Getting Wheels: development and evaluation of a psychoeducational resource for parents of children with a neuromuscular condition following recommendation of wheelchair equipment

PURPOSE

Access to credible information can facilitate parental engagement in wheelchair prescription for their child with a neuromuscular condition (NMC). In this study, we developed and evaluated acceptability, perceived usefulness and emotional responses to a psychoeducational booklet for parents of children with a NMC.

METHODS

Australian parents of children who had been recommended a wheelchair and clinicians caring for children with NMCs were invited to evaluate the booklet, Getting Wheels. The booklet included 11 chapters, each covering distinct aspects of wheelchair prescription and supportive care. Participants completed one online survey including validated and study-specific measures.

RESULTS

Twenty-seven parents (71% response rate, 78% mothers) and nine clinicians (90% response rate, 89% women) participated. All parents endorsed the booklet as addressing their information and support needs, and 93% agreed it would help parents engage in the wheelchair prescription process. All clinicians endorsed the booklet as addressing parents' information and support needs and agreed they could use the booklet in clinical practice.

CONCLUSIONS

Parents and clinicians rate Getting Wheels as acceptable for use in the context of wheelchair recommendation for children with a neuromuscular condition. Next steps include prospective examination of booklet use in clinical practice and adaptation to culturally and linguistically diverse populations.Implications for rehabilitationThe co-designed "Getting Wheels" booklet provides tailored information for use in the context of wheelchair recommendation for children with a neuromuscular condition.The emotions elicited throughout wheelchair prescription endorse the need for integrated psychosocial multidisciplinary care to improve access and support the ongoing emotional needs of this population.Parents of children who receive wheelchair recommendation between zero and two years require greater support from clinicians regarding their thoughts and feelings about wheelchair prescription.Parents of children with a neuromuscular condition and treating clinicians support provision of a tailored psychoeducational resource when a child is recommended a wheelchair.

Enhancing the Focus: How Does Parental Incarceration Fit into the Overall Picture of Adverse Childhood Experiences (ACEs) and Positive Childhood Experiences (PCEs)?

Despite the five million children in the U.S. with an incarcerated parent, there is limited research on risk and protective factors for this population. We analyzed data from the National Survey for Children's Health (2018) to: (1) examine associations among parental incarceration and other adverse childhood experiences (ACEs), (2) characterize the association between parental incarceration and youth mental health outcomes, (3) examine differences in positive childhood experiences (PCEs; collective socialization, community engagement, neighborhood amenities, and family problem solving) by parental incarceration status, (4) examine whether PCEs were protective against mental health problems and if there was an interaction with parental incarceration status, and (5) examine the interaction between PCEs, parental incarceration, and ACEs on mental health problems. Results revealed that children with incarcerated parents had higher odds of experiencing other ACEs, higher odds of having mental health problems, and experienced fewer PCEs compared to children without incarcerated parents. Further, although PCEs were associated with a lower odds of mental health problems for both children with and without incarcerated parents, they did not mitigate the negative impact of parental incarceration on mental health outcomes. While PCEs attenuated the association between ACEs and mental health, parental incarceration status did not significantly moderate the interaction. These results highlight vulnerabilities and potential protective factors for children with incarcerated parents and have important implications for the development of multilevel intervention strategies that seek to promote resilience and reduce risk for this population.

Clinician Perspectives on Opioid Treatment Agreements: A Qualitative Analysis of Focus Groups

BACKGROUND

Patients with chronic pain face significant barriers in finding clinicians to manage long-term opioid therapy (LTOT). For patients on LTOT, it is increasingly common to have them sign opioid treatment agreements (OTAs). OTAs enumerate the risks of opioids, as informed consent documents would, but also the requirements that patients must meet to receive LTOT. While there has been an ongoing scholarly discussion about the practical and ethical implications of OTA use in the abstract, little is known about how clinicians use them and if OTAs themselves modify clinician prescribing practices.

OBJECTIVE

To determine how clinicians use OTAs and the potential impacts of OTAs on opioid prescribing.

DESIGN

We conducted qualitative analysis of four focus groups of clinicians from a large Midwestern academic medical center. Groups were organized according to self-identified prescribing patterns: two groups for clinicians who identified as prescribers of LTOT, and two who did not.

PARTICIPANTS

17 clinicians from General Internal Medicine, Family Medicine, and Palliative Care were recruited using purposive, convenience sampling.

APPROACH

Discussions were recorded, transcribed, and analyzed for themes using reflexive thematic analysis by a multidisciplinary team.

KEY RESULTS

Our analysis identified three main themes: (1) OTAs did not influence clinicians' decisions whether to use LTOT generally but did shape clinical decision-making for individual patients; (2) clinicians feel OTAs intensify the power they have over patients, though this was not uniformly judged as harmful; (3) there is a potential misalignment between the intended purposes of OTAs and their implementation.

CONCLUSION

This study reveals a complicated relationship between OTAs and access to pain management. While OTAs seem not to impact the clinicians' decisions about whether to use LTOT generally, they do sometimes influence prescribing decisions for individual patients. Clinicians shared complex views about OTAs' purposes, which shows the need for more clarity about how OTAs could be used to promote shared decision-making, joint accountability, informed consent, and patient education.

A resonant sextuplet of sub-Neptunes transiting the bright star HD 110067

Planets with radii between that of the Earth and Neptune (hereafter referred to as 'sub-Neptunes') are found in close-in orbits around more than half of all Sun-like stars1,2. However, their composition, formation and evolution remain poorly understood3. The study of multiplanetary systems offers an opportunity to investigate the outcomes of planet formation and evolution while controlling for initial conditions and environment. Those in resonance (with their orbital periods related by a ratio of small integers) are particularly valuable because they imply a system architecture practically unchanged since its birth. Here we present the observations of six transiting planets around the bright nearby star HD 110067. We find that the planets follow a chain of resonant orbits. A dynamical study of the innermost planet triplet allowed the prediction and later confirmation of the orbits of the rest of the planets in the system. The six planets are found to be sub-Neptunes with radii ranging from 1.94R⊕ to 2.85R⊕. Three of the planets have measured masses, yielding low bulk densities that suggest the presence of large hydrogen-dominated atmospheres.

Hypertensive Management

Hypertension affects 1 in 3 Americans and results in nearly 900,000 inpatient admits annually due to ineffective management. As a primary factor in the development of strokes, hypertension management is essential. The approach to effectively manage hypertension should be done from a multipoint approach to ensure the specific elements that impede the effective management of hypertension within various patient populations are addressed accordingly, which includes, personal, physical, and health needs. The robust implementation of lifestyle modifications, medication therapy, and self-efficacy interventions can improve hypertension management by almost 37%.

Genetic subgroups inform on pathobiology in adult and pediatric Burkitt lymphoma

Burkitt lymphoma (BL) accounts for most pediatric non-Hodgkin lymphomas, being less common but significantly more lethal when diagnosed in adults. Much of the knowledge of the genetics of BL thus far has originated from the study of pediatric BL (pBL), leaving its relationship to adult BL (aBL) and other adult lymphomas not fully explored. We sought to more thoroughly identify the somatic changes that underlie lymphomagenesis in aBL and any molecular features that associate with clinical disparities within and between pBL and aBL. Through comprehensive whole-genome sequencing of 230 BL and 295 diffuse large B-cell lymphoma (DLBCL) tumors, we identified additional significantly mutated genes, including more genetic features that associate with tumor Epstein-Barr virus status, and unraveled new distinct subgroupings within BL and DLBCL with 3 predominantly comprising BLs: DGG-BL (DDX3X, GNA13, and GNAI2), IC-BL (ID3 and CCND3), and Q53-BL (quiet TP53). Each BL subgroup is characterized by combinations of common driver and noncoding mutations caused by aberrant somatic hypermutation. The largest subgroups of BL cases, IC-BL and DGG-BL, are further characterized by distinct biological and gene expression differences. IC-BL and DGG-BL and their prototypical genetic features (ID3 and TP53) had significant associations with patient outcomes that were different among aBL and pBL cohorts. These findings highlight shared pathogenesis between aBL and pBL, and establish genetic subtypes within BL that serve to delineate tumors with distinct molecular features, providing a new framework for epidemiologic, diagnostic, and therapeutic strategies.

Prévalence du SARS-CoV-2, étude sérologique en France chez des salariés non confinés et confinés

Objectifs: Evaluer rétrospectivement le taux de salariés, confinés (en télétravail) et non confinés, infectés par le SARS-CoV-2 après le 1^er confinement (Avril à Mai 2020).

Méthode: Un dépistage sérologique des anticorps anti-SARS-CoV-2, IgG et IgM, et un questionnaire sur leurs symptômes a été proposé aux 2090 salariés d’une même entreprise.

Résultats: La sérologie était positive pour 5,6% des 786 salariés inclus entre fin avril et juillet 2020 : 4,05% chez les non confinés, et 6,72%, chez les confinés (p=NS).

Parmi les positifs, 86,4% avaient présenté des symptômes, sans différence significative entre confinés et non confinés. Enfin, 1.7% des asymptomatiques étaient positifs.

Les symptômes n’étaient pas significativement différents entre les 2 groupes sauf pour l’anosmie-agueusie significativement plus fréquente dans le groupe des confinés.

Les symptômes significativement associés à une sérologie positive étaient l’anosmie-agueusie, la fièvre-sensation de fièvre-frissons, les courbatures, la fatigue malaise, un syndrome grippal et des symptômes respiratoires.

Ce faible taux de contamination peut être le résultat des mesures de prévention renforcées mises en place pour les salariés dès fin janvier 2020 par le Médecin du Travail pour limiter le risque de contamination au sein des locaux.

Conclusion: La prévalence du SARS-CoV-2 dans l’entreprise de fin avril à juillet 2020 était inférieure de moitié au taux rapporté dans la population d’Ile de France à la même période sans différence entre les salariés ayant poursuivi leur activité en présentiel par rapport aux confinés.

Type 1 diabetes knowledge assessment: The KAT-1 validation study

OBJECTIVE

This study sought to examine the reliability and validity of a novel pediatric type 1 diabetes knowledge assessment (KAT-1) designed for children, adolescents, young adults and their parents/guardians. The instrument was designed to be integrated into the clinic workflow to obtain objective data electronically.

RESEARCH DESIGN AND METHODS

KAT-1 was developed by a multidisciplinary team and includes 11 independent topical subscales. Forty children/caregivers participated in a pilot study; their feedback was used to improve item clarity and readability. Subsequently, a validation study was performed in 200 participants (100 children/adolescents/young adults with type 1 diabetes ages 11-21 years and 100 parents/guardians of children with type 1 diabetes ages 1-15 years) to examine correlations between the KAT-1 scores and Revised Diabetes Knowledge Test (DKT2) scores and HbA1c. An item analysis was conducted to determine internal consistency and reliability; topical subscales were evaluated using Cronbach's alpha.

RESULTS

Total KAT-1 scores were positively correlated with DKT2 scores r = 0.674, p < 0.001, and negatively correlated with HbA1c, r = -0.3, p < 0.001. All KAT-1 subscales were positively and significantly correlated with one another and with total KAT-1 score. Internal consistency of total KAT-1 score was strong (Cronbach's α = 0.938, mean score 84.6, SD = 16.1) and 9 of 11 independent topical subscales demonstrated strong internal consistency. Completion time for subscales was <5 min.

CONCLUSIONS

KAT-1 is a valid instrument to assess type 1 diabetes knowledge. The instrument's short topical subscales can be used to objectively assess specific knowledge and individualize diabetes education. KAT-1 has been integrated into our electronic health record (EPIC) and is available online at no cost.

92 CONTINUING TO ‘BE HIP’: ORTHOGERIATRIC SERVICE IMPROVEMENTS IN 2021

Background

Scotland first demonstrated that adherence to nationally agreed hip fracture standards improve patient survival, reduces the duration of admission, and reduces the need for high dependency care. Our study aims to assess adherence to the Irish Hip Fracture Standards (IHFS) in our hospital for 2021 amidst the COVID-19 pandemic, translating to improved clinical outcomes for our patients.

Methods

The IHF database was retrospectively analysed, comparing quarters 1-4 in 2021 with our 2020 results.

Results

IHFS1, patient time to the ward < 4hours, was maintained at 67% in 2021 versus 71% overall in 2020. There was improvement in IHFS2, time to surgery within 48 hours, up to 73% in 2021 versus 66% in 2020. IHFS3 was 4% in 2021 versus 3% overall in 2020. Further improvements were noted for IHFS4, with 95% of patients reviewed by a Geriatrician in 2021 versus 87% in 2020. IHFS5 also improved with 97% of patients receiving a bone health assessment in 2021 versus 87% in 2020. Moreover, IHFS6, improved with 97% of patients undergoing a specialised falls assessment in 2021 versus 87% in 2020.

Conclusion

The improvement in 2021 figures is reflective of the return of redeployed services during the COVID-19 pandemic inclusive of the Orthogeriatric Service, the Fracture Liaison Service Advanced Nurse Practitioner, the Trauma Co-ordinator, and the specialist Orthopaedic ward complete with its Orthopaedic nurses and Multi-Disciplinary Team, and improved Emergency Department pathways. These continued improvements in the IHFS further emphasise that success is dependent on a team that is joined at the hip

258 RISING TO THE CHALLENGE: ORTHOGERIATRIC SERVICE IMPROVEMENT AND COVID-19

Background

Nationally agreed hip fracture standards have contributed to the improvement of outcomes in hip fracture patients. In 2020, our hospital was awarded “The Golden Hip” for achieving highest compliance with Irish Hip Fracture Standards (IHFS) nationally for 2019.

Methods

Data from the Irish Hip Fracture Database (IHFD)was retrospectively analysed to assess our performance in 2020 versus 2019 in hip fracture patients over sixty. Multiple quality improvement interventions were put in place throughout 2019 to ensure improvement in IHFS1-6 compliance: Creation of the Hip Fracture Pathway Subgroup, IHFS 1 Breaches Audit, Orthogeriatric input at Orthopaedic inductions, weekly Multi-disciplinary Team meetings, a Nutritional Hip Fracture Pathway and addition of the Fracture Liaison Service Advanced Nurse Practitioner.

Results

There were 239 hip fracture patients in 2020 vs 249 in 2019. IHFS1 compliance improved with the percentage of patients admitted to the Orthopaedic ward within 4 hours increasing to 71% in 2020 from 56% in 2019. There was improvement in IHFS2-time to surgery &lt;48 hours- 66% in 2020 vs 60% in 2019. IHFS3-pressure ulcer rate-was at the national average, 3% in 2020 vs 2% in 2019. IHFS4 (reviewed by a Geriatrician), IHFS5 (received a bone health assessment) and IHFS6 (received a specialised falls assessment) were lower overall; 87% in 2020 vs 98% in 2019. For all quarters (Q),43% of patients met all IHFS in our hospital in 2020 vs 32% in 2019, resulting in €90,000 in Best Practice Tariff funding.

Conclusion

Lower results for IHFS 4,5 and 6 reflect the arrival of the COVID-19 pandemic which led to redeployment of the Orthogeriatric Service and redeployment of the MDT from end of Q1 to Q3. When services in 2020 were preserved,1 in 2 hip fracture patients met all IHFS, vs 1 in 3 patients in 2019. Despite the pandemic, we continued to achieve the highest level of IHFS compliance nationally, being awarded a second consecutive “Golden Hip” for 2020.

TEMPus VoLA: The timed Epstein multi-pressure vessel at low accelerations

The field of planetary system formation relies extensively on our understanding of the aerodynamic interaction between gas and dust in protoplanetary disks. Of particular importance are the mechanisms triggering fluid instabilities and clumping of dust particles into aggregates, and their subsequent inclusion into planetesimals. We introduce the timed Epstein multi-pressure vessel at low accelerations, which is an experimental apparatus for the study of particle dynamics and rarefied gas under micro-gravity conditions. This facility contains three experiments dedicated to studying aerodynamic processes: (i) the development of pressure gradients due to collective particle-gas interaction, (ii) the drag coefficients of dust aggregates with variable particle-gas velocity, and (iii) the effect of dust on the profile of a shear flow and resultant onset of turbulence. The approach is innovative with respect to previous experiments because we access an untouched parameter space in terms of dust particle packing fraction, and Knudsen, Stokes, and Reynolds numbers. The mechanisms investigated are also relevant for our understanding of the emission of dust from active surfaces, such as cometary nuclei, and new experimental data will help interpreting previous datasets (Rosetta) and prepare future spacecraft observations (Comet Interceptor). We report on the performance of the experiments, which has been tested over the course of multiple flight campaigns. The project is now ready to benefit from additional flight campaigns, to cover a wide parameter space. The outcome will be a comprehensive framework to test models and numerical recipes for studying collective dust particle aerodynamics under space-like conditions.

Dental Pain in Care Homes: Is It a Phenomenon? A Systematic Review of the Literature

Background: Evidence suggests that 80% of residents living in nursing homes have moderate to severe pain, could dental causes be an under reported contributory factor. The evidence suggests that this is an under-researched area. Our project aims were to explore and consolidate the current literature and conduct some stakeholder groups with care home managers and dentists. Our stakeholder group will be reported elsewhere. Methods: We used the SPIDER framework to set out key search terms. Which included “dementia” OR “cognitively-impaired” OR “carehome residents” AND “dental pain” OR “oralfacial pain” OR “mouth pain” AND “pain assessment” OR “pain identification”. A literature search was carried out on 8 and 9 March 2022 in the electronic databases: Cochrane, PubMed, Medline, Dental & Oral Sciences Source, CINAHL, Global Health, SocINDEX, Ovid (Medline) and Scopus. Restrictions were placed on dates and language (2012–2022 and English only). Results: The search yielded 775 papers up to the year 2020. After screening and exclusion, we were left with five papers: four quantitative and one qualitative. Conclusions: This review demonstrates that there has been very little research into oral health and/or dental pain in adults with dementia. Furthermore, the recommendations have yet to be taken forward. Identifying pain in older adults with dementia remains challenging. There is a need to develop an algorithm in conjunction with care home staff and dental practitioners in order to identify and address the pain associated with dental disease in adults with dementia.

The CHALLENGE trial: the effects of a virtual reality-assisted exposure therapy for persistent auditory hallucinations versus supportive counselling in people with psychosis: study protocol for a randomised clinical trial

Background

Many patients suffering from schizophrenia spectrum disorders continue having distressing auditory hallucinations in spite of treatment with antipsychotic medication. The aim of this trial is to examine the effect of a targeted virtual reality therapy for persistent auditory hallucinations in individuals with psychosis. The trial explores whether this type of therapy can decrease the severity, frequency and distress of auditory hallucinations and, additionally, whether it can reduce clinical symptoms and enhance daily functioning in individuals with psychosis.

Methods

The study is a randomised, assessor-blinded parallel-group superiority clinical trial, allocating a total of 266 patients to either the experimental intervention or supportive counselling. The participants will be randomised to either (1) seven sessions of virtual reality therapy or (2) seven sessions of supportive counselling to be delivered within the first 12 weeks after inclusion in the study. All participants will be assessed at baseline and 12 and 24 weeks post-baseline. Independent assessors blinded to the treatment allocation will evaluate the outcome. The primary outcome is the level of auditory hallucinations measured with the Psychotic Symptoms Rating Scales (PSYRATS-AH) total score at the cessation of treatment at 12 weeks. Secondary outcomes are frequency of auditory hallucinations, the distress caused by auditory hallucinations, perceived voice power, patient acceptance of voices, patients’ ability to respond to voices in an assertive way and social and daily function.

Discussion

Promising evidence of the efficacy of this immersive virtual reality-based therapy for auditory hallucinations exist, but evidence needs to be established in a large, methodological rigorous trial. If the therapy proves to be beneficial in reducing the severity of refractory auditory hallucinations, a large group of patients with schizophrenia and related disorders could be the target group of this short-term psychotherapeutic intervention.

Abstract 1131: Pharmacogenomic insight into targetable vulnerabilities and modifiers of response to MRTX1133 in KRASG12D-mutant models

The ability to effectively target mutated KRAS has remained elusive despite decades of research. Recently, the identification of selective KRASG12C inhibitors has provided an effective treatment option for patients harboring this particular mutation and has also provided insight toward targeting other KRAS mutants, including KRASG12D. MRTX1133 was identified via a structure-based drug design strategy as a potent, selective, and non-covalent KRASG12D inhibitor directed at the switch II binding pocket. MRTX1133 exhibited dose dependent KRAS pathway and tumor growth inhibition and demonstrated marked anti-tumor activity across a panel of models in vivo, including tumor regression &gt;30% in 8 out of 11 pancreatic ductal adenocarcinoma (PDAC) models. While evaluation of MRTX1133 across a panel of cell and patient-derived xenograft models demonstrated strong single agent activity in the majority of models tested, a subset of models were less responsive. Focused sgRNA libraries targeting ~5,000 genes were tested in MRTX1133-anchored CRISPR/Cas9 screens in vitro and in vivo in PDAC and colorectal KRASG12D-mutant cell lines. Similar to what was seen in a targeted genetic screen with our selective KRASG12C inhibitor MRTX849, several genes that act either upstream or downstream of KRAS were depleted with MRTX1133 treatment which illuminate specific targetable vulnerabilities in the context of KRASG12D inhibition. sgRNAs targeting EGFR, PIK3CA, PTPN11, mTOR, and CDK2/4/6 were depleted in MRTX1133-treated (or vehicle-treated) cell lines or xenograft models, while hallmark tumor suppressor genes RB1, KEAP1, NF1 and PTEN were enriched. The enrichment of KEAP1 sgRNAs in PDAC models parallels findings with MRTX849 in preclinical models and is in line with emerging clinical data suggesting increased capacity to scavenge reactive oxygen species (ROS) may represent a mechanism of partial resistance to a non-covalent, non-electrophilic warhead-containing KRASG12D-selective inhibitor in PDAC. Treatment using small molecules targeting selected vulnerabilities in vitro and in vivo confirmed these genetic findings. Further evaluation of dependencies utilizing an integrated analysis of RNAseq data also revealed KRAS regulates and is critically dependent on pro-survival and cell cycle genes for cancer cell viability. These data lend further insight into tumor response to KRASG12D inhibition and provide key insight into the genes that mediate the mechanism of action of, as well as confer partial resistance to MRTX1133, and identify combination targets that can augment the anti-tumor effect of MRTX1133.

Citation Format: Vickie Bowcut, Andrew Calinisan, David M. Briere, Lauren Hargis, Lars D. Engstrom, Jade Laguer, Darin Vanderpool, Xiaolun Wang, J David Lawson, Nicole Thomas, Robin Gunn, Christopher R. Smith, Julio Fernandez-Banet, Leo He, Adam Pavlicek, Lisa Rahbaek, Matthew A. Marx, Peter Olson, James G. Christensen, Jill Hallin. Pharmacogenomic insight into targetable vulnerabilities and modifiers of response to MRTX1133 in KRASG12D-mutant models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1131.

Low genetic confirmation rate in South Indian subjects with a clinical diagnosis of maturity-onset diabetes of the young (MODY) who underwent targeted next-generation sequencing for 13 genes

PURPOSE

To screen for maturity-onset diabetes of the young (MODY) variants in subjects with an early age of onset and positive family history of diabetes mellitus.

METHODS

60 subjects with onset of diabetes between 3 and 30 years of age and parental history (onset < 35 years) of diabetes were recruited after excluding autoimmune, pancreatic and syndromic forms of diabetes. Detailed pedigree chart and clinical data were recorded. MODY genetic testing (MODY 1-13) was performed and variant classification was done adhering to the ACMG guidelines.

RESULTS

Baseline characteristics of subjects were as follows: mean age of onset of diabetes 19.9 ± 7 years, mean duration of diabetes 6.3 ± 6.8 years, BMI 23.3 ± 3 kg/m² and C-peptide 1.56 ± 1.06 nmol/l. Four out of sixty (6.6%) were positive for variants classifiable as pathogenic/likely pathogenic: one patient with HNF4Ac.691C > T, (p.Arg231Trp), two with HNF 1A c.746C > A(p.Ser249Ter) and c.1340C > T(p.Pro447Leu), and one with ABCC8 c.4544C > T (p.Thr1515Met). MODY 1 and MODY 3 variants were documented in the paediatric age group (< 18 years).

CONCLUSION

A genetic diagnosis of MODY could be confirmed in only 6.6% (4/60) of patients clinically classifiable as MODY. This is less than that reported in clinically diagnosed MODY subjects of European descent. Newly published population data and more stringent criteria for assessment of pathogenicity and younger age of onset of type 2 diabetes in Indians could have contributed to the lower genetic confirmation rate. Apart from variants in the classical genes (HNF1A, HNF4A), a likely pathogenic variant in a non-classical gene (ABCC8) was noted in this study.

Comparison of a full arch digital photographic assessment of caries prevalence in 5-year-old children to an established visual assessment method: a cross-sectional study

Introduction

Digital epidemiology in dental disease screening has a number of advantages which warrant further exploration.

Aim

This study aimed to test the examination accuracy of digital images to evaluate child oral health by comparing the new method to a gold standard method. It also investigated the levels of diagnostic accuracy between different examiners, including dental care professionals and a lay examiner, when quantifying dental disease using images.

Methods

A calibrated dental examiner inspected forty 5-year-olds. In addition, three sets of digital images were taken per child. These images were assessed by six examiners. Sensitivity and specificity of caries diagnosis and inter-examiner reliability were calculated to compare the caries scores derived from examination of the images to those of the gold standard examinations.

Results

The mean values for sensitivity and specificity scores were 48.0% and 99.1%, respectively. The mean value for kappa showed moderate agreement between 0.43 and 0.73 (0.57). Mean values for agreement using intra-class coefficients were excellent (0.78) and good (0.73) for dt and dmft, respectively. No statistical difference in the validity of the caries scores was shown between the different image assessors.

Conclusions

These data demonstrate the feasibility of using digital images to screen child oral health and for nondental professionals to be recruited to carry out digital epidemiology for the oral health surveillance of children.

Do proximal hip geometry, trabecular microarchitecture, and prevalent vertebral fractures differ in postmenopausal women with type 2 diabetes mellitus? A cross-sectional study from a teaching hospital in southern India

This study from southern India showed that the trabecular microarchitecture and proximal hip geometry were significantly impaired in postmenopausal women with diabetes as compared to age and BMI matched non-diabetic controls. This is despite there being no significant difference in bone mineral density at the femoral neck and hip not between both groups. One-third of the study subjects with type 2 diabetes had prevalent vertebral fractures. Bone mineral density assessment as a standalone tool may not adequately reflect bone health in subjects with diabetes.

INTRODUCTION

There is limited information with regard to bone health in Indian postmenopausal women with type 2 diabetes. We studied the bone mineral density (BMD), trabecular bone score (TBS), prevalent vertebral fractures (VF), proximal hip geometry, and bone mineral biochemistry in ambulatory postmenopausal women with and without type 2 diabetes mellitus (T2DM).

METHODS

This was a cross-sectional study conducted at a tertiary care center. BMD, TBS, prevalent vertebral fractures, and hip structural analysis (HSA) were assessed using a dual-energy X-ray absorptiometry (DXA) scanner. Bone mineral biochemical profiles were also studied.

RESULTS

A total of 202 ambulatory postmenopausal women known to have type 2 diabetes mellitus with mean (SD) age of 65.6 (5.2) years and 200 age and BMI matched non-diabetic controls with mean (SD) age of 64.9 (4.7) years were recruited from the local community. Although the prevalence of lumbar spine osteoporosis was significantly lower among cases (30.7%) as compared to controls (42.9%), the prevalence of degraded bone microarchitecture (TBS < 1.200) was significantly higher among cases (51%) than in controls (23.5%); P < 0.001. Prevalent vertebral fractures were not significantly different in cases and controls. The various geometric indices of the proximal hip were significantly impaired in subjects with diabetes as compared to controls.

CONCLUSION

This study may highlight the utility of the trabecular bone score and hip structural analysis in subjects with diabetes, where the bone mineral density tends to be paradoxically high, and may not adequately predict fracture risk.

A comprehensive investigation of the Galilean moon, Io, by tracing mass and energy flows

Io is the most volcanically-active object in the solar system. The moon ejects a tonne per second of sulphur-rich gases that fill the vast magnetosphere of Jupiter and drives million-amp electrical currents that excite strong auroral emissions. We present the case for including a detailed study of Io within Voyage 2050 either as a standalone mission or as a contribution to a NASA New Frontiers mission, possibly within a Solar System theme centred around current evolutionary or dynamical processes. A comprehensive investigation will provide answers to many outstanding questions and will simultaneously provide information on processes that have formed the landscapes of several other objects in the past. A mission investigating Io will also study processes that have shaped the Earth, Moon, terrestrial planets, outer planet moons, and potentially extrasolar planets. The aim would be simple - tracing the mass and energy flows in the Io-Jupiter system.

Effect of nusinersen on respiratory function in paediatric spinal muscular atrophy types 1-3

INTRODUCTION

Nusinersen is used in spinal muscular atrophy (SMA) to improve peripheral muscle function; however, respiratory effects are largely unknown.

AIM

To assess the effects of nusinersen on respiratory function in paediatric SMA during first year of treatment.

METHODS

A prospective observational study in paediatric patients with SMA who began receiving nusinersen in Queensland, Australia, from June 2018 to December 2019. Outcomes assessed were the age-appropriate respiratory investigations: spirometry, oscillometry, sniff nasal inspiratory pressure, mean inspiratory pressure, mean expiratory pressure, lung clearance index, as well as polysomnography (PSG) and muscle function testing. Lung function was collected retrospectively for up to 2 years prior to nusinersen initiation. Change in lung function was assessed using mixed effects linear regression models, while PSG and muscle function were compared using the Wilcoxon signed-rank test.

RESULTS

Twenty-eight patients (15 male, aged 0.08-18.58 years) were enrolled: type 1 (n=7); type 2 (n=12); type 3 (n=9). The annual rate of decline in FVC z-score prior to nusinersen initiation was -0.58 (95% CI -0.75 to -0.41), and post initiation was -0.25 (95% CI -0.46 to -0.03), with a significant difference in rate of decline (0.33 (95% CI 0.02 to 0.66) (p=0.04)). Most lung function measures were largely unchanged in the year post nusinersen initiation. The total Apnoea-Hypopnoea Index (AHI) was reduced from a median of 5.5 events/hour (IQR 2.1-10.1) at initiation to 2.7 events/hour (IQR 0.7-5.3) after 1 year (p=0.02). All SMA type 1% and 75% of SMA types 2 and 3 had pre-defined peripheral muscle response to nusinersen.

CONCLUSION

The first year of nusinersen treatment saw reduced lung function decline (especially in type 2) and improvement in AHI.

A Broad-Based Approach to Social Needs Screening in a Pediatric Primary Care Network

OBJECTIVE

In 2016, the American Academy of Pediatrics recommended universally screening patients for social needs, and in 2018, a quality measure for social needs screening was included in some Massachusetts Medicaid contracts. However, exact guidelines for screening were not provided. We describe the results and implications from a broad-based health-related social needs (HRSN or "social needs") screening program within our large, pediatric primary care network.

METHODS

We adapted items from The Health Leads toolkit to create our network's screening tool: The Health Needs Assessment (HNA). We trained staff to use the tool and provided staff with resources to assist families with their needs. All patients with a primary care physician in the network were eligible to complete an HNA. We calculated descriptive statistics and estimated the risk of identifying a social need using multivariable regression analyses.

RESULTS

Between June 2018 and May 2019, 100,097 patients completed an HNA; 8% of patients identified a social need, and 33% of those patients requested assistance with the need(s). The multivariate analysis revealed an association between several patient characteristics-health insurance type, age, median household income by zip code, complex chronic conditions, race/ethnicity-and identifying a social need.

CONCLUSIONS

Our large, pediatric primary care network successfully instituted a broad-based HRSN screening program in response to state and national screening recommendations. We observed a low prevalence of reported social needs and a propensity to forego assistance. Additional research is needed to understand the barriers around the disclosure of social needs and requests for assistance.

Dental disease risk in children with autism: a meta-analysis

Introduction Pi and colleagues reviewed eight case-control studies comparing the oral health (decayed, missing and filled teeth [DMFT], Plaque Index [PI], Gingival Index [GI] and salivary pH) of children with autism (n = 475) to children without autism (n = 565).Method The search strategy involved the use of PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang and Chinese Scientific and Technological Journal (VIP) to find case-control studies which met pre-defined inclusion criteria and were published before September 2018. The quality of each study was evaluated using the Newcastle-Ottowa Scale and only high-quality studies were included. Means and standard deviations for outcomes measured by each included study were presented. Data were pooled using the random-effects model via Review Manager 5.3, and presented as mean differences and 95% confidence intervals. Consistency was measured using I2. Sensitivity analysis was performed by removing one study with a large sample to explore effects on heterogeneity.Results The authors found eight eligible case-control studies conducted in Asia (n = 7) or South America (n = 1). Six of the eight compared DMFT of children with autism to those without and three of the eight compared PI, GI and/or salivary pH. While a meta-analysis is presented for each of the oral health outcome areas, there are discrepancies in the reporting. The included studies in each of the meta-analysis do not correspond with the characteristics of the studies provided.Conclusions The authors suggest from their meta-analyses that children with autism experience a higher prevalence of dental disease than children without autism. However, as currently presented, the study lacks internal validity and findings are not reliable.

Bedside sonography performed by neonatology residents to confirm central vascular catheter position in neonates - A Prospective Diagnostic Evaluation study

OBJECTIVE

To evaluate the diagnostic accuracy and utility of bedside ultrasound (US) by neonatology residents to confirm position of umbilical venous catheter (UVC), umbilical arterial catheter (UAC), and peripherally inserted central catheter (PICC).

METHODS

In this prospective study, we included neonates who required UVC, UAC or PICC insertion. Two neonatology residents performed all bedside US examinations after a short period of training. Plain radiograph was taken as gold standard. Time taken for confirmation of catheter position by US and radiograph was recorded.

RESULTS

We recruited 71 neonates for UVC and UAC, and 40 neonates for PICC. Sensitivity and specificity of US in identifying a malpositioned catheter was good for UVC (94% and 66.7% respectively) and UAC (86.7% and 94.5%). Agreement between radiograph and US was good for UVC [0.718 (0.512, 0.861); p < 0.001] and UAC [0.857 (0.682, 0.953); p < 0.001]. Sensitivity (47.8%) of US in identifying a malpositioned PICC was low, though specificity (82.4%) was good. Agreement between radiograph and US in identifying PICC position was poor [0.25 (-0.084, 0.545); p 0.024]. This was due to incorrect interpretation of catheter position on radiograph in some infants, which was confirmed by the radiologist. The median time taken for US was significantly less than time taken for radiograph in confirming the position of UVC (50 vs. 155 minutes; p < 0.001)), UAC (45 vs. 128 minutes; p < 0.001), and PICC (60 vs. 136 minutes; p < 0.001).

CONCLUSION

US examination byneonatology residents has good diagnostic accuracy in confirming the position of UAC and UVC, and possibly PICC in neonates. The time taken to confirm catheter position by US is significantly less than radiograph.

Abstract PO-32: NFKBIZ 3′ UTR mutations confer selective growth advantage and affect drug response in diffuse large B-cell lymphoma

Introduction: The activated B cell-like (ABC) molecular subgroup of diffuse large B-cell lymphoma (DLBCL) is characterized by activation of NF-κB signaling. Recurrent mutations affecting genes such as MYD88, CD79A/B, and TNFAIP3 contribute to this in some cases, but there remain tumors with no known genetic basis for this pathway activation. This suggests that our understanding of ABC DLBCL drivers remains incomplete. Previously, NFKBIZ was shown to be amplified in 10% of ABC DLBCLs and to contribute to activation of NF-κB signaling. We recently described a novel pattern of mutations affecting the 3′ UTR of NFKBIZ resulting in an overall mutation rate of 30% (UTR or AMP) in ABC DLBCL. These NFKBIZ UTR mutations are mutually exclusive with MYD88 mutations, thus suggesting they may also lead to activation of NF-κB signaling. The NFKBIZ protein interacts with NF-κB transcription factors and is thought to regulate canonical NF-κB signaling. We hypothesized that NFKBIZ UTR mutations affect the normally rapid degradation of this mRNA by disrupting secondary structures recognized by RNA-binding proteins such as ribonucleases. The resulting elevated NFKBIZ mRNA levels would lead to accumulation of protein and may be a novel mechanism to promote cell growth and survival in ABC DLBCL.

Methods: NFKBIZ 3′ UTR mutations were introduced into a DLBCL cell line using the CRISPR-Cas9 system. A competitive growth assay with wild-type (WT) and CRISPR-mutant lines was performed to assess whether UTR mutations provide a growth advantage in culture (in vitro) and in mouse xenografts (in vivo). RNA-sequencing was then performed on WT and a subset of CRISPR-mutant lines and analyses were performed to identify genes upregulated by IκB-ζ in mutant lines. The IC50 of relevant drugs was determined by WST-1 assays after drug treatment on WT and mutant lines.

Results: Introduction of NFKBIZ mutations into a DLBCL cell line confirmed that UTR deletions lead to increased mRNA and protein levels. NFKBIZ UTR deletions give DLBCL cells a selective growth advantage over WT both in vitro and in vivo. RNA-sequencing of mutant and WT lines revealed possible transcriptional targets of NFKBIZ, including NF-κB targets and genes commonly overexpressed in ABC DLBCL. Novel candidate NFKBIZ targets were also discovered through this analysis, including CD274, the gene encoding PD-L1. Mutant cell lines had significantly higher IC50 compared to WT for the drugs ibrutinib, idelalisib, and masitinib, but not bortezomib, suggesting that NKFBIZ UTR mutations make cell lines more resistant to specific NF-κB pathway-targeted drugs.

Conclusions: This work directly establishes a role for NFKBIZ amplifications and 3′ UTR mutations in driving ABC DLBCL through NF-κB signaling. We demonstrate that these mutations can lead to overexpression of NFKBIZ and provide a selective growth advantage to cells both in vitro and in vivo. In addition, we found that these mutant lines were more resistant to some targeted lymphoma drugs but not others.

Citation Format: Sarah E. Arthur, Nicole Thomas, Jeffrey Tang, Christopher K. Rushton, Miguel Alcaide, Adèle Telenius, Shannon Healy, Anja Mottok, David W. Scott, Christian Steidl, Ryan D. Morin. NFKBIZ 3′ UTR mutations confer selective growth advantage and affect drug response in diffuse large B-cell lymphoma [abstract]. In: Proceedings of the AACR Virtual Meeting: Advances in Malignant Lymphoma; 2020 Aug 17-19. Philadelphia (PA): AACR; Blood Cancer Discov 2020;1(3_Suppl):Abstract nr PO-32.

Abstract PO-04: Noncoding mutations in mantle cell lymphoma disrupt regulation of HNRNPH1 by alternative splicing

Non-Hodgkin lymphomas (NHL) are a collection of cancers with each malignancy having distinct clinical management and prognosis. Mantle cell lymphoma (MCL) is particularly genetically heterogeneous and is considered incurable. Through a combination of exome, genome, and targeted sequencing of MCL tumors, we identified recurrent mutations in HNRNPH1 (heterogeneous nuclear ribonucleoprotein H1). These mutations are largely intronic or silent and are associated with a putative cis regulatory region involving a single exon. In RNA-seq data from matched cases, we identified variable representation of two distinct HNRNPH1 isoforms. Based on the reading frame of the affected exons, canonical splicing is predicted to produce a functional protein, while alternative splicing introduces a premature termination codon leading to nonsense-mediated decay. We observed a significantly higher proportion of canonical transcripts in MCL tumors bearing HNRNPH1 mutations, leading us to conclude that mutations in HNRNPH1 significantly alter its splicing. Furthermore, increased canonical splicing results in higher HNRNPH1 protein abundance as determined by immunohistochemical analysis of an MCL tissue microarray. HNRNPH1 mutation status and splicing ratio are associated with shorter survival of MCL patients. We developed an in vitro reporter minigene and introduced three specific mutations corresponding to the patient-identified mutations in HNRNPH1. These mutations lead to an increase in canonical splicing and translation of the HNRNPH1 minigene-derived peptide. Additionally, when HNRNPH1 is overexpressed, we observe a decrease of this peptide, implicating HNRNPH1 in the regulation of its own splicing. This is supported by preliminary data indicating that HNRNPH1 binds its own RNA. Beyond its own splicing, HNRNPH1 is likely also involved in the splicing of additional splicing factors. Overexpression of HNRNPH1 affects the splicing of SRSF3 and HNRNPDL, and many other targets are likely to be identified. This work elucidates a functional role for recurrent noncoding HNRNPH1 mutations and implicates HNRNPH1 expression and splicing of its downstream targets in lymphomagenesis. We continue to explore trans regulatory targets of HNRNPH1 using in vitro and cell-based models. While splicing is a growing field of interest in lymphoma biology, the unique pattern and consequences of these largely silent mutations specifically implicate alternative splicing as an oncogenic mechanism in MCL.

Citation Format: Krysta M. Coyle, Quratulain Qureshi, Prasath Pararajalingam, Nicole Thomas, Timothy E. Audas, Ryan D. Morin. Noncoding mutations in mantle cell lymphoma disrupt regulation of HNRNPH1 by alternative splicing [abstract]. In: Proceedings of the AACR Virtual Meeting: Advances in Malignant Lymphoma; 2020 Aug 17-19. Philadelphia (PA): AACR; Blood Cancer Discov 2020;1(3_Suppl):Abstract nr PO-04.

Abstract IA42: Detecting and quantifying mutations associated with treatment resistance in aggressive lymphomas using ctDNA

A significant proportion of diffuse large B-cell lymphoma (DLBCL) patients treated with immunochemotherapy containing rituximab (R-CHOP) exhibit either primary or acquired treatment resistance. The advancement of therapeutics in the relapse setting has likely been encumbered by our limited understanding of the molecular features that underlie resistance to R-CHOP. Unfortunately, our knowledge of DLBCL genetics is mostly limited to analyses conducted on diagnostic tissue biopsies, which have not been exposed to the selective pressures imposed by therapy. Identifying genetic alterations that contribute to treatment resistance may reveal additional treatment options and lead to biomarkers allowing patients to be paired with appropriate treatments. Genetic subgroups are gaining popularity as a new strategy to implement precision medicine in DLBCL (1). The relevance of these and other biomarkers in the relapse setting remains unclear due to limited genetic exploration of relapsed and refractory DLBCL (rrDLBCL). Progress has been limited, in part, by the requirement of tissue biopsies collected after relapse. It is well established that quantitative genomic techniques such as digital PCR and targeted sequencing can be used to determine the proportion of tumor DNA in plasma from lymphoma patients (2). With a sufficiently broad panel, sequencing affords additional opportunities including the ability to identify subclonal structure and population dynamics over time. This presentation will discuss our recent analysis of a large collection of ctDNA primarily comprising DLBCL patients on various clinical trials (3). Targeted sequencing of these samples and comparison to exome data from a meta-cohort of previously characterized untreated DLBCL biopsies revealed six genes significantly enriched for mutations upon relapse. We found both TP53 and KMT2D were mutated in the majority of rrDLBCLs, and these mutations persisted in the dominant clone following relapse, suggesting a role in primary treatment resistance. By inferring subclonal dynamics, we observed recurrent patterns of clonal expansion and contraction following rituximab-based therapy, with MS4A1 mutations representing the only example of consistent clonal expansion. MS4A1 missense mutations within the transmembrane domains led to loss of CD20 expression in vitro, and patient tumors harboring these mutations lacked CD20 protein expression. Our analysis nominates TP53 and KMT2D mutation status as novel prognostic factors that may facilitate the identification of high-risk patients prior to therapy. Moreover, we have demonstrated the potential to identify tumors with loss of CD20 surface expression stemming from MS4A1 mutations. Implementation of noninvasive assays to detect such features of acquired treatment resistance may allow timely transition to more effective treatment regimens. In certain scenarios whole-exome sequencing (WES) or whole-genome sequencing (WGS) can be successfully applied to ctDNA, thereby allowing the identification of mutations, structural variation, and copy number changes. Low-pass sequencing of shotgun libraries can also be used to ascertain course estimates of ctDNA levels as well as the copy number landscape (4). Given the importance of copy number and structural alterations in the inference of genetic subgroups, these methods may allow the exploration of these groups and their stability over time. Through a series of illustrative examples, this presentation will explore the benefits of each of these techniques in the study of tumor evolution and acquired treatment resistance in DLBCL.

References: 1. Morin RD, Scott DW. DLBCL subclassification: Divide and conquer? Blood 2020;135:1722–4. 2. Rossi D et al. The development of liquid biopsy for research and clinical practice in lymphomas: Report of the 15-ICML workshop on ctDNA. Hematol Oncol 2020;38:34–7. 3. Rushton CK et al. Genetic and evolutionary patterns of treatment resistance in relapsed B-cell lymphoma. Blood Adv 2020;4:2886–98. 4. Adalsteinsson VA et al. Scalable whole-exome sequencing of cell-free DNA reveals high concordance with metastatic tumors. Nat Commun 2017;8:1324.

Citation Format: Nicole Thomas, Laura K. Hilton, Neil Michaud, Kevin Bushell, Ryan Rys, Michael Jain, Lois Shepherd, Marco A. Marra, John Kuruvilla, Michael Crump, Koren Mann, Sarit Assouline, Christian Steidl, Mark S. Cragg, David W. Scott, Nathalie Johnson, Ryan D. Morin, Christopher K. Rushton, Sarah E. Arthur, Miguel Alcaide, Matthew Cheung, Aixiang Jiang, Krysta M. Coyle, Kirstie L. S. Cleary. Detecting and quantifying mutations associated with treatment resistance in aggressive lymphomas using ctDNA [abstract]. In: Proceedings of the AACR Virtual Meeting: Advances in Malignant Lymphoma; 2020 Aug 17-19. Philadelphia (PA): AACR; Blood Cancer Discov 2020;1(3_Suppl):Abstract nr IA42.

Coding and noncoding drivers of mantle cell lymphoma identified through exome and genome sequencing

Mantle cell lymphoma (MCL) is an uncommon B-cell non-Hodgkin lymphoma (NHL) that is incurable with standard therapies. The genetic drivers of this cancer have not been firmly established, and the features that contribute to differences in clinical course remain limited. To extend our understanding of the biological pathways involved in this malignancy, we performed a large-scale genomic analysis of MCL using data from 51 exomes and 34 genomes alongside previously published exome cohorts. To confirm our findings, we resequenced the genes identified in the exome cohort in 191 MCL tumors, each having clinical follow-up data. We confirmed the prognostic association of TP53 and NOTCH1 mutations. Our sequencing revealed novel recurrent noncoding mutations surrounding a single exon of the HNRNPH1gene. In RNA-seq data from 103 of these cases, MCL tumors with these mutations had a distinct imbalance of HNRNPH1 isoforms. This altered splicing of HNRNPH1 was associated with inferior outcomes in MCL and showed a significant increase in protein expression by immunohistochemistry. We describe a functional role for these recurrent noncoding mutations in disrupting an autoregulatory feedback mechanism, thereby deregulating HNRNPH1 protein expression. Taken together, these data strongly imply a role for aberrant regulation of messenger RNA processing in MCL pathobiology.

Genetic and evolutionary patterns of treatment resistance in relapsed B-cell lymphoma

Diffuse large B-cell lymphoma (DLBCL) patients are typically treated with immunochemotherapy containing rituximab (rituximab, cyclophosphamide, hydroxydaunorubicin-vincristine (Oncovin), and prednisone [R-CHOP]); however, prognosis is extremely poor if R-CHOP fails. To identify genetic mechanisms contributing to primary or acquired R-CHOP resistance, we performed target-panel sequencing of 135 relapsed/refractory DLBCLs (rrDLBCLs), primarily comprising circulating tumor DNA from patients on clinical trials. Comparison with a metacohort of 1670 diagnostic DLBCLs identified 6 genes significantly enriched for mutations upon relapse. TP53 and KMT2D were mutated in the majority of rrDLBCLs, and these mutations remained clonally persistent throughout treatment in paired diagnostic-relapse samples, suggesting a role in primary treatment resistance. Nonsense and missense mutations affecting MS4A1, which encodes CD20, are exceedingly rare in diagnostic samples but show recurrent patterns of clonal expansion following rituximab-based therapy. MS4A1 missense mutations within the transmembrane domains lead to loss of CD20 in vitro, and patient tumors harboring these mutations lacked CD20 protein expression. In a time series from a patient treated with multiple rounds of therapy, tumor heterogeneity and minor MS4A1-harboring subclones contributed to rapid disease recurrence, with MS4A1 mutations as founding events for these subclones. TP53 and KMT2D mutation status, in combination with other prognostic factors, may be used to identify high-risk patients prior to R-CHOP for posttreatment monitoring. Using liquid biopsies, we show the potential to identify tumors with loss of CD20 surface expression stemming from MS4A1 mutations. Implementation of noninvasive assays to detect such features of acquired treatment resistance may allow timely transition to more effective treatment regimens.

Is loneliness a feasible treatment target in psychosis?

PURPOSE

Loneliness is a challenge for individuals with psychosis; however, interventions rarely target loneliness in this group.

METHOD

We developed a pilot positive psychology group intervention designed to reduce loneliness in psychosis and examined its feasibility and acceptability.

RESULTS

Sixteen participants attended 5.38 (SD = 0.70) out of six sessions, with a dropout rate of 10%. Participants were significantly less lonely at post-treatment (p < 0.001, d = 1.51), and maintained their improvements from post-treatment to follow-up (p = 0.81, d = 0.07).

CONCLUSIONS

Loneliness may be a feasible and acceptable treatment target within psychosocial treatments.

Protocol for Clozapine Rechallenge in a Case of Clozapine-Induced Myocarditis

OBJECTIVE

Protocol for clozapine rechallenge in patients with a history of clozapine-induced myocarditis.

METHOD

Clozapine-related cardiovascular adverse effects including myocarditis and cardiomyopathy have limited its widespread use in treatment-resistant schizophrenia. Here, we present a case of clozapine-induced myocarditis and successful cautious rechallenge. Ms. AA, a young female patient with severe psychosis developed myocarditis during her initial clozapine titration phase, which was thus discontinued. Subsequent response to other medications was poor, and she remained significantly disabled. We reviewed blood-based biomarkers identified during the emergence of her index episode of myocarditis and developed a successful clozapine rechallenge protocol, based on careful monitoring of changes in these indices and a very slow clozapine re-titration.

RESULTS AND CONCLUSIONS

This protocol may have utility in the management of patients with a history of clozapine-induced myocarditis.

Hypophosphataemic osteomalacia due to cadmium exposure in the silver industry

Chronic heavy metal exposure and the health hazards that ensue are important public-health problems. We highlight the occurrence of hypophosphataemic osteomalacia due to chronic cadmium exposure in the silver industry in India. Three silversmiths presented similarly with clinical, biochemical and radiological evidence of hypophosphataemic osteomalacia. Considering their occupation, their blood samples were screened for heavy metals and were found to have toxic levels of cadmium. They were initiated on neutral phosphate and calcitriol. On follow-up, they reported significant reduction in severity of symptoms. It is essential to maintain a high index of suspicion in diagnosing this condition. A thorough knowledge of the occupational background of patients, as well as ambient conditions at the workplace is of utmost importance in contemplating the possibility of such rare occurrences. Moreover, regulatory agencies and policy makers ought to survey the silver industry and ensure that the metals used are within permissible safe limits of exposure.

Improvement in depression with oestrogen treatment in women with schizophrenia

Women with schizophrenia are often noted to suffer with comorbid depression. Many studies have shown associations between fluctuating oestrogen levels in the brain and mental illness. This study investigates the effect of oestradiol treatment on comorbid depressive symptoms in women with schizophrenia. This study is an 8-week, three-arm, double-blind, randomised-controlled trial. The 180 female participants were aged between 18 and 45, with schizophrenia and ongoing symptoms of psychosis Positive and Negative Syndrome Scale (PANSS) score > 60 despite a stable dose of antipsychotic medication. Depressive symptoms were assessed using Montgomery Asberg Depression Scale (MADRS) with a mean score of 73.77 at baseline. Participants received transdermal oestradiol 200 μg or transdermal oestradiol 100 μg or an identical placebo patch. The a priori outcome measure was the change in PANSS score measured at baseline and days 7, 14, 28 and 56, but in this study, we focused on the change in MADRS score at the same time points. Data were analysed by using Quade's rank analysis of covariance (ANCOVA) (Huitema 1980) with baseline MADRS score as a covariate. We found a fluctuating but overall trend towards improvement of comorbid depressive symptoms in women with schizophrenia taking transdermal oestrogen 200 mcg compared with oestrogen 100 mcg or placebo. The stronger 'antidepressant' effect of 200 mcg transdermal oestradiol was found at day 28 (p = 0.03). Our study suggests that adjunctive oestradiol treatment for depression may be a promising treatment for women with comorbid depression and schizophrenia.

Do virtual renal clinics improve access to kidney care? A preliminary impact evaluation of a virtual clinic in East London

Background

Early identification of people with CKD in primary care, particularly those with risk factors such as diabetes and hypertension, enables proactive management and referral to specialist services for progressive disease.

The 2019 NHS Long Term Plan endorses the development of digitally-enabled services to replace the ‘unsustainable’ growth of the traditional out-patient model of care.Shared views of the complete health data available in the primary care electronic health record (EHR) can bridge the divide between primary and secondary care, and offers a practical solution to widen timely access to specialist advice.

Methods

We describe an innovative community kidney service based in the renal department at Barts Health NHS Trust and four local clinical commissioning groups (CCGs) in east London. An impact evaluation of the changes in service delivery used quantitative data from the virtual CKD clinic and from the primary care electronic health records (EHR) of 166 participating practices. Survey and interview data from health professionals were used to explore changes to working practices.

Results

Prior to the start of the service the general nephrology referral rate was 0.8/1000 GP registered population, this rose to 2.5/1000 registered patients by the second year of the service. The majority (> 80%) did not require a traditional outpatient appointment, but could be managed with written advice for the referring clinician. The wait for specialist advice fell from 64 to 6 days. General practitioners (GPs) had positive views of the service, valuing the rapid response to clinical questions and improved access for patients unable to travel to clinic. They also reported improved confidence in managing CKD, and high levels of patient satisfaction. Nephrologists valued seeing the entire primary care record but reported concerns about the volume of referrals and changes to working practices.

Conclusions

‘Virtual’ specialist services using shared access to the complete primary care EHR are feasible and can expand capacity to deliver timely advice. To use both specialist and generalist expertise efficiently these services require support from community interventions which engage primary care clinicians in a data driven programme of service improvement.

(Don't) look here!: The effect of different forms of label added to fashion advertisements on women's visual attention

The present study used eye tracking technology to experimentally investigate the effect of different label formats on women's visual attention to fashion magazine advertisements, and its relationship with body dissatisfaction and appearance comparison. Participants were 260 female undergraduate students whose eye movements were recorded while viewing three thin-ideal fashion advertisements with one of five different forms of label added: no label, disclaimer label (indicating image had been digitally altered), consequence label (indicating that viewing images might make women feel bad about themselves), informational label (indicating the model in the advertisement was underweight), or graphic label (picture of a paint brush). The informational label was found to direct visual attention specifically towards the model's body. Visual attention to the body was related to state appearance comparison in general, and to increase in body dissatisfaction in the no label condition. These findings extend the existing body of research demonstrating potentially detrimental effects of labels attached to fashion magazine images.

Designing Online and Mobile Diabetes Education for Fathers of Children With Type 1 Diabetes: Mixed Methods Study

BACKGROUND

Fathers make unique and central contributions to the health of their children. However, research in type 1 diabetes (T1D) education largely ignores the needs of fathers, including during the development of online and mobile educational materials.

OBJECTIVE

The purpose of this study was to solicit and incorporate input from fathers of children with T1D into the design, content, and infrastructure of a suite of online diabetes self-management education and support (DSMES) resources.

METHODS

The study took part in three phases: (1) exploratory research, (2) website and subdomain development, and (3) evaluation. Fathers of children with T1D (n=30) completed surveys and semistructured qualitative interviews. Thematic content analysis was used to identify fathers' content and design preferences. An online DSMES website (T1DToolkit.org) and a separate mobile subdomain targeting fathers (Mobile Diabetes Advice for Dads, or mDAD) were developed. A prototype of the site for fathers was evaluated by 33 additional father participants. End user feedback was elicited via survey.

RESULTS

Participants in the exploratory phase were enthusiastic about the online diabetes resources. Preferences included high-quality design, availability via mobile phone and tablet, brief text content supplemented with multimedia and interactive features, reminders via text or email, endorsement by medical professionals, and links to scientific evidence. The mDAD subdomain received high usability and acceptability ratings, with 100% of participants very likely or likely to use the site again.

CONCLUSIONS

The development of eHealth educational platforms for fathers of children with T1D remains an unmet need in optimizing diabetes management. This study incorporated fathers' feedback into the development of a suite of online diabetes education resources. The findings will serve as the basis for future research to assess the clinical efficacy of the website, its subdomain targeting fathers, and additional subdomains targeting unique populations.

P37 Do all notochordal lesions require proton beam radiotherapy? A case series of ecchordosis physaliphora

Objectives

Ecchordosis physaliphora (EP) is a benign, usually asymptomatic, notochord tumour but may also present with a spontaneous CSF fistula. Differentiating EP from its more aggressive counterpart, chordoma is challenging but important as the clinical course and management differ significantly, with the latter requiring proton beam radiotherapy. This case series aims to further inform this discussion.

Design

Case series.

Subjects

Patients with suspected EP from 2015–2018.

Methods

Retrospective analysis.

Results

Six patients were identified. Four presented with suspected CSF leak. MRI revealed a T1-hypointense and T2-hyperintense clival lesion without enhancement. CT showed pneumocephalus, a clival defect and no mass lesion. All underwent endoscopic endonasal repair of CSF fistula with biopsy. Histology revealed physaliphorous cells with no mitoses; immunohistochemistry confirmed notochord origin (EMA, S100, CD10 and/or MNF116) and low proliferation index. In 2 patients, EP was found incidentally on imaging and these lesions have remained static on follow-up.

Conclusions

In the absence of a clival mass, notochord remnant lesions with benign histopathology can be treated as EP and patients can avoid radiotherapy. The diagnosis of EP, however, remains challenging as no distinctive histopathological marker exists to differentiate it from chordoma and until a genetic or immunohistochemical marker is identified, the diagnosis rests solely on the presence or absence of a mass on imaging.