It is safe and well tolerated. Further larger placebo controlled RCT's are now warranted examining its role in reducing exacerbations.

Effect of water calcium, copper, and silver on branchial Na+ permeability in a characid and cichlid fish

We tested the hypothesis that water Ca2+ is involved in control of branchial Na+ permeability in low pH tolerant convict cichlids and black neon tetras. We measured Na+ efflux in water with different Ca2+ concentrations during exposure to low pH, silver, and copper, at levels which are known to stimulate Na+ efflux. For convict cichlids at pH 7.5 exposure to 0 μmol L-1 Ca2+caused Na+ efflux to rise 2.5 times above controls at 100 μmol L-1 Ca2+. However, raising [Ca2+] to 500 μmol L-1 had no effect. Upon exposure to pH 3.5 (control [Ca2+]) Na+ efflux rose almost 5× and increasing the [Ca2+] 5-fold did not reduce the magnitude of stimulation. Exposure to 1 μmol L-1 silver and 25 μmol L-1 copper stimulated Na+ efflux 7×, and 2×, respectively. Raising [Ca2+] concentration during metal exposure halved the stimulation of Na+ efflux caused by silver, and eliminated the stimulation elicited by copper. For black neon tetras raising or lowering water [Ca2+] had no effect on Na+ efflux at pH 7.5. Exposure to pH 3.5 caused Na+ efflux to rise 2.5× but changing [Ca2+] had no effect. Exposure to 1 μmol L-1 silver, or 25 μmol L-1 copper caused Na+ efflux of tetras to rise 4-fold and 3-fold, respectively. Raising [Ca2+] during silver exposure reduced the stimulation of Na+ efflux by about 50%, but during copper exposure increased [Ca2+] had no effect on stimulation of Na+ efflux. These results suggest water Ca2+ plays a role in control of branchial Na+ permeability in cichlids, but perhaps not tetras. In addition, the silver and copper concentrations required to inhibit Na+ uptake and stimulate Na+ efflux were higher than the concentrations used on non-characids and non-cichlids, which indicates that our fish are much more tolerant of these metals.

Effect of Electron-donating Group on NO Photolysis of {RuNO}6 Ruthenium Nitrosyl Complexes with N2 O2 Lgands Bearing π-Extended Rings

In this study, we introduced the electron-donating group (-OH) to the aromatic rings of Ru(salophen)(NO)Cl (0) (salophenH2 =N,N'-(1,2-phenylene)bis(salicylideneimine)) to investigate the influence of the substitution on NO photolysis and NO-releasing dynamics. Three derivative complexes, Ru((o-OH)2 -salophen)(NO)Cl (1), Ru((m-OH)2 -salophen)(NO)Cl (2), and Ru((p-OH)2 -salophen)(NO)Cl (3) were developed and their NO photolysis was monitored by using UV/Vis, EPR, NMR, and IR spectroscopies under white room light. Spectroscopic results indicated that the complexes were diamagnetic Ru(II)-NO+ species which were converted to low-spin Ru(III) species (d5 , S=1/2) and released NO radicals by photons. The conversion was also confirmed by determining the single-crystal structure of the photoproduct of 1. The photochemical quantum yields (ΦNO s) of the photolysis were determined to be 0>1, 2, 3 at both the visible and UV excitations. Femtosecond (fs) time-resolved mid-IR spectroscopy was employed for studying NO-releasing dynamics. The geminate rebinding (GR) rates of the photoreleased NO to the photolyzed complexes were estimated to be 0≃1, 2, 3. DFT and TDDFT computations found that the introduction of the hydroxyl groups elevated the ligand π-bonding orbitals (π (salophen)), resulting in decrease of the HOMO-LUMO gaps in 1-3. The theoretical calculations suggested that the Ru-NNO bond dissociations of the complexes were mostly initiated by the ligand-to-ligand charge transfer (LLCT) of π(salophen)→π*(Ru-NO) with both the visible and UV excitations and the decreasing ΦNO s could be explained by the changes of the electronic structures in which the photoactivable bands of 1-3 have relatively less contribution of transitions related with Ru-NO bond than those of 0.

Outcomes of Brain Metastases with Suspicious Imaging Undergoing Resection to Evaluate for Radionecrosis vs. Tumor Progression

PURPOSE/OBJECTIVE(S)

In patients treated with stereotactic radiosurgery (SRS) for brain metastases, radiographic changes on surveillance imaging may result from treatment effect/radionecrosis (RN) or tumor progression. Distinguishing between these processes is critical to appropriate management. We report long-term outcomes for a cohort of patients who demonstrated radiographic progression on serial imaging after initial radiation and ultimately underwent resection to inform further management.

MATERIALS/METHODS

A retrospective chart review identified 76 patients with an associated 82 brain lesions between 2009 and 2022 that were initially treated with SRS, then demonstrated suspicious imaging changes developing through at least two scan time points that led to pathologic confirmation of either tumor or RN. We report clinical outcomes and details of further treatments.

RESULTS

Of the 82 lesions, 55 (67.1%) were found to be pathologically-confirmed viable tumor and were treated with repeat radiation and 27 (32.9%) were found to be strictly RN and conservatively managed. Over half of the lesions (14/27) ultimately found to be radionecrotic required use of steroids pre-operatively due to neurologic symptoms. Among the 27 that were found to be RN, the most common histology was melanoma (33.3%, n = 9). The most common dose fractionation regimen was 20 Gy in 1 fx (n = 11, 40.7%; range: 16-20 Gy x 1Fx), and the median BED (10) was 50.4 Gy (IQR 41.6 - 50 Gy). None of these lesions required further intervention with median post-surgery follow up of 24.4 months (range 1-104 months). There were 55 instances (in 51 patients) of pathologically-confirmed recurrent/progressive tumor who were consequently treated with repeat radiation with either Cs-131 brachytherapy (12 (21.8%)) or SRS (43 (78.2%)). The most common histology was NSCLC (37.2%, n = 19). The most common fractionation for repeat irradiation with SRS was 8 Gy x 3 fx (n = 15, 27.3%), followed by 5 Gy x 5 fx (n = 10, 18.2%), and 4 Gy x 5 fx (n = 8, 14.6%). Four individuals each had two lesions that were re-irradiated for local recurrence. Among patients treated with re-irradiation, the median follow-up to local failure was 15.2 months (95% CI 7.3-26.6 months). Radionecrosis was confirmed on pathology in 4/55 (7.2%) of lesions. The median follow-up from date of SRS2 to local failure was 14.1 months (95% CI 7.6-24.3 months). The 2-yr local control rate was 74.8% (95% CI 61.7-90.7%).

CONCLUSION

We recommend cautious monitoring of possible progression after radiosurgery, with consideration of resection for continuous progression, as a significant proportion of radiographic progression are ultimately pure RN. Management determined by pathology (observation for RN; additional radiation for confirmed tumor) leads to excellent control.

MRI Guided Adaptive Radiotherapy (MRgART) in Primary and Metastatic Liver Lesions

PURPOSE/OBJECTIVE(S)

The role of stereotactic body radiotherapy (SBRT) in the management of primary hepatic and metastatic tumors has increased significantly over the past few years. MR-Linac is rapidly gaining evidence in the delivery of ablative doses using MR guided adaptive radiotherapy (MRgART) with improved accuracy and dose coverage to the lesions. We report local control and toxicity of patients with primary and metastatic liver lesions treated with MR guided adaptive SBRT.

MATERIALS/METHODS

All patients were treated with MRgART on the Unity 1.5T MR Linacs at two institutions and consented to the ADAPT-MRL study (1). A 4DCT and MRI with abdominal compression were obtained at simulation and the primary MRI sequence used for online treatment included a T2 3D navigated scan. A balanced turbo field echo (btFFE) 2D cine motion scan was also acquired at every fraction to determine movement of the tumor to aid in internal target volume margin. All plans were treated with SBRT prescribed to 3-5 alternate daily fractions. Acute toxicity was reported according to Common Terminology Criteria for Adverse Events version 5 (CTCAE) v.5. Patient demographics, prescribed dose fractionation, acute toxicity and clinical response at 6 months were analyzed. Clinical response to treatment was measured according to RECIST criteria 1.1.

RESULTS

Between February 2021 to January 2023 a total of 30 patients were treated with 149 fractions to the liver. Patients were majority male (70%) with a median age of 66 (range 36-83). 16 patients were treated for primary hepatocellular carcinoma (HCC) of the liver and 14 patients for metastatic liver lesions. The median prescribed dose was 48 Gy (range 30-50Gy) in median 5 fractions (range (3-5 fractions). All patients completed treatment with no interruptions. The mean time from 'patient setup' to 'beam-off' was 52.6 minutes (range 37-73 minutes). Data on acute toxicity at 3 month follow up was available for 28 patients. Of these patients 7/28 (25%) had grade 1 or 2 toxicity and no >/ = grade 3 toxicity was reported. Clinical response at 6 months was available for 18 patients and showed complete response in 44% (8/18), partial response in 22% (4/18), stable disease in 22% (4/18) and progressive disease in 11.1% (2/18).

CONCLUSION

Our experience on MRgART to the liver has shown good local control and minimal acute toxicity in the treatment of primary and metastatic liver lesions. We continue to collect data on patient reported outcomes, clinical response and toxicity to determine the feasibility and safety of this system.

Dynamics of Irreversible NO Release from Photoexcited Molsidomine

Molsidomine (SIN-10), an orally administered NO-delivery drug for vasodilation, cannot be used to alleviate hypertensive crisis because it releases NO at a slow rate. SIN-10 may be used to treat sudden cardiac abnormalities if the rapid and immediate release of NO is achieved via photoactivation. The photodissociation dynamics associated with the NO release process from SIN-10 in CHCl₃ was investigated using time-resolved infrared spectroscopy. Approximately 41% of photoexcited SIN-10 at 360 nm decomposed into CO₂, CH₂CH₃ radical, and the remaining radical fragment [SIN-1A(-H)] with a time constant of 43 ps. All SIN-1A(-H) released NO spontaneously with a time constant of 68 ns, becoming N-morpholino-aminoacetonitrile, resulting in 41% for the quantum yield of immediate NO release from SIN-10. The results obtained can be used to realize the quantitative control of the NO administration at a specific time, and SIN-10 can be potentially used to address the phenomenon of hypertensive crisis.

Rotational Isomerization of Carbon-Carbon Single Bonds in Ethyl Radical Derivatives in a Room-Temperature Solution

The rotational isomerization of 1,2-disubstituted ethyl radical derivatives, reaction intermediates often found in the reaction of 1,2-disubstituted ethane derivatives, has never been measured because of their short lifetime and ultrafast rotation. However, the rotational time constant is critical for understanding the detailed reaction mechanism involving these radicals, which determine the stereoisomers of compounds produced via the intermediates. Using time-resolved infrared spectroscopy, we found that the CF₂BrCF₂ radical in a CCl₄ solution rotationally isomerizes with a time constant of 47 ± 5 ps at 280 ± 2 K. From this value and the rotational barrier heights of related compounds, CH₃CH₂ and CH₃CH₂CHCH₃ radicals in CCl₄ were estimated to rotationally isomerize within 1 ps at 298 K, considerably faster than ethane and n-butane, which rotationally isomerize with time constants of 1.8 and 81 ps, respectively. The time constant for the rotational isomerization was similar to that calculated using transition state theory with a transmission coefficient of 0.75.

P11.65.B GBM AGILE: A global, phase 2/3 adaptive platform trial to evaluate multiple treatment regimens in newly diagnosed and recurrent glioblastoma

Background

GBM AGILE (Glioblastoma Adaptive, Global, Innovative Learning Environment) is a biomarker based, multi-arm, international, seamless Phase 2/3 Response Adaptive Randomization platform trial designed to rapidly identify experimental therapies that improve overall survival and confirm efficacious experimental therapies and associated biomarker signatures to support new drug approvals and registration. It is a collaboration between academic investigators, patient organizations and industry, under the sponsorship of the non-profit organization, Global Coalition for Adaptive Research, to support new drug applications for newly diagnosed and recurrent GBM.

Material and Methods

The primary objective of GBM AGILE is to identify therapies that effectively improve overall survival in patients with newly diagnosed or recurrent GBM. Bayesian response adaptive randomization is used within subtypes of the disease to assign participants to investigational arms based on their performance. Operating under a master protocol, GBM AGILE allows multiple drugs from different pharmaceutical companies to be evaluated simultaneously and/or over time against a common control arm. Based on performance, a drug may graduate and move to a Stage 2 (Phase 3) within the trial, and the totality of the data can be used for a new drug application and registration process. New experimental therapies are added as information about promising new drugs is identified while other therapies are removed as they complete their evaluation. The master protocol/ trial infrastructure includes efficiencies through an adaptive trial design, shared control arm and operational processes such as risk-based monitoring and enhanced remote activities. With its adaptable structure, GBM AGILE has continued trial activation, inclusion of new investigational therapies, and enrollment globally through the challenges of a global pandemic.GBM AGILE provides an efficient mechanism to screen and develop robust information regarding the efficacy of proposed novel therapeutics and associated biomarkers for GBM and to quickly move therapies and biomarkers into clinic. GBM AGILE received initial approval from the United States FDA in April 2019, and in Europe through the Voluntary Harmonization Procedure (VHP) in April, 2021. As of 2022, AGILE has screened over 1000 patients studying multiple investigational treatments. Enrollment rates are 3 to 4 times greater than traditional GBM trials, with active sites averaging 0.75 to 1 patients/site/month.

Currently, there are 41 sites activated in the US, 4 in Canada and 2 in Switzerland and an estimated 24 sites yet to open in Germany, France, Switzerland, Italy and Austria. In addition to the continued expansion in Europe, effort is undergoing to extend the trial to China and Australia as well. Clinical trial information: NCT03970447

A cross-cultural comparison of sleep patterns between typically developing children and children with ASD living in Saudi Arabia and the United Kingdom

BACKGROUND

Sleep is crucial for child development, especially for children with ASD. While it is known that children with ASD experience more severe sleep problems and that these problems tend to persist compared to their typically developing counterparts, these findings tend to come from only Western countries. A cross-cultural study is important to understand if the prevailing understanding of sleep in children with ASD can be extended to different cultural backgrounds.

AIM

A cross-cultural study is conducted, involving typically developing children and children with ASD aged 5-12 across two countries: Saudi Arabia and the United Kingdom.

METHODS AND PROCEDURES

Using a combination of questionnaires measuring ASD severity (CARS-2), sleep quality (CSHQ), sociodemographic and lifestyle variables and sleep diaries, 244 children were sampled using a mixture of snowball and convenience sampling methods.

OUTCOMES AND RESULTS

Children with ASD experience more sleep problems compared to typically developing children in Saudi Arabia, and these problems similarly persist across time. Specifically, it was found that children with ASD in Saudi Arabia experience greater sleep onset latency and a greater number of night awakenings. Additionally, across the ASD groups, it was found that children from Saudi Arabia generally experienced poorer sleep than children in the United Kingdom in terms of shorter sleep duration, although children in the United Kingdom tended to report more instances of sleep anxiety and parasomnias.

CONCLUSIONS AND IMPLICATIONS

Several reasons such as parental education about sleep hygiene, cultural influences and social hours were put forward as potential explanations for cross-cultural differences. Findings served to emphasise the importance of culturally-appropriate interventions and public education regarding child sleep.

Visible-light NO photolysis of ruthenium nitrosyl complexes with N2O2 ligands bearing π-extended rings and their photorelease dynamics

NO photorelease and its dynamics for two {RuNO}⁶ complexes, Ru(salophen)(NO)Cl (1) and Ru(naphophen)(NO)Cl (2), with salen-type ligands bearing π-extended systems (salophenH₂ = N,N'-(1,2-phenylene)-bis(salicylideneimine) and naphophenH₂ = N,N'-1,2-phenylene-bis(2-hydroxy-1-naphthylmethyleneimine)) were investigated. NO photolysis was performed under white room light and monitored by UV/Vis, EPR, and NMR spectroscopies. NO photolysis was also performed under 459 and 489 nm irradiation for 1 and 2, respectively. The photochemical quantum yields of the NO photolysis (Φ_NO) of both 1 and 2 were determined to be 9% at the irradiation wavelengths. The structural and spectroscopic characteristics of the complexes before and after the photolysis confirmed the conversion of diamagnetic Ru(II)(L)(Cl)-NO⁺ to paramagnetic S = ½ Ru(III)(L)(Cl)-solvent by photons (L = salophen^2- and naphophen^2-). The photoreleased NO radicals were detected by spin-trapping EPR. DFT and TDDFT calculations found that the photoactive bands are configured as mostly the ligand-to-ligand charge transfer (LLCT) of π(L) → π*(Ru-NO), suggesting that the NO photorelease was initiated by the LLCT. Dynamics of NO photorelease from the complexes in DMSO under 320 nm excitation were investigated by femtosecond (fs) time-resolved mid-IR spectroscopy. The primary photorelease of NO occurred for less than 0.32 ps after the excitation. The rate constants (k_-1) of the geminate rebinding of NO to the photolyzed 1 and 2 were determined to be (15 ps)^-1 and (13 ps)^-1, respectively. The photochemical quantum yields of NO photolysis (Φ_NO, λ = 320 nm) were estimated to be no higher than 14% for 1 and 11% for 2, based on the analysis of the fs time-resolved IR data. The results of fs time-resolved IR spectroscopy and theoretical calculations provided some insight into the overall kinetic reaction pathway, localized electron pathway or resonance pathway, of the NO photolysis of 1 and 2. Overall, our study found that the investigated {RuNO}⁶ complexes, 1 and 2, with planar N₂O₂ ligands bearing π-extended rings effectively released NO under visible light.

Photoexcitation dynamics of bromodiphenyl ethers in acetonitrile-d3 studied by femtosecond time-resolved infrared spectroscopy

The efficient decomposition of polybrominated diphenyl ethers (PBDEs), onetime prevalent flame retardants, is central to the reduction of their harmful effects on human health. PBDE photodecomposition is a promising method, but its mechanism and products are not well understood. The photoexcitation dynamics of 3- and 4-bromodiphenyl ethers (BDE-2 and BDE-3) in CD₃CN were studied from 0.3 ps to 10 μs using time-resolved infrared spectroscopy. An excitation at 267 nm dissociated the Br atom from BDE-2 and BDE-3 within 0.3 ps and 14 ± 3 ps, respectively, producing a radical compound (R) and a Br atom. About 85% of R formed an intermediate (IM) that weakly interacted with the Br atom and the surrounding CD₃CN solvent in 7-12 ps. The remaining R separated from the dissociated Br and underwent slow geminate rebinding (GR) with Br within 35 to 54 ns. The IM competitively engaged in GR with the interacting Br in 40-60 ps or formed CD₃CN-bound radical compounds (RS) in 100-130 ps. The RS further degraded via either the dissociation of CD₃-producing a cyano-bound diphenyl ether (DE) in 150 or 550 ns-or the deuterium abstraction of CD₃CN in 180 or 430 ns-producing a deuterated DE. Overall, 33 ± 3 (22 ± 3)% of the photoexcited BDE-2 (BDE-3) decomposed in CD₃CN under 267 nm excitation. Efficient binding of the CD₃CN solvent to R deterred the yield-diminishing GR and slowed the rate of product formation. The observed photoexcitation dynamics of BDE suggest methods for the efficient decomposition of PBDE.

Midwavelength Infrared Colloidal Nanowire Laser

Realizing bright colloidal infrared emitters in the midwavelength infrared (or mid-IR), which can be used for low-power IR light-emitting diodes (LEDs), sensors, and deep-tissue imaging, has been a challenge for the last few decades. Here, we present colloidal tellurium nanowires with strong emission intensity at room temperature and even lasing at 3.6 μm (ω) under cryotemperature. Furthermore, the second-harmonic field at 1.8 μm (2ω) and the third-harmonic field at 1.2 μm (3ω) are successfully generated thanks to the intrinsic property of the tellurium nanowire. These unique optical features have never been reported for colloidal tellurium nanocrystals. With the colloidal midwavelength infrared (MWIR) Te nanowire laser, we demonstrate its potential in biomedical applications. MWIR lasing has been clearly observed from nanowires embedded in a human neuroblastoma cell, which could further realize deep-tissue imaging and thermotherapy in the near future.

Characterizing the features and course of psychiatric symptoms in children and adolescents with autoimmune encephalitis

Autoimmune encephalitis (AE) can present like a psychiatric disorder. We aimed to illustrate the psychiatric manifestations, course and management of AE in a paediatric cohort. Neuropsychiatric symptoms, investigations and treatment were retrospectively retrieved in 16 patients (mean age 11.31, SD 2.98) with an AE diagnosis at the liaison psychiatry services in two UK tertiary paediatric centres. Psychiatric presentation was characterised by an acute polysymptomatic (predominantly agitation, anger outbursts/aggressiveness, hallucinations, and emotional lability) onset. Antipsychotics produced side effects and significant worsening of symptoms in four cases, and benzodiazepines were commonly used. This psychiatric phenotype should make clinicians suspect the diagnosis of AE and carefully consider use of treatments.

Modulations of a Metal-Ligand Interaction and Photophysical Behaviors by Hückel-Möbius Aromatic Switching

In organometallic complexes containing π-conjugated macrocyclic chelate ligands, conformational change significantly affects metal-ligand electronic interactions, hence tuning properties of the complexes. In this regard, we investigated the metal-ligand interactions in hexaphyrin mono-Pd(II) complexes Pd[28]M and Pd[26]H, which exhibit a redox-induced switching of Hückel-Möbius aromaticity and subsequent molecular conformation, and their effect on the electronic structure and photophysical behaviors. In Möbius aromatic Pd[28]M, the weak metal-ligand interaction leads to the π electronic structure of the hexaphyrin ligand remaining almost intact, which undergoes efficient intersystem crossing (ISC) assisted by the heavy-atom effect of the Pd metal. In Hückel aromatic Pd[26]H, the significant metal-ligand interaction results in ligand-to-metal charge-transfer (LMCT) in the excited-state dynamics. These contrasting metal-ligand electronic interactions have been revealed by time-resolved electronic and vibrational spectroscopies and time-dependent DFT calculations. This work indicates that the conspicuous modulation of metal-ligand interaction by Hückel-Möbius aromaticity switching is an appealing approach to manipulate molecular properties of metal complexes, further enabling the fine-tuning of metal-ligand interactions and the novel design of functional organometallic materials.

Photodissociation Dynamics of Nitric Oxide from N-Acetylcysteine- or N-Acetylpenicillamine-bound Roussin's Red Ester

The photochemical release of nitric oxide (NO) from a NO precursor is advantageous in terms of spatial, temporal, and dosage control of NO delivery to target sites. To realize full control of the quantitative NO administration from photoactivated NO precursors, it is necessary to have detailed dynamical information on the photodissociation of NO from NO precursors. We synthesized two new water-soluble Roussin's red esters (RREs), [Fe₂(μ-N-acetylcysteine)₂(NO)₄] and [Fe₂(μ-N-acetylpenicillamine)₂(NO)₄], which have five times longer lifetime than the well-known [Fe₂(μ-cysteine)₂(NO)₄]. The photodissociation dynamics of NO from these RREs in water were investigated over a broad time range from 0.3 ps to 10 μs after excitation at 310 and 400 nm using femtosecond time-resolved infrared (IR) spectroscopy. When these RREs are excited, they either release one NO, producing a radical species deficient in one NO (R), [Fe₂(μ-RS)₂(NO)₃], or relax into the ground state without photodeligation via an electronically excited intermediate state (M). R appears immediately after photoexcitation, suggesting that one NO is photodissociated faster than 0.3 ps. A certain fraction of R undergoes geminate recombination (GR) with NO with a time constant of 7-9 ps, while the remaining R competitively binds to the solvent. Solvent-bound R eventually bimolecularly recombines with NO with a rate constant of (1.3-1.6) × 10⁸ M^-1 s^-1. For a given RRE molecule, the fractional yield of M (0.62-0.76) depends on the excitation wavelength (λ_ex); however, the relaxation time of M (6 ± 1 ns) is independent of λ_ex. Although the primary quantum yield of NO photodissociation (Φ₁) was found to be 0.24-0.38, the final yield of NO suitable for other reactions (Φ₂) was reduced to 0.14-0.29 due to the picosecond GR of the dissociated NO with R. Detailed photoexcitation dynamics of RRE can be utilized in the quantitative control of NO administration at a specific site and time, promoting pin-point usage of NO in chemistry and biology. We demonstrate that femtosecond IR spectroscopy combined with quantum chemical calculations is a powerful method for obtaining detailed dynamic information on photoactivated NO precursors such as Φ₁ and Φ₂, the GR yield, and secondary reactions of the nascent photoproducts, which are essential information for the design of efficient photoactivated NO precursors and their quantitative utilization.

Evaluation of N-acetylcysteine dose for the treatment of massive acetaminophen ingestion

METHODS

The use of N-acetylcysteine (NAC) remains the standard of care for treatment of acetaminophen (APAP) toxicity and overdose. Currently, there is growing evidence to suggest that massive acetaminophen overdose is associated with increased hepatotoxicity despite timely administration of NAC. This raises the question as to whether an increased dose of intravenous (IV) NAC should be used in the setting of massive APAP ingestion. This study aimed to evaluate the rate of hepatotoxicity after massive APAP overdose treated with 3 different NAC treatment regimens.

METHODS

This was a retrospective cohort study conducted by electronic medical record review of cases reported to a statewide poison control system between 2007 and 2020. Inclusion criteria were single APAP or APAP combination-medication ingestion; acute massive acetaminophen (APAP) ingestion (defined as APAP concentration ≥ 2 times above the Rumack-Matthew 150 nomogram); received one of the three NAC regimens: standard dose IV NAC, oral (PO) NAC, or high dose IV NAC. The risk of hepatotoxicity was evaluated using a multivariate logistic regression model with standard dose IV NAC as the base variable for comparison.

RESULTS

A total of 373 patients met inclusion for the study. Of those, 135 cases were treated with standard dose IV NAC, 121 cases treated with PO NAC, and 117 cases treated with high dose IV NAC. The risk of developing hepatotoxicity was not statistically significant between the high dose IV NAC (OR 1.05, 95% CI 0.52 - 2.09) or oral NAC (OR 0.69, 95% CI 0.33 - 1.46) when compared to standard dose IV NAC. When adjusted for APAP combination medications, initial APAP ratio, initial elevated AST/ALT, and treatment within 8 h, there remained no difference between treatment regimens.

CONCLUSION

This study was unable to detect a large absolute reduction in the rate of hepatotoxicity after massive APAP ingestion in patients treated with high dose IV NAC or PO NAC when compared to standard dose IV NAC; even when treatment was initiated within 8 h of ingestion.

Dynamics of photodissociation of nitric oxide from S-nitrosylated cysteine and N-acetylated cysteine derivatives in water

Cysteine and N-acetylated cysteine derivatives are ubiquitous in biological systems; they have thiol groups that bind NO to form S-nitrosothiols (RSNOs) such as S-nitrosocysteine (CySNO), S-nitroso-N-acetylcysteine (NacSNO), and S-nitroso-N-acetylpenicillamine (NapSNO). Although they have been utilised as thermally or catalytically decomposing NO donors, their photochemical applications are yet to be fully explored owing to the lack of photodissociation dynamics. To this end, the photoexcitation dynamics of these RSNOs in water at 330 nm were investigated using femtosecond time-resolved infrared (TRIR) spectroscopy over a broad time range encompassing the entire reaction, which includes the primary reaction, secondary reactions of the reaction intermediates, and product formation. We discovered that the acetate and amide groups in these RSNOs have strong vibrational bands sensitive to the bondage of NO and the electronic state of the compound, which facilitates the identification of reaction intermediates involved in photoexcitation. The simplest thiol available with the acetate group-thioglycolic acid-was nitrosylated; it produced S-nitrosothioglycolic acid (TgSNO) and was comparatively investigated. Transient absorption bands in the TRIR spectra of the RSNOs were assigned using quantum chemical calculations. Photoexcited cysteine-related RSNOs either decompose into RS and NO within 0.3 ps after excitation at 330 nm with a primary quantum yield (Φ1) of 0.46-1 or relax into an electronically excited intermediate state lying at 42 ± 3 kcal mol-1 above the ground state, which relaxes into the ground state with a time constant of 460-520 ps. A majority (62-80%) of the RS radical geminately rebinds with NO at a time constant of 3-7 ps. The remaining RS reacts with the neighbouring RSNO, which produces additional NO and RSSR with a (nearly) diffusion-limited rate constant that doubles the amount of NO produced; further, it remarkably extends the time window for the dissociated NO to react with the target compound. The final fraction of NO produced from these RSNOs at 330 nm was 0.32-0.58, and it depends on the geminate rebinding yield and Φ1. The detailed dynamics of the photoexcited RSNO can be utilised in the quantitative application of these RSNOs in practical use and in the synthesis of more efficient photoactivated NO precursors.

An agenda for research and action toward diverse and just futures for life on Earth

Decades of research and policy interventions on biodiversity have insufficiently addressed the dual issues of biodiversity degradation and social justice. New approaches are therefore needed. We devised a research and action agenda that calls for a collective task of revisiting biodiversity toward the goal of sustaining diverse and just futures for life on Earth. Revisiting biodiversity involves critically reflecting on past and present research, policy, and practice concerning biodiversity to inspire creative thinking about the future. The agenda was developed through a 2-year dialogue process that involved close to 300 experts from diverse disciplines and locations. This process was informed by social science insights that show biodiversity research and action is underpinned by choices about how problems are conceptualized. Recognizing knowledge, action, and ethics as inseparable, we synthesized a set of principles that help navigate the task of revisiting biodiversity. The agenda articulates 4 thematic areas for future research. First, researchers need to revisit biodiversity narratives by challenging conceptualizations that exclude diversity and entrench the separation of humans, cultures, economies, and societies from nature. Second, researchers should focus on the relationships between the Anthropocene, biodiversity, and culture by considering humanity and biodiversity as tied together in specific contexts. Third, researchers should focus on nature and economies by better accounting for the interacting structures of economic and financial systems as core drivers of biodiversity loss. Finally, researchers should enable transformative biodiversity research and action by reconfiguring relationships between human and nonhuman communities in and through science, policy, and practice. Revisiting biodiversity necessitates a renewed focus on dialogue among biodiversity communities and beyond that critically reflects on the past to channel research and action toward fostering just and diverse futures for human and nonhuman life on Earth.

An agenda for research and action toward diverse and just futures for life on Earth

Decades of research and policy interventions on biodiversity have insufficiently addressed the dual issues of biodiversity degradation and social justice. New approaches are therefore needed. We devised a research and action agenda that calls for a collective task of revisiting biodiversity toward the goal of sustaining diverse and just futures for life on Earth. Revisiting biodiversity involves critically reflecting on past and present research, policy, and practice concerning biodiversity to inspire creative thinking about the future. The agenda was developed through a 2-year dialogue process that involved close to 300 experts from diverse disciplines and locations. This process was informed by social science insights that show biodiversity research and action is underpinned by choices about how problems are conceptualized. Recognizing knowledge, action, and ethics as inseparable, we synthesized a set of principles that help navigate the task of revisiting biodiversity. The agenda articulates 4 thematic areas for future research. First, researchers need to revisit biodiversity narratives by challenging conceptualizations that exclude diversity and entrench the separation of humans, cultures, economies, and societies from nature. Second, researchers should focus on the relationships between the Anthropocene, biodiversity, and culture by considering humanity and biodiversity as tied together in specific contexts. Third, researchers should focus on nature and economies by better accounting for the interacting structures of economic and financial systems as core drivers of biodiversity loss. Finally, researchers should enable transformative biodiversity research and action by reconfiguring relationships between human and nonhuman communities in and through science, policy, and practice. Revisiting biodiversity necessitates a renewed focus on dialogue among biodiversity communities and beyond that critically reflects on the past to channel research and action toward fostering just and diverse futures for human and nonhuman life on Earth.

555 The Unintended Consequences Of COVID-19 on the Quality of Documentation of Operation-Notes

Introduction

Operation-notes are crucial as they impact on the care of patients post-operatively. During COVID-19, a sizeable proportion of General Surgical procedures were performed at a local “cold” site private hospital. This study aims to determine the direct impact of COVID-19 on the standard of operation-note documentation at a non-routine site compared to our routine site.

Method

The Royal College of Surgeons Good Surgical Practice guidance highlights 19 key-variables to record within operation-notes. 300 consecutive operations were identified between May and August 2020 and details of electronic operation-notes collected. Throughout this study period, educational emails and posters were introduced at both sites secondary to ongoing audit.

Results

228/300 (76%) operations took place at our main hospital. The remainder were commissioned to the other. Operating surgeons and anaesthetists were similar at both sites. Quality of documentation was poorer for many key variables at the cold site when compared with the main site (operating-surgeons (22% vs 91%), urgency of operation (62% vs 99%), antibiotic prophylaxis (72% vs 99%) and DVT prophylaxis (21% vs 98%)).

Conclusions

COVID-19 has resulted in many unintended consequences including a reduction in the quality of operation-notes. Moving forward, this may be reduced by improving information technology resources and increasing awareness and education.

658 An Audit of Frequency of Cancer Genetics Referral in Patients with a Family History of Colorectal Cancer

Introduction

Guidelines on the management of hereditary colorectal cancers were updated in 2019. In this study, data from patients within the colonoscopy surveillance programme for hereditary cancer at York Teaching Hospitals Trust were analysed to assess category of risk and appropriateness of referrals to regional geneticists.

Method

After examination of electronic records and clinical notes, patients were assigned a risk category of average, moderate or high according to the Amsterdam criteria and latest BSG/ACPGBI/UKCGG guidelines. Patients were then assessed to see if a concurrent referral had been made to the regional cancer genetic services.

Results

There were 228 patients. 72(31.6%) patients were in the average, 81(35.5%) in the moderate and 41(18%) were in the high-risk category. 34 (14.9%) patients with insufficient data and/or assessments were in the indeterminate category.

18 of 72 (25%) patients with average risk were unnecessarily referred to the regional genetics team, while 5/41(12%) of high-risk patients were not. A large proportion of patients with insufficient data (19/34, 55.8%) were rightly or wrongly, referred to the regional genetics team.

Conclusions

Assessment of hereditary cancer risk is difficult in the absence of good quality information. Risk assessment may be improved with use of a dedicated family history questionnaire/template - this facilitates identification of high-risk patients that benefit most from referral to geneticists.

913 An Audit of Colonoscopy Compliance Within A Screening Programme for Patients with A Family History of Colorectal Cancer (CRC)

Introduction

Guidelines on the management of hereditary CRC were updated in 2019 and have led to more stringent use of surveillance colonoscopies. Patients with ‘family history’ (FH) CRC Surveillance programme at York Hospitals Trust were studied to assess compliance with colonoscopy recommendations.

Method

Current BSG/ACPGBI guidelines recommend biennial, quinquennial, one-off or no colonoscopy surveillance for patients with Lynch syndrome, and those deemed to have high, moderate, and average risks of developing hereditary cancer, respectively.

Examination of electronic records and clinical notes were performed to determine if they were Lynch positive and/or if they could be assigned a risk category.

Results

Database of 227 patients, of which 14 were high, 61 moderate and 45 were low risk. 47 had Lynch syndrome. Compliance of colonoscopy was poor for patients with average and moderate FH risk (both 0%). Compliance was higher for patients with high risk of FH (50%) and those with Lynch syndrome (57%)

Risk was indeterminate in 24 patients due to inadequate data therefore compliance could not be assessed.

Conclusions

A large proportion of patients with low to moderate ‘FH’ risk within our current surveillance programme had unnecessary colonoscopies. Stratification of patients into the appropriate risk categories optimizes the benefit from surveillance programmes.

Aberrant Brain Signal Variability and COMT Genotype in Chronic TMD Patients

The analysis of brain signal variability is a promising approach to understand pathological brain function related to chronic pain. This study investigates whether blood-oxygen-level-dependent signal variability (BOLD_SV) in specific frequency bands is altered in temporomandibular disorder (TMD) and correlated to its clinical features. Twelve patients with chronic myofascial TMD and 24 healthy controls (HCs) underwent resting-state functional magnetic resonance imaging. The BOLD_SV was measured as the standard deviation of the BOLD time series at each voxel and compared between groups. We also examined the potential relationship between the BOLD_SV and the catechol-O-methyltransferase (COMT) Val¹⁵⁸Met polymorphism. We assessed sensory-discriminative pain in the craniofacial region, pain sensitivity to sustained masseteric pain challenge, and TMD pain frequency for clinical correlation. Patients displayed reduced BOLD_SV in the dorsolateral prefrontal cortex (dlPFC) as compared with HC in all frequency bands. In the slow-3 band, patients also showed reduced BOLD_SV in the medial dorsal thalamus, primary motor cortex (M1), and primary somatosensory cortex (S1) and heightened BOLD_SV in the temporal pole. Notably, we found a significant correlation between lower BOLD_SV (slow-3) in the orofacial M1/S1 regions and higher clinical pain (intensity/area) and higher sensitivity of the masseter muscle pain. Moreover, lower BOLD_SV (slow-3) in the dlPFC and ventrolateral PFC was associated with a higher TMD pain frequency. Participants who had the COMT ¹⁵⁸Met substitution exhibited lower BOLD_SV in the dlPFC and higher BOLD_SV in the temporal pole as compared with participants without the COMT ¹⁵⁸Met substitution. An increasing number of Met alleles was associated with lower dlPFC and greater temporal pole BOLD_SV in both HC and TMD groups. Together, we demonstrated that chronic TMD patients exhibit aberrant BOLD_SV in the top-down pain modulatory and sensorimotor circuits associated with their pain frequency and severity. COMT Val¹⁵⁸Met polymorphism might affect clinical symptoms in association with regional brain signal variability, specifically involved in cognitive and emotional regulation of pain.

Machine learning for predicting AF ablation outcomes using daily heart rhythm data at baseline

Background

While numerous studies have shown that catheter ablation is superior to antiarrhythmic drug (AAD) in treating atrial fibrillation (AF), the long term outcomes have been limited by arrhythmia recurrence. Reliable data and methods to predict ablation outcomes will thus be valuable for treatment planning.

Objective

To evaluate the utility of machine learning and various types of input variables, viz. patient characteristics at baseline, and daily heart rhythm data recorded prior to ablation for outcome prediction.

Methods

We acquired permission to analyze data collected from a randomized clinical trial that recorded daily biomeasures from >345 patients who were referred for first catheter ablation due to AF refractory to at least one AAD. After standardizing the dataset, each patient sample is characterized by a set of daily measures, viz. heart rate variability (HRV) and AF burden (AFB), which is the total minutes in AF per day. We next performed comparative analyses on 19 candidate model variants to evaluate each model's ability in identifying patients who were to experience at least one episode of AF recurrence during post-ablation period starting from day 91 up to day 365 post-ablation, per standard guidelines. We examined: i) use of a set of daily biomeasures jointly with baseline sex and age; and ii) observation lengths of the pre-ablation period. We also examined the use of baseline CHA2DS2-VASc scores, left-atrial volume (LAV), atrial diameter, medical history. We conducted multiple sets of 3-fold cross validation (CV) experiments, each fold independently trained a candidate model with 236 samples (two thirds of the dataset) and performed evaluation on the left-out samples. About 50% of cohort belongs to one class. Each fold scored a model and its input variables in terms of sensitivity (SEN), specificity (SPEC), area under receiver operating characteristic curve (AUC), etc. To circumvent risks of overfitting highly parameterized models to our training subset, we shortlisted 19 models that have few hyper-parameters, e.g. stepwise regression, random forest (RF), linear discriminant analysis (LDA).

Results

CV results demonstrated that LDA and RF gave comparable performances, with RF achieving highest AUC of 0.68±0.06 using 30 days of rhythm data prior to ablation (SEN of 65.9±7.82; SPEC of 66.3±0.57). When observation period extended to 90 days prior, AUC improved to 0.691±0.02. In contrast, use of LAV alone was not adequate to predict outcome (AUC∼0.5), and when combined with all aforementioned baseline variables, the best model achieved AUC of 0.58±0.05. Feature analyses from the trained models suggest that AFB had highest relevance in predicting outcome. Using only daily AFB, RF and LDA respectively achieved AUC of 0.608±0.04 and 0.652±0.04.

Conclusions

Our results suggest the value of pre-ablation rhythm data for improving outcome-prediction. Future work will validate these findings using large public datasets.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Huawei-Data Science Institute Research Program; Natural Sciences and Engineering Research Council of Canada (NSERC)

Photorelease Dynamics of Nitric Oxide from Cysteine-Bound Roussin's Red Ester

Nitric oxide (NO) can either boost or impede the growth of cancer cells depending on its concentration. Therefore, any anticancer treatment using NO requires precisely controlled NO administration to the target cells in terms of dosage and timing. In this context, photochemically activated NO donors were actively explored, but their detailed NO-releasing dynamics, which is crucial for their use, is not known yet. We determined detailed photoexcitation dynamics of a stable, nontoxic, and water-soluble NO precursor, cysteine-bound Roussin's Red Ester (Cys-RRE), including secondary reactions of the nascent photoproducts. The primary quantum yields of the NO dissociation from the photoexcited Cys-RRE were found to be 24-54% depending on the excitation wavelength; however, the geminate rebinding of NO with the nascent radical reduced the level of biologically available NO to as low as 12%. Such information is useful to achieve efficient NO delivery to practical chemical and biological targets.