Long-Term Impact of COVID-19 Related Disruption of National Health Service Elective Services on Emergency Major Lower Limb Amputations

BACKGROUND

The COVID-19 pandemic has affected the healthcare systems worldwide since the dawn of 2020. In March 2020, the United Kingdom government announced the first national lockdown which severely disturbed all National Health Service (NHS) healthcare elective services. Our aim is to assess the long-term impact of COVID-19 related disruption of NHS elective services on emergency major lower limb amputations (MLLAs).

METHODS

Patients' data for emergency MLLA for critical limb-threatening ischemia and diabetic foot infections performed at Aberdeen Royal Infirmary was collected through Trakcare and divided into the control prepandemic group (April 2018-March 2020) and the pandemic group (April 2020-March 2022). The statistical analysis was conducted using the IBM SPSS software (v28.0.1.1 [14]).

RESULTS

A total of 358 patients underwent MLLA and 206 (57.5%) of these had diabetes mellitus. There was a 17% increase in the number of urgent referrals and every 1 in 5 of these finally underwent an amputation. There was an increase in the absolute number of Above- and Below-Knee amputations. There was a statistically significant increase by 33% in emergency MLLAs during the pandemic period (P < 0.05). A total of 165 postoperative deaths up to December 2022 were recorded with 30-day mortality rate of 7.26% (n = 26).

CONCLUSIONS

NHS vascular management groups should update themselves with evolving technologies to optimize the care provided during future unprecedented times. Furthermore, more effective measures should also be implemented to avoid delayed presentations, which can potentially lead to higher rates of major limb amputations.

Lasting Impact of the COVID-19 Pandemic on Care and Prevention of Sexually Transmitted Infections in the Midwest

BACKGROUND

The COVID-19 pandemic reduced the general accessibility of health services. Many sexually transmitted infection (STI) testing and treatment sites modified services (e.g., reduced hours, limited walk-in availability, decreased testing capacity), changes that may result in permanent change in STI service availability. At the same time, systems were driven to innovate in ways that could benefit patients. This study aimed to describe how the COVID-19 pandemic changed STI clinical services, with a focus on long-term impacts.

METHODS

In July 2022, a phone survey was designed to assess services for STIs at the 105 STI testing and treatment providers in the St. Louis metropolitan statistical area. Sexually transmitted infection testing providers included STI clinics, primary care clinics that cater to a broad population, and community-based organizations, and excluded emergency departments and urgent care centers. In most cases, the survey was completed by a clinic manager, medical director, or nursing staff member.

RESULTS

Of the 75 locations that were interviewed, 12 (16%) had not returned to prepandemic capacity and operations as of July 2022. Five sites had closed completely since the pandemic began, 3 of which are in the northwestern region of the metropolitan statistical area. Most (58.6%) of the open clinics had added telehealth appointments.

CONCLUSIONS

Sexually transmitted infection testing sites decreased during the pandemic with lasting impact in one area of the Midwest. Resources to support STI infrastructure should be expanded. Maintaining updated information on STI care providers in the region can aid future assessments.

Physiological correlates of a simple saccadic-decision task to extended objects in superior colliculus

Our vision is best only in the center of our gaze, and we use saccadic eye movements to direct gaze to objects and features of interest. We make more than 180,000 saccades per day, and accurate and efficient saccades are crucial for most visuo-motor tasks. Saccades are typically studied using small point stimuli, despite the fact that most real-world visual scenes are composed of extended objects. Recent studies in humans have shown that the initiation latency of saccades is strongly dependent on the size of the target (the "size-latency effect"), perhaps reflecting a tradeoff between the cost of making a saccade to a target and the expected information gain that would result. Here, we investigate the neuronal correlates of the size-latency effect in the macaque superior colliculus. We analyzed the latency variations of saccades to different size targets within a stochastic accumulator model framework. The model predicted a steeper increase in activity for smaller targets compared to larger ones. Surprisingly, the model also predicted an increase in saccade initiation threshold for larger targets. We found that the activity of intermediate-layer SC visuomotor neurons is in close agreement with the model predictions. We also found evidence that these effects may be a consequence of the visual responses of SC neurons to targets of different sizes. These results shed new light on the sources of delay within the saccadic system, a system that we heavily depend upon in the performance of most visuo-motor tasks.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

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.

Abstract CT243: Phase 1 study of TAK-676 + pembrolizumab following radiation therapy in patients with advanced non-small-cell lung cancer (NSCLC), triple-negative breast cancer (TNBC), or squamous-cell carcinoma of the head and neck (SCCHN)

Background: Radiation therapy has immune-modulating effects resulting from apoptosis of tumor cells and DNA damage. The downstream generation of cytosolic DNA activates the cyclic GMP-AMP Synthase (cGAS)-STimulator of INterferon Gene (STING) signaling axis in both tumor and nearby immune cells, leading to increased induction of type I interferon (IFN-I) and other immune stimulating molecules. TAK-676 is a novel synthetic STING agonist being investigated (+/- pembrolizumab) in an ongoing first-in-human phase 1 study (NCT04420884). TAK-676 is a potent modulator of the innate immune system and leads to downstream activation of the adaptive immune system to produce antitumor responses in preclinical studies. In contrast to intratumorally injected STING agonists, TAK-676 is optimally designed for reduced serum degradation and enhanced permeability, allowing systemic IV delivery and access to tumor sites and lymphatics. The addition of TAK-676 following radiation therapy may enhance the immune response by increasing the STING-mediated IFN-I release and further stimulate T cell-mediated antitumor immunity, particularly in combination with anti-PD-1/PD-L1 therapies. Impaired IFN signaling has been linked to checkpoint inhibitor (CPI) resistance. Preclinical studies show that addition of a STING agonist may reverse the mechanisms of resistance in tumors with prior exposure to CPIs. This phase 1 trial was designed to investigate the safety and preliminary antitumor activity of TAK-676 + pembrolizumab following radiation therapy (NCT04879849).

Methods: Patients aged ≥18 years with advanced NSCLC, TNBC, or SCCHN who have progressed on CPIs with ≥2 lesions, one of which can be targeted with radiation, are being enrolled. Patients receive 8 Gy x 3 fractions of image-guided radiation therapy followed by (after a minimum of 40 hours) IV pembrolizumab 200 mg on day 1 plus escalating doses of IV TAK-676 on days 1, 8, and 15 of a 21-day cycle. TAK-676 dose escalation is guided by the Bayesian Optimal Interval design. Patients receive TAK-676 + pembrolizumab until disease progression, intolerance, or withdrawal of consent. Once pharmacologically active dose levels of TAK-676 have been observed, paired biopsies will be collected in patients with a safely accessible lesion outside the radiation field at screening and between days 15 and 21 of cycle 1. The primary objective is to determine the safety and tolerability of TAK-676 + pembrolizumab following radiation therapy; secondary objectives are to determine the recommended phase 2 dose of TAK-676 + pembrolizumab following radiation therapy, and to assess preliminary antitumor activity both locally (in the radiation field) and systemically (non-radiated lesions). As of January 2022, nearly 10% of the planned patients have been enrolled.

Citation Format: Benjamin Cooper, Steven J. Chmura, Jason J. Luke, Stephen L. Shiao, Reva K. Basho, Wade T. Iams, David B. Page, Cong Li, Richard C. Gregory, Michael H. Shaw, Kristin H. Horn, John P. Gibbs, Vicky A. Appleman, Allison J. Berger, Adnan O. Abu-Yousif, Neil B. Lineberry, Kate F. Stumpo, Aymen Elfiky, Naamit K. Gerber. Phase 1 study of TAK-676 + pembrolizumab following radiation therapy in patients with advanced non-small-cell lung cancer (NSCLC), triple-negative breast cancer (TNBC), or squamous-cell carcinoma of the head and neck (SCCHN) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr CT243.

Dynamic Management of Lung Cancer Care During Surging COVID-19

Management of patients with lung cancer continues to be challenging during the COVID-19 pandemic, due to the increased risk of complications in this subset of patients. During the COVID-19 surge in New York City, New York University Langone Health adopted triage strategies to help with care for lung cancer patients, with good surgical outcomes and no transmission of COVID-19 to patients or healthcare workers. Here, we will review current recommendations regarding screening and management of lung cancer patients during both a non-surge phase and surge phase of COVID-19.

CtBP1-Mediated Membrane Fission Contributes to Effective Recycling of Synaptic Vesicles

Compensatory endocytosis of released synaptic vesicles (SVs) relies on coordinated signaling at the lipid-protein interface. Here, we address the synaptic function of C-terminal binding protein 1 (CtBP1), a ubiquitous regulator of gene expression and membrane trafficking in cultured hippocampal neurons. In the absence of CtBP1, synapses form in greater density and show changes in SV distribution and size. The increased basal neurotransmission and enhanced synaptic depression could be attributed to a higher vesicular release probability and a smaller fraction of release-competent SVs, respectively. Rescue experiments with specifically targeted constructs indicate that, while synaptogenesis and release probability are controlled by nuclear CtBP1, the efficient recycling of SVs relies on its synaptic expression. The ability of presynaptic CtBP1 to facilitate compensatory endocytosis depends on its membrane-fission activity and the activation of the lipid-metabolizing enzyme PLD1. Thus, CtBP1 regulates SV recycling by promoting a permissive lipid environment for compensatory endocytosis.

Traumatic Posterior Hip Dislocation and Epiphysiolysis in a High School Football Player with Successful Outcome at 4 Years Follow-up: A Case Report

CASE

We describe a case of posterior hip dislocation in a 13-year-old boy after a contact football injury with attempted closed reduction resulting in complete separation of the epiphysis from the femoral neck metaphysis with associated femoral head fracture and posterior dislocation of the femoral head. Treatment was emergently performed with a greater trochanteric osteotomy, open reduction internal fixation using cannulated screws, and additional small diameter drill holes in the femoral head to promote blood flow. The patient did well postoperatively and at over 4 years follow-up had no evidence of avascular necrosis and returned to full athletics participation.

CONCLUSION

Particular attention should be taken when reducing hip dislocations in the adolescent population who may be predisposed to epiphysiolysis. Preservation of periosteal soft-tissue attachments and the use of small diameter drill holes to promote femoral head blood flow may have contributed to the excellent outcome.

Improving health behaviors in patients with peripheral arterial disease - A pilot study of supported self-management

PURPOSE OF THE RESEARCH

This pilot study reports the feasibility of a future randomized controlled trial (RCT) investigating the effect of supported self-management through low-intensity psychological intervention in patients with peripheral arterial disease (PAD) resulting in claudication. The study protocol, measurement instrument, data collection, and analysis were evaluated. Clinical outcome measures include depression and anxiety scores, smoking cessation, activity (step count), weight, and quality of life. Both Quantitative and Qualitative data were collected to evaluate participant experience and the clinical impact of a supported self-management intervention delivered in a routine clinical setting.

METHODS

Participants received an initial one to one assessment with a health psychologist. Demographic data and baseline clinical outcome measures were recorded. These included Hospital Anxiety and Depression Scale score (HADS), health-related quality of life questionnaire (EQ-5D-3 L), number of cigarettes smoked daily, weight/BMI, and daily step count. Participants each received an activity tracker to record daily step count and were followed up weekly to provide psychological input, including goal setting, overcoming barriers, and preventing relapse. Quantitative data collection was scheduled at baseline, 3 and 6 months (final follow-up). At the final follow-up, participants provided qualitative feedback reflecting upon their experience of the intervention and its impact. Descriptive statistical analysis and simple paired samples t-test were employed in data evaluation.

RESULTS

The sample size was small (n = 30). Twenty-three participants were followed up to 6 months. Depression scores improved with statistical significance from baseline to 6-month follow-up. Eight participants stopped smoking (47% reduction); a further 9 greatly reduced their intake. A borderline statistically significant increase of daily step count was achieved between baseline and 6-month follow-up. In addition, positive weight loss trends were observed in a predominantly obese or overweight cohort. The qualitative feedback highlighted participants understood and embraced the information delivered regarding the importance of health behavior change. Participants were able to link tailored action plans with what mattered to them with the help of the Health Psychologist.

CONCLUSION

This study embraces the contemporary ideology of enabling self-management of long-term conditions to improve clinical outcomes. As a pilot study, we have shown that an expanded, randomized controlled trial is both safe and feasible. A positive trend in clinical outcomes suggests this patient group may benefit from supported self-management through low-intensity psychological intervention, where other forms of early intervention have historically faltered.

Evolving from Morbidity and Mortality to a Case-based Error Reduction Conference: Evidence-based Best Practices from the Council of Emergency Medicine Residency Directors

Morbidity and mortality conferences are common among emergency medicine residency programs and are an important part of quality improvement initiatives. Here we review the key components of running an effective morbidity and mortality conference with a focus on goals and objectives, case identification and selection, session structure, and case presentation.

The role of vaccines in combating antimicrobial resistance

Vaccination is one of the most effective measures to reduce antimicrobial resistance in both human and animal pathogens. This presentation reviews the multiple pathways by which vaccines may act to reduce resistance: they can prevent infections by focal pathogens, reducing the need to use antibiotics; they can selectively protect against resistant subtypes of a pathogen; they can reduce infections by other pathogen species which are routinely treated with antibiotics (not necessarily appropriately) thus reducing bystander selection; and they could selectively reduce transmission in settings such as hospitals which may have higher proportions of resistant strains. Because vaccines are highly specific to their targeted pathogens, they are much less likely to induce resistance compared to antibiotics. Hence, they can be delivered to large populations as a preventive measure to reduce transmission. The impact of vaccination on resistance has been demonstrated for vaccines against Streptococcus pneumoniae, Haemophilus influenzae type b and influenza. Current and pipeline vaccines against pathogens such as Vibrio cholerae, Escherichia coli, Salmonella typhi, RSV, diarrhoeal viruses and nosocomial bacteria may also have potential to reduce resistance. Economic evaluations of vaccines need to be expanded to capture their benefits in reducing resistance, in order to incentivize development and introduction of the right vaccines. Accurately doing so will require health systems, epidemiological and economic research.

Drink, death, and driving: Do blood alcohol content limit reductions improve road safety?

This study exploits a natural experiment in Scotland where the legal blood alcohol content (BAC) limit was reduced from 0.8 to 0.5 mg per 100 ml of blood while staying constant in all other parts of the United Kingdom. Using a difference-in-differences design, we find that this change in the BAC level had no impact on either traffic accident or fatality rates.

Infliximab induction regimens in steroid-refractory acute severe colitis: a multicentre retrospective cohort study with propensity score analysis

BACKGROUND

Accelerated induction regimens of infliximab have been proposed to improve response rates in patients with steroid-refractory acute severe colitis.

AIM

To determine the differences in outcome for acute severe ulcerative colitis between accelerated and standard-dose infliximab METHODS: We collected data on hospitalised patients receiving differing regimens of rescue therapy for steroid-refractory acute severe ulcerative colitis. Our primary outcome was 30-day colectomy rate. Secondary outcomes were colectomy within index admission, and at 90 days and 12 months. We used propensity score analysis with optimal calliper matching using high risk covariates defined a priori to reduce potential provider selection bias.

RESULTS

We included 131 patients receiving infliximab rescue therapy; 102 received standard induction and 29 received accelerated induction. In the unmatched cohort, there was no difference by type of induction in the 30-day colectomy rates (18% vs 20%, P = .45), colectomy during index admission (13% vs 20%, P = .26) or overall colectomy (20% vs 24%, P = .38). In the propensity score-matched cohort of 52 patients, 30-day colectomy (57% vs 27%, P = .048) and index admission colectomy (53% vs 23%, P = .045) rates were higher in those receiving standard induction compared to accelerated induction but there was no difference in overall colectomy rates (57% vs 31%, P = .09). There was no significant difference in length of stay or in complication and infection rates.

CONCLUSION

In a propensity score-matched cohort, steroid-refractory acute severe ulcerative colitis patients, short-term, but not long-term, colectomy rates appear to be lower in those receiving an accelerated induction regimen.

Molecular Auger Interferometry

We introduce and present a theory of interferometric measurement of a normal Auger decay lifetime in molecules. Molecular Auger interferometry is based on the coherent phase control of Auger dynamics in a two-color (ω/2ω) laser field. We show that, in contrast to atoms, in oriented molecules of certain point groups the relative ω/2ω phase modulates the total ionization yield. A simple analytical formula is derived for the extraction of the lifetimes of Auger-active states from a molecular Auger interferogram, circumventing the need in either high-resolution or attosecond spectroscopy. We demonstrate the principle of the interferometric Auger lifetime measurement using inner-valence decay in CH_{3}F.

Twiddler’s Syndrome

Twiddler’s syndrome refers to a rare condition in which a pacemaker or automatic implantable cardioverter-defibrillator (AICD) malfunctions due to coiling of the device in the skin pocket and resultant lead displacement. This image is the chest radiograph (CXR) of a 54-year-old male who presented to the emergency department with chest pain five months after his AICD was placed. The CXR shows AICD leads coiled around the device and the absence of leads in the ventricle consistent with Twiddler’s syndrome. Patients with twiddler’s syndrome should be admitted for operative intervention.

Individual variation in the compromise between social group membership and exposure to preferred temperatures

Group living is widespread among animal species, and comes with a number of costs and benefits associated with foraging, predator avoidance and reproduction. It is largely unknown, however, whether individuals sacrifice exposure to their own preferred or optimal environmental conditions so they can remain part of a social group. Here, we demonstrate that individual three-spine sticklebacks vary in the degree to which they forego exposure to their preferred ambient temperature so they can associate with a group of conspecifics. Individual fish varied widely in preferred temperature when tested in isolation. When the same individuals were presented with a choice of a warm or cold thermal regime in the presence of a social group in one of the environments, fish spent more time with the group if it was close to their own individually preferred temperature. When a group was in a relatively cool environment, focal individuals that were more social deviated most strongly from their preferred temperature to associate with the group. Standard and maximum metabolic rate were not related to temperature preference or thermal compromise. However, individuals with a higher standard metabolic rate were less social, and so energetic demand may indirectly influence the environmental costs experienced by group members. The reduced tendency to engage with a social group when there is a large difference between the group temperature and the individual's preferred temperature suggests a role for temperature in group formation and cohesion that is mediated by individual physiology and behaviour. Together, these data highlight exposure to non-preferred temperatures as a potential cost of group membership that probably has important but to date unrecognized implications for metabolic demand, energy allocation, locomotor performance and overall group functioning.

Radiotherapy induces responses of lung cancer to CTLA-4 blockade

Focal radiation therapy enhances systemic responses to anti-CTLA-4 antibodies in preclinical studies and in some patients with melanoma1-3, but its efficacy in inducing systemic responses (abscopal responses) against tumors unresponsive to CTLA-4 blockade remained uncertain. Radiation therapy promotes the activation of anti-tumor T cells, an effect dependent on type I interferon induction in the irradiated tumor4-6. The latter is essential for achieving abscopal responses in murine cancers6. The mechanisms underlying abscopal responses in patients treated with radiation therapy and CTLA-4 blockade remain unclear. Here we report that radiation therapy and CTLA-4 blockade induced systemic anti-tumor T cells in chemo-refractory metastatic non-small-cell lung cancer (NSCLC), where anti-CTLA-4 antibodies had failed to demonstrate significant efficacy alone or in combination with chemotherapy7,8. Objective responses were observed in 18% of enrolled patients, and 31% had disease control. Increased serum interferon-β after radiation and early dynamic changes of blood T cell clones were the strongest response predictors, confirming preclinical mechanistic data. Functional analysis in one responding patient showed the rapid in vivo expansion of CD8 T cells recognizing a neoantigen encoded in a gene upregulated by radiation, supporting the hypothesis that one explanation for the abscopal response is radiation-induced exposure of immunogenic mutations to the immune system.

The Effects of Administration of Ethyl Alcohol to Mice on Megakaryocyte and Platelet Development

The effects of administration to laboratory mice of 5-20% ethyl alcohol (v:v) as drinking water on megakaryocyte and platelet development were studied and compared with data on controls given tap water.

In two separate experiments, mice given 5-15% ethyl alcohol (v:v) for 13 or 11 weeks showed decreases in platelet counts and platelet 35S uptake when compared to the control groups. Mice fed 5-20% alcohol for five weeks showed platelet counts, bone marrow megakaryocyte numbers and diameters that were significantly reduced to 72% (P <0.001), 45% (P <0.001), and 71% (P <0.01), respectively.

The data implied that ethyl alcohol ingestion had a direct inhibitory effect on megakaryocyte and platelet development in mice, which resulted in a marked reduction in the levels of circulating platelets.

Psychiatric disorders among elderly patients admitted to hospital medical wards

A psychiatric investigation was carried out on patients aged 65–80 years who were admitted to the medical wards of six general hospitals in an industrial urban area of West Germany. In all, 626 patients were screened for cognitive and affective disorder using a short standardized interview, and at the second stage all those with abnormal responses, as well as a subsample of the apparently normal patients, were examined in greater detail. After correction for inaccuracies of screening, the frequency of psychiatric illness in this patient population was estimated as 30.2%, made up of 9.1% with organic brain syndromes and 21.1% with functional mental disorders. Comparison with field-study data for the same background population showed that the hospital patients were at increased risk for mental disturbance.

At follow up after one year, outcome in terms of mortality, admission to long-term care and dependency on others was worst for patients with organic mental disorder, even after matching for age and initial severity of physical impairment. Functional mental illness was also associated with a relatively poor outcome in terms of dependency. The mental status of elderly medical patients appears to be important for the prognosis.

Abstract PR01: A DNA methylation-based classifier for accurate molecular diagnosis of bone sarcomas

Background: Bone sarcomas present a unique diagnostic challenge because of the considerable morphologic overlap between different entities. The choice of optimal treatment, however, is dependent upon accurate diagnosis. Genome-wide DNA methylation profiling has emerged as a new approach to aid in the diagnosis of brain tumors, with diagnostic accuracy exceeding standard histopathology. In this work we developed and validated a methylation-based classifier to differentiate between osteosarcoma, Ewing's sarcoma, and synovial sarcoma.

Methods: DNA methylation status of 482,421 CpG sites in 15 osteosarcoma, 10 Ewing's sarcoma, and 11 synovial sarcoma samples were measured using the Illumina HumanMethylation450 array. From this training set of 36 sarcoma samples we developed a random forest classifier from the 400 most differentially methylated CpG sites (FDR q value &lt;0.001). This classifier was then validated on 10 synovial sarcoma samples from The Cancer Genome Atlas (TCGA), 86 osteosarcoma samples from TARGET-OS, and 15 Ewing's sarcoma from a recently published series. (Huertas-Martinez et al., Cancer Lett 2016)

Results: Methylation profiling revealed three distinct molecular clusters, each enriched with a single sarcoma subtype. Within the validation cohorts, all samples from TCGA were accurately classified as synovial sarcoma (10/10, sensitivity and specificity 100%). All but one sample from TARGET-OS were classified as osteosarcoma (85/86, sensitivity 98%, specificity 100%) and all but one sample from the Ewing's sarcoma series was classified as Ewing's (14/15, sensitivity 93%, specificity 100%). The single misclassified osteosarcoma sample was classified as a Ewing's sarcoma, and later determined to be a misdiagnosed Ewing's sarcoma based on RNA-seq data demonstrating high EWRS1 and ETV1 expression. An additional clinical sample that was misdiagnosed as a synovial sarcoma based on initial histopathology was accurately recognized as osteosarcoma by the methylation classifier. Pathway analysis with MSigDB (Broad Institute) identified targets of polycomb group proteins SUZ12 and EED, possessing the H3K27 trimethylated mark, as highly enriched within classifier genes

Conclusions: Osteosarcoma, Ewing's sarcoma, and synovial sarcoma have distinct epigenetic profiles. Our validated methylation-based classifier provides increased diagnostic accuracy, including in cases where standard histopathology is inconclusive.

This abstract is also being presented as Poster A01.

Citation Format: Shengyang Wu, Benjamin Cooper, Fang Bu, Christopher Bowman, Jonathan K. Killian, Shiyang Wang, Twana Jackson, Daniel Gorovets, Richard Gorlick, Kristen Thomas, Matthias Karajannis, Matija Snuderl. A DNA methylation-based classifier for accurate molecular diagnosis of bone sarcomas [abstract]. In: Proceedings of the AACR Conference on Advances in Sarcomas: From Basic Science to Clinical Translation; May 16-19, 2017; Philadelphia, PA. Philadelphia (PA): AACR; Clin Cancer Res 2018;24(2_Suppl):Abstract nr PR01.

Preliminary evidence supports circulating microRNAs as prognostic biomarkers for type 2 diabetes

Background

Circulating microRNAs are emerging as potential prognostic biomarkers for the development of type 2 diabetes. However, microRNAs are also associated with complications from impaired glucose metabolism (e.g. endothelial cell function). Prior studies have not evaluated for associations between trajectories of circulating microRNAs with trajectories of fasting blood glucose over time and the responses to behavioral interventions to reduce risk. This study performed longitudinal assessment of microRNAs and fasting blood glucose and identified relationships between microRNAs and behavioral risk reduction interventions.

Methods

MicroRNAs (n = 353) were measured in subsets (n = 10, n = 8) of participants from previously completed clinical trials that studied behavioral risk reduction interventions. Fasting blood glucose trajectories were associated with changes in 45 microRNAs over 12 months.

Results

Following a 3‐month physical activity and dietary intervention compared with baseline, 13 microRNAs were differentially expressed. Seven microRNAs (i.e. miR‐106b, miR‐20b, miR‐363, miR‐486, miR‐532, miR‐92a and miR‐93) were commonly identified between the two analyses.

Conclusions

Further studies are needed to determine which microRNAs are prognostic biomarkers of risk for type 2 diabetes versus consequences of impaired glucose metabolism. Additional future directions of this research are to differentiate whether microRNAs are prognostic and/or diagnostic biomarkers for risk for type 2 diabetes and predictive biomarkers of responses to risk reduction interventions.

Accurate prediction of X-ray pulse properties from a free-electron laser using machine learning

Free-electron lasers providing ultra-short high-brightness pulses of X-ray radiation have great potential for a wide impact on science, and are a critical element for unravelling the structural dynamics of matter. To fully harness this potential, we must accurately know the X-ray properties: intensity, spectrum and temporal profile. Owing to the inherent fluctuations in free-electron lasers, this mandates a full characterization of the properties for each and every pulse. While diagnostics of these properties exist, they are often invasive and many cannot operate at a high-repetition rate. Here, we present a technique for circumventing this limitation. Employing a machine learning strategy, we can accurately predict X-ray properties for every shot using only parameters that are easily recorded at high-repetition rate, by training a model on a small set of fully diagnosed pulses. This opens the door to fully realizing the promise of next-generation high-repetition rate X-ray lasers.

Genome-Wide Association Study of Spot Form of Net Blotch Resistance in the Upper Midwest Barley Breeding Programs

Pyrenophora teres f. maculata, the causal agent of spot form of net blotch (SFNB), is an emerging pathogen of barley in the United States and Australia. Compared with net form of net blotch (NFNB), less is known in the U.S. Upper Midwest barley breeding programs about host resistance and quantitative trait loci (QTL) associated with SFNB in breeding lines. The main objective of this study was to identify QTL associated with SFNB resistance in the Upper Midwest two-rowed and six-rowed barley breeding programs using a genome-wide association study approach. A total of 376 breeding lines of barley were evaluated for SFNB resistance at the seedling stage in the greenhouse in Fargo in 2009. The lines were genotyped with 3,072 single nucleotide polymorphism (SNP) markers. Phenotypic evaluation showed a wide range of variability among populations from the four breeding programs and the two barley-row types. The two-rowed barley lines were more susceptible to SFNB than the six-rowed lines. Continuous distributions of SFNB severity indicate the quantitative nature of SFNB resistance. The mixed linear model (MLM) analysis, which included both population structure and kinship matrices, was used to identify significant SNP-SFNB associations. Principal component analysis was used to control false marker-trait association. The linkage disequilibrium (LD) estimates varied among chromosomes (10 to 20 cM). The MLM analysis identified 10 potential QTL in barley: SFNB-2H-8-10, SFNB-2H-38.03, SFNB-3H-58.64, SFNB-3H-78.53, SFNB-3H-91.88, SFNB-3H-117.1, SFNB-5H-155.3, SFNB-6H-5.4, SFNB-6H-33.74, and SFNB-7H-34.82. Among them, four QTL (SFNB-2H-8-10, SFNB-2H-38.03 SFNB-3H-78.53, and SFNB-3H-117.1) have not previously been published. Identification of SFNB resistant lines and QTL associated with SFNB resistance in this study will be useful in the development of barley genotypes with better SFNB resistance.

Randomized controlled trials and neurosurgery: the ideal fit or should alternative methodologies be considered?

OBJECTIVE

Randomized-controlled trials (RCTs) are advocated to provide high-level medical evidence. However, in neurosurgery, there are barriers to conducting RCTs. The authors of this study sought to analyze the quality of neurosurgical RCTs since 2000 to determine the adequacy of their design and reporting.

METHODS

A search of the MEDLINE and EMBASE databases (2000-2014) was conducted. The medical subject heading (MeSH) terms used in the search included: "neurosurgery" OR "neurosurgical procedure," "brain neoplasms," "infarction" and "decompression," "carotid stenosis," "cerebral hemorrhage," and "spinal fusion." These studies were limited to RCTs, in humans, and in the English language. The Consolidated Standards for Reporting of Trials (CONSORT) and Jadad scales were used to assess the quality of RCT design and reporting. The standardized median times cited (median citations divided by years since publication) were used to assess impact. A pragmatic-explanatory continuum indicator summary-based scale was used to assess the design of the studies as primarily pragmatic or explanatory.

RESULTS

Sixty-one articles were identified, and the following subspecialties were the most common: vascular (23, 37%), followed by functional neurosurgery and neurooncology (both 13, 21%). The following nations were the primary leaders in RCTs: US (25 studies, 41%), Germany (8 studies, 13%), and the United Kingdom (7 studies, 11%). Median sample size was 100 (interquartile range [IQR] 41.5-279). The majority of the studies (40, 66%) had pragmatic objectives. The median number of times cited overall was 69 (IQR 20.5-193). The combined median CONSORT score was 36 (IQR 27.5-39). Blinding was most deficiently reported. Other areas with a relatively low quality of reporting were sample size calculation (34.2% of surgical, 38.5% of drug, and 20% of device studies), allocation concealment (28.9% of surgical, 23.1% of drug, and 50% of device studies), and protocol implementation (18.4% of surgical, 23% of drug, and 20% of device studies). The quality of reporting did not correlate with the study impact. All studies had a median Jadad score ≤ 3. Thirty-three pragmatic studies (83%) and 5 explanatory studies (25%) met the design objectives. All pragmatic studies based on drug and device trials met their objectives, while 74% of pragmatic surgical trials met their objectives.

CONCLUSIONS

The prevalence of neurosurgical RCTs is low. The quality of RCT design and reporting in neurosurgery is also low. Many study designs are not compatible with stated objectives. Pragmatic studies were more likely to meet design objectives. Given the role of RCTs as one of the highest levels of evidence, it is critical to improve on their methodology and reporting.

Brief sexuality communication--a behavioural intervention to advance sexually transmitted infection/HIV prevention: a systematic review

BACKGROUND

Throughout the last decade substantial research has been undertaken to develop evidence-based behaviour change interventions for sexual health promotion. Primary care could provide an opportunistic entry for brief sexual health communication.

OBJECTIVES

We conducted a systematic review to explore opportunistic sexual and reproductive health services for sexual health communication delivered at primary health care level.

SEARCH STRATEGY

We searched for studies on PubMed, ProQuest, CINAHL, Jstor, Scopus/Science Direct, Cochrane database of systematic reviews, EBSCO, CINAHL, PsychoInfo, and Web of Knowledge. Both published and unpublished articles were reviewed.

SELECTION CRITERIA

All randomised controlled trials and controlled clinical trials were included. Participants of all ages, from adolescence onwards were included. Brief (10-60 minutes) interventions including some aspect of communication on sexual health issues were included.

DATA COLLECTION AND ANALYSIS

Data were extracted by two reviewers independently using a standardised form. Interventions differed from each other, hence meta-analysis was not performed, and results are presented individually.

MAIN RESULTS

A total of 247 articles were selected for full-text evaluation, 31 of which were included. Sexually transmitted infections (STIs)/HIV were less often reported in the intervention group compared with the control group. Condom use was higher in most studies in the intervention group. Numbers of sexual partners and unprotected sexual intercourse were lower in the intervention groups.

CONCLUSIONS

There is evidence that brief counselling interventions have some effect in the reduction and prevention of STIs/HIV. Some questions could not be answered, such as the effect over time and in different settings and population groups.