Development of a highly sensitive and specific intact proviral DNA assay for HIV-1 subtype B and C

INTRODUCTION

HIV reservoir quantification is essential for evaluation of HIV curative strategies and may provide valuable insights about reservoir dynamics during antiretroviral therapy. The Intact Proviral DNA Assay (IPDA) provides the unique opportunity to quantify the intact and defective reservoir. The current IPDA is optimized for HIV-1 subtype B, the dominant subtype in resource-rich settings. However, subtype C is dominant in Sub-Saharan Africa, jointly accounting for around 60% of the pandemic. We developed an assay capable of quantifying intact and defective proviral HIV-1 DNA of subtype B and C.

METHODS

Primer and probe sequences were strategically positioned at conserved regions in psi and env and adapted to subtype B&C. In silico analysis of 752 subtype B and 697 subtype C near-full length genome sequences (nFGS) was performed to predict  the specificity and sensitivity. Gblocks were used to determine the limit of blank (LoB), limit of detection (LoD), and different annealing temperatures were tested to address impact of sequence variability.

RESULTS

The in silico analysis showed that the HIV-1 B&C IPDA correctly identified 100% of the intact subtype B, and 86% of the subtype C sequences. In contrast, the original IPDA identified 86% and 12% of these subtype B and C sequences as intact. Furthermore, the HIV-1 B&C IPDA correctly identified hypermutated (87% and 88%) and other defective sequences (73% and 66%) for subtype B and C with comparable specificity as the original IPDA for subtype B (59% and 63%). Subtype B cis-acting sequences were more frequently identified as intact by the HIV-1 B&C IPDA compared to the original IPDA (39% and 2%). The LoB for intact proviral DNA copies was 0, and the LoD for intact proviral DNA copies was 6 (> 95% certainty) at 60 °C. Quantification of 2-6 copies can be performed with > 80% certainty. Lowering the annealing temperature to 55 °C slightly lowered the specificity but prevented exclusion of samples with single mutations in the primer/probe region.

CONCLUSIONS

We developed a robust and sensitive assay for the quantification of intact and defective HIV-1 subtype B and C proviral DNA, making this a suitable tool to monitor the impact of (large-scale) curative interventions.

Identifying core components of a radiotherapy comfort intervention package using nominal group technique

INTRODUCTION

A comfortable treatment position in radiotherapy may promote patient stability and improve outcomes such as accuracy. The aim of this study was to identify, prioritise and determine the feasibility of delivery of intervention components as part of a radiotherapy comfort intervention package.

METHODS

Prior research, consisting of a systematic review and qualitative interviews with patient and therapeutic radiographers, was triangulated and 15 intervention components developed. An online nominal group technique consensus meeting with 7 patients who received radiotherapy exceeding 10 min for one of three anatomical cancer sites and 3 therapeutic radiographers (TRs) participated. Four activities were undertaken: 1) discussion of comfort intervention components; 2) initial vote; 3) prioritisation of intervention components; and 4) discussion of feasibility in radiotherapy and were analysed using established quantitative and qualitative methods.

RESULTS

One intervention component was added from initial discussions to the 15 pre-determined components being discussed. 11 components were recommended as 'accepted' (n = 5) or 'accepted with caution' (n = 6) to proceed to development. The highest scoring intervention components were 'Compassionate & empathetic communication training for TRs' and 'Tailored information, e.g., TRs provide the required information only as part of preparation for treatment'. Anther that followed closely was 'Adjustments & supports provided for arms or legs during treatment by TRs'. Those 'accepted with caution' included 'Soft pads/mattress under the body to alleviate body discomfort managed by TRs'. Qualitative analysis highlighted concerns over the radiation environment and emphasised the importance of resources such as equipment, training, and time.

CONCLUSION

The recommended comfort interventions have potential to improve patient comfort during radiotherapy and should be considered to incorporate into positioning and immobilisation guidelines. However, specific intervention strategies to address these components will need to be developed and robustly evaluated.

IMPLICATIONS FOR PRACTICE

Comfort interventions might help patients relax and stay still during treatment, which could improve treatment accuracy and efficacy. Introducing these comfort interventions in practice have potential to lead to a more positive patient experience and improved overall quality of care during radiotherapy.

Nursing, midwifery, and allied health professions research capacities and cultures: a survey of staff within a university and acute healthcare organisation

BACKGROUND

There is an increasing focus on the development of research capacity and culture in Nursing, Midwifery and Allied Health Professions (NMAHP). However, better understanding of the existing research success and skills, motivators, barriers, and development needs of NMAHP professionals is required to inform this development. This study sought to identify such factors within a university and an acute healthcare organisation.

METHODS

An online survey, incorporating the Research Capacity and Culture tool, was administered to NMAHP professionals and students at a university and an acute healthcare organisation in the United Kingdom. Ratings of success/skill levels of teams and individuals were compared between professional groups using Mann-Whitney U tests. Motivators, barriers, and development needs were reported using descriptive statistics. Descriptive thematic analysis was used for open-ended text responses.

RESULTS

A total of 416 responses were received (N&M n = 223, AHP n = 133, Other n = 60). N&M respondents were more positive than their AHP counterparts about the success/skill levels of their teams. There were no significant differences between N&M and AHP in their ratings of individual successes/skills. Finding and critically reviewing relevant literature were identified as specific individual strengths; with weaknesses in securing research funding, submitting ethics applications, writing for publication, and advising less experienced researchers. The main motivators for research were to develop skills, increased job satisfaction, and career advancement; whilst barriers included lack of time for research and other work roles taking priority. Key support needs identified included mentorship (for teams and individuals) and in-service training. Open-ended questions generated main themes of 'Employment & staffing', 'Professional services support', 'Clinical & academic management', 'Training & development', 'Partnerships' and 'Operating principles'. Two cross-cutting themes described issues common to multiple main themes: 'Adequate working time for research' and 'Participating in research as an individual learning journey'.

CONCLUSIONS

Rich information was generated to inform the development of strategies to enhance research capacity and culture in NMAHP. Much of this can be generic but some nuances may be required to address some specific differences between professional groups, particularly related to perceived team success/skills and priorities identified for support and development.

Online activity - A beaming good initiative! Delivering alternative exercise opportunities for people with cystic fibrosis

BACKGROUND

Increasing physical activity in people with Cystic Fibrosis (pwCF) can positively influence their physical and mental wellbeing. Online activities provide opportunity for outpatient CF populations to enhance physical activity.

METHODS

PwCF within a large Scottish CF unit were invited to participate in a pilot study of online exercise and education sessions. Those participating shared opinions on motivation, fitness habits, types of activities enjoyed pre and during shielding, and desirable goals for online activity. Subsequently, an online activity timetable was created offering daily exercise classes. Educational presentations driven by patient request were delivered in context appropriate to health, wellbeing, and infection control needs during the pandemic and the advent of modulator therapies. Twenty-eight group exercise sessions and 12 educational sessions occurred over the six-week pilot, following which, a post-pilot questionnaire was sent to those who had participated in the sessions. Risk assessment and exercise modifications ensured safe practice and accommodation for all levels of respiratory disease.

RESULTS

Twenty-six pwCF attended one or more exercise sessions and 37 pwCF attended one or more education sessions. Group exercise and education improved time efficiency compared to in-person face-to-face delivery. The post-pilot questionnaire demonstrated increases in motivation and perceived fitness, with positive comments regarding peer support and enhanced socialization. Personal fitness goals were fully or partially achieved by 91% of participants.

CONCLUSION

Patient feedback suggested the implementation of online exercise and education sessions for pwCF was a satisfactory and convenient way to deliver exercise allowing for optimization and progression of personal goals.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

753 Sesamoid Alignment After MIS Chevron Osteotomy and Its Role to Prevent Hallux Valgus Recurrence

Introduction

Incomplete correction of the sesamoid position after corrective osteotomy is a risk factor for recurrence of the hallux valgus deformity. This study was done to report the results of sesamoid alignment after chevron osteotomy.

Method

92 patients (111 feet) had minimally invasive (MIS) distal chevron osteotomy and release of fibular sesamoid ligaments done, sesamoid position was assessed in the weight-bearing views of the foot, tibial sesamoid position in relation to the mechanical axis of the first metatarsal was classified as grades 0-3 where the normal position was graded (0) and the most lateral sublaxation was graded (3). There were 2 groups; the reduced (grade 0-1) & the dislocated (grade 2,3) groups. Preoperative and post-operative radiographs were compared. Postoperative images were done 6-8 weeks post-operatively to ensure osteotomy healing.

Results

Sesamoids alignment was corrected following the MIS chevron osteotomy; 84 feet (75.7%) were from the dislocated group and 27 feet (24.3%) were from the reduced group pre-operatively improved to 102 feet (91.9%) reduced and only 9 feet (8.1%) dislocated following the procedure with P-value < 0.00001. To ensure inter-observer reliability, images were assessed by 2 observers with Cohen’s Kappa coefficient 0.477.

Conclusions

MIS chevron osteotomy can produce significant improvement of sesamoid position which is crucial to prevent recurrence of hallux valgus.

OP0203-HPR EVALUATION OF A 10-WEEK PROGRESSIVE RESISTANCE TRAINING PROGRAMME FOR PEOPLE WITH INFLAMMATORY ARTHRITIS

Background:

Inflammatory Arthritis [IA] adversely affects well-being, function, fatigue and strength1. Guidelines recommend people with IA should exercise to improve strength and cardiovascular fitness2. In 2015, our team introduced an evidence-based Progressive Resistance Training Programme [PRTP] for IA3.

Objectives:

To evaluate the effectiveness of a PRTP within a United Kingdom National Health Service setting.

Methods:

A pre- to post-treatment evaluation was conducted. People with IA attending Rheumatology Physiotherapy were offered a supervised PRTP (1 hour x 10 weeks): 7 exercises at 70-80% 1-repetition maximum (3 x 8-12 repetitions). Treatment outcomes included Health Assessment Questionnaire [HAQ], EQ5D-5L, 30s sit-to-stand [STS], Self-Efficacy (SARAH Trial) [SE], Grip Strength and FACIT-Fatigue [FACIT-F]. Changes in outcomes were analysed using Paired Samples t-tests and standardised mean difference (SMD).

Results:

201 patients commenced the programme between May 2015 and April 2019, with 121 participants providing complete pre-post HAQ data. Diagnoses included Rheumatoid Arthritis (n=149), Psoriatic Arthritis (n=42), Juvenile Idiopathic Arthritis (n=5), Enteropathic IA (n=2), Oligoarthritis (n=1), Reactive Arthritis (n=1) and Undifferentiated IA (n=1). Age (mean ± SD) = 56.8 ± 14.8 years; number of sessions attended = 7.7 ± 3.4.

There were no differences between those recorded as not completing the PTRP (n=54; 72% women; age 55.0 ± 14.6 years; HAQ 0.99 ± 0.70) versus the others (n=147; 78% women; age 57.5 ± 14.8; HAQ 0.86 ± 0.65). A pragmatic decision was made to analyse all available data for each outcome.

Table 1.

Analysis of PRTP outcomes * Indicates clinical improvement.

Outcome measurePre-treatmentPost-treatmentMean difference(95% CI)p-valueStandardised mean difference(95% CI)HAQmax score 3 (n=121)0.83 ± 0.650.70 ± 0.67-0.13(-0.07, -0.19)p<0.001-0.20*(-0.46, 0.07)EQ5D VASmax score 100 (n=119)70.0 ± 16.376.7 ± 15.26.7(9.4, 3.9)p<0.0010.42*(0.17, 0.68)STSnumber in 30s (n=118)13.2 ± 4.916.2 ± 5.33.0(3.6, 2.5)p<0.0010.59*(0.33, 0.85)SEmax score 70 (n=117)52.3 ± 10.458.6 ± 8.06.3(8.3, 4.4)p<0.0010.68*(0.41, 0.94)Grip Strength kg force(n=62)20.3 ± 9.423.6 ± 10.63.3(4.8, 1.7)p<0.0010.33*(-0.03, 0.68)FACIT-Fmax score 52(n=58)30.9 ± 11.535.5 ± 12.04.6(7.2, 2.1)p=0.0010.39*(0.02, 0.76)

Conclusion:

All outcome measures demonstrated statistically significant improvements. Notably, minimal clinically important differences were achieved in STS and FACIT-F. STS correlates to lower limb power, balance and endurance, and is a predictor of falls4. Fatigue significantly impacts function in people with IA5, often limiting confidence and willingness to participate in exercise activities6.

Effective evidence-based PRTPs for people with IAs can be delivered by Physiotherapists. Improvements in function, wellbeing, self-efficacy, strength and fatigue are achievable, however, exploration of the clinical relevance of these observed changes is recommended. Further research exploring patients’ perspectives of the PRTP and adherence to long-term exercise is needed.

References:

[1]Cooneyet al. (2011) Benefits of Exercise in Rheumatoid ArthritisJ. Aging Res.Vol 2011

[2]Rausch Ostoffet al. (2018) 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritisAnn Rheum Dis77(9)

[3]Lemmeyet al. (2009) Effects of high-intensity resistance training in patients with rheumatoid arthritis: a randomized controlled trialArthritis Rheum16(12)

[4]Beaudartet al. (2019) Assessment of Muscle Function and Physical Performance in Daily Clinical PracticeCalcif. Tissue Int.105(1)

[5]Dureset al. (2016) Patient preferences for psychological support in inflammatory arthritis: a multicentre surveyAnn Rheum Dis75(1)

[6]Rongen-van Dartelet al. (2015) Effect of Aerobic Exercise Training on Fatigue in Rheumatoid Arthritis: A Meta-AnalysisArth Care Res67(8)

Disclosure of Interests:

None declared

AB1321-HPR DEVELOPING A SELF-MANAGEMENT INTERVENTION TO MANAGE JOINT HYPERMOBILITY SYNDROME AND EHLERS-DANLOS SYNDROME HYPERMOBILITY TYPE: AN ANALYSIS INFORMED BY BEHAVIOUR CHANGE THEORY

Background:

Joint Hypermobility Syndrome (JHS) and Ehlers-Danlos Syndrome Hypermobility Type (EDS-HT) are heritable disorders of connective tissue that can cause joint instability and pain and are associated with increased anxiety and depression. There is currently little UK guidance for supporting patients with JHS/EDS-HT1. The analysis presented here used the Behaviour Change Wheel (made up of the Theoretical Domains Framework (TDF) and Capability, Opportunity, Motivation and Behaviour (COM-B) model2) to identify possible intervention options to improve self-management in people with JHS/EDS-HT.

Objectives:

To determine recommendations for the components of a behaviour change intervention for people with JHS or EDS-HT.

Methods:

Data from: 1) A systematic review and thematic synthesis of the literature examining adults’ lived experiences of JHS/EDS3and 2) A thematic analysis of interview data where UK adults with JHS/EDS-HT (n=17, 14 women, 3 men) discussed the psychosocial impact of the condition on their lives4, were mapped onto the TDF and COM-B in a behavioural analysis. A modified Nominal Group Technique focus group (n=9, all women) explored which interventions identified by the TDF/COM-B mapping exercise were most important to them.

Results:

Participants prioritised a range of potential self-management interventions, including:

Education: Participants wanted greater support to improve their knowledge of JHS/EDS-HT, including self-help strategies for coping with injury, fatigue and overexertion, and how to evaluate information about their condition.

Training: In activity pacing, assertiveness and communication skills, and what to expect during pregnancy, when symptoms of JHS/EDS-HT can worsen.

Environmental restructuring and enablement:Support from occupational therapists to maintain independence at home. Enablement of access to CBT, mindfulness and emotional support.

Modelled behaviour:Positive first-person narratives that address how other patients with JHS/EDS-HT have coped with anxiety, depression, distress, fear, frustration and feelings of loss.

Conclusion:

This study is the first to apply theoretically-informed approaches to the management of JHS/EDS-HT. Through a modified nominal group technique, potential behaviour change interventions for addressing barriers to self-management have been prioritised. Discussion with participants indicated poor access to psychological support, occupational therapy and a lack of knowledge of JHS/EDS-HT. Future research with healthcare professional and patient stakeholder groups will further evaluate which intervention options would be most acceptable and feasible for the management of JHS/EDS-HT.

References:

[1]Palmer, S., Terry, R. Rimes, K.A., Clark, C., Simmonds, J. & Horwood, J. (2016). Physiotherapy management of joint hypermobility syndrome – a focus group study of patient and health professional perspectives. Physiotherapy,http://dx.doi.org/10.1016/j.physio.2015.05.001.

[2]Michie, S., van Stralen, M.M. & West, R. (2011). The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science, 6(42).

[3]Bennett, S.E., Walsh, N., Moss, T. and Palmer, S. (2019a) “The lived experience of joint hypermobility and Ehlers-Danlos Syndromes: A systematic review and thematic synthesis.”Physical Therapy Reviews, 24 (1-2). pp. 12-28. ISSN 1083-3196

[4]Bennett, S.E., Walsh, N., Moss, T. and Palmer, S. (2019b) “Understanding the psychosocial impact of Joint Hypermobility Syndrome and Ehlers-Danlos Syndrome Hypermobility Type: A qualitative interview study.”Disability and Rehabilitation. ISSN 0963-8288

Disclosure of Interests:

None declared

Antibiotic Resistance and Typhoid

Multiple drug (antibiotic) resistance (MDR) has become a major threat to the treatment of typhoid and other infectious diseases. Since the 1970s, this threat has increased in Salmonella enterica serovar Typhi, driven in part by the emergence of successful genetic clades, such as haplotype H58, associated with the MDR phenotype. H58 S. Typhi can express multiple antibiotic resistance determinants while retaining the ability to efficiently transmit and persist within the human population. The recent identification of extensively drug resistant S. Typhi only highlights the dangers of ignoring this threat. Here we discuss the evolution of the S. Typhi MDR phenotype and consider options for management.