Aboriginal and Torres Strait Islander youth suicide mortality and previous mental health, suicidality and service use in Queensland, Australia, from 2001 to 2021

BACKGROUND

The current study aimed to compare current suicide rates, trends, previous treatment, suicidality and mental health diagnoses for First Nations and non-Indigenous young people who died by suicide.

METHODS

Age-specific suicide rates (ASSRs) were calculated per 100,000 persons/year using suicides aged 10-19 years in the Queensland Suicide Register. Rate Ratios (RRs) and 95 % CIs compared ASSRs for First Nations and non-Indigenous youth dying by suicide in Queensland, Australia, from 2001 to 2018. Risk ratios (RiskR) with 95 % CIs compared characteristics between First Nations and non-Indigenous youth suicides. Joinpoint regression was used to identify any changes in trends and annual percentage change (APC) in suicides with 95 % CIs.

RESULTS

The First Nations youth ASSR was 24.71 deaths per 100,000 persons/year, 4.5 times the non-Indigenous ASSR (95 % CI = 3.74-5.38, p < 0.001). Both non-Indigenous and First Nations suicide trends were stable with no joinpoints (APC: 0.3 %, 95 % CI: -1.6-2.2, p = 0.78; APC: 0.9 %, 95 % CI: -0.2-2.1, p = 0.11). Less than a quarter (23.9 %) of First Nations young people had ever received mental health treatment, significantly fewer than non-Indigenous youth (RiskR = 0.80, 95 % CI = 0.71-0.90, p < 0.001). Similarly, in the three months preceding their death, only 14.5 % of First Nations young people had received mental health treatment (RiskR = 0.89, 95 % CI = 0.83-97, p = 0.015).

LIMITATIONS

Reported mental illness, suicidality and help-seeking could be underreported due to concealment from family or police.

CONCLUSIONS

The current study finds no change in the gap between the First Nations and Non-Indigenous youth suicide rates nor evidence of decrease in the First Nations youth suicide rate. There is a need for alternative approaches to Indigenous youth suicide prevention, such as assertive outreach models outside of traditional triage and mental health systems to proactively build trusting relationships with young people in communities to identify young people needing support.

"We want to change the system": a qualitative study on emergency medicine physician leadership

OBJECTIVE

The significance of physician leadership to help transform the healthcare system has been increasingly discussed. This study looked at the qualities of emergency medicine (EM) physicians that support or inhibit their work as healthcare leaders.

METHODS

Through an iterative process of semi-structured interviews and then focus groups, we examined why EM physicians pursue leadership roles, the strengths they bring and the frustrations they encounter. Thematic analysis identified factors that facilitate and inhibit the work of EM physicians as they enter leadership roles.

RESULTS

These findings can be summarized in four key themes. (1) A desire to improve the wider health system was often a prime motivator for entering a leadership role. (2) EM physicians' clinical skills such as confident decision-making, relationship building through communication, and comfort with uncertainty supported their successful transition to leadership. (3) EM physician leaders perceived shiftwork as both a potential benefit and a challenge in their leadership role and felt it needed to be carefully managed to ensure personal wellness and success. And (4) participants were not driven to take on leadership positions by financial remuneration but stated that the discrepancy between EM clinical and leadership compensation was a point of stress.

CONCLUSION

As physician leadership is explored as a mechanism to support the healthcare system's success, this project provides insights into the realities experiences by EM physicians and considerations for healthcare professionals as they encourage physicians into leadership positions.

Wellbeing After Finalization of a Workers' Compensation Claim: A Systematic Scoping Review

OBJECTIVE

A workers' compensation claim may have significant negative impacts on an injured worker's wellbeing. Wellbeing provides a good global measure of potential effects of a claim on an individual, and is important for contemporary economic modelling. The purpose of this study was to synthesize knowledge about the wellbeing of injured workers after the finalization of a workers' compensation claim and identify gaps in the current literature.

METHODS

A systematic scoping review was conducted.

RESULTS

71 full-text articles were screened for inclusion, with 32 articles eligible for this review. None of the included articles evaluated overall wellbeing. Included articles did evaluate a variety of constructs inherent in wellbeing. Injured workers were generally disadvantaged in some manner following claim finalization. The literature recommends a focus on reducing negative impacts on injured workers after finalization of a compensation claim, with a need for regulatory bodies to review policy in this area.

CONCLUSION

There appears to be potential for ongoing burden for individuals, employers, and society after finalization of a workers' compensation claim. A gap in knowledge exists regarding the specific evaluation of wellbeing of injured workers following finalization of a workers' compensation claim.

Detection of chromosomal aneuploidy in ancient genomes

Ancient DNA is a valuable tool for investigating genetic and evolutionary history that can also provide detailed profiles of the lives of ancient individuals. In this study, we develop a generalised computational approach to detect aneuploidies (atypical autosomal and sex chromosome karyotypes) in the ancient genetic record and distinguish such karyotypes from contamination. We confirm that aneuploidies can be detected even in low-coverage genomes ( ~ 0.0001-fold), common in ancient DNA. We apply this method to ancient skeletal remains from Britain to document the first instance of mosaic Turner syndrome (45,X0/46,XX) in the ancient genetic record in an Iron Age individual sequenced to average 9-fold coverage, the earliest known incidence of an individual with a 47,XYY karyotype from the Early Medieval period, as well as individuals with Klinefelter (47,XXY) and Down syndrome (47,XY, + 21). Overall, our approach provides an accessible and automated framework allowing for the detection of individuals with aneuploidies, which extends previous binary approaches. This tool can facilitate the interpretation of burial context and living conditions, as well as elucidate past perceptions of biological sex and people with diverse biological traits.

The effect of parenteral vitamin B12 on the growth rate of dairy calves over the summer and autumn on seven farms from the Central Plateau, New Zealand

AIMS

To investigate the effect of parenteral vitamin B12 supplementation on the growth rate of dairy heifer calves over the summer and autumn on seven farms from the Central Plateau of New Zealand, an area historically associated with low cobalt levels in grazing pasture.

METHODS

This was a controlled clinical trial conducted on a convenience sample of seven farms with young female calves randomly assigned to three vitamin B12 treatment groups and followed through a grazing season. Two treatment groups received either monthly SC injections of a short-acting (SA) B12 formulation or 3-monthly injections of a long-acting (LA) B12 formulation and the third group received no treatment (NT). No additional parenteral vitamin B12 was given; however, all calves received additional cobalt (0.04-0.4 mg Co/kg liveweight) in the mineralised anthelmintic drenches given orally every month. Liveweight was recorded in December/January and at the end of the trial in May/June/July depending on farm. Pasture cobalt concentrations (mg/kg DM) were measured every month using 500-g herbage samples from 100-m transects in the area about to be grazed by the trial groups.

RESULTS

There was evidence for a difference in growth rate between groups with mean final weight of 228 (95% CI = 212-243) kg for the LA groups, 224 (95% CI = 209-239) kg for the SA groups and 226 (95% CI = 211-241) kg for the NT groups respectively, (global p-value = 0.014). Calves given SA vitamin B12 were 3.77 (95% CI = 0.71-6.82) kg lighter than calves given LA vitamin B12 (p = 0.011). There was no evidence for a change in pasture cobalt concentrations (p = 0.32).

CONCLUSIONS AND CLINICAL RELEVANCE

The results of this trial raise the question as to whether the routine use of vitamin B12 supplementation in young cattle from areas traditionally thought to be cobalt deficient is necessary, and further raise the possibility that vitamin B12 supplementation by repeated injection of SA products may negatively impact growth rates.

The Clinical Impact of Electronic Patient-Reported Outcome Measures in the Remote Monitoring of Inflammatory Arthritis: A Systematic Review and Meta-analysis

OBJECTIVE

The inflammatory arthritides (IAs) make up a significant proportion of conditions followed up in rheumatology clinics. These patients require regular monitoring, but this is increasingly difficult with rising patient numbers and demand on clinics. Our objective is to evaluate the clinical impact of electronic patient-reported outcome measures (ePROMs) as a digital remote-monitoring intervention on disease activity, treatment decisions, and health care resource use in patients with IA.

METHODS

Five databases (MEDLINE, Embase, PubMed, Cochrane Library, and Web of Science) were searched, with randomized controlled trials and (nonrandomized) controlled clinical trials included, and meta-analysis and forest plots conducted for each outcome. Risk of bias was assessed using the Risk of Bias-2 tool and Risk of Bias in Nonrandomized Studies of Interventions.

RESULTS

Eight studies were included with a total of 4,473 patients, with seven studies assessing patients with rheumatoid arthritis. Compared with control, the disease activity in the ePROM group was lower (standardized mean difference [SMD] -0.15; 95% confidence interval [CI] -0.27 to -0.03) and rates of remission/low disease activity were higher (odds ratio1.65; 95% CI 1.02-2.68), but five of eight studies provided additional combined interventions (e.g., disease education). Fewer face to face visits were needed in the remote ePROM group (SMD -0.93; 95% CI -2.14-0.28).

CONCLUSION

Most studies were at high risk of bias with significant heterogeneity in design, but our results suggest there is an advantage in using ePROM monitoring in patients with IAs, with the potential for reduction in health care resource use without detrimental impact in disease outcomes.

Tools for assessing quality and risk of bias in Mendelian randomization studies: a systematic review

BACKGROUND

The use of Mendelian randomization (MR) in epidemiology has increased considerably in recent years, with a subsequent increase in systematic reviews of MR studies. We conducted a systematic review of tools designed for assessing risk of bias and/or quality of evidence in MR studies and a review of systematic reviews of MR studies.

METHODS

We systematically searched MEDLINE, Embase, the Web of Science, preprints servers and Google Scholar for articles containing tools for assessing, conducting and/or reporting MR studies. We also searched for systematic reviews and protocols of systematic reviews of MR studies. From eligible articles we collected data on tool characteristics and content, as well as details of narrative description of bias assessment.

RESULTS

Our searches retrieved 2464 records to screen, from which 14 tools, 35 systematic reviews and 38 protocols were included in our review. Seven tools were designed for assessing risk of bias/quality of evidence in MR studies and evaluation of their content revealed that all seven tools addressed the three core assumptions of instrumental variable analysis, violation of which can potentially introduce bias in MR analysis estimates.

CONCLUSION

We present an overview of tools and methods to assess risk of bias/quality of evidence in MR analysis. Issues commonly addressed relate to the three standard assumptions of instrumental variables analyses, the choice of genetic instrument(s) and features of the population(s) from which the data are collected (particularly in two-sample MR), in addition to more traditional non-MR-specific epidemiological biases. The identified tools should be tested and validated for general use before recommendations can be made on their widespread use. Our findings should raise awareness about the importance of bias related to MR analysis and provide information that is useful for assessment of MR studies in the context of systematic reviews.

1255 IMPROVING COMMUNICATION BETWEEN NEXT OF KIN AND MEDICAL STAFF FOR OUR MOST VULNERABLE PATIENTS: A QUALITY IMPROVEMENT PROJECT

Background

This project was completed by a team of junior doctors working across two general medical wards at Queen Alexandra Hospital.

Introduction

Due to persistently high bed occupancy, patients are increasingly subject to multiple moves, increasing the risk of missed or delayed communication (Toye C et al, Clin interv aging, 2019, 14, 2223-2237). Importantly, families who receive good communication from staff are more likely to feel satisfied with the care of their loved one (Ersek M et al, J pain symptom manage, 2021, 62(2), 213–222). Our aim was to increase the occurrence and comprehensiveness of documented discussions between next of kin (NOK) and the medical team, especially in vulnerable patients who may be unable to advocate for themselves.

Methods

We conducted a retrospective, cross-sectional analysis of patient notes across two PDSA cycles. NICE guidelines NG27, NG97 and NG96 provided an audit standard. Patients were identified as at-risk of poor communication if diagnosed with dementia, cognitive impairment, addiction, learning difficulties or needing an interpreter. Targeted intervention prior to re-audit included education of the medical team and introduction of a written prompt within the patient’s notes.

Results

25/55 patients were identified as at-risk in cycle one, with 39/71 patients at-risk in cycle two. Post-intervention, the number of at-risk patients with a documented NOK discussion increased from 74% to 82%. Patient treatment plan discussions increased from 81% to 97%. Discussions, where applicable, regarding escalation of care, Deprivation of Liberty Safeguards (DoLS), capacity and Mental Health Act (MHA) slightly decreased. Conversations regarding patient consent for data sharing were rarely documented.

Conclusion

Our intervention increased the proportion of documented patient discussions; however, it did highlight the need to improve the frequency of documented conversations surrounding escalation of care, DoLS, capacity and MHA. This has provided impetus for further improvement projects.

Validating low-fidelity arthroscopic simulation in medical students: a feasibility trial

INTRODUCTION

With surgical opportunities becoming increasingly restricted for orthopaedic trainees, simulation training is a valuable alternative at providing sufficient practice. This pilot study aims to assess the potential effectiveness of low-fidelity simulation in teaching medical students basic arthroscopic skills and the feasibility of its incorporation into formal student training programmes.

METHODS

Twenty-two medical students completed pre- and post-training tests on the Probing (Task 1) and Maze (Task 2) exercises from the Sawbones 'Fundamentals of Arthroscopy Surgery Training' (FAST) programme. Training consisted of practising horizon control, deliberate linear motion and probing within 25min over a period of days. Completion time and error frequency were measured. The difference in performance was assessed using a paired two-tailed t-test. Qualitative data were collected.

RESULTS

Test completion time decreased significantly by a mean of 83s (±46s, 95% confidence intervals [CI] 37 to 129) for Task 1 (p=0.001) and 105s (±55s, 95% CI 50 to 160) for Task 2 (p=0.0007). Frequency of direct visualisation errors decreased significantly by a mean of 1.0 errors (±1.0 errors, 95% CI 0.1 to 2.0) for Task 1 (p = 0.04) and 0.8 errors (±0.8 errors, 95% CI 0.1 to 1.6) for Task 2 (p = 0.04). At post-training, 82% of participants were willing to incorporate FAST into formal training.

CONCLUSIONS

Low-fidelity simulators such as FAST can potentially teach basic arthroscopic skills to medical students and are feasible for incorporation into formal training. They also give students a cost-effective and safe basic surgical training experience.

P33 The successful use of Belimumab in recurrent small bowel obstruction secondary to Lupus Enteritis

Introduction/Background

Lupus enteritis encompasses mesenteric vasculitis, enteric vasculitis, mesenteric arteritis and lupus peritonitis and is an uncommon, potentially life-threatening presentation of SLE. The prevalence in SLE patients ranges from 0.2% to 9.7% and up to 65% in SLE patients presenting with acute abdominal pain. This case brings awareness to the gastrointestinal manifestations of lupus with particular focus on the clinical and radiological features of SLE-related vasculitis of the gastrointestinal tract. It highlights the importance of recognising new ascites and hydronephrosis as a presenting feature of LE with leucopenia, low C3 and raised IgA as additional associated features.

Description/Method

A 48-year-old female presented to hospital abdominal pain and vomiting. Abdominal CT imaging revealed small bowel obstruction with extensive mural oedema and thickening of the ileum, jejunum, ascending, transverse and descending colon. Ryle’s tube was inserted and left on free drainage. Imaging also showed ascites, bilateral hydronephrosis bilateral hydronephrosis, enlarged pelvic lymph nodes, pleural effusions and a small pericardial effusion.

Past medical history included seronegative, anti-CCP positive rheumatoid arthritis for which she was on taking baricitinib 4mg daily and prednisolone 5mg daily. Otherwise she had a history of HbSC disease with previous delayed transfusion reaction, urticarial vasculitis, fully treated tuberculosis.

This was the patient’s 3rd presentation with recurrent abdominal pain, vomiting and small bowel obstruction in the preceding last 6 months. 6 weeks prior to the current presentation she underwent a laparotomy, revealing a chronic dilated ∼40cm segment of small bowel and ∼800ml ascites. Histology revealed normal mucosa with no evidence to support inflammatory bowel disease, tuberculosis or infective colitis, but was significant for sub-mucosal fat necrosis with foamy histiocytes present.

On this occasion, the clinical picture deteriorated with the development of hospital acquired pneumonia, acute kidney injury (creatinine 170, urine protein:creatinine ratio of 615) and fluid overload (albumin 27) requiring admission to intensive care unit.

Immunology results revealed ANA 1/2560 speckled, anti-dsDNA 72 IU/ml, Ro-60 positive, RNP 70 positive, C3 0.51 (ref range (0.90-1.80 g/L), C4 0.18 (ref range 0.10 – 0.40 g/L), rheumatoid factor <10, anti-CCP 154 (ref range (0-7IU/ml).

A diagnosis of systemic lupus erythematosus (SLE) with lupus enteritis and probable lupus nephritis was made. Pulsed methylprednisolone and belimumab therapy were commenced followed by the addition of mycophenolate mofetil resulting in sustained improvement in clinical, biochemical and radiological parameters and no further episodes of bowel obstruction.

Discussion/Results

LE is an uncommon but potentially life-threatening complication of SLE. Symptoms for LE can vary from mild intermittent diffuse abdominal pain, nausea, vomiting, bloating, diarrhoea to acute abdominal pain, with urinary symptoms present in up to 20%. LE is most likely to occur in patients with high disease activity, determined by disease activity measures such as the BILAG or SLEDAI. Abdominal computer tomography (CT) is the gold standard investigation with the typical features being diffuse or focal bowel wall thickening and oedema (‘target sign’), mesenteric vasodilation (‘comb sign’), dilatation of intestinal segments and ascites. Endoscopy may show ischaemia and ulcerative changes, but biopsies are often normal. Full thickness biopsies may be required. Urinary tract involvement and hydronephrosis have been described in association with LE.

There are currently no specific available guidelines or recommendations for the treatment of LE. Rapid improvement is seen following administration of high-dose glucocorticoids and additional immunosuppression using Cyclophosphamide, Rituximab Azathioprine or Mycophenolate mofetil can be used in certain cases. The relapse rate is common with predictors of recurrence reported as bowel wall thickness exceeding 9mm and those receiving glucocorticoids alone. Potentially life-threatening complications including gastro-intestinal perforation and intestinal necrosis if left untreated.

Based on the positive lupus serology, extensive bowel oedema, ascites, and bilateral hydronephrosis in addition to lymphadenopathy, pleural effusions and small pericardial effusion seen on CT imaging; LE was the top differential in this case. High dose intravenous steroids with the addition of Belimumab were promptly initiated in view of the rapid accumulation of ascites, progression of hydronephrosis and deterioration in renal function.

Key learning points/Conclusion

This case highlights the importance of recognising new ascites and hydronephrosis as a presenting feature of LE with leucopenia, low C3 and raised IgA as additional associated features.

The timely diagnosis of LE is crucial to preventing potentially life-threatening complications including gastrointestinal perforation and intestinal necrosis if left untreated.

This case explores the importance of distinguishing LE from other differentials such as infectious colitis, TB enteritis, inflammatory bowel diseases.

The diagnosis of LE can be determined through imaging studies, specifically abdominal CT scans. This case demonstrates that the typical CT findings of bowel oedema, thickening, ascites and hydronephrosis was key is identifying the diagnosis of LE.

Early identification is crucial in LE to enable the timely administration of high-dose glucocorticoids, as LE is typically steroid-responsive with an overall good prognosis once treated.

Although there is no specific immunological test to confirm a diagnosis of LE, it is essential to recognise that this constellation of clinical features: ascites, hydronephrosis, leucopenia, low C3 and raised IgA, are independently associated with LE and should prompt a potential diagnosis of LE.

Whilst the decision for further immunosuppression following glucocorticoid may be made on an individualised basis, this case of LE demonstrates that prompt treatment with monthly intravenous Belimumab is a suitable immunosuppressive option.

Prompt immunosuppression provided rapid symptomatic benefit and reversal of bowel oedema and hydronephrosis on repeat imaging.

As of yet, this is the first reported case in the literature whereby Belimumab was successfully used to treat lupus enteritis. Future studies are however needed to explore this further.

522 Early Follow-Up Quality of Life and Mental Health of Patients with Congenital Vascular Malformations Cared for in a Multi-Disciplinary Specialist Center

Aim

To evaluate the early follow-up quality of life (QoL), pain and mental health of patients with congenital vascular malformation (CVM) receiving care by a single multi-disciplinary specialist center

Method

This was a prospective observational study. All patients with CVM who received care (supportive treatment only, open surgery, targeted pharmacological therapy, embolosclerotherapy), and had follow-up, between February 1st 2018 and January 31st 2020 were included. The health-related QoL, pain, and mental health were assessed with validated questionnaires: SF-36, VAS-P and HADS. The CVM were categorized into types – low-flow (LFVM) and high-flow (HFVM), and anatomical locations. Paired t-test was used for all analyses. P&lt;0.05 were considered significant.

Results

110 patients (85 LFVM and 25 HFVM) with a mean age of 36.9 years were included. Significant improvement was found in the bodily pain domain of SF-36 and VAS-P (both P = 0.01) in all patients. However, only patients with HFVM reported significant improvement in the bodily pain domain of SF-36 (P=0.002) and VAS-P (P = 0.02). Patients who received supportive treatment only reported significant improvement in mental health (P=0.004) and social functioning (P=0.03) domains of SF-36. Meanwhile, patients treated with embolo-sclerotherapy reported significant improvement only in VAS-P (P=0.02). Patients who received targeted pharmacological therapy reported no significant early changes.

Conclusions

The effects of care on early follow-up QoL, pain and mental health of patients with CVM were heterogenous. Future research is required to understand the various factors that affect the QoL and mental health of these patients, as well as the holistic approaches to manage them.

O064 Early follow-up quality of life and mental health of patients with congenital vascular malformations cared for in a multi-disciplinary specialist center

Introduction

To evaluate the early follow-up quality of life (QoL), pain and mental health of patients with congenital vascular malformation (CVM) receiving care by a single multi-disciplinary specialist centre

Methods

All patients with CVM who received care (supportive treatment only, open surgery, targeted pharmacological therapy, embolosclerotherapy), and had follow-up, between 1 February 2018 and 31 January 2020 were included. The health-related QoL, pain, and mental health were assessed with validated questionnaires: SF-36, VAS-P and HADS. The CVM were categorized into types – low-flow (LFVM) and high-flow (HFVM), and anatomical locations. Paired t-test was used for all analyses. Differences were considered significant at P&lt;0.05.

Results

110 patients (85 LFVM and 25 HFVM) with a mean age of 36.9 years were included. Significant improvement was found in the bodily pain domain of SF-36 and VAS-P (both P = 0.01) in all patients. However, only patients with HFVM reported significant improvement in the bodily pain domain of SF-36 (P=0.002) and VAS-P (P = 0.02). Patients who received supportive treatment only reported significant improvement in mental health (P=0.004) and social functioning (P=0.03) domains of SF-36. Meanwhile, patients treated with embolosclerotherapy reported significant improvement only in VAS-P (P=0.02). Patients who received targeted pharmacological therapy reported no significant early changes.

Conclusion

The effects of care on early follow-up QoL, pain and mental health of patients with CVM were heterogenous. Future research is required to understand the various factors that affect the QoL and mental health of these patients, as well as the holistic approaches to manage them.

Take-home message

The effects of care on early follow-up QoL, pain and mental health of patients with CVM were heterogenous. Future research is required to understand the various factors that affect the QoL and mental health of these patients, as well as the holistic approaches to manage them.

Predicting intraurban airborne PM1.0-trace elements in a port city: Land use regression by ordinary least squares and a machine learning algorithm

Airborne particulate matter (PM) has been associated with cardiovascular and respiratory morbidity and mortality, and there is some evidence that spatially varying metals found in PM may contribute to adverse health effects. We developed spatially refined models for PM trace elements using ordinary least squares land use regression (OLS-LUR) and machine leaning random forest land-use regression (RF-LUR). Two-week integrated measurements of PM_1.0 (median aerodiameter < 1.0 μm) were collected at 50 sampling sites during fall (2010), winter (2011), and summer (2011) in the Halifax Regional Municipality, Nova Scotia, Canada. PM_1.0 filters were analyzed for metals and trace elements using inductively coupled plasma-mass spectrometry. OLS- and RF-LUR models were developed for approximately 30 PM_1.0 trace elements in each season. Model predictors included industrial, commercial, and institutional/ government/ military land use, roadways, shipping, other transportation sources, and wind rose information. RF generated more accurate models than OLS for most trace elements based on 5-fold cross validation. On average, summer models had the highest cross validation R² (OLS-LUR = 0.40, RF-LUR = 0.46), while fall had the lowest (OLS-LUR = 0.27, RF-LUR = 0.31). Many OLS-LUR models displayed overprediction in the final exposure surface. In contrast, RF-LUR models did not exhibit overpredictions. Taking overpredictions and cross validation performances into account, OLS-LUR performed better than RF-LUR in roughly 20% of the seasonal trace element models. RF-LUR models provided more interpretable predictors in most cases. Seasonal predictors varied, likely due to differences in seasonal distribution of trace elements related to source activity, and meteorology.

119 The Potential of Low-fidelity Arthroscopic Simulation Training in Trauma and Orthopaedic Surgery: A Systematic Review of Experimental Studies

Aim

In an era of budget tightening and work-hour guideline reductions that have significantly reduced surgical exposure, low-fidelity arthroscopic simulators have an essential role to play in surgical training. The COVID-19 pandemic has only further amplified the need for alternative training models, as 91% of orthopaedic trainees have had elective procedures cancelled. The purpose of this systematic review is to synopsise the limited literature regarding the effectiveness of low-fidelity training models in the instruction of novices, and to formulate recommendations for future studies.

Method

The Embase, PubMed, Web of Science and Scopus databases were electronically searched. Studies from any year that described the use of orthopaedic, low-fidelity arthroscopic training models in novice populations were included. Questionnaires, case studies and review studies were excluded. Risk of bias assessments were also conducted for all studies.

Results

16 studies were identified. Using the PRISMA algorithm, 6 studies were deemed relevant. A cross-study comparison revealed low-fidelity arthroscopic simulators reduced time to completion outcomes (P &lt; 0.05), increased ASSET scores (P &lt; 0.01) and confirmed face validity and transfer of skills (cadaver, live patients).

Conclusions

Low-fidelity simulator training significantly improves the arthroscopic performance of novices, without the high setup costs and practical constraints of high-fidelity equivalents. Low-fidelity arthroscopic simulators remain a promising training apparatus in an era of reduced surgical exposure (COVID-19). We have identified the need for consistent outcome measures with greater sample sizes across future studies. We recommend the use of standardised pre-intervention teaching (e.g., ABOS curriculum) and further transference, construct, and face validity evaluations to support future result interpretations.

Estimating the potential impact of interventions to reduce over-calling and under-calling of melanoma

BACKGROUND

Pathologists sometimes disagree over the histopathologic diagnosis of melanoma. 'Over-calling' and 'under-calling' of melanoma may harm individuals and healthcare systems.

OBJECTIVES

To estimate the extent of 'over-calling' and 'under-calling' of melanoma for a population undergoing one excision per person and to model the impact of potential solutions.

METHODS

In this epidemiological modelling study, we undertook simulations using published data on the prevalence and diagnostic accuracy of melanocytic histopathology in the U.S.

POPULATION

We simulated results for 10 000 patients each undergoing excision of one melanocytic lesion, interpreted by one community pathologist. We repeated the simulation using a hypothetical intervention that improves diagnostic agreement between community pathologist and a specialist dermatopathologist. We then evaluated four scenarios for how melanocytic lesions judged to be neither clearly benign (post-test probability of melanoma < 5%), nor clearly malignant (post-test probability of melanoma > 90%) might be handled, before sending for expert dermatopathologist review to decide the final diagnosis. These were (1) no intervention before expert review, (2) formal second community pathologist review, (3) intervention to increase diagnostic agreement and (4) both the intervention and formal second community pathologist review. The main outcomes were the probability of 'over-calling' and 'under-calling' melanoma, and number of lesions requiring expert referral for each scenario.

RESULTS

For 10 000 individuals undergoing excision of one melanocytic lesion, interpreted by a community pathologist, a hypothetical intervention to improve histopathology agreement reduced the number of benign lesions 'over-called' as melanoma from 308 to 164 and the number of melanomas 'under-called' from 289 to 240. If all uncertain diagnoses were sent for expert review, the number of referrals would decrease from 1500 to 737 cases if formal second community pathologist review was used, and to 701 cases if the hypothetical intervention was additionally used.

CONCLUSIONS

Interventions to improve histopathology agreement may reduce melanoma 'over-calling' and 'under-calling'.

EP15 A self-limiting symmetrical polyarthritis following COVID-19 infection

Case report - Introduction

We describe an acute onset self-limiting seronegative non-destructive symmetrical polyarthritis five weeks after laboratory confirmed COVID-19 infection.

Case report - Case description

A 37-year-old male hospital doctor of presented to the Early Inflammatory Arthritis clinic with a four-week history of acute onset joint pain, swelling and early morning stiffness in excess of two hours. The symptoms began at the left ankle with Achilles’ tendonitis but progressed over the following 72 hours to a symmetrical polyarthritis affecting the wrists, proximal interphalangeal joints, shoulders, elbows, and knees.

Approximately five weeks prior to the onset of his joint symptoms he had laboratory confirmed SARS-CoV-2 infection with six days of fever, non-productive cough, and fatigue. He did not require hospitalisation.

His past medical history was significant for biopsy proven non-alcoholic fatty liver disease. There was no prior history of inflammatory arthritis and no personal or family history of skin psoriasis, inflammatory bowel disease or uveitis. There was no preceding genitourinary or gastrointestinal upset. His family history was significant for a sister with seronegative rheumatoid arthritis for which she was taking sulfasalazine.

Examination revealed a normal BMI, synovitis at the wrists and proximal interphalangeal joints without evidence of joint effusion in the large joints. Blood tests revealed elevations in the ESR (83 mm/hour, reference range 0-10 mm/hour) and CRP (25mg/dL, reference range <5mg/dL). Serology was negative for the rheumatoid factor, anti-CCP antibodies, antinuclear antibodies, and an extractable nuclear antigen panel. Radiographs of the affected joints were unremarkable. Serological testing was positive for anti-SARS-CoV-2 IgG antibodies.

He was started on oral Prednisolone 20mg daily and an NSAID with good symptomatic response and normalisation of his ESR (5mm/hour) and CRP (<1mg/dL). The course of prednisolone was tapered over a 6-week period and he is still in steroid free remission with normal inflammatory markers at follow up. The patient was given a diagnosis of a post-viral reactive arthritis which was attributed to the preceding COVID-19 illness.

Case report - Discussion

Post infectious inflammatory arthritis has been described with many viral infections including: hepatitis virus, parvovirus B19, enterovirus, rubella, alphavirus (including Chikungunya), flavivirus (including Zika), herpes viruses (including Epstein-Barr virus), varicella, cytomegalovirus and human immunodeficiency virus (HIV). Interestingly, viral arthritis has not been reported in influenza and human coronaviruses (including SARS and MERS). Arthralgia was reported in 14.9% of laboratory confirmed COVID-19 cases in China during the early phases of the pandemic but inflammatory arthritis was not well described.

The clinical course of the inflammatory arthritis in this case was self-limiting with enthesitis and synovitis resolving within six weeks of onset with the mainstay of treatment being symptomatic relief in the form of non-steroidal anti-inflammatory drugs and corticosteroids.

Patient perspective: When I woke up that Tuesday morning with severe joint pains and stiffness, I knew something was not right. It was not like anything I have felt before in terms of my joints, having had sports injuries in the past. It was to the point where I was even struggling to go from sitting to standing. Without Prednisolone, I feel as if I would not have been able to work and may even have been house bound. I was relieved that this inflammatory arthritis did respond to Prednisolone. After six weeks of taking Prednisolone, the condition seemed to settle.

Case report - Key learning points

A self-limiting episode of inflammatory arthritis may occur following COVID-19 infection.

Reconfiguring traditional EKG interpretation with artificial intelligence – a reliable, time-saving alternative?

Background

Time and accuracy are key factors that may make or break an efficient triage and management in most medical premises, particularly so when expedited diagnosis saves lives - a not so uncommon scenario in the field of cardiology. By studying the different variables involved in cardiologist-EKG interactions that lead to the identification and management of different cardiovascular entities, we delved into the applications of Artificial Intelligence (AI) algorithms in order to improve upon the classic, but dated, EKG methodology. With this study, we pit our algorithm against cardiologists to perform a thorough analysis of the time invested to diagnose an EKG as Normal, as well as an assessment of the accuracy of said label.

Purpose

To present a faster and reliable AI-guided EKG interpretation methodology that outperforms cardiologists' capabilities in identifying Normal EKG records.

Methods

The International Telemedical System (ITMS) developed and tested an EKG assessing AI algorithm and incorporated it into the workflow of their Telemedicine Integrated Platform, a digital EKG reading program where cardiologists continuously report their findings remotely in real time. During the month of April 2019; 35 ITMS cardiologists reported a grand total of 61,441 EKG records, later subjecting them to the AI algorithm, implemented through the “One Click Report” process. Through this simple 2-step approach, the algorithm provides a suggestion of “Normal” or “Abnormal” to the cardiologist based on the patterns of the fiducial points included in said EKG reports. A comparison of the time of normal EKG diagnosis is made and the correlation between AI and cardiologists is assessed.

Results

On average, our AI algorithm discerned a normal EKG within 30.63s (95% CI 26.51s to 34.75s), in solid contrast with cardiologists' interpretations alone, which amounted to 83.54s (95% CI from 69.43s to 97.65s). This accounts for an overall saving of 52.91s (95% CI 42.45s to 63.83s) by implementing this innovative methodology in a cardiologist practice. In addition, this method correctly reported 23,213 Normal EKG records out of the total 25,013 AI output, reaching a 92.8% correlation between man and machine. The total average time saved in normal EKG readings with AI (23,213) would accrue an approximate of 20,470 minutes (ie, 42 8-hours work shifts worth of time dedicated to diagnosing a normal EKG).

Conclusions

The implementation of automated AI-driven technologies into daily EKG interpretation tasks poses an attractive time-saving alternative for faster and accurate results in a modern cardiology practice. By further expanding on the concept of an intelligent EKG characterization device, a more efficient and patient-centered clinical exercise will ensue.

Funding Acknowledgement

Type of funding source: None

Maximum artificial intelligence and complete reconstruct of population-based AMI care

Background

After creating a behemoth hub and spoke AMI network that encompasses more than 100 million patients in 5 countries, we have begun to incorporate Artificial Intelligence (AI) algorithms into our telemedicine strategy with the goal of creating comprehensive, very early AMI diagnosis and physician-free triage. In doing so, we have replaced door-to-balloon times (d2b) with symptom-to-balloon times (s2b) as an immutable objective.

Purpose

To incorporate AI attributes for very early AMI detection, triage, and management.

Methods

We expanded our effective telemedicine strategy (100 million population; 877,178 telemedicine encounters; 55% overall mortality reduction; $291 million cost savings) with a logistic reset to impact s2b. To do this, we incorporated our Single Lead 1.0 (lead I) and Single Lead 2.0 (lead V2) technology for self-administered AMI detection with our physician-free STEMI diagnosis and triage AI algorithms. Single Lead algorithms and physician-free protocols were generated by utilizing Machine Learning from our mammoth annotated EKG repository.

Results

In addition to three logistic markers of efficiency Time-to-Telemedicine Diagnosis (TTD), Door-In-Door-Out (DIDO) and Transfer Times (TT); we are monitoring s2b. A gradual release of the algorithms and single lead is occurring at the telemedicine spokes. Detailed results will be available at the time of presentation.

Conclusions

Impacting s2b, the Achilles Heel of Primary PCI, may be achieved with the use of patient-administered AMI detection tools. Incorporation of these technologies into AI algorithms will add to telemedicine efficiencies for population-based AMI care.

Funding Acknowledgement

Type of funding source: None

AI and telemedicine: total remote guidance of AMI management

Background

For a decade, Latin American Telemedicine Infarct Network (LATIN) Telemedicine has transformed AMI management in Brazil, Colombia, Mexico, Chile, and Argentina. With a hub and spoke strategy, AMI coverage was expanded to 100 million population and 877,177 telemedicine encounters were performed. Cost savings from avoiding unnecessary transfer of patients was $291 million. We are now rapidly escalating on a path to making the telemedicine process “physician-free” by utilizing Artificial Intelligence (AI) protocols.

Purpose

To demonstrate that AI can replace a cardiologist for remote AMI telemedicine guidance.

Methods

The process of total AI guidance focused on both aspects of our telemedicine strategy – accurate AMI diagnosis and tele-guidance of the entire STEMI process. We developed our innovative approach by initially creating AI algorithms for computer-aided diagnosis. Next, we incorporated logistic variables (duration of chest pain, transfer times to LATIN hub, etc) to the algorithm for physician-free triage into thrombolysis, primary PCI and pharmaco-invasive management. The intent of creating AI algorithms was early STEMI detection and triage. After the patient was efficiently transferred to the hub, a final treatment decision was made by the hub cardiologists.

Results

Three crucial areas of telemedicine efficiency are being monitored – Time-to-Telemedicine Diagnosis (TTD), Door-In-Door-Out (DIDO) and Transfer Times (TT). All are showing improvements. Detailed results will be available at the time of presentation.

Conclusions

We are encouraged with the possibility of making the entire telemedicine guidance of AMI management “physician-free”. Next-Gen improvements are being contemplated by including a Single Lead EKG for AMI detection that will impact symptom-to-balloon times.

Funding Acknowledgement

Type of funding source: None

EP10 Hyperinflammatory syndrome in a patient with rheumatoid arthritis and COVID-19

Case report - Introduction

Severe acute respiratory coronavirus 2 (SARS-CoV-2) is a novel virus that can lead to an excessive immune activation and cytokine response known as Coronavirus disease 2019 (COVID-19) which predominantly affects the lungs. Patients with chronic inflammatory disease on biological immunosuppressive treatments may be at a higher risk of contracting SARS-CoV-2. However, it is yet to be determined whether immunomodulatory medications used in inflammatory diseases have protective capabilities against severe outcomes.

Case report - Case description

A 51-year old female with a 13-year history of rheumatoid arthritis (RA) presented to hospital with fever, exertional breathlessness, and a non-productive cough. She was diagnosed with seropositive erosive RA at the age of 38 and was on 6-monthly Rituximab infusions and Leflunomide on admission. She had relatively stable pulmonary fibrosis (diagnosed in 2010). Her chest CTs in 2010 and 2018 noted bilateral basal subpleural ground glass change with limited honeycombing and spirometry study revealed FEV1 of 2.2 (82% predicted), VC of 2.7 (87% predicted), DLCO of 7.0 (78% predicted) and kCO of 1.6 (78% predicted).

On admission in March 2020, she was hypoxic (oxygen saturation of 88% in room air) and had raised inflammatory markers (CRP 341mg/dL, d-Dimer 914ng/ml, Ferritin 3141ng/ml, LDH 672U/L). Her last Rituximab infusion was 3 months prior and leflunomide was withheld on admission. SARS-CoV-2 PCR nasopharyngeal swab was positive, and she was recruited to the RECOVERY trial, being randomized to Lopinavir-Ritonavir for 10 days. Her oxygen requirements increased, and a CT pulmonary angiogram excluded pulmonary embolism but revealed ground glass changes and extensive multilobar consolidation. She was eligible for recruitment into RECOVERY-2 (tocilizumab) given the ongoing oxygen requirement and elevated CRP, but she was randomised to usual care. She was commenced on 80mg of IV methylprednisolone, a dose chosen because of its proven effectiveness in Acute Respiratory Distress Syndrome. She clinically improved and was discharged from hospital 20 days after starting Methylprednisolone with a CRP of 17mg/dL.

Two months after discharge, the patient had repeat spirometry study which noted FEV1 of 1.4 (57% predicted), VC of 1.5 (52% predicted), DLCO of 2.4 (28% predicted) and kCO of 1.0 (47% predicted). A repeat high-resolution chest CT reported significant improvement of peripheral ground glass changes and consolidation, but she is still fatigued and more breathless than previously.

Case report - Discussion

The RECOVERY trial concluded that Dexamethasone reduced mortality in intubated patients and in hospitalised patients with COVID-19 with a high oxygen requirement. The results were published after this patient was discharged.

A hyperinflammatory response to COVID-19 is seen in a subset of patients, and our own hospital data suggest that this condition affects around 5% of admitted COVID-19 patients, but that extreme hyperferritinaemia above 10,000 is extremely rare. Similar responses (known as Haemophagocytic Lymphohistiocytosis [HLH]) are seen with a variety of viral and bacterial infections, in malignancy and in inflammatory rheumatic diseases (Macrophage Activation Syndrome [MAS]), but typically HLH and MAS patients have ferritin > 10,000.

It appears unlikely that true HLH is a significant manifestation of COVID-19 infection, but moderate hyperferritinaemia is not uncommon and the results of this study, taken together with case reports and series from China and Italy suggest that similar treatments to those used in HLH may transform the prognosis for COVID-19 patients in this subset.

It is unknown whether the recent Rituximab infusion had a role in reducing the “cytokine storm” and delaying progression to severe COVID-19. However, it may be argued that the remaining T cells in B cell depleted patients are sufficient for viral clearance.

The long-term impact of SARS-CoV-2 on pulmonary function is still unclear. Our patient had a major deterioration in her lung function when compared to her baseline. There was severe reduction in gas transfer post COVID-19. However, her repeat high resolution CT chest reported substantial improvement in ground glass changes and consolidation. The long-term prognosis is still uncertain.

Initial fears that patients on DMARDs and biological therapies for inflammatory rheumatic disease would be extremely vulnerable to COVID-19 have not been confirmed, but patients with extra-articular manifestations on combinations of DMARDs and biological therapies may be a subset at higher risk.

Case report - Key learning points

Our Intensivist colleagues, early in the COVID-19 outbreak, were understandably cautious about using heavily immunosuppressive treatments for a life-threatening viral infection. Using a multi-disciplinary approach at a time when knowledge of how to treat this condition was rudimentary, along with informed consent from an intelligent and thoughtful patient, we were able to plot a middle path to suppress hyperinflammation without using massively immunosuppressive doses of steroid, with a successful outcome.

This patient illustrates one aspect of the hyper-inflammatory response seen in a subset of the most critically ill patients with COVID-19. At the time of writing, the RECOVERY 2 trial is yet to be published, but the rapid improvement in inflammatory markers including CRP and Ferritin, along with a dramatic improvement in clinical state, suggest that relatively modest doses of parenteral steroid have life-saving potential at far lower cost and greater worldwide availability than biological therapies such as Tocilizumab or Anakinra.

Trials of Tocilizumab in RECOVERY2 and of Anakinra coordinated by the Hyperinflammation Histio UK Haemophagocytosis Across Specialty Collaboration (HASC), as well as international randomised controlled trials will be critical in determining the optimal treatment strategy for this subset of critically ill COVID-19 patients. The experience of our patient suggests that one arm of such studies should include a relatively modest dose of parenteral steroid, be that Dexamethasone or Methylprednisolone, particularly given that COVID-19 is affecting countries across the developing, as well as the developed, world.

1004 Smith-&lt;Magenis Syndrome (SMS) Circadian Abnormalities And Biological Rhythms

Introduction

SMS is a rare neurodevelopmental disorder that manifests with craniofacial abnormalities, behavioral disturbances, and a severe sleep disorder. It has been reported that many SMS patients have an inverted melatonin secretion pattern (peaking during the daytime) although a small minority have near normal patterns. The goal of this study was to better characterize the intra- and inter-patient variability of melatonin secretion patterns and investigate a potential relationship with sleep behavior in SMS patients.

Methods

In this observational study, sleep behaviors of patients (N=8, 1 female, ages: 7 - 35) with SMS were characterized through caretaker surveys. On 3 separate occasions, patients had hourly serum melatonin levels sampled for 36 hours. From these data, peak serum melatonin concentration and time of peak concentration were determined. Inter- and intra-patient variability was characterized by zero lag correlation of the melatonin concentration timeseries across and within patients, respectively. The relationship between peak melatonin concentration, peak time, and sleep latency was analyzed by a generalized linear model, GLM.

Results

Peak melatonin concentrations varied across SMS patients with a range of 3.55pg/ml - 49.65pg/ml (mean 14.18 ± 15.19pg/ml). Time of peak melatonin concentrations ranged from 0400h-2100h (mean 1422 ± 6h). Correlation coefficients characterizing intra-patient variability ranged from -0.0098 to 0.89 (mean 0.55 ± 0.2533). Correlation coefficients characterizing inter-patient variability ranged from -0.75 to 0.79 (mean of 0.18 ± 0.52). Sleep latency ranged from 8.4min - 36.35min (mean of 21.99 ± 9.77 min). GLM analysis demonstrated a significant, positive effect of peak time with sleep latency (p=0.022).

Conclusion

Consistent with previous findings, our study confirms that SMS patients have abnormal circadian rhythms. Our work extends this body of literature by demonstrating a significant degree of inter-patient variability with relatively stable intra-patient variability. Preliminary evidence suggests that the timing of melatonin peak may be related to sleep onset latency.

Support

This work was supported by Vanda Pharmaceuticals Inc.

1161 Tasimelteon Shows Persistence Of Efficacy In Improving Sleep Disturbances In Patients With Smith-Magenis Syndrome (SMS) In Open-Label Extension Study

Introduction

Smith-Magenis Syndrome (SMS) is a rare (1/15,000 - 25,000 births) neurodevelopmental disorder resulting from an interstitial deletion of chromosome 17p11.2, or from a point mutation in the RAI1 gene. Severe sleep disorder is almost universal in patients with SMS and poses a significant challenge to patients and their families. Tasimelteon improved sleep symptoms in a randomized, double-blind, two-period, crossover study; and here we show that this effect persists for up to four years in an open-label extension. To our knowledge, this is the largest interventional study of SMS patients to date.

Methods

Following the 4-week crossover study, all eligible participants had the option to enroll in an open-label extension. 31/39 (79.4%) of all individuals who participated in the efficacy study have continued on tasimelteon treatment. Participants in the open-label extension provided daily diary sleep quality (DDSQ), and daily diary total sleep time (DDTST) measures via parental post sleep questionnaire and characterized behavior using the Aberrant Behavior Checklist (ABC).

Results

In the open-label extension, tasimelteon continued to show improvement in the primary endpoints of 50% worst sleep quality (mean = 0.7, SD = 0.94) and 50% worst total nighttime sleep duration (mean = 53.3, SD = 59.01) when compared to baseline. Tasimelteon also improved overall sleep quality (mean=0.7, SD=0.83) and overall total nighttime sleep duration (mean = 51.9, SD=53.03). ABC scores also improved with tasimelteon (mean= -16.3, SD = 15.82).

Conclusion

Tasimelteon continues to demonstrate persistence in efficacy (longest approximately 4 years) with similar magnitudes observed in the 4-week crossover study for sleep quality and total sleep time. Interestingly, daytime behavior also demonstrates long-term improvement in patients with SMS treated with tasimelteon. These results further confirm tasimelteon as a novel therapy for the treatment of sleep disorders in patients with SMS and may provide benefit for behavioral symptoms.

Support

This work was supported by Vanda Pharmaceuticals Inc.

Skill Development Versus Performativity Among Beginners in Aerial Practice: An Embodied and Meaningful Learning Experience

The purpose of this quasi-experimental, phenomenological study was to use embodied cognition in understanding learning experiences in skill development and performativity (e.g., storytelling and emotional expression) among 17 beginners in aerial practice (M_age = 20.59 ± 1.37 years old). Eight people were in the treatment-group class (skill development and performativity) and nine individuals participated in the control-group class (only skill development). Four themes emerged from the analysis: linking other exercises to aerial (e.g., cheerleading, dancing, and gymnastics) and uniqueness of aerial (e.g., artistic aspect while in the air); success in meeting aerial goals (at the posttest, performativity was valued more in the treatment group than the control group); exercise changes due to aerial, such as enhanced upper-body strengthening activities and stretches; and lessons learned, including importance of conditioning and small class size, switching Teaching Assistants (TAs), and silk awareness. Practitioners in community-based movement education programs like dancing and physical theater should recognize the need for embodied knowledge by emphasizing not only skill development but also performativity for enhanced learning experiences within supportive class settings. Although adding performative qualities to skill learning is more challenging than skill development alone, it can lead to enhanced performance, joy, and meaning of movement.

Temporal Aspects of Word Initial Single Consonants and Consonants in Clusters in Spanish

We examined gestural coordination in C1C2 (C1 stop, C2 lateral or tap) word initial clusters using articulatory (electromagnetic articulometry) and acoustic data from six speakers of Standard Peninsular Spanish. We report on patterns of voice onset time (VOT), gestural plateau duration of C1, C2, and their overlap. For VOT, as expected, place of articulation is a major factor, with velars exhibiting longer VOTs than labials. Regarding C1 plateau duration, voice and place effects were found such that voiced consonants are significantly shorter than voiceless consonants, and velars show longer duration than labials. For C2 plateau duration, lateral duration was found to vary as a function of onset complexity (C vs. CC). As for overlap, unlike in French, where articulatory data for clusters have also been examined, clusters where both C1 and C2 are voiced show more overlap than where voicing differs. Further, overlap was affected by the C2 such that clusters where C2 is a tap show less overlap than clusters where C2 is a lateral. We discuss these results in the context of work aiming to uncover phonetic (e.g., articulatory or perceptual) and phonological forces (e.g., syllabic organization) on timing.

Evidence for Genetic Correlations and Bidirectional, Causal Effects Between Smoking and Sleep Behaviors

INTRODUCTION

Cigarette smokers are at increased risk of poor sleep behaviors. However, it is largely unknown whether these associations are due to shared (genetic) risk factors and/or causal effects (which may be bidirectional).

METHODS

We obtained summary-level data of genome-wide association studies of smoking (smoking initiation [n = 74 035], cigarettes per day [n = 38 181], and smoking cessation [n = 41 278]) and sleep behaviors (sleep duration and chronotype, or "morningness" [n = 128 266] and insomnia [n = 113 006]). Using linkage disequilibrium (LD) score regression, we calculated genetic correlations between smoking and sleep behaviors. To investigate causal effects, we employed Mendelian randomization (MR), both with summary-level data and individual-level data (n = 333 581 UK Biobank participants). For MR with summary-level data, individual genetic variants were combined with inverse variance-weighted meta-analysis, weighted median regression, MR-Robust Adjusted Profile Score, and MR Egger methods.

RESULTS

We found negative genetic correlations between smoking initiation and sleep duration (rg = -.14, 95% CI = -0.26 to -0.01) and smoking cessation and chronotype (rg = -.18, 95% CI = -0.31 to -0.06), and positive genetic correlations between smoking initiation and insomnia (rg = .27, 95% CI = 0.06 to 0.49) and cigarettes per day and insomnia (rg = .15, 95% CI = 0.01 to 0.28). MR provided strong evidence that smoking more cigarettes causally decreases the odds of being a morning person, (RAPS) and weak evidence that insomnia causally increases smoking heaviness and decreases smoking cessation odds.

CONCLUSIONS

Smoking and sleep behaviors show moderate genetic correlation. Heavier smoking seems to causally affect circadian rhythm and there is some indication that insomnia increases smoking heaviness and hampers cessation. Our findings point to sleep as a potentially interesting smoking treatment target.

IMPLICATIONS

Using LD score regression, we found evidence that smoking and different sleep behaviors (sleep duration, chronotype (morningness), and insomnia) are moderately genetically correlated-genetic variants associated with less or poorer sleep also increased the odds of smoking (more heavily). MR analyses suggested that heavier smoking causally affects circadian rhythm (decreasing the odds of being a morning person) and there was some indication that insomnia increases smoking heaviness and hampers smoking cessation. Our findings indicate a complex, bidirectional relationship between smoking and sleep behaviors and point to sleep as a potentially interesting smoking treatment target.

PR3 vasculitis presenting with symptomatic splenic and renal infarction: a case report and literature review

Background

ANCA-associated vasculitis is a life-threatening, systemic autoimmune disease. There is an increased risk of organ infarction but in many cases this is asymptomatic. We described here the first reported case of PR3 vasculitis presenting with symptomatic bilateral renal wedge infarction.

Case presentation

A 19-year old Caucasian woman with no past medical history presented on a number of occasions over a number of weeks with progressively more severe back pain, fevers and arthralgia. On the final presentation she was noted to have developed splinter haemorrhages and her blood tests revealed impaired renal function along with elevated inflammatory markers. She was subsequently found to have high titres of serum PR3 antibodies and focal necrotising glomerulonephritis on renal biopsy, consistent with a diagnosis of PR3 ANCA-associated vasculitis. Cross-sectional imaging revealed multiple wedge infarcts of her spleen and both kidneys, confirmed on contrast-enhanced ultrasound. Large vessel, cardiac and thrombophilic causes of thromboembolism were excluded. She was treated with high-dose corticosteroids and CD20 monoclonal antibodies (rituximab) and at time of writing, 4 months after initial presentation, has entered clinical remission.

Conclusions

Here we describe the first reported case of PR3 vasculitis presenting with symptomatic renal wedge infarction. In patients with vasculitis who present with flank or back pain, infarction of abdominal organs should be considered in the differential.

Both splenic and renal infarctions are likely underdiagnosed in the setting of ANCA-associated vasculitis but may have clinical impact in contributing to infection risk and the degree or renal recovery, respectively.

Water quality criteria derivation and ecological risk assessment for triphenyltin in China

Triphenyltin (TPT) is one of the most toxic chemicals artificially discharged into aquatic environment with human activities. Due to its intensive use in antifouling paints and adverse effects on non-target species, TPT has aroused wide concern in both saltwater and freshwater environment. Nevertheless, the water quality criteria (WQC) are not available in China, which impedes the risk assessment for this emerging pollutant. This study aims to establish the WQC of TPT for both freshwater and saltwater ecosystems. With the derived WQC, a four-level tiered ecological risk assessment (ERA) approach was employed to assess the ecological risks of this emerging pollutant in Chinese waters. Through the species sensitivity distribution (SSD) methodology, the freshwater criterion maximum concentration (CMC) and criterion continuous concentration (CCC) were derived as 396 ng Sn L^-1 and 5.60 ng Sn L^-1, respectively, whereas the saltwater CMC and CCC were 66.5 ng Sn L^-1 and 4.11 ng Sn L^-1, respectively. The ecological risk assessment for TPT demonstrated that the acute risk was negligible whereas the chronic risk was significant with HQ (Hazard Quotient) values of up to 5.669 and 57.1% of coastal waters in China facing clear risk. TPT contamination in coastal environment, therefore, warrants further concern.

Experimental infection of Friesian bulls with Theileria orientalis (Ikeda) and effects on the haematocrit, live weight, rectal temperature and activity

Since 2012, New Zealand has suffered from an epidemic of infectious bovine anaemia associated with T. orientalis (Ikeda), an obligate intracellular protozoan parasite of cattle. Despite widespread agreement that T. orientalis (Ikeda) infection has impacted beef and dairy farming in New Zealand there is very little quantitative data to support this conclusion. A randomised controlled experimental study of the effect of T. orientalis (Ikeda) infection on the live weight, haematocrit (HCT), temperature and activity of 2-year-old Friesian bulls was conducted at a Massey University Research farm, Palmerston North. Ten out of seventeen 2-year-old Friesian bulls were injected intravenously with 30 mL whole blood from 2 clinical cases of Theileria-associated bovine anaemia and then followed over a period of 20 weeks. The bulls were blood sampled, had rectal temperature recorded and weighed 3 times weekly for 13 weeks and then once weekly thereafter until the end of the trial. Infection intensity was monitored using qPCR. All 10 inoculated bulls were successfully infected with T. orientalis (Ikeda). The results showed that the live weight response to infection was varied and the bulls could be divided into two groups based on this response. Four infected bulls showed a significant weight reduction of 41.5 kg (p < 0.0001), a financial loss of around NZ$112 per bull, compared with the other 6 bulls in the infected group, which were not different to the 7 uninfected controls. The live weight of the 4 poor growing bulls was significantly lower than the other 6 infected bulls from Day 71 post infection (p < 0.05). All ten infected bulls showed a similar decrease in HCT, with the lowest HCT reached around Day 60 to 80 post-infection, however the four infected bulls that grew poorly did have a significantly elevated HCT for the first 1 to 3 weeks post infection (p < 0.05). The 4 infected bulls which grew poorly also had a significantly higher infection intensity than the other infected bulls from Day 27 to Day 60 post-infection (p < 0.05). There was no pyrexia recorded in the infected group or control groups, instead there was a tendency for the infected group to have a lower rectal temperature from Day 5 to 70 post infection. The infected bulls walked on average 239 steps per day less than the control bulls, although this difference was not significant (p = 0.35). Overall the study clearly showed, by controlling infection date and infectious dose, that a proportion of cattle infected with T. orientalis (Ikeda) have significantly decreased live weight gains.

Glenoid Bone Reaction to All-Soft Suture Anchors Used for Shoulder Labral Repairs

BACKGROUND

All-soft suture anchors (ASSAs) are commonly used for shoulder labral repair and capsulorrhaphy in patients with shoulder instability. While these anchors may have some specific advantages over other types of suture anchors, little is known about the prevalence and time-dependence of bone cyst formation and tunnel expansion after implantation of ASSAs. The aim of this study was to quantify the proportions of cyst formation and tunnel expansion around ASSAs and to characterize and test for differences in abnormalities observed at different postoperative time points.

METHODS

Thirty patients who were treated with arthroscopic shoulder stabilization surgery with ASSAs (1.4 mm; JuggerKnot, Biomet) underwent a computed tomography (CT) scan of the operatively treated shoulder at 1 month (10 patients), 6 months (10 patients), or 12 months (10 patients) postoperatively. Demographic and operative data were collected, and CT scans were evaluated for cyst formation, tunnel expansion, and tunnel volume measured in cubic millimeters. Statistical analyses were performed to detect differences in these outcomes among the follow-up groups. All shoulders were stable at all time points of the study, and there were no incidents of recurrent instability during the study period.

RESULTS

Ninety-one suture anchors were evaluated in 30 patients. Tunnel expansion was identified in the large majority of patients in the 6-month and 12-month follow-up groups, with a significant increase in these proportions compared with the 1-month follow-up group (p = 0.002). Mean tunnel volumes also significantly increased over the study period (p < 0.001). The presence of cyst formation was negligible in all 3 follow-up cohorts.

CONCLUSIONS

This study demonstrated low rates of cyst formation but a significantly increased tunnel volume 6 and 12 months after shoulder labral surgery with ASSAs. There was no association with the initial tunnel location. Additional well-controlled studies with longer follow-up are needed to identify potential associations among tunnel expansion, intraoperative technique, and clinical outcomes.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Investigating genetic correlations and causal effects between caffeine consumption and sleep behaviours

Observationally, higher caffeine consumption is associated with poorer sleep and insomnia. We investigated whether these associations are a result of shared genetic risk factors and/or (possibly bidirectional) causal effects. Summary-level data were available from genome-wide association studies on caffeine intake (n = 91 462), plasma caffeine and caffeine metabolic rate (n = 9876), sleep duration and chronotype (being a "morning" versus an "evening" person) (n = 128 266), and insomnia complaints (n = 113 006). First, genetic correlations were calculated, reflecting the extent to which genetic variants influencing caffeine consumption and those influencing sleep overlap. Next, causal effects were estimated with bidirectional, two-sample Mendelian randomization. This approach utilizes the genetic variants most robustly associated with an exposure variable as an "instrument" to test causal effects. Estimates from individual variants were combined using inverse-variance weighted meta-analysis, weighted median regression and MR-Egger regression. We found no clear evidence for a genetic correlation between caffeine intake and sleep duration (rg = 0.000, p = .998), chronotype (rg = 0.086, p = .192) or insomnia complaints (rg = -0.034, p = .700). For plasma caffeine and caffeine metabolic rate, genetic correlations could not be calculated because of the small sample size. Mendelian randomization did not support causal effects of caffeine intake on sleep, or vice versa. There was weak evidence that higher plasma caffeine levels causally decrease the odds of being a morning person. Although caffeine may acutely affect sleep when taken shortly before bedtime, our findings suggest that a sustained pattern of high caffeine consumption is more likely to be associated with poorer sleep through shared environmental factors. Future research should identify such environments, which could aid the development of interventions to improve sleep.

On differences in the equation-of-state for a selection of seven representative mammalian tissue analogue materials

Tissue analogues employed for ballistic purposes are often monolithic in nature, e.g. ballistic gelatin and soap, etc. However, such constructs are not representative of real-world biological systems. Further, ethical considerations limit the ability to test with real-world tissues. This means that availability and understanding of accurate tissue simulants is of key importance. Here, the shock response of a wide range of ballistic simulants (ranging from dermal (protective/bulk) through to skeletal simulant materials) determined via plate-impact experiments are discussed, with a particular focus on the classification of the behaviour of differing simulants into groups that exhibit a similar response under high strain-rate loading. Resultant Hugoniot equation-of-state data (U_s-u_p; P-v) provides appropriate feedstock materials data for future hydrocode simulations of ballistic impact events.

Methods for a Retrospective Population-based and Clinic-based Subfertility Cohort Study: the Fertility Experiences Study

BACKGROUND

Most cohort-based research for subfertility has been conducted in clinic-based cohorts, which may differ from population-based cohorts.

METHODS

We retrospectively recruited parallel cohorts of subfertile women: one by sampling two specialty fertility clinics in Utah, and one by population-based sampling based on marriage and birth records. The index date (of first clinic visit or subfertility status) was between 2000 and 2009, and we linked the women recruited to subsequent birth certificate records through December 2010.

RESULTS

We enrolled 459 women through clinic-based sampling and 501 women through population-based sampling. Clinic-based women were older, had higher annual household income and more likely to have had a most intensive treatment of intrauterine insemination (31%) or in vitro fertilisation (46%) than women from population recruitment (19% and 14% respectively). Conversely, they were less likely to have received no medical treatment (9%) compared to women from population recruitment (41%). For both types of sampling, prior to eligibility screening, non-responders were less likely to link to a live birth than responders: 51% vs. 58% for clinic-based, and 69% vs. 76% for the population-based with an index date in 2004.

CONCLUSIONS

Population-based sampling for subfertility cohort research identifies women who were more likely to have had less intensive treatment or no treatment. However, in both clinic-based and population-based sampling, women who have had a live birth are more likely to respond to retrospective recruitment.

Effect of High-Dose Intravenous Eletriptan on Coronary Artery Diameter

The goal of this study was to evaluate the coronary vasoconstrictive effects of high doses of eletriptan compared with a standard dose of sumatriptan. Patients with no clinically significant coronary artery disease were randomized to receive high-dose intravenous eletriptan ( n = 24) vs a standard dose of sumatriptan ( n = 18; 6 mg subcutaneously) vs placebo ( n = 18). Serial angiograms were obtained. The primary non-inferiority analysis found equivalence between the mean maximum change in left anterior descending coronary artery diameter for eletriptan, -22% [95% confidence interval (CI) -26, -19], and sumatriptan, -19% (95% CI -22, -16). The change due to placebo was -16% (95% CI -20, -12). No individual cases of clinically significant vasoconstriction were observed. The results confirm that eletriptan has a broad cardiovascular safety margin, with plasma concentrations comparable to three to five times the Cmax of an oral 80-mg dose associated with modest vasoconstriction equivalent to standard therapeutic doses of sumatriptan.

Ecological risk assessment of bisphenol A in surface waters of China based on both traditional and reproductive endpoints

Bisphenol A (BPA) occurs widely in natural waters with both traditional and reproductive toxicity to various aquatic species. The water quality criteria (WQC), however, have not been established in China, which hinders the ecological risk assessment for the pollutant. This study therefore aims to derive the water quality criteria for BPA based on both acute and chronic toxicity endpoints and to assess the ecological risk in surface waters of China. A total of 15 acute toxicity values tested with aquatic species resident in China were found in published literature, which were simulated with the species sensitivity distribution (SSD) model for the derivation of criterion maximum concentration (CMC). 18 chronic toxicity values with traditional endpoints were simulated for the derivation of traditional criterion continuous concentration (CCC) and 12 chronic toxicity values with reproductive endpoints were for reproductive CCC. Based on the derived WQC, the ecological risk of BPA in surface waters of China was assessed with risk quotient (RQ) method. The results showed that the CMC, traditional CCC and reproductive CCC were 1518μgL(-1), 2.19μgL(-1) and 0.86μgL(-1), respectively. The acute risk of BPA was negligible with RQ values much lower than 0.1. The chronic risk was however much higher with RQ values of between 0.01-3.76 and 0.03-9.57 based on traditional and reproductive CCC, respectively. The chronic RQ values on reproductive endpoints were about threefold as high as those on traditional endpoints, indicating that ecological risk assessment based on traditional effects may not guarantee the safety of aquatic biota.