Association between inflammation and post-intensive care syndrome: a systematic review

Post-intensive care syndrome describes the physical, cognitive and emotional symptoms which persist following critical illness. At present there is limited understanding of the pathological mechanisms contributing to the development of post-intensive care syndrome. The aim of this systematic review was to synthesise current evidence exploring the association between inflammation and features of post-intensive care syndrome in survivors of critical illness. Relevant databases were systematically searched for studies of human participants exposed to critical illness. We sought studies that reported results for biomarkers with an identified role in the pathophysiology of inflammation obtained at any time-point in the patient journey and an outcome measure of any feature of post-intensive care syndrome at any point following hospital discharge. We included 32 studies, with 23 in the primary analysis and nine in a brain injury subgroup analysis. In the primary analysis, 47 different biomarkers were sampled and 44 different outcome measures were employed. Of the biomarkers which were sampled in five or more studies, interleukin-8, C-reactive protein and interleukin-10 most frequently showed associations with post-intensive care syndrome outcomes in 71%, 62% and 60% of studies, respectively. There was variability in terms of which biomarkers were sampled, time-points of sampling and outcome measures reported. Overall, there was mixed evidence of a potential association between an inflammatory process and long-term patient outcomes following critical illness. Further high-quality research is required to develop a longitudinal inflammatory profile of survivors of critical illness over the recovery period and evaluate the association with outcomes.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Evaluation of deep learning-based depression detection using medical claims data

Human accuracy in diagnosing psychiatric disorders is still low. Even though digitizing health care leads to more and more data, the successful adoption of AI-based digital decision support (DDSS) is rare. One reason is that AI algorithms are often not evaluated based on large, real-world data. This research shows the potential of using deep learning on the medical claims data of 812,853 people between 2018 and 2022, with 26,973,943 ICD-10-coded diseases, to predict depression (F32 and F33 ICD-10 codes). The dataset used represents almost the entire adult population of Estonia. Based on these data, to show the critical importance of the underlying temporal properties of the data for the detection of depression, we evaluate the performance of non-sequential models (LR, FNN), sequential models (LSTM, CNN-LSTM) and the sequential model with a decay factor (GRU-Δt, GRU-decay). Furthermore, since explainability is necessary for the medical domain, we combine a self-attention model with the GRU decay and evaluate its performance. We named this combination Att-GRU-decay. After extensive empirical experimentation, our model (Att-GRU-decay), with an AUC score of 0.990, an AUPRC score of 0.974, a specificity of 0.999 and a sensitivity of 0.944, proved to be the most accurate. The results of our novel Att-GRU-decay model outperform the current state of the art, demonstrating the potential usefulness of deep learning algorithms for DDSS development. We further expand this by describing a possible application scenario of the proposed algorithm for depression screening in a general practitioner (GP) setting-not only to decrease healthcare costs, but also to improve the quality of care and ultimately decrease people's suffering.

The NORDeHEALTH 2022 Patient Survey: Cross-Sectional Study of National Patient Portal Users in Norway, Sweden, Finland, and Estonia

BACKGROUND

Although many surveys have been conducted on patients accessing their own health records in recent years, there is a limited amount of nationwide cross-country data available on patients' views and preferences. To address this gap, an international survey of patient users was conducted in the Nordic eHealth project, NORDeHEALTH.

OBJECTIVE

We aimed to investigate the sociodemographic characteristics and experiences of patients who accessed their electronic health records (EHRs) through national patient portals in Norway, Sweden, Finland, and Estonia.

METHODS

A cross-sectional web-based survey was distributed using the national online health portals. The target participants were patients who accessed the national patient portals at the start of 2022 and who were aged ≥15 years. The survey included a mixture of close-ended and free-text questions about participant sociodemographics, usability experience, experiences with health care and the EHR, reasons for reading health records online, experience with errors, omissions and offense, opinions about security and privacy, and the usefulness of portal functions. In this paper, we summarized the data on participant demographics, past experience with health care, and the patient portal through descriptive statistics.

RESULTS

In total, 29,334 users completed the survey, of which 9503 (32.40%) were from Norway, 13,008 (44.35%) from Sweden, 4713 (16.07%) from Finland, and 2104 (7.17%) from Estonia. National samples were comparable according to reported gender, with about two-thirds identifying as women (19,904/29,302, 67.93%). Age distributions were similar across the countries, but Finland had older users while Estonia had younger users. The highest attained education and presence of health care education varied among the national samples. In all 4 countries, patients most commonly rated their health as "fair" (11,279/29,302, 38.48%). In Estonia, participants were more often inclined to rate their health positively, whereas Norway and Sweden had the highest proportion of negative health ratings. Across the whole sample, most patients received some care in the last 2 years (25,318/29,254, 86.55%). Mental health care was more common (6214/29,254, 21.24%) than oncological care (3664/29,254, 12.52%). Overall, most patients had accessed their health record "2 to 9 times" (11,546/29,306, 39.4%), with the most frequent users residing in Sweden, where about one-third of patients accessed it "more than 20 times" (4571/13,008, 35.14%).

CONCLUSIONS

This is the first large-scale international survey to compare patient users' sociodemographics and experiences with accessing their EHRs. Although the countries are in close geographic proximity and demonstrate similar advancements in giving their residents online records access, patient users in this survey differed. We will continue to investigate patients' experiences and opinions about national patient-accessible EHRs through focused analyses of the national and combined data sets from the NORDeHEALTH 2022 Patient Survey.

Preserving Decentralized EHR-s Integrity

A blockchain and decentralized storage technology-based architecture is proposed to support the integrity of Electronic Health Records (EHRs).

Genomic evaluation of feed efficiency in US Holstein heifers

There is growing interest in improving feed efficiency traits in dairy cattle. The objectives of this study were to estimate the genetic parameters of residual feed intake (RFI) and its component traits [dry matter intake (DMI), metabolic body weight (MBW), and average daily gain (ADG)] in Holstein heifers, and to develop a system for genomic evaluation for RFI in Holstein dairy calves. The RFI data were collected from 6,563 growing Holstein heifers (initial body weight = 261 ± 52 kg; initial age = 266 ± 42 d) for 70 d, across 182 trials conducted between 2014 and 2022 at the STgenetics Ohio Heifer Center (South Charleston, OH) as part of the EcoFeed program, which aims to improve feed efficiency by genetic selection. The RFI was estimated as the difference between a heifer's actual feed intake and expected feed intake, which was determined by regression of DMI against midpoint MBW, age, and ADG across each trial. A total of 61,283 SNPs were used in genomic analyses. Animals with phenotypes and genotypes were used as training population, and 4 groups of prediction population, each with 2,000 animals, were selected from a pool of Holstein animals with genotypes, based on their relationship with the training population. All traits were analyzed using univariate animal model in DMU version 6 software. Pedigree information and genomic information were used to specify genetic relationships to estimate the variance components and genomic estimated breeding values (GEBV), respectively. Breeding values of the prediction population were estimated by using the 2-step approach: deriving the prediction equation of GEBV from the training population for estimation of GEBV of prediction population with only genotypes. Reliability of breeding values was obtained by approximation based on partitioning a function of the accuracy of training population GEBV and magnitudes of genomic relationships between individuals in the training and prediction population. Heifers had DMI (mean ± SD) of 8.11 ± 1.59 kg over the trial period, with growth rate of 1.08 ± 0.25 kg/d. The heritability estimates (mean ± SE) of RFI, MBW, DMI, and growth rate were 0.24 ± 0.02, 0.23 ± 0.02, 0.27 ± 0.02, and 0.19 ± 0.02, respectively. The range of genomic predicted transmitted abilities (gPTA) of the training population (-0.94 to 0.75) was higher compared with the range of gPTA (-0.82 to 0.73) of different groups of prediction population. Average reliability of breeding values from the training population was 58%, and that of prediction population was 39%. The genomic prediction of RFI provides new tools to select for feed efficiency of heifers. Future research should be directed to find the relationship between RFI of heifers and cows, to select individuals based on their lifetime production efficiencies.

A country-wide teledermatoscopy service in Estonia shows results comparable to those in experimental settings in management plan development and diagnostic accuracy: A retrospective database study

Background

Teledermatoscopy accuracy has been examined in experimental settings and is recommended for primary care despite lacking real-world implementation evidence. A teledermatoscopy service has been provided in Estonia since 2013, where lesions are evaluated based on the patient's or general practitioner's suggestion.

Objective

The management plan and diagnostic accuracy of a real-world store-and-forward teledermatoscopy service for melanoma diagnosis were evaluated.

Methods

A retrospective study analyzed 4748 cases from 3403 patients using the service between October 16, 2017 and August 30, 2019 by matching country-wide databases. Management plan accuracy was calculated as the percentage of melanoma found that was managed correctly. Diagnostic accuracy parameters were sensitivity, specificity, and positive and negative predictive values.

Results

Management plan accuracy for melanoma detection was 95.5% (95% CI, 77.2-99.9). Diagnostic accuracy showed a sensitivity of 90.48% (95% CI, 69.62-98.83) and a specificity of 92.57% (95% CI, 91.79-93.31).

Limitations

Matching the lesions was limited to SNOMED CT location standard precision. Diagnostic accuracy was calculated based on a combination of diagnosis and management plan data.

Conclusion

Teledermatoscopy for detecting and managing melanoma in real-world clinical practice displays results comparable with those in experimental setting studies.

Evaluation of treatment delays in hepatopancreatico-biliary surgery during the first COVID-19 wave

INTRODUCTION

The COVID-19 pandemic has caused oncological services worldwide to face unprecedented challenges resulting in treatment disruption for surgical patients. Hepatopancreatico-biliary (HPB) cancers are characterised by rapid disease progression. This study aims to assess delays in receiving surgery for this patient cohort during the first COVID-19 wave.

METHODS

Patients undergoing surgery between April and July 2020 (COVID-19 period) were compared with a control group from the preceding year. Delay in receiving surgery was defined as more than 50 days between referral and surgery date. Statistical analysis was carried out to evaluate predictors of delay and short-term outcomes.

RESULTS

During the COVID-19 and pre-COVID-19 periods, 94 and 115 patients underwent surgery, respectively. No patients contracted COVID-19 postoperatively. Some 118 patients waited more than 50 days for surgery versus 91 who received surgery within 50 days from referral. Independent predictors for surgical delay were undergoing surgery in the COVID-19 era (odds ratio (OR) 2.2, 95% confidence interval (CI) 1.2-4.1; p=0.015), referral pathway (OR 35.1, 95% CI 4.2-296; p=0.001) and presenting pathology (OR 8.3, 95% CI 1.2-56.1; p=0.03). Short-term outcomes were comparable between groups.

CONCLUSIONS

Patient referral pathway and presenting pathology may contribute to delays in undergoing HPB cancer surgery during COVID-19 outbreaks. It is hoped that a better understanding of these factors will aid in designing shifts in healthcare policy during future pandemic outbreaks.

Predictors of recurrence following laparoscopic minor hepatectomy for hepatocellular carcinoma in the UK

AIMS

Minor hepatectomy, which is increasingly carried out laparoscopically (LLR), is a cornerstone of curative treatment for hepatocellular carcinoma (HCC). The majority of relevant publications however originate from regions with endemic viral hepatitis. Although the incidence of HCC in the UK is increasing, little is known about outcomes following LLR.

METHODS

Consecutive patients undergoing minor (involving ≤2 segments) LLR or open resection (OLR) at our institute between 2014 and 2021 were compared. Selection from a plethora of factors potentially impacting on overall (OS) and disease free survival (DFS) was optimised with Lasso regression. To enable analysis of patients having repeat resection, multivariate frailty modelling was utilised to calculate hazard ratios (HR).

RESULTS

The analysis of 111 liver resections included 55 LLR and 56 OLR. LLR was associated with a shorter hospital stay (5 ± 2 vs. 7 ± 2 days; p < 0.001) and a lower comprehensive complication index (4.43 vs. 9.96; p = 0.006). Mean OS (52.3 ± 2.3 vs. 49.9 ± 3.0 months) and DFS (33.9 ± 3.4 vs. 36.5 ± 3.6 months; p = 0.59) were comparable between LLR and OLR, respectively (median not reached). Presence of mixed cholangiocarcinoma/HCC, satellite lesions and AFP level predicted OS and DFS. In addition tumour size was predictive of DFS.

CONCLUSIONS

In the studied population minor LLR was associated with shorter hospital stay and fewer complications while offering non-inferior long-term outcomes. A number of predictors for disease free survival have been elucidated that may aid in identifying patients with a high risk of disease recurrence and need for further treatment.

Digital Health Data Capture with a Controlled Natural Language

Written text has been the preferred medium for storing health data ever since Hippocrates, and the medical narrative is what enables a humanized clinical relationship. Can't we admit natural language as a user-accepted technology that has stood against the test of time? We have previously presented a controlled natural language as a human-computer interface for semantic data capture already at the point of care. Our computable language was driven by a linguistic interpretation of the conceptual model of the Systematized Nomenclature of Medicine - Clinical Terms (SNOMED CT). This paper presents an extension that allows the capture of measurement results with numerical values and units. We discuss the relation our method can have with emerging clinical information modelling.

Migration from HL7 CDA to FHIR in Infectious Disease System of Estonia

On the basis of the Estonian National Health System, we propose a universal and reusable methodology for migrating HL7 CDA documents or their components.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

A systematic literature review of AI-based digital decision support systems for post-traumatic stress disorder

OBJECTIVE

Over the last decade, an increase in research on medical decision support systems has been observed. However, compared to other disciplines, decision support systems in mental health are still in the minority, especially for rare diseases like post-traumatic stress disorder (PTSD). We aim to provide a comprehensive analysis of state-of-the-art digital decision support systems (DDSSs) for PTSD.

METHODS

Based on our systematic literature review of DDSSs for PTSD, we created an analytical framework using thematic analysis for feature extraction and quantitative analysis for the literature. Based on this framework, we extracted information around the medical domain of DDSSs, the data used, the technology used for data collection, user interaction, decision-making, user groups, validation, decision type and maturity level. Extracting data for all of these framework dimensions ensures consistency in our analysis and gives a holistic overview of DDSSs.

RESULTS

Research on DDSSs for PTSD is rare and primarily deals with the algorithmic part of DDSSs (n = 17). Only one DDSS was found to be a usable product. From a data perspective, mostly checklists or questionnaires were used (n = 9). While the median sample size of 151 was rather low, the average accuracy was 82%. Validation, excluding algorithmic accuracy (like user acceptance), was mostly neglected, as was an analysis concerning possible user groups.

CONCLUSION

Based on a systematic literature review, we developed a framework covering all parts (medical domain, data used, technology used for data collection, user interaction, decision-making, user groups, validation, decision type and maturity level) of DDSSs. Our framework was then used to analyze DDSSs for post-traumatic stress disorder. We found that DDSSs are not ready-to-use products but are mostly algorithms based on secondary datasets. This shows that there is still a gap between technical possibilities and real-world clinical work.

New Zealand's extinct giant raptor (Hieraaetus moorei) killed like an eagle, ate like a condor

The extinct Haast's eagle or harpagornis (Hieraaetus moorei) is the largest known eagle. Historically, it was first considered a predator, then a scavenger, but most recent authors have favoured an active hunting ecology. However, the veracity of proposed similarities to carrion feeders has not been thoroughly tested. To infer feeding capability and behaviour in harpagornis, we used geometric morphometric and finite-element analyses to assess the shape and biomechanical strength of its neurocranium, beak and talons in comparison to five extant scavenging and predatory birds. The neurocranium of harpagornis is vulture-like in shape whereas its beak is eagle-like. The mechanical performance of harpagornis is closer to extant eagles under biting loads but is closest to the Andean condor (Vultur gryphus) under extrinsic loads simulating prey capture and killing. The talons, however, are eagle-like and even for a bird of its size, able to withstand extremely high loads. Results are consistent with the proposition that, unlike living eagles, harpagornis habitually killed prey larger than itself, then applied feeding methods typical of vultures to feed on the large carcasses. Decoupling of the relationship between neurocranium and beak shape may have been linked to rapid evolution.

Screening and detection of chromosomal copy number alterations in the domestic horse using SNP-array genotyping data

Chromosomal abnormalities are a common cause of infertility in horses. However, they are difficult to detect using automated methods. Here, we propose a simple methodology based on single nucleotide polymorphism (SNP)-array data that allows us to detect the main chromosomal abnormalities in horses in a single procedure. As proof of concept, we were able to detect chromosomal abnormalities in 33 out of 268 individuals, including monosomies, chimerisms, and male and female sex-reversions, by analyzing the raw signal intensity produced by an SNP array-based genotyping platform. We also demonstrated that the procedure is not affected by the SNP density of the array employed or by the inbreeding level of the individuals. Finally, the methodology proposed in this study could be performed in an open bioinformatic environment, thus permitting its integration as a flexible screening tool in diagnostic laboratories and genomic breeding programs.

21 The contrasting role of histone methyltransferases during nuclear reprogramming: SUV39H knockdown improves bovine somatic cell nuclear transfer, while the absence of EHMT2 hampers it

The persistence of somatic epigenetic memory is indicated as the main barrier for efficient nuclear reprogramming. The augmented levels of histone methylation on somatic nuclei have been shown as the major regulator of this aberrant remodelling. Although they occupy the same site, H3K9me2 and H3K9me3 are catalysed by different histone methyltransferases (HMTs), EHMT2 and SUV39H, respectively. However, the influence of these HMTs during nuclear reprogramming is unclear. Hence, the main goal of this project was to investigate the role of HMTs responsible for H3K9 methylation during nuclear reprogramming and its consequences on embryo development. For this, we employed a small interfering RNA (siRNA)-mediated knockdown approach targeting EHMT2, SUV39H1, and SUV39H2 in bovine fetal fibroblasts. The RT-qPCR analyses showed ~80% reduction in total RNA after siRNA treatments for the target genes when compared with the control vector. We then quantified the H3K9me2 and H3K9me3 levels by immunostaining. The analysis displayed that H3K9me2 levels were diminished ~50% compared with control, whereas the reduction of H3K9me3 levels was only ~25%. Cells transfected with siRNA targeting EHMT2, SUV39H1, and SUV39H2 (All-siRNA) or control vector (control) were used as a nuclear donor on somatic cell nuclear transfer (SCNT) in five biological replicates. The IVF embryos were used as a biological control for immunostaining analysis. Embryos at both 8- to 16-cell and blastocysts stage (n=10 from 5 replicates) were collected to evaluate the effect of HMT knockdown on H3K9me2 and H3K9me3 levels by immunostaining. We found a reduction of blastocyst rates in the treatment 28±6.3 (mean±s.e.m.) when compared with control 60±4.8 (P=0.004). The immunostaining analysis showed that the levels of H3K9me2 and H3K9me3 were higher in cloned (control) than IVF embryos (P&lt;0.05). Moreover, the All-siRNA group displayed a reduction in H3K9me2 levels compared with the control group and IVF through developmental stages analysed (P&lt;0.05). Differently, H3K9me3 levels were higher in the All-siRNA group at the 8- to 16-cell stage, but no difference was found between treated and control groups at the blastocyst stage. We, therefore, decided to test whether individual knockdown would display a different result. We then used cells transfected with siRNA targeting only EHMT2 (EHMT2-siRNA), targeting SUV39H1 + SUV39H2 (SUV-siRNA), or control vector (control) as a nuclear donor on SCNT in five biological replicates. Surprisingly, the SUV-siRNA group increased blastocyst production 38±4.4 when compared with the control group 29±4.4 (P=0.01), whereas the EHMT2-siRNA showed a reduction in blastocyst rates: 21±5.6 (P=0.04). Our results indicate that EHMT2 has a key role during SCNT, possibly by its crosstalk with other modifications. Even though the SUV39H knockdown induced a small reduction in H3K9me3 levels in the nuclear donor, it was enough to increase the blastocyst rates by 10%. These results will allow us to better understand the complex mechanisms involved in the persistent epigenetic memory during nuclear reprogramming.

213 WNT inhibition by dickkopf WNT signalling pathway inhibitor 1 (DKK1) cannot replace IWR-1 during derivation of bovine embryonic stem cells

Understanding the signalling pathways involved with derivation of embryonic stem cells could enhance our understanding of pluripotency in pre-implantation embryos. Recently, the small molecule IWR-1 has been shown to promote derivation of mouse epiblast stem cells and pluripotent bovine and porcine embryonic stem cells (ESC). IWR-1 blocks WNT signalling mediated by β-catenin-targeted gene expression through stabilisation of Axin2, a member of the destruction complex that induces β-catenin degradation. Here, we evaluated whether dickkopf WNT signalling pathway inhibitor 1 (DKK1) can replace IWR-1 for establishment of bovine pluripotent ESC. If so, it is likely that the actions of IWR-1 to promote pluripotency involve inhibition of WNT signalling. Treatment of bovine embryos with 100ngmL−1 recombinant human DKK1 beginning at Day 5 of development decreased (P=0.02) immunofluorescent labelling of β-catenin in the resulting blastocysts (n=41-45/group), indicating that bovine embryos are responsive to DKK1 treatment. For ESC derivation, blastocysts were plated on top of feeder cells and cultured in ESC medium supplemented with 2.5 µM IWR-1 (n=21), 100ngmL−1 DKK1 (n=34), or vehicle (n=23). Cells were passaged every 5 to 7 days in their respective treatment medium. Seven days after plating, 57.9±14.7% of blastocysts in IWR-1 ESC medium developed outgrowth, which was lower (P=0.02) than the proportion of blastocysts with outgrowth in DKK1 medium (92.4±5.2%) or vehicle (81.9±10.0%). Outgrowth size did not differ among treatments. Labelling with CDX2 indicated that the majority of cells in outgrowths were trophectoderm cells. Thus, IWR-1 inhibits competence of blastocysts to form trophectoderm outgrowths during derivation of ESC. The percent of blastocysts from which cell lines were derived after 4 passages were 48% (10/21) for IWR-1, 41% (14/34) for DKK1, and 48% (11/23) for vehicle. Immunolabelling for the pluripotency marker SOX2 showed that only cells grown in IWR-1 medium were positive, whereas most of the cells derived in the other two media were not. Thus, IWR-1 could not be replaced by DKK1 for maintaining pluripotency. Immunoreactive β-catenin was abundantly distributed on the membrane of cells cultured with IWR-1 but not with DKK1 or vehicle-treated cells. Thus, β-catenin distribution to the cell membrane is linked with bovine pluripotency. Overall, results indicate that maintenance of pluripotency by IWR-1 may involve mechanisms other than WNT inhibition, and may be related to the localization of β-catenin to the plasma membrane.

107 Follicular wave synchronization and FSH stimulation prior to ovum pickup for invitro embryo production

Invitro embryo production (IVP) has become a reliable alternative for genetic improvement in beef and dairy herds. Maximizing embryo yield and pregnancy per donor are key factors. The aim of this study was to compare ovum pickup (OPU) yields, developmental competence of cumulus-oocyte complexes (COCs), and pregnancy rates from Angus donors in a commercial IVP setting. Donors (&gt;4-year-old pluriparous open dry cows) were handled under the same feeding and environmental conditions. Treatment groups were organised as follows: Group 1: no synchronization (SYNCH; n=5); Group 2: SYNCH with no superstimulation (SOV; n=5); Group 3: SYNCH + SOV (n=5) and OPU 36h after last FSH injection; Group 4: SYNCH + SOV (n=5) and OPU 48h after last FSH injection; and Group 5: SYNCH + SOV (n=5) and OPU 72h after last FSH injection. Follicular waves in groups 2, 3, 4, and 5 were synched by gonadotrophin-releasing hormone (GnRH), prostaglandin F2α (PGF), and controlled internal drug release (CIDR). No pre-synch was used. Injections of FSH (pFSH=180mg, Folltropin) were performed IM twice a day, for three days. A minimum of three replicates were performed for each donor. A Mindray DP30V equipped with a micro-convex transducer 5.0-8.5MHz probe, disposable 20-gauge needle, and a flow rate of 15mL min−1 were used for OPU. All visible follicles (Foll) were punctured and retrieved into a 50-mL 36°C warmed tube with media (phosphate-buffered saline, bovine serum albumin (BSA), and heparin). Viable oocytes were classified according to IETS guidelines. The COCs were matured in 100µL of M199 medium supplemented with ALA-glutamine (0.1mM), Na pyruvate (0.2mM), gentamicin (5µgmL−1), epidermal growth factor (50ngmL−1), oFSH (50ngmL−1), bLH (3μgmL−1), cysteamine (0.1mM), and 10% fetal bovine serum (FBS) for 22 to 24h. Fertilization (Day 0) was carried out using highly fertile sires selected by discontinuous 40%/80% layers (PureSperm) and diluted to a final concentration of 1×106 spermmL−1. Matured oocytes were fertilized in 50µL of modified synthetic oviductal fluid (SOF) media supplemented with fructose (90µgmL−1), penicillamine (3µgmL−1), hypotaurine (11µgmL−1), and heparin (10µgmL−1). After 18h, presumptive zygotes were denuded and cultured under low oxygen tension in 50-µL drops of SOF-BSA for 7 days. On Day 3.5, 2% of FBS was added. On Day 7, fresh transferable (grade 1 and 2, IETS standards) blastocysts were implanted into synchronized recipient cows. Around Day 30, ultrasound diagnosis was performed to determined pregnancy rate (PR). We used ANOVA for comparisons of mean values and X2 test for proportions, α=0.05 (Table 1). In conclusion, synchronization, FSH stimulation, and 48-h coasting before OPU in Angus cows increased the number of collected viable oocytes and embryo development rates. More transferrable embryos and higher rates of PR per OPU were obtained using 36- and 48-h coasting, respectively. Table 1.Follicles (Foll), viable oocytes, cleavage, blastocysts, and pregnancy rates (PR) in Angus cows after ovum pickup (OPU) or invitro embryo production (IVP) SYNCH1 FSH Coasting Foll/OPU Oocytes/OPU Viable oocytes Cleavage,% Embryos,% Embryos/OPU PR,% PR/OPU NO NO NO 10.8a 9.0a 8.9a 63a 25a 2.3a 45a 1.0a YES NO NO 10.1a 8.4a 8.1a 73b 27b 2.2a 51b 1.1a YES YES 36H 16.5b 13.8b 13.6b 70c 29b 4.0b 46a 1.8b YES YES 48H 16.1b 13.4b 13.3b 69c 28b 3.8c 52b 2.0b YES YES 72H 15.6b 13.0b 12.6b 64a 22c 2.8d 55b 1.6c a-dValues with different superscripts in the same column differ (P&lt;0.05). 1SYNCH=synchronized.

Evaluating the impact of an insulin pump discontinuation action plan on patient or caregiver confidence and anxiety

Aims

Insulin pump failure and adverse events are common and therefore anticipatory education is recommended. Research in other chronic diseases shows written action plans improve confidence and adherence during an acute deterioration. However, no similar data exists for patients with type one diabetes mellitus provided with anticipatory education via an insulin pump action plan. This study evaluates whether an insulin pump action plan improves patient and caregiver confidence in managing a potential pump failure without a subsequent increase in anxiety.

Methods

Adults with type one diabetes mellitus and caregivers of children with type 1 diabetes on continuous subcutaneous insulin infusions across four New Zealand diabetes services participated. Participants completed a questionnaire examining pump-related adverse events and self-reported confidence and anxiety in managing pump failure. An insulin pump action plan and focused education by their diabetes team was provided, with a follow-up questionnaire at least 3 months later.

Results

174/270 pump patients participated initially, with a follow-up response rate of 84.5% (147/174). Despite prior provision, many could not recall having an insulin pump action plan at study commencement (101/174, 58%), and of these 92% stated they would have liked one. Patients had good levels of confidence in the reliability of their pump and infusion sets/sites (Likert scores of 4.4/5 and 3.95/5) which was not undermined by the insulin pump action plan. Confidence in managing a potential pump failure showed a small but significant increase (3.66/5 to 3.95/5, p = 0.004) present in both adults and parents, with anxiety also showing a small increase (2.16/5 to 2.38/5, p = 0.012).

Conclusion

Patient recall of prior insulin pump action plan education is poor, with the vast majority of patients interested in further written anticipatory education regarding potential pump failure. The provision of an insulin pump action plan increases self-reported confidence in managing unexpected pump failure with a small associated increase in anxiety.

155 Whole genome association analysis suggests an influence of inbreeding on bull sperm morphometry

Inbreeding depression, the genetic condition caused by mating related individuals, is particularly important in several cattle breeds with limited effective populations. This condition is often associated with decreases in performance, including fertility. Furthermore, sperm head morphometry was associated with fertility in several species. To our knowledge, the influence of inbreeding on sperm morphometry has not been widely reported in cattle. In this study, a Sperm Class Analyzer (SCA™, Microptic S.L., Barcelona, Spain) was used to characterise 7 sperm morphometry parameters in 59 Retinta bulls, including sperm head length, width, perimeter, ellipticity, elongation, regularity and rugosity. Two replicates of at least 100 sperm heads, from 2 frozen semen samples, were assessed per individual (n=200 sperm per bull). Additionally, all individuals were genotyped with the Axiom Bos1 high density SNP Array (Affymetrix, Santa Clara, CA, USA). The molecular-based inbreeding factor (FROH; mean 12.5%, range 1.75 to 33.0) had very low correlations with all sperm morphometry parameters. On average, sperm heads from bulls with higher FROH had a smaller area, but variability was high. Correlations between inbreeding and sperm shape were low and negative, length (r=−0.1449; P&lt;0.01), width (r=−0.2494; P&lt;0.01), and rugosity (r=−0.1086; P&gt;0.01) being the most informative. Whole-genome association study (GWAS) analysis, performed using molecular inbreeding as co-factor, revealed 8 SNP, located on chromosomes BTA2, BTA5, BTA7, and BTA11, significantly associated with sperm head regularity and rugosity. Genomic analysis revealed that genes SLF1 and TMEFF2 are located close to enriched SNP. Gene SLF1 (SMC5-SMC6 complex localization factor 1) is associated with the regulation of protein complex and cytoskeleton assembly, whereas TMEFF2 (transmembrane protein with EGF like and 2 follistatin like domains 2) is associated with integral components of cell membrane and cell spreading and development. Therefore, we inferred that SLF1 and TMEFF2 may be involved in variations of sperm head shape. In this preliminary study, there was evidence of a potential influence of inbreeding on sperm morphometry in a beef cattle breed. However, additional studies, ideally including more individuals and additional breeds, are necessary to determine the validity of this potential association.

79 CRISPR gene editing in bovine zygotes — mutation confirmation by integration of protein expression and DNA sequencing analyses

Confirmation of gene editing in livestock following CRISPR/Cas9 zygotic microinjection is often limited to either protein expression or gene sequencing analyses of unfixed embryos, but not both, due to the challenges of extracting DNA from fixed samples suitable for genotyping. Bovine embryos have been derived from gene-edited cell lines to screen for mutations followed by nuclear transfer, but these techniques limit embryo production efficiency, include technical challenges, and alter physiological relevance. Herein we report an integrative approach to evaluate both protein expression and the genotype of individual, fixed bovine embryos subjected to CRISPR/Cas9 microinjection. Bovine zygotes were derived from IVF and parthenogenetic activation of in vitro-matured oocytes followed by intracytoplasmic injection of CRISPR/Cas9 targeting embryonic POU5F1. Embryos were cultured for 7 days and fixed in 4% paraformaldehyde and stored at 5°C for up to 4 weeks. Fixed embryos were first subjected to immunohistochemistry to determine POU5F1 mutation success by protein expression. Binder reinforcement labels were affixed to glass slides as a substitute for adhesive spacers. Single embryos were added to 9µL of PBS with a coverslip for imaging. Individual embryos were then recovered and placed in 10µL of QuickExtract (Lucigen, Middleton, WI, USA) for DNA extraction by heating samples to 65°C for 6min and 95°C for 2min. Two rounds of PCR were applied to templates in 20-µL reactions consisting of 10µL of GoTaq Hot Start Green Master Mix (2×; Promega, Madison, WI, USA) with the addition of 0.4µL (10µM) of forward and reverse primer each and 9.2µL of template. The second PCR reaction contained 5µL of PCR product from the first reaction, nested primers, and 4.2µL of H2O. The PCR conditions were |95°C, 3 min| and 35 cycles of |95°C, 30s |56°C, 30 s|72°C, 30 s|72°C, 7 min|. The PCR product was run on an agarose gel to confirm DNA amplification of a single band, and the remainder was purified (QIAquick PCR Purification Kit, Qiagen, Hilden, Germany) and submitted (100ng) for Sanger sequencing. The CRISPR-injected embryos were aligned to wild-type embryo sequences using SnapGene (http://www.snapgene.com/) and TIDE software (https://tide.nki.nl/). Both DNA extraction (n=18/19) and Sanger sequencing (n=19/23) proved highly efficient and repeatable (83 and 95%, respectively). These methods provide an efficient, cost effective, and reproducible approach for confirmation of CRISPR gene editing in individual and fixed bovine embryos by both protein expression and gene sequencing. In addition, these techniques complement the production of gene editing in livestock after zygotic CRISPR microinjection by conclusively determining mutation efficiency through both proteomic and genomic analyses. This research was supported by a USDA NIFA AFRI ELI Postdoctoral Fellowship 2016-67012-25254 to BWD and NIFA multistate research project W3171 to PJR. BD is currently supported by a grant from the Eunice Kennedy Shiver National Institute of Child Health and Human Development of the National Institutes of Health under the award numbers T32HD087166.

Management of a temporomandibular joint synovial cyst in a case complicated by severe trigeminocardiac reflex

The trigeminocardiac reflex is a rare occurrence in patients undergoing maxillofacial surgery, with a reported incidence of 1-2%. Clinical signs and symptoms include bradycardia, nausea, with further stimulation potentially leading to cardiac dysrhythmias, ectopic beats, atrioventricular blocks and asystole. Most maxillofacial procedures, including temporomandibular joint procedures, are considered low risk. We report the first case of a tender temporomandibular joint synovial cyst whose management was complicated by severe trigeminocardiac reflex resulting in asystole. We suggest that in such cases communication between surgeons and the anaesthesia team is of paramount importance and informing the anaesthetist intraoperatively prior to the manipulation of the capsule or temporomandibular joint meniscus is recommended in the prevention or successful treatment of this condition.

150 Runs of Homozygosity Analysis and their Possible Influence on Sperm Motility in Highly Consanguineous Bulls

Inbreeding depression is associated with emergence of deleterious effects and loss of genetic variability. Widespread use of genotyping technologies and new approaches for identification of runs-of-homozygosity (ROH) provide valuable tools to better understand the effects of inbreeding depression. We have previously demonstrated that inbreeding affects sperm motility patterns in cattle (Dorado et al. 2016 Reprod. Fertil. Dev. 29, 712-720; 10.1071/RD15324), with an increase in individuals presenting a hyperactivated-like motility. In this study, we characterised ROH patterns and performed gene ontology analysis of a large, highly consanguineous cattle population. Thirty-three Retinta bulls [average inbreeding percentage FPED = 16.57% (10.25 to 30.62%)] were genotyped using the Axiom® BOS 1 High-Density SNP Array (Thermo Fisher Scientific, Waltham, MA, USA). The ROH were estimated using CGATOH package and classified upon their length into 5 categories: 1-2, 2-4, 4-8, 8-16, and >16 Mb, which are inversely related to inbreeding events occurring 50 to 3 generations before, respectively. The ROH showed an average length of 3.73 Mb (1.48 to 6.71 Mb). Total FROH was partially explained by the increase in ROH fragments longer than 8 Mb, which is consistent with recent inbreeding events that occurred in this population in the last 6 generations. Additionally, the distribution of ROH varied notably between chromosomes. For instance, >16 Mb runs (very recent inbreeding event) were absent in BTA26 and BTA29, whereas certain loci on BTA7, BTA13, and BTA24 showed >16 Mb runs in 9 animals. To identify candidate biological functions affected by inbreeding, we performed functional analysis of the genome areas covered by ROH >8 Mb (our pedigree data covered 5.87 equivalent complete generations) using the Functional Annotation Clustering tool implemented in DAVID. Candidate regions were defined by occurring in ROH >8 in more than 6 animals and by a distance <1 Mb between adjacent single nucleotide polymorphisms. Eight significant gene clusters (enrichment score >1.30; P < 0.05) were identified, with 2 of these clusters related to sperm motility. One of these clusters (score 1.72) contained 23 genes coding microtubule-related proteins, which are associated with cellular movement structures such as flagella. The other cluster (score 1.42), included 4 genes related to dynein and motile cilium assembly ATPase complexes, associated with movement of eukaryotic flagella. We observed an additional cluster representing an ATP-binding feature, which included 77 genes (score 1.43). These results indicate that inbreeding could affect sperm motility by altering microtubule structure and motility. However, the fact that ROH were unevenly distributed across the genome, even in a highly inbred cattle population, also suggests that different metabolic pathways could be affected in individuals with similar inbreeding values. Therefore, the use of inbreeding coefficients as predictors for sperm quality should be approached carefully.

Sorafenib for the Treatment of Advanced Hepatocellular Cancer - a UK Audit

AIMS

Sorafenib is the current standard treatment for advanced hepatocellular carcinoma. We carried out a national audit of UK patients treated with sorafenib as standard-of-care and those treated with systemic therapy in first-line trials.

MATERIALS AND METHODS

Sorafenib-treated and trial-treated patients were identified via the Cancer Drugs Fund and local databases. Data were collected retrospectively from medical records according to a standard case report form. The primary outcome measure was overall survival, estimated by the Kaplan-Meier method.

RESULTS

Data were obtained for 448 sorafenib-treated patients from 15 hospitals. The median age was 68 years (range 17-89) and 75% had performance status ≤ 1. At baseline, 77% were Child-Pugh A and 16.1% Child-Pugh B; 38% were albumin-bilirubin grade 1 (ALBI-1) and 48% ALBI-2; 23% were Barcelona Clinic Liver Classification B (BCLC-B) and 72% BCLC-C. The median time on sorafenib was 3.6 months, with a mean daily dose of 590 mg. The median overall survival for 448 evaluable sorafenib-treated patients was 8.5 months. There were significant differences in overall survival comparing Child-Pugh A versus Child-Pugh B (9.5 versus 4.6 months), ALBI-1 versus ALBI-2 (12.9 versus 5.9 months) and BCLC-B versus BCLC-C (13.0 versus 8.3 months). For trial-treated patients (n=109), the median overall survival was 8.1 months and this was not significantly different from the sorafenib-treated patients.

CONCLUSION

For Child-Pugh A patients with good performance status, survival outcomes were similar to those reported in global randomised controlled trials. Patients with ALBI grade > 1, Child-Pugh B or poor performance status seem to derive limited benefit from sorafenib treatment.

Reducing the blame culture through clinical audit in nuclear medicine: a mixed methods study

Objectives

To identify the barriers and facilitators of doctors’ engagement with clinical audit and to explore how and why these factors influenced doctors’ decisions to engage with the NHS National Clinical Audit Programme.

Design

A single-embedded case study. Mixed methods sequential approach with explorative pilot study and follow-up survey. Pilot study comprised 13 semi-structured interviews with purposefully selected consultant doctors over a six-month period. Interview data coded and analysed using directed thematic content analysis with themes compared against the study’s propositions. Themes derived from the pilot study informed the online survey question items. Exploratory factor analysis using STATA and descriptive statistical methods applied to summarise findings. Data triangulation techniques used to corroborate and validate findings across the different methodological techniques.

Setting

NHS National PET-CT Clinical Audit Programme.

Participants

Doctors reporting on the Audit Programme.

Main Outcome measures

Extent of engagement with clinical audit, factors that influence engagement with clinical audit.

Results

Online survey: 58/59 doctors responded (98.3%). Audit was found to be initially threatening (79%); audit was reassuring (85%); audit helped validate professional competence (93%); participation in audit improved reporting skills (76%). Three key factors accounted for 97.6% of the variance in survey responses: (1) perception of audit’s usefulness, (2) a common purpose, (3) a supportive blame free culture of trust. Factor 1 influenced medical engagement most.

Conclusions

The study documents performance feedback as a key facilitator of medical engagement with clinical audit. It found that medical engagement with clinical audit was associated with reduced levels of professional anxiety and higher levels of perceived self-efficacy.

50 SURVIVAL OF SEXED IVF-DERIVED BOVINE EMBRYOS FROZEN AT DIFFERENT PREIMPLANTATION STAGES OF DEVELOPMENT

The ability to freeze in vitro-produced bovine embryos with a high post-thaw viability is still problematic and hampers logistics of on-farm embryo transfer. The objectives of this experiment were to compare different stages of development, freezing methods, and addition of cytoskeletal stabilisers (cytochalasin-B) before freezing. Ovaries were collected from an abattoir and oocytes aspirated from 2- to 6-mm follicles. Cumulus-oocyte complexes containing compact and complete cumulus cell layers were selected and matured in groups of 50 in 400 µL of M199 medium supplemented with ALA-glutamine (0.1 mM), Na pyruvate (0.2 mM), gentamicin (5 µg mL−1), EGF (50 ng mL−1), ovine FSH (50 ng mL−1), bLH (3 µg mL−1), cysteamine (0.1 mM), and 10% fetal bovine serum (FBS) for 22 to 24 h. Fertilization (Day 0) was done using female sex-sorted semen selected with a discontinuous density gradient and diluted to a final concentration of 1 × 106 sperm/mL. Synthetic oviductal fluid (SOF)-FERT medium was supplemented with fructose (90 µg mL−1), penicillamine (3 µg mL−1), hypotaurine (11 µg mL−1), and heparin (20 µg mL−1). After 18 h, presumptive zygotes were denuded and cultured in groups of 15 to 20 in 50-µL drops of SOF-BSA for 7 days. On Day 3.5 post-fertilization, 3% FBS was added. Low oxygen tension (5% O2) was used for culture. Morulae were selected at Day 5.5–6, blastocysts at Day 6–6.5, and expanded blastocysts at Day 6.5–7. Embryo harvesting for each stage was performed from a dedicated drop/dish and discarded in order to avoid further embryo stage collections. Grade 1 morulae, blastocysts, and expanded blastocysts were selected for freezing and placed randomly into 2 groups: slow-freezing and vitrification. Before freezing, half of the embryos from each stage were exposed to cytochalasin-B for 45 min. The slow freezing protocol consisted of 1.5 M ethylene glycol (EG) + 20% FBS + 0.4% BSA, and the cooling rate was 0.5°C/min. Slow-frozen embryo thawing was performed by exposing the 0.25-mL straws to air (23°C) for 10 s and then underwater at 35°C for 1 min. The vitrification (Cryo-Top) medium was 15% (vol/vol) EG + propylene glycol. Vitrified embryos were thawed in a solution of H199 + 20% FBS and 0.25 M sucrose at 39°C. Thawed embryos from both groups were cultured in SOF-BSA + 10% FBS under cumulus/granulosa cell monolayer co-culture. Embryo assessment involved post-thaw survival (0 h), re-expansion, and hatching of the zona pellucida (72 h). Three replicates were performed for each treatment level. Fisher’s l.s.d. test with Bonferroni correction was used to determine treatment differences (P < 0.05). The post-thaw survival, re-expansion, and hatching results showed that either expanded blastocysts (84.7 ± 3.2%, 74.1 ± 3.9%, and 60.9 ± 4.4%) or blastocysts (81.7 ± 3.5%, 69.6 ± 4.2%, and 55 ± 4.6%) were preferred (P < 0.05) embryo stages for cryopreservation compared with morulae (67.6 ± 4.4%, 52.5 ± 4.6%, and 33.2 ± 4.3%). Vitrification and cytochalasin-B pre-freezing exposure (61.3 ± 3.6% and 56.6 ± 3.8%) provided better (P < 0.05) hatching results compared with slow-freezing and without cytochalasin-B (37.8 ± 3.6% and 42.5 ± 3.7%).

Insulin pump-associated adverse events are common, but not associated with glycemic control, socio-economic status, or pump/infusion set type

AIMS

While there have been many outcome-focussed studies examining insulin pump therapy, only a few have looked at potential adverse events (AEs), with none examining the relationship between AEs and pump/infusion set type, ethnicity or socio-economic status. In addition, current data on the incidence and characteristics of pump-associated AEs are confined to one paediatric centre. We aimed to describe the incidence, characteristics and potential predictors of insulin pump-associated AEs in New Zealand adults and children with T1DM.

METHODS

We approached adults and families of children with T1DM on insulin pumps in four main New Zealand centres. Participants completed a questionnaire examining pump-related issues they had experienced in the preceding 12 months.

RESULTS

Response rate was 64 % with 174 of 270 eligible people participating in the study. 84 % of subjects reported one or more AEs, with an overall AE incidence of 3.42 per person/year (95 % CI 3.14, 3.73). An event serious enough to require a hospital presentation occurred in 9.8 %, all but one reporting high ketones or diabetic ketoacidosis (DKA). Set/site problems were the AE most commonly reported (by 53 % of respondents), followed by cutaneous complications (43 %) and pump malfunction (38 %). Few predictors of AEs (of any type) were found; however, a negative binomial regression model found that a longer duration of pumping (p = 0.018) and age <18 years (p = 0.043) were both associated with fewer AEs (all types combined).

CONCLUSIONS

Insulin pump-associated AEs are very common. However, few variables are predictive of them with no relationships seen with glycaemic control, socio-economic status, pump manufacturer or infusion set type. Based on these findings, AEs should be anticipated in both adults and children, with anticipatory patient education and training recommended for their successful and safe use.

Mucosal and lacrimal flaps for endonasal dacryocystorhinostomy: a systematic review

BACKGROUND

Historically dacryocystorhinostomy (DCR) has been performed externally with very good outcomes. Current literature shows comparable success rates between endonasal and external approaches. A common reason for the failure of a DCR is the reclosure of the nasolacrimal stoma by granulation tissue and synechiae.

OBJECTIVE OF REVIEW

A systematic review and critical evaluation of the evidence relating to the preservation of nasal mucosal flaps in DCR surgery.

TYPE OF REVIEW AND EVALUATION METHOD

A systematic review using the consort guidance for review of randomised control trials.

SEARCH STRATEGY

A search of the following evidence-based medicine databases was performed: Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials, Ovid, Medline, EMBASE and PubMed. The search was limited to English language articles, and the following key words were used: Endonasal, Endoscopic, Dacryocystorhinostomy, DCR, Mucosal Flaps, between years 1970 and 2015.

RESULTS

The best available evidence was level 1B, comprising two randomised control trials and three comparative studies included in the review. The main outcome measures used were lacrimal irrigation and absence of epiphora. Two of the studies demonstrated a statistically significant benefit of mucosal sparing either with nasal mucosal flaps or with lacrimal flaps. More debridement was needed, and granulation tissue was also seen in the groups without mucosal preservation. There was no difference in surgical complications between a mucosal and non-mucosal-sparing technique.

CONCLUSIONS

The overall quality of current evidence is poor, and there does however appear to be a trend towards improved outcomes and reduced granulation in groups where nasal mucosal and lacrimal flaps were preserved, but this is not clear-cut. There was no evidence of increased complication rates with mucosal-sparing techniques. We recommend that until further good quality research is available we should be performing a mucosal-sparing technique when performing DCR routinely.