Multicenter Study of Long-Term Outcomes and Quality of Life in PHACE Syndrome after Age 10

OBJECTIVE

To characterize long-term outcomes of PHACE syndrome.

STUDY DESIGN

Multicenter study with cross-sectional interviews and chart review of individuals with definite PHACE syndrome ≥10 years of age. Data from charts were collected across multiple PHACE-related topics. Data not available in charts were collected from patients directly. Likert scales were used to assess the impact of specific findings. Patient-Reported Outcomes Measurement Information System (PROMIS) scales were used to assess quality of life domains.

RESULTS

A total of 104/153 (68%) individuals contacted participated in the study at a median of 14 years of age (range 10-77 years). There were infantile hemangioma (IH) residua in 94.1%. Approximately one-half had received laser treatment for residual IH, and the majority (89.5%) of participants were satisfied or very satisfied with the appearance. Neurocognitive manifestations were common including headaches/migraines (72.1%), participant-reported learning differences (45.1%), and need for individualized education plans (39.4%). Cerebrovascular arteriopathy was present in 91.3%, with progression identified in 20/68 (29.4%) of those with available follow-up imaging reports. Among these, 6/68 (8.8%) developed moyamoya vasculopathy or progressive stenoocclusion, leading to isolated circulation at or above the level of the circle of Willis. Despite the prevalence of cerebrovascular arteriopathy, the proportion of those with ischemic stroke was low (2/104; 1.9%). PROMIS global health scores were lower than population norms by at least 1 SD.

CONCLUSIONS

PHACE syndrome is associated with long-term, mild to severe morbidities including IH residua, headaches, learning differences, and progressive arteriopathy. Primary and specialty follow-up care is critical for PHACE patients into adulthood.

Post-acute COVID-19 complications in UK doctors: results of a cross-sectional survey

BACKGROUND

As a consequence of their occupation, doctors and other healthcare workers were at higher risk of contracting coronavirus disease 2019 (COVID-19), and more likely to experience severe disease compared to the general population. However, systematic information on post-acute COVID complications in doctors is very limited.

AIMS

This study aimed to determine the symptoms, perceived determinants, health and occupational impact, and consequent needs relating to post-acute COVID complications in UK doctors.

METHODS

An online cross-sectional survey was distributed to UK doctors self-identifying as having Long COVID or other post-acute COVID complications.

RESULTS

Of 795 responses, 603 fulfilled the inclusion criteria of being a UK-based medical doctor experiencing one or more post-acute COVID complications. Twenty-eight per cent reported a lack of adequate Respiratory Protective Equipment at the time of contracting COVID-19. Eighteen per cent of eligible respondents reported that they had been unable to return to work since acquiring COVID.

CONCLUSIONS

Post-acute COVID (Long COVID) in UK doctors is a substantial burden for respondents to our questionnaire. The results indicated that insufficient respiratory protection could have contributed to occupational disease, with COVID-19 being contracted in the workplace, and resultant post-COVID complications. Although it may be too late to address the perceived determinants of inadequate protection for those already suffering with Long COVID, more investment is needed in rehabilitation and support of those afflicted.

Rubella virus-associated necrotizing granulomatous inflammation with extensive eyelid, ocular, and orbital involvement

We present a case of cutaneous granulomatous disease associated with rubella virus in a 4-year-old girl without an identifiable immunodeficiency. In this case, a combination of anti-inflammatory, anti-viral, and anti-neutrophil therapies successfully treated vision-threatening eyelid, conjunctival, scleral, and orbital inflammation.

Evaluation of a commercial electrical stunning method for farmed grower saltwater crocodiles (Crocodylus porosus) using non-invasive EEG measurements

The aim of this study was to assess welfare outcomes of electrical stunning as a means of restraint in farmed grower saltwater crocodiles (Crocodylus porosus). Physical handling of a stunned, unconscious crocodile is far safer for the operator than handling a fully conscious animal. Electroencephalogram (EEG) was recorded before and after the application of electrical stunning at 50 Hz or 400 Hz using an electrical stunner applied to the cranial plate (Position 1: P1-50 Hz; n = 31, P1-400 Hz; n = 29) or immediately behind the skull (Position 2: P2-50 Hz; n = 29; P2-400 Hz; n = 30). For all electrical stuns, percentage total EEG power in a 10-s epoch decreased in the alpha and beta frequency bands; and increased in the delta and lower frequencies bands. All electrical stuns resulted in increased strength of signal, based on the quadratic mean EEG power in all frequency bands of the EEG. Greatest change in power occurred in the delta frequency band, with P1-50 Hz. This was greater than with P2-50 Hz; while decibel change using 400 Hz at either position was intermediate and not significantly different from either. Application of either electrical stunner at position 1 resulted in seizure-like activity and activation in low frequencies, but at position 2 this was not consistent across all animals. The ability of the electrical stunning equipment to consistently induce recoverable unconsciousness could be ranked in decreasing order as: P1-50 Hz > P1-400 Hz = P2-50 Hz > P2-400 Hz. Based on behavioural observations, all animals in the study appeared to stunned however evaluation of duration of EEG changes indicates that use of the electrical stunning equipment at 50 Hz would allow some margin for inaccuracies in tong placement, while achieving a consistently reliable stun.

Sex impacts pain behaviour but not emotional reactivity of lambs following ring tail docking

Studies in humans have shown sex differences in response to painful events, however, little is known in relation to sex differences in sheep. Understanding sex differences would enable improved experimental design and interpretation of studies of painful procedures in sheep. To examine sex differences in response to pain, 80 lambs were tested across five cohorts of 16. The lambs were penned in groups containing two male and two female lambs with their respective mothers. Lambs were randomly allocated from within each block to one of four treatment groups; FRing–Female lamb, ring tail docked without analgesia, MRing–Male lamb, ring tail docked without analgesia, FSham–Female lamb, tail manipulated and MSham–Male lamb, tail manipulated. Following treatment, lambs were returned to their pen and were video recorded for 45 mins for behavioural observations of acute pain and posture. An hour after treatment, lambs then underwent an emotional reactivity test that consisted of three phases: Isolation, Novelty and Startle. Following treatment, Ring lambs displayed more abnormal postures (mean = 2.5 ± 0.5) compared to Sham lambs (mean = 0.05 ± 0.4, P = 0.0001). There was an effect of sex on the display of acute pain-related behaviours in lambs that were tail docked (P < 0.001), with female lambs displaying more acute behaviours (mean count = +2.2). This difference in behaviour between sexes was not observed in Sham lambs. There was no effect of sex on display of postures related to pain (P = 0.99). During the Novelty and Startle phase of the emotional reactivity test, Ring lambs tended to (P = 0.084) or did (P = 0.018) show more fear related behaviours, respectively. However, no effect of sex was observed. The results of this study indicate that a pain state may alter the emotional response of lambs to novel objects and potential fearful situations. It was also demonstrated that female lambs display increased sensitivity to the acute pain caused by tail docking compared to males.

Dual treatment of cutaneous leishmaniasis with topical amphotericin B and photodynamic therapy in a pediatric patient

Cutaneous leishmaniasis is a parasitic infection that can result in scarring, contributing to significant morbidity when a cosmetically sensitive area is involved. We report a case of a 13-year-old boy with cutaneous leishmaniasis involving the face and arm. He was treated with a combination of photodynamic therapy as well as topical amphotericin with a cosmetically satisfying outcome. This combination of noninvasive treatment regimens has not been reported to our knowledge and merits further study in the pediatric population.

Inhibition of novel lipoprotein(a) receptor major facilitator superfamily domain containing 5 (MFSD5) reduces development of aortic valve calcification

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Private grant from Kowa Pharmaceuticals to Brigham and Woman's Hospital

Calcific aortic valve stenosis (CAVS) is the most prevent valvular heart disease in the western world increasing exponentially with age, with an 112% increase in CAVS deaths in the last three decades; however no therapeutic treatment is currently available. Recently, lipoprotein(a) [Lp(a)] has been demonstrated to be an independent and causal risk factor for CAVS, yet the understanding of its cellular uptake and catabolism is limited thus underscoring the need for further investigation.

This study aimed to determine a target receptor, unique for Lp(a) on the surface of valvular interstitial cells (VICs) and ascertain the role of the receptor on the development of VIC calcification.

Unbiased ligand-receptor capture mass spectrometry (TriCEPS) was used to identify target receptor, with western blotting, ELISA, qPCR, alizarin red calcium staining and immunofluorescence used to validate the targets in vitro via siRNA inhibition and overexpression. Transmission electron microscopy (TEM) was used to determine uptake of Lp(a) within excised human valves. Identification of small molecule inhibitors was assessed computationally via the L1000 dataset, with the top hit candidate validated in vitro. Genotype-phenotype studies were examined using the United Kingdom Biobank (UKBB) and the Millions Veterans Program. Linear regression was used to evaluate association between aortic stenosis and plasma Lp(a) levels, and a phenotype-wide association analysis was then performed against this generated ‘genotype’.

Ligand-receptor capture mass spectrometry was used to detect novel membrane proteins with specific binding to Lp(a); MFSD5, MRC2, LDLR were identified as possible candidates. MFSD5 RNAscope demonstrated its presence in human aortic valves. Lp(a) uptake in VICs was confirmed via western blot and TEM. MFSD5 siRNA significantly reduced dil-labelled Lp(a) uptake in human VICs (p=0.003) and HEPG2 cells (p=0.0003), conversely MFSD5 overexpression increased uptake (p=0.0345, p=0.0318), whilst specificity of MFSD5 to Lp(a) alone was shown via no change in LDL uptake following MFSD5 inhibition (p=0.616, p=0.991). MFSD5 inhibition reduced RUNX2 (p=0.0124) and Osteocalcin (p&lt;0.001) RNA expression and reduced alizarin red staining following culture in Lp(a) osteogenic media for 21 days (p&lt;0.0033). Druggability of MFSD5 was confirmed by the L1000 database, which identified aminopurvalanol as a binding partner for MFSD5 and significantly reduced Lp(a) uptake within VICs (p=0.0091). MFSD5-loss of function within the UKBB showed no significant cardiovascular association, however 50kb +/- of the MFSD5 gene showed nominal association with hyperlipidaemia and atrial fibrillation.

The current study demonstrates the novel Lp(a) receptor MFSD5 may be responsible for uptake of Lp(a) within VICs, resulting in the development of aortic valve calcification, highlighting the need for further exploration into the role of MFSD5 in aortic valve disease.

POS0057 INDUCIBLE REGULATORY SYNOVIAL MACROPHAGES: A PROOF-OF-CONCEPT STUDY FOR A CELL-BASED TARGETED THERAPY FOR RHEUMATOID ARTHRITIS

Background

Infiltration of monocyte-derived macrophages into the synovial tissue (ST) is a hallmark of rheumatoid arthritis (RA) pathology. These macrophages promote inflammation, local joint effusion, and joint damage via the release of cytokines, oxygen reactive species, and tissue damaging enzymes. However, balancing these, are the ‘regulatory’ macrophages with inflammation-resolving properties, characterised by expression of CD206 and MerTK, dominant within the ST of healthy individuals as well as RA patients in remission (1). Indeed, these cells are believed to actively contribute to the maintenance of remission.

Macrophages are known to exhibit remarkable phenotypic plasticity and understanding the role of this characteristic in regulating inflammation and pathology remains a major challenge, as does the characterization of factors in the microenvironment such as the synovium that control such macrophage characteristics. Importantly, whether the infiltrating, inflammatory macrophages of the RA ST similarly exhibit such phenotypic plasticity, and whether this occurs during the process of reaching remission, remains to be studied.

Objectives

We investigated the phenotypic plasticity of inflammatory synovial macrophages from patients with RA in vitro, investigating their ability to convert from an inflammatory macrophage population into ‘regulatory’ CD206+MerTK+ macrophages. These findings will provide a proof-of-concept as to the utility of these macrophage for a cell-based therapy in resolving inflammation in patients with RA, and will likely extend our understanding of the mechanisms of action of currently used therapeutics.

Methods

Synovial fluid (SF) mononuclear cells were obtained from patients with active early RA (<1 year; fulfilling 2010 ACR/EULAR classification criteria). Cryopreserved SFMCs were cultured for 48hr in the presence of 10 ng/mL interferon(IFN)γ, 50 ng/mL dexamethasone, 10 μg/mL Infliximab, or diluent. Following culture, cells were immunostained and analysed using a Beckman Coulter CytoFLEX flow cytometer and FlowJo software. SF macrophages were characterised by expression of CD14, CD45, CD68 (Figure 1A), and proportions of CD206+ MerTK+ macrophages measured.

Figure 1.

Synovial fluid CD68+macrophage plasticity in vitro. (A) Gating strategy depicting CD68+ CD45+CD14+ SF macrophage determination. (B) Proportions of CD206 and MerTK-expressing SF macrophages after 48hr culture in the presence of 10 ng/mL IFNγ, 50 ng/mL dexamethasone or 10 µg/mL Infliximab, or absence. Data are representative of 5 individual experiments. Data were analysed by two-way ANOVA followed by Dunnett’s multiple comparison test, *p<0.05.

Results

Prior to culture, the CD68+ macrophage populations present in SF were found to be predominantly CD206-MerTK-. After 48 hours of culture, in the absence of any stimulus, there was an increase in proportions of CD206+MerTK+ macrophages. Treatment with either dexamethasone or anti-TNF (Infliximab) resulted in a further increase in proportions of CD206+ MerTK+, M2-like macrophages. In contrast, culture with IFNγ induced a reduction in this population. Importantly, we found that the generated CD206+MerTK+ macrophages were phenotypically stable in culture following removal of these differentiating agents.

Conclusion

Our findings demonstrate that inflammatory SF cells are indeed able to polarise to regulatory, CD206+MerTK+ macrophages in vitro. The findings provide further mechanistic insights into the basis for the therapeutic benefits of glucocorticoids and TNF inhibitors, as well as providing initial proof-of-concept in the use of regulatory macrophages as a cellular-based therapy or therapeutic target for patients with RA.

References

[1]Alivernini S, MacDonald L, Elmesmari A, et al., Distinct synovial tissue macrophage subsets regulate inflammation and remission in rheumatoid arthritis. Nature Medicine. 2020;26(8):1295-306 10.1038/s41591-020-0939-8.

Disclosure of Interests

None declared

Annual prevalence estimation of lymphatic malformation with a cutaneous component: observational study of a national representative sample of physicians

Background

Lymphatic malformations (LMs) represent a potentially life-threatening, rare disease of the lymphatic system characterized by development of abnormal vessels, outpouchings, or cysts filled with lymphatic fluid. There are three morphologic types of LMs based on the size of the individual cysts: macrocystic (typically > 2 cm), microcystic (generally < 2 cm), and mixed (includes aspects of both). Macrocystic LMs typically exist beneath the skin and often can involve vascular components and/or organs. Microcystic LMs often have a cutaneous component and clinically present with lymphorrhea, bleeding, pain, itching, malodor, and functional deficits. There are no treatments approved by the US Food and Drug Administration (FDA) for either macrocystic or microcystic lymphatic malformations. The totality of the epidemiologic literature for LM is limited to the incidence of the disease among various birth cohorts. This is the first nationally representative study to estimate the national managed prevalence for patients with microcystic LM or combined LM with a cutaneous component annually across physician specialties likely to manage this condition. We conducted a retrospective observational survey of a nationally representative sample of patient-care physicians in the United States most likely to manage lymphatic malformations with a cutaneous component (LMC). Once recruited, target physicians participated via an electronic questionnaire. We weighted study physician self-estimates of the number of LMC patients treated in the past 12 months to reflect the specialists’ corresponding proportion in the national universe. All patient information was anonymous; no personally identifiable information was collected.

Results

Of the 420 physicians who visited the study website, 316 agreed to be screened and to participate (75.2% participation rate). Our survey results indicated the estimated number of unique annually managed LMC patients by target specialists is 79,920 (CI 66,600–93,250). This number corresponds to managed prevalence of 24.1 LMC patients per 100,000 population (CI 19.6/100,000–28.4/100,000).

Conclusions

The study indicates that while rare, LMC affects a substantial number of people in the US (79,920) who are being managed by one or more specialists. By better understanding the prevalence of people living with LMC who require treatment, efforts to both increase disease awareness and to identify underserved populations in need of potential new treatments can be better focused.

Welfare of Farmed Crocodilians: Identification of Potential Animal-Based Measures Using Elicitation of Expert Opinion

Simple Summary

This study focuses on an elicitation of expert opinion to identify a toolbox of animal-based measures that can be used to assess the welfare of farmed crocodilians. This is the initial step towards identifying an animal-based assessment protocol that could be used to support the international outcome-based standard developed by the crocodilian farming industry. Potential measures were identified and aligned with the four animal welfare principles and twelve criteria developed by Welfare Quality^®, focusing primarily on practical measures that could be used for monitoring farm processes or during external verification activities. The proposed measures were presented to a panel made up of animal welfare specialists (farmers, veterinarians and scientists) for judgment and scoring. Twenty-eight experts scored the proposed measures for validity (that being the relevancy to the welfare criterion and usefulness as a measure) and feasibility (that being how easy it is to observe and assess, for example, during an on-farm animal welfare assessment or routine monitoring). Future studies, involving the preliminary testing of the measures on a commercial crocodile farm, are planned to confirm validity and establish the reliability of the identified measures.

Abstract

Animal-based measures are the measure of choice in animal welfare assessment protocols as they can often be applied completely independently to the housing or production system employed. Although there has been a small body of work on potential animal-based measures for farmed crocodilians, they have not been studied in the context of an animal welfare assessment protocol. Potential animal-based measures that could be used to reflect the welfare state of farmed crocodilians were identified and aligned with the Welfare Quality^® principles of good housing, good health, good feeding and appropriate behaviour. A consultation process with a panel of experts was used to evaluate and score the potential measures in terms of validity and feasibility. This resulted in a toolbox of measures being identified for further development and integration into animal welfare assessment on the farm. Animal-based measures related to ‘good feeding’ and ‘good health’ received the highest scores for validity and feasibility by the experts. There was less agreement on the animal-based measures that could be used to reflect ‘appropriate behaviour’. Where no animal-based measures were deemed to reliably reflect a welfare criterion nor be useful as a measure on the farm, additional measures of resources or management were suggested as alternatives. Future work in this area should focus on the reliability of the proposed measures and involve further evaluation of their validity and feasibility as they relate to different species of crocodilian and farming system.

Measuring the impact of clinical practice guidelines on infantile hemangioma referrals

High-risk infantile hemangiomas may be associated with significant patient comorbidity. The American Academy of Pediatrics published clinical practice guidelines with recommendations to refer high-risk hemangiomas early. The results of this study suggest that these guidelines may have resulted in an earlier referral age of patients with high-risk IH to hemangioma specialists.

Local Anesthetic Delivered with a Dual Action Ring and Injection Applicator Reduces the Acute Pain Response of Lambs during Tail Docking

Simple Summary

Tail docking is a procedure practiced on millions of lambs all over the world. The objective is to prevent fecal soiling on the lower part of the tail, reduce soiling of the breech, and thereby lessen the risk of blowfly strike. Docking can be done with a knife or a clamp, but applying a latex ring round the tail, cutting off the blood supply so that the tail drops off a few weeks later, is the most popular method. All methods cause acute pain which diminishes substantially after the first hour. The present trial determined whether local anesthetic delivered by a prototype Numnuts^® device, a novel, dual-function applicator, would reduce this pain in two to four-week-old lambs. Comparison of lambs that were sham handled, lambs that underwent ring tail docking and a third group of lambs that underwent ring tail docking and that were injected with lignocaine using the dual function device was conducted. All lambs were returned to their pen with their mothers and videoed for three hours for behavioral signs of pain. Every five minutes for the first hour and then every ten minutes, each lamb’s posture, movement and feeding behavior was classified and quantified, and the data subjected to statistical analysis. It was concluded that applying lignocaine using the novel device greatly reduced the degree of pain observed.

Abstract

Docking the tail of lambs is a standard husbandry procedure and is achieved through several techniques including clamps, hot or cold knives and latex rings, the last of which is the most popular. All tail docking methods cause acute pain which can be reduced by application of local anesthetic, however precise anatomical injection for optimal efficacy requires considerable skill. This pen trial evaluated the ability of local anesthetic (LA) delivered with a dual function ring applicator/injector to alleviate acute tail docking pain. Thirty ewe lambs were assigned to one of three treatment groups (n = 10 per group): ring plus local anesthetic (Ring LA), ring only (Ring) and sham handled control (Sham). Lambs were videoed and their behavior categorized every five minutes for the first hour and every 10 min for the subsequent two hours after treatment. There was a significant effect (p < 0.001) of treatment on total active pain related behaviors in the first hour, with Ring lambs showing higher counts compared to Ring LA or Sham. Ring lambs also displayed a significantly higher count of combined abnormal postures (p < 0.001) than Ring LA or Sham lambs. Delivery of 1.5 mL of 2% lignocaine via the dual action device abolished abnormal behaviors and signs of pain in Ring LA lambs. However, lambs in the Ring LA group spent less time attempting to suckle compared to Ring and Sham lambs, suggesting that some residual discomfort remained.

Analgesia for Sheep in Commercial Production: Where to Next?

Simple Summary

Increasing societal and customer pressure to provide animals with ‘a life worth living’ continues to apply pressure on industry to alleviate pain associated with husbandry practices, injury and illness. Although a number of analgesic solutions are now available for sheep, providing some amelioration of the acute pain responses, this review has highlighted a number of potential areas for further research.

Abstract

Increasing societal and customer pressure to provide animals with ‘a life worth living’ continues to apply pressure on livestock production industries to alleviate pain associated with husbandry practices, injury and illness. Over the past 15–20 years, there has been considerable research effort to understand and develop mitigation strategies for painful husbandry procedures in sheep, leading to the successful launch of analgesic approaches specific to sheep in a number of countries. However, even with multi-modal approaches to analgesia, using both local anaesthetic and non-steroidal anti-inflammatory drugs (NSAID), pain is not obliterated, and the challenge of pain mitigation and phasing out of painful husbandry practices remains. It is timely to review and reflect on progress to date in order to strategically focus on the most important challenges, and the avenues which offer the greatest potential to be incorporated into industry practice in a process of continuous improvement. A structured, systematic literature search was carried out, incorporating peer-reviewed scientific literature in the period 2000–2019. An enormous volume of research is underway, testament to the fact that we have not solved the pain and analgesia challenge for any species, including our own. This review has highlighted a number of potential areas for further research.

Attention behaviours but not pain-related behaviours are modified by the presence of a twin in lambs undergoing castration by rubber ring

The social context of social species such as sheep can modify their physiological and behavioural responses to stressors, through social buffering and social facilitation. Social buffering can lead to amelioration of stress, while social facilitation can lead to stress responses in an observer animal in the presence of a conspecific in distress. The current study investigated twin lambs undergoing ring castration, grouped either homogeneously with a castrated lamb (actor), or heterogeneously with a non-castrated lamb (observer) to examine the impact of social grouping on behavioural responses. Each lamb was scored for two classes of behaviour: pain-related behaviours and postures that are putatively related to the response to castration; and attentional behaviours directed at its twin. Thus, each lamb participated in the experiment as an actor exhibiting pain-related behaviours and postures, and as an observer of its twin. When behaviours of lambs were assessed as actors, there was a significant (P < 0.05) effect of castration but no significant effect of social grouping on expression of pain-related behaviours. When behaviours of lambs were assessed as observers, homogeneous grouping of castrated lambs increased attention towards the other twin in comparison to non-castrated lambs grouped homogeneously or lambs grouped heterogeneously (P < 0.01). Non-castrated lambs grouped homogeneously demonstrated significantly lower numbers of head direction changes (P < 0.001) and lower number of ear posture changes (P < 0.05) than heterogeneously grouped or castrated lambs. This study indicates that social attention between twin lambs is not clearly dependent on pain status of the actor lamb. It suggests that in order for the observer lamb to provide significant attention to the actor lamb displaying pain-related behaviour, the observer lamb also needs to be experiencing pain concurrently. Furthermore, there is some evidence that the presence of pain-related behaviours can lead to increased attention to the surrounding environment in non-castrated lambs. Understanding the effect of concurrent experience and varying social context assists us to improve our understanding of results of other experiments on pain-related behavioural responses.

Prematurity and Dysmaturity Are Associated With Reduced Height and Shorter Distal Limb Length in Horses

The long-term effects of gestational immaturity in the premature (defined as < 320 days gestation) and dysmature (normal term but showing some signs of prematurity) foal have not been thoroughly investigated. Studies have reported that a high percentage of gestationally immature foals with related orthopedic issues such as incomplete ossification may fail to fulfill their intended athletic purpose, particularly in Thoroughbred racing. In humans, premature birth is associated with shorter stature at maturity and variations in anatomical ratios, linked to alterations in metabolism and timing of physeal closure in the long bones. We hypothesized that gestational immaturity in horses might similarly be associated with reduced height and different anatomical ratios at maturity. In this preliminary study, the skeletal ratios of horses with a history of gestational immaturity, identified through veterinary and breeder records, were compared with those of unaffected, closely related horses (i.e., sire, dam, sibling). External measurements were taken from conformation photographs of cases (n = 19) and related horses (n = 28), and these were then combined into indices to evaluate and compare metric properties of conformation. A principal component analysis showed that the first two principal components account for 43.8% of the total conformational variation of the horses' external features, separating horses with a rectangular conformation (body length > height at the withers), from those that are more square (body length = height at the withers). Varimax rotation of PC1 and analysis of different gestational groups showed a significant effect of gestational immaturity (P = .001), with the premature group being more affected than the dysmature group (P = .009, P = .012). Mean values for the four dominant indices showed that these groups have significantly lower distal limb to body length relationships than controls. The observed differences suggest that gestational immaturity may affect anatomical ratios at maturity, which, in combination with orthopedic issues arising from incomplete ossification, may have a further impact on long-term athletic potential.

A Radiographic Technique for Assessment of Morphologic Variations of the Equine Caudal Cervical Spine

Equine Caudal Cervical Morphologic Variation (ECCMV) is a congenital malformation of the caudal cervical spine distinct from the more commonly recognized Cervical Vertebral Stenotic Myelopathy (CVSM). The most common presentation of ECCMV is recognized on the sixth cervical vertebra (C6). In "normal" presentations, the transverse processes on the left and right sides have a caudal lamina projecting ventrally below the caudal vertebral body in a heel shape. With ECCMV, variations occur to the structure of the caudal ventral lamina on one or both sides of C6 and may include the seventh cervical (C7) and first thoracic (T1) vertebrae and ribs, in varying configurations. Whereas the prevalence of ECCMV is not known, it has been recognized for many years and has been reported to occur with relatively high frequency within multiple populations of domesticated horses. To date, there is no documented link between the occurrence of ECCMV and clinical signs. However, based on retrospective studies, multiple authors have recognized the potential impact on performance that this condition may have. Establishing a reliable radiographic protocol for the consistent diagnosis of ECCMV would allow quantitative, scientific evaluation of the problem and support clinicians working in this field. We present a radiographic technique, which has been illustrated by diagnosis of ECCMV in three horses and confirmation of the diagnoses in two cases via postmortem examination.

Marine plastics threaten giant Atlantic Marine Protected Areas

There has been a recent shift in global perception of plastics in the environment, resulting in a call for greater action. Science and the popular media have highlighted plastic as an increasing stressor [1,2]. Efforts have been made to confer protected status to some remote locations, forming some of the world's largest Marine Protected Areas, including several UK overseas territories. We assessed plastic at these remote Atlantic Marine Protected Areas, surveying the shore, sea surface, water column and seabed, and found drastic changes from 2013-2018. Working from the RRS James Clark Ross at Ascension, St. Helena, Tristan da Cunha, Gough and the Falkland Islands (Figure 1A), we showed that marine debris on beaches has increased more than 10 fold in the past decade. Sea surface plastics have also increased, with in-water plastics occurring at densities of 0.1 items m^-3; plastics on seabeds were observed at ≤ 0.01 items m^-2. For the first time, beach densities of plastics at remote South Atlantic sites approached those at industrialised North Atlantic sites. This increase even occurs hundreds of meters down on seamounts. We also investigated plastic incidence in 2,243 animals (comprising 26 species) across remote South Atlantic oceanic food webs, ranging from plankton to seabirds. We found that plastics had been ingested by primary consumers (zooplankton) to top predators (seabirds) at high rates. These findings suggest that MPA status will not mitigate the threat of plastic proliferation to this rich, unique and threatened biodiversity.

Using Movement Sensors to Assess Lying Time in Horses With and Without Angular Limb Deformities

Chronic musculoskeletal pathologies are common in horses, however, identifying related effects can be challenging. This study tested the hypothesis that movement sensors and analgesics could be used in combination to confirm the presence of restrictive pathologies by assessing lying time. Four horses presenting a range of angular limb deformities (ALDs) and four nonaffected controls were used. The study comprised two trials at separate paddock locations. Trial A consisted of a 3-day baseline phase and 2 × 3-day treatment phases, during which two analgesics were administered to two ALD horses and two controls in a standard crossover design. Trial B replicated trial A, except that as no difference between analgesics had been evident in trial A, only one analgesic was tested. Movement sensors were used to measure the horses' lying time and lying bouts. In trial A, ALD horses' basal mean lying time was significantly less than controls (means ± SD for ALD horses 213 ± 1.4 minutes and for controls 408 ± 46.7 minutes, P = .007); with analgesic administration, the difference became nonsignificant. In trial B, ALD horses' basal mean lying time was also significantly less than controls (ALD horses 179 ± 110.3 minutes; controls 422.5 ± 40.3 minutes, P < .001), again becoming nonsignificant with analgesic administration. Given the increases in ALD horses' lying time with analgesic administration, it is possible that their shorter basal lying time is associated with musculoskeletal discomfort. Despite the small sample size, movement sensors effectively measured this behavior change, indicating that they could be a useful tool to indirectly assess the impact of chronic musculoskeletal pathologies in horses.

Flawed mothering or infant signaling? The effects of deficient acoustic cues on ovine maternal response

The neonate distress cry, which displays a similar acoustic structure across a range of mammalian species, is highly effective in attracting, even compelling, parental care. However, if this cry is defective, as found in human and rodent neonates with poor neurobehavioral function, is the signal less enticing? Using playback recordings of a ewe's own co-twins as stimuli in a two choice test, we compared the preference of each sheep dam for acoustic features of lamb distress calls to assess the impact of signal quality on maternal response. The results of this study indicate that lamb vocalizations with acoustic parameters reflecting poor vocal fold engagement and arousal were less likely to be preferred by their dam. Additionally, these calls were associated with delayed vocal initiation and poor infant survival behavior suggestive of subtle cognitive deficit; and support the possibility that, as in deer and rodents, ovine vocalizations within a specific fundamental frequency range may well be a trigger for optimal maternal behavior. This research has important implications for understanding failed maternal-young interactions in ungulate and other species, and for verifying standardization of infant stimuli used in maternal behavior studies.

Basin-Scale Observations of Monoterpenes in the Arctic and Atlantic Oceans

We report novel in situ speciated observations of monoterpenes (α- and β-pinene, myrcene, δ3-carene, ocimene, limonene) in seawater and air during three cruises in the Arctic and Atlantic Oceans, in/over generally oligotrophic waters. Oceanic concentrations of the individual monoterpenes ranged from below the detection limit of <1 pmol L^-1 to 5 pmol L^-1, with average concentrations of between 0.5 and 2.9 pmol L^-1. After careful filtering for contamination, atmospheric mixing ratios varied from below the detection limit (<1 pptv) to 5 pptv, with averages of 0.05-5 pptv; these levels are up to 2 orders of magnitude lower than those reported previously. This could be at least partly due to sampling over waters with much lower biological activity than in previous studies. Unlike in previous studies, no clear relationships of the monoterpenes with biological variables were found. Based on our measured seawater concentrations and a global model simulation, we estimate total global marine monoterpene emissions of 0.16 Tg C yr^-1, similar to a previous bottom-up estimate based on laboratory monoculture studies but 2 orders of magnitude lower than a previous top-down estimate of 29.5 Tg C yr^-1.

Distress vocalization delay in the neonate lamb as a neurobehavioral assessment tool

Acoustic features of infant distress vocalizations including latency and rate of emission are used as indices of neurological deficit and integrity in human and rodent neonates. This paper investigates the relationship between temporal characteristics of distress calls, elicited by an isolation stimulus, and indicators of neurobehavioral development over 12 hr postpartum in the neonate lamb. Delayed vocalization initiation was found to be associated with poor locomotor and orientation behavior reflecting the capacity of the lamb to reunite with and follow its dam, and a lowered rate of signal emission following commencement of vocalization. Animals demonstrating delayed vocalization initiation also appeared more likely to be of a birth weight predisposed to fetal distress, and to urinate when exposed to a novel environment. Based on these preliminary studies, we propose that compromised emission of vocal signals is indicative of neurobehavioral deficit in the neonate lamb.

Abstract P1-16-04: First-line chemotherapy for breast cancer patients by site of care (SOC): Treatment patterns, cost and quality indicators

Background: Previous studies found differences in treatment patterns and costs by SOC for first-line chemotherapy treatment for both early stage and metastatic breast cancer (esBC and mBC) in commercial populations. This study extends the research to a predominantly Medicare population comparing chemotherapy treatment patterns, cost and quality of care in physician office (PO) and hospital outpatient (HO) centers.

Methods: First-line chemotherapy or biologic therapy for esBC and mBC patients was compared by SOC. Patients initiating infusion therapy in 2008–2012 were identified in Humana medical claims data. First-line length of therapy (LOT) in days and number of infusions (NI) were calculated. SOC cohort (HO vs PO) was based on where the patient received ≥90% of their infusions. Total healthcare costs based on medical and pharmacy claims were assessed. Differences in quality indicators, use of infusions or hospitalizations 30 days prior to death were evaluated. SOC differences were assessed using X2, T-tests and Wilcoxon Rank Sum (Wil) tests. P-values are for X2 and Wil tests. Cost-related results are from generalized linear models adjusted for age, sex, comorbidity and geographic region. LOT and NI are presented as median (IQR).

Results: A total of 2,784 esBC patients (73% PO and 27% HO) and 1,602 mBC patients (64% PO and 36% HO) were identified. Most patients (67%) were Medicare beneficiaries. Mean comorbidity index was similar by SOC for esBC patients (PO 4.2, HO 4.1, p=0.3308) but higher in HO for mBC patients (PO 7.5, HO 7.9, p=0.0003). LOT in days for esBC was greater in the PO for anthracycline-based therapy, PO 64(43-72), HO 47(43-64), p=0.0420 and taxane-based therapy, PO 64(64-106), HO 64(64-76), p=0.0005. NI for esBC was greater in the PO for patients on biologic and cytotoxic therapy, PO 21(17-29), HO 18(16-25), p=0.038 and taxane–based therapy PO 4(4-6), HO 4(4-4), p=0.0005.

No difference in LOT by SOC was seen for mBC patients; however, patients on taxane-based therapy had a greater NI at the PO 6(4-12) vs HO 5.5(4-9), p=0.0225.

Total healthcare costs were higher in the HO vs PO setting for esBC and mBC patients. Costs were 22% higher in the HO $51,191 vs PO $41,943, p&lt;0.0001 for esBC patients and 17% higher in the HO $58,105 vs PO $49,591, p&lt;0.0001 for mBC patients.

There were no statistically significant differences in use of infusions or hospitalizations 30 days prior to death among Medicare patients. Among 223 esBC and 369 mBC Medicare patients who died, use of infusions prior to death was 24% for HO and 16% for PO among esBC, p=0.2357 and 23% for HO and 26% for PO among mBC, p=0.5319. Hospitalizations prior to death were 59% for HO and 59% for PO for esBC, p=0.9940 and 60% for HO and 55% for PO for mBC, p=0.3105.

Conclusion: Differences by site of care, particularly in healthcare costs, were found in a mostly Medicare population of esBC and mBC patients. Patients in the HO setting had shorter length of therapy and fewer infusions, but had higher total healthcare costs than those in the PO setting. Quality indicators, infusions and hospitalizations prior to death were similar by site of care. Future research will focus on other quality indicators and patient satisfaction.

Citation Format: Masaquel A, Hopson S, Casebeer A, Drzayich-Jankus D, Tao Z, Stemkowski S, Howe A, Patton J, Small A, Barnett B. First-line chemotherapy for breast cancer patients by site of care (SOC): Treatment patterns, cost and quality indicators. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-16-04.

The relationship of sex role to physical and psychological health

This study examined the relationship of sex-role typology, medical and psychiatric symptomatology, and personality functioning in adolescents. Seventy-nine males and 101 females with an average age of 18.3 were administered the Bem Sex Role Inventory (BSRI), Offer Self Image Questionnaire (OSIQ), Self Rating Depression Scale (SRDS), and Cornell Medical Index (CMI). In comparison to males, females reported significantly more medical and psychiatric symptomatology, including depression. Females were also found to have more concern and empathy for others and a better developed superego. They reported greater involvement in making future plans and were more conservative in their sexual attitudes. Sex-role typology yielded no significant differences on the medical and psychiatric scales, but consistent differences were found on the OSIQ, a measure of adolescent personality functioning. In general, the results indicated that androgynous teenagers in every case differed from the undifferentiated ones, with the masculine and feminine groups occupying a mid-position. Androgynous individuals always showed a more favorable adjustment. Undifferentiated individuals had a poorer defensive structure, less adequate coping mechanisms and affective integration, more confusion about body boundaries, and more difficulty in object relations. Androgynous individuals, in short, possessed adaptive capabilities and resources, such as effective coping techniques, emotional integration, communication skills, and a well-defined self-concept (i.e., ego strength and a high level of psychological integration). Since these results were obtained on a measure constructed solely to assess adolescent functioning, it seems possible to screen and identify adolescents who may be entering adulthood lacking the emotional, social, and occupational capacity to function in an optimal fashion.

An evaluation of selected methods for the decontamination of cattle hides prior to skinning

The effectiveness of different decontamination treatments in reducing microbial loads on cattle hides was assessed. The 10-s hide treatments were conducted using a wet-and-dry vacuum cleaner filled with one of the liquids (heated to 50 °C) indicated below, followed or not by 10-min drying in the air. Also, the hide was clipped, followed or not by 10-s singeing using a hand-held blowtorch. Before and after each decontamination treatment, the hide was sampled (100 cm(2) areas) by a sponge-swabbing method to compare the total viable counts of bacteria (TVC). The largest bacterial reduction (P<0.001; 2.31log(10) cfu/cm(2)) was achieved by singeing of previously clipped hide. Treatment of hide with a food industry sanitizer solution (10% Betane Plus) resulted in significant reductions of 1.80 (P<0.001) and 1.98log(10) cfu/cm(2) (P<0.001) without and with subsequent drying, respectively. Treatment of hide with a food industry disinfectant (P3-Topactive DES) significantly reduced TVC by 0.97 (P<0.001) and 1.18log(10) cfu/cm(2) (P<0.001) without and with subsequent drying, respectively. Treatments of hide with water alone or with a food-safe detergent solution (Formula 963B), or hide clipping alone, did not produce significant decontamination effects. Since hide contamination is associated with microbial contamination of the carcasses, the results indicate that post-killing/pre-skinning hide decontamination (used alone, or in combination with carcass decontamination) has a potential to improve microbial meat safety. Nevertheless, further research is required to optimise the efficacy of these treatments in the reduction of specific pathogens under commercial conditions.

Takotsubo cardiomyopathy: an Australian single centre experience with medium term follow up

BACKGROUND

Takotsubo cardiomyopathy (TC) is increasingly recognised in patients presenting with features of acute coronary syndrome. We present a single centre experience of TC with medium term follow up.

METHODS

Fifty-two consecutive patients presenting with a diagnosis of TC were included. The clinical presentation, complications, baseline and follow-up echocardiograms and cardiac magnetic resonance imaging were analysed.

RESULTS

Fifty-one patients were female. A stressful event preceded presentation in 37 (71%) patients. Chest pain was the most common symptom (83%). Two patients presented with an out-of-hospital cardiac arrest. ST segment elevation (40%) and global T wave inversion (44%) were the most frequent electrocardiogram changes. Left ventricular assessment demonstrated typical apical ballooning in 41 patients and 11 patients demonstrated the mid-wall variant. In-hospital complications occurred in 11 patients (21%) and included acute pulmonary oedema (n = 2), cardiogenic shock (n = 5); two of whom had a significant left ventricular outflow gradient, atrial fibrillation (n = 1), left ventricular thrombus (n = 2) and a cerebrovascular event (n = 2). Left ventricular function at presentation and follow up was compared in 40 patients. The mean ejection fraction in this group at presentation was 47% (20-70%) compared with that at follow up of 63% (44-76%). There were no significant complications or recurrences at follow up.

CONCLUSIONS

While TC is a reversible condition with low rates of complications and recurrence at follow up it is, as demonstrated in our cohort, associated with significant in-hospital morbidity in a proportion of patients.

Topical antimicrobial treatment of acne vulgaris: an evidence-based review

Topical antimicrobial treatment is indicated for mild to moderate acne vulgaris. Our literature review includes searches of Ovid, MEDLINE, EMBASE, and the databases of the Cochrane Library. A detailed search strategy is included. All searches were limited to controlled trials and systematic reviews. No year limits were applied to the searches, but we focused on trials, guidelines, and reviews published since 2004, the year that the last review of topical antimicrobials was published in this journal. Several controlled trials demonstrate that benzoyl peroxide, topical antibiotics, and topical retinoids used in combination provide the greatest efficacy and safety profile for the treatment of mild to moderate acne, but there are few trials directly comparing different combinations of these topical therapies with one another. Additionally, robust studies comparing cost and efficacy of generic combinations of the above agents with proprietary fixed-dose combination therapies that may increase compliance are also lacking. Although they have not been extensively studied, alternative agents including dapsone, salicylic acid, azelaic acid, and zinc are safe and efficacious when combined with traditional therapies.

P- and S-wave delineation of the Horseshoe Atoll, Diamond-M Field, Texas, USA

This paper presents an applied workflow for displaying seismic multi-attributes and integrating the results into the interpretation of a carbonate reservoir. This analysis compares the processed volume of the conventional P-wave data (PP) with the S-wave data (SH-SH) over the same extended area to improve understanding of the morphology of the reef “build-up” structure within the Canyon Reef Formation. The final goal is to identify bypassed compartments in the reservoir.