An exposome connectivity paradigm for the mechanistic assessment of the effects of prenatal and early life exposure to metals on neurodevelopment

The exposome paradigm through an integrated approach to investigating the impact of perinatal exposure to metals on child neurodevelopment in two cohorts carried out in Slovenia (PHIME cohort) and Greece (HERACLES cohort) respectively, is presented herein. Heavy metals are well-known neurotoxicants with well-established links to impaired neurodevelopment. The links between in utero and early-life exposure to metals, metabolic pathway dysregulation, and neurodevelopmental disorders were drawn through urinary and plasma untargeted metabolomics analysis, followed by the combined application of in silico and biostatistical methods. Heavy metal prenatal and postnatal exposure was evaluated, including parameters indirectly related to exposure and health adversities, such as sociodemographic and anthropometric parameters and dietary factors. The primary outcome of the study was that the identified perturbations related to the TCA cycle are mainly associated with impaired mitochondrial respiration, which is detrimental to cellular homeostasis and functionality; this is further potentiated by the capacity of heavy metals to induce oxidative stress. Insufficient production of energy from the mitochondria during the perinatal period is associated with developmental disorders in children. The HERACLES cohort included more detailed data regarding diet and sociodemographic status of the studied population, allowing the identification of a broader spectrum of effect modifiers, such as the beneficial role of a diet rich in antioxidants such as lycopene and ω-3 fatty acids, the negative effect the consumption of food items such as pork and chicken meat has or the multiple impacts of fish consumption. Beyond diet, several other factors have been proven influential for child neurodevelopment, such as the proximity to pollution sources (e.g., waste treatment site) and the broader living environment, including socioeconomic and demographic characteristics. Overall, our results demonstrate the utility of exposome-wide association studies (EWAS) toward understanding the relationships among the multiple factors that determine human exposure and the underlying biology, reflected as omics markers of effect on neurodevelopment during childhood.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

116 Canadian Community Paediatricians' Perspectives of Sport Medicine in Residency and in Practice

Primary Subject area

Community Paediatrics

Background

Participation by children and adolescents in organized sports and recreational sporting activities is increasingly popular in Canada. Although the health and psychosocial benefits of sports for children are significant, participation in sports confers an increased risk of injury, resulting in a considerable burden of visits to emergency departments and primary care offices. Despite the frequency of sport-related injuries, there are documented gaps in sport and exercise medicine (SEM) education in paediatric training, leading to many practicing paediatricians feeling uncomfortable in managing these issues.

Objectives

We sought to describe Canadian community paediatricians’ perspectives about SEM in training and practice. This descriptive, cross-sectional cohort study of practicing Canadian community paediatricians was designed to assess: i) self-reported practice profiles with respect to sport issues; ii) perceptions of SEM training during paediatric residency; and iii) comfort level with management of sport injuries.

Design/Methods

To address these questions, a cross-sectional electronic survey of Canadian community paediatricians was conducted between February and March 2020. A survey was emailed to full members of the community paediatrics section of the Canadian Paediatric Society (CPS) (n=370) by CPS administrative staff. Participants were asked about musculoskeletal (MSK)/sport issues seen, how they manage these cases, their comfort level with diagnosis and management of sport injuries (on a 5-point Likert scale), and their perceptions of MSK/SEM training during paediatric residency.

Results

The response rate was 23.0% (85/370). A quarter of respondents (20/85; 23.4%) reported seeing MSK/sport issues very often; a third (27/85; 31.7%) were comfortable managing these patients on their own. Almost all respondents did not feel that they had received adequate SEM training during paediatric residency (81/85; 95.3%). Respondents were most comfortable managing concussion, rating their comfort 4.17/5 on a 5-point scale (95% CI=3.96-4.38), and Osgood-Schlatter’s disease 3.86/5 (95% CI=3.60-4.11). Participants were uncomfortable managing acromioclavicular joint separations 1.81/5 (95% CI=1.58-20.6) and elbow pain 2.65/5 (95% CI=2.40-2.90). Regression analysis indicated that only the frequency of MSK/sport-related visits was associated with provider comfort level (p < 0 .001).

Conclusion

Most Canadian community paediatricians do not manage many patients with sport-related issues and are not comfortable managing these patients on their own. They feel that SEM training during their paediatric residency inadequately prepared them for practice. Incorporating more SEM training into paediatric residency programs may increase comfort level with MSK/sport issues and change referral patterns and practice patterns amongst community paediatricians.

Diffuse large B-cell lymphoma: A consensus practice statement from the Australasian Lymphoma Alliance

Diffuse large B-cell lymphoma (DLBCL) is the most common lymphoma subtype, accounting for 30-40% of lymphoma diagnoses. Though aggressive, cure is achievable in approximately 60% of cases with primary chemo-immunotherapy, and in a further substantial minority by salvage therapy and autologous stem cell transplantation. Despite promising activity in early phase clinical trials, no intensified or novel treatment regimen has improved outcomes over R-CHOP21 in randomised studies. However, there remain several areas of controversy including the most appropriate prognostic markers, CNS prophylaxis and the optimal treatment for patients with high-risk disease. This position statement presents an evidence-based synthesis of the literature for application in Australasian practice. This article is protected by copyright. All rights reserved.

Amino acid digestibility of larval meal (Musca domestica) for broiler chickens

Work was undertaken to investigate the potential use of housefly (Musca domestica) larvae reared on broiler manure as a source of nutrition for poultry production in the United Kingdom. Nutritional analysis showed that larvae have a high (>45% dry wt.) protein content and a favorable amino acid profile that is rich in key amino acids, such as lysine and methionine. A broiler digestibility trial was carried out to determine the apparent ileal digestibility coefficients (AIDC) and true ileal digestibility coefficients (TIDC) of amino acids (AA) from insect larval meal (ILM) from M. domestica and fishmeal (FM) in broiler chickens. This was calculated using multiple linear regression technique based upon 3 inclusions of each protein source in a semisynthetic diet. One-hundred-forty-four day-old male (Ross 308) broilers were fed from hatch on a commercial starter diet for 20 days. Experimental diets were fed from d 21 to 28, and feed intakes were measured daily. On d 28, the trial was terminated, ileal digesta were collected for the determination of AIDC and TIDC of AA, and inflammatory responses (gizzard erosion and eye discharge) were measured. No significant differences were observed in digestibilities between protein sources for any AA. Furthermore, ILM feeding did not induce gizzard erosion or eye discharge at any inclusion. These results provide strong evidence to suggest that ILM of the common housefly can provide a successful alternative protein source to FM in broiler diets.

Survival After Emergency General Surgery: What can We Learn from Enhanced Recovery Programmes?

Enhanced recovery after surgery (ERAS) has been adopted by many centres and across whole healthcare systems. The results have shown significant reductions in length of stay and postoperative complications. However, there has been very little change in these factors and mortality in emergency surgery. Can we learn from principles of ERAS for emergency abdominal surgery?

High-dose chemotherapy with autologous stem cell transplantation in relapsed or refractory germ cell tumours: outcomes and prognostic variables in a case series of 17 patients

BACKGROUND

Optimal therapy for men relapsing after initial chemotherapy for germ cell tumours (GCT) is poorly defined. Both conventional dose salvage regimens and high-dose chemotherapy with autologous stem cell transplantation (HDCT-ASCT) have been utilised.

AIMS

To examine patients who received HDCT-ASCT for relapsed GCT within a single Australian centre.

METHODS

Records between 2000 and 2012 were analysed for baseline characteristics, treatment-related toxicity and survival. Prognosis at the time of HDCT-ASCT was classified according to the International Prognostic Factors Study Group (IPFSG).

RESULTS

Seventeen patients received HDCT-ASCT, median age 34 (21-46), with 41% having primary refractory disease and 53% with high/very high risk disease by IPFSG. The most common regimen utilised was paclitaxel/ifosfamide followed by high-dose carboplatin/etoposide (TI-CE; n = 12). The median duration of grade 4 (G4) neutropenia was 11 days (range 9-17) with febrile neutropenia in 90% resulting in four intensive care unit admissions (8%). Median duration of G4 thrombocytopenia was 10 days (range 8-19) requiring a median of two pooled platelets bags (range 0-33) per episode. Transplant-related mortality occurred in one patient (veno-occlusive disease). Twenty-seven per cent of HDCT-ASCT cycles were associated with grade 3 mucositis (median total parenteral nutrition days = 5 (0-23)). Two-year progression-free survival (PFS) and overall survival (OS) rates were 59% and 71%. Patients who received HDCT-ASCT as second or subsequent relapse fared worse than those treated with HDCT-ASCT at first relapse (hazard ratio 0.23 (95% confidence interval: 0.04, 1.37; P-value 0.09). Three-year OS for those who received TI-CE at first relapse was 90%.

CONCLUSIONS

HDCT-ASCT for relapsed GCT is effective with acceptable toxicity. There was encouraging PFS/OS, particularly in a poor-prognosis cohort.

Multi-scalar mechanical testing of the calcified cartilage and subchondral bone comparing healthy vs early degenerative states

OBJECTIVE

The calcified cartilage layer is thought to be integral to force transmission between the compliant articular cartilage (AC) above and underlying stiff bone. This study aims to determine how such a stiffness gradient across the calcified cartilage and bone changes with joint degeneration and how different scalar levels of testing are correlated.

METHOD

Using a bovine model of early osteoarthritis (OA), multiple samples of calcified cartilage on subchondral bone (SB) from sixteen bovine patellae, displaying a range of cartilage states from intact (healthy) to moderately degenerate, were tested using macroscopic three-point bending, microhardness indentation, and nanoindentation. Mechanical properties were correlated to cartilage health and microstructural morphometric measurements obtained from high resolution imaging using Differential Interference Contrast (DIC) Microscopy.

RESULTS

There was a significant decrease in the moduli obtained from tests done at increasing scalar levels. The macroscale average modulus obtained from three-point bending showed that the SB was 10 times stiffer than the calcified cartilage in healthy tissue, 5 times in tissue displaying mildly degenerate AC and 8 times with moderate degeneration. Microhardness testing of multiple points from the calcified cartilage to the SB revealed that there was a monotonic gradual increase in the mean modulus. The moduli obtained from nanoindentation testing indicated that the SB was about twice the stiffness of the calcified cartilage.

CONCLUSION

The mechanical transition from calcified cartilage to SB involves a graded continuum of increasing material stiffness. This stiffness gradient is altered in association with early degenerative change in the overlying AC, detectable only at the macro level.

Reflecting reality: pager simulations in undergraduate education

BACKGROUND

Fifth-year medical students build on their experiences of simulation and clinical placement to undertake a period of pager contact, during which they must respond appropriately to a variety of 'bleep' messages, culminating in the team management of a complex scenario.

CONTEXT

In anticipation of their graduation to foundation-year doctors, fifth-year students in their final term on clinical placement at Lancashire Teaching Hospitals experience a period of time on call, when they receive a series of pager messages that they must manage whilst on clinical placement. They are expected to manage the variety of random events as if they were doctors on call.

INNOVATION

With the agreement of all affected parties, students experience some simulated events of the type that they may experience while on call as foundation-year doctors. They are required to respond appropriately to these and are offered feedback on performance after they gather for a cardiac arrest simulation.

DISCUSSION

This has been a very popular and impactful experience for final-term undergraduates as they anticipate the challenges of becoming foundation-year doctors. The need for effective management of clinical and non-technical skills presented in an ill-defined problem space is an appropriate challenge that serves to reassure them about their capacity to manage the unexpected. [The students] are expected to manage the variety of random events as if they were doctors on call.

LAMP assay and rapid sample preparation method for on-site detection of flavescence dorée phytoplasma in grapevine

In Europe the most devastating phytoplasma associated with grapevine yellows (GY) diseases is a quarantine pest, flavescence dorée (FDp), from the 16SrV taxonomic group. The on-site detection of FDp with an affordable device would contribute to faster and more efficient decisions on the control measures for FDp. Therefore, a real-time isothermal LAMP assay for detection of FDp was validated according to the EPPO standards and MIQE guidelines. The LAMP assay was shown to be specific and extremely sensitive, because it detected FDp in all leaf samples that were determined to be FDp infected using quantitative real-time PCR. The whole procedure of sample preparation and testing was designed and optimized for on-site detection and can be completed in one hour. The homogenization procedure of the grapevine samples (leaf vein, flower or berry) was optimized to allow direct testing of crude homogenates with the LAMP assay, without the need for DNA extraction, and was shown to be extremely sensitive.

Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy

Background

Emergency laparotomies in the UK, USA and Denmark are known to have a high risk of death, with accompanying evidence of suboptimal care. The emergency laparotomy pathway quality improvement care (ELPQuiC) bundle is an evidence-based care bundle for patients undergoing emergency laparotomy, consisting of: initial assessment with early warning scores, early antibiotics, interval between decision and operation less than 6 h, goal-directed fluid therapy and postoperative intensive care.

Methods

The ELPQuiC bundle was implemented in four hospitals, using locally identified strategies to assess the impact on risk-adjusted mortality. Comparison of case mix-adjusted 30-day mortality rates before and after care-bundle implementation was made using risk-adjusted cumulative sum (CUSUM) plots and a logistic regression model.

Results

Risk-adjusted CUSUM plots showed an increase in the numbers of lives saved per 100 patients treated in all hospitals, from 6·47 in the baseline interval (299 patients included) to 12·44 after implementation (427 patients included) (P < 0·001). The overall case mix-adjusted risk of death decreased from 15·6 to 9·6 per cent (risk ratio 0·614, 95 per cent c.i. 0·451 to 0·836; P = 0·002). There was an increase in the uptake of the ELPQuiC processes but no significant difference in the patient case-mix profile as determined by the mean Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity risk (0·197 and 0·223 before and after implementation respectively; P = 0·395).

Conclusion

Use of the ELPQuiC bundle was associated with a significant reduction in the risk of death following emergency laparotomy.

The complete genome sequences of two isolates of potato black ringspot virus and their relationship to other isolates and nepoviruses

The complete nucleotide sequences of RNA 1 and RNA 2 of the nepovirus potato black ringspot virus (PBRSV) from two different isolates were determined, as well as partial sequences from two additional isolates. RNA1 is 7,579-7,598 nucleotides long and contains one single open reading frame (ORF), which is translated into a large polyprotein with 2,325 amino acids and a molecular weight of 257 kDa. The complete sequence of RNA2 ranges from 3857 to 3918 nt between the different isolates. It encodes a polyprotein of 1079-1082 amino acids with a molecular weight of 120 kDa. Sequence comparison using the Pro-Pol region and CP showed that all four isolates formed two distinct groups, corresponding to potato and arracacha, that were closely related to each other and also to tobacco ringspot virus (TRSV). Comparing our data to those obtained with other nepoviruses, our results confirm that PBRSV belongs to a distinct species and is a member of subgroup A in the genus Nepovirus based on its RNA2 size, genome organization, and nucleotide sequence.

A strategy to maintain safety in clinical incidents

NHS team leaders are often in a position where they have to not only manage and control a clinical situation but also become actively involved in delivering patient care because of low staffing levels or inappropriate skill mixes. This increases the potential for loss of situational awareness and risk to patient and staff safety. "Inner and outer circles" offers a strategy that could reduce risks and increase patient safety. It is used in pre-hospital and industrial environments and could easily be adapted to inpatient and other settings.

A multicentre retrospective comparison of central nervous system prophylaxis strategies among patients with high-risk diffuse large B-cell lymphoma

Background:

Central nervous system (CNS) relapse in diffuse large B-cell lymphoma (DLBCL) is a devastating complication; the optimal prophylactic strategy remains unclear.

Methods:

We performed a multicentre, retrospective analysis of patients with DLBCL with high risk for CNS relapse as defined by two or more of: multiple extranodal sites, elevated serum LDH and B symptoms or involvement of specific high-risk anatomical sites. We compared three different strategies of CNS-directed therapy: intrathecal (IT) methotrexate (MTX) with (R)-CHOP ‘group 1' R-CHOP with IT MTX and two cycles of high-dose intravenous (IV) MTX ‘group 2' dose-intensive systemic antimetabolite-containing chemotherapy (Hyper-CVAD or CODOXM/IVAC) with IT/IV MTX ‘group 3'.

Results:

Overall, 217 patients were identified (49, 125 and 43 in groups 1–3, respectively). With median follow-up of 3.4 (range 0.2–18.6) years, 23 CNS relapses occurred (12, 10 and 1 in groups 1–3 respectively). The 3-year actuarial rates (95% CI) of CNS relapse were 18.4% (9.5–33.1%), 6.9% (3.5–13.4%) and 2.3% (0.4–15.4%) in groups 1–3, respectively (P=0.009).

Conclusions:

The addition of high-dose IV MTX and/or cytarabine was associated with lower incidence of CNS relapse compared with IT chemotherapy alone. However, these data are limited by their retrospective nature and warrant confirmation in prospective randomised studies.

Limited role for surveillance PET-CT scanning in patients with diffuse large B-cell lymphoma in complete metabolic remission following primary therapy

Background:

The usefulness of positron emission tomography with computed tomography (PET–CT) in the surveillance of patients with diffuse large B-cell lymphoma (DLBCL) in complete metabolic remission after primary therapy is not well studied.

Methods:

We performed a retrospective review of our database between 2002 and 2009 for patients with de novo DLBCL who underwent surveillance PET–CT after achieving complete metabolic response (CMR) following primary therapy.

Results:

Four-hundred and fifty scans were performed in 116 patients, with a median follow-up of 53 (range 8–133) months from completion of therapy. Thirteen patients (11%) relapsed: seven were suspected clinically and six were subclinical (all within first 18 months). The positive predictive value in patients with international prognostic index (IPI) <3 was 56% compared with 80% in patients with IPI⩾3. Including indeterminate scans, PET–CT retained high sensitivity 95% and specificity 97% for relapse.

Conclusion:

Positron emission tomography with computed tomography is not useful in patients for the majority of patients with diffuse large B-cell lymphoma in CMR after primary therapy, with the possible exception of patients with baseline IPI ⩾3 in the 18 months following completion of primary therapy. This issue could be addressed by a prospective clinical trial.

Selected reaction monitoring method to determine the species origin of blood-based binding agents in meats: a collaborative study

Binding products or food 'glues' are used throughout the food industry to increase the meat use rate or to augment economic efficiency. Some of these binders contain thrombin from bovine and porcine blood. The European parliament has recently banned thrombin-based additives and labelling legislation governs their use in the US. A mass spectrometry screening method is available to detect the addition of thrombin agents to foods as there is a need to protect consumers and to avoid misleading trade practices. We report the details of an inter-laboratory trial to determine the transferability of this method to operators in various food testing laboratories, each using a different triple quadrupole mass spectrometer design. The trial was successful with the species origin of the binding agent contained in each of the 43 test materials being correctly reported by the participants. This is consistent with a false positive and false negative rate of 0%. This is the first collaborative study, as far as we are aware, which involves a liquid chromatography mass spectrometry (LC-MS/MS) application to approach a food authenticity issue.