Frailty trajectories preceding dementia: an individual-level analysis of four cohort studies in the United States and United Kingdom

Frailty may represent a modifiable risk factor for dementia, but the direction of that association remains uncertain. We investigated frailty trajectories in the years preceding dementia onset using data from 23,672 participants (242,760 person-years of follow-up, 2,906 cases of incident dementia) across four cohort studies in the United States and United Kingdom. Bayesian non-linear models revealed accelerations in frailty trajectories 4-9 years before incident dementia. Among participants whose time between frailty measurement and incident dementia exceeded that prodromal period, frailty remained positively associated with dementia risk (adjusted hazard ratios ranged from 1.20 [95% confidence interval, CI = 1.15-1.26] to 1.43 [95% CI = 1.14-1.81]). This observational evidence suggests that frailty increases dementia risk independently of any reverse causality. These findings indicate that frailty measurements can be used to identify high-risk population groups for preferential enrolment into clinical trials for dementia prevention and treatment. Frailty itself may represent a useful upstream target for behavioural and societal approaches to dementia prevention.

Resprouting Response among Savanna Tree Species in Relation to Stem Size, Woody Removal Intensity and Herbicide Application

Mechanical and chemical methods are widely used to control woody plant encroachment in many African countries. However, very little is known about the effectiveness of these control methods among woody species of different ages. We conducted a field experiment to determine the effects of different tree removal treatments (10%, 20%, 50%, 75% and 100%) and herbicide application (Picloram; 6 mL L-1) on the resprouting ability and vigour of 12 woody plant species. We examined 20 plots (30 m × 30 m) that were each subjected to tree removal, followed by herbicide application on half of the stems for each plot. All the tree species in this study resprouted after cutting. The applied concentration of herbicide significantly reduced the shoot production for Ehretia rigida, Vachellia robusta and Ziziphus mucronata, with a marginal effect for Dichrostachys cinerea. The diameter of stems was an important factor in determining resprouting ability, with shoot production decreasing with increasing stem diameter. However, stem diameter did not affect shoot length and diameter for all species. We found that woody plants are more likely to resprout and survive as juveniles than as adults after cutting and that herbicide only affected four of the twelve species at a concentration of 6 mL L-1. Thus, testing the amount of Picloram needed to kill certain woody species may be of importance for land users in southern African savannas.

DNA storage in thermoresponsive microcapsules for repeated random multiplexed data access

DNA has emerged as an attractive medium for archival data storage due to its durability and high information density. Scalable parallel random access to information is a desirable property of any storage system. For DNA-based storage systems, however, this still needs to be robustly established. Here we report on a thermoconfined polymerase chain reaction, which enables multiplexed, repeated random access to compartmentalized DNA files. The strategy is based on localizing biotin-functionalized oligonucleotides inside thermoresponsive, semipermeable microcapsules. At low temperatures, microcapsules are permeable to enzymes, primers and amplified products, whereas at high temperatures, membrane collapse prevents molecular crosstalk during amplification. Our data show that the platform outperforms non-compartmentalized DNA storage compared with repeated random access and reduces amplification bias tenfold during multiplex polymerase chain reaction. Using fluorescent sorting, we also demonstrate sample pooling and data retrieval by microcapsule barcoding. Therefore, the thermoresponsive microcapsule technology offers a scalable, sequence-agnostic approach for repeated random access to archival DNA files.

Providing a framework for seagrass mapping in United States coastal ecosystems using high spatial resolution satellite imagery

Seagrasses have been widely recognized for their ecosystem services, but traditional seagrass monitoring approaches emphasizing ground and aerial observations are costly, time-consuming, and lack standardization across datasets. This study leveraged satellite imagery from Maxar's WorldView-2 and WorldView-3 high spatial resolution, commercial satellite platforms to provide a consistent classification approach for monitoring seagrass at eleven study areas across the continental United States, representing geographically, ecologically, and climatically diverse regions. A single satellite image was selected at each of the eleven study areas to correspond temporally to reference data representing seagrass coverage and was classified into four general classes: land, seagrass, no seagrass, and no data. Satellite-derived seagrass coverage was then compared to reference data using either balanced agreement, the Mann-Whitney U test, or the Kruskal-Wallis test, depending on the format of the reference data used for comparison. Balanced agreement ranged from 58% to 86%, with better agreement between reference- and satellite-indicated seagrass absence (specificity ranged from 88% to 100%) than between reference- and satellite-indicated seagrass presence (sensitivity ranged from 17% to 73%). Results of the Mann-Whitney U and Kruskal-Wallis tests demonstrated that satellite-indicated seagrass percentage cover had moderate to large correlations with reference-indicated seagrass percentage cover, indicative of moderate to strong agreement between datasets. Satellite classification performed best in areas of dense, continuous seagrass compared to areas of sparse, discontinuous seagrass and provided a suitable spatial representation of seagrass distribution within each study area. This study demonstrates that the same methods can be applied across scenes spanning varying seagrass bioregions, atmospheric conditions, and optical water types, which is a significant step toward developing a consistent, operational approach for mapping seagrass coverage at the national and global scales. Accompanying this manuscript are instructional videos describing the processing workflow, including data acquisition, data processing, and satellite image classification. These instructional videos may serve as a management tool to complement field- and aerial-based mapping efforts for monitoring seagrass ecosystems.

Functional trait trade-offs define plant population stability across different biomes

Ecological theory posits that temporal stability patterns in plant populations are associated with differences in species' ecological strategies. However, empirical evidence is lacking about which traits, or trade-offs, underlie species stability, especially across different biomes. We compiled a worldwide collection of long-term permanent vegetation records (greater than 7000 plots from 78 datasets) from a large range of habitats which we combined with existing trait databases. We tested whether the observed inter-annual variability in species abundance (coefficient of variation) was related to multiple individual traits. We found that populations with greater leaf dry matter content and seed mass were more stable over time. Despite the variability explained by these traits being low, their effect was consistent across different datasets. Other traits played a significant, albeit weaker, role in species stability, and the inclusion of multi-variate axes or phylogeny did not substantially modify nor improve predictions. These results provide empirical evidence and highlight the relevance of specific ecological trade-offs, i.e. in different resource-use and dispersal strategies, for plant populations stability across multiple biomes. Further research is, however, necessary to integrate and evaluate the role of other specific traits, often not available in databases, and intraspecific trait variability in modulating species stability.

Long-term subtropical grassland plots take a long time to change: Replacement is more important than richness differences for beta diversity

We studied β diversity of grasses in a subtropical grassland over 60 years in South Africa. We examined the effects of burning and mowing on 132 large plots. We sought to determine the effects of burning and mowing, and mowing frequency, on the replacement of species and the species richness. We conducted the study at Ukulinga, research farm of the University of KwaZulu-Natal, Pietermaritzburg, South Africa (29°24'E, 30°24'S) from 1950-2010. Plots were burned annually, biennially, triennially, and a control (unburned). Plots were mowed in spring, late summer, spring plus late summer, and a control (unmowed). We calculated β diversity, with a focus on replacement and richness differences. We also used distance-based redundancy analyses to examine the relative effects of replacement and richness differences on mowing and burning. We used beta regressions to test for the effect of soil depth and its interactions with mowing and burning. There was no significant change in grass beta diversity until 1995. Thereafter, there were changes in β diversity that demonstrated the primary effects of summer mowing frequency. There was no significant effect of richness differences but a strong effect of replacement post-1995. There was a significant interaction between mowing frequency and soil depth in one of the analyses. Changes in grassland composition took a long time to manifest themselves and were unapparent prior to 1988. However, there was a change in sampling strategy prior to 1988, from point hits to nearest plants, that may also have influenced the rates of changes in replacement and richness differences. Using β-diversity indices, we found that mowing was more important than burning that burning frequency was unimportant, and there was a significant interaction effect between mowing and soil depth in one of the analyses.

Safety and efficacy of tenecteplase in patients with wake-up stroke assessed by non-contrast CT (TWIST): a multicentre, open-label, randomised controlled trial

BACKGROUND

Current evidence supports the use of intravenous thrombolysis with alteplase in patients with wake-up stroke selected with MRI or perfusion imaging and is recommended in clinical guidelines. However, access to advanced imaging techniques is often scarce. We aimed to determine whether thrombolytic treatment with intravenous tenecteplase given within 4·5 h of awakening improves functional outcome in patients with ischaemic wake-up stroke selected using non-contrast CT.

METHODS

TWIST was an investigator-initiated, multicentre, open-label, randomised controlled trial with blinded endpoint assessment, conducted at 77 hospitals in ten countries. We included patients aged 18 years or older with acute ischaemic stroke symptoms upon awakening, limb weakness, a National Institutes of Health Stroke Scale (NIHSS) score of 3 or higher or aphasia, a non-contrast CT examination of the head, and the ability to receive tenecteplase within 4·5 h of awakening. Patients were randomly assigned (1:1) to either a single intravenous bolus of tenecteplase 0·25 mg per kg of bodyweight (maximum 25 mg) or control (no thrombolysis) using a central, web-based, computer-generated randomisation schedule. Trained research personnel, who conducted telephone interviews at 90 days (follow-up), were masked to treatment allocation. Clinical assessments were performed on day 1 (at baseline) and day 7 of hospital admission (or at discharge, whichever occurred first). The primary outcome was functional outcome assessed by the modified Rankin Scale (mRS) at 90 days and analysed using ordinal logistic regression in the intention-to-treat population. This trial is registered with EudraCT (2014-000096-80), ClinicalTrials.gov (NCT03181360), and ISRCTN (10601890).

FINDINGS

From June 12, 2017, to Sept 30, 2021, 578 of the required 600 patients were enrolled (288 randomly assigned to the tenecteplase group and 290 to the control group [intention-to-treat population]). The median age of participants was 73·7 years (IQR 65·9-81·1). 332 (57%) of 578 participants were male and 246 (43%) were female. Treatment with tenecteplase was not associated with better functional outcome, according to mRS score at 90 days (adjusted OR 1·18, 95% CI 0·88-1·58; p=0·27). Mortality at 90 days did not significantly differ between treatment groups (28 [10%] patients in the tenecteplase group and 23 [8%] in the control group; adjusted HR 1·29, 95% CI 0·74-2·26; p=0·37). Symptomatic intracranial haemorrhage occurred in six (2%) patients in the tenecteplase group versus three (1%) in the control group (adjusted OR 2·17, 95% CI 0·53-8·87; p=0·28), whereas any intracranial haemorrhage occurred in 33 (11%) versus 30 (10%) patients (adjusted OR 1·14, 0·67-1·94; p=0·64).

INTERPRETATION

In patients with wake-up stroke selected with non-contrast CT, treatment with tenecteplase was not associated with better functional outcome at 90 days. The number of symptomatic haemorrhages and any intracranial haemorrhages in both treatment groups was similar to findings from previous trials of wake-up stroke patients selected using advanced imaging. Current evidence does not support treatment with tenecteplase in patients selected with non-contrast CT.

FUNDING

Norwegian Clinical Research Therapy in the Specialist Health Services Programme, the Swiss Heart Foundation, the British Heart Foundation, and the Norwegian National Association for Public Health.

Extracorporeal photopheresis for the treatment of chronic graft versus host disease

OBJECTIVES

Chronic graft versus host disease (chronic GVHD) still remains the leading cause of late morbidity and mortality for allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients. In this retrospective study, 53 consecutive allo-HSCT patients with chronic GVHD refractory to corticosteroids were treated with extracorporeal photopheresis (ECP).

METHODS

This study was performed as a retrospective single-center study. Medical records of a total of 59 patients treated with ECP for chronic GVHD were reviewed.

RESULTS

Best organ responses to ECP were observed in skin, mouth mucosa, eyes and liver. Overall response rate (ORR) to ECP was 81.2% (CR 17% and PR 64.2%). Overall survival (OS) was 84.9% and 36.7%, at 1 and 3 years, respectively. Female sex appears to have an advantage on ORR. Patients achieving ORR were able to maintain their responses with a prolonged continuation of treatments for +6 and +12 months indicating the benefits of longer ECP treatment.

DISCUSSION

We found that patients with chronic GVHD who were treated with ECP for 12 months or longer had a higher response rate. Our findings in line with the data reported previously suggest that patients responding to ECP should continue longer therapy schedules to achieve a better and sustained response. In our cohort, long-term ECP therapy was safe and well-tolerated with no significant adverse effects. Best responses were observed in the patients with skin, eye, liver and oral involvement. The ECP procedure offers the advantage relative to the problems with typical immunosuppressive agents. The female sex appeared to have an advantage based on the cumulative probability of the OR after ECP for chronic GVHD.

Plant-soil feedback from eastern redcedar (Juniperus virginiana) inhibits the growth of grasses in encroaching range

The encroachment of woody plants into grasslands is an ongoing global problem that is largely attributed to anthropogenic factors such as climate change and land management practices. Determining the mechanisms that drive successful encroachment is a critical step towards planning restoration and long‐term management strategies. Feedbacks between soil and aboveground communities can have a large influence on the fitness of plants and must be considered as potentially important drivers for woody encroachment. We conducted a plant–soil feedback experiment in a greenhouse between eastern redcedar Juniperus virginiana and four common North American prairie grass species. We assessed how soils that had been occupied by redcedar, a pervasive woody encroacher in the Great Plains of North America, affected the growth of Andropogon gerardi, Schizachyrium scoparium, Bromus inermis, and Pascopyrum smithii over time. We evaluated the effect of redcedar on grass performance by comparing the height and biomass of individuals that were grown in live or sterilized conspecific or redcedar soil. We found redcedar created a negative plant–soil feedback that limited the growth of the cool season grasses B. inermis and P. smithii, reducing their overall biomass by >60%. These effects were found in both live and sterilized redcedar soils. In live soils, some growth suppression can be attributed to the negative effects of soil microbes. The limitation of grass growth in sterile soils indicates redcedar may exude an allelochemical into the soil that limits grass growth. Our results demonstrate that plant–soil feedback created by redcedar inhibits the growth of certain grass species. By creating a plant–plant interaction that negatively affects competitors, redcedars increase the probability of seedling survival until they can grow to overtop their neighbors. These results indicate plant–soil feedback is a mechanism of native woody plant encroachment which could be important in many systems yet is understudied.

Covert and overt stuttering: Concepts and comparative findings

PURPOSE

One way of conceptualizing stuttering is on a continuum from primarily covert to primarily overt. Assertions have been made as to how those with covert stuttering might be impacted differently to those with overt stuttering, but findings from well-controlled studies remain scarce. The principal aim of the present study was to compare the impact of stuttering and emotional distress related to two subgroups of persons who stutter: people with primarily overt stuttering and people with primarily covert stuttering. In exploring this, we also offer some preliminary thoughts on challenges with the terminology surrounding the concepts of 'overtness' and 'covertness'.

METHODS

Twenty-one adults already enrolled in a multiple, single-case treatment study (Sønsterud et al., 2019, 2020) took part in the present study, and underwent a battery of tests that assessed anxiety, depression, fear of negative evaluation, and quality of life. The sub-groups were identified on the basis of self-categorization using the Tomaiuoli, Del Gado, Spinetti, Capparelli, and Venuti (2015) classification, as well as the evaluation of speech samples from two independent SLPs (Sønsterud et al., 2020). The classifications were further explored by five independent 'lay' assessors who reviewed pre-therapy video and rated participants' speech on a 4-point Likert Stuttering Probability Scale (1 = 'fluent with no doubt', 2 = 'fluent with some doubt', 3 = 'stuttering with some doubt' and 4 = 'stuttering with no doubt').

RESULTS

No significant differences were found between the primarily overt and primarily covert groups in relation to self-reported symptoms of anxiety, depression, and fear of negative evaluation. However, investigation at item level identified a significant difference in linguistic avoidance between the two groups.

CONCLUSION

There may be fewer differences between people with primarily overt and primarily covert stuttering than previously thought with regards to emotional impact, as well as most aspects of avoidance behavior.

Telepractice application for the overt stuttering assessment of children aged 6-15 years old

BACKGROUND

Despite the importance of delivering speech and language therapy services to children who stutter (CWS), there are barriers to accessing speech and language therapy. One way to improve access for those who may otherwise be deprived of speech and language therapy services, including CWS, is through telepractice (TP). However, there is currently no evidence as to the viability of TP stuttering assessments for CWS.

AIM

To investigate the validity and reliability, and acceptability of using a TP application to assess overt stuttering behaviour children aged 6-15 years.

METHODS & PROCEDURE

A total of 30 CWS, aged between 6 and 15 years, were recruited from a speech therapy clinic in King Abdulaziz University Hospital in Riyadh, Saudi Arabia. Children were divided into two testing conditions, either face-to-face (f2f)-led or TP-led testing, and the Stuttering Severity Instrument (SSI-IV) was administered, percentage of syllables stuttered (%SS) was calculated, and severity ratings (SR) assigned, either via f2f or via TP using two laptops with webcams, video conference software and a broadband internet connection. Agreement and reliability of scoring in the two testing conditions were reported in addition to findings from questionnaires exploring children's and their caregivers' perceptions both before and immediately after the TP assessment was carried out.

OUTCOME & RESULTS

A total of 30 sessions were successfully carried out, with results revealing unsatisfactory levels of agreement when applying the Bland and Altman method. However, when discrepancies were found, these were comparable with those from traditional f2f studies. Generally, parents and children exhibited high levels of satisfaction and held a positive view regarding TP pre- and post-assessment.

CONCLUSIONS & IMPLICATIONS

The results of the study suggest that conducting an overt stuttering assessment via TP for 6-15-year-olds CWS is reliable and valid. Although the TP model posed some (mainly technical) challenges for executing the assessment, high levels of satisfaction were recorded by parents and children alike. The TP system and equipment chosen in this study has provided a basis for the delivery of TP overt stuttering assessment in a clinical setting, thus addressing the barriers to access that are present for CWS. These results are preliminary, but they can be seen as a building block for future research in TP assessment studies for CWS.

WHAT THIS PAPER ADDS

What is already known on the subject Stuttering treatment via TP has been proven to be feasible and successful across a variety of treatment programs (e.g., Lidcombe, Camperdown). However, the viability of assessing stuttering via videoconferencing has never been explored in children. What this paper adds to existing knowledge Preliminary support for the assessment of overt stuttering in CWS aged 6-15 years via video conferencing. The results justify larger scale studies of this service delivery method. What are the potential or actual clinical implications of this work? The TP system and equipment chosen in this study has provided a basis for the delivery of TP overt stuttering assessment in a clinical setting, thus addressing the barriers to access that are present for CWS aged 6-15 years.

Combinatorial PCR Method for Efficient, Selective Oligo Retrieval from Complex Oligo Pools

With the rapidly decreasing cost of array-based oligo synthesis, large-scale oligo pools offer significant benefits for advanced applications including gene synthesis, CRISPR-based gene editing, and DNA data storage. The selective retrieval of specific oligos from these complex pools traditionally uses polymerase chain reaction (PCR). Designing a large number of primers to use in PCR presents a serious challenge, particularly for DNA data storage, where the size of an oligo pool is orders of magnitude larger than other applications. Although a nested primer address system was recently developed to increase the number of accessible files for DNA storage, it requires more complicated lab protocols and more expensive reagents to achieve high specificity, as well as more DNA address space. Here, we present a new combinatorial PCR method that has none of those drawbacks and outperforms in retrieval specificity. In experiments, we accessed three files that each comprised 1% of a DNA prototype database that contained 81 different files and enriched them to over 99.9% using our combinatorial primer method. Our method provides a viable path for scaling up DNA data storage systems and has broader utility whenever one must access a specific target oligo and can design their own primer regions.

Changes in white oak ( Quercus alba ) phytochemistry in response to periodical cicadas: Before, during, and after an emergence

Periodical cicadas have mass emergences once every 13 or 17 years. Plants may need to upregulate defense production in response to an emergence. Defense production is energetically expensive, so plants may downregulate their production after periodical cicada populations dissipate. We examined the defensive responses in leaves, branches, and roots of a common host, white oak (Quercus alba), prior to, during, and after a 17-year periodical cicada (Magicicada spp.) emergence in western Pennsylvania, United States. During the emergence, total tannins and condensed tannins increased in foliar tissue, while simultaneously decreasing in root tissue compared to the prior and subsequent years. Non-structural carbohydrates were low prior to the mass emergence but were re-allocated to belowground storage during the emergence year and dropped thereafter. In the year after the emergence, there was a relaxation of foliar defenses, and root defenses returned to pre-emergence concentrations. We also tested for differences in damaged and undamaged branches on the same tree during (2019) and the year after the emergence (2020). Both damaged and undamaged branches had significantly greater chemical defenses (polyphenols, total tannins, and condensed tannins) during the emergence than in the following year when there was no emergence. We propose that re-allocation of resources may help maximize oak tree fitness by moving resources away from areas that are not in immediate threat to areas that are under immediate threat. Changes in aboveground and belowground phytochemistry in response to periodical cicada mass emergences may help us better understand which resource re-allocation strategies are used by plants to minimize the effects of insect emergencies.

"Hi This Is NESTORE, Your Personal Assistant": Design of an Integrated IoT System for a Personalized Coach for Healthy Aging

In the context of the fourth revolution in healthcare technologies, leveraging monitoring and personalization across different domains becomes a key factor for providing useful services to maintain and promote well-being. This is even more crucial for older people, with aging being a complex multi-dimensional and multi-factorial process which can lead to frailty. The NESTORE project was recently funded by the EU Commission with the aim of supporting healthy older people to sustain their well-being and capacity to live independently. It is based on a multi-dimensional model of the healthy aging process that covers physical activity, nutrition, cognition, and social activity. NESTORE is based on the paradigm of the human-in-the-loop cyber-physical system that, exploiting the availability of Internet of Things technologies combined with analytics in the cloud, provides a virtual coaching system to support healthy aging. This work describes the design of the NESTORE methodology and its IoT architecture. We first model the end-user under several domains, then we present the NESTORE system that, analyzing relevant key-markers, provides coaching activities and personalized feedback to the user. Finally, we describe the validation strategy to assess the effectiveness of NESTORE as a coaching platform for healthy aging.

Diagnostic yield from cardiac gene panel testing for inherited cardiac conditions in a large Irish cohort

Background

Inherited cardiomyopathies (hypertrophic, dilated and arrhythmogenic) and cardiac ion channelopathies (long QT, Brugada and CPVT) predispose to sudden cardiac death/sudden arrhythmic death syndrome. Given their genetically heterogenous nature, multi-gene DNA sequencing panels are useful to aid genetic diagnosis.

Purpose

Investigate the diagnostic yield from cardiac gene panel testing undertaken in patients (including molecular autopsy in deceased patients) referred to four clinical services from 2002 to 2020.

Methods

Data was collected by interrogation of departmental databases, family charts, and review of molecular genetic diagnostic reports.

Results

We evaluated molecular genetic diagnostic results from 835 individuals (461 males, 374 females) from 824 families, including 58 deceased patients who underwent molecular autopsy. The median age of the cohort was 44 years (range 0.1–86 years).

Testing for hypertrophic cardiomyopathy (HCM) and long QT syndrome (LQT) genes represented 36% and 32% of the cohort, respectively, with the remaining 32% accounting for other cardiomyopathies, arrhythmia syndromes or metabolic/syndromic diseases. The overall variant detection rate was 50% across all panel types. Three hundred and fifty patients (42%) carried a single variant, 68 patients (8%) carried multiple variants (up to a maximum of four), including two individuals who carried two actionable (pathogenic/likely pathogenic) variants each and 30 individuals (5%) with one actionable variant plus a variant of uncertain significance (VUS).

The overall diagnostic yield of at least one actionable variant was 28%. At least one VUS was detected in 27% of the cohort. Molecular autopsy yielded an actionable variant in 10% of patients, while 30% of the subcohort carried at least one VUS (up to maximum of two).

We found a positive association between female sex and the likelihood of detecting an actionable variant. By decade of age, detection of actionable variants ranged from 19% (60–69 years) to 41% (0–9 years). By panel type, actionable variants ranged from 14% (Brugada) to 35% (cardiomyopathy). The burden of VUS ranged from 22% (LQT) to 46% (dilated cardiomyopathy).

Altogether 234 actionable variants were detected in 26 genes, including seven metabolic or syndromic disease genes. From those with non-metabolic/syndromic forms of disease, 84% of actionable variants were detected in well established ICC genes. Analysis of gene-disease associations for VUS detected from HCM and LQT panels revealed that 10–25% were detected in genes now deemed to have only moderate or limited evidence of disease causation.

Conclusion

Most actionable variants in this cohort were detected in well-established ICC genes, suggesting that large gene panels offer little extra sensitivity compared to historic smaller gene panels. Despite recent gene curation efforts, the high burden of VUS remains a considerable challenge in ICC management.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): National Children's Research Centre

The role of ILR monitoring in patients with a family history of SADS, a view from real clinical practice

Background/Introduction

Implantable Loop Recorder (ILR) device monitoring is an established method for long term heart rhythm monitoring in patients with inherited cardiac conditions. Many present with a family history of Sudden Arrhythmic Death Syndrome (SADS). The value of ILR findings in the investigation of SADS relatives has not been well documented.

Purpose

We aimed to evaluate the impact of ILR monitoring on the management plans of patients with a family history of SADS.

Methods

We performed a retrospective analysis of the ILR reports and electronic patient records of all patients at the inherited cardiac disease clinic with a family history of SADS and an ILR implanted. Patient demographics, ILR implant indication and specific changes to management plans were recorded and analysed using descriptive statistics.

Results

All 135 patients with ILR monitoring at the inherited cardiac disease clinic were screened and 87 patients (57.6% female, 41.7±14.0 years) with SADS relatives were included in the study. The mean follow up period was 657.9±392.3 days from ILR implant. Indications for ILR implantation included syncope (n=31, 15.7%), presyncope (45, 22.7%), palpitations (44, 22.2%), chest pain (9, 4.5%), short term heart rhythm monitor findings (6, 3.0%), ECG findings (6, 3.0%), asymptomatic indications (10, (5.1%) including patients with more than one relative with SADS, a family history of conduction disease or family history of long QT syndrome), and atypical symptoms (2 (1%) including seizures and sleep paralysis). Some patients had more than one indication for ILR at the time of implant. As a direct result of ILR monitoring, 43 (49.4%) patients had a change to their management plan. 6 specific definitions for management changes were used: Permanent pacemaker implantation (2, 2.3%), subsequent electrophysiology study (3, 3.5%), medication change (7, 8.1%), arrhythmia excluded as a cause for patient symptoms (26, 29.9%), prompted ILR implant in first degree relative (11, 12.6%) and ILR re-implant for further monitoring for premature conduction disease (1, 1.2%). Patients whose indication for ILR implant was palpitations had the highest likelihood for change of management with 27 changes associated with this indication, of which exclusion of arrhythmia as a cause for symptoms (15) was the most frequent outcome. The indications, syncope and presyncope both yield 21 management changes each.

Conclusion

The use of ILR devices in family relatives of patients with SADS provides information that may directly impact on patient management, with syncope providing the highest yield and reassurance the most common outcome in our cohort. ILR monitoring helped guide a wide range of other management strategies which included changes to medications and the need for further cardiac procedures. This data represented clinical practice in a niche patient cohort who are at risk for inherited cardiac conditions and associated arrhythmias.

Funding Acknowledgement

Type of funding sources: None. Indication for ILR vs management changeIndications for ILR implant

Gender bias in ACS management

Background

Cardiovascular disease is implicated in approximately 1 in every 3 deaths occurring in both women and men worldwide. Numerically, it is responsible for more female than male deaths each year, due largely to longer life expectancy amongst women. Consequently, guidelines from the major international bodies recommend against the use of sex as a discriminating factor in the evaluation of chest pain. Still there remains a public perception of excess cardiovascular risk in men, contributing to a delay in the seeking of medical attention by women with symptoms of acute coronary syndrome (ACS). We hypothesise the attendant concern that unconscious gender bias amongst clinicians influences the management of patients presenting with ACS from triage to invasive assessment and treatment.

Aim

To examine the relationship between patient gender and clinical management of ACS.

Methods

We conducted a retrospective cross sectional study of all patients in whom ACS was suspected during a year long period using the laboratory database of a tertiary cardiac referral centre in Ireland. In all patients for whom high sensitivity cardiac troponin T assay was ordered during the full calendar year 2019, age, sex and troponin level were recorded. We determined the likelihood of invasive angiography for male versus female patients after adjustment for age and troponin result.

Results

A total of 30,560 requests for high sensitivity cardiac troponin T (troponin) were made to the laboratory in the year ending December 2019. Excluding 464 for technical and sampling issues, 30,096 assays were included in the analysis. 43.84% (N=13,194) of samples were female and 56.16% (N=16,902) male. These samples were collected from 10,807 patients (5,294 female and 5,513 male). Median age was 58 for females and 57 for males. The upper limit of normal in our institution for serum troponin is <14ng/L and there is no adjustment for sex. 22.01% (N=1,165) of females and 33.39% (N=1,841) of males had at least one troponin level reported above the normal range. Of female patients with at least one troponin above the normal limit, 10.21% (N=119) underwent invasive coronary angiography compared to 18.52% (N=341) of males. Of females in whom all troponin results were normal, 5.84% (N=241) proceeded to invasive angiography versus 9.18% (N=337) of males.

Conclusion

Notwithstanding the limitations of lack of adjustment for risk profile, the results of this analysis demonstrate a higher rate of invasive angiography in males compared with females independently of troponin level. This is in keeping with previous research suggesting a gender gap in the approach of clinicians to ACS, and suggests an unconscious sex-based discrimination when making decisions around diagnosis and treatment. Education regarding the prevalence of coronary atherosclerosis, and interventions to alter the attitudes of clinicians, are some of the interventions suggested to close this gap.

Funding Acknowledgement

Type of funding sources: None.

The utility of the implantable loop recorder in patients with a diagnosis or family history of long QT syndrome

Background

There is limited published data on the use of implantable loop recorders (ILRs) in patients with long QT syndrome (LQTS).

Purpose

We sought to evaluate the utility of the ILR in patients who had a diagnosis of LQTS or who had a family history of LQTS.

Methods

We carried out a retrospective analysis of patients attending an Inherited Cardiac Conditions Clinic who had an active ILR and who had a diagnosis or family history of LQTS. Patient demographics, indications for ILR implantation and clinical outcomes were compiled.

Results

Nine patients with a diagnosis of LQTS and an active ILR were identified with an average age of 37 years. Genetic results were available for seven patients. Four patients had a confirmed pathogenic mutation (one KCNQ1 and three KCNH2), one patient had a variant of uncertain significance in SCN5A and two patients had negative genetic testing. Indications for implantation were syncope (n=4), recurrent altered consciousness episodes (n=1), assessment of occult arrhythmia or beta blocker complications (n=2), palpitations and dizziness (n=1) and nocturnal dyspnoea and palpitations (n=1). Mean follow-up was 706 days and average age at ILR implant was 35 years. The ILR for three patients was a second device, implanted after end of battery life of the initial ILR. ILR recordings led to a change in management in three patients: finding of paroxysmal atrial fibrillation (n=1), finding of nocturnal QTc of 511ms with a change in medications (n=1) and a pause leading to cessation of beta blocker (n=1).

Eleven patients with a family history of LQTS and active ILR were identified. Nine patients were female, and the average age was 44.4 years. Genetic test results were available for five patients. Three patients had a pathogenic mutation in SCN5A, and two patients had negative genetic testing for common LQTS genes. Indications for implantation included syncope (n=5), lightheaded episodes (n=3) and risk assessment in gene carriers (n=3). The mean duration of ILR follow-up was 680 days and average age at ILR implant was 42.5 years. Five patients had no arrhythmia detected during ILR recording, two patients had supraventricular tachycardia identified, in two patients ILR data outruled a sinister cause for a symptomatic episode, one patient had documentation of SVT and brief NSVT which led to referral for electrophysiology study and one patient had no recurrence of symptoms and a second ILR was implanted.

Conclusion

ILRs were inserted in selected patients with a diagnosis of LQTS or in patients with a family history of LQTS or who were gene carriers. Rationale for ILR implantation included risk stratification, monitoring for occult arrhythmia and rhythm-symptom correlation in symptomatic patients. The ILR impacted management in almost 50% of patients and is considered an important tool in selected patients attending Inherited Cardiac Condition Clinics.

Funding Acknowledgement

Type of funding sources: None. Table 1

Understanding Home Hemodialysis Patient Attrition: A Cohort Study

Background:

Home hemodialysis (HHD) offers a flexible, patient-centered modality for patients with kidney failure. Growth in HHD is achieved by increasing the number of patients starting HHD and reducing attrition with strategies to prevent the modifiable reasons for loss.

Objective:

Our primary objective was to describe a Canadian HHD population in terms of technique failure and time to exit from HHD in order to understand reasons for exit. Our secondary objectives include the following: (1) determining reasons for training failure, (2) reasons for early exit from HHD, and (3) timing of program exit.

Design:

A retrospective cohort study of incident adult HHD patients between January 1, 2013—June 30, 2020.

Setting:

Alberta Kidney Care South, AKC-S HHD program.

Participants:

Patients who started training for HHD in AKC-S.

Methods:

A retrospective, cohort study of incident adult HHD patients with primary outcome time on home hemodialysis, secondary outcomes include reason for train failure, time to and reasons for technique failure. Cox-proportional hazard model to determine associations between patient characteristics and technique failure. The cumulative probability of technique failure over time was reported using a competing risks model.

Results:

A total of 167 patients entered HHD. Training failure occurred in 20 (12%), at 3.1 [2.0, 5.5] weeks; these patients were older (P < .001) and had 2 or more comorbidities (P < .001). Reasons for HHD exit after training included transplant (35; 21%), death (8; 4.8%), and technique failure (24; 14.4%). Overall, the median time to HHD exit, was 23 months [11, 41] and the median time of technique failure was 17 months [8.9, 36]. Reasons for technique failure included: psychosocial reasons (37%) at a median time 8.9 months [7.7, 13], safety (12.5%) at 19 months [19, 36], and medical (37.5%) at 26 months [11, 50].

Limitations:

Small patient population with quality of data limited by the electronic-based medical record and non-standardized definitions of reasons for exit.

Conclusions:

Training failure is a particularly important source of patient loss. Reasons for exit differ according to duration on HHD. Early interventions aimed at reducing train failure and increasing psychosocial supports may help program growth.

Isolated vulvar Langerhans cell histiocytosis

•

Primary vulvar Langerhans cell histiocytosis is rare with less than 40 reported cases.

•

Diagnosis of vulvar LCH requires prompt metastatic workup to rule out multisystem involvement.

•

Treatment protocols for isolated vulvar LCH vary widely and there is not an established standard of care.

•

Continue surveillance is warranted even after prolonged periods of remission.

Herbivore-induced defenses are not under phylogenetic constraints in the genus Quercus (oak): Phylogenetic patterns of growth, defense, and storage

The evolution of plant defenses is often constrained by phylogeny. Many of the differences between competing plant defense theories hinge upon the differences in the location of meristem damage (apical versus auxiliary) and the amount of tissue removed. We analyzed the growth and defense responses of 12 Quercus (oak) species from a well-resolved molecular phylogeny using phylogenetically independent contrasts. Access to light is paramount for forest-dwelling tree species, such as many members of the genus Quercus. We therefore predicted a greater investment in defense when apical meristem tissue was removed. We also predicted a greater investment in defense when large amounts of tissue were removed and a greater investment in growth when less tissues were removed. We conducted five simulated herbivory treatments including a control with no damage and alterations of the location of meristem damage (apical versus auxiliary shoots) and intensity (25% versus 75% tissue removal). We measured growth, defense, and nutrient re-allocation traits in response to simulated herbivory. Phylomorphospace models were used to demonstrate the phylogenetic nature of trade-offs between characteristics of growth, chemical defenses, and nutrient re-allocation. We found that growth-defense trade-offs in control treatments were under phylogenetic constraints, but phylogenetic constraints and growth-defense trade-offs were not common in the simulated herbivory treatments. Growth-defense constraints exist within the Quercus genus, although there are adaptations to herbivory that vary among species.

Evaluating three stuttering assessments through network analysis, random forests and cluster analysis

PURPOSE

In stuttering, cognitive and behavioural variables interact in nonlinear fashion. These variables can be assessed by instruments which evaluate perceived impact of stuttering and stuttering severity. We applied three statistical methods in combination to the analysis of three assessment protocols to discover relationships within and between the tests to better understand variations in behavioural and social aspects of stuttering.

METHODS

Scores from Stuttering Severity Index (SSI-IV), Overall Assessment of the Speaker's Experience of Stuttering scale (OASES), and Unhelpful Thoughts and Beliefs About Stuttering scale (UTBAS), collected from 26 participants were compared using three statistical methods: network analysis, random forests, and cluster analysis.

RESULTS

Network analysis demonstrated that SSI-IV only weakly interacts with a quality of life index (OASES) and a self-perception and belief systems index (UTBAS). Random forest analyses revealed the last two measures relate strongly to each other. The results from cluster analysis suggest a) a possible regrouping of OASES items and b) a possible use of one UTBAS scale instead of the three.

CONCLUSION

A combination of three statistical methods allowed us to evaluate the three assessments in more depth. The lack of interaction between the SSI-IV on the one hand, and OASES and UTBAS on the other, suggests that the network of the three commonly used stuttering assessments may be fractured in a non-productive way. A potential gap may exist for an assessment tool that would link behavioural and social aspects of stuttering.

Effect of Sodium Benzoate vs Placebo Among Individuals With Early Psychosis: A Randomized Clinical Trial

IMPORTANCE

There is evidence that sodium benzoate (BZ) may be an effective adjunctive treatment for schizophrenia. The clinical efficacy of BZ has been investigated in chronic schizophrenia; however, the efficacy of this agent has not been studied in individuals with early psychosis.

OBJECTIVE

To examine the clinical efficacy of the adjunctive use of BZ for symptoms in people with early psychosis.

DESIGN, SETTING, AND PARTICIPANTS

Using a placebo-controlled double-masked parallel-group design, this randomized clinical trial was conducted from August 2015 to July 2018. Participants aged between 15 and 45 years experiencing early psychosis were enrolled from 5 major clinical sites in Queensland, Australia. Data analysis was conducted from October 2018 to February 2020.

INTERVENTIONS

Participants were randomized 1:1 (50 participants in each group) to receive 500 mg of sodium benzoate twice daily or placebo for 12 weeks.

MAIN OUTCOMES AND MEASURES

The primary efficacy outcome was the Positive and Negative Syndrome Scale (PANSS) total score at 12 weeks. The key secondary efficacy measures were (1) the Clinical Global Impression score, (2) the Hamilton Depression Rating Scale for depression, (3) functioning as assessed by the clinician-rated Global Assessment of Function, and (4) the Assessment of Quality of Life Scale. The PANSS subscale scores and impact on selected amino acid concentrations were also assessed.

RESULTS

The study comprised 100 participants with a mean (SD) age of 21.4 (4.1) years, of whom 73 (73%) were male individuals. The mean (SD) baseline PANSS score was 75.3 (15.4). We found no improvement in total PANSS score in the BZ group compared with the placebo group. The end result of least-squares mean difference (SE) for total PANSS was -1.2 (2.4) (P = .63). There were no differences in any subscales of the PANSS, any secondary measures, nor any amino acid concentrations. The dose of BZ was well tolerated without any clinically significant treatment-emergent adverse event differences between BZ and placebo groups.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, there was no evidence that adjunctive use of 500 mg of BZ twice daily is an effective treatment for individuals with early psychosis.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12615000187549.

What works for whom? Multidimensional individualized stuttering therapy (MIST)

PURPOSE

This study reports outcomes from a stuttering therapy approach that combines value and awareness-based elements from Acceptance and Commitment Therapy (ACT) with those of stuttering and speech modification interventions. The approach, entitled Multidimensional Individualized Stuttering Therapy (MIST), includes a combined clinician and client selection of factors across five areas: 1) general breathing patterns and body tension, 2) breathing patterns during speech production, 3) vocal features in speech production, 4) value and mindfulness-based strategies, and 5) general communication and/or presentation skills. The aims of this study were to evaluate whether the MIST a) reduces the impact of stuttering and stuttering severity, and b) has a positive impact on speaking ability, confidence in communication, avoidance-behavior, and quality of life.

METHOD

Eighteen adults, age 21-61 years took part in an A-B-A multiple case study design. Participants underwent a pre-clinic assessment phase, followed by 10 h of therapy over four sessions administered by an experienced speech-language therapist. Outcome measures examined both psychosocial and behavioral aspects of therapy three-, six- and twelve-months post-therapy.

RESULTS

Most participants chose elements from at least four of the five areas of focus. There was a significant reduction in the impact of stuttering at both 6- and 12-months post-therapy, with moderate (d = .71) to very large (d = 1.06) effect sizes. A strong association was found between overall satisfaction with MIST and improved speaking abilities. Moderate to strong associations were also found between experienced speaking abilities, confidence in communication, reduction in avoidance behaviors and improved quality of life.

DISCUSSION

Findings indicate that MIST can be effective in managing adult stuttering. The findings highlight the importance of shared decision making and personal considerations using flexible therapy approaches that integrate stuttering and speech modification interventions with value and awareness-based skills. The nature of a multidimensional individualized approach, as shown in this study, highlights the importance of adjusting the relative weighting of different subcomponents according to each individual's needs and goals.

CONCLUSION

MIST was shown to be efficacious in clinical settings and effective in real life settings. Findings were promising, despite a relatively small sample, and replication by other SLPs and with larger samples is warranted.

Synchrony matters more than species richness in plant community stability at a global scale

The stability of ecological communities is critical for the stable provisioning of ecosystem services, such as food and forage production, carbon sequestration, and soil fertility. Greater biodiversity is expected to enhance stability across years by decreasing synchrony among species, but the drivers of stability in nature remain poorly resolved. Our analysis of time series from 79 datasets across the world showed that stability was associated more strongly with the degree of synchrony among dominant species than with species richness. The relatively weak influence of species richness is consistent with theory predicting that the effect of richness on stability weakens when synchrony is higher than expected under random fluctuations, which was the case in most communities. Land management, nutrient addition, and climate change treatments had relatively weak and varying effects on stability, modifying how species richness, synchrony, and stability interact. Our results demonstrate the prevalence of biotic drivers on ecosystem stability, with the potential for environmental drivers to alter the intricate relationship among richness, synchrony, and stability.

Clinical outcomes and dislocation rates after hip reconstruction using the Bioball system

INTRODUCTION

Instability accounts for 1/3 of revision total hip arthroplasty (rTHA) performed in the UK. Removal of well-fixed femoral stems in rTHA is challenging with a risk of blood loss and iatrogenic damage to the femur. The Bioball universal adaptor (BUA), a modular head neck extension adaptor, provides a mechanism for optimisation of femoral offset, leg length and femoral anteversion. This can avoid the need for femoral stem revision in selected cases.The aim of this study is to present the clinical results and rate of instability following revision with this BUA at a minimum of 2 years follow-up.

PATIENTS AND METHODS

A review of our prospectively collected database was performed. All patients treated with the Bioball device were included. Clinical and radiologic review were performed pre- and post-surgery. Specific enquiry for instability was made. The Oxford Hip Score (OHS), EuroQol (EQ-5D) score and WOMAC scores were calculated pre-and post-operatively. Complications were recorded.

RESULTS

32 rTHA procedures were performed using the Bioball device between 2013 and 2016. 4 patients did not wish to complete post-operative questionnaires. 2 patients (2/28, 7%) complained of recurrent dislocations following their rTHA procedure. 1 patient complained of instability but no dislocation. The median pre-operative EQ-5D was 0.195 (range -0.07-0.85), OHS was 20 (range 5-43) and WOMAC was 29.8 (range 15.5-52.3). The median EQ-5D was 0.85 (range 0.59-1), OHS was 39 (range 21-48) and WOMAC was 91.1 (range 44.5-99.2) at final follow-up. There were significant improvements in the EQ-5D (p = 0.0009), OHS (p = 0.0004) and WOMAC (p = 0.0001).

CONCLUSION

The BUA is associated with significant functional improvement and relatively low dislocation rates in revision THA. It is a viable option for use in the revision setting.

Are there phylogenetic differences in salivary tannin-binding proteins between browsers and grazers, and ruminants and hindgut fermenters?

While feeding, mammalian browsers (primarily eat woody plants) encounter secondary metabolites such as tannins. Browsers may bind these tannins using salivary proteins, whereas mammalian grazers (primarily eat grasses that generally lack tannins) likely would not. Ruminant browsers rechew their food (ruminate) to increase the effectiveness of digestion, which may make them more effective at binding tannins than nonruminants. Few studies have included a sufficient number of species to consider possible scaling with body mass or phylogenetic effects on salivary proteins. Controlling for phylogeny, we ran inhibition radial diffusion assays of the saliva of 28 species of African herbivores that varied in size, feeding strategy, and digestive system. We could not detect the presence of salivary proline-rich proteins that bind tannins in any of these species. However, using the inhibition radial diffusion assay, we found considerable abilities to cope with tannins in all species, albeit to varying degrees. We found no differences between browsers and grazers in the effectiveness of their salivary proteins to bind to and precipitate tannins, nor between ruminants and nonruminants, or scaling with body mass. Three species bound all tannins, but their feeding niches included one browser (gray duiker), one mixed feeder (bush pig), and one grazer (red hartebeest). Five closely related species of small ruminant browsers were very effective in binding tannins. Megaherbivores, considered generalists on account of their large body size, were capable of binding tannins. However, the grazing white rhinoceros was almost as effective at binding tannins as the megaherbivore browsers. We conclude, contrary to earlier predictions, that there were no differences in the relative salivary tannin-binding capability that was related to common ancestry (phylogeny) or to differences in body size.

Sexual risk and HIV testing disconnect in men who have sex with men (MSM) recruited to an online HIV self-testing trial

OBJECTIVES

We report the frequency of previous HIV testing at baseline in men who have sex with men (MSM) who enrolled in an HIV self-testing (HIVST) randomized controlled trial [an HIV self-testing public health intervention (SELPHI)].

METHODS

Criteria for enrolment were age ≥ 16 years, being a man (including trans men) who ever had anal intercourse (AI) with a man, not being known to be HIV positive and having consented to national HIV database linkage. Using online survey baseline data (2017-2018), we assessed associations with never having tested for HIV and not testing in the previous 6 months, among men who reported at least two recent condomless AI (CAI) partners.

RESULTS

A total of 10 111 men were randomized; the median age was 33 years [interquartile range (IQR) 26-44 years], 89% were white, 20% were born outside the UK, 0.8% were trans men, 47% were degree educated, and 8% and 4% had ever used and were currently using pre-exposure prophylaxis (PrEP), respectively. In the previous 3 months, 89% reported AI and 72% reported CAI with at least one male partner. Overall, 17%, 33%, 54%, and 72% had tested for HIV in the last 3 months, 6 months, 12 months and 2 years, respectively; 13% had tested more than 2 years ago and 15% had never tested. Among 3972 men reporting at least two recent CAI partners, only 22% had tested in the previous 3 months. Region of residence and education level were independently associated with recent HIV testing. Among current PrEP users, 15% had not tested in the previous 6 months.

CONCLUSIONS

Most men in SELPHI, particularly those reporting at least two CAI partners and current PrEP users, were not testing in line with current UK recommendations. The results of the trial will inform whether online promotion of HIVST addresses ongoing testing barriers.

What do people search for in stuttering therapy: Personal goal-setting as a gold standard?

PURPOSE

Stuttering affects people in individual ways, and there are multiple factors which may influence a person's goals when seeking therapy. Even though there is a common consensus that speech-language pathologists should discuss the individual's goals and expectations for stuttering therapy and outcomes, few studies have systematically investigated this issue. The aims of the present study were to investigate individual motivations and goal-setting related factors in stuttering therapy. The associations between self-reported impact of stuttering and the participants' perceptions of stuttering interference in communication, speaking abilities, and relationships with other people were also investigated.

METHOD

This study is part of a wider-ranging treatment study of individualized stuttering management tailored to the participants' personal goals and preferences. A mixed method, multiple single-case design was used to address the research questions. Twenty-one adults, age 21-61 years, took part in a pretherapy interview, which also included two quantitative measures: the Client Preferences for Stuttering Therapy-Extended version (CPST-E) and the Overall Assessment of Speakers' Experience of Stuttering-Adult version (OASES-A). Findings from the study sample was compared with a Norwegian reference group, in order to check for the representativeness of the study sample.

RESULTS

Quantitative data showed that most participants wanted to focus on both physical and psychological aspects of therapy, and that 95% considered 'to gain a sense of control over the stuttering' as important. Participants' perspectives on their speaking ability and stuttering interference in communication were identified as central factors, particularly in social and professional settings. These outcomes aligned well with the finding of avoidance behaviors, such as avoiding words and speaking situations. Qualitative data identified four main areas that the participants wanted to improve: speech fluency, emotional functioning, activity and participation, and understanding of their stuttering.

CONCLUSION

The study confirms that multiple and individual factors may influence the person's goals for therapy. Goals were mainly anchored in participants' wish of better coping in real world settings. A high degree of avoidance behavior was reported, suggesting that anxiety, and in particular linguistic-related anxiety needs to be taken into account when addressing social anxiety in fluency disorders.

Visual Immunoprecipitate Assay (VIP) for Listeria monocytogenes and Related Listeria Species Detection in Selected Foods: Collaborative Study

Six foods representing a variety of food products were analyzed by the Assurance Listeria polyclonal enzyme immunoassay (EIA) and by either the Bacteriological Analytical Manual or the U.S. Department of Agriculture culture method for detecting Listeria monocytogenes and related Listeria species. Samples of each food type, at each inoculation level, were analyzed simultaneously by both methods. A total of 19 laboratories representing federal government agencies and private industry in the United States and Canada participated. Food types were inoculated with Listeria species including L. monocytogenes, with the exception of 3 lots of green beans, which were naturally contaminated. During this study, 1764 samples and controls were analyzed and confirmed, of which 492 were positive and 947 were negative by both methods. There were 159 samples that were positive by culture method but negative by the EIA and 188 that were negative by culture method but positive by EIA. Twenty-two samples were negative by EIA and by culture method but confirmed positive when Assurance selective enrichment broths were subcultured to selective agar. The Assurance polyclonal EIA for detecting L. monocytogenes and related Listeria species in foods has been adopted first action by AOAC INTERNATIONAL.

Assurance Polyclonal Enzyme Immunoassay for Detection of Listeria monocytogenes and Related Listeria Species in Selected Foods: Collaborative Study

Six foods representing a variety of food products were analyzed by the Assurance Listeria polyclonal enzyme immunoassay (EIA) and by either the Bacteriological Analytical Manual or the U.S. Department of Agriculture culture method for detecting Listeria monocytogenes and related Listeria species. Samples of each food type, at each inoculation level, were analyzed simultaneously by both methods. A total of 19 laboratories representing federal government agencies and private industry in the United States and Canada participated. Food types were inoculated with Listeria species including L. monocytogenes, with the exception of 3 lots of green beans, which were naturally contaminated. During this study, 1764 samples and controls were analyzed and confirmed, of which 492 were positive and 947 were negative by both methods. There were 159 samples that were positive by culture method but negative by the EIA and 188 that were negative by culture method but positive by EIA. Twenty-two samples were negative by EIA and by culture method but confirmed positive when Assurance selective enrichment broths were subcultured to selective agar. The Assurance polyclonal EIA for detecting L. monocytogenes and related Listeria species in foods has been adopted first action by AOAC INTERNATIONAL.

Week 48 Resistance Analyses of the Once-Daily, Single-Tablet Regimen Darunavir/Cobicistat/Emtricitabine/Tenofovir Alafenamide (D/C/F/TAF) in Adults Living with HIV-1 from the Phase III Randomized AMBER and EMERALD Trials

Darunavir/cobicistat/emtricitabine/tenofovir alafenamide (D/C/F/TAF) 800/150/200/10 mg is being investigated in two Phase III trials, AMBER (NCT02431247; treatment-naive adults) and EMERALD (NCT02269917; treatment-experienced, virologically suppressed adults). Week 48 AMBER and EMERALD resistance analyses are presented. Postbaseline samples for genotyping/phenotyping were analyzed from protocol-defined virologic failures (PDVFs) with viral load (VL) ≥400 copies/mL at failure/later time points. Post hoc analyses were deep sequencing in AMBER, and HIV-1 proviral DNA from baseline samples (VL <50 copies/mL) in EMERALD. Through week 48 across both studies, no darunavir, primary PI, or tenofovir resistance-associated mutations (RAMs) were observed in HIV-1 viruses of 1,125 participants receiving D/C/F/TAF or 629 receiving boosted darunavir plus emtricitabine/tenofovir-disoproxil-fumarate. In AMBER, the nucleos(t)ide analog reverse transcriptase inhibitor (N(t)RTI) RAM M184I/V was identified in HIV-1 of one participant during D/C/F/TAF treatment. M184V was detected pretreatment as a minority variant (9%). In EMERALD, in participants with prior VF and genoarchive data (N = 140; 98 D/C/F/TAF and 42 control), 4% had viruses with darunavir RAMs, 38% with emtricitabine RAMs, mainly at position 184 (41% not fully susceptible to emtricitabine), 4% with tenofovir RAMs, and 21% ≥ 3 thymidine analog-associated mutations (24% not fully susceptible to tenofovir) detected at screening. All achieved VL <50 copies/mL at week 48 or prior discontinuation. D/C/F/TAF has a high genetic barrier to resistance; no darunavir, primary PI, or tenofovir RAMs were observed through 48 weeks in AMBER and EMERALD. Only one postbaseline M184I/V RAM was observed in HIV-1 of an AMBER participant. In EMERALD, baseline archived RAMs to darunavir, emtricitabine, and tenofovir in participants with prior VF did not preclude virologic response.

HIV self-testing intervention experiences and kit usability: results from a qualitative study among men who have sex with men in the SELPHI (Self-Testing Public Health Intervention) randomized controlled trial in England and Wales

Objectives

SELPHI (HIV Self‐Testing Public Health Intervention) is the largest randomized controlled trial (RCT) of HIV self‐testing (HIVST) in a high‐income setting to date, and has recruited 10 000 men who have sex with men (cis‐ and transgender) and transgender women who have sex with men. This qualitative substudy aimed to explore how those utilizing self‐tests experience HIVST and the implications for further intervention development and scale‐up. This is the first qualitative study in Europe investigating experiences of HIVST among intervention users, and the first globally examining the experience of using blood‐based HIVST.

Methods

Thirty‐seven cisgender MSM SELPHI participants from across England and Wales were purposively recruited to the substudy, in which semi‐structured interviews were used to explore testing history, HIVST experiences and intervention preferences. Interviews were audio‐recorded, transcribed and analysed through a framework analysis.

Results

Men accessed the intervention because HIVST reduced barriers related to convenience, stigma and privacy concerns. Emotional responses had direct links to acceptability. Supportive intervention components increased engagement with testing and addressed supportive concerns. HIVST facilitated more frequent testing, with the potential to reduce sexually transmitted infection (STI) screening frequency. Substudy participants with an HIV‐positive result (n = 2) linked to care promptly and reported very high acceptability. Minor adverse outcomes (n = 2; relationship discord and fainting) did not reduce acceptability. Ease of use difficulties were with the lancet and the test processing stage.

Conclusions

Intervention components shaped acceptability, particularly in relation to overcoming a perceived lack of support. The intervention was broadly acceptable and usable; participants expressed an unexpected degree of enthusiasm for HIVST, including those with HIV‐positive results and individuals with minor adverse outcomes.

The working alliance in stuttering treatment: a neglected variable?

BACKGROUND

Multiple factors can influence the working alliance and treatment outcome in speech and language therapy. The 'working alliance' is an important concept in treatment and can be described as the degree to which a treatment dyad is engaged in collaborative, purposive work. To date, relatively little attention has been paid to this concept within speech and language treatment in general, and within stuttering treatment research in particular.

AIMS

To investigate the role of the working alliance within stuttering treatment, and to evaluate whether the quality of the working alliance correlated with clients' concept of motivation and treatment outcomes 6 months post-therapy.

METHODS & PROCEDURES

Eighteen adults (21-61 years) participated in this multiple single-case treatment study, with treatment facilitated by an experienced speech and language therapist. The working alliance was investigated using the Working Alliance Inventory-Short Version Revised (WAI-SR), an Extended version of the Client Preferences for Stuttering Treatment (CPST-E), the Overall Assessment of Speakers' Experience of Stuttering-Adult version (OASES-A), the Wright & Ayre Stuttering Self-Rating Profile (WASSP) and the Hospital Anxiety and Depression Scale (HADS).

OUTCOMES & RESULTS

Analyses demonstrated significant associations between the working alliance and client motivation (r = 0.781) and treatment outcomes (r = 0.644) 6 months post-treatment. The association between client-led goals and therapy tasks appeared particularly important.

CONCLUSIONS & IMPLICATIONS

The working alliance between speech and language therapists and persons who stutter matters. Within the alliance, the level of client-clinician agreement on treatment goals and therapy tasks may be of greater importance than the bond between client and clinician. Further research with greater numbers of participants is warranted.

Protocol update and statistical analysis plan for CADENCE-BZ: a randomized clinical trial to assess the efficacy of sodium benzoate as an adjunctive treatment in early psychosis

Background

CADENCE-BZ is a multi-centre, parallel-group, double-blind randomized controlled trial designed to examine the clinical efficacy and safety of an accessible food preservative, sodium benzoate, as an add-on treatment for patients with early psychosis. The original study protocol was published in 2017. Here, we describe the updated protocol along with the Statistical Analysis Plan (SAP) for the CADENCE-BZ trial prior to study completion.

Methods and materials

Two important changes were made to the original protocol: (1) improvements to our statistical analysis plan permitted a reduction in sample size; and (2) a revision in the secondary outcomes with the intent of reducing redundancy and excluding those measures that were not appropriate as outcomes.

Conclusions

We provide the updated SAP prior to the completion of the study with the intent of increasing the transparency of the data analyses for CADENCE-BZ. The final participants are currently completing the study and the results will be published in the near future.

Trial registration

Australian New Zealand Clinical Trials Registry (ACTRN12615000187549). Registered on 26th February 2015.

The effect of time to surgery on outcomes and complication rates following total hip arthroplasty for fractured neck of femur

INTRODUCTION

Total hip arthroplasty is recommended for elderly patients with fractured neck of femur who are independently mobile, have few co-morbidities and are not cognitively impaired. Providing a daily total hip arthroplasty service is challenging for some units in the UK and considering that these patients may be physiologically distinct from the average hip fracture patient, loss of the best practice tariff as a result of surgical delay may be unjustified. The aim of this study was to determine whether time to surgical intervention for patients eligible for total hip arthroplasty had a negative impact on patient complications, length of stay and functional outcomes.

METHODS

All patients undergoing total hip arthroplasty for fractured neck of femur at our institution over a ten-year period were identified. Complications and functional outcomes were compared between patients receiving total hip arthroplasty before and after 36 hours.

RESULTS

Of 112 consecutive patients undergoing total hip arthroplasty, 70 responded to a questionnaire or telephone consultation. Four patients were excluded owing to delayed presentation, the presence of advanced rheumatoid arthritis or a pathological fracture. Two-thirds (64%) of the remaining 66 patients underwent surgery within 36 hours of presentation. There were no significant differences between the groups of patients receiving surgery before or after 36 hours with regard to postoperative length of stay, complications, Oxford hip scores or visual analogue scale scores for state of health.

CONCLUSIONS

Delaying surgery for patients eligible for total hip arthroplasty as per the National Institute for Health and Care Excellence guidelines is justified and should not incur loss of the best practice tariff.

UK trial of the Osseointegrated Prosthesis for the Rehabilitation for Amputees: 1995-2018

BACKGROUND:

Amputation of a limb impacts on patients' self-perception and quality of life. Prostheses directly anchored to the skeleton are being investigated, aiming to avoid soft tissue complications.

OBJECTIVES:

We report outcome data for the UK trial of the Osseointegrated Prosthesis for the Rehabilitation of Amputees Implant System with a minimum of 9-year follow-up.

METHODS:

Eighteen transfemoral amputees received unilateral implants between 1997 and 2008. Five were implanted before a formalised protocol, called Osseointegrated Prosthesis for the Rehabilitation of Amputees, was developed. Mean follow-up of the Pre-Osseointegrated Prosthesis for the Rehabilitation of Amputees group is 11.4 years (1.8-18.6 years), while for the Post-Osseointegrated Prosthesis for the Rehabilitation of Amputees group it is 12.3 years (2.9-15.9).

RESULTS:

The Kaplan-Meier cumulative survivorship is 40% for the Pre-Osseointegrated Prosthesis for the Rehabilitation of Amputees group and 80.21% for the Post-Osseointegrated Prosthesis for the Rehabilitation of Amputees group. Five implants (28%) have been removed, three (17%) for deep infection, one (5.6%) for chronic pain, later proven to be infected and one (5.6%) due to implant fracture secondary to loosening due to infection. Two patients (11%) have peri-implant infections suppressed with oral antibiotics. Eleven cases (61%) of superficial infection were successfully treated with antibiotics. 36-Item short-form health survey and Questionnaire for persons with a Transfemoral Amputation showed significant improvements in quality of life up to 5 years after implantation.

CONCLUSION:

This small cohort of patients demonstrates osseointegrated prosthesis allows prolonged usage and improves patients' quality of life compared to conventional prostheses.

CLINICAL RELEVANCE

These prostheses may provide a future gold standard for amputees and this study provides the first outcome data over such a time period to be reported from outside of the developers group.